INTRODUCTION

Adolescence is understood as the stage of life between childhood and adulthood, permeated by a complex process of biopsychosocial development and growth. According to the World Health Organization ¹ , adolescence corresponds to the second decade of life, from ten to nineteen years of age.

Countries in the American continent have recently experienced the spread of the Zika virus ² . The Brazilian Epidemiological Bulletin No. 18/2016 reported 91,387 suspected cases of Zika virus fever in the country, of which 31,616 were confirmed. In the Northeast, more specifically in Sergipe, 348 cases of the disease were recorded, with an incidence rate of 15.5/100,000 inhabitants ³ . Currently, there is a decline in the number of cases and associated birth defects. However, this reduction does not rule out the need for efforts to control the virus, since there are still crucial questions that remain unanswered, particularly those related to the gestational safety of pregnant women and whether this reduction is related to the absence of transmission ⁴ .

In addition to vectorial transmission of this arbovirus ⁵ , there are possibilities of sexual transmission ^6,7,8 , which represents a real challenge for women of reproductive age, due to the risk of conceiving a baby with Congenital Zika Syndrome (CZS). Since most mothers of children affected by Zika are very young ⁹ , Brazilian adolescents do not always have access to information/services on reproductive health and prevention of unplanned pregnancies. To prevent the spread of the Zika virus and its consequences, investment in sexual education ⁹

should be made . Health Education Strategies have shown that play and creativity provide a significant increase in adolescents’ knowledge about STIs/AIDS ¹⁰ and arboviruses, specifically dengue ^11,12 . Based on the above, it is understood that play is an important and valuable resource in the teaching-learning process because it arouses curiosity, facilitates the understanding of knowledge and favors the retention of learning. Thus, the objective of this study was to verify the effect of playful educational interventions on knowledge about the Zika virus and contraceptive methods, aimed at adolescents. METHODS

A randomized clinical trial was conducted 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 based on: 1) The school’s need to address sexual education; 2) Information from the State Health Department on newborns with microcephaly due to congenital infection, confirmed/suspected cases of Zika virus and medium risk classification for Aedes aegypti infestation ^12,13 .

The research was approved by the Research Ethics Committee of Tiradentes University, opinion No. 1,858,861, and the ethical and legal aspects were considered and protected, in accordance with Resolution No. 466/2012. The eligibility criteria adopted were: adolescents regularly enrolled, studying between the 8th grade of elementary school and the 3rd year of high school and within the age range established by the World Health Organization. Adolescents with any relevant cognitive impairment reported by the teacher were not included in the study.

A 1:1 ratio between Educational Workshop Groups (GOE) and Control Groups (CG) was adopted. Aiming for a small to medium effect size (W=0.129) in a Chi-Square test with 1 degree of freedom (two variables of two levels), a significance level of 5% and a power of 80%, a sample size of 466 adolescents was estimated (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 school in Nossa Senhora do Socorro consisted of 475. Of this population, 256 adolescents from the school in Carmópolis and 264 from the school in Nossa Senhora do Socorro responded to the call at the scheduled time.

Due to the possibility of follow-up losses and exclusion after randomization, a randomization table was prepared with the adolescents who responded to the call. Distribution was performed using the R Core Team 2017 Software, in random assignment without replacement, into two experimental groups (Educational Workshop Group and Control Group), in equal proportion by grade. After randomization, no exchange of participants between groups was allowed. There were a few losses among the population groups of students, after application of the first questionnaire (pre-intervention), ending the trial with 500 students equally distributed between the schools (Figure 1).

Data were collected at the school and consisted of three stages: a) application of a questionnaire (pre-intervention) to identify 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, prepared from studies relevant to the topic. The first questionnaire consisted of five questions related to sociodemographic aspects and sexual behavior, while the second had four questions related to the Zika virus and contraceptive methods. To apply the questionnaires, content analysis validation was previously performed by experts with six professionals from the areas of health and education.

Activities with Educational Workshop Group (GOE)

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

At the beginning of the workshops, motivational dynamics were used to introduce facilitators and members of the GOE and to agree on the process to ensure full participation (consent form) and avoid any form of interaction/contamination of information with the other group, in addition to “experimental mortality” (situation in which participants stop participating during the process). The questionnaire was applied in the post-intervention stage in a different spatial manner for the respective groups, eight days after the beginning of the educational workshops.

Activities with the Control Group (CG)

In the CG session, an environmental action was developed in a school space without care to eliminate possible Aedes sp. foci through sustainable practice, using tires, plastic bottles and other disposable materials as decoration for the environment. The activity was developed on different days to the GOE and the CG participants were not guided on the relevance of the action for prevention. It is important to note that after the questionnaire was reapplied, the CG received detailed, open-ended information about sexual education through 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 using contingency tables (Pearson’s chi-square test), bivariate ANOVA, and comparison of means (Student’s t-test and simple analysis of variance); the odds ratio (OR) was calculated for the association measurement with a 95% confidence interval, using a significance value of p<0.05. The tests were applied to assess the frequency of the data and to compare the responses between the two groups in the pre- and post-intervention period, with the aim of verifying whether there were differences in opinions between the groups.

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

Where

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

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

RESULTS AND DISCUSSION

Sociodemographic profile and sexual behavior of adolescents

The adolescents were on average 15.9 (±1.6) years old in both groups, the majority were female (GOE 148; 59.2%; GC139; 55.6%), Catholic (GOE 111; 44.4%; GC 99; 39.8%) and stated that they had already gone through menarche/semenarche (GOE 225; 90.4%; GC223; 89.9%). Regarding education, the majority of adolescents were in high school (GOE 152; 60.8%; GC 147; 58.8%) with access to sex education in the school environment (GOE 187; 74.8%; GC183; 73.5%). Regarding sexual behavior, although the majority in both groups stated that they had no experience (GOE 160; 64.0%; GC 135; 54.0%), this variable was statistically significant (p=0.023). However, the mean age of adolescents at the time of their first sexual intercourse did not differ between the groups (GOE 15.0±1.5 years; GC 14.7±1.6 years; p=0.125). A two-way bivariate ANOVA was applied, that is, evaluating total knowledge pre- and post-intervention according to the variables “group” and “first sexual intercourse”, and did not show significant results for the interaction (F=0.084; p=0.772). Between the groups of adolescents (control and educational workshop), no statistically significant difference was found in relation to the adolescents’ knowledge about contraceptive methods and access to sexual education in the school environment.

Adolescents’ knowledge about Zika virus and contraceptive methods

Adolescents were asked about the ways in which Zika virus is transmitted to humans. The most correctly indicated methods in both groups were mosquitoes, transplacental transmission, and blood-borne transmission, and finally, sexual transmission, totaling 50.8% of correct answers in the GOE and 48.9% in the CG (Table 1). Among the incorrect alternatives, the most cited was breastfeeding. It is worth mentioning that some adolescents in both groups reported not knowing how the infection is transmitted (GOE 9.6%; CG 10.0%), or that all the alternatives presented were incorrect (0.4% in both groups). The values ​​obtained during the pre-intervention period did not show differences between the groups (p<0.05). After the application of the game “Aedes Play”, a tendency for change was observed in the responses of the adolescents in the GOE (Table 2), who expressed almost twice as many correct answers (88.7%) in relation to the CG (47.3%), highlighting the sexual routes (vaginal, anal and oral) and the blood, transplacental and vectorial routes (p<0.001). Among the incorrect alternatives, urine was the only variable that did not present a significant difference. It is worth mentioning that only 17.6% of the adolescents in the CG continued to state that they were unaware of any form of transmission (p<0.001).

The adolescents were also asked about the ways to prevent/control the Zika virus in the pre-intervention stage (Table 1). The most well-known among the adolescents were avoiding the accumulation of stagnant water, using insect repellent and condoms. Furthermore, approximately 30% of the adolescents in both groups did not know at least one way to control/prevent the Zika virus (GOE 32.4%; GC 34.0%; p=0.704), or expressed incorrect prevention methods (GOE 13.2%; GC 7.6%), such as consulting a specialist, avoiding open wounds, getting vaccinated at the health center, sunscreen, taking home remedies and others. The values ​​obtained in this stage showed that there were no significant differences between the knowledge of the groups of adolescents, except in relation to protective screens. After the intervention with the board, there was a significant change in knowledge on the part of the GOE, highlighting condoms, protective screens, mosquito nets, long clothing, insect repellent, avoiding the accumulation of stagnant water and insecticide (Table 2). Some adolescents from the GOE mentioned other solutions for preventing the Zika virus, such as using air conditioning (11.6%) and avoiding infected blood (2.8%). Furthermore, all adolescents from the GOE (100%) mentioned at least one form of control/prevention, while 34.8% of the control adolescents did not know how to mention any (p<0.001). It is worth mentioning that both groups expressed incorrect prophylactic measures, in different and significant proportions (GOE 1.2%; GC 14.4%; p<0.001), such as drinking filtered water, moving to a new neighborhood, taking antibiotics, getting vaccinated at the health center, 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 adolescents in the GOE were able to mention more types of STIs (3-5 mentions versus 1-2 in the CG), with the categories “Other STIs” and “Zika virus” standing out significantly (p<0.05). In addition, the GOE was more likely to mention the Zika virus when compared to the CG, which can be justified by participation in playful educational workshops, curiosity about the new infection and surprise at the possibility of sexual transmission. Regarding AIDS/HIV, knowledge by both groups remained similar (p<0.05), corresponding to 90.4% and 90% of the GOE and CG, respectively (Table 2). It is worth noting that the minority of the CG still showed significant lack of knowledge about the types of STIs.

There is heterogeneity in the transmission routes of the Zika virus, which can be transmitted by the Aedes aegypti mosquito during blood feeding, through unprotected sexual intercourse, through the placental and perinatal routes, through transfusion of infected blood and accidentally in a laboratory environment ^5,6,7,8 . Among the forms of human sexual transmission, the vaginal routes stand out6,oral¹⁴ and anal ¹⁵ . Other body fluids, such as urine and saliva, have become the target of studies as forms of contamination to humans, however, there is insufficient evidence to prove transmission by these routes ^{2 . Although the} Aedes aegypti mosquito is indicated as the main vector of the Zika virus in the Americas, there is evidence that other mosquitoes act as possible vectors of transmission: Aedes albopictus ¹⁶ and Culex quinquefasciatus ¹⁷ . Board games have been widely used in teaching and learning about arboviruses for schoolchildren. Experimental studies with children and young people have shown that participants in this game/discussion showed a significant increase in knowledge, greater coping skills and a change in attitude towards self-care ^11,12 . While previously adolescents referred to their parents as those responsible for ensuring that mosquito breeding sites for the vector mosquito did not spread, in the post-experiment period these adolescents took an active role in control actions ¹¹ . 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-level protective measures, with different mechanisms of action. Given the potential for sexual transmission, condom use and other recommendations related to sexual conduct have been intensified, especially among adolescents and women of reproductive age, due to the risk of newborns with microcephaly or Congenital Zika Syndrome ¹⁸ . Regarding contraceptive methods, it was observed in the pre-intervention stage that the most prominent expression was “I do not know” (GOE 46.9%; GC 47.1%), especially in relation to subcutaneous implants, patches, diaphragms and IUDs (p<0.05) (Table 3). The expression “I know and know how to use” (GOE 29.3%; GC 30.2%) was the second most used, with male and female condoms standing out, followed by the emergency contraceptive pill and oral pill. The responses between groups showed no significant difference (p<0.05).

After the intervention with the contraceptive methods memory game, it was noted that the GOE had a significant increase in knowledge, with the expression “I know and know how to use” being mentioned approximately four times more when compared to the control group (GOE 85.6%; CG 28.9%), with the patch standing out with an increase to 80.4%, diaphragm (72.0%), calendar method (70.4%), subcutaneous implant (68.0%) and IUD (67.6%). Regarding the answers chosen by the adolescents in the CG, “I don’t know” prevailed (42.8%) regarding the contraceptive methods of the pre-intervention period.

A study carried out in São Paulo corroborates the results of this research, by showing that adolescents have greater knowledge about the male condom, female condom, pills (conventional and morning-after), affirming the scarce knowledge and handling of the other methods ¹⁹ . Although the GOE adolescents came into contact with various methods and demonstrated correct application of 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 – a strategy for postponing motherhood/fatherhood – should be the focus of work to promote safe sexuality to address health problems, reduce morbidity and mortality resulting from early pregnancies associated with the risk of Zika virus infection and microcephaly ²⁰ . However, when carrying out educational actions to promote health, it is necessary to understand the importance of intrinsic factors, such as perceptions, values, beliefs and feelings, which can influence sexual conduct/behavior and the correct and consistent use of contraceptives ²¹ .

After the interventions, the GOE adolescents were asked about their satisfaction with the educational workshops, and they said they were “very satisfied” (86.4%) and “satisfied” (13.6%), with no responses such as “somewhat satisfied” or “dissatisfied”. These data corroborate other interventionist studies using educational technologies ^10,11 by highlighting the satisfaction of the participants in the teaching-learning process and demonstrating that play can overcome the traditional teaching model, since it provides opportunities for student participation in an interactive, fun and awareness-raising way.

Regarding the final score of the questionnaire, differences were obtained between the two moments for the two groups, with an average increase of 40 points in the GOE (pre-intervention: 34.2 ± 9.8; post-intervention: 74.6 ± 9.9; p<0.001) and a decrease of 7 points in the GC (pre-intervention: 34.1 ± 10.7; post-intervention: 27.3 ± 11.5; p<0.001). No differences were observed 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 can be justified by the students having participated in other curricular activities at school, other than those related to the study.

CONCLUSION

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

The “I don’t know” or incorrect answers found in the study indicate the need to intensify health guidance and reevaluate the educational actions implemented in schools and communities, since knowledge is an essential element, necessary to control the arbovirus and mitigate its consequences.

It is emphasized the need 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 agents for multiplying knowledge in controlling the Zika virus and their sexual/reproductive health rights.

ACKNOWLEDGEMENTS

To the Coordination for the Improvement of Higher Education Personnel (CAPES) and the Foundation for Research and Technological Innovation Support of the State of Sergipe (Fapitec) for their financial support (CAPES/FAPITEC Notice No. 05/2014, CTI Center in Basic Education).