Development and Evaluation of Video-Based Educational Materials for Nutritional Management of Cancer in Children Among Healthcare Professionals and Caregivers

A good audio-visual educational material for caregivers on nutrition management of pediatric oncology patients can improve treatment effectiveness, recovery rate, and nutritional status of patients. This study aimed to develop and evaluate a series of video-based educational materials for nutritional management of pediatric oncology patients among healthcare professionals and caregivers.

(44.7%) cases involving girls. In total from 2012 to 2016, a total of 82,601 deaths due to medically and non -medically certi ed cancer were reported by the National Registration Department for the period 2012 to 2016 [3].
Cancer also causes malnutrition especially in pediatric patients who need adequate nutrients for their rapid growth phase. Mouth ulcers, nausea and vomiting, and diarrhea are among the side effects of treatment that interfere with the normal digestive function and absorption of food of the patient. This disorder results in high-risk children suffering from nutrient de ciencies. A study conducted in the pediatric oncology ward of a Malaysian university hospital found that 58.6% of children were malnourished [4]. A large number of more than half the number of patients is a matter of great concern and should be taken seriously. They can also experience weight problems of either being overweight or underweight, depending on the type of cancer and the treatment they are undergoing [5,6] There is also a risk of death from cachexia if the loss of lean body mass occurs suddenly and is not treated immediately.
The American Cancer Society (2016) de nes caregivers as individuals who are always together helping cancer patients [7]. Caregivers manage cancer patients at no cost, they are usually the spouse, family member, or close friend of the cancer patient. Apart from that, some professionals provide paid care for cancer patients. The role of caregivers is somewhat limited as they are not trained to care for and manage cancer patients. Throughout the pediatric cancer treatment process, caregivers are very important individuals in ensuring that the nutritional needs of these children are adequate in addition to relying on the hospital staff. This is because the hospital may not be able to give full focus to a patient.
So, caregivers need to manage the nutrition of cancer children in terms of ingredient selection, cooking methods, nutritional requirements, and cancer side effects almost entirely. However, authentic reference material needs to be identi ed rst before the input is used. In educating patients, educational materials play an important role in helping to convey accurate and clear nutritional information to the community Several studies have proven the effectiveness of educational materials for the management of pediatric cancer [9,10]. A recent interventional study conducted among the caregivers of pediatric cancer patients in Malaysia using a printed educational material was reported to be bene cial [11]. While ndings from the study revealed that the booklet was effective in increasing the knowledge of the caregivers in the nutritional management of pediatric cancer patients, they also suggested that the booklet should be adopted into a series of educational videos to tackle anticipated limitations faced by caregivers such as availability of the printed version, the cost of purchasing the booklet and the time commitment required to read it. Hence, this study was conducted to ll in the gaps with the aim to develop and evaluate a videobased educational material for nutritional management of pediatric cancer patients among healthcare professionals and caregivers.

Study Design
This study consisted of three phases: 1) Selection of subtopic and content re nement, 2) Development of audio-visual educational materials, 3) Evaluation by health professionals and caregivers of pediatric cancer patients for acceptability and relevance. This study was conducted fully online from December 2020 until June 2021 during Movement Control Order in Malaysia due to the Covid-19 pandemic. Ethical approval for this study was obtained from the University's Research Committee (reference: UKM PPI/111/8/JEP-2021-266). All participants provided written informed consent prior to the start of the study. The process of subtopic selection and re nement of content involved 5 expert panels (consisting of 2 oncology pediatric specialists, 2 oncology pediatric dietitians, and 1 academic dietitian), and 5 caregivers of pediatric cancer patients. Meetings with expert panels were held three times through an online meeting platform (Google Meet), with each session lasting approximately 1-2 hours discussing the relevance of the content, and suitability of the content, graphics, and speci c terms. The process also consists of panels exchanging information based on the present situation of children with cancer. Additionally, feedback and comments were also obtained from caregivers of pediatric cancer patients through drop comments on Google Drive for video improvements.
Phase 2: Development of audio-visual educational materials Following expert panel consultation, four topics were chosen to be adopted into a series of 5 videos with the following titles: 1) Introduction to cancer and its treatment, 2) The side effects of cancer treatment and how to manage them. 3) Nutrition management in children with cancer, and 4) You ask, we answer. The videos were developed in the Malay language, and each video ranged between 3 and 8 minutes. All of the videos were created using free graphic design and video editing applications available online utilizing Canva (Canva Pty. Ltd) and Inshot (Inshot Inc.) respectively. Basic terminology and language were used in the videos, as well as appealing and colourful graphics, pictures with subtitles, clear voice recording, and culturally relevant examples.

Phase 3: Evaluation by healthcare professionals and caregivers of paediatric cancer patients
Ten healthcare professionals consisting of 5 medical doctors and 5 dietitians from medical universities and hospitals in Malaysia who are citizens with a minimum of 5 years working experience in the eld of medicine and/or nutrition and dietetics were invited to participate in this study. The number of experts evaluating the videos in this study exceeds the recommended number of at least ve expert panels suggested by previous studies [12]. Additionally, 5 caregivers aged 18 years old and above who are Malaysian citizens and members of the paediatric cancer support group of the university's hospital were also invited to evaluate the videos. To be eligible to participate in this study, caregivers must also be able to speak and read in the Malay language. These 10 healthcare professionals and 5 caregivers were not involved in the phase I of this study.
The evaluation process was conducted online via emails and WhatsApp where the participants were provided with a link to access a Google Drive folder that contained: i) 5 series of educational videos that need to be evaluated, and ii) google forms of PEMAT-AV (M). An individual evaluation form was provided for each video. This study uses PEMAT-AV (M), the Malay version of the Audio-Visual Patient Educational Material Assessment that has been translated into Bahasa Malaysia by Wong et al. (2018) [13] based on the original English version as an evaluation tool [14]. It comprises 13 statements for understandability and 3 for actionability, and each item on PEMAT scored as either 1 (agree) or 0 (disagree). The total score for understandability and actionability was computed and reported as a percentage. A higher understandability and actionability score imply that the education material is easy to understand and apply. A comment section is also provided to highlight any future improvements that could be made.

Results
Phase 1: Selection of subtopic and re nement of content Development of audio-visual educational material (video series). The video series is constructed based on the content re nement of the 60 pages booklet Chung et al 2018. From 7 topics overall, only 4 topics were selected to be adopted into video series. An online meeting was held proposing the selected topics to the expert panels. The proposed contents (Table 1) were well-received by the expert panels. All the feedback and comments given during the meeting were noted for the betterment of audio-visual educational materials. Majority of the panels agreed on the use of appropriate font type and size. They also emphasized on the incorporation of realistic pictures and illustration to draw interests and aid in a better understanding towards the information. The developed video series has four topics ( Table 2) with a total duration of 29 minutes. The average length of the video is 5.8 minutes. Each video has voice-over to facilitate the written information. The use of attractive and appropriate visual aids is being optimized in all the videos. Upon completing the video series, another meeting was held with the same expert panels to review the nal contents. Acceptance towards the video series among health professionals and caregivers is determined by using PEMAT-AV; in this case, PEMAT-AV(M) is used. A total of 10 health professionals comprising medical doctors (n = 5) and dietitians (n = 5) were selected. Majority of them were Malay (90%) and female (80%). Socio-demographic information of the healthcare professionals is presented in Table 3.

PEMAT-AV(M) evaluation
The score of PEMAT-AV(M) answered by the healthcare professionals and caregivers is calculated and tabulated. Healthcare professionals' cumulative score for understandability is 98.61 ± 0.64% meanwhile for actionability is 98.67 ± 1.82% (Table 5). Video 2, 4 and 5 achieved 100% actionability score. Caregivers' understandability and actionability scores, as in cumulative, are 99.49 ± 0.52% and 99.56 ± 0.99 % respectively (Table 6). The video series were noted to be attractive, helpful, and informative. Video 5 is said to be the most relevant by health professionals considering the current COVID-19 outbreak. Due to diversity in educational background and participants' literacy level, the contents were delivered in simple layman terms which made it easy to understand. The narrator verbalized coherently, enhancing the understandability and actionability of the video series. Healthcare professionals and caregivers made speci c comments to improve the videos in the open-ended section; regarding the consistency, need for elaboration of terminologies and audio-visual quality (Table 7).

Discussion
This study has successfully developed a video series on oncology pediatric nutrition management that are relevant among the healthcare professionals and caregivers. The videos were developed to serve as useful practice guidelines for caregivers in managing their children's nutrition. Accompanied with high acceptance from the healthcare professionals, this video series can be used to educate and empower the caregivers with the right knowledge to help their children throughout the cancer treatment, thus reducing the risk of malnutrition and further improve the patient's quality of life.
The content of these videos was developed based on a booklet entitled Oncology Pediatric: Nutritional Management for Caregivers to address the lack of local educational materials of nutritional management for children with cancer and tackle the bad malnutrition among patients [11]. There was a signi cant improvement of knowledge, attitude and practice among caregivers recorded after reading the booklet. However, the booklet can have limitations such as the buying cost and time taken to nish it. Educational tools in the form of video are proven to be impactful and effective in interventional studies and in some cases, educational technology was slightly superior to traditional educational methods as information aids. The parents of children diagnosed with cancer preferred video as it allowed them to replay and recall information that they could not have picked up or understood beforehand [10]. Video has higher engagement probability because it combines various types of media, thus preventing distraction by extraneous details.
Based on the discussion with expert panels during phase 1, only ve topics were chosen from the total seven topics of the booklet. The video's topic was aligned with parents who stated that they wanted more information on understanding the disease, side effects and extra content on practical or day-to-day management of their children's cancer [10]. The panel experts agreed that the videos should be seven minutes at most to spark interest, maintain focus and attention and not be time-consuming [12]. The terms used were suitable for laymen while maintaining the real health context as plain language, a patient-centered approach for clear communication, is preferred by all health literacy levels [15].
The video series was evaluated by the healthcare professionals consisting of doctors and dietitians who have above ve years of experience in their respective eld and caregivers. PEMAT-A/V is used to evaluate the videos developed to ensure the relevance and acceptance of the videos among healthcare professionals and caregivers. It was a systematically developed questionnaire that consists of two domains which are understandability and actionability. A PEMAT score of above 70% is considered understandable or actionable while below 70% is considered poorly understandable or actionable. Overall, higher score means higher understandability and actionability of the videos developed. The current study is the rst in Malaysia to develop and evaluate videos on oncology pediatric nutrition management for caregivers. This video series has gone through many processes from the development of booklet from scratch by the previous study to nally, the nalized content of the videos after rounds of discussion with expert panels. The feedback received by the healthcare professionals and caregivers in this study will also surely contribute to the video's improvement. In future studies, videos can cover on real life experience of the caregivers in managing the patients' nutrition as it can help the videos to be more relatable and practical.

Conclusions
A video series entitled oncology pediatric nutrition management for caregivers that contained ve short videos was successfully developed and evaluated by the healthcare professionals and caregivers in this study. The videos are well-accepted and relevant by the healthcare professionals and caregivers as proven by the high score of PEMAT understandability and actionability.

Consent for Publication
Consent for publication was obtained from each individual person and their parent or legal guardian.

Availability of data and materials
The datasets obtained from this study are available from the corresponding author on request.
Competing Interests