Introduction

Diabetes mellitus (DM) is one of the most prevalent diseases in adults worldwide, being one of the main causes of loss of years of healthy life and productive capacity. In addition, this situation worsens with the increase in life expectancy. DM can result in serious complications such as neuropathy, retinopathy, blindness, nephropathy, diabetic foot, and amputation when not adequately controlled.(¹)

Diabetic foot is a serious complication characterized by the triad of ulceration, neuropathy, and peripheral arterial disease (PAD) in varying degrees in the lower limbs. Foot ulceration is an important complication of DM, being associated with high levels of morbidity, mortality, and reduced quality of life, in addition to significantly increasing the financial costs of care.(²,³)

The lifetime incidence rates of DM-related foot ulceration are 19-34%, with an annual incidence rate of 2.0%. After a successful cure, recurrence rates are 40% at one year and 65% at 3 years. This evidences that prevention of diabetes-related foot ulceration is essential to reduce the risk to patients and, thus, reduce the high costs involved in caring for diabetic foot complications.(³,⁴)

Diabetic foot infections require frequent medical monitoring, daily ulcer care, and antimicrobial therapy. Such infections may also require surgical procedures with high associated healthcare costs, and the diabetic complication is the one that most often requires hospitalization.(⁵) Although complications are serious and costly, there are care, examinations, and tests that can help prevent and assess the risk for diabetic foot, e.g., assessment of the physical aspects, temperature, and vasculature of the feet and sensitivity (tactile, vibratory, and pain) and motor tests. Therefore, professionals must remain updated and seek training to perform such tests and care.

Currently, there is a tendency to include all diabetic patients in centers integrated by multidisciplinary teams trained in the specialized management of diabetic foot, as half of these patients are unaware of having this diagnosis. Thus, healthcare teams must be able to identify the risks of developing diabetic foot and develop health education strategies so that diabetic patients have the autonomy to keep their extremities healthy.(⁶)

Professionals can take courses (face-to-face or online), read, train in workshops, etc. to stay up-dated.(⁷) In this study, we proposed to validate an instructional video class (highlighting that the proposal is a complementary material produced during the professional doctorate in Nursing) to compose an online training course to assess the risk of diabetic foot aimed at primary health care nurses.

Video classes can be important tools when well executed and supported by expert guidance. However, they may not bring the expected results without practical application and expert guidance, especially on topics with which the professional does not have frequent contact.(⁸,⁹)

Learning through video classes (or mediated by information and communication technologies) is effective, contributing to the updating and training of professionals in various areas, especially due to its flexible nature. Furthermore, video classes can be viewed as many times as necessary until the proposed concepts are learned.(¹⁰) Audiovisual resources contribute to the teaching-learning process and can capture viewers' attention when well-designed. They stimulate and expand nurses' knowledge, improving their performance in patient care.

It is important to highlight that the validation of educational technologies by a body of specialized judges is an essential process to ensure that they meet the learning objectives. Validation allows for ensuring the effectiveness, relevance, and reliability of educational technologies, maintaining content accuracy, information reliability, and conceptual accessibility. This stage also allows the proposal to be constructed or adapted based on the systematic use of available knowledge.(¹¹)

Therefore, our objective was to build and validate a video lesson on diabetic foot risk assessment to compose the teaching materials used in an online training course and to equip the work of primary health care nurses.

Methods

This was a methodological study with a quantitative approach and the use of the item content validity index (CVI) and the confidence interval (CI) to validate the proposal. Initially, a literature review was performed to select content relevant to the class topic. After analyzing the information provided mainly by the Brazilian Diabetes Society and the International Working Group on the Diabetic Foot (IWGDF) team, the script for the video class was created considering the following topics: presentation and introduction, assessment of the foot and shoes, skin and toenails, and musculoskeletal, vascular and neurological systems, tests of the neurological system, ankle-brachial index, and general orientation.

The video lesson was produced in a studio and Falkenbach's proposal (2005) was used as a theoretical framework. To prepare an educational video, the author recommended adopting the following steps: analysis and planning, modeling, implementation, evaluation, maintenance, and distribution.(¹²) Technical, literary, and graphic image scripts were prepared for teleprompter.(¹³)

The video lesson was edited, colored, and finalized using the Adobe Premiere software. The opening and closing animations were created using the Adobe After FX® program and a soundtrack from the YouTube Audio Library (royalty-free) was used, resulting in a video lesson lasting 15 min and 45 s.

After completing the video class, accounts were created on the YouTube and Bit.ly platforms. The video lesson was uploaded to the YouTube.com platform and a sharing link was generated. To facilitate access to the video, the link was inserted on the bit.ly.com platform to generate a QR Code (Figure 1). Through it, access to the video on YouTube is obtained by reading the code on a smartphone.

After the video lesson editing was completed, the material was made available to experts in the areas of design and health for evaluation and validation, or product adjustment.

Two categories of experts participated in the study: a) for the graphic and image projects, nine specialists from the area of communication (advertising and propaganda, journalism, and graphic design) participated; they had a minimum of a bachelor's degree plus two years of professional experience in the area and evaluated the video class considering the technical aspects of framing, script, sound, and image; b) for content, technical language, and didactic sequence, 21 specialists in the health area participated; nurses with a minimum master's degree and at least two years of experience in the topic "Diabetic foot", as proven in the Lattes platform curriculum.

After the selection of the judges (experts in design and the health field), invitations were sent to participate in the study. The collection instrument was prepared electronically on the Google Forms platform and sent along with the link to access the video class. A total of 15 invitations were sent to design experts, and nine of them returned agreeing to participate. Invitations (45) were sent to health experts, and 21 of them agreed to participate in the validation study. The collection was carried out between September 26 and October 10, 2023.

Information about the participants' profiles and the video lesson items was collected. The questions for the expert evaluation item were based on the article by Silva and Salomé.(¹⁴) An assessment instrument was proposed with questions using a Likert-type scale and the possible answers were as follows: (1) not relevant or not representative item; (2) the item needs a major change; (3) the item needs a minor revision; and (4) relevant or representative item.(¹³)

The responses given by the evaluators were used to calculate the CVI, which indicated the validity of the video lesson based on the number of evaluators who assigned a value of 4. The items analyzed were considered valid if CVI>0.78 in each of their aspects.(¹⁵)

The evaluation instrument was constructed so that experts could evaluate aspects of products relevant to their areas:

• a. Design and Media specialists: suitability of the video class title; quality of the graphic image script; quality of the literary script; quality of the image, and quality of the audio of the video class;

• b. Health specialists: suitability of the title; quality of the literary script; quality of sound and image; clarity in the presentation of topics and oral language; the content facilitates teaching and learning on the subject; the content follows a logical sequence; the images, scenes, and photos allow transferring the learned content to professional practice; the sequence of content and form of presentation allows keeping the nurses' attention to the class.

In the end, an open question was asked so that participants could make criticisms and/or suggestions about the product presented.

The study complied with the Ethical Aspects of Research Involving Human Beings (Resolution 466/12) with autonomy for target individuals through the Free and Informed Consent Form (FICF), commitment to maximum benefits and minimum harm and risk, and significant advantages and minimum burden for vulnerable subjects, ensuring that foreseeable harm was avoided. The project was approved by the Research Ethics Committee (REC) of UNESP, Botucatú School of Medicine (CAAE: 57901722.1.0000.5411).

Results

Table 1 shows that female gender (55.6%), age >33 years (88.9%), and training time =6 years (88.9%) predominated among design specialists. Among health specialists, female gender (95.2%), age 3645 years (57.2%), and training time >10 years (95.2%), including masters (71.4%), and doctors (28.6%) predominated.

Table 2 shows that the five items evaluated by the design experts obtained CVI 0.88 (4) and 0.77 (1), remaining within the 95%CI. "Quality of graphic image script" was the only item rated 2 (needs major change). In the assessment performed by health experts (sound and image quality; oral language), the items investigated obtained CVI 1.00 (7) and 0.95 (2). The overall CVI averages for the areas were 1.00 (health) and 0.97 (design).

In general, the number of suggestions given by the experts was not significant and thus a new recording of the video lesson was not justified. The main suggestions from the design experts were about the framing and audio quality in the video lesson. The health experts also did not make suggestions or criticisms that would justify a new recording. Among the items evaluated, they positively highlighted the objectivity, clarity, and ease of understanding the class. Among the suggestions from the design experts, the following were highlighted: use of off for recording; higher quality recording in the studio; better framing of the close-up when the circle indicates the procedure. Considering the few suggestions for revision or deletion of items, a new class was not recorded nor was a new edition performed. The educational technology was validated in the general framework thus ensuring the quality of the material as a learning tool. Therefore, the class was considered suitable to compose an online training course on risk assessment for diabetic foot aimed at Primary Health Care (PHC) nurses.

Discussion

Digital information and communication technologies have been great allies in professional training and continuing and permanent education. They favor the learning, acquisition, expansion, and updating of knowledge and practices that improve the provision of health services.(⁹)

Video production in the health sector has gained ground and several publications offer subsidies to improve health techniques such as bed baths, perioperative period of robotic surgery, creation of technological projects for the health area, bladder self-catheterization, cardiorespiratory arrest, prevention of ulcers in the diabetic foot, cardiopulmonary resuscitation, etc. Thus, this proposal is another possibility to improve the services provided to diabetic patients.(⁸,⁹,¹⁶,¹⁷,¹⁸,¹⁹,²⁰,²¹,²²)

The expert review phase was a crucial step in ensuring that the proposal to create educational technologies is viable. In the results presented, the designers' analyses were more critical, being related to specific aspects of script and production. The health professionals' analyses were more favorable, with fewer critical points and few suggestions for improvement. These results showed that the proposal achieved its objective regarding the transmission of knowledge, techniques, and skills to perform tests and assess the risk of diabetic foot, although the technical quality of the video could be improved.(²³)

Validating an educational technology is a fundamental step; based on the expertise of the judging committee, the legitimacy and credibility of the instrument produced were assessed before its distribution or dissemination to the target audience. By adopting the CVI as a validation index, the possibility of analyzing the relevance and quality of each proposed item was opened, allowing adjustments and revision only where they are necessary.(²⁴)

The need for constant professional updating requires the creation of strategies that allow improving work practices. As academic graduation in health is limited, continuing education must be available in the daily lives of health professionals to continually improve the services provided, expanding knowledge beyond academic experience.(⁷)

Several studies focused on the identification, tracking, and care of diabetic foot were identified, highlighting the relevance and current status of the topic. Such studies highlight the importance of care aimed at this condition, highlighting the need to train and qualify professionals for risk assessment, management of the condition, and health education for self-care.(²¹,²²,²³,²⁴,²⁵,²⁶)

Proposals for learning, qualification, and training using educational technologies provide knowledge more interactively, favoring the improvement of services provided and positively impacting the promotion of health in the community. Educational technologies aimed at the care and management of DM-related illnesses are still in an early stage of production despite the advantages mentioned and the increase observed in this research in recent years. These technologies show promise for both professional training and patients' self-care and health education.(²³)

Audiovisual resources are essential to better understand information and thus their validation by experts is essential. Once the quality and relevance of educational technology are confirmed, it can become a tool for building knowledge and expanding the supply of resources for training and education in health. Thus, we highlight the relevance of the engagement of nurses and other health professionals in the construction and use of new technologies both in teaching and in their daily practice.(²⁷,²⁸)

The study had limitations in obtaining expert participation due to the amount of feedback obtained after invitations were sent. A greater number of expert evaluators could have brought other views and perceptions, contributing to improving the proposed video class.

Conclusion

The video lesson on diabetic foot has been validated and can be used as an instrument for updating and professional training, contributing to updating and training nurses to perform tests and risk assessments. The use of video lessons can strengthen health education and professional qualification, preventing the worsening of chronic diseases. Risk assessment and diabetic foot care can prevent negative outcomes such as limb amputation, which impact patients' lives in addition to the high costs for the public health system. Moreover, the use of educational technologies in continuing health education must be part of public policies to provide health services in preventive and curative ways.

References

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