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Effect of the board game as educational technology on schoolchildren’s knowledge on breastfeeding 1

ABSTRACT Objective: to evaluate the effect of the board game as an educational technology on schoolchildren’s knowledge on breastfeeding. Method: cluster-randomized clinical trial, held in nine schools, with 99 children in the third grade of elementary school (control group = 51 and intervention group = 48). The pretest was conducted in both groups; intervention consisted in the application of the educational technology immediately after pretest to the intervention group; and the post-test was applied on the 7th and 30th days to both groups. For the analysis of children’s knowledge on breastfeeding, we considered the pre- and post-test score means, using the Mann-Whitney test - for comparing the means between groups - and the Wilcoxon test - within the same group. Results: there was no statistically significant difference between the groups in the pretest. In the follow-up, when comparing the groups, there were higher means in the intervention group, on the 7th (19.68 ±1.788) and on the 30th (20.16±1.260) days, with statistically significant difference. Within the intervention group, there was significant increase of the means in the pretest (15.89±3.082) for the 30th day (20.16±1.260). Conclusion: such educational intervention has significantly contributed to the increase in scores of children’s knowledge on breastfeeding for the intervention group. UTN: U1111-1184-7386.


Introduction
Worldwide, despite the benefits of breastfeeding for children's and women's health, considering its economic and environmental advantages, only 37% of children younger than six months are exclusively fed with breast milk. Several factors can affect this practice, among which outstands the influence of the family -the primary network. Therefore, actions for promoting breastfeeding should include the family and be invested since early ages, during childhood, enabling the promotion of the positive culture of breastfeeding (1)(2)(3)(4)(5) .
In the primary network, exposing the child to the practice of breastfeeding, at home or in public environments, can be an opportunity to learn, whereas the school -the secondary network -is a formal learning space able to complement children's knowledge acquired within family and social contexts (6) .
This may favor the awareness of this practice as appropriate, encourage young people to choose healthier behaviors, and contribute to the success of breastfeeding (6)(7) .
The implementation of educational interventions in school demonstrates a positive effect on students' knowledge concerning breastfeeding. There are several pedagogical strategies: classes with active participation, reading activities, videos, Q&A games, and roleplaying stories (7)(8)(9) . However, we note that, among these technologies, the board game was not employed.
This type of game has been applied to the themes of oral health, prevention of diseases (dengue fever), and quality of life with positive results in the increased knowledge of children (10)(11)(12) . This indicates that it can be an effective tool in teaching contents comprising breastfeeding for schoolchildren.
Constructivist theories support the educational potential of games for the children's cognitive development, stimulated by the competitive spirit and the interaction with adults and peers more capable than them (13)(14) . In this context, board games emerge as an active and playful pedagogical strategy, able to motivate students in learning about breastfeeding. Therefore, we aim to evaluate the effect of the board game as educational technology on schoolchildren's knowledge on breastfeeding.

Method
Cluster-randomized clinical trial, two treatment groups, single blind, held in the period from June 20 to The choice was based on the third period of cognitive development (concrete operations), which corresponds to children aging between 7 and 10 years. At this stage, there is loss of egocenter, greater tendency for socialization, development of the capacity to perform logical relations of thought, greater understanding and respect for the rules, and evolution of games as collective activities (13)(14) . These features meet the educational technology applied in our study.
The sample consisted of third graders studying at municipal public schools of the city of Recife, Pernambuco, with regular attendance in the collection period, aging between 7 and 10 years, able to read words and sentences, indicated by the teacher of the class. Children on medical leave due to illness or with disabilities, identified by the teacher, were excluded from the research. Student dropout, or leave of absence due to medical reasons, and children who did not participate in all steps of the research were considered losses. 2) simple random sampling for selection of schools in each group: in total, there were 9 schools, 5 for the CG Data collection was performed using an instrument (15) in a questionnaire format, created and validated for this research, structured in: 1) socioeconomic data (guardian/legal representative of the child) and breastfeeding-related data, which included independent variables; and 2) the children's knowledge on breastfeeding, which contained 21 items (statements and illustrations), with response options "right," "wrong," and "I don't know," identified by adapted emotions (16) .
For correct responses, one point was awarded, and for the wrong ones, or that which the student could not answer, zero. Thus, the total score could vary between  bias in the study, and we considered that all children were naturally exposed to breastfeeding in their social network, through the contact with family, community, school, health services, and media. Therefore, scholars from the CG did not undergo intervention.
Third step: the post-test was applied to schoolchildren from the CG and the IG on the 7th and 30th day after the pretest. The time interval for the follow-up in similar studies varies in the literature, and there may be periods of one day, one month, three months, and up to six months (8,17) . In our study, the option for conducting the post-test on the 7th and 30th days after the pretest was based on literature and on the incentive to cognitive development mediated by this playful resource when enabling children to take the game to their homes and being encouraged to play with it during this period (13)(14) .
Masking out of children in relation to allocation of groups was impossible due to the type of intervention In the assessment of children's knowledge on breastfeeding, we found normality of the score means at baseline, using the Kolmogorov-Smirnov test. We used the Student's t-test for comparison among groups.
In the knowledge score on the 7th and 30th days, distribution of the score means was anormal, thus we applied the Mann-Whitney test for comparing knowledge between the groups and the Wilcoxon test for comparing the means in the same group between baseline and the 30th day. All findings were established considering the significance level of 5%. Reporting Trials (CONSORT) were followed (18) .

Results
In total, 171 children were assessed for eligibility,    according to the CONSORT model (17) . Recife, PE, Brazil, 2016 However, means verified in the follow-up, for the IG, showed higher values than those for the CG, with statistically significant difference between the groups in the 7th and 30th days. There was significant increase in the score means of children's knowledge on breastfeeding between the baseline and the thirtyday time, both for the IG and the CG, according to In the results of the pre-and the post-test, for both CG and IG, evaluated by 21 items, we found that at baseline 2 items have shown statistically significant difference (3 and 7) and, on the 7th and 30th days, 8 items (3, 4, 6, 7, 10, 11, 12, and 13). In the pretest, we found hit percentage above 80% for the CG in 12 items, and for the IG, in 10 items. In the follow-up, we found on the 7th and on the 30th days 15 and 14 items for the CG, and 20 and 21 items for the IG, respectively, as evidenced in Table 3.
In the interview on the 7th day, all children of the IG claimed to have played with the board game. Of these, 60.4% played less than six times, and 39.6%, six times or more. Children mentioned one or more people who played with them, 60.4% accounting for sister/ brother; 41.7%, friends; 31.3%, mom; 14.6%, aunts; and 10.4%, fathers.
According to the score means regarding knowledge of the groups, considering the variables sex, age, exposure to breastfeeding, and number of times children played with the game, we found that: when it comes to sex, there was statistically significant difference when comparing the means among groups in the follow-up, and IG scholars had higher score mean for both sexes; on the 30th day, for the CG, girls had higher mean when compared with boys, with statistically significant difference; as for the age, there was statistically significant difference between the score means when comparing the groups, and higher means were found for IG schoolchildren, at the age group from 8 to 9 years, on the 7th and 30th days.
Exposing children to breastfeeding, verified at baseline, indicated statistically significant difference at follow-up, showing higher means concerning the knowledge score for the IG both on the 7th and on the 30th days. Regarding the children's experience with the game, for the IG, we found statistically significant difference when comparing the score means on the 7th and 30th days; the higher score means regarding children's knowledge were verified on the 30th day and comprised children who played with the game six times or more, according to Table 4.

Discussion
Our results confirm the hypothesis that children who participated in the educational intervention with the board game (IG) have higher score means concerning the knowledge on breastfeeding when compared with those who did not participate (CG). These findings corroborate the results of studies whose authors evaluated educational interventions aimed at children (7)(8) and teenagers (6)(7)(19)(20) attending school on the subject of breastfeeding, which reported increased knowledge for the treatment group.
For children of the CG, there was little increase in the score means of knowledge on breastfeeding, although they did not participate in the intervention.
When comparing both groups, however, we found that for children of the IG, there was an increase in the score means higher than that for children of the CG.

Despite benefits of complementary breastfeeding
and exclusive breastfeeding (1) , the early and inadequate introduction of liquids and other foods before the sixth month of the child's life is common (21) . Types of foods vary according to age. In the first month, the supply of tea, water, juice, and non-breast milk prevails; in the sixth month there is increased consumption of all these foods, including fruits, porridge, and salty foods (22) .
According to schoolchildren aging from 5 to 11 years, in England, the infant feeding of babies has a variety of foods that may be offered individually or in combination. Formula feeding and baby bottle were the most mentioned when compared with breast milk Foods, such as porridge or purées made of fruits, vegetables, meats, and chocolate, have also been described (23) .
Although these results are from the European continent, which has distinct characteristics when compared with Brazil, research conducted in the Brazilian scenario reported the inclusion of foods and other liquids in the baby's feeding before the age of six months of life (21)(22) . This indicates that this practice is common even in countries from different continents.
The inadequate children's perception about infant feeding, with information contrary to breastfeeding (1) , for early interruption of exclusive breastfeeding, and the use of artificial nipples is associated with the lack of breastfeeding after six months of the child's life (24)(25) .
More than half of children surveyed at the pretest concerning the use of artificial nipples, in both groups, said that pacifiers should be avoided in such a way not to harm breastfeeding (item 11). However, the percentage of hits regarding the use of baby bottle (item 12) was low, accounting for about 35% at baseline. After intervention, there was a significant increase in the correct answers of both items for the IG, which accounted for a percentage of hits close to or above 90%. These results, referring to the pretest, may indicate that children have contact with information on breastfeeding by the media, the family, and the society. These children may have learned that pacifiers should not be used; on the other hand, they must have noticed or even used a baby bottle as a means to feed themselves (9) .
Another noteworthy aspect is item 13, concerning breastfeeding in public, which obtained high percentage of hits at baseline in both groups. However, on the 30th day, we identified statistically significant difference, since there was an increase in the number of children for the IG who responded correctly.
The perception of breastfeeding in public as embarrassing or less acceptable when compared with breastfeeding in a private environment or from people close to the mother is mentioned by children (9) , teenagers (19)(20) , and adult men (26)  others, from the care aimed at the baby to the sharing of knowledge acquired at school.
Members of the primary social network often advise women on the infant feeding of the child, usually based on their beliefs, attitudes, and previous experiences with such practice (27) . In this network, they can provide support by assisting women in the household chores and child care. When observing difficulties or need for more information on the management of breastfeeding, women can be advised to seek help from health professionals of the secondary network (28) .
The school is the ideal place to discuss breastfeeding and to demonstrate to young people the importance of such behavior to health (6) , helping to demystify myths and beliefs unfavorable to breastfeeding and to resume it as something natural and physiological. This may reflect on the education of adults more apt to support this practice in the future (7) , especially concerning the positive and active support of the baby's father or partner who influences on the self-confidence of women in breastfeeding (29) .
In our study, the mediation of a person who applied the intervention, the social interaction provided by the board game, as well as the repetition of the game at home with other family members and/or people from children's social network, enabled the establishment of schemes and the accommodation of the content concerning breastfeeding.
However, other factors were also important for this process, because, from the technology design step to the application of the intervention, we were careful with Rev. Latino-Am. Enfermagem 2018;26:e3049.
several aspects related to the game, contents, and the technology approach, aiming to achieve the cognitive development (33) .
In this context, a board game addressing oral health, when compared with a didactic activity using cards between schoolchildren aged between 5 and 10 years, proved to be more effective in increasing students' knowledge in younger age groups (5 to 7 years) (12) . It is possible that the search for pleasure and entertainment have stimulated children to play more often with the board game, providing social interaction with other people and fostering the cognitive development (13)(14) .
Regarding children's exposure to breastfeeding, we observed that most children in both groups claimed to have been breastfed and have witnessed a woman breastfeeding. Children are able to respond if they were breastfed or if they saw this practice in their social environment (8) , to describe and to draw scenes in which women breastfeed at home (23) . Therefore, they are exposed to breastfeeding by being aware they were breastfed as a baby and identifying this practice in their family everyday lives or in their social environment, which may corroborate the choice for breastfeeding in their adulthood lives.

Conclusion
The board game as educational technology was effective in increasing children's scores of knowledge on breastfeeding for the IG, which we verified on the 7th