Prevention of sexually transmitted diseases among visually impaired people: educational text validation

ABSTRACT Objective: to validate an educational text in the context of Sexually Transmitted Diseases (STD) for visually impaired persons, making it accessible to this population. Method: a validation study, in a virtual environment. Data collection occurred from May to September 2012 by emailing the subjects, and was composed by seven content experts about STDs. Analysis was based on the considerations of the experts about Objectives, Structure and Presentation, and Relevance. Results: on the Objectives and Structure and Presentation blocks, 77 (84.6%) and 48 (85.7%) were fully adequate or appropriate, respectively. In the Relevance block, items 3.2 - Allows transfer and generalization of learning, and 3.5 - Portrays aspects needed to clarify the family, showed bad agreement indices of 0.42 and 0.57, respectively. The analysis was followed by reformulating the text according to the relevant suggestions. Conclusion: the text was validated regarding the content of sexually transmitted diseases. A total of 35 stanzas were removed and nine others included, following the recommendations of the experts.


Introduction
In the context of sexuality, sex is presented as an important component of a healthy sexual experience.
When inserted in this scenario, Sexually Transmitted Diseases (STD) are disorders resulting from nonprevention during sex. Factors such as the lack of information may contribute to the occurrence of STDs.
The lack of knowledge in the context of sexual health can be considered a limiting factor among visually impaired persons, as these people require specific components for access to information, such as the use of technologies. In addition, authors consider that STDs pose a risk to the population with vision, but for the visually impaired persons who are subject to social stigmas, these risks become much larger (1) .
Despite the advances, and with public policies having turned to the pursuit of access to education, health and social life of people with disabilities, little has been observed regarding effective actions to encourage and include their emotional and sexual experiences (2) .
These people should be encouraged to practice healthy sex through education on sexual health including contraception and condom use. As shown in the study, visually impaired people also need guidance, taking advantage of technological innovations and advances in which nurses can create various strategies to boost nursing care to this clientele (3) . The technologies for the visually impaired correspond to specific resources adapted to allow the execution of a particular activity impossible from the absence of vision.
The study identifies technologies used in the learning process such as sponken books, the Amplified Reading System and Thermoform (high-relief), in addition to computing resources such as a Braille printer, screen magnification feature and voice synthesizers, also called screen readers (4) .
The reduced availability of resources for education in health and risk prevention behaviors related to sexual and reproductive health of these clients has been perceived (5) . It is therefore important to create a technology in this context which is validated by judges on the topic of STDs for the promotion of information and encouraging the use of condoms with the view that a large number of visually impaired people can acquire this health knowledge.
The learning process in health involving this population is possible through creative projects.
Research conducted with visually impaired people has shown that the use of rhyming text has proved to be an effective strategy in addressing STDs. In designing the subjects, this technological resource used a simple and easy to understand language, thus promoting learning and comprehension (6) .
In the quest for developing materials that promote the inclusion of information for the visually impaired, expert validation by the use of specific methods is recommended which verifies accessibility and efficiency of the resource to be used (4) . Considering the validation process that is considered necessary, the objective of this study was to validate an educational text in the context of STDs for the visually impaired.

Methods
This is a validation study, classified as an analysis of process or implementation, as well as results and impact. In addition to information on how the process developed, the verification of the research process to elucidate descriptive information was also carried out. The analysis of results verifies if objectives have been achieved, while impact evaluates if the degree of intervention was effective (7) .

The virtual environment of the Laboratory of Health
Communication of the Nursing Department of the Federal University of Ceará was used as the study site.
Data collection took place between May and September 2012, through the Internet by email.
Seven content experts were the study subjects.
The search for the subjects was in consultation with Lattes Curriculum, and through the indication of selected participants. In this way, the non-probability of intentional sampling was used for the selection of participants. For inclusion in the sample, the title of doctor was required, as well as experience in teaching, research and practice of the profession, and scientific articles published in appropriate thematic journals.
For data collection, an adapted (for appearance and content) and validated instrument developed in a previous study (3)   For CI analysis, the following values and their respective classifications were used as reference: insignificant (less than 0.20), minimal (between 0.21 and 0.40), bad (between 0.41 and 0.60), good (between 0.61 and 0.80) and excellent (between 0.81 and 1.0) (9) . The items were considered valid for groups ranked "good" and "excellent." For items with "insignificant" rating, "minimal" and "bad", the necessary corrections were made with respect to the experts' suggestions.
The legal provisions were complied with and all subjects signed the informed consent form (CF). The project was approved by the Ethics Committee of the Federal University of Ceará under protocol 37/12.

Results
The analyzes are presented as three blocks of items related to the assessment tool: Objectives, Structure and Presentation, and Relevance. The Objectives block observed goals or purposes for using the text. The Structure and Presentation block refers to how the present text involves the overall organization, structure, presentation strategy, coherence and adequacy. Finally, the Relevance Block understood characteristics relating to the degree of significance of the material. Table 1 shows the levels of agreement between judges according to each block and item. In dealing with the main topics related to prevention (item 2.6) and use of structured language in simple language (item 2.7), most experts showed agreement.
An expert evaluated these as inappropriate or fully inadequate, and requested some terms be replaced to facilitate the understanding of "obtain," "sexual abstinence" and "elephantiasis." The amendments were accepted and these were replaced or removed.
In the Relevance block, items 3.

Discussion
In accordance with what was found, seven items For preparing and using educational material on health, how to introduce and present the information can be as decisive as the motivation in continuing to use it, and therefore learning. It is necessary to emphasize the development of educational methods to promote learning, learning transfer, organizational knowledge and excellence (10) . Regarding the prevention of STDs for the visually impaired, it is necessary to consider the motivational impact this can promote depending on how it is introduced, which can be decisive for the user in continuing to use the material.
With the suggestions made by the specialists in respect of the symptoms of the diseases, it was possible to clarify and correct information. In relation to the onset of symptoms in the characterization of Syphilis, study addressed that syphilis rose spots are presented as rounded erythematous macules initially appearing in the secondary stage of Syphilis (11) . Conforming to the analysis, the word used in the text is now "marks" instead of "spots," a term easily understood that corresponds to an injury without necessarily characterizing it. and late Syphilis can start at the end of the latent phase, and extend for several years (12) .
Considering Syphilis, when there is no one correct approach, vertical transmission results in higher incidence of miscarriages and occurrences of congenital diseases. Prenatal care is a key strategy to reduce the incidence of congenital Syphilis and transmission of HIV from mother to child, with early diagnosis and appropriate treatment (13) . Thus, the addition of a verse emphasizing prenatal care was needed. It is known that the only way to prevent congenital Syphilis is early diagnosis in pregnant women.  (14) . At the request of the experts and based on the literature, corrections were made.
As also observed by experts, the author shows that the majority of infections caused by HPV are asymptomatic or subclinical in both sexes. This means that men can have the same range of manifestations in terms of lesions as seen in women, and small lesions that rapidly progress in a matter of weeks are often detected in clinical practice, even in healthy young people, especially in recent contamination and together with other STDs (15) . Thus, the explanation for the occurrence in both sexes refers to the issue of equal responsibility for both men and women in the prevention of not only HPV, but STDs in general.
A study conducted on a profile of male users of a STD referral service reported that the adequate late treatment of HPV is a main concern, where it can result in cervical and penile cancer if not treated properly (16) .
With regards to the approach of Hepatitis B recommended in the text, and according to the literature, viral Hepatitis is the major cause of liver disease and Hepatitis B and C can potentially evolve into chronic Hepatitis, Cirrhosis and Hepatocellular Carcinoma which increases mortality from chronic liver diseases (17) .
For the treatment of STDs, the authors state that there currently is no capable cure for genital herpes and that some antiviral drugs are able to decrease the time of the disease and prevent the onset of lesions.
Furthermore, daily therapy by symptomatic patients may reduce the risk of transmission to their sexual partner (18) .
We could see the relevance of the information presented in the text and that their corrections were relevant. Therefore, it follows that education aimed at the issue of STDs should be a constant reality for the population, with the goal of people reflecting and understanding that prevention is the main way to control these diseases and minimize their impact (19) .
In Brazil, STDs are considered a serious public health problem. Unfortunately many health centers throughout the country lack appropriately trained medical and nursing staff to assist patients with these diseases (20) . For prevention, condom use is highlighted in the first stanza, as suggested by the experts, and emphasizes the paramount importance of safe sexual practice.
In addition to the prevention highlighted in the text, recent studies have been conducted in seeking to discuss and verify the impact that the vaccine for women can have on the prevention of HPV (21)(22) . For Hepatitis B, research shows that this vaccine has proved to be an important factor in the prevention of infection, and is being included in immunization programs (17) .
To find out about STDs and their particularities, it is thought that the knowledge provided and the fear itself of these diseases is enough to be able to encourage change in behavior and attitude. As such, this information should be accessible to the needs of the visually impaired persons.  (23) . Thus, in order to raise awareness of the existence and occurrence of STDs, the opportunity for reflection by individuals and prevention must be offered; and in the event of a risky/ dangerous situation, awareness about seeking out a health service. Therefore, the use of suitable, attractive and available resources is required.
The size of the educational material is a factor that may help or hinder its use. It is necessary to limit the size of the educational material, because the smaller and more concise it is, the more accessible it will be to the public. The size should be sufficient enough to mention the necessary and essential information.
Pages in large numbers with lots of information may discourage health learning (10) . Reducing the material was one aspect corrected to match the request of the experts, by choosing the most prevalent STDs.
Over 30 different types of viruses, bacteria and parasites are sexually transmitted, with the most common STD being chancroid, genital herpes, genital warts, human immunodeficiency virus (HIV), hepatitis B, gonorrhea, chlamydia, syphilis and trichomoniasis (20) .
A study by Community Health Agents (CHA) cites Donovanosis and Lymphogranuloma as STDs, which are little known and identified (24) . Chancroid was not kept in the text and Hepatitis B was added as per the expert advice on the composition of the technology.

Conclusion
The text was validated regarding the content of A limitation of this study was in the difficulty in identifying experts corresponding to the inclusion criteria, as well as their limited availabilty, which hindered being able to get 7 participating expert subjects.