Construction and validation of educational material for the health promotion of individuals with HIV

Objective: to develop and validate an educational technology for individuals living with the human immunodeficiency virus. Method: a methodological study, for the elaboration of educational material. The educational needs, content selection, and illustrations were defined from interviews with the target population. Afterward, we carried the writing, the material layout elaboration, and assembly and, subsequently, it was validated by specialists. The content validation was established from the Level Content Validity Index higher than 0.8. Results: the educational material was prepared for adults living with the human immunodeficiency virus, with a focus on health promotion and quality of life, and was prepared in five volumes. The validation was made by 22 multi-professional judges selected according to the criteria established in the study. All items were evaluated as relevant by the judges and the average obtained with the index was 0.97. Conclusion: the booklet has been validated in terms of content, language, and appearance by experts in the field. We believe that through this technology it is possible to contribute to the health literacy and empowerment of individuals living with the human immunodeficiency virus, strengthening their autonomy.


Introduction
More than three decades after the discovery of Studies point out the importance of comprehensive care to these patients, as well as their empowerment, strengthening their autonomy and responsibility regarding the treatment progress (4)(5) .
Thus, studies show that health education is an effective means that can contribute to this debate and subsidize interventions for improving the ILWHA quality of life. Educational strategies are one of the adherenceto-treatment pillars, as it is for the prevention of the HIV spread, and proposes well-being subsidies (6)(7) .
The use of educational material is characterized by being an emancipatory technology, especially by the possibility of allowing ILWHA to change their attitude and adhere to preventive practices since it brings information capable of acting on the empowerment of individuals, by enabling them to learn and activate their potential for self-care and favoring the process of communication and guidance among the health team, patients and relatives (8) .
In Brazil, although studies have described a variety of educational materials as an educational tool in various settings, populations, and purposes (8)(9)(10)(11)(12) , there is still a need to build and validate educational materials for adult ILWHA through applied and theoretically based planning, aiming to provide health information in a meaningful way to ensure the empowerment of ILWHA, strengthening their autonomy and responsibility for the progress of treatment, so that they can understand their health and make informed decisions in achieving a better quality of life.  The sample was consecutive and the saturation of the data was used as a criterion for the finalization of the collection (13) .

Method
To process the qualitative data, we used the lexical type analysis technique, with the help of the software Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires (IRaMuTeQ), the details of this analysis have already been described above (14) .
In the second stages, we performed a review of the The construction of this material has as theoretical reference the stages of learning from the Social Cognitive Theory by Bandura (1997) (14) and the Health Literacy, and followed the methodological steps by Doak, Doak, and Root (1996) (15) . In order to prepare the educational material, we adopted the recommendation on the use www.eerp.usp.br/rlae The photographs were taken by two professional photographers and sought to capture images that were attractive and appropriate to the target audience and that referred to situations related to the topics, in order to motivate reading. Besides the care with the language, the textual elaboration, the disposition of the images and the organization of the items of each page followed the steps that drive the Social Cognitive Learning, outlined by Bandura in 1997 (14) . There is no consensus in the literature on the number of judges needed for a validation study. In this study, the sample calculation for determining the number of expert judges took place according to the formula for a proportion-based sample calculation (16) n= Zα².P(1-P)\e². In the formula: "Zα²" is the confidence level adopted; "P" the expected proportion of experts who agree with each item evaluated; and "e" refers to the acceptable proportional difference from what is expected. The confidence level of 95%, the coefficient Zα of 1.96, the proportion of 85% of specialists and a difference (error) of 15% were adopted (16) . Thus, according to the above, the final estimated sample consisted of 22 specialists. However, in order to reach the estimated sample, 44 invitations had to be made, of which 50% were able to attend to the invitation. For each item in the questionnaire, a numeric value has been added so that for the options "totally agrees" and "agrees", the value +1 has been added because they are positive assessments; for the option "partially agrees", the value 0 (zero) has been added because it is a partial option; and for the options "totally disagrees", the value -1 has been assigned because it is a negative assessment option. From these values, the CVI was calculated. to or greater than 0.8, we did the binomial test, with a significance level of 5% (18) .

Results
We built an instructional printed educational material. The first version of the booklet was a material containing 77 pages of content, organized in a questionsand-answers format without text diagramming and insertion of photographs. After the diagramming, the material had 212 pages divided into 05 volumes, size approximately half an A4 sheet -27.2 cm.
The final version of the booklet was printed in 4x4 color printing, the cover in a 170 g glossy couche paper, and the kernel in 115 g glossless couché paper.
As for the adequacy of the educational material, was obtained and the I-CVI of each item evaluated separately was higher than 0.80 (Table 1).

In the validation of the booklet, there was
100% agreement of the judges on the content "to be understood" and 95% on the content "to be relevant" The S-CVI/AVE was calculated for each judge and from their mean, the S-CVI was calculated as shown in Table 2.
The agreement among the judges on the adequacy and relevance of the booklet was significant for all except for the judges 13 and 16 who most frequently indicated partially agrees (Table 3).      the materials usually have a mismatch between the instructions and the individuals to whom they are directed, although they are widely used in various aspects of health care (18) .
The contents that subsidized the construction of the educational booklet included several themes involving aspects related to physical and mental health, sexual practices, family planning, confronting the stigma, discrimination, and the rights of individuals living with HIV/AIDS.
In the volume 1, topics on nutrition, benefits of healthy eating, and physical activity for improving immunity were presented. The choice of topics related to body care is a concern already described in other studies by ILWHA, with healthy eating and physical activity being pointed out as part of healthy self-care, important elements for the QL of participants (19) .
The maintenance of a balanced and healthy diet, as well as physical activity, are considered to be care measures that contribute to health promotion and are fundamental to keep up physical and emotional health. Such health practices provide improved QL for the individuals, lowering mortality rates and increasing adherence to antiretroviral treatments, which are directly linked to improving the immune system (20) .
In volume 02, we approached the care of body and mind. The physical impacts of the TARV have long been the main concern on the impact of QL on ILWHA, however as new generations of drugs have been implanted in the health system, we could perceive a decrease in the prevalence of the most severe symptoms (21)(22) . Nevertheless, there has been a dramatic growth in symptoms of mental malaise among ILWHA over the years, especially in developing countries (23) .
These mental health problems can also arise as a side effect of antiretroviral treatment or the stigma, so that understanding which aspects really determine this relationship is even more complex (18) .
Volume 03 focused on moving forward. It is well known that the impact of the diagnosis still sharpens feelings of doubt, uncertainty, insecurity and lack of support mainly due to the stigma imbedded in cultural roots of HIV history, in this perspective, the knowledge of ILWHA through educational technologies strengthens their empowerment and helps in decision making, providing a foundation for a biopsychosocial well-being (8) .
The The way sexual minorities are differently affected by HIV and its impact on the quality of life (6) , has motivated this study to take into account the diversity of affective-sexual partnerships, both in the content and representations (photos and illustrations).
Still, in volume 05, rights were addressed: the desire to have children, family planning, and the fundamental rights for ILWHA. And although HIV brings fears and apparent limitations to ILWHA (24) , the desire for plans related to maintaining or building affective-sexual and family relationships, as identified in this study, is legitimate and can be found in others studies with different populations of ILWHA, such as men who have sex with men(24), pregnant woman (25) and serodifferent couples (26) .
The reproductive rights of ILWHA are the same for those not infected by the virus. However, we perceive that such rights can be oppressed by a lack of information related to transmission, fear, and stigma in the face of perceived guilt for the condition (27) .
Thus, we highlight the importance of educational materials, like the one developed in this study, which comes to collaborate with the increase of information for ILWHA, empowering them in the search for the accomplishment of their rights (28) .
In the validation of the booklet, there was 100% agreement of the judges that the content will be understood and 95% that the content will be relevant and meets the possible needs of the target audience, which makes the educational material applicable. This agreement of the judges on the applicability of the material is observed in other studies of educational booklet validation (8,29) .
The criterion of understanding, relevance, and applicability of educational material is of paramount importance since it is not enough for educational material to have valid and understandable content.
If it is not applicable, it is, therefore, necessary to critically rethink all the material.
The judges showed a positive evaluation of the booklet and indicated the material as an excellent resource for ILWHA to consult within and outside the health environment. Moreover, the collection was considered a complement for the practical guidelines by health professionals on the subject, mainly because of the style with which the content was added and, subsequently, organized: once exposed in a conversational way, organized in a question-andanswer format, the target audience, when reading the material, can then feel more motivated to follow the proposed guidelines.
Translating technical and scientific language into a language accessible to the population, particularly to those with lower health literacy, is a challenge. The development of the booklet as educational material from the educational needs and with the participation of the target population was a fundamental strategy in this study. We thus hope that this technology will facilitate communication and access to information amongst ILWHA and the healthcare team.
As a limitation, we point out the fact that in the first stage, the study included only ILWHA who were linked to health services and with participants from only one region of the country. In this way, there may be differences in educational needs in other cultural and social realities and contexts. Even so, the complementation of this stage with the literature sought to reduce this limitation.

Conclusion
The booklet was prepared out of the educational needs and with the participation of the target population and was validated in terms of content, language, and appearance by specialists in the field. We believe that We also believe that the use of these technologies, especially illustrated with photos, helps to reduce the stigma attached to ILWHA and helps to increase information, allowing the user to understand the new perspectives of living with HIV and answer questions about the subject.
In the validation of the booklet, we identified the judges' agreement on the understanding of the contents and the relevance in meeting the target audience, which makes the educational material applicable and an important intervention tool for health professionals and of access to the target population.
Finally, in order to analyze the contribution that the educational booklet can provide in the teaching-learning process of the target audience, mainly as an educational intervention in the context of comprehensive care for ILHIV, future studies will be carried out with a view to validating the appearance of the material and assessing the readability index by the ILWHA and its application in clinical practice.
We finally highlight that the booklet was made available in the printed version for public health institutions and also for the target audience in its online version, as it can reach a higher number of ILWHA in the whole country.