VIDEO CLIP FOR LEARNING THE PHYSIOLOGY OF LACTATION: EVALUATION BY THE FAMILY SUPPORT NETWORK FOR BREASTFEEDING WOMEN

ABSTRACT Objective: to evaluate the adequacy of using a care-educational technology with video clips for learning the physiology of lactation by the family support network for breastfeeding women. Method: a methodological study guided by the Knowledge Translation in Action Model. The collection procedure was carried out from July to September 2022 in the city of Santa Cruz do Sul, state of Rio Grande do Sul, Brazil. After the childcare consultation, each puerperal woman indicated one or more members of her support network to participate in the research. In face-to-face interviews, 52 participants answered the following instruments: Assistive Technology Assessment and Face Validation of Educational Technologies in Health. Normality of the variables was verified using the Kolmogorov-Smirnov test. The quantitative variables with normal distribution were described by mean and standard deviation. Face Validity Index and Cronbach's Alpha were calculated. Results: the video clip was evaluated as adequate (1.75) in all attributes: Interactivity (1.75), Objectivity (2.00), Relevance and efficacy (2.00) and Clarity (2.00). Face validity was excellent (0.969). Both instruments obtained Cronbach's Alpha values of 0.883 and 0.852, respectively, indicating reliability in this population. Conclusion: the video clip for learning the physiology of lactation is suitable for use by the family support network for breastfeeding mothers.


INTRODUCTION
Expanding breastfeeding might prevent 823,000 infant deaths annually 1 .However, worldwide, the prevalence of exclusive breastfeeding up to the age of five months old is nearly 50% in the lowest income countries and decreases with increasing wealth 2 .Almost half of the mothers report insufficient milk as the main reason for introducing milk formula in the first months of life and prematurely interrupting breastfeeding.Self-reported insufficient milk can generally be avoided or treated with appropriate support 3 .
This support includes breastfeeding promotion with counseling in health units and in the community, as diverse evidence indicates that breastfeeding problems tend to originate from insufficient lactation knowledge and management immediately after birth 4 .The interventions that extend into pregnancy and the postpartum period are most successful in improving the breastfeeding results 5 .
Promoting breastfeeding, providing guidance on its benefits and describing its physiology, can exert an impact on understanding, attitudes and intentions regarding breastfeeding 6 .Therefore, knowing the physiology of lactation is essential to understand breastfeeding management, as the interaction of hormones affects initial and continuous production of milk 7 .Thus, this learning is important to offer assistance in a coherent way with the functioning of milk production, even counteracting the information about self-reported insufficient milk.
However, the physiology of lactation is a complex and abstract subject that involves the interaction of hormones, breast tissue development and breast milk production [7][8] .In view of this, using educational technology represents a knowledge translation strategy to mediate health education actions with the users [9][10] .Educational materials such as videos enable effective learning on the topic of breastfeeding 11 ; however, among the contents that make up the tools for promoting breastfeeding, the one on lactation physiology represents a gap.3] , for the promotion of learning the physiology of lactation.
Considering that breastfeeding is not an exclusive responsibility of women 3 , who need support to initiate and maintain breastfeeding, it is necessary to recognize the impact of the support network in establishing and maintaining breastfeeding 14 .A number of studies investigating the breastfeeding support network have shown that all the advice provided by the husband/partner and mother of the nursing woman represents support to deal with the difficulties of breastfeeding [14][15] .Therefore, BF promotion should be initiated during prenatal care and involve members of the breastfeeding mother's support network, including the family [16][17] .
That said, it is explained that the study objective was to evaluate the adequacy of using careeducational technology of video clips for learning the physiology of lactation by the family support network for breastfeeding women.

METHOD
This is a methodological study with a participatory approach, guided by the Knowledge Translation in Action Model 10 and based on the care-educational technology translated into a video clip called "Lactashow: o ciclo da lactação" ("Lactashow: The Lactation Cycle") and validated by specialists [12][13] .
The data collection locus was the municipality of Santa Cruz do Sul, state of Rio Grande do Sul, Brazil.The city is located in the Vales region, nearly 150 km from the state's capital.It has an estimated population of 132,271 inhabitants 18 .Primary Health Care consists of 34 units: six distributed in the districts, 22 located in urban areas and six without any assigned territory.The Family Health Strategy

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(FHS) coverage percentage in the municipality is 50.26% and that of Primary Care is 72.23% 19 .The data were collected in the area covered by the FHS in the South region of the municipality.
The inclusion criteria corresponded to people aged at least 18 years old indicated by each breastfeeding mother as members of her support network.Participants with visual or communication impairments, health professionals and breastfeeding mothers/companions with conditions that contraindicate the breastfeeding practice were excluded.
For sample calculation, it was considered that 55% of the sample should evaluate the technology as good, so that it is classified as adequate 20 .Starting from a population of 100 potential participants, and considering a margin of error of ten percentage points and 95% confidence, the sample calculation was performed using the WINPEPI 11.65 program, indicating a minimum of 49 respondents.The sample was selected for convenience: all puerperal women who accessed the health service for the first consultation of their NBs were invited to indicate member(s) of their support network to evaluate the video clip, regardless of previous experience in breastfeeding.The first consultation was the strategic moment for the invitation, as they were generally accompanied by someone from their support network.The research sample consisted of 52 members from the support network.
To characterize the population, the participants answered questions about gender, age and bond with the puerperal woman.In order to achieve the objectives proposed by the research, the following data collection instruments were used: Assistive Technology Assessment (Avaliação de Tecnologia Assistiva, IATA) 21 and Face Validation of Educational Health Technologies (Validação de Aparência de Tecnologias Educacionais em Saúde, IVATES) 22 .
Data collection took place from July to September 2021, after approval of the research project by the UFSM CEP, in compliance with the measures to prevent COVID-19 transmission.The collection procedure took place through face-to-face interviews, after the childcare consultations at the health unit.After concluding the consultation requirements, the collector invited them to participate in the research, without compromising care at the health service.In case of acceptance, each puerperal woman was invited to indicate someone else from her support network.Subsequently, the informed consent form was presented to the indicated person, informing the mean times required to view the video clip (2 minutes) and to fill out the instruments (10 minutes).
The data were entered into Excel and subsequently exported to SPSS v.20.0 for statistical analysis.In IATA, the means of the attributes for the items that comprised them were considered.The classification was considered as inadequate when the mean was equal to 0; as partially adequate when the mean was between 0.1 and 1; and as adequate when the mean was from 1.1 to 2 20 .IVATES was analyzed by means of the Face Validity Index (FVI).The sum of the I-FVI was performed and the result was divided by the total number of items.The number of participants who answered 4 or 5 was computed and divided by the total number of items; where FVI ≥ 0.78 was considered as excellent; between 0.60 and 0.77 as in need for improvements in the appearance of the educational technology in health; and FVI < 0.60 was classified as poor and in need of being redone 22 .
The categorical variables were described by means of frequency and percentages.Normality of the variables was verified using the Kolmogorov-Smirnov test.The quantitative variables with normal distribution were described by mean and standard deviation.FVI and Cronbach's Alpha were also calculated.

RESULTS
The sociodemographic characterization corresponding to the sample of 52 participants showed that they were aged between 19 and 65 years old, with a mean of 32.08 (SD=10.5),and predominantly female (n=28; 53.8%).As for the bond with the puerperal women, there was predominance of partners (n=23; 44.3%); family members of the mothers such as mothers (n=10; 19.3%), sisters (n=8; 15.4%),
The video clip obtained a mean of 1.75 (SD=0.32),evaluated as appropriate by the target audience from the postpartum women's support network.All attributes were classified as adequate, namely: interactivity with a mean of 1.75 (SD=0.36),objectivity with a mean of 2.00 (SD=0.33),relevance and efficacy with a mean of 2.00 (SD=0.49),and clarity with a mean of 2.00 (SD=0.39)(Table 1).In the Interactivity attribute, the target audience considered that the content meets the users' needs (76.9%).As for offering Interaction and involvement in the educational process (67.3%), some participants considered that it partially does so (32.7%), which may indicate an alert for when applying the ET in the next knowledge translation cycle, in which barriers to its use will be analyzed.
In the objectivity attribute, the items that obtained the best results were the following: "It stimulates learning about the content addressed" (73.1%), "It stimulates learning new content" (71.2%) and "It has an appealing presentation strategy" (90.4%).In another three items, more participants considered that it partially meets the expectations: "It enables access to the topics presented" (65.4%), "It provides autonomy to the users regarding its handling" (63.5%) and "It allows easy searches for information" (61.5%).
The Relevance and efficacy attribute had a positive evaluation in the "It provides adequate resources for use" item (82.7%).The items with the highest number of participants considering that they partially meet the expectations refer to the following: "It arouses interest in using it" (59.6%), "It stimulates changes in behavior" (61.5%) and "It reproduces the content addressed in different contexts" (69.2%).

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The Clarity attribute indicated that the target audience considered all items as adequate: "It presents information in a simple way" (73.1%) and "It allows reflecting on the content presented" (75%).
Face validity was excellent with an overall FVI of 0.97.All 12 items were satisfactorily evaluated by the target audience, also achieving the Excellent classification (Table 2).Cronbach's alpha coefficient was also calculated, which evaluate internal consistency of the instruments in the researched sample.According to the statistical calculations, IATA obtained 0.883 and IVATES, 0.852, which indicates adequate performance.

DISCUSSION
The video clip was evaluated as excellent, indicating that it is suitable for its intended objectives.In the literature, there are other technologies on the topic of lactation that have been validated with target audiences using different instruments.In a methodological study, an adapted instrument with 7/12 a Likert-type scale was applied for content validation with pregnant women, postpartum women and family members of newborns.This is an educational technology in video format to encourage breastfeeding and which achieved a result classified as satisfactory (CVI=1.0) 23.
In a non-systematized search, that was developed using information sources that index articles published in journals with national and international circulation, it was not possible to identify studies that applied the IATA instrument to evaluate technologies on the topics of lactation or breastfeeding.Thus, it is possible to use studies applied to other populations to discuss the results of the video clip assessment.In addition, the Cronbach's Alpha coefficient result for IATA in this research indicates that the Assistive Technology Assessment instrument provides subsidies for evaluating the material in view of the objective proposed, allowing the users (target audience of the technology) to judge the quality of the content presented.This shows the possibility of applying the assessment tool to different contexts or populations.
Following the overall assessment, it was possible to verify the assessment by attributes: Interactivity, Objectivity, Relevance and efficacy, and Clarity.The Interactivity assessment indicated that the puerperal women's support network considered that the video clip meets the expectations regarding adequacy, interaction and access to the content, as well as the users' autonomy regarding the educational-assistance technology.It is noted that the "content suitable to the users' needs" item received the most satisfactory evaluation.In this way, it is noted that the content addressed in the educational video meets the need for knowledge of those involved about the physiology of lactation.
In a study that used IATA, the accessibility use of an assistive technology on prostate and breast cancer by visually impaired people in two Portuguese-speaking countries was evaluated 24 .It was evidenced that using technology in audio format, with engaging, appealing, accessible and motivating language, promotes the listeners' reflection on the topic addressed.
The result obtained in the Objectivity attribute means that the puerperal women's support network positively evaluated the learning process about the content on the physiology of lactation, the new knowledge on the topic, access to the information and the appealing strategy of the video clip.The "It has an appealing presentation strategy" item was the most evidenced among the others.A study that used IATA to assess the suitability of an assistive technology for preventing drug use from the perspective of visually impaired people in Brazil and Portugal evidenced that the technology achieved the objectives for which it was developed.This indicates that it provides relevant information on the topic in order to contribute to accessing information and learning 25 .
When evaluating the Relevance and efficacy attribute, the members of the support network assessed the use of adequate video clip resources, desire to use it, change in behaviors and application of knowledge about the physiology of lactation in different contexts.Among the items, "It provides adequate resources for use" was the most expressive.In the same aforementioned study from Portuguese-speaking countries on the use of an educational technology about prostate and breast cancer for visually impaired people, the video was positively evaluated by the target audience because it contributed to men and women reflecting on modifiable factors that contribute to cancer development 24 .
Using educational technologies makes it possible to stimulate reflection in the target audience and changes in behavior 26 .Thus, the positive assessment by the target audience about the relevance of the video clip contributes to the potential use and possible efficacy of this educational technology with the support network of puerperal women to promote learning about the physiology of lactation.
The Clarity attribute assessment means that the information addressed was concise, clear and objective, favoring the process to learn the content about the physiology of lactation by the support network for puerperal women.A study that created and validated, also with the target audience, a 8/12 booklet on the use of a colostomy occluder as a technological support for an educational intervention, pointed out that simple and direct information for laypeople exerts a positive impact on learning 27 .
As for face validation, the video clip was assessed as excellent, indicating that the images and their characteristics were satisfactorily evaluated by the puerperal women's support network.Face validation of educational materials contributes to the optimization and applicability of educational technologies with the target audience 22 .In the study where an educational technology was produced and validated in video format for people and families with a colostomy, it was evidenced that interactive and appealing images can contribute to raising awareness, motivation and education on the topic addressed 28 .
In a study that validated an educational booklet for the prevention congenital syphilis transmission, it was pointed out that the use of accessible material, suitable for the target audience and with simple and objective information and appealing and enlightening illustrations, favored the process of knowledge construction and adaptation to cultural wisdom.It was shown that reading the educational booklet promoted behavioral changes consistent with the ET objective 29 .
Using an educational video with organized scenes, simple illustrations, expressive images and in adequate number, complemented with texts in accessible language, contributes to raising awareness and changing behaviors, in addition to translating information into accessible language 23,28 .Face validation through lines, colors and images in harmony with the textual information of the educational technology is an important tool for reducing the knowledge gap between Nursing and the target audience 22 .
Regarding the population sample studied, it was evidenced that, during application of the research, 44.3% of the puerperal women were accompanied by their partners.The importance of the partners in the support network of puerperal women for breastfeeding was evidenced in a qualitative study conducted with ten women, mothers of at least one Brazilian child aged 1-24 months old, in a city in from inland Rio de Janeiro.This study pointed out the importance of welcoming and support from the partners, thus creating a new family model for those involved, generating the term "motherfather-infant trinomial" 17 .
With this, it is noticed that collective knowledge construction between a puerperal woman and her support network can exert a positive impact on breastfeeding.Involvement of the fathers exerts positive effects on breastfeeding intention, exclusivity and duration 30 .
The sample studied also showed that the age range was between 19 and 65 years old, with a mean of 32.08.In a methodological study about the production and validation of educational technologies in health, in video format to encourage breastfeeding with families and using the Content Validity Index, it was evidenced that among the 20 participants, their age varied between 18 and 40 years old, with a mean of 27.1 23 .
Therefore, the age profile of the validation population in question is similar to already published studies, pointing to the potential use of the educational technology in other scenarios where the puerperal women's support network has these characteristics.Given the above, the participating population of different age groups, either young or older, was able to understand the objective of the educational-assistance technology and considered the content and image of the proposed video as positive.In this way, when clear and concise, the knowledge perpetuated through educationalassistance technology, has the potential to be used as a tool for learning the physiology of lactation in order to promote breastfeeding support.
As for the study limitations, among the participants there was no indication of the partner's mother (mother-in-law of the puerperal woman) as a member of the support network, and data from the participants' previous experience with the topic of lactation were not collected.This might have been related to the assessment results.

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It is noted that the availability of a video clip for use by the support network for breastfeeding women can contribute to teaching, as it offers undergraduate students in the health area a tool to be used in health education actions with the support network for puerperal women.Its objective is to promote learning about the physiology of lactation in a playful way, with content that meets the needs of this population segment and portrays their reality, presented in clear and understandable language, enabling interactivity.Its access is available free of charge, on resources such as smartphones and/ or tablets, depending on how each user prefers to access it in their everyday lives.
In assistance, it can contribute to health education activities to introduce the topic of breastfeeding as a tool for professionals who mediate such activities.It will be useful, for example, in actions promoted by the FHS teams in prenatal and/or childcare consultations, in waiting rooms and/or activities in the community, in order to include members from the support network for puerperal women and subsidize learning of the topic.In addition, it will be able to promote the professionals' interaction with the target audience in a playful way and to raise awareness about the topic of breastfeeding.It also enables multiplication of the video clip among peers, which can be offered for access via television, computer and/or tablets, depending on the available resources.In the research, the evaluation of this audiovisual resource may contribute to the application of care-assistance technologies in order to continue research on the assessment of health technologies.

CONCLUSION
The video clip, called "Lactashow: o ciclo da lactação", was assessed as suitable for use by the family support network for breastfeeding women, being recognized as a health education tool for introducing the topic of breastfeeding.The resource met the Interactivity, Objectivity, Clarity, Relevance and efficacy attributes, in addition to having its face validity classified as excellent.
The Knowledge Translation in Action Model made it possible to consider the perspective of those who will use aforementioned technology, as a path applied to research to engage the target audience.Use of this video clip, now validated for this target audience, can be applied in the local context where this research was developed or even in similar contexts, including the possibility of adaptations to other contexts and verification of barriers to its use.
The instruments employed made it possible to collect data to meet the objective proposed, and its internal consistency result in the researched sample signaled adequate performance.Therefore, it is a contribution in the face of the lack of studies that applied IATA and points out the pertinence of its use in technology assessment studies with similar populations.

Table 1 -
Evaluation by the support network of puerperal women about the video clip attributes for learning the physiology of lactation, Santa Cruz do Sul, Rio Grande do Sul, Brazil, 2022.(n=52)

Table 2 -
Evaluation by the support network of puerperal women about the appearance of the video clip for learning the physiology of lactation, Santa Cruz do Sul, Rio Grande do Sul, Brazil, 2022.(n=52)