Artigos

Conteúdo (article):

CONSTRUÇÃO DE TECNOLOGIA MHEALTH PARA PROMOÇÃO DA SAÚDE EM PLANEJAMENTO REPRODUTIVO: INOVAÇÕES NA ATENÇÃO PRIMÁRIA

BUILDING MHEALTH TECHNOLOGY FOR HEALTH PROMOTION IN REPRODUCTIVE PLANNING: INNOVATIONS IN PRIMARY HEALTH CARE

Edilson Rodrigues de Lima1
E-mail: edilsonrodriguesdelima73@gmail.com
ORCID: 0000-0002-3021-3336

Adriana Barbieri Feliciano1
E-mail: adrianabf@ufscar.br
ORCID: 0000-0003-2524-9876

Tanyse Galon2
E-mail: tanyse.galon@uftm.edu.br
ORCID: 0000-0001-6407-5739

Camila Almeida Neves de Oliveira3
E-mail: camila.ano@univasf.edu.br
ORCID: 0000-0002-3674-2378

Heloisa Cristina Figueiredo Frizzo2
E-mail: heloisa.frizzo@uftm.edu.br
ORCID: 0000-0002-7661-0353


1 Universidade Federal de São Carlos, SP.
2 Universidade Federal do Triangulo Mineiro, MG.
3 Universidade Federal do Vale do São Francisco, PE.

RESUMO
O Planejamento Reprodutivo é um direito humano básico reconhecido, sendo fundamental a garantia da qualidade do processo de trabalho dos provedores de saúde na Atenção Primária. Objetivou-se construir um protótipo de aplicativo móvel sobre planejamento reprodutivo para auxílio à educação permanente de enfermeiros na Atenção Primária em Saúde. Estudo metodológico embasado pelas quatro etapas: modelagem, projeto de navegação, design abstrato da interface e implementação. Nesta perspectiva, foi construído com base na categorização temática de conteúdos dos artigos oriundos da revisão integrativa, totalizando 24 moblets. Para acesso à tecnologia educacional apresenta-se a tela inicial, contemplando a tecla que dá entrada ao aplicativo, aos conteúdos, as demais interfaces e apresentação da temática envolvida. Enfatizaram-se conteúdos relevantes para uma abordagem centrada na pessoa, com acesso rápido e fácil aos conteúdos dispostos em apenas um click, envolvendo aspectos fundamentais: promoção do acolhimento, escuta qualificada, criação de vínculo e confiança e aconselhamento contraceptivo. Destarte, a sua aplicabilidade com linguagem simples, de fácil acesso e usabilidade, com conteúdo claro e embasado em evidências atualizadas ofertará maior qualidade e eficiência do cuidado.
Palavras Chave: Planejamento Familiar; Promoção da Saúde; Enfermagem; Tecnologia Educacional; Contracepção.

ABSTRACT
Reproductive Planning is a recognized basic human right and is essential to guaranteeing the quality of health providers’ work processes in Primary Health Care (PHC). This study aimed to build a prototype of a mobile application on reproductive planning to aid the ongoing education of nurses in PHC. This methodological study is based on four stages: modeling, navigation design, abstract interface design, and implementation, and was built based on the thematic categorization of article contents stemming from an integrative review, totaling 24 moblets. The initial screen is presented to access educational technology, including the key that enters the application, the contents, the other interfaces, and the presentation of the theme involved. Relevant content was emphasized for a person-centered approach, with quick and easy access to content available in just one click, involving key aspects: promoting welcoming, qualified listening, creating bonds and trust, and contraceptive counseling. Therefore, its applicability with simple language, easy access, and usability, together with a clear content based on up-to-date evidence, will offer greater quality and efficiency of care.
Keywords: Family Planning; Health promotion; Nursing; Educational technology; Contraception.

INTRODUCTION
Historically, obstacles and struggles in favor of recognizing the real health needs of women in their entirety have been pressing over the decades, while discussing this context of women\'s health and its specificities, from the perspective of reproduction, has not been an easy task in contemporary times.
One of the targets of the UN Sustainable Development Goals (SDGs) is to “ensure universal access to sexual and reproductive health” by 2030, including actions to aid in Reproductive Planning (RP)(1). This component denotes that individuals have the right to define the course of their own lives, that is, if and when to have children, how many, and with whom they wish to share their reproductive journey, are integral parts of this right(2), without segregation, embarrassment or repression, and hostility, by separating motherhood from sexual life(3).
RP sheds light on the magnitude of sexual education and knowledge about sexual and reproductive health(4). Health professionals involved in this care have the privilege and responsibility to ensure informed decision-making by users. It is important to note that high-quality RP services and their providers must respect, protect, and fulfill the human rights of all clients, in turn contributing to positive sexual health outcomes(2), as well as providing opportunities for improving interpersonal relationships with users, promoting patient-centered care and their satisfaction with the health service(5).
In the Brazilian context, RP is also characterized as a priority measure by ministerial bodies and is set forth in current public health policies, by fully guaranteeing the components of conception and contraception and offering contraceptive counseling(3). These services must be well-organized in order to guarantee the quality and adequate quantity of contraceptives that meet the population\'s demand. However, in the daily life of health services, the reality is quite different, revealing a lack of contraceptive methods or difficult access to contraceptives, as well as a need to increase the available options(6), given that most women who experience an unplanned pregnancy report the non-use, discontinuation, or improper use of contraceptive methods(1). The United Nations Population Fund (UNFPA) reports that, due to the suspension of services resulting from the COVID-19 pandemic, approximately 12 million women in the 115 low- and middle-income countries analyzed in this study, including Brazil, lost access to RP services, resulting in 1.4 million unplanned pregnancies. Thus, at the national level, the apprehension concering this negative panorama in sexual and reproductive health can be found in areas farthest from large centers, such as the North and Northeast regions of Brazil(7).
Failures in RP are still present in Brazil and worldwide, as these services do not reach all women. These gaps need to be incorporated into public policies, by expanding access and knowledge for women who need it most, with nurses being responsible for promoting educational practices, counseling, and clinical activities that give priority to the empowerment of men and women to make decisions with quality contraceptive counseling(8), performing four types of activities pertinent to RP in an integrated manner: counseling, free informed choice, dual protection, and monitoring(9).
The increase in mobile application-type devices has strengthened a new area, the so-called mobile health, which is widely used by health professionals as mobile technologies for diagnosis, monitoring, and intervention in health conditions. This technology also provides greater knowledge and empowerment to support health care(10). Above all, high accuracy regarding the quality of the applications in question becomes essential, positively impacting the safety of their users through information based on updated scientific evidence(11-12).
From this perspective, it is relevant and necessary for professionals to have tools at hand that can support them in this field of knowledge, through the proposal and applicability of a technological product that can provide greater efficiency and quality in the care provided. However, it is understood that, to date, no mobile application has been built for the Brazilian context, and nothing has been published in journals concerning nursing care in contraceptive counseling based on the assumptions previously mentioned in this study. To fill this gap, we highlight the construction of the mobile application entitled “Planner(Já): Nursing Care in Reproductive Planning”.
By recognizing the relevance of Primary Health Care (PHC) and its interlocution with nursing care in the context of PR, as well as the weaknesses of the Health Care Network (HCN) and of this professional in relation to the presented theme, it is understood that continuing education shows potential in this arduous process of action. Therefore, this article aims to build a prototype of a mobile application on RP to aid in the continuing education of nurses in PHC.

METHOD
This study is a methodological investigation, based on the development of a mobile application aimed at aiding nurses during RP consultations, carried out from September 2022 to August 2023. This study aims to describe the construct or behavior to be measured, structure the instrument items according to the culture of the target population, and develop guidelines for respondents with reliability and validity(13).
This work followed four main stages to build the hypermedia system, a prototype of a mobile application: modeling, navigation design, abstract interface design, and implementation(14-15).
To contemplate the modeling stage, the conceptual model of the application was developed based on an Integrative Literature Review (ILR)(16).
Data collection was conducted using the ILR to develop/build the mobile device. The PICO strategy – an acronym for (P) Patient/Population, (I) Intervention of interest, (C) Comparison intervention of interest, and (O) Outcome(s) of interest – was used to identify results relevant to the study question in an attempt to better define the descriptors. Therefore, it was possible to formulate the following study question: What theoretical knowledge supports the development of a technological solution in the form of a Mobile Application (APP) to optimize the care provided by the nursing staff in Reproductive Planning (RP) in Primary Health Care (PHC) aimed to Health Promotion?
The selected articles, in addition to answering the study question, met the following criteria: original articles, published in Portuguese, English. or Spanish. Duplicate and non-primary studies (such as literature reviews, editorials, commentaries, and letters to the editor) were excluded. The searches were conducted independently by two researchers in the electronic databases presented in Figure 1, carried out through the Journal Website of the Coordination for the Improvement of Higher Education Personnel (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – CAPES), through remote access via the Federated Academic Community (Comunidade Acadêmica Federada – CAFe) at the Federal University of São Carlos (UFSCar), accounting for 22 articles, through the presentation and use of the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) flowchart(17).
Figure 1

After data collection and analysis, the information was organized and used to develop the construct. The characterization of essential information from primary studies, carried out through an integrative review, provided important evidence and support for the development of the application, through the incorporation of the content of the construct by means of national and international references.
After a complete reading the 22 articles selected for the review, it was possible to confirm the relevance of the data and content, which add important value to the proposed study. Thus, to better understand and develop the educational technology to support decision-making by nurses in RP, thematic categories were created to develop the textual content of the application.
The next stage, the Navigation Project, consisted of organizing the hypermedia access structures, seeking to facilitate user navigation through the application, with the definition of menus, indexes, and scripts. Based on the conceptual model created in the previous stage, the content was arranged to make it easier for the user to access and use the application, establishing information that will be displayed to the user and ensuring how they will be interconnected.
Next, in the Abstract Interface Design stage, the system\'s presentation was determined and which interface objects could be viewed by the user were identified, as were the responses that each object should generate, illustrating how the interface was developed to captivate the user, providing clear and objective language to facilitate learning.
In the final stage, related to Implementation, all of the created content is transformed into the application to be executed. Therefore, the development of the application passes through the prototype creation phase, in which the interface should be focused on the user, attempting to promote easy use with simplified access to the content. An application for access via mobile phone should focus on the characteristics of simplicity, quality, and functionality in a quick, active, dynamic sense. It should also captivate users through content and functions that are easy to understand. The Figma tool was used to develop the design, which was carried out by the authors themselves. This tool has free access via Google through a user registration email. The images and photos were downloaded from the Unsplash website – Beautiful Free Images & Pictures – which is available free of charge with no need for a license to use the images. Therefore, it is important to reiterate that all of the steps were interconnected in an interdependent manner. Moreover, it is expected that, in the future, the applicability of the application will be tested with the target audience in order to begin the validation processes.
As this is a systematic methodological study, based on the appropriation of secondary data from the public domain, there was no need to submit this work to a Research Ethics Committee (Comitê em Ética e Pesquisa – CEP). Furthermore, all necessary procedures were followed for the proper execution of this scientific research.


RESULTS
By consolidating evidence from the ILR, it was possible to verify the relevance of the both the data and the content, which add important values to the proposed study and contribute to the development of the content that substantiated the building of the proposed technology. Aimed at facilitating the understanding and construction of educational technology to support decision-making by nurses in RP, the thematic categorization of the evidence was chosen, which enabled the textual development of the application’s content, displayed in Table 1 below:
Chart 1

When summarizing the evidence of these categories, it is important to understand that: (1) knowledge and accessibility concerning contraceptive methods are factors that directly influence choice and adherence, through information sharing and effective partnership participation; (2) it is important for trained professionals to meet RP demands, since their knowledge, attitudes, and practices influence counseling; (3) comprehensive care is important for the real health needs of the population, offering contraceptive counseling, health education, and autonomy in their decisions; (4) the nurse is an essential part in providing care and creating bonds between users and health services; (5) it is important to incorporate health technologies in the field of contraception, especially with the advent of the COVID-19 pandemic; (6) contraceptive counseling is an important tool in choosing the method, thus providing greater knowledge and offering the user more confidence in choosing according to their needs; and (7) the availability and uniform supply of all available contraceptive methods is of utmost importance, especially as regards Long-acting Reversible Contraceptives (LARCs), such as Intrauterine Devices (IUDs), with an adequate overcoming of organizational barriers imposed by health services to ensure access to the method and avoid the fragmentation of care within the HCN.
From this perspective, according to the gaps presented, it was possible to delineate the learning objectives of the prototype. Moreover, its development was carried out based on the understanding that the interface should be user-focused and with the objective of promoting easy use with simplified access to content and the applicability of actions. In the first screen, the prototype welcomes the user, with a home screen highlighting the theme and the name of the application, denoting proximity and better identification of the product, as well as presenting its visual identity with the option of the lilac tone and its symbology consistent with the scope of the study. The application was built with a total of 24 moblets (1 to 24). The home screen offers access to the educational technology, including a key that provides access to the application, the content, and the other interfaces, along with the presentation of the theme involved, as seen in Figure 2.
Figure 2

Next, the contents related to the other moblets are presented sequentially, and, with regard to user interactivity with the application, six moblets are arranged which, when clicked, lead to a new screen interface with other moblets, focusing on the specificity and organization of the information proposed in each subtopic of the moblet, as well as making the information available with a simple user\'s touch, as is better detailed in Figure 3.
Figure 3

Moblet I provides access to educational technology by presenting the application\'s home screen, including the key that accesses the Main Menu (moblet II), other interfaces, and content produced based on thematic categorization. It also indicates the theme and purpose of the study, as well as the importance of health professionals within the context of RP.
Moblets III to V present users with content related to laws and ethical and moral precepts, which provide support for nursing professionals to safely and autonomously exercise care and offer assistance in RP. It is important to note that these were products related to categories 1, 2, and 3.
The RP consultation must follow a logic that begins with the creation of bonds and trust between the people involved in the providing of medical care. In this sense, moblet VI, related to Clinical Practice, as well as moblets VII, VIII, and IX, represent the context in the form of a guide for a person-centered approach that prioritizes welcoming, qualified listening, contraceptive counseling, aid in the promotion of health for a more efficient and qualified approach by the professionals involved in the care, as well as an efficient HCN in sexual and reproductive health in order to reference complex cases of resolution and the detailing of the contraceptive methods available within the scope of the Unified Health System (SUS). This content was created through the contextualization of categories 3 and 6.
In this context, to provide comprehensive care for the real health needs of the population, access to programs, supplies, and healthcare units is also necessary, seeking to overcome the obstacles and barriers in order to reach the community as a whole. When it comes to RP, professionals must provide and predict the most commonly used methods to meet the needs of users within the HCN. Moblets X to XVIII present details of the most accessible and widely used methods in PHC, their indications and adverse events, as well as the importance of dual protection to prevent Sexually Transmitted Infections (STIs). These contents were prepared according to that proposed in categories 4 and 5.
Sexual and reproductive health actions and services, along with ongoing and continuous education and health promotion activities, should be an integral part of the context of RP care. Health professionals, especially those in PHC, should use these tools to provide additional care for users and professionals themselves, thereby ensuring a greater efficiency and quality of care.
RP providers need to be prepared for the different realities of women, men, and people with gender diversity. Providing care without discrimination and stigma is a key factor in achieving comprehensive care. Moblet XIX presents an approach to gender inclusion in the context of reproductive planning, through the content of category 7.
Therefore, it is important to highlight that nursing consultation is essential to achieving the objectives of comprehensive care. Moblets XX and XXI present essential aspects to be included in the nursing consultation, through a consolidation of information that must be collected for a detailed analysis by the health professional and by giving priority to a holistic approach to support comprehensive care in sexual and reproductive health. Moblets XXII and XXIII present the eligibility criteria proposed by the WHO for effective conduct and the most well-informed choice of the proposed contraceptive method, content related to categories 4 and 5. Finally, moblet XXIV provides access to the screen corresponding to the references used to build the product.

DISCUSSION
This ILR identified that the incorporation of digital technologies in the context of PHC has been valid, given that they are relevant tools necessary to maintain and provide health care for the population. In this context, the nursing profession has been the category with the greatest adherence to digital technologies, as it understands that health technologies bring facilities to its professional practice, with a positive impact on care results. Applications currently act as information tools due to their potential for accessibility and health education(18-19).
In continuity, it is understood that it is urgent to incorporate the responsibility of health providers in assisting in shared decision-making, with an emphasis on promoting person-centered RP, thus contributing to greater adherence and confidence in the qualified choice of the proposed method(20).
The Planner(Já) application emerges from this logic, proposing a clinical practice based on the assumptions of contraceptive counseling with conscious and shared decision-making between the health professional and the user, thus favoring the application of relational technologies, such as welcoming and qualified listening. It aims to propose the qualification of RP care by training and guiding the nurse in conducting a consultation that prioritizes comprehensive care, with the provision of updated information based on the best evidence available in the literature. Its construction was initially based on the weaknesses observed in clinical practice, with specific consultations, far from the recommendations proposed in the guidelines and without subsequent continuous monitoring. It focsed mainly on providing the main contraceptive methods, difficulties in professional training in this area to meet the true user demands, the lack of user knowledge concerning the basic information of the chosen method, among other relevant points, corroborated by the execution of this ILR (21-22). In this sense, the application prototype was designed and built following these theoretical assumptions, by integrating information from scientific studies of the ILR, and giving priority to clarity and objectivity for nurses\' adherence to the technology, as well as considering the subjectivity inherent to this field of knowledge, with the incorporation of an expanded view of the person and their uniqueness, converging with specialized national literature(23).
Firstly, regarding the visual identity of Planner(Já), the color lilac was chosen, as it expresses the feeling of harmony and emotional well-being, and, according to color psychology, it denotes empathy related to caring for others, becoming representative of women\'s struggle for equal rights(24) and one of the main colors of feminism and the LGBTQIAPN+ movement(25).
RP should be offered at all levels of health care and to the entire community without distinction of sexual orientation and meeting the new family configurations, including the LGBTQIAPN+ population, when considering the heteronormative and traditional model, especially in PHC, since it is the first instance of the HCN for those seeking care to resolve these demands(26). Taking this into account, from moblet I onwards, we sought to show providers the importance of their own health care within this new care model, seeking to attract their attention and include them in this process, with continuity presented in moblets III, IV, and V by focusing attention on the concepts, ethical and legal principles, and values.
Person-centeredness is an increasingly emphasized dimension of quality, defined as care that respects and responds to the patient\'s preferences, needs, and values, providing care based on the user\'s individuality for all clinical decisions(27). Contraceptive counseling is an excellent opportunity to improve interpersonal relationships with users by promoting person-centered care and their satisfaction with the health service(5).
The World Health Organization (WHO) defines RP as a way of thinking and living voluntarily, always valuing the wellbeing and health promotion of individuals, based on knowledge, the context of life, and responsible decisions centered around people, family, and the community(28). Therefore, it is understood that shared contraceptive counseling only involves the provision of information and methods available in the health unit, including key clinical aspects, attention to medical eligibility criteria, correct use, knowledge of possible adverse effects, guidance on the importance of dual protection, longitudinality of care, among others, as provided in moblets VI to XVIII.
Health professionals play an extremely important role in disseminating information about sexual and reproductive health, in such a way that their knowledge, attitudes, and practices influence counseling. Knowledge builds an attitude, and knowledge and attitude together shape behavior(28). Thus, nursing consultations in RP must encompass this new care logic, understanding the uniqueness of the woman when receiving medical care, through a complete anamnesis, with a thorough physical examination and incorporation of her speech throughout this process, as presented in the proposed nursing consultation form, through moblets XXII and XXIII.
A sustainable RP program is based on the provision of evidence-based care and its updates. Thus, the WHO developed the medical eligibility criteria for the use of contraceptive methods as a recommendation that should be adapted to the local conditions of each country, and a digital tool called Medical Eligibility Criteria for Contraceptive Use was recently launched, covering these criteria and aiming to facilitate the care of professionals through recommendations for safe, effective, and acceptable use by women(29). In this perspective, it is important to highlight that the applicability of health technologies in the nursing care practice is relevant in order to contribute to the qualification of the care provided and the incorporation of new possibilities, thereby expanding the perception of the health professional together with the user. Thus, the integration of such applications as Planner(Já) in the experience of nurses working in PHC can strengthen their performance in relation to RP, moving away from the purely biological premise to the incorporation of the social field.

FINAL CONSIDERATIONS
The development of Planner(Já) is relevant, as the prototype is a key tool in the scope of PHC, contributing to raise awareness among nurses regarding the essential aspects of RP consultations that give priority to comprehensive care, as well as to optimize their performance in the perspective of contraceptive counseling with shared decision-making.
One limitation is the fact that the technological product has not yet passed through the evaluation stage. Therefore, the intention is to carry out a validation of the content and appearance with experts in the field, as well as to conduct a trial of the application with a target audience, with a view to ensuring greater reliability, a fact that will be better demonstrated in future studies.
In the meantime, digital technologies, in addition to providing the qualification of care, aim to empower health professionals to improve their care skills, through methodologies that are easy to access and use, that can be used at any time, and that are becoming increasingly present in people\'s daily lives. It is essential for these professionals to take advantage of the technologies under development, adding them to their daily work and supporting decision-making with the individual under their care in order to achieve true comprehensive care.

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