VACCINATION IN PREGNANCY: CONSTRUCTION AND VALIDATION OF EDUCATIONAL TECHNOLOGY

ABSTRACT

Objective:

to build and validate the content of an educational technology to guide pregnant women about immunization.

Method:

a methodological study carried out from December 2020 to October 2021 in Belém, Pará, Brazil. It consisted of two stages: Construction through an Integrative Literature Review and face and content validation with 16 judges using a Likert scale for data collection and the Content Validity Index for analysis.

Results:

a double-sided table flipbook was created on immunization, which was assessed by 100% of the judges as relevant, with a mean Content Validity Index per block greater than 0.86.

Conclusion:

the technology was built with technically correct information and validated by experts in the respective areas. It is understood that its use will ease the prenatal Nursing practice, considering it to be a tool capable of arousing interest and encouraging dialogue between professionals and pregnant women, solving doubts in the immunization context.

DESCRIPTORS:
Immunization; Educational Technology; Education; Prenatal; Nursing.

RESUMO:

Objetivo:

construir e validar o conteúdo de uma tecnologia educacional para orientar gestantes sobre imunização.

Método:

estudo metodológico realizado em dezembro de 2020 a outubro de 2021, em Belém, Pará, Brasil. Constou de duas etapas: Construção por meio de Revisão Integrativa da Literatura e validação de aparência e conteúdo com 16 juízes utilizando escala Likert para coleta dos dados e o Índice de Validade de Conteúdo para análise.

Resultados:

elaborou-se um álbum seriado de mesa, com dupla face, sobre imunização que foi avaliado por 100% dos juízes como pertinente com média do Índice de Validade de Conteúdo por blocos superior a 0,86.

Conclusão:

tecnologia construída com informações tecnicamente corretas e validada junto a especialistas nas respectivas áreas. Entende-se que seu uso facilitará a prática da enfermagem no pré-natal, considerando ser ferramenta capaz de despertar interesse e favorecer o diálogo entre profissionais e gestantes, sanando dúvidas no contexto da imunização.

DESCRITORES:
Imunização; Tecnologia Educacional; Educação; Pré-Natal; Enfermagem.

RESUMEN

Objetivo:

elaborar y validar el contenido de una tecnología educativa para orientar a mujeres embarazadas sobre la inmunización.

Método:

estudio metodológico realizado de diciembre de 2020 a octubre de 2021, en Belén, Pará, Brasil. Constó de dos etapas: Elaboración por medio de Revisión Integradora de la Literatura y validación de apariencia y contenido por 16 jueces usando una escala Likert para la recolección de datos y el Índice de Validez de Contenido para el análisis.

Resultados:

se creó un cuadernillo doble faz sobre inmunización, que fue evaluado como relevante por el 100% de los jueces, con un Índice de Validez de Contenido promedio por sección superior a 0,86.

Conclusión:

tecnología elaborada con información técnicamente correcta y validada por expertos en las respectivas áreas. Se considera que su uso facilitará la práctica de la enfermería prenatal, es una herramienta capaz de despertar interés y fomentar el diálogo entre profesionales y gestantes, resolviendo dudas en el contexto de la inmunización.

DESCRIPTORES:
Inmunización; Tecnología Educativa; Educación; Prenatal; Enfermería.

HIGHLIGHTS

1. Construction and validation of Educational Technology on vaccination during pregnancy.

2. Nurses’ role in the immunization context.

3. Favoring prenatal health education.

HIGHLIGHTS

1. Construction and validation of Educational Technology on vaccination during pregnancy.

2. Nurses’ role in the immunization context.

3. Favoring prenatal health education.

INTRODUCTION

The gestational period is a physiological process that generates physical, psychological and social changes in women, influenced by countless factors such as alterations in their biological, socioeconomic and cultural characteristics¹.

Recognizing these characteristics, the Ministry of Health (Ministério da Saúde, MS) assumed as one of its commitments the promotion of safe motherhood throughout the entire pregnancy and puerperal process, such as prenatal care, considering health care humanization². The perspective of humanized birth emphasizes the importance of women understanding their pregnancy so that they are aware of pertinent information and the care they need to receive focused on their particularities. This shows empowerment and their leading role during pregnancy³.

It is important to highlight the importance of pregnant women fully complying with the vaccination schedule. A number of studies have indicated that pregnant women produce IgG antibodies through immunization, which are transported via the placenta and may exert beneficial effects both on the fetus and on the mother⁴. However, despite highlighting vaccination efficacy during pregnancy, it is understood that not all immunobiologicals are routinely recommended due to concerns in relation to the risk/benefit ratio during this period⁵.

The gestational period is characterized by immunological and physiological changes in women, which favor alterations in the susceptibility of mothers and fetuses to infections, along with modifications in the immune response⁶. Therefore, the importance of vaccinating pregnant women to protect maternal and child health from vaccine-preventable diseases, such as diphtheria and tetanus, is ruled out with the double adult vaccine, the triple acellular bacterial vaccine (dTpa) against diphtheria, tetanus and pertussis, and the recombinant hepatitis B and influenza virus vaccines⁷.

In addition to that, vaccination coverage is lower than expected in certain population subgroups, particularly the obstetric one, as a result of persistently high social inequality in the country and of the sum of social inequalities and the gestational population⁷. In this particular context, the use of Educational Technologies (ETs) stands out as a significant means of fostering dialogue between patients and the health team, thereby easing comprehensive and informative communication among all parties involved, including these patients’ families⁸. ETs can contribute and offer essential clarifications to pregnant women, contributing to teaching and learning activities and mediating the educational practices of those who use them. They stand out as tools that help people critically reflect on their own knowledge and explore possibilities for changing their practices⁹.

The educational process in health serves as a means of disseminating knowledge, promoting health and preventing diseases, particularly those that can be prevented through vaccination, as the knowledge of the population, especially pregnant women, in relation to the importance of vaccination can contribute to eradicating these diseases¹⁰. Among the health professionals engaged in educational initiatives, nurses are constantly challenged to seek alternatives that provide them with the necessary support to collaborate with people, groups and communities, with ETs as strong allies in this process¹¹.

In addition to the importance of elaborating ETs, it is noted that, for their effective use, they must undergo a validation process that involves the analysis of various items, such as objectives, structure and relevance. This process must be carried out by experts in the focus area, in addition to other important aspects¹⁰. Thus, the validation of an ET presents itself as a way of qualifying a new intervention/instrument or improving an existing one through systematic use of available knowledge¹².

The absence of scientific productions on the construction of ETs centered on the study topic stands out, and including health education in the Pre-Natal Program practices appears to be a contemporary and necessary strategy, especially when it emerges from knowledge exchange, evolving into an act of creating and transforming thoughts and actions⁸.

In this scenario, it is understood that there is a need to expand educational actions with pregnant women carried out in a dialogical and comprehensive manner, as well as that ETs can assist in these actions and in unique assistance during prenatal care. Therefore, the objective of this study was to build and validate the content of an educational technology to guide pregnant women about immunization.

METHOD

A methodological design study developed from December 2020 to October 2021 in the municipality of Belém, Pará, Brazil. The Standards for Quality Improvement Reporting Excellence - SQUIRE was followed¹³.

The participants were 16 judges, including 13 nurses, a graphic designer, a pedagogue and a Portuguese language teacher, to assess the content, face and form of the ET, in addition to the requirements necessary to inform with correctness, precision and accessible language for the technology’s target audience.

The number of judges was based on the recommendation to work with a minimum number of nine judges in validation processes¹⁴. They chose the snowball technique, which is a form of non-probability sampling where the initial participants in the study nominate new ones who in turn indicate others and so on, until the necessary number of participants is reached¹⁵.

For inclusion, a score calculation adapted for this study was used, similarly to another validation study¹⁶. A minimum score of five points was considered and the experts’ suitability to the selection criteria was verified through their CVs on the Lattes Platform. Those who did not meet the 30-day deadline for returning the validation instrument would be excluded; however, all of whom complied. The criteria and scores considered are presented in Table 1:

Table 1
Criteria and scores for selecting the expert judges to validate the Educational Technology on immunization in the gestational period. Belém, PA, Brazil, 2021

Scoring criteria	Score
thesis or dissertation in the area of interest*	2 points/paper
Monograph or specialization in the area of interest	1 point per paper
Participation in groups/projects in the area of interest	1 point
Teaching experience in the area of interest	0.5 point/year
Practical work in the area of interest	0.5 point/year
Papers’ orientation in the area of interest	0.5 point per paper
Authorship of papers in the area of interest published in journals	0.25 point per paper
Participation in paper evaluation boards in the area of interest	0.25 point per paper

Note:
• ^*
  The following were considered as areas of interest: immunization or women’s health, especially prenatal care. Source: Feitosa, Stelko-Pereira, Karla (2019)¹⁶

The study was developed in two stages: In the first one, an Integrative Literature Review (ILR) was carried out, processed in six stages: 1) Identification of the topic and selection of the research question; 2) Definition of inclusion and exclusion criteria for the studies; 3) Definition of the diverse information to be extracted from the studies selected; 4) Evaluation of the studies included; 5) Interpretation of the results; and 6) Presentation of the review/knowledge synthesis¹⁷.

To build the ILR, the following databases were defined: Literatura Latino Americana e do Caribe em Ciências da Saúde (LILACS), Scientific Electronic Library Online (SciELO) and Medical Literature Analysis and Retrieval System Online (MEDLINE). To cover the 1^st stage, the topic of “Practices on prenatal immunization” was chosen and the research questions were defined as follows: “Which content is important to inform pregnant women about immunization during pregnancy?” and “Which educational strategies have been used to inform pregnant women about immunization?”

For the 2^nd stage, the inclusion criteria were established as follows: original articles published in Portuguese, English and Spanish, from January 2016 to December 2020, and available free of charge in full text. Secondary research studies such as literature reviews, whether integrative or systematic, were excluded. In the 3^rd stage, selection of studies took place, carried out in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) methodology¹⁸. Studies repeated in more than one database were considered only once.

In the 4^th stage, to evaluate the articles included, the data were compiled into a script adapted by the authors based on an instrument developed and validated¹⁹. In the 5^th stage, the textual data analysis was conducted by using the Interface de R pour les Analyzes Multidimensionnelles de Textes et de Questionnaires (IRaMuTeQ) software, version 0.7 alpha 2, which is widely employed in the scientific literature and allows for the statistical analysis of a text corpus²⁰.

In the 6^th stage, the result obtained by the software was interpreted, ending with the construction of the ET in the form of a double-sided table flip album, created in CorelDRAW X7® 2015 by the authors, following the layout, color and typography choice stages.

For content validation, the judges were contacted by email with an invitation letter and, after confirming their interest in participating, they received the Free and Informed Consent Form (FICF) in their email addresses and a link to the online platform designed to access the ET elaborated and the validation form.

Upon accessing the link, they were directed to a free platform website developed by the researchers, where they were able to download the ET in PDF format and the validation form in DOCX format, which were to be sent along with the signed FICF to the email address of the researcher in charge.

The validation instrument was built based on a Likert scale²¹ adapted for this study, with 29 items divided into five blocks (General Impression; Objectives; Structure and Presentation; Relevance; and Verbal Language) for the experts and 11 items divided into three blocks (General Impression, Aesthetic Quality and Portuguese Language) for the graphic designer, pedagogue and Portuguese language teacher. The items are presented with 4 options²² and scored from 1 to 4, where 1-Totally adequate, 2-Adequate, 3-Partially adequate and 4-Inadequate.

The Content Validity Index (CVI) was used to assess the judges’ agreement on the ET. The calculation was made by adding up the agreement corresponding to the items that were marked as Totally adequate and Adequate by the judges and divided by the total number of items in each block, considering a CVI cutoff point of 0.80²³.

The research was approved by the Research Ethics Committee of a Public University with opinion No. 4,485,320. The participants were identified by means of an alphanumeric code, using the letter J (Judge) and the number of the instruments answered in ascending order.

RESULTS

When preparing the ILR to build the educational technology, 187 publications were initially identified, 30 of which were repeated among the databases. After reading the titles and abstracts, 66 primary studies were considered for full-reading. In this reading it was found that 20 of the materials answered the study guiding question, of which 10 (52.63%) were located in LILACS, seven (36.84%) in MEDLINE and three (10.52%) in SCIELO.

In relation to the topics covered in the publications, nine (47.36%) were focused on the vaccines that make up the vaccination calendar for pregnant women, six (31.57%) dealt with the importance of health professionals, especially nurses, in their work during prenatal consultations and five (26.31%) were about pregnant women’s acceptance of vaccination.

The results of the studies were organized into a text corpus that enabled the formation of a word cloud using the IRaMuTeQ software (Figure 1). The corpus content consisted of 20 texts that resulted in 22 text segments, with identification of 656 words and 158 hapax (words with a frequency of one). The following words stood out: vaccination, pregnant woman, importance, perform, dTpa vaccine, hepatitis B vaccine, health professional and prenatal care, which are related to aspects about the importance of the work done by health professionals, especially nurses, in health education activities, vaccines to be offered and compliance with the vaccination schedule during the prenatal period.

Figure 1
Word cloud about vaccination during pregnancy. Belém, PA, Brazil, 2021

Based on these highlighted topics, it was decided to build an educational technology in the form of a table flipchart with the purpose of assisting health professionals during the prenatal consultations to inform/guide on immunization during the gestational period. The album was called “Flipchart on Immunization for pregnant women during prenatal care” (Figure 2), containing 18 double colored pages, size 210 mm x 297 mm and consisting of textual and illustrative content.

The titles are presented in the Unicorn Calligraphy and Gabriola fonts, ranging in size from 40 to 70, and the texts in Catamaran and Gabriola, from 20 to 28. It features a cover, presentation page, illustrative pages of guidance for pregnant women (front), guide pages for health professionals on the topics covered (back) and bibliographic reference. It consists of seven sessions related to doubts about immunization during pregnancy, such as: “Do you know why it is important to get vaccinated during pregnancy?”, “Which vaccines do pregnant women need?”, “Which vaccines are forbidden for pregnant women?”, “Attention with special vaccines, such as yellow fever!”, “What if the pregnant woman’s calendar is up to date?”, “If the pregnant woman does not know which vaccines she has already had, how can she find out?” and “A pregnant woman will be able to get the vaccines up to how many gestational weeks?”

It is noted that all content was organized in simple language in the text intended for pregnant women, with illustrations that allude to the diverse information presented and a guide text for professionals to provide guidelines on the sessions. Polychromy was used to highlight the information, as seen in Figure 2:

Figure 2
Cover, guidance page for pregnant women and guide page for health professionals that make up the table flip chart. Belém, PA, Brazil, 2021

In the validation, the flipchart was evaluated by 16 judges: 13 (81.25%) nurses specialized in the subject matter, one (7.69%) graphic designer, one (7.69%) pedagogue and one (7.69%) Portuguese language teacher. Of the nurses, 10 (76.93%) had expertise in immunization and three (23.07%) in prenatal care.

Of the total number of judges, 12 (75%) were female and four (25%) were male, aged between 24 and 63 years old and with a mean of 35.25. A total of four (30.76%) had MSc degrees and 12 (96.23%) were specialists. In relation to working time, they had between three and nine years of service, with a mean of six years.

The CVI was calculated by blocks and in general, among the specialists (Table 2) and the graphic designer professional, pedagogue and Portuguese language teacher (Table 3), considered favorable as they presented indices by blocks greater than 0.86.

Table 2
Results of the Content Validity Indices, by blocks and in general, according to the evaluation by the expert judges. Belém, PA, Brazil, 2021

Variables	Objectives	CVI*	Overall CVI*
General impression	Evaluate the judges’ impression regarding the educational material, such as layout, diagramming and font size.	0.91	0.92
Objectives	Evaluate the desired objectives by using the ET.	0.92
Structure and Presentation	Evaluate how to present the guidelines, which includes general organization, structure, presentation strategy, coherence and formatting.	0.88
Relevance	Evaluate the characteristics of the significance degree of the educational material presented.	0.90
Verbal Language	Assess whether the language used in the ET is easy to understand.	0.86

• ^*
  CVI = Content Validity IndexSource: The authors (2021).

Table 3
Results corresponding to the Content Validity Indices, by blocks and in general, according to the assessment by the professional judges: graphic designer, pedagogue and Portuguese language teacher. Belém, PA, Brazil, 2021

Variables	Objectives	CVI*	Overall CVI*
Quality of the Interface	Evaluate the judges’ impression regarding the educational material, such as layout, diagramming and font size.	0.88	0.87
Aesthetic Quality	Evaluate the quality of the texts and images.	0.88
Portuguese Language	Evaluate adequacy to the educated standard.	0.86

• ^*
  CVI = Content Validity IndexSource: The authors (2021).

Based on the results, it can be asserted that the flipchart was validated, taking into account what was sought to be evaluated in it. The adjustments suggested by some judges were made, such as replacing figures and/or substituting and increasing the font size on the guidance pages intended for pregnant women.

DISCUSSION

The flipchart was prepared based on diverse evidence from the literature that pointed out the necessary content in the immunization context to be addressed by health professionals during prenatal consultations. In this context, ET use presents itself as a strategy that assists in educational actions, contributing positively to health promotion and to preventing and eradicating vaccine-preventable diseases, such as its use in immunization during prenatal consultations. Sharing accurate and easy-to-understand information is crucial for pregnant women to understand the importance of keeping their vaccination schedule updated²⁴.

The flipchart had its content validated by the judges given that the CVI values, both in the five blocks and in the overall calculation, were above 0.86, as recommended in the literature²³,²⁵. It is noted that the presentation, objectives proposed, relevance and clarity in sharing information were considered in this process. With this, it is reiterated that when assessing these aspects, the scientific rigor required in ET validation processes is met²⁶.

Validation by nurses working in the immunization or prenatal consultation sectors, was important because they are routinely in contact with the ET target audience, thus knowing the main questions and desires experienced by these pregnant women²⁶. In addition to calculating the CVI, the suggestions proposed by the judges were valued, as they made it possible to adapt the flipchart to the target audience needs¹¹.

As for the technology being a tool that enables understanding about immunization during the gestational period, content validation showed the importance of nurses duly trained in prenatal care, providing health education on the topic and enabling pregnant women to understand the guidelines provided, given that dissemination of information in technical language is notorious in the health sector, making it difficult for the target audience to understand it²⁷. With this, Nursing leading role as a health educator stand out, using validated ETs capable of sharing safe and appropriate information with the target audience²⁸.

Building ETs in different contexts and health scenarios makes it possible to standardize the guidelines provided regarding various topics, as in the case of this study, immunization during the gestational period, providing educational interventions based on technically correct information and targeted to the target audience needs¹⁴,²⁹.

In the context of pregnant women, it is highlighted that guidelines on immunization during prenatal care are necessary so that they have greater adherence to updating the vaccination schedule appropriately and understand the importance of carrying out this practice, as it is commonplace to associate vaccination with fear, pain and uncertainty about their effectiveness²⁴,²⁸.

One of the study limitations is its construction based on a literature review, instead of shared with the pregnant women, which, in the authors’ opinion, would be the ideal way. The restrictions imposed by the pandemic precluded this. The scientific rigor for carrying out the literature review and the researcher’s experiences in the immunization area helped to contextualize the final product with the quality that would be legitimized by content validation.

CONCLUSION

The study achieved its objectives by presenting a validated ET applicable in educational activities in prenatal care as an instrument capable of encouraging pregnant women to correctly and completely comply with the vaccination schedule.

Having completed construction and validation of the flipchart’s content, the importance of carrying out its semantic validation is highlighted, giving voice to the target audience as well as allowing future updates on women’s immunization and health.

It is understood that using this material will ease the Nursing practice during prenatal consultations, considering that it constitutes an illustrated technology capable of arousing interest and encouraging dialogue between professionals and pregnant women who have doubts about the importance of immunization to guarantee the health of women and infants alike.

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ACKNOWLEDGMENTS

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES); Universidade Anhanguera of São Paulo, Pirituba, for the opportunity to do the Master’s Degree, for the support through the 013/2021 public notice.

Edited by

Associate editor: Dra. Tatiane Trigueiro

Publication Dates

• Publication in this collection
  27 Nov 2023
• Date of issue
  2023

History

• Received
  28 Feb 2023
• Accepted
  21 Aug 2023