Construction and validation of educational materials for the prevention of metabolic syndrome in adolescents

ABSTRACT Objective: To develop and validate an educational technology focused on prevention of metabolic syndrome among adolescents. Methods: This was methodological research. Using an integrative review, the available publications on the subject were analyzed. Then, this knowledge was used to describe the theoretical content and, with the help of a graphic designer, the art and layout of the pages were developed. In the third phase, the booklet was evaluated and validated by 21 specialists and 39 adolescents. Data collection included three different questionnaires, according to the focus of evaluation of each group of participants, analyzed for reliability (Cronbach’s Alpha) and agreement by Infraclass Correlation Coefficient. Results: The mean score attributed by technical content experts was 91.7%, and the content validity index, measured by experts responses, was 0.98, showing high reliability and agreement. In addition, the level of agreement of the positive responses given by adolescents was 88.4%. Conclusion: the educational booklet has proved to be a valid and reliable tool to be used for promoting adolescent health.

The target audience, selected based on the results found in a previous study, was also accessed (9) . In the mentioned study, the author evaluated 421 students from the municipal public schools of the city of Picos-PI, According to the specific focus of each group of participants, three instruments were used: the first focused on content and technical aspects, the second on design experts, and the third was geared toward the target audiences.
The assessment questionnaire sent to content and technical experts was the Suitability Assessment of Materials (SAM), which identifies the difficulty and convenience of educational materials. This is a threepoint Likert scale in which a list of statements related to content, writing style, graphic illustration, presentation, motivation and cultural suitability are evaluated and rated as: one = inadequate, two = partially adequate, and three = adequate. The final scores should be equal to or greater than 60%, in order to consider the material adequate (10) .
The assessment questionnaire for design experts presented questions regarding the characteristics of the illustrations. Similar to the previous questionnaire, the rating for the answers used a Likert scale type, in this case a four-point scale, defined as: one = totally Moura IH, Silva AFR, Rocha AESH, Lima LHO, Moreira TMM, Silva ARV. disagree, two = disagree, three = agree, and four = totally agree. In this case, the Content Validity Index (CVI) was used to validate the instrument; value greater than 0.78 were accepted as valid (11) .
The last instrument, the assessment questionnaire for the target audience, contained items on organization, writing style, presentation and motivation domains; a minimum of 75% agreement on positive responses was required (12) .
The professional information about the experts, and the sociodemographic and clinical data of the adolescents, was organized in Excel 8.0 software; a descriptive analysis with calculation of absolute and relative frequencies was obtained, as well as measurement of central tendency (mean and median), and of dispersion (standard deviation and interquartile range).
The reliability of the instruments was analyzed using Cronbach's Alpha and the Infraclass Correlation Coefficient (ICC) to evaluate agreement among the experts, at a significance level of 5%. Both statistical tests are presented in a ranged scale between 0 and 1, and values higher than 0.8 were acceptable (13) . These  (14) .

Results
In the booklet development, the theoretical content was based on the knowledge available in the literature, ensuring complete information for adolescents, without being tiresome. This is reflected, for example, in the To guarantee interactivity of the booklet for adolescents, two games throughout were inserted the history: a word-hunter to remember/memorize the components of MS, and a seven errors game to help with how to choose healthy foods. The booklet was develop for a young population, specifically adolescents; so all content choices and illustrations were defined according to the needs of these individuals.
Next, eight content experts were part of the booklet validation portion of the study; they were predominantly female (62.5%), with a mean age of 33.5+4.0 years.
All the participants were nurses, and 75% pursued a doctoral-level degree. In addition, there were six technical experts, with a median age of 35.0 years, the majority of whom were female (66.7%); there was an equal participation of nurses, physicians and nutritionists.
Both content and technical experts responded to the SAM questionnaire. Table 1 shows each question, according to the attributes to be checked, and the number of individuals who rated the item as "inadequate", "partially adequate", and "adequate".
The data shows that only one expert evaluated item 1.3 as "inadequate". Considering that no suggestions were added, and that the others experts evaluated the item as "adequate" (11) or "partially adequate" (02), no change was made in the booklet.  The evaluation of the booklet was followed by the collaboration of seven professionals with design experience, mean age of 30.4 + 9.7 years, and male prevalence (71.6%). These individuals answered an adapted questionnaire, which enabled the qualification of the illustrations. Table 2 presents the answers attributed to each statement made, in which the experts could indicate, "Totally disagree", "disagree", "agree", or "totally agree", and the calculated CVI for each item.
www.eerp.usp.br/rlae Rev. Latino-Am. Enfermagem 2017;25:e2934. Adolescents were asked to respond to an adapted questionnaire (12) , seeking to analyze the organization, writing style, presentation and motivation of the booklet with the target audience.   After adapting the material according to expert observations, the validation process was finalized

Discussion
In this study, the validation process was conducted with the participation of several professionals, representing a very favorable aspect, as it was possible to obtain significant specialized knowledge within the theme addressed by the material. Therefore, as in other research, a multidisciplinary, complete educational material was developed (15)(16) .
The use of technology based on the active participation of the multiprofessional team is fundamental to improving the quality of care. In addition, the contributions suggested by the population were also fundamental to the process, because they represent the target of these health actions. Therefore, there was a concern to include the adolescents in the analysis of the booklet, as was done in other studies in the area (17)(18) .
In general, the answers of the experts were concordant, as can be seen in the presented results. From the answers obtained in the SAM, given by content and technical experts (Figure 1), the mean score obtained was 91.7%, with high reliability and agreement.
Corroborating with these data, other methodological studies of educational technology development also validated their materials with high statistical indexes: the development of material for patients submitted to orthognathic surgery was concluded with an internal consistency of 0.972 and ICC of 0.601 (7) ; the booklet for healthy eating during pregnancy was validated with a level of concordance between the experts ranging from 0.818 to 0.954 for the evaluated items (19) .
The validation by experts in the design area also achieved excellent indices, with a global CVI equal to 0.98, as well as high reliability (Cronbach's alpha=0.917)  It is necessary to emphasize that, although the booklet was well evaluated by the experts, suggestions and observation were added, in order to guarantee a quality piece of educational material for the population; these details enrich the final product and improve its applicability, by reformulating information, replacing terms and reviewing illustrations (17) . From this perspective, the difficulty faced by the author in dealing with such a demanding public is clear.
The educational booklet is a working proposal to support health education, which must be able to teach and stimulate the reader's willingness to take responsibility for himself; nevertheless, the integrated use of this resource with other active methodologies is fundamental.

Conclusion
At the end of the study, it is possible to conclude that the proposed objective was achieved. The educational booklet entitled "Metabolic Syndrome: How can it be prevented?" was validated regarding content, language, and presentation with experts, and for writing style, presentation, and understanding with the target population.
We hope that this educational booklet will actually be used for health promotion in the population, especially adolescents, so that they reflect on their current lifestyle and adopt the recommendations indicated in the material. From this perspective, nurses and other health professionals, as subjects committed to public health, play a critical role, whose responsibility is to act with a focus on health education and disease prevention.
Finally, the reflection presented here is also focused on the environment for young people. Schools, families, and the community must be prepared to facilitate the routine of healthy eating, physical activity, and weight and stress control, as well as to reduce alcohol consumption and tobacco use.