An educational flipchart to support arbovirus prevention in primary health care

An educational flipchart to support arbovirus prevention in primary health care | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article An educational flipchart to support arbovirus prevention in primary health care Luis Fernando Reis Macedo, Yvinna Marina Santos Machado, Alzenir Rosa Viana, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8757656/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Arbovirus infections remain a major public health challenge in Brazil, particularly in Primary Health Care (PHC), where health education and prevention actions are central to reducing transmission and community risk. Educational technologies can support PHC teams by standardizing key messages and facilitating communication with the population. This study aimed to develop and validate a flipchart educational technology on arbovirus infection prevention for use by PHC professionals. Methods A methodological study was conducted from July 2022 to February 2023 in three phases: (1) literature/document review to support content development; (2) construction of the flipchart; and (3) content and face validation by 17 judges, including preceptors and second-year residents from a multiprofessional public health residency program (PRMSC/URCA). The judges evaluated four domains, objectives and content, text and language, appearance, and relevance, using a 4-point Likert scale. Validity was assessed using the Content Validity Index (CVI). Results Eight documents were eligible and informed the content of the flipchart. The validation results showed a CVI of 1.00 for objectives and content and 1.00 for text and language. The appearance domain presented a CVI of 0.98, and relevance a CVI of 0.99. The overall CVI was 0.99. Conclusion The developed flipchart demonstrated high content and face validity and may support PHC professionals in health education, health promotion, and disease prevention practices related to arbovirus infections. Trial registration not applicable. Educational technology Arbovirus infections Health promotion Primary health care Figures Figure 1 Introduction Arboviral diseases represent an important public health problem due to their epidemic occurrence and their potential to cause a wide range of clinical manifestations, including severe forms and inflammatory, hemorrhagic, and neurological complications. Among the main arboviral diseases of interest in Brazil are dengue, chikungunya, and Zika, transmitted predominantly by the mosquito Aedes aegypti [ 1 ]. In Brazil, the incidence of these diseases is associated with environmental and climatic factors, showing seasonal patterns and increased cases during warmer and rainier periods, conditions that favor vector proliferation [ 2 ]. In addition, territorial vulnerabilities, such as the absence or inadequacy of basic sanitation and improper water storage conditions, may increase breeding sites and contribute to community spread [ 3 ]. In this context, prevention is a central component to reduce incidence and mitigate individual and collective impacts. Primary Health Care (PHC) constitutes a strategic setting for health promotion and disease prevention actions, integrating territory-based interventions and educational practices aimed at the population [ 2 , 4 , 5 ]. Studies indicate essential strategies for arbovirus prevention within PHC, including: (1) vector control, through elimination of breeding sites and environmental measures (such as sealing water containers, cleaning gutters, and properly disposing of containers that accumulate water) [ 6 , 7 ]; (2) health education, providing guidance on prevention, signs and symptoms, and recommended actions in suspected infection [ 8 ]; (3) epidemiological surveillance, through timely case notification and monitoring of viral circulation in the area; (4) immunization, when indicated according to guidance from the Ministry of Health and state and municipal health departments [ 1 ]; and (5) appropriate clinical management, including early identification and follow-up of cases, helping to reduce complications and interrupt transmission chains in the territory [ 5 , 9 ]. PHC stands out as the preferred entry point to the health system, strengthening bonding, longitudinality, comprehensiveness, and care coordination [ 10 ],[ 11 ]. In this setting, the use of educational resources and health technologies can enhance health communication, support health education practices, and increase the effectiveness of preventive actions in the territory [ 12 ]. Therefore, it is relevant to develop a scientifically grounded and validated educational technology aimed at PHC professionals to support educational actions with the population, contributing to arbovirus prevention and strengthening care and health promotion practices. As a Brazilian educational technology, its application may be expanded to different contexts. However, the development of the instrument prioritized populations living in the Northeast region of the country, with emphasis on the state of Ceará, given the increase in notifications in recent years [ 5 ]. Thus, the material was designed to support the health team in care delivery and preventive actions related to dengue, Zika, and chikungunya, fostering a comprehensive approach and potential improvement in quality of life. Methods Study design This was a descriptive methodological study aimed at developing and assessing the content and face validity of an educational technology in the form of a flipchart, designed to support PHC professionals in delivering educational practices and health promotion actions for arbovirus prevention. The study was conducted between July 2022 and February 2023 and was grounded in instrument development and validation frameworks proposed by Polit and Beck [ 13 ], as well as Brazilian technical and regulatory documents related to the prevention, diagnosis, and management of dengue, Zika, and chikungunya. Study setting The study was carried out in the city of Crato, Ceará, Brazil. Crato is located in the Cariri macroregion, at the foothills of the Chapada do Araripe. The municipality covers an area of 1,158.150 km² and has an estimated population of 133,913 inhabitants, according to the Brazilian Institute of Geography and Statistics (IBGE) [ 14 ]. Phases of technology development The methodological process was organized into three phases: (1) documentary review and content synthesis; (2) construction of the flipchart; and (3) validation by judges (content and appearance), following recommendations for the development and validation of educational instruments/technologies. Phase 1 – Documentary review and content synthesis The documentary review followed four steps: (1) search and selection of educational/informational materials, booklets, guides, and manuals from the Ministry of Health addressing arbovirus prevention, health promotion, and the diagnosis and management of dengue, Zika, and chikungunya; (2) data extraction from selected materials; (3) synthesis of findings; and (4) presentation and grouping of information [ 15 ]. Eligibility criteria were defined as follows. Inclusion: educational/informational materials, booklets, guides, and manuals from the Ministry of Health addressing arbovirus prevention, health promotion, and the diagnosis and management of dengue, Zika, and chikungunya. Exclusion: materials published before 2012. Sources were searched in a directed and purposive manner, considering the volume of publications on the topic and the need to follow current guidance for arbovirus control adapted to the present context. In addition, as the technology was intended for use by professionals working within Brazil’s Unified Health System (SUS), priority was given to Ministry of Health materials that were up to date and aligned with international guidelines. The search was conducted between August and September 2022 in the Health Information Locator (LIS), ColecionaSUS, and the Latin American and Caribbean Health Sciences Literature database (LILACS), accessed through the Virtual Health Library (BVS), using the advanced search form. The search was limited to the period 2012–2022 and to non-conventional documents. The descriptors used were: prevention, arboviruses, Aedes aegypti, dengue, Zika, and chikungunya, combined with the Boolean operator AND and intercalated searches (Table 1 ). Table 1 Search strategy. Search strategy LIS ColecionaSUS LILACS Total Prevention AND arboviruses 7 10 6 23 Prevention AND Aedes aegypti 32 15 10 57 Prevention AND dengue 41 26 394 463 Prevention AND Zika 53 6 136 195 Prevention AND chikungunya 23 10 97 130 Total 868 Two independent, non-blinded researchers selected materials initially by titles and abstracts, also prioritizing Ministry of Health sources. The researchers held alignment meetings via Google Meet to resolve disagreements. After screening titles and abstracts, they downloaded the materials, organized them into folders, and documented reasons for exclusion. Following selection of Ministry of Health materials, documents underwent detailed reading and data extraction for qualitative appraisal, prioritizing current guidance. Two non-blinded researchers independently synthesized the main points regarding arbovirus prevention, health promotion, and the technology-related diagnosis and management of dengue, Zika, and chikungunya to inform the instrument. All extracted information was reviewed by a third researcher, who approved its use for the subsequent phase. Phase 2 – Flipchart construction The flipchart “Flipchart: Together for the prevention of arbovirus infections” was developed based on the theoretical framework identified in the documentary review and on the synthesis and organization of the information gathered in the previous phase. This stage included selection of illustrations, text layout and design, and final editorial review of the pre-validation version. The instrument was designed to be engaging and easy to understand, using Canva Pro for layout and design. Phase 3 – Validation by judges For validation, judges were selected from collaborating professionals (preceptors, coordinators, and faculty) and residents from the Multiprofessional Residency Program in Collective/Public Health at the Regional University of Cariri (PRMSC/URCA). This program focuses on in-service training within SUS technical-assistance settings and includes the professional categories Biology, Physical Education, Nursing, Pharmacy, Physiotherapy, and Nutrition. Residents’ activities are developed primarily through partnership with the Municipal Health Department of Crato. At the time of the study, PRMSC/URCA included 33 enrolled residents and approximately 28 field preceptors and faculty/tutors across the six professional tracks. Eligibility criteria for judges were: for collaborators (preceptors, coordinators, or faculty): at least 6 months of involvement with PRMSC/URCA; minimum master’s degree; involvement in tutoring activities in one of the professional tracks; participation in arbovirus prevention training and/or publications related to arboviruses. For residents: active enrollment in PRMSC/URCA; completion of specialization requirements; second-year residency status (R2); and participation in arbovirus prevention training and/or publications related to arboviruses. After judges were selected, validation was conducted by providing the technology in PDF format together with an invitation letter and an electronic form via Google Forms, distributed through WhatsApp and email. In addition to basic sociodemographic information, the form assessed four domains: objectives and content, text and language, appearance, and relevance. Items were rated using a 4-point Likert scale: 1 (inadequate), 2 (partially adequate), 3 (adequate), and 4 (totally adequate). To determine agreement among judges, the Content Validity Index (CVI) was calculated for each item [ 4 ]. The calculation involved summing the item ratings and dividing by the total number of responses, allowing estimation of judges’ level of agreement across domains and dimensions. A CVI threshold of ≥ 0.80 was adopted as the minimum acceptable value for new instruments [ 13 ]. CVI calculations are presented in Table 2 , along with judges’ comments for each variable and whether suggestions were fully accepted, partially accepted, or not accepted by the researchers (Table 3 ). The flipchart was then revised according to the judges’ feedback, resulting in the final version of the educational technology. Ethical considerations This study was conducted in accordance with internationally recognized ethical guidance for research involving humans (Declaration of Helsinki) and complied with Brazilian regulations for research involving human participants (National Health Council Resolutions No. 466/2012 and No. 510/2016). The study protocol was reviewed and approved by the Research Ethics Committee of the Universidade Regional do Cariri (URCA) (approval number: 5,687,936). All participants were informed about the study objectives and procedures, that participation was voluntary, and that they could withdraw at any time without any penalty. Informed consent was obtained before data collection. Confidentiality was ensured by using anonymized/de-identified data and restricting access to the dataset to the research team. Data handling followed applicable Brazilian data protection requirements (LGPD, Law No. 13,709/2018). No identifying information is reported in this manuscript.. Results Literature review The literature search retrieved a total of 868 documents (Table 1 ). Of these, 831 were excluded because they were not educational/informational materials, booklets, guides, or manuals from the Ministry of Health addressing arbovirus infection prevention, health promotion, and the diagnosis and management of dengue, Zika, and chikungunya. Thus, 37 documents were critically assessed in full, and eight were selected [ 7 – 9 , 16 – 20 ] for data extraction because they provided satisfactory information on health promotion and arbovirus prevention and were used to compose the flipchart. Construction of the technology To construct the instrument, a script was developed and organized into frames, sequentially numbered according to the flow of information, containing the texts that would constitute the flipchart content. Scientific information was incorporated into the educational material using action verbs, emphasizing self-prevention. All researchers contributed to the design and structuring process. It is noteworthy that the researchers who created the technology live in Northeast Brazil and, in their clinical practice, have experienced outbreaks of dengue, Zika, and chikungunya. To foster familiarity and engagement with the target audience in future use, the instrument’s appearance was designed with Northeastern Brazilian themes and cordel-inspired illustrations, using a black, gray, and white color palette. The language used in the instrument was intentionally adapted to be more understandable to the community, avoiding technical and scientific terminology commonly used in health care, with a focus on popular language. The flipchart was only submitted for validation after approval by all researchers. Validation of the technology Seventeen judges participated in the validation process. Among them, 10 (58.8%) were female and seven (41.2%) were male, aged 26–49 years (mean 33.8 years). Nine (52.9%) were residents and eight (47.1%) were collaborators (preceptors, coordinators, or faculty) of the PRMSC/URCA. Regarding professional background, eight (47.1%) were nurses, three (17.6%) nutritionists, three (17.6%) physiotherapists, one (5.9%) biologist, one (5.9%) physical education professional, and one (5.9%) pharmacist. Academic degrees included nine (52.9%) specialists, six (35.3%) master’s degree holders, and two (11.8%) doctoral degree holders. Regarding workplace setting, 12 (70.6%) worked in the Family Health Strategy (FHS) and five (29.4%) in a higher education institution. The validation instrument assessed judges’ perceptions of the technology in relation to objectives and content, text and language, appearance, and relevance. Overall, the form comprised 23 items distributed across four sections (Table 2 ). The items in each section evaluated whether the intended aspects were achieved through the development of the technological artifact. After receiving responses, CVI calculations were performed to synthesize the judges’ opinions. The total CVI was 1.00 for objectives and content, 1.00 for text and language, 0.98 for appearance, and 0.99 for relevance. The overall CVI, calculated as the mean across all items, was 0.99, as shown in Table 2 . Table 2 Validation of the flipchart by judges. Evaluation criteria Inadequate Partially adequate Adequate Totally adequate Agreement n (%) CVI Objectives and Content 1.1 The flipchart addresses key aspects that should be presented in arbovirus prevention. 0 0 5 12 17 (100%) 1.00 1.2 It includes the information that should be covered in arbovirus prevention. 0 0 7 10 17 (100%) 1.00 1.3 All important concepts are addressed clearly and objectively. 0 0 10 7 17 (100%) 1.00 1.4 The information presented is scientifically correct. 0 0 7 10 17 (100%) 1.00 1.5 The content is motivating and encourages continued reading/page progression. 0 0 8 9 17 (100%) 1.00 1.6 Messages are presented clearly and objectively. 0 0 11 6 17 (100%) 1.00 1.7 There is a logical sequence of the proposed content. 0 0 9 8 17 (100%) 1.00 Total 1.00 Text and Language 2.1 The text is compatible with the target audience. 0 0 9 8 17 (100%) 1.00 2.2 Terminology is appropriate for the target audience. 0 0 9 8 17 (100%) 1.00 2.3 Information is well structured regarding coherence and spelling. 0 0 8 9 17 (100%) 1.00 2.4 Writing style corresponds to the target audience’s knowledge level. 0 0 10 7 17 (100%) 1.00 2.5 The font type used facilitates reading. 0 0 7 10 17 (100%) 1.00 Total 1.00 Appearance 3.1 Illustrations (images) are relevant to the content of the material. 0 1 5 11 16 (94.1%) 0.94 3.2 Font size of titles, subtitles, and text is adequate. 0 0 5 12 17 (100%) 1.00 3.3 Text and figure colors are appropriate and easy to understand. 0 0 9 8 17 (100%) 1.00 3.4 The amount of information contained in the flipchart is adequate. 0 0 8 9 17 (100%) 1.00 3.5 The number of pages is adequate. 0 0 4 13 17 (100%) 1.00 Total 0.98 Relevance 4.1 It may promote behavior change among professionals regarding arbovirus prevention. 0 1 10 6 16 (94.1%) 0.94 4.2 It can circulate in the scientific field in the area of health. 0 0 9 8 17 (100%) 1.00 4.3 The flipchart is appropriate to assist health professionals in arbovirus prevention. 0 0 8 9 17 (100%) 1.00 4.4 The flipchart provides the main functions needed for arbovirus prevention. 0 0 10 7 17 (100%) 1.00 4.5 The flipchart addresses aspects necessary for health promotion. 0 0 10 7 17 (100%) 1.00 4.6 The flipchart is suitable for use by the target audience as a supportive tool in care delivery. 0 0 8 9 17 (100%) 1.00 Total 0.99 Overall 0.99 The instrument also received improvement suggestions and judges’ comments regarding objectives and content, text and language, appearance, and relevance (Table 3 ). In a meeting, the researchers evaluated all suggestions and decided whether to accept them fully, partially, or not at all for the final version of the instrument. A total of 11 (78.6%) suggestions were fully accepted, two (14.3%) were partially accepted because they addressed post-infection care (outside the prevention focus), and one (7.1%) was not accepted because it suggested producing a new colored version, which diverged from the researchers’ proposal of a single cordel-inspired version in a black, white, and gray scale. Table 3 Judges’ suggestions and considerations. Domain Judges’ suggestions Adopted? Objectives and Content Judge 4: Add the importance of self-care, increased fluid intake, rest, warning signs. Partially Judge 11: Add information on seasonal periods with higher numbers of cases, coinciding with the rainy season in each region. Yes Judge 11: Where is diagnosis performed? In cases of complaints about lots/houses with water accumulation, what contact should be used to report it? Partially Judge 12: Insert a concise concept/definition of arboviruses. Yes Judge 12: Include dialogue among health professionals about prevention practices. Yes Judge 12: State the obvious in some part of the flipchart, e.g., to avoid dengue breeding sites, there should be no standing water. Yes Judge 14: Add information on the importance of not littering and not disposing waste in open areas. Yes Text and Language Judge 1: Introduce some regional/colloquial words with captions, e.g., “joint pain” instead of “pain in the joints.” Yes Judge 12: Continue using the imperative mood. Yes Appearance Judge 12: Change the title to “Flipchart: Together for the prevention of arbovirus infections.” Yes Judge 12: Structure the flipchart starting with an introductory page presenting the objective of the technology. Yes Judge 12: For the cover illustrations, replace with the façade of a Primary Care Unit and include professionals from the health team. Yes Judge 12: Create two versions of the flipchart, one colored and one black-and-white. No Judge 17: Include the university logo on the flipchart cover. Yes Judges’ comments (Relevance) Judge 1 I consider this flipchart very important for health education practice and it will contribute greatly to the work of professionals who have access to this instrument. Judge 6 Wonderful flipchart—authentic, incredible, and it will certainly be very useful. Judge 12 I liked the images that represent people without identifying gender or biological sex. Congratulations on the initiative; I look forward to the final version and the contribution, and certainly the publication, that this study will bring. Judge 15 The material is very good. After implementing all suggested changes, a second evaluation round by judges was not conducted, as the overall CVI had already indicated the validity of the new technology. The final version of the instrument, “Flipchart: Together for the prevention of arbovirus infections,” comprised seven pages (one cover page, one presentation page, four content pages, and one dialogue page encouraging prevention practices). The final version is illustrated in Fig. 1 . Discussion The development of educational technologies addressing arboviral diseases represents a relevant strategy to strengthen health education actions for families and communities [ 15 ]. In the present study, the flipchart “Together for the prevention of arbovirus infections” demonstrated high agreement among expert judges across the evaluated domains, supporting its suitability as an educational resource to assist health promotion and prevention activities in PHC. The use of illustrations and clear language may facilitate communication and knowledge acquisition regarding arbovirus prevention and control measures, particularly in community-based settings. In Brazil, the control of dengue, Zika, and chikungunya relies on health surveillance actions that integrate health promotion, prevention, and control measures, constituting an important space for articulating technical approaches and knowledge⁵. Therefore, the development of tools designed to support preventive practices may contribute to strengthening PHC and reinforcing community health approaches, with emphasis on mitigating emerging diseases that continue to pose challenges to Brazilian public health [ 21 ]. When discussing the use of educational technologies for arbovirus prevention, it is also important to consider the epidemiological context of these infections. In 2022, the state of Ceará reported 172,398 suspected arbovirus cases, of which 77,420 were confirmed, representing a 160.5% increase compared with 2021. Among confirmed cases in 2022, 34,988 were dengue, 42,399 chikungunya, and 33 Zika [ 5 ]. In addition, climate-related phenomena affecting the country, particularly Northeast Brazil, have been associated with the broader dissemination of arbovirus vectors, contributing to the persistence and expansion of these diseases [ 4 , 5 ]. In this context, prevention plays a central role in PHC, a key setting for implementing organized and effective actions, given that care practices in the territory inherently rely on education, dialogue, and reciprocal learning with communities [ 22 ]. Evidence from PHC settings has highlighted the applicability of educational technologies focused on dengue and Zika prevention among practicing professionals, describing innovative processes of popular education and continuing education in health and reporting improvements in knowledge regarding these infections [ 12 ]. Moreover, within the broader framework of health education, health promotion, and disease prevention, multiprofessional work is essential, as it supports collective practice based on reciprocal collaboration and a comprehensive perspective on users’ needs, enabling multiple approaches and coordinated technical and relational interventions among different professional categories [ 1 , 21 ]. Collective forms of health education in PHC may involve diverse social actors and collaborative practices that foster innovation and successful outcomes, representing central contributions and opportunities for interprofessional teamwork [ 6 ]. In this regard, PHC teams should prioritize encouraging and guiding the population to play an active role in controlling breeding sites and risk environments in both urban and rural contexts, inside and outside households, where arboviral infections remain frequent [ 10 ]. Health technologies aimed at arbovirus prevention are also relevant because they may support professional practice by facilitating the acquisition, use, and consolidation of knowledge, skills, and decision-making processes [ 22 ]. Educational technologies, in particular, are important for the teaching–learning process by mediating interaction between the health professional, the user, and the educational material itself [ 15 , 21 ]. This study has limitations. First, the flipchart was not validated with the end users/target population, which should be addressed in future research to assess comprehension, acceptability, and usability in real-world contexts. In addition, the instrument may be tested in future effectiveness studies, such as controlled or cluster-based designs in PHC settings, to evaluate outcomes related to knowledge, preventive practices, and implementation in routine care. Conclusion This study developed and validated a flipchart on arbovirus infection prevention for use by Primary Health Care professionals in education, health promotion, and disease prevention practices within the care context. The technology was considered relevant and achieved an overall Content Validity Index (CVI) of 0.99, meeting the recommended threshold for new instruments. As a contribution, this study provides a practice-oriented educational technology that consolidates scientific knowledge into an easy-to-understand resource. The flipchart supports community-focused care by promoting preventive practices and reinforcing the importance of environmental measures as part of arbovirus control. Declarations Ethical approval The study was conducted according to the Declaration of Helsinki and Brazilian ethical regulations (National Health Council Resolutions No. 466/2012 and No. 510/2016). Approval was granted by the Research Ethics Committee of the Universidade Regional do Cariri (URCA) (approval number: 5,687,936). Declarations of Helsinki (World Medical Association). Consent to participate Informed consent was obtained from all participants prior to data collection, using an electronic informed consent form. Consent to publish Not applicable. This manuscript does not contain any individual person’s data in any form. Clinical trial number not applicable. Funding This research received no external funding. Author Contribution LFRM: Conceptualization; Methodology; Investigation; Formal analysis; Data curation; Writing – original draft; Writing – review & editing; Visualization; Project administration. YMSM: Methodology; Investigation; Data curation; Writing – review & editing. ARV: Methodology; Investigation; Data curation; Writing – review & editing. MMST: Supervision; Methodology; Writing – review & editing. JMM: Investigation; Data curation; Writing – review & editing. ICSLB: Supervision; Conceptualization; Methodology; Writing – review & editing. Data Availability The datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request. References Santos LLM, Aquino EC, Fernandes SM, Ternes YMF, Feres VC. Dengue, chikungunya, and Zika virus infections in Latin America and the Caribbean: a systematic review. Rev Panam Salud Publica. 2023;47:1. https://doi.org/10.26633/RPSP.2023.34 . Roster KO, Martinelli T, Connaughton C, Santillana M, Rodrigues F. Estimating the impact of the COVID-19 pandemic on dengue in Brazil. Preprint. 2023. https://doi.org/10.21203/RS.3.RS-2548491/V1 . Almeida LS, Cota ALS, Rodrigues DF. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8757656","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":608129320,"identity":"915a922c-7ad8-4200-9702-d261e17a353d","order_by":0,"name":"Luis Fernando Reis Macedo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5klEQVRIiWNgGAWjYFACxgYGhgIGHgZ2IJ1gAxLhIUaLAVAZzwGgljSitICAARBLJAAJYrSYtzc3f2AwOCwjP/ON2YMHCTb25gy8xz7g0yJz5mCbBFALj8HtHHODhIS0xJ0NfMkz8GmRkEhsYwBrkc4xk0j8cTjB4ACPMV6HScg/BDuMR37mGTOJhIT/9oS1SDA2gB3GcIMHpOUA4waCWngS2yQSDNJ5DM6klQG1JCfubOZLxq+F/fjjDx8qrO3l2w9vk/yRYGdvzt57GK8WMEhA5hgwE9aABgxI1jEKRsEoGAXDHQAA9vFAemgGYcQAAAAASUVORK5CYII=","orcid":"","institution":"Universidade de São Paulo","correspondingAuthor":true,"prefix":"","firstName":"Luis","middleName":"Fernando Reis","lastName":"Macedo","suffix":""},{"id":608129321,"identity":"038d15c3-8f48-451f-9545-14c1e3ba73b6","order_by":1,"name":"Yvinna Marina Santos Machado","email":"","orcid":"","institution":"Universidade Regional do Cariri","correspondingAuthor":false,"prefix":"","firstName":"Yvinna","middleName":"Marina Santos","lastName":"Machado","suffix":""},{"id":608129322,"identity":"5e818fc9-05f7-4a04-8fdb-10e1dccaa633","order_by":2,"name":"Alzenir Rosa Viana","email":"","orcid":"","institution":"Universidade Regional do Cariri","correspondingAuthor":false,"prefix":"","firstName":"Alzenir","middleName":"Rosa","lastName":"Viana","suffix":""},{"id":608129323,"identity":"e8f52e50-2750-485b-85aa-8644c2d98eef","order_by":3,"name":"Marlene Menezes de Souza Teixeira","email":"","orcid":"","institution":"Universidade Regional do Cariri","correspondingAuthor":false,"prefix":"","firstName":"Marlene","middleName":"Menezes de Souza","lastName":"Teixeira","suffix":""},{"id":608129324,"identity":"be771013-1647-4149-a24c-2bacbe996833","order_by":4,"name":"Jessyca Moreira Maciel","email":"","orcid":"","institution":"Universidade Regional do Cariri","correspondingAuthor":false,"prefix":"","firstName":"Jessyca","middleName":"Moreira","lastName":"Maciel","suffix":""},{"id":608129325,"identity":"a9366177-4b71-467c-b2b1-0fa83aa412b5","order_by":5,"name":"Izabel Cristina Santiago Lemos de Beltrão","email":"","orcid":"","institution":"Universidade Regional do Cariri","correspondingAuthor":false,"prefix":"","firstName":"Izabel","middleName":"Cristina Santiago Lemos","lastName":"de Beltrão","suffix":""}],"badges":[],"createdAt":"2026-02-01 16:24:54","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8757656/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8757656/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105051584,"identity":"c3b68520-d96d-46a7-9891-50af0156b017","added_by":"auto","created_at":"2026-03-20 10:27:21","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":430924,"visible":true,"origin":"","legend":"\u003cp\u003eIllustrative representation of the final version of the flipchart.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8757656/v1/f883101163d9fb629adb36de.png"},{"id":105562795,"identity":"c1288467-541e-4d3c-ba25-a087cfe734bc","added_by":"auto","created_at":"2026-03-27 12:44:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1515177,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8757656/v1/3b5398c0-7805-449e-8167-c62bc747636b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"An educational flipchart to support arbovirus prevention in primary health care","fulltext":[{"header":"Introduction","content":"\u003cp\u003eArboviral diseases represent an important public health problem due to their epidemic occurrence and their potential to cause a wide range of clinical manifestations, including severe forms and inflammatory, hemorrhagic, and neurological complications. Among the main arboviral diseases of interest in Brazil are dengue, chikungunya, and Zika, transmitted predominantly by the mosquito Aedes aegypti [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Brazil, the incidence of these diseases is associated with environmental and climatic factors, showing seasonal patterns and increased cases during warmer and rainier periods, conditions that favor vector proliferation [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In addition, territorial vulnerabilities, such as the absence or inadequacy of basic sanitation and improper water storage conditions, may increase breeding sites and contribute to community spread [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this context, prevention is a central component to reduce incidence and mitigate individual and collective impacts. Primary Health Care (PHC) constitutes a strategic setting for health promotion and disease prevention actions, integrating territory-based interventions and educational practices aimed at the population [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStudies indicate essential strategies for arbovirus prevention within PHC, including: (1) vector control, through elimination of breeding sites and environmental measures (such as sealing water containers, cleaning gutters, and properly disposing of containers that accumulate water) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]; (2) health education, providing guidance on prevention, signs and symptoms, and recommended actions in suspected infection [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]; (3) epidemiological surveillance, through timely case notification and monitoring of viral circulation in the area; (4) immunization, when indicated according to guidance from the Ministry of Health and state and municipal health departments [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]; and (5) appropriate clinical management, including early identification and follow-up of cases, helping to reduce complications and interrupt transmission chains in the territory [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePHC stands out as the preferred entry point to the health system, strengthening bonding, longitudinality, comprehensiveness, and care coordination [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e],[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In this setting, the use of educational resources and health technologies can enhance health communication, support health education practices, and increase the effectiveness of preventive actions in the territory [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Therefore, it is relevant to develop a scientifically grounded and validated educational technology aimed at PHC professionals to support educational actions with the population, contributing to arbovirus prevention and strengthening care and health promotion practices.\u003c/p\u003e \u003cp\u003eAs a Brazilian educational technology, its application may be expanded to different contexts. However, the development of the instrument prioritized populations living in the Northeast region of the country, with emphasis on the state of Cear\u0026aacute;, given the increase in notifications in recent years [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Thus, the material was designed to support the health team in care delivery and preventive actions related to dengue, Zika, and chikungunya, fostering a comprehensive approach and potential improvement in quality of life.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis was a descriptive methodological study aimed at developing and assessing the content and face validity of an educational technology in the form of a flipchart, designed to support PHC professionals in delivering educational practices and health promotion actions for arbovirus prevention. The study was conducted between July 2022 and February 2023 and was grounded in instrument development and validation frameworks proposed by Polit and Beck [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], as well as Brazilian technical and regulatory documents related to the prevention, diagnosis, and management of dengue, Zika, and chikungunya.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy setting\u003c/h3\u003e\n\u003cp\u003eThe study was carried out in the city of Crato, Cear\u0026aacute;, Brazil. Crato is located in the Cariri macroregion, at the foothills of the Chapada do Araripe. The municipality covers an area of 1,158.150 km\u0026sup2; and has an estimated population of 133,913 inhabitants, according to the Brazilian Institute of Geography and Statistics (IBGE) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003ePhases of technology development\u003c/h3\u003e\n\u003cp\u003eThe methodological process was organized into three phases: (1) documentary review and content synthesis; (2) construction of the flipchart; and (3) validation by judges (content and appearance), following recommendations for the development and validation of educational instruments/technologies.\u003c/p\u003e\n\u003ch3\u003ePhase 1 – Documentary review and content synthesis\u003c/h3\u003e\n\u003cp\u003eThe documentary review followed four steps: (1) search and selection of educational/informational materials, booklets, guides, and manuals from the Ministry of Health addressing arbovirus prevention, health promotion, and the diagnosis and management of dengue, Zika, and chikungunya; (2) data extraction from selected materials; (3) synthesis of findings; and (4) presentation and grouping of information [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEligibility criteria were defined as follows. Inclusion: educational/informational materials, booklets, guides, and manuals from the Ministry of Health addressing arbovirus prevention, health promotion, and the diagnosis and management of dengue, Zika, and chikungunya. Exclusion: materials published before 2012.\u003c/p\u003e \u003cp\u003eSources were searched in a directed and purposive manner, considering the volume of publications on the topic and the need to follow current guidance for arbovirus control adapted to the present context. In addition, as the technology was intended for use by professionals working within Brazil\u0026rsquo;s Unified Health System (SUS), priority was given to Ministry of Health materials that were up to date and aligned with international guidelines.\u003c/p\u003e \u003cp\u003eThe search was conducted between August and September 2022 in the Health Information Locator (LIS), ColecionaSUS, and the Latin American and Caribbean Health Sciences Literature database (LILACS), accessed through the Virtual Health Library (BVS), using the advanced search form. The search was limited to the period 2012\u0026ndash;2022 and to non-conventional documents. The descriptors used were: prevention, arboviruses, Aedes aegypti, dengue, Zika, and chikungunya, combined with the Boolean operator AND and intercalated searches (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSearch strategy.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSearch strategy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLIS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eColecionaSUS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLILACS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevention AND arboviruses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevention AND \u003cem\u003eAedes aegypti\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevention AND dengue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e394\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e463\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevention AND Zika\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e136\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e195\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevention AND chikungunya\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e130\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e868\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTwo independent, non-blinded researchers selected materials initially by titles and abstracts, also prioritizing Ministry of Health sources. The researchers held alignment meetings via Google Meet to resolve disagreements. After screening titles and abstracts, they downloaded the materials, organized them into folders, and documented reasons for exclusion.\u003c/p\u003e \u003cp\u003eFollowing selection of Ministry of Health materials, documents underwent detailed reading and data extraction for qualitative appraisal, prioritizing current guidance. Two non-blinded researchers independently synthesized the main points regarding arbovirus prevention, health promotion, and the technology-related diagnosis and management of dengue, Zika, and chikungunya to inform the instrument. All extracted information was reviewed by a third researcher, who approved its use for the subsequent phase.\u003c/p\u003e\n\u003ch3\u003ePhase 2 – Flipchart construction\u003c/h3\u003e\n\u003cp\u003eThe flipchart \u0026ldquo;Flipchart: Together for the prevention of arbovirus infections\u0026rdquo; was developed based on the theoretical framework identified in the documentary review and on the synthesis and organization of the information gathered in the previous phase. This stage included selection of illustrations, text layout and design, and final editorial review of the pre-validation version. The instrument was designed to be engaging and easy to understand, using Canva Pro for layout and design.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePhase 3 \u0026ndash; Validation by judges\u003c/h2\u003e \u003cp\u003e For validation, judges were selected from collaborating professionals (preceptors, coordinators, and faculty) and residents from the Multiprofessional Residency Program in Collective/Public Health at the Regional University of Cariri (PRMSC/URCA).\u003c/p\u003e \u003cp\u003eThis program focuses on in-service training within SUS technical-assistance settings and includes the professional categories Biology, Physical Education, Nursing, Pharmacy, Physiotherapy, and Nutrition. Residents\u0026rsquo; activities are developed primarily through partnership with the Municipal Health Department of Crato.\u003c/p\u003e \u003cp\u003eAt the time of the study, PRMSC/URCA included 33 enrolled residents and approximately 28 field preceptors and faculty/tutors across the six professional tracks. Eligibility criteria for judges were: for collaborators (preceptors, coordinators, or faculty): at least 6 months of involvement with PRMSC/URCA; minimum master\u0026rsquo;s degree; involvement in tutoring activities in one of the professional tracks; participation in arbovirus prevention training and/or publications related to arboviruses. For residents: active enrollment in PRMSC/URCA; completion of specialization requirements; second-year residency status (R2); and participation in arbovirus prevention training and/or publications related to arboviruses.\u003c/p\u003e \u003cp\u003eAfter judges were selected, validation was conducted by providing the technology in PDF format together with an invitation letter and an electronic form via Google Forms, distributed through WhatsApp and email. In addition to basic sociodemographic information, the form assessed four domains: objectives and content, text and language, appearance, and relevance. Items were rated using a 4-point Likert scale: 1 (inadequate), 2 (partially adequate), 3 (adequate), and 4 (totally adequate).\u003c/p\u003e \u003cp\u003eTo determine agreement among judges, the Content Validity Index (CVI) was calculated for each item [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The calculation involved summing the item ratings and dividing by the total number of responses, allowing estimation of judges\u0026rsquo; level of agreement across domains and dimensions. A CVI threshold of \u0026ge;\u0026thinsp;0.80 was adopted as the minimum acceptable value for new instruments [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCVI calculations are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, along with judges\u0026rsquo; comments for each variable and whether suggestions were fully accepted, partially accepted, or not accepted by the researchers (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The flipchart was then revised according to the judges\u0026rsquo; feedback, resulting in the final version of the educational technology.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003e This study was conducted in accordance with internationally recognized ethical guidance for research involving humans (Declaration of Helsinki) and complied with Brazilian regulations for research involving human participants (National Health Council Resolutions No. 466/2012 and No. 510/2016). The study protocol was reviewed and approved by the Research Ethics Committee of the Universidade Regional do Cariri (URCA) (approval number: 5,687,936). All participants were informed about the study objectives and procedures, that participation was voluntary, and that they could withdraw at any time without any penalty. Informed consent was obtained before data collection. Confidentiality was ensured by using anonymized/de-identified data and restricting access to the dataset to the research team. Data handling followed applicable Brazilian data protection requirements (LGPD, Law No. 13,709/2018). No identifying information is reported in this manuscript..\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eLiterature review\u003c/h2\u003e \u003cp\u003eThe literature search retrieved a total of 868 documents (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Of these, 831 were excluded because they were not educational/informational materials, booklets, guides, or manuals from the Ministry of Health addressing arbovirus infection prevention, health promotion, and the diagnosis and management of dengue, Zika, and chikungunya. Thus, 37 documents were critically assessed in full, and eight were selected [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR17 CR18 CR19\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] for data extraction because they provided satisfactory information on health promotion and arbovirus prevention and were used to compose the flipchart.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eConstruction of the technology\u003c/h2\u003e \u003cp\u003eTo construct the instrument, a script was developed and organized into frames, sequentially numbered according to the flow of information, containing the texts that would constitute the flipchart content. Scientific information was incorporated into the educational material using action verbs, emphasizing self-prevention. All researchers contributed to the design and structuring process. It is noteworthy that the researchers who created the technology live in Northeast Brazil and, in their clinical practice, have experienced outbreaks of dengue, Zika, and chikungunya. To foster familiarity and engagement with the target audience in future use, the instrument\u0026rsquo;s appearance was designed with Northeastern Brazilian themes and cordel-inspired illustrations, using a black, gray, and white color palette.\u003c/p\u003e \u003cp\u003eThe language used in the instrument was intentionally adapted to be more understandable to the community, avoiding technical and scientific terminology commonly used in health care, with a focus on popular language. The flipchart was only submitted for validation after approval by all researchers.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eValidation of the technology\u003c/h2\u003e \u003cp\u003eSeventeen judges participated in the validation process. Among them, 10 (58.8%) were female and seven (41.2%) were male, aged 26\u0026ndash;49 years (mean 33.8 years). Nine (52.9%) were residents and eight (47.1%) were collaborators (preceptors, coordinators, or faculty) of the PRMSC/URCA. Regarding professional background, eight (47.1%) were nurses, three (17.6%) nutritionists, three (17.6%) physiotherapists, one (5.9%) biologist, one (5.9%) physical education professional, and one (5.9%) pharmacist. Academic degrees included nine (52.9%) specialists, six (35.3%) master\u0026rsquo;s degree holders, and two (11.8%) doctoral degree holders. Regarding workplace setting, 12 (70.6%) worked in the Family Health Strategy (FHS) and five (29.4%) in a higher education institution.\u003c/p\u003e \u003cp\u003eThe validation instrument assessed judges\u0026rsquo; perceptions of the technology in relation to objectives and content, text and language, appearance, and relevance. Overall, the form comprised 23 items distributed across four sections (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The items in each section evaluated whether the intended aspects were achieved through the development of the technological artifact.\u003c/p\u003e \u003cp\u003eAfter receiving responses, CVI calculations were performed to synthesize the judges\u0026rsquo; opinions. The total CVI was 1.00 for objectives and content, 1.00 for text and language, 0.98 for appearance, and 0.99 for relevance. The overall CVI, calculated as the mean across all items, was 0.99, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eValidation of the flipchart by judges.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEvaluation criteria\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInadequate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePartially adequate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdequate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotally adequate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAgreement n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCVI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObjectives and Content\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.1 The flipchart addresses key aspects that should be presented in arbovirus prevention.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.2 It includes the information that should be covered in arbovirus prevention.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.3 All important concepts are addressed clearly and objectively.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.4 The information presented is scientifically correct.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.5 The content is motivating and encourages continued reading/page progression.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.6 Messages are presented clearly and objectively.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.7 There is a logical sequence of the proposed content.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e1.00\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eText and Language\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.1 The text is compatible with the target audience.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.2 Terminology is appropriate for the target audience.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.3 Information is well structured regarding coherence and spelling.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.4 Writing style corresponds to the target audience\u0026rsquo;s knowledge level.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.5 The font type used facilitates reading.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e1.00\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAppearance\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.1 Illustrations (images) are relevant to the content of the material.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16 (94.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.2 Font size of titles, subtitles, and text is adequate.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.3 Text and figure colors are appropriate and easy to understand.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.4 The amount of information contained in the flipchart is adequate.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.5 The number of pages is adequate.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.98\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRelevance\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4.1 It may promote behavior change among professionals regarding arbovirus prevention.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16 (94.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4.2 It can circulate in the scientific field in the area of health.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4.3 The flipchart is appropriate to assist health professionals in arbovirus prevention.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4.4 The flipchart provides the main functions needed for arbovirus prevention.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4.5 The flipchart addresses aspects necessary for health promotion.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4.6 The flipchart is suitable for use by the target audience as a supportive tool in care delivery.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.99\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOverall\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.99\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe instrument also received improvement suggestions and judges\u0026rsquo; comments regarding objectives and content, text and language, appearance, and relevance (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). In a meeting, the researchers evaluated all suggestions and decided whether to accept them fully, partially, or not at all for the final version of the instrument. A total of 11 (78.6%) suggestions were fully accepted, two (14.3%) were partially accepted because they addressed post-infection care (outside the prevention focus), and one (7.1%) was not accepted because it suggested producing a new colored version, which diverged from the researchers\u0026rsquo; proposal of a single cordel-inspired version in a black, white, and gray scale.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eJudges\u0026rsquo; suggestions and considerations.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDomain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJudges\u0026rsquo; suggestions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAdopted?\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eObjectives and Content\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJudge 4: Add the importance of self-care, increased fluid intake, rest, warning signs.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePartially\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJudge 11: Add information on seasonal periods with higher numbers of cases, coinciding with the rainy season in each region.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJudge 11: Where is diagnosis performed? In cases of complaints about lots/houses with water accumulation, what contact should be used to report it?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePartially\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJudge 12: Insert a concise concept/definition of arboviruses.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJudge 12: Include dialogue among health professionals about prevention practices.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJudge 12: State the obvious in some part of the flipchart, e.g., to avoid dengue breeding sites, there should be no standing water.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJudge 14: Add information on the importance of not littering and not disposing waste in open areas.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eText and Language\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJudge 1: Introduce some regional/colloquial words with captions, e.g., \u0026ldquo;joint pain\u0026rdquo; instead of \u0026ldquo;pain in the joints.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJudge 12: Continue using the imperative mood.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAppearance\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJudge 12: Change the title to \u0026ldquo;Flipchart: Together for the prevention of arbovirus infections.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJudge 12: Structure the flipchart starting with an introductory page presenting the objective of the technology.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJudge 12: For the cover illustrations, replace with the fa\u0026ccedil;ade of a Primary Care Unit and include professionals from the health team.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJudge 12: Create two versions of the flipchart, one colored and one black-and-white.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJudge 17: Include the university logo on the flipchart cover.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eJudges\u0026rsquo; comments (Relevance)\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eJudge 1\u003c/strong\u003e \u003cp\u003eI consider this flipchart very important for health education practice and it will contribute greatly to the work of professionals who have access to this instrument.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eJudge 6\u003c/strong\u003e \u003cp\u003eWonderful flipchart\u0026mdash;authentic, incredible, and it will certainly be very useful.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eJudge 12\u003c/strong\u003e \u003cp\u003eI liked the images that represent people without identifying gender or biological sex. Congratulations on the initiative; I look forward to the final version and the contribution, and certainly the publication, that this study will bring.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eJudge 15\u003c/strong\u003e \u003cp\u003eThe material is very good.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eAfter implementing all suggested changes, a second evaluation round by judges was not conducted, as the overall CVI had already indicated the validity of the new technology. The final version of the instrument, \u0026ldquo;Flipchart: Together for the prevention of arbovirus infections,\u0026rdquo; comprised seven pages (one cover page, one presentation page, four content pages, and one dialogue page encouraging prevention practices). The final version is illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe development of educational technologies addressing arboviral diseases represents a relevant strategy to strengthen health education actions for families and communities [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In the present study, the flipchart \u0026ldquo;Together for the prevention of arbovirus infections\u0026rdquo; demonstrated high agreement among expert judges across the evaluated domains, supporting its suitability as an educational resource to assist health promotion and prevention activities in PHC. The use of illustrations and clear language may facilitate communication and knowledge acquisition regarding arbovirus prevention and control measures, particularly in community-based settings.\u003c/p\u003e \u003cp\u003eIn Brazil, the control of dengue, Zika, and chikungunya relies on health surveillance actions that integrate health promotion, prevention, and control measures, constituting an important space for articulating technical approaches and knowledge⁵. Therefore, the development of tools designed to support preventive practices may contribute to strengthening PHC and reinforcing community health approaches, with emphasis on mitigating emerging diseases that continue to pose challenges to Brazilian public health [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhen discussing the use of educational technologies for arbovirus prevention, it is also important to consider the epidemiological context of these infections. In 2022, the state of Cear\u0026aacute; reported 172,398 suspected arbovirus cases, of which 77,420 were confirmed, representing a 160.5% increase compared with 2021. Among confirmed cases in 2022, 34,988 were dengue, 42,399 chikungunya, and 33 Zika [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In addition, climate-related phenomena affecting the country, particularly Northeast Brazil, have been associated with the broader dissemination of arbovirus vectors, contributing to the persistence and expansion of these diseases [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In this context, prevention plays a central role in PHC, a key setting for implementing organized and effective actions, given that care practices in the territory inherently rely on education, dialogue, and reciprocal learning with communities [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEvidence from PHC settings has highlighted the applicability of educational technologies focused on dengue and Zika prevention among practicing professionals, describing innovative processes of popular education and continuing education in health and reporting improvements in knowledge regarding these infections [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Moreover, within the broader framework of health education, health promotion, and disease prevention, multiprofessional work is essential, as it supports collective practice based on reciprocal collaboration and a comprehensive perspective on users\u0026rsquo; needs, enabling multiple approaches and coordinated technical and relational interventions among different professional categories [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCollective forms of health education in PHC may involve diverse social actors and collaborative practices that foster innovation and successful outcomes, representing central contributions and opportunities for interprofessional teamwork [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In this regard, PHC teams should prioritize encouraging and guiding the population to play an active role in controlling breeding sites and risk environments in both urban and rural contexts, inside and outside households, where arboviral infections remain frequent [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHealth technologies aimed at arbovirus prevention are also relevant because they may support professional practice by facilitating the acquisition, use, and consolidation of knowledge, skills, and decision-making processes [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Educational technologies, in particular, are important for the teaching\u0026ndash;learning process by mediating interaction between the health professional, the user, and the educational material itself [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study has limitations. First, the flipchart was not validated with the end users/target population, which should be addressed in future research to assess comprehension, acceptability, and usability in real-world contexts. In addition, the instrument may be tested in future effectiveness studies, such as controlled or cluster-based designs in PHC settings, to evaluate outcomes related to knowledge, preventive practices, and implementation in routine care.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study developed and validated a flipchart on arbovirus infection prevention for use by Primary Health Care professionals in education, health promotion, and disease prevention practices within the care context. The technology was considered relevant and achieved an overall Content Validity Index (CVI) of 0.99, meeting the recommended threshold for new instruments.\u003c/p\u003e \u003cp\u003eAs a contribution, this study provides a practice-oriented educational technology that consolidates scientific knowledge into an easy-to-understand resource. The flipchart supports community-focused care by promoting preventive practices and reinforcing the importance of environmental measures as part of arbovirus control.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003e The study was conducted according to the Declaration of Helsinki and Brazilian ethical regulations (National Health Council Resolutions No. 466/2012 and No. 510/2016). Approval was granted by the Research Ethics Committee of the Universidade Regional do Cariri (URCA) (approval number: 5,687,936).\u003c/p\u003e \u003cp\u003eDeclarations of Helsinki (World Medical Association).\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent to participate\u003c/strong\u003e \u003cp\u003e Informed consent was obtained from all participants prior to data collection, using an electronic informed consent form.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent to publish\u003c/strong\u003e \u003cp\u003eNot applicable. This manuscript does not contain any individual person\u0026rsquo;s data in any form.\u003c/p\u003e \u003ch2\u003eClinical trial number\u003c/h2\u003e \u003cp\u003enot applicable.\u003c/p\u003e \u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research received no external funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eLFRM: Conceptualization; Methodology; Investigation; Formal analysis; Data curation; Writing \u0026ndash; original draft; Writing \u0026ndash; review \u0026amp;amp; editing; Visualization; Project administration. YMSM: Methodology; Investigation; Data curation; Writing \u0026ndash; review \u0026amp;amp; editing. ARV: Methodology; Investigation; Data curation; Writing \u0026ndash; review \u0026amp;amp; editing. MMST: Supervision; Methodology; Writing \u0026ndash; review \u0026amp;amp; editing. JMM: Investigation; Data curation; Writing \u0026ndash; review \u0026amp;amp; editing. ICSLB: Supervision; Conceptualization; Methodology; Writing \u0026ndash; review \u0026amp;amp; editing.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSantos LLM, Aquino EC, Fernandes SM, Ternes YMF, Feres VC. Dengue, chikungunya, and Zika virus infections in Latin America and the Caribbean: a systematic review. Rev Panam Salud Publica. 2023;47:1. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.26633/RPSP.2023.34\u003c/span\u003e\u003cspan address=\"10.26633/RPSP.2023.34\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoster KO, Martinelli T, Connaughton C, Santillana M, Rodrigues F. 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Texto Contexto Enferm. 2020;29:1\u0026ndash;14. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1590/1980-265X-TCE-2018-0492\u003c/span\u003e\u003cspan address=\"10.1590/1980-265X-TCE-2018-0492\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Educational technology, Arbovirus infections, Health promotion, Primary health care","lastPublishedDoi":"10.21203/rs.3.rs-8757656/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8757656/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eArbovirus infections remain a major public health challenge in Brazil, particularly in Primary Health Care (PHC), where health education and prevention actions are central to reducing transmission and community risk. Educational technologies can support PHC teams by standardizing key messages and facilitating communication with the population. This study aimed to develop and validate a flipchart educational technology on arbovirus infection prevention for use by PHC professionals.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA methodological study was conducted from July 2022 to February 2023 in three phases: (1) literature/document review to support content development; (2) construction of the flipchart; and (3) content and face validation by 17 judges, including preceptors and second-year residents from a multiprofessional public health residency program (PRMSC/URCA). The judges evaluated four domains, objectives and content, text and language, appearance, and relevance, using a 4-point Likert scale. Validity was assessed using the Content Validity Index (CVI).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eEight documents were eligible and informed the content of the flipchart. The validation results showed a CVI of 1.00 for objectives and content and 1.00 for text and language. The appearance domain presented a CVI of 0.98, and relevance a CVI of 0.99. The overall CVI was 0.99.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe developed flipchart demonstrated high content and face validity and may support PHC professionals in health education, health promotion, and disease prevention practices related to arbovirus infections.\u003c/p\u003e\u003ch2\u003eTrial registration\u003c/h2\u003e \u003cp\u003enot applicable.\u003c/p\u003e","manuscriptTitle":"An educational flipchart to support arbovirus prevention in primary health care","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-20 10:27:17","doi":"10.21203/rs.3.rs-8757656/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-14T06:42:58+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-14T01:14:58+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-06T18:01:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"48862700387551312013590561676265372737","date":"2026-03-27T03:44:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"125500120298462837699036512572702293329","date":"2026-03-23T11:33:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-18T09:01:43+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-03T16:00:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-23T06:38:03+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-11T04:45:19+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Public Health","date":"2026-02-11T04:35:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"caa774a6-5c67-48eb-a146-84d52bbf0d15","owner":[],"postedDate":"March 20th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-17T14:55:13+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-20 10:27:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8757656","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8757656","identity":"rs-8757656","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}