Revista Adolescência e Saúde

Revista Oficial do Núcleo de Estudos da Saúde do Adolescente / UERJ

NESA Publicação oficial
ISSN: 2177-5281 (Online)

Vol. 16 nº 1 - Jan/Mar - 2019

Original Article Imprimir 

Páginas 21 a 32

Knowledge about Zika virus and contraceptive methods: Randomized trial with adolescents in Northeast Brazil

Conocimiento sobre Zika virus y métodos contraceptivos: Ensayo randomizado con adolescentes en el Noreste brasileño

Conhecimento sobre Zika vírus e métodos contraceptivos: Ensaio randomizado com adolescentes no Nordeste brasileiro

Autores: Herifrania Tourinho Aragao1; Suelen Maiara dos Santos2; Alef Nascimento Menezes3; Anna Carolina Mota Lopes Fraga Lemos4; Geza Thais Rangel e Souza5; Cláudia Moura de Melo6

1. Doutor Student by the Postgraduate Program in Health and Environment at the Tiradentes University (UNIT). Master in Health and Environment by the UNIT. Aracaju, SE, Brazil
2. Graduation in Nursing by the Tiradentes University (UNIT). Scholar of Scientific Initiation of the Program for the Integration of Science, Technology and Innovation with Basic Education (Cores of CTI-EB) - CAPES/FAPITEC, Aracaju, SE, Brazil
3. Graduation in Biomedicine by the Tiradentes University (UNIT). Scholar of Scientific Initiation of the Program for the Integration of Science, Technology and Innovation with Basic Education (Cores of CTI-EB) - CAPES/FAPITEC, Aracaju, SE, Brazil
4. Master in Health and Environment by the Tiradentes University (UNIT). Teacher of Sciences in Basic Education at the State Education Network of Sergipe. Aracaju, SE, Brazil
5. Doctor in Ecology of Continental Aquatic Environments by the Estate University of Maringá (UEM). Postdoctoral by the Tiradentes University (UNIT). Teacher in the course of Biological Sciences at the Biological Sciences Department in the Federal Institute of São Paulo (IFSP). São Paulo, SP, Brazil
6. Doctor in Animal Biology by the Estate University of Campinas (UNICAMP). Postdoctoral by the University of Chile (UChile). Permanent Teacher of the Program of Postgraduate in Health and Environment of the Tiradentes University (UNIT). Researcher of the Technology and Research Institute (ITP), Aracaju, SE, Brazil

Herifrania Tourinho Aragao
Av. Murilo Dantas, n° 300, Farolândia
Aracaju, SE, Brasil. CEP: 49.032-490

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How to cite this article

Keywords: Contraception; Educational Technology; Adolescent; Arbovirus Infections; Zika Virus.
Palabra Clave: Anticoncepción; Tecnología Educacional; Adolescente; Infecciones por Arbovirus; Zika virus.
Descritores: Anticoncepção; Tecnologia Educacional; Adolescente; Infecções por Arbovirus; Zika vírus.

OBJECTIVE: Evaluate the effect of educational interventions on the knowledge of adolescents related to Zika virus and contraception.
METHODS: Participated 500 adolescents from public schools of Sergipe, allocated in random and egalitarian designation for the control (CG) and educational workshop (EWG) groups. In the educational interventions directed to the EWG were applied playful methodologies like illustration album, Memory Game of the contraceptive methods and Board "Aedes Play". It was also used a questionnaire to evaluate the difference of responses between groups, before and after the intervention. For the data analysis it was applied the Chi-square test, T test, Odds Ratio and ANOVA.
RESULTS: Both groups in the pre-intervention period had limited knowledge about the routes of transmission and prevention of Zika virus, and about 42% did not know the use of contraceptive methods. After the intervention, the EWG presented a greater knowledge in comparison to the CG (p<0.05).
CONCLUSION: It is possible to conclude that the playful-educational strategies are adequate for the broadening of knowledge related to the prevention of the transmission of STIs, since the group in which the educational workshops were applied presented a correct response pattern greater than the Control Group, who demonstrated a higher relative risk of contracting STIs.

OBJETIVO: Evaluar el efecto de intervenciones educativas en el conocimiento de los adolescentes relacionado al Zika virus y contracepción.
MÉTODOS: Participaron 500 adolescentes de escuelas públicas de Sergipe, distribuidos en designación aleatoria e igualitaria para los grupos control (GC) y taller educativo (GTE). En las intervenciones educativas dirigidas al GTE fueron aplicadas metodologías lúdicas como álbum ilustrativo, juego de memoria de los métodos contraceptivos y Tablero "Aedes Play". También fue utilizado un cuestionario para evaluar la diferencia en las respuestas de los adolescentes entre los grupos, antes y después de la intervención. Para análisis de los datos, se aplicó el test Chi-cuadrado, el teste T, la Razón de Posibilidades y ANOVA.
RESULTADOS: Ambos grupos en el periodo preintervención presentaron escaso conocimiento sobre las vías de transmisión y prevención del Zika virus y, aproximadamente 42% desconocía sobre el uso de los métodos contraceptivos. Luego de la intervención, el GTE presentó un mayor conocimiento en comparación al GC (p<0,05).
CONCLUSIÓN: Se puede concluir que las estrategias lúdico-educativas son adecuadas para la ampliación del conocimiento relacionado a la prevención de la transmisión de EST, visto que el grupo en que fueron aplicados los talleres educativos presentó un estándar de respuestas correctas mayor que el Grupo Control, que a su vez demostró un mayor riesgo relativo de contraer EST.

OBJETIVO: Avaliar o efeito de intervenções educativas no conhecimento dos adolescentes relacionado a Zika vírus e contracepção.
MÉTODOS: Participaram 500 adolescentes de escolas públicas de Sergipe, alocados em designação aleatória e igualitária para os grupos controle (GC) e oficina educativa (GOE). Nas intervenções educativas direcionadas ao GOE foram aplicados metodologias lúdicas como álbum ilustrativo, jogo da memória dos métodos contraceptivos e Tabuleiro "Aedes Play". Também foi utilizado um questionário para avaliar a diferença nas respostas dos adolescentes entre os grupos, antes e após a intervenção. Para análise dos dados, aplicou-se o teste Qui-quadrado, o teste T, a Razão de Chance e ANOVA.
RESULTADOS: Ambos os grupos no período pré-intervenção apresentaram escasso conhecimento sobre as vias de transmissão e prevenção do Zika vírus e, aproximadamente 42% desconhecia sobre o uso dos métodos contraceptivos. Após a intervenção, o GOE apresentou um maior conhecimento em comparação ao GC (p<0,05).
CONCLUSÃO: Pode-se concluir que as estratégias lúdico-educativas são adequadas para a ampliação do conhecimento relacionado à prevenção da transmissão de IST's, visto que o grupo em que foram aplicadas as oficinas educativas apresentou um padrão de respostas corretas maior que o Grupo Controle, que por sua vez demonstrou um maior risco relativo de contrair IST's.


Adolescence is understood as the stage of life between childhood and adulthood, permeated by complex process of biopsychosocial development and growth. According to the World Health Organization1, adolescence corresponds to the second decade of life, from ten to nineteen years.

The countries of the American continent have recently experienced the spread of Zika virus2. The Brazilian Epidemiological Bulletin No. 18/2016 released 91,387 cases of suspected Zika virus in the country, of which 31,616 were confirmed. In the Northeast, more specifically in Sergipe, 348 cases of the disease were registered, with an incidence rate of 15.5/100 thousand inhabitants3. Currently, there is a decline in the number of cases and associated congenital defects. However, this decrease does not rule out the need for efforts in viral control, since there are still crucial issues that remain unanswered, particularly related to the gestational safety of pregnant women and whether this reduction is related to the absence of transmission4.

In addition to the vector transmission of this arbovirose5, there are possibilities of sexual transmission6,7,8, which represents a real challenge for women of reproductive age, because of the risk of conceiving a baby with Congenital Syndrome of Zika (SCZ). Since most mothers of children affected by Zika are very young, 9 and not always Brazilian adolescents have access to information/services on reproductive health and prevention of unplanned pregnancies.

In order to avoid the dispersion of the Zika virus and its sequels one must invest in sex education9. Health Education Strategies have shown that playfulness and creativity provide a significant increase in adolescents' knowledge about STI/AIDS10 and arboviruses, specifically dengue11,12.

Based on the above, it is understood that play is an important and valuable resource in the teaching-learning process because it sharpens the curiosity, provides understanding of the knowledge and favors the learning fixation. Thus, the objective of this study was to verify the effect of playful educational interventions on knowledge about Zika virus and contraceptive methods, aimed at adolescents.


A randomized clinical trial was carried out in public schools in the urban area of the municipalities of Nossa Senhora do Socorro and Carmópolis, Sergipe. The selection of these spaces was established starting from: 1) The school's need to approach sexual education; 2) Information from the State Department of Health on newborns with microcephaly due to congenital infection, confirmed/suspected cases for the Zika virus and classification of medium risk for Aedes aegypti infestation12,13.

The research was approved by the Research Ethics Committee of Tiradentes University, opinion no. 1,858,861, and ethical and legal aspects are contemplated and protected, according to Resolution 466/2012. The eligibility criteria adopted were: adolescents who were regularly enrolled, between the 8th year of elementary school and the 3rd year of high school and in the age group established by the World Health Organization. Adolescents with some relevant cognitive deficiency were not included in the study by the teacher.

A ratio of 1: 1 was adopted between Educational Workshop Groups (GOE) and Control (CG). A small-to-medium effect size (W = 0.129) in a Chi-square test with 1 degree of freedom (two variables of two levels), significance level of 5% and power of 80%, a sample size of 466 adolescents (233 each group). Based on the eligibility criteria, the target population of the public school in Carmópolis consisted of 458 adolescents, while that of the Nossa Senhora do Socorro school consisted of 475. Of this population, 256 adolescents from the school in Carmópolis and 264 from the school in Nossa Senhora do Socorro attended the call at the scheduled time.

Due to the chance of post-randomization follow-up and exclusion losses, a randomization table was drawn up with the adolescents who attended the call. The distribution was performed using the R Core Team 2017 Software, in random designation without replacement, in two experimental groups (Educational Workshop Group and Control Group), in an equal proportion per series. After randomization, participants were not allowed to swap between groups. There were a few losses among student population groups after the first questionnaire was applied (pre-intervention), with 500 students equally distributed among the schools (Figure 1).

Figure 1. Methodological flowchart for sample selection in the present study.

The data were collected in the school space and the collection was constituted by three stages: a) application of a questionnaire (pre-intervention) to identify the adolescents and their knowledge; b) development of educational workshops (educational intervention); c) reapplication of the questionnaire (post-intervention).

Two semi-structured and pre-coded questionnaires were used, based on studies pertinent to the topic. The first questionnaire was composed of five questions related to sociodemographic aspects and sexual behavior, while the second one presented four questions related to Zika virus and methods of contraception. For the application of the questionnaires, content validation through expertise with six health and education professionals was previously performed.

Activities with Group of Educational Offices (GOE)

Three educational and thematic workshops were developed (one per day), using playful games made by the authors themselves (Figure 2). Each workshop was composed of groups of ten to twenty participants, with a minimum duration of 1 hour and 30 minutes and maximum of 3 hours, containing the following themes: "Risk in the development of sexuality - ISTs" (serial and illustrative album); "How should I use contraceptive methods?" (Memory game and experience of using the male/female condom); "Emergency of the Zika virus in sexual and reproductive health" (giant board - "Aedes Play").

Figure 2. Adolescents from public schools participating in the dynamics, Sergipe-Brazil.

At the beginning of the workshops motivation dynamics were employed for the presentation between facilitators and GOE members and the pacing of the process to ensure full participation (consent term) and to avoid any form of interaction/contamination of information with the other group, besides the "Experimental mortality" (situation in which participants stop participating during the process). The application of the questionnaire in the post-intervention stage occurred in a different spatial form for the respective groups, eight days after the beginning of the educational workshops.

Activities with the Control Group (CG)

In the session of the GC, environmental action was developed in a school space devoid of care to eliminate the possible foci of Aedes sp. through sustainable practice, using tires, plastic bottles and other disposable materials as environmentally friendly. The activity was developed on days other than the GOE and the participants of the CG were not advised on the relevance of the action for prevention. It should be emphasized that after the re-application of the questionnaire, the CG received detailed and dialogued information about sex education through the use of newspapers/pamphlets.

Data analysis

The results were analyzed using the Statistical Package for Social Sciences (SPSS), version 21.0. The associations between the variables were made through contingency tables (Pearson's Chi-square test), bivariate ANOVA and comparison between means (Student's t-test and simple variance analysis); in the association measure, the odds ratio (RC) was calculated with a 95% confidence interval, using a significance level of p <0.05. The tests were applied to evaluate the frequency of the data and to compare the responses between the two groups in the pre- and post-intervention period, in order to verify if there were differences of opinions between groups.

To assess whether there was improvement in reproductive and sexual knowledge, one was assigned weight to the number of correct answers (63 in total). The sum of the hits was then standardized to a scale of zero to one hundred using the equation:

At where

A is the number of correct answers, S is the standardized note.

In order to determine the effects of the independent variable (Intervention of Sexual and Reproductive Education) on the dependent variable (improvement in reproductive and sexual knowledge between groups), the covariance analysis (ANCOVA) was performed, respecting the design with repeated measures and multiple groups . As well, two-way bivariate ANOVA was applied to evaluate the existence of association between groups and first relation.


Sociodemographic profile and sexual behavior of adolescents

The adolescents presented a mean of 15.9 (± 1.6) years of age in both groups, most of them female (GOE 148, 59.2%, GC139, 55.6%), adherents of the Catholic religion (GOE 111, 44.4%, GC 99, 39.8%) and stated that menarche/semenarche had already occurred (GOE 225, 90.4%, GC223, 89.9%). With regard to schooling, the majority of adolescents had high school (GOE 152, 60.8%, GC 147, 58.8%) with access to sex education in school settings (GOE 187, 74.8%, GC183, 73.5%).

Regarding sexual behavior, although the majority in both groups affirmed that they did not have experience (GOE 160, 64.0%, GC135, 54.0%), this variable was statistically significant (p = 0.023). However, the mean age of adolescents at the time of first sexual intercourse did not differ between groups (GOE 15.0 ± 1.5 years, GC 14.7 ± 1.6 years, p = 0.125). The bivariate ANOVA was applied with two factors, that is, evaluating the total knowledge before and after intervention as a function of the variables "group" and "first sexual intercourse", with no significant results for the interaction (F = 0.084, p = 0.772). Among the groups of adolescents (control and educational workshop), no statistically significant difference was found regarding adolescents' knowledge about contraceptive methods and access to sex education in school settings.

Knowledge of adolescents about Zika virus and contraceptive methods

Adolescents were questioned about the transmission of the Zika virus to humans, with the mosquito, transplacental and blood routes being the most correctly identified in both groups, and finally the sexual pathways, accounting for 50.8% of in the GOE and 48.9% in the CG (Table 1). Among the incorrect alternatives, the most cited was breastfeeding. It is worth noting that some adolescents from both groups reported not knowing the forms of infection transmission (GOE 9.6%, GC 10.0%), or that all alternatives exposed would be incorrect (0.4% in both groups). The values obtained during the pre-intervention period showed no differences between the groups (p <0.05).

After the application of the "Aedes Play" game, a trend of change in the GOE adolescents' responses was observed (Table 2), which expressed almost twice as many correct answers (88.7%) compared to CG (47.3 (vaginal, anal and oral) and the blood, transplacental and vector pathways (p <0.001). Among the incorrect alternatives, urine was the only variable that did not present a significant difference. It is worth noting that only 17.6% of the adolescents in the CG continued to report that they did not know any form of transmission (p <0.001).

Adolescents were also questioned about the ways of prevention/control of the Zika virus in the pre-intervention stage (Table 1). The best known among adolescents were avoiding the accumulation of standing water, the use of repellent and condoms. In addition, about 30% of the adolescents in both groups did not know at least one form of control/prevention of the Zika virus (GOE 32.4%, GC 34.0%, p = 0.704), or expressed incorrect prevention (GOE 13.2%, GC 7.6%), such as specialist consultation, avoiding open wounds, vaccinations, sunscreen, taking home medications and others. The values obtained in this step showed that there are no significant differences between the knowledge of the groups of adolescents, except in relation to the protection screens.

After the intervention with the tray, there was a significant change in knowledge on the part of the GOE, highlighting the condom, protective screen, mosquito net, long clothing, repellent, avoiding accumulation of standing water and insecticide (Table 2). Some adolescents from the GOE cited other solutions for Zika virus prevention, such as using air conditioning (11.6%) and avoiding infected blood (2.8%). In addition, all GOE adolescents (100%) cited at least one form of control/prevention, while 34.8% of the adolescents did not know any (p <0.001). It is worth noting that both groups expressed incorrect prophylactic measures, in a differentiated and significant proportion (GOE 1.2%, GC 14.4%, p <0.001), such as drinking filtered water, changing neighborhoods, taking antibiotics, put, sunscreen and others.

In the context of the intervention regarding the sexual transmission of the Zika virus in this study, other STIs were addressed. In the post-intervention period (Table 2), it was observed that GOE adolescents were able to cite more types of STIs (from 3-5 citations versus 1-2 from CG), with a significant emphasis on the categories "Other STIs" and "Zika virus" (p <0.05). In addition, GOE presented a greater possibility of citing the Zika virus when compared to CG, which may be justified by participation in play educational workshops, curiosity about the new infection and surprise with the possibility of sexual transmission. Regarding HIV/AIDS, knowledge by both groups remained similar (p <0.05) corresponding in 90.4% and in 90% of GOE and CG, respectively (Table 2). It isn´teworthy that the minority of the CG still showed a lack of knowledge about the types of STIs in a significant way.

There is a heterogeneity in the transmission routes of the Zika virus, which can be transmitted by the Aedes aegypti mosquito during blood repatriation, by the unprotected sexual act, by transplacental and perinatal routes, by transfusion of infected blood and accidentally in a laboratory environment5,6,7,8. Among the forms of human sexual transmission, the vaginal, oral, and anal pathways15 stand out. Other body fluids, such as urine and saliva, have become the target of studies as forms of human contamination; however, there isn´t enough evidence to prove the transmission by these pathways2.

Although the Aedes aegypti mosquito is the main vector of the Zika virus in the Americas, there is evidence that other mosquitoes act with possible transmitting vectors: Aedes albopictus16 and Culex quinquefasciatus17.

In the teaching-learning of arboviruses for the school public, the board game has been widely used. Experimental studies with children and adolescents have shown that the participants in this game/discussion presented a significant increase in knowledge, a greater coping ability and a change of attitude in self-care11,12. While adolescents previously referred to parents as responsible for ensuring non-proliferation of vector mosquito breeding grounds, at the time of the experiment, these adolescents took an active role in control actions11. There is still no specific treatment or vaccine available for Zika virus infection. However, general measures focus on avoiding vector bites and include both individual and community-based measures of protection with different mechanisms of action. Given the potential of sexual transmission, condom use and other recommendations related to sexual behavior have been intensified, especially among adolescents and women of reproductive age, due to the risk of birth of newborn with microcephaly or Congenital Syndrome of Zika18. on contraceptive methods, the predominant expression was "Unknown" (GOE 46.9%, GC 47.1%), especially in relation to subcutaneous implantation, patch, diaphragm and IUD (p < 0.05) (Table 3). The term "I know and I know" (GOE 29.3%, GC 30.2%) was the second most used, with emphasis on male and female condoms, followed by the emergency contraceptive pill and oral pill. The responses between groups did not present a significant difference (p <0.05).

After the intervention with memory game of contraceptive methods, it was observed that the GOE had a significant increase in knowledge, whose expression "I know and I know" was approximately four times more mentioned when comparing with the control group (GOE 85.6%; (28.4%), with an increase of 80.4%, diaphragm (72.0%), table line (70.4%), subcutaneous (68.0%) and IUD %). Regarding the responses chosen by the CG adolescents, the "Unknown" (42.8%) prevalence of contraceptive methods in the pre-intervention period prevailed.

A study carried out in São Paulo confirms the results of this research, evidencing that adolescents have a greater knowledge about the male condom, female condom, and pills (conventional and the following day), stating the lack of knowledge and handling of the other methods19. Although GOE adolescents came into contact with a variety of methods and demonstrated a correct application in the knowledge about their use and importance, this does not directly translate into safe sexual practices. The adolescents' lack of knowledge about the correct use of contraceptive methods - postponement strategy of maternity/paternity - should be a focus of work in the promotion of safe sexuality to face the health problems, the reduction of morbimortality due to early pregnancies associated with the risk of infection by Zika virus and microcephaly20. However, it is important to understand the importance of intrinsic factors, such as perceptions, values, beliefs and feelings that can influence sexual behavior and behavior and the correct and constant use of contraceptives21.

After the interventions, GOE adolescents were asked about their satisfaction with the educational workshops, and were "very satisfied" (86.4%) and "satisfied" (13.6%), with no satisfied "or" dissatisfied ". These data corroborate with other interventionist studies using educational technologies10,11 by demonstrating the satisfaction of the participants in the teaching-learning process and demonstrating that the play can overcome the traditional model of teaching, since it allows the student participation in an interactive, fun and conscientious way.

Regarding the final score of the questionnaire, differences between the two moments were obtained for the two groups, with a mean increase of 40 points in the GOE (pre-intervention: 34.2 ± 9.8; post-intervention: 74.6 ± 9.9; p <0.001) and a 7-point decrease in CG (pre-intervention: 34.1 ± 10.7; post-intervention: 27.3 ± 11.5; p <0.001). There were no differences between the groups in the pre-intervention (p = 0.098), however, there were differences in the post-intervention (p <0.001). The decrease in the GC score in the post-intervention period may be justified by the students participating in other curricular activities at the school, other than those related to the study.


It was verified that the strategies of health education (games and discussion) contributed significantly to increase knowledge about the Zika virus and contraception. The applied methodology does not assure that there will be changes in risk behaviors and their effect on long-term knowledge. However, the study raises the importance of daring and creating in the school environment, based on the assumption that the playful intervention of the research favored the educational approach and uses a simple technology, cheap, handmade and cheap manufacturing.

The "do not know" or incorrect answers verified in the study point out the need for intensification in the health orientations and reassessment of the educational actions implemented with the school and community, since knowledge is an essential element, necessary to control arbovirus and mitigate its consequences.

It is necessary to continue the preventive actions developed in the study in other spaces, such as health institutions and environments frequented by adolescents, to transform them into knowledge multipliers in the control of the Zika virus and its sexual/reproductive health rights.


To the Coordination of Improvement of Higher Education Personnel (CAPES) and to the Foundation for Support to Research and Technological Innovation of the State of Sergipe (Fapitec) for the financial support (CAPES/FAPITEC Call No. 05/2014 CTI Core Elementary Education).


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