EDUCATIONAL TECHNOLOGIES USED TO TEACH SELF-MANAGEMENT AFTER HEMATOPOIETIC STEM CELL TRANSPLANTATION: A SCOPING REVIEW

ABSTRACT Objective: to map the scientific evidence on the educational technologies used to teach self-management in hematopoietic stem cell post-transplantation. Method: a scoping review, based on JBI recommendations. The searches took place between January and February 2022, in databases and repositories of dissertations and theses. The PCC strategy was used, namely: P (Population) - patients (patient participation); C (Concept) - educational technologies and self-management (instructional technology, self-management); and C (Context) - post hematopoietic stem cell transplantation (bone marrow transplantation). Studies that discussed the educational technologies used to teach self-management after hematopoietic stem cell transplantation, available in full electronically, were included. Editorials, letters to the editor and opinion articles were excluded. Duplicate studies were considered only once. The data are presented in figures and chart format. Results: sixteen studies were selected to compose the final sample, most of which showed that the most used educational technologies in the context of hospital discharge after hematopoietic stem cell transplantation are websites, software, movies, online videos or not, care plans, posters, books and booklets aimed at teaching. Conclusion: the use of educational technologies in teaching and patient health education is a reality present in services at any level of health care. The highlight of the approach to this topic is anchored in how these technologies are used and whether they are properly defined for each patient, according to the results of this study.


INTRODUCTION
The definition of technology refers to scientific knowledge applied for practical purposes in any field, which includes methods, techniques and instrumentation.To this end, technological development is part of a context of change and innovation, in response to some specific demand from society 1 .
There are different ways of classifying technologies and, among Brazilian health professionals, the most used or widespread classification is that of Merhy, which divides technologies into soft, soft-hard and hard 2 .The aforementioned researcher deals with technology in a broad way, when he considers that the soft ones relate to human and work relationships, such as reception, active listening and professional-patient and patient-patient bond.Soft-hard technologies are related to structured knowledge, such as theories, protocols and lines of care, and hard technologies are the material resources themselves, such as machinery, diagnostic tests, among others 3 .
In the field of health, especially nursing, technologies are used in all aspects of division of labor, whether in teaching, research, care or management 4 .With regard to teaching patients in the health area, the use of educational technologies (ET) stands out.This type of technologies are devices used in the mediation of teaching and learning processes, consisting of facilitating instruments, situated between man, the world and education, with the purpose of educating for the elaboration of knowledge that favor the creation and modulation of scientific knowledge.ET are characterized as tools that are strengthened by action and interaction centered on the integral development of man, inserted in the dynamics of social transformation in a permanent effort to renew education [5][6] .
ET should not just be seen as a trend; they need to be increasingly linked to health care in daily services 1 .Thus, it is important to reflect on how these technologies are inserted in nurses' practice 6 .Understanding the importance of these tools in the care environment and in society, raises a more complete and complex understanding, when considering the knowledge conveyed by patients' cultural values and their association in the solution of everyday problems, in a way that enables the ability to transform knowledge/doing into health.However, to use an ET, especially in the health area, it is necessary for the health educator/professional to first understand the importance of being a facilitator of the teaching-learning process 1 .
In the meantime, nurses stand out for exercising the role of educator when they develop prevention, promotion, protection and health rehabilitation actions based on educational strategies that facilitate meaningful learning in care.For this, they need to know and use coherent concepts, capable of improving care with popular know-how and technical-scientific knowledge 7 , as well as using support tools in conducting this process, such as ET.
Thus, planning educational activities for patients is one of the challenges of nursing care.To this end, it is worth emphasizing the use of ET capable of meeting patients' needs, hence the importance of thinking about and defining a valid technology for each individual.According to the literature, there are two ways to classify ET: dependents, when their operation is linked to electronic resources for use (computer, smartphone, tablet, internet); and independent, when they do not use electrical resources for use (poster, booklet, serial album, leaflets, folder, manual, string literature, guide, comics, newspaper, textbook, mural) 1 .
The use of ET to mediate health education and guidance during consultations, consultations, hospitalization and hospital discharge proves to be an excellent strategy to achieve and enhance the objectives of teaching patients in the health area, as long as each individual's specificities are respected, such as level of education and access to technologies dependent on electronic resources or the internet.

4/19
Faced with the impact of diagnosis and treatment, patients have certain levels of anxiety, especially those with onco-hematological diseases 8 , for instance.This fact increases the difficulty to assimilate, in an efficient way, important information verbalized in orientation moments 9 .Therefore, the challenge of educating becomes greater given the complexity of this patient 10 .
Among onco-hematological patients, those submitted to hematopoietic stem cell transplantation (HSCT) stand out, considered a widespread therapy for the treatment of leukemias, lymphomas, myelomas, myelodysplastic syndrome, some forms of anemia, autoimmune and metabolic diseases, among others 11 .It is estimated that around 50,000 transplants of this type are performed worldwide each year.In 2021, in Brazil,3,826 patients of different age groups and of both sexes underwent HSCT 12 .
HSCT consists of the infusion of hematopoietic stem cells (HSC), which can come from bone marrow, peripheral blood or umbilical cord and placental blood.As for its classification, it concerns the type of donor, when: in autologous transplantation, the cells come from the patients themselves; in allogeneic, HSC were donated by a relative or a volunteer donor from the Brazilian National Registry of Bone Marrow Donors (REDOME -Registro Nacional de Doadores de Medula Óssea) with human leukocyte antigen compatibility; and in syngeneic, in which the cells are from an identical twin brother [11][12][13] .
Due to the complexity of treatment and because it requires protective isolation on days of hospitalization, distancing from family, work, daily activities and hobbies, patients tend to be mentally overloaded.In addition, the expected and adverse effects of chemotherapy and other drugs, as well as toxicities, make them very sensitive and exhausted 8 .All these factors, associated with other peculiarities of each individual, hinder the teaching-learning process required in moments of guidance and health education, especially in the post-HSCT period.
In HSCT services, health education is an essential part of nurses' work process, especially to guide care after hospital discharge.The post-transplant adaptation phase requires extreme care that is guided by the team.Therefore, there is a need for patients to be willing to be active subjects to improve their physical, emotional, functional, social and family well-being 10 .
In this regard, ET have a notorious relevance in the provision of health care to patients, at all levels of care, especially those of medium and high complexity, which require a greater collection of guidelines and changes in daily habits, in search of improvement in quality of life 10 .
The use of ET in raising awareness of self-management on the part of patients in the process of hospital discharge makes it possible to raise new knowledge, and these tools provide access to educational content based on scientific evidence that can favor the practice of attitudes for harm prevention or even the identification of urgent and emergency situations 5 .It is important here to differentiate the concepts of self-care and self-management, which are different but interconnected.Self-care, according to Dorothea Orem, is characterized as self-care, in which individuals carry out actions and strategies to maintain their health and quality of life in appropriate conditions [14][15] .
Self-management, considering the context of taking care of oneself, refers to the subset of self-care focused on managing the health-disease process.Moreover, it is associated with a person's ability to manage physical, psycho-socio-emotional and spiritual changes, treatments and potential lifestyle changes.There are self-management programs for patients with chronic diseases that present interventions, through the experiences of other individuals, with a view to developing skills and abilities to self-monitor signs and symptoms and manage decision-making to control health status, such as the Patient Expert Program 16 .
Patients submitted to HSCT must practice self-management in all phases of treatment.However, it is in the post-transplant period that such care must be intensified and patients must have the largest possible amount of information to guide them, considering the sudden change in lifestyle required for the therapy to be effective and for achieving a cure or the prospect of greater survival.

5/19
Hence the importance of knowing the range of ET options available that can support the moments of guidance and health education that will be decisive for the execution of quality post-HSCT care 17 .
Considering the above, the present research can contribute significantly to the scope of HSCT, and its results can support the practice of nurses who work in the area, by allowing to know the main ET used for teaching self-management of patients in the context post-HSCT.Furthermore, it is intended to promote discussions regarding the types of technologies used and identify gaps on this topic.
To this end, the following research question was elaborated: which ET are used to teach self-management after HSCT?The objective was to map scientific evidence on ET used to teach self-management after HSCT.

METHOD
This is a scoping review (ScR), with a protocol registered in the Open Science Framework (OSF) (https://osf.io/q7hbu/).This method allows mapping the main concepts, clarifying areas of research and identifying gaps in knowledge [18][19][20] , as is the case of ET used for teaching self-management in the post-HSCT.
This review was developed based on the PRISMA-ScR 21 recommendations and the method proposed by the JBI 19 , which establishes five steps: 1) identification of the research question; 2) identification of relevant studies; 3) selection of studies; 4) data extraction and analysis; and 5) data grouping, synthesis and presentation.
For the first stage, research question identification, the PCC strategy was used, namely: P (Population) -patients undergoing transplantation (of any age and both sexes); C (Concept) -ET and self-management; and C (context) -post-HSCT.Thus, the guiding question elaborated to reach the objective was: which ET are used to teach self-management after HSCT?
As inclusion criteria, research related to ET used for teaching self-management after HSCT with patients of any age and both sexes, fully published in any language, and that were available in full through the remote access of the Federated Academic Community (CAFe -Comunidade Acadêmica Federada), through the Journal Portal of the Coordination for the Improvement of Higher Education Personnel (CAPES -Coordenação de Aperfeiçoamento de Pessoal de Nível Superior) of the Ministry of Education (MEC), were listed.There was no temporal delimitation in order to rescue all possible studies on the subject, as guided by the JBI manual [18][19][20] .Editorials, letters to the editor, opinion articles were excluded, and duplicate articles were considered only once.
As a way of ensuring that there are no studies with the same theme registered in the OSF or published in available literature, a broad search was carried out on the platform and in databases, to identify protocols or reviews that dealt with a similar subject, and they were not found.Based on this diagnosis, steps were taken to consolidate the ScR.
The second stage was subdivided into two phases: one corresponded to the selection of descriptors in research published and available in the National Library of Medicine (PubMed) and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases, according to the JBI manual; 18 in the other, the appropriate descriptors were searched in the Medical Subject Heading Terms (MeSH), namely: patients; educational technology; hematopoietic stem cell transplantation; self-management.
Two searches were carried out to select the largest number of studies in PubMed and CINAHL, in order to identify the most used keywords in published studies, applying the following crossings: patients AND educational technology AND hematopoietic stem cell transplantation; and educational technology AND hematopoietic stem cell transplantation AND self-management.

6/19
After selecting the descriptors and their synonyms, searches were carried out between January and February 2022 in the following databases and repositories of theses and dissertations, in fulfillment of the third stage: PubMed; Scopus; Web of Science (WoS); Science Direct, CINAHL; Latin American and Caribbean Literature on Health Sciences (LILACS), COCHRANE, The National Library of Australia's Trobe (TROVE), Academic Archive Online (DIVA), CAPES, Education Resources Information Center (ERIC), DART-Europe E-Theses Portal, Electronic Theses Online Service (EThOS), Repositório Científico de Acesso Aberto de Portugal (RCAAP), National ETD Portal, Theses Canada, Theses and dissertations from Latin America.The adopted strategy was built using the Boolean operators OR and AND referring to each item of the PCC strategy, as described in Chart 1. OR TS=(("technology, educational" OR "educational technologies" OR "technologies, educational" OR "instructional technology" OR "instructional technologies") )) AND TS=(("self-management") )) OR TS=((selfmanagement OR "management,self"))) AND TS=(("hematopoietic stem cell transplantation") )) OR TS=(("hematopoietic stem cell" OR "hematopoietic progenitor cells" OR "bone marrow transplantation")).

7/19
The selection stage involved searches in databases in which the studies were identified and had their titles and abstracts read and analyzed by two reviewers, who worked in pairs, to select potential eligible materials.There was no disagreement regarding the inclusion of selected studies.
Subsequently, all included files were read in full by a pair of reviewers independently, with the purpose of answering the research question, achieving the proposed objective, using the inclusion and exclusion criteria.In addition, the reference lists of selected studies were analyzed in order to find important complementary studies that answered the guiding question.
To carry out the fourth stage, data were extracted, using a spreadsheet prepared in Microsoft Excel ® 2017, by the authors and organized according to the following variables: identification, author, year of publication, country where the research was carried out, database, study design, sample, ET used for teaching self-management in post-transplantation of HSC and level of evidence.The level of evidence of studies was classified according to the JBI 18 , categorized from one (I) to five (V).The doubts raised were resolved by consensus among the authors.
Data on the country where the study was carried out, language and year of publication were analyzed descriptively using simple statistics and presented in figure format, and the other variables are organized in Chart 2 to facilitate visualization and interpretation of results, thus concluding the fifth step.
As this is not research with human beings, there was no need for appreciation by an ethics committee.However, it is important to highlight that the copyrights were respected with correct citation and referencing of studies.OR "instructional technology" OR "instructional technologies") AND ("self-management") OR ("selfmanagement" OR "management,self") AND ("hematopoietic stem cell transplantation") OR ("hematopoietic stem cell" OR "hematopoietic progenitor cells" OR "bone marrow transplantation").

RESULTS
The initial search obtained 3,101,278 studies in the databases and repositories of listed dissertations and theses, however,49,858 of these were available in full text format for analysis.After applying the exclusion and inclusion criteria and subsequent reading of the title and abstract, 43 studies were selected for reading.
After removing duplicate files from data sources, a total of 42 studies were read in full.Of these, 26 studies were excluded because they did not answer the study question or were not related to post-HSCT, and 16 were selected to compose the sample because they answered the guiding question and suited the purpose of this research, as shown in Figure 1.Among the countries in which the documents were prepared, the United States of America (USA) stands out, with nine (56.2%) publications, followed by Brazil, with four (25%).Furthermore, studies developed in Italy, Iran and the United Kingdom were selected, as shown in Figure 2.
Most studies are in English (12; 75%) and four (25%) in Portuguese.With regard to the year of publication, there is a highlight for the years 2018 and 2021, as shown in Figure 3.In Chart 2, the studies were organized according to code, reference, year of publication, country of origin, data source, study type and sample, ET type and level of evidence.As for the identified ET, 12 (75%) of studies dealt with dependent, three (18.75%)with independent and one (6.25%)with the joint use of technology dependent, independent and verbal guidance.

DISCUSSION
This section is structured in three parts: the first deals with ET dependent on electronic means/ devices and the internet; the second deals with independent ET; and the third deals with the use of dependent ET associated with independent ET and verbal guidance.

Educational technologies dependent on electronic media/devices and the internet
Most studies resulting from the analysis of results showed that the research found investigated the ET classified as dependent [23][24][25][26][28][29][31][32][33][34]37 . The use of the nternet as a modality to inform patients in the post-HSCT period proves to be effective as it is a dynamic and fast means of meeting the needs of post-HSCT survivors 23,35 .In addition to being able to maintain interaction with the team responsible for clinical care 25 , the internet, within existing possibilities such as websites, conversation applications and online video platform, meets important requests from patients in terms of choosing the content to be accessed as well as the available audiovisual format and the ability to control the amount and timing of the information they receive 23 .
Study involving the use of mobile applications to promote the provision of information to patients have resulted in improved self-care, self-management, communication about the current state of health between professionals and patients, and support for coping with imposed situations 38 .Moreover, mobile applications and websites can also be a space for sharing with other users so that, in addition to monitoring quality of life, it fosters social support among patients [24][25] .
Another important way to share the experience of the new and complex routine of the transplanted patient is telehealth.A study carried out in the USA showed that patients with access to this type of technology tend to have benefits in terms of solving problems with access to the medical team 23 , such as lower costs for patients, monitoring for greater medication adherence, and better access to health care information 39 .
Online videos on sharing platforms are one of the types of ET that have gained prominence in recent years, which have easy and quick access and are inclusive for people with visual and hearing impairments 37 .A randomized clinical trial conducted in the USA also used videos with young adults to encourage self-management and help focus on the elements that he considers most important in his life.Such a strategy can be considered a source of support during HSCT 40 .On the other hand, internet access is still selective, and disfavors poorer social classes and people with little education.
In addition to these, games become important ET for self-management of health, especially for children and adolescents.They have the ability to educate in an interactive way, bring students a naturalness towards the findings and can be used both to complement the guidelines at the time of discharge and informally at home.These technologies enable awareness of the condition as well as early detection and timely intervention in the effects of treatment 32 .
A study carried out in the USA developed a mobile game to encourage physical activity among HSC transplant recipients.The need to create a motivational game that engages HSCT patients to be physically active is important for this population, as exercise, in addition to being safe during treatment, can improve physical function and quality of life as well as help reduce risk of falls, blood clots, nausea and fatigue 41 .
It is worth noting that the ET employed in the health field are not an end in themselves, i.e., they alone may not be able to provide all the necessary information and content to patients.To this end, it is important that health professionals are motivated and trained to use it, with the necessary 12/19 guidelines and, above all, they must recognize the objectives and expected results generated by the technology adopted/chosen 8 .
These technologies can and should be added to professionals' verbal guidance in order to cover the widest variety of patient learning styles 29,31 with a view to consolidating what research proves: that knowledge reduces anxiety and depression and, consequently, increases transplant recipients' quality of life 23,35 .

Independent educational technologies
The independent ET evidenced by studies selected to compose the sample were educational posters 36 , booklets 30 , individual plans 22,35 and guides for orientations 21 .The development of these technologies, when considering the scientific literature and evidence-based practice, demonstrates the scientific responsibility of these contents and meets patients' search for complete, coherent and scientifically proven information.In addition to this, it favors those who do not have the internet or who do not have the ability to handle it, in addition to some of them being configured as accessible at any time or place.
The ease of handling independent ET, especially booklets, is due to their accessible understanding, in addition to the clarity, objectivity and presence of images, which provides the reader with an understanding of the subject addressed.Therefore, it is understood that using a booklet to support self-management guidelines is intended to alleviate moments of insecurity and uncertainty for patients 30 .
A study carried out in Brazil developed a booklet to educate and guide post-HSCT patients about graft versus host disease (GVHD), dealing specifically with the care that patients must have for the prevention and management of this complication so feared by patients undergoing allogeneic HSCT 42 .
On the other hand, it is known that chronic patients with low levels of education have difficulty using this type of ET.Such an obstacle prevents the understanding of health instructions and can lead to a lack of self-confidence in the ability to practice self-management, presenting itself as another factor that impairs compliance with treatment 43 .
Another independent ET is the individual care plan or individual therapeutic project, as it is better known in Brazil, defined as a set of proposals and therapeutic behaviors articulated in a unique way 44 .Nurses, professionals who are at the forefront of educational processes in health services, together with the multidisciplinary team, have an important role in identifying patients' needs, level of knowledge and education, thus being able to develop and fully implement a proposal with all the care aimed at maintaining life safely and with quality 45 .
In addition, there are guides/guidelines/consensus guidelines.There are several types of documents available in the literature, from those that present HSCT in detail 13 as well as materials focused on specific aspects, such as food/nutrition 46 .There are also those that treat some diseases, such as sickle cell anemia 47 , or a type of HSCT 48 .With regard to these materials, the important thing is for health professionals to define the most appropriate one to meet patients' learning needs at the moment.
In addition to the materials mentioned above, a cross-sectional study carried out in Germany emphasizes the need to develop guidelines and recommendations that address the risks and rehabilitation needs of post-HSCT patients.The rehabilitation of patients undergoing this type of transplant differs from the others and requires a lot of technical-scientific knowledge and experience in the management of conducts and interventions by nurses and a multidisciplinary team 49 .

13/19
Dependent educational technology associated with independent and verbal guidance Depending on the educational need imposed by patients, there is a need to link two or more types of ET to verbal guidelines in order to achieve satisfactory levels of learning.This could be proven through a randomized clinical trial carried out in Italy with patients who underwent allogeneic HSCT, in which it was possible to recognize that the use of video and informative material for individual learning followed by verbal guidelines notably improved knowledge and practical skills for self-management 27 .
A study carried out in the USA highlights the exchange of experiences and verbal guidelines between patients and also with the clinical team.Support groups were mentioned as an important tool for the development of self-management, seen as necessary even before performing the transplant as a means of encouragement.Some of the topics discussed concerned the expected side effects and the changes to be made in daily life to improve quality of life after HSCT 50 .
This interaction can be classified as a soft ET, as it deals with a relational technology, according to Merhy's classification, which can be mediated by dependent and/or independent ET.In a study carried out in the USA, patients reported that only the guidelines given verbally or in writing are inconsistent, and transplant service professionals stated that it was difficult to find up-to-date educational material 51 .
With regard to the need for relationships with other patients undergoing HSCT, one can understand the importance of alternatives for health education with a focus on self-management, through strategies to promote the autonomy and empowerment of patients, such as the Patient Expert Program, which aims to equip subjects so that they develop skills with professionals, for the proper management and self-management of their health condition [52][53] .
This patient becomes a multiplier of information and experiences, and the use of dependent or independent ET, combined with verbal guidance provided by the health team or exchange of experiences between patients, can facilitate the development of relationships on an ongoing basis and encourage collective activities in order to encourage care self-management 1 .
Given the above, it can be understood that the use of independent ET linked or not to dependent ET and verbal guidelines are important means for the development of a culture of self-management by post-HSCT patients.It should be noted that, sometimes, nursing professionals still apply technologies in an unthought of way.It is necessary to reflect on some important points before using any type of educational or care tool, such as "what for", "for whom", "what is the purpose", "what is the context", "what materials are used" and "what is the expected result".This reinforces the commitment and technical-scientific, ethical-political and care-educational competence of the profession, and can encourage the strengthening of nursing as a subject and science [53][54] .
This study has limitations related to the predominance of studies with a low level of evidence, because the methodologies come from experience reports and qualitative studies.This ScR focused only on the post-HSCT scenario, which may have reduced the number of studies in the final sample.Despite these limitations, this review highlights the methodological rigor required by the JBI and the mapping of evidence on the ET used by nurses to teach self-management in the post-HSCT context.
Contributions to nursing and health are based on the impact that health education has on self-care management for chronic patients.Thus, studies like this one, which explore the use and creation of ET within the scope of HSCT, are incentives for the adoption of actions that encourage the development of safe practices and that favor the quality of nursing care provided.

CONCLUSION
The use of ET by professionals in teaching and educating patients in health is a reality present in services at any level of health care.The highlight of the approach to this topic is anchored in how these technologies are used in patient education and whether they are defined appropriately for each patient, according to the results of this study.It is also important for health professionals to know the types and possibilities of ET that can be used when providing guidance, especially with patients undergoing HSCT.
Among the results presented, the application of dependent and independent ET in isolation is observed as well as the combination of the two possibilities linked to verbal guidelines as a way of effectively meeting patients' educational needs.Among the most researched by the studies are applications, software, websites and videos, which indicates a growing computerization and use of digital resources for teaching health and encouraging self-management.However, it is important to consider users' learning specificities as well as professionals' knowledge about the types and ways of using ET.
Finally, it should be noted that the well-planned implementation of ET guides the learning that must be aligned with the contents necessary for self-management in the post-HSCT period, in order to provide quality of life and longer survival for patients.
Furthermore, it is worth noting the scarcity of studies that address the construction and validity of ET used in the post-HSCT context, a fact that emerges as a suggestion for further studies to be developed in the area.It is also encouraged that researchers carry out experimental studies in order to demonstrate the effectiveness of the technologies developed in the research and their impact on HSCT survivors' quality of life.
Definition of search strategies in each database.Natal, RN, Brazil, 2022.
-Characterization of publications according to year of publication, country of origin, data source, study design and sample, type of educational technology and level of evidence.Natal, RN, Brazil, 2022.(N=16).