ARTIGO ARTICLE 561 Evaluation of informative materials on leishmaniasis distributed in Brazil: criteria and basis for the production and improvement of health education materials Avaliação de material informativo sobre leishmanioses distribuído no Brasil: critérios Zélia Maria Profeta da Luz 1,2 e subsídios para a elaboração e o aperfeiçoamento Denise Nacif Pimenta 1 de materiais educativos para a saúde Ana Rabello 1 Virgínia Schall 3 1 Laboratório de Pesquisas Abstract Based on categories related to structure, content, language, and illustrations, the pre- Clínicas, Centro de sent study provides an evaluation of the quality of educational materials on leishmaniasis avail- Referência e Treinamento em Leishmanioses, Centro able to health services in Brazil. The 18 publications evaluated consisted of four handbooks, four de Pesquisas René Rachou, guided studies, four booklets, and six leaflets. Of the total publications assessed, nine were pro- Fundação Oswaldo Cruz. duced by the Brazilian National Health Foundation (FUNASA), five by State and Municipal Av. Augusto de Lima 1715, Belo Horizonte, MG Health Departments jointly with FUNASA, and one by the Pan-American Health Organization. 30190-002, Brasil. The evaluations were also performed by three professionals: a physician specialized in leishma- [email protected] niasis, a parasitologist, and an information/communications expert. The publications failed to 2 Departamento de Parasitologia, Universidade specify key items such as target public, objective, and bibliography. The illustrations, especially Federal de Minas Gerais. in the booklets and leaflets, failed to clarify the text, portrayed biased concepts, and omitted Av. Antônio Carlos 6627, credits and scale. According to this study, informative materials on leishmaniasis distributed in Belo Horizonte, MG 31270-901, Brasil. Brazil present major limitations which jeopardize the quality of information they contain. 3 Laboratório de Educação Key words Leishmaniasis; Evaluation; Educational Materials; Health Education em Saúde, Centro de Pesquisas René Rachou, Fundação Oswaldo Cruz. Resumo Baseado nas categorias estrutura, conteúdo, linguagem e ilustrações, o presente estudo Av. Augusto de Lima 1715, mostra uma avaliação da qualidade da informação de material informativo sobre leishmanio- Belo Horizonte, MG 30190-002, Brasil. ses disponível para os serviços de saúde no Brasil. Dos 18 exemplares analisados, quatro eram manuais, quatro estudos dirigidos, quatro cartilhas e seis folhetos. Nove exemplares foram pro- duzidos pela Fundação Nacional de Saúde (FUNASA), cinco por Secretarias de Saúde, três por Secretarias em colaboração com a FUNASA e um pela Organização Pan-Americana da Saúde/Organização Mundial da Saúde. Para a avaliação foram convidados: um médico espe- cialista na doença, um parasitologista e um especialista da área de informação. Verificou-se nas publicações, ausência de itens como: público alvo, objetivo e bibliografia. Em ilustrações, as imagens, especialmente nas cartilhas e folhetos, não elucidavam o texto e chamou a atenção a presença de idéias preconceituosas, a ausência de crédito à autoria das ilustrações e de escala. O material informativo avaliado apresentou limitações que comprometeram a informação. É im- portante que os órgãos de saúde pública estejam atentos à qualidade do material educativo pro- duzido, por ser este recurso pedagógico valioso na construção do conhecimento transformador. Palavras-chave Leishmanioses; Avaliação; Material Informativo; Educação em Saúde Cad. Saúde Pública, Rio de Janeiro, 19(2):561-569, mar-abr, 2003 562 LUZ, Z. M. P. et al. Introduction in the case of schistosomiasis (Schall & Diniz, 2001). Although educational materials are fre- Leishmaniasis is a serious public health prob- quently produced and used in Brazil as part of lem in Brazil. American tegumentary leishma- disease control programs, little is known about niasis (ATL) and American visceral leishmania- the efficacy of such information. Recently, with sis (AVL) are diagnosed in almost all regions of evidence of serious errors and inadequacies in the country (Waldman et al., 1999). Over the several such publications, some public institu- last ten years (1990-2000), despite control mea- tions and researchers have begun to evaluate sures, there has been a sharp increase in the and require improvements in them. An exam- number of cases reported in urban areas. The ple is the Ministry of Education and Sports, main factors involved in the change in the epi- which is taking steps to evaluate the publica- demiological profile of the disease are proba- tions listed in the National Textbooks Plan bly the ecological characteristics in each re- (PNLD, 2002), identifying parameters to assess gion, the virulence of Leishmania parasites, the quality of the textbooks from the first and vector domiciliation (Oumeish, 1999). In through the eighth grades. Criteria were set to addition, migration of non-immune individu- potentially evaluate quality in terms of correct als from rural areas to poor urban suburbs has content and pertinence of the text, in addition been a key contributing factor to the expansion to identifying and eliminating biased con- of AVL in cities like Natal, Fortaleza, João Pessoa, cepts, using general parameters combined São Luis, and Salvador (Desjeux, 2001). In Greater with specific ones depending on the area of Metropolitan Belo Horizonte, with 4,293,433 knowledge. inhabitants, 95%-100% of whom living in the In the present study we also develop para- urban area (IBGE, 2002), autochthonous cases meters to perform an initial analysis of the of ATL have been reported in 32 (89%) of the quality of informative materials on leishmani- municipalities (Luz et al., 2001). The number of asis currently used in Brazil. The study thus AVL cases has increased steadily since the first adopts an exploratory design combining quan- reported case in 1989, to 94 cases in the year titative and qualitative approaches to assess 2000. In addition, AVL case fatality in Greater educational materials on leishmaniasis avail- Metropolitan Belo Horizonte is high; some 10% able to health services in the country as an ef- of fatal cases can be associated with the lack of fort to create standards to achieve greater effi- qualified health professionals for early diagno- ciency in this kind of information. sis and prompt treatment. In 19 (61.3%) of the municipalities in Greater Metropolitan Belo Horizonte, no referral services were available Material and methods for diagnosis of the infection. Twelve (39%) of the municipalities had health services for Informative materials on leishmaniasis were leishmaniasis evaluation, but only eight (67%) requested by letter from the regional offices of had basic specific diagnostic tests available (Luz the Brazilian National Health Foundation (FU- et al., 2001). Measures to improve health ser- NASA) and State and Municipal Health Depart- vices and training of health professionals are ments. Additionally, all existing materials were therefore essential. Moreover, it is important to consulted at the library of FUNASA and the have high-quality informative materials avail- Brazilian Health Ministry. The material was able, including handbooks, booklets, leaflets, grouped in the following categories: booklets, and posters, which are potentially valuable leaflets, guided studies, and handbooks. The tools that can contribute to routine health ser- research was conducted in two phases. In the vices and control programs with community first phase we established four sets of parame- participation. Nevertheless, in order to be ef- ters, structure, content, language, and illustra- fective, such materials should be preceded by tions, based on the general criteria previously scientific investigation and produced within described by the Brazilian Ministry of Educa- well-defined criteria in order to foster knowl- tion and Sports (PNLD, 2002). An open-ended edge and cognitive potential within the reality questionnaire was prepared (Table 1), and eval- of the target population. The use of illustra- uation of all the materials was performed using tions does not necessarily enhance the materi- the questionnaire guide. We observed the fol- als’ readability or ensure understanding of their lowing for each parameter: message (Lefèvre, 1981). In addition, informa- • Structure: (1) size of text (number of pages); tive materials on diseases in Brazil can tend to (2) suitability of extension in relation to the tar- copy each other, reproducing the same errors get public; (3) quality of printing; (4) quality of for decades, as shown by one group of authors illustrations; (5) authorship; (6) target public. Cad. Saúde Pública, Rio de Janeiro, 19(2):561-569, mar-abr, 2003 EVALUATION OF INFORMATIVE MATERIALS ON LEISHMANIASIS 563 • Content: (1) correct information; (2) infor- Table 1 mation appropriate for the target public; (3) excess or insufficient concepts; (4) important Questionnaire for evaluation of informative materials on leishmaniasis. concepts approached with proper emphasis; (5) presence of appropriate, accurate, and up- 1. Concerning the structure/format, what is your opinion of: to-date bibliographic references. a) Size (dimensions) of material? • Language: (1) clearness; (2) objectivity; (3) b) Is the size of text (number of pages) adequate? presence/absence of biased concepts; (4) at- c) Quality of paper? tractive layout; (5) adequate and organized d) Quality of illustrations? bibliographic references. e) Does