EDUCATIONAL TECHNOLOGY ON BREASTFEEDING IN PREPARATION FOR DISCHARGE FROM THE NEONATAL UNIT: A MIXED STUDYABSTRACT
Objective: to evaluate the use of the educational technology “Descomplicando a Amamentação” in the knowledge construction of family members of premature newborns about breastfeeding in preparation for discharge from the neonatal unit.
Method: an incorporated mixed methods study with QUAN notation (qual), conducted in five stages: initial interview; pre-test; intervention (mobile application); post-test; final interview. The study was conducted between December 2022 and July 2023, at the Neonatal Unit of a University Hospital in Rio de Janeiro, with the participation of 15 family members. The textual data from stage 1 were processed in the R Interface pour les Analyses Multidimensionnelles de Textes et de Questionnaires, while colorimetric marking was used in stage 5, both interpreted according to Thematic Content Analysis. The characterization data and data from stages 2 and 4 were quantitatively analyzed with simple descriptive statistics.
Results: preparation for discharge in the neonatal unit regarding breastfeeding before the intervention was mainly focused on the mothers during each feeding, with guidance from professionals on the baby’s positioning and latch. This approach was ad hoc, without standardization, did not involve all family members, and educational technologies were not used. After using the “Descomplicando a Amamentação” application, there was a 28.9% increase in the total number of correct answers, highlighting its importance in preparing for discharge, with this aspect being reinforced by the interviews.
Conclusion: the application positively helped in the knowledge construction of family members of premature newborns. It is suggested that family members be involved in preparing for discharge throughout hospitalization, including the use of educational technologies.
DESCRIPTORS:
Family; Patient discharge; Infant premature; Breastfeeding; Educational technology
RESUMO
Objetivo: avaliar o uso da tecnologia educacional “Descomplicando a Amamentação” na construção do conhecimento de familiares de recém-nascidos prematuros sobre o aleitamento materno no preparo de alta da unidade neonatal.
Método: estudo de métodos mistos incorporados, com notação QUAN (qual), realizado em cinco etapas: entrevista inicial; pré-teste; intervenção (aplicativo móvel); pós-teste; entrevista final. Foi conduzido entre dezembro de 2022 e julho de 2023, na Unidade Neonatal de um Hospital Universitário do Rio de Janeiro, com participação de 15 familiares. Processaram-se os dados textuais da etapa 1 no Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires, enquanto na etapa 5 utilizou-se a marcação colorimétrica, ambas interpretadas segundo a Análise Temática de Conteúdo. Analisaram-se os dados de caracterização e das etapas 2 e 4 quantitativamente com estatística descritiva simples.
Resultados: o preparo de alta na unidade neonatal sobre o aleitamento materno, antes da intervenção, era voltado principalmente para as mães durante cada mamada, com orientação dos profissionais sobre o posicionamento e a pega do bebê. Essa abordagem ocorria de forma pontual, sem padronização, não envolvia todos os familiares e não eram utilizadas tecnologias educacionais. Após o uso do aplicativo "Descomplicando a Amamentação" houve um aumento de 28,9% no número total de respostas corretas, destacando sua importância no preparo de alta, aspecto reforçado pelas entrevistas.
Conclusão: o aplicativo auxiliou positivamente na construção do conhecimento de familiares de recém-nascidos prematuros. Sugere-se envolver os membros da família no preparo de alta ao longo da internação, incluindo o uso de tecnologias educacionais.
DESCRITORES:
Família; Alta do paciente; Recém-nascido prematuro; Aleitamento materno; Tecnologia educacional
RESUMEN
Objetivo: evaluar el uso de la tecnología educativa “Descomplicando a Amamentação” en la construcción de conocimientos de las familias de recién nacidos prematuros sobre la lactancia materna en la preparación al alta de la unidad neonatal.
Método: estudio incorporado de métodos mixtos, con notación QUAN (qual), realizado en cinco etapas: entrevista inicial; prueba previa; intervención (aplicación móvil); prueba posterior; entrevista final. Se realizó entre diciembre de 2022 y julio de 2023, en la Unidad Neonatal de un Hospital Universitario de Río de Janeiro, con la participación de 15 familiares. Los datos textuales de la etapa 1 fueron procesados en la Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires, mientras que en la etapa 5 se utilizó el marcaje colorimétrico, ambos interpretados según el Análisis de Contenido Temático. Los datos de caracterización y los datos de los pasos 2 y 4 se analizaron cuantitativamente con estadística descriptiva simple.
Resultados: la preparación al alta de la unidad neonatal en cuanto a la lactancia materna, antes de la intervención, estuvo dirigida principalmente a las madres durante cada toma, con orientación de los profesionales sobre el posicionamiento y el agarre del bebé. Este abordaje se produjo de forma puntual, sin estandarización, no involucró a todos los miembros de la familia y no se utilizaron tecnologías educativas. Después de utilizar la aplicación "Simplificando la Lactancia Materna", hubo un aumento del 28,9% en el número total de respuestas correctas, destacando su importancia en la preparación para el alta, aspecto reforzado por las entrevistas.
Conclusión: la aplicación ayudó positivamente en la construcción de conocimientos de los familiares de recién nacidos prematuros. Se sugiere involucrar a los familiares en la preparación para el alta durante la hospitalización, incluido el uso de tecnologías educativas.
DESCRIPTORES:
Familia; Alta del paciente; Recien nacido prematuro; Lactancia Materna; Tecnología educacional
INTRODUCTION
The World Health Organization (WHO) defines prematurity as birth before 37 complete weeks of gestation. This condition implies the newborn has immature organs and the need for prolonged care in neonatal units, especially with regard to feeding. Breast milk stands out as the ideal food to promote the healthy growth and development of these premature babies, especially given their greater vulnerability to various health problems compared to babies born at term1.
Encouraging breastfeeding and providing guidance on this practice by health professionals are crucial elements to be emphasized to the families of premature newborns, aiming to increase breastfeeding rates from admission to the neonatal unit until hospital discharge. To do so, it is necessary to encourage early ‘skin-to-skin’ contact and expressed breast milk, providing adequate support and information for this even before the newborn is able to breastfeed directly2.
The discharge process should include preparing families from the moment they are admitted through various educational strategies which are appropriate to the real needs of each family3. Freire’s guiding ideas have been integrated into health education practices performed by nurses, who, when using education to transform reality and promote the autonomy of students, need to take on the role of learners with the families of premature newborns. This approach results in a liberating and critical educational practice that values the family’s prior knowledge4.
The six key ideas cited in the educational process are as follows: 1) Educational action should begin with a reflection on the human being and an analysis of the student’s context; 2) The individual becomes a subject by reflecting on their situation and environment; 3) By reflecting and committing to their context, the human being builds their identity and is capable of transforming reality through relationships with others; 4) Understanding and responding to the challenges of the context allows the individual to acquire a critical and creative experience and not just accumulate information; 5) The human being is a creator of culture and a builder of history; and 6) Education should enable the individual to transform the world and relate to others, creating culture and history4.
The use of educational technologies emerges as an additional and facilitating tool to promote health education among family members and professionals, contributing to promote breastfeeding and individual and collective knowledge construction in preparing for discharge5-6. In view of this, a mobile application called “Descomplicando a Amamentação” was recently developed, which was validated and satisfactorily evaluated by expert judges in the area of pediatric, neonatal and obstetric nursing, as well as by the target audience with regard to semantics, appearance and usability7-8. The application is available for free download for Android® devices in the Google Play Store®.
This application seeks to promote the autonomy of pregnant women, postpartum women, and family members of newborns and infants in relation to breastfeeding. This educational technology employs different tabs with relevant information, including a digital booklet and an interactive quiz, and has the potential to stimulate critical thinking and autonomy of users considering the ease of access to information7. However, it was still necessary to understand whether the application can actually promote knowledge construction of family members in different contexts.
The scarcity of literature on the evaluation of mobile applications in discharge preparation in neonatal units can make it difficult for health professionals to make informed decisions about adopting these technological tools in their daily practices. Thus, the guiding question arose: does the “Descomplicando a Amamentação” educational technology facilitate knowledge construction by family members of premature newborns about breastfeeding during discharge preparation from the neonatal unit? Therefore, the objective was to evaluate the use of the “Descomplicando a Amamentação” educational technology in knowledge construction of relatives of premature newborns about breastfeeding in preparation for discharge from the neonatal unit.
METHOD
This is an incorporated mixed methods study with QUAN (qual) notation9, conducted between December 2022 and July 2023 in the Neonatal Unit, composed of the Neonatal Intensive Care Unit (NICU) and the Intermediate Care Unit (ICU), of a University Hospital in the city of Rio de Janeiro, Brazil. The study was developed in five stages, namely: 1st: initial interview; 2nd: pre-test; 3rd: intervention (mobile application); 4th: post-test; 5th: final interview. A combination of quantitative and qualitative methods was used to provide more comprehensive understanding of the object studied, with the main emphasis on the quantitative approach to measure the change in family members’ knowledge regarding the intervention used. The qualitative method was incorporated to complement the quantitative analysis, aiming to understand the experiences of family members in preparing for discharge before and after the intervention.
The population consisted of family caregivers of premature newborns, and the sample was selected based on convenience and availability during the study period10. The inclusion criteria were: mothers, fathers and family members of premature newborns, over 18 years of age, with babies admitted to the neonatal unit. The exclusion criteria were: mothers, fathers and family members of premature newborns, with difficulties in participating in the study due to some type of compromise in their physical or mental health status and/or women infected with HIV and/or HTLV1 and HTLV2 (maternal infections in which breastfeeding is not recommended). A total of 17 family members were approached, of which two were excluded because they did not complete steps 4 and 5 due to hospital discharge the day after steps 1, 2 and 3, thus totaling 15 participants, with no dropouts.
Potential participants were invited to participate in the study directly at the Neonatal Unit due to the ease of constantly finding them there. After acceptance, the participants were initially characterized by asking about their degree of kinship with the newborn, age, sex, profession, professional activity and education. This survey was conducted by filling out the first part of the instruments by the first author. The script for the individual interview in the first stage consisted of initial open-ended questions to guide this stage: 1) How have you been prepared during your baby’s hospitalization regarding breastfeeding?; 2) When does this preparation take place?; 3) How does this preparation take place?; 4) Who has carried out this preparation with you?; 5) What facilities have you found?; 6) And what are the difficulties?; 7) What are your doubts about breastfeeding??
Next, the knowledge of family members of premature newborns prior to the intervention was assessed in the second stage using an individual printed pre-test form. This form was created by the authors, and contains questions related to the information in the application using accessible and easy-to-understand language, and presents 15 questions in the form of statements (Chart 1). Participants marked the desired answer with an “X”, choosing between the options (T) for True, (F) for False, and (DK) for I don’t know.
Questions and correct answers of the data collection instrument, Rio de Janeiro, RJ, Brazil, 2024.
Then in the third stage of the intervention, the participants were presented with the “Descomplicando a Amamentação” application on a mobile device provided by the first author. They were also invited to install the application on their own mobile devices by searching for the application name on Google Play or using the access QR Code (Figure 1), thus allowing their personal use after hospital discharge.
Main menu and QR Code to access the “Descomplicando a Amamentação” application. Rio de Janeiro, RJ, Brazil, 2024.
The participants were subsequently asked to answer a new printed individual form during the post-test in the fourth stage which contained the same questions used in the second stage. Thus, the participants were given the opportunity to choose different answers from those selected in the pre-test. The post-test was conducted on the same day of the intervention or the following day, varying according to the availability and/or choice of each family member, with the aim of identifying their knowledge about premature newborns after the intervention in the discharge preparation.
Next, the participants answered a new individual interview script in the fifth stage consisting of two open-ended questions: 1) How did this application contribute to your knowledge regarding breastfeeding your baby during this preparation?; and 2) Do you consider that this application helped to answer your questions about breastfeeding? The interviews conducted during the first and fifth stages were recorded on a cell phone and later transcribed in full, composing the textual corpus for the qualitative analysis. Participants signed the authorization form for the use of voice sound for research purposes. All stages took place in private rooms, according to the sector’s availability during the study, and only in the presence of the first author. This approach was adopted to guarantee confidentiality of the participants and avoid consulting external sources and/or the mobile application when filling out the pre- and post-test forms, minimizing possible biases. This strategy enabled a more precise analysis on the use of this educational technology in knowledge construction about breastfeeding, making it possible to verify changes in the number of correct answers before and after the intervention with the application.
An average total time of 45 minutes was estimated for participation in stages 1, 2 and 3, and an average time of 25 minutes in stages 4 and 5. The participants were given the necessary time to complete both the pre-test and the post-test to promote reflection and knowledge construction, with the duration varying for each person. This time was essential for critical analysis of the information already known and newly learned. The end of data collection was determined by the theoretical saturation of the data, at which point the responses in the qualitative phase became recurrent and the addition of new information did not significantly contribute to understanding the study object11.
However, even after the recordings were finished at the end of the interviews in stage 5, some doubts were clarified regarding the pre-test and post-test questions when necessary or requested, and there was an exchange of knowledge between the family member and the interviewer (first author). These exchanges intensified, especially when participants agreed to correct the pre-test and post-test, allowing the student to reflect on what they had learned using the technology, comparing their experiences, realities or previous knowledge with the scientific literature presented in the application. However, these moments of clarification and exchange of knowledge were not included in the analysis, as they were beyond the scope of the study, which aimed to understand the use of educational technology in knowledge construction.
The qualitative stage was based on Freire’s theoretical framework4. Therefore, the textual data were processed using the Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires (IRAMUTEQ) program to analyze the transcripts from stage 1. Classical Textual Statistics was used for an initial analysis of the textual corpus, revealing the relationship between the frequency and the number of lexical units in the text. A Word Cloud organized the words in a cloud format, highlighting the most frequent words in a centralized manner and in a larger size. Lemmatization was used in the processing, which involves reducing words to their basic forms or roots, and nouns, verbs, adjectives and unrecognized forms were considered as active forms.
The data were then subjected to Thematic Analysis in its basic stages12 for the analysis of stage 5 (also with a qualitative approach), without the use of textual data processing software. Thus, the transcribed content was initially subjected to skimming in the pre-analysis, which involved intense contact by the researchers with the material for a primary classification using colorimetric marking in the Microsoft Word text editor. The content was categorized in exploring the material, segregating textual fragments and sentences with similar meaning cores into four distinct colors, which were organized in an analytical framework. The different meaning cores were subsequently regrouped, which resulted in forming three thematic categories for stage 5.
It is important to note that both the findings from stages 1 and 5 were interpreted according to Thematic Analysis12 to identify and understand the core meanings present in the text segments, based on the theoretical framework of the study through an inferential and interpretative process of the data. Therefore, the theoretical framework used guided the data interpretation in both stages, ensuring that the analysis was aligned with the educational and critical principles proposed by the author4.
Characterization of the participants in stages 1 and stages 2 and 4 were quantitatively analyzed using simple descriptive statistics. The data collected were tabulated in a Microsoft Excel spreadsheet and analyzed based on absolute and relative frequency. Descriptive statistics enabled analyzing the number of correct answers in the pre-test and post-test questions, as well as the characterization variables. The correct answers between the pre-test and post-test were considered to calculate the percentages, with the “I don’t know” answers being classified in the error category.
Data integration in the study occurred by connection between quantitative and qualitative approaches9, allowing a more complete assessment of family members’ knowledge before and after the intervention. Quantitative data obtained through pre- and post-tests assessed changes in family members’ knowledge about breastfeeding. These findings were complemented by qualitative data obtained through interviews, which deepened the understanding of family members' experiences in preparing for discharge before and after using the application. Combining the results allowed us to correlate changes in knowledge with reported experiences, providing a more in-depth analysis of the impact of the intervention. Chart 2 presents a summary of the methodological design, as well as the way in which the study results were integrated.
Summary of the methodological design by stages, procedures and products, Rio de Janeiro, RJ, Brazil, 2024.
The study was approved by the Research Ethics Committee in accordance with Resolutions 466/2012 and 510/2016 of the National Health Council. Data were collected after signing the Informed Consent Form and the Authorization Form for Use of Voice Sound for Research Purposes. The confidentiality and anonymity of the participants were guaranteed with the use of an alphanumeric code.
RESULTS
Among the 15 relatives of premature newborns (100.0%), 14 (93.3%) were female. Regarding kinship, 12 (80.0%) were mothers, one (6.7%) was a father, one (6.7%) was a grandmother and one (6.7%) was an aunt. For the age groups, nine participants (60.0%) were between 18 and 30 years old, five (33.3%) were between 31 and 40 years old and one (6.7%) was over 41 years old. Regarding occupation, three (20.0%) reported being “stay-at-home mothers”, while other occupations included two (13.3%) saleswomen, one (6.7%) examination technician, one (6.7%) night security guard, one (6.7%) dental assistant, one (6.7%) nurse, one (6.7%) administrative technician, one (6.7%) student, one (6.7%) daily cleaner, one (6.7%) daily cleaner and saleswoman, one (6.7%) physiotherapist and personal trainer, and one (6.7%) who did not report profession or occupation; eight (53.3%) worked. Most of the participants had high school education (66.6%), while three (20.0%) had elementary education, and two (13.3%) had higher education.
Regarding the sector of stay, 13 premature newborns were identified in the intermediate unit (IU), while two were in the NICU. These were predominantly late and moderately premature newborns who were mainly hospitalized to remain in the incubator due to jaundice, weight gain, apnea or in transition to breastfeeding directly from the mother’s breast for those who were being fed by gavage or a cup with expressed milk or formula.
After processing the initial interviews by IRAMUTEQ using Classical Textual Statistics, the textual corpus consisted of 15 texts, totaling 5,576 occurrences of words, of which 634 were distinct words and 297 words had only one occurrence (hapax). Using the Word Cloud method, it was possible to identify the most frequent words represented graphically, with each word having its size proportional to the number of times it was repeated. Thus, words with greater importance in the statements of family members were identified, highlighted by their size and central position in the cloud (Figure 2).
Thus, the ten most recurrent words were: “be” (f=108), “stay” (f=59), “only” (f=50), “breast” (f=45), “help” (f=41), “breastfeed” (f=39), “give” (f=38), “milk” (f=38), “latch” (f=38), “staff” (f=34). From this perspective, it was possible to identify the recurrence of the word “be” 108 times, evidencing how this term was important in the statements of the deponents in describing when and how the preparation for breastfeeding took place before the intervention.
The preparation has been happening when I am going to breastfeed, and then they start helping me, everyone is watching and my daughter frowns because everyone is watching (P5). I am not actually breastfeeding, but I am pumping (P8).
It was found that preparation for discharge occurred in both the direct context of breastfeeding the baby at the mother’s breast and through the practice of expressing milk, according to family members. However, knowledge construction about breastfeeding mainly occurred during the breastfeeding moment, punctually, without the use of any type of educational technology.
He has the right time to breastfeed, so when that moment comes, the girls (nursing team) are around, help him pick him up, help him put him in the correct position (P10). The preparation has been happening when I am going to breastfeed (P5).
However, an opposite scenario was identified, in which two of the family members reported that they were not being prepared regarding breastfeeding during the hospitalization and that there was no discussion with any professional about the subject. Furthermore, P3 highlighted that she had not been prepared to breastfeed, even before the hospitalization.
No one ever said anything. It didn't happen here at the hospital and no one ever talked about it at home and I didn't research it either (P3).
From the words that appear in the cloud, such as “teach”, “breastfeed”, “breast”, “help” and “latch”, it can be inferred that care was being provided as professionals in the sector taught mothers how to position the baby for breastfeeding or helped to create a calm environment for breastfeeding. However, no family member mentioned the use of educational technologies by the health team to support discharge preparation with regard to breastfeeding.
They taught me that I have to put him facing me, to position my breast (P9). They help me put him in the correct position (P10). When I’m going to breastfeed, there’s always someone nearby, asking if I’m doing well, if I need help. It’s not just talking; when I need it, they (nursing staff) pick him up from the crib and give him to me, help me get more comfortable, hold my breast to help him latch on better (P13).
The term “stay” appears in the word cloud, and is frequently mentioned by family members, suggesting connections with the emotional state and uncertainties and concerns of mothers regarding breastfeeding.
Because if he can’t breastfeed, I get nervous and start crying, and then everything goes wrong. I’m afraid of breastfeeding alone without anyone around and not being able to get him to breastfeed properly (P12). I’m afraid she'll start breastfeeding when the doctor gives her the go-ahead this week and we won't be able to, she won’t latch on, she’ll have difficulty breastfeeding and it won’t be enough for what she needs (P11).
In view of the qualitative findings in stage 1, it was noted that there was a lack of use of educational technologies in preparing the discharge of family members of premature newborns with regard to breastfeeding. From this perspective, the quantitative data in stages 2 and 4 showed a change in the knowledge of family members after the intervention (mobile application) used in stage 3. Thus, when evaluating the number of correct answers in the use of the educational technology “Descomplicando a Amamentação” in the knowledge construction of family members of premature newborns about breastfeeding during preparation for discharge from the neonatal unit, it was observed that the total number of correct answers in a universe of 225 (100%) possible correct answers increased from 152 to 196 after using the application, representing a percentage increase of 28.9%.
In the comparison between the correct answers in each question about breastfeeding before and after the use of the educational technology, an increase in the number of correct answers was found in most of them (n=12; 80.0%). The number of correct answers remained unchanged (n=2; 13.3%) in two questions, and there was a reduction in one (n=1; 6.7%) (Table 1).
Correct answers of family members of premature newborns about breastfeeding in pre-intervention and post-educational intervention tests (n=15), Rio de Janeiro, RJ, Brazil, 2024.
The five largest variations in correct answers in the post-test were about ‘supplemented breastfeeding (20.0% to 73.3%)’, ‘offering milk in a cup, glass or spoon when it is not possible to breastfeed directly from the mother’s breast, avoiding the use of bottles (53.3% to 100.0%’, ‘World Breastfeeding Week (53.3% to 100.0%)’, ‘composition of the final milk from a feed (33.3% to 73.3%)’ and ‘breast milk should not be boiled or heated (60.0% to 93.3%)’.
It was observed that 40% of the questions (questions 1, 4, 8, 9, 13 and 15) in the post-test showed a percentage increase, reaching 100% of correct answers. These questions address exclusive breastfeeding, the role of family support in breastfeeding, promoting the well-being of the mother and baby, the benefits of breastfeeding for the mother, the provision of breast milk in a cup, glass or spoon, and World Breastfeeding Week. It is worth noting that only question 10, about the information that it is necessary to breastfeed the baby every three hours because breast milk is weak, with the correct answer ‘(F) False’, showed a reduction of 13.3% in the number of correct answers.
Complementing the numerical data presented, the qualitative analysis of the final interviews confirmed that the family members felt more prepared for breastfeeding after using the application. Thus, the qualitative data added to the quantitative findings revealed that the increase in correct answers in the post-test was supported by changes in the family members’ confidence regarding breastfeeding. Thus, the analysis of the responses from the final interview revealed three analytical categories which help to understand the contribution of the “Descomplicando a Amamentação” application in the knowledge construction of the family members of premature newborns in preparing for discharge in relation to breastfeeding through its use by the participants.
Contribution of the application to the families of premature newborns
The use of the “Descomplicando a Amamentação” educational technology by the participants in the study showed that it positively contributed to the knowledge construction for all family members. Most participants highlighted that the learning was useful, especially because doubts can arise at any time, especially at home, and the application offers a readily accessible source of information, without the need for professional assistance.
An important point noted was the use of visual resources and accessible language, which facilitated understanding and learning the information. In addition, the convenience of having reliable information readily available was highlighted by users as a significant benefit of this tool.
It helped a lot. I don’t like to bother the girls because they have a lot to do. Being able to research on my cell phone to get my questions answered is really good (P14). I liked that it has images, it’s not just text and it’s easy to understand. There are no difficult words. It’s in our language, so it’s much easier to absorb the instructions. I’ll be honest, sometimes people here use difficult words that I don’t even know what they are, but I’m embarrassed to ask (P12).
The participants considered the app very interesting and useful for families, especially due to the interactive learning method provided by the “Quiz” (question and answer game) of “Descomplicando a Amamentação”.
It helped a lot. I really liked that little game, because we think we already know everything, that it’s obvious, and then when the time comes, we don’t know anything (P10). I found your app very interesting. I think it will help a lot of families. Even this little answer game is really cool (P2).
Removing doubts from relatives of premature newborns using the application
Using the “Descomplicando a Amamentação” allowed participants to clarify several important doubts. Among the most highlighted topics were the correct latch of the baby during breastfeeding, freezing breast milk, deconstructing the myth that breast milk is weak, and correcting the belief that consuming canjica and dark beer helps increase milk production.
I cleared up the doubt about freezing milk (P1). I thought it certainly helped me, especially the issue of weak milk and latch, which you always warn me about, but when we see the picture it’s easier. Also the issue of dark beer and canjica, I didn’t know it was a myth, because in Ceará everyone does these things, so for me it helped too, it’s a countryside thing, but it worked (P5).
Acquisition of the application by family members of premature newborns
Participants expressed interest in downloading the “Descomplicando a Amamentação” app on their mobile devices for personal use, and also expressed a desire to introduce it to other family members. They understood it as a useful tool to help with breastfeeding and shared the desire to disseminate the information obtained with the app to help other family members in their breastfeeding journey. One mother also expressed a desire for it to be available in the App Store, for iOS and not just Android®.
I want to introduce it to my daughter (P2). I want to have it on my cell phone so I can always study it, so I can do everything right at home (P12). I really liked the app, now I have to make it available for iOS too so I can promote it more (P8).
In summary, the results of the study demonstrate that the use of the “Descomplicando a Amamentação” educational technology significantly contributed to knowledge construction of family members of premature newborns about breastfeeding in preparation for discharge from the neonatal unit. The integration of quantitative and qualitative findings reinforces this conclusion, highlighting both the growth in the number of correct answers to questions related to the topic, as well as the positive reports from participants about the importance, clarity and usefulness of the application.
DISCUSSION
This study found that guidance aimed at building knowledge about breastfeeding during discharge preparation in the neonatal unit predominantly occurred at the exact moment of breastfeeding, without the use of educational technologies. However, another study highlighted that the preparation of family members responsible for home care of the newborn should not be limited to the period close to discharge, as evidenced in this study. On the contrary, preparation should be gradual and cover the entire hospitalization period of the premature newborn13. In addition, the use of educational technologies is recommended because it helps to empower family members during the hospital stay, as well as in the transition process of the newborn to the home environment5.
The study showed that in the context of educational activities aimed at preparing family members of premature newborns in the neonatal unit, the approach which stood out was that it involved explaining the procedures to the parents, followed by the execution - by them - of these procedures, while being observed and guided by the nurse in charge, which is consistent with the current findings with regard to teaching practical actions. Family involvement in the care of premature newborns not only aims to promote the establishment of bonds, but also aims to reduce parental fear after hospital discharge14. Similarly, in the present study, family members expressed the importance of professional assistance in positioning the baby correctly and receiving guidance on the appropriate breastfeeding technique, highlighting the relevance of professional support in achieving successful breastfeeding.
However, cases were also identified in which the opposite occurred, with family members reporting that they were not receiving adequate preparation regarding breastfeeding their children during the hospitalization period. In agreement with these findings, a study conducted in a Brazilian city located in a triple border region found that not all mothers received guidance even within the hospital environment, or had opportunities to talk when their children were hospitalized. Furthermore, some mothers did not have the chance to experience the process of caring for their premature children before hospital discharge15. The lack of communication between the team and the family places the responsibility on the family members of the premature newborn to assimilate all the information provided to them to breastfeed their baby alone, whether through scientific evidence or cultural beliefs, which can generate insecurity about caring for the child at home14-15.
Based on the findings in the qualitative stage, it is assumed that care is being provided as professionals in the sector teach the mother how to place the baby on her breast to breastfeed, with the preparation focus centered on the mother at the time of each feeding, when she learns from the health professional how to position the baby on her breast. However, despite the nursing team practicing communication with the premature infant’s family members during feedings, it is clear that care is still provided in a fragmented manner, since the team acts and the family often ends up being merely a spectator of the care for their baby, which also corroborates the findings in the literature16, and with the gaps in knowledge verified by the results in the pre-test.
The term “stay” referred to the practice of breastfeeding independently, without the assistance of a professional to provide safety, as well as to fear and nervousness regarding the ability to breastfeed sufficiently, since they are not used to this practice. In this context, the emotional state of mothers during hospitalization of the premature baby is identified in another study as a factor that makes breastfeeding difficult, highlighting the frightening experience of having a premature baby17, and which needs to be considered and worked on when preparing for discharge.
The quantitative and qualitative analysis between the pre- and post-tests demonstrated that the use of the “Descomplicando a Amamentação” application by the participants made a significant contribution to the knowledge construction of the relatives of premature newborns about breastfeeding, evidenced by the considerable increase in the percentage of correct answers and by the participants’ own testimonies after use. In this regard, the results found in this study share similarities with a Peruvian study that evaluated the impact of educational videos on improving the practical skills and knowledge of informal caregivers of patients with stroke. This intervention resulted in an increase in the skill score from 21.6 to 56.1 points and in knowledge from 11.6 to 21.6 points18. Furthermore, in line with the current findings, an educational workshop to assess the knowledge of pregnant women about breastfeeding achieved an increase in the number of correct answers in most of the questions in both the immediate and late post-test19.
The results are also consistent with a study conducted in Pernambuco, where questions about the milking technique, storage and administration of expressed milk obtained higher averages of correct answers. This made it possible to assess the knowledge construction of mothers’, since they presented statistically significant increases in the average points in the post-test in 7 of the 15 questions20. The findings are also consistent with another Brazilian study that used an educational video as an intervention to contribute to the self-perception of signs of labor and obstetric risk, reaching a percentage of 100% of correct answers in the post-test21.
The target audience of another study positively evaluated a prototype mobile application on breastfeeding for health professionals, receiving predominantly positive feedback according to the current research, with most evaluations classified as excellent or good22. Although the cited study is not directly aimed at the target audience of the present study, which is family members, its relevance remains, as it provides a basis for the acceptance and effectiveness of educational technologies on the same topic. This type of resource therefore aims to assist in the individual teaching-learning process, and is considered of great importance for professional practice in breastfeeding assistance, aiming to improve the care quality based on the best evidence, in accordance with the purpose of the application evaluated herein.
The presence of images and accessible language in this educational tool facilitated understanding the information, offering a reliable source of knowledge. Corroborating these findings, a similar investigation sought to create and validate an educational technology on breastfeeding in the form of a booklet. The illustrations were developed to reflect the diversity of the Brazilian population, representing different ethnicities so that the target audience could identify with it and feel represented23. Interactive and engaging images play a crucial role in raising awareness, motivating, reassuring, and educating, conveying complex information more effectively than text alone24.
Developing and validating an educational game emerges as an effective alternative to stimulate users’ interest and curiosity in relation to the content, making them active and critical participants in constructing their own knowledge25. In this context, the interest shown by participants in the “quiz” of the “Descomplicando a Amamentação” application highlights its effectiveness as a tool for learning and reinforcing knowledge, which is reflected in the quantitative data and is complemented by the information obtained in the qualitative stage. According to the testimonies of family members, they were able to resolve their doubts through the technology, without the help of a professional, and in turn expressed the desire to continue using it after discharge at home and to share it with their family members.
The results highlighted four main themes in which this educational technology application helped to clarify doubts: proper latch, freezing breast milk, the myth of breast milk weakness, and the myth about including canjica and dark beer in the mother’s diet to increase milk production. This finding is in line with another study that emphasized doubts regarding latch and proper positioning, as well as the provision of supplemental milk related to the concern of having enough milk26. Therefore, clarifying doubts about myths related to breast milk weakness and the inclusion of foods to increase milk production is crucial, as these issues can directly influence introducing formulas to supplement or replace breastfeeding, if they are not clarified.
A study on COVID-19 highlighted that the use of applications on mobile devices is one of the main strategies in health education actions aimed at patients and their families27. Thus, the expression of interest in downloading “Descomplicando a Amamentação” for personal use and sharing it with other family members reinforces the positive perception of the app’s effectiveness, as evidenced by the data integration. The suggestion that it be made available on the App Store for iOS indicates the need to increase its accessibility among users to assist in health education, and consequently contribute to the construction of each individual’s knowledge.
The study was conducted in a single neonatal unit in the state of Rio de Janeiro, limiting generalization of the results. New studies in other contexts are recommended to identify possible differences in the discharge preparation of family members of premature newborns and to evaluate the app’s applicability in different scenarios.
It is hoped that this study will encourage the use of educational technologies, such as the “Descomplicando a Amamentação” app, in the discharge preparation of family members of premature newborns. It has great potential to improve the care of nurses and multidisciplinary teams, in addition to helping to build families’ knowledge about breastfeeding, aiming to reduce neonatal morbidity and mortality and promote continued breastfeeding at home after hospital discharge.
CONCLUSION
The study revealed that discharge preparation in the neonatal unit on breastfeeding, before the intervention was mainly focused on mothers during each feeding, with guidance from professionals on the correct positioning and latching of the baby on a timely basis. However, there was no standardization of this preparation in the neonatal unit, it did not always involve all family members and educational technologies were not used.
Integrating quantitative and qualitative results indicated that the “Descomplicando a Amamentação” application positively helped in the knowledge construction of family members of premature newborns, providing clear information and useful visual resources. The increase in the correct answer rates on breastfeeding after the intervention, together with the participants’ testimonies, highlighted its importance in discharge preparation. It is therefore suggested that family members be involved in discharge preparation throughout the hospitalization period, including the use of educational technologies in the form of mobile applications in the health education process.
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NOTES
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ARTICLE ORIGIN
Extracted from the Dissertation - “Preparo de alta de familiares de recém-nascidos prematuros acerca do aleitamento materno antes e depois da utilização de uma tecnologia educacional”, presented to the Postgraduate Program in Nursing at the Universidade Federal do Estado do Rio de Janeiro, in 2024.
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FUNDING INFORMATION
This research received financial support from the Emergency Program for Strategic Consolidation of Stricto-sensu Academic Postgraduate Programs - CAPES 2022, from the Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES) - Finance code 001, and from the National Council for Scientific and Technological Development (CNPq) - Process 302140/2023-9.
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APPROVAL OF ETHICS COMMITTEE IN RESEARCH
Approved by the Ethics Committee in Research of the Hospital Universitário Gaffrée e Guinle/ Universidade Federal do Estado do Rio de Janeiro, opinion n.º 5,735,022, Certificate of Presentation for Ethical Assessment 63613822.2.0000.5258.
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TRANSLATED BY
Christopher J. Quinn.
