Construction of a video about condom use for deaf and hearing people

Objective: to build assistive technology, in video format, for deaf and hearing people about sexual health and condom use. Methods: methodological study consisting of the stages of pre-production, production and post-production. In pre-production we built the script, storyboard and scenes, following the principles of Lev Semenovich Vygotsky’s Theory of Learning. In production there was the development of the animation and recording of the scenes by the Libras interpreter. In post-production the final editing of the video took place. Results: the video “Condom: learn to use correctly”, lasting nine minutes and 25 seconds discusses the sexual and reproductive system of man and woman; mode of action, benefits and care with the use of condoms. Given the scarcity of educational materials on the subject, accessibility resources were used to build a video for deaf and hearing people. Conclusion: the construction of the video as an assistive technology directed to the deaf was successfully accomplished. Descriptors: Educational Technology; Condoms; Persons with Hearing Impairments; Nursing. *Extraído da Tese “Tecnologia assistiva para educação de surdos sobre saúde sexual e uso do preservativo”, Universidade Federal do Ceará, 2019. 1Universidade Federal do Ceará. Fortaleza, CE, Brasil. 2Escola Superior de Enfermagem do Porto. Porto, Portugal. 3Universidade Estadual do Ceará. Fortaleza, CE, Brasil. Autor correspondente: Sarah de Sá Leite Rua Alexandre Baraúna, 1115, Rodolfo Teófilo. CEP: 60430-160. Fortaleza, CE, Brasil. E-mail: sarahsaleite@hotmail.com EDITOR CHEFE: Ana Fatima Carvalho Fernandes EDITOR ASSOCIADO: Renan Alves Silva Aline Cruz Esmeraldo Áfio1 Sarah de Sá Leite1 António Luís Rodrigues Faria de Carvalho2 Paulo César de Almeida3 Cristiana Brasil de Almeida Rebouças1 Lorita Marlena Freitag Pagliuca1 Como citar este artigo: Áfio ACE, Leite SS, Carvalho ALRF, Almeida PC, Rebouças CBA, Pagliuca LMF . Construction of a video about condom use for deaf and hearing people. Rev Rene. 2021;22:e62438. DOI: https://doi.org/10.15253/2175-6783.20212262438 Áfio ACE, Leite SS, Carvalho ALRF, Almeida PC, Rebouças CBA, Pagliuca LMF Rev Rene. 2021;22:e62438. 2 Introdução Preservativo é um método contraceptivo barato, viável e prático, utilizado mundialmente na vida sexual de homens e mulheres, atendendo à dupla função de prevenção de transmissão de infecções sexualmente transmissíveis/vírus da imunodeficiência humana (IST/HIV) e gravidez não planejada(1). É dever do Estado prover informações acessíveis a todos sobre os métodos contraceptivos para promover o exercício responsável e igualitário de seus direitos, no entanto pessoas surdas apresentam dificuldades na aceitação e uso correto destes dispositivos, devido à inibição causada pelas barreiras comunicacionais na sua inserção em programas de promoção da saúde(2). Há consenso na literatura acerca da relevância de disseminar a temática da sexualidade em todas as culturas e níveis sociais, sendo destacada a necessidade da participação da escola e familiares na educação sexual dos surdos(3). Preconceitos existentes na sociedade se refletem na assistência à saúde desse público, sendo descritos como inseguros, reservados, imprudentes, impulsivos e nervosos, estigmatizando e negligenciando a sexualidade das pessoas surdas. Frequentemente, famílias não entendem aspectos relacionados com a saúde sexual e reprodutiva dos surdos, sendo a midia social e amigos as principais fontes de informação acerca deste tema(4). Em pesquisa realizada em Gana, dois terços dos participantes surdos desconhecem amplamente as consequências do sexo desprotegido(5). Estudo transversal nas Filipinas mostrou que alunos surdos, casualmente, conversam sobre experiências sexuais com seus colegas, não usam preservativos e possuem conhecimento inadequado acerca da natureza e transmissão de infecções sexualmente transmissíveis(6). Ademais, a busca por serviços de saúde raramente é feita por surdos para prevenção e promoção da saúde, sendo observada a prevalência do cuidado no âmbito curativo, devido às barreiras de comunicação entre surdos e profissionais de Saúde(7). Diante da especificidade da cultura surda, relacionada primariamente com a comunicação, aliada aos mitos e tabus envolvidos na temática de sexualidade, é preciso ampliar o olhar para integrar práticas educativas inclusivas, tendo em vista ser improvável que suas necessidades sejam alcançadas por programas para a população, em geral. Assim, faz-se necessária a utilização de comunicação inclusiva por meio de uma linguagem visuoespacial, sendo característica do uso da Língua Brasileira de Sinais (Libras)(8). É notável a dificuldade de adaptar materiais educativos para surdos direcionados para o uso do preservativo, principalmente àqueles sem educação formal, representando problema para a assistência em saúde desta população. Desse modo, o enfermeiro, ao elaborar materiais educativos acessíveis apoiados em ferramenta tecnológica adequada, poderá promover orientações eficazes, esclarecendo dúvidas ou medos, minimizando tabus sociais, além de promover autonomia e atitudes favoráveis. Dentre as tecnologias educativas descritas na literatura, com a finalidade de ofertar cuidados baseado em resultados eficazes, destaca-se o vídeo educativo, como uma ferramenta mais utilizada por esta população, devido à sua dinamicidade, apresentando benefícios no processo de ensino-aprendizagem(9). Assim, com o intuito de enfocar as relações inter e intrapessoais numa perspectiva positiva da deficiência, a fim de transmitir conteúdo com equidade de informação, esse estudo fundamentou-se na Teoria da Aprendizagem proposta por Vigotski. Essa teoria, além de favorecer novos posicionamentos a respeito de pessoas surdas, como sujeitos corresponsáveis pelo seu processo de aprendizagem; potencializa aspectos não deficientes, sendo a surdez compensada pela interação com instrumentos diversos, tendo a língua de sinais um papel preponderante neste processo, sendo, portanto, influenciada por aspectos socioculturais(10). Logo, a tecnologia educativa construída pode-


Introduction
Condoms are an inexpensive, feasible, and practical contraceptive method that is used worldwide in the sexual lives of men and women, serving the dual function of preventing the transmission of sexually transmitted infections/human immunodeficiency virus (STI/HIV) and unplanned pregnancy (1) .
It is the duty of the state to provide accessible information to all about contraceptive methods to promote the responsible and equal exercise of their rights, however, deaf people present difficulties in the acceptance and correct use of these devices, due to the inhibition caused by communication barriers in their insertion in health promotion programs (2) .
There is a consensus in the literature about the relevance of disseminating the theme of sexuality in all cultures and social levels, highlighting the need for school and family participation in the sexual education of the deaf (3) .
Prejudices existing in society are reflected in the health care of this public, being described as insecure, reserved, reckless, impulsive and nervous, stigmatizing and neglecting the sexuality of deaf people. Often, families do not understand aspects related to sexual and reproductive health of the deaf, being the social media and friends the main sources of information about this issue (4) .
In a research carried out in Ghana, two-thirds of deaf participants were largely unaware of the consequences of unprotected sex (5) . A cross-sectional study in the Philippines showed that deaf students casually talk about sexual experiences with their peers, do not use condoms, and have inadequate knowledge about the nature and transmission of sexually transmitted infections (6) .
Moreover, the deaf rarely seek health services for prevention and health promotion, being observed the prevalence of care in the curative scope, due to communication barriers between deaf and health professionals (7) .
Given the specificity of the deaf culture, primarily related to communication, coupled with the myths and taboos involved in the issue of sexuality, it is necessary to broaden the view to integrate inclusive educational practices, considering it is unlikely that their needs are met by programs for the population in general. Thus, it is necessary to use inclusive communication through a visuospatial language, being characteristic of the use of the Brazilian Sign Language (Libras) (8) .
It is notable the difficulty of adapting educational materials for deaf people directed to the use of condoms, especially those without formal education, representing a problem for health care for this population. Thus, the nurse, by developing accessible educational materials supported by appropriate technological tools, can promote effective guidance, clarifying doubts or fears, minimizing social taboos, and promoting autonomy and favorable attitudes.
Among the educational technologies described in the literature, with the purpose of offering care based on effective results, the educational video stands out as a tool most used by this population, due to its dynamics, presenting benefits in the teaching-learning process (9) .
Thus, in order to focus on inter and intrapersonal relationships in a positive perspective of disability, in order to transmit content with equity of information, this study was based on the Learning Theory proposed by Vygotsky. This theory, besides favoring new positions in respect to deaf people, as subjects co-responsible for their learning process; enhances aspects not deficient, being the deafness compensated by the interaction with various instruments, having the sign language a preponderant role in this process, being, therefore, influenced by sociocultural aspects (10) . Therefore, the educational technology built can be used in teaching and extension in the training and qualification of human resources for Health, in schools, during health care, websites focused on education or social networks. In this sense, it is expected that the dissemination of the technology built will strengthen the sexual and reproductive rights of deaf and hearing people. In this sense, the objective of the study was to build assistive technology, in video format, for deaf and hearing people about sexual health and condom use.

Methods
This is a methodological study with the purpose of developing, evaluating, and improving educational strategies (11) , consisting of three stages for video applications, namely: pre-production (Planning), production (Filming), and post-production (Editing) (12) .
In pre-production, the script was built, an instrument composed of writing the synopsis or general summary of what will be presented in the video; a script with a succinct, understandable description of how the actions evidenced in the video scenes will be developed, and; the Storyboard, sequential drawings of the scenes to be elaborated.
The script composition was based on Vygotsky's Theory of Learning, which considers learning as a social-historical process. Five main axes of this theory were advocated for the development of the script's story: Zone of Proximal Development (ZDP) in a perspective in which the learner (deaf) has previous experience and the teacher is the facilitator; Mediation, illustrating the relationship of the learner with the world either by signs (cultural experience) or by instruments (communication through libras); Completeness, seen holistically, treating the social, cultural individuals and not only focusing on disability; Compensation, brought in a social way, with the overcoming of disability through inclusive education and; Plasticity, which involved the adaptive process of the subject in society for the development of intelligence, facilitating the teaching-learning process (10) .
It is noteworthy that the content present in the script was built based on official reference documents established by the Ministry of Health, World Health Organization and Brazilian Federation of Gynecology and Obstetrics Associations. It presented 21 scenes, divided into seven parts according to the exposed content: Introduction; Sexually Transmitted Infections; Male and Female Anatomy and Physiology; Benefits of Condoms and Male and Female Condoms.
In the second stage, characterized as production, the script was recorded in Brazilian Sign Language (Libras) by an interpreter born in Fortaleza, Ceará, Brazil, with experience in the area, because she works in a public university of the state of Ceará during Languages/Libras graduation, and audio, in order to allow communication with listeners, so that the video meets the criteria of universal design contemplating deaf and hearing people. Libras interpreters used neutral--colored clothes, without prints, so as not to divert attention during the performance of the movement.
It is noteworthy that the recording and editing of the video for Libras and audio for Portuguese occurred in a professional studio, with Chroma Key background to facilitate the animation montage. We adopted dark yellow subtitles to allow greater efficiency in reading. It is noteworthy that there was synchronization between image, sound and subtitles.
The video was produced in animation format, by a specialist in the field of cartoons for the adaptation of the characters and selection of scenarios. The classic animation was used, which consists of hand drawings on a transparent film, with figures one by one, with few changes so that, on the screen, the final drawings gain movement. This step relied on a professional designer and video editor.
In the third stage, called post-production, the animated scenes were edited and organized, including those translated into Libras and audio of the scenes presented. In addition, Portuguese subtitles were inserted simultaneously to facilitate communication with listeners and deaf people with bilingual education.
The study was conducted according to the ethical precepts of research involving human beings and received approval from the Research Ethics Committee of the Federal University of Ceará under opinion No. 2,533,100/2018.

Results
The educational video was called Condom: learn how to use it correctly, aimed at deaf and hearing people of both genders, and discussing how the body works, in order to facilitate understanding of the mode of action, benefits, and care with the use of condoms.
A fictitious situation was created in which a couple that acquired Sexually Transmitted Infection (STI) wants to know how they acquired it and how they can prevent themselves against this infection. Thus, the couple seeks assistance in the health service, and the nurse discusses the topics selected from the manuals on sexual and reproductive health. See below, the synopsis: a deaf couple that contracts Sexually Transmitted Infections wants to know ways of prevention and seeks guidance through a Nursing Consultation.

Favorable axes Story of the script about condom use
Proximal development: teaching-learning process Couple is apprentice and nurse facilitator, allows for differentiated learning.
Mediation: relation of signs and instruments Interaction, communication, spatial language, manual alphabet, and inclusion of knowledge.
Integrality: humanization of education Holistic needs met social, sexual, emotional, and communicative; provides learning about condom use.
Compensation: overcoming and evolving Deafness compensated by sign language in the learning process.
Plasticity: adaptation, evolution and intelligence Deaf people are smart, learning support to sexual and reproductive health, social equity. The script argument was developed based on the content developed and followed the logical sequence of a fictional situation for understanding about condoms, being portrayed below, a story with three characters: Bruno, Leticia, and Nurse, who are presented by a narrator in a basic health unit. The narrative is based on a nursing consultation, which discusses reproductive anatomy and physiology, use of the male condom (packaging, opening, position, and place for disposal), aiming at the prevention of Sexually Transmitted Infections and unplanned pregnancy.
To prepare the script, we paid attention to the development of short sentences, active voice, and linearly, in order to meet the peculiarities of the target audience, using the guiding axes of Vygotsky's theory, corroborating the learning of deaf people, as seen in Figure 1.
Thus, after the analytical elaboration with Vygotsky's assumptions, the script was structured and organized in seven blocks and 21 scenes, with details of the information, characters, and scenarios ( Figure 2).

Blocks Scenes
1. Introduction 1. Images of heterosexual and homosexual couples talking, strolling, dating; represents scenes of reality related to the sexuality of young people and adults.
2. Narrator asks about knowledge about STI prevention and invites to watch the video.

Mechanism of action and care
11. Introduces the two types of condoms and barrier mechanism for preventing STIs and unintended pregnancy.

Screen with list of benefits and images.
13. It maintains the strategies of scene 12 and presents condom care.  The final version of the video resulted in nine minutes and 25 seconds of duration, stored in MP4 file, with 720P resolution and composed of animations, audio narration and Libras. The viewing win-dow of the Libras interpreter occupied approximately 1/6 of the screen size, which allows highlight and visibility for the sign language. Figure 3, below, illustrates the main scenes of the educational video.

Discussion
The study presented as a limitation the non--generalization of the findings, because sign language is not universal, suffering modifications depending on each region or country. Thus, it is expected that this research may lead to the development of intervention studies in order to evaluate the effectiveness of this audiovisual technology in different regions and cultures for this population.
This study contributes to the development of educational materials based on educational technology for deaf and hearing, which can be applied to different teaching strategies, resulting in an important contribution to health promotion and autonomy of the subjects. Moreover, the construct produced by this study helps nurses in their clinical practice, conside-ring that it can be used in sexual and reproductive health education strategies for deaf and hearing people The campaign published by the World Health Organization called Nursing Now brought reflections about the empowerment of nurses in the insertion of health practices in all populations (13) . Thus, the understanding of the modes of communication is essential to the understanding of the deaf culture, as well as for the development of educational technologies in health, especially in the field of sexual and reproductive health.
For health education to be effective, it is essential to construct content designed specifically for a person or population group, respecting cultural aspects. In addition, it is important that the text be well delimited, highlighting the benefits (gains) and costs (losses) associated with behaviors and decision--making. This information should be transmitted through diversified teaching strategies in didactic and technological terms that mobilize attention and motivate its use (14) . Thus, the content of the constructed video describes beyond the mode of condom use since it contemplates its benefits and consequences of incorrect use or non-use of the method.
The association of the Vygotskian theory to the story of the script sought to interconnect the potential and actual knowledge of the deaf. Thus, the purpose of the script of the educational video was to provide an ideal scenario capable of attracting the interest, curiosity and motivation of viewers through a story to share best practices of nursing on male and female condom use, facilitating the understanding of the theme.
Although knowledge about condoms and STI transmission risks cannot predict self-efficacy about prevention measures (15) , the conscious use of this barrier method is understood as a right that supports contraceptive choice with knowledge, experience, and necessary clarity.
A research conducted in 2,735 primary health care units in the state of São Paulo found that 56.8% of the services offered in these health institutions are focused on sexual and reproductive health, with a fo-cus on prevention of sexually transmitted infections and family planning (15) . However, it is known the incipiency of some health services regarding the deaf, which hinders the access of this clientele to human and material resources offered by such services, highlighting the need to address such a relevant topic with this audience.
The use of health-specific terms needs to be carefully analyzed so that the use of educational technologies is feasible and avoids wasting human and material resources on dissemination, as well as the distribution of poorly understood content. Consulting the target audience during the construction of the content is valid to avoid these problems. In the constructed video it was necessary to use some technical terms, being carried out a detailed description and illustrations in animation for better understanding.
Authors of an educational video on genetic counseling for the deaf suggest that before building technologies for health education, the functional health literacy of the target audience should be investigated, in order to know their ability to understand information in order to make appropriate decisions regarding self-care (16) . This can be investigated by assessing the ability to understand a text with health information, in addition, the use of instruments such as the Test of functional health literacy in adults (TOFHLA) can measure this knowledge (18) , but should, however, be adapted to the deaf for better application of the resource.
In addition, they reaffirm that the use of different illustrations and digital media supports learning. They emphasize that they should present a consistent and normal rhythm with frequent pauses, so that the viewer can process the information while the graphics or text are being displayed in the video (16) . Thus, consistent with the literature, this media technology used similar strategies in order to facilitate learning.
The apprehension of health information for the deaf considers, in addition to the mode of communication, the sign language, that is, their literacy in health. Thus, even if the information is available in Libras, these may be difficult to understand by the target audience, given the low functional literacy in health of this population. It is noteworthy that this factor is not restricted to the level of education, but to reading habits in the health field (17) .
It is noteworthy that the bilingual approach used in the video, sign languages and Portuguese, are presented as favorable in the construction of educational technologies, considering that the deaf are familiar with verbal language, because they live in a society of listeners. This statement is verified as evidenced in a randomized clinical trial with 150 deaf people that evaluated the knowledge of deaf people in both modes of presentation of online technology on genetic counseling, monolingual and bilingual, and found that the bilingual approach contributed more to the access of information of deaf users with low education than a monolingual approach (18) .
Digital educational materials enable the integration of different resources, among them, verbal and non-verbal, being considered ideal for deaf people. Thus, the use of these technological resources can build a privileged space of knowledge for these people, corroborating the formation of critical and autonomous users, who discover and create their own answers. Authors state that educational tools for this audience should concentrate images, signs and colors, due to their communication being essentially visual (19) .
Although information about condom use is widely disseminated in the media, not all of it considers settings and target populations, as well as interventions based on scientific evidence, making such information inconsistent.
The scarcity of information on the sexual and reproductive health of the deaf is related, besides the distorted view of society in general, to the language skills presented by health professionals who, most of the time, do not know Libras and, mainly, to the lack of communication with parents, both due to the difficulty of using the language, and to their reluctance to address the issue with their children during adolescence.
Therefore, making male and female condoms available and providing knowledge about their use are relevant strategies for sexual health of the population. Meanwhile, the constructed video is a technological resource that presents scientific support to be used in different scenarios for the promotion of knowledge in sexual and reproductive health, including deaf people with the listeners.

Conclusion
This research built an educational video about sexual health and condom use with duration of nine minutes and 25 seconds, with the purpose of promoting health, providing learning about male and female condoms. It was concluded that the construction of the video as an assistive technology directed to the deaf was successfully accomplished.

Acknowledgments
To the Coordination for the Improvement of Higher-Level Personnel (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior) for granting PhD scholarships to Sarah de Sá Leite and Aline Cruz Esmeraldo Áfio; and to the National Council for Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico) for financial support through process no. 439644/2018-6.

Collaborations
Áfio ACE and Leite SS contributed to the conception and design, writing of the article, relevant critical review of the intellectual content, and final approval of the version to be published. Carvalho ALRF contributed to the relevant critical review of the intellectual content. Almeida PC contributed to data analysis and interpretation. Rebouças CBA and Pagliuca LMF contributed to the final approval of the version to be published.