HOW TO TEACH INCURABLE SEXUALLY TRANSMITTED INFECTIONS TO UNDERGRADUATE NURSING STUDENTS: A SCOPING REVIEW

Objective: to group and synthesize the studies that address the teaching of Incurable Sexually Transmitted Infections for undergraduate Nursing students in the world (1989-2020). Method: a scoping review according to the Joanna Briggs Institute. The search strategy was carried out in PubMed, CINAHL, Embase, Web of Science and LILACS. Two reviewers selected and extracted the data independently. Results: after searching and removing duplicates, 41 studies met the established criteria and were included. Content analysis resulted in three categories: Teaching Scenarios and Strategies; Teaching Focus; and Teaching Effectiveness. Final considerations: the educational actions were effective in increasing knowledge, reducing stigma and anxiety, and increasing sensitivity in promoting Nursing care. Teaching this theme is important in the profession’s work on epidemiological indices and in the training of Nursing students for prevention and promotion in health. DESCRIPTORS: Sexually Transmitted Diseases; Nursing Education; Higher Education; Nursing Students; Infections. HIGHLIGHTS


INTRODUCTION
Sexually Transmitted Infections (STIs) have different etiologies and symptoms 1 .Transmission is through sexual contact with an infected person without using a condom, during pregnancy/delivery/breastfeeding, or through contact with mucous membranes or bodily secretions of infected individuals 2 .
The World Health Organization (WHO) points out that more than 1 million people acquire STIs daily in the world.STIs can have serious consequences and are among the 10 most frequent causes for seeking health services, in addition to having health, social and economic consequences 3 .When not properly treated, they exert a significant impact on health and can have serious consequences, such as cardiovascular and neurological diseases, infertility, miscarriages and stillbirths, among others [3][4] .They are commonly associated with issues such as stigma and domestic violence and negatively affect quality of life 4 .
Of the more than 30 bacteria, viruses and parasites, eight of these pathogens are associated with the highest incidence values of STIs.Four of them are curable: syphilis, gonorrhea, chlamydia and trichomoniasis; and four are incurable: hepatitis B, herpes simplex virus (HSV), HIV/AIDS and human papilloma virus (HPV).The focus of this study is directed to the Incurable STIs due to the high epidemiological rates 5 , and because, although there are treatments to reduce the aggravating symptoms, such STIs are incurable, which makes people use health resources throughout their lives.
Additionally, the importance of a qualified approach to these topics during health professionals' undergraduate studies is highlighted, in particular from the Nursing area 6 .The university space is fundamental for scientific and technological development 7 , as well as for promoting a solid knowledge base for the students so that, among other aspects, they can include the social determinants of health in order to guarantee the quality of the educational process, guided by a curriculum plan consistent with the epidemiological reality.In this sense, the question is as follows: How has the teaching of Incurable Sexually Transmitted Infections been approached in Nursing Undergraduate Courses?Therefore, the objective of the study is to group and synthesize the studies that address the teaching of Incurable Sexually Transmitted Infections for undergraduate Nursing students in the world (1989-2020).

Study design
A scoping review conducted in accordance with the Joanna Briggs Institute (JBI).As recommended by the methodology, an a priori protocol was prepared and published to guide this review [8][9] .Through rigorous and systematic procedures, scoping reviews aim at mapping the literature about a thematic area with the intention of providing a descriptive view of the reviewed studies 8 .
The research question was elaborated through the Population, Concept and Context (PCC) strategy for scoping reviews 8 .Therefore, P (Population) refers to undergraduate Nursing students; C (Concept) to the teaching of Incurable STIs; and C (Context) to the teaching scenario during undergraduate Nursing studies.Therefore, the guiding question was defined as follows: "How has the teaching of Incurable Sexually Transmitted Infections been approached in Nursing Undergraduate Courses?".
The inclusion criteria were the following: studies aimed at teaching Incurable STIs METHOD (Hepatitis B, HSV, HIV or HPV) to undergraduate Nursing students; methodologies used in the teaching of the topic; studies available in full, free of charge, in Portuguese, English and Spanish; and qualitative and quantitative studies, mixed methods, guidelines, theses and dissertations.The exclusion criteria were as follows: studies aimed at educating Health or Nursing professionals; Nursing students' knowledge and perceptions regarding STIs; technical level and graduate students in Nursing; studies whose focus was generalist on the teaching of STIs; and studies on the curriculum, course and/or academic discipline, which only contained a description and not the implementation of any educational action.
The time frame chosen for this review is associated with the emergence of the global HIV/AIDS epidemic with the first cases recorded in 1981 10 , and studies published until December 2020 were included.It should be noted that, although the initial search period was 1981, it was only from 1989 that studies adhering to this scoping review were found.

Data collection and organization
A three-step-search strategy was developed by a librarian with experience in the health sciences.To determine the correct terms, a search was carried out in DeCS, MeSH and Embase's Emtree tool where, in addition to the exact descriptors, alternative terms and synonyms are presented.The exact descriptors used were "Nursing Education", "Sexually Transmitted Diseases", "Nursing" and "Nursing Students".Subsequently, alternative terms were added and, in the "Sexually Transmitted Diseases" descriptor, the exact and alternative descriptors of each Incurable STI were also included with the AND and OR Boolean operators.
The search strategies were applied on February 23 rd , 2021, in PubMed, Web of Science, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS) (Chart 1).

Data analysis
For extraction of the results, an instrument was developed in order to identify the main characteristics of the studies found, such as the name of the author(s); year of publication; country of origin; objective/purpose; study population and sample size; methodology/ method; type of intervention; results; and main discoveries.The data extracted were accessed using content analysis to find consensus across the records, as well as to summarize and synthesize results 11 .The analysis took into account diverse information regarding the scenario where the educational activity took place, instruments and resources used, namely: STIs addressed, detailing how the activity took place, limitations encountered and results obtained.Thus, it was possible to find similarities in the development of these practices and list three categories: Teaching Scenarios and Strategies; Teaching Focus; and Teaching Effectiveness.

Ethical aspects
For being a literature review, this study was not submitted to any Ethics Committee for Research involving Human Beings; however, Resolution No. 466/12 of the National Health Council was respected, with regard to analysis and sharing of the results.

RESULTS
A total of 3,687 results were found in the initial search, 2,796 after removing duplicates, with inclusion of 41 studies in this review.Specific details of the study selection stages are shown in the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews (PRISMA-ScR) flowchart (12) (Figure 1).With regard to the 295 studies excluded, it is worth noting the difficulty accessing articles in full and their access availability due to the initial time frame dating back to the 1980s.Of these, 176 studies were not available despite going through a screening process by a librarian.The remaining 119 studies were excluded for not meeting the inclusion criteria.The full description of the articles included can be found in Chart 2.
As a way to evaluate the educational actions/interventions, 32 studies (78.05%) used the pre-and post-test with instruments available in the literature and prepared by the authors (Chart 3).The findings indicate various methodologies and educational actions/interventions carried out for undergraduate Nursing students at the global level.Through content analysis, it was possible to define three categories: Teaching Scenarios and Strategies; Teaching Focus; and Teaching Effectiveness.
The use of technologies (e.g., computers with scenarios) was also pointed out to assist in the educational actions 16,19,22,43,52 and role-playing 33 to train Nursing students 45,49 .Additionally, nine studies included people with HIV+ to participate in their educational activities, integrating students into this population [24][25]27,[30][31]34,40,48,52 . Contact with HIV+ peple created opportunities for the students to face their myths, fears and prejudices, as well as to improve their understanding and awareness about the discrimination suffered by people with HIV 34 .
Additionally, some studies included other health professionals with the intention of increasing the knowledge range and introducing multidisciplinary work to people with HIV 48 , participation of an expert nurse in the area 30,34 , an expert teacher in the area 20 and a specialist in infectious diseases 38,40 .In 20 studies it was possible to identify the description of resources that have been used to assist in the implementation of educational actions aimed at Nursing students (Figure 2).
The studies addressed ethical issues related to the infection and to the health care for this population 14,24,29,35,37,45,47 , the psychosocial impact exerted by the infection 27,29,51 , Nursing care for people with HIV/AIDS 15,18,[27][28]35,44,49 , health needs 14,25 , pre-delivery/intrapartum/ postpartum and newborn care 35 , current problems and challenges in caring for clients with HIV/AIDS 22 , ART use in adults and children and palliative care for PLHIV 47 ; and pre-and postexposure prophylaxis, sexual health education, violence and transgender populations 51 .
Stigma appeared as the learning focus associated with health care in three studies.The approach of increasing knowledge to decrease fears about the possibility of HIV transmission during casual contacts, information about HIV epidemiology, transmission misconceptions and ways to prevent the disease, including (PPE) use in the hospital, was found in one study 39 ; and another study resorted to an intervention to reduce HIV stigma for Nursing students and ward staff via tablets 52 , social stigmas and work relationships with individuals with HIV 29 .
Two studies addressed more than one STI, in the form of an educational theatrical piece in the style of a comedy written in partnership with teachers, students from the Group to Combat Drugs and AIDS, and students from the theater group 38,50 .In turn, three studies focused on interventions for HPV, with activities aimed at teaching HPV, cervical cancer risk factors, prevention and signs and symptoms 36,43,46 .As for the approach to knowledge and awareness about various aspects of Hepatitis B and C, one study addressed the etiology, transmission means, diagnosis, prevention, treatment and information sources 42 .
The teaching focus for Incurable STIs covers aspects related to epidemiology, transmission and treatment, among others.It manages to go further and addresses important issues such as stigma, students' anxiety and management of people with HIV.It is noted that the first studies covering the end of the 1980s and the 1990s focused on introducing the theme of AIDS in order to introduce the students to what the epidemic was about.
There are few studies that address the teaching of HPV or hepatitis B and no study has addressed HSV, evidencing that teaching has been mostly associated with HIV/AIDS in the last 40 years.

Teaching Effectiveness
The studies used different teaching methodologies to promote knowledge about the theme.In 40 studies it is possible to identify a description of the outcome enabled by the action/intervention in promoting the teaching of the theme for Nursing students.
Studies using internships showed positive results in improving the students' concerns, fears and discomfort 15,51 .The use of extension projects eased the students' understanding of autonomy in the health-disease process and collective health 7 , as well as knowledge about STIs and the need to maintain training and expand discussions 50 .
Didactic teaching and experiential learning with HIV+ people and role-playing brought about an increase in knowledge, empathy or attitudes towards HIV 24,33 .An educational intervention on stigma and HIV transmission showed an increase in the students' general mean knowledge level 39 .In a participatory learning activity followed by the lecture method, there was also an increase in the knowledge level 41 .
Studies aimed at controlling the anxiety level in the students showed that using lectures on HIV/AIDS 26 and participation in anxiety awareness exercises in an experimental Petry S, Padilha MI, Mazera MS, Silva AR format 21 are positive for reducing anxiety and contributing to learning.
The knowledge and attitudes towards AIDS through lectures indicate that there were significant differences in relation to the homophobia degree and knowledge about AIDS 13 .Also regarding HIV knowledge, a number of studies pointed to an increase in the number of correct answers 29,32,47 and greater knowledge gain in relation to HIV prevention, treatment and general knowledge 47 .As for the care of patients with HIV, a study points out that the educational intervention carried out by specialist professionals in the area and PLHIV was positive in terms of care provision 48 .
There are also positive results regarding an optional course on HIV/AIDS where conversations with PLHIV contributed a remarkable experience for the students 14 .The students indicated greater knowledge and impact of the experience in their lives 27 ; participation in a specific event on the theme of AIDS means that the students developed empathy with individuals and families 25 ; and the course resulted in the students feeling comfortable providing basic Nursing care to people without knowing whether or not they were HIV+ 22 .
There are also positive evaluations about the peer-multiplier format 35,37 , with important changes in the stigma level scores for the students who had no experience with people with HIV/AIDS.After the intervention, in a workshop format, a considerable increase in the perception of stigma is evidenced 37 .The study used body mapping, a tool to ease the students' understanding of the experiences of living with HIV and a strategy to educate PLHIV about their own health, and brought about students' reflections on the unawareness of their stigmas and relevant information regarding HIV 40 .
There is also the use of comparative methods to assess which strategy exerted the greatest influence on the students' knowledge level 20,28,[30][31][43][44] . Lecturs on AIDS and the use of structured controversy indicate that the students who participated in the structured controversy were more positive about the intention to provide care to HIV+ patients 20 .However, when the lecture and discussion is compared to video and discussion, the former was more effective in knowledge acquisition 28 .
Additionally, in HIV teaching, when lecture and discussion is compared to lecture and experiential learning method, the former is more effective 30 ; lecture (basic educational content on HIV) and lecture plus experimental method that included role-playing presented a weak, although statistically significant, relationship between the perception and willingness to provide care to patients with HIV 31 .
In the dialoged lecture, the Intervention Group had access to a hypermedia about STIs, and it is stated that the students had limited knowledge about them and that few mentioned experience in the course or previous internship in an STI assistance service 43 .Expository teaching and the concept mapping method increased the scores of both groups; however, the scores using the conceptual mapping technique for attitudes towards patients with HIV/AIDS were higher than those obtained with the lecture method 44 .
As for the use of technologies in teaching, there were positive results regarding the attitudes related to the care of HIV+ people, in relation to Informatics in Nursing.Students who participated in the class using a computer program had higher scores in less time than those who participated in the lecture and discussion 16 ; just as the use of an educational computer program in two formats pointed to concept mapping as a tool with positive results on the theme of AIDS 19 .Another study that used educational sessions via tablets shows an increase in knowledge, a decrease in misunderstandings and less concern with acquiring HIV in the workplace 52 .
Regarding the use of clinical simulation, in a training program for Chilean students using actors on the theme of HIV treatment, improvements were shown in terms of knowledge, increased risk perception and decreased stigma and discrimination 45 .A research study with Nursing students who participated in simulation through role-playing and music resulted in significant improvements in knowledge about AIDS; however, in the attitudes related to AIDS, there was an improvement only in the Intervention Group 23 .
As for the educational actions aimed at HPV, in an educational intervention in the form of an educational program about HPV and cervical cancer, an increase in the knowledge level after the intervention was pointed out 36 .A research study conducted with Nursing students as peer-multipliers indicated a statistically significant increase in knowledge after the intervention 38 .A program of activities carried out with health courses brought about positive results regarding the educational intervention focused on HPV; and the students were able to identify effective preventive measures for cervical cancer after the campaign 46 .
General knowledge about Hepatitis B and C improved after an intervention in a lecture, more specifically in the following aspects: etiology and transmission mean; age group commonly affected; and blood, sexual fluids and needle prick as transmission routes 42 .
These results show that most of the studies are effective in their educational interventions, contributing significant improvements in terms of knowledge, attitudes, perception, anxiety and stigma, among other factors.
Despite the various promising results regarding the educational interventions, two studies show that their interventions did not obtain positive results.With regard to comfort in providing care to patients with HIV/AIDS, there was no difference between the pre-and post-test scores, concluding that the intervention in the workshop format did not affect the students' general comfort degree to provide care 18 .Another study showed that using highfidelity simulation (HFS) as a teaching strategy for knowledge about HIV did not present statistical significance 49 .

DISCUSSION
Teaching Incurable STIs requires the teachers' pedagogical competence to articulate different types of knowledge and motivate students to assume (co)responsibility for the learning process.To choose the best teaching methods, it is important to consider several aspects, such as educational objectives, teachers' experience and types of students, among others 53 .
In the studies found, it is possible to identify different ways of promoting teaching for Nursing students, with the following among them: lectures, theoretical-practical fields, extension projects, events (training, programs, workshop), and use of technologies (simulation, tablet, computer programs), among others.Among the strategies adopted in the teaching-learning process, some teachers still prioritize methodological procedures centered on the traditional expository strategy, with the use of audiovisual resources such as a projector and videos 54 .
Although there is a guideline for the implementation of active methodologies, it is still possible to observe lack of knowledge, resistance and difficulties in the use of such methodologies in the teaching practice in health 54 .Breaking away from traditional teaching requires skills and competencies, as well as a desire to innovate.Professors need to learn new methodologies that assist in the development of teaching capable of transforming Nursing practices.The use of active methodologies stimulates and develops the students' critical capacity and, as health technology advances, the expectations of new graduated nurses also increase 53,55 .
Nursing students need stimuli to develop clinical reasoning and prioritization and respond to the patients' changing needs 55 .However, despite being considered traditional Petry S, Padilha MI, Mazera MS, Silva AR The findings meet the objective of this research and evidence that Incurable STIs are in fact being taught.Undergraduate Nursing students are being introduced to the topic CONCLUSION teaching, lectures related to educational interventions in the face of incurable STIs also present positive results in terms of their effectiveness in building Nursing students' knowledge.In comparative studies, for example, lectures appear as a more effective methodology than the intervention methodology 28,30 .
It is also important to highlight the use of technologies for the development of educational interventions.Ease of access to information coming from the Internet and its immense availability of digital resources ends up configuring a new profile of students, the digital natives, with the need for quick answers to questions and the expectation that technologies will be incorporated into the teaching environment 56 .
Faced with this reality, the use of simulated, and virtual realities with increasingly complex manikins arises, with the objective of preparing future Nursing professionals, as well as providing safety before effectively initiating the practices with humans.Using these technological resources allows recognizing possible errors in the procedures, which can be corrected before being applying them to a patient.These strategies enhance the students' critical thinking 57 .These experiences become opportune to ease understanding and selfawareness of the limitations 51 .
With regard to the reduction of new HIV/AIDS cases, access to health care and reduction of disparities and inequalities in health related to HIV, nurses and Nursing students can and should play an important role in achieving these objectives.A number of research studies point out that Nursing students' attitudes, fears and negative perceptions are associated with lack of knowledge, and education about AIDS, for example, can develop positive attitudes in care provision [58][59][60] .To this end, it becomes necessary for Nursing educators to equip their students with knowledge and understanding about the topic, as well as that assist in the development of clinical skills during undergraduate studies 48 .On the other hand, they also have a professional duty to develop strategies that reduce negative attitudes and disseminate preventive education to reduce the individual and social risk of society in general.Appropriate education can reduce fear of contagion, discrimination and stigma and promote positive attitudes towards the care to be provided to this population [60][61] .
There are some limitations related to this scoping review that should be mentioned.The fact that it was a study with a wide time scope rendered access to the full content of studies published in the 1980s and 1990s more difficult, being discarded as potential results.The scoping review focus is to provide breadth rather than depth of evidence on some particular area or topic; therefore, scoping reviews are inherently limited.In addition to that, a scoping review depends on the quality and availability of the diverse information reported in the studies included, which can vary considerably across studies and affect reliability of the results.The study selection process and the synthesis of the results depend on the reviewers' subjective interpretation, which can introduce bias and limit validity of the results.Finally, scoping reviews do not include a critical assessment of the methodological quality of the studies included, which may affect reliability of the conclusions and practical implications.
It is hoped that these findings help visualize the world panorama of how the teaching of the theme has been introduced to undergraduate Nursing students and influence the conduction of future studies.That brings about reflections on the need for teaching HPV, Hepatitis B and HSV, which appeared in evidently smaller numbers when compared to teaching HIV/AIDS. of HIV/AIDS, in the vast majority, and occasionally to HPV and Hepatitis B. As for HSV, no study was evidenced in this review.In this way, management and concern with HIV/AIDS continues to be a protagonist in teaching the theme of incurable STIs.
Varied resources and strategies were found in the educational activities, which shows the advancement of methodologies and inputs to qualify teaching.As for the topics that have been addressed in the educational activities targeted at incurable STIs, different approaches are identified, but with focuses much more centered on the care clinic than on the care relationships between Nursing professionals and people with incurable STIs.It is worth noting the studies that focus on the importance of the profession with regard to prevention and promotion in health and in the students' training as a whole.
As for the effectiveness of the interventions, all of them show important results in the development of Nursing students' knowledge, attitudes, reduction of stigma and care provision to people with HIV/AIDS.Some studies place Nursing students in the role of peer-multipliers, that is, more committed to this theme and, from their undergraduate studies, to improving their role in health promotion in the face of STIs.
National Council for Scientific and Technological Development (CNPq) -Funding Code 001.