Evaluation of the effectiveness of the serious game aleitagame as an educational resource in teaching about mammillary injuries

Objective: to evaluate the effectiveness of an educational intervention using the serious game AleitaGame as an educational resource in teaching about mammillary injuries. Method: a quasi-experimental, single group, before and after, non-randomized study, developed between August and October 2021. The intervention was carried out with 43 professionals working in a hospital in Rio Grande do Norte. Data were analyzed using descriptive and inferential statistics. Results: the educational resource had a positive effect, with a significant increase in the knowledge of the participants of the educational intervention (p<0.05). Regarding the evaluation of participants’ satisfaction about AleitaGame as an educational resource, most participants considered all items in the “content”, “language”, “organization and layout”, “motivation and learning” categories to be excellent. Conclusion and implications for practice: the results of the study are inviting criteria for professors in the area to start incorporating AleitaGame in their classrooms, as well as for using the resource as a strategy for the continuing education of professionals in health services. The serious game is available on the link: <https://aleitagame.github.io/>.


INTRODUCTION
Defined as "the foundation of life", breastfeeding provides the child with the best possible nutrition, in addition to providing better physical and mental health throughout life.There are, in the literature, descriptions of evidence of the positive effects of breastfeeding on children's health in the short term, such as the reduction of mortality and morbidity related to diarrhea and respiratory infections, as well as in the long term, in the prevention of overweight/obesity, type 2 diabetes, type 1 diabetes and leukemia. 1n order to strengthen it within the scope of health services, in 1991 the Baby-Friendly Hospital Initiative was created by the World Health Organization (WHO) and the United Nations International Children's Emergency Fund (UNICEF).Among the various strategies proposed, step 2 stands out for the success of breastfeeding (BF), which aims to train the entire health care team in the practices necessary for the implementation of the BF promotion policy in accredited hospitals.2 There are many teaching demands in this area to encompass the complexity of the subject.Thus, the training is aimed at improving the knowledge of the professionals of the multidisciplinary team about breastfeeding in a context in which mothers may have numerous difficulties and at different times.In this case, the maximum number of professionals trained to deal with clinical management in BF favors the possibility of solving these situations and increases the chances of establishing and/or maintaining it exclusively, as recommended by the WHO, which proposes as a goal for 2030 a prevalence of at least 70% of children under 6 months of age being exclusively breastfed.3 Among the reasons given for not breastfeeding, there are problems in the breast, such as painful nipples, flat or inverted nipples, nipple fissure, breast engorgement, obstructed ducts and mastitis.4 Mammillary trauma is defined as a change in the normal anatomy of the mammillary skin, such as the presence of a primary lesion caused by a change in color, thickness or liquid content, and not only as a break in the skin.5 Some national studies that evaluated the knowledge of health professionals about breastfeeding concluded that they have a good general knowledge of the topic.However, within this evaluation perspective, little is portrayed on the specificity required in the care of nipple-areolar lesions, which deserve special attention in promoting the continuity of BF, especially the exclusive one up to six months.6,7 Thus, the implementation of an educational intervention focused on professional training becomes relevant.The use of active methodologies and educational technologies can make this process more attractive and dynamic, with the use of a serious game being the teaching material used to promote knowledge on the subject in this study.
From this perspective, the serious game, entitled AleitaGame, was developed in a Doctoral research in Nursing, with the objective of enabling the game participant to approach real cases related to nipple-areolar injuries in the context of breastfeeding.
AleitaGame is composed of three fictitious professional performance scenarios: hospital ward (rooming-in), basic health unit (clinic) and home visit (baby's room).In these scenarios, cases of inadequate breastfeeding technique, nipple candidiasis and ankyloglossia, respectively, are studied.Interaction with the game is self-instructional, so that the game participant guides and tests their knowledge in an individualized way.Scoring occurs from their interaction with the game and from hits and misses in the knowledge assessment stages.In addition, in all scenarios, there is an exploration phase aimed at providing information regarding the evaluation and decision-making in the case studied.Finally, for each scenario, support material is available in case the game participant feels the need or is interested in delving into the topic. 8he game has a practical pedagogical approach to assess learning, with intervention for theoretical discussion in the care of breastfeeding women who are experiencing complications related to breastfeeding. 8he growing integration of technological resources in health education, especially with the emergence of the pandemic, reinforces the importance of innovative resources in the process of continuing education for health professionals.
Hence, the following research question arises: what is the effectiveness of the serious game "AleitaGame" as an educational resource used in the continuing education of health professionals?
Therefore, the objective of this study is to evaluate the effectiveness of an educational intervention using the serious game AleitaGame as an educational resource in teaching about mammillary injuries.

METHOD
This is a quasi-experimental, single-group, before and after, non-randomized study to assess the effectiveness of a serious game as an educational resource for professionals in the multidisciplinary team and to assess the satisfaction of professionals in relation to the use of the serious game as an educational resource.
The research stems from a master's dissertation developed within the scope of the Postgraduate Program in Health Education, at the Federal University of Rio Grande do Norte, with defense in the year 2022, 9 which continued the doctoral study in which the game was developed. 8he study was carried out in a hospital linked to a Higher Education Institution that is a reference in obstetric and pediatric medium complexity, as well as in intensive and semi-intensive neonatal care and gynecological surgeries in the state of Rio Grande do Norte.
The study population included all professionals involved in the preceptorship of the institution's Multiprofessional Residency in Maternal and Child Health, totaling 110 people.There was no refusal to participate, but the sampling was for convenience, so that the professionals who were working during the data collection period participated in the research, totaling 43 participants.The invitation to the participants took place within the activities

Evaluation of the effectiveness of the serious game AleitaGame
Pereira FCS, Medeiros LP, Salvador PTCO of Agosto Dourado (Golden August, in free translation), month alluding to breastfeeding.
To assess the effectiveness of the game, a pre-and post-test instrument was developed and validated, based on a methodological framework adapted from Pasquali's psychometry (development) and two-step Delphi (validation), with the participation of six judges. 10The evaluation took place between April and May 2021.The instrument was considered valid, with a Content Validity Coefficient of 0.99.
The game consists of 10 multiple-choice questions, with four alternatives each, divided into four questions about breastfeeding technique, three about fungal infection and three about ankyloglossia.
To assess satisfaction, a structured questionnaire adapted from the Suitability Assessment of Materials (SAM) was used.Composed of 19 questions, the instrument aims to assess satisfaction based on the "content", "language", "organization and layout", "motivation and learning" categories.Each of the instrument's variables is evaluated on a 3-point Likert scale, where: 2-excellent; 1-adequate; 0-not suitable. 11ata were collected in person, between August and October 2021, respecting distancing and number of people recommendations.The data collection instrument was made available through a Google Forms link, which was subdivided into the following parts: consent form; participant profile; pretest; link to AleitaGame; post-test; and satisfaction assessment.
After completing the pre-test, participants viewed the link to access AleitaGame.Before starting to navigate the game, they received guidance from a facilitator and had help to clarify doubts, when requested, with regard to technical aspects of navigation through the game and/or access to the research instruments.The navigation of the game lasted an average of one hour.
The data were organized in an Excel ® for Windows ® database and later transported to the Statistical Package for the Social Sciences (SPSS) version 20.0 software, where they were analyzed in two stages.The evaluation of effectiveness was performed by comparing the means of correct answers in the pre-and posttest instruments, using the Wilcoxon test, adopting a statistical significance level of 5% (p<0.05).Satisfaction assessment was performed using simple descriptive statistics, with calculation of number and percentage to assess the percentage of agreement of the subjects regarding the criteria evaluated by the SAM.
The research complied with the ethical and scientific rigors recommended by Resolutions nº 466/12 and 510/2016 of the National Health Council, with approval by the Research Ethics Committee (CEP), with CAAE number: 40424520.7.0000.5292and Opinion number: 4,462,449/2020, of December 14, 2020.

RESULTS
A total of 43 professionals participated in the research, divided into eight professional categories (Table 1).
The training time ranged from 0 to 23 years, with a mean of 11.37 (SD=5.572)and the time working in the maternal-infant area ranged from 0 to 25 years, with a mean of 4.65 (SD=4.364).
It is noteworthy that the training time referred to the last degree of the professional, which demonstrates that there are professionals who already worked in the maternal and child area before the current degree.
Regarding the degree, five (11.6%) have only a technical level, three (7.0%)have incomplete higher education, seven (16.3%) only have a higher education degree and 28 (65.1%) have postgraduate studies.
With regard to participation in training on breastfeeding, 38 participants (88.4%) answered yes and five (11.6%) answered no.
Twenty-two (51.2%) participated in training on mammillary injuries and 21 (48.8%) did not participate.Although more than half of the participants had already participated in training on mammillary injuries, most responded that they had little knowledge on the subject (Figure 1).
When asked if they consider knowledge about mammillary injuries care important for professional practice, 42 (97.7%)respondents answered yes and one (2.3%)answered no.
Regarding the assessment of knowledge by comparing the scores obtained in the pre-and post-test, the descriptive analysis showed an increase in the percentage of correct answers for questions 3, 5, 7, 8 and 9 and a reduction in correct answers for questions 2, 4 and 10.Questions 1 and 6 had no change in the number of correct answers between the pre and post-test (Table 2).
With regard to the assessment of the effectiveness of AleitaGame, the results presented show statistically significant differences (Table 3).Thus, it can be said that the educational

Evaluation of the effectiveness of the serious game AleitaGame
Pereira FCS, Medeiros LP, Salvador PTCO resource had a positive effect, with a significant increase in the knowledge of the participants of the educational intervention.
Regarding the evaluation of the participants' satisfaction with AleitaGame as an educational resource, the general impression of the game was evaluated as excellent, since at least 86% of the participants considered all items in the "content", "language", "organization and layout", "motivation and learning" categories to be excellent.(Table 4).
None of the items in the aforementioned categories was assessed as not adequate.In the category related to "illustrations and typography", 83.3% rated the item that deals with captions in the illustrations as excellent and 2.3% considered the item not suitable.Items 2 (The content meets the purpose of the game) and 19 (The game brought important knowledge that could be applied in practice) were the ones with the highest percentage of maximum evaluation, both with 97.7%.Table 4 presents the evaluation results for all categories.
In addition, participants reported access to new and relevant information for their professional practice.

DISCUSSION
The profile of the participants corroborates the distribution of the quantity, by category, of the health institutions.However, there was an absence of the medical category, which is a very important component in the promotion of BF in institutions, as this profession is the one that most frequently assists in childbirth, as demonstrated in the study "Born in Brazil: National Survey on Labor and Childbirth". 12ost of the participants are nurses and nursing technicians, in line with research data carried out by the Osvaldo Cruz Foundation (FIOCRUZ), which presents Nursing as the largest professional category working in the field of health in Brazil. 13egarding the effectiveness of AleitaGame, a positive result was observed in the matter of knowledge assessment after educational intervention, thus corroborating the objective of this   Evaluation of the effectiveness of the serious game AleitaGame Pereira FCS, Medeiros LP, Salvador PTCO tool.Serious Games is the name for the category of games that have learning as their main objective, through their dynamic, responsive and visual nature, stimulating motivation, strong user involvement and meaningful learning.Learning from experience is the dominant pedagogical paradigm in serious game design.It is learning through active, self-directed exploration rather than learning from instruction. 14he three AleitaGame scenarios represent some of the environments of the complex Health Care Network, which provide the opportunity to offer care for mammillary injuries.Thus, the hospital, basic health unit and home scenarios demonstrate the different contexts in which this complication can arise at different levels of health care, as well as representing three different complications, confirming the importance and scope of the topic.
In this context, it is known that learning is a complex phenomenon.[17] The literature shows that serious games in the health area were designed for three target audiences: health service providers; patients; and public users.Examples of topics studied in the first category are: knowledge of diseases; general health; health service management; medicines; mental health; nutrition; pedagogical content; sexuality; among others.Other examples that can express the second category were games aimed at behavioral and emotional skills, clinical competence, cognition, decision-making, language, memory, reading and writing, selfcontrol, social and others. 14fter carrying out this study, AleitaGame advances in its development in terms of evaluation and validation, the latter not yet carried out with the target audience in the game, bringing it closer to its completion and the feasibility of educational software as an educational resource in the training of health professionals. 16n addition, it contributes to the advancement of science, both in the area of education and in the training of professionals in the field of health and health education, considering its differentiated conceptions.][19][20][21] Finally, the evidence of knowledge improvement, as well as the positive results regarding the evaluation of the educational resource itself, are inviting criteria for teachers in this area to start incorporating AleitaGame in their classrooms, as well as for using the resource as a strategy for continuing education of professionals in health services.The serious game is available on the link: <https://aleitagame.github.io/>.

CONCLUSION AND IMPLICATIONS FOR PRACTICE
The statistical analysis of the data showed a gain in knowledge after the educational intervention.Therefore, AleitaGame proved to be an effective educational resource to improve the knowledge of professionals about mammillary injuries resulting from breastfeeding, in addition to presenting itself as an innovative educational tool, which follows the paradigm shift in health education.Some limitations were found in the course of the research, such as the moments of aggravation of the pandemic, which prevented or limited the performing of face-to-face activities.Another challenge encountered was the logistics to make computers available, since browsing the game is not well used on mobile devices, such as smartphones and tablets.
As methodological limitations, we highlight the lack of a control group, the type and size of the sample, which make it difficult to generalize the results to other municipalities in the state of Rio Grande do Norte and Brazil, in addition to the possibility of bias related to the memory of the participants due to the short time interval between pre-test, intervention and post-test.
It is expected that continuing education activities increasingly incorporate innovative teaching tools, in addition to other actions to promote breastfeeding that can generate positive effects on the quality of care and service indicators.The adoption of active methodologies in the different teaching scenarios provides integration between theory and practice and tends to qualify the teaching-learning process in the service both for professionals and for undergraduate and graduate students inserted in these scenarios.
The accomplishment of the study points to challenges related to changes in the practices of continuing education in health services, as well as to the demand of professionals for new teaching methods that stimulate critical and reflective thinking.
Finally, it is important to carry out other studies related to the evaluation of educational interventions in the continuing education of health professionals in order to qualify the teaching-learning process of workers and the consequent qualification of care.

Figure 1 .
Figure 1.Assessment of self-knowledge about mammillary injuries, in absolute numbers, 2022.Source: prepared by the authors.

Table 1 .
Professional categories that participated in the survey.Santa Cruz, Rio Grande do Norte, Brazil, 2021.
Source: prepared by the authors.

Table 3 .
Average of correct answers in the pre and post-test.Santa Cruz, Rio Grande do Norte, Brazil, 2021.
Source: prepared by the authors.* Wilcoxon Test

Table 2 .
Pre and post-test correct answers.Santa Cruz, Rio Grande do Norte, Brazil, 2021.
Source: prepared by the authors.
Source: prepared by the authors.