Women's health vulnerability to the vertical transmission of syphilis: a cross-case synthesisAbstract
Objective: To analyze the elements of women’s health vulnerability to the vertical transmission of syphilis.
Methods: This is a multiple-case synthesis. Nine women participated, who had children diagnosed with congenital syphilis and resided in Sobral, Ceará, Brazil. Data collection took place from August 2019 to January 2020. Case description and case treatment from scratch were applied as general strategies, and cross-case synthesis was used as the analytical technique for the evidence, supported by the Health Vulnerability model by Florêncio and Moreira (2021). The Qualitative Data Analysis software (WebQDA)® was used.
Results and Discussion: The variables that stood out were functional literacy, perception of vulnerability, condom use behavior, and the moment of diagnosis.
Final Considerations: The study contributed to society by enabling the visualization of vulnerability as a dynamic process, in which the individual and the social are inseparable and allow for an understanding that health promotion practices support women in their processes of becoming vulnerable.
Keywords:
Health Vulnerability; Women; Congenital Syphilis
Resumo
Objetivo: Analisar os elementos de vulnerabilidade em saúde de mulheres à transmissão vertical da sífilis.
Métodos: Trata-se de uma síntese de casos múltiplos. Participaram nove mulheres que possuíam filhos diagnosticados com sífilis congênita, residentes em Sobral, Ceará, Brasil e a coleta de dados ocorreu de agosto de 2019 a janeiro de 2020. Aplicaram-se a descrição do caso e o tratamento de caso a partir do zero como estratégias gerais e a síntese cruzada dos casos como técnica analítica das evidências, amparada pelo modelo de Vulnerabilidade em Saúde de Florêncio e Moreira (2021). Utilizou-se o software de Análise Qualitativa de Dados (WebQDA)®.
Resultados e Discussão: As variáveis que se destacaram foram letramento funcional, percepção da vulnerabilidade, comportamento do uso do preservativo e momento do diagnóstico.
Considerações finais: O estudo contribuiu para a sociedade, possibilitando a visualização da vulnerabilidade como dinâmica, em que o sujeito e o social são indissociáveis e permitem entender que as práticas de promoção da saúde apoiam as mulheres nos seus processos de vulnerabilização.
Palavras-chave:
Vulnerabilidade em Saúde; Mulheres; Sífilis Congênita
Introduction
Sexually transmitted infections (STIs) are undergoing a process of feminization, and syphilis is among them. An analysis of the historical series from 2012 to 2022 for acquired syphilis between men and women in Brazil reveals that 750,848 (42.3%) cases occurred in men and 1,022,516 (57.7%) in women. Of the cases in women, 485,115 (47.4%) were reported as acquired syphilis and 537,401 (52.6%) as syphilis in pregnant women (Brazil, 2023a). Thus, it is evident how prevalent syphilis is among the female population, including pregnant women. When its vertical transmission is considered, it leads to congenital syphilis (CS), a condition of major public health impact.
In 2022, the national detection rate of syphilis in pregnant women was 32.4 per 1,000 live births; the incidence rate of congenital syphilis was 10.3 per 1,000 live births; and the mortality rate from congenital syphilis was 7.8 per 100,000 live births. In Ceará, a lower detection rate of syphilis in pregnant women is observed, at 25.2 cases per 1,000 live births, alongside a higher incidence of congenital syphilis, at 13.3 cases per 1,000 live births (Brazil, 2023a). Therefore, the syphilis situation in Brazil is concerning, particularly regarding CS, which is preventable and can lead to consequences for the newborn, either in early or late childhood.
Considering this, prenatal care is crucial for preventing vertical transmission, yet obstacles can arise during this monitoring process. Mesquita et al. (2022) analyzed the discourse of health professionals who provided prenatal care to pregnant women with syphilis and identified several vulnerability conditions that directly interfere with treatment adherence, such as: a lack of understanding of the disease, low educational level, drug use, homelessness, and having multiple partners. Consequently, it is understood that vertical transmission is permeated by subjective factors, involving the woman’s interpersonal relationships and social and support networks, which must be considered in her care (Lima et al., 2023).
It is also believed that the pandemic context may have further aggravated this situation, as healthcare attention was intensely focused on controlling COVID-19 cases, potentially interfering with the notification and treatment of other health issues, such as syphilis in pregnant women (Ribeiro et al., 2020).
Health vulnerability (HV) is understood as a human condition resulting from the interaction between the individual and the social, based on power relations, which can lead to conditions of precariousness when the empowerment of the individual or the collective is not being experienced. Precariousness can result in psychological, relational, physical, or social problems, while empowerment is related to support networks, reflection, spirituality, positive feelings, and health promotion practices (Florêncio; Moreira, 2021). Thus, the experienced situation of vulnerability can constitute a condition that provides an opportunity for a positive attitude from the individual in the face of adverse situations, which develops the potential for resilience (Melo et al., 2020).
Therefore, the elements of HV must be considered in the prenatal care of women with syphilis so that they can complete their treatment adequately. The care provided to women in situations of vulnerability to syphilis, who may also have other STIs, needs to transcend epidemiological profiles and health reports. It must consider the woman holistically: as a being belonging to a social group, who possesses unique characteristics constructed and accepted collectively, which interfere with her way of perceiving herself and understanding her health needs.
In this context, the research question arises: what are the elements of women’s health vulnerability to the vertical transmission of syphilis? It is understood that it is necessary to know the situations of vulnerability and their elements being experienced by the woman before and during the gestational period so that prenatal monitoring can be planned and conducted based on these vulnerabilities.
This study aimed to analyze the elements of women’s health vulnerability to the vertical transmission of syphilis through a cross-case synthesis.
Methods
This is a multiple-case study (Yin, 2015) conducted in the municipality of Sobral, Ceará, Brazil, located approximately 230 kilometers from the state capital, Fortaleza. The municipality was chosen because it serves as the hub of the Decentralized Health Area (ADS) and has the highest number of congenital syphilis cases in the region. It also presents a diversity of social, economic, and cultural characteristics, providing a broader perspective for the investigation of women’s health vulnerabilities.
The case study approach was chosen due to the need to better explore the complexity of health vulnerabilities among women who are mothers of children diagnosed with syphilis. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was used to ensure the quality of the study (Souza et al., 2021).
This study is part of a larger research project titled “Vulnerability of Women to STIs: an analysis of situations experienced by mothers of children with congenital syphilis,” funded by the Cearense Foundation for the Support of Scientific and Technological Development (Fundação Cearense de Apoio ao Desenvolvimento Científico e Tecnológico), which ran from 2018 to 2020. The project was approved by the Research Ethics Committee (CEP) under protocol number 3.137.516.
Three data sources were used, which were collected by two master’s degree nursing students: the congenital syphilis (CS) case notification form, the woman’s medical record during pregnancy, and a semi-structured interview.
The CS Notification Forms were used to identify and locate the cases, as well as the Primary Healthcare Units (UBS) responsible for their catchment area. According to the Information System for Notifiable Diseases (SINAN) and the Information System on Live Births (SINASC), 13 cases of congenital syphilis in children under one year of age were reported in 2017, presenting a detection rate equivalent to 4.2 in this age group (SINAN, 2022; SINASC, 2017).
Of the 13 women, four declined to participate. Thus, nine women who had children diagnosed with congenital syphilis in 2017 participated in the study, residing in seven different neighborhoods of the municipality and one in a district area. The year prior to the start of the research was selected due to the time required for case confirmation and closure, allowing for the completion of the notification.
Medical records containing information on the women’s prenatal care were accessed at the UBS, and the interviews were conducted at the participants’ homes. One woman preferred the interview to take place at the unit. It should be noted that the interviews only occurred after initial contact with the health team and confirmation from the women, with the date and time set by them. The Informed Consent Form (ICF) was read, and after it was signed, the interview was conducted. The interviews lasted an average of 30 minutes and were recorded and transcribed verbatim by the master’s students from the Graduate Program in Family Health at the Federal University of Ceará (UFC). To protect the anonymity of the participants, the word “Woman” followed by an Arabic numeral was used to identify them throughout the study, according to the sequence in which they were interviewed.
The analysis of evidence in a case study involves examining, categorizing, and recombining data to produce a finding. This requires general analytical strategies and an analytical technique (Yin, 2015). In this study, developing the case description and building the case analysis from the ground up were used as general strategies, and cross-case synthesis was used as the analytical technique. The women represented the unit of analysis for the research, with the objective of investigating their health vulnerabilities.
For the analysis, an initial general reading of all data was performed. Subsequently, the interviews were organized into tables to facilitate the selection and classification of speech excerpts. Initially, keywords were assigned to each speech excerpt according to the idea expressed in the testimonies. After reviewing all keywords, they were grouped based on similarity and reviewed again. Subsequently, subcategories were created to group the keywords, which were also reviewed and then incorporated into categories, organized according to the Health Vulnerability model. The model characterizes HV as a diverse, dynamic, and multiple phenomena, involving a continuous movement between the elements that constitute the individual and their relationships, presenting an analogy to music. The operational definitions of the concept demonstrate how HV situations can be experienced and produced, highlighting power relations in the field of social inequities, which represent precariousness (Florêncio & Moreira, 2021). Thus, the model presents itself as a relevant basis for understanding the findings of this study, given that addressing syphilis and its vertical transmission has been considered a significant challenge due to the context surrounding a socially determined disease (Oliveira et al., 2023; Paixão et al., 2023).
In the cross-case synthesis, the strategy of case description was adopted. From the categories that emerged from the discourses, a summary of each case was developed, and subsequently, combinations and cross-referencing were performed between the cases to detect similarities and contrasts among them.
In comparing the cases, it was necessary to assign variables to each case based on the analysis of the discourses; thus, seven variables were identified and related across the cases. Subsequently, to carry out the cross-case synthesis, four variables that best characterized the women in the study were selected: functional literacy, perception of vulnerability, condom use behavior, and the timing of diagnosis.
To support the evidence analysis process, the Qualitative Data Analysis software (WebQDA)® was used. This software is widely used in qualitative research and allows for content analysis, featuring a series of user-controlled tools and functions that work together to assist the researcher in their analysis (Machado & Vieira, 2020).
Results and Discussion
The participants were characterized according to the conceptual definitions related to the individual and the social, as shown in Table 1. The variables referring to the individual element included: age, education level, race, occupation, parity, pregnancy planning, age at first pregnancy, and religion. The variables related to the social element were marital status, people with whom they reside, number of rooms in the house, family income, beneficiary of government aid, timing of the gestational syphilis diagnosis, and the number of prenatal consultations.
The women were characterized by an age range of 20 to 33 years. The predominant level of education was incomplete elementary school, and the race was almost entirely mixed-race, except for one indigenous woman. The predominant religion was Catholic. The current pregnancies were mostly unplanned, the first pregnancy occurred during adolescence, and the women have more than one child.
The family context was marked by women in stable unions, mostly living with a partner and children. The socioeconomic situation indicates a family income of less than one minimum wage, with the receipt of government aid, and the number of rooms in the residence varied from two to six. Occupation was mostly marked by unemployment, with a minority in precarious jobs. The programmatic situation regarding care in health services reveals that the majority were diagnosed with gestational syphilis at the time of delivery, and in seven cases, the number of prenatal consultations exceeded the amount recommended by the Ministry of Health.
In international studies with the same characterization, it was evidenced in New York, United States, that the age remains the same as that found in this study, from 20 to 30 years (50%), with a high or very high level of poverty (64.7%) and Black race (42.7%) (Slutsker; Hennessy; Schillinger, 2018). Regarding social vulnerability, in Shanghai, China, 91.5% of women diagnosed with syphilis during pregnancy lived in a stable union; furthermore, the study showed that unemployed and multiparous women were less likely to receive an early diagnosis of syphilis during pregnancy (Du et al., 2019).
It is noticeable that the international context shows similarities regarding some elements of Brazilian social vulnerability. In Brazil, the population most affected by syphilis is female, Black, and young (Brazil, 2023a). In Niterói, Rio de Janeiro, the highest number of cases occurred in women aged 20 to 35 years (67%), with low education, less than eight years of study (62.7%), and of mixed-race (53%) (Heringer et al., 2020). In Maringá, Paraná, the most frequent age range was 20 to 30 years (50%), with up to eight years of schooling (86%), but the most evident race was White (56%) (Favero et al., 2019).
Unplanned pregnancy showed a significant association with complications during gestation, in which gestational syphilis was the third most present, behind only urinary tract infection and gestational diabetes (Bonatti et al., 2018). Therefore, the prevention of unplanned pregnancy through Reproductive Planning actions within Primary Health Care (PHC), ensuring sexual and reproductive rights, must be strengthened.
When a pregnancy is planned, there is greater satisfaction for the woman upon its discovery, in addition to favoring an early start to prenatal care and better indicators such as a higher number of prenatal consultations and receiving guidance on childbirth (Santos et al., 2019). Thus, access to information in reproductive planning empowers the woman and her sexual partner in decision-making regarding pregnancy, minimizing her condition of vulnerability.
Thus, the health vulnerabilities found in the characterization of the study participants, related to the individual element, concern biological conditions, considered by Florêncio and Moreira (2021) as the physical situation. These were: age between 20 and 33 years, mixed-race, age at first pregnancy during adolescence, having more than one child, and unplanned pregnancy. Also noteworthy is the functional literacy marked by low education; and regarding the psycho-emotional situation, the beliefs that may be linked to religion - in this study, Catholic.
A study on the knowledge, attitude, and practices of university students regarding STIs and prevention methods found that inadequate knowledge was associated with religion (Moreira; Paixão; Melo, 2022). Religious belief can also postpone the start of sexual life for young people and contribute to sexual abstinence, but it can sometimes discourage condom use (Gräf et al., 2020).
Furthermore, when investigating PHC users, Lima et al. (2022) identified that low education and low income increase the risk of individuals having unsatisfactory Functional Health Literacy by five and four times, respectively. Thus, the importance of adapting the forms of communication and language used by PHC professionals is understood, so that they can conduct the educational process on safe sexual practices assertively, acting on these situations of vulnerability.
Functional literacy is characterized by the knowledge and skills of the individual to access, understand, evaluate, and apply information, which makes them capable of making decisions; thus, literacy can either strengthen or weaken the processes of becoming vulnerable (Florêncio; Moreira, 2021). Thus, the individual, from the perspective of HV, is characterized as a social statement, in which they are constituted from their relationships in the world.
In the field of relationships, the stable union is a present characteristic among women with syphilis in pregnancy, both internationally and nationally. Trust in a partner, due to maintaining a stable relationship or being married, can make a woman not perceive herself as vulnerable to syphilis, providing a sense of security for not using a condom (Costa; Cerqueira-Santos, 2018).
Regarding the occupation of women, studies show a relationship between maternal syphilis and performing unpaid activities (Padovani; Oliveira; Pelloso, 2018; Conceição; Câmara; Pereira, 2020). This fact may be related to low education and the number of children, where women dedicate their time to childcare, in addition to lacking social support for this care. Consequently, because they do not perform paid activities and the family income is low, there was a predominance of women who are covered by government aid, unanimously through the Bolsa Família Program, and those who were not receiving it at the time of the interview reported waiting for the process to receive it.
Considering access to government programs, Freitas et al. (2019), in their study on social determinants, found that women enrolled in programs like Bolsa Família were more likely to receive prenatal care in the Unified Health System (SUS) with a higher number of consultations. In contrast, they also found that despite the increase in prenatal coverage, there were inequalities in access to consultations and tests, with associations mainly related to the woman’s education level and the Human Development Index (HDI) of the city.
The difficulty in adequately following prenatal care protocols was revealed as a characteristic of the programmatic situation of the services, which produces vulnerability, since most syphilis diagnoses were made at the time of delivery. The late diagnosis of gestational syphilis is an obstacle to preventing vertical transmission, requiring that programs and strategies for the prevention and control of vertical transmission be strengthened and followed correctly (Mesquita et al., 2022).
During prenatal care, systematic testing of the pregnant woman for syphilis is recommended through rapid tests and/or the Venereal Disease Research Laboratory (VDRL) test in the first and third trimesters. If the result is positive, treatment should be started immediately to prevent congenital syphilis. And for the treatment to be considered adequate, it must be completed according to the clinical stage of the disease, using benzathine penicillin, and started up to 30 days before delivery (Brazil, 2023b).
When there is no correct monitoring and testing of pregnant women, the diagnosis may only be made at the time of delivery, by which time the opportunity for adequate treatment will have passed, characterizing a case of congenital syphilis. However, Cardoso et al. (2018) argue that diagnosis at the time of delivery, although it does not prevent vertical transmission, allows the newborn (NB) to be treated, preventing late congenital syphilis and other consequences of the disease such as neurosyphilis.
These characterizing aspects of the participants were considered in the process of in-depth study of each case. Thus, from the multiple-case study, it was possible to perceive the congruences and dichotomies among the research subjects. To compare the cases, the following vulnerability situations that emerged from the women’s discourses were analyzed: the woman’s perception of vulnerability, the timing of the gestational syphilis diagnosis, condom use during pregnancy, functional literacy, sexual-affective relationships, social support, and partner treatment.
Four variables that were most present among the women studied were selected: functional literacy, perception of vulnerability, condom use behavior, and the timing of diagnosis, as presented in Figure 1. Florêncio and Moreira (2021) emphasize the interaction between elements in the production of health, since conditions of precariousness strengthen the processes of becoming vulnerable, while agency weakens them.
It is understood that there is an interrelation between these elements, as the lack of understanding about the disease was present in women with unsatisfactory functional literacy, which can compromise the decision to use a condom and is also related to the perception of vulnerability to STIs (Moura et al., 2021). Thus, the limited knowledge about syphilis and other STIs, combined with low education, represents a vulnerabilizing condition for the participants, often involving a lack of awareness of rights and responsibilities.
No [do you know how you got the disease?]. No [did you ask the professionals anything?]. No, I didn’t either. (Woman 5)
He [the doctor] asked if I knew about this disease. I said no. I only found out after the baby was born. (Woman 4)
Oh, I didn’t know, you know, I was a bit... I thought it was a simple disease, you know, I was shocked. Then I asked him [partner], he stayed quiet and said nothing. (Woman 9)
Less access to information, a reduced understanding of the importance of health care, and especially infection prevention measures are related to low education (Favero et al., 2019). In turn, the lack of information, linked to low education, directly contributes to the women’s lack of understanding of the disease, representing a continuous process of becoming vulnerable. The low education level identified in this study corroborates the literature, showing that less information influences the understanding of the importance of health care, especially regarding prevention measures, making it difficult to interrupt the chain of syphilis transmission (Conceição; Câmara; Pereira, 2020).
It is understood that these findings are directly related to the women’s non-perception of vulnerability. The low perception of vulnerability to syphilis hinders conscious attitudes and behaviors regarding prevention in sexual relations, thus strengthening the condition of vulnerability through the belief that a stable relationship is a device of social protection. Florêncio and Moreira (2021) describe the non-perception of risk, or of risk behavior and the need to adopt preventive measures as operational definitions of the HV model. The following statements demonstrate this perception among the participants:
I only use condoms with clients, with him [partner] I don’t. I should be using it with him, right? Because he’s shameless. (Woman 7)
When I don’t use it, it’s because he doesn’t want to. It’s because he keeps saying I’m taking the shot, that there’s no need. (Woman 1)
Then he [partner] would say there was no need. That his came back negative and that there was no need. That his was negative and mine was positive with a slightly high titration. (Woman 2)
It is observed that, in the perception of the women in this study, syphilis is linked to the partner’s infidelity, either due to a history of promiscuity and infidelity or the partner’s profession. Truck drivers are described as a bridge population for STIs due to the number of sexual partnerships. Costa and Cerqueira-Santos (2018) pointed out that 63.4% of truck drivers in stable relationships have sex with sex workers without consistent condom use, verifying the risk behavior that represents them as a bridge population.
Woman 7 reflects that, despite her occupation as a sex worker, she has the habit of using condoms with her clients; however, with her partner, she does not, viewing the condom as a work tool, which places her in a position of vulnerability in the relationship with her partner. Sousa et al. (2017) identified female sex workers who understand love as a strategy for protection against STIs and disregard condom use with a partner with whom there is sentimental involvement, due to the place he occupies in her life and family context. In contrast, other women in the same study perceived themselves as more vulnerable in their personal universe than in their professional space, referring to the promiscuity of men in stable relationships, and discussing the need for women “inside the home” to use condoms.
It is noteworthy that even female sex workers, who have knowledge about condom use and perceive the vulnerability, do not use them with their regular partner. It is noted that, when questioned about their relationship with their partner, the women in the study become aware of the need for prevention through condom use in sexual relations with their regular partner, perceiving their vulnerability at that moment. On the other hand, this perception is not sufficient to influence their behavior and attitude towards their partner.
Social vulnerability is the product of relationships and the different ways the individual interacts with one or more other individuals; there is a sense of belonging since there is a sharing at the community level. These relationships with the world are sometimes permeated by power relations (Florêncio; Moreira, 2021). Unequal power relations were present in the results of this research, as although the women perceived themselves as vulnerable to syphilis and other STIs, and understood that prevention occurs through condom use, they did not use them in their sexual relations. Gender relations directly influence the strengthening of women’s vulnerability. Female subordination leads to the exclusion of her power of choice, decision, and her freedom for sexual life, exposing her to syphilis (Heringer et al., 2020).
Furthermore, a stable union fosters a low perception of vulnerability, due to the belief that emotional ties are a protective factor, which leads to non-use of condoms (Moura et al., 2021). A woman with low functional literacy has less power in negotiating condom use with her partner, which leaves her more vulnerable and reduces her self-perception of vulnerability (Favero et al., 2019).
Thus, the case study allowed for an immersion into the singularities of the women, individually and collectively, seeking to highlight similarities and dichotomies between the vulnerabilities experienced by them in their various contexts, which give rise to a low perception of vulnerability, linked to submission to the partner, especially regarding condom use.
Understanding HV as multidimensional, knowledge of sexual history and how sexual-affective relationships occur are allies in identifying vulnerabilities. Thus, it becomes possible to promote an approach centered on the individual, allowing them to be known as a whole, since women may not be adequately aware and sensitized about the vulnerability to which they are exposed in sexual relations (Slutsker; Hennessy; Schillinger, 2018).
The behavior of individuals in situations of vulnerability, when an attitude is taken consciously and not instinctively, raises the individual’s position in power relations in an empowered way (Florêncio; Moreira, 2021). Therefore, it is understood that HV is dynamic, and can be weakened or strengthened, depending on the available conditions and resources. In the context involving congenital syphilis, it is understood that situations of vulnerability are not exclusively linked to the individual’s health in its biological field, but also involve various aspects related to the structures and services offered.
In this sense, the importance of prenatal care in PHC is evident. Prenatal care seeks to ensure the healthy development of the pregnancy, based on following protocols for the discovery of conditions during gestation, to prevent vertical transmission (Mesquita et al., 2022). Active case finding and timely diagnosis for early treatment are control strategies for congenital syphilis and should be part of prenatal care. However, this vulnerability regarding the programmatic situation of the services that monitor the pregnant women in the study is perceived, as some women were diagnosed only at the time of delivery:
When she [the hospital nurse] came to tell me [the diagnosis] I remembered that the nurse [from the UBS] hadn’t ordered my VDRL, then I figured, because I knew the other one had never been treated, he didn’t order it, if I had known I could ask for it, I would have done it. (Woman 7)
[...] I did all my prenatal care correctly, I did all the exams, normal, I did the tests for HIV, Syphilis, everything and nothing showed up and when I was about to have her, I even started thinking maybe they didn’t, they mixed up the exam, or something, because during the 9 months of pregnancy it was never “discovered,” you know. (Woman 8)
The programmatic situation is related to the characteristics and processes of institutions that provide services to the population, with an emphasis on the health sector, marked mainly by infrastructure and work processes. It also includes elements such as difficulty in access, violation of human rights, and insufficiency in the implementation of public policies (Florêncio; Moreira, 2021; Azevedo et al., 2022).
In this study, the fragility of the programmatic situation of the women’s health services strengthened their vulnerability, since being diagnosed only at the time of delivery made it impossible for the woman to participate and have autonomy over her treatment for the prevention and control of congenital syphilis.
It is also emphasized that prenatal care should integrate health promotion activities for pregnant women and their partners. Based on the findings of this study, the fragility of these actions is evident, given the participants’ limited knowledge about the disease, configuring unsatisfactory functional literacy. It is also highlighted that the promotion of women’s sexual and reproductive autonomy must be strengthened, improving their self-perception of their conditions of vulnerability and favoring changes in behavior and attitude.
Even though programmatic vulnerability encompasses several elements, including professional and organizational ones, it is amenable to agency (Azevedo et al., 2022). At times, the SUS health services, when faced with unexpected situations, tend to be resilient, with the aim of ensuring care, safety, and quality of services (Jatobá; Castro Nunes; Carvalho, 2023). However, in complex situations, this movement should not be left solely to health professionals, as the involvement of the State is necessary to guarantee access to the fundamental rights of these women.
Final considerations
This study allowed for the description of the elements of health vulnerability (HV) in women who experienced a diagnosis of gestational syphilis, as well as the vertical transmission of syphilis. Aspects related to the individual and social concepts of the health vulnerability model were identified, encompassing behavioral and relational elements with other individuals and health services.
It is understood that the vertical transmission of syphilis is socially determined, affecting populations in unfavorable social conditions, and therefore remains a health issue that is difficult to control. Thus, the findings are relevant for Primary Health Care (PHC) managers, as they transcend the epidemiological aspects of syphilis and acknowledge important vulnerabilities experienced by women diagnosed with gestational syphilis and their children with congenital syphilis. It is believed that this can inform the development and adaptation of policies based on aspects of the individual and their singularities. For this reason, management must take a careful look at service organization to support professionals in developing assertive health education actions during prenatal care, promoting adequate treatment to prevent transmission and reinfection.
Thus, the need for attention and the development of promotion and prevention policies focused on strategies that address women’s vulnerabilities is perceived, in order to enable their empowerment and create processes that weaken HV, strengthening gender relations in a more egalitarian manner.
The study’s originality is highlighted by its holistic approach to women whose children were diagnosed with congenital syphilis, from the perspective of health vulnerability, considering both the individual and the social aspects, as they are inseparable. Thus, it highlights the challenge for health services, especially PHC, to address issues within therapeutic plans that transcend the context of health and disease. In this sense, further research is suggested to focus on the power relations and syphilis involving the fathers of children diagnosed with congenital syphilis, in order to broaden the perspective on power relations and understand how men perceive themselves in the face of a syphilis diagnosis.
The study contributed to society by disseminating the concept of health vulnerability and broadening the view of health and the contexts in which the individual is embedded. It also allows for the visualization of vulnerability as a dynamic process, at times being precarious, at others being strengthened. Furthermore, by understanding the inseparability of the individual and the social, health promotion practices can support women in their processes of weakening vulnerability and achieving empowerment.1
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All research data are available in this text.
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1
A. L. M. Mesquita: conception and design of the research; acquisition, analysis, and interpretation of data; drafting of the manuscript, revision, and approval of the final version. M. A. M. da Silva and V. de A. Mazza: conception and design of the research; analysis and interpretation of data; revision and approval of the final version. C. A. S. L. de Freitas: conception and design of the research; revision and approval of the final version. The authors are responsible for all aspects of the work, ensuring the accuracy and integrity of any part of the publication.
All research data are available in this text.
Source: the authors (2020).