CIN: Computers, Informatics, Nursing
& Vol. 32, No. 5, 242–247 & Copyright B 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
F E A T U R E A R T I C L E
Development and Validation of a Theory-Based Multimedia Application for Educating Persian Patients on Hemodialysis HOSSEIN FEIZALAHZADEH, MSc MANSOUREH ZAGHERI TAFRESHI, PhD HAMID MOGHADDASI, PhD MANSOUREH A. FARAHANI, PhD HAMID TAYEBI KHOSROVSHAHI, MD ZAHRA ZAREH, BSc FAKHRSADAT MORTAZAVI, MD Recent progress in our health systems makes it mandatory to provide effective patient education to achieve highquality care and optimize health outcomes. Patient education is vital and the most important role and responsibility of a nurse. To date, nurses use various educational methods, such as talking directly to patients and using written materials (pamphlets) to educate patients. These methods have their own advantages as well as disadvantages. On Author Affiliations: School of Nursing and Midwifery (Mr Feizalahzadeh and Dr Zagheri Tafreshi), and School of Allied Medical Sciences (Dr Moghaddasi), Shahid Beheshti University of Medical Sciences; Faculty of Nursing and Midwifery, Center Nursing Care Research, Iran University of Medical Sciences (Dr Farahani); and Faculty of Medicine (Drs Khosrovshahi and Mortazavi) and Emam Reza Hospital (Ms Zareh), Tabriz University of Medical Sciences, Tabriz, Iran. This article is based on a nursing PhD dissertation and a research project approved by the Shahid Beheshti University of Medical Sciences, with the registration number 1391-1-86-9148. The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article. Corresponding author: Mansoureh Zagheri Tafreshi, PhD, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Vali-Asr Avenue, Cross of Vali-Asr and Neiaiesh Highway, Opposite to Rajaee Heart Hospital, Tehran, Islamic Republic of Iran, Postal Code: 1996835119 (
[email protected]). DOI: 10.1097/CIN.0000000000000052
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Although patients on hemodialysis require effective education for self-care, several issues associated with the process raise barriers that make learning difficult. Computer-based education can reduce these problems and improve the quality of education. This study aims to develop and validate a theory-based multimedia application to educate Persian patients on hemodialysis. The study consisted of five phases: (1) content development, (2) prototype development 1, (3) evaluation by users, (4) evaluation by a multidisciplinary group of experts, and (5) prototype development 2. Data were collected through interviews and literature review with open-ended questions and two survey forms that consisted of a five-level scale. In the Results section, patient needs on hemodialysis self-care and related content were categorized into seven sections, including kidney function and failure, hemodialysis, vascular access, nutrition, medication, physical activity, and living with hemodialysis. The application designed includes seven modules consisting of user-controlled small multimedia units. During navigation through this application, the users were provided step-by-step information on self-care. Favorable scores were obtained from evaluations by users and experts. The researchers concluded that this application can facilitate hemodialysis education and learning process for the patients by focusing on their self-care needs using the multimedia design principles. KEY WORDS Computer-based education & Hemodialysis & Multimedia application & Patient education
the other hand, several factors, including time and cost, make the patient education service difficult.1,2 Thus, nurses fail to meet the educational needs of the patient, and not surprisingly, most patients continue to report a lack of adequate information regarding their illness, treatment, and self-care. Patients on hemodialysis are typical clients who need effective education for self-care because of their specific chronic condition. Several studies have demonstrated that effective patient education leads to positive health outcomes, for example, adherence to treatment, and reduced mortality rate,3,4 However, because of some additional factors, such as the increasing number of patients; extensive
CIN: Computers, Informatics, Nursing & May 2014 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
physiopsychosocial variations; complex dietary, fluid, and treatment regimens; and time constraints, nurses who provide education to patients on hemodialysis encounter additional problems,5,6 making it increasingly difficult to meet the educational needs of these patients. Fortunately, advances in information and communication technologies, particularly computer-based patient education,7,8 have provided good opportunities to reduce problems, create new and flexible learning environments, and improve the quality of patient education services. Flexibility, repeatability, active learning, multimedia, and feedback are some of the advantages of computer-based education.9 Studies conducted in the field of computer-based patient education, for example, in patients with heart failure7,10,11 and diabetes,12 pregnant women,13 and adolescents,14 have reported positive outcomes such as increased self-care knowledge and adherence to treatment. Results from one study revealed that patients from six hemodialysis centers, who were divided into two groups, multimedia interactive CD education and control, demonstrated significant improvement in terms of knowledge, self-care behavior, and a sense of control over life in the intervention group compared with that in the control group.15 In another study, patients with end-stage renal disease who were educated with a multimedia interactive DVD showed better improvement in terms of knowledge, predialysis uncertainty, and decision regret compared with the control group.16 Despite the effectiveness of computer-based patient education, to the best of our knowledge, studies often do not have a specific theoretical framework for their software or application design. Researchers appear to have analyzed computer-based patient education in a variety of areas, based on factors such as research objectives, samples, and contexts. Consequently, nurses may find it difficult to depict and assume an explicit scientific basis, particularly learning psychology for computer-based patient education that would prevent its appropriate use and evaluation. To improve the quality and effectiveness of computerbased education, Mayer17 has offered his cognitive theory of multimedia learning. In this theory, deep learning requires an active cognitive process and assumes that each person has two separate channels with limited capacity to process visual and verbal stimuli. He offers 10 multimedia design principles based on the findings during experimental research on this theory.17 These principles provide guidelines for multimedia designing and development in a way that promotes optimal cognitive processing and facilitates learning. On the other hand, with the increasing production of multimedia learning objects, concerns about their quality, accuracy, and usefulness have been raised. Therefore, some valid tools have been developed, such as the Learning Object Review Instrument (LORI), as a framework to evaluate the quality of multimedia learning resources.18
Considering multimedia learning theory as our theoretical framework and valid tools such as LORI as an evidencebased evaluation framework to meet quality evaluation criteria, we can guide the patient-specific multimedia application design, development, and evaluation processes. It will provide a theory-based multimedia application of the optimum level of quality that is more effective and useful for patient education and learning. Thus, the aim of our present study is to describe the development and validation process of Mayer’s theoryand evidence-based multimedia applications, to educate Persian patients on hemodialysis. We believe it is a step forward to improve patient education.
METHODS Software engineers use several different models for software development19; iterative design is a well-recognized, cyclic process, in which designers develop a software prototype, test the prototype with users, and modify the prototype based on results to satisfy all users.20 To achieve the research objectives, we developed, evaluated, and modified a prototype of a multimedia application using an iterative design combined with the participation of patients on hemodialysis, hemodialysis staff, and other experts. The study consisted of five phases: (1) content development, (2) prototype development 1, (3) evaluation by users, (4) evaluation by a multidisciplinary group of experts, and (5) prototype development 2. Data were collected by interviews and literature review with open-ended questions as well as two survey forms consisted of a fivelevel scale. The study protocol was approved by the ethics committee at the Shahid Beheshti University of Medical Sciences. All participants provided written informed consent and the principles outlined in the Declaration of Helsinki were followed throughout the study.
Content Development To identify the self-care needs of patients while still providing educational content, it is essential to answer the following questions: What are the self-care needs and priorities of patients on hemodialysis? What is the nature of content required to educate these patients? To answer these questions, the first author of this article (H.F.) interviewed and collected comments from patients on hemodialysis and from a multidisciplinary group of hemodialysis staff recruited by purposive sampling from three hemodialysis centers in Tabriz, Iran, using these open-ended questions. Results from an extensive literature review and participants’ comments provided the basic information and content needed to develop the application.
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Development of Prototype 1 A digital camera was used to capture images and films based on educational objectives. We used Microsoft Office Picture Editor (Microsoft, Redmond, WA), and Adobe Photoshop (Adobe Systems, San Jose, CA) to edit images, Microsoft Office PowerPoint 2007 for simulation and animation, and Windows Movie Maker to produce video clips (PowerPoint and MovieMaker both Microsoft, Redmond, WA). Xilisoft Video Converter Ultimate software (Xilisoft, Haidan, Beijing, China) was used to cut and convert audio files and video clips into various formats. Audio, video, and image files were saved in the Windows Media Audio file, Windows Media Video file, and JPEG formats, respectively. Microsoft Office PowerPoint 2007 was used for creating presentations; its features were used to develop the content as an auto-run, user-controlled multimedia application (named Hemodialysis and Essential Care [HEC]) consisting of training modules. Mayer’s17 multimedia design principles (including coherence, signaling, redundancy, spatial contiguity, temporal contiguity, segmenting, pretraining, modality, and personalization), LORI,18,21 and Fox’s22 research findings were used as frameworks and guidelines to design the application.
Users’ Evaluation In the prototype 1 design and development phase, researchers were in constant contact with patients on hemodialysis and the associated the staff with the application. Based on their feedback, the multimedia application was modified, for example, in terms of error links, icons, graphics, and other design elements. In addition, for the purpose of evaluation of users, patients on hemodialysis from three hemodialysis centers in Tabriz, after using the prototype 1, responded to a five-level scale (very low = 1 to very high = 5) survey form developed by researchers. This survey included 11 quality evaluation criteria for digital learning objects, regarding the degree to which the application met these criteria. The criteria included quality of content and graphics, usefulness, legibility, comprehensibility, and ease of application set up on a personal computer, interfacing with action keys and navigation. In addition, two questions were asked about their satisfaction and interest related to the application, and an open-ended question sought any other recommendations they may have. Thus, the highest possible score was 65, and the lowest was 13.
Experts’ Evaluation In this phase, a multidisciplinary group of experts from Shahid Baheshti and Tabriz Universities of Medical Sciences reviewed the prototype 1 and provided their comments on a five-level scale (very low = 1 to very high = 5) survey 244
form developed by researchers, consisting of 40 quality evaluation criteria of digital learning objects, about the degree to which the application meets these criteria. The criteria were categorized into nine dimensions, including Mayer’s multimedia designing principles (10 items), content (seven items), goal setting (four items), feedback (one item), motivation (three items), presentation design (nine items), usability (four items), and accessibility and reusability (each one item). Thus, the highest possible score was 200, and the lowest was 40. In addition, an open-ended question was posed on additional recommendations.
Prototype 2 At the end of the prototype 1 process, the feedback from participants in phases of evaluation by users and experts was reviewed, the recommendations were integrated, and the application was modified.
RESULTS Content Development In this phase, 14 patients on hemodialysis and 12 hemodialysis staff participated; the latter comprised eight nurses, three nephrologists, and one dietitian. According to patients, the most important self-care need was healthy nutrition, and according to the staff, the most important self-care needs of the patient were the principles of healthy nutrition, vascular access care, drug care, and psychosocial problems. After integrating the findings and results from the literature review, we categorized the content related to patients on hemodialysis self-care needs into seven sections, including kidney function and failure, hemodialysis, vascular access, nutrition, medication, physical activity, and living with hemodialysis.
Prototype 1 In the second phase, a prototype application was developed that provided content in the main menu, in addition to seven modules consisting of small and user-controlled multimedia units. Each module consists of two main and some subsidiary sections. The main section includes educational objectives, films, audios, animations, images, short texts, and self-test. During navigation, the user receives step-by-step self-care information. Furthermore, for additional information on text and image formats, the patient can enter the subsidiary part and return to continue with the main section. Time spent on educational modules varies between 14 and 45 minutes and totals 167 minutes. To be legible and easy to see and navigate, images, icons,
CIN: Computers, Informatics, Nursing & May 2014 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
other patients on hemodialysis. In other words, based on the evaluation by patients, the application (prototype 1) meets all the evaluation criteria to a favorable degree.
T a b l e 1 Demographic Features of Patients Who Participated in the User Evaluation Percent Frequency 10 20 30 20 10 10 10 90 0 100
1 2 3 2 1 1 1 9 0 10
Variable Elementary Education Postelementary Diploma BS MS PhD Female Sex Male Yes Previous hemodialysis No education
Row
Evaluation by Experts
1
2 3
A multidisciplinary group of experts, including seven RNs, one nephrologist, one curriculum development expert, and one information technology specialist, participated in this phase. The mean age and work experience of the experts were 43 T 5.88 and 16.3 T 5.83 years, respectively. Table 2 illustrates the application evaluation scores based on the experts’ responses.
Prototype 2 and fonts were set in large font (20-point bold Titr and Nazanin fonts), and fewer action keys were required. The background color of the slides in the main parts was light blue, whereas the text in the subsidiary parts was white. The memory capacity required to save and run the application from a CD is 1.2 gigabyte. This application works offline and does not require an online connection. Moreover, the entire educational content in text format, with a nutrition pyramid and other important information needed to be healthy, is attached to the main part of the application.
Changes to prototype 1 were made on the basis of the recommendations and feedback from participants and included improvement in graphic quality, for example, color diversity to highlight important points, correction, and audio insertion for the educational objectives, inserting music for some quiet scenes, and correcting typographical errors. Finally, prototype 2 or the last version of the HEC multimedia application was developed.
DISCUSSION Evaluation by Users Ten patients on hemodialysis participated in this phase. The mean age of the users was 44.5 T 12.16 years. Table 1 shows users’ demographic characteristics. The total score obtained based on the user survey forms was 52.5 T 3.27 compared with the highest possible score (65). All participants expressed high levels of satisfaction and interest toward the use of the application and declared that they will recommend it to
Patients on hemodialysis need self-care education to gain additional information to manage their own care. The HEC multimedia application has been developed using a software engineering approach and an iterative design, with the participation of patients on hemodialysis, hemodialysis staff, and other multidisciplinary experts. An integration of Mayer’s multimedia design principles and other literature was used as a guideline to design the application. In the first developmental step, the self-care
T a b l e 2 Application Evaluation Scores Based on the Responses of Experts Row 1 2
3
Evaluation Dimension
Item No. Highest Possible Score Achieved Score Mean
Mayer’s multimedia designing principles Evidence-based Content Goal setting Feedback Motivation Presentation design Usability Accessibility Reusability Sum Total sum
10 7 4 1 3 9 4 1 1 30 40
50 35 20 5 15 45 20 5 5 150 200
38.8 28.6 15.5 3.7 10.9 36.3 17.20 4.1 3.7 120 158.8
T 4.63 T 4.40 T 2.36 T 0.94 T 2.37 T 3.16 T 2.29 T 0.73 T 0.82 T 13.20 T 17.49
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needs of the patient were considered, which is a fundamental step in the patient education process leading to effective education and learning.23 The HEC application, using multimedia design principles, can facilitate the patient education process and lead to effective learning by focusing on self-care needs. This application provides information in the standard teaching framework and in the form of simple, understandable, objective, user-controlled, and small multimedia units. While using the HEC application, patients will receive step-by-step information, knowledge, and skills on self-care. Results from evaluation by experts demonstrated that the application has a sufficient level of Mayer’s multimedia design principles and other essential quality criteria required to meet digital learning objectives, and they approved of it. However, to the best of our knowledge, no published research evidence was found in the field using Mayer’s multimedia design principles in patients on hemodialysis education, but results of a systematic review study revealed that the use of multimedia features facilitates patient education and learning.24 Although studies have shown that a person’s health status is not a barrier to using technology,20 we used large font size and a few action keys for navigation on the HEC application to eliminate any concern about its usability among patients with some problems such as weakness, fatigue, low mobility, and decreased vision. The user test, particularly user interface, is the most important aspect of the software evaluation process.25 In this study, our users evaluated the HEC application as one with high-quality content, easy to interface and navigate, favorable, interesting, and satisfying. For an effective patient education process, several factors, such as context and cultural background should be considered, in addition to physical characteristics of patients23 were considered in the development process of the HEC application. Welch et al20 and Griffith et al26 considered a patient’s physical and other characteristics to develop the Dietary Intake Monitoring Application and an interactive computer-based education program, respectively. Auto-run and standard high-quality file formats are other characteristics of the HEC application, leading to ease of running the program on personal computers with Windows 2000 or later and less disruption in patient education process and educational message transmission. Although the files are large, it is not a major drawback because the program can be run offline, and there is always accessibility to portable high-capacity storage devices such as CDs. This study is the first part of a broader study conducted in the field of computer-based education for patients on hemodialysis. Evaluating the effects of any patient education program or methods is essential to the evaluation process,23 and we intend to conduct a clinical trial to 246
evaluate the effects of the HEC application on patients’ self-care knowledge, behavior, quality of life, and other clinical outcomes. The high cost of development and implementation of computer-based applications for patient education should be considered. Fortunately, in Iran, most hospitals and clinics are equipped with computers and health information systems, and all healthcare staff have an International Computer Driving License; thus, in the context of our study, the digital gap is not very high, and the cost will not be prohibitive.
CONCLUSION The HEC multimedia application has been developed using a software engineering approach and an iterative design, with the participation of patients on hemodialysis, related staff, and experts. The study results showed that it could facilitate the education process of patients on hemodialysis.
LIMITATIONS Only patients who have an appropriate level of cognition, physical status, literacy, and computer skills participated in this study; thus, the findings cannot be generalized to other patients on hemodialysis.
NURSING PRACTICE IMPLICATIONS 1. The HEC application is useful for educating patients on hemodialysis, caregivers, and even hemodialysis staff. 2. The findings of the present study will be useful for educational software development, for other patients as well. 3. Microsoft Office PowerPoint 2007 was used for creating the presentations, and its features were used to develop the application. Thus, nurses can easily use it to develop educational applications for their patients. 4. It is important to develop patient-specific applications that are theory or evidence based and simple, with minimal setup and running requirements. To increase the quality, usefulness, and usability of such applications, it is extremely important to include both the experts and patients in the development and evaluation processes.
Acknowledgments The authors acknowledge all the staff of Shahid Beheshti and Tabriz Universities of Medical Sciences who assisted in this study.
CIN: Computers, Informatics, Nursing & May 2014 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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