The interviews, conducted between April and July 2023, identified information gaps and needs that informed the educational video. Reporting of the qualitative component was guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ) [8], whose checklist is provided in Supplementary Table S2.

Caregivers aged 18 years or older who accompanied children scheduled for elective surgery were recruited by convenience sampling during the preanesthetic assessment in the pediatric inpatient unit of a Brazilian tertiary university hospital.

Caregivers were excluded if the child had a chronic condition or a history of multiple surgeries, or if literacy, communication, or cognitive limitations prevented them from understanding the consent form, providing informed consent, or responding coherently to the interview. These criteria were assessed pragmatically, without formal health literacy or cognitive instruments.

Data were collected using a semistructured interview guide developed by the authors based on the literature and the clinical experience of the research team. The instrument included sociodemographic questions and four open-ended questions about the preanesthetic period, the anesthetic procedure, the postoperative period, and the educational video, as well as 16 probing questions used when necessary. The guide was pretested with two caregivers, resulting in minor language adjustments, and their data were not included in the final analysis. The complete interview guide is available in Supplementary Appendix 1.

The interviews were conducted by the principal investigator, an anesthesiologist experienced in pediatric anesthesia and familiar with the clinical setting, who had no prior relationship with the participants and no involvement in their clinical care or decision-making. After consent was obtained, the interviews were audio-recorded, transcribed, and anonymized. Thematic saturation was monitored through field notes, concurrent reviews, preliminary coding, and recurrence of responses. It was reached at the eighth interview and confirmed in the ninth and tenth, which yielded no new concerns, informational needs, codes, or categories. Data collection was therefore concluded after ten interviews, consistent with saturation criteria described in the qualitative research literature [9,10]. Under the supervision of a senior researcher, the principal investigator conducted thematic content analysis following Bardin’s framework. The analysis included transcript reading, identification of meaning units, coding, grouping into thematic categories, and interpretation of the data. ATLAS.ti®, version 25, was used solely to organize, code, and retrieve the data.

Categories were descriptively quantified as counts and percentages of the total units of meaning to identify the most frequent information needs and inform the video content [11,12]. Percentages were calculated based on the total number of coded meaning units, without inferential purposes.

The narrative review was conducted between August and December 2023 and updated in 2025 to support the scientific and educational content of the video. Searches were performed in PubMed, SciELO, and LILACS using combinations of the following terms in Portuguese, English, and Spanish: “pediatric anesthesia,” “health education,” “educational video,” “preoperative preparation,” “preoperative education,” “caregivers,” “parents,” and “parental anxiety”.

Recent publications were prioritized, along with relevant guidelines and seminal studies. The selection addressed caregivers’ information needs, communication, preoperative preparation, anxiety reduction, and pediatric anesthesia safety. The findings, together with the qualitative data obtained from caregivers, informed the video script and storyboard.

The script and preliminary video were developed between January and December 2024. The script followed a four-column audiovisual format created for this project, comprising the 1) scene number, indicating its sequence; 2) on-screen text, containing all written information displayed; 3) visual description, detailing the setting, characters, actions, animations; and 4) narration, containing the exact voice-over text. It also specified the characters, setting, visual identity, animations, narration style and other technical elements to ensure consistency across the script, storyboard, and final video. The video was produced in Brazilian Portuguese by a company specializing in professional audiovisual content.

The initial version of the video was evaluated by experts between January and June 2025 using a structured instrument in a single round, during which all participants assessed the same version.

The experts were selected using an adapted Fehring scoring system [13], considering academic qualifications, professional experience, and scientific production in the field. Potential experts were identified through the Lattes Platform and peer recommendations.

After accepting the invitation by email, the experts received the preliminary version of the video and the instrument validated by Teixeira and Mota [14], which consisted of 21 items distributed across three domains: objectives, structure and presentation, and relevance. The instrument assessed the content validity of the educational material using a four-point Likert scale: Totally Adequate (TA), Adequate (A), Partially Adequate (PA), and Inadequate (I), with additional space for suggestions.

Internal consistency was assessed using Cronbach’s alpha and interpreted descriptively as exploratory. I-CVI was the proportion of “Totally Adequate” or “Adequate” ratings; domain CVIs were mean I-CVIs, and S-CVI/Ave and S-CVI/UA summarized scale-level validity. I-CVI ≥ 0.78 and S-CVI/Ave ≥ 0.90 were considered satisfactory [15]. Modified kappa adjusted for chance agreement and was interpreted as fair (0.40–0.59), good (0.60–0.74), or excellent (> 0.74) [16]. Ninety-five percent confidence intervals were calculated for item-, domain-, and scale-level estimates. Analyses were performed using R version 4.5.1.

Validation with family members of patients hospitalized for surgical treatment was conducted between July and August 2025, using the same eligibility criteria as in Step 1. After informed consent was obtained, the video was individually presented on an electronic device in a single session, followed by administration of the Teixeira and Mota instrument [14], which consisted of 25 items distributed across the domains of objectives, organization, style, appearance, and motivation. The instrument assessed the semantic and face adequacy of the video for the target audience using the previously described Likert scale and included a space for suggestions.

For target audience validation, the same statistical procedures used for the expert panel were applied to assess the semantic and face adequacy of the video. These included Cronbach’s alpha for internal consistency, the I-CVI for each item, mean I-CVIs for each domain, the S-CVI/Ave and S-CVI/UA for overall adequacy, 95% confidence intervals for item-, domain-, and scale-level indices, and the modified kappa coefficient (κ*) for each item to account for chance agreement.

The final version of the educational video was produced between September and December 2025, based on responses to the validation questionnaires, the CVI calculations, and suggestions from the experts and target audience.

Ten family members participated in the study, with a median age of 34.0 years (IQR: 27.8–39.0); 40.0% were aged 25–30 years, 40.0% were aged 31–40 years, and 20.0% were older than 40 years. The median patient age was 5.5 years (IQR: 4.0–7.8); 40.0% were aged 0–4 years, 30.0% were aged 5–7 years, and 30.0% were aged 8–9 years. Regarding their relationship with the patient, 70.0% of participants were mothers and 30.0% were fathers. Regarding educational attainment, 10.0% had completed elementary school, 10.0% had incomplete high school education, 60.0% had completed high school, and 20.0% had completed higher education.

The content analysis identified recurring questions and information needs regarding the perioperative anesthetic process. Descriptive frequencies indicated the recurrence of the categories. Preoperative fasting was the most frequent topic, accounting for 16 meaning units (28.6%) related to its duration, rationale, and whether water or other liquids could be consumed. Intraoperative monitoring and type of anesthesia each accounted for nine meaning units (16.1%); postoperative agitation accounted for eight (14.3%); shivering or feeling cold accounted for five (8.9%); and postoperative pain, allergy to anesthesia, and intraoperative awareness each accounted for three (5.4%). These categories guided the selection and organization of the video content. Representative excerpts and their contributions are presented in Supplementary Table S3.

The narrative review identified complementary evidence regarding caregivers’ information needs and the technical and scientific foundations of pediatric anesthesia. The main findings are summarized in Supplementary Table S4.

The studies showed that family members seek clear, timely, and accessible information about fasting, anesthesia, the operating room, procedure duration, risks, adverse effects, pain, recovery, and postoperative care [2,17,18]. They also identified knowledge gaps [19] and highlighted the use of educational materials, such as videos and printed brochures, as a vital complement to verbal guidance, in order to improve comprehension, ensure safety, and increase overall family satisfaction [6,18,19].

Textbooks, guidelines, consensus statements, and reviews addressing preoperative assessment, fasting, respiratory symptoms, general, inhalational, and regional anesthesia, analgesia, nausea and vomiting, emergence delirium, and postanesthesia recovery ensured technical accuracy, alignment with current recommendations, and responsiveness to caregivers’ needs [20–23].

The video script was organized into four columns and 20 scenes based on family members’ questions, the prior knowledge of the authors and institutional professionals, and the literature review. The first version was a 3-minute and 40-second 2D animation integrating illustrations, text, and narration to facilitate comprehension.

Of the 37 invited experts, 22 completed the video assessment in a single round, yielding a 59.5% response rate. Of these, 15 scored above five on the adapted Fehring scale, while seven with lower scores were retained because of relevant clinical or academic expertise. Panel characteristics are presented in Supplementary Table S5.

The questionnaire showed high internal consistency (Cronbach’s alpha = 0.94). I-CVI values ranged from 77.3% to 100%. Mean domain-level CVIs were 97.3% (95% CI: 92.2–99.4) for objectives, 92.1% (95% CI: 88.0–95.2) for structure and presentation, and 94.5% (95% CI: 88.5–98.0) for relevance. The S-CVI/Ave was 94% (95% CI: 91.4–95.9), and the S-CVI/UA was 23.8%. Modified kappa values ranged from 0.771 to 1.000, indicating agreement beyond chance.

Item 2.4, on sociocultural appropriateness, had the lowest score, with 17 of 22 favorable ratings (I-CVI = 77.3%; 95% CI: 54.6–92.2; κ* = 0.771). Because it was below the predefined cutoff, the video language was revised to improve clarity, accessibility, and sociocultural appropriateness. Item-level results are shown in Table 1, and the suggested modifications in Table 2.

For target audience validation, 15 caregivers of hospitalized pediatric patients were invited. Twelve were included, while three were excluded for not meeting the eligibility criteria. Participants’ sociodemographic characteristics and the children’s previous surgical and anesthetic history are presented in Supplementary Table S6.

Cronbach’s alpha was 0.750. Among caregivers, I-CVI values ranged from 91.7% to 100%, with mean values of 97.2% for objectives, 97.2% for organization, 98.6% for style, 97.9% for appearance, and 98.6% for motivation. Domain-level 95% CIs ranged from 85.5–99.9% to 92.5–100.0%. The overall S-CVI/Ave was 98.0% (95% CI: 95.7–99.3%), and the S-CVI/UA was 76.0%. Modified kappa values ranged from 0.916 to 1.000. Items with 11 favorable ratings had an I-CVI of 91.7% and a κ* of 0.916, whereas items with universal agreement had values of 100%. Despite the wide intervals due to the small sample size, the estimates were high across all domains (Table 3). The suggested modifications are presented in Table 2.

After validation by the expert panel and the target audience, the final version of the video was finalized in 4 min and 40 s (Figure 1). Recommendations from both groups were analyzed and incorporated when relevant, while preserving the original content objectives.

Figure 1.

Images from the video “Guidance for Caregivers on Pediatric Anesthesia,” with English translation for publication.