REVIEW ARTICLE

STRATEGIES FOR HEALTH LITERACY RELATED TO SEXUALLY TRANSMITTED INFECTIONS: SCOPE REVIEW

Larissa Müzel de Sousa1, Lucas Cardoso dos Santos2, Samantha Ribeiro3, Juliane Andrade1

1 São Paulo State University Júlio de Mesquita Filho (Unesp), Botucatu, SP, Brazil

2 Federal University of São Paulo (Unifesp), São Paulo, SP, Brazil

3 Family Health Association, UBS/AMA Integrada Vila Barbosa, São Paulo, SP, Brazil

ABSTRACT

Objective: To map the strategies of health literacy aimed at sexually transmitted infections performed by patients and health professionals. Method: Scope review that followed the recommendations of the Joanna Briggs Institute, with searches performed in the databases: Latin American and Caribbean in Health Sciences, Scientific Electronic Library Online, Web of Science, Scopus, Cumulative Index to Nursing and Allied Health Literature, National Library of Medicine National Institutes of Health, Embase, Google Scholar and ProQuest. Results: Nineteen studies comprised the final sample with a greater representation of those developed in the United States of America and published in 2022. Health literacy strategies developed by patients and health professionals are carried out in different ways, causing clinical, relational, and intellectual benefits, applying scales for evaluation, in which health education activities are more frequent. Conclusion: Health literacy is a technology of care necessary for the promotion of health at the individual and collective level, for patients and health professionals, with regard to sexually transmitted infections, because it allows informed decision-making, empowerment, and autonomy.

Descriptors: Health Literacy; Sexually Transmitted Infections; Health Promotion.

INTRODUCTION

Sexually Transmitted Infections are among the most frequent public health problems in Brazil and worldwide. Every day more than 1 million new cases of curable Sexually Transmitted Infections are registered worldwide among people aged 15 to 49 years, with this value equivalent to more than 376 million new cases of chlamydia, gonorrhea, syphilis and trichomoniasis annually(1-2). In addition, in 2021, in Brazil, of the notifiable diseases, 40,880 were related to HIV infection, 11,238 deaths due to aids, 167,523 of acquired syphilis, 74,095 of syphilis in pregnant women, 27,019 of congenital syphilis and 192 deaths from congenital syphilis(3-4).

Sexually Transmitted Infections have a profound impact on the health of the population, since, if they are not diagnosed and treated in a timely manner, they can evolve to severe complications, in the short and long term(1). In addition to the physical consequences, Sexually Transmitted Infections diagnoses have social and psychological impacts, before an established culture, with strong association with stigma, guilt, discrimination, domestic violence, among other violences (1-2).

Health Literacy (HL) becomes relevant in terms of the promotion, prevention, diagnosis and treatment of Sexually Transmitted Infections, since its definition lies in the capacity that an individual has to find, understand, communicate, interpret, use information and seek care in order to make appropriate decisions related to his or her well-being(5-6). However, it is important to highlight that HL is not the same as health education, but rather the result of the same (7).

In Saudi Arabia, more than 40% of respondents in a survey were unaware of transmission, prevention and problems associated with HPV infection(8). Thus, HL in relation to Sexually Transmitted Infections is presented as a protective component, since lower levels of literacy are directly linked to the lack of adherence to treatment and the decrease in the understanding and knowledge that an individual has of his or her own health(9).

Health professionals play an important role in promoting HL, as they are considered an essential source of information, guidance and training for patients and family members. On the other hand, they present few skills and attitudes in the recognition of patients and families with low HL levels (10-11), directly interfering with the quality of care provided.

Thus, investigating the HL strategies aimed at Sexually Transmitted Infections can contribute to enhance the actions of health promotion, prevention and protection, as well as providing care technologies to professionals with a view to increasing the autonomy and empowerment of users, individually and collectively, in health care. Therefore, the study herein intends to map the strategies of HL aimed at sexually transmitted infections performed by patients and health professionals.

METHOD

This is a scope review that aims to map the main concepts that support a research field and provide an overview of the existing evidence, presenting an exploratory and descriptive character(12). It was conducted according to the method proposed by Joanna Briggs Institute (JBI) for scope reviews(12) and reported based on the guidelines Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR)(13). The protocol was registered on the Open Science Framework (OSF) platform on October 17th, 2023 (Register ID: osf.io/9fbh7) with the Digital Object Identifier (DOI):  https://doi.org/10.17605/OSF.IO/S7VMG

The scope review consists of nine steps: 1 “To define and align the objective and the question; 2. To develop and align the inclusion criteria with the objective and question; 3. To describe the planned approach to search, selection, data extraction and evidence presentation; 4. looking for evidence; 5. selecting the evidence; 6. extracting evidence; 7. evidences analysis; 8. presentation of results; and 9. To summarize the evidences regarding the purpose of the review, draw conclusions and observe any implications of the conclusions”(12).

A preliminary search was conducted in the Prospective Register of Systematic Reviews (PROSPERO), Medline (PubMed), Cochrane Database of Systematic Reviews, JBI Evidence Synthesis and OSF. Systematic reviews or scope reviews published or ongoing on the subject have not been identified.

PCC mnemonic strategy was considered: P (Population = patients and health professionals); C (Concept = HL); C (Context = sexually transmitted infections). The review question was: what HL strategies aimed at sexually transmitted infections are carried out by patients and health professionals?

This scope review included studies in full, quantitative, qualitative, and mixed methods, as well as editorials, texts, and opinion articles. In addition, any documents that applied HL scales or those that used strategies with the intention of stimulating the autonomy of the participants and capturing the benefits arising from these, according to the reference of HL(7), as protocols, guidelines, booklets, institutional documents, reports, conference articles, and other relevant materials were also considered for inclusion. Temporal, linguistic, and geographic cutouts were not considered for the search with the objective of expanding the results of the review. The exclusion criteria were based on articles that did not address HL strategy in Sexually Transmitted Infection; not available in full, despite unsuccessful attempts with the authors.

Initially, a search was performed in PubMed and CINAHL (EBSCO) to identify articles on the topic, followed by an analysis of the words of the text contained in the title and in the abstract, and the index terms used ​​to describe the articles. This stage informed the search strategy based on the descriptors in Health Sciences (DeCS) and Medical Subject Headings (MeSH), combined by the Boolean operators “OR” and “AND”, adapted to databases: National Library of Medicine National Institutes of Health (PubMed), Latin American and Caribbean in Health Sciences (LILACS), Scientific Electronic Library Online (SciELO), Web of Science, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Embase (Elsevier). The gray literature was researched from Google Scholar, first 80 findings, and ProQuest, with active filter for dissertations and theses (Figure 1). It is reiterated that the selection of databases was based on its relevance and wide coverage of publications in the health area, as well as its indexing process.

Figure 1 - Search strategies for health literacy strategies related to sexually transmitted infections, adapted to the respective information resources. Botucatu, SP, Brazil, 2023

The searches were carried out on June 02nd, 2023, in the information resources mentioned above, with subsequent selection, extraction and mapping of the findings, respectively. The articles found went to the bibliographic reference manager EndNote Web (Clarivate Analytics, PA, USA) with removal of duplicates. Later, the remaining studies were referred to the Rayyan tool. For the selection of articles, three reviewers participated, and the third was called to resolve disagreements between the first and the second reviewer. This process occurred both in the selection of titles and abstracts and in the full reading of the texts. We also used the hand searching strategy in which the same procedure was applied.

After this process, the studies were inserted in a spreadsheet in Google Drive adapted from JBI(12) to summarize the findings and identify the strategies of HL described in which the evaluation of methodological quality was not considered, as per JBI guidelines(12). Finally, the results were presented in the form of narrative summary and figures.

RESULTS

The total of articles identified in the databases was 1139, and at the end 19 studies answered the question of this review and the eligibility criteria(14-32), with each step described in Figure 2.

Figure 2 - Flowchart of selection of articles, adapted, after removal of duplicates and application of inclusion and exclusion criteria, based on PRISMA-ScR. Botucatu, SP, Brazil, 2023

Source: Flow diagram PRISMA-ScR adapted from Tricco et al., 2018

Of the 19 articles found in this review, 11 were developed in the United States of America (USA)(14-16,18,20,22-23,25-27,31), two in Canada(17,19) and Thailand(28-29) and one in Scotland(24), Portugal(32), Iran(30) and a study without location identification(21). In relation to the year of publication, a study was represented in the years 2001(14), 2003(15), 2005(16), 2011(17), 2013(18), 2015(19), 2019(22), 2023(32), two in 2016(20-21), 2020(23-24), 2021(25-26) and five in 2022(27-31).

The strategies developed aimed to reach a specific group in each identified study. In three(14,19-20), the HL strategies related to Sexually Transmitted Infections developed by both health professionals and patients, and all the others included only users(15-18,21-32) (Figure 3).

HIV: Human Immunodeficiency Virus; HL: Health Literacy; ACS: Community Health Agent; STI: Sexually Transmitted Infections; REALM: Rapid Estimate of Adult Literacy in Medicine; ACTG: Adult AIDS Clinical Trials Group; TOFHLA: Test of Functional HL in Adults; NVS: Newest Vital Sign: A HL Assessment Tool; MMSE: Mini Mental State Exam (MMSE); eHEALS: Electronic HL Scale; SCI: Self-as-Carer Inventory; BEHKA: Brief Estimate of Health Knowledge and Action; BRIEF: Brief HL Screening Tool; AHL-C: Assessment of HL in Cancer Screening; CCK: Cervical Cancer Knowledge; PHQ-9: Cervical Cancer Self‐Efficacy Scale, Patient Health Questionnaire-9.

Figure 3 - Synthesis of the main findings found in the review. Botucatu, SP, Brazil, 2024

The benefits of HL could be combined into three groups: Clinical, relational, and intellectual, as shown in Figure 4.

HL: Health Literacy; HIV: Human Immunodeficiency Virus; STI: Sexually Transmitted Infections.

Figure 4 – Clinical, relational, and intellectual benefits of HL Strategies. Botucatu, SP, Brazil, 2024

In addition, many articles found used HL level assessment with participants through scales that evaluated specific literacy for a given disease(26,31), interpretation and reading-related literacy(14-16,18-19,21,26), numerical literacy(18), and the individual’s behavior in relation to his or her HL level(23,25,32), electronic HL level(22,25-26) and those that evaluated HL in general(27,32).

DISCUSSION

The present study enabled the identification of HL strategies related to Sexually Transmitted Infections that varied from the different objectives, methodological paths, and participants, which gave significant heterogeneity to the revealed findings.

The health education sessions stood out before the mapping of HL strategies aimed at Sexually Transmitted Infections carried out by patients and health professionals. These play a primary role in individual and collective care and health promotion and disease prevention(33), representing a strategy for the HL development(33-34).

HL is a variable that has different influence factors, such as knowledge, literacy, the social group that the patient and professional are inserted, and therefore different instruments have been considered in the research(14-16,18-19,21-23,25-27,31-32). It is possible to evaluate the ability to read and understand health information and determine the level of HL of the population, allowing health professionals to identify which patients will need special guidance in the use of the services, greater instructional support and from this plan equitable care actions(35-36).

The approach to patients with STI implies the implementation of specific HL strategies, since this is permeated by challenges such as stigmas, prejudices, limitation in the training of professionals in relation to HL, the uniqueness of individuals, time of consultation, absence of public health policies, among others(19-20,24). Therefore, it is imperative to offer means of access, support, interpretation, and use of health information by users, whether oral, digital, or written; the awareness of health services teams about HL in their practices; the reorganization of workflows in such a way that HL and its assumptions are integrated, highlighting the decision-making by users(37).

It is noticed a greater use of different HL strategies related to Sexually Transmitted Infections aimed at patients when compared to health professionals. This can be attributed to factors such as lack of time to approach HL, limited resources, little incentive in the workplace to deal with educational issues and HL in services, in addition to the assumption that professionals already have the necessary knowledge. This view contributes to the unpreparedness of professionals in dealing with HL in practice, impacting the quality of the service provided(34). These factors highlight the need for HL advances in the permanent education and practice of health professionals, as well as public policies that emphasize the importance of HL for professionals with investment in their training.

Nursing, as the largest health workforce in the world, is highlighted with regard to HL, because it identifies gaps in the knowledge, problems and health needs of the population; promotes the autonomy of patients by offering guidance on disease prevention, treatment and management; he develops research on HL; organizes lectures, workshops and campaigns in schools, health units and communities; and leads initiatives aimed at vulnerable groups such as sex workers, people living with HIV/aids and others(38). Therefore, as a care manager, it plays a crucial role in the training of other professionals, strengthening the process of permanent education.

Regarding users, the following are highlighted: informed decision-making, autonomy in managing their own well-being, reduction of stigma, increased adherence to treatment and promotion and prevention of diseases and diseases as determining factors for better clinical outcomes and greater safety in care, in addition to HL being a cost-effective component(33). At the same time, the construction of a bond and trust relationship strengthens social interactions, favors the sharing of essential health information, improves patient satisfaction, and contributes to the improvement of health outcomes(39-40).

Thus, the use of HL can contribute significantly in the process of construction, implementation, and implementation of public policies in the context of Sexually Transmitted Infections, promoting permanent education, strengthening the relationship between health professionals and users, reduction of inequalities and reflection on daily practices at work and health services(38,41).

It is also essential to consider the differences between North and Global South countries in the fight against HIV that reveal significant discrepancies in access to diagnosis and treatment, public health policies, and international cooperation. While the South has made significant progress through cooperation and reduction of drug costs, highlighting Brazil’s leading role in South-South cooperation, the North still faces challenges with the increase in new cases and the cuts in investments aimed at HIV prevention organizations(42-43).

Thus, the relevance of the present study is precisely because it maps different strategies of HL focused on Sexually Transmitted Infections and that can be used in different contexts, contributing to the improvement of the quality of life in the individual and collective scope and in the reduction of health inequalities, it is a crucial step to ensure effective and inclusive interventions and contributing to the reduction of stigmas, increased equity in access to information and improvement in both promotion, prevention and adherence to treatment.

Among the limitations of this review is the lack of access to two studies found, but not analyzed for non-access, the low methodological quality of some researches as small sample and absence of control group, in addition to the non-analysis of heterogeneity and risk of bias of the included studies because it is a scope review that according to the JBI method should present descriptive and exploratory character, and not analytical. Finally, the lack of understanding by health professionals, individuals, and researchers about what HL is can present itself as a factor that directly interferes with the results found in this review, since the descriptor used was “Health Literacy” and many articles may have addressed this topic, but without mentioning it.

CONCLUSION

The study enabled the identification of the existing HL strategies in the literature regarding Sexually Transmitted Infections, which despite presenting some challenges in their implementation, showed positive results related to the understanding, prevention and control of Sexually Transmitted Infections. The lack of training, especially of health professionals, and the existing prejudice regarding the subject were identified as one of the biggest limitations to be overcome in the implementation of the HL, being necessary to approach this technology early in undergraduate courses in health, with continuity in training and training.

In addition, it was also possible to identify the importance of evaluating the HL level of the population from different scales, this enables care actions to be planned and implemented according to the individual's health comprehension capacity and health needs. Finally, HL is a key component for health promotion at an individual and collective level, for users and health professionals, with regard to Sexually Transmitted Infections, as it allows informed decision-making and the promotion of empowerment and autonomy.

CONFLICT OF INTERESTS

The authors have declared that there is no conflict of interests.

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Submission: 18-Dec-2023

Approved: 21-Apr-2025

Editors:

Rosimere Ferreira Santana (ORCID: 0000-0002-4593-3715)

Geilsa Soraia Cavalcanti Valente (ORCID: 0000-0003-4488-4912)

Ana Carla Dantas Cavalcanti (ORCID: 0000-0003-3531-4694)

Corresponding author: Juliane Andrade (juliane.andrade@unesp.br)

Publisher:

Escola de Enfermagem Aurora de Afonso Costa – UFF

Rua Dr. Celestino, 74 – Centro, CEP: 24020-091 – Niterói, RJ, Brazil

Journal email: objn.cme@id.uff.br