Introduction

Health literacy has aroused wide interest in the scientific, political, economic and assistance fields, becoming an area of significant visibility as it constitutes an important social determinant of the population’s health and quality of life. It is a widely referenced concept and defined as the incorporation of technological resources for the dissemination, communication and processing of information about the conditions necessary for the adoption of safe practices.(¹,²)

In the literature, educational interventions favor the shared construction of critical and reflective knowledge, and when associated with digital media, they allow, at different reading levels, languages and teaching methods, patient training, as well as the development of self-care skills, as well as for active participation in health decisions.(³,⁴)

From this perspective, health education constitutes an expressive practice in different contexts and levels of care, associated with the valorization of knowledge, practices and cultures, as well as the dissemination of information on a large scale and the implementation of care interventions, especially with regard to strategies for combined prevention of infection by the Human Immunodeficiency Virus (HIV).(³,⁵,⁶)

Considering HIV infection as a global challenge that, despite the structuring of programs for epidemiological surveillance, still presents high indicators of incidence, prevalence and mortality, it is necessary to develop, incorporate and evaluate technologies in health behaviors, in monitoring the flow of care, diversity, availability, access and combination of prevention methods.(⁷)

The use of mobile devices in healthcare practices offers opportunities to expand access to information, reach and engage key populations, resulting in screening, risk assessment, monitoring of vulnerable groups and expansion of information dissemination, use and access to prevention combination of HIV.(⁸,⁹)

In this context, it is considered that health information, when based on evidence, constitutes an important strategy for preventing and controlling HIV infection and despite the structuring of official websites and portals, the available technologies are, for the most part, aimed at health professionals and use technical language, attributes that make access to information difficult for the key population, population segments with a disproportionate prevalence of infection when compared to the general population.(⁸)

In nursing, technologies can facilitate the large-scale dissemination of information, representing an attractive, innovative and effective tool to promote and maintain changes in health behaviors such as frequent testing, linking to infection treatment or adherence to prophylaxis, pre-exposure against HIV.(⁷)

Considering that misinformation about strategies for combined prevention still comprises a significant reality in Brazil, generating epidemiological impacts, contributing to low risk perception and compromising adherence to sexual health care and that the incorporation of technology into care practices has been gaining scientific recognition of the potential of technologies to implement public health policies, this study was structured to answer the following question: What is the evidence of validity of a website developed for combined HIV prevention?

Given the magnitude of the problem, the objective of this investigation was to analyze the evidence of content validity of a website on combined HIV prevention for the general population.

Methods

This is an educational content validation study based on the website development method conducted in four stages: definition; architecture; design and implementation.(¹⁰,¹¹) This study describes the fourth stage consisting of the testing and evaluation stage of the contents inserted on the PREVINAIDST website by the general population (considered as people who have greater exposure and vulnerability to HIV infection).

Virtual web survey data collection was carried out using the Research Electronic Data Capture (REDCap®) online platform. People aged 18 years old or over, who had access to the internet, had an active sex life and who lived in Brazil, selected for convenience, participated in this investigation. These are individuals who make up the general population and who need specialized information on combined HIV prevention. Incomplete completion of the questionnaires proposed for technological assessment were excluded.

Recruitment took place from January to August 2022 through a profile created on the social media Instagram®, in which interactions in publications promoting the technology were analyzed, as well as in posts made by the research group. In this sense, the invitation to participate consisted of a brief text aiming to present the study, justification, relevance, risks and benefits, as well as the link to access the data collection instruments in case of agreement.

To collect data, a specific questionnaire was used that assessed sociodemographic conditions, as well as participants’ knowledge about HIV prevention methods and previous health behavior.

In the validation process, a questionnaire adapted from other studies was developed, used to evaluate the attributes of pertinence and relevance of information, as well as content, verbal language, ease of navigation, attractiveness, innovation and usability.(¹⁰,¹¹) For each purpose consensus, a Likert-type questionnaire was used, with response variation in four points (1 - strongly disagree; 2 - disagree; 3 - agree; 4 - strongly agree).(¹²,¹³)

For data analysis, descriptive statistics were performed, by calculating absolute and relative frequencies, in addition to measures of central tendency and dispersion to outline the profile and characterization of study participants. Agreement indicators were estimated by the Content Validity Index for Items, which measured the representativeness of the items in relation to the evaluated aspects. Scores equal to or greater than 0.80 (80% agreement) were considered as minimum or satisfactory agreement, calculated by dividing the number of items classified as agree or strongly agree by the total number of items, as proposed in other studies.(¹²,¹⁴-¹⁵) The Global Content Validity Index was also calculated through the sum of all indices calculated separately, divided by the number of items.

This study was approved by the Research Ethics Committee of the Ribeirão Preto School of Nursing of the University of São Paulo, and the favorable opinion for its implementation was issued under process number 5.068.52 (Certificate of Presentation of Ethical Appreciation: 48656021.2.0000.5393). Participants voluntarily provided consent by signing the online Informed Consent Form.

Results

This study was carried out with 24 participants who evaluated the PREVINAIDST website (Figure 1). The majority were female (70.8%), with a mean age of 30.7 years (SD 10.8) and completed higher education (75%) and 23 (95.8%) were HIV-negative. Furthermore, there was a prevalence of self-declared white people (75%), heterosexuals (62.5%), single (62.5%), HIV-negative (95.8%) and 23 (95.8%) coming from different municipalities in the state of Sao Paulo.

Regarding HIV infection prevention strategies, it was identified that only 11 (45.8%) participants knew about PrEP, 45.8% reported having prior knowledge about Post-exposure Prophylaxis, 41.7% about strategies for combined prevention and 10 (41.7%) were aware of the treatment strategy as prevention with the achievement of an undetectable viral load and the non-transmissibility of HIV to sexual partners. Furthermore, 50% of participants knew the rights of people living with HIV. In the assessment of health behaviors, it was found that 62.5% of participants reported having vaginal sex without a condom, 29.2% anal sex without a condom and that 58.3% underwent periodic testing for HIV. The consumption of alcohol and other drugs through sexual partners was not a frequent practice, being mentioned by only 16.7% of participants. In this investigation, only three participants (12.5%) were receiving care support for the use of HIV Pre-Exposure Prophylaxis.

In evaluating the content, the total agreement validity index was 0.97, indicating relevance, logical organization, reliability and satisfaction, as well as great potential for learning, sharing information and adherence to combined HIV prevention strategies by the population general. The results of the agreement validity indicators were also verified in the assessment of verbal language (0.99). In this attribute, all items showed an agreement greater than 0.80, suggesting that the structuring and use of media, as well as subtitles, colors and textual sources were appropriate and contributed to understanding the content.

From the same perspective, the website showed evidence of validity regarding the navigation structure (0.98), since the arrangement of content, layout and links, as well as the arrangement of topics and information about the developer team, security and privacy favored interaction and contributed to easier access. The lowest agreement coefficient was recorded in the item “window overlap”, which, although it presented a satisfactory indicator (0.88), required reformulations regarding the resolution and size of the media for access on mobile devices. Table 1 presents the agreement indicators identified in the evaluation of content, verbal language and navigation resources.

Table 2 describes the agreement validity indicators regarding attractiveness (0.98), innovation (0.98) and usability (0.83). Despite having a score equal to or greater than 0.96 for most items, the evaluation by the general population also showed that the website has an unprecedented design (0.96), as well as being an innovative means of disseminating information. (1.0). Thus, it is considered that the visual composition, content, language, arrangement and quantity of information, as well as the audiovisual resources, the colors used and the media contributed to greater interactivity and technological attractiveness. In the evaluation of innovation, the website design was considered unprecedented (0.98) and addresses different strategies that enable HIV prevention in seronegative people (0.96) and serodifferent couples (1.0), and an information dissemination technology reliable (1.0).

Discussion

The proposed educational technology presented educational content that was semantically validated by the general population. The prevention of HIV infection constitutes a public health problem in the country, with Brazil having the largest population of individuals living with HIV/AIDS in Latin America.(16) Despite the advances made in the field of prevention, widespread availability of resources for prevention, therapeutic advances and the structuring of public policies, comprehensive lines of care and epidemiological surveillance programs and implementation of PrEP in the national program and provided by the SUS free of charge for Brazilian populations at risk of HIV infection, the infection numbers caused by HIV are increasing.(¹⁷)

Key populations and adolescent and young women continue to face high risk of new HIV infections. Each week, approximately 37 young women aged 15 to 24 were infected with HIV. Furthermore, there is a significant gender disparity in diagnostic outcomes, with men showing a more favorable trajectory compared to women.

By considering the complex, multidimensional and universal nature of the infection, as well as the potential of health technologies for prevention, the results of this study express the relevance of investing in building and validating educational technologies aimed at HIV prevention. The PREVINAIDST website is a resource developed for information and guidance on sexual practices and risk of HIV transmission, as well as the factors that increase the risk of sexual transmission of HIV, and the different biomedical, behavioral and harm reduction strategies that can be combined for HIV prevention. Additionally, it allows access to other educational technologies developed by the research group, such as booklets, educational videos and podcasts. Furthermore, the website is configured as an internet-based platform or social media, allowing interaction between developers and users, whether through access on mobile devices or web-based resources.

The incorporation of technologies for screening, monitoring, prevention, diagnosis and treatment of Sexually Transmitted Infections in care practice is widely referenced, given their wide availability, ability to reach a wider audience and to enhance indicators of care quality, process and clinical outcome .(¹⁸)

From this perspective, it is highlighted that technologies have great potential to contribute to tackling the HIV infection epidemic as they can facilitate the dissemination of information on a large scale and the effective delivery of tools to promote and maintain behavioral modification, such as routine testing among HIV-seronegative individuals and linkage to HIV prophylaxis and treatment.(⁷)

Scientific evidence has demonstrated the potential and importance of web-based information and communication strategies, indicating their configuration as a promising tool for expanding vulnerable population access to existing testing and counseling services.(¹⁹) An international study also described the effectiveness of mobile technologies (mHealth) for HIV prevention among adolescents.(²⁰)

In this investigation, the validation process was carried out by the general population and involved, in its majority, young adults, female, self-declared heterosexual and HIV-negative, demonstrating the potential of the website to guarantee access to information for different population groups and not just those of greater vulnerability to HIV infection as gender minorities.

From the same perspective, limitations in knowledge about strategies aimed at pre- and post-exposure prophylaxis, as well as the rights of people living with HIV and viral load indicators, were investigated and highlighted. In the same context, an investigation demonstrated similar results, indicating that low knowledge about HIV prevention strategies is a significant reality in Brazil, and highlighting associations with high individual vulnerability and greater risk for infection.(²¹)

Alcohol consumption, a practice identified in 16.7% of the studied sample, when carried out abusively constitutes a risk factor for low adherence to prevention and treatment strategies, as well as for viral load suppression, a worse clinical outcome in infected patients. and reduced quality of life.(²²,²³)

In the technological assessment process, satisfactory validity indicators were verified in all domains investigated: content (0.97), verbal language (0.98), navigation structure (0.97), attractiveness (0.98), innovation (0.98) and usability (0.83).

The structuring of the content considered the participants’ knowledge limitations and gathered evidence favorable to the combination of prevention strategies. In the evaluation of the general population, satisfactory indicators were identified in all items, showing that the information on the website is relevant and reliable, as well as presenting a logical organization, favoring learning, control and risk reduction.

It is noteworthy that the development of content on combined prevention aimed at HIV-seronegative and seropositive people is relevant, since in general, knowledge about some prevention strategies such as pre- and post-exposure prophylaxis is surprisingly low, both in countries developed countries as well as in developing countries, such as Brazil.(²⁴-²⁷)

A Brazilian study carried out with female sex workers also indicated that knowledge about pre- and post-exposure prophylaxis is insufficient and that assured access to combined prevention technologies in Brazil is still limited, especially in relation to the use of female condoms and HIV treatment. and vaccination for hepatitis B.(²⁵)

In the same direction, Brazilian researchers have shown that knowledge about pre- and post-exposure prophylaxis is low, that this condition can compromise secondary prevention efforts and that educational interventions are necessary to promote popular awareness and safety during sexual practices.(²⁶)

The assessment of written language suggested the media resources, fonts, subtitles and colors used resulted in greater comprehension and understanding of the content. Furthermore, this structuring associated with the arrangement of topics and information about functionalities, security and privacy contributed to interaction and easier access.

Evidence favorable to attractiveness and usability was also verified, reflecting the unprecedented design that configures the website as an innovative method for disseminating information to groups vulnerable to HIV infection. This result was considered relevant because it highlights the need for specific content, since most health policies and campaigns aimed at combating HIV are exclusively targeted at specific subgroups.(²⁷)

Regarding the innovative aspect, it should also be noted that there are different Brazilian websites available on combined prevention, however, the majority focus on disseminating guidelines aimed at health professionals, such as the provision of technical reports considered not accessible or attractive to the general population.

The innovative nature of the PREVINAIDST website also stands out as it seeks to be a platform that allows a communication interface between researchers and users, thus allowing interaction, creation and exchange of content. In view of this, it is noteworthy that the validation process with the general population made it possible to evaluate the relevance of the content and adequacy of the language, in addition to promoting a participatory process in the construction of content based on the real needs of the population.

As a limitation of the study, it is noted that the validation of the website occurred online, predominantly involving people with higher education, a population subgroup with greater access to the internet, and, therefore, may have skills in handling computerized tools. Furthermore, although participants who validated the content present high-risk behaviors for HIV, they differ from the most incident population described in recent epidemiological bulletins, such as men who have sex with men, aged between 13 and 24 years.

However, the website has different educational tools such as electronic booklets, which will also be made available in printed format for the general population, which can facilitate greater access to information for the public who have limitations in the use of digital education technologies. It is expected that the website will be an important tool for disseminating, sharing and raising awareness among the population, and can also be used by health professionals in educational activities.

Conclusion

The evaluation of the PREVINAIDST website by the general population demonstrated evidence of validity and reliability regarding the attributes structured content, adopted verbal language and navigation resources, indicating high potential for information and learning, as well as for expanding access to care, dissemination, sharing and adherence to combined HIV prevention strategies. Furthermore, the agreement indicators related to attractiveness, technological innovation and usability were considered satisfactory, providing scientific, technological and operational support for the technology developed. New studies are needed to evaluate the effectiveness of this educational technology on knowledge about HIV prevention and preventive health behaviors in the population.

Acknowledgements

To the National Council for Scientific and Technological Development (CNPq) for the financial support Universal Notice – MCTI/CNPq nº428304 2018 4; Level 2 research productivity scholarship for RKR, level 1B research productivity scholarship for EG, postdoctoral scholarship for DMR. The Coordination for the Improvement of Higher Education Personnel (CAPES), master’s scholarship for FML, doctoral scholarship for MA and HCE.

References

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