Health Education and Health Promotion

Utilization of Puberty Reproductive Health Digital Pocket Book for Deaf Students during the Covid-19 Pandemic

Document Type : Original Research

Authors

A.G. Wuryandari 1
I. Murtiyarini 1
E.Y. Ichwan 2
J. Julaecha 3

1 Department of Nursing, Faculty of Health, Health Polytechnic of Health Ministry, Jambi, Indonesia

2 Department of Midwifery, Faculty of Health, Health Polytechnic of Health Ministry, Jakarta, Indonesia

3 Institute of Health Science Baiturrahim, Jambi, Indonesi

Abstract
Aims: Technology can facilitate the limitations of health literacy for children with special needs. Therefore a design is needed that is adapted to the limitations of children with special needs, especially deaf children. This study aimed to develop reproductive health reading materials on puberty for deaf students based on digital pocketbooks.

Materials & Methods: The present study is a design and development research with qualitative and quantitative approaches (mixed method) with ADDIE steps. This study involved 15 deaf children in SMALB class X to XII who were selected using a purposive sampling method. Data were collected through in-depth interviews. This study was conducted during the Covid-19 pandemic, so surveys and other research activities were online. The qualitative results were analyzed using content analysis, and quantitative results were analyzed using the Wilcoxon test.

Findings: Most students said they had never been invited to discuss what changes would occur when they entered puberty. The knowledge of deaf students significantly increased after receiving reproductive health promotion intervention using digital pocketbooks (p=0.001).

Conclusion: Parents and deaf students need comprehensive reproductive health literacy adapted by focusing on digital-based text and images to be widely accessible.

Keywords

Reproductive health
Puberty
Learning
Education
Student
Covid-19
Subjects
Introduction
The Covid-19 pandemic has rapidly encouraged the use of technology in various aspects of life, especially for access to information and education. Technology can facilitate the limitations of health literacy for children with special needs. Therefore a design is needed that is adapted to the limitations of children with special needs, especially deaf children [1, 2], like learning programs and activities, namely paying attention to preparing students with the skills to make the best decisions for themselves, one of which is related to reproductive health.
Adolescence is a phase where children begin to experience puberty. Lack of reproductive health information may contribute negative impact on adolescents. Teenagers will look for information on their own through the internet or other sources that cannot be justified. It will have an impact on adolescents' misconceptions regarding their reproductive health [3].
The ability to take care of children with special needs is very important, especially regarding health and personal hygiene, so they look normal and do not show extreme weakness or disability. Reproductive health is one of the important things that children with special needs should know in a special needs school (SLB/SMPLB/SMALB) as prospective parent. They need to understand themselves in terms of reproductive health correctly. Therefore, it has to be introduced to them properly [4]. Unfortunately, students with hearing loss have not met the need for reproductive health information pleasingly in several regions of Indonesia [5]. Other studies in Indonesia state that students are satisfied with learning through e-books, both from the media and material aspects. Students also are motivated to dig up information from e-books because the learning is done independently and supported by pictures and animations [6].
In general, technology-based approaches and the use of digital media in educational interventions are associated with helping to develop research, collaboration, critical, creativity, and communication skills [7, 8]. Many studies suggest that the use of practical activities with digital media, whereby students engage in planning, collaboration, and production, is an effective learning strategy [9–11]. There is an increasing tendency to use technology in RSHE, such as videos, computer activities, text messaging, and games [12]. Young people have been found to value the use of technology, for example, in online safety interventions, because it fits their media culture and provides fun [13].
Books as learning media should facilitate and attract students' interest in mastering learning materials. Utilizing smartphone technology with features for making Android-based applications can help educators find out the smartphone's practical and interesting functions [14, 15].
The digital pocketbook in this study was developed based on science, technology, engineering, and mathematics (STEM). Digital pocketbooks are usually in PDF format, but it is more sophisticated and interesting when assisted with an android Appy Pie application [16]. Appy Pie is a website that presents templates for creating android applications easily and attractively. It does not require special skills in computer programming, so it is easy to operate on smartphones [17]. The advantage of Appy Pie is that it can include learning materials in text, links, images, videos, and interactive quizzes [18]. However, the weakness of this learning media can only be implemented by installing it on Android, as well as the limitations of the material discussed [19]. Using android pocketbooks as learning media has been widely practiced, especially in education. However, it is still rarely done for children student with special needs.
Children, students, and adults with disabilities have the right to be educated about the natural functions of their bodies and their sexuality. To fully protect and understand themselves, they need and have the right to expect appropriate and timely sexual health education as part of their efforts to become self-determined individuals [20, 21]. Therefore, the present study aimed to develop reproductive health reading materials on puberty for deaf students based on digital pocketbooks.

Materials and Methods
The method used in this research is design and development research (Research and Development) with qualitative and quantitative approaches (mixed method) with the stages of the Analysis, Design, Development, Implementation, and Evaluation (ADDIE) step flow, starting with problem analysis, background analysis, and literature analysis, then entering the determination stage.
The study population was deaf students in the Special High School (SHS) of Prof. Dr. Sri Soedewi MasjchunSofwan, SH Jambi. This study involved 15 deaf children in SMALB class X to XII who were selected using a purposive sampling method. The deaf children in this study met the inclusion criteria: children in grades X and XII who had never been involved in the same research before and could use an Android cell phone. In contrast, children who did not get permission from their parents were not included in the study.
The product design was an e-book for reproductive health about puberty. The next stage was a formative assessment by conducting product validation and testing activities, starting with a self-evaluation of the product by a self-evaluation by the researcher regarding visible and possible errors. The evaluation results were revised and followed in the expert assessment stage, which theoretically evaluates the material, design, and technical quality. The results of the expert evaluation were revised by the team, focusing on the effectiveness or impact of using the product, its appeal, and its application from the user's perspective. Before the product is tested at the field test level, the team's assessment results were used as revision material.
The first stage of this research was needs analysis. The author used the interview method using a structured list of questions for students and parents. The Covid-19 pandemic impacted the research process. Some parent interviews were conducted by telephone, while student interviews were carried out directly and gradually accompanied by deaf teaching teachers. Data were collected through in-depth interviews. The results obtained were analyzed using a descriptive method of content (content analysis).
The research team first looked at design research from secondary data sources, then combined it with preliminary exploratory research on multimedia design to develop contextual research, observation, interviews, experiential sampling methods, sourcebooks, and previous research. The designer reframed the problem through initial ideas, experimentation, and review to arrive at the right solution. The research team proposed to collect the needs analysis results and input from partner researchers and design the initial reproductive health pocketbook for further evaluation by experts after receiving expert judgment. An expert assessment instrument focuses on two domains, namely the content domain, to assess the feasibility of media materials, and the developed acceptability domain, to assess the level of user acceptance (deaf students) of the multimedia to be developed.
After a one-on-one assessment, the researcher discussed involving experts to identify problems, analyze the causes of problems, determine ways to solve problems and brainstorm among experts in designing models or products needed by deaf students. The inputs were considered and adjusted to the available resources for later revision of the digital pocketbook media.
The last step of this development research was evaluating the development of learning media to see the effectiveness of the use of learning media by measuring data on student learning outcomes. In this evaluation stage, the pretest and posttest results were compared to see whether student learning outcomes using the developed learning media can increase students' knowledge and understanding of reproductive health. The Digital Pocket Book on Reproductive Health for Deaf Students was accessed at https://litmas.poltekkesjambi.ac.id/book/.
Design principles were applied to create a pocketbook that was easy for deaf students to use. Visual design is created by arranging components so important points in the material are not missed. The components in designing pocketbooks were considered, including 1) Color: bright colors were used in this pocketbook to create a feeling of happiness. The three main colors are pink, blue, and white. These three colors increase the sense of visual interest. 2) Icons: according to research by early adopters, deaf children already had experience using smartphones. The icons used in this pocketbook used sign language to make it easier for users and a personal approach. 3) Dimensions: all components of the pocketbook were designed not too small. By using the digital function, the user can adjust the dimensions comfortably. It is because deaf children find it difficult to interpret too much information. Its size also limits the collection of information on a single screen.
The research data were analyzed using the Wilcoxon test in SPSS 16.0 software. P-value <0.05 was considered significant.

Findings
Needs analysis
The frequency of information regarding digital media access and the results of the needs analysis obtained from interviews with deaf students are shown in Tables 1 and 2.
Most students said they had never been invited to discuss what changes would occur when they entered puberty. The female students stated that they were only taught to use sanitary napkins and how to take a shower after menstruation, especially those who were Muslim. The male students who are Muslim are only taught how to take a “compulsory” bath without ever being invited to discuss what they experience and feel during the changes in puberty.
Expert design and assessment (expert judgement)
The recapitulation of expert assessment results based on two domains, namely the content and acceptability domains, are seen in Table 3. All aspects assessed by the three experts received an average value of 3.94 digital pocketbooks.

Table 1) Frequency distribution of information regarding digital media access for deaf students


Table 2) Results of analysis of digital media needs for promotion of reproductive health in puberty for deaf students


Development evaluation
Changes in the level of knowledge of male and female students before and after receiving reproductive health promotion intervention using digital pocket book media are shown in Table 4.
All male and female respondents experienced an increase in knowledge after receiving reproductive health promotion intervention using digital pocketbooks, and it was proven that digital pocketbooks had an significant effect (p=0.001).

Table 3) Average score of content domain experts and acceptance domains


Table 4) The effectiveness of reproductive health digital handbook for male and female students


Discussion 
The trial results of using digital reproductive health pocketbooks showed no barriers for students to access books through their respective gadgets. The material and use of animation in pocketbooks attracted students' attention and helped deaf students understand that media development could be further developed using multimedia technology. Interactive learning can overcome the limitations of deaf students.
Reproductive health education needs to be initiated through the family, which has the main role in educational guidance. However, obstacles often occur in teaching because people still consider it taboo and shy to talk about sensitive things such as sex. Following the rapid technological developments, if the taboo culture is still deeply rooted in the family and even in society causes children to seek information out of curiosity, which is a factor in teaching errors. What sources do children read? Cultural taboos should be eliminated in the reproductive health counseling process, where families are worried that free sex will occur in children. This wrong assumption needs to be supported by an open mind from the family to accept all the material [3, 22, 23].
The learning concept of deaf students mostly comes from visuals (pictures/videos) or can be seen in real terms. The existence of visual media, sign language, text, and role-playing for deaf and mute students will make it easier for deaf students to understand video methods and sign language lessons more effectively to increase their knowledge of deaf children about health. Interactive multimedia effectively provides reproductive health information and is worthy of being used as a learning medium. In addition to the media, reproductive health education for adolescents must be provided continuously and gradually, adjusted to their needs and age and their ability to capture [24, 25].
This study further reinforces previous findings, which reported that learning media using Android-based construct regarding the introduction of numbers 1 to 100 and calculations 1 to 20 for mentally disabled children in grade V elementary school is feasible to use, with the average results of the questionnaire assessment with an approval level of 42.5 [26]. It is also in line with research reporting that Android tablet-based Communication Board media affects student attractiveness [27]. Android-based mathematics learning media can also increase the concentration and interest in learning mentally disabled students [28].
The literature study conducted by the research found no media for promoting reproductive health for deaf adolescents issued by the Ministry of Health or government agencies. Promotional media currently need innovations to promote reproductive health by considering more attractive media and the existence of information technology that will expand the scope of targets for health promotion.
The learning media is designed and adapted to the limitations of deaf students by maximizing their sense of sight, not only focusing on the material's content but also considering the visuals and dimensions of the media used. Learning media should also be accompanied by an explanation from the teacher or assistant for deaf students [29-32].
Seven factors must be considered when developing services for children who are deaf or hard of hearing, namely: 1) The level of hearing difficulties, 2) language proficiency, 3) communication approach strategy, 4) availability of information technology media, 5) family support, 6) choice of communication access and, 7) additional factors that can influence such as economic and social status.
The study results indicate that deaf students can use internet technology and digital literacy sources. This result is in line with the research of Utami et al. [33], who conducted research at Padang State University. The results showed that deaf students could learn using the blended learning model. Some of the factors discussed in this study are the characteristics of students and the examination of the required context, consisting of the ability to use ICT tools, the ability to use the internet, and learning needs. The expectations of deaf students towards the blended learning model are classroom teachings using visual media and more varied online teaching, such as videos with subtitles and sign language. Another research also states that the solution to overcome the limitations while increasing knowledge of reproductive health in persons with hearing loss is to develop media that use more animation [34].
Limitations
Since this study was done on students who are deaf, there is a possibility of misinterpretation of what the researcher expects from the questions given during the needs analysis stage. Several emphasis sentences are limited to students' understanding of sign language; moreover, they are still young in education, and some terms may need help. When parents or accompanying teachers try to use other, more straightforward sentences, it may change the more significant meaning. To overcome this condition, the researcher asked parents or accompanying teachers to repeat each question item slowly and reassuringly repeat the students' answers.
Suggestions
- Future studies should conduct RCT in the population of this study in two groups to compare the potential of this pocketbook.
- The prevailing culture in Indonesia and several other countries in Asia can also be an essential factor to be assessed as controlling for biased results, where the topic of reproductive health is still taboo to discuss.

Conclusion
The development of digital literacy for reproductive health education for deaf students is a basic need for students and parents or student companions. Using technology for digital literacy can decrease the limitations of deaf students.

Acknowledgements: We would like to thank the director of the Department of Nursing, Jambi Health Polytechnic, for supporting this research.
Ethical Permission: This study was ethically approved by the Health Research health study (code LB.02.06/2/037/2021).
Conflict of Interests: There is no conflict of interest to declare.
Authors’ Contribution: Wuryandari AG (First Author), Introduction Writer/Methodologist/Main Researcher/
Discussion Writer (35%); Murtiyarini I (Second Author), Introduction Writer/Methodologist/Main Researcher (25%); Ichwan EY (Third Author), Statistical Analyst/Discussion Writer (20%); Julaecha J (Fourth Author), Statistical Analyst/Discussion Writer (20%)
Funding: This study did not receive any financial support from any party.
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Health Education and Health Promotion
Volume 10, Issue 4
Summer 2022
Pages 819-825