Estratégias metodológicas para elaboração de material educativo: em foco a promoção do desenvolvimento de prematuros Methodological strategies for the elaboration of educational material: focus on the promotion of preterm infants’ development

Resumo O objetivo deste estudo foi descrever e analisar o processo de elaboração de um material educativo para a promoção do desenvolvimento da criança nascida prematura. Os procedimentos incluíram: pesquisa exploratória participativa com o público destinatário, revisões integrativas de literatura sobre o tema e sistematização dos conteúdos por meio de referenciais teóricos robustos. A Educação Popular em Saúde orientou a elaboração do material educativo e a abordagem participativa, a Teoria Bioecológica do Desenvolvimento Humano balizou a análise e sistematização dos conteúdos, e o Simply Put a organização gráfica do material. O modelo teórico do desenvolvimento da criança nascida prematura e a sistematização e organização dos dados propiciou a elaboração de um material educativo interativo, uma tecnologia em formato de livro destinada à família. As múltiplas estratégias de pesquisa e os referenciais teóricos conferiram rigor metodológico, ampliando o potencial de ação do material educativo, que aproxima a experiência familiar ao conhecimento científico atualizado potencializando a promoção da saúde da criança. Palavras-chave Educação em saúde, Desenvolvimento infantil, Recém-Nascido Prematuro, Materiais Educativos e de Divulgação, Tecnologia educacional Abstract This study aimed to describe and analyze the process of elaborating educational material to promote the development of preterm infants. The procedures included participative exploratory research with the target audience, integrative reviews of the literature on the subject, and systematization of contents through robust theoretical references. Popular Education in Health guided the elaboration of the educational material, and the participatory approach; the Bioecological Theory of Human Development conducted the analysis and systematization of the contents; and Simply Put guided the graphic organization of the material. The theoretical model of the development of preterm infants, and data systematization and organization, allowed the elaboration of an interactive educational material, a technology in a book format for the family. The multiple research strategies and theoretical references have provided methodological rigor, increasing the educational material’s action potential, which draws family experience closer to the updated scientific knowledge, thus enhancing child health promotion.

introduction This paper shows the methodological path, references and research strategies used in the elaboration of the educational material "History of Sofia: family battles and achievements in the care and development of the preterm child", which seeks to support a relevant collective health issue, namely, promotion of development in preterm condition.
Prematurity is a significant global health problem due to the increasing number of births in this condition [1][2][3] and because it is the precursor of many morbidities and disorders in child development with possible lifelong repercussions [4][5][6][7] . Disorders in the functional development are those that affect the ability to perform activities of daily living and exercise the expected social role for the age group, which are significantly prevalent in the preterm population 5,6 .
The national guidelines for professionals dealing with preterm children reinforce that intervention should include family orientation, emphasizing its partnership in the care and development of the child 8 . However, systematized educational materials for guidance and family support are scarce, especially to this public with specific guidance needs.
The lack of systematization of family orientation is highlighted by Chiodi et al. 9 as a concern of caregivers and professionals, noting that educational materials are useful tools that could be provided to parents for instruction and home consultation when necessary. The relevance of research devoted to the elaboration of family guidance educational materials has also been emphasized 10 .
The Ministry of Health of Brazil, through its National Popular Education and Health Policy 11 , and its references, I 12 and II 13 Cadernos de Educação Popular e Saúde 12,13 (Notebooks of Popular Education and Health) recognize educational actions as essential and fundamental strategies for coping with public health issues and health promotion. The systematic review by Silva et al. 14 showed the positive impact of participatory educational strategies, such as the use of educational materials during home visits, in facing crucial health issues, generating favorable outcomes such as the reduced rates of prematurity and low birth weight and increased exclusive breastfeeding. A similar outcome was also observed in the study by Santana et al. 15 . These favorable outcomes of educational interventions in family empowerment to improve care and enhanced development of preterm children are recognized globally as good health promotion strategies 2 .
Educational materials are a care technology 16 that enhances health interventions and teamwork, as they not only mediate playfully the process of empowering subjects to promote their health, but are also permanent tools of care since they can be consulted when necessary.
Many studies and publications focus on to the methodological explanation of the construction and validation of measurement instruments 17,18 as well as the presentation of research geared dedicated to the development and validation of standardized instruments for the evaluation of child development 19 , including those for preterm children. However, few are intended to guide the methodological construction of educational materials, especially those aimed at guiding and empowering the family to promote child development, despite its acknowledged and expressive role in the positive results in children's health, when correctly oriented 2,9,14,15 .
In the first years of the life of the preterm child, there is great concern about the physiological and growth aspects, by both the families and the professionals. Development is often understood as synonymous with growth and adequate if weight or height increase, for example, to the detriment of the perception of the acquisition of functional abilities 6 . Also, there is a tendency to overprotect and limit the independence of the preterm child 6 . The cumulative effect of biological and social aspects and caregiving attitudes on child development is often not perceived 6 . All of these factors reinforce the need for a systematic, comprehensive, development-oriented guidance using appropriate and accessible educational technologies.
In order for educational materials to be appropriate to the intended audience, and to the construct to be disseminated and elaborated, they must be built using robust methodological bases, with valid and reliable construction strategies and adequate theoretical references 12,13 . Also, they must count on the active participation of members of the target group [20][21][22] . Before the recognized importance of educational materials in child health, a question arises: How do we prepare educational materials adequate and representative of the needs of the population for which it is intended, based on popular education?
Thus, this study aimed to describe and analyze the methodological process of elaborating educational material aimed at promoting the functional development of preterm children.

Methods
This is a methodological study focused on the description and analysis of the process of elaborating an educational material to promote the development of preterm infants, guided by the reference of popular education and health, and the bioecological theory of human development. This study is part of a broader research and complied with all ethical precepts, including approval by a Research Ethics Committee in October 2013.

theoretical and methodological references
The reference of the Popular Education and Health [11][12][13] according Paulo Freire oriented the elaboration of educational material, concerning its methodological stages and strategies, and the Bioecological Theory of Human Development 23 focused on the analysis and systematization of its contents.
Popular education advocates the participatory method as a premise for the empowerment and autonomy of subjects to care for their health. This emancipatory methodology considers the understanding and experience of the subject living in the world and acting in the transformation of his reality. It proposes that this often fragmented and underdeveloped understanding be the object of the action of popular education in health, through horizontal and problem-posing discussions, according to the situations experienced by individuals and communities 12,13 .
The bioecological theory of human development 23 conceives the human development anchored and directed by the components: Process, Person, Context and Time.
The Process is the central axis of development and refers to the reciprocal, systematic interactions established over an extended period between the developing subject and the people, objects, and symbols present in their proximate environment 23 . The Person is the developing individual with his/her individual, genetic, psychosocial and behavioral characteristics, who acts in the environment and his/her development, and also generates responses from the context in which he/she is inserted 23 . The Context is the environment in which the Person develops and is divided into Microsystem, the near environment in which the subject is inserted and in which he establishes direct interactions; Mesosystem, referring to the relationship between the microsystems; Exosystem, environment in which the Person is not directly inserted, but that influences its development; and Macrosystem, the set of values, ideology and beliefs that permeate the Person's 23 environment. Time is the element related to the changes and stabilities of the Person's development over time and the historical time in which he/she lives 24 . Figure 1 shows the schematic model of the bioecological theory of human development, with PPCT 24 components.

the methodological path
The methodological path to identify the content and composition of the educational material followed the precepts of the construction of measurement instruments in the health area 18 adapted for the elaboration of educational material, excluding only the specific aspects of measuring instruments. Table 1 summarizes the objectives of each stage for the composition of the educational material, the resources used to reach each stage and the definitions established in the organization of the material.
After establishing the resources and definitions for the composition of the educational material, we continued defining and applying strategies for the selection, organization, and structuring of material contents and illustrations.
The first strategy developed was an exploratory study with representatives of the target population. Through semi-structured interviews with 12 caregivers of preterm children, monitored in a referral service to care for this population, we verified caregivers' understanding of the development of their children, their needs, concerns and care components to promote children's development. The interviews were conducted in a participatory and dialogical way, using a structured script and playful strategies, such as illustrative frameworks. They sought to explore the experience of caregivers and the issues that emerged from it. A qualitative analysis of data content was carried out following the Bioecological Theory of Human Development reference 23 .
The second strategy established for the elaboration of educational material was a literature review. Two integrative reviews of the literature on care practices promoting home-based functional development were carried out. The guiding questions were: "What are the care practices that promote the functional development of preterm infants up to three years of age?" and "Which factors/elements are involved in the care provided by the family to the preterm child after leaving the NICU?" The revisions followed the steps of the Integrative Review 25 and occurred in January/February and August/September 2015, respectively.
In the first integrative review, we searched the Science Direct, Scopus, and Web of Science databases with the following descriptors and their combinations, in both English and Portuguese: preterm, child care and development. In the second review, the Latin American and Caribbean Health Sciences Literature (Lilacs), Psycinfo [APA, PsycNet], Scientific Electronic Library Online (SciELO), Physiotherapy Evidence Database (PEDro), Virtual Health Library (BVS), Institute of Education Sciences (Eric) databases were included. Other descriptors and their combinations in English and Portuguese were also included: preterm infant, development promotion, health education, family education, nurture intervention and health promotion.
The inclusion criteria were full-text papers in English or Portuguese, published in journals indexed in said databases in the last five years. We excluded papers that investigated age groups different from those recommended for the educational material and those with themes that did not fit the guiding questions.
After reading the title and the abstract, the papers that were read in full and organized in a table of analysis with data of identification, authorship, year of publication, type of study, subjects of the research, objective/evaluation and the primary results were selected. In this stage, papers that did not meet the inclusion criteria after full-text reading were excluded.
Following the systematization of the contents, we also decided to use textbooks, articles, documents, and legislation, considered as essential references, for their relevant content for the establishment of the theoretical and operational bases of the systematization of the educational material. These were mainly texts on the theoretical reference of analysis and the methodological reference for the construction of educational materials, contents that are absent or not detailed in the papers that came from the review.
The third methodological strategy was seeking references that guided the operational elaboration of the sections of an educational material intended for the population. The reference selected and used for the development of the educational material was the Simply Put -A guide for creating easy-to-understand materials, elaborated by the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services 26 . It provides strategies for constructing health education materials that are more comprehensible, especially for low-educated populations, pointing out recommendations for the whole formulation process, including: aspects of the content, language used, graphic form and layout of texts and images, visual aspects, color play, typefaces. It also points other recommendations, such as focus on the construct conveyed and type of information to be worked on, as well as the expected action of the subject because of the use of the material in practice.
The use of the methodological strategies and theoretical references employed guided the preparation of the educational material in a systematic way and with methodological rigor, as described below. After being prepared, the material was submitted for evaluation and validation by professionals and the target audience, and this content will be addressed in another paper since it is not the object of our discussion here.

Results
In addition to the descriptive analysis shown in the publication of the exploratory study with the families, all the content of this stage was organized in a database containing aspects of the family experience, understanding about children's development, and the needs pointing out by caregivers; so, they were worked with the results of the bibliographic review, as content of the proposed educational material.
In the review, we selected 76 papers, of which 49 were excluded as they did not meet the established inclusion criteria. Thus, 27 full-text papers were included for study and composition of the educational material. Most studies were retrieved from the Science Direct database (8), followed by Web of Science (7), Scielo (5), Scopus (5) and PsycInfo-APA (2). chart 1. Description of the stages, their objectives, resources, and results for the composition of the educational material on the promotion of the preterm infant's development. Most of the 27 included studies were in English (23) and published in 2014 (16). The types of study were: case-control (6), descriptive (11), cohort (6), systematic (2) or critical review (1), and survey (1). The full reference and primary results of each selected paper were compiled in a summary table synthesizing its main findings and contributions. This organization facilitated the identification, selection, and systematization of the specific contents to be included in the proposed educational material.

Recommended
The texts and sources of research and theoretical basis considered as a critical reference in the composition of educational material were related to the bioecological theory of human development, the functional development, the prematurity, and the rights of Brazilian children and adolescents.
The understanding of prematurity from the theoretical reference of the Bioecological Theory of Human Development, the exploratory study with the families in the research' first stage, and the literature review enabled the elaboration of a theoretical model for understanding the PPCT 22 model for the preterm infants, expressed in Figure 2, which defined the content of the educational material.
The contents of the papers and documents selected for the study were systematized in two tables of evidence, according to the Human Development Biological Model Reference 23 and the areas of functional development 27,28 . In Tables 2  and 3, the categories established are listed with the bibliographic references that originated them, and according to the corresponding theoretical references.
This systematization allowed all contents to be organized to compose the educational material since they were distributed comprehensively in clusters that underpinned the chapters of the material in a book format. Next, the chapters were drafted, using strategies for the elaboration of an engaging text and accessible language, according to the Simply Put criteria 26 and the Popular Education and Health references 12,13 .
Thus, the systematized data were worked out in the form of a story that portrays the experiences of a family that lived the condition of the birth of a preterm child and dialogues with the reader, indicating relevant information for the care of the child and the promotion of functional development. Interactive spaces were designed throughout the text for the reader to fill in his experiences. A framework of functional abilities expected by age group was also elaborated, in-cluded at the end as a booklet, allowing the family to follow the development of the child by area of functional development and age.
The material in plain text file was formatted with a structure that included chapter indications; highlights in the text, with bold or colored text boxes, referring to vital information from research and literature review; indications of interactive spaces with the reader; and descriptions of the shape, location and type of illustration to be included in each piece of material and the insert. This first version was submitted to a specialized professional company for layout and illustration, contracted with resources obtained through a research funding agency.
The researchers periodically reviewed the material during the process of layout and illustration in direct contact with the company, considering the information dissemination. This procedure aimed to enhance the inclusion of illustrations that ensured adequate information to the theoretical reference used and the precepts established by the official health institutions in Brazil and the world.
The first version of the 55-page layout and illustrated material was made available for the content and face validation process with judges and the target audience. It still did not contain the bibliographical references nor the reports of the families, planned as part of the final content, but just indication that they would be included. Following the validation process, the material was revised, adjusted and printed. The printed material was forwarded for distribution to participating health services and to services where research continuation was established. Also, it was posted on the website of the educational institution where the research was developed and was made available to official sites of association of caregivers of preterm infants and the Ministry of Health.

Discussion
This study sought to contribute with proposals for the construction of educational materials, describing and justifying the methodological strategies of the process of elaborating an educational material geared to promoting the functional development of preterm children. Streck 22 warns of the need to seek open and consistent criteria for research with the reference of Popular Education and with participatory methodologies, which were followed in this study, namely, social relevance, quality of description and interpretation, reflexivity, quality of the relationship between subjects and practicality of knowledge.
Also, were followed recommendations by scholars regarding the construction and validation of instruments 17,18 and researchers who developed and validated educational technologies using similar methods, for multiple purposes 29,30 , for child health 31,32 and support to the family of preterm infants 33 .
The use of the PPCT model of the Bioecological Theory of Human Development 23 in systematizing the results of the research with the families of preterm children 34 and the literature review was consistent with the objective of supporting the family through the creation of educational material for the care and promotion of the development of the premature child. This is because the promotion of child development is an effect of the Proximal Processes established between the Persons interacting in Contexts and Time 23 . Thus, the interaction processes experienced by the child in his early years, especially in the family context, define his biopsychosocial well-being and quality of life 58 .
Thus, the strength of the educational material is seeking to ensure the relationship between the scientific and empirical evidence and the PPCT model, since all elaboration was based on the components of Process, Person, Context and Time. Defining such a theoretical basis is consistent for the family promoting child development since the proximal processes acting as drivers and reliable predictors of human development can minimize or even detain contextual influences of vulnerability 23 . The emphasis on the driving force of the proximal processes in the development of the child can also be visualized in the format of a history dialogued with the family, emphasizing the interactions between family and child in the continuum of development of all the Persons of the family core.
The format of a story dialogue with the reader used in the educational material is consistent with the reference of popular education and health. The material as a mediating tool already carries this conception of questioning with care- givers of preterm infants the care to promote development, which is being worked from characters who live similar experience, seeking an identification. The book on popular education and health 12 emphasizes: Popular health education is not a process of knowledge transmission, but of expanding the spaces of cultural interaction and negotiation between the various stakeholders involved in a given social problem for the shared construction of knowledge and political organization required for its overcoming. Instead of seeking to spread correct concepts and behaviors, it seeks to question, in an open discussion, what is bothering and oppressing. 12 (p.21).
The focus on functional development as a critical construct of the material stems from it continues the emerging need to consider the preterm person/child in its Contexts and Processes. It also presents a proposal that conveys somehow the expanded concept of health 59 and the conceptual model of the International Classification of Functioning, Disability and Health (ICF) 60 , which considers the impairments of body structure and function as components of a model that establishes with equal value to the other components activity, participation, and environmental factors. This is all in tune with the bioecological model of human development 23,24,58 .
The search for participation and dissemination of the material to the target audience during its construction also refers to the call to set academic research as a catalyst for political and social transformations. It envisages that research participants transcend the role of informants and receivers of conclusions, participating in the production of knowledge about their unique realities 22 . This contributes to the consolidation of the Popular Education References 12,13 and the Bioecological Theory 23 at the core of health research and practices.

Final considerations
This study describes the methodological steps for the elaboration of an educational material aimed at promoting the development of the preterm infants from the participatory research with the target population, literature review and key theoretical references to support the construction of educational materials.

Micro and Mesosystem
The family (family, friends, neighbors, grandparents) or health care (services and professionals) support network is crucial to sustaining the child's care and development. public allowed a greater rigor and an increased scope of the educational material. Strategies of approximation with the knowledge of the population, the search for updated scientific literature and search for literature on the organization of appropriate educational and informational materials were used as tactics of equal magnitude and importance in the elaboration of educational material, and this triple strategy was recommended for studies with a similar objective.
The theoretical references vigorously sustained the systematization of the contents of the educational material and were strengthened as strategies of research and organization of knowledge for health practice. The search and selection of references that are consistent with the health issue and with the educational construct to be worked on in research that is dedicated to the elaboration of educational material such as health interventions are indicated.

collaborations
Both authors participated in all phases of the preparation of this paper, including design and outline, analysis and interpretation of data, as well as drafting of the paper. Lemos e Veríssimo, 2015 34 Knowledge of specific tests that the child must be submitted to. Lemos e Veríssimo, 2015 34 Positioning and ways to carry the child. Lemos  Preterm infants have lower scores than the normative population in functional performance evaluation tests and independence to perform activities of daily living in three main areas of functional development: self-care, mobility and social function even with age adjustment.

Lemos e Veríssimo, 2015 34
Cumulative effects of various environmental and biological factors influence the functional development of preterm infants.

Lemos e Veríssimo, 2015 34
Premature infants have a less stimulating environment quantity and quality towards functional development. Functional development may be related to the care practices and the context in which the subjects are inserted.