Development and validation of an educational booklet for healthy eating during pregnancy

OBJECTIVE: to describe the validation process of an educational booklet for healthy eating in pregnancy using local and regional food. METHODS: methodological study, developed in three steps: construction of the educational booklet, validation of the educational material by judges, and by pregnant women. The validation process was conducted by 22 judges and 20 pregnant women, by convenience selection. We considered a p-value<0.85 to validate the booklet compliance and relevance, according to the six items of the instrument. As for content validation, the item-level Content Validity Index (I-CVI) was considered when a minimum score of at least 0.80 was obtained. RESULTS: five items were considered relevant by the judges. The mean I-CVI was 0.91. The pregnant women evaluated positively the booklet. The suggestions were accepted and included in the final version of the material. CONCLUSION: the booklet was validated in terms of content and relevance, and should be used by nurses for advice on healthy eating during pregnancy.

objectives to be achieved by the target audience (2) .
The participatory approach used in the development of educational materials enables the identification of the needs of pregnant women, which indicate the inclusion of contents in the booklet that correspond to their own demands (3) .
National and international health agencies recommend that primary health care should adopt educational strategies and offer pregnant women guidance on a healthy diet and good nutrition, in order to promote health and achieve positive effects on maternal and fetal well-being (4)(5)(6) .
The inadequacy of the diet during pregnancy is a public health problem and increases the risk of low birth weight, deficient fetal growth, neural tube defects, maternal obesity, preeclampsia, gestational diabetes and premature birth (7) . The study that developed the Healthy Eating Index for Brazilian Pregnancy (HEIP-B) found that 62.6% of pregnant women reported diets classified as "in need of improvement," thus reinforcing the need to address nutrition education during pregnancy (8) .
Adequate nutrition is considered important during pregnancy, and nutritional counseling beginning in the first trimester of pregnancy is a way to provide and promote behavioral change and, consequently, to reduce disease through lifestyle modifications. Moreover, it points to the use of the booklets as a way to improve nutritional counseling for patients (9) .
As new materials focused on health education are developed by professionals, these need to be evaluated to maximize their effectiveness (1) . The understanding of the procedures for content validation is important for researchers and health professionals concerned with the use of more reliable and appropriate instruments for a given population (10) . A study based on the opinion of experts and pregnant women was conducted for the construction and validation of an educational booklet for health promotion during pregnancy (3) . A similar process was applied in the evaluation of educational materials for patients undergoing orthognathic surgery (11) .
One study evaluated 59 pieces of written educational materials used for patient education. Of these, 25  considering the life cycle; guidance and promotion of good nutritional activities that stimulate consumption of regional food; and, consideration of Brazilian cultural aspects (5) .
Considering the importance of these aspects, the study aimed to describe the process of validating an educational guide for a healthy diet with regional foods during pregnancy.

Methods
This was a study developed by use of a methodological approach in three steps: development  (1) . The theoretical framework upon which the material development was based was the assumptions of Motivational Interview (MI), in which two basics principles were used: to promote self-efficacy and to help address ambivalence (13)  was the beginning of the organization of content on a healthy diet; foods that are allowed and to be avoided during pregnancy; the benefits of a healthy diet for the pregnant woman and her child; food preparation hygiene; and recipes using regional foods.
For evaluation of the booklet, the concept of content validity and appearance were used, namely, a judgmentbased instrument that sought to measure the adequacy of assessment items with respect to the content, as well as having agreement between the judges (15) .
A protocol for trial was designed to evaluate the content and appearance of the booklet by the judges, with six items (  (16) .
It is noteworthy that in the selection of judges,

Recommendations of the Judges
Cover Display a more confident image of the father in relation to regional foods. Better illustrate the image of the woman's mother (grandmother).

Page 5
Replace the packaging of whole wheat flour for oats. Add the text: eat fruits, vegetables, legumes and grains daily.
Page 6 Make the regional food image more visible. In the text, start with the phrase: Eat healthy foods...

Page 7
Display the text in the active voice, as illustrated. Edit caption: Healthy Eating: healthy mother and child.
Page 8 Emphasize the regional food images. Edit caption: Healthy Eating with regional foods.

Page 9
Write the dilution of sodium hypochlorite and water. Reverse the order of the image: the clock should come prior to dilution information.

Page 10/11
Remove the image of the "Chef" and add the image of the pregnant woman.

Page 12
Illustrate with meals fractionated by the pregnant woman. Maintain the caption, however, divide it into two parts. The text was modified: "Consume regional foods every day. You can prepare a variety of meals for breakfast, lunch, dinner and snacks in between meals. " graphics and texts about the positive consequences of healthy eating.   These study findings, that composed a basis for the illustrations of the most consumed regional foods by pregnant women, are a matter of concern since women presented a low intake of fruits, vegetables, roots and tubers. The decrease in consumption of these foods is part of the reality of the Brazilian population. However, it would be necessary to increase by approximately 20% the consumption of cereal, tuber and roots, and by 30% for fruits and vegetables (5) . A study conducted in Australia with 409 pregnant women showed that only 7% of pregnant women consumed vegetables, 13% fruit, and 21% alcohol (18) .
As for the concept of healthy diet, the World Health Organization includes the increased consumption of fruits, vegetables, legumes, whole grains and dried fruit, as well as a limited energy intake coming from fats and limited intake of sugars and salt (sodium) (4) . However, pregnant women should be encouraged to consume natural foods, considering the availability of regional foods, as they are sources of carbohydrates, vitamins, fiber and minerals. These foods make up the group of roots, tubers, vegetables and fruits, essential for nutritional adequacy in pregnancy (6) . Therefore, regional foods that were included in the booklet illustrations were: manioc/cassava, yam, sweet potato, pumpkin, corn, beans, coconut, banana and others.
The theoretical basis for this research enabled the authors to coordinate ideas and develop the first version of the booklet. A study of social representation regarding nutrition in pregnancy (14) helped to clarify the key points (e.g., foods that should be avoided in pregnancy and the benefits of healthy eating). Thus, the aim was to achieve the objectives of the booklet and the needs of the target audience.
In the process of analyzing the content and the appearance of the educational material, contributions were included from pregnant women and judges who were experts in women's health, public health and health education.
The judges provided information relevant to modification of the writing and graphics; 100% of the judges agreed on the applicability of the educational material for clinical nursing practice. The women judged this to be a relevant primer to provide guidance during prenatal visits.
Educational material effectively produced can change the reality of a population, so we must consider which information is intended and what is expected (12,19) .
In this sense, the study suggested that pregnant women suggested the inclusion of recommendations on proper eating habits during the development of educational material (3) . Another study had nutritional counseling as a strong point of importance, in which 94.6% of the nurses agreed that guidelines on maternal nutrition during pregnancy was a widely required task in health care (9) .
The  (1) . Moreover, images must achieve a high level of attention and interest in reading the material, with acceptance of the population of individuals from different educational levels (20) . Judges and pregnant women identified these aspects during the assessment of the booklet under study.
The analysis of educational level among the women who participated in the review of the booklet identified a mean of 8.5 years of study. In the process of reading ability, one cannot pre-determine the level of education of the target group. It is recommended as suitable to use the range of six to eight years of study (17) . Authors showed that the level of education was of six years among the population who participated in the evaluation of educational material (20) . A study acknowledged this as a limitation of access to information for the target Rev. Latino-Am. Enfermagem 2014 July-Aug.;22(4):611-20.
population and elucidated that patients with low education would likely rate the educational material with lower scores in language items (21) . It was observed that a considerable section of a booklet validation for women who underwent mastectomy was the division of patients into groups according to the level of education, i.e., primary education, secondary education and higher education (22) .
In the development process of this booklet, we considered the aspects to motivate reading and learning by pregnant women. The judges evaluated the content and the graphics as relevant to motivate the learning of the target population (p-value=0.909 and I-CVI=0.90). Studies showed that 100% of the judges who participated in the validation process of educational material agreed that content and graphics motivated patients and addressed their doubts (11,22) .
Health and education professionals are motivated to use the educational material as teaching tools in patient/ student learning (19) . Therefore, scholars share the view on the importance of motivation to stimulate learning.
Furthermore, one must consider the interaction of text and graphics in the preparation process of written health educational materials (1,17) .
In this sense, the educational booklet shows illustrations and text on pages 9, 10 and 11 on food hygiene and recipes for regional foods (pumpkin soup and mashed manioc). On page 13 there are suggestions for regional foods that can be used for breakfast, lunch, dinner and snacks. Such text and illustrations are intended to motivate pregnant women in food hygiene and preparation of food using accessible items from their region or communities. The women said that the recipes figured prominently and helped in their learning of other meal preparation. Corroborating the studied booklet, authors used a flipchart for a population of preschoolers, encouraging the preparation of recipes with regional foods, including recipes of beef and cashew burgers, flour with banana, pumpkin puree and cassava leaf juice (23) . A study used the MI principles to develop an educational video aimed to enhance the consumption of healthy foods during pregnancy (24) . It is important to note that the MI is an important method for the practice of health promotion, becoming a valuable tool in primary care and guidance and awareness among nurses-patients (25) .
With regard to the types of instruments used for evaluation of the booklet, the lack of a specific pattern was observed. Studies used different instruments with adaptations proposed by the authors (19,21) . Studies applied the Suitability Assessment of Materials (Doak, 1996) to review the adequacy of the educational material (12,20,22) . To validate the process judgment, some studies used a qualitative approach with the focus group technique (3,19) and content analysis (2) . Other studies used the quantitative method (20)(21)(22) .
Quantitative analysis of the evaluation of the content and appearance of this booklet reached an S-CVI value of 0.93 and an average I-CVI value of 0.91, i.e., >0.80. In this way, the educational material, Healthy Eating with Regional Food, was considered validated.
Another study showed similar results with respect to the content validity index of figures and guidance within the booklet (23) . during low-risk prenatal care, aiming at qualified prenatal care and satisfactory results for maternal and neonatal health (6) .
In regard to the limitations of this study, we present the use of different assessment instruments for judges and the participating pregnant women, as this did not allow the establishment of a relationship between the perceptions of the two groups. Regarding illustrated regional foods; we portrayed the ones most consumed in the Northeast region of Brazil and in the State of Pernambuco, which may limit the use of the booklet in other regions of the country.

Conclusion
The educational material was validated for its content and relevance. The evaluation process included health professionals (judges) and pregnant women.
The construction of the booklet involved scientific knowledge and teamwork, as well as engaging design and layout artists and advertising professionals. The contributions of judges and pregnant women were considered until the development of the materials' final version. The booklet is relevant, being considered as a new teaching material for health education activities, in order to motivate mothers to have a healthy diet, using regional foods.
The online version of the booklet is available to the public in the collection of the Pernambuco's E-health Network Library (Rede NUTES). However, efforts have been made to ensure the availability that the booklet in hard copy for public health institutions. A clinical trial is being developed to evaluate the effectiveness of an educational guide for behavior change with respect to the use of regional foods during pregnancy.