Easter College DEPARTMENT OF NURSING Easter School Road, Guisad, Baguio City

DEGREE OF KNOWLEDGE REDARDING SEXUALLY TRANSMITTED INFECTIONS AMONG COMMERCIAL SEX WORKERS

An undergraduate research proposal presented to the Faculty of the Department of Nursing

In partial fulfillment of the requirements in Research Related Learning Experience 1

Submitted:

BSN IV-B Le monet group

Andiso, Warren Jae Nawen, Crisanto Tuazon, Ryn dale Viray, Ralph Laurence Dacanay, Laarni John, Lorna Lasdacan, Zasskia Jane Leon, Mary Jane Madarang, Tabetha Kathleen Martinez, Manette Medina, Shehannah Grail Yap-eo, Sheena

Gay-as, Mark U. (Research Adviser)

June 2013

Background of the Study There are many professions individuals can choose from, although not all these profession are morally and legally accepted. Prostitution in that case is one of those professions. Prostitution is the performance of sexual acts for female. It exists throughout the world, largely in urban areas. Some prostitutes work for themselves, others work for men known as Pimps or for women called Madams. Despite the fact that their profession earns them money from every client, both prostitutes and clients face a risk of contracting sexually transmitted diseases, including Autoimmune Deficiency Syndrome (Michele S. Shedlin, World Book P 15 pages 830-831, 2010). STIs are disease acquired through sexual contact with an infected person. STIs are the most common infectious disease in the United States and are epidemic in most parts of the world. Portals of entry of STDs, causing microorganisms and sites of infections, include the skin and mucosal linings of the urethra, cervix, vagina, rectum, and oropharynx. Approximately 19 million Americans become infected with STDs annually. STDs have severe health consequences, and in addition, it also represents a financial burden estimated to be as high as $15.3 billion per year. The use of protective barriers from transmission of STD-related organisms has been broadly promoted, especially since the recognition of HIV/AIDS.

STDs are hidden epidemics of enormous health and economic consequence in the United States. They are hidden because many Americans are reluctant to address sexual health issues in an open way and because of the biologic and social characteristics of these diseases. All Americans have an interest in STD prevention because all communities are impacted by STDs and all individuals directly or indirectly pay for the costs of these diseases. STDs are public health problems that lack easy solutions because they are rooted in human behavior and fundamental societal problems. Indeed, there are many obstacles to effective prevention efforts. The first hurdle will be to confront the reluctance of American society to openly confront issues surrounding sexuality and STDs. Despite the barriers, there are existing individual- and community-based interventions that are effective and can be implemented immediately. That is why a multifaceted approach is necessary to both the individual and community levels.To successfully prevent STDs, many stakeholders need to redefine their mission, refocus their efforts, modify how they deliver services, and accept new responsibilities. In this process, strong leadership, innovative thinking, partnerships, and adequate resources will be required. The additional investment required to effectively prevent STDs may be considerable, but it is negligible when compared with the likely return on the investment. The process of preventing STDs must be a collaborative one. No one agency, organization, or sector can effectively do it alone; all members of the community must do their part. A successful national initiative to confront and prevent STDs requires widespread public awareness and participation and bold national leadership from the highest levels. (ref., Sexually Transmitted Disease Surveillance 2010 by CDC)

AIDS is the final, life-threatening stage of infection with human immunodeficiency virus. Also called acquired immunodeficiency syndrome. The name refers to the fact that HIV severely damages the immune system, the body most important defense against disease. AIDS is caused by two viruses that belong to a group called retroviruses. The first AIDS virus was isolated by researchers in France in 1983 and researchers in the United States in 1984. This virus became known as HIV-1. In 1985, scientists in France identified another closely virus that also produces AIDS. This virus, named HIV-2, occurs mainly in West Africa. HIV-1 occurs throughout the world. HIV is a causative agent of AIDs which is transmitted through sexual contact. As determined by the Communicable Disease Control, sets a point in the continuum of HIV pathogenesis in which the host has clinically demonstrated profound immune dysfunction (Medical and Surgical Nursing Vol. 2, page 2143, 12th edition). Statement of the Problem The research was conducted to determine the degree of knowledge regarding sexually transmitted disease among prostitute. Specifically, this research aimed to answer the following questions: 1. What is the degree of knowledge regarding sexually transmitted disease among commercial sex workers? 2. What are the preventive measures that they know to avoid STI? 3. Do they seek medical treatment monthly/yearly?

Objectives

Assumption 1. A fraction of the target respondents are aware of sexually transmitted infections. 2. A fraction of the target respondents are knowledgeable on the prevention of sexually transmitted infections. 3. Preventive measures for STIs are practices among a fraction of the target respondents.

Hypothesis There is a significant association of the knowledge regarding the prevention of sexually transmitted infections and individuals hired for prostitution.

Significance of the Study The following are the areas that will benefit from our study.

Clinical Practice The outcome of the research can aid nurse practitioner to determine the extent of knowledge, preventive measures and medical treatment regarding STDs among commercial sex workers. Through this, nurses would be able to have a better understanding to whom they would work with. Similarly, such understanding can guide them in dealing prostitute. Nursing Education Finding with this study will be very helpful for nurse education because knowing their extent of knowledge, preventive measures and medical treatment regarding STI among commercial sex workers, student nurses can give them idea about preventive measures and medical treatment. Nursing Research This research about preventive measures could serve as reference for other researches.

Scope and Limitation The purpose of the study is to determine their knowledge on the health effects of their job and preventive measures for STIs among commercial sex workers. The respondents are estimated as five to ten female commercial sex workers who are working at Magsaysay Avenue, Baguio City. They were chosen regardless of gender, religion, cultural affiliation. The qualitative study is to know their degree of knowledge, preventive measures, and medical treatment regarding STIs.

Chapter 2 Review of Related Literatures Sexually Transmitted Infection is also called STI, are infections that are spread primarily through person-to-person sexual contact. There are more than 30 different sexually transmissible bacteria, viruses and parasites. The most common conditions they cause are gonorrhea , chlamydial infection, syphilis, trichomoniasis , chancroid, genital herpes, genital warts, human immunodeficiency virus (HIV) infection and hepatitis B infection. Several, in particular HIV and syphilis, can also be transmitted from mother to child during pregnancy and childbirth, and through blood products and tissue transfer ( WHO, 2013). It is also known as Venereal Disease an illness that has a significant probability of transmission between humans or animals by means of human sexual behavior, including vaginal intercourse, oral sex, and anal sex. While in the past, these illnesses have mostly been referred to as STDs or VD, in recent years the term sexually transmitted infection (STI) has been preferred, as it has a broader range of meaning; a person may be ''infected'', and may potentially infect others, without showing signs of ''disease''. Some STIs can also be transmitted via the use of IV drug needles after its use by an infected person, as well as through childbirth or breastfeeding. Sexually transmitted infections have been well known for hundreds of years (News Medical, 2013).Studies showed that people with STI are at greater risk for contracting the human immunodeficiency virus that causes AIDS. It is the most infectious disease in the US and are epidemic in most parts of the world. Portals of entry of STD-causing microorganisms and sites of infection include the skin

and mucosal linings of the urethra, cervix, vagina, rectum and oropharynx (Smeltzer et al, 2008). The following are the sexually transmitted disease: A. Gonorrhea (GC, Clap, Drip) Causative Agent: Bacteria: Neiserria gonorrheae. Typically passed by direct contact between the infectious mucous membranes, e.g. genitals, anus, and mouth of one person with the mucous membranes of another. Contaminated fingers can pass the organism from infected mucous membranes to the eyes. Incubation: Usually 2-10 days, possibly 3 days or more. Signs and symptoms: Genitals(penis or cervix), anus, throat, and eyes can be infected. Males: Burning urination and pus discharges from infection of urethra(5-10% have no symptoms). Females: May have vaginal discharge although up to 80% have no symptoms for cervical infection of rectum; often no symptoms or mild sore throat for gonorrhea at the throat. Infection of eyes is rare in adults.

B. Syphilis (Sy, bad blood, the pox) Causative Agent:

Treponema pallidum. Passed by direct infectious sore. Incubation: 10 days to 3 months, with average of 21 days. Signs and Symptoms: Primary stage: painless chancre (sore) at site of entry of germs, swollen glands. Secondary stage: Symptoms usually appear 1 week-6 months after appearance of chancre and may include rash, patchy hair loss, sore throat and swollen glands. Primary and secondary sores will go away even without treatment, but the germs continue to spread throughout the body. Latent syphilis may continue 5-20+ years with no symptoms, but the person is no longer infectious to other people. A pregnant woman can transmit the disease to her unborn child (congenital syphilis). Late syphilis: Varies from no symptoms to indication of the body organs such as the brain, heart and liver.

C. Chylamydia (Chylamydia: Chylamydia trachomatis) Causative Agent:

Chylamydia trachomatis. Passed during sexual contact; infants can become infected during vaginal delivery. Highly contagious. Incubation: 2-3 weeks for males; Usually no symptoms in females. Signs and symptoms: Symptoms tend to develop slowly and are often mild. Many cases have no symptoms. Females: Sometimes a slight vaginal discharge; itching and burning of vagina, painful intercourse; abdominal pain; fever in later stages. Males: Discharge from penis; burning and itching of urethral opening; burning sensation during urination. D. Gardianella Vaginitis (Nonspecific Vagintis) Causative Agent: Varies Signs and symptoms: Most persons do not have any symptoms, especially rare in males. Female symptoms may include a slight grayish or yellow odorous vaginal discharge and mild itching or burning sensation. E. Trichomoniasis (Trich)

Causative Agent: Protozoan-Trichomonas vaginalis. Usually passed by direct sexual contact. Can be transmitted through contact with wet objects, such as towels, wash clothes and douching equipment. Incubation: 4-20 days, with average being 7 days. Signs and symptoms: Many women and most men have no symptoms. Females: White or greenish-yellow odorous discharge; vaginal itching and soreness, painful urination. Males: Slightly itching of penis, painful urination, clear discharge from penis. F. Hepatitis B Introduction: Hepatitis is a disease of the liver which can be cause by viruses, bacteria, protozoa, toxic chemicals, drugs and alcohol. There are several types of viral hepatitis namely: Hepatitis A, B, non A and non B, (C) and D (delta), C, E. Of these, hepatitis B, a sexually transmitted disease is considered to be the most serious due to the possibility of severe complications such as massive liver damage and hepatocarcinoma of the liver. Signs and symptoms:

Loss of appetite Easy fatigablity Malaise Joint and muscle pain (similar to influenza) Low grade fever Nauseas and vomiting Right-sided abdominal pain Jaundice (yellowish discoloration of skin and sclera) Dark-colored urine

Mode of transmission: A. From person to person through: Contact with infected blood through broken skin and mucous membrane of the mouth,

the rectum and the genitals. Sexually contact via the vaginal and seminal secretions Sharing of personal items with an infected person which may cause skin break (razor,

nailclipper, clipper, toothbrush, etc.). B. Parental transmission through:

others.

Blood and blood product-by transfusion of blood from carriers and non-carrier. Use of contaminated instruments for injection, ear piercing, acupuncture and tattoing. Use of contaminated hospital and laboratory equipment such as dialysis apparatus and

C. Perinatal transmission: This can occur during labor and delivery through leaks across the placenta and can be

precipitated by injury during delivery. It may also occur through exposure of the infant to maternal secretions in the birth canal. High risk Groups to Hepatitis B infection: Newborns, infants and children of infected mothers. Children in localities where the occurrence of hepatitis B cases is high. Sexually and household contacts of acute cases and carriers. Health workers exposed to handling blood/blood products as doctors, dentists, medical

technologists, technicians, attendants and others. Sexually promiscuous individuals as active heterosexual and homosexual. Commercial sex workers( hospitality girls). Drug addicts using intravenous drugs

Possible outcomes of Hepatitis B infections: Most people get well completely and develop life-long immunity. Some people do not get well and the hepatitis B virus remains in their blood. Almost 90% of infected newborns become carriers. About 25% of these carriers develop

fatal liver complication in adult life.

HIV/AIDS Human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS) HIV/AIDS first occurred in Africa and spread to the Caribbean Island. It was reported in the USA in 1981 in cases where soon describe in other countries. This sexually transmitted disease spread so rapidly that it soon occurred in epidemic proportion in several countries of the world including the Philippines. It is currently pandemic. Causative agent: Retrovirus- human T-cell lymphotrophic virus 3 (HTLV-2)

Mode of transmission: Sexual contact Blood transfusion

Contaminated syringes, needles, nipper, razor blades Direct contact of open wound/mucus membranes with contaminated blood, body fluids,

semen and vaginal discharges

Incubation period: Variable. Although the time from infection to the development of detectable antibodies

and generally 1-3 months, the time from HIV infections to diagnosis of AIDS has an observe range of less than 1 year to 15 years or longer. According to new data released by the federal Centers for Disease Control and Prevention last 2013, there were 19.7 million new venereal infections in the United States in 2008, bringing the total number of existing sexually transmitted infections (STIs) in the U.S. at that time to 110,197,000 in 2013. The average female prostitute enters her job when she is only 16 or 17 years of age. Female prostitutes leave prostitution less frequently than their male counterparts. This is mainly because a smaller proportion of male prostitutes work for pimps. 92% of women engaged in prostitution said they wanted to leave prostitution, but couldnt because they lack basic human services such as a home, job training, health care, counseling and treatment for drug or alcohol addiction. In terms of racial makeup in America, nearly 40% of prostitutes are white European/American, one-third is African American, and almost 20% are Latina. Girls involved in prostitution are increasingly getting younger, dropping

from 14, to 13 and 12 years of age. Child prostitution in the United States began to escalate in the late 1980s after new laws made it more difficult for officials to detain runaway children. 75 95% of all prostitutes were sexually abused as children. Many prostitutes are high school dropouts, come from poor and abusive homes, move from place to place, and are alcoholics or drug addicts. Over the last decade the street price for oral sex has dropped from $20-$30 to $2-$3. In New York City, 26% of street prostituting women were homeless or on the verge of becoming so. 90% reported having children taken away because of their situation. According to the survey conducted in the Asian countries particularly in the Philippines, it showed an exceptionally high prevalence rate of chlamydiosis among Filipino FCSWs ranging from 27% to 36%, the principal mode of transmission was heterosexual contact. Because there is no vaccine or cure, HIV prevention depends on ones ability to modify risky behaviors. With Female Commercial Sex Workers, risk reduction typically means consistent and appropriate condom use. However, safe sex practices may be difficult to maintain when ones livelihood depends on customers who expect or demand sex without a condom (Morisky, et al 2008). Based on the records of the City Health Department (CHD) there were 188 new cases of HIV reported in Cebu City last year, which also reported a total of 7,175 new cases of sexually transmitted diseases (STDs). It also showed that majority of the individuals with STDs are registered female sex workers aged between 18 and 24 years old. The number of STD cases in 2012 is slightly higher than the number of cases recorded in 2011, which saw 6,867 cases of STDs (Cantelejo, 2013).

Some of the things that increase a person's chances of getting an STD are:

Sexual activity at a young age. The younger a person starts having sex, the greater his or her chances of becoming infected with an STD.

Lots of sex partners. People who have sexual contact not just intercourse, but any form of intimate activity with many different partners are more at risk than those who stay with the same partner.

Unprotected sex. Latex condoms are the only form of birth control that reduce your risk of getting an STD, and must be used every time. Spermicides, diaphragms, and other birth control methods may help prevent pregnancy, but they don't protect a person against STDs. Larissa Hirsch, MD

June 2010

Theoretical Framework

Leventhal and Cameron (52) provided a very useful overview of the history of adherence research. They outlined five general theoretical perspectives on adherence:

The recently developed information-motivation-behavioural skills model (IMB model)(67,68), borrowed elements from earlier work to construct a conceptually based, generalizable, and simple model to guide thinking about complex health behaviours. The IMB constructs, and how they pertain to patient adherence, are outlined below. - Information is the basic knowledge about a medical condition that might include how the disease develops, its expected course and effective strategies for its management. - Motivation encompasses personal attitudes towards the adherence behaviour, perceived social support for such behaviour, and the patients' subjective norm or perception of how others with this medical condition might behave. - Behavioural skills include ensuring that the patient has the specific behavioural tools or strategies necessary to perform the adherence behaviour such as enlisting social support and other self-regulation strategies. The interventions were based on a blend of socialcognitive theory at the individual level and social influence theory at the organizational level. According to social cognitive theory (Bandura, 1987), behavior change is enhanced by training individuals to exercise influence over their own behaviors and their social environment. This situation is best achieved not only by intervening for heightened awareness and knowledge but

also by enhancing resources and social support. The following popper user interface control may not be accessible. Bandura (1987) has conceptualized the basic elements of socialcognitive theory to consist of personal determinants in the form of cognitive, affective, and biological factors, behavior, and the environment. This theoretical framework was applied to HIV/AIDS-related behaviors by exposing participants to interventions designed not only to promote safer sex guidelines but also to develop individual skills and self-beliefs that would enable risk reduction in the face of counteracting influences (Bandura, 2004).

Paradigm of the study Figure 1 shows the relationship of the different variables in the study. The independent variable is the sexually transmitted disease which is classified into general information and preventive measures. The dependent variable which is sought to be measured is the respondents degree of knowledge, classified into four categories: high, moderate, low and no knowledge. The moderating variable age is categorized into two-younger and middle-aged women; while educational attainment as elementary, high school and college.

Figure 1.
Independent Variable Sexually Transmitted Disease >General information regarding breast cancer >Preventive measures Dependent variable Level of knowledge >high >moderate >low >no knowledge

Moderating Variable Age a. Younger women b. Middle-aged women Educational attainment a. Elementary b. High school c. College

Chapter III Methodology

This chapter discusses the methods and procedures, which includes the research design, locale and population, data gathering tool or instrumentation, data gathering procedure and treatment of data that was used to identify and resolve any existing problem. Research design In achieving the objective of our study, the researchers will use non-experimental descriptive study which is used to observe, describe and document aspects of a situation as it naturally occurs. Locale and Population

The study will be conducted along Magsaysay Avenue, Baguio City. The location was chosen because because of the accessibility and availability of the respondents. Five to ten female respondents will be regardless of age. Data Gathering Tool The researchers will be utilizing a self made questionnaire that will be used as a method of gathering data. The items in the questionnaire will be based on the review of related literature which covers general knowledge and preventive measures of sexually transmitted diseases. The first part of the questionnaire would be a letter informing the respondents of its purpose, asking for participation and cooperation. The succeeding part would compromise of a checklist asking for demographic data particularly the age and the educational attainment of the respondent.