Validation of educational material for the care of people with intestinal stoma.

Abstract Objective: to validate an educational booklet for people with intestinal stoma as a technological resource in the teaching of self-care. Method: a methodological research for the construction and validation of an educational booklet by nine expert judges and 25 people with stomas. The agreement index of at least 80% was considered to guarantee the validation of the material. Results: regarding the objectives of the booklet, all the judges evaluated the items as “adequate” or “totally adequate”, with a content validity index of 1.00. Regarding the structure and presentation of the booklet, the total index was 0.84. Regarding relevance, the total was 0.97 and the general index of the educational booklet was 0.89, confirming the validation with the judges. All items of the organization, writing style, appearance and motivation of the material were considered as validated by the target audience, reaching a total agreement index of 0.99. Conclusion: in the context of health education, the booklet was considered valid and suitable for the care of people with intestinal stoma, and can be used in teaching, research, extension and care for people with intestinal stoma.


Introduction
Elimination stoma is the name given to an opening created artificially in the abdomen, by surgical procedure, to communicate the internal environment of the intestinal or urinary tract with the external environment, where the elimination of feces and urine occurs. The intestinal stoma can be classified into two types, according to the affected site, subdivided into ileostomy and colostomy (1) .
The main causes that lead to the making of a stoma are those of neoplastic origin, which compromise the  (2) . In addition, other causes, such as inflammatory intestinal diseases and abdominal trauma, can also cause the making of a stoma (3) .
Living with this condition causes several changes in the life of a person and their family members, which have an impact on physical, psychological and social aspects. The acquisition of a stoma demands new skills for self-care, knowledge about body changes and a new health perspective, as well as coping strategies for a better adaptive process (4) .
At this time, the support of family and friends, as well as of the health professionals, is essential for people with stomas. The need for the care provided by the nursing team to this population throughout the perioperative period is emphasized, with the responsibility to provide guidance on the surgical procedure and all stages, ranging from hospitalization, to post-operative care and after discharge from hospital (5)(6) .
In the post-operative phase, the interventions of the team should be directed towards the realization of self-care, through the resumption of activities of daily living, in addition to particular adjustments and participation in support groups, where the exchange of experiences about living with the stoma and the adaptive process (7) .
During the nursing consultations, it is possible to notice several difficulties in self-care, which result in low self-esteem and self-efficacy, associated with the handling and adaptation of the collection equipment, due to complications in the stoma and peristomal area. It is also evident that these people attribute such difficulties to the lack or insufficiency of guidance on the stoma and the necessary care in the pre-and postoperative periods (8)(9) .
It is necessary, on the part of the nursing team, to establish educational strategies to satisfy both the specific needs of rehabilitation and the improvement of the quality of life of this population (10) . In Nursing, health education is a fundamental instrument for a good quality care, as the nurse acts on the teachings of self-care for people with stoma and their families (11) .
The increasing use of educational materials (booklet) as resources in health education has assumed an important role in the teaching-learning process, mainly in the therapeutic intervention (12) . They are useful for this population, since they favor knowledge, and develop their attitudes, skills and autonomy.
The purpose of health education is to encourage the person's independence, based on knowledge exchange, in order to encourage self-care and adherence to the necessary treatments (12) . Thus, the objective was to validate an educational booklet for people with intestinal stoma as a technological resource in the teaching of self-care.
For the validation stage, recommendations on the ideal number of expert judges and the target audience were considered (13) . Therefore, nine nurses and 25 people with intestinal stoma participated in the content and appearance validation stage, respectively. Content validation makes up the assessment of the universe of information that provides the structure and basis for formulating questions that adequately represent the content (13) .
After signing the Free and Informed Consent Form, the characterization questionnaire, the educational material in printed version, and the content validation instrument were sent. To this end, a semi-structured questionnaire (14) was adapted with 17 assertions, organized in a Likert scale format with five judgment options: totally adequate, adequate, partially adequate, not applicable and inadequate. Each statement corresponded to an evaluation item, distributed in three evaluation domains (Objective, Structure and organization, and Relevance). There were also spaces for suggestions and general comments.
After making the necessary adjustments to the booklet, through the suggestions made by the experts, validation with the target audience followed, using an adapted instrument (13) , with 13 questions regarding organization, writing style, appearance, and motivation.
There were three answer options for each question: positive (yes/easy to understand/clear/interesting), impartial (in part/I don't know) and negative (no/difficult to understand/confused/uninteresting), according to each type of questioning (15) . Rev. Latino-Am. Enfermagem 2020;28:e3269.
For analysis of the items judged by the target audience, data with an agreement level greater than 0.80 for positive responses (16) were also considered validated. The subjects were identified in their statements by the letter "P" followed by an Arabic number from 1 to 25 (P1, P2, P3...), according to the order of their participation in data collection.

Results
The first version of the educational material submitted for validation by the expert judges was of 32 pages, entitled "Learning to care for the intestinal stoma". The contents of this booklet contained an initial presentation and, in sequence, the following subjects, which were presented First, the judges evaluated the educational booklet as to the objectives to be achieved with its use. No item was deemed inappropriate or partially adequate or marked as "not applicable". It was found that, regarding the objectives of the booklet, all items were considered valid, since all the judges classified them as "adequate" or "totally adequate", which gave a CVI of 1.00 for the proposed objectives, as exposed in Table 1. Subsequently, the judges evaluated the booklet as to its structure and presentation and no item was deemed "inappropriate" or as "not applicable". It was considered validated, reaching a total CVI of 0.84. However, some were judged to be partially adequate by 22.2% of the judges, as shown in Table 2  The messages are presented in a clear and objective way.
The information presented is scientifically correct.
There is a logical sequence of the proposed content.
The material is appropriate to the socio-cultural level of the proposed target audience.
The information is well structured in agreement and spelling. The writing style corresponds to the level of knowledge of the target audience. The information on the cover, back cover, acknowledgments and/or presentation is consistent.
The illustrations are expressive and sufficient.  (Table 3), there were no items judged as "inappropriate" or "not applicable". Only one judge classified the item "The material proposes to the person with a stoma to acquire knowledge regarding the management of self-care with the stoma" as "partially adequate". In terms of relevance, the total CVI was 0.97, since the other judges classified all items as "adequate" or "totally adequate". Consequently, the general CVI of the educational booklet is 0.89, confirming the validation of appearance and content with specialists in the field. The themes portray the key aspects that must be reinforced.
The material proposes to the person with a stoma to acquire knowledge regarding the management of self-care.
The material addresses the issues necessary to prevent complications.
It is suitable for use by any health professional in their educational activities. The corrected and printed version of the booklet was delivered individually and, only after the material was handled and read, were they asked to answer the validation instrument, applied by the researcher. Table 4 shows the result of the evaluation of the material by the public with an intestinal stoma. Is the structure of the educational booklet organized? 25 0 1

Writing style
As for the understanding of the phrases, they are: (Easy to understand/Difficult/Do not know) 25 0 1 The written content is: There were no negative answers in the items evaluated by the target audience. All the items of the organization, writing style, appearance, and motivation of the material were considered validated, as they reached a total agreement index of 0.99. Only one answer from the "organization" item, in the question "Does the cover catch your attention?", was considered an "impartial answer", and the person with a stoma did not justify the reason why the cover did not fully attract his attention.
Another item that had an impartial answer was about the following question: "Did you feel motivated to read the booklet until the end?" As a justification, it was replied: Rev. Latino-Am. Enfermagem 2020;28:e3269. After the entire validation process, the educational booklet was completed with 34 pages and started to be offered by professionals in the field. The image of the material cover is shown in Figure 1. In this way, the educational booklet is also seen as a resource to assist professionals in health education, seen as a way of caring to strengthen the capacity and autonomy of others. Thus, health education, as it constitutes a dialogical intervention, allows for continuous training (12) , and educational technology in printed format has been widely used to improve knowledge, satisfaction, participation in treatment and As a limitation of the study, there is the high cost of the printed material to be made available to the target population, as well as the difficulty of using the online booklet by people who do not have access to this resource. In addition, people with a low cognitive impairment and dementia will find it difficult to assimilate the information contained in the material.

LEARNING THE CARE FOR
Thus, new validation studies with audiovisual technologies are suggested to overcome these limitations and assist this population in the care of the stoma. As well as adding technologies that can be reproduced and disseminated, in order to assist in the scientific advancement and health of this population.

Conclusion
The The booklet can assist in the autonomy and self-care of people with stomas, as well as in supporting professionals in assisting this population.