Serial album validation for promotion of infant body weight control

ABSTRACT Objective: to validate the content and appearance of a serial album for children aged from 7 to 10 years addressing the topic of prevention and control of body weight. Method: methodological study with descriptive nature. The validation process was attended by 33 specialists in educational technologies and/or in excess of infantile weight. The agreement index of 80% was the minimum considered to guarantee the validation of the material. Results: most of the specialists had a doctoral degree and a graduate degree in nursing. Regarding content, illustrations, layout and relevance, all items were validated and 69.7% of the experts considered the album as great. The overall agreement validation index for the educational technology was 0.88. Only the script-sheet 3 did not reach the cutoff point of the content validation index. Changes were made to the material, such as title change, inclusion of the school context and insertion of nutritionist and physical educator in the story narrated in the album. Conclusion: the proposed serial album was considered valid by experts regarding content and appearance, suggesting that this technology has the potential to contribute in health education by promoting healthy weight in the age group of 7 to 10 years.


Introduction
Over the last three decades, the prevalence of excess weight in children, which includes overweight and obesity, has increased substantially, presenting itself as one of the great challenges of public health in the current context (1) .
This epidemiological and nutritional picture is explained, in large part, by the changes that have been occurring in the food pattern, resulting in more and more common obesogenic diets (2) . Add to this the reduction of physical activity and an increase in the practice of sedentary activities, such as watching television (3) .
In addition, other factors associated with the etiology of obesity in children are: parental obesity, maternal diabetes, maternal smoking, gestational weight gain (4) , inadequate sleep (5) , influences of the family and school environment (6) , socioeconomic and educational aspects of the family (7) , among others.
This increase in infant excess weight is concerning, since in a study with children and adolescents aged 8 to 18 years, obese individuals, compared to eutrophic ones, were more likely to have hypertension, hyperinsulinemia, higher value of the homeostatic resistance assessment model (HOMA-IR), hypertriglyceridemia, low HDL-C, high LDL-C and increased uric acid (8) .
In addition to cardiometabolic outcomes, obesity in children has been associated with obesity in adulthood, mental health problems, asthma, obstructive sleep apnea, orthopedic difficulties, early maturation, polycystic ovary syndrome, and hepatic steatosis (9) .
In this context, interacting with children about habits that reduce the risk of obesity is relevant for health promotion and prevention of complications (9) . Thus, it is necessary to encourage the creation and use of educational technologies capable of mediating the interaction between health practitioners and children, aiming at the joint construction of knowledge about childhood obesity.
Associating care with educational actions aims to share practices and knowledge in a horizontal relationship.
Thus, it is believed that the technologies are tools, processes or materials created to expand the possibilities of health practitioners to perform care practices and, consequently, improve the quality of care (10) .
Although it is relevant, in access to online search devices, there was a shortage of validated educational technologies on weight control and, mainly, having a target audience composed of Brazilian children. Thus, in view of the need to intervene in the problem of childhood obesity and to develop new technologies that are easily accessible and used by health and education professionals, a serial album was built with the purpose of empowering children from 7 to 10 years on the importance of maintaining healthy habits and, as a consequence, controlling body weight.
At this juncture, it is worth emphasizing that, in order to give greater credibility and reliability to the educational materials that it is intended to implement, it is opportune to use an evaluation process to maximize their effectiveness (11) . In view of this, the present study was developed with the objective of validating the content and appearance of a serial album targeted at children aged 7 to 10 years addressing the topic of prevention and control of body weight.

Method
This is a methodological study, of descriptive character, through the opinion of a group of specialists.
The process of construction of the serial album took place between the months of April and August of 2014 and the validation by specialists occurred between September and October of the said year.
The first version of the serial album was entitled "Excess weight in children" and, for the construction thereof, part of the theoretical content on the subject was gathered. Thus, we used publications from the National Survey on School Health (PeNSe) (12)(13) and from the World Health Organization (8,14) .
In addition, the content was planned based on the reality of health education, assistance and research with children and adolescents accompanied at the Center for Childhood Obesity (COI), Campina Grande/Paraíba, in the Northeast region of Brazil (5,15) .
The album was written according to the story of the Silva family whose set of characters was composed of two children (Maria and Francisco), the father (Seu José), the mother (Dona Lúcia), the grandmother (Dona Carminha) and the nurse Ana. These names were selected because they were considered common among the Brazilian population.
In addition to the narration of the story, other pictures were inserted that served as a script for the dialogue between the children and the artist's serial album.
The illustrations were elaborated by a designer, who used Adobe Ilustrator® and Corel Draw® to edit the images, and another specialized professional was responsible for the layout of the serial album through Photoshop®.
In the end, the serial album consisted of 20 pages: cover page, nine pictures and the respective nine scriptsheets and a technical file with the names of the makers (PhD student, advisors, illustrator and designer). Figure   1 shows the cover and the pictures of the first version of the serial album, besides the technical file. Figure 2 shows the summary description of the contents of the cover, the figures and the script-sheets of the serial album.  Picture and script-sheet 5 -Consequences of excesso weight Psychological consequences, such as low self-esteem, and physical consequences of excess weight (sleep disorders, heart disease, fatigue at minimum effort).

Picture and script-sheet 6 -Healthy eating
Information on healthy eating, such as the appropriate number of daily meals and the time spent on each meal.
Picture and script-sheet 7 -Unhealthy eating Discussion on hypercaloric and low-nutrient foods.
Picture and script-sheet 8 -Hydration and physical activity Benefits of water intake and daily practice of physical activity.
Picture and script-sheet 9 -End Review of subjects covered and presentation of positive changes in characters' habits. Higher Level Personnel), using the following keywords: "obesity", "overweight", " childhood obesity" and "educational technology". Then, invitation letters were sent to the possible experts by e-mail, also asking the indication of other participants that met the selection criteria, resulting in some having been selected by snowball sampling, which is a method of sampling that is useful for studying difficult-to-access or difficult-tostudy populations for which there is no precision about their quantity, which is the case of this study (17) . The Lattes Curriculum of the professionals indicated were analized to verify compliance with the inclusion criteria.
A total of 79 experts from different regions of the country were invited to address food diversity and other habits, customs and cultural contexts. Of these, 17 did not return the contact, eight did not agree to participate in the study and 21, although having accepted the invitation, did not send the instrument completely filled within the stipulated time. Thus, the final sample consisted of 33 specialists.
The following documents were forwarded to the experts: a Free and Informed Consent Form (FICFs) in two copies, the first version of the serial album entitled "Excess weight in Children", and the data collection instruments.
Data collection was performed using two instruments: one for characterization of the specialists and the second one called the Serial Album Analysis Protocol, organized in two sections. The first section was adapted from another study that also evaluated a serial album (18) and was related to the appearance of the cover page and the pictures and the internal content of each script-sheet; while the second, also adapted (19) , was about evaluating the album as a The instruments were adapted (18)(19) because they addressed other themes and, in the case of the second section, because it is a type of technology different from a serial album, necessitating, therefore, adjustments in some evaluative items. Both original instruments were not submitted to a scientific validation process.
The data were double typed in an electronic database and, after the consistency analysis, a descriptive study was carried out to characterize the specialists and their respective analyzes. The data are presented by means of proportions, means and standard deviations.
In order to analyze the content validity of the script-sheets, we used the Content Validity Index (CVI), calculated through two mathematical equations: the I-CVI (item-level content validity index) and the S-CVI/ Ave (scale-level content validity index) (20) . In this study, It should be noted that the CVI ranged from 0 to 1 and the serial album would be considered valid if it presented a S-CVI Global greater than or equal to 0.80 (21) . The items that obtained percentage below 80% of agreement were reformulated based on the suggestions of the experts and the scientific literature. Among the eight professionals who did not accept to evaluate the serial album, six justified personal reasons and two did not find that the prevention of excess weight in children could be a topic of interest and nursing intervention, even refusing the invitation with this justification. Table 1 shows the S-CVI/Ave of the cover page, the nine pictures and the nine script-sheets of the serial album. The set of picture and script-sheet 8 was considered the best. The script-sheet 2 and picture 9 had the mean exactly at the limit. Only script-sheet 3 did not reach the cut-off point.
Some experts considered that script-sheet 3 had a difficult-to-understand content for children aged 7 to 10 years due to the presentation of the World Health Organization chart for the classification of body weight by the z-score of individuals aged 5 to 19 years (22) . For this reason, the chart was removed from picture 3 and script-sheet 3.
On the script-sheet 2, the main point discussed by the experts was related to the Body Mass Index (BMI), which presented a text that may be incomprehensible to children. Thus, the text on BMI was excluded.
In the case of picture 9 of the serial album, some  After reflecting on the suggestions of the experts, the illustrator and the designer were again contacted in order to develop changes in the pictures and texts, thus obtaining the second version of the serial album. Figure   3 shows the two alterations made, respectively, in the cover page and in the illustration of the characters of the story of the serial album.

Discussion
In this study, the album "An Eye on the Weight" on child body weight control was validated by specialists with extensive experience in the area of educational technologies and/or excess child weight. This educational material represents a technological innovation in Brazil, considering that, although the topic of childhood obesity has been much discussed, few validated technologies were found addressing this theme, especially with children as a target audience.
It is emphasized that the serial album is a technology that is easy to use in health services and schools, because it is classified as independent, that is, it does not depend on electrical resources for use (10) .
In addition, a positive feature of this album was the creation of characters and the narration of a story, which allows a playful approach to the theme.
This playful aspect was also focused by another Brazilian study, in which the authors developed a serious game for schoolchildren with the topic of human digestion, healthy eating and physical exercise and obtained a positive evaluation from a group of health and computer specialists (23) . In addition to this game, a smartphone application was found that aims to promote healthy behaviors among children; this was elaborated by researchers from South Korea (24) .
The elaboration of different health technologies assists professionals, who can take advantage of them as a way to assist their clientele and promote autonomy and independence, whether in closed institutions, in education in health or in any environment (25) .
Although the educational approach of the serial album validated in this study was mainly the traditional one, in which the educator explains to the student healthy habits and behaviors (26) , it is emphasized that the application of this material aims to stimulate dialogue with children through questions about individual habits and opinions about the story.
On the theme of the serial album, it is believed that, in order to restraint the growing tendency of excess weight, interventions should start in childhood (14) .
Thus, aiming at promoting the health of all children, regardless of nutritional classification, the purpose of the educational material was redefined, which came to focus on raising awareness of the target audience about the importance of taking care of body weight through healthy habits and not only highlighting obesity. Thus, the serial album came to be entitled "An Eye on Weight", and not "Excess weight in children".
In the validation process, the evaluation of the specialists was of paramount importance for the improvement of the material and it is valid to highlight the scope of a professional diversity, resulting in a multidisciplinary work.
In this context, it should be emphasized that the factors related to weight changes are not limited to feeding and, therefore, this reaffirms the importance of a multidisciplinary follow-up focusing on the establishment of healthy habits, related to diet and practice of physical activity associated to the provision of psychological support (27) . the Family Health Strategy and the school (31) .
Thus, this scenario change also resulted in the exclusion of characters (father, mother and grandmother) and the inclusion of two other health professionals: nutritionist Fernanda and physical educator Carlos.
As already mentioned, body weight control includes the participation of professionals from different areas; besides these, there are physicians, psychologists, Rev. Latino-Am. Enfermagem 2018;26:e2998.
pedagogues, physiotherapists, occupational therapists, among others (27) . Nevertheless, the insertion of a more complete team could confuse the children participating in the application of the album, and they possibly would not understand the function of each professional.
Another change in the serial album was the union of pictures 6 (healthy eating) and 7 (unhealthy eating), and this happened because some experts suggested not labeling foods as 'healthy' and others as 'unhealthy', mainly because those 'unhealthy' foods might look very appetizing to the child's eyes and the 'healthy' ones would look like bad tasting foods.
Finally, the picture and the content of the script- Regarding the limitations of this study, one of them may be the predominance of specialists from the Northeast region (51.5%), which may suggest a tendency to the habits of this region. However, it is noteworthy that 79 specialists from all regions of the country were invited and, from this, it was verified they had difficulty in returning the contact and in completing the instrument. In addition, it is worth mentioning that the sample size reached, which was 33 specialists, was much higher than the minimum required, which was 22.
Another possible limitation is the fact that the experts had not been questioned whether they had knowledge about education for children aged 7 to 10 years. Thus, in order to reduce this limitation, it is suggested as a future study an evaluation of the serial album by pedagogues.
Finally, the scientific advance in the area of health education of Brazilian children stands out, since the proposed serial album has been validated by specialists in content and appearance. Therefore, it is intended to contribute with health professionals in the process of raising children' awareness in a playful and educational way regarding the risks associated with childhood obesity. As future studies, it is suggested the validation of the serial album by the target audience and the construction of another version with specific content for the parents and/or legal guardians for the children.

Conclusion
The proposed serial album was validated by experts with experience in educational technologies and/or excess child weight with S-CVI Global equal to 0.88, which suggests that this technology can be used in health education activities with the aim of promoting healthy behaviors though the learning of skills related to body weight control.
We believe that this process of adapting the educational technology to the suggestions of the specialists was an essential step to make the material more appropriate to children and with greater scientific rigor.
Thus, the result of this research can be a relevant educational instrument for application in specific activities or in conjunction with a program of interventions to combat childhood obesity, either in health units or schools. It should be noted that, according to the validation made by specialists, the illustrations were considered clear, attractive and relevant, and the content was evaluated as easy to understand for children in the age group of 7 to 10 years. However, in order to improve this technology, it is suggested a further study for the evaluation of the album by the target audience.