BOARD GAME ON HEALTHY LIFESTYLE FOR PEOPLE WITH CORONARY ARTERY DISEASE

ABSTRACT Objective: to develop and analyze content and face validity evidence of a board game to promote healthy lifestyle habits for patients with coronary artery disease. Method: this is a psychometric study of development and validity of a board game for health education. Data collection was carried out between October 2021 and January 2022. Initially, the game rules were described and, sequentially, themes related to cardiovascular prevention were identified, used as a basis for card development. The game was submitted to assessment by 14 experts in terms of clarity, theoretical relevance, practical relevance, image visibility and relationship between image and text, through a Likert scale score. The content validity coefficient was calculated for each round, with a coefficient greater than 0.57 being considered valid. New assessment rounds were performed until the appropriate coefficient was reached. Results: the board game was built containing images of anthropomorphized hearts alluding to healthy lifestyle habits and 45 spaces. A total of 69 cards were developed containing the themes of healthy eating, physical activity and the importance of smoking and alcohol cessation. In the first round of assessment, three cards did not reach the minimum content validity coefficient. They were reformulated and sent to a second round of assessment, and was considered validated in this new round. Conclusion: the game, its rules and its content showed adequate content validity evidence after the second round. Further studies to analyze its effect on lifestyle modification should be carried out.


INTRODUCTION
Coronary artery disease (CAD) represents an important cause of global and national morbidity and mortality.In Brazil, in 2022, there were 161.958 hospitalizations for acute myocardial infarction (AMI) with 14.590 deaths attributed to CAD 1 .In 2015, AMI, a complication of CAD, was the disease that most generated expenses for the Unified Health System (SUS -Sistema Único de Saúde), with a total of approximately 22.4 billion reais 2 .
Considering the costly scenario caused by cardiovascular diseases (CVD) and especially by AMI, the need to manage modifiable risk factors closely related to the genesis and outcome of this disease is highlighted.Thus, dyslipidemia, type 2 diabetes mellitus, hypertension, sedentary lifestyle, smoking, excessive alcohol intake, stress and inadequate nutrition with high-fat, high-calorie and high-sodium foods are elements subject to behavioral transformation through health education 3 .
Guiding patients and their families regarding the incorporation of a healthy lifestyle is part of a process called health education, which can be defined as an educational and participatory approach that aims to help health consumers learn how to incorporate health-related behaviors (knowledge, skills and/or attitudes) in daily life with the aim of promoting good health, increasing their competence and confidence for self-management 4 .
This educational process is characterized by a systematic, sequential, logical, planned and scientifically based course of action that consists of two main interdependent operations: teaching and learning that together play their roles whose result leads to changes in mutually desired behaviors, i.e., this educational process aims to achieve changes in individuals' knowledge, attitudes and skills 5 .
The educational process aimed at behavioral change with a focus on promoting cardiovascular health can be based on one or more nursing theories, with Nola Pender's medium-range theory called Health Promotion Model (HPM) being one of those that stand out in promoting the incorporation of a healthy lifestyle 6 .
This health promotion model is based on three theories of human behavior, i.e., value theory that assumes that people are more susceptible to changes based on a pre-established goal, social cognitive theory that is characterized in the confidence that a person has in their ability to successfully perform an action, being considered as one of the variables for health-promoting behavior and rationalized action and planned action that reinforces that a patient's behavior is a result of their conscious choices [6][7] .
Educational interventions are necessary to achieve the three theories that make up Nola Pender's HPM and these actions can be carried out in different ways, including face-to-face consultations, consultations via telephone, through applications for mobile phones, messages to mobile phones and board games or electronic games [8][9][10] .
Systematic reviews [8][9] found that telehealth techniques used for health education of people with CAD are effective in promoting blood pressure and diet management, reducing abdominal circumference, total cholesterol, triglycerides and body mass index, improving medication compliance and physical activity practice.Techniques included phone calls, text messages, web pages, cell phone apps, and telemonitoring and primarily addressed diet, exercise, symptom management, anxiety, depression, and psychosocial support 9 .
Educational interventions in health aim to increase the health literacy degree, which can be defined as the degree to which individuals have the ability to obtain, process and understand information and basic health services necessary to make appropriate health decisions 11 .The choice of the type

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of health intervention should be based on a person's literacy level, culture, language, socioeconomic level and also on the digital literacy degree, because depending on the technological resource used for health education, this can promote educational development or even be a barrier when there is a lack of knowledge in technology use 11 .
Among the various forms of health education for patients with chronic diseases such as CAD, the strategy of educational games can be used for this purpose, given the evidence of improvement in knowledge and self-care from the use of educational games 10 .
Despite the available evidence, studies on the validity of educational games in the area of cardiology are scarce, and no studies on the development and validity of board games for the Brazilian population that aim to equip patients with CAD with the necessary tools with regard to selfmanagement and self-care of their health.This study aimed to develop and analyze content and face validity evidence of a board game to promote healthy lifestyle habits for patients with CAD.

METHOD
This is a psychometric study of the construction and analysis of validity evidence of a health education board game for patients with CAD.A psychometric study is understood to be those studies that aim to assess the metric properties of a given instrument or educational material adapted or developed, i.e., verify whether a given instrument or educational material gathers adequate validity evidence, which can be understood as the degree to which the evidence and theory related to the instrument's main construct support the product's applications, and it is recommended that the first phase of these studies be the content validity evidence analysis [12][13] .The project was approved by the Research Ethics Committee of the university under study, and was developed from October 2021 to November 2022.
The study's first phase was the game development stage.In this regard, recommendations for CVD prevention were investigated in national and international guidelines, which, in turn, guided the game content.Concomitantly, a prototype of the type of game, its rules and theoretical content was developed [14][15][16][17][18][19][20][21] .Later, a professional was hired to design the game and its cards.
After designing the game and its content, an electronic form was created using Google Forms ® containing all the game rules, the game board and the game cards for content and face validity evidence analysis by health professionals.Potential experts were selected from a search on the CNPq portal Plataforma Lattes, using the terms "coronary disease", "health education" and "cardiology", based on prior knowledge of researchers who publish in the area of CVD prevention, as they are co-authors and/ or participants of study group of these researchers or by indication of other experts.Data collection was carried out between October 2021 and January 2022.
All participants were invited via email and signed an Informed Consent Form online before accessing the Google Forms ® topics.Experts assessed the game cards, the game board and the game rules in relation to clarity, theoretical relevance, practical relevance, image visibility, font visibility and relationship of the text to the image through a 3-point Likert-type: 1 for inadequate, 2 for partially adequate and 3 for adequate.Definitions regarding clarity, theoretical relevance and practical relevance were made available in the header of the form [12][13] .For each question on the form, an open field was made available for suggestions by experts to improve the material.
Expert characterization was carried out using descriptive statistics, including absolute and relative frequencies for qualitative variables, and mean and standard deviation for quantitative variables.

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For the analysis of agreement among evaluators, the Content Validity Ratio (CVR) calculation was chosen, which is characterized by a linear transformation of judges' agreement that varies from -1 to +1, where values close to 1 correspond to perfect agreement.The CVR calculation was carried out according to the following formula CVR=ne-(N/2)/ N/2, in which ne -number of experts who marked the score 3 and N -number of judges [22][23] .
In this study, we chose to calculate the CVR proposed by Lawshe 17 and revised by Ayre, which provides the degree of statistical significance of content validity and the acceptable critical CVR value according to judge panel size.3] .
Considering the sample of 14 experts, the critical CVR considered for the two rounds was 0.57 at a significance level of 0.04 [22][23] .Topics that did not reach the necessary critical CVR were reformulated according to evaluators' suggestions and submitted to a second round of assessment with the same participants of the first round.

RESULTS
A priori, the idealized game was a board game because it allows the interaction of patients and family members in the learning process, and the game rules were based on other recreational board games.This game was initially titled "JESC EDUCA-COR" (Jogo de Educação em Saúde Cardiovascular (Cardiovascular Health Education Game), linked to the EDUCA-COR extension project) of the university.The game design as well as the color palette and illustrations were developed by a hired professional, following the researchers' guidelines and preferences.
The game consists of a dispute between two to three players, in which the one who first reaches the end of the board wins.Once the players are defined, they must roll a dice: the one who rolls the highest number starts.Then, the player must roll the dice again and go through the corresponding number of spaces.After advancing the spaces, the player must answer a question from a pile of cards.The opponent will read the card, which contains a statement that must be judged as true or false by the player.In every footnote of the cards, there is a justification written in smaller font.If the player gets the statement right, they can advance one more space, otherwise, they must remain in the same space.
In total, 69 cards were produced, covering the healthy eating, physical activity and tobacco and alcohol use domains (Supplementary Material 1).In the healthy eating domain, 31 cards were prepared.Considering the CVD prevention guidelines, the food guide for the Brazilian population, the cardioprotective food guide, statements focused on encouraging healthy and minimally processed food consumption, identifying foods that should be avoided and consumed in moderation, eating frequency, healthy routines during meals and way of preparing food (Figure 1) 3,[7][8][9][10][11][12][13] .
In the physical activity domain (24 cards), aspects such as the importance of physical exercise for heart health, examples of physical activities and the importance of stretching and use of suitable clothes for physical exercise as well as clinical warning signs during physical activity stood out (Figure 2).For the tobacco and alcohol consumption domain, 14 cards were developed, which addressed the harm caused to health by cigarettes and alcohol, the positive consequences of ceasing smoking and alcoholism, and the therapeutic options available and subsidized by SUS for nicotine and alcohol dependence treatment.

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After developing the game and the cards, they were sent to 26 professionals, of which 14 responded, most of them female, nurses, with an mean age of 39 years and with an education degree at the stricto sensu level and specialization in cardiology (Table 1).

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In the analysis regarding the game title -first presented as "JESC EDUCA-COR" -, clarity and practical relevance did not reach satisfactory CVR, and experts' suggestions to change the name of the game to "DESAFIO EDUCA-COR" were accepted.As for game appearance and rules, all questions achieved a satisfactory CVR (see Table 2); however, judges' suggestions to remove the image of red blood cells that illustrated part of the board were met, arguing that they were perhaps confusing to players' understanding.The final version of the board appearance can be seen in Figure 3.Of the 31 cards from the food domain, three did not obtain the minimum CVR value to be considered valid.There was disagreement regarding the content of one card and the images of two cards.The disagreement regarding content was about the theme of light and diet foods, which, according to the evaluators, should be better explained in the card.After discussion among the researchers, it was decided to remove the card from the game, as it is a complex subject for an educational game, as suggested by the experts.
The second card from the food domain brought the alert to industrialized seasonings and contained the illustration of natural seasonings, with evaluators suggesting replacing only the figure with sachets of ready-made seasonings.Finally, the third card covered good practices at meal times and it was suggested that there be an illustration of people gathered having a meal.
All physical activity and tobacco and alcohol use domain charts reached the minimum CVR value required to be validated.However, as suggested by experts, the incentive to practice Tai Chi Chuan was removed from card number 10 of the physical activity domain, leaving only dance as a suggestion, considering the socioeconomic profile of SUS users.Also, according to experts' suggestions, in one of the cards of the tobacco and alcohol use domain, it was decided to include the Reference Center for Alcohol, Tobacco and Other Drugs (CRATOD -Centro de Referência de Álcool, Tabaco e Outras Drogas) as one of the primary care services that can promote and assist in smoking cessation.
After reformulating the title and appearance of the game and the three cards of the food domain, they were sent to the 14 evaluators for a new opinion.In this round, all reassessed items exceeded the critical cutoff point of CVR and were considered valid by experts, as shown in Tables 2 and 3.
Table 3 lists the final CVR means for each game domain, and the final version of the game cards can be seen in Supplementary Material 1.

DISCUSSION
Cardiovascular prevention programs aim to reduce CVD morbidity and mortality and the socioeconomic burden generated by treatment costs and loss of individual productivity.For this to occur, patients and their families must have adequate self-care knowledge and skills 3,[14][15][16][17][18][19] .However, the knowledge of patients with CAD about secondary prevention is inadequate, and information source reliability is weak 15 .This study sought to develop and validate a tool that can be used as an educational intervention in the context of cardiovascular prevention, based on guidance on the importance of changing lifestyle habits that are closely related to CAD progression, such as obesity, sedentary lifestyle and smoking.
The literature points to a lack of knowledge about cardiovascular prevention.In this light, the guidelines on cardiovascular prevention emphasize the incorporation of a healthy lifestyle and habits as a goal for a healthy life 3,[14][15][16][17][18][19][20][21] .For this reason, the subjects of healthy eating, physical activity and tobacco and alcohol use were selected, a priori, in the game developed in this study, since changing such habits have a positive impact on morbidity and mortality from CVD 14,15 .However, many other issues can and should be addressed in health education for patients with CVD, such as mental health, socioeconomic aspects, medication adherence and symptom recognition 3,[14][15][16][17][18][19]24 .
Studies using board games have found a reduction in depression in institutionalized older adults 25 , improvement in cognitive ability in patients with Alzheimer's disease 26 , healthy eating promotion, smoking cessation and safer sex 18 .Specifically in the area of cardiology, a randomized clinical trial conducted in Thailand found that a board game was associated with improved knowledge and selfcare behavior in patients with heart failure up to three months after the game session 27 .
The content addressed in the board game is in line with all guidelines recommendations for CVD prevention, i.e., guidelines were addressed on the need to choose foods with less fat; the need to avoid ultra-processed foods, due to the greater risk of fat and sodium, which could lead to increased blood pressure levels; encouraging the consumption of foods such as fruits, vegetables and greens; the frequency of up to 3 hours for food consumption; some recommended practices during food preparation, such as preference for grilling or baking food and removing visible fat before preparation.Some guidelines were also included regarding eating routine, mainly in relation to maintaining meal times, the need for complete chewing of food and avoiding distractions during meals 3,[14][15][16][17]21 .
With regard to physical activity, the recommendations are consistent with those published by the World Health Organization (WHO) regarding the frequency for moderate (150 minutes/week) and vigorous (75 minutes/week) physical activity; the benefits of physical activity for mental health and the cardiovascular system; the need for stretching and the time to perform it before and after the exercises, with a view to reducing the risk of muscle injuries; the importance of hydration during physical exercises and a balanced diet; and on clothing that aims to improve comfort and safety in physical activity 3,[14][15][16][17][18][19] .The smoking and alcohol domain is another extremely important topic in health education for CVD prevention, mainly because these lifestyle habits tend to substantially increase arterial stiffness, increased lipid levels and atherosclerosis progression.Therefore, the benefits of interrupting smoking habits were included in the cards, especially drug treatments and nicotine replacement therapies aimed at controlling tobacco dependency and the places made available by SUS to monitor these dependencies 3,[14][15][16][17][18][19] .
Before applying the board game aiming at health education, attention should be paid to the phase that precedes its application, i.e., content validity evidence analysis in relation to clarity (whether the information is clear regardless of the educational stratum), practical relevance (if they were really important in relation to the main construct of the game) and theoretical relevance (if the cards in the game were related to the proposed construct/aspect).In addition to the indicators in relation to the game's content, this study also assessed the game's general appearance (colors, font visibility and relationship between the text and the figure), aiming at greater patient enthusiasm during the game and that the images would bring a complement to the cards' textual information [12][13] .
It is recommended that this analysis should be carried out by a group of experts with a high level of training in the specialty and clinical experience, which is consistent with the profile of the experts involved in this study, since the group of experts were mostly professionals with stricto sensu graduate degree, with clinical experience in cardiology, working in the care and research areas [12][13] .
After validity with experts, the game must be submitted to validity evidence analysis by the target population so that studies that assess the effect of the board game in modifying lifestyle can be carried out, identified here as a study limitation.

CONCLUSION
The board game "Desafio Educa-cor" was developed with the main themes related to healthy lifestyle habits and obtained satisfactory content and face validity evidence after assessment by a heterogeneous group of experts.Such an instrument can be used as a resource for health education of patients with CAD and also for future research, both in relation to clinical validity and the consequences of the test in the game's target population.

Figure 1 -
Figure 1 -Examples of cards that addressed healthy eating.

Figure 2 -
Figure 2 -Examples of cards that addressed physical activity practice.

Figure 3 -
Figure 3 -Final version of the game board after suggested modifications.São Paulo, SP, Brazil, 2022.

Table 2 -
CVR of the first and second round in relation to game title, rules and appearance in relation to indicators assessed by experts.São Paulo, SP, Brazil, 2022.

Table 3 -
Mean CVR of assessment rounds and final mean CVR for each game domain in relation to indicators assessed by experts.São Paulo, 2022.