The research, conducted between October 2022 and May 2023, emerged from a well-recognized problem in surgical oncology. Health literacy, defined as a patient’s ability to obtain and interpret basic health information in order to make appropriate decisions, is a decisive factor in surgical outcomes. Patients who understand their procedures tend to prepare better, comply more fully with preoperative instructions, and engage more actively in their own recovery. Conversely, poor health literacy has been associated with avoidable complications, delayed recoveries, and heightened anxiety. The researchers, led by Cassiane de Santana Lemos of São Paulo State University’s Botucatu Medical School, argued that well-designed educational materials, validated both by experts and by the patients who actually use them, can accelerate health learning and support recovery in this vulnerable population.

The project unfolded in two distinct methodological stages. In the first stage, the team designed the content and visual layout of the educational material, drawing on established instructional design principles to ensure that the final product would be readable, logically organized, and visually accessible. In the second stage, the material entered formal validation. Specialist nurses were recruited to evaluate the content using the Health Educational Content Validation instrument, a standardized tool for judging the accuracy, relevance, and clarity of patient-facing health materials. Simultaneously, a group of patients who had already undergone colorectal surgery assessed the material using the Suitability Assessment of Materials, known in the literature as the SAM instrument, which scores educational resources on factors such as readability, graphic design, cultural appropriateness, and self-efficacy support.

The resulting product was named the “Patient Guide – Colorectal Surgery,” a 24-page booklet organized into 14 topics that follow the patient’s chronological journey through the surgical experience. The guide covers the preoperative period, hospital admission, and postoperative care, walking readers through what to expect at each stage. This trajectory-based structure reflects a deliberate instructional choice: rather than presenting fragmented medical facts, the guide mirrors the lived sequence of surgery, allowing patients to anticipate each phase and prepare questions for their care teams. The authors credited the Hollister company for assistance with the artistic production of the material, an element they treated as central to the guide’s usability rather than a cosmetic afterthought, since layout, typography, and illustration all factor directly into SAM scoring.

The expert validation phase involved six nursing professionals, whose agreement rates exceeded 80 percent, with particularly strong consensus in the domains of relevance and objective. These figures carry real technical meaning in psychometric terms. Content validation instruments measure the extent to which a panel of judges independently agrees that each item of a material is pertinent and aligned with its intended purpose, and agreement levels above 80 percent are conventionally interpreted as strong evidence that the content is appropriate for its target population. The Content Validity Ratio, a statistic that quantifies the proportion of judges endorsing each item while correcting for the level of agreement expected by chance, was used to analyze concordance between the judges, giving the validation process a quantitative backbone that distinguishes it from informal expert review.

The patient assessment phase provided the second and arguably more important half of the validation evidence. Eleven individuals who had undergone colorectal surgery evaluated the guide, and the majority of them, 45.45 percent, had experienced rectosigmoidectomy, the surgical removal of the rectosigmoid portion of the bowel. Across every domain of the SAM instrument, the guide scored either adequately or in the superior range, meaning that the very people for whom the material was designed judged it readable, understandable, motivating, and actionable. Perhaps most strikingly, the patient ratings achieved an overall reliability of Cronbach’s alpha equal to 0.89, a coefficient indicating high internal consistency. In plain terms, the patients responded to the guide’s qualities in a coherent and stable way, suggesting that their positive assessments were not the product of random variation but of genuine, shared perceptions of the material’s quality.

The significance of this dual validation extends beyond the 24 pages of the guide itself. Educational materials in clinical settings are frequently produced without any systematic evaluation, relying on the intuition of the clinicians who write them. The Brazilian team instead applied a psychometric framework, treating the patient guide as an instrument whose properties could be measured, quantified, and verified before deployment. This approach aligns with growing international interest in enhanced recovery after surgery, or ERAS, protocols, which depend heavily on patient engagement and preoperative education to shorten hospital stays and reduce complications. A validated guide of this kind, the authors note, can be used both inside and outside the hospital by health professionals, embedding itself across the entire perioperative continuum rather than serving a single moment of care.

The study also carries a broader philosophical ambition. The authors describe their goal as helping the surgical patient become “a protagonist in their self-care,” a framing that recasts patient education as empowerment rather than mere information delivery. When patients understand the operations they will undergo, the sensations they should expect, and the warning signs that demand attention, they transition from passive recipients of care to active participants in their own recovery. That shift has measurable clinical consequences: engaged patients are more likely to perform breathing exercises, mobilize early, adhere to dietary guidance, and report problems before they escalate. The ethics approval for the study came from the Research Ethics Committee of the Faculdade de Medicina de Botucatu, and all participants signed informed consent forms, underscoring the study’s adherence to formal research governance.

The research was supported financially by the Fundação de Amparo à Pesquisa do Estado de São Paulo, FAPESP, under process number 2022/12950-2, reflecting institutional investment in health services research as a lever for improving surgical care. The team included researchers from the Nursing Department of São Paulo State University’s Botucatu campus and the School of Nursing at the University of São Paulo, a collaboration spanning two of Brazil’s major public universities. The corresponding author, Cassiane de Santana Lemos, and her colleagues, including Mayara Spin, Raquel Rondina Pupo da Silveira, Eduarda Cruz de Oliveira, Daniel de Santana Barreto, Arethusa Neves da Silva, Gabriela Crespan Sarzi, and Vanessa de Brito Poveda, declared no competing interests, and the article was published as open access under a Creative Commons Attribution 4.0 license, making the methodology and findings freely available to clinicians and researchers worldwide.

For the estimated millions of patients worldwide who undergo colorectal surgery each year, the study offers something concrete: evidence that a carefully constructed, formally validated patient guide can deliver reliable health education at scale. The authors concluded that the material is valid and suitable for use in patients undergoing colorectal surgery, and that it can support health professionals in hospital and community settings alike. As health systems worldwide grapple with aging populations, rising cancer burdens, and chronic shortages of time in clinical consultations, tools that transfer understanding efficiently from clinician to patient are likely to become increasingly valuable. This study demonstrates that such tools can be built to standard, measured with statistical precision, and trusted by the people who matter most: the patients themselves.

Subject of Research: Construction and validation of educational material for patients undergoing colorectal cancer surgery

Article Title: Construction and validation of educational material for patients undergoing colorectal cancer surgery: a psychometric study

Article References: de Santana Lemos, C., Spin, M., da Silveira, R. R. P., de Oliveira, E. C., de Santana Barreto, D., da Silva, A. N., Sarzi, G. C., & de Brito Poveda, V. (2026). Construction and validation of educational material for patients undergoing colorectal cancer surgery: a psychometric study. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15241-3

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15241-3

Keywords: health literacy, patient education, colorectal surgery, psychometrics, perioperative nursing, health communication, educational technology, validation study, SAM instrument, content validity, surgical recovery, patient self-care