Self-care from the perspective by female sex workers to prevent and face the SARS-CoV-2 pandemic

Couto, Pablo Luiz Santos; Rodrigues, Vanda Palmarella; Boery, Rita Narriman Silva de Oliveira; Correia, Andresa Teixeira Santos; Vilela, Alba Benemérita Alves

doi:10.1590/1413-81232023281.10192022

Abstract

The objective was to identify the meanings attributed to self-care and its relationship with the actions taken by female sex workers in preventing and coping with COVID-19. Qualitative study supported by the Self-Care Nursing theory. An in-depth interview was carried out with 30 female sex workers from the Alto Sertão Produtivo Baiano. The IRAMUTEQ software was used to analyze the speeches, with the Descending Hierarchical Classification dendrogram. Four classes were observed, revealing the meanings attributed to self-care: the idea that self-care promotes quality of life and well-being; money as a facilitating instrument for self-care actions, both in preventing COVID-19 and in coping with difficulties; in addition to the notion that self-care contributes to the care of those around them. It is concluded that the female sex workers demonstrated to understand the concept of self-care in association with the notion of precaution, while prevention is carried out through the recommendations made by competent bodies. Furthermore, a self-care deficit was noticed due to the conditions present in the sexual service and the difficulties imposed by the pandemic.

Key words:
Sex workers; Women’s Health; Self-care; Nursing theories; Pandemics

Introduction

The world was faced with the evolution and worsening of the COVID-19 pandemic, a syndrome resulting from the SARS-CoV-2 virus (Severe Acute Respiratory Syndrome Coronavirus 2)¹1 Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, Ren R, Leung KSM, Lau EHY, Wong JY, Xing X, Xiang N, Wu Y, Li C, Chen Q, Li D, Liu T, Zhao J, Liu M, Tu W, Chen C, Jin L, Yang R, Wang Q, Zhou S, Wang R, Liu H, Luo Y, Liu Y, Shao G, Li H, Tao Z, Yang Y, Deng Z, Liu B, Ma Z, Zhang Y, Shi G, Lam TTY, Wu JT, Gao GF, Cowling BJ, Yang B, Leung GM, Feng Z. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med 2020; 382:1199-1207., reaching a plateau and subsequent decrease in cases, as there was progress of vaccination. The advance of the virus and its consequences went beyond the aspects related to the illness and cure process, impacted social, cultural, political and economic dynamics in several countries and exposed the inequities that socially vulnerable social groups suffer, such as women inserted in the paid sex market²2 Adebisi YA, Alaran AJ, Akinokun RT, Micheal AI, Ilesanmi EB, Lucero-Prisno DE. Sex workers should not be forgotten in Africa's COVID-19 response. Am J Trop Med Hyg 2020; 103(5):1780-1782.^,³3 World Health Organization (WHO). Statement on the second meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV) [Internet]. 2020 [cited 2020 dez 27]. Available from: https://www.who.int/news/item/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov).
https://www.who.int/news/item/30-01-2020... .

The concept of vulnerability breaks with the notion of risk behavior, as it brings up other ideas of exposure and involvement to diseases, as well as extrapolating the idea of culpability that the term risk presented, turning responsibility to social and state aspects⁴4 Padoveze MC, Juskevicius LF, Santos TR, Nichiata LI, Ciosak SI, Bertolozzi MR. The concept of vulnerability applied to Healthcare-associated Infections. Rev Bras Enferm 2019; 72(1):299-303.^,⁵5 Ayres JR. Vulnerabilidade, direitos humanos e cuidado: aportes conceituais. In: Barros S, Campos PFS, Fernandes JJS, organizadores. Atenção à saúde de populações vulneráveis. Barueri: Manole; 2014. P. 1-25.. Therefore, the situations that provoke vulnerabilities, which emerged with the COVID-19 pandemic, have potentiated remediable damages, but due to the lack of public policies, they make it difficult to obtain the quality of life and well-being of disadvantaged people, denying them basic human rights²2 Adebisi YA, Alaran AJ, Akinokun RT, Micheal AI, Ilesanmi EB, Lucero-Prisno DE. Sex workers should not be forgotten in Africa's COVID-19 response. Am J Trop Med Hyg 2020; 103(5):1780-1782.

3 World Health Organization (WHO). Statement on the second meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV) [Internet]. 2020 [cited 2020 dez 27]. Available from: https://www.who.int/news/item/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov).
https://www.who.int/news/item/30-01-2020...

4 Padoveze MC, Juskevicius LF, Santos TR, Nichiata LI, Ciosak SI, Bertolozzi MR. The concept of vulnerability applied to Healthcare-associated Infections. Rev Bras Enferm 2019; 72(1):299-303.

5 Ayres JR. Vulnerabilidade, direitos humanos e cuidado: aportes conceituais. In: Barros S, Campos PFS, Fernandes JJS, organizadores. Atenção à saúde de populações vulneráveis. Barueri: Manole; 2014. P. 1-25.^-⁶6 Howard S. Covid-19: Health needs of sex workers are being sidelined, warn agencies. BMJ 2020; 369:m1867..

The World Health Organization (WHO) guidelines for the adoption of strategies to mitigate, control and prevent the contamination of this virus permeated through social distancing and strict restrictions on population movement in cities, closing/control of borders, use of masks and alcohol in gel, mass confinement of communities and regions that experienced/experience an outbreak, as well as testing with diagnosis and social isolation of infected people¹1 Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, Ren R, Leung KSM, Lau EHY, Wong JY, Xing X, Xiang N, Wu Y, Li C, Chen Q, Li D, Liu T, Zhao J, Liu M, Tu W, Chen C, Jin L, Yang R, Wang Q, Zhou S, Wang R, Liu H, Luo Y, Liu Y, Shao G, Li H, Tao Z, Yang Y, Deng Z, Liu B, Ma Z, Zhang Y, Shi G, Lam TTY, Wu JT, Gao GF, Cowling BJ, Yang B, Leung GM, Feng Z. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med 2020; 382:1199-1207.^,⁷7 Kramer A, Kramer KZ. The potential impact of the Covid-19 pandemic on occupational status, work from home, and occupational mobility. J Vocat Behav 2020; 8;119:103442.. However, Latin American countries and, in this specific study, Brazil, adopted dubious strategies (herd immunity or encouraging the misuse of drugs with no scientifically proven efficacy) and different from those regulated by the WHO. Thus, there was an increase in the morbidity and mortality rate resulting from COVID-19 in population groups that experience marginalization from the State, such as female sex workers²2 Adebisi YA, Alaran AJ, Akinokun RT, Micheal AI, Ilesanmi EB, Lucero-Prisno DE. Sex workers should not be forgotten in Africa's COVID-19 response. Am J Trop Med Hyg 2020; 103(5):1780-1782.

3 World Health Organization (WHO). Statement on the second meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV) [Internet]. 2020 [cited 2020 dez 27]. Available from: https://www.who.int/news/item/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov).
https://www.who.int/news/item/30-01-2020... ^-⁴4 Padoveze MC, Juskevicius LF, Santos TR, Nichiata LI, Ciosak SI, Bertolozzi MR. The concept of vulnerability applied to Healthcare-associated Infections. Rev Bras Enferm 2019; 72(1):299-303.^,⁷7 Kramer A, Kramer KZ. The potential impact of the Covid-19 pandemic on occupational status, work from home, and occupational mobility. J Vocat Behav 2020; 8;119:103442.^,⁸8 Cluver L, Lachman JM, Sherr L, Wessels I, Krug E, Rakotomalala S, Blight S, Hillis S, Bachman G, Green O, Butchart A, Tomlinson M, Ward CL, Doubt J, McDonald K. Parenting in a time of COVID-19. Lancet 2020; 395:e64..

For progressive feminist theorists, sex work is understood as a consensual labor activity and must be regulated in order to guarantee labor rights and legal protection/support from the State, in addition to stigma-free access to health services, respect for human dignity. and public safety⁹9 Leite GS, Murray L, Lenz F. O Par e o Ímpar: o potencial de gestão de risco para a prevenção de DST/HIV/AIDS em contextos de prostituição. Rev Bras Epidemiol 2015; 18(Supl. 1):7-25.

10 Silva AP, Blanchette TG. Por amor, por dinheiro? Trabalho (re)produtivo, trabalho sexual e a transformação da mão de obra feminina. Cad Pagu 2017; 50:e175019.

11 Silva AP, Santos CRC, Carvalho MG. Entre prazeres e sofrimentos: vivências subjetivas de trabalhadoras sexuais em São Paulo. Cad Psicol Social Trab 2018; 21(2):181-195.

12 Piscitelli A. Economias sexuais, amor e tráfico de pessoas- novas questões conceituais. Cad Pagu 2016; 47:e16475.

13 Broqua C, Deschamps C. Transactions sexuelles et imbrication des rapports de pouvoir. In: Broqua C, Deschamps C, editors. L'échange economico-sexuel. Paris: Éditions EHESS; 2014. p. 7-17.^-¹⁴14 Gichuna S, Hassan R, Sanders T, Campbell R, Mutonyi M, Mwangi P. Access to Healthcare in a time of COVID-19: Sex Workers in Crisis in Nairobi, Kenya. Glob Public Health 2020; 20:1-13.. During the pandemic, these women have received subsidies and support from other bodies of society, such as the sex workers union and Non-Governmental Organizations (NGOs)¹⁵15 Pasini E. Limites simbólicos corporais na prostituição feminina. Cad Pagu 2015; 14:181-200.

16 Couto PLS, Gomes AMT, Porcino C, Rodrigues VV, Vilela ABA, Flores TS, Suto CSS, Paiva MS. Entre dinheiro, autoestima e ato sexual: representações sociais da satisfação sexual para trabalhadoras sexuais. Rev Eletr Enferm 2020; 22:59271.^-¹⁷17 Thng C, Blackledge E, Mclver R, Watchirs Smith L, McNulty A. Private sex workers' engagement with sexual health services: an online survey. Sex Health 2018; 15(1):93-95..

In this context, the importance of the essence of self-care is understood and, therefore, it is necessary to verify the actions and practices that female sex workers have adopted to prevent and face the pandemic. In view of this, the Nursing Theory that deals with self-care, approaches the object of study, as it is important for the analysis of the actions employed by them and, in addition, reveals the notion that anyone, when able, can care of him and/or others, composing the theoretical framework of this study¹⁸18 Hartweg DL, Pickens J. A concept analysis of normalcy within Orem's self-care deficit nursing theory. Self Care Depend Care Nurs 2016; 22(1):4-13..

This theory includes three dimensions, called self-care theory (points out why the individual, under adequate conditions, takes care of himself and meets his health needs), self-care deficit theory (the reasons that make individuals in need nursing care) and nursing systems theory (deep into the explanation of how interpersonal relationships are created and maintained in order to promote nursing and produce care)¹⁹19 Orem DE. Nursing: Concepts of practice. 6ª ed. St. Louis: Mosby; 2001.. For this study, the dimension focused on the theory of self-care will be adopted.

In this way, the results to be presented here may point out ways for health professionals, such as nurses, to rethink the care given to female sex workers, focused on their needs, demands and understandings. In this way, it will contribute to a practice consistent with the promotion of self-care, in addition to the treatment and prevention of sexually transmitted infections (STIs) and the acquired immunodeficiency virus (HIV), enabling effective, individualized care, based on encouraging well-being and quality of life, different from what previous research results have shown²2 Adebisi YA, Alaran AJ, Akinokun RT, Micheal AI, Ilesanmi EB, Lucero-Prisno DE. Sex workers should not be forgotten in Africa's COVID-19 response. Am J Trop Med Hyg 2020; 103(5):1780-1782.^,⁴4 Padoveze MC, Juskevicius LF, Santos TR, Nichiata LI, Ciosak SI, Bertolozzi MR. The concept of vulnerability applied to Healthcare-associated Infections. Rev Bras Enferm 2019; 72(1):299-303.^,¹⁴14 Gichuna S, Hassan R, Sanders T, Campbell R, Mutonyi M, Mwangi P. Access to Healthcare in a time of COVID-19: Sex Workers in Crisis in Nairobi, Kenya. Glob Public Health 2020; 20:1-13.^,¹⁷17 Thng C, Blackledge E, Mclver R, Watchirs Smith L, McNulty A. Private sex workers' engagement with sexual health services: an online survey. Sex Health 2018; 15(1):93-95..

Furthermore, the following guiding questions were outlined: What is the notion of female sex workers about self-care? What actions have these women taken to face and prevent contamination by SARS-CoV-2? To answer such questions, the objective was to identify the meaning of self-care and its relationship with the actions taken by female sex workers in the prevention and confrontation of COVID-19.

Method

This is a descriptive and qualitative study, based on the theoretical framework of the Nursing Self-Care Deficit Theory (NSDT), by Dorothea Orem, based on the first dimension “theory of self-care”¹⁹19 Orem DE. Nursing: Concepts of practice. 6ª ed. St. Louis: Mosby; 2001.^,²⁰20 Queiro´s PJP, Vidinha TSS, Almeida Filho AJ. Autocuidado: o contributo teórico de Orem para a disciplina e profissão de enfermagem. Rev Enferm Refer 2014; IV(3):157-164.. NSDT, considered the general theory, has in its definition the relationship of the practice of actions that allow the improvement and maturation of individuals and the development of self-care in specific spaces and times, whose goals are the preservation of life and personal well-being¹⁹19 Orem DE. Nursing: Concepts of practice. 6ª ed. St. Louis: Mosby; 2001..

It is considered that self-care is comprehensive and, therefore, universal and subjective, as it involves aspects of human experiences, not being limited to daily, mechanical, manual and instrumental activities¹⁸18 Hartweg DL, Pickens J. A concept analysis of normalcy within Orem's self-care deficit nursing theory. Self Care Depend Care Nurs 2016; 22(1):4-13.^,²⁰20 Queiro´s PJP, Vidinha TSS, Almeida Filho AJ. Autocuidado: o contributo teórico de Orem para a disciplina e profissão de enfermagem. Rev Enferm Refer 2014; IV(3):157-164.. The theory involves self-care, the activities inherent to it, as well as the therapeutic requirement related to this proposal. Thus, it is considered that the ability of the person to take care of himself makes up the functions of human beings, performed at different times by the individual, in order to ensure the preservation of health, well-being and development of life¹³13 Broqua C, Deschamps C. Transactions sexuelles et imbrication des rapports de pouvoir. In: Broqua C, Deschamps C, editors. L'échange economico-sexuel. Paris: Éditions EHESS; 2014. p. 7-17.^,¹⁴14 Gichuna S, Hassan R, Sanders T, Campbell R, Mutonyi M, Mwangi P. Access to Healthcare in a time of COVID-19: Sex Workers in Crisis in Nairobi, Kenya. Glob Public Health 2020; 20:1-13., considering the balance between excess and lack of care so that the individuals are able to pay attention to their own needs¹⁹19 Orem DE. Nursing: Concepts of practice. 6ª ed. St. Louis: Mosby; 2001.^,²⁰20 Queiro´s PJP, Vidinha TSS, Almeida Filho AJ. Autocuidado: o contributo teórico de Orem para a disciplina e profissão de enfermagem. Rev Enferm Refer 2014; IV(3):157-164..

The research development place was in the municipality of Guanambi, seat city of the Alto Sertão Produtivo Baiano and which has 19 municipalities in its region of coverage, with a total of just over 400,000 inhabitants¹⁶16 Couto PLS, Gomes AMT, Porcino C, Rodrigues VV, Vilela ABA, Flores TS, Suto CSS, Paiva MS. Entre dinheiro, autoestima e ato sexual: representações sociais da satisfação sexual para trabalhadoras sexuais. Rev Eletr Enferm 2020; 22:59271.. The participants in this study were female sex workers who, according to eligibility criteria, were 18 years of age or older and had been in the sexual service for at least 1 year (considering that the experience allows for a broader view of the sexual service). As the participation of sex workers was by prior invitation, 39 women were invited by Community Health Agents (CHA) and 09 of them did not accept to continue in the research because they did not feel comfortable with some questions and, therefore, the collection was ended with 30 participants.

The conformation of the sample (participants) took place by invitation, using the snowball technique²¹21 Costa BRL. Bola de Neve Virtual: O uso das redes sociais virtuais no processo de coleta de dados de uma pesquisa científica. Rev Interd Gest Social 2018; 7(1):15-37., with the help of CHA who work in the neighborhoods where the women’s homes and workplaces are located, in order to locate them, indicate and, thus enabling the invitations. It should be noted that this technique is used for delimiting a non-probabilistic sample for convenience, understood as a Snowball recruitment procedure²¹21 Costa BRL. Bola de Neve Virtual: O uso das redes sociais virtuais no processo de coleta de dados de uma pesquisa científica. Rev Interd Gest Social 2018; 7(1):15-37..

The collection of information was carried out by one of the researchers responsible for the study (who has experience with the subject, for developing research and outreach projects with the selected group) carried out individually, with each of the 30 female sex workers participating in the study, during the September and October 2020. Meetings took place in reserved rooms within the Family Health Strategy (FHS) units of the neighborhoods where the various establishments - bars, restaurants, pensions and inns - where women developed paid sex work were located. For those who were not from the city, a visit to the work place (bars and ruffian houses, spaces where they rent available rooms) and/or residence through the Community Health Agents (CHA) of the territory was scheduled.

A questionnaire was used in order to proceed with the sociodemographic characterization of the participants and a script composed of two questions that guided the in-depth open interview: “tell me what you mean by self-care” and “tell me about the actions or self-care strategies you have adopted in this pandemic period”.

The interviews lasted about of 25 minutes each. The answers were recorded on a cell phone, and then transcribed in full in Microsoft Word 2016 software. With 22 women, the collection was carried out in 03 FHS units and eight in their homes or workplaces. The transcripts of the speeches were made by the authors, on the same day that the interviews were concluded.

After transcribing and organizing the information in the database (textual corpus), the responses were processed in the software Interface de R pour lês Analyses Multidimensionnelles de Textes et de Questionnaires (IRAMUTEQ), which performs the semantic-lexical content analysis¹⁶16 Couto PLS, Gomes AMT, Porcino C, Rodrigues VV, Vilela ABA, Flores TS, Suto CSS, Paiva MS. Entre dinheiro, autoestima e ato sexual: representações sociais da satisfação sexual para trabalhadoras sexuais. Rev Eletr Enferm 2020; 22:59271.. Such analysis takes place from the decoding of signs, identification of similarities and semantic divergences in the content of the answers, for classification of codes and text units, decoding of elements with lexical and semantic similarity, for the conformation of lexical classes, which are commonly named of categories¹⁶16 Couto PLS, Gomes AMT, Porcino C, Rodrigues VV, Vilela ABA, Flores TS, Suto CSS, Paiva MS. Entre dinheiro, autoestima e ato sexual: representações sociais da satisfação sexual para trabalhadoras sexuais. Rev Eletr Enferm 2020; 22:59271..

Subsequently, with the delimitation of the classes, the analysis was carried out using the method of Descending Hierarchical Classification (DHC). Using the DHC resource, the responses were organized into a corpus and, subsequently, divided into text segments for classification according to the semantic-lexical content and vocabulary, originating the classes by means of the largest chi-square (X²) of the words that composed the corpus¹⁶16 Couto PLS, Gomes AMT, Porcino C, Rodrigues VV, Vilela ABA, Flores TS, Suto CSS, Paiva MS. Entre dinheiro, autoestima e ato sexual: representações sociais da satisfação sexual para trabalhadoras sexuais. Rev Eletr Enferm 2020; 22:59271.. In this study, the classes will be presented according to the meanings present in the semantic-lexical content and the text segments that compose them, resulting from DHC.

For writing quality and transparency, the Consolidated Criteria for Reporting Qualitative Research (COREQ) was used. The study was linked to an umbrella project, being approved by the Research Ethics Committee at Faculdade Guanambi, with protocol number 2,007,080 on April 7, 2017. In order to guarantee the anonymity of the participants and preserve the identities of each one, codes were adopted to name them, the letter ‘P’, followed by a number (example: P. 01).

Results

Among the 30 women, sex workers, who participated in this study, the majority were between 18 and 35 years old (78.2%), only completed elementary school (53.6%); declared herself to be black (59.4%), Catholic (55.1%), had worked in this profession for less than five years (68.1%); they were not satisfied with the profession (55.9%), used condoms in sexual intercourse (63.7%) and reported use of hormonal oral contraceptives (66.6%).

As for the DHC dendrogram (Figure 1), four classes were generated from 2,334 text segments extracted from the interviews, with 97.7% of the analyzed corpus being used, enabling the understanding of the words and phrases said by the participants in the elementary context units (ECU), from the questions asked.

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Figure 1
Class Dendrogram for Descending Hierarchical Classification. Alto Sertão Produtivo Baiano-BA, Brazil, 2022.

In order to understand this structure of content division until reaching the classes, the heterogeneous semantic-lexical content that underwent successive divisions until reaching homogeneity are presented in Figure 1. In the dendrogram there are two large thematic blocks and four classes, namely: the first referring to classes 1 and 2; the second composed of classes 3 and 4.

In the first class, 20.6% of the ECUs were used, whose lexical content with the highest X² revealed how female sex workers perceive and understand self-care: well-being, quality of life, healthy and healthy life. It is noted that the answers refer to the conception that they have of self-care, which involves taking care of them, from achieving a healthy life to get well-being and quality of life.

The second class is responsible for 29.2% of the ECUs, in which the elements with the highest X² denoted that the money (income and profit) obtained from the paid sexual service is important for the adoption of self-care practices and actions: money, need, income and street. Here, money proves to be preponderant so that they have the disposition and courage to implement self-care, especially when they experience the absence of support and protection from the State and society. On the other hand, it can be seen in the speeches that, for survival, many give up taking care of themselves and their families regarding the prevention of COVID-19, due to the need to break with social distance to be with clients, even if wearing masks, in order to guarantee income.

In turn, the third class retained 23.3% of the ECUs in which the most important words reveal, through text segments, the attempt of many female sex workers to practice self-care with actions to prevent and face the adversities that emerged with the pandemic: prevent, client, coronavirus and care. However, they come up against the reduction of clients, relying only on the help of close people and colleagues to obtain the minimum of inputs that allow them to implement self-care.

It is noteworthy that in the last class, 25.6% of the ECUs were used and the most relevant elements (with high chi-squares) that allow such an understanding were: caring, worried, self-care and children. The content with the semantic-lexical similarity that contributed to this fourth class reveals that the understanding of self-care is reflected in caring for the other. The text segments suggest that the needs demanded by close people who need support are a stimulus for the practice of self-care. Although they are survival strategies, the actions present in their speeches refer to self-care or its deficit. For the women studied here, self-care has an interface with the need to help those who need their support.

Chart 1 contains the classes and the Elementary Context Units (ECUs) that support them, with a view to organizing and better visualization of what each class has as meaning.

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Chart 1
Organização das classes com a contextualizam das respectivas UCEs, que remetem a noção de autocuidado e a relação deste com as ações adotadas por trabalhadoras sexuais na prevenção e enfrentamento à COVID-19. Alto Sertão Produtivo Baiano-BA, Brasil, 2022.

Finally, an addendum to the excerpts of the speeches should be added, which reveal that prevention involves common actions such as maintaining hygienic habits (washing the hands and showering when people get home), not going out if you have any symptoms suggestive of COVID -19, change clothes as soon as you arrive from the street and, if you have a meeting with clients, avoid kissing. In turn, they have faced the problems imposed by the pandemic through a social support network, in the belief in a deity, as well as in the misuse of some psychoactive substance.

Discussion

The profile of female sex workers presented here is consistent with previous studies⁹9 Leite GS, Murray L, Lenz F. O Par e o Ímpar: o potencial de gestão de risco para a prevenção de DST/HIV/AIDS em contextos de prostituição. Rev Bras Epidemiol 2015; 18(Supl. 1):7-25.^,¹¹11 Silva AP, Santos CRC, Carvalho MG. Entre prazeres e sofrimentos: vivências subjetivas de trabalhadoras sexuais em São Paulo. Cad Psicol Social Trab 2018; 21(2):181-195.^,¹⁶16 Couto PLS, Gomes AMT, Porcino C, Rodrigues VV, Vilela ABA, Flores TS, Suto CSS, Paiva MS. Entre dinheiro, autoestima e ato sexual: representações sociais da satisfação sexual para trabalhadoras sexuais. Rev Eletr Enferm 2020; 22:59271.. Both in Malaysia and Belo Horizonte (Brazil), it was shown that women in the paid sex market were at the base of the social pyramid, with a low level of education¹⁷17 Thng C, Blackledge E, Mclver R, Watchirs Smith L, McNulty A. Private sex workers' engagement with sexual health services: an online survey. Sex Health 2018; 15(1):93-95.^,²²22 Brandão BMGM, Angelim RCM, Marques SC, Oliveira RC, Abrão FMS. Living with HIV: coping strategies of seropositive older adults. Rev Esc Enferm USP 2020; 54:e03576.^,²³23 França M. A vida pessoal de trabalhadoras do sexo: dilemas de mulheres de classes populares. Sex Salud Soc 2017; 25:134-155.. Other published research has shown that, although these people make up a group of vulnerability to STIs/AIDS, over decades of public policy focus, effectiveness in health education strategies for health promotion and STI prevention has been perceived, which makes it possible for many of them to adhere to the use of condoms and hormonal contraceptives⁹9 Leite GS, Murray L, Lenz F. O Par e o Ímpar: o potencial de gestão de risco para a prevenção de DST/HIV/AIDS em contextos de prostituição. Rev Bras Epidemiol 2015; 18(Supl. 1):7-25.^,¹⁶16 Couto PLS, Gomes AMT, Porcino C, Rodrigues VV, Vilela ABA, Flores TS, Suto CSS, Paiva MS. Entre dinheiro, autoestima e ato sexual: representações sociais da satisfação sexual para trabalhadoras sexuais. Rev Eletr Enferm 2020; 22:59271.^,²³23 França M. A vida pessoal de trabalhadoras do sexo: dilemas de mulheres de classes populares. Sex Salud Soc 2017; 25:134-155.^,²⁴24 Couto PL, Gomes AM, Pereira AB, Carvalho JS, Silva JK, Boery RN. Use of hormonal contraceptives by prostitutes: a correlation with social vulnerability markers. Acta Paul Enferm 2019; 32(5):507-513..

The fact that most of them adhere to methods of preventing STIs and unplanned pregnancy reinforces the importance of the work of the health team, especially nurses, in the context of the FHS. In this sense, these professionals implement education and health promotion actions for populations in vulnerable situations, such as sex workers, as is the case with female sex workers in the Alto Sertão Produtivo Baiano¹⁶16 Couto PLS, Gomes AMT, Porcino C, Rodrigues VV, Vilela ABA, Flores TS, Suto CSS, Paiva MS. Entre dinheiro, autoestima e ato sexual: representações sociais da satisfação sexual para trabalhadoras sexuais. Rev Eletr Enferm 2020; 22:59271.^,²⁴24 Couto PL, Gomes AM, Pereira AB, Carvalho JS, Silva JK, Boery RN. Use of hormonal contraceptives by prostitutes: a correlation with social vulnerability markers. Acta Paul Enferm 2019; 32(5):507-513..

When pointing to self-care, it is understood that the performance and execution of ordinary and everyday activities, which are practical, allow people to have benefits such as achieving quality of life, having well-being and leading a healthy life¹⁴14 Gichuna S, Hassan R, Sanders T, Campbell R, Mutonyi M, Mwangi P. Access to Healthcare in a time of COVID-19: Sex Workers in Crisis in Nairobi, Kenya. Glob Public Health 2020; 20:1-13.^,²⁰20 Queiro´s PJP, Vidinha TSS, Almeida Filho AJ. Autocuidado: o contributo teórico de Orem para a disciplina e profissão de enfermagem. Rev Enferm Refer 2014; IV(3):157-164.. However, even though they have some good habits and self-care, it is understood that there is a lack of self-care in many moments, as sex workers as adults have some disabilities or limitations for the self-promotion of continuous and effective practices⁹9 Leite GS, Murray L, Lenz F. O Par e o Ímpar: o potencial de gestão de risco para a prevenção de DST/HIV/AIDS em contextos de prostituição. Rev Bras Epidemiol 2015; 18(Supl. 1):7-25.^,¹⁴14 Gichuna S, Hassan R, Sanders T, Campbell R, Mutonyi M, Mwangi P. Access to Healthcare in a time of COVID-19: Sex Workers in Crisis in Nairobi, Kenya. Glob Public Health 2020; 20:1-13.. This situation can be evidenced in the barriers and difficulties (stigma and institutional prejudice) encountered when accessing health services and having difficulty in contacting and establishing closer relationships with nurses (called self-care agents) for effective guidelines, congruent with science and their reality⁹9 Leite GS, Murray L, Lenz F. O Par e o Ímpar: o potencial de gestão de risco para a prevenção de DST/HIV/AIDS em contextos de prostituição. Rev Bras Epidemiol 2015; 18(Supl. 1):7-25.^,¹⁴14 Gichuna S, Hassan R, Sanders T, Campbell R, Mutonyi M, Mwangi P. Access to Healthcare in a time of COVID-19: Sex Workers in Crisis in Nairobi, Kenya. Glob Public Health 2020; 20:1-13.^,²⁰20 Queiro´s PJP, Vidinha TSS, Almeida Filho AJ. Autocuidado: o contributo teórico de Orem para a disciplina e profissão de enfermagem. Rev Enferm Refer 2014; IV(3):157-164..

The care practices promoted by nurses in primary care, free from prejudice and stigma, attract marginalized populations and make them invisible by the State to the health service and contribute to adherence to care and guidelines provided²³23 França M. A vida pessoal de trabalhadoras do sexo: dilemas de mulheres de classes populares. Sex Salud Soc 2017; 25:134-155.^,²⁴24 Couto PL, Gomes AM, Pereira AB, Carvalho JS, Silva JK, Boery RN. Use of hormonal contraceptives by prostitutes: a correlation with social vulnerability markers. Acta Paul Enferm 2019; 32(5):507-513.. The women in this present study are in line with others who perform the same profession, since, in a recent research, it was pointed out that social groups in situations of vulnerability go less and less to health services, as a result of institutional prejudice²2 Adebisi YA, Alaran AJ, Akinokun RT, Micheal AI, Ilesanmi EB, Lucero-Prisno DE. Sex workers should not be forgotten in Africa's COVID-19 response. Am J Trop Med Hyg 2020; 103(5):1780-1782.. The women studied here, from their testimonies, indicate that they sought the FHS Units.

The care provided by nursing to people is essential for the adoption of self-care practices, as guidelines passed on in a simple, clear and objective way must be congruent with reality²⁵25 Barboza NSR, Fassarella CS, Souza PA. Self-care by discalced carmelite nuns in the light of Orem´s Theory. Rev Esc Enferm USP 2020; 54:e03637.. In this specific case, for women in the sexual market, health services must adapt to the particularities experienced/pointed out by them, such as working hours, respect for autonomy and decisions made about their bodies (using sexual practice to obtain income) and psycho-emotional and social demands¹⁵15 Pasini E. Limites simbólicos corporais na prostituição feminina. Cad Pagu 2015; 14:181-200.^,²³23 França M. A vida pessoal de trabalhadoras do sexo: dilemas de mulheres de classes populares. Sex Salud Soc 2017; 25:134-155..

Such questions (guidelines passed on in a simple way, respect for individualities and other subjective demands) are relevant to the Self-Care Theory, as it highlights that subjective aspects of the human being are universal requirements for self-promotion of measures that meet personal needs, as aspects of emotions and the human psyche, when impaired, interfere with basic human needs¹⁹19 Orem DE. Nursing: Concepts of practice. 6ª ed. St. Louis: Mosby; 2001.. Thus, any action within the scope of self-care is a reflection of the effectiveness of assistance with the other and, in the understanding of those who receive these acts, achieves direct benefits for themselves¹⁸18 Hartweg DL, Pickens J. A concept analysis of normalcy within Orem's self-care deficit nursing theory. Self Care Depend Care Nurs 2016; 22(1):4-13.^,¹⁹19 Orem DE. Nursing: Concepts of practice. 6ª ed. St. Louis: Mosby; 2001..

In this sense, female sex workers showed that the notion of self-care corroborates the concept proposed in the theoretical framework of NSDT. This favors advances by pointing out a direct relationship between the adoption of healthy lifestyle for achieving independence, well-being and a positive assessment of quality of life, an attempt to balance activity and rest¹⁹19 Orem DE. Nursing: Concepts of practice. 6ª ed. St. Louis: Mosby; 2001.^,²⁵25 Barboza NSR, Fassarella CS, Souza PA. Self-care by discalced carmelite nuns in the light of Orem´s Theory. Rev Esc Enferm USP 2020; 54:e03637.. Studies carried out with female sex workers in France and Kenya indicated that groups of female sex workers adopt alternative strategies for the lack of support and assistance from the State, using the income from sexual services¹³13 Broqua C, Deschamps C. Transactions sexuelles et imbrication des rapports de pouvoir. In: Broqua C, Deschamps C, editors. L'échange economico-sexuel. Paris: Éditions EHESS; 2014. p. 7-17.^,¹⁴14 Gichuna S, Hassan R, Sanders T, Campbell R, Mutonyi M, Mwangi P. Access to Healthcare in a time of COVID-19: Sex Workers in Crisis in Nairobi, Kenya. Glob Public Health 2020; 20:1-13.. Thus, they can obtain better health conditions and a positive self-perception of their situations in times of a pandemic, when many nations are absent from supporting these women²2 Adebisi YA, Alaran AJ, Akinokun RT, Micheal AI, Ilesanmi EB, Lucero-Prisno DE. Sex workers should not be forgotten in Africa's COVID-19 response. Am J Trop Med Hyg 2020; 103(5):1780-1782.^,¹⁴14 Gichuna S, Hassan R, Sanders T, Campbell R, Mutonyi M, Mwangi P. Access to Healthcare in a time of COVID-19: Sex Workers in Crisis in Nairobi, Kenya. Glob Public Health 2020; 20:1-13.^,²⁶26 Jozaghi E, Bird L. COVID-19 and sex workers: human rights, the struggle for safety and minimum income. Can J Public Health 2020; 111(3):406-407..

However, it stands out in the results that even though they try to do self-care, there is a deficit in this care¹⁹19 Orem DE. Nursing: Concepts of practice. 6ª ed. St. Louis: Mosby; 2001.^,²⁰20 Queiro´s PJP, Vidinha TSS, Almeida Filho AJ. Autocuidado: o contributo teórico de Orem para a disciplina e profissão de enfermagem. Rev Enferm Refer 2014; IV(3):157-164., due to the need for survival, having to expose themselves to the risk of contamination by the new coronavirus. This occurs, while they stop doing social distancing (even wearing masks, there is sexual contact) to meet with clients. Even though the quality of life and well-being are relegated to a second place (from the point of view of preventing COVID-19), it is undeniable that for them not to die of hunger and to support their families is a priority.

The self-care deficit arises when people are unable to take care of themselves and, therefore, demand the activation of nursing systems¹⁹19 Orem DE. Nursing: Concepts of practice. 6ª ed. St. Louis: Mosby; 2001.^,²⁰20 Queiro´s PJP, Vidinha TSS, Almeida Filho AJ. Autocuidado: o contributo teórico de Orem para a disciplina e profissão de enfermagem. Rev Enferm Refer 2014; IV(3):157-164., especially for guidance and health education actions to mitigate the transmission chain of COVID-19, as well as creating mechanisms together with organized civil society to meet the demands arising from the lack of money for subsistence, as well as contributing to the mobilization to guarantee the rights of female sex workers.

It should be noted that the quality of life goes beyond the issues that involve the health-disease process, as it encompasses different factors such as psychosocial well-being, mental health, self-esteem, and health condition. With regard to this group of women, there must be a reduction of stigmas, acceptance by society, as well as other aspects that complement the human being such as food, rest, good night’s sleep (in their case, rest during the day, because work at night), in addition to acquiring income to meet these and other needs²2 Adebisi YA, Alaran AJ, Akinokun RT, Micheal AI, Ilesanmi EB, Lucero-Prisno DE. Sex workers should not be forgotten in Africa's COVID-19 response. Am J Trop Med Hyg 2020; 103(5):1780-1782.^,²⁶26 Jozaghi E, Bird L. COVID-19 and sex workers: human rights, the struggle for safety and minimum income. Can J Public Health 2020; 111(3):406-407.^,²⁷27 Domingues JP, Oliveira DC, Marques SC. Quality of life social representations of people living with HIV/AIDS. Texto Contexto Enferm 2018; 27(2):e1460017..

The NSDT points out three types of requirements necessary for self-care, among which are the universal, development and health deviations¹⁹19 Orem DE. Nursing: Concepts of practice. 6ª ed. St. Louis: Mosby; 2001.. As for universals, the origin lies in what is known and validated and discusses the structural and functional integrity of the human being at all stages of the life cycle, being common to any person. The universals include air, food and water intake, as well as a balanced maintenance between work and rest²⁰20 Queiro´s PJP, Vidinha TSS, Almeida Filho AJ. Autocuidado: o contributo teórico de Orem para a disciplina e profissão de enfermagem. Rev Enferm Refer 2014; IV(3):157-164.. Therefore, the requirements aimed at development focus on the promotion of vital processes, preventing harmful conditions resulting from some event, such as difficulties and problems arising from home or work¹⁹19 Orem DE. Nursing: Concepts of practice. 6ª ed. St. Louis: Mosby; 2001.^,²⁰20 Queiro´s PJP, Vidinha TSS, Almeida Filho AJ. Autocuidado: o contributo teórico de Orem para a disciplina e profissão de enfermagem. Rev Enferm Refer 2014; IV(3):157-164., in this study, from the paid and consented sexual service, practiced by women.

With regard to profit and income, another association pointed out by the female sex workers presented here was between money and self-care. The financial resource obtained from sex work is essential for subsistence and suppression of needs, both for themselves and their families, in addition to acquiring means and actions to ensure a healthy life, as well as to take care of the physical, emotional and spiritual aspects to the fullest²⁶26 Jozaghi E, Bird L. COVID-19 and sex workers: human rights, the struggle for safety and minimum income. Can J Public Health 2020; 111(3):406-407.^,²⁸28 Cruz NL, Ferreira CL, Martins E, Souza M. O cuidado com a saúde das mulheres profissionais do sexo: uma revisão narrativa. Disciplinarum Sci 2016; 17(3):339-352.. The remuneration once earned in the pre-pandemic period subsidized the livelihood of these women and their family nucleus¹⁵15 Pasini E. Limites simbólicos corporais na prostituição feminina. Cad Pagu 2015; 14:181-200.^,¹⁶16 Couto PLS, Gomes AMT, Porcino C, Rodrigues VV, Vilela ABA, Flores TS, Suto CSS, Paiva MS. Entre dinheiro, autoestima e ato sexual: representações sociais da satisfação sexual para trabalhadoras sexuais. Rev Eletr Enferm 2020; 22:59271.^,²⁸28 Cruz NL, Ferreira CL, Martins E, Souza M. O cuidado com a saúde das mulheres profissionais do sexo: uma revisão narrativa. Disciplinarum Sci 2016; 17(3):339-352.. With this income, they are able to access the private health service, in the hope of a consultation free of estrangement, since many professionals who provide assistance in the Unified Health System do not always receive them in a universal, comprehensive and equitable way⁹9 Leite GS, Murray L, Lenz F. O Par e o Ímpar: o potencial de gestão de risco para a prevenção de DST/HIV/AIDS em contextos de prostituição. Rev Bras Epidemiol 2015; 18(Supl. 1):7-25.^,²³23 França M. A vida pessoal de trabalhadoras do sexo: dilemas de mulheres de classes populares. Sex Salud Soc 2017; 25:134-155.^,²⁴24 Couto PL, Gomes AM, Pereira AB, Carvalho JS, Silva JK, Boery RN. Use of hormonal contraceptives by prostitutes: a correlation with social vulnerability markers. Acta Paul Enferm 2019; 32(5):507-513.^,²⁸28 Cruz NL, Ferreira CL, Martins E, Souza M. O cuidado com a saúde das mulheres profissionais do sexo: uma revisão narrativa. Disciplinarum Sci 2016; 17(3):339-352., because they perpetuate stigmas through institutional prejudice.

Leading a healthy life, being healthy and acquiring money are preponderant factors for a portion of these women and are related by them to their self-care, respect for their intimacy and self-love¹³13 Broqua C, Deschamps C. Transactions sexuelles et imbrication des rapports de pouvoir. In: Broqua C, Deschamps C, editors. L'échange economico-sexuel. Paris: Éditions EHESS; 2014. p. 7-17.^,¹⁵15 Pasini E. Limites simbólicos corporais na prostituição feminina. Cad Pagu 2015; 14:181-200.^,²⁹29 Couto PLS, Gomes AMT, Pereira SSC, Vilela ABA, Flores TS, Porcino C. Situations of health vulnerabilities experienced by sex workers in times of COVID-19 pandemic. Rev Baiana Enferm 2021; 35:e37327.. In the course of the COVID-19 pandemic, adopting actions to prevent and mitigate the transmission of the new coronavirus in some situations is only possible with income, which has decreased with the reduction of clients and the lack of state support. This situation stems from the demand to buy masks, gel alcohol, personal hygiene materials, food, as well as quarantine and maintain social distance, which is difficult, as they have to meet with clients in many situations, exposing themselves and indirectly their family members, to the risk of contamination²2 Adebisi YA, Alaran AJ, Akinokun RT, Micheal AI, Ilesanmi EB, Lucero-Prisno DE. Sex workers should not be forgotten in Africa's COVID-19 response. Am J Trop Med Hyg 2020; 103(5):1780-1782.^,⁶6 Howard S. Covid-19: Health needs of sex workers are being sidelined, warn agencies. BMJ 2020; 369:m1867.^,¹⁴14 Gichuna S, Hassan R, Sanders T, Campbell R, Mutonyi M, Mwangi P. Access to Healthcare in a time of COVID-19: Sex Workers in Crisis in Nairobi, Kenya. Glob Public Health 2020; 20:1-13.^,²⁹29 Couto PLS, Gomes AMT, Pereira SSC, Vilela ABA, Flores TS, Porcino C. Situations of health vulnerabilities experienced by sex workers in times of COVID-19 pandemic. Rev Baiana Enferm 2021; 35:e37327..

The ability of these women to implement self-care is noticeable, however the difficulties do not refer to their physical condition, but are linked to the lack of resources to obtain means that allow them to self-care¹⁴14 Gichuna S, Hassan R, Sanders T, Campbell R, Mutonyi M, Mwangi P. Access to Healthcare in a time of COVID-19: Sex Workers in Crisis in Nairobi, Kenya. Glob Public Health 2020; 20:1-13.^,¹⁹19 Orem DE. Nursing: Concepts of practice. 6ª ed. St. Louis: Mosby; 2001.^,²¹21 Costa BRL. Bola de Neve Virtual: O uso das redes sociais virtuais no processo de coleta de dados de uma pesquisa científica. Rev Interd Gest Social 2018; 7(1):15-37.^,²⁵25 Barboza NSR, Fassarella CS, Souza PA. Self-care by discalced carmelite nuns in the light of Orem´s Theory. Rev Esc Enferm USP 2020; 54:e03637.. In this way, they reach the third phase of self-care delimited by the theory of NSDT, which is the productive one (actual ability to take care of oneself), as they presented in the text segments the ability to perform self-care activities that maintain, restore and/or improves health and well-being¹⁹19 Orem DE. Nursing: Concepts of practice. 6ª ed. St. Louis: Mosby; 2001.^,²⁰20 Queiro´s PJP, Vidinha TSS, Almeida Filho AJ. Autocuidado: o contributo teórico de Orem para a disciplina e profissão de enfermagem. Rev Enferm Refer 2014; IV(3):157-164..

With the presentation of such a context, female sex workers try to implement strategies that favor self-care, reinventing themselves to guarantee income during the pandemic, such as the use of technological means for the purpose of virtual sexual practice with former clients. The attempt to avoid transmission of SARS-CoV-2 is valid, with the adoption of personal hygiene habits, the use of masks and gel alcohol and paying attention to the signs and symptoms of COVID-19. However, other aspects of human needs are overlooked by them, among which, the pattern of sleep and rest compromised and the lack of physical activity, not only in this pandemic period.

Studies revealed that the adoption of video calls for virtual sexual activity with clients was identified as an alternative for sex workers in Europe, the United States and Latin America⁷7 Kramer A, Kramer KZ. The potential impact of the Covid-19 pandemic on occupational status, work from home, and occupational mobility. J Vocat Behav 2020; 8;119:103442.^,¹⁴14 Gichuna S, Hassan R, Sanders T, Campbell R, Mutonyi M, Mwangi P. Access to Healthcare in a time of COVID-19: Sex Workers in Crisis in Nairobi, Kenya. Glob Public Health 2020; 20:1-13.^,³⁰30 Couto PLS, Pereira SSC, Vilela ABA, Gomes AMT, Merces MC. COVID-19 coping-prevention strategies for female sexual workers in the context of various countries. Texto Contexto Enferm 2021; 30:e20200560.. On the other hand, problems with sleep patterns and lack of physical activity were/are part of the daily life of women who have sex work as a profession, because during the night they work and during the day they rest little, to take care of other tasks¹⁶16 Couto PLS, Gomes AMT, Porcino C, Rodrigues VV, Vilela ABA, Flores TS, Suto CSS, Paiva MS. Entre dinheiro, autoestima e ato sexual: representações sociais da satisfação sexual para trabalhadoras sexuais. Rev Eletr Enferm 2020; 22:59271.^,²⁸28 Cruz NL, Ferreira CL, Martins E, Souza M. O cuidado com a saúde das mulheres profissionais do sexo: uma revisão narrativa. Disciplinarum Sci 2016; 17(3):339-352.. Even so, they present an understanding of the need to change their lifestyle, a necessary item for self-care. The loss of some basic human need, such as sleep satiety, the willingness to carry out daily activities, the practice of physical exercise, tends to neglect care for themselves and, especially, care for others¹⁹19 Orem DE. Nursing: Concepts of practice. 6ª ed. St. Louis: Mosby; 2001.^,²⁵25 Barboza NSR, Fassarella CS, Souza PA. Self-care by discalced carmelite nuns in the light of Orem´s Theory. Rev Esc Enferm USP 2020; 54:e03637..

The understanding of self-care for these women touches on the idea of caring for the other, that is, taking care of children, other family members and co-workers. Thus, in their conception, it is important to be well and healthy, to be on the street and guarantee the money that will make it possible to meet the demands of those who are close to them. In another sense, “for caring for the other to be effective, instead of wanting the best for the other, one understands their aspirations, their challenges and their capacities [...] observe their abilities, desires and needs, know and respect their aspirations”²⁵25 Barboza NSR, Fassarella CS, Souza PA. Self-care by discalced carmelite nuns in the light of Orem´s Theory. Rev Esc Enferm USP 2020; 54:e03637.(p.5).

Recent research, carried out during the pandemic, with African female sex workers, has shown that the main reason for entering this type of service is, in addition to ensuring ways to prevent COVID-19 (although contradictorily, as some meet with clients), to ensure that children, relatives and some colleagues can eat and take care of personal hygiene²2 Adebisi YA, Alaran AJ, Akinokun RT, Micheal AI, Ilesanmi EB, Lucero-Prisno DE. Sex workers should not be forgotten in Africa's COVID-19 response. Am J Trop Med Hyg 2020; 103(5):1780-1782.^,²⁶26 Jozaghi E, Bird L. COVID-19 and sex workers: human rights, the struggle for safety and minimum income. Can J Public Health 2020; 111(3):406-407.. Studies prior to the pandemic, carried out in Brazil, revealed that the maintenance of personal needs and those of close people are some of the reasons for them to perform the profession¹⁵15 Pasini E. Limites simbólicos corporais na prostituição feminina. Cad Pagu 2015; 14:181-200.^,¹⁶16 Couto PLS, Gomes AMT, Porcino C, Rodrigues VV, Vilela ABA, Flores TS, Suto CSS, Paiva MS. Entre dinheiro, autoestima e ato sexual: representações sociais da satisfação sexual para trabalhadoras sexuais. Rev Eletr Enferm 2020; 22:59271.^,²³23 França M. A vida pessoal de trabalhadoras do sexo: dilemas de mulheres de classes populares. Sex Salud Soc 2017; 25:134-155.^,²⁸28 Cruz NL, Ferreira CL, Martins E, Souza M. O cuidado com a saúde das mulheres profissionais do sexo: uma revisão narrativa. Disciplinarum Sci 2016; 17(3):339-352..

In this sense, health deviations (indicated in the NSDT as identified or diagnosed problems) within the scope of human systems, have characteristics that refer to situations that are perpetuated inflexible and lasting over time, indicating the assistance needs demanded by people in the experience of the health and illness process. Self-care actions are essential to satisfy the health deviation requirements, which must be transformed into components of the difficulties presented by each human being¹⁹19 Orem DE. Nursing: Concepts of practice. 6ª ed. St. Louis: Mosby; 2001.^,²⁰20 Queiro´s PJP, Vidinha TSS, Almeida Filho AJ. Autocuidado: o contributo teórico de Orem para a disciplina e profissão de enfermagem. Rev Enferm Refer 2014; IV(3):157-164.^,²⁵25 Barboza NSR, Fassarella CS, Souza PA. Self-care by discalced carmelite nuns in the light of Orem´s Theory. Rev Esc Enferm USP 2020; 54:e03637..

Human systems are complex, as the demands and needs that arise increase as the demands of health deviation are potentiated, whose satisfaction takes place in specific spaces and time with the help of resources used by therapeutic self-care agents¹⁹19 Orem DE. Nursing: Concepts of practice. 6ª ed. St. Louis: Mosby; 2001.^,²⁰20 Queiro´s PJP, Vidinha TSS, Almeida Filho AJ. Autocuidado: o contributo teórico de Orem para a disciplina e profissão de enfermagem. Rev Enferm Refer 2014; IV(3):157-164.^,²⁵25 Barboza NSR, Fassarella CS, Souza PA. Self-care by discalced carmelite nuns in the light of Orem´s Theory. Rev Esc Enferm USP 2020; 54:e03637.. For Orem, in her theory, such an agent is a maturing or more capable adult who accepts the challenge of fulfilling the responsibility of understanding and helping to meet the therapeutic need precipitated by the action of taking care of himself and others who are dependent¹⁹19 Orem DE. Nursing: Concepts of practice. 6ª ed. St. Louis: Mosby; 2001..

It can be pondered that the effectiveness of protecting the demands of others happens when the “I” is forgotten to the detriment of offering a legitimate effort based on the real need of the other and on the practice developed by the promoter of self-care¹⁹19 Orem DE. Nursing: Concepts of practice. 6ª ed. St. Louis: Mosby; 2001.^,²⁰20 Queiro´s PJP, Vidinha TSS, Almeida Filho AJ. Autocuidado: o contributo teórico de Orem para a disciplina e profissão de enfermagem. Rev Enferm Refer 2014; IV(3):157-164.^,²⁵25 Barboza NSR, Fassarella CS, Souza PA. Self-care by discalced carmelite nuns in the light of Orem´s Theory. Rev Esc Enferm USP 2020; 54:e03637.. Therefore, the most effective way to pay attention to the close person is to start with the promotion of actions that bring benefits to the own demands²⁰20 Queiro´s PJP, Vidinha TSS, Almeida Filho AJ. Autocuidado: o contributo teórico de Orem para a disciplina e profissão de enfermagem. Rev Enferm Refer 2014; IV(3):157-164.^,²⁵25 Barboza NSR, Fassarella CS, Souza PA. Self-care by discalced carmelite nuns in the light of Orem´s Theory. Rev Esc Enferm USP 2020; 54:e03637..

The limitations of this study are anchored in the fact that it was carried out in a poor region of Northeast Brazilian and far from the big centers, which restricts the extension of results to other scenarios, both in the country and in the world. Another factor is the lack of scientific texts that deepen the relationship between nursing theories, especially self-care and female sex workers. The results found, arising from several investigations, had the object supported by the theory of Ethno-nursing. In addition, there is a lack of investigations on empirical data intertwined with novel coronavirus pandemic period, which imposes limits on the discussion and restricts comparisons with other contexts.

Conclusion

Female sex workers have an understanding of the concept of self-care, however in association with precautionary measures, as they are unaware of the theoretical framework of NSDT. In their view, as long as there are health conditions, self-care is important to lead a healthy life, achieve well-being and quality of life. However, as they are in a situation of social vulnerability, income from paid sexual service is a necessary factor to perform self-care and avoid infection by SARS-CoV-2. For this reason, it is suggested that they are in a self-care deficit, as in some situations they found themselves in need of earning money and, for this, they had to meet with clients, breaking with social distancing, abdicating self-care in detriment of survival.

The prevention practices most reported by female sex workers were stricter maintenance with hygiene and personal cleanliness and avoiding leaving the house when they felt a symptom that they considered to be associated with COVID-19 and avoiding kissing with clients. In order to face this pandemic period, many found help in their support networks, such as colleagues and organizations that support sex workers. The solidarity that exists between them is highlighted, as they understand the specificity of the moment of the pandemic and the potential reduction of clients, revealing another aspect of self-care, which is taking care of the other. In addition, they resorted to divinity and religious practices and others, in turn, misused psychoactive substances, such as prescription drugs.

By presenting the results of this study, in the context of the COVID-19 pandemic, with the theoretical contribution of NSDT, from the perspective of its first dimension, self-care, this study becomes relevant for health professionals and nurses to rethink its praxis. This reflection will reverberate in a form of care focused on the demands of vulnerable population groups, such as female sex workers, equitable, comprehensive, universal, and individual, based on demands that go beyond what is already stated in science, such as sexual health and STI/HIV prevention. Thus, assistance can be guided by minimizing stigmas and prejudices, welcoming these women in order to trust the professional and favoring the promotion of care and self-care, with a focus on quality of life.

References

¹
Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, Ren R, Leung KSM, Lau EHY, Wong JY, Xing X, Xiang N, Wu Y, Li C, Chen Q, Li D, Liu T, Zhao J, Liu M, Tu W, Chen C, Jin L, Yang R, Wang Q, Zhou S, Wang R, Liu H, Luo Y, Liu Y, Shao G, Li H, Tao Z, Yang Y, Deng Z, Liu B, Ma Z, Zhang Y, Shi G, Lam TTY, Wu JT, Gao GF, Cowling BJ, Yang B, Leung GM, Feng Z. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med 2020; 382:1199-1207.
²
Adebisi YA, Alaran AJ, Akinokun RT, Micheal AI, Ilesanmi EB, Lucero-Prisno DE. Sex workers should not be forgotten in Africa's COVID-19 response. Am J Trop Med Hyg 2020; 103(5):1780-1782.
³
World Health Organization (WHO). Statement on the second meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV) [Internet]. 2020 [cited 2020 dez 27]. Available from: https://www.who.int/news/item/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov)
» https://www.who.int/news/item/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov)
⁴
Padoveze MC, Juskevicius LF, Santos TR, Nichiata LI, Ciosak SI, Bertolozzi MR. The concept of vulnerability applied to Healthcare-associated Infections. Rev Bras Enferm 2019; 72(1):299-303.
⁵
Ayres JR. Vulnerabilidade, direitos humanos e cuidado: aportes conceituais. In: Barros S, Campos PFS, Fernandes JJS, organizadores. Atenção à saúde de populações vulneráveis. Barueri: Manole; 2014. P. 1-25.
⁶
Howard S. Covid-19: Health needs of sex workers are being sidelined, warn agencies. BMJ 2020; 369:m1867.
⁷
Kramer A, Kramer KZ. The potential impact of the Covid-19 pandemic on occupational status, work from home, and occupational mobility. J Vocat Behav 2020; 8;119:103442.
⁸
Cluver L, Lachman JM, Sherr L, Wessels I, Krug E, Rakotomalala S, Blight S, Hillis S, Bachman G, Green O, Butchart A, Tomlinson M, Ward CL, Doubt J, McDonald K. Parenting in a time of COVID-19. Lancet 2020; 395:e64.
⁹
Leite GS, Murray L, Lenz F. O Par e o Ímpar: o potencial de gestão de risco para a prevenção de DST/HIV/AIDS em contextos de prostituição. Rev Bras Epidemiol 2015; 18(Supl. 1):7-25.
¹⁰
Silva AP, Blanchette TG. Por amor, por dinheiro? Trabalho (re)produtivo, trabalho sexual e a transformação da mão de obra feminina. Cad Pagu 2017; 50:e175019.
¹¹
Silva AP, Santos CRC, Carvalho MG. Entre prazeres e sofrimentos: vivências subjetivas de trabalhadoras sexuais em São Paulo. Cad Psicol Social Trab 2018; 21(2):181-195.
¹²
Piscitelli A. Economias sexuais, amor e tráfico de pessoas- novas questões conceituais. Cad Pagu 2016; 47:e16475.
¹³
Broqua C, Deschamps C. Transactions sexuelles et imbrication des rapports de pouvoir. In: Broqua C, Deschamps C, editors. L'échange economico-sexuel. Paris: Éditions EHESS; 2014. p. 7-17.
¹⁴
Gichuna S, Hassan R, Sanders T, Campbell R, Mutonyi M, Mwangi P. Access to Healthcare in a time of COVID-19: Sex Workers in Crisis in Nairobi, Kenya. Glob Public Health 2020; 20:1-13.
¹⁵
Pasini E. Limites simbólicos corporais na prostituição feminina. Cad Pagu 2015; 14:181-200.
¹⁶
Couto PLS, Gomes AMT, Porcino C, Rodrigues VV, Vilela ABA, Flores TS, Suto CSS, Paiva MS. Entre dinheiro, autoestima e ato sexual: representações sociais da satisfação sexual para trabalhadoras sexuais. Rev Eletr Enferm 2020; 22:59271.
¹⁷
Thng C, Blackledge E, Mclver R, Watchirs Smith L, McNulty A. Private sex workers' engagement with sexual health services: an online survey. Sex Health 2018; 15(1):93-95.
¹⁸
Hartweg DL, Pickens J. A concept analysis of normalcy within Orem's self-care deficit nursing theory. Self Care Depend Care Nurs 2016; 22(1):4-13.
¹⁹
Orem DE. Nursing: Concepts of practice. 6ª ed. St. Louis: Mosby; 2001.
²⁰
Queiro´s PJP, Vidinha TSS, Almeida Filho AJ. Autocuidado: o contributo teórico de Orem para a disciplina e profissão de enfermagem. Rev Enferm Refer 2014; IV(3):157-164.
²¹
Costa BRL. Bola de Neve Virtual: O uso das redes sociais virtuais no processo de coleta de dados de uma pesquisa científica. Rev Interd Gest Social 2018; 7(1):15-37.
²²
Brandão BMGM, Angelim RCM, Marques SC, Oliveira RC, Abrão FMS. Living with HIV: coping strategies of seropositive older adults. Rev Esc Enferm USP 2020; 54:e03576.
²³
França M. A vida pessoal de trabalhadoras do sexo: dilemas de mulheres de classes populares. Sex Salud Soc 2017; 25:134-155.
²⁴
Couto PL, Gomes AM, Pereira AB, Carvalho JS, Silva JK, Boery RN. Use of hormonal contraceptives by prostitutes: a correlation with social vulnerability markers. Acta Paul Enferm 2019; 32(5):507-513.
²⁵
Barboza NSR, Fassarella CS, Souza PA. Self-care by discalced carmelite nuns in the light of Orem´s Theory. Rev Esc Enferm USP 2020; 54:e03637.
²⁶
Jozaghi E, Bird L. COVID-19 and sex workers: human rights, the struggle for safety and minimum income. Can J Public Health 2020; 111(3):406-407.
²⁷
Domingues JP, Oliveira DC, Marques SC. Quality of life social representations of people living with HIV/AIDS. Texto Contexto Enferm 2018; 27(2):e1460017.
²⁸
Cruz NL, Ferreira CL, Martins E, Souza M. O cuidado com a saúde das mulheres profissionais do sexo: uma revisão narrativa. Disciplinarum Sci 2016; 17(3):339-352.
²⁹
Couto PLS, Gomes AMT, Pereira SSC, Vilela ABA, Flores TS, Porcino C. Situations of health vulnerabilities experienced by sex workers in times of COVID-19 pandemic. Rev Baiana Enferm 2021; 35:e37327.
³⁰
Couto PLS, Pereira SSC, Vilela ABA, Gomes AMT, Merces MC. COVID-19 coping-prevention strategies for female sexual workers in the context of various countries. Texto Contexto Enferm 2021; 30:e20200560.

Publication Dates

Publication in this collection
06 Jan 2023
Date of issue
Jan 2023

History

Received
27 June 2022
Accepted
12 Aug 2022
Published
14 Aug 2022

Este é um artigo publicado em acesso aberto sob uma licença Creative Commons

[1] ¹
Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, Ren R, Leung KSM, Lau EHY, Wong JY, Xing X, Xiang N, Wu Y, Li C, Chen Q, Li D, Liu T, Zhao J, Liu M, Tu W, Chen C, Jin L, Yang R, Wang Q, Zhou S, Wang R, Liu H, Luo Y, Liu Y, Shao G, Li H, Tao Z, Yang Y, Deng Z, Liu B, Ma Z, Zhang Y, Shi G, Lam TTY, Wu JT, Gao GF, Cowling BJ, Yang B, Leung GM, Feng Z. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med 2020; 382:1199-1207.

[2] ²
Adebisi YA, Alaran AJ, Akinokun RT, Micheal AI, Ilesanmi EB, Lucero-Prisno DE. Sex workers should not be forgotten in Africa's COVID-19 response. Am J Trop Med Hyg 2020; 103(5):1780-1782.

[3] ³
World Health Organization (WHO). Statement on the second meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV) [Internet]. 2020 [cited 2020 dez 27]. Available from: https://www.who.int/news/item/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov)
» https://www.who.int/news/item/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov)

[4] ⁴
Padoveze MC, Juskevicius LF, Santos TR, Nichiata LI, Ciosak SI, Bertolozzi MR. The concept of vulnerability applied to Healthcare-associated Infections. Rev Bras Enferm 2019; 72(1):299-303.

[5] ⁵
Ayres JR. Vulnerabilidade, direitos humanos e cuidado: aportes conceituais. In: Barros S, Campos PFS, Fernandes JJS, organizadores. Atenção à saúde de populações vulneráveis. Barueri: Manole; 2014. P. 1-25.

[6] ⁶
Howard S. Covid-19: Health needs of sex workers are being sidelined, warn agencies. BMJ 2020; 369:m1867.

[7] ⁷
Kramer A, Kramer KZ. The potential impact of the Covid-19 pandemic on occupational status, work from home, and occupational mobility. J Vocat Behav 2020; 8;119:103442.

[8] ⁸
Cluver L, Lachman JM, Sherr L, Wessels I, Krug E, Rakotomalala S, Blight S, Hillis S, Bachman G, Green O, Butchart A, Tomlinson M, Ward CL, Doubt J, McDonald K. Parenting in a time of COVID-19. Lancet 2020; 395:e64.

[9] ⁹
Leite GS, Murray L, Lenz F. O Par e o Ímpar: o potencial de gestão de risco para a prevenção de DST/HIV/AIDS em contextos de prostituição. Rev Bras Epidemiol 2015; 18(Supl. 1):7-25.

[10] ¹⁰
Silva AP, Blanchette TG. Por amor, por dinheiro? Trabalho (re)produtivo, trabalho sexual e a transformação da mão de obra feminina. Cad Pagu 2017; 50:e175019.

[11] ¹¹
Silva AP, Santos CRC, Carvalho MG. Entre prazeres e sofrimentos: vivências subjetivas de trabalhadoras sexuais em São Paulo. Cad Psicol Social Trab 2018; 21(2):181-195.

[12] ¹²
Piscitelli A. Economias sexuais, amor e tráfico de pessoas- novas questões conceituais. Cad Pagu 2016; 47:e16475.

[13] ¹³
Broqua C, Deschamps C. Transactions sexuelles et imbrication des rapports de pouvoir. In: Broqua C, Deschamps C, editors. L'échange economico-sexuel. Paris: Éditions EHESS; 2014. p. 7-17.

[14] ¹⁴
Gichuna S, Hassan R, Sanders T, Campbell R, Mutonyi M, Mwangi P. Access to Healthcare in a time of COVID-19: Sex Workers in Crisis in Nairobi, Kenya. Glob Public Health 2020; 20:1-13.

[15] ¹⁵
Pasini E. Limites simbólicos corporais na prostituição feminina. Cad Pagu 2015; 14:181-200.

[16] ¹⁶
Couto PLS, Gomes AMT, Porcino C, Rodrigues VV, Vilela ABA, Flores TS, Suto CSS, Paiva MS. Entre dinheiro, autoestima e ato sexual: representações sociais da satisfação sexual para trabalhadoras sexuais. Rev Eletr Enferm 2020; 22:59271.

[17] ¹⁷
Thng C, Blackledge E, Mclver R, Watchirs Smith L, McNulty A. Private sex workers' engagement with sexual health services: an online survey. Sex Health 2018; 15(1):93-95.

[18] ¹⁸
Hartweg DL, Pickens J. A concept analysis of normalcy within Orem's self-care deficit nursing theory. Self Care Depend Care Nurs 2016; 22(1):4-13.

[19] ¹⁹
Orem DE. Nursing: Concepts of practice. 6ª ed. St. Louis: Mosby; 2001.

[20] ²⁰
Queiro´s PJP, Vidinha TSS, Almeida Filho AJ. Autocuidado: o contributo teórico de Orem para a disciplina e profissão de enfermagem. Rev Enferm Refer 2014; IV(3):157-164.

[21] ²¹
Costa BRL. Bola de Neve Virtual: O uso das redes sociais virtuais no processo de coleta de dados de uma pesquisa científica. Rev Interd Gest Social 2018; 7(1):15-37.

[22] ²²
Brandão BMGM, Angelim RCM, Marques SC, Oliveira RC, Abrão FMS. Living with HIV: coping strategies of seropositive older adults. Rev Esc Enferm USP 2020; 54:e03576.

[23] ²³
França M. A vida pessoal de trabalhadoras do sexo: dilemas de mulheres de classes populares. Sex Salud Soc 2017; 25:134-155.

[24] ²⁴
Couto PL, Gomes AM, Pereira AB, Carvalho JS, Silva JK, Boery RN. Use of hormonal contraceptives by prostitutes: a correlation with social vulnerability markers. Acta Paul Enferm 2019; 32(5):507-513.

[25] ²⁵
Barboza NSR, Fassarella CS, Souza PA. Self-care by discalced carmelite nuns in the light of Orem´s Theory. Rev Esc Enferm USP 2020; 54:e03637.

[26] ²⁶
Jozaghi E, Bird L. COVID-19 and sex workers: human rights, the struggle for safety and minimum income. Can J Public Health 2020; 111(3):406-407.

[27] ²⁷
Domingues JP, Oliveira DC, Marques SC. Quality of life social representations of people living with HIV/AIDS. Texto Contexto Enferm 2018; 27(2):e1460017.

[28] ²⁸
Cruz NL, Ferreira CL, Martins E, Souza M. O cuidado com a saúde das mulheres profissionais do sexo: uma revisão narrativa. Disciplinarum Sci 2016; 17(3):339-352.

[29] ²⁹
Couto PLS, Gomes AMT, Pereira SSC, Vilela ABA, Flores TS, Porcino C. Situations of health vulnerabilities experienced by sex workers in times of COVID-19 pandemic. Rev Baiana Enferm 2021; 35:e37327.

[30] ³⁰
Couto PLS, Pereira SSC, Vilela ABA, Gomes AMT, Merces MC. COVID-19 coping-prevention strategies for female sexual workers in the context of various countries. Texto Contexto Enferm 2021; 30:e20200560.

Class	ECU
Class I - “Self-care as a means of achieving well-being and quality of life”	For self-care, I think it’s the same as taking care of your own body, your health and your well-being (P. 01). As I see my needs, I find a way to take care of myself, to seek a healthier life (P. 04). It’s not waiting for help or asking anyone for help, that is, it’s you on your own, so we have to observe our body, our mind always, see what bring us well-being and quality of life (P. 11). So, taking care of myself in prostitution has to do with earning money to meet my needs [...] so, we have better quality of life and well-being (P. 22).
Class II - “If before I needed money to do self-care, who will say now with the pandemic”	It has been difficult, there has been a reduction in clients and money, so it is difficult to eat well, buy alcohol, a mask. We use them, but they are donations of all these products. I wear a mask, I wash my hands, but that way, when there is alcohol available, I use it (P. 01). [...] you have to feel good about yourself, you have to be excited, you have to have conditions and we need the money. This is a conflict, because at times we don’t have the right idea of how to take care of ourselves, because we are worried about making money and ending up meeting with the few clients (P. 10). Normally I do it as care in terms of health, but it is difficult now, income has dropped, many clients have disappeared; there are only a few. But I try to eat, not get hungry and be alert to any sign to seek the health service (P. 13). I try to take care of myself, wear a mask, use gel alcohol, but I need money, many people like me did not receive help from the government (P. 18). I can take care of myself when I’m well, happy, excited, but there’s no money to eat, to buy things, hygiene material, alcohol [...] (P. 24). We don’t have government assistance, we don’t have the regulation of our profession, we are almost without clients, lacking money to get the basic to live (P. 28).
Class III - “It is difficult to go through the pandemic, but I try to prevent myself and face the difficulties”	Going through this pandemic has been difficult, but I’m glad I count on the support of some friends, neighbors and the organized movement of sex workers. Wow, it has given me a lot of support, getting materials and food (P. 02). So, I try to take care of myself when I leave the house, I have one or another client. But I take care of myself, I take a shower when I arrive, I take off my clothes right away, it’s true that I don’t kiss a client on the mouth, not even before or during a pandemic (P. 09). Wow I feel like my life has stopped and I can do anything but pray and trust God that this will pass. My mother lives here with me, we always do vigil and pray the rosary (P. 14). I try to organize myself, sleep during the day, because at night I stay awake. Now, with the pandemic, I’m video calling with some clients, the old ones. I avoid leaving the house and keeping an eye on symptoms. If I go out, I wear a mask (P. 17). Things are difficult, little money coming in and I find myself desperate at times. There are days at night that I take a few drops of the medicine my mother takes for depression, to try to get some sleep and forget about this pandemic (P. 21). If I go out, when I arrive I try to take a shower right away, because of the coronavirus. I saw this on television. Also, I wear a mask to leave the house (P. 26). I would like to do more physical activity, some exercise, but I don’t have the mood. I didn’t stop making a living in the pandemic, but there less clients. I try to sleep more, take care of myself, wear a mask, use gel alcohol, but I need money. (P. 29)
Class IV - “Taking care of myself, I take care of my family and my colleagues!”	I got COVID, when I saw the first symptoms I went to the health center, took the test and it was positive. I stayed in an isolated house, but look, I was worried about where I would get money from. Then some colleagues, they gave me food, I ate, I took the medicine they gave me (P. 03). Sometimes we who are p[...] we don’t even think about taking care of ourselves, we are more concerned with the child, with the family, in earning money for what they need. Therefore, our self-care is the relief and happiness of seeing who we love well and ensuring their happiness (P. 12). My self-care is being attentive to what my son and father need and earning money for them. Now in the pandemic, if I have too much, I help a colleague who has no client. Of course, then what I need, but first them, because then I’m fine, I’m willing and I think about taking care of myself and having a healthier life (P. 21). We do not have government assistance [...]. Then, we have to get by, with one helping the other. One guiding the other with the information that we are getting. One lending money, giving food, a mask, hygiene products to those in need (P. 30).

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