The Effect of a Training Video With Audio Description on the Breast Self-Examinations of Women With Visual Impairments

Abstract

Introduction: Breast cancer is a significant health problem affecting the health of women globally. Breast self-examination is a procedure applied for the early detection of breast cancer. Given the barriers that women with visual impairments face to access health care and health education, there is a need to develop materials for breast self-examination training as a skills-based practice for this group. This study evaluated the effect of a training video with an audio description on the breast self-examination of women who were visually impaired. Methods: The universe of this quasi-experimental study comprised women who were visually impaired (N = 70) who were registered members of the Manisa Altinokta Blind Association in Turkey. The women who participated in the study volunteered and met the selection criteria (n = 60). They were divided into two groups by lot. The audio description group listened to a breast self-examination training video with an audio description (n = 30). The control group listened to the training video accompanied by typical sound, without audio description (n = 30). Before and after a training video, all women performed breast self-examination on a female mannequin torso. The skills of women in breast self-examination were evaluated using a checklist by a midwife who was non-researcher. Results: The skills differed significantly between the two groups after the video training (p < 0.05). The audio description group correctly performed most of the skills required for breast self-examination. None of the women in the groups were able to apply steps for such self-examination before the training. Discussion: A breast self-examination training video with audio description can improve the self-examination skills of women with visual impairments. Implications for Practitioners: Women with visual impairments benefit from watching a breast self-examination training video with an audio description before performing self-examinations. Training videos with audio descriptions should, therefore, be prepared for the health education of individuals who are visually impaired.

Keywords

visual impairment breast self-examination training video audio description skill

Globally, it was estimated that there were 43.3 million people with visual impairments (i.e., blindness or low vision) in 2020, 23.9 million of whom were female (GBD [Global Burden of Disease Study] 2019 Blindness and Vision Impairment Collaborators, 2021). In Turkey, there were 1.039 million visually impaired people, of whom 561,000 were women in 2020 (Turkey Family Labor and Social Services Ministry, 2020). Legal blindness is defined persons with a visual acuity of 20/200 or less with 1/10 of the normal visual power with all corrections or whose visual field does not exceed the angle of 20 degrees. The visual acuity between 20/70 and 20/200 is considered low vision (Turkey National Education Ministry, 2008). The number of people affected by vision loss increases as the population increases and grows older (Flaxman et al., 2017; GBD 2019 Blindness and Vision Impairment Collaborators, 2021). Being a woman with visual impairment increases disadvantages and health risks in many ways.

Breast cancer is a significant health problem that affects most women worldwide. According to the latest global statistics, one in four of all cancers in women are breast cancers (24.2%) (WHO, 2020). The rate of breast cancer in women in Turkey is 24.8% (Başara et al., 2021). Early diagnosis is vital for the treatment of breast cancer (Carvalho et al., 2015). For this reason, breast cancer early diagnosis and screening information should be provided to all women. Breast self-examination, clinical breast examination, and mammography are essential for the early detection of breast cancer (Panel et al., 2017; Rajan, 2012). In Turkey, cancer screening tests and services are supplied free of charge by the Ministry of Health (Turkey Health Ministry, 2018). Breast self-examination is a screening test that assists women to recognize changes in breast tissue. Every woman should conduct a breast self-examination once a month after the age of 20 years (Albeshan et al., 2020; Heo et al., 2013; WHO, 2006). Breast self-examination should be performed by palpation a few days following the menstrual period. During menopause, women are advised to examine themselves regularly on the same day every month (Albeshan et al., 2020; Rajan, 2012; Turkey Health Ministry, 2018; WHO, 2006). Breast self-examination should be taught to women who are visually impaired for diagnosis of breast abnormalities (Carvalho et al., 2014, 2015; Cruz et al., 2015; Merten et al., 2015; Rajan, 2012; Sulyvan de Castro et al., 2013).

Women who are visually impaired face difficulties accessing health services (Carvalho et al., 2015; Merten et al., 2015; Rajan, 2012), which prevents them from sufficiently benefiting from preventive health care. Although it is known that health education is vital in preventive health services, unfortunately, women who are visually impaired have problems accessing these services due to communication barriers (Carvalho et al., 2015; Cruz et al., 2015). Therefore, to develop health-protective behaviors in women with visual impairments, individual or group health training programs should be planned and made accessible (Merten et al., 2015; Rajan, 2012; Sulyvan de Castro et al., 2013).

Today, materials such as brochures and booklets prepared in braille, audiobooks, and three-dimensional (3D) models are used in the health education of people who are visually impaired. These educational materials need to be developed and be accessible to all people with visual impairments (Carvalho et al., 2014, 2015; Cruz et al., 2015). In recent years, audio description has been used frequently to make visual elements more accessible to people with visual impairments (Hutchinson & Eardley, 2020; Ludíková & Finková, 2012; Romero-Fresco & Fryer, 2013; Walczak, 2017). In recent years, audio description has been widely used in movies (Romero-Fresco & Fryer, 2013), television series (Güven, 2018; Schmeidler & Kirchner, 2001), museums (Hutchinson & Eardley, 2020), and training of individuals who are visually impaired (Ibáñez Moreno et al., 2016; Souza & Ferreira, 2021; Wall Emerson & Anderson, 2018). People who are blind or who have low vision can understand expressions more easily using audio descriptions and report being satisfied with this experience (Hutchinson & Eardley, 2020; Wall Emerson & Anderson, 2018). However, the use of audio description in health education is not common. Adding audio description to health education videos can provide a more effective training method for people with visual impairments (Carvalho et al., 2014, 2015).

A need to develop skills-based breast self-examination practice training materials for women with visual impairments was identified. Because there were not any such training video that included audio description for women who are visually impaired women in Turkey, one was developed. Accordingly, this study investigates the effect of a breast self-examination training video that includes audio description on the breast self-examination skills of this population of women.

Methods

The research design of this study is quantitative and quasi-experimental.

Participants

The researchers identified 70 women with visual impairments aged above 18 years who were registered with the Manisa Altinokta Blind Association, the only such association in Manisa Province of Turkey. These potential participants were contacted with the support of the head of the Manisa Altinokta Blind Association. Each woman was invited to attend a one-on-one meeting at the association's offices. The researchers selected all participants without using any sampling method. The sample included all women with visual impairments who met the inclusion criteria—those who were legally blind (20/200 visual acuity or less) or had low vision (visual acuity of 70/20 to 20/200)—who agreed to participate (n = 60). Six women who were deaf or hard of hearing and four women who did not agree to participate were excluded from the study. The study groups were determined by lot. The women in the first group comprised the audio description group (n = 30), and the second group constituted the control group (n = 30) (see Figure 1). The study was conducted between March 2018 and 2019.

Figure 1.
Flow diagram for study participants and data collection.

Ethical Considerations

Ethical approval for this study was obtained from the Medical Faculty Ethics Committee of Manisa Celal Bayar University, and the tenets of the Helsinki Declaration were adhered to. Written permission was received from the Manisa Altinokta Blind Association management board and women before collecting data. The researcher gave the information to the women about the purpose and process of study at the onset of the study. The women signed the informed consent form. There were no incentives for participation in this study. Participation was voluntary, and women could withdraw at any time in the study.

Measures

Sociodemographic Questionnaire Form

The sociodemographic questionnaire form included 11 items related to age, education, employment, marital state, family type, number of children, the onset of visual impairment, knowledge of breast self-examination, family history, and application of breast self-examination.

Champion’s Health Belief Model Scale

The champion’s health belief model (CHBM) was used to evaluate the participants’ beliefs and behaviors related to breast self-examination to determine whether there were any differences between the groups. The scale developed by Victoria L. Champion, which consists of six subscales, has 42 items: sensitivity to breast cancer, perception of seriousness or caring, perception of benefit with regard to the application of breast self-examination, perception of barriers for self-examination, perception of confidence or self-efficacy, and health motivation (Champion, 1999). The subscales used depend on the aim of each study. Three subscales were used in this study: sensitivity, seriousness or caring, and health motivation. Each subscale is scored on a five-point Likert type array labeled from (1) strongly disagree to (5) strongly agree. Karayurt and Dramali (2007) adapted the CHBM scale in the Turkish version. They found that the Cronbach’s alpha and test–retest reliability of subscales values ranged from 0.58 to 0.89 and from 0.89 to 00.99, respectively. In this study, it was found that Cronbach’s alpha value of the subscales ranged from 0.79 to 0.95.

Breast Self-examination Assessment Checklist

The breast self-examination skill checklist was prepared by the researcher based on expert opinions for evaluating such skills in women who are visually impaired. The checklist for consisted of nine tasks or steps. It was adapted based on breast cancer’s early detection and screening and guidelines of WHO (2006) and the Turkey Health Ministry (2017). Each step of the checklist performed completely was evaluated as “Yes.”

Training Materials

Training Video With Audio Description

A breast self-examination training video for the women with visual impairments was created by adding audio description to another training video that had been previously prepared by the researcher for women who were deaf or hard of hearing. The extended audio description was made by professional experts from the Audio Description Association in Ankara, Turkey, a unique institution in this field. The education scenario of the video was prepared by the researcher based on breast self-examination education guidelines (Turkey Health Ministry, 2017; WHO, 2006). The final video lasted 7 minutes and 33 seconds. The audio description group’s video was longer than the video for the control group because the audio description added length to the video. The descriptions were delivered via secondary audio placed during pauses in the audio.

Training Video Without Audio Description

The breast self-examination that did not include audio description, and used only typical audio, was used for the control group. Therefore, the duration of the video was shorter than the video with audio description. The duration of this video was 2 minutes and 34 seconds. The video content of the audio description and control groups were the same.

Breast Examination Simulator

The breast examination skills trainer torso is a task trainer mannequin with left and right breasts attached to an adult upper torso. It has a realistic look and texture: the left and right breasts model pathologies for breast self-examination training. The breast examination simulator was used by the women both before and after the training sessions.

Data Collection

Data were collected in three stages, using face-to-face interviews. The data collection for each participant took 40 minutes on average.

Stage One

The sociodemographic questionnaire form and CHBM scale were read to each woman by a researcher, and their responses were noted on the form. The women who knew about breast self-examination were given the opportunity to examine the torso task trainer, then were requested to perform an examination on the simulator. A midwife, who was not informed about the study groups, evaluated the breast self-examination skills of each woman and marked them on a checklist based on whether she completed every step.

Stage Two

The audio description group watched the breast self-examination training video that included audio description. By comparison, the control group watched the training video with standard audio, without description.

Stage Three

After the video training, the midwife assessed women’s breast self-examination skills. Women were requested to perform breast self-examination on the breast examination simulator. The midwife marked the performance steps of women on the breast self-examination skill assessment form (checklist).

The video training environment and assessment method were similar for both groups. Each step of the research was explained to both groups using descriptive language. The women’s skills were observed and marked on the checklist by the midwife who was experienced in breast self-examination training. After data collection, the control group listened to the breast self-examination training video with audio description.

Data Analysis

SPSS version 22.0 software was used for the statistical analyses of these data. The Chi-squared test and the Fisher’s exact test were undertaken to verify the homogeneity of sociodemographic variables and the differences in the checklist steps for breast self-examination in both groups. The sociodemographic characteristics were analyzed with descriptive statistics. The CHBM scale scores did not normally distribute according to the skewness (±1.96) and kurtosis (±1.96) values. The analysis for comparing the means of subscales was used the Mann–Whitney U test. The result was considered statistically significant when the p-value was 0.05 or lower.

Results

The study included 60 women, 30 women in the audio description group, and 30 women in the control group, registered in Manisa Altinokta Blind Association, the only association in Manisa providing services to people with visual impairments. About half were 38 years old or younger (53.3% in the audio description group and 50.0% in the control group). The mean age of the audio description group was 38.43 ± 9.45 years (range from 23 to 64 years), and the control group was 39.66 ± 11.03 years (range from 21 to 65 years). There were not statistically significant differences between the groups in age, education, employment, marital status, family type, number of children, the onset of blindness, and the degree of visual impairment (p > 0.05; see Table 1).

Table 1.
Participant Characteristics.

Variable Intervention group n(%) Control group n(%) X²/Z p

Age (years)

38 years and below 16 (53.3) 15 (50.0) 0.796 0.50

39 years and above 14 (46.7) 15 (50.0)

Age in years^a (M ± SD) 38.43 ± 9.45) 39.66 ± 11,03 −0.429 0.66

Education

None 3 (10.0) 3 (10.0)

Elementary 8 (26.7) 21 (70.0)

High school 19 (63.3) 6 (20.0) 0.012 0.50

Working status^b

Working 7 (23.3) 4 (13.3)

Not working 23 (76.7) 26 (86.7) — 0.50

Marital status

Married 18 (60.0) 20 (66.7)

Single 12 (40.0) 10 (33.3) 0.592 0.39

Types of family

Nuclear family 20 (66.7) 23 (76.7)

Extended family 10 (33.3) 7 (23.3) 0.390 0.28

Number of children

1 10 (55.6) 6 (28.6)

2 4 (22.2) 8 (38.1) 2.938 0.23

3 4 (22.2) 7 (33.3)

Onset of blindness

Birth 21(70.0) 19 (63.3)

Later on 9 (30.0) 11 (36.7) 0.584 0.39

Degree of visual impairment

Low vision (70/20 to 20/200) 10 (33.3) 12 (40.0) 0.287 0.59

Blindness (20/200 or less) 20 (66.7) 18 (60.0)

a
Mann–Whitney U test.

b
Fisher's exact test.

A significant difference was not found between the groups in the family history of breast cancer or knowledge of, information sources for, and applications of breast self-examination (p > 0.05; see Table 2).

Table 2.
Breast Self-examination Practice.

Variable Intervention group n (%) Control group n (%) X ² p

Family history of breast cancer^a

Have history 6 (20.0) 2 (6.7) 0.254 0.12

None 24 (80.0) 28 (93.3)

BSE knowledge status

Yes 24 (80.0) 21 (70.0) 0.371 0.27

No 6 (20.0) 9 (30.0)

BSE knowledge sources^a

TV, radio 8 (33.3) 8 (38.1)

Internet 8 (33.3) 5 (23.8) 2.790 0.59

Health care professionals 4 (16.7) 2 (9.5)

Friends or family 4 (16.6) 6 (28.6)

Previous BSE

Yes 6 (20.0) 1 (3.3) 0.103 0.05

No 24 (80.0) 29 (96.7)

a
Fisher's exact test.

BSE = breast self-examination.

CHBM subscales of sensitivity, seriousness or caring, and health motivation were used to determine beliefs and behaviors related to breast self-examination of the participants before the training. No differences were found in the sensitivity or seriousness or caring subscales (p > 0.05), while a significant difference was found in the health motivation subscale between the audio description and control groups (p < 0.05; see Table 3).

Table 3.
Champion’s Health Belief Model Scale Sensitivity, Severity, Motivation Subdimensions for Breast Self-examination.

Variable Intervention group (n = 30) Control group (n = 30) Z ^a p

Mean ± SD Mean ± SD

Sensitivity 6.83 ± 2.6 6.53 ± 2.6 −0.402 0.68

Seriousness 24.43 ± 4.4 23.26 ± 5.7 −0.193 0.84

Motivation 27.36 ± 4.0 23.70 ± 3.4 −3.533 0.00

a
Mann–Whitney U test.

The women in the audio description and control groups were not able to perform breast self-examination on the torso mannequin before the video training. For this reason, we could not compare their breast self-examination skills prior to and after training. After the video training, significant differences were found between the audio description and control group’s skills (p < 0.05). The significant differences between the breast self-examination skills of the groups included: keeping the fingers flat and together; palpating the entire breast using spiral, up-and-down, and radial techniques; palpating the axilla; and squeezing the nipple gently to check discharge (p < 0.05). All participants in the audio description group performed completely and correctly the skills of noting any differences in shape, size, nipple or skin puckering, dimpling; using the pads of the three middle fingers; palpating unusual lump or mass under the skin, and palpating nipples and areola. The least frequently applied skill in the audio description group was palpation of the collarbone (63.3%), while none of the control group were able to perform this skill. The most frequently correctly applied skill in the control group was palpation of an unusual lump or mass under the skin (86.7%; see Table 4).

Table 4.
Women's Breast Self-examination Skills After the Video Training.

Skill Intervention group n (%) Control group n (%) X ² p

Note any differences in shape, size, nipple or skin puckering, dimpling

Yes 30 (100.0) 8 (26.7) — —

No 0 (0.0) 22 (73.3)

Use the pads of three middle fingers, not fingertips

Yes 30 (100.0) 2 (6.7) — —

No 0 (0.0) 28 (93.3)

Keep the fingers flat and together

Yes 28 (93.3) 1 (3.3) 48.65 0.00

No 2 (6.7) 29 (96.7)

Palpate the entire breast using the spiral, up and down and radial techniques

Yes 25 (83.3) 5 (16.7)

No 5 (16.7) 25 (83.3) 26.65 0.00

Palpate unusual lump or mass under the skin

Yes 30 (100.0) 26 (86.7) — —

No 0 (0.0) 4 (13.3)

Palpate nipples and areola

Yes 30 (100.0) 7 (23.3) — —

No 0 (0.0) 23 (76.7)

Palpate the axilla

Yes 28 (93.3) 8 (26.7)

No 2 (6.7) 22 (73.3) 27.77 0.00

Palpate up the collarbone

Yes 19 (63.3) 0 (0.0) — —

No 11 (36.7) 30 (100.0)

Squeeze the nipple gently to check the discharge

Yes 27 (90.0) 2 (6.7) 41.71 0.00

No 3 (10.0) 28 (93.3)

Discussion

In this study, we aimed to examine the effect of an audio description training video on the breast self-examination skills of women who are visually impaired. The skills of the audio description group, who listened to a training video with audio description, were evaluated and compared with those of the control group, who listened to a training video without audio description.

Breast self-examination should be performed regularly at the same time every month in a certain order and using particular techniques. Health professionals should inform all women about how to perform breast self-examination. Visual materials (e.g., videos, illustrated brochures, and booklets) and 3D models are frequently used in such training (Abera et al., 2017; Albright & Toy, 1993; Dogham et al., 2019; Heo et al., 2013; Swapna, 2016; Veitch et al., 2019). For women with visual impairments, however, it is necessary to add audio to visual materials used in health education or to provide documents in braille (Rajan, 2012). Although the use of 3D models for educating blind people can facilitate learning, insufficient descriptive expressions may prevent complete learning (Wall Emerson & Anderson, 2018). Some women with visual impairments have heard about breast self-examination but do not know when or how to perform it. Their lack of knowledge in this area may be related to their inability to access the health system and problems in the relationship between health professionals and patients with visual impairments (Cruz et al., 2015). Similarly, few women in our study reported receiving information about breast self-examination from health care professionals. Even the women who claimed they knew about breast self-examination could not demonstrate it on the model before the training, because they did not know how to do the examination.

After breast self-examination training, the audio description group’s breast self-examination skills were significantly higher than those of the control group (p < 0.05). Almost all women who listened to the training video with audio description completed thoroughly and accurately most of the breast self-examination skills. This result confirms previous findings that the knowledge and skills of women improve after breast self-examination–related educational studies (Albeshan et al., 2020; Heo et al., 2013; Koçak et al., 2019; Raithatha et al., 2018; Swapna, 2016). Although none of the women in the control group were able to perform breast self-examination before the training, a few women were able to do it after the training. In contrast, almost all women who listened to a training video with audio description implemented breast self-examination successfully after the training, providing evidence that the audio description in such training video significantly increases the learning of women who are visually impaired.

Checking the armpit and area just above collarbone is important to identify enlarged lymph nodes (Albeshan et al., 2020; Sharma, 2013; Swapna, 2016; Turkey Health Ministry, 2017). However, palpation of the collarbone is the least frequently performed skill by women in breast self-examination skill training (Koçak et al., 2019). In our study, palpation of the collarbone was the least frequently performed skill for the women in the audio description group, which may be because the women focused on examining breast tissue.

In this study, the health motivation subdimension mean score of CHBM was found to be high in the audio description group. The risk perception related to breast cancer influences the motivation of women to conduct breast self-examination (Yang et al., 2010). The fact that the rate of women in the audio description group with a family history of breast cancer was higher than the control group was thought to increase the awareness of breast cancer and motivation for breast self-examination.

It is critical that health education courses for women with visual impairments be accessible and useable. The use of advanced technologies today facilitates access to online training for this population. Breast self-examination training given to women with visual impairments through online education in the virtual learning environment has increased women’s satisfaction with their educational experiences (Carvalho et al., 2014, 2015). The breast self-examination training video with audio description from our study was shared on an online platform after the training so that anyone can access it. This video can be used by women with visual impairments and health professionals.

Limitations

There are two major limitations in this study that future research can address. First, the study did not monitor the long-term effects of the breast self-examination skills training. The other limitation was the sample size because Manisa, where the research was conducted, has only one association for people who are visually impaired.

Conclusion

Breast self-examination is an effective, simple, and free method used for the early detection of breast cancer. Women who are visually impaired who watched the breast self-examination training video with audio description were more likely to perform the required skills correctly, demonstrating that training videos with audio description can be prepared for health education of women who are visually impaired, especially to develop health-protective skills, such as breast self-examination. The women’s breast self-examination skills can reassessed at a later time.

For individuals with visual impairments to gain health care skills, explanatory descriptions should be added to visual expressions. While preparing health education materials, support by audio description professionals is recommended, but health professionals can be trained in audio descriptions, as well.

Variable	Intervention group n(%)	Control group n(%)	X²/Z	p
Age (years)
38 years and below	16 (53.3)	15 (50.0)	0.796	0.50
39 years and above	14 (46.7)	15 (50.0)
Age in years^a (M ± SD)	38.43 ± 9.45)	39.66 ± 11,03	−0.429	0.66
Education
None	3 (10.0)	3 (10.0)
Elementary	8 (26.7)	21 (70.0)
High school	19 (63.3)	6 (20.0)	0.012	0.50
Working status^b
Working	7 (23.3)	4 (13.3)
Not working	23 (76.7)	26 (86.7)	—	0.50
Marital status
Married	18 (60.0)	20 (66.7)
Single	12 (40.0)	10 (33.3)	0.592	0.39
Types of family
Nuclear family	20 (66.7)	23 (76.7)
Extended family	10 (33.3)	7 (23.3)	0.390	0.28
Number of children
1	10 (55.6)	6 (28.6)
2	4 (22.2)	8 (38.1)	2.938	0.23
3	4 (22.2)	7 (33.3)
Onset of blindness
Birth	21(70.0)	19 (63.3)
Later on	9 (30.0)	11 (36.7)	0.584	0.39
Degree of visual impairment
Low vision (70/20 to 20/200)	10 (33.3)	12 (40.0)	0.287	0.59
Blindness (20/200 or less)	20 (66.7)	18 (60.0)

Variable	Intervention group n (%)	Control group n (%)	X ²	p
Family history of breast cancer^a
Have history	6 (20.0)	2 (6.7)	0.254	0.12
None	24 (80.0)	28 (93.3)
BSE knowledge status
Yes	24 (80.0)	21 (70.0)	0.371	0.27
No	6 (20.0)	9 (30.0)
BSE knowledge sources^a
TV, radio	8 (33.3)	8 (38.1)
Internet	8 (33.3)	5 (23.8)	2.790	0.59
Health care professionals	4 (16.7)	2 (9.5)
Friends or family	4 (16.6)	6 (28.6)
Previous BSE
Yes	6 (20.0)	1 (3.3)	0.103	0.05
No	24 (80.0)	29 (96.7)

Variable	Intervention group (n = 30)	Control group (n = 30)	Z ^a	p
Sensitivity	6.83 ± 2.6	6.53 ± 2.6	−0.402	0.68
Seriousness	24.43 ± 4.4	23.26 ± 5.7	−0.193	0.84
Motivation	27.36 ± 4.0	23.70 ± 3.4	−3.533	0.00

Skill	Intervention group n (%)	Control group n (%)	X ²	p
Note any differences in shape, size, nipple or skin puckering, dimpling
Yes	30 (100.0)	8 (26.7)	—	—
No	0 (0.0)	22 (73.3)
Use the pads of three middle fingers, not fingertips
Yes	30 (100.0)	2 (6.7)	—	—
No	0 (0.0)	28 (93.3)
Keep the fingers flat and together
Yes	28 (93.3)	1 (3.3)	48.65	0.00
No	2 (6.7)	29 (96.7)
Palpate the entire breast using the spiral, up and down and radial techniques
Yes	25 (83.3)	5 (16.7)
No	5 (16.7)	25 (83.3)	26.65	0.00
Palpate unusual lump or mass under the skin
Yes	30 (100.0)	26 (86.7)	—	—
No	0 (0.0)	4 (13.3)
Palpate nipples and areola
Yes	30 (100.0)	7 (23.3)	—	—
No	0 (0.0)	23 (76.7)
Palpate the axilla
Yes	28 (93.3)	8 (26.7)
No	2 (6.7)	22 (73.3)	27.77	0.00
Palpate up the collarbone
Yes	19 (63.3)	0 (0.0)	—	—
No	11 (36.7)	30 (100.0)
Squeeze the nipple gently to check the discharge
Yes	27 (90.0)	2 (6.7)	41.71	0.00
No	3 (10.0)	28 (93.3)

Footnotes

Acknowledgements

The authors would like to thank all the women for their participation in this study, and the Audio Description Association (Ankara, Turkey), and midwife Melike KOÇAK (MSc).

Authorship Statement

SÇ and SIC conceptualized and designed the study and conducted the intervention, analyzed the data. SÇ wrote the first draft of the article. All authors revised the manuscript for important intellectual content and approved the final submitted version to be published.

Authors’ Note

This article is based on the midwifery master’s degree thesis completed by the first author at the University of Manisa Celal Bayar University Health Sciences Institute, Turkey.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Selda İldan Çalım

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Variable	Intervention group (n = 30)	Control group (n = 30)	Z ^a	p
Variable	Mean ± SD	Mean ± SD	Z ^a	p
Sensitivity	6.83 ± 2.6	6.53 ± 2.6	−0.402	0.68
Seriousness	24.43 ± 4.4	23.26 ± 5.7	−0.193	0.84
Motivation	27.36 ± 4.0	23.70 ± 3.4	−3.533	0.00