Development of video-based educational materials for kidney-transplant patients

Introduction Treatment adherence has been evaluated as a major predictor of long-term outcome, and education has been suggested to improve adherence. Considering the characteristics of adult learners, it is necessary to implement educational programs that meet the needs of transplant patients. Multimedia education may be well-suited for this. This study aims to develop video education materials in accordance with transplant patients’ self-care needs. Methods This study includes a literature review and patient interviews aimed at developing video education materials for the self-care needs of patients who underwent renal transplant surgery at a university hospital in Seoul. Ten patients were interviewed about the desired educational content, accessibility, and other preferences. After verifying the validity of the data, the video scenarios were produced and satisfaction surveys were conducted. Results Eleven self-care education items were identified through interviews with 10 kidney transplant patients. The expert validation of video-based educational content result was high (mean CVI = 0.94). The mean score of the patients’ satisfaction evaluation of the completed 7-minute video instructional materials was also high (4.55 on a 5-point Likert scale). Conclusion Findings indicate that the video education materials will meet the needs of adult learners and mitigate the limitations of the existing education programs by increasing interest and motivation and may contribute to increased treatment adherence and ultimately, positively effect self-care for new transplant patients.


Introduction
Treatment adherence has been evaluated as a major predictor of long-term outcome, and education has been suggested to improve adherence. Considering the characteristics of adult learners, it is necessary to implement educational programs that meet the needs of transplant patients. Multimedia education may be well-suited for this. This study aims to develop video education materials in accordance with transplant patients' self-care needs.

Methods
This study includes a literature review and patient interviews aimed at developing video education materials for the self-care needs of patients who underwent renal transplant surgery at a university hospital in Seoul. Ten patients were interviewed about the desired educational content, accessibility, and other preferences. After verifying the validity of the data, the video scenarios were produced and satisfaction surveys were conducted.

Results
Eleven self-care education items were identified through interviews with 10 kidney transplant patients. The expert validation of video-based educational content result was high (mean CVI = 0.94). The mean score of the patients' satisfaction evaluation of the completed 7-minute video instructional materials was also high (4.55 on a 5-point Likert scale).

Conclusion
Findings indicate that the video education materials will meet the needs of adult learners and mitigate the limitations of the existing education programs by increasing interest and motivation and may contribute to increased treatment adherence and ultimately, positively effect self-care for new transplant patients.

Introduction
Globally, an aging population and greater prevalence of chronic disease has increased the number of patients with end-stage renal disease (ERSD) who require transplantation or dialysis [1]. The former procedure is considered the gold standard because it preserves 70-80% of normal kidney function, whereas dialysis only preserves 15-20%. Moreover, transplantation allows patients to freely engage in physical activity, thus elevating patient satisfaction [2]. South Korea performs around 2,000 kidney transplantations annually; 2,108 were performed in 2018 and 2,293 in 2019 [3]. These numbers are about 1.8 times higher than those of 1,142 and 1,238, performed in 2008 and 2009, respectively; kidney transplantations are expected to continue to increase in the future [3]. Furthermore, kidney transplantation rates are projected to continue increasing.
Post-transplantation survival rates are improving with the advancement of surgical techniques and immunosuppressants, leading to a decrease in drug-related adverse effects [4]. Nevertheless, patients who undergo kidney transplantation are associated with serious risks, including rejection, cardiovascular disease, and infection. Thus, they require persistent postoperative management, including strict regulations for medication and diet. Kidney transplants largely fail due to treatment noncompliance, which negatively influences quality of life for transplant recipients [5]. One study on compliance among transplant recipients reported noncompliance by 20-37% of adult patients [6]. Treatment noncompliance is associated with 50% of acute rejection and 15% of organ loss, causing negative short-and long-term physical effects, along with economic losses [6,7]. Clearly, programs that improve compliance should be a critical part of clinical management for promoting patient well-being. To that end, numerous studies have investigated intervention programs to improve treatment compliance [8,9]. In South Korea, several studies have examined the effects of educational interventions for kidney-transplant patients [10,11], but they have focused largely on knowledge transfer. To the best of our knowledge, no one has attempted to develop a protocol that could potentially induce changes in treatment compliance.
Recently, there has been growing interest in educational videos or other multimedia that enhance knowledge retention and stimulate interest, even without the physical presence of an instructor. As an example, a multimedia dietary education program for gastrectomy patients successfully improved their nutritional status [12]. Additionally, audiovisual education on TV or video was more effective at altering behavior than spoken or written education for glaucoma patients [13]. Video-based education reduced repetitive time consumption of nurses caring for hemodialysis patients while simultaneously also maintaining patient compliance [14]. Thus, the pedagogical effectiveness of multimedia is equal or superior to conventional methods, while also being transferable across different locations and situations [15]. In clinical settings, for instance, video-based programs can provide valuable information to patients despite the shortages in personnel and time that preclude traditional educational methods [12]. Given the link between education and treatment success, kidney-transplant patients would greatly benefit from the development of practical multimedia educational materials.
The objective of this study was to develop an educational program that can improve patient self-management compliance after kidney transplantation. Specifically, we first aimed to determine the difficulties experienced by kidney-transplant patients during treatment compliance, along with the probable causes. Next, we aimed to create informational videos that could provide the knowledge required for improved treatment compliance.

Study design
The research used multiple descriptive case studies to investigate the educational demands of patients undergoing outpatient care after kidney transplantation. Data from the case studies were then used to formulate video-based educational materials.

Procedures
Literature review. A literature search was conducted on the educational demands of kidney-transplant patients. Specifically, we analyzed text education materials or YouTube video data provided online by domestic and international hospitals and organizations (Korean transplant society, Seoul National University Hospital, Severance Hospital, Jackson Memorial Hospital health system, Nebraska medicine, UW medicine, ITNS, UHN) to kidney transplant patients.
Survey of educational demands among kidney-transplant patients. After receiving approval from the IRB at the hospital affiliated with Y-University in Seoul (Project No.: 3-2017-0312), we conducted 30-40-minute interviews between March 1 and May 31, 2018 with patients receiving post-kidney transplant care at the surgical outpatient department. We extracted a random sample of 10 kidney-transplant patients and obtained their consent before interviews. We amended and supplemented the questions during the interviews used in the research by Kim [16]. Based on this, semi-structured questions were formulated and used in this study. Interviews were conducted one-on-one in the counseling room to protect the privacy of the subjects and were recorded after obtaining consent. The interview was conducted by one researcher. Three questions were asked: knowledge related to disease, contents of drug use, and questions about life affecting treatment (S1 Appendix).
Construction and expert validation of educational videos. Based on the survey results and the literature review, educational scenarios were developed and filmed. Content validity was verified by an expert panel consisting of one board-certified transplant surgeon, three nurses with at least 5 years of experience (one coordinator, two nurse specialists), and one professor at a college of nursing. Each educational item was scored for suitability on a four-point scale; items with a content validity index (CVI) � 0.80 were selected.
Video production. Production included image or video capture and narration recording. To improve the reliability of the information obtained during interviews, a transplant surgeon participated directly in screening the content. An active production director and two filming experts assisted with filming and editing. The finalized video was produced in Premiere Pro and lasted 7 minutes and 37 seconds (https://www.youtube.com/watch?v=qYu9T-01OpU or https://www.youtube.com/watch?v=-hiOTmgj3UQ).
Satisfaction assessment for video materials. The same 10 kidney-transplant patients who participated in the survey were also asked about areas for improvement and overall satisfaction with the resultant educational videos. Because this part of the study focused on using feedback to polish the educational materials, there was no need to calculate the number of subjects needed for statistical analysis. Satisfaction assessments were conducted between August 1 and September 31, 2018. To protect patient privacy, the video viewing and questionnaire completion occurred in an outpatient treatment room, one person at a time. In addition to the time required for watching the video, interview-based feedback and satisfaction assessment took 10 minutes.
The satisfaction questionnaire was an amended version of an instrument for assessing video programs [17]. Items (content difficulty, language suitability, interest, motivation, effectiveness, duration appropriateness, screen-composition suitability, audio quality, and picture quality) were scored on a five-point Likert scale, with higher scores indicating greater satisfaction. We also received verbal feedback on the video content by the patients.

Literature review
Currently, in Korea, medical personnel provide education on self-care after kidney transplantation before discharge, and thereafter provide regular group education or online textual education materials presented by hospitals and transplantation societies. The number of patient education data produced by each hospital and posted on YouTube has recently started to increase, but the number has not yet been large.

Educational demands survey
Educational objectives and methods. Based on patient interviews, we clarified the desired educational objectives, as well as duration, medium, and frequency of educational materials. Patients desired information about post-transplant kidney management that would allow them to use the transplanted kidney for as long as possible. They preferred receiving educational content through a cell phone, because this option places fewer restrictions on both location and frequency of access ( Table 2). Educational content. Patient interviews revealed that they wanted specific explanations regarding issues that could arise due to treatment noncompliance, which they felt would motivate post-transplant self-management. Specific items were preferred as educational content included post-kidney transplant rejection and coping methods, importance of taking immunosuppressants, as well as post-transplant dietary management (Table 3). In addition, Table 2

Content
Interview statement

Educational objectives "Our primary interest as transplant recipients is how long we can use the kidney. We want information about the actions and precautions required to increase kidney longevity."
Education duration and medium educational demand was present for "other emergency medication," "managing complications," "coping skills for emergency situations," and "social welfare information."

Construction and expert validation of video-based educational content
Mean CVI was 0.94. The lowest CVI (0.85) was for post-transplant mental health and quality of life, social welfare information, and other emergency medications. The highest CVI (1.00) was for post-transplant daily living, coping skills for emergency situations, immunosuppressant medication, meals, managing complications, as well as rejection and treatment. We selected all items with CVI � 0.80 (Table 4).

Satisfaction assessment for video-based educational materials
The results of satisfaction assessment revealed that patients strongly agreed with "The picture quality was good" (5 points), whereas "Watching the educational content as a video was entertaining" earned the lowest score (4 points; Table 5). The mean score was 4.55 points, and all nine categories scored �4 points, demonstrating high satisfaction in the video-based educational materials. In addition, participants reported liking the strong presentation of the importance of health care at the beginning of the video. They also liked the explanation of side effects and the precautions about daily life.

Discussion
In this study, we succeeded in developing a video-based education program through an educational demands survey administered to kidney-transplant patients. Our interviews revealed that patients were most interested in transplant rejection and methods of coping. Patients expressed alarm at the idea of experiencing rejection-related complications at home and therefore, desired the relevant educational content to be delivered beforehand in a manner that facilitated free access at any time. Additionally, patients reported that they had trouble remembering the provided information on discharge because they were disoriented during that period. Patients also reported that their personal interest in the content meant they would tolerate longer videos (i.e., over 3 mins), so we took this feedback into consideration when deciding on video length. The developed video scenarios were based on patient reports of interest in how long they can use the kidney and the effects of following or not following the educational content. The latter point, in particular, is in line with adult learning theory, suggesting that "when adults learn something, they invest considerable effort in identifying the benefits they obtain from learning and the potential negative consequences of not learning" [18]. Our video is now being used for education on patient discharge and has had over 5,000 views on You-Tube in the 16 months since being uploaded (November 8, 2018). Our study had several limitations. First, we did not include any measurement tools that would indicate whether compliance was improved, so we did not verify whether treatment compliance actually increased. In addition, it was confirmed only immediately after education how well the patients understood the education contents. To determine treatment compliance, sustained actions post-discharge are more important than actions performed immediately after the discharge. Thus, in a future study, we plan to evaluate how our video influenced patient behavior, and how long the understanding of education lasted. Second, though we conducted patient interviews to identify the educational demands, the responses have not been evaluated using a properly structured qualitative analysis. Third, our video is currently only available in Korean; videos in other languages are necessary to accommodate the increasing number of international transplant patients. Finally, our video may not be useful for older people who are not familiar with the latest technology. Therefore, there is a need for follow-up studies to increase the treatment performance of the elderly after kidney transplantation.
In spite of these limitations, we believe we succeeded in delivering quality educational content that patients actually needed through the combined use of literature review and interviews. We also increased accessibility by making the video available online, allowing patients access anywhere at any time. Our addition of subtitles ensured accurate delivery of content and improved understanding from viewers. Finally, we used simple terminology that can be readily understood by the general public, so that the patient's family or colleagues can view the materials and help the patient to maintain the health of the transplanted kidney.

Conclusions
We developed video-based educational materials customized to meet the educational demands of kidney-transplant patients. We overcame the limitations of previous educational programs implemented at organ transplant centers, including restrictions on access, burden on medical personnel, and low patient interest. We believe this educational material will increase treatment compliance and therefore, improve quality of life among transplant patients. Given these promising results, we recommend the development of more video-based educational materials that account for variation in health literacy among patients.