Abstract

Objective:

to build and validate the content of educational video scripts, focusing on behavioral changes for the self-care of people with diabetes.

Method:

this work was a methodological study, anchored in the transtheoretical model of behavioral change, developed between September 2021 and November 2022, involving two stages: theoretical procedures and empirical and analytical procedures. Validation was carried out by nine judges in the first round and six in the second. In data collection, a Likert-type scale was used, divided into nine criteria and subsequently analyzed based on the content validation index (above 80%) and binomial test.

Results:

four scripts were constructed based on the topics: self-assessment of behavior, stages of the motivation for change stage, reflections on daily behaviors, adoption of healthy habits, and relapses in the change process. The content achieved an average Validation Index of 0.93 and 1.0 in the first and second round, respectively.

Conclusion:

the scripts constructed constitute tools with the potential to support health education actions used with people with diabetes in an attempt to change behaviors.

Key words:
Validation studies; Nursing; Educational technology; Self-care; Diabetes mellitus

Introduction

Self-care actions for people with diabetes mellitus can diminish the chances of cardiovascular complications by 80%; however, there is a need to implement efficient educational approaches to promote these actions¹1 Adu FA, Poku CA, Adu AP, Owusu LB. The role of social support and self-management on glycemic control of type 2 diabetes mellitus with complications in Ghana: a cross-sectional study. Health Sci Rep 2024; 7(4):e2054.^,22 Sá JS, Santana MDO, Santos MG, Benedito JCS, Teston EF. Tecnologias educacionais utilizadas para promoção do autocuidado de pessoas com diabetes mellitus: revisão integrativa. Rev Bras Enferm 2023; 76(Supl. 4):e20230049.. Daily difficulties in changing habits, frustration, emotional suffering, little compromise with self-care actions, low level of knowledge, poor efficiency in terms of concluding actions, and poor family support have all been indicated as hurdles for self-care actions¹1 Adu FA, Poku CA, Adu AP, Owusu LB. The role of social support and self-management on glycemic control of type 2 diabetes mellitus with complications in Ghana: a cross-sectional study. Health Sci Rep 2024; 7(4):e2054..

Support for self-care, offered by healthcare professionals, is a key component of the Model of Chronic Care and of the national and international guidelines for caring for people with diabetes³3 Powers MA, Bardsley JK, Cypress M, Funnell MM, Harms D, Hess-Fischl A, Hooks B, Isaacs D, Mandel ED, Maryniuk MD, Norton A, Rinker J, Siminerio LM, Uelmen S. Diabetes self-management education and support in adults with type 2 diabetes: a consensus report of the american diabetes association, the association of diabetes care & education specialists, the academy of nutrition and dietetics, the american academy of family physicians, the american academy of PAs, the american association of nurse practitioners, and the american pharmacists association. Diabetes Care 2020; 43(7):1636-1649:. This component emphasizes the need for training and preparing people to manage their own health care, since such an engagement has proved to be essential for behavioral changes and the prevention of complications⁴4 Lubega M, Ogwok J, Nabunya B, Mbalinda SN. Role of community-based health clubs in promoting patients' health education for diabetes self-care management: an interventional qualitative study in a Ugandan urban setting. BMJ Open Qual 2023; 12(4):e002473..

The report from the European Union’s Strategic Development Plan, 2016-2021⁵5 European Union. State of Health in the EU: Companion Report 2019 [Internet]. 2019. [cited 2022 dez 17]. Available from: https://health.ec.europa.eu/system/files/2019-11/2019companion_en_0.pdf
https://health.ec.europa.eu/system/files... , points out that the use of educational technologies that are safe and accessible according to the specificities of different groups, is something required to decrease social inequality rather than exacerbating it. Key interventions in self-care actions, therefore, may be decisive for decreasing some grievances caused by chronic health conditions and may be able to foster an alignment in terms of co-responsibility of people with DM, thus improving their quality of life⁶6 Moura NS, Lopes BB, Teixeira JJD, Oriá MOB, Vieira NFC, Guedes MVC. Literacy in health and self-care in people with type 2 diabetes mellitus. Rev Bras Enferm 2019; 72(3):700-706..

However, concerning this theme, the literature shows no available studies with well-founded theoretical bases focused on the development of educational technologies aimed at behavioral change, self-care, and health promotion. Available studies that suggest the use of technologies in the care for people with DM treated the production and validation of a short-length video about foot care, based on the reference by Dorotheia Orem⁷7 Menezes LGC, Guedes MVC, Oliveira SKP, Rocha RM, Pinheiro AKB, Silva LF, Moura DJM, Coelho MMF. Production and validation of the short film Pés que te quero(r): educational technology for people with diabetes. Rev Bras Enferm 2022; 75(5):e20210329.; focused on the validation of a multimedia app on a mobile platform to provide patients with knowledge on foot care⁸8 Marques ADB, Moreira TMM, Carvalho REFL, Chaves EMC, Oliveira SKP, Felipe GF, Silveira JAN. PEDCARE: validation of a mobile application on diabetic foot self-care. Rev Bras Enferm 2021; 74(Supl. 5):e20200856.; and dealt with the identification of barriers for self-care, but they did not mention the use of educational technologies or any well-founded theory⁹9 Caro-Bautista J, Espinar-Toledo M, Villa-Estrada F, Lupiáñez-Pérez I, Kaknani-Uttumchandani S, García-Mayor S. Development and psychometric validation of an instrument to identify barriers to self-care among spanish patients with type 2 diabetes on the basis of theory of planned behavior. Value Health 2019; 22(9):1033-1041..

Some studies highlight the importance of having self-care actions geared toward people with DM, focused on the engagement of the individuals with their health condition and the need for self-care³3 Powers MA, Bardsley JK, Cypress M, Funnell MM, Harms D, Hess-Fischl A, Hooks B, Isaacs D, Mandel ED, Maryniuk MD, Norton A, Rinker J, Siminerio LM, Uelmen S. Diabetes self-management education and support in adults with type 2 diabetes: a consensus report of the american diabetes association, the association of diabetes care & education specialists, the academy of nutrition and dietetics, the american academy of family physicians, the american academy of PAs, the american association of nurse practitioners, and the american pharmacists association. Diabetes Care 2020; 43(7):1636-1649:^,1010 Allegrante JP, Wells MT, Peterson JC. Interventions to support behavioral self-management of chronic diseases. Annu Rev Public Health 2019; 40:127-146.. Therefore, there is a need for the development and the implementation of educational technologies focused on behavioral changes and the adoption of a healthy lifestyle (regular sleep, proper management of medication, stress management, and practice of physical exercises), which can lead to better physical and mental health for people with chronic conditions¹¹11 Riegel B, Barbaranelli C, Carlson B, Sethares KA, Daus M, Moser DK, Miller J, Osokpo OH, Lee S, Brown S, Vellone E. Psychometric testing of the revised self-care of heart failure index. J Cardiovasc Nurs 2019; 34(2):183-192..

Considering the above arguments, the following question arises: Are educational videos, based on behavioral changes and self-care of people with diabetes, valid in terms of content? To find the answer for this question, the current study had, as its objectives: constructed and validate the content of scripts of educational videos aimed at behavioral changes and self-care of people with diabetes.

Methodology

Ethical aspects

This study was approved by the Ethics Committee on Research Involving Human Beings of the Universidade Federal de Mato Grosso do Sul (CEP/UFMS), logged under combined decision no. 5,405,988 and was conducted in accordance with Resolution no. 466/2012 from the National Health Council. The free and informed consent form, signed by the researchers, was sent by e-mail to all individuals who were invited to participate in this study. This form was subsequently signed and returned, via e-mail, by those who agreed to participate.

Design, time, and place of the study

This is a methodological study developed in two phases: theoretical procedures and empirical and analytical procedures. The scripts were created between September 2021 and March 2022, and submitted to content validation in the period of April to November 2022. The SQUIRE guide of the EQUATOR network was used in the description of the study’s report.

Sample, inclusion and exclusion criteria

This study counted on the participation of professionals contacted by a search conducted in the Lattes platform (http://lattes.cnpq.br/) using the descriptors: “diabetes mellitus”, “health education”, “educational technology”, and “self-care”. The inclusion criteria were: being a nurse, working in teaching and/or in the Family Health Strategy (FHS), and having a minimum score of five points in the Fehring criteria¹²12 Fehring RJ.The Fehring Model. In Carrol-Johnson RM, Poquete M. Classification of nursing diagoses: proceeding of tenth conference. Philadelphia: Lippincott Company; 1994., which considers the graduation, academic studies, and professional experience in the care for patients with diabetes. The study excluded the participants that did not meet the determined deadline (15 days to return the script evaluation in each round).

A total number of 125 professionals were initially found, and out of those, 54 fit in the previously defined criteria and were invited to participate in the study via e-mail. Twenty accepted to participate, and nine returned a fully completed evaluation form. This sample of judges fits into the interval between six and twenty, which is recommended for the evaluation of evidence validity in various situations¹³13 Pasquali L. Instrumentação psicológica: fundamentos e práticas. Porto Alegre: Artmed; 2010.. In terms of the contingent of invited specialists, the present study reached a number that is higher than the minimum recommended in literature¹⁴14 Góes FSN, Fonseca LMM, Camargo RAA, Oliveira GF, Felipe HR. Educational technology "Anatomy and Vital Signs": Evaluation study of content, appearance and usability. Int J Med Informatics 2015; 84(11):82-987..

The main researcher and guide elaborated four scripts for educational videos, each with six to eight scenes, involving four characters and with an estimated length of five to eight minutes, considering that long videos tend to disperse the attention of the viewer¹⁵15 Dantas DC, Góes FGB, Santos AST, Silva ACSS, Silva MA, Silva LF. Production and validation of educational video to encourage breast feeding. Rev Gaucha Enferm 2022; 43:e20210247.^,1616 Guimarães EMR, Barbosa IV, Carmo TG, Probo DRG, Rolim KMC. Construction and validation of an educational video for patients in the perioperative period of robotic surgery. Rev Bras Enferm 2022; 75(5):e20210952.. The scripts were sequential, and the content of each video emphasized a specific theme. The strategy of having the scripts in continuity was chosen in order to clarify the development of the main character, who goes through every phase of behavioral change presented by the theoretical model (the adopted reference).

One integrative review study²2 Sá JS, Santana MDO, Santos MG, Benedito JCS, Teston EF. Tecnologias educacionais utilizadas para promoção do autocuidado de pessoas com diabetes mellitus: revisão integrativa. Rev Bras Enferm 2023; 76(Supl. 4):e20230049. showed that educational technologies identified for the promotion of self-care in people with diabetes, focused on foot care, prevention of neuropathy, self-management of health, knowledge and expectations of people with diabetes, and prevention of severe complications, which backed researchers’ decision in the choice of technology and the focus on self-care and behavioral change issues.

To write the scripts, a pre-production sequencing was followed: (1) synopsis: central ideas introduced in a paragraph; (2) argument: summarized text, written in prose and without dialogues; and (3) scripts: description of visual and audio aspects of the story¹⁷17 Comparato D. Da criação ao roteiro: teoria e prática. São Paulo: Summus; 2009.. Each content presented in the scripts took into consideration the life habits that had a direct influence on the management of chronic conditions, as described in the Basic Attention Notebook (Caderno de Atenção Básica)¹⁸18 Brasil. Ministério da Saúde (MS). Estratégias para o cuidado da pessoa com doença crônica: diabetes mellitus [Internet]. 2013. [acessado 2022 dez 22]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/estrategias_cuidado_pessoa_diabetes_mellitus_cab36.pdf
https://bvsms.saude.gov.br/bvs/publicaco... , and in a stage of the Trans-theoretical Model of Behavioral Change (modelo transteórico da mudança de comportamento - MTT)¹⁹19 Prochaska JO, Norcross JC. Systems of psychotherapy: a transtheoretical analysis. New York: Oxford University Press; 2018.. This is relevant because the treatment of diabetes requires, with or without pharmacological treatment, the adoption of healthy life habits, such as a balanced diet, physical exercise, moderation in the consumption of alcohol, and non-smoking,

For the development of the scripts, we produced a chronogram of meetings of the main researchers every 15 days while formulating the study to discuss and verify if the basic elements of the content covered in each video were clear, and if the phase of motivation for behavioral change was coherent with the reference concept¹⁹19 Prochaska JO, Norcross JC. Systems of psychotherapy: a transtheoretical analysis. New York: Oxford University Press; 2018..

According to the MTT recommendations, there are five stages of readiness for change: (1) Pre-contemplation, when the individual has no awareness of the inadequate behaviors; (2) Contemplation - the individual realizes that there is a behavioral problem and begins to consider the possibility of change; (3) Preparation - the individual makes specific plans for action and makes small changes in behavior; (4) Action - the moment when the plans for change are performed/implemented; and (5) Maintenance - when the individual works on consolidating the change and preventing relapses¹⁹19 Prochaska JO, Norcross JC. Systems of psychotherapy: a transtheoretical analysis. New York: Oxford University Press; 2018..

Script 1 treated the need for self-assessment of current behavior (in terms of nutrition and the practice of physical activities), an essential element for behavioral change and management of a chronic condition. The focus of this script was on helping people with diabetes to identify life habits that require change, through the choices and/or attitudes of the main character, which was described as in the precontemplation stage¹⁹19 Prochaska JO, Norcross JC. Systems of psychotherapy: a transtheoretical analysis. New York: Oxford University Press; 2018. in terms of the need for behavioral change. The cognitive processes addressed consciousness raising, self-reevaluation, environmental reevaluation, emotional relief, and social deliberation.

Script 2 treated the stage of contemplation¹⁹19 Prochaska JO, Norcross JC. Systems of psychotherapy: a transtheoretical analysis. New York: Oxford University Press; 2018. in which the character managed to consider the pros and cons of the behavioral change. The content was the management of stress, addressed in a with a motivational consultation with nurse who helped in the process of self-assessment of the character’s behavior.

Script 3 reinforced that people with diabetes need to reflect on health habits and behaviors. It presented a fictitious situation, using the following stages of change: action and maintenance and behavioral processes¹⁹19 Prochaska JO, Norcross JC. Systems of psychotherapy: a transtheoretical analysis. New York: Oxford University Press; 2018.: helping relationships, counter-conditioning, stimulus control, reinforcement management, and self-deliberation.

Finally, script 4 treated failures and relapses¹⁹19 Prochaska JO, Norcross JC. Systems of psychotherapy: a transtheoretical analysis. New York: Oxford University Press; 2018., taking into consideration the admission of such a possibility, the support to people with diabetes, and valuing maintenance strategies, these being strategic actions of encouragement of self-care. In this final script, the behavioral processes included were: counter-conditioning, relationships helping, and stimulus control.

The conclusion of each script was based on encouragement to reflect and self-evaluate the care actions performed by each individual, built according to the recommendations of the Manual of Supported Self-Care for Professionals²⁰20 Cavalcanti AM. Type 2 Diabetes Mellitus: care guideline for people with Type 2 Diabetes Mellitus. Curitiba: Secretaria Municipal da Saúde; 2010.. It is important to mention that in pre-production and technical construction, a guide for video production was used as a reference, guiding the process of script production²¹21 Fleming SE, Reynolds J, Wallace B. Lights...camera...action! a guide for creating a DVD/video. Nurse Educ 2009; 34(3):118-121..

Validation of content: empirical and analytical procedures

The present study focused on the validation of content by specialist judges. Therefore, semantic validation (conducted with people with diabetes and health professionals who work in Primary Health Care (PHC) will be the objective of a future study that is a part of the matrix project.

For content validation, the study followed the Delphi technique, with the participation of pre-selected judges. The use of this technique enables analytical procedures to occur concomitantly with empirical procedures, which favors the carrying out of statistical analyses of the judges’ answers in each round and allows for the verification of adequacy indexes in comparison to previously established levels, making it possible to provide feedback to the group of specialists in order to improve the material being validated.

The online questionnaire, made available via google forms, was divided into two parts: the first treated general information (identification, qualification, and professional experience), while the second part dealt with questions related to the evaluation of the script, following some criteria related to the concept idea, dramatic construction, rhythm, characters, dramatic potential, dialogues, visual style, referent public, and production estimate⁶6 Moura NS, Lopes BB, Teixeira JJD, Oriá MOB, Vieira NFC, Guedes MVC. Literacy in health and self-care in people with type 2 diabetes mellitus. Rev Bras Enferm 2019; 72(3):700-706., among others used in video validation studies²²22 Nascimento LA, Rodrigues AP, Joventino ES, Vieira NFCV, Pinheiro PNC, Ximenes LBXL. Validation of educational vídeo to promote self-efficacy in preventing childhood diarrhea. Health 2015; 7(2):192-200.^,2323 Pessoa NRC, Lira MN, Maciel ACMP, Mendonça AEO, Frazão CMFQ, Ramos VP. Construction and validation of content of a video on self-care with arteriovenous fistula. Enferm Clin 2020; 30(5):317-325..

The words related to the criteria of audiovisual production presented dichotomic answers (Yes or No), and the adequation of each criterion was evaluated with answers in a Likert scale of four points (4 - totally adequate; 3 - adequate; 2 - partially adequate, and 1 - inadequate). After the evaluation of each category, the judges were provided with space to present justifications or propose suggestions.

Analysis of results and statistics

Data was collected in two moments (first and second Delphi round), then organized and digitized in Excel 2010 spreadsheets and submitted to descriptive and inferential analysis in the Statistical Package for the Social Sciences (SPSS) program, using the Content Validation Index (CVI), specifically the Item Content Validity Index (I-CVI), the Content Validation Index for scale based on average (S-CVI/AVE) and the Content Validation Index for scale based on universal agreement (S-CVI/UA)²⁴24 Yusoff MSB. ABC of contente validation and contente validity index calculation. Educ Med J 2019; 11(2):49-54.. IVC scores below 0.8 were adjusted according to suggestions of the judges and returned for further evaluation in order to improve the levels of agreement in relation to the adequacy criteria.

The binomial test was applied (non-parametric version of the t-test of a sample, for a set of dichotomous categorical data) to compare the proportions of the dichotomous variables which significantly differ from 0.8, with a significance level of 5%²⁵25 Muniz MLC, Galindo Neto NM, Sá GGM, Pereira JCN, Nascimento MC, Santos CS. Construction and validation of an educational video for nursing students about obstetric cardiopulmonar yarrest. Esc Anna Nery 2022; 26:e20210466., considering a 95% confidence interval (95%CI) and a p-value ≤ 0.05 as the parameter for statistical significance.

Results

The nine judges participating in the first Delphi round of validation of the educational videos and the six participating in the second were all females and had up to five years of experience in PHC. The average age was 50.89 in the first round and 49.67 in the second. In both rounds, there was predominance of judges who were professors and with a doctorate degree in nursing. In Table 1, other characteristics are presented.

Chart 1 shows the suggestions presented by the judges in the two rounds. It can be noticed that judges two, five, and nine made no suggestions in either round. The suggestions presented in the first round were analyzed by the main researchers and incorporated into the re-writing of the scripts for the second round of evaluation. No divergence was identified among the judges in relation to any of the evaluated elements.

In the criteria of dramatic construction, dialogues, and referent audience, emphasis was placed on the need to revise the language to make it more accessible (Chart 1).

In Table 2, one can note that all of the criteria reached validation indexes by item, above 0.80, and that the criteria rhythm, dramatic potential, and visual style were validated unanimously by the judges, other criteria, such as the concept idea, dramatic construction, characters, dialogues, referent audience, and estimate of production) obtained a I-IVC of 0.89. Moreover, the average IVC was 0.93 and the universal agreement, 0.33. We highlight, as a matter of curiosity, that, if we consider in the first round only the six judges who participated in the second, the criterion of character would also show an I-IVC 1.00, and the average IVC and the S-IVC/UA would be, respectively, 0.91 and 0.44 (data not shown in the table).

After completing the modifications in the four scripts, an increase in I-IVC, S-IVC/AVE, and S-IVC/UA was observed in five criteria, given that all of them reached the maximum index of 100% agreement in two rounds.

We can notice in Chart 2 that all of the validation criteria of the scripts received suggestions for improvement, except for the criterion estimate of production. The main suggestions of the judges were related to the use of simpler language and the inclusion of characters’ social characteristics. Moreover, the judges also reinforced the family and professional connections of the main character (Ana).

For the purpose of promotion, use the camera in your cellular phone to read the validated scripts (Figure 1).

Discussion

The scripts of the educational videos with focus on self-care for people with diabetes reached the evidence of content validation recommended in the literature. The educational material was evaluated by health professionals, primarily nurses with expertise in Diabetes Mellitus and health education.

In terms of holistic care, health education is undeniably related to extension of care²⁶26 Lopes JL, Baptista RCN, Domingues TAM, Ohl RIB, Barros ALBL. Development and validation of a video on bed baths. Rev Lat Am Enferm 2020; 28:e3329.. In this sense, nursing has had an active participation in the construction of technological tools for the support of teaching/learning. The creation and validation of educational videos, for instance, facilitates the perspectives of communication with a broader audience and constitutes a more visually attractive type of material¹⁵15 Dantas DC, Góes FGB, Santos AST, Silva ACSS, Silva MA, Silva LF. Production and validation of educational video to encourage breast feeding. Rev Gaucha Enferm 2022; 43:e20210247..

It is important to highlight that the use of theoretical references in the development and validation of educational technologies (ET) tends to make such tools more adequate for the realities of health professionals and can better meet the demands of the intended audience, as it is also more attractive, making the process of teaching-learning easier and favoring health promotion²⁵25 Muniz MLC, Galindo Neto NM, Sá GGM, Pereira JCN, Nascimento MC, Santos CS. Construction and validation of an educational video for nursing students about obstetric cardiopulmonar yarrest. Esc Anna Nery 2022; 26:e20210466.. Considering the scarcity of studies in the literature concerning educational technologies based on behavioral theories²2 Sá JS, Santana MDO, Santos MG, Benedito JCS, Teston EF. Tecnologias educacionais utilizadas para promoção do autocuidado de pessoas com diabetes mellitus: revisão integrativa. Rev Bras Enferm 2023; 76(Supl. 4):e20230049., the use of TTM as a theoretical reference directed the entire process of development of the scripts created in the present study. The emphasis on the motivational stages for the behavioral changes proposed in each video may provide subsidies for strategic actions of health education with focus on the self-assessment of health conditions and on the promotion of self-care for people with diabetes.

It is important to mention that behavioral changes require the identification of factors that may influence the effectiveness of self-care and the management of the chronic conditions by individuals with Diabetes Mellitus 2²⁷27 Portela RA, Silva JRS, Nunes FBBF, Lopes MLH, Batista RFL, Silva ACO. Diabetes mellitus type 2: factors related to adherence to self-care. Rev Bras Enferm 2022; 75(4):e20210260.. Therefore, specific content related to self-care activities for people with diabetes was followed in the production of the scripts. That content included: the use of medication, glycemic monitoring, practice of physical activities, nutrition in general, and stress management. Consonant with the study that dealt with the creation and validation of an app for foot care for people with diabetes, those phases require appropriate pedagogical strategies and methods⁸8 Marques ADB, Moreira TMM, Carvalho REFL, Chaves EMC, Oliveira SKP, Felipe GF, Silveira JAN. PEDCARE: validation of a mobile application on diabetic foot self-care. Rev Bras Enferm 2021; 74(Supl. 5):e20200856..

The content specialists were nurses and professors with experience in PHC. It is important to consider the experiences and diverse situations that those professionals have to share regarding the management of Diabetes Mellitus 2 in different contexts, since they are the ones who deal, on a daily basis, with the difficulties associated with the process of behavioral changes²⁸28 Al Mahrouqi AS, Mallinson RK, Oh KM, Weinstein AA. Patients' and nurses' perceptions of diabetes self- management in oman: a quality study. Int J Environ Res Public Health 2022; 19(11):6929.. Therefore, our study sought to select specialists with expertise in the issues and/or thematic areas of the videos, with the purpose of ensuring rigor and robustness to the assessment process.

From this standpoint, the judges produced contributions referring to the relationships between self-care habits and clinical results; to understanding the reality experienced by the users; to making language simpler; to explaining the relationship between the reality and self-care, supported by the connections between professionals and users; as well as to the contributions related to the stages of behavioral change, thereby incrementing the specific content. It is important to mention that the comments brought relevant information for the alignment of content and to provide scientific knowledge and quality to the evaluated material, which is something commonly done in other studies of validation of educational videos¹⁵15 Dantas DC, Góes FGB, Santos AST, Silva ACSS, Silva MA, Silva LF. Production and validation of educational video to encourage breast feeding. Rev Gaucha Enferm 2022; 43:e20210247.^,1616 Guimarães EMR, Barbosa IV, Carmo TG, Probo DRG, Rolim KMC. Construction and validation of an educational video for patients in the perioperative period of robotic surgery. Rev Bras Enferm 2022; 75(5):e20210952..

Hence, some criteria, which were validated in the first round, received suggestions. Regarding the concept idea, there was a suggestion to emphasize that the continued practice of physical exercises may reduce complications and not sporadic practice. In consonance with this suggestion, one review study showed that the practice of physical activities is associated with the quality of life and adherence to the management of diabetes²⁹29 Jardim RMFVS, Leal MCC, Marques APO, Barbosa LS, Cavalcanti MCF, Gomes FMA. Factors associated with the practice of physical activity in older diabetic primary care patients. Geriatr Gerontol Aging 2020; 14(1):61-70.. Likewide, another study found that there is low adherence (22.6%) to the practice of specific physical exercise (lasting 30 minutes, 5 to 7 times a week) by people with diabetes²⁷27 Portela RA, Silva JRS, Nunes FBBF, Lopes MLH, Batista RFL, Silva ACO. Diabetes mellitus type 2: factors related to adherence to self-care. Rev Bras Enferm 2022; 75(4):e20210260.. With the incorporation of the suggestions, the target audience may assimilate the need to maintain self-care actions and self-assessment of their daily actions regarding physical exercises, as well as understand their relevance in the reduction of grievances and in the management of the disease.

About the characters, the main suggestions were based on the support network, which was collective, made up of professional teams or through family support. Concerning that kind of support, the judge who suggested its inclusion claimed that its absence may distance the viewer from the problem situation presented in the final piece. Moreover, a systematic review study³⁰30 Hamidi S, Gholamnezhad Z, Kasraie N, Sahebkar A. The effectsof self-efficacy and physical activity improving methods on the quality of life in patients with diabetes: a systematic review. J Diabetes Res 2022; 2022:2884933. highlighted the need for support as part of the change strategy. Furthermore, family and social factors may influence the management of the chronic condition by the individual and encourage changes in lifestyle, these factors being essential for the process. Likewise, partner support and educational activities in groups significantly favor the maintenance of general self-care actions.

The implementation of communication by mobile phone apps, such as WhatsApp, and the inclusion of the main characters in an online support group was also a suggestion for the adequation of the scripts. The justification comes from the easy access of these means of communication, which creates closer interaction with PHC professionals. Other strategies, such as video-conferences, video-calls, and text messages, have all been used in educational programs for self-care of people with diabetes³⁰30 Hamidi S, Gholamnezhad Z, Kasraie N, Sahebkar A. The effectsof self-efficacy and physical activity improving methods on the quality of life in patients with diabetes: a systematic review. J Diabetes Res 2022; 2022:2884933.. Taking this into account, we chose to include in the scripts, the strategic communication with Community Health Agents and tele-monitoring, considering the advantages that those resources bring in terms of decision-making and counseling for the development of abilities to control glycemic glucose, glycated hemoglobin (HbA1c), blood pressure, and body weight³¹31 Doupis J, Festas G, Tsilivigos C, Efthymiou V, Kokkinos A. Smartphone-based technology in dianetes management. Diabetes Ther 2020; 11(3):607-619..

Adequating language to the target audience was the most frequent suggestion, which appeared in many of the criteria. The need for use of a more simplified language was a finding present in another validation study³²32 Silva JRS, Nunes FBF, Lopes MLH, Batista RFL, Silva ACO. Diabetes mellitus type 2: factors related to adherence to self-care. Rev Bras Enferm 2022; 75(04):e20210260., particularly since it identified a significant association between poor health literacy and people with diabetes and Arterial Hypertension³³33 Lovrić B, Placento H, Farčić N, LipičBaligač M, Mikšić Š, Mamić M, Jovanović T, Vidić H, Karabatić S, Cviljević S, Zibar L, Vukoja I, Barać I. Association between health literacy and prevalence of obesity, arterial hypertension, and diabetes mellitus. Int J Environ Res Public Health. 2022; 19(15):9002.. Bearing that in mind, we altered words that were considered overly complex, such as diet and transtheoretical model, changing to a more informal and empathetic language with the substitution of those terms for healthy eating and theoretical change model; both changes were validated in the second round.

Concerning the final validation, we should mention that the loss of three judges from the nine initial ones did not compromise the results achieved in this study, since the number of final participants was in accordance with literature³⁴34 Silva NF, Silva NCM, Ribeiro VS, Iunes DH, Carvalho EC. Construction and validation of an educational video on foot reflexology. Rev Eletr Enferm 2017; 19:1-10.

35 Lima MB, Rebouças CBA, Castro RCMB, Cipriano MAB, Cardoso MVLML, Almeida PC. Construction and validation of educational video for the guidance of parents of children regarding clean intermittent catheterization. Rev Esc Enferm USP 2017; 51:e03273.^-3636 Gorla BC, Jorge BM, Oliveria AR, Rocha LACR, Assalin ACB, Girão FB. Short-term central venous catheter: Production of educational videos for the Nursing team. Esc Anna Nery 2022; 26:e20210392.. Our sutdy also observed a high level of agreement regarding the final contents of the scripts. Despite the suggestions, the contents of the scripts were considered valid; therefore, the percentages of agreement in all of the items were close to or above the expected agreement, from a statistical point of view.

In the space provided in the data collection instrument for notes and written suggestions, in a highly emphatic manner, some of the judges highlighted the positive points of the formulation of educational technology. One of the judges stated that the explanation, offered by the main character, of the phases of change was an excellent teaching strategy. This statement allows us to infer that the discernment of a patient with diabetes, and the recognition of the phases of change, is often non-linear, hence the need to make the process clearer and feasible for those individuals.

This study corroborates with the development of knowledge in the field of health, more particularly in the area of nursing, and more specifically for health professionals who work in PHC, since the contents of the scripts for the educational videos were validated by the specialist judges. After having been recorded, the videos will be submitted to validation by people with diabetes and by health professionals, enabling the videos to be used as a technology for the support of healthcare servicea, thus confirming their reliability, creativity, and commitment to the wellbeing of the users of health services. Studies of this nature reinforce the need for the formulation and validation of these tools so as to promote advancements in nursing.

Limitations of the study

We can consider the number of scripts used in this study to be a limitation, since this might have demanded more time from the judges to evaluate and may well have increased the time for the return of the evaluated material to the main researcher. Moreover, the results found in the present study should not be overgeneralized, since this study used the minimum recommended number of judges. However, the diverse representation of professionals from different areas and their geographic distribution were elements present in our study, which supported the practical reflections brought by the results.

The fact that semantic evaluation was not conducted does not limit our ability to infer the level of understanding that the target audience has concerning the scripts. The next phase of the study, however, will include the recording of the videos and the semantic and appearance validation performed by people with diabetes and by health professionals.

Conclusion

The content of the four scripts of educational videos created for the promotion of self-care and behavioral changes in people with diabetes were validated in terms of content. They were written according to four themes: self-assessment, phases of motivation, reflections on behaviors, and healthy habits and relapses during the process of change. Moreover, in the future, other scripts will follow the next required stages for the creation of educational videos, and, possibly, other psychometric measurements will be required to improve the subsequent stages of the study.

The contents of the scripts have the potential to subsidize healthcare actions aimed at people with diabetes, with a focus on behavioral change and the promotion of self-care. We hope that the results of the present study encourage other researchers to build and validate more technologies for the self-care of people with chronic conditions, focused on effectiveness and the promotion of health and the prevention of complications.

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