The effect of educational support intervention including peer groups for infant care on the growth rates of infants, breastfeeding self-efficacy and quality of life of their mothers in Iran: study protocol

According to global nutritional goals and policies, by 2025, the rate of exclusive breastfeeding at 6 months should reach at least 50% [1]. The amount of exclusive breastfeeding varies in countries and even in different regions of the same country, such that exclusive breastfeeding has been reported in Japan is 21% [2], India 7.8% [3], Canada 6% [4], and Ghana 6.51% [5]. In Iran, according to reports, exclusive breastfeeding is 22.7% in urban areas, and 24% in rural areas, which is significantly different from WHO goals [6]. As one of the most sensitive stages of life, infancy is a period that needs to be correctly known, and precisely cared. The maintenance and promotion of children's health as a vulnerable group has a special place in health services, improving the level of knowledge and removing the false beliefs of mothers in caring for infants will lead to an increase in mother's self-confidence [7].

According to many studies, paying attention to care in the first years of an infant's life is of particular significance [8]. Accordingly, to prevent underweight, interventional measures should be taken before the age of two [9]. The mother's satisfaction with the quality of the baby's nutrition is a predictive variable of the breastfeeding self-efficacy score [10], according to studies, the mean score of breastfeeding self-efficacy in a study in Iran was 47.01, and in another study, this rate was 48.1 [11, 12]. The responsibility of infant care since birth has been to a large extent on the shoulder of mothers. As such, raising the awareness of mothers, their empowerment and improving their quality of life are the main objectives of the healthcare system. Mothers may experience various physical and mental complications during childbirth and the postpartum period, which can affect the natural process, and quality of their life [9, 13]. Quality of life is a feeling of well-being that arises from satisfaction or dissatisfaction with various life aspects that are of great importance to the individual; it includes the areas of health, occupation, socio-economic, psychology and family, and is a significant healthcare measurement criterion [14]. Chen et al.'s study showed that the quality of life of mothers who used different breastfeeding patterns and had a breastfeeding duration of 6 months or more had higher quality of life, this rate is also reported to be higher in mothers who exclusively breastfeed for up to 6 months [15]. Given the fact that most postpartum problems related to mother and infant are solved easily and through education, paying attention to the method, content and modality of these educations seems to be important [16]. The creation of positive self-efficacy, especially self-efficacy in breastfeeding, seems to be a prerequisite for mothers' empowerment [17]. The continuation of breastfeeding is easier in mothers with high self-efficacy in breastfeeding. According to researchers, mothers with more successful breastfeeding will more successfully raise their children and will have a stronger sense of accepting their motherly role. Bandura believes that one's level of empowerment and self-efficacy can be improved by adopting appropriate educational strategies and interventions in acquiring the necessary skills, and knowledge [18].

Today, e-learning is used by patients as the main part of healthcare. E-learning has been introduced by the World Health Organization as an appropriate way of communicating with clients [19, 20]. While virtual space and direct education through telemedicine have an overt role in the health system, the role of covert education through other clients with similar health problems cannot be ignored. In education through the experiences of peers, simple and safe learning is created based on the similar features of the members of a group; in this method, clients share their healthcare-related experiences [21]. Additionally, peer groups are better able to encourage their peers to choose appropriate health behaviors; they are also able to share common strengths, weaknesses, and experiences [22]. The need of mothers for breastfeeding-related scientific information and caring for their infants in encountering misconceptions reveals the need for education on the key points [23]. The positive role of educational programs in improving breastfeeding outcomes has been confirmed in various studies. However, no study has hitherto investigated the effect of a virtual educational-supportive program of infant care by sharing peer experiences on the growth indicators of infants, breastfeeding self-efficacy and quality of life of mothers. Thus, the present study will be conducted to bridge this gap.

This study seeks to design and implement an educational support program for infant care by sharing the experiences of peers, which will be able to affect the indicators of infant growth, breastfeeding self-efficacy, and quality of life of mothers.

The hypothesis is that after the intervention, the mean scores of infant growth indicators, mothers' breastfeeding self-efficacy, and mothers' quality of life will increase compared to the control group.

This clinical trial study is an educational support intervention protocol for infant care which will be conducted in two phases. The educational support program will be designed in the first phase. This program will be designed based on the review of previous studies and considering the opinions of the panel of experts in health education and promotion, pediatric nursing, and mother-infant health. The program includes educational sessions on breastfeeding, growth and development of infants and cares for children under one year of age in a virtual group where a physician, a nurse, a midwife and a healthcare provider are also present. Using the opinions of the experts, the peer group will discuss various points and the research team will finalize the program based on priorities. Reminder text messages will be sent to the participants to remind them of the educational program. The second phase of the educational intervention will be conducted experimentally as a pretest–posttest design for the intervention and control groups.

This clinical trial study will be conducted at the health centers in Yazd, Iran. Mother-infant pairs living at Yazd will be recruited from three health centers in the upper, lower and center of the city will be included in the study and will receive primary health care related to their infants according to the intervention program (virtual group and expert and peer training). In this study, the control group will have the routine services of health centers. These services include visiting the health center in person and checking the growth and development of the infant and receiving care information from the health team members.

The design of the intervention and the identification of the target audience in this phase will be based on the review of the texts and similar studies as well as the opinions of experts. The educational support program will include virtual training sessions on breastfeeding, growth and development of infants and care for children under one year of age in a WhatsApp group where a physician, a nurse, a midwife and a healthcare provider are among the members. Moreover, the experiences of the peers will be used through discussions and the exchange of information. The studied population will be mother-infant pairs less than one year of age referring to Yazd health centers. The researcher will receive the mothers' phone numbers through the Sib system and will call to the mothers, and hold a face-to-face meeting at the health center.

In this step a randomized controlled clinical trial will be design to assess the efficacy of the prepared protocol. Participants will randomly be allocated into two groups. In the experimental group we will implement our designed protocol, and the control group will not receive any intervention, but they are evaluated as the same as the experimental group. For ethical issues all educational material will offer at the end of the study (Fig. 1).

The present study will be provided useful protocol about the effect of an educational support intervention for infant care and the sharing of peer group experiences on infants' growth rates, breastfeeding self-efficacy, and quality of life of their mothers.

In other studies conducted in this direction, Masayo Awano et al. [25], Mirghfourvand et al. [26], Azimi and Nasiri [27], Heidari et al. [28], Almohanna et al. [29], Rezaian et al. [30]. Araban et al. [24] showed that educational interventions in the field of infant care and breastfeeding are effective in increasing the quality of life and breastfeeding self-efficacy. Gonzales et al. argued that breastfeeding self-efficacy is a substantially significant variable in influencing breastfeeding outcomes. Breastfeeding self-efficacy in the early postpartum period is an important predictor of breastfeeding duration [31]. Educational intervention programs in the field of women's health can be effective [32, 33].

It is hoped that group training and counseling of mothers and sharing their experiences will increase exclusive breastfeeding and increase mothers' awareness. Increasing the knowledge and attitude of mothers, skills in correct breastfeeding techniques and solving breastfeeding problems in many cultures, including Iranian culture, will be possible with the support of the people around [34].

One of the strengths of this study will be to increase the self-confidence and self-efficacy of mothers to promote breastfeeding. Peer training will be a significant positive point of this study. In this method, the active participation of mothers and cooperation with health care workers will help to promote growth, knowledge and experimental skills. Sharing mothers' experiences and receiving group training will strengthen the enthusiasm and sense of empathy in mothers, and mothers will realize that breastfeeding problems exist for all mothers, so they will be motivated to promote breastfeeding. Another strength of this study will be the language, culture and social characteristics shared by mothers. Breastfeeding self-efficacy is a modifiable and potential factor that will play an effective role in promoting breastfeeding. Also, Breastfeeding self-efficacy will be a suitable theoretical framework to guide effective interventions in improving children's health.

Generalizing of the results of the study according to the cultural, social and nutritional differences in different societies will be one of the challenges of this study. The non-generalization of the study results to mothers of premature infants and mothers with twin infants or mothers and infants with special conditions will be a restriction. The limitation of the statistical population, the busyness of mothers, neglect of educational packages, receiving information by mothers from other members of the health team, and sharing information and experiences of mothers outside the group and without the supervision of researchers will be other restrictions of this study. This study may not be generalizable because people without telephones will be excluded from participating in the intervention, and this is another limitation of this study.

However, According to the investigations, the current educational package not only combines virtual education and peer experiences in strengthening the education of mothers, but also it can improve mothers' physical and mental health and reduce medical costs by using telephone follow-up in supporting the mothers of infants. Additionally, the strategy used in this protocol can be used for education and support in pre-pregnancy, pregnancy and childbirth care. The strategies of this program could be important and cost-effective, and therefore we hope that the success of such a program is a step forward in improving maternal and infant health status.