Culturally grounded health communication to support self-care among pregnant women with diabetes: Development and content validation of an educational cordel in Brazil.

Abstract

Diabetes in pregnancy requires sustained self-care and clear guidance across hospital, home, and primary care settings. Conventional educational materials may be less accessible to women facing social vulnerability or limited health literacy. Culturally grounded communication may improve the understandability and relevance of discharge guidance. We conducted a methodological study in two public tertiary maternity hospitals in Fortaleza, Brazil, to develop and content-validate an educational cordel, a traditional Brazilian form of rhymed popular literature. The material was developed through a structured evidence search, collaboration with health researchers and cordelistas, and pilot testing. It was evaluated by 22 hospitalized pregnant women with gestational diabetes mellitus or pre-existing type 2 diabetes and by 40 expert judges. Item-level Content Validity Indices (I-CVIs), scale-level CVI by averaging item values (S-CVI/Ave), Cronbach's alpha, and Kendall's coefficient of concordance were calculated. All target-population items achieved an I-CVI of 1.00, and the S-CVI/Ave was 1.00. The evaluation responses showed modest internal consistency (raw alpha = 0.67; standardized alpha = 0.66). Among expert judges, I-CVIs ranged from 0.95 to 1.00 and the S-CVI/Ave was 0.99. Internal consistency of expert responses was high (raw alpha = 0.96; standardized alpha = 0.97), whereas Kendall's W was 0.039, indicating weak concordance in the relative ranking of items despite high absolute favorable agreement. The educational cordel showed strong preliminary evidence of content validity, cultural relevance, and acceptability for hospitalized pregnant women with diabetes. The findings support further testing in larger and more diverse samples, using standardized measures of understandability and actionability and designs that evaluate effects on knowledge, self-care, continuity of care, and clinical outcomes.