Influência de estratégia de educação em saúde mediada por álbum seriado sobre a autoeficácia materna para amamentar

Influência de estratégia de educação em saúde mediada por álbum seriado sobre a autoeficácia materna para amamentar

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  - 610 -  Original Article Text Context Nursing, Florianópolis, 2013 Jul-Set; 22(3): 610-8. INFLUENCE OF HEALTH EDUCATION STRATEGY MEDIATED BY A SELF-EFFICACY BREASTFEEDING SERIAL ALBUM 1 Regina Cláudia Melo Dodt 2  , Ádria Marcela Vieira Ferreira 3  , Ludmila Alves do Nascimento 4  , Andréa Cavalcante Macêdo 5  , Emanuella Silva Joventino 6  , Lorena Barbosa Ximenes 7  1  Research supported by the National Council for Scientic and Technological Development, process 475692/2010 2  Ph.D. in Nursing. RN at the Albert Sabin Children’s Hospital and Assis Chateaubriand Teaching Maternity Hospital. Assistant Professor of Faculdade Metropolitana da Grande Fortaleza. Fortaleza, Ceará, Brazil. E-mail: 3  Residence Home Care Nurse. Ceará, Brazil. E-mail: 4  Master’s student of the Nursing Graduate Program Federal University of Ceará (UFC). Fortaleza, Ceará, Brazil. E-mail: 5  Undergraduate student of the Nursing Undergrauduate Program of UFC. Fortaleza, Ceará, Brazil. E-mail: 6  Doctoral student of the Nursing Graduate Program UFC. CNPq scholarship. Fortaleza, Ceará, Brazil. E-mail: 7  Ph.D. in Nursing. Associate Professor of the Nursing Department, UFC. CNPq researcher. Fortaleza, Ceará, Brazil. E-mail: ABSTRACT: The objective was to verify the self-efcacy of new mothers before and after an educational intervention. We opted for a quantitative study involving 100 new mothers of a public maternity hospital in Fortaleza-CE, Brazil. Before and after the application of the serial album “I can breastfeed my child”, interviews were performed using two forms: the rst was used to collect identication data of the participants and the second was the Breastfeeding Self-Efcacy Scale Short Form. We found an increase in scores on the scale after the educational intervention, particularly in mothers with specic characteristics, with a statistically signicant association between the following variables: age between 20 and 29 years; married/consensual union; from ve to seven household members; engaged in paid work outside the home; and family income from two to eight minimum wages. We concluded that the educational intervention implemented with women who had just given birth was effective in increasing maternal breastfeeding self-efcacy, which may result in improving breastfeeding rates. DESCRIPTORS : Breastfeeding. Self-efcacy. Postpartum period. Health education. Nursing. INFLUÊNCIA DE ESTRATÉGIA DE EDUCAÇÃO EM SAÚDE MEDIADA POR ÁLBUM SERIADO SOBRE A AUTOEFICÁCIA MATERNA PARA AMAMENTAR RESUMO: Objetivou-se vericar a autoecácia da puérpera em amamentar, antes e após a intervenção educativa. Optou-se por um estudo quantitativo, desenvolvido com 100 puérperas de uma maternidade pública de Fortaleza-CE. Antes e após aplicação do álbum seriado “Eu posso amamentar o meu lho”, foram realizadas entrevistas utilizando dois formulários abordando dados de identicação da puérpera e a Breastfeeding Self-Efcacy Scale Short Form . Constatou-se um aumento dos escores da escala após a utilização da intervenção educativa, sobretudo em puérperas com características especícas, já que se observou associação estatisticamente signicante entre as seguintes variáveis: idade entre 20-29 anos; estado civil casado/união consensual; número de cinco a sete moradores na casa; puérperas que exerciam atividades remuneradas fora do lar e rendas familiares de dois a oito salários mínimos. Conclui-se que a tecnologia educativa implementada às puérperas foi ecaz no aumento da autoecácia materna em amamentar, podendo resultar, consequentemente, no alcance de boas taxas de aleitamento materno. DESCRITORES:  Aleitamento materno. Autoecácia. Período pós-parto. Educação em Saúde. Enfermagem. INFLUENCIA DE ESTRATEGIA DE EDUCACIÓN EN SALUD MEDIADA POR ÁLBUM ILUSTRADO ACERCA DE LA AUTOEFICACIA MATERNA PARA AMAMANTAR RESUMEN: El objetivo fue vericar la autoecacia de puérperas en amamantar, antes y después de la intervención educativa. Estudio cuantitativo, con 100 mujeres de maternidad pública de Fortaleza-CE, Brasil. Antes y después de la aplicación del álbum ilustrado “Yo puedo amamantar a mi hijo”, fueron realizadas entrevistas con dos encuestas para abordar datos de identicación de la puérpera y Breastfeeding Self-Efcacy Scale Short Form . Hubo aumento en las puntuaciones de la escala después de la intervención educativa, especialmente en las madres con características especícas, con asociación estadísticamente signicativa entre las variables: edades entre 20-29 años; estado civil casado/unión libre; número de cinco a siete miembros del hogar; madres que realizaban trabajo remunerado fuera del hogar; rentas familiares de dos a ocho sueldos mínimos. La tecnología educativa implementada a las puérperas fue ecaz cuanto al aumento de la autoecacia materna en amamantar, resultando, por lo tanto, en el alcance de buenos índices de lactancia materna. DESCRIPTORES:  Lactancia materna. Autoecacia. Periodo de posparto. Educación en salud. Enfermería.  - 611 -Text Context Nursing, Florianópolis, 2013 Jul-Set; 22(3): 610-8. INTRODUCTION Breastfeeding directly influences infant mortality, since it can reduce numbers of deaths in children under ve years of age by 13%. 1  However, while recognizing the many benets of breastfeed - ing for both mother and child, breastfeeding rates in Brazil remain low in view of the high rates of early weaning. 2 The lack of mothers’ knowledge regarding breastfeeding, their personality and their attitude toward breastfeeding, 3  in addition to breastfeed- ing self-efcacy, are signicant factors that can directly interfere with early discontinuation of this practice. 4 Recognizing that self-efcacy is the con - dence in oneself that one can successfully ex - ecute the behavior required to produce a desired outcome related to health, 5  it is appropriate for nurses to consider this aspect, by means of health education strategies, particularly in the context of care provided to new mothers and their newborns. Some researchers have achieved results from interventions in health education that were able to positively modify the sense of self-efcacy in breastfeeding in many contexts, including: Pelotas (in the state of Rio Grande do Sul), through videos, brochures and home visits by a breastfeeding sup - port team; 6  in Australia through interactive books; 7   and in Japan through a program that utilized pamphlets and DVDs. 8   While recognizing the importance of de - veloping health education interventions regard -ing breastfeeding during pregnancy in order to avoid an excess of information in the postpartum period, the majority of professional support and guidance must occur in the postpartum period. During the postpartum period, the mother and family are faced with huge changes in their rou - tine, coupled with anxiety. 9  Therefore, rooming-in can be considered a useful adjunct for breast - feeding promotion, 10  enabling the rendering of all basic care to both mother and child in the postpartum period, in addition to promoting the educational characteristics aimed at the practice of breastfeeding. 11 The nurse who assists in rooming-in must reect critically on educational practices, envi -sioning strategies for breastfeeding education. Given proximity to the mother, the nurse has the opportunity to supervise the rst attempts at breastfeeding, getting to know the real needs of both mother and child, answering questions and caring for the mother promptly and avoid - ing future complications related to lactation, thus favoring the breastfeeding process. 12 In view of the above, the following question arose: what is the impact of an educational strategy promoting self-efcacy in breastfeeding for post - partum women? It is believed that the existence of a health education strategy applicable to the context of rooming-in can be a tool to support the nurse who works in this area, in order to raise not only maternal self-efcacy in breastfeeding, but also increasing the Exclusive Breastfeeding (EB) rates and extension of supplementary breastfeed - ing. Thus, the present study aimed to compare maternal self-efficacy in breastfeeding before and after an educational intervention, according to the sociodemographic and obstetric prole of puerperal women. METHOD This is a pre-experimental study utilizing the pre-test/post-test model with one group, 13  using a quantitative approach. The study was developed in a large public maternity hospital, which is a tertiary referral center for prenatal and neonatal care, located in the city of Fortaleza-CE. The sample included all women in the im - mediate postpartum period, who were hospital - ized and who were rooming in during the period from February to July of 2011, resulting in a total of 100 postpartum women. The selection of these women occurred by convenience, according to the following inclusion criteria: postpartum women with term infants, who were rooming in with their children and were at least six hours postpartum. The exclusion criteria adopted were: females un - der 12 years of age, regardless of whether they had delivered a child; adolescents without the autho - rization and/or consent of their legal guardian to participate in the study; women who experienced clinical or obstetrical complications in the postpar - tum period; and women with a condition which precluded breastfeeding. Data collection occurred in three phases: 1. Evaluation before the educational intervention (maternal self-efcacy in breastfeeding; sociode - mographic and obstetric data); 2. Educational intervention mediated by the serial album “I can breastfeed my baby”; 14  and 3. Evaluation after the Inuence of health education strategy mediated by a self-efcacy...  - 612 -Text Context Nursing, Florianópolis, 2013 Jul-Set; 22(3): 610-8. educational intervention (maternal self-efcacy in breastfeeding). The rst phase took place in the postpartum woman’s room, with the participant comfortable in bed. An interview was performed using two instruments: a form covering sociodemographic data, obstetric history and data regarding the cur- rent pregnancy/delivery, and the Breastfeeding Self-Efcacy Scale – Short Form (BSES-SF) to assess maternal self-efcacy in breastfeeding. The BSES-SF was developed, 15  translated in Brazil 16  and validated using Cronbach’s alpha (=0.74). 4  It consists of 14 items divided into two domains (Technical, eight items, and Intrapersonal Thinking, six items), whose pattern of response varies in a Likert scale pattern with ve options (I totally disagree; I disagree; I sometimes agree; I agree; I fully agree). Total scale scores vary from 14 to 70 points, so that the higher the score the mother obtains in the sum of the items, the higher her breastfeeding self-efcacy. The second phase of the study was the ap - plication of the educational strategy, implemented with the aid of the serial album “I can breastfeed my child”. 14  This phase was held only once, in - dividually with each postpartum woman, at her bedside in the Rooming-in Ward and lasting an average of 45 minutes. The serial album is comprised of two parts: eight illustrations on the back, which are exposed to the postpartum woman; and seven script forms on the opposite side, which are visible to the professional. The illustrations and script forms included in the album were derived from the BSES_SF items based on the Theory of Self-ef -cacy, 5  and also from a literature survey regarding breastfeeding. This educational technology was submitted for evaluation by ten judges, resulting in a Content Validity Index of 0.92 for the gures and 0.97 for the script forms. 14 Finally, the third phase occurred before the postpartum woman was discharged from the hospital. A second interview was held, and the BSES-SF was again administered. It should be noted that the researcher who introduced the serial album during phase 1 was not the same researcher who applied the scale in phase 3. This was done purposely to minimize bias or any kind of tendency during data collection. The data were processed using Statisti - cal Package for Social Sciences (version 18.0) software. The absolute frequency distribution, relative, averages and standard deviations were calculated, and the comparison of averages of the scale scores by means of the Student t test were performed for the data, which were compared with sociodemographic and obstetric variables, and those of pregnancy and actual delivery, cho -sen according to international studies. 8,17  A level of signicance of below 0.05 was established. The results were analyzed in accordance with pertinent literature. The study was approved by the Research Ethics Committee of Assis Chateaubriand Teach - ing Maternity Hospital, according to the expert opinion 42/08. All recommendations and legal requirements for research activities involving hu - man beings were complied with. In addition, the participants signed the Informed Consent Form, agreeing to participate in the study. RESULTS Regarding the analysis of sociodemographic data regarding the 100 women included in the study, the majority were aged 20-29 years (48%), were married or living in a consensual union (70%), worked in the home exclusively (47%), had a family income of one minimum wage (41.4%), and contributed to the support of up to four people per household (64%).In table 1, it can be observed that there was an increase in the average of the scores on the BSES-SF after the educational intervention, with a statistically signicant association between the score on the BSES-SF and the following sociode - mographic variables: age between 20-29 years (p=0.010); married/consensual union marital status (p=0.006); presence of ve to seven residents in the household (p=0.004); working outside the home (p=0.001), family income of two minimum wages (p=0.013) and family income of three to eight (p=0.022) minimum wages. Regarding the obstetric data, one can see a predominance of primiparous women (59%) who had only one child (64%) and previous experience in breastfeeding (92.1%). With regard to the cur - rent pregnancy, most had received prenatal care (94%), with an average of 6.41 visits (SD ± 2.25) and a vaginal delivery (52%). Dodt RCM, Ferreira AMV, Nascimento LA, Macêdo AC, Joventino ES, Ximenes LB  - 613 -Text Context Nursing, Florianópolis, 2013 Jul-Set; 22(3): 610-8. Table 1 - Comparison between the mean scores on the BSES-SF before and after the educational intervention, according to the sociodemographic variables of the mothers. Fortaleza-CE, 2011 VariablesBefore interventionAfter interventionBSES-SF Scoresn%MDPMDPpAge (in years) 14 – 19 36 36 54.7 7.49 56.4 4.96 0.11420 – 29 48 48 55.1 5.96 57.7 5.88 0.010 30 – 45 16 16 57.3 5.97 59.6 5.62 0.214 Marital status Married/consensual union 70 70 55.8 6.73 57.9 5.33 0.006 Other 30 30 54.2 6.06 56.9 6.14 0.074 Occupation Student 20 20 55.2 5.93 57.2 5.19 0.216Housewife 47 47 55.9 6.18 56.6 6.34 0.474Fixed job 33 33 54.6 7.37 58.7 5.24 0.001Family income* (n=99) 1 SM (minimum wage) 41 41.4 55.9 6.42 56.6 5.32 0.5082 SM 37 37.4 54.5 6.78 56.8 6.31 0.013 3–8 SM 21 21.2 55.6 6.39 60.1 5.15 0.022Number of house dwellers ≤ 4  64 64 56.1 6.05 57.3 5.66 0.1345–7 32 32 53.2 6.76 57 6.13 0.004 8–12 4 4 59.2 8.73 61.7 4.57 0.650 * Minimum Wage (SM) during the study = R$ 545.00. As for table 2, a statistically signicant as - sociation between the mean scores on the BSES-SF before and after the educational intervention and obstetric history/current pregnancy data can be observed. Thus, self-efcacy in breastfeeding was inuenced by the following variables: primipar - ity (p=0.027) and multiparity (p=0.037); having one living child (p=0.036) or two living children (p=0.054); having previously breastfed (p=0.034); having received prenatal care (p=0.004) and hav - ing had a caesarian section (p=0.021) or a vaginal delivery (p=0.045). Table 2 - Comparison between the mean scores on the BSES-SF before and after the educational intervention, according to the variables and data regarding the current pregnancy/childbirth. Fortaleza-CE, 2011 VariableBefore interventionAfter interventionBSES-SF Scoresn%MSDMSDpPrimaparity Primipara 59 59 54.6 6.86 56.7 5.76 0.027  Multipara 41 41 56.3 5.93 58.4 5.75 0.037Live children 1 64 64 54.5 6.85 56.4 6 0.036 2 25 25 57.5 5.51 59.9 4.94 0.054 3–6 11 11 55 6.05 57.7 4.98 0.247 Previous breastfeeding (n=38) Yes 35 35 56 5.48 58.5 4.67 0.034 No 3 3 59.2 7.66 62 6.67 0.108 Inuence of health education strategy mediated by a self-efcacy...  - 614 - Text Context Nursing, Florianópolis, 2013 Jul-Set; 22(3): 610-8. VariableBefore interventionAfter interventionBSES-SF Scoresn%MSDMSDpPregnancy/deliveryPrenatal care Yes 94 94 55.3 6.52 57.4 5.86 0.004 No 6 6 54.8 7.22 57 4.74 0.189 Type of delivery Cesarean 48 48 54.8 5.53 57 5.83 0.021 Vaginal 52 52 55.8 7.32 57.8 5.79 0.045 When comparing the mean scores on the BSES-SF before and after the educational interven - tion, it can be seen from Table 3 that the use of the serial album was effective in promoting maternal self-efcacy because there was an increase in total scores on the BSES-SF, as well as an increase in the technical and intrapersonal thinking domains, with a statistically signicant association between total scale scores (p=0.002) and the intrapersonal thinking domain (p < 0.001). Table 3 – Comparison of the total scale score averages and the domains before and after educational intervention. Fortaleza-CE, 2011 VariablesBefore interventionAfter interventionBSES-SF ScoresMSDMSDpTotal scale score  55.3 6.52 54.7 5.79 0.002Intrapersonal domain  23.0 3.85 32.9 3.08 < 0.001Technical domain  32.3 3.85 32.9 3.08 0.153 DISCUSSION The development and implementation of certain educational technologies may favor be - havioral changes, especially when working with specic concepts such as self-efcacy, which may result in the individual feeling more self-condent in performing certain health promotion behaviors routinely. Self-efcacy may be affected by such inter - ventions depending upon the specic character - istics of the population. Thus, in this study, it was found that health education, mediated by the serial album “I can breastfeed my child”, inuenced the increase in maternal self-efcacy, particularly among postpartum women who were between 20 and 29 years of age, married or living in a consen - sual union, living in residences with ve to seven people, and who were employed and earning more than two minimum wages. Authors argue that greater accessibility to information, and living in better family socioeco - nomic conditions, favors higher rates of breast - feeding for a longer period of time. 18   Even for the mothers in this study, within the ages of 20-29 years and with signicant differ - ences in breastfeeding self-efcacy, it is necessary to perform educational strategies mediated by self-efcacy and aimed at promoting breastfeed - ing, as research indicates that younger mothers have lower breastfeeding rates in relation to older women, in addition to decreased BSED-SF scores during their pregnancy. 19  Another study corroborates this finding, having identied that adolescent mothers quite often lack condence in themselves or experienced an unwanted pregnancy and do not have parental or partner support, causing them to disregard best feeding practices with their newborn, 20 thus contributing to early weaning. Married women or women in a stable rela - tionship may feel more condent about breast - feeding, emphasizing that the paternal element can be a predictor for both the start and duration of breastfeeding. 21  Nevertheless, some partners do not support EB, preferring baby formulas or mixed feeding. Some of the reasons reported by partners for failure to support exclusive breastfeeding are: Dodt RCM, Ferreira AMV, Nascimento LA, Macêdo AC, Joventino ES, Ximenes LB
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