Validation of an interactive electronic book for cardiovascular risk reduction in people living with HIV

Abstract Objective To validate interactive digital educational material in the form of an electronic book about the prevention and reduction of cardiovascular risk from the perspective of people living with the Human Immunodeficiency Virus. Method This is a methodological study based on the theory of evaluation research, of the results analysis type, which involves technological production. The data were collected throughout Brazil by means of a virtual questionnaire consisting of items for general, visual, language, usability, content and appearance assessment of the educational material. A minimum Agreement Index of 80% was adopted in order to certify validity. Results 309 individuals living with the Human Immunodeficiency Virus participated in the study, the majority (84.3%) being male, aged between 19 and 65 years old and with complete higher education (29.3%). More than 90% of the participants assessed the book as suitable for solving doubts and providing preventive care for cardiovascular health. All the items evaluated reached an index above 0.80. The general evaluation of all the items reached a mean of 0.92, with general assessment (0.97) and content assessment (0.94). Conclusion The educational material proved to be valid, adequate and relevant to promote literacy in health, and could contribute to health promotion and to the prevention of cardiovascular diseases.


Introduction
The advent and large-scale availability of the antiretroviral therapy (ART) has transformed the Human Immunodeficiency Virus (HIV) infection into a chronic disease (1) . Treatment reduced the number of deaths attributed to opportunistic infections and increased the longevity of people living with HIV (PLHIV). However, other chronic comorbidities have emerged, such as cardiovascular diseases (CVDs), which became one of the main causes of morbidity in this population (2)(3) .
Traditionally, CVDs result from the interaction of multiple risk factors dichotomized between modifiable (smoking, inadequate diet, sedentary lifestyle, dyslipidemia, hypertension and diabetes) and non-modifiable (advanced age and family history) (4)(5) .
In addition, a number of studies have shown that these risk factors for CVDs are more frequent in PLHIV undergoing regular ART, evidencing living with the infection as a specific risk factor for CVDs (3,6) and that, added to the traditional factors, they predispose PLHIV to an even greater risk for the development of diseases (6)(7) .
Thus, changing the lifestyle habits, such as increased physical activity, weight reduction and education about healthy eating practices is essential to mitigate the modifiable risk factors for CVDs in PLHIV (7)(8) . Such changes can be achieved through education in health, which seeks to increase people's empowerment in relation to their health care (9) , as well as improving literacy in health, which plays a prominent role in the primary and secondary prevention of CVDs (10) .
Literacy in health has emerged as a major area of interest, being essential for research and health care in various chronic disease conditions. It is defined as "the degree to which individuals can find, understand and use information and services to make health-related decisions and initiate actions for themselves and others" (11) . Low literacy in health is associated with challenges for those living with HIV, including drug non-adherence and worse health outcomes (12) .
Difficulty accessing reliable information and/or lack of understanding are significant barriers to the effectiveness of literacy in health (13)(14) ; therefore, the elaboration of educational materials in accessible language, as well as their validation by their target audience, can contribute to reducing such barriers.
In this context, digital educational materials, including the interactive electronic book (e-book), are information technologies that have provided a greater degree of interaction with health knowledge (15) , especially when compared to passive learning carried out through static information sources (16) . E-books represent an important strategy to improve literacy in health and work on self-care through behavioral change, complementing the health team's traditional educational efforts to reduce risk and prevent CVDs among PLHIV (16) .
Therefore, this study aimed at validating interactive digital educational material in the form of an e-book about the prevention and reduction of cardiovascular risk from the perspective of people living with HIV/AIDS (PLHIV).

Study design
This study was part of a larger project entitled "Development, validation and effectiveness of educational technologies focused on the behavior, preventive practices and lifestyle of people living with HIV/AIDS". This was a methodological study based on the theory of evaluation research, of the results analysis type, which involves technological production (17) . The e-book focused on reducing cardiovascular risk in PLHIV.
The study was conducted in three stages. The first two began with the process of construction and validation of content and appearance by health experts (in relation to content and layout) and with experts in the field of information technology (evaluating the interfaces and functionalities of the e-book). For this, a literature review was conducted and then the book was built in digital format and validated, as described in the previous study (18) .
In this third stage, in order to continue the validation process of the material, validation was carried out with the target audience regarding the general assessment and aspects such as visual, appearance, language, usability and content of the e-book in order to obtain the final version of the material (19) .
The e-book entitled "Take care of your heart: Strategies to reduce cardiovascular risk in people living with HIV/AIDS" (20) has its interface built in HTML5 and Java Script and generated a file in the Electronic Publication (ePUB) format. The content was written in order to meet the needs of the population; therefore, an accessible language with no technical terms was used to assist in understanding the content. Thus, in order to facilitate its interpretation, infographics and videos were created to make the Virtual Learning Environment (VLE) more dynamic and interactive (18) .
The e-book was built with the aim of promoting usability and accessibility (18) , providing the user with an www.eerp.usp.br/rlae easy-to-use, dynamic and interactive tool, and is available for free download at Apple Books on the iOS ® platform or in Google Play on the Android ® platform, being able to broadly reach PLHIV throughout Brazil.
In general, the material includes guidelines on knowledge about the risk for CVDs and addresses aspects of the modifiable risk factors: smoking, sedentary lifestyle, stress, obesity, diabetes mellitus, hypertension and dyslipidemia. In addition, the content about the risk for CVDs in PLHIV and the interventions/strategies for their reduction was assessed, including healthy eating, smoking cessation, encouragement of physical activity and stress relief based on the scientific literature (4,19,21) .

Population, selection criteria and sample
The study sample consisted of 312 people living with HIV who were literate and had access to the Internet. The

Study variables
The online quiz was elaborated containing sociodemographic and behavioral variables: gender, age (full years old), schooling, current work situation, individual income (minimum wages), Brazilian region of residence.

Instrument used to collect the information
For validation with the participants belonging to the target audience, a questionnaire was developed that assessed the visual aspect, language, usability, content, appearance and general evaluation of the educational material, on a Likert-type scale, with five levels of judgment (22) . For the general evaluation: Excellent, Good, Indifferent, Bad and Very Bad; for the visual variable: Excellent, Good, Fair, Bad and Very Bad; for the language, usability, content and appearance variables: Totally Agree (TA), Agree (A), Neither Agree nor Disagree (N), Totally Disagree (TD) and Disagree (D).

Data collection
To carry out data collection, invitations were sent to PLHIV groups throughout Brazil via social media (Facebook ® and Instagram ® ) and in WhatsApp ® groups, as well as on the profile of the research group on the pages of these social media. In addition, the invitation was also posted on official pages of research partners and other researchers and health professionals from different regions of the country. Fliers with a QR code were also printed for direct access to the study questionnaire and distributed in Specialized Care Services (SCSs) to PLHIV.
The recruitment invitation consisted of a brief exposition text presenting the study with the inclusion criteria followed by the link or QR code that directed the participants to the virtual data collection platform (Survey Monkey ® ). The study home page already presented the full Free and Informed Consent Form (FICF). After reading it, the participants were able to select two possible answer options: "I agree to participate in the research" or "I do not agree to participate in the research". Those who agreed to participate in the study received the online questionnaire, which was made available for access via computers or mobile devices (cell phones).

Data analysis
The data collected on the Survey Monkey ® platform were transferred to an Excel spreadsheet and to the Statistical Package for the Social Sciences (SPSS) ® statistical program, version 22.0. Descriptive statistical analyses were performed by calculating absolute and relative frequencies for the qualitative variables and, for the quantitative variables, calculations of central tendency (mean) were used. To certify the validity of each item addressed in the assessment instruments, a minimum Agreement Index (CI) of 80% was adopted among the participants, following the reference values of other validation studies (23)(24) .
To assess the degree of inter-rater agreement, the inter-rater reliability coefficient was used (first-order  (25) .
Group 2: pictures, motivation to read, topics covered and indication of the e-book to someone else.

Ethical aspects
The project was submitted and approved by the Research Ethics Committee, under opinion number 3,915,295. Data confidentiality and anonymity was guaranteed to all the research participants.

Results
The 309 PLHIV who participated in the study came from 25 states, covering the five Brazilian regions, with the largest share being from the Southeast with 50.5% (n=156) and the Northeast with 24.3% (n=75). Table 1 shows that the sample was predominantly made up of men, with 84.8% (n=262), aged between 19 and 65 years old and with a mean of 32.7 years old (±9.6).
In addition, most of the participants had completed higher education, 29.1% (n=90); 65.0% (n=201) were inserted in the formal or informal labor market; and 38.2% (n=118) had an income of one to two minimum wages.  When asked about pertinence of the content, understanding, motivation for reading and sequencing of the e-book, the participants indicated approval with more than 80% of agreement in all questions, with emphasis on the contents addressed, pointed out as pertinent by 97.4% (n=301) of the participants (Figure 1).   Table 3 shows the data related to the assessment of the inter-rater agreement of the e-book, which showed "almost perfect agreement" among the evaluators regarding the aspects assessed in Group 2 and "acceptable agreement" among the evaluators regarding the aspects assessed in Group 1.

Discussion
In this study, it was verified that the e-book elaborated was considered valid from the perspective of the target audience in terms of visual, language, usability, content, appearance and general evaluation. It is noteworthy that validation of materials is an important stage for the development of educational materials (26) and validation by its target audience allows identifying and working on the aspects that evidence its readability.
A study conducted in the United States showed that all types of educational materials related to cardiovascular health exceed the reading ability of their target audience and that this distance between readability of the material and the population's reading level negatively affects understanding of the information offered and, consequently, success of their use as a basis for decisionmaking focused on self-care (13) .
Transposing this issue to the Brazilian reality, where the majority of the territorial population (50.4%) has not completed elementary school (27) , it is necessary to develop interactive educational materials, easy to understand and that promote and facilitate self-management in health for this population (14) .
The contents covered were considered pertinent and include aspects related to the main cardiovascular risk factors and guidelines aimed at prevention (4,28) . Our findings corroborate another Brazilian study, which points out that addressing CVDs among PLHIV is a priority and emphasizes the importance of managing both traditional and specific risk factors related to HIV infection to reduce the risk of CVDs in these individuals (29) .
The construction and validation of interactive digital educational materials allows the general population to have access to relevant and appropriate contents for health promotion and disease prevention based on scientific evidence. This is relevant, since a large part of the content produced by science ends up without dissemination and/or practical application, feeding a vicious circle of exclusion of the majority of the population that does not have access to this means (30) .
Although CVDs have complex mechanisms and etiologies that are difficult to understand (13) , it was observed that, regarding readability of the e-book, the text was considered interesting, with an adequate sequence and easy to understand.
The readability assessment is paramount and is considered as a quality metric that should be evaluated before online publication of any educational material (13) .
This aspect is relevant, as educational materials and instructions routinely include technical language and complex explanations or do not contain understandable illustrations, making them difficult for the target audience to understand (10) . Clear and simple communication helps people feel more involved in their health care and increases their chances of following their care plans and adherence to the treatment (26,31) .
In this context, the content and language addressed should also be highlighted, as they must be accessible and free of technical terms to assist in understanding the content, in addition to providing interactivity between the reader and the educational material. In addition to that, in the development of educational materials, the language must be objective, avoiding the use of long and detailed sentences, as they can provide dispersion and make reading tiring (31) .
In this study, more than 80.0% of the participants reported motivation to read the e-book and assessed the content addressed as pertinent to planning self-care for cardiovascular health. For the educational material to be current and relevant, it is indispensable that it is inserted in the social context of the target population, and that it meets its needs and particularities (32-33) . Therefore, themes and topics covered in educational contents must meet the needs of people, providing empowerment on the topic addressed (31) .
Regarding usability of the e-book, the study participants rated it as easy to use. It consists of videos, audios and links to access other pages that supplement the content addressed and make its use more playful, in addition to easy access and sharing through the social networks. Therefore, the ease of use of a tool is directly related to the level of satisfaction of the user who consumes it, since poorly designed interfaces can result in disinterest or discredit by the user (34)(35) .
Educational materials made available virtually have been used as tools to improve knowledge, adherence to the treatment and self-care, from a perspective of health promotion and disease prevention (10,36) . Given the above, another challenging point is the basic use of digital resources (digital literacy) and the target audience's ability to explore resources more broadly (digital literacy) (13)  In addition to knowledge, the subjects' self-efficacy and motivation are considered as the basis for behavioral change (18) . Therefore, the use of technology, associated with quality information, can promote greater interest on the part of the subjects and, therefore, foster knowledge and motivation for change with a view to a better quality of life (18) .
In addition, we emphasize that the educational material can be used during Nursing consultations, as well as by other health professionals and/or literacy in health activities, to complement and reinforce the information provided. It is noteworthy that nurses play a fundamental role in the development of educational interventions in the health services and, in particular, they can benefit from the use of digital technologies to improve PLHIV's literacy in health.
Thus, we ratify the importance of elaborating and validating educational materials with the target population, in order to provide a safe and effective material that works as a facilitator for lifestyle change, seeking to encourage the performance of activities that promote healthier lifestyle habits. An easy-to-understand, interactive, accessible, usable, up-to-date and freely available content e-book is made available to PLHIV.
The limitation found in the study refers to the restriction of the results to groups that have access to the Internet, with a high schooling level and more used to handling computerized tools; therefore, with more ease to consume educational technologies built in this format.

Conclusion
The interactive educational material elaborated called "Take care of your heart" was considered valid by the PLHIV. It is also noteworthy that it was an unprecedented study on this topic in Brazil, and that it allowed creating a product consisting in relevant contents, easily accessible and freely available to the population.
From this, the relevance of the clinical validation process with the target population is highlighted, as the material elaborated must be easy to understand and read by those for whom it is intended, so that its objective can be achieved.
It is suggested that new studies address the application of this e-book for specific population groups, such as older adults, women, and low-educated and lowincome people living with HIV, in order to identify new gaps that may have not yet been addressed.