Development and validation of educational multimedia to promote public health literacy about healthy cognitive aging

Abstract Objectives Health literacy (HL) about healthy cognitive aging is essential in preventing cognitive decline and promoting cognitive well‐being. It is important that one such HL module should be scientifically designed, delivered in a technically sound manner to the audience, and specific to the context. The present study thus aimed at developing and validating educational multimedia about cognitive health. Methods The study followed a methodological framework and was carried out across three phases, that is, identification of themes, development and validation of educational script and design, and validation of educational multimedia. The module was scripted based on the Integrated HL framework and the recommendations made during the modified nominal group technique among the research team. Seven speech‐language pathologists (SLPs), with expertise in the field of cognitive sciences, and 15 representatives of the general public validated the module using the Educational Content Validation Instrument in Health and the Patient Education Materials Assessment Tool for Audiovisual Materials questionnaire. Results The scientific content of the educational script received satisfactory agreements among the experts (content validity index [CVI]: 0.93) and representatives of the general public (CVI: 0.86). The technical aspects of the educational multimedia were rated to have high understandability (experts: 92.8%; representatives of general public: 98.8%) and actionability (experts and representatives of general public 100%). Conclusion Overall, the developed educational multimedia scored optimally with respect to the objective, structure, relevance of the content, actionability and understandability of the multimedia. The developed module holds the potential to be used at community and national level health educational programs or awareness campaigns to enhance public knowledge and beliefs pertaining to cognitive health. Patient or Public Contribution SLPs with expertise in the field of cognitive science and representatives from the general public were included to validate and obtain feedback on the developed educational multimedia.

Patient or Public Contribution: SLPs with expertise in the field of cognitive science and representatives from the general public were included to validate and obtain feedback on the developed educational multimedia.

K E Y W O R D S
cognition, health education, health promotion, multimedia, patient education

| INTRODUCTION
Health literacy (HL) is a key indicator of health outcomes.4][5][6] As such, HL has been considered a global public health objective in the 21st century to improve health outcomes and promote health promotion through improved education and communication strategies. 7][10] These studies have advocated for the substantial role of HL programs in improving health-related knowledge and beliefs.Another relevant healthcare domain where the role of HL is warranted and is being researched is cognitive health.
Cognitive health is becoming increasingly important, given the exponential rise in the current and predicted prevalence of cognitive deficits like dementia. 11As per the GBD 2019 Dementia forecasting collaborators, 57.4 million people have dementia worldwide as of 2019, with the number expected to rise to 152.8 million by 2050. 12cording to the 'Dementia in India-2020' research, 14 million Indians over 60 were predicted to have dementia by 2050, up from the current estimate of 5.3 million. 13Dementia has been recognized as a public health priority by most national and international organizations (World Health Organization, Alzheimer's Disease International, Global Alzheimer's and Dementia Action Alliance).Thus, increasing public awareness regarding cognitive health has been emphasized as one of the most important goals of the 'Global Action Plan on the public health response to Dementia'. 14In this regard, studies have shown a direct and reciprocal link between HL levels and cognitive functions. 5Poor cognitive performance has been associated with low HL and may eventually be the cause of it.
Individuals with low HL have also been reported to experience a noticeably faster loss of cognitive ability over time. 15,16Conversely, those with higher HL and education levels tend to engage more in cognitive, social and physical activities, [17][18][19] which may indirectly assist in preventing age-linked cognitive decline.Increasing knowledge about cognitive health may have a positive influence on one's 'need for cognition', that is, the desire to engage in cognitively demanding activities. 18Further, adequate knowledge may also aid in the early detection of cognitive deviations. 3Thus, cognitive HL could play a significant role in promoting cognitive wellbeing.
A recent systematic review revealed that dementia literacy interventions improve self-efficacy among nonhealth professionals in managing and caring for individuals with dementia and their knowledge of dementia. 20However, the review concluded that more evidence is needed linking to dementia beliefs, attitudes and preventive behaviour.Five-week intervention program in health education by Du and Hu 21 was reported to be successful in enhancing the knowledge about Alzheimer's disease (AD) and encouraging healthy lifestyle among Chinese older adults without AD.Another study examining the efficacy of Preventive Dementia Massive Open Online Course among global participants suggested that the program improved self-efficacy and understanding of dementia risk reduction, higher willingness to maintain healthy behaviours, and improved use of the knowledge to modify health behaviour change which could potentially lower the risk of developing cognitive disorders. 22These studies reinforce the successful role of HL programs in influencing cognitive health-related knowledge and beliefs.The majority of existing studies focus on dementia literacy, that is, risk factors for dementia, signs and symptoms of dementia, and assessing and managing dementia.HL programs focusing on healthy cognitive aging may help promote a healthy cognitive lifestyle.
According to the Centers for Disease Control and Prevention, consumers have little access to information regarding cognitive health, and perceptions of brain health vary by ethnicity, culture and geography. 23Language and culture give the experience background for understanding health information. 24The way that a person receives healthcare information is influenced by culturally ingrained ideas, values and preferences that they have.In the Indian context, a recent survey conducted on the general public and healthcare personnel revealed that adults had vague to average knowledge about dementia with poor attitudes and practices towards dementia preventive strategies. 25However, there exists a dearth of scientifically developed educational HL modules for enhancing cognitive health among the Indian population.This, along with alarming dementia statistical predictions, warrants the need to develop cognitive HL programs within the Indian context.Thus, the present study aimed at developing and validating an educational multimedia program about cognitive health.
A multimedia mode was chosen for the present study as it has been proven to be more effective in capturing participants' attention, enhancing their experience, contentment, knowledge and in altering their behaviour with longer retention of information. 26Multimedia programs integrate textual, audio and visual elements that support and enrich each other to enhance learning and captivate audiences. 27 reducing the need for reading and providing information through multiple modalities, multimedia education programs offer the ability to improve communication and education to those with low HL. 27

| Study design
The present study followed a methodological framework according to the recommendations made by similar studies in other health domains. 28,29The study was conducted between January 2022 and February 2023.Ethical approval was obtained from the Institutional Ethics Committee (IEC KMC MLR 05-2022/171).

| Participants
Development of the educational multimedia on cognitive health required a systematic process that involved stakeholders like experts and representatives from the general public.Seven speech-language pathologists (SLPs) with greater than 5 years of experience in the field of cognitive science were included as experts in this study.
Representatives of the general public included five young adults (18-40 years), five middle-aged adults (41-65 years), and five older adults (66+ years) from middle socioeconomic status (ascertained using modified Kuppuswamy scale 30 ), with optimum proficiency in the English language (Minimum score of 'Seven' on Language Experience and Proficiency Questionnaire 31 ).To minimize any bias in perceptions, it was also ensured that all the general public representatives had no prior association with individuals having Alzheimer's or dementia in their immediate family.The demographics of the participants are provided in Table 1.Informed consent was obtained from all participants at the beginning of the study.

| Procedure
The study was conducted in three phases, that is, theme identification, script development and validation, followed by video development and validation (Figure 1).

| Phase 1: Identification of themes
The first phase focused on identifying the essential themes for educational multimedia.The integrated HL framework 1 was used to develop the educational material, as it informs important aspects to consider for users to experience the continuum.A modified nominal group technique (mNGT) was employed to brainstorm and establish consensus on the themes. 32The mNGT follows a systematic process wherein the ideas searched from existing literature are combined with the self-generated ideas of each panel member, followed by clarifications, discussions and voting among them to shortlist the most relevant themes. 32The mNGT panel included the authors of the current study, with Author 1 serving as the facilitator and Authors 2-4 as members.Each panelist possessed over 3 years of experience in the field of cognitive science.In the present research, the mNGT was carried out in five steps: literature search and web search for fact sheets on healthy cognitive aging, silent generation of ideas, round robin, clarification and ranking the order of presentation of themes.
At the outset, the panelists were explained that the primary objective of this mNGT was to identify the key themes they thought should be addressed in an educational video about healthy cognitive aging for the general public.In the first step, all the important themes in the cognitive health module provided by the National Institute of Aging 33 were documented.In the following step, silent generation of ideas, panel members were shown all the themes extracted from the literature on a whiteboard and were asked to silently generate additional ideas for themes beyond what was extracted in the first  Validation Instrument in Health (ECVIH). 357][38] The instrument has been used to validate educational content presented in various forms, such as multimedia content, print content, digital content and many more.It consists of 18 questions with a focus on the video's objective (intention and aim), structure and presentation (organization), and relevance (significance, impact, motivation and interest).The items are rated as disagree (Score 0), partially agree (Score 1) or strongly agree (Score 2).A comment section was provided in the questionnaire for participants to provide specific suggestions.The participants' feedback and suggestions, if any, were taken into consideration for refining the scripted content before converting it into a multimedia.visual Materials (PEMAT-A/V) questionnaire. 39There are 17 items in the PEMAT-A/V, 13 of which are related to actionability and four to understandability.Each response is given a score of one (for agree), zero (for disagree), or not applicable (no score and noted as not applicable).PEMAT-A/V has been reported to have strong levels of internal consistency, reliability and construct validity. 39Additionally, a comment section was provided at the end of the questionnaire for participants to provide specific suggestions.

| Data analysis
The data of the ECVIH instrument was analyzed to obtain content validity index (CVI).Items rated 'disagree' were assigned a score of zero.Items rated 'strongly agree' and 'partially agree' were given a score of one.Both Based on the recommendation by Yusoff, 40 a CVI value of 0.83 or higher for experts and 0.78 or higher for representatives of the general public was considered satisfactory for the validation process, depending on the sample size of each participant group.
The responses to the PEMAT-A/V were examined to obtain an understandability and actionability score for the developed multimedia educational video.The understandability score was calculated by dividing the total number of items rated as agreed on understandability items by the number of understandability items rated (determined by excluding the 'not applicable' items).The actionability score was calculated in the same manner by including actionability items.For each subscale, the scores were multiplied by 100 to obtain the percentage value.Scores under 70% showed that the information's understandability or actionability was poor, with higher percentages suggesting stronger understandability and actionability. 39

| RESULTS
The results of the mNGT used to identify themes for the educational multimedia are provided in themes were generated based on the National Institute of Aging, 33 along with silent generation of ideas by the research team.These 24 themes were narrowed to nine following the clarification stage.The order of presentation of these themes, as determined by the ranking process, is depicted in the last column of Table 2.
Based on these nine themes, the first version of the script was drafted and reviewed by the research team.The feedback received during the first round of review from the research team (Authors 3-6) included suggestions for using shorter phrases for simplicity, incorporating examples when discussing the importance of cognition and signs of pathological cognitive aging, mentioning cognitive skills that remain unchanged or increase with age alongside skills that decline with normal cognitive aging, and removing excessive information about the rationale behind each risk factor.Furthermore, the research team proposed writing the script in a dyadic manner to reflect a two-way interaction between the audience and narrator.
The revised script then received consensus from the research team during the second group discussion.The researchers found the revised script to be balanced with respect to the information and ready to effectively communicate essential knowledge about cognitive aging to the intended audience.The key elements of the finalized script, along with the theme-specific details, strategies used for conveying the content and duration of each segment, are described in Table 3.
The results pertaining to the content validation of the educational script done using the ECVIH questionnaire 35 are depicted in Table 4.The table displays agreement ratings of both experts and representatives of the general public, along with the I-CVI and S-CVI scores for the educational script.The content of the script attained minimum acceptable agreements among the experts (CVI: 0.93) and representatives of the general public (CVI: 0.86). 40  attributes.The rate of speech, along with well-timed pauses and clear segment titles, was considered appropriate.Overall, the group found the revised video to be engaging and lively, with optimal comprehension and smooth flow of information, making it easier for the audience to connect with the content.
The multimedia was then presented to the participants for evaluating its understandability and actionability using PEMAT-A/V. 39The descriptive statistics of the PEMAT-A/V individual item ratings are provided in

| DISCUSSION
To address the concerning global and national forecasts of cognitive disorders such as Alzheimer's and dementia, 12,13 it is crucial to improve cognitive HL through the use of scientifically sound educational resources.In a similar direction, the present study focused on scientifically scripting and validating content for public HL in cognitive health, which was then transformed into an educational multimedia format.The following section describes the fundamental elements of educational multimedia, such as its content and delivery method, by drawing upon relevant literature and its underlying theoretical principles.Additionally, reflections and recommendations for future projects in this area are provided.
F I G U R E 2 Snippets of the educational multimedia on cognitive health.

| Content-based aspects of educational multimedia
The content of the developed educational script was validated using ECVIH, 35 and demonstrated optimal validation scores by experts and representatives of the general public across its different domains, such as objective, structure, presentation and relevance.
These findings are congruent with the results of other methodologically similar studies that have demonstrated acceptable validation scores for educational multimedia in other health domains. 29,36satisfactory agreement on the 'objective' domain implies that the developed educational material appropriately represents the information about cognitive health, supports the teaching-learning process, clears up misconceptions about cognitive health, promotes reflection on cognitive health and inspires behaviour change for healthy cognition, as opined by the experts and representatives of general public for the educational multimedia.These satisfactory results could be attributed to the theoretical foundations considered when framing the script of the present educational multimedia.
The structure and content of the script were based on the integrated HL framework.Leveraging the resources provided by recognized organizations that offer comprehensive information created and verified by experts in the field may have proven helpful in assisting with the selection of themes and scripting the draft.In addition, using a structured consensus method, such as mNGT, 32 which aims to foster agreement among participants during idea generation by ensuring balanced participation from group members, 41 may have played a role in identifying pertinent themes.[44][45] With regard to the 'structure and presentation' and 'relevance', the educational material was considered to be organized, structured, strategic, consistent, sufficient, encourages learning, contributes to knowledge about cognitive health, and sparks interest in it.The satisfactory agreement on the structure and presentation of the educational material by experts and representatives of the general public could be attributed to the 'TED-like' strategy used to communicate the present HL content.TED and TED-like talks are important mediums for disseminating scientific knowledge to the general audience. 46Educational interventions in a 'TED-like' style have proven effective in other healthcare domains. 34,47The educational content of the current educational multimedia was scripted in a 'TED-like' style that included a lead speaker named 'Dr.
Cognition' delivering a talk titled 'Towards healthy cognitive aging' using a PowerPoint presentation format.Further, informational value, relevance, and social connections are the primary determinants of user acceptance of any HL-related video. 48The educational script in the present study was written in a format that reflects dyadic communication between a speaker and his audience to enhance social connections.Additionally, each section of the script included appropriate examples from everyday life to augment comprehension of the intended message and enhance information value.It seems that the inclusion of such strategies might have contributed to optimal CVI score for the domain of 'structure and presentation' and 'relevance' of the present HL material.

| Delivery-based aspects of the educational multimedia
The present content was chosen to be delivered through a multimedia format.The use of multimedia in health education is generally justified by the notion that creating a mental representation through multisensory experiences increases the likelihood that information will be remembered, and as a result, the likelihood that recommendations will be followed. 49Multimedia educational materials have been reported to be more interesting to participants than printed materials. 48To validate the robustness of the present multimedia, we used PEMAT-A/V to assess its understandability and actionability. 39Overall, the developed multimedia education received high understandability and actionability scores from both experts (92.8% and 100%, respectively) and representatives of the general public (98.8% and 100%, respectively).The understandability ratings showed that the module was perceived to be intelligible and included concise information that was simple to grasp.The module employed everyday English rather than technical terms, and ensured that any medical terminology was accompanied by subtitles and definitions to avoid any misinterpretation of the content.Though the module did not use any tabular content, it made use of appropriate visual aids, such as photographs and illustrations, to aid easier understanding among the audience.The actionability score implies

2. 5 |
Phase 2: Development and validation of educational scriptThe second phase focused on drafting the script based on the determined themes following the order established through the ranking process.The first version of the script was written by Authors 1 and 2 in a 'TED-like' style,34 which included the main character (Dr.Cognition) giving a talk on cognitive health titled 'Towards healthy cognitive aging' to a large audience.The first draft of the script underwent review by the research team (Authors 3-6) during a group discussion.Based on the suggestions of the research team, revisions were made to the script.The revised version was written in a dyadic manner such that it reflected a two-way interaction between the main speaker, Dr. Cognition, and the audience.The second draft was reviewed again by the research team (Authors 3-6) during another group discussion and a consensus was established among them.The script was then content validated by seven SLPs and 15 representatives from the general public using the Educational Content

2. 6 |
Phase 3: Development and validation of educational multimedia In the third phase, the educational multimedia was developed by an animation artist based on the validated script.The educational video was developed in a two-dimensional animated form using Adobe Illustrator, Adobe After Effects and Animaker software.The initial F I G U R E 1 The development and validation phases of the educational multimedia.ECVIIH, Educational Content Validation Instrument in Health; PEMAT-A/V, Patient Education Materials Assessment Tool for Audiovisual Materials.draft of the multimedia underwent independent review by the research team (all authors).Based on the consolidated feedback provided by the research team, modifications were communicated by Author 1 to the animation artist.The revised animated video was broadcasted to the research team during a joint meeting to establish consensus among the team members.Subsequently, the video was presented to the participants (seven SLPs and 15 representatives of the general public) for content validation of its understandability and actionability.The animated video was individually shown to each participant in a distraction-free room through a 14ʹʹ laptop screen, with audio presented over headphones.Validation was conducted using the Patient Education Materials Assessment Tool for Audio- item-level CVI (I-CVI) and scale-Level CVI (S-CVI) were calculated.I-CVI is the proportion of experts rating the items as 'partially agree' or 'strongly agree' ([total no. of partially agreed/strongly agreed items]/[number of experts]).The average of I-CVI score for each item on the scale is the S-CVI ([sum of I-CVI scores in the scale]/[number of items in the scale]).
No descriptive comments were obtained from the participants in the comment section of the questionnaire.The validated script was then used to develop the animated video, which was first independently reviewed by the research team (all authors).The suggestions of the research team included aspects like alternating between multiple angles of the main character (front view and lateral view) and the audience (front view and lateral view), adding more movements to the main character, such as hand gestures, making the character walk around the stage, using warm colours throughout the scenes, removing any distracting and unnecessary gestures or animations in the video, reducing the rate of speech of the voice-over, adding more pauses across sentences, and providing introduction titles for each segment of the video.The modified version of the video was broadcasted to the research team (all authors) during a joint session wherein no further suggestions were obtained, and consensus was reached among the members regarding the video's T A B L E 3 Description of the educational multimedia.

Table 2
. The table presents a list of themes identified at each stage of mNGT.In the initial two steps, 24 T A B L E 2 List of potential themes identified during modified nominal group technique.Abbreviations: NIA, national institute of aging; MCI, mild cognitive impairment.

Table 5
The relevance ratings on the item scale by participants.
. In the understandability section, the majority of the experts and representatives of the general public reported that the content of the educational video had a clear and evident purpose (Item 1), with appropriate word choice and style (Items 3, 4, 5), organization (Items 8, 9, 10, 11), and appropriate use of photographs (Item18).Most T A B L E 4