RESEARCH ARTICLES

Schoolchildren's knowledge about disabled people: labyrinth game in health promotion

Jacqueline Mota da Silva^I; Lorita Marlena Freitag Pagliuca^II; Aline Tomaz de Carvalho^III; Mariana Gonçalves de Oliveira^IV; Paulo César de Almeida^V

^I Master's student, Graduate Nursing Program, Nursing Department, Universidade Federal do Ceará. Fortaleza, Ceará, Brazil. E-mail: jacque18ms@gmail.com
^II Ph.D. in Nursing from Universidade de São Paulo. Full Professor, Nursing Department, Universidade Federal do Ceará. Fortaleza, Ceará, Brazil. E-mail: pagliuca@ufc.br
^III Ph.D. candidate, Graduate Nursing Program, Nursing Department, Universidade Federal do Ceará. Fortaleza, Ceará, Brazil. E-mail: aline.nurse@gmail.com
^IV Ph.D. candidate, Graduate Nursing Program, Nursing Department, Universidade Federal do Ceará. Professor, Faculdade de Ensino e Cultura do Ceará and Centro Universitário Estácio do Ceará. Clinical Nurse, Secretaria Municipal de Fortaleza. Ceará, Brazil. E-mail: marianagdoliveira@yahoo.com.br
^V Ph.D. in Public Health from Universidade de São Paulo. Full Professor, Universidade Estadual do Ceará. Fortaleza, Ceará, Brazil. E-mail: pc49almeida@gmail.com
^VI Acknowledgements to the Brazilian Scientific and Technological Development Council for the Scientific Initiation Grant.

DOI: http://dx.doi.org/10.12957/reuerj.2015.10611

ABSTRACT

This quantitative, cross-sectional study examined schoolchildren's knowledge about disabled people before and after application of a labyrinth game. The study participants were 94 ninth-year middle school students at public and private schools in two towns in Ceará State, in the second semester of 2013. Students' knowledge was assessed by applying an educational game, with pre- and post-testing. The results showed that, after the game, the percentage of correct answers increased, with statistical significance at the public (p<0.001) e particulares (p=0.001), gêneros feminino (p<0.001) e masculino (p=0.004), faixas etárias de 13-14 anos (p<0.001) e 15-17 anos (p=0.003). Conclui-se que houve apreensão do conhecimento acerca do tema abordado. A inclusão da pessoa com deficiência deve ser uma temática frequentemente discutida no âmbito escolar, com vistas à sensibilização do estudante para criar e participar da escola inclusiva ideal. Palavras-Chave: Enfermagem; educação em saúde; jogos e brinquedos; pessoas com deficiência.

INTRODUCTION

Nurses have been the main actors in the care process through health education. As educators, nurses are expected to contribute to individual and collective awareness raising by questioning the responsibilities and the rights to health, stimulating actions that comply with the principles of the Unified Health System (SUS), such as accessibility, equity, universality and popular participation¹. The educational activities go far beyond the health disease process and should be developed to favor the development of personal attitudes related to the lifestyle concept and stimulate reflection, questioning and shared action².

The national health policy considers disabled people (DP) as people with permanent losses or abnormalities in their physiological or anatomical structure, which cause disability for them to perform activities within the standards that are considered normal for human beings³. The disabilities that affect physiological or anatomical functions include visual, hearing and physical impairments.

The discrimination of these clients is associated, among other aspects, with the lack of knowledge on the rights of DP and how to welcome them. What the social inclusion of this population is concerned, they should be fully and unconditionally inserted in the social systems, independently of the type and degree of the disability. Therefore, they are entitled to social experiences, including access to the same resources available to any and all citizens ⁴. With a view to effective inclusion, attitudinal barriers need to be overcome, which are related to the socially and historically constructed stigmas, prejudices and stereotypes present in society.

Adolescence – between the ages of 12 and 18 years – is a period that involves biological and cognitive, social and life perspective changes, which direct individuals towards adult age⁵ and should be experienced in a balanced manner, so as to avoid negative reflections in the future⁶. Therefore, the theme DP is relevant for discussion with adolescents, subjects who are establishing their values and who, when sensitized, can incorporate knowledge and develop favorable attitudes to the welcoming of DP. In that context, nursing should accomplish social and educational interventions that promote adolescents' empowerment⁷, with a view to creating awareness of their role as builders of a more equalitarian society.

The labyrinth game has been adapted to explore the theme DP. The content addresses the history and citizenship of disabled people, visual, hearing and physical impairments. A labyrinth was constructed with three entries that give access to routes that may reach the exit or not; at different points along the trajectory, there are figures corresponding to questions or curiosities about the theme, written in letters. To continue in the labyrinth, the players should read the letters with curiosities to the group and correctly answer the questions asked. When the player does not know the answer, the turn changes to the other team. The team that first reaches the exit wins. Along this trajectory, everybody learns and discusses the theme with the colleagues.

As the educational game is useful for health education with adolescents and society needs to learn how to cope with and participate with a view to the inclusion of DP, this study was aimed at verifying the students' knowledge before and after applying the labyrinth game on DP.

LITERATURE REVIEW

Nurses look for new teaching forms and techniques for the purpose of health promotion, such as the use of educational technologies that address health and education and make individuals gain awareness and a critical attitude, with a view to change⁸.

Educational games are perceived as activities that offer an appropriate environment for teaching-learning and address sensitivity and emotions⁹. Games have been used as learning tools for thousands of years¹⁰ and can promote knowledge on different health-related topics. They are useful tools for health education with adolescents, as a good strategy to gain further attention from that public¹¹ and promote knowledge and information transmission, besides granting immediate emotional satisfaction to the participants¹².

Educational technologies in the form of games offer advantages like competition and attention among the players, contribute to encourage the rest of the participants to develop their cognitive and affective potential and psychomotor mastery, besides engagement, social interaction, development of alliances, mutual respect; and improve different performance aspects¹³.

One educational game is the labyrinth game, which contains one entry and a system of passages with possible routes to reach the end. To play, a route needs to be defined that leads to the exit, a mental trajectory needs to be outlines and the possibilities imposed by junctions need to be observed. The player should make decisions based on assertions and denials regarding the existing routes¹⁴.

As an important mediator in the teaching-learning process, the labyrinth game is a playful educational technology; it comprises effective learning criteria, as it calls attention to a certain theme (intentionality/reciprocity); arouses discussion on its meaning and the knowledge produced, based on the activity, can be taken into the field of reality. Therefore, it is an important health promotion tool for nurses to use¹⁵.

METHOD

Cross-sectional and quantitative study, based on the application of an educational labyrinth game, undertaken in two cities in the interior of Ceará. The population consisted of 290 students from the ninth year of basic education, 148 from two public schools and 142 from two private schools. From these four schools, 56 and 38 students were randomly selected, respectively, composing a sample of 94 adolescents. The data were collected between July and December 2013, when the directors of the respective institutions indicated one class per school, so as to avoid information exchange among students from different classes in the same grade.

The pre-test was applied, followed by the game itself and the post-test, so as to assess the students' learning. The tests consisted of 10 questions each, containing three questions of low, four questions of medium and three questions of high complexity. Each pre-test question contained the same complexity and theme as its numerical correspondent on the post-test.

The research variables were: type of school, gender, age range (13 to 14 and 15 to 17 years), type of disability and complexity level of the questions.

To analyze the data, the means and standard deviations were calculated for the ages: McNemar's test was used to compare the proportions before and after the educational activity and Wilcoxon's test to compare the means and medians before and after the activity. Significance was set at 5%.

Approval for the study was obtained from the Institutional Review Board at Universidade Federal do Ceará, under opinion 251/11, in compliance with National Health Council Resolution 466/2012, which establishes the Guidelines and Standards for Research Involving Human Beings, respecting the principles of autonomy, non-maleficence, beneficence, justice and equity, among others. All students participated in the research voluntarily and completed the Informed Consent Form, which their parents or responsible caregivers signed as well.

RESULTS AND DISCUSSION

In the sample of 94 (100%) adolescents, female (61.7%) public school (59.6%) students between 13 and 14 years of age (67%) were predominant. The sociodemographic variables are displayed in Table 1:

TABLE 1: Distribution of students according to characteristics. Fortaleza, CE, 2013. (N=94).

As regards the mean and median number of correct answers on the pre and post-test of the educational activity, both increased, for the total scale as well as the sociodemographic variables. Significant results were obtained in all variables, with p<0.0001 and p=0.001, respectively, for the public and private schools; p<0.0001 for the female gender and p=0.004 for the male gender; p<0.0001 and 0.003 for the age ranges 13-14 and 15-17 years, respectively, as displayed in Table 2.

TABLE 2: Mean and median correct answers according to students' characteristics. Fortaleza, CE, 2013.

In the total scale, the expected statistical significance was obtained in five cases, with a higher percentage of correct answers on the post-test, related to visual impairment in the low-complexity questions (p<0.0001); the history and citizenship and visual impairment in the medium-complexity questions (p<0.0001 for both); and hearing impairment (p<0.0001) and physical impairment (p= 0.001) in the high-complexity questions, as displayed in Table 3:

TABLE 3: Distribution of students according to moment of educational activity, complexity level and themes of questions. Fortaleza, CE, 2013. (N=94).

In the total sample, the results indicate a higher percentage of correct answers after the educative activity, which evidences that the labyrinth game enabled the students to get to know the reality of DP and learn how to behave correctly with these clients. This result supports a study that used the educational game to improve eating habits in adolescent students, in which a significant learning improvement was also found after the intervention ¹⁶. Similarly, the use of the labyrinth for health education on venomous animals found that the game intermediates knowledge on the theme addressed and that, through awareness raising, the participants in the activity can turn into information multipliers for the family and other people they have contact with¹⁷.

Private students presented greater preliminary knowledge on the theme, with a higher mean and median number of correct answers on the pre-test. On the other hand, the public school students evidenced greater learning after the game. In a study that compared the target orientations of public and private school students, the students from the public networks revealed greater interest in the learning target, indicating greater interest and pleasure in the learning process, being capable of facing challenging tasks¹⁸. Differently, a study assessed difficulties to learn writing and another reading, and both found better performances for private students and related this to the fact that they attended more favored environments with more appropriate learning conditions^19,20.

Although the female gender presented a higher median number of correct answers on the pre-test, no significant differences were found in the post-test results between girls (mean 7.2) and boys (mean 6.8), with a median number of 7.0 correct answers for both. Thus, male and female students evidenced similar learning. This result supports a study that assessed students' motivation and learning in the use and development of games, which found no significant difference between the male and female gender²¹. On the other hand, a study on the assessment of male and female adolescents' concentrated attention evidenced that girls are more able to concentrate their attention, which is important in the development of learning, memory and problem solving²².

Students between 13 and 14 years of aged performed similarly to 15 to 17-year-old students, with significant results on most questions solved (mean 5.7 on the pre-test and 7.0 on the post-test). Hence, the subjects' age did not interfere in the learning index on DP achieved through the game. Young adolescents, between 10 and 15 years of age, prefer active educational activities that involve interaction with peers. They are intellectually curious about the world and about themselves and respond positively to the opportunities to connect their realities with the contents offered in school ²³.

When stratifying the results per complexity level, the students performed better in the medium and high-complexity levels (three questions with p<0.0001 and one with p=0.001), while the low-complexity level revealed only one question with p<0.0001. Differences were found in the themes address; the theme visual impairment revealed better results (two questions with p<0.0001) when compared to physical impairment (one question with p=0.001) and hearing impairment (one question with p<0.0001).

In the low-complexity questions, the theme visual impairment obtained significant results. In this theme, congenital blindness was discussed in the pre-test, and eye trauma in the post-test. The large number of errors in the pre-test (94.7%) evidenced that the adolescents are unable to distinguish between congenital blindness and childhood blindness. In the post-test, the error percentage was only 238.3%; the majority correctly demonstrated the learning about possible causes of eye trauma (traffic accidents, physical aggressions and foreign body).

The difference between congenital and acquired blindness is hardly discussed in common sense, but 75% of all cases of blindness can be prevented or treated ²⁴. Congenital blindness results from prenatal causes, such as genetic factors, embryo development changes, central nervous system damage and perinatal complications. The second can result from traumas, progressive or infectious diseases²⁵. A study evidenced that young people are more vulnerable to eye trauma, with foreign bodies as the main cause of the problem²⁶. Therefore, it is important for the students to understand the causes of visual impairment for the sake of prevention.

In the medium-complexity questions, history and citizenship and visual impairment obtained a significantly high number of correct answers on the post-test (p<0.0001). What the theme history and disability is concerned, the periods in the history of DP were addressed, which are: exclusion, segregation, integration and inclusion²⁷, which range from ancient times, when this population was considered invalid and incapable of living in society, until current times, when their rights to several social services and environments is recognized.

In the high-complexity questions, the themes hearing and physical impairment (p<0.0001 and p=0.001) stand out. With regards to hearing impairment, car accidents were highlighted as causes of deafness. Traffic accidents have served as an important contributing factor to Brazilian morbidity and mortality rates²⁸ and have lead to increased victimization, involving severe lesions, disabilities and even death²⁹. Discussing this theme with adolescents is therefore essential to promote responsible attitudes in traffic, with a view to preventing accidents.

Concerning the theme physical disability, questions were asked about how to behave correctly towards these people. Actions like always addressing the DP when the theme refers to him/her; keeping crutches close to the person using these objects for locomotion; and called the DP by the name express healthy attitudes that should be stimulated in the population³⁰. Addressing the different disabilities to demystify existing prejudices against DP is important to assume an active posture towards the inclusion process, contributing to disabled people's development and the construction of their autonomy.

The discrimination of DP remains present in the school environment and fellow students mark disabled students. Disabled students are often targets of physical threats, verbal violence and social isolation³¹. The fight against the discrimination of DP is possible through actions aimed at raising the school community's awareness of its general engagement in the construction process of an inclusive culture, where community members understand the reasons for the equality between DP and so-called non-disabled students, provide mutual support and cooperation and find the same opportunities to learn and participate in school life³².

Inclusive education supposes a school that is prepared to welcome all children and young people from their community and, therefore, adapts its curriculum and reorganizes its practices and functioning. The students should understand how to related with the DP and know the school's physical structure, which should offer ramps, elevators, bathrooms and accessible drinking fountains, among other resources³³. Mainstream education teachers also need preparation to receive DP³⁴. Thus, the school tends to respond to the diversity of its students, from the most gifted to the most vulnerable ones, value and involve all stakeholders in the education process³⁵.

CONCLUSION

The study showed the students' knowledge before and after the educational game. They learned about the types of disability addressed, in view of the significant results in both school types - public and private, both genders and age ranges. As regards the content addressed, better results were found on the theme visual impairment when compared to hearing and physical impairment.

Nursing should assume its educative role and act for the development process of an inclusive culture in schools. The inclusion of DP should be a theme present and frequently discussed in the school environment. Therefore, this study supports further research on inclusive education and the rupture of attitudinal barriers in society.

Despite the positive research results, the sample used does not statistically represent the group of students, as a convenience sample was selected that does not include many subjects. Therefore, the game needs to be applied in larger populations in future studies.

REFERENCES

1. Sousa LB, Torres CA, Pinheiro PNC, Pinheiro AKB. Práticas de educação em saúde no Brasil: a atuação da enfermagem. Rev enferm UERJ. 2010; 18:55-60.

2.Teston EF, Oliveira AP, Marcon SS. Necessidades de educação em saúde experienciadas por cuidadores de indivíduos dependentes de cuidado. Rev enferm UERJ. 2012; 20:720-5.

3.Ministério da Saúde (Br). Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Política Nacional de Saúde da Pessoa Portadora de Deficiência. Brasília (DF): editora MS; 2010.

4.Monteiro LG, Oliveira SMQ, Rodrigues SM, Dias CA. Responsabilidade social empresarial: inclusão de pessoas com deficiência no mercado de trabalho. Rev bras educ espec. 2011; 17:459-80.

5.Schoen-Ferreira TH, Azna-Farias M, Silvares EFM. Adolescência através dos séculos. Psicol Teor Pesq. 2010; 26:227-34.

6.Moreno EAC, Silva AP, Ferreira GA, Silva FP, Frazão IS, Cavalcanti AMTS. Perfil epidemiológico de adolescentes vítimas de bullying em escolas públicas e privadas. Rev enferm UERJ. 2012; 20:808-13.

7.Coelho MMF, Torres RAM, Miranda KCL, Cabral RL, Almeida LKG, Queiroz MVO. Educação em saúde com adolescentes: compartilhando vivências e reflexões. Cienc Cuid Saúde. 2012; 11:390-5.

8.Mariano MR, Pinheiro AKB, Aquino PS, Ximenes LB, Pagliuca LMF. Jogo educativo na promoção da saúde de adolescentes: revisão integrativa. Rev Eletr Enf [Internet]. 2013;15:265-73. [citado em 09 abr 2014]. Disponível em: http://dx.doi.org/10.5216/ree.v15i1.17814

9.Yonekura T, Soares CB. The educative game as a sensitization strategy for the collection of data with adolescents. Rev Latino-Am Enfermagem. 2010; 18:968-74.

10.Hogan M, Kapralos B, Cristancho S, Finney K, Dubrowski A. Bringing community health nursing education to life with serious games. Int J Nurs Educ Scholarsh. 2011; 8: [Internet] 2011 [cited in 2014 Apr 09]. Available from: http://www.degruyter.com/view/j/ijnes.2011.8.issue-1/ijnes.2011.8.1.2072/ijnes.2011.8.1.2072.xml

11.Boctor L. Active-learning strategies: the use of a game to reinforce learning in nursing education - a case study. Nurs Educ Pract. 2013; 13:96-100.

12.Barbosa SM, Dias FLA, Pinheiro AKB, Pinheiro PNC, Vieira NFV. Jogo educativo como estratégia de educação em saúde para adolescentes na prevenção às DST/AIDS. Rev Eletr Enf [Internet] 2010 [citado em 09 abr 2014]; 12: 337-41. Disponível em: https://revistas.ufg.br/index.php/fen/article/view/6710/6951

13. Akl EA, Kairouz VF, Sackett KM, Erdley WS, Mustafa RA, Fiander M, Gabriel C, Schünemann H. Educational games for health professionals. Cochrane Database Syst Rev. 2013; 3: 1-47.

14.Macedo L, Carvalho GE, Petty ALS. Modos de resolução de labirintos por alunos da escola fundamental. Psicol Esc Educ. 2009; 13:15-20.

15.Croscato G, Pina JC, Mello DF. Utilização de atividades lúdicas na educação em saúde: uma revisão integrativa da literatura. Acta Paul Enferm. 2010;23:257-63.

16.López IJP, Fernández MD. Un juego de cartas durante los recreos escolares mejora los hábitos alimentarios en adolescentes. Nutr Hosp. 2012;27:2055-65.

17.Ramos ELP, Moura RGF, Macedo MM, Siqueira LHC, Sposito NEC, Kataguiri VS. Uma abordagem lúdica dos animais peçonhentos no ensino fundamental. Rev Extensão. 2012; 11:45-53.

18.Zenorini RPC, Santos AAA, Monteiro RM. Motivação para aprender: relação com o desempenho de estudantes. Paidéia. 2011; 21:157-64.

19.Landerl K, Wimmer H. development of word reading fluency and spelling in a consistent orthography: an 8-year follow-up. J Educ Psychol. 2008; 100:150-61.

20.Pontes VL, Diniz NLF, Martins-Reis VO. Parâmetros e estratégias de leitura e escrita utilizados por crianças de escolas pública e privada. Rev CEFAC. 2013; 15:827-36.

21.Vos N, Meijden H, Denessen E. Effects of constructing versus playing an educational game on student motivation and deep learning strategy use. Computers & Education. 2011; (56): 127-37.

22.Barbosa ACM, Justen DE, Coser J, Longhi JM, Bohm TEF, Calvetti PÜ. Prática do processo psicológico básico: atenção em jovens da comunidade. Rev CIPPUS. 2013; 2:191-204.

24.World Health Organization. Health topics. Blindness. Gêneva (Swi): WHO; 2014. [cited in 2014 Nov 30]. Avaliable in: http://www.who.int/topics/blindness/en/.

25.Demir T, Bolat N, Yavuz M, Karaçetin G, Dogangün B, Kayaalp Levent. Attachment characteristics and behavioral problems in children and adolescents with congenital blindness. Archives of Neuropsychiatry. 2014; (51): 116-21.

26.Lima MA, Pagliuca LMF, Almeida PC, Andrade LM, Caetano JA. Levantamento dos casos de traumatismo ocular num hospital de emergência. Rev Rene. 2010; 11:58-65.

27.Braga MMS, Schumacher AA. Direito e inclusão da pessoa com deficiência: uma análise orientada pela teoria do reconhecimento social de Axel Honneth. Soc Estado. 2013; 28:375-92.

28.Reichenheim ME, Souza ER, Moraes CL, Jorge MHPL, Silva CMFPF, Minayo MCS. Violência e lesões no Brasil: efeitos, avanços alcançados e desafios futuros. Lancet. 2011; 6736:75-89.

29.Camargo FC, Hemiko H. Vítimas fatais e anos de vida perdidos por acidentes de trânsito em Minas Gerais, Brasil. Esc Anna Nery 2012; 16:141-6.

30.Assembleia Legislativa do Rio Grande do Sul. Dicas de convivência com pessoas com deficiência. [site na Internet] 2011 [citado em 09 abr 2014]. Disponível em: http://www.portaldeacessibilidade.rs.gov.br/uploads/1309442549Cartilha_Dicas_de_Convivencia_PCD_Faders_e_AL_RS.pdf

31.World Health Organization. [site on internet]. World report on disability. [cited in 2014 apr 09] Available from: http://whqlibdoc.who.int/publications/2011/9789240685215_eng.pdf?ua=1

32.Ferreira WB. Direitos da Pessoa com Deficiência e inclusão nas escolas. [site na Internet] 2010 [citado em 09 abr 2014]. Disponível em: http://www.dhnet.org.br/dados/cursos/edh/redh/03/03_ferreira_direitos_deficiencia.pdf.

33.Correia PM, Manzini EJ. Um estudo sobre as condições de acessibilidade em pré-escolas. Rev Bras Educ Espec. 2012; 18:213-30.

34.Crochít JL, Pedrossian DRS, Anache AA, Meneses BM, Lima MFEM. Análise de atitudes de professoras do ensino fundamental no que se refere à educação inclusiva. Educ Pesq. 2011; 37:565-82.

35.Sanches I. Do 'aprender para fazer' ao 'aprender fazendo': as práticas de educação inclusiva na escola. Rev Lusófona Educ. 2011; 19:135-56.