Educational technologies on sexually transmitted infections for incarcerated women

Objective: to analyze in the scientific literature the educational technologies on sexually transmitted infections used in health education for incarcerated women. Method: an integrative review carried out by searching for articles in the following databases: Scopus, Cumulative Index of Nursing and Allied Health, Education Resources Information Center, PsycInFO, Medical Literature Analysis and Retrieval System Online, Latin American Literature in Health Sciences, Cochrane, and the ScienceDirect electronic library. There were no language and time restrictions. A search strategy was developed in PubMed and later adapted to the other databases. Results: a total of 823 studies were initially identified and, after applying inclusion and exclusion criteria, eight articles were selected. Most of them were developed in the United States with a predominance of randomized clinical trials. The technologies identified were of the printed materials type, isolated or associated to simulators of genital organs, videos, and games. Conclusion: the technologies on sexually transmitted infections used in health education for incarcerated women may contribute to adherence to the prevention of this serious public health problem in the context of deprivation of liberty.


Introduction
Sexually Transmitted Infections (STIs) are associated with more than 30 microorganisms. Of the eight most incident STIs, four are curable, namely: syphilis, gonorrhea, chlamydia, and trichomoniasis.
However, hepatitis B, herpes, human immunodeficiency virus (HIV), and human papilloma virus (HPV) remain incurable despite the existence of treatment (1) .
Worldwide, more than 1 million curable STIs occur every day. In this sense, the prevention and control of these infections happen as an excellent strategy in the field of public health. In 2016, the World Health Organization launched a global initiative to reduce STIs (2016-2021). Among its principles are universal health coverage, use of evidence-based interventions, promotion of human rights with gender equality and equity in health, and empowerment of the most affected by STIs (2) .
Incarcerated women are in this group, having the STI problem enhanced during their deprivation of liberty (3) . These women are more likely to be infected with an STI when compared to the general population (4)(5)(6) .
The Bangkok rules, an international document on the treatment of incarcerated women, state that they should receive education and information on how to prevent STIs (16) . Sometimes coming from less favored segments of society, these women have little knowledge about STI prevention (17)(18) . This raises the need to develop health education actions with a focus on minimizing the number of cases.
Educational technologies come as a health education strategy to be considered in the teachinglearning process. These tools can, for example, stimulate lifestyle changes in the individual field, contribute to the control of risk factors considered modifiable, and favor adherence to treatments (19) .
The acquisition of new knowledge may not guarantee changes in behavior; however, in many situations, lack of knowledge can lead to inappropriate self-care behaviors. Thus, when shared among people in a concrete way, the information based on solid evidence may be able to produce changes in lifestyle regarding self-care practices in the prevention of STIs (20) .

Method
An integrative review developed based on the following stages: formulation of the problem; literature search; data evaluation; data analysis; and presentation of the results (21) . As a way of assisting data collection, we proceeded with the elaboration of a search protocol, which contained the following information: theme; objective; guiding question; search strategies (database, descriptors, and intersections); inclusion and exclusion criteria; and data collection procedure.
The research question was elaborated based on the PICo strategy: (P) -Population (incarcerated women); (I) -Interest (educational technology on STIs); (Co) -Context (health education) (22) . Thus, the following question was obtained: What are the evidences available in the literature related to educational technologies on STIs used in health education for incarcerated women?
The selected databases were Scopus, Cumulative An asterisk was added to the descriptors to retrieve studies that presented words stemming from the same radical. The descriptors were combined using the Boolean operators "AND" and "OR". Articles indexed with MeSH terms were selected, as well as their presence or their synonyms in the title/abstract. Initially, the search strategy was developed in PubMed and was later adapted for the other databases and electronic library (Figure 1).  The articles were exported to the EndNote online program to remove duplicate studies. Then, the titles and abstracts of the articles were examined in EndNote itself and those that met the selection criteria were considered for the next phase. These were organized according to the selection database/library, in an Excel spreadsheet.
Subsequently, the article was read in full. The selection was carried out independently by two researchers, and the differences were solved by consensus.

Results
A total of 823 articles were identified and eight were selected after applying the inclusion and exclusion criteria, as shown in Figure 2.
Publications between 1997 and 2018 were identified, with a predominance of 2015, which presented four publications (26,(30)(31)(32) . Each article was published in a different journal. Only two articles were published in journals linked to the areas of behavioral and social sciences (31) and interpersonal violence (32) . The others were associated with the health area. As for the type of study, five were randomized clinical trials (25)(26)(30)(31)(32) and three were descriptive studies (26,(31)(32) .
The educational technologies used on STIs for incarcerated women were printed materials with two interventions with this type of material associated with genital organ simulators (31)(32) , followed by video (28)(29)(30) and games (27) . It should be noted that the educational technologies described were not used in isolation, but as part of an educational intervention that involved, for example, group (26,29,31) sessions or combinations of group and individual sessions (25,32) . Regarding the types of STIs, HIV was the object of two technologies (26,28) and one study addressed HIV and the Hepatitis C virus (25) .
The other studies addressed STIs/HIV (27,(29)(30)(31)(32) . As for the level of evidence, one randomized clinical trial was classified as 1B (28) , and four as 2B (25,27,(29)(30) . The other studies were classified as having a level of evidence of 4 (26,(31)(32) . A chart was created to summarize the main characteristics of the studies (Figure 3).   (25) United States To evaluate a standard educational intervention and an improved individualized intervention (standard educational intervention + motivational interview) to reduce the risk of HIV * in women who use drugs in rural prisons.

Randomized clinical trial n=400
Printed material (cards) 2B Fogel, et al., 2015 (30) United States To test the effectiveness of an adapted, evidence-based behavioral intervention for the prevention of HIV * /STDs † among incarcerated women.

United States
To report the justification for the intervention, feasibility, acceptability, and pre-post results in a small initial feasibility study conducted with 14 women who received the intervention before release from prison, with follow-up assessments at 2, 5, and 8 months after release.

United States
To assess the effectiveness of an intervention to reduce STD † incidents, improve HIV * preventive behaviors, and improve the psychosocial outcomes.
This may reflect the growing number of studies aimed at The health demands of this population are complex, which is enhanced by the low visibility in the USA public policies. As a consequence, fewer resources are allocated when compared to the male prison population, which results in the inability of the prison institutions to respond to the women's health needs (35) . This reality is aggravated when considering the panorama of underdeveloped countries that face numerous problems in sensitive social sectors such as health, education, and security, and which have to deal with a limited amount of financial resources.
Regarding the language, it is understandable that, as English is the main language used by the scientific community to disseminate research studies (36) , it has had an absolute presence. STIs are considered a serious public health problem (1) and this explains the fact that the studies have been published especially in health journals. However, this is a problem that, when associated with incarceration, can be dealt in a crosssectional manner, which justifies the presence of articles published in other areas of knowledge (31)(32) .
The research studies of the randomized clinical trial type were the main study designs adopted by the authors and showed that the interventions performed were tested following a method capable of producing robust evidence. The results from studies of this nature represent one of the best evidence available in the scientific community, given the rigor with which they are conducted (37) . This reflects the high level of evidence obtained by most of the studies, although among the clinical trials, only 1 has obtained level 1B. This occurred due to the follow-up losses greater than 20% present in the other trials, which makes them be classified as 2B (23) .
The interventions in which the technologies described above were used varied as to the manner of employment, making evident a broader process that involved group and individual sessions (25)(26)29,(31)(32) and in, some cases, even follow-up after freedom was granted (27)(28)30) . This reinforces the concept that technology is another tool to assist the professionals in the health education process and that the results obtained cannot be attributed exclusively to their employment, but to the intervention as a whole.
Regarding the STIs, there was a strong presence of HIV/AIDS. The prevalence of HIV in prisons is higher than in the community (38) . In this sense, fighting HIV infection in prison settings represents an enormous challenge for both the health and the judiciary system. In addition, it is necessary to consider the repercussions that HIV infection can cause in both the individual and collective fields. Likewise, the costs associated with prevention are notably lower than those spent on treatments (39) .
The printed material was frequently used as educational technology in the studies analyzed, sometimes associated with other technologies or strategies, such as simulators of genital organs (31)(32) . It is known that the prison setting has limitations regarding the entry of technological resources, even if educational.
Digital technologies or those that need access to the Internet are hardly used in this setting. This is related to the choice of printed materials, such as folders, pictures, photos, and booklets (31)(32) .
Other resources such as videos and games were also used (27)(28)(29)(30) . These technologies can be built and used to boost the teaching and learning process without the need for Internet access, which favors their use in prison settings.
Videos are educational technologies that can be used in health education, either in isolation or in association with other technologies (40) . In the context of the STIs, brief interventions based on videos can be considered economical tools in the prevention of new cases, especially in places where the time of the health professionals is limited or where prevention programs with a longer duration are not available (41) .
As for the use of games, these allow the student to memorize information, stimulate learning and greater involvement, conditions that favor its use at different moments in the teaching-learning process (42) . The game can be used as a prevention and continuous care strategy for specific diseases, such as HIV. Thus, by means of an interactive and dynamic approach, important behavioral changes related to health can be achieved (43) .
Regardless of the technology to be used, it is important to consider active methods in the health education process and to understand that their use is more than the simple insertion of a technological resource (44) . A systematic review with meta-analysis showed that active learning methods promoted better performance of underrepresented students (ethnic, racial, and low-income minorities) in science, technology, engineering, and mathematics courses when compared to traditional classes (45) .