Critical Literacy in Health among sex professionals in Porto Murtinho: Self-care and Risk of STI 1

: This study aims to analyze the perceptions of female sex workers in the city of Porto Murtinho (MS) on the concepts of self-care and prevention of sexually transmitted infections (STIs), and how their opinions on the subject can affect decision-making in health. The research is based on a qualitative approach developed through semi-structured interviews recorded in audio and analyzed according to the epistemology of emergence. Data collection took place in Porto Murtinho, a city that makes up the Bioceanic Route under construction to connect Brazil to Paraguay as part of a regional socioeconomic development project. In all, 8 women were interviewed who, despite revealing a sexual prevention routine and professional autonomy, reinforced the role of critical health literacy as a tool for permanent self-care and health promotion. In addition, the relationship between the implementation of the Bioceanic Route and its possible negative impact on safety and social determinants in health is highlighted, since the consequent increase in the flow of people and services in the region corroborates the growth of prostitution and sex tourism. With this, it is concluded that more effective public health policies must be taken to ensure greater health literacy for these women, as well as the need to encourage academic debate on the subject.


INTRODUCTION
This study aimed to analyze the implications of a work focused on health literacy involving female sex workers in the city of Porto Murtinho, in the State of Mato Grosso do Sul, since this city has become very important due to the fact that Porto Murtinho borders (wet border) with Carmelo Peralta, in Paraguay, and it is estimated that in 2022 the crossing will take place by bridge, no longer by ferry, optimizing travel time, increasing traffic and also sectors related to tourism, which will be crucial for Corre Bioceânico Road is effective.This Route is one of the most important projects for the development of Mato Grosso do Sul and will connect the city of Porto Murtinho with the Republic of Paraguay, from a bridge, passing through Paraguay, Argentina until reaching Chile and will have a length of 2,200 kilometers between Campo Grande and the ports of northern Chile.The Corridor aims to facilitate the ecological process between these countries, strengthen tourism, promote the union of the peoples of the southern cone of the continent, increase export competitiveness to Asia and stimulate the creation of new regional trade flows.This project will lead to a supposedly growing demand from foreign tourists in search of the national territory, mainly in the region between Campo Grande and Porto Murtinho, and the joint itineraries (City of Bonito and the Pantanal).
It was also our object of study to verify whether sex workers protect themselves against the transmission of Sexually Transmitted Infections (STIs), to describe the perception of sex workers about sexual exploitation, to assess the reasons that led them to enter this job market and finally to discuss how multimodal language can mediate the understanding of key concepts of sex workers about caring for their sexual health.
In view of the above, this study is justified due to the importance that STIs have in society, since lack of knowledge about transmission methods and risk factors leads to complications for the health of individuals and expenses for the health system that could be avoided with primary prevention.In this sense, this research brings the vision of health literacy, which contributes to increasing the efficiency of health actions.It is worth mentioning that the Bioceanic Route will generate inevitable changes for the city of Porto Murtinho and for the various sectors of society involved.Thus, it is necessary to carry out a study that focuses on this current reality, enabling the State to work to alleviate this problem.

HEALTH LITERACY AND STIS
According to Chinn and Kramer (2011), Critical Health Literacy is the ability to make health decisions in the context of everyday life.Thus, with this ability, individuals will be able to seek and obtain health-related information and acquire a sense of control over their lives.It is possible Critical Literacy in Health among sex professionals in Porto Murtinho: Self-care and Risk of STI 3 de 10 to say that someone with this good health education will be able to check information on the internet and consult with a doctor regularly.Still according to this author, critical health literacy is composed of three domains that make up the concept: the critical evaluation of information, the understanding of the social determinants of health and collective action.The author Nutbeam (2000) states that the results of health promotion represent the personal, social and structural factors that can be modified to change the determinants of health.In this context, health literacy represents the social, cognitive, and personal skills that influence individuals' ability to access, understand, and use information to promote good health.Furthermore, the results of health promotion are the immediate target of planned health promotion activities, as these measures are essential for maintaining collective health.
According to Rudd, Rosenfeld and Simonds (2012), in the last ten years there has been an increase in research correlating critical health literacy with the individual's health outcomes, indicating participation in health promotion, disease prevention, management of a chronic disease etc.This new field of research, also according to these authors, contributes to understanding the determinants of health and discussions and communications on the reform of health services.On the other hand, research indicates that a good amount of health information is inaccessible, thus, there will not be an effective exchange of information.In view of this, effective communication and health literacy are necessary so that sex workers can have autonomy in their lives and have the possibility of perpetuating adequate health.
Prostitution consists of paid sexual practice, which generally does not require the presence of an affective bond between the parties, that is, there is an exchange of sexual pleasures for material goods.This practice constitutes one of the oldest commercial activities in human history, being considered by some authors as the oldest (Penha, et al., 2012).However, it was only in 2002 that the inclusion of the category "sex workers" in the Brazilian Classification of Occupations, by the Ministry of Labor and Employment, was achieved.It is worth emphasizing that this achievement was an initial step in advancing towards the labor rights of the category, since this process will make it easier for the public authorities to regulate, combat sexual exploitation, and, above all, allow professional dignity and enjoyment of labor rights to these people (Brasil, 2012).
Historically, interventions related to the health of sex workers have focused on reducing the risk of acquiring STIs.Since the 1980s, the Ministry of Health has adopted strategies to face the HIV/AIDS epidemic, with emphasis on the National Policy for Integral Attention to Women's Health, the Charter of Rights of Health Users and the National Policy for Integral Health for LGBT.In relation to prostitution, there are two approaches in the world.The first is the development of public policies for punishment and the second is the creation of Non-Governmental Organizations that train sex workers on measures to prevent contamination/transmission of STIs, with Brazil falling under the second action (Penha, et al 2015).
Thus, we observe that the population of sex workers is exposed daily to situations of risk of STI transmission.Among the Reproductive Tract Infections, we have Sexually Transmitted Infections (STIs), endogenous infections (eg, vulvovaginal candidiasis) and iatrogenic infections (eg, postpartum).Among these, STIs are caused by more than 30 etiological agents (viruses, fungi, bacteria and protozoa) and are transmitted by: blood, from mother to child during pregnancy, during childbirth or breastfeeding, and, mainly, through sexual contact (Brasil, 2015).
For the emergence, dissemination and maintenance of an STI epidemic to occur there must be an interaction of three factors: (1) transmission efficiency of the etiological agent, Breno Evangelista de SOUSA; Natanael dos Santos de ARAÚJO; Ruberval Franco MACIEL 4 de 10 (2) sexual partner variation rate, corroborating socioeconomic, cultural and behavioral aspects and (3) duration of infection.It is important to emphasize that these three factors do not affect the population evenly, as there are specific groups that need greater attention, called key populations: gays, men who have sex with men, transvestites/transsexuals, people who use drugs and sex workers (Brasil, 2015).Thus, it is valuable that these professionals are received and instructed correctly about the complexity of their profession, that is, it is necessary that they acquire literacy about the risk factors of their profession.As exposed by Authors Torres, Davim and Costa (1999) already addressed the relationship between the problem of insertion in prostitution and the growing development of cities, as regional and local tourism provide a significant increase in this practice, especially in adolescence.This problem is also shared with the various sectors of society, such as tourism companies, hotel and motel chains, nightclubs, among others, thus contributing to attracting these young women.In this sense, it is worth addressing the context of the Bioceánico Highway Corridor, as this will impact the city of Porto Murtinho, in Mato Grosso do Sul.
Asato, Gonçalves and Wilke (2019) already point out the concern that the construction of a bridge between these two cities can generate: sex tourism, in addition to general insecurity, such as cargo theft.This tourism can be intensified because, in addition to fishing, there are not many alternatives for income generation and development for the population.On the other side of the bridge, the city of Carmelo Peralta must also be seen as part of the confrontation of the problems, due to the fact that the city is a center of fishing tourism, in which child prostitution is exacerbated at the beginning of the fishing season.

METHODOLOGY
This study identifies itself as a qualitative research of an interpretative and exploratory nature, with characteristics of the epistemology of emergence and the rhizomatic perspective (Maciel, 2016).From this, this research was based on two post-structuralist perspectives as methodological possibilities.The first is the re-signification of the rhizomatic perspective (Deleuze;Guattari, 1995) and the second is the epistemology of postmodern emergence (Somerville, 2008;Maciel, 2016).There is an advantage in this method, as there are more open possibilities for redesigning the research, in terms of redefining the objectives and research questions, and also for organizing the data to be analyzed.The choice for the rhizomatic perspective is justified, in this proposal, since it can enable more pluralized discussions, as opposed to the binary interpretation logic.
The epistemology of emergence aims to shift the gaze of the participating researchers to investigate aspects that were not previously considered, as well as, it intends to contemplate non-canonical ways for the data collection process.As an expected risk, it was the chance for professionals to feel embarrassed and suffer psychologically about the questions asked.Thus, it was up to us researchers to properly approach these women so that they could feel free to talk about their profession.

Context
The research proposal encompassed the following inclusion criteria: women aged 18 years or over who act as sex workers and who work in the city of Porto Murtinho and sign the Informed Critical Literacy in Health among sex professionals in Porto Murtinho: Self-care and Risk of STI 5 de 10 Consent Form or put their thumb on the Informed Consent Form if they are not literate.These women were approached in hotels and inns where they were allocated.This city was chosen due to the fact that it is an important link in the Bioceanic Route, connecting the state of Mato Grosso do Sul to the other constituent countries and also because the construction of the bridge that will connect Carmelo Peralta will intensify trade, the movement of vehicles and people, tourism, etc.Therefore, this municipality is the ideal place for data collection.

Data collection instruments
The research was carried out using audio-recorded interviews, addressing in the sessions the forms of transmission of STIs and self-care practices with the professionals, since, from this, the researcher will seek to identify aspects regarding the perception of these women about the inherent risks of their profession.A semi-structured interview script was prepared with questions about the participants' perception of their current state of health.The interviews were transcribed according to the norms of conversation analysis.The researcher's field diary was used at the end of each interview and the study was carried out in four stages: Selection of sex workers in Porto Murtinho; Interview with the participants using Emergence Epistemology through open questionnaires with the aid of audio recording.Thus, the dialogue will be fluid and it will be possible to focus on issues related to individual perception, critical self-analysis and finally; Survey of data from the interview/transcription.The interviews will be analyzed in the light of the central theme: critical health literacy -sex workers' perception of the risk of STI transmission.Thus, excerpts identified that dialogue with the research objectives and with the theoretical support.According to the epistemology of emergence, themes were also listed that were not previously planned by the researcher and that emerged from the research locus and finally, elaboration of the analysis and production of the scientific article for publication.

RESULTS AND DISCUSSIONS
Interviews were conducted with a total of 8 participants, who met the listed inclusion criteria, ranging from 27 to 55 years old.During the interviews with the professionals, following the perspective of epistemology, the plurality of experiences can be observed, mainly with regard to the origin of each one of them, which bring with them their previous baggage.The fear of the judgment of the other towards their profession was a point of great importance and prevalence during the interviews.On several occasions, they brought up this point, because in view of the city being small, people knew each other a lot.Below, we present the results of this research.
For the discussion, the five main emerging aspects will be listed in line with the design of the qualitative research in question.For this reason, we will discuss how sex workers see their profession, listing their habits, risks of contagion and methods of protection against STIs, in addition to discussing their personal and family life regarding their objectives for entering the profession and also their relationship with the Bioceanic Route.

Emergence 1: Access to health and prejudice regarding the profession
The women of Porto Murtinho know that they have the right to care through the SUS in basic health units and in emergency medical care, however, they all have a private gynecologist, Breno Evangelista de SOUSA; Natanael dos Santos de ARAÚJO; Ruberval Franco MACIEL 6 de 10 where they have a self-care routine, they see themselves regularly, at least twice a year.They pay for this consultation with the money they receive from the programs and also from other complementary sources, such as beauty salons and restaurants.Women report that they do not have access to a gynecologist through the SUS, so it is necessary to carry out consultations privately.
Interviewee 1: Wow, I live in a small town, the only thing they don't have, like, is a public gynecologist, but I saw a private one today.I went to a private clinic for a complete blood count, a routine exam, you know?I loved it, I liked it a lot, but it is not available at the city center.
The reason why they prefer not to consult each other at the UBSF in Porto Murtinho would be due to the prejudice inherent in society about their profession.They say that "the population of Porto Murtinho is very talkative".That is, they are afraid of having their privacy exposed by health professionals.
Interviewee 2: It's complicated here at the post, they don't have professional ethics.Women are very talkative, so people leave here and go to other cities.But if one of the girls gets sick, or if anyone else, they take care of it right away.
In the Unified Health System (SUS), people have access to scheduled consultations and also on demand with general practitioners, through the Basic Health Units (UBSF).In some of these units there are some specialists, such as pediatricians and gynecologists, but not all of them.For a consultation with a gynecologist through the SUS, the person needs to go to a UBSF and, based on the evaluation of the general practitioner, that woman may be referred to a tertiary care hospital, through an outpatient consultation, if necessary.However, sometimes it is necessary to wait for this specialized consultation, which can take months.Thus, sex workers, as they cannot wait these months, choose to have consultations in the private system.In the Emergency Care Units (UPA), which are open 24 hours a day, their operation is different, as priority assistance is provided on an urgent and emergency basis.That is, if a woman is experiencing severe vaginal bleeding, she will be referred to a hospital if necessary.However, if that same woman has vaginal bleeding that is not severe, she will be advised to look for a UBSF to be able to investigate this bleeding on an outpatient basis.

Emergence 2: Self-care, stis and use of condoms / contraception
Combined prevention is the combination of different actions to prevent STIs, HIV, viral hepatitis and their associated factors (Brasil, 2015).This action is not just based on a single action, such as using condoms, for example, but on several actions such as using condoms, vaccination, diagnostic tests and treating people with STIs.Thus, ideally, sex workers should maintain a longitudinal follow-up to better approach this situation and increase their safety at work.At all times, sex workers demonstrate knowledge about STIs, transmission methods and the risks that their profession poses to their health.They refer to the use of male condoms in the vast majority of sexual relations with clients, even oral sex.
Interviewee 3: I don't understand the prejudice, because we have sex with a condom, have oral sex with a condom, take care of ourselves, take care of our appearance, then these girls stay there, from the family, go out with a married man, have sex, get pregnant and stay there.
The only condition they mention not using condoms would be if they have a long-term client and they are in an exclusive relationship with each other.This fact is a problem, as unprotected Critical Literacy in Health among sex professionals in Porto Murtinho: Self-care and Risk of STI 7 de 10 sex can lead to infection with STIs.Thus, we can say that the professionals are aware of the risks of acquiring STIs, but the frequency of protection is flawed.
Only one reported a history of gonorrhea.The others deny STIs and continuous use medication.They mention carrying out rapid tests regularly, but are unaware of pre-exposure and post-exposure prophylaxis, a discussion that arose during the discussion, as I thought it was very important that they knew what to do if they ever had risk exposure, such as coming into contact with third-party fluids.
Post-exposure prophylaxis (PEP) of risk for HIV infection is based on the use of antiretrovirals to prevent a person from developing HIV after risky contact with STIs.It can be used in cases of unprotected sex, even in sexual violence, as it greatly reduces the incidence of infection by this virus.This measure is important so that these women can have more security and quality of life, due to the problems that HIV infection brings to the human body.Despite this importance, the fact that they are not familiar with the PEP is worrying.That is, if by chance they accidentally expose themselves, they would not know that PEP exists and can be very useful.
With an adequate approach to this population, we will be able to mitigate the impacts and risks that these women face in their daily lives.For this, Critical Health Literacy is essential, as professionals will be able to choose the best method of protection for them, judge the information they receive and consult regularly with their respective doctors.Below, interviewee 6 exemplifies the role and responsibility that health professionals have on this topic.
Interviewee 6: I had no idea that this medication existed, no one had told me about it before, not even at the doctor's appointment.But this is important for our health and I will tell my friends.
Interviewee 6 helps us to understand the intrinsic relationship between the health of these women and the importance of putting into practice the concept of Critical Health Literacy.As an example, we can mention HIV, the human immunodeficiency virus, which is transmitted mainly through unprotected sexual contact.In addition to the implications that this infection causes for individual health, this disease strongly implies collective health and the Unified Health System, as a result of the actions that the State needs to take to reduce this negative impact, which could be minimized with the use of condoms and PEP, which we have mentioned.

Emergence 3: Reasons they are sex workers and work routine
Reis et al (2014) state that Health Education enables the dissemination of information in order to prevent injuries and promote health so that the health educator transmits content and also teaches how to think critically.
The women interviewed refer to having a work routine that they create themselves.In this way, they are not subjugated by pimps, but work at the hours they want and in what best suits their routine.Only one woman interviewed is from Porto Murtinho, the others are from São Paulo, Curitiba and Campo Grande.They travel to Porto Murtinho only during the fishing season, which occurs between March and November, as it is during this same period that fishermen go to Porto Murtinho, as these are the main men who hire the women in the city.In the fishing season, they rent houses to shelter in, usually with discounts, as they are already known.They work as sex workers in order to increase their income and be able to live well, buy goods and take care of their beauty and health, in addition to helping their families.They don't have fixed working hours, but they work when it's better and when there's more movement.For this, the Breno Evangelista de SOUSA; Natanael dos Santos de ARAÚJO; Ruberval Franco MACIEL 8 de 10 women count on the help of people who work in hotels and inns, who inform when there is a good movement for work, according to the arrival and departure of fishermen.
Interviewee 5: It's not easy money, but it's fast, because it comes out now.Then I go to the store, buy a bag, go to the salon, get my hair done.
In this dialogue, we can perceive the situation of vulnerability in which they live, at the same time that we notice a certain autonomy at work, since they are the ones who make their own work schedules.

Emergence 4: Relationship between the Bioceanic Route and the profession
The Bioceanic Route will be able to increase the number of people that the sex workers will serve, as the number of trucks and truck drivers that will pass through there will increase substantially.A problem to be highlighted is the increase in violence and robberies, related for example to the theft cargo, in addition to the increase in sex tourism, resulting from fishing, as this is an important source of income and leisure for people who live and do tourism in this locality.
The women interviewed say that the Bioceanic Route will increase the flow of people in the city, but this will negatively affect the profession, as the city is small, at the moment they would not be able to support the flow.What would happen, according to them, is that the violence rate would increase and the city would be less safe, as it would attract bad people to the city.They report that the city does not have adequate parking for truck drivers, which would lead them to park on the side of the highway, making women have to move there.Thus, as it would be a place farther from the city, they would have to travel there, which would be dangerous.
Interviewee 4: It doesn't matter to us, because it's going to be a bit far, it's going to increase the number of people, but here, for example, there's no parking.Then it will fill up with mobsters, it will become dangerous.How are they going to leave the car far away and come on foot?It will be dangerous for us to walk on the street.
In this context, Health Literacy is once again essential to encourage healthy behaviors, increase the learning experience and improve the behavioral determinants of this population in order to improve self-care for the health of this group.

Emergence 5: Reasons why they entered the profession and how the family relationship works
They report that this profession is not easy, as they have to dedicate themselves if they want to earn money.However, the return is fast, which allows them to sustain themselves.When the season ends, they return to their city of origin and to their families, who are generally unaware of what they do in Porto Murtinho, some mothers suspect, but do not know.They do not count, as the existing prejudice would affect the relationship, at least momentarily.But despite that, if the family knew, after a while they would accept it, they speculate.In conversation, they claim that there was no trigger or specific reason for entering the profession.The initiation began in adolescence, when they realized that it was quick money and they could buy what they needed.Critical Literacy in Health among sex professionals in Porto Murtinho: Self-care and Risk of STI 9 de 10

FINAL CONSIDERATIONS
The Bioceanic Route is an important development project in Mato Grosso do Sul that will connect the city of Porto Murtinho with the Republic of Paraguay through a bridge.This action will increase people traffic, income and will directly affect the life and routine of sex workers who live in Porto Murtinho, which will lead to impacts on income, safety and increase the risks inherent to the profession.Thus, Critical Health Literacy is of great value and discussion so that we can understand the factors and aggravating factors present, since this topic is emerging and still little discussed in the literature.
In view of this, it is concluded that an approach based on the study of Critical Health Literacy expands the means for better assistance to sex workers, in addition to improving the relationship between the educator and the population addressed, which is essential to mitigate the negative impacts that this profession can have on the lives of professionals.