INTRODUCTION

Acquired Immune Deficiency Syndrome (HIV) infection is considered a pandemic of complex and unsTable dynamics, and therefore becomes increasingly challenging for public health. The UNAIDS report, 2021, shows that globally, from the beginning of the epidemic until June 2021, about 79.3 million people have been infected with HIV, and that since 2010, the number of people undergoing treatment has more than tripled¹.

With the advent of technological advances, Sexually Explicit Media (SEM) gained prominence, due to a possible association of its use with the increase in cases of Sexually Transmitted Infections (STIs), including HIV/AIDS², which are described as any content in which there is explanation of genital organs or sexual acts, and which have the capacity to modify or stimulate the observer's sexual desires³.

The consumption of SEM is a matter of controversy as to the effects it can have on the health of consumers. Positive influences on sexual development and sexual practices are identified, since many adolescents and young people use these media as tools to learn about sexual orientation and to understand their desires ^4,5. Nevertheless, a study points to negative influences such as the acceptability of the practice of sex without condoms⁶.

Advances in antiretroviral therapy (ART)⁷, the emergence of Pre-Exposure HIV prophylaxis (PREP) and serological testing are some ways used to ensure the production of films with scenes that demonstrate the absence of condom use and ensure the sexual health of actors. One of the reasons for this expansion of SEM without a condom is the need of the industry to meet the increase in demand for videos that retract this practice⁸.

To raise the implementation of new strategies to cope with HIV/AIDS, with important implications for future efforts and preventive policies against this infection, it is important for health professionals, educators, managers and other members of society to know how the use of SEM may be associated with the sexual behavior of the population and with the increase in cases of HIV/AIDS. In this sense, the availability of reliable and validated questionnaires is important, as it will allow them to be applied in the processes of health situation assessment in an objective and organized way and according to the culture of the Country⁹.

This study aims to describe the process of validation of appearance, clarity and relevance of the content of the instrument "Consumption of online sexual media and HIV/AIDS risk practices" for Brazil.

MATERIALS AND METHOD

This is a methodological study, with a quantitative approach, conducted from January 2021 to January 2022, online throughout Brazil. It was developed in three stages: adaptation of the instrument; validation of appearance, clarity and relevance of the content by the committee of judges and semantic verification with the application of pre-test with users of social networks.

For the validation process, the Delphi technique was chosen, which requires methodological rigor and occurs in stages, from the refinement of the judgments of a committee of experts on a given theme. The process of appreciation, evaluation and validation is carried out in rounds by the judges anonymously, without prejudice to the reliability of the study^10,11.

The original version of the instrument aims to evaluate the influence of sexually explicit media consumption (SEM) of the "bareback" type in the practice of anal sex without a condom by men who have sex with men (MSM)¹².

The instrument was adapted by the researchers of this study with a view to meeting not only a specific population category, but the general population and had five dimensions: 1. Sociodemographic data (age; profession; sex; personal and family income; marital status; education and occupation; 2. Health Conditions/Information (history of present or past STIs, HIV serological status, some other comorbidity; information on HIV/AIDS, pep and prep); 3. SEM consumption: preference for movies with scenes with condoms or without, age at which they started watching pornography, how many scenes they usually see per week (considering that a scene contains an average of 20 minutes), main way of accessing pornography, if the consumption of pornography "bareback" alters their sexual practices; 4. Sexual practices (condom use, use of PrEP and PEP, use of other forms of prevention, use of stimulant drugs when having sex, group sex, for money, anal sex without condom s and without lubricant, sex with HIV + patient with detecTable viral load or with unknown viral load, number of partners in the last six months, use of licit and illicit drugs); 5. Access to health services (Information on STIs/AIDS received in health services; receipt of medicines and STU/AIDS prevention in health services, testing in the last 12 months and in life; hepatitis B vaccination; search for health service; convenience of care hours).

The sample consisted of five judges, as Nielsen ¹³ suggests, which states that a sample between three and five judges is sufficient to evaluate an instrument, and the efficiency for five experts is equivalent to 75%. Coluci and collaborators, 2015, bring in their recommendations that the instrument be evaluated by a quantitative of five to ten judges for its validation in the health area. Therefore, the committee of judges had five health professionals, doctors with experience in HIV/AIDS, research and validation and adaptation of instruments ¹⁴.

For the invitation of the experts in the two rounds, a previous contact was made via e-mail, and sent: the cover letter, the instructions for evaluating the items to be analyzed, the adapted instrument, the Free and Informed Consent Form, and the research project. It was also informed in the contact about the period of 10 days for return of the evaluated material.

In the first phase of the study, the original instrument was adapted to the context of online sexual media and to the general population, after the search in the scientific literature, and in the second stage, the content validation of the adapted instrument was validated, with the Delphi technique, in two rounds, as necessary for this study. Each item was analyzed for appearance, understanding and relevance of the content, using the Likert scale. As for appearance and understanding, the options were: 1 (bad); 2 (reasonable); 3 (good); 4 (particularly good); and 5 (excellent). For the relevance of the content, it was considered: 1 (not relevant); 2 (not relevant); 3 (moderately relevant); 4 (relevant); and 5 (highly relevant)¹⁵.

The Content Validity Index (CVI) was calculated, which indicates the proportion of evaluators regarding agreement on the items of the instrument regarding the appearance, understanding and relevance of the content. The items with a minimum proportion of 0, of agreement between the experts were considered valid and the lowest were reviewed¹⁶.

After the validation stage, the third phase of the study was performed, with semantic verification from the application of the pre-test of the instrument adapted to the study population with ten people. The participants were guided, through a script, to analyze in each item the following aspects: clarity, relevance and appearance; and assign values from 1 to 5, considering 1 the worst grade and 5 the best. Subsequently, the Positivity Index was calculated. Figure 1 summarizes the validation process.

Figure 1. Flowchart of the instrument validation process. 

The data were processed in IBM^® SPSS^® software with descriptive statistical analysis. A double entry Table was constructed, with items arranged in the left margin and criteria in the first row, for arrangement of the evaluations and subsequent calculation of the Content Validity Index (CVI), which was generated from the sum of the answers assigned at levels 4 and 5 (on a Likert scale) divided by the number of judges. An agreement of at least 80% was a criterion of decision on the correspondence of the item to the latent trait to which it refers and, consequently, maintenance of the same. The total CVI for the item corresponded to the average obtained in the criteria of "relevance" and "appearance and understanding". Items with were kept CVI≥80%. The items with lower measures were corrected for further assessment by the judges and the same criterion was adopted for CVI¹⁶.

To analyze the pre-tests with the target population, the Positivity Index was calculated, applying in the numerator the number of positive responses of each dimension and each item and, in the denominator, the total number of responses to the item. The answers with grades 4 and 5 were considered positive and points 1, 2 and 3 were considered positive¹⁷.

The study was approved by the Research Ethics Committee on March 13, 2020, Opinion n. 3,915,991. The "Guidelines for procedures in research with any stage in virtual environment" of February 25, 2021, were followed.

RESULTS

The validation of the instrument "Consumption of online sexual media and HIV/AIDS risk practices" had the participation of five female specialists, all with doctorates, researchers and studies in the area of infectious diseases and HIV, from different regions of the country as a way to receive evaluations and recommendations the peculiar regional characteristics, whose professions are: three are nurses (60%) and two are infectious diseases.

The instrument submitted to validation contains five domains, the first consisting of items directed to the personal characteristics of the participants, and which comprised the initial conformation of the instrument. The items in this section presented in the first round, CVI favorable for relevance (86.2%), but unsatisfactory for appearance and understanding, with CVI of 76.9%. The judges recommended the formulation of a single question about religion (total CVI = 60.0%) and change on marital status (total CVI of 70.0%). Items with total CVI below 80% were excluded and, therefore, this section obtained CVI for relevance of 92.0%, for appearance and comprehension, 82.0%, and Total CVI of 87.0%.

The total CVI for sexual health questions was satisfactory (93.4%), with values of 97.8% for relevance and 88.9% for appearance and understanding. Recommendations were met for better understanding of the items, with specification of the body area in the item on symptoms (total CVI = 90.0%), exemplifying STIs (total CVI = 80.0%) and explanation of technical terms. Regarding the self-test, one specialist pointed out the little access and dissemination and the non-implantation in some places, also requiring attention to the explanation of what the self-test is about (total CVI = 80.0%). In general, the judges suggested the reorganization of items to reduce subordinate questions.

The items related to the consumption of explicit sexual media obtained CVI of 100.0% for both criteria. Some contributions were also made. A judge suggested that questions be added about access to pornography and the maintenance of activities of daily or labor life, real-time interaction, and face-to-face interaction with people in these videos. Another expert, in the items that address the habit of watching pornography, suggested the addition of "erotic art" in the writing. The adjustments made did not imply a new evaluation, with a view to obtaining a total CVI of 100.0% for this section.

The section referring to sexual practices also obtained total satisfactory CVI (94.2%), with CVI of 95.8% for relevance and 92.6% for appearance and understanding. For the item on the practice of sex "without a condom even with a fixed partner", the word "same" was instructed not to bias the answer and another judge recommended dividing the item into two questions: with a fixed partner and with an eventual partner (total CVI = 100.0%). It was suggested the elimination of items that question the relationship because they were addressed in the first section of the instrument (total CVI = 80.0%).

Regarding measures to prevent STIs, the withdrawal of the commercial name of the medication was instructed (total CVI = 90.0%). For the item "With how many partners have you had sex in the last 6 months?" it was suggested to add "with penetration" and switch to the 12-month interval (total CVI = 100.0%), whose adjustment was also used in the questioning of points of cruising (total CVI = 80.0%). The total CVI of the section was 91.7%, with values of 90.0% for relevance and 93.3% for appearance and understanding.

To standardize the recommendation of reduction of subordinate variables, the category "no means/no information seeking" (total CVI = 100.0%). Another writing suggestion was "health service/medical-psychological care" (total CVI = 80.0%). The item referring to the quality of care in the health service was considered unsTable, questioning the contribution to the research and was eliminated with total CVI of 70.0%. Table 1 shows the Content Validity Indexes of each section and global.

Table 1. Content Validity Index by section of the instrument to evaluate the influence of online sexual media consumption in the 1^st round. Teresina, PI, Brazil, 2021. 

Legend: CVI - Content Validity Index

Table 2 lists the changes suggested by the judges for the qualification of the instrument submitted for validation in the first round.

Table 2. Changes made in the items of the instrument after suggestions of the judges. Teresina/PI, Brazil, 2021. 

After alterations, the instrument was again submitted to the evaluation of the specialists and obtained a total CVI of 100.0% for the five sections and, consequently, for the set of items of the last version. In addition, small suggestions were made.

Then, the latest version was evaluated by the target audience, comprised of seven (70.0%) men and three (30.0%) women, with an average age of 28.1 (±4.5), ranging from 23 to 31. Regarding occupation, three (30.0%) were students, two (20.0%) administrative assistants, two (20.0%) teachers, two (20.0%) operational/administrative managers and one (10.0%) care nurse, totaling six (60.0%) participants with complete higher education and four (40.0%) with complete high school.

The evaluation of the latest version of the instrument by the target audience obtained a final positivity index of 99%. The measures of positivity in the sections ranged from 98% in "personal characteristics" to 100.0% in three sections: "sexual health issues", "consumption of explicit sexual media" and "sexual health service", according to Chart 3. Among the observations of the participants, it was highlighted that the instrument managed to cover most of the problems pertinent to the object for which it was constructed, and it was suggested to add an explanation or synonym for the term "prophylaxis", because health professionals better know it.

Table 3. Positivity index of the sections of the instrument to evaluate the influence of online sexual media consumption according to the target audience (n=10). Teresina, PI, Brazil, 2021. 

Legend: PI - Positivity Index

Among the observations of the participants, it was highlighted that the instrument managed to cover much of the problem pertinent to the object for which it was constructed, and it was suggested to add an explanation or synonym for the term "prophylaxis", because health professionals better know it.

DISCUSSION

The instrument was evaluated with maximum Content Validity Index for personal characteristics, questions about sexual health, consumption of explicit sexual media, sexual practices and health service for sexual health, as well as for the set of items. Thus, it was presented as a valid tool for evaluating the influence of online sexual media consumption on HIV risk practices.

In the section of personal characteristics, the presentation of the variables gender, gender identity and sexual orientation carry important sociocultural expressiveness, in which the attention of the specialists in contemplating various categories was evidenced. Although there is clarity for those who understand the subject, many participants may not understand the terms "cis", "trans" and '"non-binary" regarding gender identity, as well as the terms "pansexual" and "asexual" in the item on sexual orientation, which justified the addition of an explanatory note.

It is therefore important to emphasize that gender refers to binary concepts: man or woman. Sexual orientation refers to the sexual attraction felt by someone, and one dimension is independent of the other. Thus, not every man and woman is straight, who are attracted by the other sex. They can be attracted to the same sex, being gay people. It is important not to forget that there are people with attraction to both sexes, these are bisexual ¹⁸. This can be said of gender identity: not every person is naturally cisgender, or that identifies with the sex from birth. Like other people, a transsexual person, who does not identify with the sex from birth, can be bisexual, straight or gay person, depending on the gender he adopts and the gender with which he or she is affectively attracted ¹⁹.

The questioning about the "marital status" was rejected, possibly because the target audience focus of the study was composed of individuals who have greater sexual exposure, so that the type of relationship that best defines the participant seemed to be a better approach.

The HIV test is simple, easy to handle and allows the individual to perform his or her own testing through an oral fluid sample (FS) or a blood sample. It consists, therefore, in a strategy to make tests more accessible, confidential and available in addition to carrying out in health centers²⁰.

Regarding sexual health issues, the experts directed attention to technical terms to ensure the understanding of the target audience, with emphasis on the terms "self-test", "PEP" and "PrEP".

The use of PEP is characterized as a medical emergency and, therefore, should be initiated as early as possible, ideally in the first two hours after exposure, with a limit to 72 hours after exposure ²¹. Pep is recommended by the World Health Organization (WHO) since 2014, due to the positive results in animal studies, after occupational exposures in health professionals, after non-consensual sexual exposures and vertical transmission ^22,23.

In addition, in Brazil, combined prevention is adopted, a strategy that combines different methods of HIV prevention, combined according to the individual characteristics and the moment of life of each person. The basic premise established is that comprehensive prevention strategies should observe, concomitantly, these different foci, considering the specificities of the subjects and their contexts.

PrEP is the most current preventive form to be included among the preventive methods used in Combined Prevention and is currently the crucial point of the debate on the new possibilities of coping with HIV and is characterized by the daily use of a single Entrictitabine Tablet (FTC) combined with Tenofovir Desoproxila Fumarate (TDF). Prophylaxis has its efficacy strongly associated with adhering and can reach 96% in participants with polite treatment support ²⁴.

Moreover, in the item that deals with the use of PrEP, an expert questioned the use of the term "will", because he understood that it is "need" or "perception of vulnerability", so the response category was replaced by "No, but I have the will/need". It is worth mentioning that, on the one hand, there is the percentage of individuals who recognized the development of HIV risk practices, and, on the other hand, there is the group that plans/wishes to exercise other sexual practices, extolling the thought about achieving some protection in these experiences. Therefore, both the terms "will,” and "need" seemed appropriate for this item of the instrument.

The effect of risk perceptions on the actual adoption of PrEP includes not only the impact on the willingness to use PrEP, but also the possibility that perceived risk may motivate individuals to seek preventive services and thus learn about PrEP ²⁵.

As for sexual practices, the division of the question about exposure with a fixed partner and with an eventual/casual partner was important to contemplate different perspectives and experiences of the participants of future research. The experts agreed on the topics of approach to risk behaviors, with emphasis on sex with penetration, HIV-positive partner, group sex, use of alcohol or illicit drugs, and points of arrest.

The section on health services for sexual health was directed to the investigation of the search for information and access to sexual health with medical-psychological care. For younger people, certain questions may lead them not to seek health services, such as: fear of the diagnosis of LST, care with the presence of the person responsible and the choice of sex of the health professional who will serve them. One study pointed out that, on average, the structure of care and the available human resources related to primary care is not enough. In addition, for adolescents, it is necessary to emphasize the rights to autonomy and confidentiality, as well as the performance of training and training for the multidisciplinary team that provide care^26,27.

The authors identified that the care and treatment of STIs were not determined by primary health care professionals, as an important competence for the performance in sexual and reproductive health care, despite being the reference for the performance of the rapid test for HIV, viral hepatitis (B and C), and syphilis. Similarly, in order to achieve comprehensive care, it was verified the need to expand actions beyond preventive actions regarding sexual and reproductive health.

Given the possibility of the instrument "Consumption of online sexual media and HIV/AIDS risk practices" being applied by other health professionals, the study is identified as a limitation of the study, regarding semantic analysis, the fact that the judges' committee is composed only of doctors and nurses, although all have experience in the theme, which was minimized due to the application of the instrument in the target population.

The validation of the instrument "Consumption of online sexual media and HIV/AIDS risk practices" contributes to the health area, especially for sexual health, because it allows the acquisition of a tool that allows the assessment of the influence of sexual media consumption on HIV risk practices, enabling the investigation of vulnerabilities, identification of risk situations and development of strategies for the reduction and/or elimination of harm to the population.

CONCLUSION

The validation process of the instrument "Consumption of sexual media and HIV/AIDS risk practices" resulted in a last version with five dimensions and 56 items. In the first Delphi round the overall CVI was 87%, and 100% in the second. In the evaluation of the target population, the instrument reached a Positivity Index of 99%.

Therefore, due to the high rates achieved and, according to the parameters for validation, the instrument in its last version "Consumption of sexual media and risk practices for HIV/AIDS" allows us to analyze reliably and quality the influence of sexual media consumption on risk practices for HIV/AIDS, and also for other STIs.

It is noteworthy that this instrument can and should always be improved and adapted to possible new forms of exposure and new social behaviors. Thus, it is suggested the development of future research on this theme, as well as the dissemination and use by education and health institutions, in order to enhance and achieve the identification of the situation of sexual practices in the face of the consumption of sexual media and the elaboration of strategies for elimination and/or risk reduction.