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Design and validation of an evaluation instrument on knowledge of schoolchildren about breastfeeding

Abstract

Objective:

To validate an evaluation instrument of knowledge of schoolchildren about breastfeeding.

Methods:

A method research developed in three stages: design of the instrument, validation of the content with 22 judges and validation of appearance with 10 schoolchildren from the primary school. Data were analyzed by absolute frequencies, standard-deviations, binomial test and content validity index - CVI. Observations of judges were analyzed and when necessary items of the instrument were changed.

Results:

In content validation, the first version of the instrument had 32 items and most of them were considered adequate by judges and the I-CVI achieved was equal or above than 0.80. After changes, the instrument was composed by 21 items. In validation of the appearance, most of items achieved I-CVI equal or above 0.80.

Conclusion:

The instrument content and appearance were validated. The instrument created and validated in this study could be used to evaluate knowledge of schoolchildren about breastfeeding.

Keywords
Breast feeding; Validation studies; School health; Education, primary and secondary

Resumo

Objetivo:

Validar um instrumento para avaliação do conhecimento de escolares acerca do aleitamento materno.

Métodos:

Pesquisa metodológica, desenvolvida em três etapas: construção do instrumento, validação de conteúdo com 22 juízes e de aparência com 10 escolares do ensino fundamental. Os dados foram analisados por meio de frequências absolutas, médias, desvios-padrão, teste binomial e Content Validity Index - CVI. As observações dos juízes foram analisadas e quando necessário o instrumento foi modificado.

Resultados:

Na validação de conteúdo, a primeira versão do instrumento continha 32 itens que na maioria foram considerados adequados e atingiram I-CVI igual ou acima de 0,80 entre os juízes. Após as modificações, o instrumento passou a ter 21 itens. Na validação de aparência, a maioria dos itens alcançou I-CVI igual ou acima de 0,80.

Conclusão:

O instrumento foi validado em conteúdo e aparência, podendo ser utilizado na avaliação do conhecimento de escolares sobre aleitamento materno.

Descritores
Aleitamento materno; Estudos de validação; Saúde escolar; Ensino fundamental e médio

Introduction

Breastfeeding is efficient to reduce child morbimortality, strengthen the bond between mother and child, and provide benefits to the woman's health and to the environment, in addition, it contributes for a healthy society.(11. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Saúde da criança: aleitamento materno e alimentação complementar. 2a ed. Brasília (DF): Ministério da Saúde; 2015.) Although the advantages, the prevalence of exclusive breastfeeding in most of countries is below 50% in children younger than six months of age. This low prevalence shows the need of action to support maternal breastfeeding from gestation to delivery and after delivery, mainly considering specific realities of each region. Among supporting resources for women the educational system is one that can be used.(22. Victora CG, Bahl R, Barros AJD, França GV, Horton S, Krasevec J, et al. Breastfeeding. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016; 387(10017):475-90.,33. Feldman-Winter L. Evidence-based interventions to support breastfeeding. Pediatr Clin N Am. 2013; 60(1):169-87.)

In Brazil, the Health School Program - HSP, launched in 2007, reinforces the need to plan health actions at schools to collaborate with an integrative education for students. Although not explicit referral is made concerning maternal breastfeeding, the HSP emphasizes the recommendation to mothers based on “10 steps for healthy feeding of children younger than 2 years” that include exclusive and complementary breastfeeding.(44. Brasil. Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Atenção Básica. Saúde na escola. Brasília (DF): Ministério da Saúde; 2009.)

School is a place for pedagogical interventions on breastfeeding, and this is also a place for effective learning of correct knowledge and deconstruction of myths and believes on breastfeeding. These actions can encourage schoolchildren to take a more conscious and healthy behaviors, improve development of positive attitudes toward breastfeeding, provide great support for women who breastfed, and possibly, increase future intention to breastfeed and enhance students reflection on success of breastfeeding.(55. Glaser DB, Roberts Kj, Grosskopf NA, Basch CH. An evaluation of the effectiveness of school-based breastfeeding education. J Hum Lact. 2016; 32(1):46-52.,66. Ho YJ, McGrath JM. Effectiveness of a breastfeeding intervention on knowledge and attitudes among high school students in Taiwan. J Obstet Gynecol Neonatal Nurs. 2016; 45(1): 71-7.)

To achieve such actions there is a need to broad the focus on educational strategies for breastfeeding promotion beyond the women- nourishment. These strategies should include other audience such as students, children, and adolescents. The nursing professional has a crucial role to implement such strategies using pedagogical approach by promoting health education activities in the school.(55. Glaser DB, Roberts Kj, Grosskopf NA, Basch CH. An evaluation of the effectiveness of school-based breastfeeding education. J Hum Lact. 2016; 32(1):46-52.,77. Gijsen LI, Kaiser DE. [Nursing and health education in Brazilian schools: an integrative literature review]. Cienc Cuid Saude. 2013; 12(4):813- 21. Portuguese.)

An integrative review on breastfeeding promotion carried out in primary education school identified eight studies on the subject. However, only four studies approached knowledge of schoolchildren from primary school on breastfeeding. Their results showed that knowledge was inadequate with unfavorable beliefs regarding breastfeeding practice. In addition, these studies did not approach the knowledge of children about breastfeeding on the perspective of the social network to support breastfeeding women.(88. Martins FD, Leal LP, Guedes TG, Javorski M, Pontes CM. Promotion of breastfeeding on primary education: integrative review. Rev Eletr Enf. 2016; 18:e1198.)

During the analysis of educational interventions on breastfeeding in the school(55. Glaser DB, Roberts Kj, Grosskopf NA, Basch CH. An evaluation of the effectiveness of school-based breastfeeding education. J Hum Lact. 2016; 32(1):46-52.,99. Bottaro MS, Giugliani ER. Effectiveness of an intervention to improve breastfeeding knowledge and attitudes among fifth-grade children in Brazil. J Hum Lact. 2009; 25(3):325-32.,1010. Fujimori M, Morais TC, França EL, de Toledo OR, Honório-França AC. The attitudes of primary school children to breastfeeding and the effect of health education lectures. J Pediatr. 2008; 84(3):224-31.) we did not observe descriptions related with validation processes of instruments used to determine the knowledge of schoolchildren about breastfeeding. The lack of information makes difficult the application of the instrument by other researchers and it can compromise the reorganization of health actions and comparison of results from other researchers.(1111. Revorêdo LS, Dantas MM, Maia RS, Torres GV, Maia EM. Content validation of an instrument for identifying violence against children. Acta Paul Enferm. 2016; 29(2):205-17.)

In this perspective, we identified the need to design and validate a reliable and precise instrument to measure the knowledge of schoolchildren on breastfeeding. Such instrument should consider the playful behavior related with schoolchildren, in addition the instrument should be attractive to this audience. We designed and validated an instrument to evaluate knowledge of schoolchildren about breastfeeding. An instrument can guide actions on health education in schools on breastfeeding, and it may become a parameter to measure the effect of interventions.

Methods

This was a methodological study developed in 2016 that included three steps: design of an instrument, validation of its content with judges, and validation of its appearance with the target-audience.(1212. Polit DF. Fundamentos de pesquisa em enfermagem: avaliação de evidência para a prática da enfermagem. 7a ed. Porto Alegre: Artmed; 2011.) Design of the instrument was based on an integrative review on promotion of breastfeeding in primary school,(88. Martins FD, Leal LP, Guedes TG, Javorski M, Pontes CM. Promotion of breastfeeding on primary education: integrative review. Rev Eletr Enf. 2016; 18:e1198.) recommendations of the Brazilian Ministry of Health,(11. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Saúde da criança: aleitamento materno e alimentação complementar. 2a ed. Brasília (DF): Ministério da Saúde; 2015.) articles about public breast- feeding,(1010. Fujimori M, Morais TC, França EL, de Toledo OR, Honório-França AC. The attitudes of primary school children to breastfeeding and the effect of health education lectures. J Pediatr. 2008; 84(3):224-31.,1313. Gale L, Davies N. Young people's attitudes towards breastfeeding: a survey of 13-15-yearold pupils in a south London school. Br J Midwifery. 2013; 21(3):195-201.,1414. Seidel AK, Schetzina KE, Freeman SC, Coulter MM, Colgrove NJ. Comparison of breast-feeding knowledge, attitudes, and beliefs before and after educational intervention for rural Appalachian high school students. South Med J. 2013; 106(3):224-9.) constructs by Sanicola on primary and secondary school,(1515. Sanicola L. As dinâmicas de rede e o trabalho social. São Paulo: Veras Editora; 2015.) relevant people involved (partner, grandmother and nurse)(1616. Monte GC, Leal LP, Pontes CM. [Social support networks for breastfeeding women]. Cogitare Enferm. 2013; 18(1):148-55. Portuguese.) and supportive actions toward women during breastfeeding, including actions related with the child. This support can be classified into five types: emotional (showing empathy, tenders and concern with encouragement for breastfeeding), instrumental (direct helping for care of women and their baby), information (provide counseling, suggestions and feedback on performance of women on breastfeeding), presence (stay with the woman during breastfeeding) and self-support (action on support people with themselves).(1717. Sousa AM, Fracolli LA, Zoboli EL. [Family practices related to breastfeeding maintenance: literature review and meta-synthesis]. Rev Panam Salud Pública. 2013; 34(2):127-34.)

The instrument was called Knowledge of schoolchildren about breastfeeding and target-population was children from third year of primary school I, aged between seven and ten years. The instrument was structured in two parts: the first part includes sociodemographic data (responsible and child), previous experience with maternal breastfeeding and exposition of children for breastfeeding, previous experience with breastfeeding and exposition of child to breastfeeding, and the second part includes the knowledge of children on breastfeeding.

The instrument first version was composed by 32 items, presented by affirmations and illustrations on breastfeeding with the answers options: “right”, “wrong”, and “I don't know” represented by faces adapted from the study by Medeiros et al.(1818. Medeiros AM, Batista BG, Barreto ID. [Breastfeeding and speech- language pathology: knowledge and acceptance of nursing mothers of a maternity]. Audiol Commun Res. 2015; 20(3):183-90. Portuguese.) This approached was used to facilitate the understanding of children. Illustrations were designed by a student from the Graphic Design Course of the Center of Art and Communication at Federal University of Pernambuco, who based her creation in pre-selected images from the internet that resemble the content to be used in items. During the creative process, illustrations were evaluated a variety of times by investigators’ team and changes were made until the illustration was considered adequate to the item (Appendix 1 Appendix 1 First version of evaluation instrument of knowledge of schoolchildren about breastfeeding ).

The content was validated by 22 intentionally selected(1212. Polit DF. Fundamentos de pesquisa em enfermagem: avaliação de evidência para a prática da enfermagem. 7a ed. Porto Alegre: Artmed; 2011.) judges(1919. Lopes MV, Silva VM, Araújo TL. Methods for establishing the accuray of clinical indicators in predicting nursing diagnoses. Int J Nurs Knowl. 2012; 23(3):134-9.) who worked on areas related with maternal and child health and education. Selection was based on criteria adapted from Fehring:(2020. Fehring RJ. Fehring Model. In: Carrol-Johson RM, editor. Classification of nursing diagnosis: proceedings of the conference of North American Nursing Diagnosis Association. Philadelphia: Lippincott; 1994.) academic education, professional performance (teaching, research, extension), updating course and scientific output. Those who achieved a minimal grade of seven were invited to participate in our study. We searched for judges in a website of nursing graduate programs, research groups archives, and in the Lattes Curriculum of National Council for Scientific and Technological Development - CNPq (this curriculum is part of a Brazilian database in which researchers can include information about their education and scientific output).

An invitation was sent by e-mail for judges and for those who accepted to participate in the study an online access was given by Google Forms® tool to consent form, instrument on the knowledge of schoolchildren about breastfeeding, and protocol of the instrument validation.

Validation protocol was created based on Rubio's study,(2121. Rubio DM, Ber-Weger M, Tebb SS, Lee ES, Rauch S. Objectifying content validity: conducting a content validity study in social work research. Soc Work Res. 2003; 27(2):94-104.) which was adapted for our study. The protocol was structured as: I- socioeconomic characterization, and II- evaluation criteria of items: coherence of content with illustration (yes/no), clarity of population language (yes/no); clarity degree (1- not clear, 2- little clear, 3- quite clear, 4- very clear), presence of item in the instrument (yes/no), and degree of relevance (1- irrelevant, 2- little relevant, 3- relevant and 4- very relevant). In each item and in the final protocol of validation a space was provided for comments and suggestions. After ending the validation of the content, the instrument was readjusted and illustrations were improved by the student of Graphic Design Course in order to address the judges recommendations.

The second version of the instrument contained 21 items (Appendix 2 Appendix 2 Final version of the school's knowledge assessment tool on breastfeeding ) and it appearance was validated by ten children, who were selected by convenience, from local municipality school of the Sanitary District IV in the city of Recife-PE. We included children who were enrolled in the third year of primary school, who had good frequency in classes during school term, and who were aged 7 to 10 years old. According to the responsible teacher, all students were able to read words and complete sentences. We excluded children who were in sick leaving and had special needs.

The study was presented to the director of the school and responsible teacher for the class to obtain support in data collection that was done by five research assistants who were graduate and undergraduate nursing students of the Federal University of Pernambuco, and who had received previous training for data collection.

The authorization of parents/legal responsible occurred in meetings done in the beginning of the class, which was scheduled by the help of the teacher. Information collected involved socioeconomic data. All parents/legal responsible signed the consent form. Children were invited to participate in the study by showing them, individually, a cartoon history to explain procedures of the study that also included adapted information regarding consent form. The language used in cartoon was easy to understand and adequate to children age.

The validation of appearance occurred in the school. Each child was interviewed in a private room. During the interview data collection instrument was applied and, subsequently, the validation protocol was completed by the interviewer. The validation protocol was adapted from Rubio's study,(2121. Rubio DM, Ber-Weger M, Tebb SS, Lee ES, Rauch S. Objectifying content validity: conducting a content validity study in social work research. Soc Work Res. 2003; 27(2):94-104.) structured as such: I- socioeconomic characteristics (responsible for the child), and II- evaluation criteria of appearance: understanding of illustrations (yes/no), understanding of phrases (yes/no), degree of understanding of phrases (1. I didn't understand anything, 2. I understood few things, 3. I understood plenty of things, 4. I totally understood and I have not doubts). The answers options were represented by faces adapted from the material by Medeiros et al,(1818. Medeiros AM, Batista BG, Barreto ID. [Breastfeeding and speech- language pathology: knowledge and acceptance of nursing mothers of a maternity]. Audiol Commun Res. 2015; 20(3):183-90. Portuguese.) printed in a ruler and given to the child in the beginning of the interview. For each item, a question was made in order to investigate the wishing of the child to change any phrase/illustration (yes/no) and a space was provided for suggestions from the child.

Data were typed into the IBM® SPSS® Statistics software, version 20.0, for descriptive analysis. The content validity was analyzed using a binomial test to verify the proportion of adequacy of each item according to judges, and ideal value was equal or higher than 85%, considering adequate if test did not present statistical significance (p>0.05). The content validity index - CVI was used both for content validation and appearance validation, ideal value was equal or higher than 0.80 to classify the instrument as valid.(1212. Polit DF. Fundamentos de pesquisa em enfermagem: avaliação de evidência para a prática da enfermagem. 7a ed. Porto Alegre: Artmed; 2011.,2222. Polit D, Beck CT. The content validity index: are you sure know what's being reported? Critique and recommendations. Res Nurs Health. 2006; 29(5): 489-97.)

The research was approved by the Ethical and Research Committee of the Health Science Center from the Federal University of Pernambuco, no 2.075.070.

Results

In process of content validation most of the 22 judges were women (95.5%), nurses (95.2%) and only one judge was from the education area (4.5%). Most of judges had a doctoral degree (72.7%). Twenty professionals (90.9%) were professors and only two (9.1%) worked in health care. Areas of working were nursing (36.4%), pediatric nursing/child and adolescent health (18.1%), obstetric nursing/women health (9%), public health (4.5%) and others (31.8%). Judges mean age was 48.5 (±10.02) years. Years of education varied from 7 to 40 years, mean of 24.64 (±9.79) years, the length of time in current position ranged from 2 to 39 years, mean 20.45 (±11.34).

In content validity analysis concerning the content coherence with illustration, most of items were considered adequate in judges’ assessment. However, thirteen (1, 2, 3, 4, 7, 8, 14, 16, 17, 23, 24, 25, 28) items were identified as inadequate, and the lowest proportion identified was in item 1 (40.9%).

The items 9, 16, 17, 19, 23, 24 and 25 were considered inadequate in the following criteria clarity, understanding and adequacy of language, and the item 14 had the lowest value (63.6%). Concerning clarity, judges evaluated as inadequate the eight items (2, 8, 9, 16, 17, 19, 23, 24, 25), reaching the lowest proportion in item 17 (50%). Nine items (14, 16, 17, 19, 23, 24, 25, 28, 29) had inadequacy in the presence criterion. Of these, items 16 and 23 achieved the lowest values, 36.4% each, in topic about presence.

Upon individual verification of I-CVI eleven items (14, 16, 17, 19, 21, 22, 23, 24, 25, 28, 29) did not achieve the minimal score of 0.80, and the lowest value was 0.36 (16, 23, 25). In judgment of 32 items, the mean I-CVI was 0.81. The relevance proportion (S-CVI/AVE) reached a value greater than 0.80 to sixteen judges and the S-CVI was 0.82 (Table 1).

Table 1
Concordance of judges in validation of items related with content coherence with illustration, clarity, understanding and adequacy of language, clarity degree, presence in the instrument and relevance of item

After analysis of content validation, we opted to exclude eleven items (14, 15, 16, 17, 22, 23, 24, 25, 28, 29, 32) because they had values of I-CVI lower than 0.80 in the assessment of judges. In the second version of the instrument, 21 items that achieved satisfactory I-CVI were maintained (Appendix - Chart 2), and for this reason, we considered unnecessary to resend them for judges to be revalidate. Still, we decided to accept the recommendations of judges. In summary, for changes in illustration, it was recommended the different skin color of characters - mainly for best show the broad racial mix of Brazilian population, change illustration of women breastfeeding a baby on stand or seat position, and drawing characters’ with an entire body to give complete viewing of each character. Other suggestions are presented in chart 1.

Chart 1
Description of suggestions of judges, acceptation or refusal of researchers

In relation to scholars, eight were girls with mean age of 8.50 (±0.52) years, from the city of Recife (05) or metropolitan region of Recife (05). The majority of legal responsible was the mother (06) with mean age of 40.50 (±9.44) years who were married or had a consensual union (08) and incomplete primary school (06). The most frequent professional status reported by parents/legal responsible was unemployment (04) or unemployed receiving government financial aid (03), half of participants did household tasks (05) and their family income were between one and two Brazil national minimum wage (5) (Brazil national minimal age at the time was R$880,00).

In validation of appearance, there was predominance of children who affirmed to understand the illustration and phrases. Most of evaluated items had I-CVI between 0.90 and 1.00, only two of them (3 and 4) had I-CVI lower than 0.70 each (Table 2). The mean of I-CVI was 0.94 for the 21 items of the instrument, the relevance proportion (S-CVI/AVE) was above 0.80 for each child and S-CVI reached the value of 0.94. Five children affirmed that they would change something in illustrations (items 5, 6, 10, 14 and 15), however, only one described the change concerning the item 6 in which was suggested the removal of milk container and the sign of prohibit, and in item 10, the exclusion of the calendar. However, about this latter considering that only one child suggested the change, the authors of the study decided to keep the illustrations in its original format.

Table 2
Assessment of children about the 21 items of the instrument of knowledge on breastfeeding and support for social network

Final version of the completed instrument was composed by 21 items (Appendix 2 Appendix 2 Final version of the school's knowledge assessment tool on breastfeeding ). When using the instrument the researcher must attribute the value of point for each answer one for “right” answers, zero for “wrong” and “I don't know” answers. Therefore, the final score could vary between 0 and 21 points.

Discussion

The difference in our instrumental was its format including illustrations that considered the ludic aspect in order to drawn the attention of schoolchildren on the subject. Therefore the instrument more suitable to children and formed on them the knowledge about breastfeeding, including actions of social network support.(1717. Sousa AM, Fracolli LA, Zoboli EL. [Family practices related to breastfeeding maintenance: literature review and meta-synthesis]. Rev Panam Salud Pública. 2013; 34(2):127-34.) In addition, the instrument was validated regarding its content and appearance, and it could be used by other researchers and contribute for planning of education actions in health in the school related with the learning needs of children.

In content validation, we observed that most of judges were doctors and had professional experience in maternal-child health; judges profile gave more credibility to the assessment.(1111. Revorêdo LS, Dantas MM, Maia RS, Torres GV, Maia EM. Content validation of an instrument for identifying violence against children. Acta Paul Enferm. 2016; 29(2):205-17.) Most of judges agreed in relation to relevance of items, which was verified by satisfactory concordance and values of I=CVI that corroborated with minimal value recommended by the literature concerning the validity of an instrument.(2222. Polit D, Beck CT. The content validity index: are you sure know what's being reported? Critique and recommendations. Res Nurs Health. 2006; 29(5): 489-97.) We excluded eleven items because of the low concordance of judges. Those that remained in the instrument were changes in terms of standardization, clarity and suitability to the target-population.

Four items (3, 26, 27, 30) of the text was not changed because they achieved a satisfactory I-CVI. However, we considered some requested made to improve the illustration. In item 3, the suggestion to remove the term “health” was not considered because this term was used to highlight children the benefit of breastfeeding for woman health. Of note is that only 30.5% of schoolchildren of the fifth to eight grade of the primary school at Mato Grosso could specify the advantages in practice of breastfeeding to women health.(1010. Fujimori M, Morais TC, França EL, de Toledo OR, Honório-França AC. The attitudes of primary school children to breastfeeding and the effect of health education lectures. J Pediatr. 2008; 84(3):224-31.) Breastfeeding can prevent breast cancer, reduce changes for woman development of ovarian cancer and diabetes type II, in addition breastfeeding can increase the period between gestations.(22. Victora CG, Bahl R, Barros AJD, França GV, Horton S, Krasevec J, et al. Breastfeeding. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016; 387(10017):475-90.)

Despite of these benefits, among other, the decision of breastfeeding is influenced by internal and external factors, and support for family is essential for maintenance of breastfeeding.(22. Victora CG, Bahl R, Barros AJD, França GV, Horton S, Krasevec J, et al. Breastfeeding. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016; 387(10017):475-90.,2323. Kornides M, Kitsantas P. Evaluation of breastfeeding promotion, support, and knowledge of benefits on breastfeeding outcomes. J Child Health Care. 2013; 17(3): 264-73.) In this context, the judges highlighted that item 26 about the help by grandmother could sound an imposition. However, the use of term “could” gives the idea of support and not imposition, for this reason, the item was not changed, considering that he/she obtained an adequate I-CVI.

In relation to support of social network to women, judges evaluated the item 27 as irrelevant because of age and level of knowledge of children in given this type of information to the mother. However, children have the knowledge about child feeding, although, sometimes, it had the inadequate knowledge by mentioning the use of artificial milk, bottle feeding and other types of foods.(2424. Angell C, Alexander J, Hunt JA. How are babies fed? A pilot study exploring primary school children's perceptions of infant feeding. Birth. 2011; 38(4):346-53.) Considering that target-population were children from the third year of primary school I, the permanence of item was reinforced to promote a positive support among them to women-mother- nourishment due to the adequate instruction about breastfeeding.

Among subjects that must be discussed with children, some of them considered the social network support (primary and secondary) to woman during the breastfeeding support, highlighting the important influencers and support actions that can contribute.(1515. Sanicola L. As dinâmicas de rede e o trabalho social. São Paulo: Veras Editora; 2015.,1616. Monte GC, Leal LP, Pontes CM. [Social support networks for breastfeeding women]. Cogitare Enferm. 2013; 18(1):148-55. Portuguese.) The support of primary network to women is essential in the beginning and maintenance of breastfeeding and it can be delivery in different ways: be present, by offer supportive care with the baby and by help with house tasks.(2525. Souza MH, Nespoli A, Zeitoune RC. Influence of the social network on the breastfeeding process: a phenomenological study. Esc Anna Nery. 2016; 20(4):e20160107.) These supporting actions are represented in a number of items of instrument (19, 20, 21, 22, 26, 27, 28, 29, 30). In item 30, it was suggested to replace the term “happy” to “support”, however, we opted for not change because the child would understand easily the phrase in its original form.

The second version of the instrument had 21 items. In validation of the appearance with the children, most of items had satisfactory I-CVI values. Although one child suggested the change in items 6 and 10, we opted to maintain the illustrations (6 and 10) in order to show that breastfeeding is always ready for the baby, in addition to more practical and economic compared with artificial milk (item 6) and lead to the idea of exclusive breastfeeding within 6 first months of child's life (item 10) according to what is preconized by the Brazilian Ministry of Health.(11. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Saúde da criança: aleitamento materno e alimentação complementar. 2a ed. Brasília (DF): Ministério da Saúde; 2015.)

The fact that an each item of the instrument contained illustrations was intentionally sought, in addition to represent the content in clear and accessible language, therefore, drawing the attention of the child. The use of illustrations is commonly mention in the literature in educational manuals,(2626. Dodt RCM, Ximenes LB, Oriá MOB. Validation of a flip chart for promoting breastfeeding. Acta Paul Enferm. 2012; 25(2):225-30.2828. Rodrigues AP, Nascimento LA, Dodt RC, Oriá MO, Ximenes LB. Validation of a flipchart for promotion of self-efficacy in breastfeeding. Acta Paul Enferm. 2013; 26(6):586-93.) however, they are not found in instruments to evaluate the knowledge about the breastfeeding among children, and, therefore, it constitutes a differential aspect of our study.

Upon the final of validation of appearance process, the final instrument was made up of 21 items and it achieved adequate I-CVI values in assessment by most schoolchildren aged seven to ten years. Limitations of this study was that psychometric tests were not carried out(2929. Medeiros RK, Ferreira Júnior MA, Pinto DP, Vitor AF, Santos VE, Barichello E. [Pasqualis model of content validation in the Nursing researches]. Rev Enferm Ref. 2015; 4(4): 127-135. Portuguese.) and the not inclusion of children with different age and socioeconomic level. For this reason, the instrument should applied for other population for validation of appearance.

Conclusion

This study enabled to design and validate an instrument to evaluate the knowledge of schoolchildren, aged seven to ten years old, about breastfeeding, including important social supports relevant to woman during breastfeeding. To design an instrument with illustration promoted a ludic aspect, drawn the attention and favored the interest of child during responses. The process of content validation and appearance validation achieved concordance and values of I-CVI were satisfactory, therefore attesting the precision and reliability of the instrument to measure and investigate the phenomenon. Our instrument can be used with safety by nurses and health professionals to evaluate the knowledge of schoolchildren about breastfeeding and, therefore, to guide educative actions in the school for promotion of breastfeeding.

Acknowledgements

We thank the Coordination of Improvement of Person- al Higher Education (CAPES) to the doctoral scholarship provided to Fernanda Demutti Pimpão Martins.

Appendix 1 First version of evaluation instrument of knowledge of schoolchildren about breastfeeding



Appendix 2 Final version of the school's knowledge assessment tool on breastfeeding



Referências

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    Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Saúde da criança: aleitamento materno e alimentação complementar. 2a ed. Brasília (DF): Ministério da Saúde; 2015.
  • 2
    Victora CG, Bahl R, Barros AJD, França GV, Horton S, Krasevec J, et al. Breastfeeding. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016; 387(10017):475-90.
  • 3
    Feldman-Winter L. Evidence-based interventions to support breastfeeding. Pediatr Clin N Am. 2013; 60(1):169-87.
  • 4
    Brasil. Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Atenção Básica. Saúde na escola. Brasília (DF): Ministério da Saúde; 2009.
  • 5
    Glaser DB, Roberts Kj, Grosskopf NA, Basch CH. An evaluation of the effectiveness of school-based breastfeeding education. J Hum Lact. 2016; 32(1):46-52.
  • 6
    Ho YJ, McGrath JM. Effectiveness of a breastfeeding intervention on knowledge and attitudes among high school students in Taiwan. J Obstet Gynecol Neonatal Nurs. 2016; 45(1): 71-7.
  • 7
    Gijsen LI, Kaiser DE. [Nursing and health education in Brazilian schools: an integrative literature review]. Cienc Cuid Saude. 2013; 12(4):813- 21. Portuguese.
  • 8
    Martins FD, Leal LP, Guedes TG, Javorski M, Pontes CM. Promotion of breastfeeding on primary education: integrative review. Rev Eletr Enf. 2016; 18:e1198.
  • 9
    Bottaro MS, Giugliani ER. Effectiveness of an intervention to improve breastfeeding knowledge and attitudes among fifth-grade children in Brazil. J Hum Lact. 2009; 25(3):325-32.
  • 10
    Fujimori M, Morais TC, França EL, de Toledo OR, Honório-França AC. The attitudes of primary school children to breastfeeding and the effect of health education lectures. J Pediatr. 2008; 84(3):224-31.
  • 11
    Revorêdo LS, Dantas MM, Maia RS, Torres GV, Maia EM. Content validation of an instrument for identifying violence against children. Acta Paul Enferm. 2016; 29(2):205-17.
  • 12
    Polit DF. Fundamentos de pesquisa em enfermagem: avaliação de evidência para a prática da enfermagem. 7a ed. Porto Alegre: Artmed; 2011.
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Publication Dates

  • Publication in this collection
    Sep-Oct 2017

History

  • Received
    23 May 2017
  • Accepted
    18 Sept 2017
Escola Paulista de Enfermagem, Universidade Federal de São Paulo R. Napoleão de Barros, 754, 04024-002 São Paulo - SP/Brasil, Tel./Fax: (55 11) 5576 4430 - São Paulo - SP - Brazil
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