Home self-care after gynecological surgeries: elaboration and validation of educational material

Abstract

Objective

To build and validate educational material with guidelines for home self-care in the postoperative period of gynecological surgeries.

Methods

This is a methodological study, collected in August 2019, at a university hospital, through content selection, language adaptation, inclusion of illustrations, building of a pilot manual, layout and validation of a pilot manual by six expert judges and 11 women in the postoperative period of gynecological surgeries. The semi-structured form Suitability Assessment of Materials and the Educational Content Validation Instrument in Health were used, for the group of judges, and the semi-structured form and the Suitability Assessment of Materials, for the target audience. Analyzes were performed using descriptive statistics, calculation of the Suitability Assessment of Materials instrument and the Content Validity Coefficient of the Educational Content Validation Instrument in Health, in addition to content analysis.

Results

The booklet contained eight pages with guidelines on intestinal motility, pain management, return to activities of daily living, body mechanics, food, prevention of venous thromboembolism, nausea/vomiting relief, sexual activity, surgical wound care, symptoms and use elastic waistband. Its validation was classified by most judges and by the target audience as “superior”. Judges’ suggestions were analyzed and incorporated into the final version, and the target audience considered the material to be enlightening, accessible and necessary. The layout contributed to superior assessment of the booklet.

Conclusion

The educational booklet proved to be a valid and reliable instrument to be used in promoting the health of women regarding care during the postoperative period of gynecological surgeries in the home environment.

Self care; Health promotion; Educational and promotional materials; Gynecologic surgical procedures

Resumo

Objetivo

Construir e validar material educativo com orientações para autocuidado domiciliar no pós-operatório de cirurgias ginecológicas.

Métodos

Estudo metodológico, com coleta efetuada em agosto de 2019, em hospital universitário, por meio da seleção de conteúdo, adaptação da linguagem, inclusão de ilustrações, construção de manual piloto, layout e validação do manual piloto por seis juízes especialistas e 11 mulheres em pós-operatório de cirurgias ginecológica. Utilizaram-se o formulário semiestruturado Suitability Assessment of Materials e o Instrumento de Validação de Conteúdo Educativo em Saúde, para o grupo de juízes, e o formulário semiestruturado e o Suitability Assessment of Materials, para o público-alvo. Análises foram efetuadas mediante estatística descritiva, cálculo do instrumento Suitability Assessment of Materials e do Coeficiente de Validade de Conteúdo do Instrumento de Validação de Conteúdo Educativo em Saúde, além da análise de conteúdo.

Resultados

A cartilha continha oito páginas com orientações sobre motilidade intestinal, manejo da dor, retorno às atividades da vida diária, mecânica corporal, alimentação, prevenção de tromboembolismo venoso, alívio de náusea/vômito, atividade sexual, cuidados com a ferida operatória, sintomatologia e uso de cinta elástica abdominal. Sua validação foi classificada pela maioria dos juízes e pelo público-alvo como “superior”. As sugestões dos juízes foram analisadas e incorporadas à versão final, e o público-alvo considerou o material esclarecedor, acessível e necessário. A diagramação contribuiu com a avaliação superior da cartilha.

Conclusão

A cartilha educativa mostrou-se um instrumento válido e confiável para ser utilizado na promoção da saúde de mulheres quanto aos cuidados durante o período pós-operatório de cirurgias ginecológicas no ambiente domiciliar.

Autocuidado; Promoção da saúde; Procedimentos cirúrgicos em ginecologia; Materiais educativos e de divulgação; Estudos de validação

Resumen

Objetivo

Elaborar y validar material educativo con instrucciones para el autocuidado domiciliario en el posoperatorio de cirugías ginecológicas.

Métodos

Estudio metodológico, cuya recopilación se realizó en agosto de 2019 en un hospital universitario, mediante la selección de contenido, adaptación del lenguaje, inclusión de ilustraciones, elaboración de manual piloto, diseño y validación del manual piloto por seis jueces especialistas y 11 mujeres en posoperatorio de cirugías ginecológicas. Se utilizó el formulario semiestructurado Suitability Assessment of Materials y el Instrumento de Validación de Contenido Educativo en Salud para el grupo de jueces, y el formulario semiestructurado y el Suitability Assessment of Materials, para el público destinatario. Los análisis fueron realizados mediante estadística descriptiva, cálculo del instrumento Suitability Assessment of Materials y del Coeficiente de Validez de Contenido del instrumento de Validación de Contenido Educativo en Salud, además del análisis de contenido.

Resultados

La cartilla contenía ocho páginas con instrucciones sobre motilidad intestinal, manejo del dolor, retorno a las actividades cotidianas, mecánica corporal, alimentación, prevención de tromboembolismo venoso, alivio de náuseas/vómitos, actividad sexual, cuidados con la herida quirúrgica, sintomatología y uso de faja elástica abdominal. La validación fue clasificada como “superior” por la mayoría de los jueces y por el público destinatario. Las sugerencias de los jueces fueron analizadas e incorporadas en la versión final, y el público destinatario consideró que el material es esclarecedor, accesible y necesario. La maquetación contribuyó con la evaluación superior de la cartilla.

Conclusión

La cartilla educativa demostró ser un instrumento válido y confiable para utilizarse en la promoción de la salud de mujeres con relación a los cuidados durante el posoperatorio de cirugías ginecológicas en el ambiente domiciliario.

Autocuidado; Promoción de la salud; Procedimientos quirúrgicos ginecológicos; Materiales educativos y de divulgación

Introduction

Gynecological surgery is a therapeutic resource for diseases that affect the female genital tract, such as breasts and pelvis. In Brazil, between the years 2013 to 2018, approximately 1.5 million surgical procedures were performed on the genitourinary system, which focus on gynecological interventions for hysterectomy (surgical removal of the uterus) and colpoperineoplasties (corrections of pelvic organ prolapses).(¹-³)

Hysterectomy is one of the most frequent gynecological operations performed worldwide, whose approaches to the procedure can be abdominal, vaginal or laparoscopic.(⁴-⁶) Colpoperineoplasties aim to combine a good anatomical correction of the prolapse and improve the discomfort, dysfunction and quality of life of patients.(⁷,⁸)

Postoperative care, especially home care, requires actions aimed at the surgical wound, the reorganization of self-care with basic human needs and the management of activities of daily living. In addition, possible changes, such as acute pain, unusual secretions and bleeding, should be alerted, since they are associated with increased risks of infections and hemorrhages.(⁹) Thus, the planning of hospital discharge must be carried out, respecting the therapy that was proposed by the health team, from the moment of arrival until discharge of patients from the hospital, aiming at reducing hospitalization time and allowing continuity of care at home.(¹⁰) In this context, nursing has a fundamental role through health education and continuity of care in Primary Care.

Health education enables the understanding of information, favoring adherence to self-care and a commitment to the subjects’ own health, which has positive implications for their recovery.(¹¹) Therefore, nurses, as members of the multidisciplinary team, can use technologies as facilitators of their relationship with patients and provide a more effective teaching and learning process.(¹²) Among the technologies, educational materials stand out, such as booklets, leaflets and posters, which are resources used to generate communication and allow the dissemination of knowledge, simplifying concepts and providing greater understanding and memorization, in an easy and dynamic way.(¹³)

The study is justified due to the gap in the scientific literature on educational material for home care after gynecological surgeries. In this sense, the existence of an instructional material can favor the standardization of behaviors, communication, awareness of the guidelines and continuity of care after discharge.

This research aimed to build and validate educational material with guidelines for home self-care in the postoperative period of gynecological surgeries.

Methods

This is a methodological study, which was based on the development, elaboration, validation, adequacy and completion of an educational instrument aimed at self-care guidelines for patients who underwent gynecological surgeries.(¹⁴,¹⁵)

The study was carried out in a federal university hospital in a capital of northeastern Brazil, in the obstetric-gynecological clinic. In this unit, patients are assisted in the pre- and postoperative periods of gynecological surgeries, with a specialized multidisciplinary team.

The sample consisted of six health professionals who became expert judges from different areas of the multidisciplinary team (two nurses, two gynecologists, a physiotherapist and a nutritionist) and 11 representatives of the target audience, i.e., women in the postoperative period. gynecological surgeries. Sampling occurred for convenience, in August 2019. The number of judges participating in the study was suggested by scientific literature.(¹⁶)

Judges working at the federal university hospital where the study was conducted and in a specific area of gynecology and who have been assisting the gynecological clinic for at least 6 months were included. Professionals who were away from their service activities due to vacation, illness or other reasons were excluded. All professionals contacted agreed to participate in the research. However, one was excluded for being away due to occupational disease.

For the selection of the target audience, women in the immediate postoperative period of gynecological surgeries, admitted to the obstetric-gynecological clinic and with preserved cognitive ability, literate or illiterate with a companion who knew how to read and write were included. Women in the immediate postoperative period of gynecological surgeries who had some discomfort or postoperative complication or were under the influence of medications that altered psychic functions (memory, orientation, thinking and sleep) were excluded. Among the invited women, a patient who was feeling sick was excluded.

Booklet building was based on a study on the preparation of guidance manuals for health care(¹⁷) and on the classification of basic human needs, according to Wanda Horta’s theory.(¹⁸) The study followed the following steps: first, the content was delimited and selected by means of a review conducted by the scoping review method in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyzes extension for Scoping Reviews (PRIMA-ScR), whose description it is the subject of another study not yet published; then language was adapted, and the approved information was reviewed by a linguistic professional, who sought to organize the content present in the educational material into short, inviting and easy-to-read messages; in the third stage, the content was selected, which included the illustrations, since visual communication serves as an instrument to exemplify instructions;(¹⁹) in the fourth stage, the educational material prototype building took place, based on the sequential organization of the selected content in themes, which were thoroughly analyzed, in order to order the subjects in sequence and facilitate their understanding and practice by the target audience; in the fifth stage, the booklet layout was developed, with the contribution of a graphic design professional to produce the pilot manual (this last stage was carried out before validation, as it is believed that appearance, already in the booklet format, would raise the quality and attractiveness of the educational tool); in the last stage, the pilot manual was qualified by experts (expert judges) and the target audience.

Material assessment by experts took place after delivery of the booklet, by means of responses to the semi-structured form on training questions; the Suitability Assessment of Materials (SAM), validated for Portuguese, which assessed the quality of educational material from the domains of content, literacy requirements, illustrations, layout and presentation, learning fostering and cultural adequacy. It was possible to classify the items as superior, suitable, not suitable and not applied by means of a formula to calculate their results considered from values above 70%; and Health Educational Content Validation Instrument, which made it possible to specifically assess the content in terms of its objective, its structure and its relevance, with Content Validity Coefficient being calculated, which is acceptable when greater than 0.80.(²⁰,²¹)

Material assessment by the representatives of the target audience occurred after the presentation of the project, acceptance of participation, delivery of the booklet and response to the semi-structured instrument (on sociodemographic issues, health service care and the perception of the booklet) and SAM.(²⁰) For illiterate participants, the reading was performed by the companions.

The data were interpreted in order to validate whether the educational material provides guidelines for self-care pertinent to patients undergoing gynecological surgeries. For this purpose, descriptive statistics were used through the description of participant characterization, SAM calculation, as instructed by the instrument, and the calculation of the Content Validity Coefficient of the Health Educational Content Validation Instrument, obtained from the average of each item assessed, divided by the maximum value that the item can reach and the result being considered superior to the one with results greater than 0.80.(²⁰)

The considerations made by participants were analyzed using Bardin’s content analysis technique, according to pre-analysis, material exploration and treatment, inference, and interpretation of results phases. Pre-analysis consisted of choosing documents for constituting the corpus, formulating hypotheses and objectives. In turn, material exploration, involved coding the corpus of analysis, material classification and categorization. Treatment, inference and interpretation of results involved conducting critical and reflective analysis of content so that the data became meaningful and valid.(²²)This technique allowed building the categories Clarification, Dissemination of guidelines, and Ease of access.

As it is a project that involved human beings, in order to receive methodological and ethical endorsement, the project was previously approved by a Research Ethics Committee (CAAE (Certificado de Apresentação para Apreciação Ética - Certificate of Presentation for Ethical Consideration) 86689318.5.0000.5183), according to resolution 466/2012 of the Brazilian National Health Council (Conselho Nacional de Saúde). All participants signed the Informed Consent Form.(²³)

Results

Educational material building

From the scoping review (first stage), 14 studies were included, of which 60 statements were selected that dealt with the postoperative guidelines, being organized in the themes: food, intestinal motility, nausea/vomiting relief, pain management, return to activities of daily living, surgical wound care, body mechanics, prevention of venous thromboembolism, sexual activity, symptomatology, guidance on the abdominal elastic band, and unexpected symptoms. Based on such themes, under the aegis of the psychobiological needs focused on the specificities of gynecological surgeries, such contents were organized into eight sessions, presented in eight textual pages, in the form of a brochure and in a color version.

Educational material validation

The educational material was validated by six judges, two medical professionals, two nurses, a nutritionist and a physiotherapist, who worked in assistance and gynecological care. The judges were, on average, 36.8 years old (standard deviation of 2.92), training time of 13 years (standard deviation of 2.96) and time of experience in the postoperative period of 8 years (standard deviation of 6). All had academic degrees, ranging from specializations to PhD, and, in addition to the post-operative hospital area of gynecological specialty, 50% worked in other services or educational institutions.

The judges performed the material assessment based on the use of SAM and the Health Educational Content Validation Instrument, according to the results presented in Table 1.

Table 1
Assessment of suitability assessment of materials items and the Health Educational Content Validation Instrument, according to experts

SAM domains	Assessment factors
	Superior n(%)	Suitable n(%)	Not suitable n(%)	Not applicable n(%)
Content	4(67)	2(33)	0	0
Literacy requirement	4.2(70)	1.8 (30)	0	0
Illustration	4.4(73)	1(17)	0.4(6.7)	0.2(3.3)
Layout and presentation	4.7(78)	1(17)	0	0.3(5)
Learning fostering/motivation	4(67)	2(33)	0	0
Cultural adequacy	4(67)	1(17)	1(17)	0
SAM - overall mean	83%
HECVI	CVC
Objectives: purposes, goals and aims	0.87
Structure/presentation: organization, structure, strategy, coherence and sufficiency	0.86
Relevance: significance, impact, motivation and interest	0.86

• Some percentages do not add up to 100% due to rounding. SAM - Suitability Assessment of Materials; HECVI - Health Educational Content Validation Instrument; CVC - Content Validity Coefficient.

Through SAM, the educational material quality was classified as “superior” by an average of 83.3% of judges. Through the Instrument for Validation of Educational Content in Health, the Content Validity Coefficient of the educational material for objective, structure/presentation, and relevance was also calculated, which presented results higher than the coefficient that confirmed content validation (> 0.80). In addition to the responses to such assessment instruments, the experts added suggestions for improving the educational material, which were included in the final version of the booklet. The contributions provided are exposed in Chart 1 and referred to the change in terms, examples and explanations.

After assessment by professionals, the educational material was assessed by 11 patients in the postoperative period of gynecological surgeries, whose mean age was 53.8 years (standard deviation of 11.1). Regarding occupation, housewives (n=4; 36.3%), retired (n=3; 27.2%), home secretaries (n=2; 18.1%), caregiver (n=1; 9%) or farmer (n=1.9%). Regarding education, seven (64%) had incomplete primary education, three (27%) complete high school and one (9%) had no education. Among the types of surgeries, four patients underwent total abdominal hysterectomy, two, total abdominal hysterectomy with salpingo-ophorectomy, one total vaginal hysterectomy with colpoperineoplastia and four colpoperineoplastia. Regarding the family environment, nine (82%) women lived with a family member and two (18%) alone; eight (73%) reported having help from someone to perform home services; three (27%) stated that they would have to go to a family member’s house during the postoperative period.

When asked if they had already received guidance from postoperative care, nine (82%) denied, and the rest claimed to have received explanations from university extension project graduates on guidance for self-care after postoperative hospital discharge. About the educational material, all assessed it as “superior” in all domains (content, language and appearance) through SAM. As for the perception of the booklet, the exhibitions of the categories (Clarification, Dissemination of guidelines, and Ease of access) followed.

With regard to the theme Clarification, the following are the statements.

Look here (spoke to the sister who was as a companion), you were saying that I would be hollow and not feel like it, but listen to what you have here: the removal of the uterus does not decrease your femininity, you see this is all psychological. She (sister) kept talking that I would no longer feel like anything (sexual intercourse), but I have already told him that it has nothing to do with. (Patient 6)

The guidelines that exist, very good. Sometimes you don’t know, then you’re going to do it all wrong. (Patient 7)

Any questions about food, anything goes there and looks, follow the instructions. Feed what can and cannot, very good, the time I did not speak. Wow, the shower I like I’m already seeing that can’t, right? The first time I think it was up to this (which caused complications). (Patient 8)

Another indicator of the importance of the educational material referred to the theme Dissemination of the guidelines, especially for family members who could be responsible for patient care.

The family will understand better, the booklet is beautiful and has very important things. (Patient 3)

The family will see that they cannot do things/ they have tips. (Patient 4)

Show the family, for the family to understand. My sister needs to read. (Patient 6)

It is important for the family to read, especially my daughter-in-law, who is too young. (Patient 7)

The family is already oriented also if you need to do, already know how to take care of others. It was good to already have one of these.(Patient 8)

I think it’s very important, it’s good for the family too. (Patient 11)

Participants’ statements regarding Ease of access to guidelines are followed.

To understand, mainly understand and have things that have in the booklet that already takes away doubts, especially those who have never had surgery and do not know how it will be. (Patient 1)

Especially people who have had a first surgery to answer questions is important. And the material is fine, it’s explaining everything. (Patient 5)

After assessing the patients, the final educational material was organized as follows: Cover - with the title “ORIENTAÇÕES PARA O AUTOCUIDADO DOMICILIAR PÓS-CIRURGIAS GINECOLÓGICAS”, authorship and representative image of a woman; page 1 - presentation of the booklet and guidance on food; page 2 - guidelines for pain relief and how to prevent thrombus; page 3 - guidelines for self-care with the surgical wound and information on symptoms after hysterectomy; page 4 - tips for everyday life; page 5 - guidance on sexual intercourse and activities that should be avoided; page 6 - guidelines on the use of elastic bands and unexpected symptoms; page 7 - location for providing information on ways to contact health services; page 8 - title of the material, authorship and thanks and back cover (Figure 1).

Figure 1
Validated version of the booklet

Discussion

The educational material has a methodological basis that confirms its validation and the possibility of being used in health services, as an educational tool for educated women (or with educated caregivers), in the postoperative period of gynecological surgery. The presence of this technology supports and provides health education, allowing professionals, especially nurses, to provide care for patients and develop methods and ways to generate a teaching-learning process according to needs, aiming to promote quality of life and establishing a relationship of dialogue and, consequently, of fostering reflection.(²⁴)

Among the steps for developing an educational technology is a vast search in scientific literature.(¹⁹,²⁵) Conducting this scoping review allows the composition of a theoretical basis and allows authors to organize, structure and select content, thus contributing to the formation of educational material, as occurred in this study on home self-care after gynecological surgeries.(²⁶) Such content is important, since it is understood that postoperative recovery is a complex process, which requires a holistic view of the restoration of aspects, physiological, psychological, social and economic.(²⁷)

After the preparation of the educational material, it is important to seek its validation. To this end, it is emphasized the diversity of professional areas that made up the group of evaluating judges. Such variety stands out as a favorable aspect, as it allows joining different types of knowledge and specific knowledge, standardizing the conducts and orientations in a multidisciplinary way.(²⁸,²⁹)

From booklet assessment by the judges, it was evidenced that it presented values considered acceptable for its use, considering that the average SAM score and the Content Validity Coefficient were acceptable, which demonstrates its validity. Other methodological studies of building and validation of booklets also showed satisfactory values.(³⁰,³¹)

Although cultural adequacy was considered suitable by 83% of judges, the inadequacy for the others suggested the need for adjustments. Moreover, an average of 6.7% and 3.3% considered the illustrations not suitable and not applicable, respectively, modifications being suitable to bring women in the postoperative period of gynecological surgeries to information about home care and, consequently, assist in the health education process. In this context, the modifications suggested by the judges were carried out and reinforced validation, which contributed to achieving the established objective. Such effectiveness enabled a higher quality and reliability of information as well as a better level of coherence.(³²)

It is important to note that the booklet was also validated by the target audience, since, depending on the educational level, people may require a more specific imagery and literary presentation. The target audience showed variability in the level of education, which allowed a broad assessment of the level of material clarification, since there was a better understanding of the booklet by all, including those who required help from the companion to carry out the reading. Such uneducated participants were not excluded, as they characterize a large part of the public that accesses the public health service, for which the booklet was developed.

Patients rated the material as “superior” and exposed the informational role, portability and disclosure to family members and accessibility to the guidelines on the postoperative period. Printed materials have good acceptance by the target audience, as they allow reading to be carried out in any environment, contributing significantly to patients’ autonomy and their better adaptation to treatment, which reduces complications.(³³)

It is important to emphasize that several factors can interfere in obtaining suitable information about the postoperative period of gynecological surgeries (educational level, sociocultural aspects, stress at the time of discharge, service routine and quality of the guidelines provided), which can lead to information forgetfulness, misunderstanding or, even, non-obtaining. Therefore, having this educational material can, in addition to providing relevant information about home care, allow continuity of treatment at home and reduce the distress of patients and/or caregivers, due to its informative character, easy understanding and completeness of information.

The booklet represents a significant contribution to the health area, with emphasis on the professionals who provide assistance to patients in the postoperative period of gynecological surgeries, in primary or hospital care. This subsidy is due to the fact that the educational material serves as a strategy for health education actions, aiming at clarifying information and building dialogue with patients and their families.(¹²,¹⁹,²⁶,²⁸)Thus, the educational material presented can be an alternative to assist in raising the awareness of patients and family members, fostering the assumption of an active posture in relation to self-care and can provide greater adherence to treatment.

The minimum number of representatives of the target audience is exposed, which is justified by the time limit defined for the completion of the study. However, there was no interference in the quality of the results, considering the sociodemographic diversity of the participating population and the wealth of information obtained during data collection with this audience, as well as the non-inclusion of judges from other areas of knowledge, such as design graphic.

Conclusion

The production of educational material aimed at the needs of home self-care after gynecological surgeries was successful in its development process as well as validation through the contribution of expert judges (Suitability Assessment of Materials of 83% and Instrument of Validation of Educational Content in 0.86) and target audience (100% Suitability Assessment of Materials). Judges’ suggestions were incorporated into the final version. The target audience presented considerations favorable to the material, categorizing it as important for access, clarification, dissemination and the practice of self-care at home. The educational booklet proved to be a valid and reliable instrument to be used in promoting the health of women regarding care during the postoperative period of gynecological surgeries in the home environment.

Chart 1. Synthesis of changes made after suggestions from judges

Judges’ considerations	Modifications made
Exchange of terms	Replaced “yes” by “prefer”
	Replaced “no” by “avoid”
	Replaced “soft” by “laxatives”
	Replaced “inflammatory” by “inflammatory”
Exemplification	“facilitate digestion e.g., papaya, lettuce, zucchini”
	“industrialized e.g., inlaid, canned, fried, with lots of fat”
	“produce many gases (farts): raw onion, cabbage, sweet potato”
	“help to heal: egg white, lean meats (e.g., chicken, fish), fruits (e.g., cashews, acerola, orange, lemon), vegetables and assorted vegetables”
Explanations	“Chills and fever (if 37.8°C or more)”
	“plenty of water (at least 8 glasses per day)”

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Publication Dates

• Publication in this collection
  26 Nov 2021
• Date of issue
  2021

History

• Received
  3 Dec 2019
• Accepted
  1 Mar 2021