INTRODUCTION

Hypertensive disorders of pregnancy (HDP) include chronic hypertension, gestational hypertension, preeclampsia or eclampsia, and chronic hypertension with super-added preeclampsia ⁽¹⁾. This group of clinical conditions complicate up to 10% of pregnancies and are one of the leading causes of maternal, fetal, and neonatal morbidity and mortality worldwide ⁽²⁾. Currently, the exact etiology of HDP remains unknown, which is why it has been considered a disease of a heterogeneous and multifactorial nature ⁽³⁾. In this regard, Ahmed et al., ⁽⁴⁾ describe that in order to prevent or control the risk of HDP, interventions that address a wide range of factors are required through the implementation of actions aimed at pregnant women’s self-care and lifestyle modification.

In this sense, the available scientific evidence reports that education is one of the most frequent strategies in intervention studies aimed at improving perinatal maternal health outcomes in women with or without a diagnosis of HDP ^{(5) (6) (7) (8)}. Several authors ^{(7 9 10))} affirm that health education programs have a positive impact on pregnant women’s level of knowledge and attitudes towards HDP, as well as on their self-care behaviors, allowing lifestyle changes in the face of modifiable risk factors and the early identification of their signs and symptoms. This results in the timely detection and treatment of this condition, and most likely, in the reduction of its negative consequences.

Intervention studies ^{(7 8 11)}, carried out in women with HDP or at risk of developing this complication, have produced a wide variety of educational materials constructed according to the objectives proposed in the studies; however, there is little evidence about processes and criteria used in the design and validation of the material used. Among the educational materials used are brochures, graphic cards, stickers or magnets, flipcharts, primers, videos and mobile applications. It is important to highlight that most of these resources are aimed at improving the level of knowledge about HDP and its risk factors, signs and symptoms, complications, diagnosis, and treatment. Also, very few of them are aimed at improving self-care behaviors which are considered to be a fundamental component in the reduction or control of the risk of the disease.

In relation to the above, health education, as one of the main strategies of health promotion and disease prevention, requires that the content and design of the educational material be validated, so that it adapts to the characteristics and needs of the target population, facilitates the transmission of the message, favors teaching-learning strategies, strengthens knowledge, and promotes self-care ⁽¹²⁾. Therefore, the present study seeks to have an educational material oriented to improving not only pregnant women’ knowledge but also their self-care behaviors in the face of HDP.

According to Herrera et al., ⁽¹³⁾ there is a need to design educational materials based on theoretical frameworks, so that the information is not only technically sound, but is guided by theories that have demonstrated effectiveness during their application in various populations. For this reason, the educational material designed in this study is based on the Theory of Planned Behavior (TPB) ⁽¹⁴⁾. The TPB was selected due to its ability to describe, explain, and predict the behavior of pregnant women in specific health situations, including HPD ⁽⁸⁾. The TPB poses that a person's intention to perform a behavior is influenced by three factors: The first of them is of a personal nature and is called attitudes; the second one is related to social pressure and is known as subjective norms, and the last one focuses on the control of factors and is known as perceived behavioral control ⁽¹⁴⁾. In this way, the analysis of the theory allowed to identify motivational support (willingness to achieve a behavior), behavioral (behaviors) and educational (knowledge) factors as key components that contribute to promoting a better level of knowledge and health behaviors in pregnant women in the face of HDP.

Once the forms of support were established, this study opted to design an educational booklet aimed at strengthening pregnant women’s positive attitudes, social and family support, control over behavioral factors and intention to carry out self-care behaviors in the face of HDP. In addition, the booklet is expected to improve pregnant women’s level of knowledge about the characteristics of the disease and its self-care behaviors, in order to support health actions aimed at preventing or reducing the risk of HDP.

From this perspective, the importance of this study lies on making available an educational material that can be used by health professionals responsible for women’s care during the prenatal stage. In addition, the design of this material responds to the need to have nursing care tools that are based on theories, as explained by Herrera et al., ⁽¹³⁾, because they strengthen nursing identify through the scope of greater autonomy that can be seen reflected in the exercise of their professional work ⁽¹⁵⁾. Therefore, the TPB, as a theoretical framework that serves as the basis for the educational material proposed in this study, seeks to promote the development of knowledge, research and practice around perinatal maternal care. Accordingly, the objective of this study was to design and validate an educational material to improve the knowledge and self-care behaviors of pregnant women in the face of hypertensive disorders of pregnancy.

MATERIALS AND METHODS

Methodological research developed between January 2022 and January 2023 in the city of Bucaramanga, Colombia. The process was carried out in two phases: 1) design and 2) validation of the educational material.

RESULTS

Phase 2. Validation of educational material

Five experts participated in the technical validation, including four nurses and a psychologist. Two of them had undergraduate academic training, one had specialization studies, one held a master's degree, and one had a doctorate. The experts had an average of 18.1 years of work experience in the healthcare area, 16 years teaching, and 5 years of research

Table 1 presents the items in the technical validation instrument, the number of experts and the percentage of agreement. In the results obtained, the criterion of induction to action reached a level of approval of 100%; the criteria of attraction, acceptance and identification got between 80% and 100% approval; and the criterion of comprehension obtained between 20% and 100% approval. In the latter, item 11, which as related to the use of clinical terminology, presented the lowest percentage of approval, with observations aimed at avoiding the use of abbreviations and technical terms, and incorporating the definition of concepts, as described in Table 2. In general, the approval level of the experts reached an average of 90.58%, which is considered favorable in the technical validation of the booklet.

Table 1. Results of the technical validation of the booklet. 

Table 2. Observations of the technical validation of the booklet. 

The comments issued by the experts were satisfactory and included the following comments: "It is an educational material that is easy to implement in prenatal control and in maternity courses", "it is a useful booklet in the practice of perinatal maternal nursing care", "it is an interactive resource that supports and motivates pregnant women to know and apply care actions in the face of HDP”. Table 2 presents a synthesis of the improvement observations made by the experts in regards to the criteria of attraction, comprehension and acceptance.

The population validation was carried out with the participation of 20 pregnant women, with a minimum age of 17 years and a maximum of 43, mean of 25.15 years. Most of them Colombian nationality (80%), resided in the urban area (85%), were in a free union (80%), took care of their homes (70%), had high school degrees (75%) and belonged to a 2 (low) socioeconomic stratum (65%), according to the classification of the National Administrative Department of Statistics (DANE) ⁽²⁵⁾. In the obstetric history, most of the participants were multigravid (60%), with a minimum gestational age of 13 weeks, and a maximum of 37.5, with a mean of 24.77 weeks. The results of the population validation of the booklet show approval rates between 80% and 100%, with an average score of 98.07% in the five criteria evaluated, as evidenced in Table 3.

Table 3. Results of population validation of the booklet. 

The assessments made by the participants during the population validation process highlighted the following: "the booklet contains everything that is required to know about high blood pressure in pregnancy", "the illustrations are very beautiful, colorful and complement the information in the texts", "practical activities are a way to interact with the booklet and strengthen what you have learned", "the colors that identify each unit are quite striking", "the information contained in each unit is very well organized". The main observations on improving population validation focused on the criteria of attraction, comprehension and induction to action. These are presented in detail in Table 4.

Table 4. Observations of the population validation of the booklet. 

The final version of the booklet was made taking into account the qualitative observations of the experts and the pregnant women who considered that the material in its initial version required reforms in the following aspects: a) the title “I decide to take care of myself in the face of hypertensive disorders of pregnancy” was modified by “I decide to take care of myself in the face of high blood pressure in pregnancy”; b) the abbreviation HDP and the terms periodontal, antioxidants, assisted reproduction, protein in urine and mellitus were eliminated; the terms hypertensive disorders of pregnancy were replaced by high blood pressure in pregnancy, stewed for stews, sodium by salt, neonates by newborns, pelvic floor by perineum, and post-traumatic stress syndrome by alterations in mental health, these adjustments were made in order to improve the comprehension of the material; c) the illustrations on the cover and main page of units 1 and 5 were modified to make them more representative of the content; d) units 3, 4 and 5 included a form for the daily recording of behaviors performed by the pregnant women in relation to nutrition, rest, exercise and mental health; e) the length of the paragraphs included a maximum of 5 lines; f) grammar, spelling, and punctuation were checked and corrected; and g) the blue color of unit 5 was changed to a lighter shade. Once the final version of the booklet was obtained, registration with the Colombian Book Chamber was carried out and the editorial process was started.

DISCUSSION

The identification of women’s needs during the prenatal stage and the capacity of the health sector to respond to the current challenges of maternal and perinatal morbidity and mortality due to obstetric complications, specifically by HDP, demand health education strategies that are solidly constructed and rigorously validated, in which it is essential to design and use relevant and effective educational materials for the target audience ⁽²⁶⁾. In this sense, the results achieved in this study show that best practice principles should be considered in the design and validation of written health education materials ⁽¹⁶⁾, in order to obtain a material that allows pregnant women to increase their knowledge and to acquire self-care behaviors in the face of HDP.

In the first phase of this study related to the design process of the booklet "I decide to take care of myself in the face of high blood pressure in pregnancy", the fulfillment of the characteristics proposed by Hoffmann ⁽¹⁶⁾ in terms of content, organization, language, illustration, design, learning and motivation is highlighted. These findings are important considering the results of similar studies, such as that conducted by Cáceres et al., ⁽²⁷⁾, which report that an adequate review of the scientific evidence and attention to detail related to writing, design and illustration, allowed them to obtain a valid material to provide education on humanized childbirth to pregnant women and their families, reaching an average Content Validity Index of 0.94 in the technical validation and an average of 97.9% in the population validation.

The technical and population validation phase of this study was carried out with the participation of 5 experts and 20 pregnant women, reaching a score of more than 70% in the five criteria proposed by Ziemendorff and Krause ⁽²³⁾. These findings are consistent with those obtained in the studies by Velazquez et al., ⁽²⁸⁾, Herrera et al., ⁽¹³⁾ and Correa ⁽²⁹⁾, in their results they demonstrated approval rates higher than 70% in the technical validation, and 60% in population validation. We agree with these authors, especially in the design of an educational material aimed at a target population with a specific health situation and according to the recommendations described in the literature for the construction of health materials, as well as the use of the same criteria for the technical and population validation of written, educational, and communication materials.

Establishing a comparison between the technical and population validity indices of the studies cited above, in this study, the technical validity scores are lower than those reported by the pregnant population. However, it is important to highlight that, although the validity of the booklet has the accepted values for this test (≥ 70%), the experts made observations and recommendations that allowed identifying points of improvement in the criteria of attraction, understanding, and acceptance. In this regard, authors such as Canul et al., ⁽¹²⁾ and Salazar et al., ⁽⁽³⁰⁾, have documented that educational materials should be reviewed by expert personnel in the subject in order to unify judgments of both form and content, which allow if necessary to reformulate the information, to organize the content, to modify terms or images, and to ensure not only the clarity and comprehension of the message, but also the applicability and quality of the educational material.

Similarly, the population validity allowed us to identify that the criteria of acceptance, identification and induction to action were the best qualified, with the recommendation in this last criterion of the inclusion of a daily record format of the care described inside the booklet. In the characteristics of attraction and comprehension, a minimum percentage referred to the need for adjustments in terms of color, illustrations, and terminology. These results are similar to those obtained by Canul et al., ⁽¹²⁾, in their validation study of educational materials on healthy eating. They found that modifications were required in several aspects: in the criterion of attraction, in terms of the use of more striking colors and images according to the cultural context; in the criterion of comprehension, in regards to the use of a more comprehensive language; and in the criterion of induction to action, in relation to reinforcing eating behavior with foods typical of the region. These aspects highlight the need for educational materials to not only transmit information and be visually attractive, but also to strengthen and propitiate behavior changes depending on the context in which the individual is located ⁽¹²⁾. In this sense, it is important to recognize that it is the sociocultural characteristics of people that determine their vision of the world, shape their own conceptions of health and disease, and influence their interests and abilities to learn ⁽²⁶⁾.

The results of this study confirm the importance of designing and validating educational materials under a participatory approach and with a rigorous and structured methodology, which allows for the identification of points of improvement and the implementation of pertinent modifications. This would guarantee the creation of educational materials that are in accord with the characteristics and needs of the population, and the fulfillment of the objectives proposed in health education interventions ⁽¹²⁾.

This study allowed for the construction and validation of a booklet with strengths in its content language, organization, illustration and design, conditions that induce learning and arouse the interest of pregnant women to acquire self-care behaviors in the face of HDP. The booklet also met the validity criteria of educational materials in health; therefore, it can serve as a potential resource in educational processes aimed at improving the level of knowledge and self-care practices of pregnant women in the face of HDP. Finally, this educational material constitutes a contribution to the application of the Theory of Planned Behavior in the practice of perinatal maternal care, by improving in pregnant women the intention to acquire health behaviors from their attitudes, social and family support, and the control over their own behavior.

Among the limitations, it is important to highlight the lack of validation studies of educational materials aimed at strengthening pregnant woman's knowledge and self-care behaviors in the face of the HDP, as well as the unification of the evaluation criteria that would allow contrasting the findings obtained in this study. Another limitation is that the booklet was built on the sociocultural characteristics of a single Colombian environment, which may lead to the need for future cultural, nutritional, and lifestyle adaptations that identify pregnant women in other national and international contexts.

CONCLUSIONS

The construction of the booklet "I decide to take care of myself in the face of high blood pressure in pregnancy” was supported by the scientific evidence available in HDP and TPB. The validation process showed scores greater than 70% in the criteria of attraction, comprehension, acceptance, identification, and induction to action used by experts and pregnant women. The recommendations made by these were incorporated in the final version of the booklet. In this way, a valid and reliable material was obtained that can be used by nursing and other health professionals in the development of interventions aimed at strengthening the knowledge and self-care of pregnant women in face of the HDP.

However, the construction and validation of the booklet is only a model of how nursing professionals can design and develop new educational resources for the implementation of health education interventions based on theories. As such, this study contributes to the expansion of the Theory of Planned Behavior and strengthens its usefulness in teaching, research, and practice of women’s care during the prenatal stage.