Construction and validation of podcast for teen sexual and reproductive health education

Abstract Objective: to construe and validate a podcast for teen sexual and reproductive health education. Method: a methodological study was conducted based on Freire’s perspective. The podcast was construed based on the Knowledge about Sexuality Questionnaire applied to 60 adolescents and an integrative literature review. Eleven experts conducted the validation process. Internal consistency was evaluated using Item-level Content Validity Index ≥0.78 and Cronbach’s alpha ≥0.700. Results: four podcast episodes were produced with the adolescents’ participation using the radio play format, addressing sex and sexuality, contraceptive methods, human immunodeficiency virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) and other sexually transmitted infections. The podcast episodes last between 8 and 11 minutes and was validated with Item-level Content Validity Index = 0.87 and Cronbach’s alpha = 0.951. Conclusion: the podcast was validated for teen sexual and reproductive health education and constitutes a tool for health professional practices, particularly nurses, as well as autonomous use by adolescents.


Introduction
Sexual and reproductive health education is permeated by censorship and restrictions based on prejudices, taboos and power relations. As this dimension concerns the life cycle, these limitations are even more noticeable when dealing with adolescents, with actions promoting individual accountability, shaming and behavior changes vertically guided by non-inclusive public policies (1) .
Teenagers, especially those living in developing countries, face additional challenges in terms of sexual and reproductive health, given the sex-related misconceptions, adult negligence and/or inattention, social, cultural and access barriers (2) .
Adolescence is marked by growth spurts, manifestation of secondary sexual characters, and cognitive transformations that corroborate the appreciation of new intrapersonal, interpersonal, and environmental bonds (3) . Hence, sexuality finds a locus of greater development and self-perception in this period.
Discussing sexual health involves discussing the act itself, including practices and experiences related to satisfaction, pleasure, affection, feelings and health.
Sexual experiences, although presenting similar traits between individuals, are of unique development, modified according to the social and cultural context in which the adolescent lives, and may represent risks to health, quality of life and be a factor of vulnerability (2) .
In our understanding, therefore, we must advance the debate about the full exercise of sexuality in adolescence, providing subsidies to promote adolescent health in the dimensions of pleasure, intimacy and fulfillment. We seek to strength adolescent autonomy and empowerment, overcoming normative-preventive discourses that envision sexual health as a risk (4) .
Educational technologies shows potential in the education process to promote adolescent health, as it allows audience participation and the approach of different topics, resulting in inclusion and adequacy to health needs (5) .
Among the technologies used in health-related fields, the podcast has been gaining relevance in educational processes (6)(7) . It consists of an online audio resource, accessed via computer, mobile phone and audio players, capable of gathering various information, such as lectures, interviews and commentaries (6) .
Its novel character lies in the flexibility of its modes of reproduction and sharing; autonomy in its use in a place and time relevant to the user; and in the dissemination of knowledge that overcomes geographical barriers, such as that imposed by the global COVID-19 pandemic (6,8) .
Under health promotion, health education proposals consolidated on the recognition of needs, health planning, teamwork, popular education and participation, represent advances consistent with assertive professional performance before the new modes of health production in the territories (9) .
In this context, the podcast becomes a relevant tool to facilitate teen access to information about sexual and reproductive health, free of inter-relational constraints and incentivizing self-care. It is also a powerful tool for professional health practice as an educational resource.
Hence, this study sought to create and validate a podcast for teen sexual and reproductive health education.

Method Study design
This is a methodological study (10) based on Freire's perspective (11) for the construction of an educational technology, divided into four stages: theoretical framework, identification of themes, elaboration of educational technology and validation of the material ( Figure 1).  Paulo Freire's work on critical pedagogy, adopted here as a theoretical reference, argues that individuals apprehend their study subject through a dialectical interaction with reality. It consists, therefore, in an ethical, liberating and transformative education which relates with the different ways one see and experience the world, seeking to consciously transform it (11) .
We sought to mobilize popular education, participation and dialogue as essential elements to construct the podcast aiming at meaningful learning, drawing on the knowledge, experiences and community of the target public (11) .
Among Freire's propals, we adopted his itinerary of the culture circle to guide the construction of the podcast, encompassing the stages of thematic research, to unveil the teen's knowledge, worldview, previous experiences and vocabulary; coding and decoding, to investigate and debate the topics listed for later scripting; and critical unveiling, in which the proposed episode scripts are seen as products of a participative and dialectical process (12) .

Stage 2 -Identification of themes
To bring together the theoretical framework, the relevant teen-related health education themes and the use of podcasts as educational technology, we conducted an integrative literature review. This was based on six steps: definition of research question, search and selection of primary studies, data extraction, critical evaluation of primary studies, summary of results and presentation of review (13) .
The research question, "What themes and educational technologies have been used to promote adolescent health?", was formulated following the PICO strategy (Patient, Intervention, Comparison, Outcome) (5) . Online (SciELO) databases using advanced search (5) .
We used the following search strategies:
Data were extracted according to an instrument constructed by the authors focused on pinpointing the prevalent themes and the technologies used to promote teen health. Methodological quality was evaluated using the Critical Appraisal Skills Program (CASP). Results were summarized and presented as texts (5) .
To understand the sexual and reproductive health education needs, complement the bibliographic survey and ensure teen participation, we applied the Knowledge about Sexuality Questionnaire (QCS) (14) .

Stage 3 -Elaboration of educational technology
This stage focused on constructing the podcast and consisted of three phases: inviting adolescents to collaborate in the project, planning the recordings and producing the podcast. We adopted the radio play format, which involves theater, literature and music, to produce a dramatization outside the simple narration, creatively discussing everyday themes.
After listing the themes to be discussed, we planned the critical appropriation, wrote the scripts and recorded the episodes.
Based on Freire's culture circles and concepts of popular education, participation and dialogue, the construction emerged from the interaction between adolescents interested in participating in the process and nursing undergraduates, advised by the proposing researcher.

Stage 4 -Validation of the material
In this stage, the podcast was validated by experts, who were invited to suggest exclusions, additions or changes to parts or the whole technology. For validation, experts closely examine the technology construed based on established scores, quantifying their agreement with content validity.

Study setting
The study was conducted at a state vocational school, which offers vocational high school education to adolescents, providing technical training in Business Administration, Computing, and Nursing. The institution was chosen for convenience, considering the partnership to execute the activities of the extension project and develop a school radio, involving the students in the production, editing, and dissemination of audio content in the school environment, such as the podcast.

Period
The study was conducted between March 2020 and June 2021.

Population, selection criteria and sample
The study population consisted of 440 adolescents enrolled at the chosen school. Due to the sanitary and epidemiological conditions of the period, resulting from the COVID-19 pandemic, about 30% (n=132) of the students were regularly attending the school activities via remote classes and/or classroom activities. Sampling was performed using G*Power 3.1.9.7, setting a 0.05 sampling error, 0.95 confidence level and 0.50 estimated effect. We obtained a sample of 54 adolescents, and the final sample included 60 adolescents. A faculty member and ten nursing students also participated in conducting the study phases, as well as eleven experts. Validation was conducted by means of an instrument previously used to validate a podcast for health education on leprosy, consisting of items related to content (8 items), functionality (6 items), appearance (9 items) and sound environment (7 items) (16) . Experts

Study variables
The online questionnaire used for data collection, applied via Google Forms, included sociodemographic questions for the adolescents (gender, age in complete years, ethinicity/color, religion, and marital status) and for the experts (gender, age, degree, title and teaching field, research, care, and/or management). www.eerp.usp.br/rlae 5 Leite PL, Torres FAF, Pereira LM, Bezerra AM, Machado LDS, Silva MRF.

Instrument used for data collection
To i denti fy the adol escents' knowl edge needs, we applied the Knowledge about Sexuality Questionnaire (QCS). This instrument consists of 25 statements with dichotomous answers (true/false), divided into six dimensions: first sexual intercourse and sexual concerns, sexuality and sexual pleasure, contraception and safe sex practices, pregnancy prevention, Sexually Transmitted Infections (STI) and Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS), and sexual and reproductive health counseling and care (14) .
We also formulated additional questions about their knowledge and attitudes regarding sexual and reproductive health, such as: knowledge about STIs, how to protect oneself, use of condoms in sexual relations, situations in which they do not use condoms, known contraceptive methods, how to obtain condoms and the main source of information on sexual and reproductive health.

Data collection
To survey the teenagers' knowledge needs, data The third stage comprised the pre-production, production, and post-production of the podcast. In preproduction the adolescents defined the characters and their actors and wrote the technical scripts, which were then appreciated by the coordinator, forwarding suggestions for adjustments as needed.
In production, the radio play was recorded via Google Meet, respecting social distancing. Next, the audio from the video was extracted and sent to post-production, involving editing, inclusion of soundtrack and effects, mixing, and mastering in Cantasia Studio 9 software version 2020.012.
The educational technology was then made available to the experts for evaluation and validation, along with the evaluative instrument, invitation letter, and Informed Consent Form (ICF), assuring their desire to participate in the study. Three rounds of invitation/reminder for participation were sent at 15-day intervals.

Data processing and analysis
The collected data were entered in a Microsoft Office   (17) .
For data analysis, we calculated the Content Validity Index (CVI), which estimates inter-expert congruence on the evaluated aspects. The Item-level Content Validity Index (I-CVI) was calculated, corresponding to the number of experts who attributed 3 (relevant) or 4 (highly relevant) to a given item divided by the total number of experts, considering excellent the index greater than or equal to 0.78 (18) . Cronbach's alpha estimated the instrument's internal consistency, with a desired value greater than or equal to 0.700 (19) .

Ethical aspects
The project was submitted to and approved

Results
Our results constructed and validated a podcast with four episodes on sexual and reproductive health aimed at teens, named Teen Talk.
The use of Circle of Culture itineraries contributed to ensure the participation of teens during episode theorization, scripting, and recording. In investigating our vocabulary universe, we sought to approximate the terms teens use to describe the relevant aspects of their sexual and reproductive health, such as "aunt flow" and "catch a disease," referring to menstruation and sexually transmitted infections, respectively.
Then, from the themes and generating words we coded and decoded, we aimed to use situations, spaces, and preferences common to the realities of the participants in our episodes. Among these, we highlight meetings between teens in city squares, the predominance of educational activities and lectures in schools and basic health units, and teens' contact with health information via digital media, such as live broadcasts on social networks.
To problematize the themes which emerged at our first meeting, we proposed to dialogically explore each specific theme. This problematization was essential to strengthen participants' understanding of the singularities of the discussed theme and its representation in episode scripts. The scene unfolds during a class break, in which three friends talk about the onset of sexual activity, coitus interruputs, and pregnancy. From a characters' doubts, they agreed to consult a professional in a Basic Health Unit to solve them. A nurse welcomes the teens and advises them on pregnancy, menstrual cycle, withdrawal bleeding, and sexuality. Contraceptive methods (9 min) The scene initially takes place in a group of messages on a social network, in which five friends set up meeting in the city square.
From a rumor about a schoolmate, they discuss contraceptive methods. In this context, the colleague in question is pregnant because she uses coitus interruptus as a contraceptive method.
The characters talk about condom use, birth control pills, and emergency pills. Teens with greater knowledge advise her to seek health services to obtain adequate guidance.
[…] ANA: -Yes, maybe we never had any guidance on that. HIV/AIDS* (7 min) The scene deals with a round of conversations on HIV/AIDS* which two health professionals conducted at the school. The conversation establishes the differences between HIV* and AIDS*, transmission forms, prevention, signs, symptoms, diagnosis, and treatment. Dealing with other STIs † , such as herpes, syphilis, and HPV ‡ , the scene takes place in a Basic Health Unit and involves a health education activity with an active methodology of true or false assertive questions on the subject. In total, six statements were offered, followed by teens' knowledge of them and a brief explanation. (which is equivalent to the number of specialists who agree or fully agree with a given item), we observed that its value was greater than 0.78 in most evaluated items, except for 4,1, 4.3, and 4.5 (Table 1).
We considered the internal consistency of the evaluated items as satisfactory, with a 0.951 Cronbach's alpha for the used instrument.

Specialists suggestions Modifications made
Change in the title of the first episode -Changed the title from "Sex and sexuality" to "Sexual relation and sexuality." Insert introductory note in episodes -Included introductory notes to each episode, objectively contextualizing it.
Improve character intonation -Made the intonation and vibration of the speeches of characters representing health professionals more engaging and inviting. -Improved intonation of characters to show desirable feelings, such as excitement.
More representative sounds -Included usual sounds and noises common to each setting, such as the school and the square.

Main impressions
Main suggestions -Greater development of characters and ambiance.
-Improvements in sound setting. -Greater detailing of the covered topics.
Main positive points for specialists -Sensitivity to work the theme with a language close to the target audience's.
-Radio play. -Inclusion of teens in the construction process.
Main negative points for specialists -Mostly heterosexual and cisgender approach.
-Lack of accessibility for the hearing impaired.
-Approaches many aspects of the same topic in the same episode.

Discussion
The podcast has become a popular asynchronous educational technology due to its ease of use, practicality, convenience, and repeatability, when compared to traditional teaching methods, and can offer much information since listeners only need a device which plays audio (20) . In the United States, for example, in 2019, 51% of the population over 12 years of age listened to podcasts (21) .
In this perspective, we developed the Teen Talk  (20) . With the insertion of Digital Information and Communication Technologies in teens and young people's daily life, podcasts gain more and more space in learning environments, whether schools or health services.
Teens become the audience of health educational actions due to the vulnerabilities during this life phase, which favor a greater injury predisposition. We should stress that factors such as difficult family lives, contact with violence, religious and cultural conditions, low/lack of incentive to education, and curiosity toward risks, enable a greater possibility of acquiring STIs and/or unwanted pregnancies (22) .
A study conducted in public schools in Recife and Olinda (PE) indicates that health and education professionals use technological resources as differentials in educational actions on sexual and reproductive health since they bring educators closer to students, forming a tighter and more participatory support network on such a sensitive subject in this life phase. Innovating the approaches to sexual and reproductive health is relevant given teens' daily technology use (23) .
Recording and listening to oneself and colleagues in developing the podcast better consolidates knowledge than reading materials on the same topic. Constructing this technology demands a greater commitment and analysis of the presented theme from involved individuals (in this case, teens and nursing students), expanding their participation in the production of knowledge and developing a more meaningful and participative learning (24) .
Nowadays, podcasts gain prominence by sharing knowledge via various possibilities and by offering educators and health professionals a better development of their teaching-learning process in educational activities. This is due to its encouraging characteristics, when inserted in didactic activities, since, in addition to the opportunity of presenting a theme in a contextualized way, it motivates debates on disciplinary or interdisciplinary issues in its listeners (25) .
Thus, the possibility of approaching subjects about their sexual and reproductive health via a radio play is opportune since teens can imagine and experience the transmitted scenes, finding contextual recognition and anchoring themselves to give meaning to the learning process. The motivation to listen to podcasts relates to the convergent interaction of humor resources and the theoretical approach (26) .
Talking about sexual and reproductive health requires a facilitating posture and a clear approach to bring daily situations from its audience since the closer the theme is to reality, the easier their understanding and feeling of safety to manifest themselves. Thus, when suggesting the use of a tool as a component in teens' daily life, educators should be available to bond with this audience (27) .
A study using podcasts in medical education showed contributory concurrency: content producers used it to promulgate and disseminate knowledge, whereas listeners appropriated this content to empower themselves and better elaborate their doubts (26) , showing the contributing potential to both parties involved in the development and Sexual education, when developed before sexual debut, can contribute to raising awareness on safe sex.
Thus, it is essential to provide spaces for reflection on sexual behaviors to reduce injury exposure (27) .
During this study, the Brazilian population was oriented to maintain social distancing, changing their routines, forms of organization, and social action due to the COVID-19 epidemiological and sanitary situation.
These changes in ways of thinking and acting promoted adaptations in school and health educational actions. Thus, the need to enable digital learning tools, including health education, is urgently needed, and podcasts materialize themselves as a favorable tool for learning continuation since its language enables its audience to understand verbal and non-verbal interventions (20) .
The literature has shown that using this type of content in educational actions is an effective resource to build knowledge since they can be easily used on the go, integrated into personal space, time, and content (28) .
However, including students in its production is as important as delivering ready material as they acquire the role of protagonists in the process, exercising their empowerment and autonomy and strengthening their confidence for future activities (24) . www.eerp.usp.br/rlae 11 Leite PL, Torres FAF, Pereira LM, Bezerra AM, Machado LDS, Silva MRF.
This study found that the internal consistency of specialists' response ranged from 0.704 to 0.954, showing that the information contained in the educational material is coherent and valid for use by its target audience.
Validation studies, such as game studies on sexuality for teens, found similar values, whose Cronbach's alphas ranged from 0.79 (29) to 0.88 (30) .
Specialists' suggestions and criticisms enabled an external unbiased look at the developed process, redirecting the proposal to better fit its objective.
The limitations of this study include prioritizing themes according to previous surveys of teens' knowledge and the duration of the podcast episodes, which failed to thoroughly contemplate them. To do so, we would need to produce new episodes. We also highlight the restriction of access to content for people with hearing impairment, which we could solve by making our scripts available.
Finally, the absence of studies with similar purposes in the literature reduces its comparative potential with other realities. We found that assessing the usability of this tool is relevant for teens.
This study advances nursing and health promotion by proposing the innovative use of podcasts to approach topics related to teens' sexual and reproductive health, a tool built based on scientific literature and its target audience's knowledge needs, ensuring their participation in its development. Our results contribute to the health education process by using podcasts in health promotion spaces, such as schools and basic health units, as well as teens' self-instruction. Its innovative character is due to the scarce use of podcasts to educate in areas other than medicine and by the adequacy of its language to teens, expanding its usability and impact as an educational resource for learning.

Conclusion
This study built and validated the educational Teen Talk podcast as an educational tool to promote teens' sexual and reproductive health, developed in a participatory and shared way among all involved individuals. Its validation by a body of specialists reinforces its potential for thematically approaching teens' sexual and reproductive health either in health professionals' (such as nurses) spaces and actions or for teens' autonomy.
Using podcasts as an educational resource has some advantages: low cost, easy access by smartphone, availability at any time and place, unlimited possibility of repetitions, accessible language, and suitability to the reality of the public to whom it is intended.
The participatory use of audio in educational actions still preserves participants' image since many teens refuse to participate due to shyness. Thus, educators find, in educational podcasts, a dynamic tool which simplifies content and facilitates health education teaching-learning.