Clinical signs and symptoms of sexually transmitted infections communicated in Libras *

* Extracted from the end-of-course paper “Comunicação em Libras: sinais e sintomas relacionados a infecções sexualmente transmissíveis”, Undergraduate Nursing Program, Universidade Estadual da Paraíba, 2014. 1 Universidade Estadual da Paraíba, Departamento de Enfermagem, Campina Grande, PB, Brazil. 2 Universidade Estadual da Paraíba, Programa de Pós-Graduação em Saúde Pública, Campina Grande, PB, Brazil. ABSTRACT Objective: To validate a video containing image representations of clinical signs and symptoms of sexually transmitted infections expressed in Libras. Method: Methodology development study conducted in an audio communication school. Thirty-six deaf people were selected. A video containing image representations of clinical signs and symptoms of sexually transmitted infections expressed in Libras was produced. Semantic validation was performed by deaf students and content validation by three judges who are Libras experts. The validation results were subjected to the Content Validity Index, where an index score > 0.80/80% was considered as agreement among judges. Results: Seven signs and symptoms related to sexually transmitted infections were validated and obtained satisfactory Content Validity Indexes, most of them with 100% representativeness and agreement. Conclusion: The validation process made the expressions of signs and symptoms related to sexually transmitted infections represented in Libras valid for establishing effective communication in the area of the study, turning it into a care tool that facilitates and standardizes communication with deaf people through Libras.


INTRODUCTION
The complaints reported by the women include: rejection or overprotection by their families, difficulties to study and qualify themselves professionally, in addition to obstacles to experience sexuality and motherhood (9) . Furthermore, there are few studies that address sexual and reproductive life, or the socio-cultural determinants of the sexual lives, including unprotected sex, of people with disabilities. As a rule, studies focus on sexual violence against people with mental disabilities (10) . However, sexually transmitted infections (STIs) affect people of both sexes, from all ethnic groups and every social level, and are transmitted through intimate contact with an infected person. This means that, in the case of the deaf, health professionals need to use Brazilian Sign Language, also known as Libras, to care for and empower them to live healthy sexual and reproductive lives.
In Brazil, deaf people use Libras, the study and teaching of which is disseminated in higher education institutions under Law 10436/ 02 (11) , which recommends offering Libras as a curricular discipline in Special Education, Teaching and Speech Therapy courses. These legal assurances also establish that the SUS must ensure comprehensive health care for people with hearing disabilities, for different levels of complexity and medical specialties, to guarantee support for the training and education of professionals working in the SUS network, in the use of Libras and its translation and interpretation.
Although Law 10436 / 2002 is in full force, the authors of a study conducted with a sample of 25 undergraduate courses in the health area, offered by higher education institutions located in northeastern Brazil, found that the pedagogical structure of these courses sought to train and equip professionals with the necessary expertise and skills for professional practice, without referring to the teaching of Libras (12) .
The lack of interpreters and health professionals trained to communicate with the deaf is a problem in health care. Added to this, are the social determinants that hinder these users from partaking of health assets and services. This situation is corroborated by British researchers who studied the health conditions of 298 deaf adult users of British Sign Language (BSL). The report from this study noted that deaf people face great difficulties in health care access and communication during medical visits. In addition, the health of these participants, when compared with the general population, is poor, and exposes them to preventable health problems (13) .
There is a clear need for studies focusing on the use of Libras so that socialization of the results may contribute to improved communication between the deaf and health professionals. From this perspective, the following question guided this study: How do the deaf express clinical signs and symptoms of sexually transmitted infections in Libras?
In this regard, the study is relevant because issues related to affective-sexual experiences and sexually transmitted diseases and AIDS have been the subject of scientific literature in health and are highly discussed topics in Brazilian society. Another reason is that regardless of the legal provisions recommending the use of Libras in health services, compliance with the guidelines of these legal documents continues to fall short. This is why socializing the results of studies demonstrating the expression, in Libras, of STI signs and symptoms, contributes to the training of nursing professionals in terms of making them more qualified to meet the basic needs of this social segment.
Based on the assumption that deaf people face communication difficulties in health services, and that some health professionals lack knowledge of Libras, which affects the care given to the deaf, the objective of this study was to validate a video containing image representations of clinical signs and symptoms of sexually transmitted infections expressed in Libras. EDAC offers elementary and secondary education to 264 deaf students enrolled. Its objectives include: teach and use Libras to enhance the acquisition of knowledge within the pedagogical structure of the courses and facilitate the process for deaf students to learn written language.

METHOD
After authorization from EDAC, the dates and times for data collection were scheduled. The following people were selected: a) a random group of 36 deaf people; b) a group of three judges (Libras teachers and interpreters), invited according to accessibility; c) two deaf people who knew Libras and how to use it to reproduce the signs and symptoms of STIs.
The researchers decided to invite an odd number of judges to avoid ambiguous issues in case of a tie. The general eligibility criteria for inclusion in the above two groups were: being 18 years old or older, being proficient in Libras and knowing Portuguese.
With respect to the Libras judges, two specific inclusion criteria were added. The first was to have Prolibras -a national exam for Libras proficiency certification. This exam certifies deaf or hearing people fluent in Libras, who have completed university or high school, such as Libras instructors, and recognizes their competence in the use and teaching of this language or in its translation and interpretation. The second was to have a formal employment relationship with EDAC, as a teacher.
In the initial phase of building the content, there was a literature review and Questionnaire I was administered to the deaf participants, containing the variables: gender, age, marital status, level of education, job, household income, housing conditions, leisure, smoking, alcohol use, family medical history, previous signs and symptoms of health issues and STI-related signs and symptoms. The language used to identify the clinical signs and symptoms was not the standard one used by health professionals, but rather a simple and clear language based on common sense that would be better understood by some of the deaf students, as well as the Libras judges, since both were unfamiliar with some of the specific technical terms used in the health field.
Eight signs and symptoms related to STIs were compiled, which were reproduced in Libras, by two of the deaf students selected. This representation was filmed and recorded on video, and then presented to the deaf participants from the sample for semantic evaluation using an instrument with the signs and symptoms contained in the film, accompanied by the options ( ) YES or ( ) NO. Marking the answer YES was interpreted as Excellent, worth 5 points, and considered a relevant and representative item. Marking the answer NO, meaning Very Poor, worth 1 point, was considered as not relevant and not representative.
Following this, the film validated by the deaf participants was submitted to the judges for their consideration. The instrument used by the judges was a Likert scale, containing a list of the eight clinical signs and symptoms reproduced by the deaf students, with a scoring range from 1 to 5, corresponding to the following concepts: Very poor: not relevant and not representative, with a score of 1 point; Poor: not relevant or not representative, with a score of 2 points; Average: item requires major revision to be representative, with a score of 3 points; Good: item needs little revision to be representative, with a score of 4 points; Excellent: relevant or representative item, with a score of 5 points.
The results obtained from the judges were analyzed using the Content Validity Index (CVI), which measures the proportion or percentage of judges who are in agreement on certain aspects of the instrument and its items. The following formula was used to obtain the CVI: CVI = number of responses "4" or "5"/total number of responses (14) .
Items which achieved a score with an agreement rate > 0.80/80% among the judges were considered validated (15) . The score of 1 was applied, representing 100% agreement among the judges participating in the validation process. The validated content results were transformed into drawings and presented in figures.
The project was submitted to and approved by the Research Ethics Committee of the State University of Paraíba, CAAE No. 0700.0.133.000-11. Participants were explained about the researchers, the objectives and benefits of the study, assurances regarding the confidentiality and privacy of information related to personal identification and their right to drop out of the study at any time, without any kind of onus. Each participant signed a free and informed consent form, wherein it was also explained that the images resulting from the study would be recorded on video for use in publications to socialize the images.

RESULTS
A total of 36 deaf people were studied, in an age range from 18 to 36 years, being 23 men and 13 women, among whom 30 were single. There were 27 workers who earned from one to two minimum wages and 20 of them were from ages 18 to 23.
The STI signs and symptoms referred to by the deaf students as known ones were the following: vaginal discharge, discharge via the urethra, pain during sexual intercourse, sore in the male genital region, sore in the female genital region, small blisters in the male genital region, small blisters in the female genital region and bleeding during sexual intercourse.
In terms of the semantic validation of the expressions in Libras of these signs and symptoms contained in the film, all the deaf participants from the assigned group selected the images expressed by the two deaf students as true and reliable, marking them with a YES on the questionnaire. Therefore, this consolidated material was scored as excellent (5) and obtained a score of 1, with 100% representativeness and agreement.
This result slightly dissents with the evaluation of the filmed content by the Libras judges as far as the scores attributed to each clinical sign and symptom related to STIs expressed by deaf persons 1 and 2. Table 2 presents the results of the CVI calculation, based on the evaluation of the video by the deaf participants and Libras judges. It was noted that there were 45 "4"or "5" responses out of a total of 48, resulting in an overall CVI of 0.94. Figure 1 presents the validated symbolic images of the signs and symptoms related to STIs contained in the video which were considered valid in the CVI calculation.

DISCUSSION
The sociodemographic profile in this study corroborates what was reported in the literature, where most are single men, between 18 and 35 years old, unemployed, with eight years of education and a monthly income below two minimum wages (16) .
During the production of the video, these deaf participants expressed little knowledge about the signs and symptoms of the STIs. However, this finding differs from that of another study in Paraíba, involving 300 women with active sex lives, where it was detected that they had insufficient knowledge about STIs (17) . It also differs from the results of a study on the social representations of deaf adolescents regarding sexual activities and the health-disease process, in that the authors report that most of these participants are uninformed and confused in terms of dealing with diseases, especially STIs (18) .
These findings indicate the need for intervention through health education, to increase knowledge about these diseases and how to prevent them. This need is also supported by reports that, in the contemporary social context, media is used to expose people to different sex-related situations, without them being properly informed, in regard to their sexual lives and the potential risks involved in the sexual practice. This phenomenon requires that health professionals seek to understand this problem and develop methods and materials accessible to those people who are susceptible to STDs, especially HIV/AIDS (19) .
In the validation of the signs and symptoms expressed by the deaf students, the judges from the study sample were qualified, since all three have Prolibras certification, as well as teaching experience with Libras, working as teachers linked to EDAC. In turn, the deaf students who participated were an important factor in the rich and integrated partnership with the judges, due to the everyday use of Libras at EDAC and within the deaf community, thus demonstrating the necessary knowledge and skills to express the clinical signs of the STIs that were presented to them, contributing on both a theoretical and practical level.
All the judges were in agreement with the aspects of the questionnaire and its items and considered the instructions for filling it out to be adequate, enabling an analysis of each item individually and, then, the questionnaire as a whole. They also did not request any changes to the images presented.
Of the eight images of clinical signs and symptoms related to STIs expressed in Libras, six were excellent in terms of representativeness and agreement, with the maximum CVI, making them representative and valid for use in a clinical environment. However, two images expressed in Libras -vaginal discharge and bleeding during sexual intercourse -did not obtain full agreement and representativeness among the judges. The lower scores for these two image expressions suggest the need for further consideration and analysis when used in the patient care environment, since, besides helping to identify the symptoms of possible sexually transmitted infections they can also be used for health education.
In this regard, the experts' validation made the expressions of signs and symptoms of STIs in Libras suitable for establishing effective communication between health In addition to the content validation performed in this study, it must be added that health professionals, especially nurses, need to seek training in Libras to provide the deaf with systematized and humanized quality care and break down existing communication barriers. This need is corroborated in another study which notes that all of the participants reported difficulty interacting with health professionals, communicating mainly through the assistance of a relative, or using lip reading, images or mimicry (16) .
Deaf participants in another study in Paraíba, in the northeast region of Brazil, mentioned the use of writing, lip reading and, especially, the presence of a family member as communication strategies used by health professionals when providing care. They also referred to the loss of privacy and the right to understand their health-disease process, as well as the ineffectiveness of these communication strategies for their full integration and participation in society (20) .
It is worth noting that communication with the deaf, when mediated by an accompanying person or interpreter, besides breaking the professional-patient bond, hinders access to information and direct contact with the patient, thereby breaching the confidentiality of the issues related to the latter. Apart from this ethical issue, there are other factors that contribute to the difficulties in the care given by nurses to the deaf, such as unfavorable working conditions, the limitations of the deaf themselves and the values and understanding on the part of the deaf and nurses, in addition to meta-contextual conditions represented by public policies (21) .
Finally, authors report the need for more studies related to deafness, focusing on all the professionals involved in the direct care of deaf patients, since it is important that all communication be effective. A communication program is also needed for people with hearing loss of any degree and nature, so that they can know and use Libras, as well as posters and signs with sign systems, to enable them to have access to the information they need when visiting a health unit (22) .

CONCLUSION
In this study, the representations of the following STI signs and symptoms in Libras were validated: pain during sexual intercourse, bleeding during sexual intercourse, sore in the male genital region, sore in the female genital region, discharge via the urethra, small blisters in the male genital region and small blisters in the female genital region. The representation of discharge via the urethra did not meet the parameters established for the validation, with changes needed for a new validation procedure.
The results of this study demonstrate that the proposed objectives were achieved and the guiding question was answered, which was to represent, in Libras, the clinical signs and symptoms of STI's, whose images were validated by judges. The use of these validated images, at any level of care, creates a positive link between deaf people and health professionals. Therefore, the main contribution of the study is that it provides health professionals with a health care tool that facilitates developing the care provided to deaf people, by enabling efficient and effective direct communication between the deaf and health professionals.
The limitations of the present study stemmed from the lack of similar studies in the databases consulted, to establish convergences, similarities or distances between the results. Validation results were found, but with different and divergent themes than those studied here. In addition, the findings of this study, which pertain to a specific social segment, characterized as the deaf, cannot be generalized for the plural society.
Deaf people's knowledge about STIs requires professional proximity so that they can discuss this topic. Such proximity must be a continuous process, with an emphasis on sexual and reproductive rights and proficiency in Libras, which requires interdisciplinary training of professionals working in health services to overcome the shortcomings identified, as a result of communication difficulties.
Future studies on this topic are recommended, as well as other samples of deaf people and judges in different scenarios, to make signs and symptoms of diseases expressed in Libras a consolidated tool that is used in care practices and health education.