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Health system in syphilis control, from the nurses' perspective


Caroline Soares NobreI; Conceição de Maria de AlbuquerqueII; Mirna Albuquerque FrotaIII; Maria de Fátima Antero Sousa MachadoIV; Camila Santos do CoutoV

INurse. Master in Collective Health at the Universidade de Fortaleza. Ph.D. candidate in Public Health at Instituto de Saúde Coletiva da Universidade Federal da Bahia. Salvador, Bahia, Brasil. E-mail:
IINurse. Master in Health Education at Universidade de Fortaleza. Professor at the Nursing School at the Universidade de Fortaleza. Fortaleza, Ceará, Brasil. E-mail:
IIINurse. Ph.D. in Nursing at the Universidade Federal do Ceara. Professor at the graduate course in Collective Health and at the undergraduate course in Nursing at the Universidade de Fortaleza. Leader of the Research Nucleus in Child Health Fortaleza, Ceará, Brasil. E-mail:
IVNurse. Ph.D. in Nursing at the Universidade Federal do Ceara – UFC. Associate Professor, Universidade Regional do Cariri. Crato, Ceará, Brasil. E-mail:
VNurse. Master in Collective Health at the Universidade de Fortaleza. Fortaleza, Ceará, Brasil. E-mail:





Objective: to learn the nurses' perspective regarding the health system in syphilis control. Method: this qualitative study involved semi-structured interviews of thirteen nurses from a secondary, syphilis-referral hospital in Fortaleza, Ceará, in 2012. The content analysis technique was used to interpret the resulting corpus. Results: in the core themes identified, the salient categories were: Primary care is "failing" and "There is a flaw in health education!" Conclusion: it is believed that new resources and actions are needed for health professionals, coming mainly from educational interventions focusing on comprehensive health care so as to establish means to improve services.

Descriptors: Congenital syphilis; nursing; unified health system; integrality in health.



Sexually transmitted diseases (STD) rank as the most common public health pathologies in the world. On account of their seriousness, contagiousness, incidence and prevalence, as well as their serious stigma, precocious diagnosis and adequate treatment prove difficult.

Syphilis stands out among the STD. It is concerning that despite existing efficient treatment against the causing agent, with low cost and easy access, high contamination rates are identified. Syphilis is expected to cause perinatal deaths, miscarriages, congenial syphilis (CS), and births of premature and low weight babies. However, in the past years, health attention seems to be primarily concerned with the immunodeficiency virus (IDV), although estimated prevalence of syphilis is 4 times higher1,2.

Health attention networks have differentiated functions in face of the pathology, the primary of which must promote health education actions, attract and conduct diagnosis exams, report on reactive cases, and forward them to institutions of medium complexity. Secondary ones receive them and exercise the function of prenatal follow-up, identified as risk ones, conduct treatment, and follow up on care up to birth time3.

From the perspective of the Single Health System (SHS), secondary and tertiary attention must face the challenge, as much as primary attention does, to set up spaces for discussion of practices aiming at the repositioning of health thinking/doing, in particular that of the dichotomy cure/prevention4. Such a challenge bears a narrow relation with achieving integrality in face of health services.

Integral assistance stands out, which must be anchored on the articulation of each and all steps along care promotion and health attainment, avoiding fragmentation. Within this frame health education stands out as an articulated means between comprehension of reality and search for alternatives in attitude changes from the professional's stand5.

Health education can be a means in this realization developed in secondary attention as an emerging trend in nursing towards the management of a dialectic move. The nurse is called upon to rebuild his/her practice of immediate care, towards a comprehensive model, from the perspective of action-reflection-dialogic action, in which education is part and parcel of assistance6.

Clinic must not be regarded from the perspective that prevention and health promotion are under the charge of primary attention, in face of the SHS constitutional proposal. Therefore, we aimed at assessing the nurses' stand on syphilis control on the health system.



Syphilis is still a world problem, with 12 million people infected every year. Yearly two million cases of pregnancies are infected, 25% of which resulting in stillborn or miscarriages, and the other 25% are low-weight newborns or are seriously infected, both cases associated to a higher risk of perinatal deaths. Nevertheless, congenial syphilis is underestimated, in general7.

The 2012 Health Department (HD) epidemiological report evinced that the number of syphilis cases reported has been increasing every year, reaching 14,321 cases in 2011. As for CS, over nine thousand cases were reported in the country, concentrated in the Southeast and Northeast regions. Ceará ranks second with 6.8 cases out of 1,000 newborns8.

Actions aiming CS elimination are based on active health surveillance over the pregnant women, by means of backtracing and treatment on all levels in health attention. In this context, health education is a primary factor, aiming at the subject's empowerment so that guidance provided is understood and conducted9.

The HD has encouraged actions which make it possible to base assistance on prevention, such as forwarding and adequate treatment for syphilis cases, by means of conception of guidebooks and protocols which assign health professionals' actions to adequate treatment and prevention of the cases10.



Exploratory-descriptive case with qualitative approach, addressing the world of beliefs, values, and principles, meanings, aspirations, comprehending a much more complex space of the relations, phenomena, and processes, which cannot be undervalued as sheer variables 11.

This research was developed at a hospital of secondary profile within the municipal network, a reference in the public health system for syphilis cases, located in Fortaleza- Ceará. It is provided with a Neonatal Unity (NU) complex and the Collective Lodging (CL), where data were collected. Informants were constituted of thirteen nurses who assisted the newborns bearing CS who accepted to participate in the study. To assess the size of the sample a conceptual tool was used, the base of which is at ideal quality, which mirrors – on both quantity and intensity – the multiple dimensions of the phenomenon. It also searches action and interaction quality along the process on sense redundancy and convergence so that research can build up and stand true12.

Data collection was conducted from January to June, 2012. First, as informants were identified, they were given an invitation to all possible participants, nurses in the unities, aiming at an introduction to the research. After signing the Informed Consent Form (ICF), a semi structured interview was carried out, consisting of two significant parts; the first addressed identification data and the second addressed the guiding question: What do you think of the health system when it comes to cases of congenial syphilis?

Interviews were recorded and fully transcribed. To preserve anonymity, one of the ethical principles on the research, subjects were identified by the letter "N" as in nurse, followed by the numbering corresponding to the chronological order interviews were conducted. After careful reading, data were organized, interpreted, analyzed, and brought down to categories to meet the report by means of the content analysis technique.11.

Data validation was made clear upon accurate and careful description of interviews by means of grouping, documentation, and classification of corpus. Thus, theme nuclei were identified, in which the following categories stand out in this article: Primary attention is "holding loose" and "There's a shortcoming in health education!.

The ethical component was observed at all stages of the research as provided for by the HD by means of Resolution 466/12. Anonymity of those involved was preserved. The research was approved by the Ethical Committee in Research at the Universidade de Fortaleza with Evaluation Nº 195/2010.



Primary attention is "holding loose"

Primary attention is the gateway to health services, which are comprised by a network of interconnected systems. Medical appointments and/or prenatal follow-up stand to mother-child assistance as the quality mirror for health service provided for in primary attention. The speeches unveil a gap in mother-child assistance, which triggers alarming problems in secondary and tertiary attention. Participants describe prenatal as lacking quality, in such a way as the lack of qualified professionals is pointed out, as well as the lack of material and structure for excellence.

Attention network should be capable of avoiding, minimizing, or even discontinuing the evolution of a health-disease process, which comprises the capacity to promote and sustain health, diagnosis, and adequate treatment in time and with available technology at the system gateway13.

However, integrality of the sectors turns out to be a challenge faced at all attention levels, for it aims at both the complaint-conduct logic and the fragmentation of therapy interventions. It means to approach health practices from the integral perspective, that is, to think over health practices from a broad reading of individuals' lives5.

[...] primary attention is "holding loose", for if one arrives with congenial syphilis it is because, unfortunately, diagnosis was not made at primary attention. (N4)

[...] quite a few pregnant women had medical appointments, the doctor prescribed an exam in the first quarter, but it took a month to make the appointment, another month to receive it, at times the baby arrives before the result is out and the return visit to the obstetrician [...] the team fails to stand up for syphilis, to charge, to make active search (N11)

[...] it falls short quite a bit [...] there are quite a few people without a prenatal, sometimes stating they realized that after a long while, they do not undergo treatment during pregnancy [...] had just two medical appointments because there was a lack of professionals, a lack of general conditions (N10)

Effectiveness of prenatal assistance cannot be evaluated by the number of medical appointments made, but rather by the quality of services rendered. Among the pregnant women in a study who had prenatal follow up, over 10% did not have the exam, either that or, if they did, never had access to the result14. Actions directed to eliminating CS depend, invariably, on qualification in health assistance, essentially in the hands of professionals and managers involved in the care and/or those who conduct prenatal follow-up15,16.

As an example, teenage pregnancy is emphasized on the reports as being discriminated against by professionals. They believe those cases to be borderline cases in lack of attention in public health, which shows disqualification in health assistance at one of its most complex axes, such as education and health promotion.

By maintaining actions restricted to service protocols, health service fails communicating with adolescents and ensuring access to preservatives, to family planning, to sexual health assistance.. That situation is associated to the very lack of prevention input and to the poor organization of work processes, fact which makes adolescents vulnerable to STD and to unplanned pregnancies17.

We see that's sort of free, a lot of young girls with syphilis [...] girls at 14 years old, how come? (N13)

[...] we have lots of teenage mothers with syphilis cases. Mothers at 17, third child with congenial syphilis. We must trace back our sins way back [...] (N8)

Research identifies a high number of adolescents with gestational syphilis16,18. When it comes to adolescence, those pieces of research suggest that adolescents and youngsters with low schooling levels are more highly vulnerable to STDs. However, the small concern with prevention seems to be related to the usual behavior in teenage years rather than to lack of information.

Partners with contaminating status stand out as a usual and inevitable concern with syphilis-related information and risk factors to the pathology. Professionals interviewed stated that women take a participant stand in both prenatal medical appointments and educational teams.

In a few cases, partners refuse treatment, therefore there is infection again. The HD provides for the treatment of sexual partners despite diagnostic confirmation. Once they have no treatment, the pregnant woman is regarded as inadequately treated, and consequently, there is characterization of a CS case3.

[...] even after detection, we have problems about having mothers follow treatment, as well as theirs partners (N2)

[...] couples are advised to wear preservatives [...] avoiding both transmission and treatment. Female partners are usually in for treatment but not the male partners, so there is recurrent contamination at high levels. (N12)

[...] to come in with some so that the person can undergo treatment, quite a few females do but not their partners. (N9)

Research results show lack of reference to the partner's treatment, as well as to infection control as a preventive measure of a CS record19,20. Both the partner's and the pregnant woman's lack of treatment results from team disqualification in face of a positive syphilis result, as well as from the long wait for the exam result and return. Thus, treatment prescription in due time fails.

Family and partner's support proves crucial during pregnancy. In cases of STD, it is difficult for the couple to face the situation on account of social and sexual constraints showing with suspicion generated in the couple's relation. Professional support becomes central for guidance and questions that might show up. There is lack of encouragement and active search so that both can undergo treatment and can be guided about it.

Therefore, health education is an integral practice which must be conducted at all moments and spaces, whether in primary or secondary attention, as an activity that promotes interaction between different knowledges and emphasizes the link with the community21.

"There is a shortcoming in health education !"

Health education appears as a major part to the lowering of incidence levels in CS. It is believed to be the encouraging means so that the population can participate in the disease-health process, by means of prevention as a light and effective technology against pathologies.

There is a gap in prenatal assistance quality concerning the dissemination of knowledge on acquired and congenial syphilis. The theme should be introduced timely and diligently in the undergraduate curricula. In addition, stimulation to continuing professional education becomes a core measure to ensure problem resolution19,22.

[...] unities that maintain programs concerning congenial syphilis, but still, cases are alarming [...] there is a shortcoming in health education, it is a whole of a structure involved, a social issue, the less enlightened, the less they participate (N1)

[...] prenatal care, the pregnant woman fails to go for both prenatal and treatment [...] education is missing (N2)

Health education must be done with those mothers at primary attention, especially on prenatal and family planning, because quite a few of them ignore all about syphilis. (N8)

Prenatal must improve as well as information on the disease must get clearer for the population. (N5)

The outlook on health education in the professionals' speeches and actions is based on both the knowledge dissemination model and on the curative method of health assistance. Such a conception is interconnected to the notion of prevention and information dissemination to the population. Teaching and guiding tasks show in the speeches and practices by those professionals, where professional knowledge stands out over unenlightened knowledge, as an attempt to change behavior and life habits among the population23.

Health professionals are identified as having low collective and empowering approaches, which point to social and political users' participation24. As the only and isolated error at the "gateway", primary attention is referred to as the major source of lack of structure, of financial incentives, and of qualified professionals, the lack of which is believed to account for high syphilis rates in secondary attention.

Shortcomings in primary attention are countless; however over time, the SHS has been enhancing primary attention as a major factor for profile change in secondary and tertiary attention. Responsibility is there, but investments in infrastructure, materials, and professionals are scarce. Reports do not unveil incompetence about the system, but rather deficiencies in primary attention.



This research stemmed from the need to understand nursing role and function related to high CS rates found at a health institution. That configures a public health problem because that pathology – as a compulsory report disease – is an evaluation indicator of cross sector assistance at the Single Health System.

The nurse's role is played in a fragmented way and is concerned with the individual's cure. Such professionals show unanimous disbelief about the conducts to eradicate the pathology, on account of the existing gaps in the mechanic form, interpreted by the professional, of prophylaxis and treatment, as well as of the lack of protocol reliability, for they do not show effective results.

Inertia is added to the whole set of problems, as if there were nothing else to be accomplished. Countless barriers to coping with CS appeared. Granted the limitations those professional come across in face of the available resources and the scarce means of capacitation so that they can find out either new solutions or alternatives to face the context.

Integrality in primary attention appears in an independent and dissociated mode. Limitations of this research must be enhanced in the sense that there are no generalizations in its findings, but instead a perspective on concepts and protocols formulated by the health system observed at a single reference institution for syphilis cases.

Nurses feel responsible for their units, in special for the curative part, without a dialog with primary attention aiming at follow-up, attempt at awareness or even investigation to ensure reporting on how those cases reach secondary attention. Hospital professionals find themselves unable to participate in the solution to congenial syphilis-related issues, so that they blame the problem solely on primary attention. Therefore, new actions are proposed starting at educational interventions, enhancing integrality about health attention for the building up of qualification means and professional empowerment.



1.Lorenzi DRS, Fiaminghi LC, Ártico GR. Transmissão vertical da sífilis: prevenção, diagnóstico e tratamento. Femina [Internet]. 2009 [acesso em 05 Mar 2015]; 37(2):83-90. Disponível em:

2. Peate I. The resurgence of syphilis. Br J Nurs [Internet]. 2017 [acesso em 18 Fev 2018]; 26(2):73. Disponível em:

3. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância, Prevenção e Controle das Doenças Sexualmente Transmissíveis, Aids e Hepatites Virais. Manual Técnico para Diagnóstico da Sífilis / Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Vigilância, Prevenção e Controle das Doenças Sexualmente Transmissíveis, Aids e Hepatites Virais. – Brasília: Ministério da Saúde, 2016 [acesso em 18 Fev 2018]. Disponível em: file:///C:/Users/herik/Downloads/manual_sifilis_10-2016.pdf

4.Bonfada D, Cavalcante JRLP, Araújo DP, Guimarães J. A integralidade da atenção à saúde como eixo da organização tecnológica nos serviços. Ciênc saúde coletiva [Internet]. 2012 [acesso em 05 Mar 2015]; 17(2): 555-60. Disponível em:

5. Mello VS, Santos RS. A sífilis congênita no olhar da enfermagem. Rev enferm UERJ[Internet]. 2015[acesso em 18 Fev 2018]; 23(5):699-704. Disponível em:

6.Rigon AG, Neves ET. As matrizes das concepções de educação em saúde de enfermeiros no contexto hospitalar. Rev enferm UERJ [Internet]. 2012 [acesso em 10 Mar 2015]; 20(5):631-36. Disponível em:

7. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de DST, Aids e Hepatites Virais. Protocolo Clínico e Diretrizes Terapêuticas para Atenção Integral às Pessoas com Infecções Sexualmente Transmissíveis / Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de DST, Aids e Hepatites Virais. – Brasília: Ministério da Saúde, 2015 [acesso em 22 Jun 2017]. 120 p.: il. Disponível em:

8. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância, Prevenção e Controle das Doenças Sexualmente Transmissíveis, Aids e Hepatites Virais. Manual Técnico para Diagnóstico da Sífilis / Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Vigilância, Prevenção e Controle das Doenças Sexualmente Transmissíveis, Aids e Hepatites Virais. – Brasília: Ministério da Saúde, 2016 [acesso em 22 Jun 2017]. Disponível em:

9. Lazarini FM, Barbosa DA. Educational intervention in Primary Care for the prevention of congenital syphilis. Rev. Latino-Am. Enfermagem [Internet]. 2017 [acesso em 19 Fev 2018]; 25:e2845.

10.Bittencourt RR, Pedron CD. Sífilis: abordagem dos profissionais de saúde da família durante o pré-natal. J Nurs Health [Internet]. 2012 [acesso em 15 Mar 2015]; 2(1):9-17. Disponível em:

11.Minayo MCS (Org.), Deslandes SF, Gomes R. A pesquisa social: teoria, método e criatividade. 1ª ed. Petrópolis: Vozes; 2016.

12. Minayo MCS. Amostragem e saturação em pesquisa qualitativa: consensos e controvérsias Revista Pesquisa Qualitativa. São Paulo (SP), 2017; 5(7): 01-12

13.Tanaka OY. Avaliação da atenção básica em saúde: uma nova proposta. Saude soc [Internet]. 2011 [acesso em 15 Mar 2015]; 20(4): 927-34. Disponível em:

14.Araújo MAL, Silva DMA, Silva RM, Gonçalves MLC. Análise da qualidade dos registros nos prontuários de gestantes com exame de VDRL reagente. Rev APS [Internet]. 2008 [acesso em 15 Mar 2014]; 11(1):4-9. Disponível em:

15. Macêdo VC, Lira PIC, Frias PG, Romaguera LMD, Caires SFF, Ximenes RAA. Fatores de risco para sífilis em mulheres: estudo caso-controle. Revista de Saúde Pública [Internet]. 2017 [acesso em 19 Fev 2018]; 51: 1-12. Disponível em:

16. Cardoso ARP, Araújo MAL, Cavalcante MS, Frota MA, Melo SP. Análise dos casos de sífilis gestacional e congênita nos anos de 2008 a 2010 em Fortaleza, Ceará, Brasil. Ciênc. saúde coletiva 23(2):563-74.

17. Monteiro MOP, Costa MC, Vieira GO; Silva CAL. Fatores associados à ocorrência de sífilis em adolescentes do sexo masculino, feminino e gestantes de um Centro de Referência Municipal/CRM - DST/HIV/AIDS de Feira de Santana, Bahia. Adolesc. Saude, Rio de Janeiro, 2015; 12(3):21-32.

18.Costa COM, Santos BC, Souza KEP, Cruz NLA, Santana MC, Nascimento OC. HIV/AIDS e sífilis entre gestantes adolescentes e adultas jovens: fatores de exposição e risco dos atendimentos de um programa de DST/HIV/AIDS. Rev. baiana de saúde pública. 2011 [acesso em 20 Jun 2015]; 35(1): 179-95. Disponível em:

19. Soares LG, Zarpellon B, Soares LG, Baratieri T, Lentsck MH, Mazza VA. Gestational and congenital syphilis: maternal, neonatal characteristics and outcome of cases. Rev Bras Saude Mater. Infant. 2017: 17(4):781-89.

20. Saraceni V, Pereira GFM, Silveira MF, Araujo MAL, Miranda AE. Vigilância epidemiológica da transmissão vertical da sífilis: dados de seis unidades federativas no Brasil. Rev Panam Salud Publica. 2017; 41(e44):1-8.

21.Cerveira DPP, Parreira BDM, Goulart BF. Educação em saúde: percepção dos enfermeiros da atenção básica em Uberaba (MG). Ciênc saúde coletiva [Internet]. 2011 [acesso em 15 Jun 2015]; 16(1):1547-54. Disponível em:

22.Matthes ACS, Lino APS, Costa CA, Mendonça CV, Bel DD. Sífilis congênita: mais de 500 anos de existência e ainda uma doença em vigência. Pediat mod [Internet]. 2012. [acesso em 15 Jun 2015]; 48(4):149-54. Disponível em:

23.Pinafo E, Nunes EFPA, González AD, Garanhani ML. Relações entre concepções e práticas de educação em saúde na visão de uma equipe de saúde da família. Trab educ saúde[Internet]. 2011 [acesso em 15 Jun 2015]; 9(2): 201-21. Disponível em:

24.Tesser CD, Garcia AV, Vendruscolo C, Argenta CE. Estratégia saúde da família e análise da realidade social: subsídios para políticas de promoção da saúde e educação permanente. Ciênc saúde coletiva [Internet]. 2011 [acesso em 15 Jun 2015]; 16(11): 4295-306. Disponível em: