Effect of a board game on imprisoned women's knowledge about ... - BMC Public Health

The Previna board game was designed to be a complementary tool in the teaching and learning process about STIs for imprisoned women. The results showed that this educational technology significantly increased the players' knowledge about STIs and that this increase in knowledge remained significant during follow-up. This suggests that there was knowledge retention in the period researched. The increase in knowledge was also present in other studies that used board games for educational purposes [13,14,15,16].

The knowledge retention observed in this study is a result that draws attention, as the school teachers frequently mentioned that the women had difficulty retaining the contents taught in the classroom. This suggests that the approach to content may or may not favor this process. In this way, the board game can be used to present educational content to adult students in order to address their learning needs [14] and to make learning more significant and engaging.

Regardless of the teaching method chosen, the teacher must employ strategies during the classes that are capable of increasing the student's motivation, improving knowledge retention and learning results [16]. It is known that, in the prison environment, the system itself limits some actions. Thus, it is increasingly important to use accessible technologies that may streamline the knowledge construction process and make it more active.

The increase in knowledge remained significant after 15 days, suggesting short-term knowledge gain. Previous studies have also evidenced short-term knowledge gains through learning using games [14, 17,18,19].

It is important to highlight that the knowledge mean in the pre-test (23.62; SD = 3.23) was expressive since, from a total of 32 items present in the instrument, approximately 74% were answered correctly. Such result shows that there is certain level of knowledge on the subject matter in the sample under study. A similar result was found by a study that evaluated knowledge about HIV and the Hepatitis C Virus (HCV) among imprisoned North American women and identified high levels of knowledge about HIV and HCV, despite extensive reports of risk behaviors as sex work (44%) and history of injecting drug use (75.5%). [20].

This can be the result of educational actions developed in a previous period, such as the extension project entitled "Sexual and Reproductive Health Care for women in custody", carried out in the prison unit in partnership with the Nursing Department of the Federal University of Pernambuco, started in 2013 [21] and which had its activities interrupted due to the COVID-19 pandemic in 2020.

In addition, the imprisoned women in question were students at a prison school and the content on STIs may have been worked on in a previous period and in a transversal way, as part of YAE activities and within the scope of knowledge areas such as Natural Sciences, as provided by the Common National Curriculum Base [22, 23]. However, if the game was able to increase knowledge about STIs in this context, it is possible that it will present more expressive results if the baseline knowledge levels are lower.

In relation to the item that presented the worst performance in the pre-test (item 7) and which deals with STI contagion through the use of shared bathrooms, it is noticed that this is a myth widely spread in our society. Some papers also evidenced this view by parents and teachers in Kenya [24], by seafarers in Montenegro [25] and about a possible toilet disease, with signs and symptoms similar to STIs by young Nigerian women, who believed they acquired the disease from using a toilet with poor hygiene conditions [26].

In addition to that, a study on the perspectives of risk factors for STIs by Brazilian imprisoned women evidenced that sexual behavior and unprotected sex were not understood as the main ways of acquiring STIs in this environment, but sharing the bathroom as a risk potentiator [2]. In view of this, it is important to reinforce the ways in which STIs are transmitted among this population group, which does not mean saying that hygiene care in these places should be neglected. It is also noted that there was a significant increase in the means for this item after the intervention.

Item 26, which deals with the existence of a cure for herpes and corresponds to a false item, presented the worst performance among the items, both in the immediate post-test and in post-test 2, and the increase in means was not significant, although it was an STI addressed in the board game through 4 cards. This can be the result of unfamiliarity with this STI by women and that it is not so publicized. A study on knowledge about STIs in a male imprisoned population showed that the interviewees had difficulty identifying diseases such as genital herpes [27]. Thus, it is important to think of strategies to broaden discussions about this disease in order to increase knowledge on the subject matter, mainly because, despite the existence of antivirals for treatment, there is still no cure [28].

A total of 13 items presented statistically significant differences. However, depending on the number of analyses, it should be noted that some of these findings may be due to type I error. Item 2, which deals with the main signs of STIs appearing in the intimate parts, despite already obtaining a baseline mean above 0.8, managed to significantly increase the number of correct answers after the intervention. It is important to note that the game, as well as the moment when the questions were discussed at the end of data collection, reinforced the understanding that this was not the only place where signs of STIs could appear, but that such areas frequently present some alteration due to the infections [29, 30].

Items 6 and 9, which deal with STI transmission by women who have sex with women and through piercing, also presented statistically significant differences. On the subject matter, a Brazilian research study on vulnerability to STIs among women who have sex with women showed lack of risk perception for STIs (56.7%) and HIV (67.3%) [31] by this group.

In addition to that, in the prison environment, some practices such as body modifications resulting from tattoos and piercings can increase the risk of viral hepatitis infection [32]. Thus, lack of knowledge on the subject matter can increase sexual risk behaviors and promote neglect of individual care measures aimed at STI prevention.

Items 14 and 15, which addressed HIV transmission through kissing on the mouth and the difference between HIV and AIDS, initially with means below 0.30, also presented statistically significant differences. During the game, the ways in which HIV is transmitted and the difference between HIV infection and AIDS stood out. A study conducted with aged Brazilians also identified that 38.1% believed that kissing on the mouth was a means of HIV transmission [33]. Likewise, the conception that HIV and AIDS were the same thing was also found among Brazilian adolescents [34].

Items 19, 20 and 21, which deal with Hepatitis B and C transmission through syringes, needles and nail pliers, as well as with the existence of a vaccine against Hepatitis B, started with means above 0.75, suggesting knowledge about the subject matter, and rose significantly during follow-up. An important result, considering that the use of syringes, needles and nail pliers is a constant factor in this environment [35, 36]. Likewise, being aware of the Hepatitis B vaccine is the first step in preventing this infection, which has an increased risk of affecting the prison population [37].

In relation to items 22 and 23, which deal with HPV and the occurrence of genital warts and cervical cancer, respectively, it was observed that the initial means were lower. Slightly more than half of the interviewees gave correct answers to the items in the pre-test phase. Such fact can be the result of knowledge gaps about the consequences of HPV infection. A study with imprisoned American women identified that 42% and 57% gave correct answers to the questions about HPV causing genital warts and cervical cancer, respectively [38]. During the game, the cards about HPV infection may have contributed to the results obtained in the follow-up, as the increases were statistically significant.

Finally, items 24 and 25, which deal with gonorrhea and chlamydia infections and that also showed statistically significant differences, with improved results, it was noticed that both items presented an initial knowledge mean of 0.5. A study that evaluated young Greeks' knowledge about STIs identified that only 17.6% considered that gonorrhea can cause infertility [39]. It is known that these infections have serious consequences for women and also for their children [28, 40], being opportune that more frequent discussions take place to inform this population group about prevention and harm reduction strategies.

In terms of the items where no statistically significant differences were observed, it is noted that, of the total of 19 items under these conditions, 15 started with means above 0.8 in the pre-test, showing that there is already relative knowledge on the subject matter. Thus, the differences produced in the following measurements were insufficient to be considered significant. In addition to that, item 27, which deals with the need to seek professional help in case of an STI, was correctly answered by all women at all three measurement moments.

Contrary to this pattern, there are items 18, 26, already discussed, and 32. The first deals with the existence of a cure for syphilis. Despite an expressive mean, 0.75 in the pre-test, there were many doubts about the item. According to some women, in a previous period there was a lecture at the unit, which mentioned non-existence of a cure for syphilis, based on the premise that the exams would always be positive for a previously infected person, even if they had undergone adequate treatment. This leads to the belief that there was misunderstanding about the idea of a serological cure. This is defined as at least a 4-fold reduction in the treponemal titers or seroconversion to non-reagent results [41]. Thus, the presence of treponemal titers in the exam does not necessarily mean that the disease is present. The treatment can be considered successful when the aforementioned decline occurs, after using antibiotic therapy, in a period of 12 months for early syphilis and 24 months for late syphilis [42].

Item 32, which started with an even lower mean in the pre-test (0.53) and deals with imprisoned women's vulnerability to STIs when compared to free women, was a subject matter of great controversy. Despite the game portraying this idea, based on scientific studies [4, 43, 44], it was common for imprisoned women to disagree with this information. This is because the unit provides access to a series of preventive services that, under conditions of freedom, they would have difficulty enjoying, taking into account the social vulnerability of the environment where they were previously inserted. This reinforces the idea that imprisonment can also be seen as a unique opportunity to work on health promotion and disease prevention with a population group that is naturally vulnerable in several aspects.

Finally, the Previna board game made it possible for imprisoned women to increase the mean of correct answers to the items present in the knowledge assessment instrument and, therefore, fulfilled its objective of increasing knowledge about STIs.

The fact that this is a quasi-experimental study does not allow making causal assertions about the board game. In addition to that, the evaluation of the board game effect only considered the short-term, not being possible to identify knowledge retention in the medium- and long-term; the imprisoned women were students at a prison school, which means that the data do not necessarily reflect the reality of incarcerated women as a whole; only the knowledge outcome was evaluated; and only one prison unit was analyzed, although it is the one with the largest number of imprisoned women in the state.