Creation and validation of an educational video for deaf people about cardiopulmonary resuscitation *

ABSTRACT Objective: to create and validate an educational video for teaching deaf students about cardiopulmonary resuscitation. Method: methodological study consisting in the creation of an educational video, validation of its content by 22 nurses with expertise in cardiorespiratory arrest, and evaluation by 16 deaf students. For data collection, the following validated instruments were used: the Instrument for Validation of Educational Content used for the validation by nurses and the Assistive Technology Assessment Questionnaire for the evaluation by deaf students. The criterion for validation was concordance higher than 80%, analyzed through the content validation index and binomial test. Results: the final version of the video lasted seven minutes and thirty seconds, covered the steps that should be performed by a lay person to help a victim of cardiorespiratory arrest, presented animations and the narration in the Brazilian sign language. All the items obtained agreement among nurses and of among deaf students equal or superior to 80%. Conclusion: the video was considered to present valid content by the judges and comprehensible content by deaf students. Thus the video represents an inclusive technology for health education of deaf people about cardiopulmonary resuscitation.


Recommendations from the American Heart
Association highlight the relevance of teaching cardiopulmonary resuscitation (CPR) to lay people (1) because of its association with greater survival chance of cardiac arrest (CA) victims in the prehospital setting (2) . Thus, it is important to invest in efforts so that such education can be offered to the maximum number of people who have the capacity to identify a case of CA and physical conditions to perform CPR (3) .
Among the target public are the deaf people, who have no cognitive or motor impairment and only differ from the majority of the population for their auditory impairment. Although physically and mentally fit, they are in disadvantage when it comes to accessing information about identification of a CA and performance CPR, as they face communication barriers and a scarcity of available health education material in sign language (4)(5) .
Considering that the use of technological resources contributes to the success of health education and that communication with the deaf occurs through visual means, it is worth highlighting the feasibility of using videos as a resource for the provision of health information (6) , according to observed in a study conducted in California whose results showed the effectiveness of a video about cancer aimed at health education for deaf people (7) .
Video also represent an effective option for teaching lay people regarding CPR (8)(9) . So, considering that videos are an effective resource for teaching deaf people and for multiplying information on CA, it is necessary to build and validate a video about CPR accessible to the understanding of the deaf people.
T he const ruc t i on and val i d at i on of an educational video for deaf people about CPR is relevant because it provides a didactic resource that can be used for training of a great number of people with standardized instructions and also corroborates with a self-directed and flexible learning process, because it provides the possibility of autonomy for the learners to watch the video in any moment they prefer and as many times as they deem it necessary (8)(9)(10) . Such educational technology can also contribute to the practice of health and education professionals who work with deaf students, to enable accessibility and empowerment to act correctly in cases of CA.
Moreover, it is worth noting that nursing has a relevant role in health education, because nurses carry out their professional activities in Thus, this study aimed to create and validate an educational video for teaching deaf students about cardiopulmonary resuscitation.

Method
Methodological study consisting in the creation of an educational video, validation by judges, and evaluation by deaf students representatives of the target audience.
Recommendations for the construction of audiovisual materials were followed, from preproduction (storyboard planning and design), production and post-production (11) . The initial step was the construction of the storyboard, which consists of the graphic sequence of actions (similar to a comic strip), with a layout that accurately corresponds to what will be the final product (11) .
The selection of the content about safety of the scene, correct identification of CA, call for help, and realization of the CPR followed the recommendations directed to lay people of the Brazilian Society of Cardiology, the American Heart Association, and the Asian and European Councils of Resuscitation (1,8,(12)(13) .
The storyboard with the scenes and drawings of the animations was built by a design company hired for this purpose under the supervision of the researcher. The choice for the development of video with digital animations instead of scenes recorded with actors was due to the fact that animations allow aesthetic improvement of the drawings, besides requiring less time for production and having a more attractive appearance than the recordings of scenes with actors.
After construction, the storyboard was submitted to content validation by judges with expertise in Basic Life Support (BLS). The sample calculation was performed with the equation for finite populations n = Za 2 .P (1-P)/e 2 . In this equation, Za (confidence level) was stipulated in 95%, P (proportion of experts agreeing with the item) was set at 85% and "e" (expected difference) was 15%, so that the calculated sample was 22
In order to recruit participants for this stage,   the Premiere program, and the interpreter was exposed in the lower right corner, in an area that corresponded to 1/6 of the screen.
As the video is a technology aimed at teaching and demonstrating information, its preparation focused on the reference of Gagné's instructional events. This reference includes components necessary for the content of an instruction to promote cognitive activation, mental processing, and long-term memory storage. These events focus on attracting the attention of student, informing objectives, stimulating memories and previous knowledge, presenting visual stimuli (images, arrows and flowcharts) and exposing content in organized blocks, with increasing order of complexity (14) .
In the construction of the video, the first event (catching the attention of the student) was In view of this recruitment strategy, there was no calculation to define the number of participants that would be part of the sample of this stage of the study; this number was defined by the number of students who agreed and volunteered to participate. Thus, 16 students agreed to participate in the study and signed the ICF.
The video was presented on a 32-inch television, with deaf students accommodated in school desks.
After watching the video, the participants completed the Assistive Technology Assessment Questionnaire (15) , which is a validated instrument for verifying the understanding of assistive educational technologies.  The binomial test, with significance level of 5%, was used to verify if the agreement ratio was statistically equal to or greater than 0.8 (16) .

Resolution 466/12 and was approved by the Ethics
Committee of the Federal University of Ceará (Opinion 2,108,475).

Results
The final version of the video had a duration  In the validation of storyboard content presented in the video, there was a minimum 86% of agreement on the objectives, structure and presentation. Among the items referring to relevance, the lowest agreement was 77% in the item about adequacy of the size of the material. The five judges who disagreed with this item reported that the time programmed for the video (approximately seven minutes) was too long and did not present suggestions of adjustments/modifications, however, as the binomial test of such item was not significant, such agreement was considered statistically equal to or greater than 80%, so that the item was considered valid and there was no change.
There was 86% agreement of the judges in the item "the information has accurate content". The three judges who disagreed presented as justification the  (Table 1). In addition, there was a minimum agreement of 93% regarding the relevance and efficacy and unanimous agreement on clarity and interactivity, as observed in Table 2.

Discussion
The content that subsidized the construction of the video contemplated the safety of the scene, correct identification of the problem, call for help, and correct way to perform the CPR. These contents were relevant to be addressed in the video, because, once performed correctly, contribute to reduce the probability of death.
Regarding the first information presented by the video (safety of the scene), the American Heart Association and the European Resuscitation Society emphasize the need to verify such safety before any approach to the victim (1,9,17) . Results from Norwegian research with lay people who rescued patients who had undergone a CA in out-of-hospital settings showed that the situation of rescuing is permeated by worry and nervousness (18) . It is, therefore, understandable that the attention given to the victim may lead to negligence about the safety of the place, so that the risks that may Other relevant steps presented in the sequence of the content of the video concern the correct way to identify a CA and the request for help. When considering the incompatibility of life with the CA, fast assistance of specialized professionals becomes of major importance.
However, the access of health professionals to the victim depends directly on the identification of the grievance, so that the mobile medical service be called right away (8) .
As soon as an out-of-hospital CA is identified, the task to call the mobile emergency service (12)(13) (19) . It is, therefore, important to highlight the relevance of the educational video to present information about the telephone contact of the Brazilian prehospital service.
The content used in the construction of the educational video also included, in particular, the correct realization of CPR, which explains the position of the rescuer, the point of the victim's chest where the compressions must applied, the rate and depth that characterize high quality compressions (12)(13) .
The correct realization of these conducts is related to the effectiveness of the CPR and the probability of return of spontaneous circulation, as it is pointed out in the results of a North American multicenter study carried out with 8719 participants, where there was a correlation of correct rate and depth with the lowest mortality (20) .
When considering that the correct performance of CPR professionals, it is recommended that the population be oriented to treat as a CA all cases where there is no responsiveness or breathing (3,(12)(13) . Thus, the presence of such content in the video is relevant to multiply information on the identification of CA cases, which will trigger the realization of the subsequent steps of care.
In the view of the nurses who participated in the validation, the video presented sufficient and necessary information. This result corroborates Brazilian methodological researches on the validation of a booklet on first aid at school and a video for parents of children using clean intermittent catheters, whose results showed that the evaluators agreed with the pertinence and adequacy of the content presented (21)(22) .
These Brazilian findings corroborate a study not understood by the population for which they were created (27) .
In this context, it is necessary that educational technologies be evaluated by representatives of the public who will use them, so that confusing   (29)(30) . Although the deaf students considered it easy to use the video, some of them disagreed about whether it was easy to seek information in the video, because they cannot control the technological resources that allowed them to pause and/or review some parts of the material.
In this context, it is necessary to stress the need to empower the population to use educational technologies, especially deaf students, in order to stimulate autonomy, so that the search for information comprehensible for deaf students, not only makes it possible to use them during educational interventions, but also for self-instruction to build knowledge even in the absence of health professionals/instructors. In addition, the material contributes to the multiplication of information about CA, a theme little disseminated in Libras, for a public who, once trained to act correctly, may intervene and contribute to reducing mortality.

Conclusion
An educational video on cardiopulmonary resuscitation was developed for deaf students. Its The video can enable deaf students to access content on CPR and it is, therefore, a viable technological resource to be used by nursing and other health professionals in health education. It is necessary to investigate the effectiveness of using the video in the knowledge and ability of deaf students about CPR.