Development and validation of an interactive educational technology on spotted fever

Objective: to develop and validate an interactive educational technology on spotted fever, to offer an innovative teaching method. Method: a methodological study that covered the following stages: analysis and diagnosis; instructional planning, didactic design, review, and validation and production of technology. Results: the analysis and diagnosis were obtained from experiences in education and health activities for spotted fever. In the instructional planning, it was defined that the technology would be presented in the form of an Interactive Laboratory, with learning stations. The production of the Laboratory was carried out by a multidisciplinary team made up of a carpenter, an electrician, and a plastic artist, among others. The review and validation process was subdivided into two stages: appearance and content validation by professionals in the fields of biology, and education and semantic validation by students of the Nursing and Pedagogy courses. The results of the appearance and content validation showed a content validity index over 0.8 for the vast majority of the variables. In the semantic validation, the Laboratory was evaluated positively by the students. Conclusion: the trajectory followed for the construction of the Interactive Laboratory on spotted fever gave academic and scientific support to the product, offering an innovative educational resource with pedagogical potential that values significant learning.


Introduction
Spotted Fever (SF) is an emerging zoonosis with high lethality, which has presented itself as a new challenge for public health, since its incidence and prevalence have increased in a worrying way in the last 10 years in Brazil and worldwide. This increase was possibly due to the disease having urbanized, and being no longer limited to rural and forest regions (1)(2)(3)(4)(5) .
Brazilian SF is an infectious disease caused by the Rickettsia rickettsii bacterium, transmitted to man through the bite of the infected Amblyomma spp tick.
The tick phases that most affect humans are larvae and nymphs, popularly known as micuins and red, which are difficult to visualize and perceive (6) . Capybaras have notoriety in the epidemiological chain of the disease, as they are the main reservoirs of the bacteria, in addition to being hosts for SF transmitting ticks (7) . The occupation of areas with riparian forests by man brought him closer to the capybaras, which created a favorable environment for the infestation of man by the tick and transmission of the disease (2) .  (8) . In 2018 the state of São Paulo added an alarming number of 103 cases, of which 49 died (9) .
As already described, SF is not a disease restricted to Brazil, including other countries in Latin America, such as Colombia, Argentina, and Mexico, which have also registered an increase in the number of cases of the disease. In Argentina, the lethality rate is even higher than in Brazil, being between 40% of the diagnosed cases (10) . In Colombia, a study found that, in 2015, the cumulative incidence of infection for the disease reached 6.23%, but this incidence may be even higher due to SF being considered a neglected disease, sometimes underreported when confused with other febrile illnesses (11) . A serious mistake, considering that, if SF is not diagnosed and treated in a timely manner, it evolves to death in a few days (11)(12)(13) . In Mexico, the significant increase in the incidence of SF in 2015 led the country to declare an epidemiological emergency to contain the cases (14) .
In the United States, SF is also a public health problem, and its incidence went from 1.7 cases per 1 million people in 2000 to 13.2 cases per million in 2016 (15) . In the 2004-2016 period, 650,000 cases of vector-borne diseases were reported, of which 75% were caused by ticks (16) .
In order to reduce the problem, the Ministry of Health in Brazil adopted a strategy to identify environments with potential risk for the presence of SF and offered technical training to professionals in the Unified Health System network in these regions (17) . To this end, it implemented instructional materials in the format of video lessons on actions of epidemiological and environmental surveillance (18) . Unfortunately, these actions were not satisfactory, since the prevalence of the disease is still frequent, which stimulates the development of new actions for preventive education of the population. In fact, one of the gaps observed on the topic in the bibliographic review was the absence of educational materials on the theme, as well as educational interventions in health.
On an ongoing basis, researchers have revealed that health education cannot be limited to just activities that address the transmission of information, since the process of learning demands the construction of strategies in which the didactic and pedagogical aspects meet the cultural dimensions, psychosocial, economic, and political aspects of a given community (19)(20) . In this sense, when planning health education actions, the researcher needs to recognize the context to detect the factors that may contribute or hinder its development, with the transmission of information being only part of the process (21) . The population needs to recognize the need for actions so that they are incorporated into their daily lives, in order to improve the public health scenario in Brazil (22) .
In the planning of health education projects, the construction of educational technologies (ETs) that take into account the aforementioned aspects is crucial for the teaching-learning process (23) . An ET consists of a systematic set of scientific knowledge that allows planning and execution in order to control, monitor, and evaluate the educational process, so as to interrelate with knowledge and autonomy (24) , allowing the individual to live new experiences (25) .
It is worth mentioning that the construction of an ET requires the preparation of the educator, in order to understand the elements that make up the teachinglearning process, in addition to genuine respect for the protagonism of the student, arousing curiosity to increase their awareness of the world (24,26) . In this perspective, this study was based on Ausubel's theory of meaningful learning, which values students' prior knowledge in order to build and reconstruct knowledge based on pleasant and effective learning (27)(28) .
In this way, a learning environment, based on this theory, seeks to create diverse learning situations with encouragement to interactive learning. For this, it is necessary that the didactic material is potentially www.eerp.usp.br/rlae 3 Bragagnollo GR, Camargo RAA, Guimarães MN, Santos TS, Monteiro ELM, Ferreira BR. significant, to actually involve the student in the understanding of important concepts. In this process, it is crucial to value the students' previous knowledge, based on their critical and creative thinking, which provides the integration of existing knowledge with the new one (27)(28) .
The current study aimed to develop and validate an interactive ET on SF to offer an innovative teaching method.

Method
This was a methodological study (29) , based on the stages proposed by Abreu (30) : planning (analysis and diagnosis and instructional planning), production (didactic design and review and validation), implementation and evaluation (evaluation). Here, we will present the planning and production stages. The implementation and evaluation of the ET was planned to be carried out in the future. The descriptors "Rocky Mountain Spotted Fever", "Health promotion", "Prevention", "Health education", "Lyme Disease", "Fiebre Maculosa de las montañas rocosas", "Promoción de la salud", "Prevención", "Educación en salud", "Enfermedad de Lyme", "Febre maculosa das montanhas rochosas", "Prevenção", "Promoção da saúde", "Educação em saúde", and "Doença de Lyme" were crossed by the boolean operators "AND" and "AND NOT" in different ways for the maximum production related to the theme.
To compose the list of articles, studies were selected that presented at least one descriptor related to SF and The information obtained from the review supported instructional planning, in which the objectives, method, strategies, and specifications of the resources necessary to build the ET were detailed, as well as the content and its sequence (32) . The review also contributed to the development of the didactic design of ET on SF, when it was defined that it would be presented in the form of an interactive and self-explanatory laboratory, using learning stations. Thus, the activity was set up to allow the participant to learn in an autonomous, dynamic and playful way, sharpening the use of the senses when exploring and experiencing the educational environments of each station (33)(34)(35) .
The writing of the script provided a look at the final version of the ET, based on the didactic design (36) . A joiner, an electrician, an artist, a tailor, and a draftsman were the professionals responsible for the production of the ET, which took 9 (nine) months to be built. Subsequently, the content, strategies, and proposed activities that constituted the ET were analyzed and evaluated (30) using a specific model (37) to validate its appearance and content.
For the semantic validation, the model suggested by the DISABKIDS ® group was used, which has been recognized by the scientific community (38) .

Professionals in the fields of biology and education
of any age and gender, in an intentional non-probabilistic selection, made up a committee of 9 (nine) judges who carried out the validation of the ET's appearance and content. Thus, we comply with Pasquali's recommendation (37) with an odd number of specialists www.eerp.usp.br/rlae 4 Rev. Latino-Am. Enfermagem 2020;28:e3375.
to obtain a consistent measurement. After consulting the curriculum vitae on the Lattes Platform, those with more than 5 (five) years of training and who worked in the previously mentioned areas during the information collection period were selected (39) .
For the evaluation of the ET, we elaborated an instrument based on another study related to ETs (40) , with adjustments, so that the judges were able to evaluate the objectives, content (general organization, structure, presentation, coherence, and formatting), appearance and language (signs expressing ideas and concepts); as well as the clarity, objectivity, ease and understanding of the ET. The items of this instrument were organized in a 5 (five) point Likert scale format (37) , where the judges indicated whether they fully agree (5) manual, is at least 3 (three) participants for each age group and subset of items in the instrument. In the present study, as the age group was not a criterion for differentiating answers, the students were divided according to the specifics of the courses. The sample was probabilistic obtained by manual draw, in order to maintain homogeneity between groups.
The purpose of semantic validation was to ascertain, through interviews with the subjects that compose the population for which the material is intended, the level of understanding and acceptance of the terms, the relevance of the items, the existence of some difficulty, and the possible need of adaptation (41) .
Validation took place in two stages: the first evaluated the general impression on the ET in order to identify whether the contents were clear and consistent, using a general impression form. In the second stage, a specific semantic validation was performed, in which the participants analyzed a subset of items, described below.
In accordance with the guidance of the DISABKIDS ® Group (38) , the students were subdivided into 2 (two) groups to assess the clarity, relevance, and adequacy of each item. Group  The forms used in this phase were made available by the DISABKIDS ® group in Brazil (42)(43) . The limitation of four (4) variables per group is justified to avoid tiredness of the research participants.

Descriptive statistics and the Content Validity
Index (CVI) were used to analyze the data of the evaluation stage by the committee of judges. The calculation for each variable was performed by dividing the sum of the agreement of the items marked with grades 4 (four) and 5 (five) by the committee of judges by the total number of items answered (44) . For semantic validation, data evaluation was also performed using  (46) .

Results
In     Table 1.  and this has proved to be appropriate to contribute to changes in knowledge in a significant way (51)(52) .
When analyzing ETs developed in countries like the United States (53) , Spain (54) , Colombia (55) , Chile (56) , Venezuela (57) , and Brazil (24,35,(58)(59)(60) , it was possible to understand that the best results are directly associated with the interaction that these resources provide. That is, these studies show that it is essential to consider the users' prior knowledge and doubts in the elaboration of ETs; to this is added the relationship between the quality of educational materials and the use of defined principles and types of elaboration (61)(62)(63) .
Accordingly, studies carried out in Brazil (64)(65) , Venezuela (66) , United States (67) , and Italy (68) that worked with ETs obeying scientific criteria and seeking to know the target population, adopted strategies with the potential to gather modifying knowledge for the teaching-learning process.
The instructional planning of the current study was built in a systematic way to understand the scenario in which we were inserted, facilitating the choice of the approach and the type of action for the transformation of the practice and, consequently, of the reality, and trying to build a creative, consistent, and innovative design.

A number of methodological studies developed by
Nursing reveal that creativity associated with scientific knowledge strengthens and expands health education, offering new ways of thinking, organizing and managing care, which provides an innovative environment for the production of knowledge, enabling the autonomy of the subjects and promoting quality of life (69)(70) .
However, in order for the ET to fulfill its objective, validation as a scientifically reliable product is essential, and it is also tested for its effectiveness and suitability for its application (69) . In fact, carrying out the validation of an educational resource is crucial for researchers and health professionals to be able to trust and evaluate whether it is convenient for a given population (23) . colostomy and cancer highlights the importance of validation by specialists, since an educational material, when well produced and validated, can really contribute to modifying the reality of the subjects for whom it is intended (69) .
The use of appearance and content validation by specialists (judges) has been adopted by several researchers in ET assessments. Our work, employing this type of validation, obtained CVI values similar to those found in the literature (64)(65)69,(71)(72)(73)(74) .
Interestingly, the target audience (semantic validation) also satisfactorily evaluated the interactive laboratory on SF. In addition, the participants brought Therefore, it is worth noting that the elaboration of an ET is not an elementary task, it requires commitment and involvement of a multiprofessional team, from the initial phases of its project to its distribution to the end user (71) .
As for the limitation of this study, we can mention the cost for the development of an ET, since there is a demand for third party service contracts and consumables. Therefore, fundraising must be taken into consideration before starting the contract.
The interactive laboratory produced made the most of human potential in the construction of knowledge, by proposing an integration of different ways of apprehending new knowledge, extrapolating the visual and auditory sensations. In addition, it added experiences that transport the apprentices to a scenario very close to the real one, causing feelings and driving attitudes, in order to awaken behavior changes.
Finally, it should be noted that creativity was one of the main pillars for this study, since the individual's holistic involvement in the teaching-learning process was valued, using the playful and the imaginary through sensory experiences. Still, the theoretical framework which was selected also contributed to the fact that creativity was the main element in the planning of the ET, although always under methodological rigor.

Conclusion
This methodological study, which produced and validated an ET for health education on SF, was based on the needs of people who frequent an area at risk for the disease. It is considered that the trajectory followed provides academic and scientific support to the product constructed and also contributes with pedagogical potential as a propositive ET with an interactive approach, an essential requirement to value meaningful learning.