Artigos

Conteúdo (article):

Coping and disease prevention actions in sex service: structure of the social representations by female sex workers

Ações de coping e prevenção de agravos no serviço sexual: estrutura das representações sociais de trabalhadoras sexuais

Acciones de afrontamiento y prevención de enfermedades en el trabajo sexual: estructura de las representaciones sociales de las trabajadoras sexuales

Pablo Luiz Santos Couto – Programa de Pós Graduação em Enfermagem e Saúde, Departamento de Saúde II, Universidade Estadual do Sudoeste da Bahia. Jequié, Bahia, Brasil. E-mail: pablocouto0710@gmail.com. Orcid: https://orcid.org/0000-0002-2692-9243
Antônio Marcos Tosoli Gomes – Faculdade de Enfermagem, Universidade do Estado do Rio de Janeiro. Rio de Janeiro, Rio de Janeiro, Brasil. E-mail: mtosoli@gmail.com. Orcid: https://orcid.org/0000-0003-4235-9647
Luiz Carlos Moraes França - Programa de Pós Graduação em Enfermagem, Faculdade de Enfermagem, Universidade do Estado do Rio de Janeiro. Rio de Janeiro, Rio de Janeiro, Brasil. E-mail: lcmoraesfranca@hotmail.com. Orcid: https://orcid.org/0000-0002-6370-115X
Tarcísio da Silva Flores – Centro Universitário Unifg. E-mail: tarcisiosflores@gmail.com. Orcid: https://orcid.org/0000-0001-6350-2698
Carle Porcino – Programa de Pós Graduação em Enfermagem e Saúde, Escola de Enfermagem, Universidade Federal da Bahia. Salvador, Bahia, Brasil. E-mail: carle.porcino@outlook.com. Orcid: https://orcid.org/0000-0001-6392-0291
Alba Benemérita Alves Vilela – Departamento de Saúde II, Universidade Estadual do Sudoeste da Bahia. Jequié, Bahia, Brasil. E-mail: albavilela@gmail.com. Orcid: https://orcid.org/0000-0002-1187-0437
Cleuma Sueli Santos Suto - Departamento de Educação, CAMPUS XII, Universidade do Estado da Bahia (UESB), Senhor do Bonfim, Bahia, Brasil. E-mail: cleuma.suto@gmail.com Orcid: https://orcid.org/0000-0002-6427-5535
Priscila Cristina da Silva Thiengo de Andrade - Programa de Pós Graduação em Enfermagem, Faculdade de Enfermagem, Universidade do Estado do Rio de Janeiro. Rio de Janeiro, Rio de Janeiro, Brasil. E-mail: proprithiengo@gmail.com. Orcid: https://orcid.org/0000-0003-0840-4838

Corresponding author:
Pablo Luiz Santos Couto
Address: Avenida José Moreira Sobrinho, s/n, Bairro Jequiezinho. CEP: 45200-000.
Phone: (71) 99144-2107
E-mail: pablocouto0710@gmail.com


ABSTRACT
The objective was to analyze the structure of social representations bay female sex workers on coping strategies and take-care myself. Quali-quantitative study, supported by the Theory of Social Representations, in its structural approach. The free evocation of words test was used as an instrument, applied to 191 women, from the five largest and most populous cities in the Southwest Region of Bahia. The evoked words were analyzed using the four house frame, similarity index and the two centrality tests mise-en-cause and choix-par-bloc. Tha social representations are structured around central elements: God, money, taking care of your health, safe sex. Which possibly demonstrates that they develop religious coping, (self)care actions when developing protected sexual relations, as well as concern about keeping their bodies healthy, free from other diseases; Money is central, due to the need to have a source of income to develop coping and meet needs. The sexual service performed by women is marked by intersectional inequities that increase vulnerabilities, which demands attitudes and behaviors to protect biopsychoemotional health.
Keywords: Sex Workers; Women\'s Health; Vulnerable Populations; Social Representation; Adaptation, Psychological.

RESUMO
Objetivou-se analisar a estrutura das representações sociais de trabalhadoras sexuais sobre estratégias de coping e prevenção de agravos. Estudo quali-quantitativo, apoiado na Teoria da Representações Sociais, na sua abordagem estrutural. Usou-se como instrumento o teste de evocação livre de palavras, aplicado a 191 mulheres, procedentes dos cinco maiores e mais populosos municípios da Região Sudoeste da Bahia. As palavras evocadas foram analisadas com o quadro de casas, índice de similitude e os testes de centralidade mise-en-cause e choix-par-bloc. As representações sociais estão estruturadas nos elementos centrais: deus, dinheiro, cuidar da saúde, sexo seguro. O que, possivelmente, demonstra que elas desenvolvem o coping religioso, ações de (auto)cuidado ao desenvolverem relações sexuais protegidas, bem como a preocupação em manter os corpos saudáveis, livre de outros doenças; o dinheiro se apresenta central, devido a necessidade de terem uma fonte de renda para desenvolver o coping e suprir necessidades. O serviço sexual exercido por mulheres é marcado por iniquidades interseccionais que potencializam vulnerabilidades, o que demanda atitudes e comportamentos para proteção da saúde biopsicoemocional.
Palavras-chave: Profissionais do Sexo; Saúde da Mulher; Populações Vulneráveis; Representações Sociais; Adaptação Psicológica.

RESUMEN
El objetivo fue analizar la estructura de las representaciones sociales de las trabajadoras sexuales sobre estrategias de afrontamiento y prevención de lesiones. Estudio cuali-cuantitativo, sustentado en la Teoría de las Representaciones Sociales, en su enfoque estructural. Se utilizó como instrumento el test libre de memoria de palabras, aplicado a 191 mujeres, provenientes de los cinco municipios más grandes y poblados de la Región Suroeste de Bahía. Las palabras evocadas fueron analizadas con el diagrama de la casa, el índice de similitud y las pruebas de centralidad de puesta en causa y choix-par-bloc. Las representaciones sociales se estructuran en torno a elementos centrales: Dios, dinero, cuidar la salud, sexo seguro. Lo que posiblemente demuestra que desarrollan acciones de afrontamiento religioso, de (auto)cuidado al desarrollar relaciones sexuales protegidas, así como preocupación por mantener su cuerpo sano, libre de otras enfermedades; El dinero es central, debido a la necesidad de contar con una fuente de ingresos para desarrollar el afrontamiento y satisfacer las necesidades. El servicio sexual realizado por las mujeres está marcado por inequidades interseccionales que aumentan las vulnerabilidades, lo que exige actitudes y comportamientos para proteger la salud biopsicoemocional.
Palabras clave: Trabajadoras Sexuales; Salud de la Mujer; Poblaciones Vulnerables; Representaciones Sociales; Adaptación psicológica.

INTRODUCTION
The exposure of sex workers to situations of vulnerability (various types of violence, absence of labor rights, difficulties in accessing health services and basic social rights, institutional stigma and prejudice, absence of the State and intersectional inequities), favors the emergence of damages that make it difficult both to obtain quality of life and well-being, as well as to cope with possible problems1-3.
African and Latin American countries3, such as Colombia4 and Mexico5, as well as Brazil1,6-7, as in this study, have seen their governments adopt dubious and ineffective strategies for the implementation of basic human rights that guarantee the citizenship of this group of women, dissonant from what is directed by the World Health Organization (WHO)3,6,8-9.
In the case of Brazil, even though there is a National Policy for Comprehensive Attention to Women’s Health (PNAISM, as per its Portuguese acronym), built on the basis of a holistic view of women’s health, it should at least be useful for the promotion of the health of sex workers, which does not occur in its entirety, precisely because the focus is only on the prevention of Sexually Transmitted Infections and HIV/AIDS10.
Although sex service is recognized by the Brazilian Ministry of Labor and Employment (MTE, as per its Portuguese acronym) with the expression “sex worker” in the Brazilian Classification of Occupations of MTE, as a profession since 2002, they are denied basic rights to the working class, keeping them in conditions of vulnerability11-12.
Thus, (re)thinking about the concept of vulnerability is to highlight social and state aspects, such as public policies and services offered by the State, which, instead of breaking down access barriers, contribute to obstacles that destabilize the health-disease process of segmented and marginalized population groups, making it difficult to produce responses, attitudes and strategies to cope with vulnerability situations, which are configured in coping13-14.
The concept of vulnerability differs from the notion of risk or risk behavior, as it touches on the exposure of people and social groups to health problems, in addition to making it possible to undo the conceptions of responsibility and blaming the person as responsible for his/her illness15-16.
It is noteworthy that sex work performed by cisgender women, from the perspective of progressive feminist theorists, is understood as a labor activity, whose paid and consensual practice of sex is negotiated directly with customers, with the exchange of sexual pleasure (of the customer) for income or other means that enable means of sustaining and subsisting, as pointed out in studies conducted in Brazil6-17, Malaysia18 or France18.
Faced with exposure to various vulnerability situations, sex workers tend to adopt ways of coping with the adversities present in the daily routine of sex service, with behaviors, practices and attitudes, which converge into coping strategies14. The theoretical component of coping points to the understanding of the psychological adaptation of people with cognitive-behavioral care/self-care actions used to manage stressful situations that cause physical and psycho-emotional disorders, such as overcoming problems and negative emotions13-14.
Accordingly, this study may point out ways for health professionals to rethink their praxis and the care provided to sex workers, focused on the needs, demands and behavioral practices signalized by them in their social representations, so that one could provide a type of care congruent with reality. It will also allow the focus of care not to be restricted to the treatment and prevention of sexually transmitted infections (STIs) and the human immunodeficiency virus (HIV), but to the promotion of biopsychosocial health, well-being and quality of life, by understanding them as holistic beings.
Furthermore, the following guiding questions were outlined: what elements structure the central nucleus of the social representations (SR) of sex workers about their coping and disease prevention strategies in the exercise of sex service? In order to help to respond to this question, the goal of this study was to analyze the structure of the social representations of sex workers about coping strategies and disease prevention.

METHOD
This is a qualitative-quantitative study, based on the Social Representations Theory (SRT), in its structural approach. The advantage of this type of research is complementarity, when quantitative-qualitative methods intersect, and two of the languages of human communication, that is, words and numbers, are increased19.
SRT fits this study proposal because it provides methodological mechanisms that help in the interpretations of a given context or social phenomenon, through the view that a group of belonging has about social phenomena20. From this perspective, the structural approach of SRT, also called Central Nucleus Theory, unveils the way in which the structure of SR is organized around a central nucleus21-22.
The place where the study was developed was the Southwest Region of Bahia, specifically in the five largest and most populous municipalities located in the semi-arid region of Bahia: Vitória da Conquista, Jequié, Guanambi, Bom Jesus da Lapa and Brumado. In order to reach the investigated social group, it was started from information from an extension project developed by the main researcher of this study, still in 2017, in the Municipality of Guanambi-BA, at the Testing and Counseling Center (CTA, as per its Portuguese acronym) for STIs/AIDS, with sex workers; and, from there, the women indicated the others. In this sense, the places where the research was developed were in the various establishments that the workers used to negotiate the service: street markets, bars, restaurants, boarding houses, inns and gas stations on the banks of the BR-116 highway in the cities of Vitória da Conquista and Jequié.
The eligibility criteria were to be over 18 years of age and to be inserted in sex service for at least one year (the experience allows a broader view of sex service). It should be underlined that there was no prior determination of how many women among the five cities that made up the research universe should participate, as it was through the acceptance of the invitation and one indicating the other by the criterion related to selection and recruitment of participants called snowball23.
Although the snowball dispensed with the use of exclusion criteria23, it was adopted as a determinant to exclude the participants those who did not respond to the instrument in its entirety, and 23 participants were dismissed among the 224 who initially made themselves available. The final sample, with the participants who participated, was composed of 191 women who performed paid sex service. The number of sex workers from each of the five cities that responded to were: Vitória da Conquista (71), Jequié (48), Guanambi (31), Bom Jesus da Lapa (27) and Brumado (14).
The collection of information was developed by two of the researchers responsible for the study, individually, in reserved spaces, in the workplaces that were indicated by the workers and at times when they were without customers. It took place between November 2022 and January 2023. A script composed of items for sociodemographic characterization and an inducing expression was used, which guided the Free Word Association Test (WAT)21,24, the adopted data collection technique. The aforementioned expression was: “What comes to your mind when I talk about coping and prevention of diseases in the exercise of sex service?”. The interviewees should immediately respond to/evoke (within 30 seconds) five words that came to mind in relation to the inducing expression.
The words evoked by means of WAT were analyzed with the aid of the EVOC 2003 software through the hierarchization expressed by the frequency and average order of evocation, through the chart of four boxes, where they were distributed, considering the aforementioned criteria, called prototypical analysis25. The chart of four boxes allows the visualization and inferences of the structuring elements that constitute the possible central nucleus and the periphery system (first and second periphery and contrast zone)21.
Still from the analysis of the evocations for the understanding of the central nucleus, it was proceeded with the analysis of similarity by co-occurrence, since this is an essential technique for detecting the degree of connectedness of the various elements represented by means of the chart of four boxes26. For this research, the manual technique was adopted, which occurs between pairs of words, divided by the number of subjects, resulting in the similarity index: (Similarity = number of co-occurrences between two nicknames / number of subjects that evoked two or more words in the quadrant)25-27.
Two techniques of centrality confirmation were chosen, namely mise-en-cause (MEC) and choix-par-bloc (CPB). MEC, also called questioning and denial techniques, is characterized by the unconditionality or non-negotiation of the elements that are proposed as the central nucleus22,27.
It is considered that the analysis with MEC takes place with the percentage calculation of one of the three responses given by the participants, “yes”, “no” or “maybe”. Accordingly, when a negative response to a negative question is greater than 75%, it is inferred that the lexicon that makes up the question structures the representational nucleus22,27.
CPB enables the exploration of the relationship that is established between the elements that make up the possible central nucleus (always two by two), based on the hierarchy of the evoked terms. The importance of each term or expression is calculated according to the value that the participant assigns/attributed to each item placed in a block of issues, which varies from +1 (most characteristic), -1 (least characteristic) and 0 (remaining indifferent words). Accordingly, the average highlight for each item is calculated, with the sum of the total values added to the relationship between two elements, dividing it by the number of people who made up the centrality stage. Therefore, the connection of each item is calculated by the number of relationships between two words22,27.
The centrality tests had the participation of 42 sex workers among the 191 in the initial sample, from three of the five municipalities (19 from Guanambi 14 from Bom Jesus da Lapa and 09 from Brumado). The tests were applied in April 2023, after the initial analysis of the results pointed out in the chart of four boxes, with those that accepted to participate in this stage. In older studies25,26, they pointed out that the minimum number of people to test the centrality would be 60. However, a more recent study indicates that this number can be randomized and non-probabilistic; therefore, less than 60 because it will depend on the profile of the participants, as well as the initial sample22.
Throughout the process of operationalizing the research and writing the article, the authors followed all the standards and criteria of quality rigor required in qualitative studies, ruled by the guidelines of the Consolidated Criteria for Reporting Qualitative Research (COREQ). The study was linked to the results of a thesis, arising from a major project, which complied with national and international standards of ethics in research with human beings, such as Resolution nº 674/2022, of the Brazilian National Health Council, being submitted and approved by the Research Ethics Committee of the State University of Southwest Bahia, from the Brasil platform, approved in November 2022 by protocol number 5.735.368 /2022 and CAAE number 60984022.9.0000.0055.

RESULTS
The chart of boxes, referring to the stimulus “coping with and prevention of health problems in sex work”, displays the configuration of the possible structure of SR regarding the way they face vulnerability situations and problems when they are in sex service. The values that were stipulated as determinants for the most relevant elements to constitute the central nucleus and the peripheries were present in the Rangmot report, issued by the EVOC software, were: minimum frequency = 19, intermediate frequency > 34 and Average Order of Evocations (AOE) = 2.9. It was found that the inducing expression produced a total of 957 evoked terms, 48 of which were different.
Chart 1

The terms present in the probable central nucleus (Chart 1) referring to the expression used as induction guide the visualization of the evocations that had a higher frequency and were responded to quickly (lower AOE), forming the upper left quadrant. The main expressions associated by the participants were: “access to benefits”, “God” and “support network”, characterizing symbology to the social memory that structures the SR of these women.
In turn, the associations responded to the inducing expression, highlighted in the first periphery of the chart, had a higher frequency and AOE (which were not evoked as quickly, conferring a characteristic of this session). This quadrant is composed of words considered at the same time flexible and clear; however, they are easily in the central nucleus. The terms are: “money”, “self-esteem”, “health care”, “condom”, “preventive”, “rapid test” and “contraceptive”.
In the lower left quadrant, known as the contrast zone (or mute), we can locate the words that had a lower frequency than the two previous quadrants, but it was evoked promptly and in the impetus of the application of the inducing expression. By owning such property, we have: “Bolsa Família (government financial aid, intended for poor families)”, “knowledge”, “information” and “safe sex”.
Everything that was expressed by the group of women and who make up the mute zone has a characteristic of complementarity to the possible central nucleus, as well as in the first periphery, which suggests the inference that they have collective ways of caring for themselves and meeting their own needs and those of their relatives.
Next, the maximum tree of similarity (Figure 1) displays how the connections between the terms evoked for the expression coping/taking care of oneself in sex work are formed, with the greater degrees/strengths of connections and, consequently, the connections that exist with the different elements of the possible representational structure.
The way Figure 01 is arranged displays the word “condom” as the most important term for the spatial organization of the central nucleus, since, although it is in the first periphery (it has the highest frequency, but with an AOE that is not the highest), it has the largest number of connections, six in total, including the term that makes up the central nucleus: “God”.
Figure 1

The element “condom” establishes the largest number of stronger connections, namely: preventive (0.151), rapid test (0.126), God (0.101) and personal hygiene (0.101). Next, the lexicons “health care” and “self-esteem”, each with a high degree of connection: “health care”-health unit (0.138) and self-esteem-God (0.101).
Therefore, the terms “God”, “access to benefits” and “money” make three important connections, among some of the aforementioned with the high connection value, as well as the one between “access to benefits” and “money” (0.101). Of the words that are in the possible central nucleus, the only one that only makes a connection and, not so strong, is “support network”.
All elements that included the results of the prototypical analysis and that were significant in the chart of four boxes 01 (central nucleus, first periphery and contrast zone) had their centrality tested with MEC and CPB. The tests allowed us to confirm or refute, in fact, what structures the central nucleus of SR for sex workers in the current study.
The first to be applied and analyzed was MEC, where the nicknames that emerged from the prototypical analysis were arranged so that they responded to “yes”, “no” or “maybe”, if a certain element was not central. All negative responses for each element that obtained a percentage equal to or greater than 75% were considered an indication of centrality, as displayed in Table 01.
The results derive from negative responses to a negative question, that is, there is the conformation of a double negation to recognize centrality in this questioning technique.
Table 1

According to Table 01, referring to MEC, the negative responses, considered statistically significant and, therefore, candidates to be central, were: money, health care and safe sex, all with 100% double denial, as well as God (88.1%).
The element “God”, which included the possible central nucleus of the chart of boxes of the prototypical analysis (Chart 01) had its centrality confirmed in MEC. The expressions “access to benefits” (38.1%) and “support network” (40.5%), even present in the same space as “God”, had low percentages in double denial, with their centrality not confirmed, considered not so relevant to coping with them.
The expressions “money” and “health care”, even though they are part of the first periphery of Chart 01, may be indicative of centrality, since they obtained high percentages. It is also noteworthy that, among the terms that made up the contrast zone (Chart 01), “safe sex” obtained a high percentage, necessary to confirm its centrality.
In the second centrality test, CPB (see Figure 02), which is the successive block choice, there was a test of the same words used in MEC, whose purpose was to favor the understanding between the connections that are formed between the nicknames with a high percentage, as well as the number of connections evidenced there, as the most characteristic for “coping” and “taking care of oneself” in sex service.
In the application of CPB, after the participants chose the words, according to their importance, the similarity calculation was developed with the support of a spreadsheet made in Microsoft Excel, organized in a new similarity tree, for better visualization.
Figure 2

In Figure 02, it can be seen that the elements that established the most connections were: “safe sex” and “health care” (04), “God” and “condom” (03), “money” and “knowledge” (02). It is noted that the elements “safe sex”, health care”, “God” and “money”, in this sequence, have their centrality confirmed, as they appear in prominence in the first analyses (chart of four boxes and similarity by co-occurrence) and are reinforced in the centrality tests, MEC and CPB.
In the CPB of Figure 02, “safe sex” is linked to “preventive”, “condom”, “rapid test” and “God”. Associated with this idea, there is the notion of body care, since it is the work instrument of their bodies and must be healthy.
The notion of preventive practices for the promotion of sexual and reproductive health was noted in the axis “condom” (personal hygiene, preventive, CTA and rapid test); “God”, as another element of connections, can indicate the issue of faith as a way of coping and strength to overcome the vulnerability situations to which women are exposed.
“Health care” is another relevant expression, which perhaps denotes that body care is beyond the prevention of infectious diseases, that is, it is also in the prevention of unplanned pregnancy (contraceptive) or other problems (“health unit”). The expression “access to benefits” takes on meaning when one sees the connections with the lexicons “public policies” (this one with the term “Bolsa Família”), “rights” and “money”.
The schematic model below displays a clear and visual way to facilitate the understanding of the representational structure, with the help of multi-analysis, as displayed in Figure 03, whose central nucleus of SR is located in the intersection zone between the circles.
Figure 3

DISCUSSION
As for the SR that the sex workers elaborated about the coping adopted in sex service, they refer to the concept given by psychology, which places the person’s ability to adapt to the various stressful situations during the phases of human development, such as the death of a family member, a problem or disease, unemployment and sociodemographic problems13-15. For this reason, the ability to face adverse contexts involves the use of cognitive and motor resources that enable people in vulnerability situations to preserve their physical, psychosocial and spiritual integrity13,26,28.
In addition to the cognitive function of allowing understandings and explanations, SR also have the function of situating people and their groups within the social field. Here, one can reach the point that favors the reflection of sex workers as individual and collective beings, whose existence in the world is not understood without making correlations with the other people who make up groups of belonging20,26. Thus, it is seen that such strategies adopted as coping are knowledge, techniques and skills experienced and learned on a daily basis, whether in the family environment or during sex service13-14.
With SRT, the meanings given to something or phenomenon are constructed and come to exist within a social reality, which makes them known. They are incorporated into consensual universes, whose knowledge is apprehended in the relationships between beings and in the means of communication, in a capping and uncapping process with interindividual exchanges20,21.
By representing faith in a higher being (God) as a form of coping, it shows the importance that belief in a deity has for the survival and overcoming of daily challenges for people who make up vulnerable population groups7.
No less important, it is worth highlighting the spiritual coping developed by the participants of this study, represented in the element “God”. It is important to bring up the concept of religious coping, defined as the use of faith, spirituality or religiosity to manage stressful situations or cope with adversities, when it is not possible to have the support of instances of society and/or the State29, as the need for adaptation arises in relation to the faced processes, the diseases and problems to which they are exposed, with direct interference in both their physical and psycho-emotional health29-30.
Results of previous studies developed both in Brazil (in Belo Horizonte and in the Alto Sertão Produtivo Baiano) and in the Amazonian border with Colombia and Peru show the importance of belief in God and faith as a representation of QoL, as a means to balance emotions, maintain mental health and endure the problems and dangers to which they are exposed daily1,6,31.
The mental elaborations that make it possible to evidence SR are revealed to the extent that the practices developed in daily life show the reality that vulnerable groups are inserted in and how much they influence and are influenced by it, in an exchange of experiences, ideas and attitudes in the daily life of the profession20,24.
The socio-culturally constructed stigma about HIV transmission by sex workers, as well as the social representation that they are a “deposit of STIs/HIV/AIDS”, as already pointed out by previous national and international studies10-11,13,17-18,32-33, cease to make sense to the extent that the notion of prevention of sexual and reproductive health permeates the structure of SR of the participants of this study, evidenced by the lexicons: “health care”, “condom”, “preventive”, “rapid test” and “contraceptive”.
An encouraging result, with regard to self-care measures to promote sexual and reproductive health, keeping the body healthy, because it is also not interesting to expose the customer to the dangers of acquiring an STI and, consequently, not to make comments, making an advertisement with other possible customers when sharing information about the conditions of women, especially in the area or street (place where this work is performed), where there is a frequency of men who have a friendship relationship1,6,13,32.
The initiatives developed by public health services, such as CTA, must increasingly overcome the various socio-cultural barriers, with a view to reaching vulnerable people, favoring the creation of a favorable environment that supports behavior change, through knowledge about coping strategies9,33.
Currently, countries such as Malaysia17, Iran34 and France18 have shown a high adherence to the preventive practices proposed by public policies, corroborating the findings present here and in other studies conducted in Brazil6,10,35, since CTAs have developed actions to promote health and prevent problems, especially infectious diseases9-12.
Self-esteem was related to a form of coping in a previous qualitative study developed with sex workers in Belo Horizonte, which criticized the symbolic idealization of “dirty” women, “without hygiene”, since they had a routine of self-care: such as prevention and care for the health of their bodies, intimate hygiene habits and concern with physical appearance; therefore, a way of experiencing the feeling of emotional and psychic well-being, such as self-love and concern with the health of their work instrument, the body itself1,18,35.
Sex workers living in both developed and developing or poor countries are exposed to a harsh reality: the lack of regularization or recognition of paid sex service as a profession6,9,18,35. In Canada, the readjustment of law C-36 (Law for the Protection of Exploited Communities and Persons) has been discussed in recent years, in order to readjust and amend it, by prohibiting anyone from buying or advertising sex services, except the woman herself36-37. In Brazil, sexual exploitation is considered a crime, while the free exercise of sex work is recognized as a profession, but without regulation or guarantees of labor rights1,6,31.
It is not by chance that there is the element “support network” in the possible representational structure of this study and the term “Bolsa Família” in the contrast zone. This signals that they understand the minimal support of the government, but especially of non-governmental organizations (NGOs), as networks that sustain personal and social demands of the group of sex workers, in the face of the absences and negligence of the State6,9,18,35.
Results of previous research, of an ethnographic qualitative nature and based on SRT, pointed out that support networks (such as NGOs) and state welfare programs for financial support, such as Bolsa Família, are essential for income supplementation and survival4,6,31.
Well-defined coping strategies in the field of public health are initiatives that need to break the barrier of stigma to reach populations considered vulnerable, such as sex workers, in order to create an environment that is favorable to the guarantee of human rights9,11,33. Such recommendations have been made over the last decades by the World Health Organization to enable mechanisms for care, coping and assistance in an intersectoral manner11,36.
In the United Kingdom, there is an example of public policies to support people in vulnerability conditions, as it has contributed £750 million (€855 million; $922 million) in subsidies to the charity sector for the basic needs of these people. Allied to this fact is the issue of the COVID-19 pandemic, as funding has been allocated for temporary and emergency housing for people in need or who have lost their source of income in that country3.
The money acquired from sexual service is essential for their livelihood and that of their families, enabling them to buy consumer goods and promote their own health, in addition to accessing private health services, revealed in previous research in France18 and Brazil1,6-7, which pointed out that the professionals at the head of the Brazilian Unified Health System (SUS, as per its Portuguese acronym) tend to develop a flawed care with regard to the precepts of universality, integrality and equity. In addition, results of qualitative studies (SRT) of yesteryear showed that money had its representation associated with sexuality, given that their aim in sex work is to earn an income6,17.
The elements that structure the possible SR of coping with and preventing diseases highlight the relationship that sex workers have with the represented object, with the environment in which they are inserted and, therefore, express the adopted social practices, strictly concatenated in the interrelationships they establish20,24.
The limitations lie mainly in the conduct of the research, which took place in a poor region of Northeastern Brazil and far from the large centers. There were also difficulties in obtaining studies that pointed out the relationship among SRT, sex workers and coping, making it difficult to discuss and compare with sex workers from other realities and contexts. As this study is an offshoot of a larger study, data collection was too long and those who contributed were tired and anxious to finish the application of the instruments.
By presenting the results of this study, in the context of paid and consensual sex service, deepened in SRT, it becomes relevant and unprecedented, as it will allow health professionals, when rethinking care, to focus it on guidelines that reinforce the actions already developed and, also, that they can implement others, congruent with scientific knowledge, equitable, integral, universal, individual and free of discrimination.
Accordingly, it will help to minimize stigmas and prejudices and welcome them, so that they trust the professional with instructions on effective preventive actions and ways of coping, as well as ways of minimizing and overcoming the vulnerabilities imposed on them. It should be emphasized that knowing SR present in social thinking will allow attention to be paid to the holistic aspects that interfere in the health-disease process.

CONCLUSION
It is concluded that the central nucleus of SR about coping and prevention of diseases in sex service, for sex workers in the Southwest Region of Bahia, are structured in the elements: “God”, “money”, “health care” and “safe sex”. This indicates that they develop religious coping as a protective factor against emotions and psycho-spiritual conditions. The self-care actions were represented in protected sexual intercourses, as well as the concern with keeping bodies healthy, free from other problems, as well as in the concern with the prevention of other diseases that go beyond STIs/HIV/AIDS. Money, as a central element, indicates the need to obtain a source of income to develop other coping strategies and meet personal and family needs, such as children. Thus, the structure of SR of this group of women in the exercise of sex service points to the development of attitudes and behaviors, sometimes based on common sense and others on scientific knowledge disseminated among them for the protection of integrative and holistic health.

Authorship contributions:
Pablo Luiz Santos Couto – conception and design or the analysis and interpretation of data writing of the article or its critical review approval of the version.
Antônio Marcos Tosoli Gomes – conception and design or the analysis and interpretation of data writing of the article or its critical review approval of the version.
Luiz Carlos Moraes França - analysis and interpretation of data writing of the article or its critical review approval of the version.
Tarcísio da Silva Flores – analysis and interpretation of data writing of the article or its critical review approval of the version.
Carle Porcino – conception and design or the analysis and interpretation of data writing of the article or its critical review approval of the version.
Alba Benemérita Alves Vilela – conception and design or the analysis and interpretation of data writing of the article or its critical review approval of the version.
Cleuma Sueli Santos Suto - analysis and interpretation of data writing of the article or its critical review approval of the version.
Priscila Cristina da Silva Thiengo de Andrade - analysis and interpretation of data writing of the article or its critical review approval of the version.
REFERENCES
1- França M. Práticas e sentidos da aprendizagem na prostituição. Horiz Antropol [Internet]. 2018;23(47):325-49. doi: http://dx.doi.org/10.1590/s0104-71832017000100011
2- 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. doi: https://doi.org/10.1016/j.jvb.2020.103442
3- Howard S. Covid-19: Health needs of sex workers are being sidelined, warn agencies. BMJ. 2020;369:m1867. doi: https://doi.org/10.1136/bmj.m1867
4- Vasquez JMC. La prostitución en Colombia, un camino hacia la formalización. El Ágora USB [Internet]. 2021;21(2):748-759. doi: http://dx.doi.org/10.21500/16578031.5101
5- Montes LMG, López RQ. Reflexiones sobre los cuerpos negados: mujeres mayas contemporáneas en Tahdziú, México. Sex Salud Soc [Internet]. 2019:32(40-64). https://dx.doi.org/10.1590/1984-6487.sess.2019.32.04.a
6- Couto PLS, Montalvao BPC, Vieira ARS, Vilela ABA, Marques SC, Gomes AMT, et al. Social representations of female sex workers about their sexuality. Invest Educ Enferm [Internet]. 2020;38(1):e03. doi: https://doi.org/10.17533/udea.iee.v38n1e03
7- Silva APS, Santos CRC, Carvalho MG. Entre prazeres e sofrimentos: vivências subjetivas de trabalhadoras sexuais em São Paulo. Cad Psicol Social Trab [Internet]. 2018:21(2):181-95. https://doi.org/10.11606/issn.1981-0490.v21i2p181-195
8- World Health Organization (WHO). Emergency Committee. Statement on the second meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus (COVID-19). 2020 [cited 2020 Dec 27]. Available from: https://www.who.int/news-room/detail/30-01-2020-statement-on-the-second-meeting-of-the-international-healthregulations-(2005)-emergency-committee-regarding-the-outbreakof-novel-coronavirus-(COVID-19)
9- 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 [Internet]. 2021;35: e37327. doi: http://dx.doi.org/10.18471/rbe.v35.37325
10- 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):507-13. doi: http://dx.doi.org/10.1590/1982- 0194201900071
11- 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(Suppl 1):7-25. doi: https://doi.org/10.1590/1809-4503201500050003
12- Gonçalves JR, Ribas SEM. Validade de acordo ou convenção coletiva de trabalho em face das normas previstas na reforma trabalhista. Rev Interfaces. 2021;9(2):997-1007. doi: http://dx.doi.org/10.16891/2317-434X.v9.e2.a2021.pp997-1007
13- Couto PLS, Porcino C, Pereira SS da C, Gomes AMT, França LCM, Vilela ABA. Mental health of female sex workers in the COVID-19 pandemic: stressors and coping strategies. Ciênc saúde coletiva [Internet]. 2022;27(9):3571–82. doi: https://doi.org/10.1590/1413-81232022279.16462021
14- Sousa AR, Santana TS, Moreira WC, Sousa AFL, Carvalho ESS, Craveiro I. Motions and coping strategies of men to the COVID-19 pandemic in Brazil. Texto Contexto Enferm. 2020; 29:e20200248. doi: https://doi.org/10.1590/1980-265X-TCE-2020-0248
15- Bertolozzi MR, Nichiata LYI, Takahashi RF, Ciosak SI, Hino P, Val LF, et al. Os conceitos de vulnerabilidade e adesão na Saúde Coletiva. Rev esc enferm. USP [Internet]. 2009;43(spe2):1326-30. doi: https://doi.org/10.1590/S0080-62342009000600031
16- Ayres JR. Vulnerabilidade, direitos humanos e cuidado: aportes conceituais. In: Barros S, Campos PFS, Fernandes JJS (Orgs.). Atenção à saúde de populações vulneráveis. Barueri: Manole; 2014, pp 1-25.
17- Thng C, Blackledge E, McIver R, Smith LW, McNulty A. Private sex workers’engagement with sexual health services: an online survey. Sexual Health [Internet]. 2018;15(1):93-5. doi: https://doi.org/10.1071/SH16243
18- Broqua C, Combessie P, Deschamps C, Rubio V. La sexualité au cœur des échanges intimes. Jour des Anthropol [Internet]. 2019;(156-157):21-35. doi: https://doi.org/10.4000/jda.7996
19- Turato ER. Tratado de metodologia da pesquisa clínico-qualiativa: construção teórico-epistemológica, discussão comparada e aplicação nas áreas de saúde e humanas. 6 ed. Petropólis, RJ: Ed. Vozes, 2013.
20- Moscovici S. Representações Sociais: Investigações em Psicologia Social. Rio de Janeiro: Vozes, 2015.
21- Wolter RP, Sá CP. As relações entre representações e práticas: o caminho esquecido. Rev Int Cienc Soc Hum [Internet]. 2013;33(1-2):87-105.
22- Wolter RP, Wachelke J, Naiff D. A Abordagem Estrutural das Representações Sociais e o Modelo dos Esquemas Cognitivos de Base: Perspectivas Teóricas e Utilização Empírica. Temas Psicol [Internet]. 2016;24(3):1139-52.
23- Vinuto J. A amostragem em bola de neve na pesquisa qualitativa: um debate em aberto. Temáticas [Internet]. 2014;22(44);203-20.
24- Jodelet D. A representação do corpo e suas transformações. São Paulo: Fundação Carlos Chagas; 2017.
25- Pontes APM, Oliveira DC, Gomes AMT. The principles of the Brazilian Unified Health System, studied based on similitude analysis. Rev Latino-Am Enferm [Internet]. 2014;22(1): 59-67.
26- Sá CP. Estudos de Psicologia Social. História, comportamento, representações e memória. Rio de Janeiro: Ed. UERJ; 2015.
27- Moliner P, Guimelli C. Les représentations sociales. Grenoble: Presses universitaires de Grenoble, 2015.
28- Hirata H. Gênero, classe e raça: interseccionalidade e consubstancialidade das relações sociais. Tempo Social [Internet]. 2014;26(1).
29- Corrêa CV, Batista JS, Holanda AF. Coping religioso/espiritual em processos de saúde e doença: revisão da produção em periódicos brasileiros (2000-2013). PsicoFAE [Internet]. 2016;5(1):61-78.
30- Panzini RG, Bandeira DR. Coping (enfrentamento) religioso/espiritual. Rev Psiqui Clínica [Internet]. 2017;34(1):126-35.
31- Olivar JMN. Banquete de homens: sexualidade, parentesco e predação na prática da prostituição feminina. Rev Bras Cienc Soc [Internet]. 2021;26(75):89-189. doi: https://doi.org/10.1590/S0102-69092011000100005
32- Leal CBM, Souza DA, Rios MA. Aspectos de vida e saúde das profissionais do sexo. Rev Enferm UFPE online [Internet]. 2017 ;11(11):4483-91.
33- REZA-PAUL, S., et al. Community action for people with HIV and sex workers during the COVID-19 pandemic in India. WHO South-East Asia. Jour Publ Health [Internet]. 2020;9(‎2):104-6. Available from: https://apps.who.int/iris/handle/10665/334192
34- Karamouzian M, et al. How sex work becomes an option: Experiences of female sex workers in Kerman, Iran. Cult Health Sex [Internet]. 2016;18(1):58-70.
35- Gois ARS, Santos CNS, Filho JCS, Garcia EGC, Oliveira RC, Abrão FMS. Social representations of homosexual sex workers, transvestites and transgender women about acquired immunodeficiency síndrome. Rev Enfer Actual Costa Rica [Internet]. 2020;38:121-35. doi: http://dx.doi.org/10.15517/revenf.v0i38.38533
36- Lam E. Migrant sex workers left behind during COVID-19 pandemic. Can J Public Health [Internet]. 2020;111(4):482-3. doi: https://doi.org/10.17269/s41997-020-00377-4
37- Jozaghi E, Bird L. COVID-19 and sex workers: human rights, the struggle for safety and minimum income. Can J Public Health [Internet]. 2020;11(3):406-7. doi: https://doi.org/10.17269/s41997-020-00350-1