SciELO - Scientific Electronic Library Online

vol.31 issue3Strategies to enhance the profession of nursing as a key partner in improving primary care across the hemisphereAnthropometry versus subjective nutritional assessment in cancer patients author indexsubject indexarticles search
Home Pagealphabetic serial listing  

Services on Demand




Related links


Acta Paulista de Enfermagem

Print version ISSN 0103-2100On-line version ISSN 1982-0194

Acta paul. enferm. vol.31 no.3 São Paulo May/June 2018 

Original Article

Elaboration and validation of a reader on childhood diarrhea prevention

Leidiane Minervina Moraes de Sabino1

Ádria Marcela Vieira Ferreira1 

Emanuella Silva Joventino1 

Francisca Elisângela Teixeira Lima1 

Jardeliny Corrrêa da Penha1 

Kamila Ferreira Lima1 

Ludmila Alves do Nascimento1 

Lorena Barbosa Ximenes1 

1Universidade Federal do Ceará, Fortaleza, CE, Brazil.



Elaborate, validate and evaluate an educational reader to promote maternal self-efficacy in the prevention of childhood diarrhea.


Methodological study, developed based on the elaboration, validation and evaluation of educational material by 30 content judges and three technicians. For the validation, the clarity of the language, practical pertinence and theoretical relevance were considered, calculating the Content Validity Index for each item; and the tool Suitability Assessment of Materials (SAM) was applied to evaluate the reader.


The reader was titled “You can prevent diarrhea in you child” was elaborated in the framework of Self-Efficacy Theory. The content judges attributed a global Content Validity Index (CVI) of 0.88 for language clarity, 0.91 for practical pertinence and 0.92 for theoretical relevance; and the technical judges attributed CVI of 0.96, 1.00 and 1.00 for the same items assessed, respectively. The assessment of the content and technical judges based on the SAM tool classified the material as “superior”, with average coefficients of 88.7% and 90.1%, respectively.


The reader was considered appropriate in terms of face and content validation to promote maternal self-efficacy in the prevention of childhood diarrhea.

Key words: Diarrhea, infantile; Self efficacy; Health promotion; Validation studies; Mother-child relations


Diarrhea is considered a global public health problem with high morbidity and mortality rates, mainly in developing countries.(1) In Brazil, the State of Ceará, located in the Northeast, is one of the states with the worst environmental and health conditions, favoring the presence of risk factors for the disease, especially in children.(2) In 2016, 3,711 cases of diarrhea in children under five years of age were registered in the city of Fortaleza, CE.(3)

Considered as a multifactorial disease, diarrhea can be prevented by adopting measures to protect against infectious agents.(4) The need for prevention strategies is highlighted, aimed at families of children under five years of age, which can improve knowledge and maternal confidence in preventive care for childhood diarrhea.(5)

Thus, an educational video based on Bandura’s Theory of Self-Efficacy titled “Childhood Diarrhea: you can prevent it”, applied to mothers of children under five years old, permitted enhancing maternal self-efficacy to prevent childhood diarrhea and reducing the cases of diarrhea up to two months after this intervention. After this period, however, the mothers’ self-efficacy decreased, suggesting the need to develop and use other technologies in this area to keep up the implementation of interventions to prevent this condition.(5,6)

Thus, it was decided to elaborate an educational reader the promotion of maternal self-efficacy in the prevention of childhood diarrhea, using the Theory of Self-Efficacy as a reference framework. Readers are printed materials useful to describe health-related subjects, and can be used as a tool for health promotion, which facilitates the educational process.(7)

The use of this reader can contribute to improve educational activities for the prevention of childhood diarrhea performed by nurses, and will help the mothers in their childcare behaviors in the care of their child, increasing their confidence and influencing the reduction of cases of morbidity and mortality in children under five years of age due to diarrhea.

Therefore, the objective was to elaborate, validate and evaluate an educational reader for the promotion of maternal self-efficacy in the prevention of childhood diarrhea.


It is a methodological study, in which an educational reader was developed to promote maternal self-efficacy in the prevention of childhood diarrhea, based on the elaboration, validation and evaluation of that educational material.

Initially, the educational reader was elaborated, whose content was based on the items of the Maternal Self-Efficacy Scale for Prevention of Childhood Diarrhea (EAPDI) and the scenes of the educational video “Childhood Diarrhea: you can prevent it”. Therefore, the reader was constructed in the light of Bandura’s Theory of Self-Efficacy.(6) It is highlighted that both the EAPDI and the video mentioned were validated and had their reliability proven.(8,9)

In this construction stage of the reader, it is worth noting that theoretical and methodological references have been used which emphasize elements that should be considered in the elaboration of printed educational materials with a view to improving the readers’ comprehension.(10-13)

Initially, the script of the reader was developed and the Flesch Readability Test was applied to ensure easy reading. The test classifies the textual comprehension as follows: very easy, easy, difficult and very difficult; also classifying the sentences in the active and passive voice.(14) Afterwards, a qualified design professional developed the illustrations and layout of the reader.

The reader was then submitted to validation, involving content and technical judges, to enhance the credibility of the material elaborated.(15) Thirty content judges, who were specialists in the thematic area of the reader; and three technical judges, graphic design experts, participated in this validation stage. They were recruited and selected according to the criteria described by Jasper.(16) The number of judges followed the recommendations suggested by the authors regarding the number of evaluators for this type of study.(17,18)

The instrument used for the validation was a five-point Likert scale, ranging from “very low” to “very high”, which permits evaluating each page of the reader based on: clarity of language, practical pertinence and theoretical relevance. In addition, space was provided for the judges’ suggestions.(19)

The judges also evaluated the educational material using SAM. This tools makes it possible to evaluate the material in the following areas: content; language fit for the population; graphical illustrations, lists, tables and graphs; layout and type; stimulation for learning and motivation; cultural appropriateness.(10)

After validation and evaluation of the educational reader by content and technical judges, their suggestions were analyzed and the technical professional responsible for the illustration and diagramming of the reader was again contacted to modify and adapt the material according to the judges’ recommendations.

The data obtained were organized, processed and analyzed using the Statistical Package for the Social Sciences (SPSS), version 20.0. As far as the data analysis was concerned, for the textual evaluation of the reader based on the application of the Flesh Readability test, the following indices were adopted: 100-75: very easy; 74-50: easy; 49-25: difficult; 24-0: very difficult.(14) To analyze the content validation of the educational reader, the CVI was calculated. Items were considered valid if the interrater agreement corresponded to CVIs equal to or greater than 0.80.

The data obtained by the application of the SAM questionnaire were organized in Excel. The obtained scores were processed using percentage analysis, as follows: 70% to 100% of the scores, “superior” educational material; from 40 to 69%, “adequate”; and 0 to 39%, “not suitable”.(10)

The study received approval from the Research Ethics Committee of the Federal University of Ceará (UFC), under opinion 1.116.855, in compliance with Resolution 466/12.(22)


The reader titled “You Can Prevent Diarrhea in Your Child!” was organized into eight sub-topics: 1. How to know if your child has diarrhea; 2. How to take care of your child’s hygiene; 3. Learn how to take care of your hygiene; 4. Cleaning the environment helps prevent disease; 5. Let’s learn how to wash the fruits and vegetables; 6. See how to take care of your child’s nutrition; 7. Know the importance of vaccination for your child; 8. How to care for the child with diarrhea.

In relation to the elaboration of the material, the main characters present in the pages of the reader were portrayed on the cover. We sought to use simple and direct language to favor the population’s understanding. In the illustrations, we sought to approach the cultural reality of the reader’s target audience. In the layout, we used Arial font, size 16 points for the body of the text and 18 points for the subtitles.

Based on the script, the Flesch readability test was applied to the 44 paragraphs of the reader. Of these, 34 (77%) were considered very easy and 10 (23%) were easy. In the analysis of the complete reader, the test revealed a score of 91, classifying the material as very easy to read, with all phrases written in the active voice.

The first version of the reader consisted of 32 pages, 21 pages for content, eight pre-textual and post-textual pages and three blank pages the mothers can use to make notes.

Thirty content and three technical judges validated the first version of the reader. The 30 content judges were nurses, 24 of whom held a specialization degree, 20 an M.Sc. and 15 a Ph.D. Of these, 17 judges were teachers and 13 were active in care practice. As for the training of the technical judges, two were advertising agents and one was a musician. In addition, two had completed a specialization course in graphic design, two judges were working in the area of graphic design and one in art direction.

The CVI of each page of the reader was calculated considering the clarity of the language, the practical pertinence and the theoretical relevance; and later the global CVI, which is represented in table 1.

Table 1 Distribution of CVIs for each page according to the content and technical judges’ analysis 

Page/Theme Clear language Practical relevance Theoretical relevance
C* T** C* T** C* T**
Cover 0.9 1 0.93 1 0.9 1
Presentation 0.9 1 0.93 1 0.93 1
Page 7/ Definition of childhood diarrhea 0.76 1 0.93 1 0.93 1
Page 8/ Care with child hygiene 0.86 1 0.9 1 0.93 1
Page 9/ Care with child hygiene 0.83 1 0.9 1 0.9 1
Page 10/ Care with child hygiene 0.83 1 0.9 1 0.9 1
Page 11/ Care with maternal hygiene 0.8 1 0.9 1 0.9 1
Page 12/ Environmental cleaning 0.96 1 0.96 1 0.93 1
Page 13/ Environmental cleaning 0.93 1 0.86 1 0.93 1
Page 14/ Environmental cleaning 0.96 1 0.96 1 0.96 1
Page 15/ Environmental cleaning 0.86 1 0.9 1 0.86 1
Page 16/ Washing fruit and vegetables 0.93 1 0.93 1 0.96 1
Page 17/ Washing fruit and vegetables 0.86 1 0.9 1 0.93 1
Page 18/ Food 0.9 1 0.9 1 0.96 1
Page 19/ Food 0.83 1 0.93 1 0.9 1
Page 20/ Food 0.8 1 0.86 1 0.83 1
Page 21/ Food 0.9 0.66 0.9 1 0.9 1
Page 22/ Food 0.86 1 0.86 1 0.9 1
Page 23/ Vaccination 0.96 0.66 1 1 1 1
Page 24/ Diarrhea management conducts 0.96 1 0.96 1 0.96 1
Page 25/ Diarrhea management conducts 0.93 1 0.83 1 0.9 1
Page 26/ Closure 0.96 1 1 1 1 1
Global CVI 0.88 0.96 0.91 1.00 0.92 1.00

*Content Judges **Technical Judges

For most pages in the reader, the CVI was superior to 0.80. For pages 7, 21 and 23, the CVI was lower than 0.80 with regard to clear language. Changes were made in the language based on the judges’ recommendations.

In addition, the judges gave relevant suggestions on the readers, mainly: update how long the fruit and vegetables should be left to soak for the sake of hygiene; and change the scenario on some pages (type of refrigerator and stove, foods shown in the refrigerator and on the meal table), recovering the population’s reality. In addition, the inclusion of a new page was requested to discuss care for the child with diarrhea and signs of alert for diarrhea. All of these recommendations were accepted after the researchers’ analysis.

The judges also evaluated the reader using the tool SAM (Table 2).

Table 2 Assessment of educational reader by content and technical judges 

Domains Higher Appropriate Inappropriate Total – Mean agreement (%)
C* T** C* T** C* T** C* T**
a) Clear objective 23 3 7 - - - 88.3 100
b) Content discusses behavior 28 3 2 - - - 96.7 100
c) The proposal is limited 24 3 6 - - - 90 100
d) Abstract or review 16 - 5 2 9 1 61.7 33.3
2. Language fit for the population
a) Level of reading 22 3 8 - - - 86.7 100
b) Active voice style 25 2 5 1 - - 91.6 83.3
c) Vocabulary uses common words 23 3 7 - - - 88.3 100
d) Context first 26 2 4 1 - - 93.3 83.3
e) Learning mediated by advanced signs 27 3 3 - - - 95 100
3. Graphical illustrations, lists, tables and graphs
a) Cover 24 2 6 1 - - 90 83.3
b) Type of illustrations 28 3 2 - - - 96.7 100
c) Relevance of illustrations 28 3 1 - 1 - 95 100
d) Lists, tables, graphs and forms 26 3 1 - 3 - 88.3 100
e) Captions are used 23 3 4 - 3 - 88.3 100
4. Layout and type
a) Layout factors 24 2 6 1 - - 90 83.3
b) Type 26 3 4 - - - 93.3 100
c) Subtitles are used 23 3 7 - - - 83.3 100
5. Stimulation for learning and motivation
a) Interaction is included in the text and/or figures 15 - 13 3 2 - 71.7 50
b) Desired behavioral standards are modeled or shown in specific terms 26 2 4 1 - - 93.3 83.3
c) Motivation/self-efficacy 23 3 7 - - - 88.3 100
6. Cultural Appropriateness
a) Cultural game – logic, language and experience (LLE) 22 3 8 - - - 86.7 100
b) Cultural Image and Examples 27 2 2 1 1 - 93.3 83.3
Total 88.7 90.1

*Content Judges **Technical Judges

According to the analysis of the judges’ evaluation, they considered the educational reader to be “superior”, reaching an agreement percentage of 88.7% among the content judges and 90.1% among the technical judges. The judges also assigned a score of zero to ten concerning the recommendation to use the reader, averaging 9.26 by the content judges and 9.66 by the technical judges.

After the judges’ analysis, the final version of the reader consisted of 32 pages, 22 pages of content, eight pre-textual and post-textual pages and two blank pages for notes.


As a limitation of the study, the validation of the readers only by content and technical judges is highlighted. Its clinical application to the mothers who will use this material in practice is important.

The use of this reader will support the practice of nurses and other health professionals who carry out educational activities, being an important tool to promote maternal self-efficacy in the prevention of childhood diarrhea.

The educational reader “You Can Prevent Diarrhea in Your Child!” was developed using Bandura’s Self-Efficacy Theory as a framework because, as self-efficacy is developed, people intensify their efforts to achieve or even exceed the desired result.(6)

The reader was divided into eight topics to facilitate the understanding and organization of the content, so as to make it more interactive, so that the reader is motivated to follow the message addressed.(23) Simple language was used, so that individuals with a low level of education can read and understand the material, enhancing the reader’s motivation.(10,24) The reality of the families’ daily life was portrayed in the reader, as individuals who participate in educational approaches become more prone to adopt new behaviors when there is a relationship of trust and closeness to their reality.(15)

After the preparation of the first version of the reader, it was validated by content and technical judges, achieving a minimum CVI of 0.8, which is the recommended value in the literature.(9,21,25) It is emphasized that validation is essential after the elaboration of educational materials, as judges knowledgeable on the subject need to be able to evaluate the material and suggest improvements.(15,26,27) In addition, it is recommended that there should also be a group of judges knowledgeable in the field of graphic design in material validation studies.(28)

As to the judges’ requests, changes were made in the time that fruits and vegetables should remain submerged in water with sodium hypochlorite;(29) and in some illustrations, the aim was to improve the socio-cultural adaptation, acknowledging the need to portray the contextual reality of the reader in the elaboration of the educational materials.(24)

The overall evaluation of the reader, based on the sum of the average SAM scores among the items of the six domains, revealed that the technical judges considered the material to be “superior”. The SAM instrument can reveal weaknesses in the instruction of a material, which could reduce its suitability for use by the target audience.(10)

In the content domain, the content and technical judges rated the abstract or review item as “adequate” and “not suitable”, respectively. Although some judges considered it pertinent to include this item in the reader, it was decided not to insert it; because it was elaborated in eight topics, according to authors’ recommendations, who indicate that the division of the material into topics presents the subjects dynamically, allowing the closing of each subject; and the figures in each page of the reader were intended to aid in the textual review, contributing to knowledge acquisition.(23,24)

In the field of stimulation for learning and motivation, although the technical judges considered the item “interaction is included in the text and/or pictures” as “adequate”, it is known that the reader is intended to encourage the reader to adopt the same behavior as the character, motivating the performance of responses similar to those of the character. Thus, the importance of inserting the Theory of Self-Efficacy in the elaboration of the material is emphasized, as can allow the reader to feel able to perform the care portrayed in the booklet.(5,6)

The domains language; graphical illustrations, lists, tables; layout and type; and cultural appropriateness were evaluated as “superior”. The adequacy of these domains is fundamental in the communication of health education, and it is important that the materials are creative to attract the public’s attention and more likely to achieve positive results.(30) In addition, it is essential that the population’s living and cultural conditions be pictured in the reader, as it encourages the target audience to visualize its own reality, alluding to the fact that, if the character is able to prevent diarrhea in her child, so will the mothers living in similar situations.(15)

The content and technical judges’ evaluation classified the educational reader as appropriate in terms of language clarity, practical pertinence and theoretical relevance. The reader was considered “superior” based on the application of the SAM tool, considering content; language fit for the population; graphical illustrations, lists, tables and graphs; layout and type; learning stimulation and motivation; and cultural appropriateness.


The educational reader “You can prevent diarrhea in your child” was considered valid educational material in terms of content and face validation to promote maternal self-efficacy in the prevention of childhood diarrhea.


Acknowledgements to the organizations that funded this research (Ceará Scientific and Technological Development Support Foundation – FUNCAP and Brazilian Scientific and Technological Development Council – CNPq) and to the judges who participated in the validation and evaluation of the educational reader.


1. Bühler HF, Ignotti E, Neves SM, Hacon SS. [Spatial analysis of integrated health and environmental indicators for morbidity and mortality due to infant diarrhea in Brazil, 2010]. Cad Saude Publica. 2014; 30(9): 1921-34. Portuguese. [ Links ]

2. Bühler HF, Ignotti E, Neves SM, Hacon SS. [Spatial analysis of integrated determinant indicators of mortality from acute diarrhea in children under 1 year of age in geographical regions]. Cien Saude Colet. 2014; 19(10): 4131-40. Portuguese. [ Links ]

3. Fortaleza (cidade) Prefeitura Municipal. Secretaria Municipal de Saúde. Consolidado das notificações de Casos de diarreia aguda por Secretaria Executiva Regional [Internet]. 2016 [citado 2016 Jan 13]. Disponível em: [ Links ]

4. Atencio R, Bracho A, Porto L, Callejas D, Costa L, Monsalve F et al. Diarrheic syndrome due to rotavirus in immunized and non-immunized children under 5, in the city of Maracaibo, State of Zulia, Venezuela. Kasmera. 2013; 41: 59-68. [ Links ]

5. Joventino ES, Ximenes LB, Penha JC, Andrade LC, Almeida PC. The use of educational video to promote maternal self-efficacy in preventing early childhood diarrhoea. Int J Nurs Pract. 2017;23(3)e12524. [ Links ]

6. Bandura A. On the functional properties of perceived self-efficacy revisited. J Manage. 2012; 38(1):9-44. [ Links ]

7. Siddharthan T, Rabin T, Canavan ME, Nassali F, Kirchhoff P, Kalyesubula R et al. Implementation of patient-centered education for chronic-disease management in Uganda: an effectiveness study. PLoS One. 2016; 11(11): e0166411. [ Links ]

8. Joventino ES, Ximenes LB, Almeida PC, Oriá MO. The maternal self-efficacy scale for preventing early childhood diarrhea: validity and reliability. Public Health Nurs. 2013; 30(2):150-8. [ Links ]

9. Nascimento LA, Rodrigues A, Joventino ES, Vieira NF, Pinheiro PN, Ximenes LB. Validation of educational video to promote self-efficacy in preventing childhood diarrhea. Health (Irvine. Print). 2015; 7(2):192-200. [ Links ]

10. Doak CC, Doak LG, Root JH. Teaching patients with low literacy skills. 2nd ed. Philadelphia: J.B. Lippincott; 1996. [ Links ]

11. Moreira MF, Nóbrega MM, Silva MI. [Written communication: contribution for the elaboration of educational material in health]. Rev Bras Enferm. 2003; 56(2):184-8. Portuguese. [ Links ]

12. . Centers for Disease Control and Prevention (CDC). Simply put. A guide for creating easy-to-understand materials [Internet]. CDC [cited 2015 Jan 26]. 2009. Available from: [ Links ]

13. Deatrick D, Aalberg J, Cawley J. A guide to creating and evaluating patient materials. guidelines for effective print communication [Internet]. Corporight [cited 2015 Jan 26]. 2010. Available from: [ Links ]

14. Martins TB, Ghiraldelo CM, Nunes MG, Oliveira ON. Readability formulas applied to textbooks in brazilian Portuguese. São Paulo: Universidade de São Paulo; 1996. (Notas do ICMC-USP, Série Computação). [ Links ]

15. Lima MA de, Pagliuca LM, Nascimento JC, Caetano JA. Virtual guide on ocular self-examination to support the self-care practice for people with hiv/aids. Rev Esc Enferm USP. 2014; 48(2):285-91. [ Links ]

16. Jasper MA. Expert: a discussion of the implications of the concept as used in nursing. J Adv Nurs. 1994; 20(4) 769-76. [ Links ]

17. Fehring R. Validating diagnostic labels: Standardized methodology. In: Hurley ME., editors. Classification of nursing diagnoses. St. Louis (MO): Mosby, 1986. p.183-90. [Proceedings of the Sixth Conference]. [ Links ]

18. Lynn MR. Determination and quantification of content validity. Nurs Res. 1986; 35(6):382-5. [ Links ]

19. Pasquali L. Instrumentação psicológica: fundamentos e práticas.. Porto Alegre: Artmed, 2010. [ Links ]

20. Polit DF, Beck CT. The content validity índex: are you sure you know what’s being reported? Critique and recommendations. Res Nurs Health. 2006; 29(5):489-97. [ Links ]

21. Norwood S. Research strategies for advanced practice nurses. Upper Saddle River (NJ): Prentice Hall Health; 2006. [ Links ]

22. Brasil. República Federativa. Resolução nº. 466, de 12 de dez de 2012. Aprova as diretrizes e normas regulamentadoras de pesquisas envolvendo seres humanos. Brasília (DF): Diário Oficial da República Federativa Brasileira; 2013 Jun 13. [ Links ]

23. Saffari M, Ghanizadeh G, Koenig HG. Health education via mobile text messaging for glycemic control in adults with tupe 2 diabetes: a systematic review and meta-analysis. Prim Care Diabetes. 2014; 8(4):275-85. [ Links ]

24. Grudniewicz A, Bhattacharyya O, Mckibbon KA, Straus SE. Redesigning printed educational materials for primary care physicians: design improvements increase usability. Implement Sci. 2015; 10:156. [ Links ]

25. Veras JE, Joventino ES, Coutinho JFV, Lima FE, Rodrigues AP, Ximenes, LB. Risk classifi cation in pediatrics: development and validation of a guide for nurses. Rev Bras Enferm. 2015; 68(5):913-22. [ Links ]

26. Cavalcante LD, Oliveira GO, Almeida PC, Rebouças CB, Pagliuca LM. Assistive technology for visually impaired women for use of the female condom: a validation study. Rev Esc Enferm USP. 2015; 49(1):14-21. [ Links ]

27. Costa PB, Chagas AC, Joventino ES, Dodt RC, Oriá MO, Ximenes LB. Development and validation of educational manual for the promotion of breastfeeding. Rev Rene. 2013; 14(6):1160-7. [ Links ]

28. Teixeira E, Medeiros HP, Nascimento MH. Referências metodológicas para validação de tecnologias cuidativo-educacionais. In: Nietsche EA, Teixeira E, Medeiros HP. Tecnologias cuidativo-educacionais - Uma possibilidade para o empoderamento do(a) enfermeiro(a)? Porto Alegre: Moriá; 2014. 213p. [ Links ]

29. Brasil. Ministério da Saúde. Departamento de Atenção Básica. Dez passos para uma alimentação saudável: guia alimentar para crianças menores de dois anos: um guia para o profissional da saúde na atenção básica. 2a ed. 2 reimpr. Brasília (DF): Ministério da Saúde; 2013. [ Links ]

30. Machado AP, Lima BM, Laureano MG, Silva PH, Tardin GP, Reis PS, et al. Educational strategies for the prevention of diabetes, hypertension, and obesity. Rev Assoc Med Bras. 2016; 62(8):800-8. [ Links ]

Received: December 15, 2017; Accepted: June 4, 2018

Corresponding author. Leidiane Minervina Moraes de Sabino. E-mail:

Conflicts of interest: none to declare.


Sabino LMM, Ferreira AMV, Joventino ES, Lima FET, Penha JC, Lima KF, Nascimento LA and Ximenes LB participated in the project design, data interpretation, relevant critical review of the intellectual content and approval of the final version for publication.

Creative Commons License  This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.