{"paper_id":"2b678c7e-d48d-4c87-b88c-7f001901eaaf","body_text":"Infertility is clinically defined as the failure to achieve pregnancy after 12 months\nor more of regular unprotected sexual intercourse. It is a growing public health\nproblem worldwide, with a lifetime prevalence of between 17% and 26% ( 1 ) . It should also be noted that the\nchance of a fertile couple becoming pregnant is approximately 15% to 25% per month,\nand after a year of trying, this cumulative rate will be approximately 80%.\nTherefore, appropriate medical interventions and an investigation into infertility\nare necessary ( 2 ) .\nIt is imperative that, for many couples, the desire to become pregnant is a\nnecessity, but one that comes up against important health conditions. Pregnancy and\nmotherhood are health issues and should, therefore, be ensured through public\npolicies that guarantee full access to services for infertility treatment and/or\nassisted human reproduction (AHR), overcoming access barriers as a matter of\nreproductive justice ( 3 ) .\nIn this scenario, nurses play a crucial role in care comprehensiveness in the\nAssisted Human Reproduction and Fertility Program, providing support, welcoming,\nclarifying medical instructions and offering educational guidance, specifically\nduring welcoming, with special attention to patient education, focusing on physical\nand psychological care, guidance on procedures, promoting quality of healthcare and\nsensitivity to the needs and stories of couples/individuals ( 4 ) .\nWith the progress of the AHR area in recent times, nursing has gained prominence in\nthis scenario, fundamentally ensuring humanized welcoming, in addition to acting as\nthe main articulator of information, conduct with the multidisciplinary team and in\nthe AHR program team coordination, promoting assistance targeted to couples’ needs,\nguiding and preparing them in all procedures as part of welcoming ( 5 ) .\nIn the state of Pará, the infertility care service provided by the Brazilian Health\nSystem (In Portuguese,  Sistema  Único  de Saúde  -\nSUS) is provided at the Maternal and Child Reference Unit (In Portuguese,\n Unidade de Referência Materno Infantil  - UREMIA), which\nwelcomes infertile couples of all social classes and genders, trying to become\npregnant through an assisted reproduction program. In this service, educational\ntools, such as educational technologies (ETs), are not used during the welcoming of\ninfertile couples. Thus, it is believed that the link between ET and medicalization\nand humanization/welcoming values nurses’ work in relation to reproductive\nbiotechnologies ( 5 , 6 ) .\nIt is known that ET, as a tool, can mediate the planning, implementation and\nassessment of the teaching-learning process used in educational meetings,\nstrengthening the construction of knowledge between student and educator ( 7 ) . As strategies for health\neducation, ETs contribute to increasing access to information regarding illness,\ndiagnosis, treatment and access to healthcare services, considering the social and\nfamily context ( 8 ) . ETs can be\nconsidered a significant educational and care resource, and can be used in health\neducation activities ( 7 ) .\nTherefore, it is believed that investing in the welcoming and production of ET for\nthis clientele can reduce the fears, anxiety and impact of couples in relation to\nthe “desire to become pregnant”, as well as clarify doubts regarding reproductive\nhealth, necessary tests, and the situation and functioning of the Assisted Human\nReproduction Program ( 9 ) .\nThus, this study aimed to describe the process of developing an educational\ntechnology for nurses with a view to mediating the welcoming of couples in AHR.\n\nThis is development research ( 9 ) \nwith methodological interface ( 10 ) , developed in two phases. The first phase (situational\ndiagnosis in the context of AHR) was research with a qualitative approach,\naccording to COnsolidated criteria for REporting Qualitative research\nrecommendations. The second phase (product development) ( 9 )  was based on the\ncontext ( 11 ) . The\ncontext-based production method consisted of collecting\ninformation/considerations about the target audience and with the target\naudience (couples served in the AHR program), obtained through primary data\nproduction, making it possible to identify significant topics and, from them,\ndevelop ETs ( 11 ) . It should be\nnoted that this study has not yet been made available on the service and\nparticipants have not yet been able to access the final version; however, it\nwill go through the stages of continuity projects ( 12 ) , with subsequent assessment with the target\naudience in future studies.\nPhase I - Situational diagnosis in the context of assisted human reproduction\nPlace\nThe study was developed in a UREMIA, a state reference in AHR, linked to the SUS,\nlocated in the city of Belém, Pará, Brazil.\nTwenty infertile couples who sought treatment for AHR at UREMIA participated in\nthe study. Inclusion criteria were couples aged between 18 and 40 years, who had\nbeen followed up at the referral unit for at least six months. Exclusion\ncriterion was couples in which a woman had undergone a hysterectomy and/or had\nan underlying disease under treatment (uterine fibroids, endometriosis).\nParticipants were approached in the waiting room, before the consultation with a\nnurse, and at that time, they were invited to participate in the study, and\nthose who accepted were taken to a private room where they were welcomed by the\nresearcher and informed about the procedures to be performed.\nData were collected between June and September 2019. Semi-structured interviews\nwere conducted using a script constructed with 22 questions about couples’\nsociodemographic profile and conditions. The questions were related to: couples’\nknowledge about the Assisted Human Reproduction Program; reasons for seeking\ncare in the program; means and ways for the program to help couples in\nwelcoming; suggestions for meaningful content to be shared in an ET; and\nsuggestions for an interesting ET format to gather content with a view to\nhelping infertile couples receiving care in the program.\nThe interviews were transcribed by the researchers and organized into a text\n corpus . Subsequently, the  corpus  was\nanalyzed using the three stages of thematic content analysis, with the support\nof  Interface de R pour les Analyses Multidimensionnelles de Textes et de\nQuestionnaires  (IRAMUTEQ ® ) software, according to the\nReinet method ( 13 ) .\nIRAMUTEQ ®  enables the identification of context in which words occur,\nperforming a lexical analysis of the textual material and dividing the text into\nhierarchical classes, which are identified from text segments (TSs) that share\nthe same vocabulary, thus making it easier for the researcher to understand\ntheir content. The class is defined as a grouping made up of several TSs with\nhomogeneous vocabulary ( 14 ) .\nThe Descending Hierarchical Classification (DHC) method was chosen, in which\ntexts were classified according to their respective vocabularies, and the set of\nthem was divided by the frequency of reduced forms. The focus was on acquisition\nof TS classes that presented similar vocabularies among themselves and different\nfrom TSs of other classes. For DHC analysis, it was necessary to have a\npercentage of use of at least 75% of TSs by IRAMUTEQ ® , considering\nthat if retention was lower than the proposed one, the  corpus \nwas not representative for this type of analysis or that the\n corpus  content was very diverse, not allowing them to be\nhierarchized ( 14 ) .\nThus, after processing, the categories generated from DHC classes were subjected\nto the thematic analysis process.\nThis study followed the ethical precepts of research involving human beings,\nlisted in Resolution 466/2012, and was approved by the Research Ethics Committee\nof a public university in northern Brazil. Participants’ consent was obtained\nthrough the Informed Consent Form, under Opinion 3.308.311. To preserve\nanonymity, participants were given the letters “IC” for infertile couples,\nfollowed by the number corresponding to the order in which the interviews were\nconducted.\nPhase II - Development of educational technology on the support of couples in\nassisted human reproduction\n\nThe characteristics of the 20 participants indicated that their ages ranged from\n18 to 40 years. Of these, 12 (60%) reported being in a stable union and eight\n(40%) were married. Regarding their level of education, 14 (70%) had completed\nhigh school and six (30%) had incomplete high school. Moreover, 19 (95%) couples\nreported a family income of one minimum wage and one (5%) couple reported a\nfamily income of more than one minimum wage. Concerning religion, 12 (60%) of\ncouples considered themselves Catholic and eight (40%) considered themselves\nEvangelical.\nThe text  corpus  presented 20 text units, 76 TSs, 407 distinct\nforms and 2,667 occurrences of words in the text, with an average frequency of\nthe forms of 35,092,105, generating six distinct semantic classes. Sixty-two TSs\nwere used out of a total of 76, which corresponded to 81.58% of the\n corpus , characterizing the TSs. The DHC identified the\nrelationship between the classes and the words with the greatest association in\nthese classes and their respective chi-squares and frequencies, having reported\nonly those that met the established criterion [χ 2  (1) ≥ 3.84, p <\n0.05], i.e., the significant words ( Figure\n1 ).\nFrom this, the thematic categories emerged from semantic group 1, which are\ncontents related to the Assisted Human Reproduction Program, and from semantic\ngroup 2, which are contents related to technological production, originating\nfrom the six classes generated by IRAMUTEQ ® , which lexically explored\nthe text  corpus  “Educational technology for couples in the\nAssisted Human Reproduction Program”. The respective thematic categories were\ninterpreted based on the content analysis proposed by Bardin ( 12 ) , organized in a flowchart\nformat ( Figure 2 ).\nIn this category, in the arrangement of classes VI and V, it was found that\nthe words “sperm” (n = 15) and “couple” (n = 10) were the most prominent and\nthe most specific, with high significance. The word “child” (n = 37), in\nturn, was the most cited, which encompassed a unique meaning, as it\nexpressed couples’ cognitive association about the Assisted Human\nReproduction Program. The words that stood out were “treat”, “assistance”,\n“advise”, “follow up”, “egg”, “disease”, “uterus”, “pregnancy”, “desire”,\n“want” and “husband”, revealing the limited knowledge that couples have\nabout the Assisted Human Reproduction Program. The couples, therefore,\nreported:\nThe Assisted Human Reproduction Program provides guidance to\ncouples on how to become pregnant. They can take my egg and my\nhusband’s sperm and implant it in me, and the program monitors the\nprocess. We think that’s it!  (IC-01)\nIn our opinion, the Assisted Reproduction Program will advise\ncouples who want to become pregnant. It will tell them who can, what\nis needed, whether they need to do any tests, etc. I think that’s\nit!  (IC-03)\nThe program will combine my egg and my husband’s sperm. I want\nto become pregnant and have a child, so that when we get older, we\nwill have someone to help us, to find out the difficulty that\nprevents us from becoming pregnant, and the professionals can solve\nthe difficulty we have in becoming pregnant and treating this\ndisease.  (IC-06)\nIn category II, classes 2 and 3 merged, and the words “reason” (n = 8) and\n“get” (n = 9) stood out the most, i.e., they achieved high significance in\nthis class. The words “program” (n = 44), “become pregnant” (n = 41) and\n“child” (n = 37) were the most cited and were not statistically significant;\nhowever, they add relevant meaning to the context of the category, as they\nrepresent the main reason that led couples to seek the service, the desire\nto become pregnant, have a child and discover the cause of the difficulty in\nbecoming pregnant. The couples stated:\nThe main reason we sought out the program was to help us become\npregnant and have a child, receive guidance on sexual intercourse,\ntreatment to become pregnant and, finally, place an egg and a sperm\nin my uterus to become pregnant.  (IC-17)\nThe main reason is to want to become pregnant and have a child!\nWe want help to have a baby. A healthy child!  (IC-19)\nThe following words that stood out were “test tube”, “baby”, “treatment”,\n“disease”, “think”, “help” and “dream”, confirming couples’ reasons for\nseeking the Assisted Human Reproduction Program services. Thus, they\nsaid:\nFulfilling my dream of carrying our child, giving me the\nguidance and information I needed to become pregnant. \n(IC-06)\nSince they make test tube babies, we want to have one. We don’t\nhave any diseases; I think he can help us become pregnant and have\nchildren and find out why it’s difficult to become\npregnant.  [...]  the program will watch the\nconception of a child. I looked for the program to find out the\ndisease that prevents us from having children. We want to become\npregnant even if it’s a test tube!  (IC-09)\nThe main reason is for me to have a child and become pregnant,\nbecause I have never been pregnant! To make this dream come true, I\nbelieve the program will treat this disease and examine my eggs and\nmy husband’s sperm.  (IC-15)\nCategory III emerged from the association of words contained in classes 1 and\n4, and it was found that the words “folder” (n = 14) and “arrive” (n = 4)\nstood out the most, being more specific and reaching high significance in\nthis class. The word “test” (n = 22) obtained a degree of significance and\nwas cited in both classes, which encompassed a special meaning by expressing\nthe association of couples’ doubts about the tests necessary to enter the\nAssisted Human Reproduction Program. The couples, therefore, mentioned:\nCould you have a folder with information like this: what is the\nprogram? How do I join? What tests are required? Who can do\nthis?  (IC-04)\nThat has information on how to get to the unit, what is needed\nto be part of it, if tests are needed? What is the program about\nassisted reproduction? All this in a folder!  (IC-06)\nA folder with more complete information: how does the program\nwork? What is the program? Who can participate? How can I be\nreferred here? What tests are needed?  (IC-12)\nThe following words that stood out were “necessary”, “explain”,\n“information”, “participate”, “refer”, “function” and “guide”, revealing\ncouples’ suggestions regarding the content to compose a folder, which was\nthe ET of choice to be developed in this study.\nIt was inferred that the couples suggested a folder because it was clear and\nprecise, easy to handle and objective to read. It was also clear from the\nreports that the couples were eager for information about how the Assisted\nHuman Reproduction Program works, as well as the tests, the therapeutic\nitinerary, the referrals, the admission, among others, as observed in the\nstatements:\nIt could be a folder with more information, such as explaining\nwho can and cannot become pregnant, how old you can be to undergo\nassisted reproduction, and if the person has had a tubal ligation,\nthey can be part of this program. Explain the tests and\nreferrals!  (IC-01).\nMore information, such as who can participate, the tests they\nneed, how to get here. These things could all be in a\nfolder  (IC-08).\nWe suggest a folder with information about what the program is,\nhow it works, who can participate, how to get here, and whether\ntests are required. A folder informing who can and cannot\nparticipate?  (IC-11).\nBased on the topics that emerged, the folder format was chosen, considering\nparticipants’ interests and the content needed for welcoming. The folder was\nprepared on two A4 sheets (21 cm x 29.7 cm), divided into three parts, aiming at\nthe possibility of being folded when printed, totaling six pages, in landscape\norientation. Calibri and Times New Roman fonts were used, varying in font size,\nbeing 12 for the body of the text, 14 for the topics, and 20 for the title. The\ntitle “Assisted Human Reproduction Program” contemplated the folder’s\nobjective.\nThe folder was structured into five topics: “What is the Assisted Human\nReproduction Program?”; “Who can participate?”; “How is the referral to the\nprogram made?”; “What tests are necessary?”; “How does the Assisted Human\nReproduction Program work?”. The main information was made available with an\nobjective demonstration of the expected action, avoiding accumulation of\nguidelines, with short, simple sentences and use of active voice.\nFurthermore, the ideas in the folder were exemplified through colorful\nillustrations with a predominance of the color blue, due to its symbolism of\ntrust and security, making it an ideal choice for topics that require additional\nreinforcement and seriousness, such as healthcare services. It is also a\nversatile color that allows for harmonious and attractive compositions, making\nthe folder more visually interesting and welcoming for the reader. The\nillustrations are composed of images and drawings that allude to the information\npresented in the texts. For the final version, support was obtained from an IT\nprofessional and a layout professional, who followed Corel DRAW GraphicsSuite X6\nprogram stages ( Figure 3 ).\n\nThe age of the couples interviewed in this study was within the age limit recommended\nby the Federal Council of Medicine, which recommends a maximum age of 50 for women\nto become pregnant through artificial insemination. The limit was proposed because\nof obstetric risk, congenital malformation and comorbidities (diabetes and\nhypertension), considering that, after the age of 50, risks of hypertension in\npregnancy, diabetes and premature births increase ( 15 ) .\nAnother relevant fact regarding the age variable for assisted reproduction is in\nrelation to egg donors’ age, which cannot exceed 35 years, which influences the egg\nquality and, consequently, its fertilization. In relation to cis men, it is\nrecommended that they donate to sperm banks at an age under 50, since children of\nolder fathers run a greater risk of developing health problems ( 15 ) .\nIn relation to couples’ marital status, given the social advance in the creation of\nnew family arrangements, the demand for AHR methods by people in stable unions, as\nin this study, has increased, mainly due to the high rate of infertility. Thus,\nscientific advances have allowed for increased access to these services and the\nrealization of people’s sexual and reproductive rights, regardless of their marital\nstatus ( 16 ) .\nLow socioeconomic and educational levels were also a relevant finding in this study,\nand these variables may be factors that influence the success of counseling until\nfollow-up in the program, since, at times, there is no prioritization of\nreproductive techniques, especially within the SUS, which, in this way, creates and\nmaintains an economic barrier, excluding those who cannot afford to pay for AHR\nmedications, procedures and services. Furthermore, the supremacy of AHR in the\nprivate sector deepens inequalities and vulnerabilities with the impossibility of\naccess to these technologies ( 5 , 17 ) .\nFurthermore, in relation to health literacy, especially of women seeking the assisted\nhuman reproduction program, it is an aspect that confronts the SUS principles of\nequity and comprehensiveness, since the intersection of social markers is an\nimportant barrier to access, with an exclusionary treatment of these women, since\nthey sometimes present themselves as non-cisgender, low-income, with low education\nand non-white, reinforcing that this profile, historically, does not have easy\naccess to healthcare services in Brazil, confronting the SUS principles of equity\nand comprehensiveness ( 3 ) .\nRegarding religious factors, all couples in this study had some religion; in this\nregard, respect for the universality of access to health and treatment, with the\nState’s compliance with the Universal Declaration of Human Rights, not allowing\nreligious perspectives to be a barrier to access to AHR services, is an important\nmeasure, since the notion of procreation has long been encompassed by erroneous\nconceptions and taboos, such as civil and religious unions between cisgender men and\nwomen ( 17 ) .\nIt is worth noting that the word “child” was the most cited in category I, which\nencompassed a unique meaning, as it expressed couples’ cognitive association with\nthe assisted human reproduction program. The study showed that women associate the\nconcept of family with feelings of love, affection, support and perpetuation of the\nspecies, associated with the idea of completeness to fill a gap and give continuity\nto the family, through the dimensions of an idealized family model based on kinship\nand blood ties ( 18 ) .\nConcerning the other words that stood out, such as treat, assistance, advise,\naccompany, egg, disease, uterus, pregnancy, desire, want and husband, the limited\nknowledge that couples have about the Assisted Human Reproduction Program was\nrevealed. From another perspective, they verbalized that the Assisted Human\nReproduction Program “treats uterine disease”, “advises and accompanies during\npregnancy” and “advises the couple/parents on the desire/want to have a child”.\nIn this context, the study on the profile of infertile couples undergoing the AHR\ntechnique concluded that knowledge related to infertility issues, its causes and\nservices was scarce among the population and healthcare professionals ( 19 ) .\nIt is also revealed that one in six couples has difficulty becoming pregnant. The\nstudy showed that health conditions in both sexes that can lead to infertility are\nrelated to varicocele, vasectomy, genetic causes, hormonal changes, living with HIV\nor no apparent cause for cisgender men and endometriosis, tubal, ovulatory and\nuterine changes, immunological causes, and non-apparent causes for cisgender\nwomen ( 20 ) .\nThe reports also showed an intense desire to become pregnant, which is deposited in\nthe reproduction program, even if it is “ in vitro ”, since couples\nsee the service as a means of helping to resolve the difficulty of becoming\npregnant. Given this context, assisted reproduction offers real possibilities for\nmen and women who have difficulty becoming pregnant and having a child ( 21 ) .\nThe relationship between nurses and AHR is still incipient. Moreover, there is a lack\nof formal and protocol-based information on the subject since the nursing training\nprocess, which can be a dilemma, since nurses’ performance is based on scientific\nfoundations using technologies ( 5 ) .\nIn this context, it was also noted from the reports that couples are eager for\ninformation about how the Assisted Human Reproduction Program works, as well as\nabout the tests, therapeutic itinerary, referrals and ways of accessing the\nprogram.\nTherefore, it can be inferred that the suggestion that couples prepare a folder, such\nas ET, may be an important strategy, since the folder is a textual genre that\nawakens interest in the language, since, when used in accessible language, it\npromotes effective communication between people with flexibility and versatility\nboth in the production and presentation of a topic, in addition to allowing the use\nof languages and images adapted to the target audience, which facilitates the rapid\nunderstanding of the ideas and concepts addressed in this work ( 22 , 23 ) .\nStudies show that ETs are valid instruments for mediating caring actions in different\ncontexts that relate to the target audience’s characteristics and demands, through\nthe use of senses, perceptions, emotions, speech, social and cultural contexts,\nsupporting the construction of a message that demonstrates its true\nmeaning ( 24 , 25 ) .\nOne of the limitations of this study is the choice of informants from a single AHR\nprogram. Therefore, further studies are suggested including couples enrolled in\nother programs, in order to explore other conditions.\nThe results of this study reinforce the importance of support, both by healthcare\nprofessionals and, especially, by nurses, in AHR programs, as it is a possibility of\nlistening, approaching and supporting couples, favoring broad and integrative\nassistance that elucidates the role of couples in the quality of the decision to be\nmade.\n\nCouple conditions indicated the need for informed welcoming, and the collection and\napplication of social evidence favored the development of a context-based ET. It was\nconcluded, therefore, that the process of building technologies based on social\nevidence, as the first stage of the technological product development cycle, is a\nstrategy that can support nurses’ work process in the welcoming carried out in AHR\nprograms, through continued validity of the instrument with the target audience.\nThe words that emerged supported the inference of couples’ insufficient knowledge,\nand information collection from the couples assisted in the program made it possible\nnot only to define the content, but also to choose the type of ET. Text organization\nwas guided by the words with the highest frequency and high degree of significance,\nbeing appropriate to the target audience’s language, culture and knowledge, based on\nboth the context and scientific evidence.\n\nThe entire dataset supporting the findings of this study has been made available on\nSciELO Data and can be accessed at:  https://wp.scielo.org/wp-content/uploads/Guia_curadoria_pt.pdf","source_license":"CC-BY-4.0","license_restricted":false}