Effectiveness of Kangaroo Care Education Programme on Mothers, Nurses, and Infants Outcomes in Neonatal Intensive Care Unit
Phase: NA
Conditions: Kangaroo-Mother Care Method
Sponsor: University of Malaya

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STUDY PROTOCOL  
 
 
 
EFFECTIVENESS OF KANGAROO CARE EDUCATION 
PROGRAMME ON MOTHERS, NURSES, AND INFANTS OUTCOMES  
IN A NEONATAL INTENSIVE CARE UNIT 
 
 
 
 
 
 
 
8/6/2017 
 
 
 
 
 
 
 
 
 
 
 

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CHAPTER 1: INTRODUCTION 
 
1.1 Background  
 
A neonatal intensive care unit (NICU) is a unit that specializes in the treatment of ill preterm 
infants. The World Health Organization (WHO) 2013 defined a preterm birth as one where 
an infant is born alive prior to 37 weeks of pregnancy. Preterm infants are sub-categorised 
depending on gestational age: extremely preterm (below 28 weeks), extremely preterm (28-
<32 weeks), moderately preterm (32-<34 weeks), and late preterm (34-37 weeks) WHO 
(2013). Generally, preterm or premature infants have a low birth weight (LBW), weighing 
less than 2500 grams. To achieve a balance of fluids and nutrients, premature infants are 
placed in an incubator and observed closely until they reach a predetermined weight 
according to hospital protocol. 
1.1.2 Premature infant 
According to the WHO (2012) Global Action Report on premature births, it is estimated that 
15 million infants (1 in 10) are born prematurely each year (that is before 37 weeks of 
gestation) and this number is escalating. Prematurity is the world's leading cause of newborn 
deaths and many prematurely surviving babies face the possibility of disability for a lifetime. 
Complications of premature birth are the dominant cause of death for children under the age 
of 5, accounting for about 1 million deaths in 2015. Premature birth prevalence ranges from 5 
to 18% of all infants born over 184 countries. In Malaysia, based on the National Obstetrics 
Registry, the incidence of premature births for 14 tertiary care hospitals in 2012 was 11.3%, 
and this was deemed a serious health issue (New Straits Times, 2014).  
 
1.1.3 Kangaroo care 

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Kangaroo care (KC) is a simple evidence-based nursing practice intervention that can benefit 
premature newborns’ lives by helping to increase weight gain, reducing the length of 
hospitalization, and increasing breastfeeding rates. KC was started in Colombia in 1978 as a 
way to address mother and baby separation issues, overcrowding, and a lack of incubators in 
infant care hospitals (Charpak, Ruiz-Pelaez & Figueroa de Calume, 1996). KC is termed for 
its similarity to how kangaroos carry their babies and was originally designed to look after 
preterm infants in places where incubators were either inaccessible or unreliable. Basically, 
KC is introduced in order to simulate an incubator whilst naturally fostering mother-infant 
attachment. This is supported by the theory that neonates, as well as preterm infants, should 
not be separated from their mothers. Therefore, KC is essentially a natural incubator used by 
the mother.   
According to this principle, a preterm infant is positioned in a vertical position on its mother's 
bare chest or in a slightly upturned position between her breasts with head turned to one side; 
its arms and legs flexed (frog-leg position), and with its umbilicus and abdomen on the upper 
belly of its mother.  The infant is then covered to keep it warm, and so that the maternal body 
heat can help control its body temperature (Ludingtone-Hoe, 2008). In KC, the preterm infant 
is stimulated by mechanisms such as vestibular stimulus of the mother's breathing and chest 
movements, hearing stimulus of the mother's voice, normal respiratory sounds and her 
heartbeat, and mother's skin touch stimulation.  
These types of stimulation are essential for the growth and development of the preterm infant.  
KC provides a biological environment where the infant can get the basic needs of its early 
days i.e. warmth for development, nutrition such as breast milk for growth and close 
observation for example, apnoea in prematurity. According to WHO (2015), nearly three-
quarters of premature birth-related deaths can be avoided by a cost-effective intervention that 
involves giving KC treatment, antenatal corticosteroids, and antibiotics to premature infants. 

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Antenatal corticosteroids, early initiation of continuous positive airway pressure (CPAP), and 
KC have enhanced preterm infant survival and are a cost-effective treatment (Bhutta, Das 
Bahl, Lawn, Salam, Paul, Sankar, Sankar, Blencowe, Rizvi, Chou, & Walker, 2014). KC may 
be safely started at greater than 28 weeks of postconceptional age (Cattaneo, Davanzo, Uxa., 
& Tamburlini;1998 & 2007). 
KC is a simple type of nursing care starting from the Neonatal Intensive Care Unit(NICU). 
which assists preterm infants throughout the whole process of growth and development. 
Contact with and assistance from the preterm infant's mother is essential in order for her to 
demonstrate strong accountability in her attention to her preterm newborn. The KC 
techniques implemented by the postnatal mother in this universe of neonatal care come from 
her context of life, even though her behaviors originate from the guidance of health 
professionals. Nevertheless, in order to continue exclusive breastfeeding, the socio-cultural 
network seeks to have a greater influence on the treatment of premature infants. KC is now 
available for premature infants who need neonatal intensive care, including those who are 
extremely premature and with a ventilator assistance as well. 
In addition, it was stated at the second International Workshop on KC held in Bogota, 
Colombia, that KC is a fundamental right of the neonatal as an integral part of LBW 
management, in all settings and at all care levels in all countries. To support this, KC training 
must, therefore, be structured and involve mothers’ and nurses’ initiatives for KC application 
to be successful in the neonatal setting and after the mothers return home. In addition, this 
can also be achieved by providing KC guidelines and protocol information through high-
quality public health programs and through home-visiting as a central service for young 
mothers with LBW infants. According to Purbasary, Rustina, and Budiarti, (2017) home 
visiting will support and determine the capacity of young mothers to apply KC with their 
LBW infants. 

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Over the past three decades, KC has been known as a safe and effective technique for infant 
care; practicable for increasing the survival of LBW newborns, especially in low- and 
middle-income countries. Despite, much investment in implementation, education, and 
training, some countries find it hard to increase their efforts to support KC, and individual 
organizations are still struggling to institutionalize KC in a sustainable manner. A greater 
understanding has developed over the past decade about the health system mechanisms to be 
followed in implementing KC. KC may be started early once the infant is clinically stable. 
However, for those with a severe illness or for those unstable preterm infants requiring 
special treatment, it is recommended to wait until the infant has stabilized before initiation of 
KC. This is supported by Thukral, Chawla, Agarwal, Deorari, & Paul, (2008).  
Although many researchers have stated that KC is a fundamental element developmentally 
congruous with therapy for hospitalized preterm care which has short and long-term 
beneficial effects for infants (Ludington-Hoe, 2013), resource limitations, increased staff 
turnover and an inadequate supply of trained nurses inhibits the implementation of KC in the 
hospital setting. Limitations, such as facilities, staff shortages, high turnover of experienced 
staff, and insufficient numbers of nurses qualified in KC inhibits the performance of KC in 
the hospital setting (Lee, Martin-Anderson, Dudley, 2012).  
According to Ghani, Edvardssonb & Amir (2020), current or potential obstacles include the 
absence of a clear framework or guidelines for supporting KC techniques, lack of ability and 
incentive to adopt KC practices, mothers not interested in KC, lack of professional 
coordination, staffing and time constraints, and a medical birth environment that prioritizes 
interventions over KC.  
As well as the limited resources for enforcing KC, the perceptions of mothers and nurses 
must also be at the forefront of KC's success in the NICU.   Accordingly, nurses are the key 
drivers in providing relevant information and positive views on reactions to KC, knowledge 

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on KC, and ability to perform the KC technique. Furthermore, nurses in the NICU must be 
dedicated to successfully implementing KC as a continuous basic quality neonatal care 
practice. According to Cho, Kim, Kwon, Cho, Kim, Jun, & Lee (2016), KC has substantial 
positive effects on physiological functions, such as respiratory rhythm, enhances bonding, 
and health, and has the capability to relieve mother’s stress, as well as contributing to infant’s 
weight gain. Mothers of LBW infants lack confidence to care for their babies (Smith, 
Bergelson, Constantian, Valsangkar, & Chan, 2017). This might mean that young mothers do 
not realize the big impact the nature and effect of their attachment with their premature infant 
has, because they have insufficient information, experience, and strength, and they might not 
be physically or psychologically mature, psychologically or physically (Kuo, Chuang, Lee, 
Liao, Chang, & Lee, 2012). Therefore, this study aims to identify the perceptions, knowledge, 
and perceived barriers that primipara or multipara mothers with premature infants face when 
implementing KC in relation to to their confidence and ability to perform KC until their 
premature infants reach 3-months-old. 
A study was done by Norimah, Marlina, & Rashidah (2018) on infant weight gain patterns at 
PPUKM Malaysia. The mean gestational age score for infants in the experimental group was 
M=38.13;(SD=2.05) while the mean gestational age in control group was M=37.6 (SD= 
2.26). The findings revealed that, within four weeks, there was a significant (p<0.00) 
difference in improvement in weight gain pattern beween the groups. In the experimental 
group, the weight increased from 2.89 kg to 3.38kg in contrast with the control group, where 
there was a slight gain from 2.98kg to 3.33kg after the four  week study period. However, the 
study explored only the efficacy of breastfeeding and weight gain patterns among term 
babies. No study has been done in a local setting regarding the efficacy of KC in association 
with weight gain among preterm infants. Therefore, the researchers would like to explore the 
weight gain status of premature infants with respect to kangaroo care and breastfeeding rates. 

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NICU is a physically complex setting and mothers require proper supervision in order to be 
able to work within the environmental limitations. The environment is a robust predictor of 
achievement or failure of breastfeeding awareness (Norimah et.al., 2018). Hence, mothers 
depend on nurses to provide precise, detailed and reliable feedback on breastfeeding their 
high-risk infants. Even though mothers have background knowledge on breastfeeding 
obtained via websites, reliable information on breastfeeding should be provided by the health 
care providers (Norimah et al., 2018). 
The Third National Health and Morbidity Survey (NHMS III) conducted in Malaysia 
revealed a 94.7 percent overall prevalence of breastfeeding among children less than 12 
months of age (95 percent confidence interval, 93.0-95.9 percent). However, the overall 
prevalence of under 6 months of exclusive breastfeeding was very low: 14.5 percent (95 
percent confidence interval, 11.7–17.9 percent).The Second National Health and Morbidity 
Survey (NHMS II) found that the average prevalence of children breastfed in Malaysia was 
88.6%.The rate of exclusive breastfeeding was just 29% at four (4) months postpartum (Ho, 
Salim, Aris, Ibrahim, Hassan Nudin, Salleh, Hamid, 1999; & Fatimah, Siti Saadiah, Tahir, 
Hussain Imam, Ahmad Faudzi, 2010). In 1983, the Baby-Friendly Hospital Initiative (BFHI) 
was effectuated by all government hospitals. In addition, a report on exclusive breastfeeding 
rates among infants under 4 months in Malaysia was conducted in 2006. The evidence 
showed a decrease of 19.3%, 15.5%, and 23.9%, while breastfeeding rates dropped by 14.5%, 
11.7% and 17.9% for infants below 6 months (Fatimah et al., 2010). The survey also showed 
that exclusive breastfeeding was more common in rural areas (30.7%, 95 % CI 23.3-39.2) 
than in urban areas (12.9%, 95 % CI 8.9- 18.5), (Fatima et al., 2010). Statistics from the 
Kuala Lumpur Maternity Hospital (MHKL) indicate that up to 100 per cent of mothers 
breastfed their babies while 92.2 per cent breastfed exclusively before hospital discharge 
(Department of Obstetrics and Gynaecology MHKL, 2010). Although all mothers in 

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Malaysia initiate breastfeeding, Malaysia has the lowest prevalence among South East Asian 
countries of 6-month exclusive breastfeeding rates (Fatimah et al., 2010). According to 
Sulaiman, Liamputtong, & Amir (2016), although there is literature on the risk of giving 
formula milk to infants, most infants still do not receive exclusive breastfeeding for up to six 
(6) months as recommended by WHO, 2001; Al-Sahab, Lanes, Feldman, & Tamim, (2010). 
These studies show that working women need to be encouraged by their immediate families 
and their colleagues at work to continue breast-feeding after returning to work. This is a 
concern for public health, as 70% of urban women work in Malaysia and during their 
reproductive years (Fatimah et al., 2010).  
According to Hassan (2014), in Malaysia, there is no legal provision for female workers to 
breastfeed or express breastmilk at work. According to Mohd. Azri, Azrina, & Maheran 
(2017) in their recent study in the Kuala Muda District area, in order to ensure exclusive 
breastfeeding in the registered nursery, it should be ensured that caregivers are  able to give 
breastmilk while in the nursery. Therefore, to support breastfeeding partially or exclusively 
every single person involved in taking care of a baby has an essential role to play in 
encouraging partial or exclusive breastfeeding. 
A previous study by Engler, Ludington-Hoe,Cusson, Adams, Bahnsen,  Brumbaugh, Coates,  
Grieb,  McHargue,  Ryan, Settle and  Williams (2002) on nurses’ perception of KC revealed 
that a positive perception of the nursing evidence-based practice of KC would encourage 
nurses to integrate KC in the NICU setting for the care and treatment of premature infants. 
According to Kymre and Bondas (2013), KC is the right nursing intervention for the dying 
premature infant. It has the advantage of providing a shared sense of connection between the 
mother and the preterm baby and it impacts the nurses in the context of caring for the 
critically ill infant.   

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A study in Indonesia (Bergh, Charpak, Ezeonodo, & Udani, 2012) stated that the supporting 
factors for KC practice were only viewed positively at the vital administrative level. 
However, KC was only considered a trial at the district or city level. Therefore, nurses’ 
knowledge of KC is vital in order to incorporate this evidence-based treatment for premature 
infants. For better results in disseminating knowledge related to KC, some researchers have 
provided strategies to study models, learning, and training. When a nurse is knowledgeable in 
KC, this will help her to professionally encourage mothers to apply KC as one of the 
developmental care strategies required by their preterm infants. A sound knowledge and a 
positive perception on the part of nurses about caring for premature infants are crucial to 
guide and promote KC (Waiswa, Nyanzi, Namusoko-Kalungi, Peterson, Tomson, & Pariyo, 
2010). Therefore, this study significantly correlated KC with nurses’ perception, knowledge, 
and practice regarding KC.  In Utomi & Huang (2019) and Engler et al. (2002), KC was 
found to be a nursing intervention related to systematic evidence-based practice. For this 
reason, KC is often the only available method of caring for premature infants in many 
developing countries. 
Therefore, KC is widely recognized as an effective intervention in the NICU and endorsed as 
a routine procedure to improve the outcomes of premature infants in relation to weight gain, 
length of hospitalization stay (LOS), and breastfeeding rates. However, this practice is 
uncommon in Malaysia, and only a few hospitals have implemented KC, but without a proper 
protocol or guidelines. From our observation, not every mother in the NICU feels the bonding 
relationship of a normal mother with her premature infant, as they can not act like real 
mothers, while some of the mothers are afraid to touch or handle their tiny babies for the first 
time. Therefore, it is important to provide empirical evidence to convince the mother with a 
preterm infant about perception, knowledge, and how to reduce the stress preventing them 
from implementing KC. In addition, it is also important for nurses to identify the level of 

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stress faced by mothers whose infants were admitted to the Intensive Neonatal Care Unit 
(NICU). This is one approach for mothers who do not feel overwhelmed by the presence of 
their premature babies and who can perform the KC techniques comfortably. In addition, the 
researchers also evaluated nurses' perceptions of KC perceptions, knowledge, and practice as 
routine practice that should be supported for quality neonatal care in the NICU.  
Mothers and nurses in NICUs in Malaysia have previously initiated KC in a few hospitals, for 
example in Pulau Pinang, Klang Valley, Seremban, and Kelantan, but with limited 
information regarding guidelines and protocol for KC application with preterm infants.  
Therefore, the researchers have taken this opportunity to comprehensively assess mothers’ 
and nurses’ perspectives regarding KC implementation in relation to perception, knowledge, 
perceived barriers, stress, and practice of KC. Therefore, the aims of this research are to 
further explore the effect of KC on premature infant outcomes at three (3) months old in 
relation to weight gain, length of hospitalization stay and breastfeeding rate after conducting 
a structured kangaroo care educational program (KC-EP) for mothers and nurses in the NICU 
in Malaysia. Observing the increasingly high number of premature infant deliveries in 
Malaysia, a study of the feasibility of implementing KC, to be implemented gradually, in the 
Malaysian setting, is valuable. Other than that, in this study, the researchers have discovered 
that not only mother with premature infant outcomes but also nursing outcomes regarding KC 
implementation are involved. Therefore, exploring KC implementation with regards to both 
parties who care for preterm infants will help benefit and enhance the quality of premature 
infant outcomes in relation to weight gain, decrease in length of hospitalization stay and 
escalation in breastfeeding rates. The researchers also provided a KC-EP and then followed-
up the outcomes of the mother –infant dyads until the infants were 3 months old in order to 
evaluate the effectiveness of the KC-EP that had been given to the mothers. The researchers 
also provided significant information on the evidence-based nursing practice of KC. KC 

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helps to effectively improve weight gain, reduce the length of hospitalization stay, and 
increase breastfeeding rates among premature infants if their mothers consistently perform 
KC using the proper position and technique as well. 
1.1.4 Mothers’ and nurses’ perspectives on perception, knowledge, perceived barriers 
and the practice of kangaroo care. 
The quality of the health care systems and nursing also affects the scaling up of evidence-
based neonatal treatments such as KC and breastfeeding. KC's physiological effects and 
health benefits have been extensively established in various settings among preterm and low-
birth weight (< 2000 g) infants (Lawn, Mwansa-Kambafwile, Horta, Barros, & Cousens, 
2010; Bergh et al., 2014).  
The mother’s care is essential to indicate and strengthen her knowledge on KC during her 
infant’s hospitalization in the NICU (Ong, Abdullah, Danaee, Soh, Soh, Kee Lee, &  Daw 
Hussin, 2018). In another study, premature infants were claimed to have benefits from 
receiving KC and their mother’s involvement in their care  i.e. infant vagal tone maturity was 
accelerated and a good sleeping pattern was observed, as well as mothers were more sensitive 
during later interactions (Feldman & Eidelman, 2003). 
A previous study by Engler et al., (2002) on the perception, knowledge, practice, and barriers 
regarding KC among nurses revealed that a positive perception of KC  and a greater  
knowledge of evidence-based nursing practice will encourage nurses to integrate KC in the 
care and treatment of preterm infants in the NICU. According to Kymre and Bondas (2013), a 
positive perception and good knowledge of KC is the right nursing intervention for the dying 
preterm infant. It demonstrates the value of having mutual connections between both the 
mother and the premature infant, which influences the nurses' engagement in caring for the 
critically ill infant. A survey in Indonesia (Bergh et al., 2012) noted that it was widely 
regarded only at the central government level as the enabling factor for KC activities. At the 

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district or city level, however, KC was seen only as an obstacle. Hence, the knowledge and 
practice of KC by nurses is essential for the adoption of evidence-based practice in preterm 
infant care. Some researchers presented a technique for studying modeling, learning, and 
training with better results in the dissemination of information about KC-related knowledge 
and practice. If the nurse is knowledgeable and skilled in KC, it would help the mothers to 
promote and use KC professionally as one of their neonate’s developmental care needs. 
Nurses with a good perception, knowledge, and practice of caring for the preterm infant is 
essential for the promotion of KC (Waiswa et al., 2010). The nurses' perspectives of KC 
related to perception, knowledge and practice were discussed in the previous study done by 
Utomi & Huang (2019); and Engler et al. (2002) found that KC practitioners are more likely 
to develop a caring attitude and to have a positive perception of nursing practices related to 
scientific evidence. For this reason, KC is often the only available method of caring for 
premature infants in many developing countries. 
1.1.5 Maternal Stress  
Prematurity is a condition that may hinder or interfere with parenting interactions between 
the mother and the preterm infant by preventing the mother from holding and caring for her 
baby (Coşkun & Günay, 2020; Çelebioğlu, & Polat, 2010; Törüner & Büyükgönenç, 2017). 
According to Brandon et al. (2011), Howland, Pickler, Mccain, Glaser & Lewis (2011), 
following their premature infant’s admission to the NICU, mothers may experience 
developed background anxiety and stress pertaining to prematurity, lack of familiarity and 
opportunity in relation to neonatal care, that may change their primary motherhood 
capability.  
In addition, circumstances such as premature infant prognosis, uncertainty, fear of failure, 
inability to perform maternal roles, and feelings of distress and fatigue may cause mothers to 

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experience numerous worrying feelings such as anxiety, confusion and stress (Alışır, Šeker, 
Güler, Anaç & Türkmen, 2010; Erdem & Çelepkolu, 2014). The high levels of stress suffered 
by premature infant mothers are one of the most significant factors prohibiting mothers from 
getting involved in breastfeeding and neonatal care (Küçükoğlu, Aytekin, & Gülhaş, 2015). 
In contrast, other studies reported that mothers have poorer physical health related to the 
insecurity of their premature infant's health status, which may affect their emotions. The 
stress and exhaustion felt by mothers may also adversely affect their  post-birth stress (Hill & 
Aldag, 2007; Mortazavi et al.,2014). 
Mothers who have LBW infants lack confidence to care for their infants (Smith, Bergelson, 
Constantian, Valsangkar, and Chan, 2017). It could happen that young mothers do not realize 
that the nature and effect of their attachment with their premature infant could have a big 
impact because they have insufficient knowledge, exposure and abilities, and they may not be 
physically or psychologically mature enough for reproduction (Kuo, Chuang, Lee, Liao, 
Chang, & Lee, 2012). This research is aimed to evaluate the effect of KC education on 
perception, knowledge and perceived barriers to KC on preterm infant-mothers’ confidence 
levels and their capability to perform KC. Research conducted by Cho, Kim., Kwon, Cho, 
Kim, Jun, & Lee, (2016) revealed that KC had a constructive effect on physiological 
functions such as respiratory rate, enhanced bonding, safely and efficiently reduced stress on 
mothers, plus contributed to infant’s weight gain. 
 
1.1.6 Weight gain 
An interventional study was done by Norimah et al. (2018) on infant weight gain patterns at 
Pusat Perubatan University Kebangsaan Malaysia (PPUKM) between an experimental group 
of infants mean score gestational age M=38.13;(SD=2.05) and a control group mean score 

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gestational age M=37.6 (SD= 2.26). The findings revealed that, within four weeks, the weight 
gain pattern for the intervention group of infants had increased significantly (p<0.00). In the 
experimental group, the weight gain had increased from 2.89 kg to 3.38kg compared to the 
control group, which gained from 2.98kg to 3.33kg after the four week study period. 
However, the study only explored the efficacy of breastfeeding and weight gain patterns 
among term babies. No study has been done in a local setting regarding the efficacy of KC in 
association with weight gain among premature infants. Therefore, the researchers would like 
to explore the weight gain status of preterm infants in relation to KC and breastfeeding rates. 
1.1.7 Breastfeeding rates  
During the last trimester, preterm infants are unable to get adequate nutrients and immune 
response components passed from the placenta because their organs and systems are not fully 
mature. This is why they need special attention and also more breast milk (Arslan & 
Yeniterzi, 2013; Bağ, Yaprak, Halıcıoğlu, Parlak, & Harputluoğlu, 2006). Therefore, 
breastfeeding should be regarded as a priority for its nutritional, immunological, 
psychological and economic benefits. The NICU is a medically complex setting and mothers 
require adequate guidance to cope with the various changes in their roles. The environment is 
a good indicator of whether breastfeeding learning will fail or succeed (Norimah et.al.,2018). 
Mothers depend on nurses to provide reliable, informative and exact breastfeeding knowledge 
regarding their high-risk infant’s care. Despite the mother having obtained a background 
knowledge of such information via websites, reliable information on breastfeeding should be 
provided by health care professionals (Norimah et al., 2018). 
Nonetheless, the United Nations International Children's Emergency Fund (UNICEF,2018) 
estimates that 77 million babies worldwide do not get breast milk in their first hour of life, 
which can increase the risk of neonatal mortality by up to 80%. 

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Therefore, breastfeeding or expressed breast milk (EBM) is the essential nutrient that 
enhances the growth and development rate of premature infants (Brown, Raynor & Lee, 
2011).  
The Second National Health and Morbidity Survey (NHMS II) found that in Malaysia there 
was an 88.6% overall prevalence of children breastfed for some period of time. At 4 months 
postpartum, the prevalence of exclusive breastfeeding was just 29% (Fatimah et al., 1999). 
The Baby-Friendly Hospital Initiative (BFHI) was introduced in all government hospitals in 
1983. A subsequent national survey conducted in 2006 found that the overall prevalence of 
exclusive breastfeeding in Malaysia for babies under 4 months of age fell to 19.3%, 15.5% 
and 23.9%, while the overall prevalence of exclusive breastfeeding below 6 months was 
dropped to 14.5%,11.7% and 17.9% (Fatimah et al., 2010).  
The survey also revealed that exclusive breastfeeding was substantially more common in 
rural areas (30.7%, 95 % CI 23.3-39.2) compared to urban areas (12.9%, 95 % CI 8.9-18.5) 
Fatimah et al. Al., (1990). The available data at the Kuala Lumpur Maternity Hospital 
(MHKL) showed that up to 100 % of mother-infant dyads were breastfeeding and 92.2 % 
were breastfeeding exclusively prior to hospital discharge (MHKL Department of Obstetrics 
and Gynaecology, 2010). While almost all Malaysian mothers start breastfeeding, Malaysia 
has the lowest prevalence among Southeast Asian countries of 6-month exclusive 
breastfeeding rates (Fatimah et. al., 2010). Literature has been developed on the 
consequences of formula feeding (Sulaiman et. al., 2013). Most infants do not receive the 
World Health Organization's mandated 6-month exclusive breastfeeding (WHO 2001; Al-
Sahab et.al., 2010). Previous research indicated that working women need to be encouraged 
by their close relatives and their colleagues at work in order to continue breastfeeding after 
returning to work. It is a public health concern as 70 % of women in urban Malaysia are 
working and the remainder are working in their reproductive years (Fatimah et al. 2010). 

16 
There is no constitutional provision in Malaysia for women workers to breastfeed (or express 
milk) at work (Hassan, 2014). Previous research in the Kuala Muda District by Azri, Azrina, 
& Maheran (2017), found that childcare workers may also serve as another potential resource 
in registered nurseries to maintain exclusive breastfeeding. The encouragement of 
breastfeeding in part or exclusively for each person involved in taking care of the baby, 
therefore, has a major role to play in promoting partial or exclusive breastfeeding. 
 1.1.8 Structured teaching program on kangaroo care. 
At Bogota's second International Workshop on KC, Colombia, it was announced that KC is a 
fundamental right of the newborn for handling low birth weight in all settings and at all care 
levels in all countries. Therefore, to support the above fact, KC training must be organized 
and it requires the efforts of the mothers and nurses for KC implementation in the neonatal 
environment. Nevertheless, only a few hospitals in Malaysia have initiated KC i.e; Pulau 
Pinang, Klang Valley, Seremban and Kelantan, but with limited information regarding the 
guidelines and protocol for  KC with preterm infants.  
The researchers took this opportunity to comprehensively assess the mothers’ and nurses’ 
perspectives towards KC implementation on perception, knowledge, perceived barriers, 
stress, and practice of KC. Therefore, the aim of this study was to further explore the 
effectiveness of a KC-EP provided for mothers and nurses regarding preterm infant outcomes 
at 3 months old on in terms of weight gain, LOS and breastfeeding rates after conducting a 
KC-EP for mothers and nurses in the NICU, Malaysia. 
Several studies suggest that KC is a fundamental component of a developmentally 
appropriate treatment for hospitalized premature intervention that sustains beneficial effects 
for infants in the short and long term (Ludington-Hoe, 2013). However, no article has been 
published to prove the effectiveness of KC, with proper structured teaching, guidelines, and 

17 
protocol for KC to be safely implemented among premature infants, in terms of weight gain, 
LOS, and breastfeeding rates in the Malaysian setting. 
1.2 Problem Statement 
Prematurity among births and morbidity is increasing and prolongs the separation of infants 
from their mothers. KC is not yet standardized and is not widely implemented, and our nurses 
are not committed to KC techniques. Possibly this may be due to lack of commitment, lack of 
awareness and/or, lack of knowledge among nurses and mothers in the NICU. 
There is no formal training on KC techniques. Based on an in-depth analysis of the existing 
literature, it was decided that a scholarly intervention would be the best information transfer 
tool for this research, explicitly targeting mothers and nurses to overcome the above issues. 
The educational intervention designed for this study included theoretical and practical 
sessions of KC using guidelines, principles and procedures from the United States Institute 
for Kangaroo Care (USIKC, 2018).  
Kangaroo Care is globally recognized as effective interventions and is recommended as 
routine neonatal care in the NICU. However, this practice is uncommon in Malaysia and only 
a few hospitals have implemented KC, but without proper guidelines or protocols. From our 
observations, not every mother recognizes a natural maternal bonding attachment with her 
preterm infant in the NICU. Therefore, it is important to obtain empirical evidence in order to 
explore the perception, knowledge, and perceived barriers to KC as well as levels of stress of 
those whose premature infants are admitted to the NICU. The researchers also evaluate 
nurses' personal beliefs regarding their perceptions, knowledge and practices in support of 
KC as a routine nursing intervention in the NICU for the quality of premature infant care. 
In addition, the limitations of contextual curriculum resources in nursing subjects may affect 
the quality of trained nurses and prevent KC from being implemented in the hospital 
environment. Limitations such as facilities, shortage of staff, availability of experienced staff, 

18 
and insufficient number of nurses trained in KC prevented the implementation of KC in 
hospitals (Lee et al., 2012). Certain current or potential obstacles, according to Ghani, 
Edvardsson, & Amir (2019), include the lack of comprehensive policies and guidelines to 
endorse KC procedures, and the lack of ability and incentive to adopt KC techniques. 
Mothers are not interested in KC, there is a lack of professional cooperation, there are 
personnel and time constraints, and a medical birth climate that does not prioritize KC 
involvement, as well as limited resources to enforce KC. Nurses are, therefore, the key 
drivers in providing relevant information and positive views regarding response to KC, 
knowledge of KC and ability to implement KC techniques. In a year, more than 15 million 
babies are born too early. More than 1: 10 infants (Liu et al., 2016) die each year from 
complications due to a preterm birth. According to the World Health Organization [WHO] 
(2018), complications of a preterm birth are the prominent cause of death for children under 5 
years of age and were responsible for about 1 million deaths in 2015. The inequality in global 
survival rates is serious. Some premature infants born at 32 weeks of age suffer from a lack 
of qualified cost-effective treatments, such as supplying comfort for breastfeeding, and 
critical care for infections and respiratory problems. The use of sub-optimal technology in a 
low-income setting has led to an inability to care for neonatal preterm infants (WHO, 2018). 
For example, over 90% of preterm infants (less than 28 weeks) who are born in low-income 
countries (die?) within the first few days of life, while less than 10% of preterm infants die in 
high-income countries (WHO, 2018). As reported by the Vital Statistics of Malaysia, (2019) 
the incidence of live births was 501,946, while the number of deaths was 172,031. The 
average death rate was 1 death every 3 minutes, 20 deaths per hour and 471 deaths a day. In 
addition, neonatal mortality <28 days was 46 deaths per 10,000 live births. Of these, the male 
mortality rate (57.5%) was higher than the female (42.5%). However, for the death of a baby 
less than 1 year there were 72 deaths for every 10,000 live births. Subsequently, as reported 

19 
by the University of Malaysia Medical Center (UMMC), Department of Patient Information 
Management, Department of Statistics (2017), there were 5,495 total births in 2011 compared 
to 5,298 in 2015. This indicates a decline in births from 2011 to 2015. However, the number 
of premature infants increased from (2.54%, n=140) in 2011 to (8.49%, n=450) in 2015 and 
required special treatment in the NICU. Prematurity of infants with low birth weight (LBW) 
is a common problem in Malaysia. This is similar to a large population study, carried out in 
Austria by Waldhoer, Wald, & Heinz (2008), of 10,240 infants. Malaysian mothers' lower 
weight before pregnancy was a major risk factor associated with LBW infants. To my 
knowledge, only a few related studies have been conducted in Malaysia. In view of the 
limited research on KC in premature infants in Malaysia, the objective of our study was to 
evaluate the effectiveness of KC for premature infants in terms of weight gain and 
maintaining breastfeeding rate. 
Seeing the increasing number of premature infants delivered in Malaysia, the feasibility of 
gradually implementating KC in Malaysian hospitals is valued. In addition, in this study, the 
researchers found that not only the mother's personal belief about KC but also nursing 
expectations were essential in assessing the efficacy of KC for premature infants in this 
environment. Therefore, exploring KC implementation for both parties who care for the 
premature infant will help to support and improve the quality of premature infant outcomes. 
The incidence of premature infant prolonged hospitalization in neonatal settings appears to be 
increasing. Although comprehensive studies and clinical initiatives designed towards its 
reduction have been done abroad,  no study has been conducted yet in Malaysia. In relation to 
this, according to the Little Aussie Premature’ Foundation (2017), from 190 premature births, 
the average length of hospital stay was from 36 to 11 days depending on their gestation, from 
32 to 36 weeks of gestation, when born. However, according to Dimes Perinatal Data Center 
(2011), the average hospital stay for newborns admitted to the NICU was 13.2 days,  while 

20 
those born at 34 -36 weeks and admitted to a special care center stayed an average of  4.9 
days longer than those born at 39-41 weeks. Biswas, Malpani & Ekka (2016) found that the 
KC group was discharged earlier than the control group with means of (11.4±4.3 vs 
17.68±8.64) days (p<0.05) among newborns with a birth weight less than 1500gram at a 
hospital in central India.  Jefferies (2011) revealed that KC was reduced in hospitalization for 
low birth weight infants. The LOS among premature infants was studied in a systematic 
review and meta-analysis of randomized controlled trials on probiotics preventing candidal 
colonization and invasive fungal sepsis in preterm neonates by Hua-Jian., Guo-Qiang., Qiao., 
Christi., & Zhong (2017). This study revealed that candida is the third most common cause of 
late-onset sepsis in preterm infants in NICUs, and invasive fungal infections have increased 
dramatically at a range of 1.6% to 9% in VLBW; < 1500 g is associated with an increase in 
the LOS. Therefore, implementing the KC technique in the NICU setting will help to 
decrease hospitalization stay and reduce infection among premature infants in Malaysia. 
The Newborn Guidelines of the World Health Organization (WHO, 2013) recommends that 
post-natal mothers continue appropriate, successful, or exclusive breastfeeding for their 
infants for the first six months. The Baby-Friendly Hospital Initiative (BFHI) promotes 
breastfeeding in antenatal and postnatal settings around the world and has demonstrated 
substantial increases in breastfeeding levels and practices everywhere it is implemented 
(Nyqvist, Haggkvist, Hansen, et al., 2012). Malaysia's government, especially the Ministry of 
Health, has already done a tremendous job of promoting breastfeeding. However, according 
to Bachtiar, Hussain, Lanham-New., & Horton (2011) in their study in the Klang Valley, only 
33% of mothers were breastfeeding their infants at four months and, by six months, just 21% 
of mothers had breastfeed their infants exclusively.  
At the same time, although Malaysia's government has actively endorsed breastfeeding in all 
of its hospitals, the pick-up rate for breastfeeding is still unsatisfying. The same resource 

21 
shows that most mothers practice KC techniques to breastfeed their premature infant, so KC 
will help to achieve the goals of the National Breastfeeding Policy (NBP), at least for the first 
three months after discharge. The findings suggest that during hospitalization mothers really 
need reliable information and support from nurses. However, the workload of nurses and 
strict monitoring of premature infants in the NICU will affect the process and delay the 
delivering of health education on breastfeeding.  
Therefore, evaluating the awareness of mothers regarding breastfeeding their preterm infants 
during hospitalization and mothers' willingness to continue breastfeeding before being 
discharged is important to enable mothers to continue breastfeeding after returning home. In 
the recent study done by Norimah, Marlina & Rashidah, (2018) it was stated that the 
breastfeeding failure rate was due to NICU staffing environment. The main reason was the 
lack of continuity of nurses to teach and advise mothers individually on breastfeeding at the 
community and health center level. According to Alina & Zaharah (2010), the mothers 
reported receiving contradictory guidance on breastfeeding in the NICU, and had various 
difficulties in initiating breastfeeding, ranging from concerns about the health of their 
premature infant to lack of knowledge and support in the NICU. Regarding the environmental 
issues the mothers and premature infants were kept apart due to sickness or employment. 
Even though they are separated, it is important to enable mothers to care for their premature 
infants (Norimah et al., 2018). Each mother needs to understand how to express breast milk 
(EBM) to feed her preterm infant in order to sustain lactation in a separation situation. 
However, breastfeeding of premature infants in the NICU depends on early and successful 
support for breast milk expression. The researchers found that the NICU environment and the 
staff's approach to promoting breastfeeding were a barrier in the context of successful 
conveyance of knowledge.  

22 
Therefore, this study attempts to address the gap by assessing the barriers and enabling 
breastfeeding through implementing the KC technique with premature infants. In relation to 
this, the researchers understand that  practicing KC will also help to promote NBP goals i.e. 
an appropriate or exclusive breastfeeding effectuation until at least three months old. 
Therefore, the need to express breast milk (EBM) or earlier breastfeeding itself is paramount 
to help little preemies remain appropriate for breastfeeding, gain weight and weigh at least 
1.8kg before being discharged. Moreover, it has become a major challenge for nurses, 
particularly for NICU staff, to encourage maternal participation in the care of their preterm 
infants in the NICU (Wigert, Hellstrom, & Berg, 2008). Studies have shown that mothers 
have not been offered the right conditions to participate in caring for their premature infants 
in the NICU. Having her premature infant admitted to the NICU may negatively affect the 
mother’s ability to care for her premature infant, especially during her infant’s 
hospitalization. Prior to a mother’s participation, maternal stress levels in handling her 
infant’s admission (Ahn & Kim, 2007; Brecht et al., 2012; Chourasia, Surianarayanan, 
Adhisivam, & Bhat, 2013; Howe, Sheu, Wang, & Hsu, 2014), and NICU related maternal 
ability (Lee, Wang, Lin, & Kao, 2013) need to be evaluated.  This is to ensure that a better 
strategy that would benefit both the mother and their premature infants can be implemented. 
Hence, it is very important to conduct an intervention study to create a solid basis to guide 
nursing practice in the NICU; this would have a progressive influence on the preterm infant’s 
growth and development in order to reduce maternal stress (Melnyk & Fineout-Overholt, 
2011).   
It is also not known whether the didactic intervention would directly influence the 
perceptions of mothers and nurses; enhance the application of KC; and improve premature 
infant outcomes. The purposes of the study are described in the following section. 
1.3  Significance of The Study 

23 
 
a) Nursing Policies 
 
Standard guidelines and policies for KC implementation among premature infants, thus 
encouraging collaboration between health care providers and neonatal nurses, are needed. 
Administrative direction and written declarations are crucial if all parties incorporated in 
neonatal care are to implement KC with an understanding of their own and others’ roles, 
accountability and responsibilities. The policy should further promote the involvement of all 
nurses in proper monitoring of the performance of KC and successfully documenting 
detection of KC implementation by the mother and premature infant against KC. However, 
the provision of additional nursing staff to ease NICU workloads is not easy, especially 
because of nursing shortages and the need to make effective use of human resources due to 
global economic concerns. The development of new approaches to offset bedside teaching 
and easing the workload of nurses can increase nurses' emphasis on quality neonatal care. 
 
b) Nursing practice 
 
Nurses should encourage mothers to provide KC either in the hospital or in the community 
setting to improve the quality of health of their premature infants. Education and care should 
be given to every mother whose infant has LBW because it is premature and she should be 
encouraged to do KC. Furthermore, KC has demonstrated the advantage of homeostasis 
compared with standard treatments (incubators, radiator coolers, or open beds). Premature 
babies receiving KC tend to sustain a stable body temperature and demonstrate improved 
breathing patterns (Conde-Agudelo, Belizan, Diaz-Rossello, (2014); Christensson, Siles, 
Moreno, Belaustequi, De La Fuente, Lagercrantz, Puyol, Winberg, (1992); Rojas, Mario, 
Kaplan, Michael, Quevedo, Maria, Sherwonit, Elaine, Foster, Lauren, Ehrenkranz, Richard, 
Mayes, Linda, (2003)). Regarding preterm infant hospitalization in general, KC is associated 
with a reduced risk of infection, serious illness, and mortality.  

24 
 c) Nursing education  
Nurse educators should have the responsibility of increasing the perception, knowledge, 
practice, and skills of student nurses regarding the kangaroo care technique by arranging in-
service education in institutions and also at the hospital level. They should also take active 
steps to include kangaroo care content in the section on development and growth in neonatal 
care in the nursing curriculum. Thus, during their practical posting, the students will advocate 
for mothers in the NICU, hospital, clinic or at the community level to routinely implement 
KC with their premature infants. This will be recorded in a logbook so the students can 
achieve the objectives of their posting in an NICU setting in relation to the topic of obstetric, 
gynaecology, neonatology and peadiatric nursing. 
Nurse administrators should concentrate on workshops, continuous nursing education(CNE), 
and in-service education as this will update their perception, knowledge, and practice 
regarding continuing KC and promoting exclusive breastfeeding. Nurses play a vital role in 
the care and management of hospitalized preterm infants. 
d) Mothers and premature infants 
First, early bonding and attachment between a mother and her preterm infant will relieve the 
mother's physiological and psychological stress. Second, calming practices (holding, 
touching, talking) and the smell and warmth of the mother's body help to regulate the 
premature infant's basic behavior, and may contribute to the ability of the infant to control its 
state. Third, the KC protocol facilitates the individualized attachment between mothers and 
their preterm infants. Such attachment helps the mother improve her compassion for and 
reaction to interactive signs from her preterm infant, particularly during feeding.  
In addition, the interactions between the mother and her preterm infant are likely to promote 
growth and development, as well as the recovery and stabilization of the mother's situation by 
reducing maternal distress, thus fostering the bond between mother and preterm infant. 

25 
Finally, breastfeeding after birth motivates and promotes responsive interactions for the 
maternal and preterm infant bonding attachment. It provides a mother with confidence to take 
care of her premature infant, increases breast milk supply and is low cost. Practicing KC 
means a mother’s visiting rate is increased and this helps to encourage breastfeeding. 
The findings of this study determine that KC, as one of the most relevant nursing 
interventions, might effectively promote bonding between the mother and preterm infant, as 
well as foster the growth and development of the infant. The benefits to the premature infant 
are that it normalizes infant physiology, provides warmth to the baby, promotes lactation, 
ensures more successful breastfeeding, provides a sense of security to the baby, improves the 
weight gain of the baby, reduces hospitalization stay, promotes baby-mother bonding and 
promotes deep sleep in the premature infant. 
 e) Organization 
Implementing KC will help to reduce the LOS, and fewer infections will occur in the NICU. 
The organization can cut the purchasing cost of third level antibiotics or other expensive 
medications required to cure nosocomial infections in the NICU setting. It will also reduce 
outbreaks in the NICU. 
f) Nursing Research 
  The KC intervention can be introduced into hospitals all over Malaysia. It is a simple, low 
cost, and highly effective intervention. Thus, the KC-EP can be provided to nursing students, 
nurses, and healthcare providers with the purpose of encouraging weight gain, reducing LOS, 
improving breastfeeding rates, and, therefore, enhancing the quality of neonatal care. A study 
can also be conducted with a large number of samples in different settings. A similar 
comparative study can also be conducted including mothers, fathers and other family 
members with a follow-up at six (6) months old for exclusive breastfeeding assessment. 
1.3.3 Missing gaps in the existing literature 

26 
In a previous national survey on aspects of nursing done by Engler, Ludington-Hoe, Cusson, 
Adams, Bahnsen, Brambaugh, (2002), in relation to perceptions, knowledge, barriers, and 
practice related to KC, it was indicated that nurses need training resources to address 
obstacles to KC practice, stressing that knowledge and competence are necessary to 
reproduce KC securely and efficiently. Such training must also focus on the importance of 
KC for mothers and preterm infants in order to overcome the lack of knowledge and 
awareness about KC amongst mothers and nurses in Malaysia in general. Therefore, an 
intervention study needs to be conducted to evaluate the efficacy of KC-EP to shed light on 
the mechanisms behind these obstacles for the advantage and efficacy of KC for all preterm 
infants, mothers and nurses.  
In previous studies, only nurses were investigated in terms of perception, knowledge, 
barriers, and practice. Therefore, it is possible to undertake a comprehensive study of the 
relevant issues not only for nurses but also for mothers of premature infants in order to 
determine KC-EP effectiveness. 
In previous regional research by UNICEF (2004), during the neonatal period, premature 
infants with LBW are more prone to develop neonatal morbidities like acute respiratory 
failure. Those who survive in the neonatal phase tend to be more vulnerable to neonatal 
morbidity, relative to term infants and those of normal weight, including gastrointestinal 
disease, respiratory disorders, central nervous system, immunology, vision and hearing 
(Behrman & Butler 2007). KC will promote evidence-based nursing practice and have 
various advantages for mothers, premature babies and nurses. The differences between this 
study and the previous study are that the researchers are evaluating the mother's perspective 
and premature infant’s outcome starting from the day of admission until the infant reaches 3 
months old. The researchers also evaluate the nurse's perspective as caregiver in the NICU 
setting before and after the educational intervention program is conducted. 

27 
As stated by Ong (2017), the nurse who is in charge of EBM is concurrently tasked with 
other administrative tasks due to a shortage of staff as well as the considerable amount of 
time and limited space to undertake KC. Moreover, the nurses responsible for advocating KC 
in the unit are also engaged in the work of administrative documentation. There is, therefore, 
insufficient time available to prepare and advocate for mothers to undertake KC in the unit. 
As reported by Chan, Labar, Wallb, and Atuna (2016), these reasons tend to reveal that 
shortages of staff, staff turnover, lack of knowledge, lack of awareness of the value of KC 
among nurses generate barriers to implementing kangaroo care within a facility (Seidman et 
al.,2015). 
KC is not the ordinary routine approach in many NICUs in Malaysia. Knowledge and 
awareness of these techniques among neonatal nurses is still inadequate. This study shows 
that nursing staff require KC awareness and training to properly understand the effectiveness 
of KC so it is consistently enforced in the NICU and at home.  
Even though over the past three decades, KC has been developed as a safe and effective 
technique for preterm infant care with the ability to enhance the survival rates of LBW 
infants, especially in low- and middle-income countries, in Malaysia a structured curriculum 
for KC, applicable in the local context, has not yet been designed.  
This is despite numerous attempts to introduce, educate and train individuals and 
organizations in a sustainable way to improve coverage of KC. For this reason, KC is often 
the only available method of caring for premature infants in many developing countries. 
In a study by Bergh, Charpak, Ezeonodo & Udani (2012), it was reported that research on KC 
application, training and education practices and approaches was discussed at an international 
workshop, and further evidence was gathered from personal experiences, unpublished 
research presented by colleagues, and published materials. The study provides an illustration 
of some of the community's core implementing and training issues, and concerns about the 

28 
collaborative outcomes. Only nurses’ perception, knowledge, barriers, and practice were 
discussed in the previous studies. The study also suggested a triangular transition change involving 
transition agents, and the choice of implementation and educational models. The specific positions 
of the change agents, addressed as drivers, trainers and implementers, were discussed.  
KC teaching and training should be strengthened by the same fundamental conceptual 
definition and should be supported by awareness-raising, dedicated leadership, 
multidisciplinary collaboration, and ongoing top management support. It should be based on 
empirical evidence, conducted in line with existing educational best practices, and should be 
appropriate and applicable locally. 
 
1.4 Research Questions 
KC has gained acceptance as a chosen and effective technique for the quality care of 
premature infants. However, it is still a new phenomenon in the NICU in Malaysia; also no 
data has been published regarding the effectiveness of KC in relation to the perception, 
knowledge and, practices of nurses. In addition, emotional stress also occurs among those 
mothers whose preterm infants have been admitted to the NICU. This study also explores the 
outcomes of mothers in terms of their perception, knowledge, barriers and level of stress 
regarding KC implementation as well as the outcomes for their premature infants; weight 
gain, LOS and breastfeeding rates associated with compliance with the practice of KC in a 
Malaysian setting. In view of the lack of literature on a locally contextualized education 
model for the teaching of kangaroo care, I questioned the need for drafting such an education 
programme. The main research question of this thesis is;  
Can a locally contextualised kangaroo care education programme aimed towards both 
mothers and NICU nurses be effectively implemented?  
To answer the above research question, the following were analysed.  

29 
1. Are there any statistically significant changes in mothers’ perception, knowledge, 
perceived barriers regarding KC and their level of stress after participation in a KC-
EP between control and experimental groups of mothers at pre-intervention (T0), 1-
month post-intervention (T1) and 3-months post-intervention (T2)?  
2. Does KC improve premature infants’ weight gain, LOS, and breastfeeding rates 
between a control and an experimental group at pre-intervention (T0), 1-month post-
intervention (T1) and 3-months post-intervention (T2)? 
3. Are there any statistically significant changes in the nurses’ perception, knowledge 
and practice of KC before and after participation in a KC-EP? 
1.5  Objectives of The Study 
The general and specific aims of the study are as follows: 
 
1.5.1 General Objective 
 
The general objective of this study was to evaluate the effectiveness of a special KC-EP for 
mothers’, nurses’, and premature infants’ outcomes in the neonatal intensive care unit 
(NICU). 
1.5.2 Specific Objectives 
This study aimed to evaluate a KC-EP supporting KC among mother-infant dyads and nurses.  
The specific objectives of this study were to: 
1. compare the effectiveness of KC-EP in terms of  mothers’ perception, knowledge, and 
perceived barriers regarding KC and their level of stress after participation in a KC-
EP between control and experimental groups of mothers at T0, T1 and T2. 
2. compare premature infants’ weight gain patterns, LOS and breastfeeding rates 
between control and experimental groups at T0, T1, and T2. 

30 
3. compare nurses’ perception, knowledge, and practice of KC before and after 
participation in a KC-EP for nurses.  
1.6  Hypothesis 
The following hypotheses guided the study: 
• H1: A KC-EP can improve perception, knowledge, and perceived barriers in relation 
to KC, and levels of stress among mothers. 
• H2: KC is effective in improving weight gain patterns, LOS, and breastfeeding rates 
among premature infants. 
• H3: A KC-EP can improve nurses’ perception, knowledge, and practice in relation to 
KC implementation. 
1.7 Conceptual and Operational Definitions 
 
1.7.1 Effectiveness of kangaroo care  
 
According to the Oxford Advanced Learner’s Dictionary (2005), effectiveness is defined as 
producing an intended result or a successful result. In this study, effectiveness refers to 
measuring maternal, nurses’ and infant outcomes before and after the implementation of KC. 
Maternal outcomes include maternal perception, knowledge, and perceived barriers regarding 
KC and stress, assessed using the adopted tools Kangaroo Care Questionnaires (KCQs) and 
Parental Stressor Scale: Neonatal Intensive Care Unit, Parental and Relationship (PSS: 
NICU: P&R), while the nurses’ outcomes include the perception, knowledge and practice of 
kangaroo care, and premature infant outcomes are weight gain patterns, LOS and 
breastfeeding rates.  
1.7.2   Kangaroo care (KC) 

31 
As stated by Ludington-Hoe et al., 2010 & 2018; Charpak & Ruiz-Palaez, 2011, KC is 
defined as the simple intervention of chest-to-chest, skin-to-skin contact between an infant 
and a significant mother. The preterm infant’s head is turned to one side so that the ear of the 
infant is above the mother’s heart. Wearing only a diaper, the infant is placed in a prone frog-
like position (arms and legs flexed), head turned to one side and neck straight (open airway) 
for a minimum of one hour per session so as to complete one cycle of sleep (active sleep, 
quiet sleep and return to active sleep), Ludingtone-Hoe et al., 2018.  
In this study, KC refers to a special holding technique where the premature infant is held in a 
vertical upright position. The premature infant wears only a diaper or a head cap/booties 
(optional for infants with a body weight <1500grams) and is placed on the mother’s bare 
chest (between the mother’s breasts). The infant’s head is turned sideways facing either right 
or left, both knees and elbows are bent (M position) to form a frog-like posture. The 
premature infant’s head and torso are covered from its feet until the auricular lobule (earlobe) 
with either the mother’s clothes, a tube or a small blanket to retain warmth in order to 
promote the infant’s growth and development. 
 
 
1.7.3 Neonatal Intensive Care Unit (NICU)  
NICU refers to a specialized setting in a hospital that provides comprehensive and continuous 
care for premature infants, aged from 22 weeks to less than 37 weeks, who need immediate, 
persistent and sustained close monitoring, and the help of highly technical specialist 
assistance, medications, and manpower to ensure maintain normal growth and development. 
The NICU increases the quality of care of preterm infants.  
1.7.4 Premature Infant 

32 
According to Phillips, Goldstein, Hougland (2013), a baby born before 37 weeks of gestation 
(more than 3 weeks prior to the due date) is referred to as a preterm infant. In this study, a 
premature infant refers to an infant born alive earlier than usual, with a corrected age between 
28 weeks to 36 + 6 weeks’ gestation on its first admission to the NICU. 
1.7.5 Perception 
The definition of perception from the Cambridge English Dictionary (2020) is the way one 
thinks and feels about something. Perception in this study refers to how mothers think about, 
interpret, and accept the benefits obtained from KC in relation to their personal beliefs about 
premature infant care. 
 1.7.6 Knowledge 
Knowledge is the understanding of or information about a subject you acquire through 
experience or study, known either by one person or by people in general (Cambridge English 
Dictionary, 2020). Nevertheless, knowledge in this study refers to the collection of 
information on a specific subject, such as the input and understanding of KC. 
 
 
1.7.7 Perceived barriers 
A perceived barrier is something that prevents or makes it harder for something to happen, 
according to the Cambridge English Dictionary (2020). In this study, the perceived barrier 
refers to measurements considered relevant or which make it difficult to conduct KC. 
 1.7.8 Maternal stress 

33 
A mother who feels worried and nervous (Cambridge English Dictionary 2020) is under 
maternal stress. Maternal stress in this study refers to the stress experienced by mothers who 
can not cope or deal with the experiences caused by a difficult situation, such as premature 
infant admission to the NICU. 
1.7.9 Nursing Practice 
The scope of nursing practice is seen in the variety of roles, tasks, commitments, and abilities 
which registered nurses are trained and authorized to perform (Scope of Nursing). Practice: 
Definition, Decision-Making, and Delegation, 2006). In this study, it includes nurses in the 
NICU being competent, confident, and responsible in the initiation of kangaroo care with 
premature infants, who require certain technical support and equipment. 
1.7.10 Weight gain pattern 
Weight gain pattern is characterized as an increase in weight and includes an increase in 
muscle mass, adipose cells, and excess fluids, such as water, or other factors, according to the 
Oxford Advanced Learner’s Dictionary (2005). In this study, weight gain for a premature 
infant refers to an increase in muscle mass, fat deposits, and excess fluids, such as milk, 
based on a daily weigh in;1 day = 24 hours. The weight gain of a premature infant represents 
the amount of increase or decrease in infant body weight in a day; 1 day equals 24 hours.  
 
1.7.11 Length of hospitalization stay (LOS) 
The Organization for Economic Co-operation and Development OECD (2020) reports that 
LOS is the total duration of time that patients spend in hospital. It is normally determined by 
the number of admissions or discharges divided by the number of days stayed by all 
hospitalized patients over a year. In this study, LOS relates to the number of days that the 
preterm infant spent in the hospital starting from the day of admission to the NICU until it 

34 
was allowed to be discharged or return home (in a day; 1 day = 24 hours); The length of 
NICU stays represents the number of days the premature infant spent in the intensive care 
unit recorded in days (1 day equals to 24 hours). 
1.7.12 Breastfeeding rates 
Breastfeeding is the method of providing nutrients that are essential for healthy growth and 
development to young infants, according to WHO (2020). Colostrum is the sticky, yellowish 
breast milk formed at the end of pregnancy and is accepted as the perfect nutrition for the 
newborn; feeding begins within the first hour of birth. In this study, breastfeeding rate refers 
to the rate preterm infants started breastfeeding or taking EBM, partially or exclusively, 
starting from 29 weeks, and continued breastfeeding along with appropriate formula milk for 
the first 3 months and beyond or were weaned at a certain week of gestation. 
1.8  Organisation of thesis   
The thesis is organized in six chapters to facilitate clarification and understanding of the 
study. 
Chapter One presents an introduction to the research, and contains background, statement 
of problems, study significance, research questions, objectives, hypothesis, and 
operational definitions. 
Chapter Two contains an appraisal of the literature on subjects, practice, 
recommendations, and previous studies on KC among premature infants related to weight 
gain, LOS, breastfeeding rates and KC-EP and conceptual framework. 
Chapter Three includes a description of the methodology, research design, research tools, 
sampling procedures, and methods of collecting data. This section also describes the 
specifications of the pilot test, data analysis strategies, and ethical considerations.  

35 
Chapter Four describes the major results from the quantitative design. This includes the 
results of the effectiveness of the KC-EP for mothers’, premature infants’ and nursing 
outcomes; comparison of mothers’ perception, knowledge, perceived barriers and level of 
stress between control and experimental groups at T0, T1 and T2; comparison of premature 
infant weight gain, LOS and breastfeeding rates between control and experimental groups 
at T0, T1 and T2; comparison of nurses’ perception, knowledge and practice at pretest-
posttest. Results for the mothers’, premature infants’ and nursing outcomes are presented. 
It also presents the association between the demographic characteristics of the 
participants and the main outcomes of the study.  
Chapter Five presents a discussion of the results of this study. Quantitative findings are 
incorporated into the discussion of the specific issues arising from the findings. The 
findings of the current study can be used to complement and reach conclusions in relation 
to previous research. 
Chapter Six provides the conclusion of the study, followed by the consequences and 
guidelines for nursing, education and clinical practices. Each section addresses the 
limitations and strengths of the study. The chapter ends with an overview of the findings 
of the study. 
 
1.9. Summary 
This chapter outlines the study's background, significance, objectives, research objectives, 
questions, aims, and hypotheses. It presents an explanation of the study-guiding conceptual 
framework. The provision of background information and the significance of the KC 
technique, the KC-EP and its practice highlight the importance of the study for the premature 
infant.     

36 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CHAPTER 2: LITERATURE REVIEW 
 
 
2.1 Introduction 
 
The literature concerning kangaroo care (KC) among preterm infants in the Neonatal 
Intensive Care Unit (NICU) context is presented in this chapter. This chapter begins with a 
brief description of literature search strategies and their results, then identifies and retrieves 

37 
relevant published studies and articles. The conceptual framework is derived from the 
Donabedian Quality of Care Framework Model (Rochefort & Clarke, 2010), which will guide 
the development of this study. 
2.2 Literature Search 
A computer search was used to identify relevant studies and articles. A review of the 
literature in this study included KC use and effect of KC on infant outcomes: weight gain, 
length of hospitalization stay (LOS), and breastfeeding rates. In addition, a search on 
mothers’ outcomes including perception, knowledge, perceived barriers in relation to KC, 
Parental Stressor Scale: Neonatal Intensive Care Unit, Parental and Relationship (PSS: 
NICU: P&R) and effect of a structural kangaroo care educational program (KC-EP) on KC 
was conducted. While for nurses’ outcomes, the search included perception, knowledge and 
practices (initiating KC with monitoring devices). The KC-EP on KC was also delivered to 
the nurses. Criteria were set during the search process for relevant studies and articles to be 
reviewed and analyzed in this study. 
2.2.1 Criteria 
Criteria for inclusion and exclusion were established to guide the exploration of related 
studies and articles. The inclusion criteria used were as follows;  
2.2.1.1 English language studies and articles 
2.2.1.2 
Primary search studies and articles (peer-reviewed research, 
dissertations, evidence-based clinical practice guidelines (EBCP) and 
evidence-based intervention practice (EBIP); 
2.2.1.3 
Secondary search studies and articles (systematic reviews); 

38 
2.2.1.4 
Studies and articles relating to the effectiveness of KC with premature 
infants pertaining to weight gain, hospitalization stays, and 
breastfeeding.  
 The exclusion criteria were: 
 
2.2.1.4             Non- English articles; 
2.2.1.5 
Studies and articles related to KC use among term babies, KC related 
to mortality, morbidity, and pain. 
2.2.2 Sources  
A comprehensive search was conducted on scholarly articles, books, dissertations, and 
conference proceedings relevant to KC use. In addition, citation search engines, such as 
GOOGLE and GOOGLE SCHOLAR, were also used. A hand search was carried out at the 
T.J. Danaraj Medical Library of the University Malaya to complete the systematic search in 
order to uncover important works not identified through keyword or citation search. The 
electronic database search was performed on databases subscribed to by the University of 
Malaya database digital library service: 
2.2.2.1 MEDLINE Complete @ EBSCOhost, 
2.2.2.2 Evidence Based Medicine (EBM) Review @ Ovid, 
2.2.2.3 Journals @ Ovid Full Test. 
The databases were as follows for the cumulative index of literature concerning Nursing and 
Allied Health: 
2.2.2.4 Web of Science database 
 
2.2.2.5 PubMed with Full-text database 
2.2.2.6 CINAHL with Full-text database. 
2.2.3 Keywords 
The keywords used in the database search included:  

39 
i) KC related keywords (KC/KMC /Skin to skin contact /Chest to chest /LBW, 
premature infant /guidelines) 
ii) Premature infant outcome related keywords (weight gain /decrease of hospitalization 
/length of hospital stay and breastfeeding) 
iii) Mother outcome related keywords (recommendation perception /knowledge /barrier 
/stress level /breastfeeding) 
iv) Nurse outcome related keywords (recommendation perception /knowledge /practice)  
v) Effectiveness/Structured Teaching Program (STP)/Kangaroo Care/Kangaroo Mother 
Care 
Boolean operators AND, OR, and NOT were used to combine or exclude keywords 
during the literature search. These helped to connect search words together to either 
narrow or broaden the set of results. The results were limited to English full-text studies 
and articles over the last 10 years. 
2.2.4 Results of Key Studies 
The search on electronic databases and reference mining yielded 161 full-text articles 
applicable to the effectiveness of KC and its association with infant, maternal and nursing 
outcomes. Of these 25 duplicated articles were removed. Of 136 articles screened by abstract, 
only 40 articles met the inclusion criteria for further critical review of the contents, there were 
a total of 29 original articles assessing KC use and the association between weight gain, 
hospitalization, breastfeeding and/or outcome. EndNote and Mendeley were used for 
managing references and bibliographies. A flow chart shows the systematic approach used in 
the literature review (Figure 2.1) 
 
 
161 articles returned from electronic 
databases and reference mining 
25 duplicates removed 
136 articles screened by abstract 

40 
 
 
 
 
 
 
 
 
 
             
 
 
 
 
 
2.3 Neonatal Intensive Care Unit (NICU) 
The NICU is a unit that provides medical and surgical action for infants after birth who 
require extraordinary attention. The conditions for admission include premature birth, low 
birth weight, breathing difficulty and septicity or infection. Combining unconventional 
technology and medical expertise, the NICU is responsible for the specialized care of the 
preemies. The most common medical conditions of premature infants requiring care in the 
93 excluded: 
• 44 - KC use among term baby, KC-related 
to thermo-regulation, parameters;  
• 27 - KC related to mortality and morbidity; 
• 19 - Editorials/reviews 
•  3  - Intervention program for term baby 
 
43 articles were 
critically 
Figure 2.1: Flow chart of the systematic approach used in the literature review. 

41 
NICU are, for example, heart problems, respiratory distress, infections or birth defects. The 
NICU provides special premature infant care such as intermediate and continuing care 
especially for those born too soon. Every NICU has hospital guidelines and a protocol with 
discharge planning criteria that must be met for all premature infants. The basic discharge 
criterion is that every infant has a recommended more appropriate weight-gain target of 
1.7kg. Premature infants in the NICU are divided according to intensity or level of effective 
action needs: 
2.3.1 Level 1: Basic Newborn Care 
The Level I nursery has a health care provider team which takes care of infants born at 
around 40 weeks and are in a stable condition (for example, their homeostasis is being 
maintained; they can breathe and maintain their body temperature on their own). This nursery 
is also for stable premature infants born between 35 weeks’ to 37 weeks’ gestation and for 
premature infants born earlier than 35 weeks’ gestation or who are sick while waiting to be 
transferred to a nursery if they need a progressive care level. 
2.3.2 Level II: Special Care Nursery 
The level II Special Care Nursery (SCN) has a health care team which takes care of 
premature infants delivered at 32 weeks’ gestation, weighing over 1,500 grams (3.3 pounds). 
These preterm infants might have some health conditions but they  are not so severe that they 
need a higher standard of care. This nursery is also feasible for preterm infants born before 32 
weeks of gestation, or are less than 1,500 g when relocated to a higher care level, infants who 
have just returned to the NICU and are growing and doing very well before they can go home 
and infants who really need technology to help them breathe. Such infants can only remain 
for about 24 hours or less in this kind of nursery; they are moved to a higher level of 
treatment if they need longer breathing assistance. 

42 
2.3.3 Level III: NICU 
Level III: The NICU has a health care team looking after preterm infants born before 32 
weeks of gestation with a weight of less than 1,500 grams, and infants of any age or weight 
who are severely ill and require technology to help them breathe and continue to survive. 
Preferably, preterm babies in this circumstance who might need a level of care are identified 
before birth and are born in a level III nursery and thus do not have to be transferred (moved) 
after birth from a lower nursery. This nursery has a complete range of healthcare 
professionals such as pediatric subspecialists (for instance, doctors specializing in the 
treatment of the heart, lungs, or kidneys of children), highly specialized nursing staff, and 
facilities to care for very ill infants. 
 2.3.4 Level IV: Regional NICU 
This is the uppermost level of infant care. This nursery has a specialist team looking after 
infants who need special surgery for defects, abnormalities, and other problems. This nursery 
has a wide range of healthcare professionals, which include pediatric subspecialists and 
trained nurses, and devices to care for infants who are really sick. 
 
 
2.3.5 Premature Infant 
A premature infant is one born before 37 complete weeks, according to Phillips, Goldstein, 
Hougland (2013). Furthermore, the classification of prematurities such as mild, moderate, 
and severe is based on gestation as follows, according to About Kids Health (2016): 
 i) 
Mild prematureness applies to an infant born within 33 to 36 weeks of gestation, 
and/or is approximately 1500 and 2500 grams in birth weight. 

43 
ii) 
Moderate prematureness relates to an infant born between 28 and 32 weeks of 
gestation, with a birth weight ranging from 1000 to 1500 grams. 
 iii) 
Extreme prematureness refers to an infant born before 28 complete weeks of 
gestational or with a birth weight of less than 1000 grams 
2.3.6 Premature Infant Outcomes 
In general, premature infant outcomes are related to the development of the NICU in terms of 
the technologies and medical treatment provided. Therefore, to introduce KC is to foster an 
understanding of the additional care available for preterm infants in the NICU setting. 
Preterm infant outcomes are usually based on the gestation of the preterm infant when born, 
weight at birth and scope of medical complications.  
However, preterm infant outcomes actually depend on the prematurity of the infant as well, 
the longer the preterm infant has endured in the uterus, the more the organs are developed 
and the readier they are for the challenges of the outside world.  
2.3.7 Patterns of Weight Gain 
Patterns of weight gain are closely monitored for all infants in the NICU setting. Preterm 
infants with slow growth tend to be slower in development according to research studies. 
Weight gain in the premature infant depends on the gestation and prematurity of the infant. A 
few days after birth, the infant will start losing some weight but then regain it after a while. 
According to Davidson, Ladewig & London, (2012) KC helps to increase growth parameters 
among premature infants. Thus, if the infant is born very soon and is also very tiny, its weight 
gain might be as little as about 5 gm a day, whereas the gain in weight could be as high as 20 
gm a day for bigger infants as well as those delivered closer to their due date. Discharge 
policies also include a specific bodyweight criterion prior to discharge, regardless of where 
the premature infant has been treated in the hospital or medical care service. Most hospitals 

44 
have a predetermined weight protocol, which premature infants should meet before they can 
be allowed to return home. Some hospitals evaluate the routine pattern of the premature 
infant's weight gain. If it corresponds to their criteria of a healthy weight gain, the infant may 
be allowed to be discharged. In this study setting, weight gain is monitored three times a 
week. Discharge criteria are a baseline body weight of between 1.7kg to 1.8kg, a good 
sucking reflex, being clinically stable and the mother having the confidence to take care of 
her premature infant (after attending a briefing session on the care of the premature infant: 
personal hygiene, feeding and Cardio Pulmonary Resuscitation (CPR) in the NICU by the 
doctor in charge). 
2.3.8 Length of Hospitalization Stay (LOS) 
Premature infants will often stay longer in the NICU to ensure that they get the right fluid and 
nutritional balance, and are gaining weight. Incubators or special warmers help the premature 
infant to stay warm in the NICU setting. KC has been shown to shorten infants’ LOS. A 
shortened LOS is associated with the benefits of reducing medical treatment bills and 
preventing infection due to the immature, innate, and adaptive immune system of the 
premature infants ( any ref /). 
 
2.3.9 Breastfeeding Rates 
Breast milk is an impeccable nutrition for preterm infants which helps to protect them against 
infection and is associated with gaining weight. However, in order to breastfeed a premature 
infant successfully, the mother-infant dyad requires practical advice and psychological 
support from health care providers such as nurses. The nurse in the NICU setting is supposed 
to help mothers by giving them time, adequate information and support, as well as practical 
knowledge of mother-to-mother breastfeeding groups; Weimers, Svensson, Dumas, Navér., 

45 
& Wahlberg, (2006). The staff must be aware of any written policy based on recent evidence-
based practice to improve the chances of breastfeeding success. The unit should also play a 
critical supporting role to provide accurate input on the management and benefits of 
breastfeeding for the preterm infant. Three research studies examining the effects of KC on 
breastfeeding rates in preterm infants showed positive correlations between these two factors.  
Infants who received KC were much more likely than infants who did not receive this care to 
breastfeed more frequently, more extensively, and for a longer period of time. Breastfeeding 
has been demonstrated to enhance the development and growth of infants while giving 
infants important antibodies to enable them to fight illnesses that might affect them 
throughout the beginning portion of their lives. This is especially important in preterm 
infants, who may already be compromised in their general health, ability to grow and immune 
system functioning. 
2.4 Kangaroo care (KC) 
Immediately after birth, a premature infant requires a significant level of medical attention in 
the NICU for its survival. This separation involves mothers the opportunity to begin the 
process of attachment. KC is one method for reuniting mothers in the NICU with their 
premature infants, and it improves the quality of health outcomes. This method is considered 
an effective and alternative way of caring for the neonate. Dr. Roy and Dr. Martinez first 
introduced the approach at the Maternal and Child Institute in Bogotá, Colombia, in 1979. 
Hence, it is good to encourage KC for the treatment of preterm infants. According to Ahn, 
Lee. & Jin Shin (2010), preterm infants receiving KC showed greater gains in body weight, 
and there was a beneficial effect on maternal attachment in the control group.  
KC is defined as a special holding technique for preterm infants in the NICU which keeps the 
infant in an upright position. The infant wears only a diaper and a head cap and is in a 
position between the mother's breasts (mother's bare chest). The head is turned sideways 

46 
facing either right or left and both knees and elbows are bent to form a frog-like posture. 
During the procedure, the infant’s head and back are covered from below the auricular lobule 
(earlobe) with the mother’s clothing or a tube, ensuring the premature infant is in a safe and 
comfortable condition. 
 2.4.1 Studies on Kangaroo Care 
KC is a unique method or technique of caring for a premature infant in which the infant is 
placed in chest-to-chest, skin-to-skin (ventral surface) contact from the umbilicus to the 
sternum so it is upright against the mother’s ventral surface. The KC method fosters health 
and weight gain, promotes effective thermal control, increases breastfeeding rates, prevents 
infection, and enhances bonding between mother and infant, (Ludingtone-Hoe, et al.,1990, 
2010, 2018; Charpak et al., 2010). 
An observational study done by Singh, Amritanshu., & Mukherjee (2014) in the Department 
of Pediatrics from July 2011 to June 2014 at Katihar Medical College concluded that KC is a 
useful and realistic tool for LBW infants. Further research was carried out by the Mahboobeh 
et al. (2016) on the level of KC application and its barriers from the perspective of nurses 
working in NICUs in Isfahan, Iran. Two important and basic factors of KC, including the 
infant’s age at which KC was initiated and its duration during 24 hours, were investigated. 
The findings revealed that KC was initiated at the age of 8 days among preterm infants with a 
mean weight of 1510 g and gestational age of 32 weeks, with an average period of 32 min 
once daily. According to Ahn, Lee, & Jin Shin (2010-), a South Korean study of over 20 pairs 
of mothers and infants of less than 36 weeks, who had ten sessions of 60 minutes KC for 
three weeks, demonstrated the beneficial effects of KC on Korean preterm infants’ growth 
and their mothers’ depression. 

47 
From another study by Suman, Rekha & Ruchi (2008) it was reported that KC was acceptable 
to most mothers and families. Most mothers reported happiness (71.5%), they performed KC 
effectively (75.5%), without assistance (80.39%), and believed their baby enjoyed KC (65%). 
The KC infants received KC for a cumulative mean of 33.78 + 15.12 days or 13.5 hours a 
day. However, there were a few mothers who had provided KC for almost 24 hours at home.  
In relation to this, Parmar, Kumar, Kaur, Parmar, Kaur, & Basu, (2009) conducted an 
assessment to identify the acceptability of KC to mothers, relatives, and healthcare 
professionals (no definition of acceptability was present). KC was provided by mother 
(n=60), father (n=40), mother-in - law (n=32) or close relative (n=21) to infants (n=135) with 
a mean birth weight of 1460g. A pre-specified questionnaire containing 15 questions 
(questions presented in the paper) and using a Likert scale was used to interview the KC 
providers. For the analysis, data were stratified into two subgroups (mother or other 
provider). Almost all mothers (96%) said they comprehended the KC technique very well, 
although 12 percent said they needed an extra training course. Even though half of the 
mothers were initially nervous about KC, nearly all (98%) managed to keep their baby in the 
KC position and claimed it was much more comfortable and less stressful than being away 
from their baby. Overall, 96% of mothers found increased confidence and emotions with KC; 
94% believed they brought a positive commitment to the treatment of their infant, and 98% 
felt encouraged to continue with KC at home. The negative aspects of KC  identified by 
mothers were that it was associated with daily living tasks like bathing (18%) and privacy 
issues (6%). KC was supported by a high proportion of other KC providers (husbands, 
82.5%; mothers-in-law, 84%; other family members, 81%). Although the data from the 
mothers are presented in some detail in the paper, results from other KC providers are sparse. 
It would have been valuable to present comparative data for all groups of providers to 

48 
investigate whether differences in attitudes, beliefs and perceptions about KC existed 
between providers.  
A study among healthcare workers by Parmar et al., (2009) involved 14 doctors and 16 
nurses who were interviewed using a 17-items questionnaire.  The data from both groups 
were pooled for analysis due to the similarity of their responses. Most healthcare workers 
(94%) believed KC to be a useful care technique for LBW infants, with a similar proportion 
(93%) believing it saved resources through a reduction in the use of heaters. However, while 
79% reported that implementation of KC resulted in no increase in their workload, 18% were 
unsure. Perceived maternal benefits of KC were improved mood, increased confidence and 
better lactation (94%, 97%, 80%, respectively). Perceptions of premature infant benefits were 
more mixed, with 57% believing KC had a positive effect (e.g. fewer episodes of crying), 
while 37% were unsure and 7% perceived no effect. However, all healthcare workers agreed 
that premature infants who had prolonged episodes of KC gained weight more rapidly, had 
fewer infections, and were discharged early. 
In addition, the attitudes of nurses working in the NICU were assessed using an 11-items 
questionnaire. All nurses believed KC to be a useful method of care for LBW infants which 
should be introduced in other hospitals. Over one third (33%) of nurses believed that KC had 
increased their workload and that it was taxing to implement it in the NICU, while 44% 
believed the supervision of KC interfered with the care of other neonates in the NICU. 
However, over half (56%) of the nurses perceived there to be no associated workload 
increase. All nurses believed that KC promoted bonding between mothers and premature 
infants, 78% thought that KC increased maternal lactation, and 78% perceived mothers to be 
happy with this method of care. Therefore, this shows that KC has benefits for both mothers 
and premature infants in increased clinical performance, breastfeeding rates and bonding. It 
increases weight gain, decreases hospital stay, increases and prolongs breastfeeding 

49 
prevalence, even though the research found that barriers to KC for premature infants may 
comprise a lack of evidence-based intervention practice for nursing staff, shortage of time, 
physical or psychological ill-health and inappropriate settings for mothers. Therefore, 
providing continuing education and support by the management will assist neonatal nurses to 
enhance their knowledge and empower mothers to carry out KC. Other than that, mothers 
also need input and encouragement to begin KC. In addition, KC education and guidance 
provided to neonatal nurses on the proper methods and procedures of KC treatment will 
increase their awareness and confidence to communicate information about the value of KC 
and share it on the basis of experience with the premature mothers in the NICU. Therefore, 
nurses can recognise issues and address maternal obstacles regarding the NICU 's adoption of 
KC and can continue until the infant is allowed to return home. 
From January to April 2016, Almutairi & Ludington-Hoe (2016) conducted a cross-sectional 
study on KC knowledge, attitude and practice at three teaching hospitals in Nepal. The survey 
was carried out among doctors and nurses who were working in the Gynaecology, Neonatal, 
Paediatrics and Obstetrics wards using a pre-test questionnaire. The study revealed that the 
respondent rate for the survey was 65% for doctors and 95.3% for nurses. The survey showed 
that both doctors and nurses had knowledge about KC, but 37.7% of physicians and 48.8% of 
nurses felt KC was mainly used for premature infants with LBW (<2500grams) (p<0.013). 
However, just a quarter of the physicians and half of the nurses accepted that KC is routinely 
practiced in their ward (p<0.016), while 22.2% of respondents said that the key reason for not 
continually performing KC in their unit could be a lack of skill and knowledge. Thus, the 
knowledge and attitude of the majority of doctors and nurses regarding KC was actually 
good, but their practice was not uniform. 
According to Almutairi & Ludington-Hoe (2016), KC is performed routinely in less than 20 
percent of the 996 NICUs in the United States, and this is mainly because of the inadequate 

50 
knowledge and skills of the nurses. Education and training enhance knowledge and skills 
acquisition, however, the consequences of a KC certification program for the knowledge and 
confidence of nurses were unexplained. Therefore, Almutairi & Ludington-Hoe (2016) 
conducted research on the impact of KC training on the knowledge and skills of nurses in the 
United States. A pretest - posttest quasi-experimental design was used for this study. During a 
2.5-day course on KC evidence and skills, the Kangaroo Care Knowledge and Skills 
Confidence Tool was distributed to 68 registered nurses.  The study showed that the mean 
score for the nursing staff in posttest knowledge was (M= 88.54, SD= 6.13), significantly 
higher than their mean pretest score (M= 78.7, SD= 8.30), t[54]= -9.1, p<0.000), as was the 
highest confidence score for skills (pretest M= 32.06, SD= 3.49; posthest M= 26.80, SD= 
5.22), t[53]= -8.459, p<0.000). The knowledge and skills of the nurses in relation to KC in 
the United States was significantly improved after continuing education, indicating the need 
for continuing education in this specific field. 
Admission to a neonatal intensive care unit for a newborn infant usually indicates that the 
mother is physically separated from her infant. Therefore, KC is a neonatal care technique 
which continues to support the role of the mother as the biological parent and probably helps 
to reduce or eliminate the barrier to the unification of the mother–infant dyad. A retrospective 
design survey on 23 Swedish mothers' experience of continuous KC was carried out by 
Blomqvist & Nyqvist (2011) with the aim of examining the personal experiences of mothers 
with first babies receiving prolonged KC from birth at a Swedish neonatal intensive care unit 
until they were discharged. The relevant infant restrospective data was acquired from the 
medical records of the infants. A survey with a questionnaire on child care and KC was 
specifically designed for this study. Results for mothers with infants born at 31-41 weeks of 
gestational age, birth weight ranging from 1715-3700 g, showed strong acceptance of 
providing continuous KC during their infant’s stay in the NICU. The evaluations of this 

51 
method by the mothers were predominantly positive. The negative feedback indicated a lack 
of knowledge about the technique being applied in practice. Mothers were well able to utilize 
this care approach if they had the help and support they required. The research further 
proposed that mothers whose infants are enrolled in the NICU in settings similar in 
appearance to those in the study must also be given the opportunity to be physically present 
and to provide their infants with KC, to the extent that they are able and willing to do so, as 
required by the diagnosis and treatment of their infant's health. 
2.4.2 Kangaroo Care Studies in Proper Positioning of Head, Neck, And Body 
Comparative research on the impact of supine and prone posture on cardiovascular and 
respiratory parameters and temperature regulation in preterm infants was performed by 
Heimann et al., (2010). This study controversially discussed and compared the influence of 
thermal regulation and cardiorespiratory parameters in relation to the standard positioning of 
premature infants: skin to skin care (SSC), prone position (PP) and supine position (SP) in the 
daily care of premature infants. The researchers compared SSC to PP, the position indicated 
for preterm infants, and SP, the most secure position for term infants. Among 18 of the 
premature infant’s is breathing  spontaneous; [median gestational 28 weeks (24–32); 
chronological age 36 days (7–64) and weight 1,543g (750–2,100)], heart and respiratory rate, 
breathing patterns, episodes of desaturation (< 85%, < 88% and < 80 %), oxygen saturation 
and rectal temperature were analyzed using polygraphy (Alice 3 ® and 3.5 ®) in a 6-hour 
measuring cycle of three continual series (120 min each in SP, SSC and PP) and compared 
(Wilcoxon test). The results showed no impact on thermal regulation and cardiorespiratory 
parameters. Other than that, during SSC, they found no significant increase in the number of 
apneic attacks and bradycardic episodes and no physiological difference in parameters: 
breathing pattern, oxygen saturation, respiratory rate, and desaturation compared to SP and 
PP. Episodes of désaturation were <85 but ≧80 and <80% more common in SP than in PP 

52 
(p<0.0421 and p< 0.0319). In SSC and PP the heart rate increased compared with SP (154.86 
bpm, SD 11.55, and 153.33 bpm, SD 15.95 vs. 150.25 bpm, SD 14.64; p< 0.0013 and p = 
0.0346). The temperature level during SSC and PP was not significantly higher than in SP 
except that there was an increase between the start and the end of the 6-hour measuring phase 
(37.05°C, SD 0.2 vs. 37.30°C, SD 0.3; p< 0.0436). Consequently, the findings indicated that 
there were no significant SSC-mediated improvements in the quantity and consistency of 
desaturation and skin temperature in preterm infants compared with PP. The three aspects of 
safety with KC are: proper positioning, preventing falls and KC sleep. In proper positioning, 
as in the above study, whenever KC is being carried out, the premature infant should be 
elevated away from the horizontal to facilitate respiratory expansion (Bohnhort, 2010; 
Heinmannet al., 2010). The preterm infant’s hands should be at the level of its shoulder so 
that it can raise its head and move it to avoid asphyxiation. Many studies on infant safety 
have been conducted, the most recent study being conducted by Kristoffersen, Stoen, Frances 
Hansen, Wilhelmsen & Bergseng (2016). The prospective quasi-experimental cohort study 
was conducted at three Norwegian research sites: at the NICUs and maternity wards. In 
accordance with hospital guidelines, 90 preterm infants (KC = 47; incubator = 43) who were 
delivered vaginally with a gestation of 32 weeks/0 days to 34 weeks/6 days were provided 
KC. For all infants at or older than 32 weeks one of the hospitals practiced SSC immediately 
after birth; the other two hospitals' prematures were taken to an incubator immediately after 
birth and the mothers visited every two hours. In the first hour after birth, both infants 
received their first feed by gavage or syringe. 
2.4.3 Kangaroo Care Studies and Weight Gain  
A prospective case-control study conducted by Biswas, Malpani & Ekka (2016) on newborns 
weighing less than 1.5kg in a tertiary level NICU at a teaching hospital in Central India, 

53 
found that the KC technique produced a daily weight gain of on average (23.99 vs.15.58g, 
p<0.01). A prospective study conducted on Kangaroo care (KC) showed it reduced neonatal 
deaths and neonatal sepsis, and enhanced growth outcomes in preterm infants. The study 
contrasted the efficacy of infant care using KC in the ward with the efficacy of infant care in 
Intermediate Intensive Care (IIC) in stable preterm infants (birth weight < 1100 g) to 
stimulate the growth velocity up to term age adjustment. When they reached a weight of 1150 
g, one hundred and forty-one infants were randomized to KC in the ward (n=71) or IIC 
(n=70). Infants in the KC group were transferred directly after randomization to the Kangaroo 
ward care (KWC) and those in the IIC category were cared for in the IIC until they reached a 
weight of 1250 g when they were relocated to the KWC. In both groups the average weight 
gains as well as weight, length, and head circumference were comparable at term corrected 
age. In the KWC group, there was a significant decline in IIC post-randomization stay and a 
rise in weight gain prior to discharge. The frequency of apnea within the IIC group was 
significantly increased. Early KWC is just as effective as IIC in enhancing the growth 
outcomes of stable preterm infants (birth weight < 1100 g) at term gestation. Sharma, Murki 
& Pratap (2016) reported that KC had a positive and healthy effect on maternal care with 
stable premature infants weighing 1150g without adverse effects. Suman et al. (2008), 
however, found a significantly higher weight gain in the KC group compared to other studies, 
while Ramanathan et al. (2001) also reported a greater weight gain in the KC group during 
the first week of life than those in the control group (15,9±4,5 vs. 10,6±4,5 g / day). 
Ghavane, Murki, Subramanian, Gaddam, Kandraju, & Thumalla, (2012) conducted an RCT 
study at one of the Hyderabad hospitals. The study compared the effect of KC and 
conventional care in a neonatal unit on growth and breastfeeding among VLBW infants at a 
corrected age of 40 weeks. One hundred and forty birth-weight neonates < 1500 g were 
randomized. The study found that the average weight gain (g / kg / day) from time of 

54 
randomization  to term age outcomes revealed that the mean score for both groups was 
similar, during randomization with birth weight, age in days and weight. The average post-
randomization weight gain (g / kg / day) (23.3 ± 8.7 g vs. 22.64 ± 9.1 g, p > 0.67) and the 
breastfeeding rate (85.9% vs. 87.0%) were comparable in terms of age. There was no 
significant difference in weight gain (g / kg / day) between the two groups from 
randomisation to hospital discharge (15.64 g vs 18.01 g, p<0.12). Equally distributed were 
morbidities and mortality, such as apnoea, hypothermia, hypoglycemia, sepsis, and length of 
hospital stay. On average, the KC group actually saved 11.5 days of intermediate treatment. 
Therefore, Ghavane et al. (2012) supported KC as an effective technique to be carried out in 
the neonatal unit, without any rise in morbidity or mortality among stable infants with very 
low birth weight (VLBW). Other recent studies include a mixed-methods survey undertaken 
in Uganda. WHO (2015) states that KC “should commence as early as newborns are 
clinically stable”, while most deaths occur in unhealthy neonates. Therefore, the survey 
determined the rate of admission for neonates fulfilling the recommended instability criteria, 
evaluated the feasibility of providing KC to unstable infants, and examined the suitability of 
this approach for parents and healthcare professionals at the Jinja Regional Referral Hospital 
in Uganda.  
In this study, the researcher included a sample of neonates that met the predetermined criteria 
for instability. The mothers were instructed to provide KC as early as possible, and the 
median duration of KC was measured for each episode every day. A semi-structured 
interview was carried out with parent-infant dyads and healthcare providers to explore the 
acceptability of KC. The researchers transcribed the original data, birth weight, chronological 
age, and clinical treatments, which were obtained from hospital records, and evaluated the 
percentage of clinically unstable neonates, defined in the first 48 hours as a need for medical 
care, and then analyzed the data using the thematic content approach. A total of 254 neonates 

55 
were included in the study, 10 samples in the feasibility sub-study and another 20 samples in 
the acceptability sub-study. The median length varied from 115 to 134 minutes for each KC 
episode. The median ranged from 4.5 to 9.7 hours in terms of daily duration. The results 
indicated that 75% of all those interviewed personally felt that KC could be used in neonates 
who were undergoing other medical treatment at the same time. Obstacles, however, included 
a lack of infrastructure (beds/room, monitoring devices), privacy concerns, insufficient 
training, and mothers (not?) being inspired to fully commit to KC. Recommendations usually 
involved counseling sessions for clients/peers, the working population, parents, and 
community. The destabilization conditions were solved easily as well, as 89% of the neonates 
had been identified as unstable in the audit. The median individual time for KC ranged from 
115 to 134 minutes. The median daily duration was from 4.5 to 9.7 hours. Over 75 % of 
interviewees felt that KC could be used with neonates receiving other medical treatment at 
the same time. A reliable evidence-based approach remains necessary to continuously 
describe the stability requirements for KC in order to enhance the quality of neonatal care. 
Therefore, at Jinja Hospital in Uganda, the use of KC for unhealthy neonates weighing about 
2000g was considered practical and acceptable.  
2.4.3 Kangaroo Care Studies and Length of Hospitalization Stays (LOS) 
A study on KC and LOS conducted by Biswas, Malpani & Ekka (2016) found that duration 
of stay was shorter among infants using the KC technique. This study revealed that infants in 
the KC group were released earlier than in the control groups (11.46±4.32 vs. 17.68±8.64 
days) (p<0.05). Besides that, Ramanathan et al. (2008) also reported a decrease in length of 
hospitalization stay (16.6 vs. 20.7) in a KC group of premature infants. Similar results were 
found in various other studies about the shorter length of hospital stays (Hann, Malan, 
Kronson, Bergman & Huskisson, 1999; Charpak, Ruiz-Peláez, Charpak & Rey-Martinez, 
(1994). 

56 
The randomized controlled trial conducted by Rao and colleagues (2008) included time to 
discharge as one of the outcome measures in the study. Preterm infants were discharged when 
they showed a weight gain/day of (KC 23.99g vs. conventional care 15.58g; p<0.001), even 
though there was a difference between the time allowed for discharge between groups (KC 
12.78 days versus conventional care 12.86 days; p>0.93).  
2.4.4 Kangaroo Care Studies and Breastfeeding 
An observational study carried out by Singh, Amritanshu & Mukherjee (2014) in the 
Department of Community Medicine at Katihar Medical College's Department of Pediatrics, 
among 100 infants with weights ranging from 1650 grams to 2000 grams, concluded that 
KC's other benefits are that it encourages exclusive breastfeeding and enhances the 
confidence of mothers in holding their small infants. 
A further research on the beneficial impact of KC on breastfeeding was also conducted in 
Central India from November 2012 to September 2013 over an 11-month period. The 
researchers reported that breastfeeding was established in the KC group at 68.5%, as well as 
in the discharge control group at 34.2%, favoring the KC group (p<0.05). In addition to this, 
it was found that exclusive breastfeeding was more prevalent in the KC group than in the 
control group. The proportion of breastfeeding preterm infants was greater at 40 weeks (KC: 
94.4%; control: 72.0% p<0.002), three months (KC: 89.6%; control: 62.2% p<0.002), and six 
months (KC: 84.6%; control: 55.5% p<0.006) post-conception age, the difference being 
statistically significant. 
 
  Breastfeeding Policy (NBP) in Malaysia suggests exclusive breastfeeding for the first six 
months and then continued breastfeeding for up to two years. Several programs to encourage 
breastfeeding have been introduced in this country since the 1990s. In response to assess the 
frequency of breastfeeding practice, a maximum of 2167 mothers or caregivers of children 

57 
under the age of 2 years were recruited in the 2006 Third National Health and Morbidity 
Survey (NHMS III), which represented 804,480 of the approximate total number of children 
under the age of 2 years in Malaysia. The participants were asked whether the infant was 
provided with various types of liquid or solid food at any point during the corresponding 24-
hour period. The average prevalence of breastfeeding for infants under 12 months of age was 
94.7% (CI: 93.0-95.9). The estimated prevalence of exclusive breastfeeding below 6 months 
was 14.5% (CI: 11.7-17.9). Timely initiation prevalence was 63.7% (CI: 61.4-65.9), and 
continued breastfeeding prevalence was 37.4% for up to two years (CI: 32.9-42.2). The 
findings indicated that the programs implemented in the last 10 years were beneficial in 
enhancing the prevalence of continuous breastfeeding, immediate commencement of 
breastfeeding and sustained breastfeeding for up to two years. However, the challenge is to 
strengthen the exclusive practice of breastfeeding, and long-term community-based initiatives 
need to be carried out in conjunction with the current health care system, with an emphasis on 
limiting the use of water and formula for infants, particularly in the first six months. 
Hake-Brooks & Anderson (2008) conducted a randomized control trial (RCT) to assess KC's 
effect on breastfeeding success in postpartum to 18-month-old mother-infant dyads. The 
study showed that KC was freely available to the preterm infant and was not limited in any 
way. The mean daily level of KC contact was 4.47 hours. However, a key weakness was the 
lack of a description of the method of allocation of concealment, and infants were treated 
routinely in the control group. A total of 66 mother and preterm infant dyads were included in 
the study sample (birth weight of 1,300-3000 g), of those who had declared their intention to 
breastfeed. The KC mother-infant dyads were breastfeeding significantly longer than the 
conventional dyads (KC 5.08 months versus conventional 2.05 months; p<0.003) 
respectively. KC mother-infant dyads also breastfed more exclusively (p<0.047). The KC 
dyads were breastfeeding with full exclusivity (100: breast milk, breastfeeding status index 

58 
level 1 or 2) at discharge and at follow up at 1.5, 3, and 6 months. The broad range of birth 
weights of the study sample (up to 3000g), long periods of daily KC and small study sample 
limit the generalizeability of the study’s findings, particularly with regards to preterm infants, 
and makes comparison with other research more difficult. However, what is apparent here is 
an association between KC and better breastfeeding outcomes for the premature infant, which 
should not be overlooked. 
Another RCT study by Suman, Udani & Nanavati (2008) found that 98% of preterm infants 
who obtained KC for 13.5 hours a day were exclusively breastfed at the postpartum age of 40 
weeks, in contrast to 76% of non-KC premature infants. The previously described 
multinational RCT of Cattaneo et al. (1998) among low birth weight infants included rates of 
exclusive breastfeeding at discharge and daily mean weight gain in infants as two of the 
outcome measures. Results from this study showed that rates of exclusive breastfeeding at 
discharge were slightly higher across all three countries e.g. Ethiopia, Indonesia, and Mexico, 
in premature infants who received KC, compared with those randomized to conventional care 
(88% vs. 70%). Even Mexico's findings showed a significant difference between the two 
groups. (KC vs. conventional care: 80% vs. 16%, p-value is not provided).  
A prospective national cohort survey on exclusive breastfeeding factors among preterm 
infants in the NICU in Denmark was conducted by Ragnhild et al  (2014). The comparison 
study was performed between September 2009 and December 2011, at a gestational age of 
between 24 and 36 weeks, with 1,221 mothers and their premature infants (1,488). The study 
was based on a survey and formal interviews over the telephone. The findings found that 68% 
of preterm infants had been breastfed entirely, 17% were partially breastfed and 15% were 
not breastfed at discharge. Some of the infants were fed with expressed breast milk from 
bottles. As a result, 77% had been exclusively breastfed, 15% were partially breastfed and 8 
percent had essentially not been breastfed after discharge respectively. The exclusive 

59 
breastfeeding rate at discharge changed significantly amongst responding groups between 
53% to 83% (p < 0.01). The rate for use of a nipple shield was 35% to 67% (p < 0.01), while 
the rate for use of a pacifier was from 60% to 100% (p < 0.01), and the use of the test-
weighing from 0% to 87% (p > 0.01). When counting one infant per mother, 76% of infants 
whose weight was measured at most breastfeeding sessions were exclusively breastfed at 
discharge compared to 69% of infants whose weight was not measured at most breastfeeding 
sessions (p<0.02). 
The corresponding proportions were measured one month after discharge and showed 59% 
and 57% respectively, with no statistically significant difference. From this survey, limiting 
the use of a pacifier and test-weighing seemed to have an effect on exclusive breastfeeding at 
discharge OR 0.6 (95% CI 0.4–0.8) and 0.4 (95% CI 0.3–0.6) respectively. The clinical 
practices associated with ineffective breastfeeding duration, started with breast milk 
expression at 12–24 hours (OR 1.6 (95% CI 1.0–2.4) and 24–48 hours (OR 1.8 (95% CI 1.0–
3.1)) vs. 6 hours postpartum, and the use of nipple shields (OR 1.4 (95% CI 1.1–1.9). The 
survey revealed that early expressing of breast milk, before 12 hours postpartum, raised 
breastfeeding rates, and it indicated that the use of nipple shields should be restricted. Test-
weighing and limiting the use of a pacifier may enhance the establishment of exclusive 
breastfeeding. However it should be noted most of the above studies are conducted more than 
five years ago.  
Further research is thus necessary on how to encourage mothers to start exclusive 
breastfeeding as early as possible and continue exclusively after discharge. According to The 
Academy of Pediatrics, (2013) practicing KC for an uninterrupted 60 minutes during the first 
12 weeks and continuously for the first 3 months of corrected age will naturally encourage 
the mother to not cease exclusive breastfeeding at least until 3 months of corrected age. 
 

60 
2.4.5 Kangaroo Care Studies on Perception, Knowledge, Perceived Barriers and Stress  
Engler et al. (2002) carried out descriptive research to evaluate nurses' knowledge and skills 
regarding perceived barriers to and perceptions of KC. A non-validated questionnaire was 
sent to 1,133 nurse managers at all hospitals considered to provide neonatal intensive care 
services in the United States, asking that the questionnaire be completed by the nurse most 
familiar with KC. The response rate was 59%. A total of 82% of the respondents reported that 
they implemented KC, and they were equally concerned about this technique of care. 
Generally, those nurses who performed KC in the NICU usually had more favorable views of 
KC than those who did not perform KC.  
The major barriers to implementing KC were identified as safety concerns and an 
unwillingness among other healthcare staff, mothers, or other relatives to engage in KC, as 
misinterpretations about KC were evident, with 40% of nurses assuming that low gestation or 
low preterm weight were contraindications to KC. The use of closed questions was a 
limitation of the questionnaire as it did not allow participants to freely express their views. 
The request by the study investigator that the questionnaire be completed by the nurse who 
was most familiar with KC opens up the potential for bias, since these nurses were likely to 
have the greatest levels of knowledge about KC. The response rate was only moderate.  In the 
1980s, as advances in medical technology enabled health care providers to keep premature 
infants alive and to save increasing numbers of preemies, the number of premature infants 
who entered the NICU grew dramatically. Accommodating a larger number of infants in the 
open bay design also exposed every infant to all of the noxious elements of the NICU 
environment. Therefore, the staff realized that the NICU was creating a lot of stress for the 
infants and that infants were losing sleep (Gottfried,1985). Therefore, in terms of survival, 
premature infants were found to have multiple long term sequelae related to their prematurity 
and residence in the busy, developmentally inappropriate NICU.  In the late 1990s, 

61 
researchers showed that premature infants do much better and have a faster recovery in 
smaller rooms because smaller rooms minimize many of the deleterious effects of the NICU 
environment (Fajardo, et al.,1994). Generally, KC improves in smaller room environments as 
it is an individualized microenvironment in which the infant usually goes to sleep 
(Ludington-Hoe et al.,2006) 
a) Kangaroo Care Studies on Perception 
Perceptions of healthcare workers were assessed via a self-administered questionnaire, again 
validated by experts (response rate = 73.3%). Perceptions of KC were positive and included 
the belief that KC made the premature infant feel secure (21.2%) and made the mother feel 
more confident (45.6%) and satisfied (72.7%). The majority (60.1%) of healthcare workers 
felt that KC should be promoted more widely both in their own and other hospitals.  
Nirmala et al. (2006) carried out a study to assess KC perceptions among healthcare staff, and 
mothers with neonates with a birth weight range of 1070g-2460 g. KC expectations were 
assessed in a survey of 45 mothers over a 6-week period (attrition rate = 8%) and 33 health-
care staff. A checklist used for the interviews with mothers was previously checked by nine 
experts but this was not included in the report and the questions were not summarized. No 
feedback is available about interviewees or their interaction with participants in the study. All 
mothers, however, felt that KC had improved attachment and helped them feel useful, 
contented, and grateful to be contributing to their infant's care; 86.7 percent reported no 
difficulties providing KC to their infants, and 30% believed that their milk production had 
now increased. Nonetheless, 88% said they planned to start with KC at home. Evalotte & 
Gene (2015) conducted a study of three high-tech NICUs in Sweden, two level II NICUs, and 
one level III NICU mostly on the views of nurses. For preterm infants between 32 to 36 
weeks, the study defined KC as a few hours a day or almost continuous KC. A qualitative 

62 
study design was used to illustrate the views of the nurses about continuous KC. The study 
comprised of 129 participants with 98.4% of the participants female, had a mean age of 42 
(SD+11) years, and were employed part-time (59.2%). Most participants had been employed 
in the study setting for several years (< 1 year, 12%; 1-5 years, 28%; 6-10 years, 15%; > 10, 
45%). This study contained three categories of licensed pediatric nurse: intensive care nurses, 
n = 25 (4-4.5 years of University); practical nurses, n = 57 (three years of High School); and 
registered nurses, n = 47 (three years of University). The findings showed that, although 
nurses were aware of continuous KMC  24/7 days a week for mother-infant dyads, it was not 
routinely practiced in their unit. The nurses explained that, if it were practiced continuously, 
it would end up a burden to the nurses and to the mother herself. The nurses were afraid they 
would not be able to provide adequate care to the mother-infant dyads. The nurses were also 
concerned about the mother’s health due to the too high demands of KC. Therefore, the 
nurses explained that, if the goal was to implement KC, a new nursing policy must be 
provided before implementation in order for it to be respected and considered by both parties 
and to be beneficial for nurses, mothers and infants. Nonetheless, for each of the premature 
infants in the experimental group, the researchers would introduce KC for just 1 hour a day, 
or 4 to 5 hours a week. Mothers were advised to start KC until the infant reached 3 months 
old of corrected age. The Pediatric Academy, (2013) recommends that KC be performed as 
often as feasible during the postpartum period, for the first three months of life. 
 
 
b) Kangaroo Care Studies on Knowledge 
Flynn and Leahy-Warren, (2010) published a report on the views and knowledge of neonatal 
nurses about KC in Ireland. The study found that fifty-six neonatal nurses (90.3%) agreed 

63 
that the kangaroo care method was a secure approach to the stable development of premature 
infants, accepting its advantages for both infants and parents. Overall level of knowledge of 
the KC method among neonatal nurses varied from good to excellent and the lowest score 
was 35/51. The analysis revealed that nurses were not convinced about KC with intubated 
infants, who usually require blood pressure support, umbilical lines and phototherapy. This 
indicates the need to provide KC training to encourage the development of more positive 
thoughts and to increase staff information regarding possible adverse effects on infants. 
c) Kangaroo Care Studies on Practice 
Leonard et al. (2008) conducted a phenomenological study to determine the expectations of 
parents who performed KC with their premature infants. Data were collected through 
interview sessions, observation, and writing. Six parents (four mothers and two fathers) had 
in-depth interviews, and the data were analyzed using thematic analysis. Eight themes 
emerged from the data collected: (1) unpredictable, unexpected and unsure; (2) birth 
experience; depression and obstacles; (3) personal connection; (4) modifications, rights and 
responsibilities; (5) evaluating achievement; (6) encouraging and supporting networks; (7) 
existing-in difficulties; and (8) willing to live outside of the hospital with infants. The 
mothers reported feeling powerless after the birth of their premature infant and had been 
unable to hold their infant, which had interfered with the bonding process. They also found it 
difficult to put their trust in healthcare workers. While in the NICU, at first, the mothers felt 
completely incompetent. KC facilitated bonding and increased parental confidence despite 
early anxieties, though KC providers demonstrated the effort and responsibility associated 
with this process of care. Parents knew that their premature infant's effective care was mainly 
determined by the weight gain of their infant, and expressed feelings of pride when their 
infant responded to KC  practice. 

64 
d)  Kangaroo Care Studies on Barriers 
Mahboobeh et al.(2016) reported that 60% of nurses in their survey stated that the main 
barrier to KC was the inconsistent attendance of mothers in the ward. Other mother-related 
barriers were that mothers were also afraid of touching their premature infant, were afraid of 
ward devices or had twin or triple infants. The mean (SD) score for institutional barriers was 
28.9 (13.4). This domain had three sub-domains including educational barriers, personal 
barriers, and equipment and space barriers. In the domain of educational barriers, the most 
important KC barrier was parents’ inadequate education and understanding about the 
importance of KC. In the domain of personal barriers, the need for a physician's order for KC 
was the most important.                       
To identify perceived sources of resistance to the implementation of KC among healthcare 
professionals, mothers or other family members, Charpak and Ruiz-Pelaez (2001) conducted 
an e-mail survey using an open-ended questionnaire. The survey involved the co-ordinators 
of functioning KC programs in 15 developing countries. The researchers also made 15 site 
visits to institutions that had reported problems in establishing these programs. Four broad 
determinants for resistance were identified: (1) KC component against which resistance 
emerged (i.e. position, nutrition, early discharge, the intervention as a whole); (2) source of 
resistance (i.e. mother, other family member, healthcare professional); (3) concern or reason 
for this resistance and (4) frequency and location of a particular resistance factor. 
 
 
i) Sources of Barriers 
The same sources of resistance were experienced during the implementation of many KC 
programs. Sources of resistance among healthcare professionals included the almost universal 

65 
perception that KC is a substandard form of treatment, an alternative for poor men in 
developing countries, and a widely held belief that KC presents an extra workload. 
Resistance among both mothers and healthcare professionals was related to cultural 
perceptions that KC was 'unfit' or 'uncommon' as it was between a naked infant and the KC 
provider. However, this belief was only evident in societies where the physical expression of 
feelings is considered unacceptable and public expression of emotion inappropriate. There 
was also widespread resistance (albeit of varying strength) among both mothers and 
healthcare professionals pertaining to privacy during KC, with both groups expressing 
discomfort when mothers were exposed to unknown people while they were learning the KC 
method.  Other sources of resistance included reluctance to promote the wearing of bonnets 
and caps by infants during KC, experienced primarily by healthcare providers in low-income 
countries with a warm climate; the refusal of husbands or other family members (e.g. 
mothers-in-law) to grant permission for the mother to provide KC; and reluctance among 
mothers and healthcare professionals to allow fathers to provide KC. 
ii) Recommendations to Overcome Barriers 
Charpak and Ruiz-Pelaez (2001) included recommendations for helping to overcome sources 
of resistance to KC. They recommended that, prior to the implementation of a KC program, 
an open discussion be held with health care professionals about the broad evidence base for 
KC, and examples presented illustrating its use in developed countries. It should be 
highlighted to healthcare professionals that training mothers well in the provision of KC will 
ease nurses’ workload and that KC is an investment that is well worthwhile in terms of the 
broad direct and indirect benefits offered. Culturally rooted resistance should be addressed at 
the local level, for example, by identifying culturally-appropriate devices to assist mothers or 
other KC providers to carry out this method of care. It is generally accepted that training and 
education on KC is best conducted in an open group setting which allows for interaction in a 

66 
supportive and stimulating environment; however, it is also acknowledged that this situation 
provides little privacy and may be intimidating for some mothers, particular where KC 
providers are of mixed gender (e.g. mothers and fathers). The provision of screens or private 
rooms is recommended, and this can help to protect modesty, while some mothers feel more 
comfortable interacting with female healthcare workers.  
e)  Kangaroo Care Studies On Parental and Relationship Related Stress  
The effects of KC on both preterm infants and their mothers in South Korea were observed 
by Ahn., Lee, & Shin, (2010). The findings showed that all mothers had moderate levels of 
anxiety before KC was introduced but, after three weeks, scores for anxiety decreased in both 
groups. KC mothers displayed higher bonding levels than control mothers (p < 0.003). KC 
gave confidence to mothers in caring for their preterm infants through the experience of 
holding their premature infants regardless of their health status.  
The findings of this study could be transferable to similar settings in other countries, although 
it is not possible to give an opinion on the applicability of the findings, specifically to infants 
with a birth weight < 2000 g, because the birth weight of the preterm infants is not known. 
Cho et al  (2016) conducted a quasi-experimental design study with a nonequivalent control 
group. A pretest and posttest were used to investigate the effects of KC on the physiological 
response of preterm infants>33 weeks of corrected gestation hospitalized , maternal-infant 
attachment, and maternal stress from May 2011 to October 2011. For each experimental and 
control group, twenty infants were recruited equally. KC was conducted as an intervention 
for 30 minutes each session, for a total of 10 times, three times a week. The findings showed 
that the parameters in the post KC: respiratory rate were significantly different between the 
two groups (F=5.701, p<.020), although maternal-infancy attachment scores in the 
experimental group were increased after the test (F=25.881, p<.001), and mother stress scores 
(F=47.320, p<.01) were decreased in the control group. Hence, KC was shown to have 

67 
positive significant effects on physiological functions and normalized respiration rates, 
enhanced maternal-infant attachment and reduced maternal stress. Other than that, in order to 
stabilize the physiological functions of the preterm infant, KC can be one of the most 
successful nursing intervention strategies in the neonatal intensive care unit for the treatment 
of preterm infants.  
 
 
f) Studies on the effectiveness of a Structured Teaching Programme  
    (STP) on kangaroo care among mothers. 
 
A study in Gujarat conducted by Gayathri, Sampada, Hiral, Manisha, Silvi & Yashvanthi 
(2016) assessed knowledge regarding KC among mothers of LBW babies at the Hospital in 
Rajkot District, Gujarat. A pre-experimental design with one group pretest was used. Thirty 
mothers were selected using the convenient sampling technique. A structured knowledge 
questionnaire was used to administer the pre-test, which was followed by a structured 
teaching programme,. The post-test was administered after seven days using the same 
structured knowledge questionnaire to test the effect of the STP on KC among mothers with 
low birth weight infants. The questionnaire scores were classified according to levels of 
knowledge, such as insufficient level of knowledge, moderate level of knowledge and 
satisfactory level of knowledge. The study revealed a marked increase in the overall post-test 
knowledge score compared to the pre-test, which indicated the efficacy of the STP (t=3.04;  
p<0.005). It was reported that STP was a successful way of delivering knowledge to upgrade 
KC for LBW infants and their mothers in Gujarat. 
 Chia, Sellick & Gan (2006) strongly supported the use of KC in the NICU in their review of 
the attitudes and practices of Australian nurse practitioners. While most nurses reported good 
attitude practices, they identified a number of theoretical and technical concerns that needed 
to be addressed in order to ensure that KC is effective and safe with low birth weight infants. 

68 
The study was carried out at a major public hospital in Melbourne, with a total of 34 nurses 
working in the NICU. The two-phase study design included a descriptive component, and 
four participants were then selected for the in-depth follow-up interview to explore issues 
related to promoting KC in more depth. Notable constraints for promoting KC in the NICU 
were found to be extreme staff burdens, lack of knowledge, lack of management resources, 
and absence of clear protocols, specifically for LBW infants. 
Another study by Panchal &Ravindra (2016) found that a Planned Teaching Program (PTP) 
on KC was an effective method of educating the postnatal mother in Dhiraj Hospital, 
Vandodara. The study was conducted among 50 postnatal mothers, using the non-probability 
convenience sampling technique, in Dhiraj Hospital. The mothers were assessed through a 
pretest and posttest following a PTP on knowledge regarding KC in terms of its definition, 
benefits, preparation and position. The difference in knowledge between pretest and posttest 
scores was 18.87, which is more than 1.699 at the 0.05 level of significance. However, 
investigation of an association between participants' pretest and posttest knowledge scores 
and their socio-demographic variables revealed that there were no significant associations 
with age group, gender and economic condition but there was a significant association 
between place of residence and origin of participants' previous knowledge. However this 
study only focused on maternal outcomes. There is a need to evaluate KC on infants’ 
outcomes.  
 
2.5 Conceptual Framework 
The conceptual framework for this study comes from the context of the Donabedian quality 
of care Framework. It is a conceptual model which provides a framework for evaluating 
health services and assessing health care quality. Quality of care explains the extent to which 

69 
personal and family health services improve the probability of desired health outcomes and 
are compatible with the existing knowledge of the professional (Institute of Medicine, 1990). 
Avedis Donabedian developed this model as a generally accepted framework for assessing 
the key dimensions of quality in healthcare (Bureau régional de l'Europe de l'organisation 
Mondiale de lasanté, 1998; Kelley and Hurst, 2006; Mullan, 2001). The model emerged from 
the research performed by Donabedian in terms of quality of health care and patient 
outcomes. The model's core definition describes the strengths of healthcare and healthcare 
services as systemic components, and focuses on particular initiatives or quality care 
activities that provide skilled healthcare. The outcomes are the health-care procedure test 
processes. This model indicates that each component has an impact or influence on the other 
components; structural characteristics (healthcare environment or healthcare provider) have a 
possible effect on both process and outcome, and outcomes will be affected by changing the 
efficiency (Donabedian 1996, 2005). In a recent study, the relational dimension of mothers, 
infants, and nurses was considered; a specific cognitive-behavioral and learning system and a 
nurse system were used to improve the process of assessing perception, knowledge, and 
practice that leads to the success of the KC technique and the involvement of mother-infant 
dyads and nurses. 
According to the model, quality of care knowledge can be derived from three elements, 
which are structure, process, and outcomes. (The 1996 Donabedian, 2005). The following are 
the three components involve:. 
 2.5.1 Structure Components 
The structure component refers to the relative characteristics of the caregiver and the setting 
where treatment is given. These characteristics include personnel, education, training, 
expertise, and certification. The contexts in which support is given are defined in terms of the 

70 
appropriateness of staffing, facilities, safety precautions, and the entire organization of the 
institution. The researcher applied the Donabedian structural component model in this study, 
which focuses on the characteristics of infants, mothers, nurses, and the organization. The 
structural aspect of the study includes only the characteristics of the mother-infant dyads and 
nurses, since the characteristics of the organization go beyond the research objectives. Infant 
attributes include personal and nutritional profiles. The personal data components include 
infant characteristics such as gender, race, weight at birth(g), weight at study initiation(g), 
gestational age at birth, gestational age when initiating KC, duration of KC, when it was 
commenced and when it was completed, and mode of feeding. While the mothers’ 
characteristics include maternal age (years), race, religion, marital status, delivery type 
(spontaneous vertex delivery(SVD) or cesarean section(CS), parity (primipara or multipara), 
educational level, occupation, employment status, household income (Ringgit Malaysia), 
breastfeeding status and post-partum stress. Nursing characteristics include nurses’ age, 
gender, race, educational level, nursing educational level, working experience (SRN), 
working experience in NICU, post-basic neonatology status, KC training and marital status. 
Characteristics of mother-infant dyads and nurses have been reported in previous studies to 
affect the study process or outcomes. Studies have shown that experienced nurses have better 
knowledge on the KC technique than those with less experience. Successful implementation 
of the KC technique includes appropriate nursing education, training of mothers on the KC 
technique, monitoring of the application of KC by nurses, and arranging for a blend of staff 
with varying skill levels and experience of KC. It is also essential to address institution-
specific barriers to KC application, and to develop institution-specific strategies to overcome 
these barriers (Wallin et al., 2005; Bergman & Jurisco, 1994; Cattaneo et al., 1998). This 
study aims to evaluate the outcomes in terms of premature infant weight gain, LOS and breast 
breastfeeding rates, while maternal outcomes include perception, knowledge, perception of 

71 
barriers in relation to KC and parental and relationship related stress after participation in a 
KC-EP. Nursing outcomes include perception, knowledge, confidence level in the initiation 
of KC with premature infants with monitoring devices, confidence level to initiate KC with 
premature infants with ventilator support and perceived barriers to KC after participation in a 
KC-EP at the NICU, UMMC in the Klang Valley. Demographic characteristics of mothers 
might influence the outcomes of mothers in this study such as age, race, religion, delivery 
type, parity of mother, educational level, occupation status, employment status, maternity 
leave, KC trainning and post-partum stress. Therefore, these factors are known as explanatory 
variables used as process parameters in the collection of mother-infant outcomes data.  
2.5.2 Process Components 
In The Donabedian model (1981), the process aspect relates to the training and practice of 
mothers and nurses. Nurses have a significant role to play in the measurement and 
transmission of knowledge and skills in order to enable the successful implementation of KC 
by mothers with preterm infants. For the successful implementation of KC, nurses need 
adequate knowledge and skills related to strategies for convincing mothers of the importance 
of KC for their infant’s well-being. Feeley & Gardner, 2006; Guttormson et al., 2010; Walker 
& Gillen (2006) stated that educational programs are crucial for improving nurses’ 
knowledge, skills and attitude so they can perform this role effectively and efficiently. 
However, in this study, the KC-EP is conducted to enhance nurses’ perceptions, knowledge, 
and confidence level in relation to the initiation of KC with premature infants with 
monitoring devices, increase their confidence level in initiating KC with premature infants 
with ventilator support and overcome their perception barriers regarding KC implementation. 
KC is an opportunity to help premature infants live a better life. Thus, a specific agreement 
should be established between the mother-infant dyad and the nurses (and other health 
professionals) on this method of therapy (Wallin et al., 2005; Nirmala & Rekha, 2006). KC 

72 
will not be effective when mothers are not committed or do not agree with it. Thus, for  
successful implementation of KC in a healthcare facility, face-to-face facilitation between the 
mother and the nursing staff is necessary. Chia, Sellick & Gan (2006) maintain that it is 
crucial to inform both mothers and nursing personnel to ensure a significant decrease in 
infant mortality through the implementation of KC. Educational intervention is seen as being 
essential in order to upgrade the efficiency of practice, application, and compliance with 
evidence-based practices (Payen et al., 2007; Tanios et al., 2009; Weir & O'Neill, 2008).  
The unique strength for the implementation of KC is in the attitudes of the mother and 
nursing staff, as they contribute to the mother's commitment. A study conducted at Harare 
Central Hospital (Kambarami, Mutambirwa & Maramba, 2002) demonstrated the mothers' 
optimistic attitudes towards KC, and they recommended that KC be promoted through the 
media (television and radio) throughout the country. While KC can be performed at home 
(Quasem et al., 2003), and mothers are able to provide it (Quasem et al., 2003), it has been 
mentioned that even mothers experience discomfort when their infants grow bigger (Quasem 
et al.,2003). These factors may have a detrimental impact on the attitude of a mother towards 
KC continuing at home. In this current study setting, KC is not widely practiced and there is 
an absence of clear guidelines or protocol. It is predicted that mothers would change and 
nurses’ knowledge and skills in relation to KC improve by conducting a KC-EP and having 
trained nurses; this would boost the level of treatment for preterm infants directly and 
indirectly. This present project thus focuses on the efficacy of the KC-EP in its effects on the 
outcomes of mother-infant dyads and nursing.The KC-EP is accepted as a process after pre-
assessment is done. The structured KC-EP includes a theoretical and a practical session after 
pre-assessment is delivered to mother-infant dyads and nurses using the Kangaroo Care 
Questionnaire Survey (KCQs) as an assessment tool. The theoretical and practical sessions 
are aimed at enhancing mothers’ and nurses’ perception, knowledge and confidence level 

73 
regarding the initiation of KC with premature infants with monitoring devices, with 
premature infants with ventilator support, and overcoming perceived barriers, and improving 
skills and attitude in relation to KC implementation among preterm infants (28 to 36+ 6 
weeks’ of gestation). The practical session is intended to enable nurses and mothers to gain 
knowledge and skills related to the KC technique following the guidelines provided for 
premature infants. How the mothers and nurses perform is documented in the checklist 
provided at the posttest, but the skills are not evaluated as is beyond the scope of this study.  
There are, however, factors relating to staff, patients, and doctors that have been highlighted 
as obstacles to the effective adoption of these techniques and algorithms (Miller et al., 2012; 
Tanios et al., 2009). Therefore, in this current study, these barriers must be identified to 
enhance the success of adoption and increase the willingness of mother-infant dyads and 
nurses to practice KC for premature infant quality of care.  
2.5.3 Outcome Components 
The results of the structure and the process are in the Donabedian model. Therapeutic options 
include outcomes as well as the beliefs, confidence, and knowledge of mothers and nurses 
related to health care (Donabedian, 1996, 2005). In this study, the effects of the KC-EP are 
measured at different phases of the study in relation to the outcomes of the mother-infant 
dyads and nurses. The results for mother-infant dyads and nurses will be measured by their 
personal satisfaction when attempting to implement KC, such as perception, knowledge, level 
of confidence regarding the initiation of KC with premature infants with monitoring devices, 
confidence level to initiate KC with premature infants with ventilator support and perceived 
barriers toward KC implementation which reflect personal beliefs, satisfaction, feelings and 
thoughts related to KC. 
                   (Independent variables)                  
                          (Dependent variables) 
                                                                                                                          
Structure 
Process 
Outcome 

74 
                                                                    
 
   
 
                                                                                               
 
 
 
 
 
                                                                                                        
            
 
 
 
 
 
 
 
 
                                                                                                                                                                                
 
 
 
 
 
 
 
 
 
 
       
 
Figure 2.2: Conceptual Framework of Study from the Admission Day, Discharge And 
Follow–Up at 3 Months Old. 
 
 
2.6 Conclusion 
The literature suggests setting KC performance goals and using standardized guidelines and 
protocols for KC. However, to ensure success in the implementation of KC, the literature also 
emphasizes the need for the proper training of nurses and mothers. 
 
Education Intervention 
Programme 
 
 
 Kangaroo care                 
Education Programme 
(KC-EP) 
 
• 
Theoretical 
 
• 
Practical (hands-on) 
 
 
 
 
Maternal outcome 
- Perception 
- Knowledge 
- Perceived barriers 
- Stress 
 
 
 
 
Infant outcome 
-Weight gain patterns 
-Length of hospitalization 
stay 
-Breastfeeding rates 
 
 
 
 
 
 
Nurses outcomes 
- Perception 
- Knowledge 
- Practice 
 
 
 
Mother Demographic Characteristics:               
- Age (years) 
- Race 
- Religion 
- Marital status 
- Delivery type (SVD or C/S) 
- Parity (Primipara or Multipara) 
- Highest educational level 
- Occupational status 
- Employment status 
- Maternal leave status 
- Household income(RM) 
- Breast feeding status 
- Post-partum depression (Pre &  Post) 
- KC training 
 
Infant Demographic Characteristics: 
- Gender 
- Race 
- Gestational age on admission (weeks) 
- Corrected age on recruitment (weeks) 
- Corrected age on discharge (weeks) 
- Birth weight (gram/kg)  
- Body weight on recruitment (grams/kg) 
- Body weight on discharge(grams/kg) 
- Body weight at 1st month old (grams/kg) 
- Body weight at 3rd months old (grams/kg) 
- Duration of hospitalization stay(days) 
- KC initiation (before discharge) 
- KC completed(weeks) 
- Mode of feeding (EBM or BF) 
- Initiate breastfeeding (weeks) 
- Weaned breastfeeding (weeks) 
 
Nurse Demographic Characteristics: 
- Age (years) 
- Race 
- Religion 
- Highest educational level 
- Nursing educational level 
- Working experience (RN) 
- Working experience NICU 
- Marital status 
- Practice KC in NICU 

75 
Based on the literature review, it was noted the intervention studies focused on the outcomes 
measured in a unilateral manner, focusing on either mother, premature infant or nursing 
outcomes. No study has been found yet on measuring compliance with KC in order to 
improve the effectiveness of KC-EP according to weight gain, LOS, and breastfeeding rates 
at 3 months old for premature infants in Malaysia. Some of the studies also did not assess or 
report the adherence level to reflect the effectiveness of the intervention on outcomes.  
Therefore, the focus of this study is aimed at introducing a KC-EP for mothers and nurses. 
The focus is on proper KC guidelines and protocols, and their benefits for the quality of care 
of premature infants. This is to enhance the effect of the KC-EP on mother and nursing 
outcomes. The study also aims to assess and explore mothers’and nurses’ compliance rates in 
providing KC in order to make it a standardized and uniform practice in the NICU, which is 
then continued at home. 
 
 
 
 
 
 
CHAPTER 3: METHODOLOGY 
3.1 Introduction 
This chapter sets out the research methods used to discuss the present research questions of 
this study. It provides a detailed overview of the research design, study setting, population 

76 
and sampling method, research instruments, collecting data procedures, and data analysis 
plan. 
 3.2 Research design and methodology 
Research is a systematic process aimed to identify the latest facts, ideas, or information and 
generate new findings about a specific phenomenon. Analysis methodology includes 
examining the assumptions, principles, and procedures of a specific investigative approach, 
and is characterized as the framework that applies to the whole research process (Cresswell, 
2009). Research design is described as the total plan for acquiring or verifying new 
knowledge in such a way as to ensure that perhaps the answer(s) retrieved are relevant and 
truthful (Rebar, Gersch, Macnee & McCabe, 2011, p.175). The study design and 
methodology used in the present study are explained in the following sections below. 
 3.3 Study Design 
This is a quasi-experimental(QED), longitudinal design study to collect data on the 
effectiveness of a kangaroo care education programmme (KC-EP) for mothers’, nurses’ and  
infants’ outcomes. The QED is often described as a non-randomized, pre-post intervention 
study that is common in healthcare research when it is not logistically practicable or ethical to 
carry out a randomized control trial (Levin & Kate, 2007). This study met all four criteria of  
Harris, McGregor, Perencevich, Furuno, Zhu, Peterson, & Finkelstein (2006). Each reason is 
discussed below. In a human study, randomization in the intervention of known efficacy 
would not be allowed, unless the effectiveness is not known or doubtful. According to Jotzo, 
Martina & Christian (2005), psychological and mental support is required in critical 
circumstances, i.e. after premature birth. In the emotionally sensitive NICU environment, it 
seems unethical to provide some mothers with help, but other people oppose randomization 
for other reasons. A QED is an empirical instrument used to measure the causal effect of an 

77 
intervention on the basis of longitudinal evidence to decide whether the intervention has led 
to improvements in the outcomes of the target population. This study evaluated the effect of 
an educational programme on the outcomes of mothers, nurses, and preterm infants regarding 
KC techniques.  
A QED design is considered an adequate technique for evaluating the causal and successful 
relationship between the independent and dependent variables found when a fully 
experimental or randomized control trial (RCT) design is not feasible (Harris et al., 2006). 
RCT is also not realistic for research into small-scale continuing education. Due to the aspect 
of non-random assignment to the control group or experimental group, a quasi-experimental 
research design was chosen as a multilevel intervention for the preterm infant. The 
experimental group participated in a structured training programme on evidence-based 
experience and skills: a KC-EP for mothers and nurses. The mother-infants dyad in the 
control group followed the standard unit practice, and both groups had homogeneous or 
similar characteristics. 
3.3.1 Difficulty in randomizing the samples. 
The NICU is a critical and intensive care unit. Randomization of the samples will be difficult, 
as admission can not be predicted and samples fulfilling the requirements will be limited. 
 3.3.2 Difficulty of randomization by study setting 
The educational program can often not be randomized to individual environments because it 
is hard to prevent mothers from communicating with each other and from influencing the 
experimental groups, particularly if they are all in one ward. Thus data collection potentially 
masks the true effect. 
 3.3.3 Small available sample size 

78 
For situations where only a limited sample size is necessary to assess the feasibility of an 
intervention, randomization may not be adequate to achieve equilibrium (Levin & Kate, 
2006). Finding an alternative design, though, is easier. 
3.4 Study Setting 
There are ten public hospitals and two teaching hospitals in the Klang Valley which provide 
neonatal care for preterm infants. Kuala Lumpur Hospital, Ampang Hospital, Selayang 
Hospital, Sungai Buloh Hospital, Tengku Ampuan Rahimah Hospital, Banting Hospital, 
Kajang Hospital, Serdang Hospital, Putrajaya Hospital, and Shah Alam Hospital are among 
the ten public hospitals. The two hospitals in the northern region are Hospital Besar Alor 
Setar and Hospital Besar Pulau Pinang. The University Malaya Medical Center (UMMC) and 
the University Kebangsaan Malaysia Medical Center (UKMMC) are both teaching hospitals. 
The researchers sought authorization to conduct the study at the above hospitals. Of these 
hospitals, only UMMC replied. The setting of this study was the neonatal intensive care unit 
(NICU) at UMMC. UMMC is a tertiary referral hospital that receives patients from all over 
Malaysia. It is also a research hospital, with a culture that is expected to support a study on 
the effectiveness of KC.In addition recent statistical data shows an increase in the percentage 
of premature births from (2.54%, n=140) in 2011 to (8.49%, n=450) in 2015.   
The NICU unit is fully equipped and has trained staff to handle severely premature infants, as 
low as 22 weeks’  gestational age.  The NICU, UMMC currently has 39 admission beds and 
12 incubators only. The beds are allocated as follows, namely beds 1 to 12 are provided for 
Intensive Care Unit (ICU) babies, while beds 13 to 25 are for High Dependency Unit (HDU) 
babies, and beds 26 to 39 are for the recovery unit. Statistically, over a month, about 38 to 40 
infants are admitted to this unit. These infants will be nursed and treated according to their 
condition, some of them will be nursed under an open radiant warmer, in an incubator or 
bassinet. Occasionally, if the beds are fully occupied, those stable premature infants who 

79 
have attained a weight of 1.8 kg can be discharged. If this is not possible, the premature 
infant will be transferred to another ward, such as a pediatric ward i.e. Pediatric ward A(PA) 
or Pediatric ward B(PB), for the continuation of observation and treatment. 
3.5 Ethical Consideration 
This study has been approved by the Medical Research Ethics Committee of the University 
Malaya Medical Centre (UMMC). Research ID:201765-5310 (Appendix A). Letters to 
conduct research in the Neonatal Intensive Care Unit (NICU), UMMC, Klang Valley were 
obtained from the Hospital Director, Head of Pediatric Department, (Appendix B), Nursing 
Director in charge and Ward Manager in NICU (Appendix C). Approval was received via 
email from Susan Ludingtone-Hoe to use the Kangaroo Care Questionnaire Survey (KCQs) 
tool and from Margaret Miles to use the Parental Stressor Scale: Neonatal Intensive Care 
Unit,  Parental and Relationship (PSS: NICU: P&R) scale only. Lastly, mothers and nurses 
were reassured that the study was confidential. Anonymity was established by using codes. 
After a clear and detailed explanation on the study, informed consent was obtained from the 
mothers and nurses (Appendix D & G). 
3.6 Population and Sampling 
A population is a group of individuals to whom the researchers want to generalize their 
findings (Gay & Airasian, 2003). A population is also a group of people with unique 
characteristics which differentiate it from other groups (Cresswell, 2002; Kerlinger & Lee, 
2000). The population was comprised of all mothers who had preterm infants admitted to the 
University Malaya Medical Center (UMMC), neonatal intensive care unit (NICU). 
Furthermore, the nurses were working in the NICU, UMMC. The population was estimated 
as stated below. 

80 
The UMMC, as a referral center, recorded an average of five thousand four hundred and 
ninety four (5494) mothers giving birth in 2011 and five thousand two hundred ninety eight 
(5298) in 2015, respectively (Table 3.1).The average number of premature infants admitted to 
UMMC was about 450 - 500 admissions yearly. For this study, the population was all 
mothers whose premature infants were admitted to the NICU at UMMC during the study 
period and they were recruited non-randomly based on infant admission days. 
Table 3.1: Total Newborn Births and Total Premature Births at UMMC from 2011 To   
                  2015 
 
 (Source: UMMC, Patient Information Management Section, Statistics Department, 2017) 
 Year 
2011 
2012 
2013 
2014 
2015 
Total births 
5494 
6275 
6402 
5497 
5298 
Total 
premature 
births 
140 
(2.54%) 
136 
(2.16%) 
190 
(2.98%) 
263 
(4.78%) 
450 
(8.49%) 
 
3.6.1 Target population 
A target population is the total collection of people from whom a sample could be taken (Ary, 
Donald, Jacobs, Lucy Cheser, Razavieh, Asghar, & Sorensen, 2010). The target population in 
this research was mothers whose preterm infant’s corrected age was between 28 to < 36 + 6 
gestational weeks, and also nurses working in the NICU, UMMC.  
 
 
3.7 Criteria for sampling 
All mothers admitted to the NICU during the study period who had preterm infants were 
recruited according to the following criteria: 
 3.7.1 Inclusion and exclusion criteria 

81 
The decision to perform kangaroo care (KC) does not rely solely on the degree of 
neurodevelopment or postpartum age, but also on the stability of the infants. After birth, or 
within a few hours, days, or weeks, the baby can still be in an incubator or cradle as well as 
be clinically stable.  
The selection of infants was based on the following criteria: 
• premature infant at corrected age between 28 weeks to 36+6 weeks’ gestation.   
• infant clinically stable, eligible for KC, and admitted to the NICU.        
The exclusion criteria for infants were: 
• surgical infant i.e cleft lip, cleft palate, spina bifida, exomphalos and omphalocele. 
• infant required medical treatment eg. prolonged phototherapy treatment. 
• trisomy 21. 
Mothers with preterm infants in the NICU who were able to perform the KC technique. 
Therefore, the selection criteria for mothers were as follows: 
• all mother-premature infants with corrected age between 28 to 36+6 weeks of gestation.  
• mothers who were older than 18 years old and were able to give their consent. 
• mothers who could speak and read either English or Malay. 
• mother had no medical or surgical condition which required medication which interfered  
  with breastfeeding and was eligible to perform KC for her preterm infant. 
The exclusion criteria for mothers were: 
• mothers who had previous premature infants. 
• mother of quadruplets or more 
• mother who had any medical and surgical conditions that required medication   
  which interfered with breastfeeding and was not eligible to perform KC for her premature 
infant 

82 
Nurses also play a significant role in caring for mothers and babies during the maternal, 
perinatal and postnatal phases. They need to have expertise and confidence in their skills to 
provide neonatal treatment. The target group of nurses was registered nurses employed in 
UMMC's NICU. They were all invited to participate in this analysis to ensure the sample size 
was sufficient. 
3.7.2 Sample Size Calculation for Mother-Infant Dyads 
The sample size for mother-infant dyads was calculated using the two-sample independent t-
test. This was based on a previous study and this study's primary outcome (Rao, Udani, & 
Nanavati, 2006). The two-tailed comparison group was used in the sample size calculation 
using the formula below. The mean difference in weight gain was 8.41 (Rao et. al., 2006) pre 
and post-intervention, while 0.8 was the standard deviation. These values were applied in the 
formula based on the study done by Rao et., al (2006). 
The formula, n = 2[Zα/2 + Z β]²S² 
                               (µ1 - µ2)²  
 
Thus, Z α/2 = 1.96     Z β = 0.842 
     µ1 - µ2 = 0.54       S = 0.8 
The formula, n = 2[1.96 + 0.84]² [0.8]² 
                                     (0.54)²   
 
n = 2 [ 2.802]² (0.64) 
               0.29 
 
n = 2 [7.85] (0.64) 
              0.29 
 
n = 10.05 
       0.29 
 
Thus, n = 34.65 = 35 subjects for each group. 
Additional 30% = 50 subjects for each group. 

83 
An additional 30% was added to the estimated sample size to account for possible missing 
values and non- responses. The final sample size calculated was 50 for the sample population, 
and 50 for the experimental group. 
The two groups of preterm infant-mothers were recruited from those who were admitted to 
the NICU. The first set of samples ( n=50) was recruited from early February 2018 until July 
2018.The preterm infant-mother dyads who were admitted within these months were 
allocated to the control group, while recruitment for the experimental group of preterm 
infant-mother dyads (n=48) was initiated from early September 2018 until April 2019, after 
completion of the intervention program for the nurses. In both groups, the sample size for the 
control group was (n=48) and the experimental group (n=48), for a total sample size of 
(n=96). 
 
3.7.3 Sample Size Calculation for Nurses 
The universal sampling method was used to recruit neonatal nurses in view of the small 
number of nurses available as the target population for this study. Therefore, all the available 
nurses i.e 46 nurses and 1 head nurse were invited to participate in the study on a voluntary 
basis.  
3.8 Research Instrument 
 
A questionnaire was the primary analysis instrument for data collection. A questionnaire is a 
well-established tool for social science research data collection (Dillman & Smyth, 2007). 
The measurement scale was chosen for this study from the review of the literature and from 
previous research. For this study, two sets of research tools were used to collect the mothers 
and nursing outcomes. Questionnaire I [Appendix E(a) & E(b)] was for the mothers and 
Questionnaire II (Appendix H) was for the nurses.  Questionnaire I was provided in two 
major languages i.e. English and translated  Malay version for better understanding for the  
mothers in Malaysia who is not well versed in English. Questionnaire II was available in 

84 
English, while the instrument for the premature infants was the Kangaroo Care Progress 
Record (KCPR) or booklet with English and Malay versions provided (Appendix I) 
3.8 Mothers 
3.8.1 Questionnaire I  
This questionnaire contained two sections: Section A, Mother's demographic characteristics 
and Section B, which consisted of four main parts: Parts I, II, III examined mothers’ 
perception, knowledge, and perceived barriers related to the KC technique and Part IV 
measured their maternal stress levels when their premature infant was admitted to the NICU. 
There were 57 items. [Refer to Appendix E(a) and E(b)]. 
Section A: Demographic Characteristics  
Section A collected the demographic characteristics of mothers in the NICU at UMMC. All 
fourteen (14) variables were designed to gather the baseline data and follow the study's 
objectives. The variables included in this study were maternal age (years), race, religion, 
marital status, delivery type: spontaneous vertex delivery (SVD) or caesarean section, parity 
of mother: primipara or multipara, highest educational level, occupational status, employment 
sector status, maternity leave status, household income (RM), breastfeeding status, post-
partum stress status (pre and post) and KC training course. The rationale for using these data 
was to assess if the variables chosen had any effect on the perception, knowledge, perceived 
barriers, and level of stress of the participants. 
Section B: Perception, Knowledge, Perceived Barriers, And Stress. 
a) Part I: Mother’s Perception of Kangaroo Care 
Part I, the mother’s perception of KC, was adapted from the original KCQs tool, developed 
by Arthur J Angler, & Eileen Brumbaugh., Ludingtone-Hoe et al. (2013). A similar 
questionnaire was used for the nurses’ perception of KC. However, there were differences 
between nurses and mothers in the items in the informational needs questionnaire; each item 

85 
in the mothers’ perception section was slightly modified according to the mothers’ needs. For 
the nine (9) items that were modified refer to Appendix B. A 5-point Likert response format 
was adopted. The descriptor strongly disagree (1) was the lowest scale, followed by disagree 
(2), neither agree nor disagree (3), agree (4) and strongly agree (5). Out of 20 items there 
were five items (4,5,8,17,19) that were reversely rated. To identify the level of change in 
mother’s perception regarding the KC technique, the perception scores were transformed into 
mean scores and then divided into two groups: high perception was below M=2.92 and low 
perception was above M=2.92.  
b) Part II: Mother’s Knowledge on Kangaroo Care 
Part II of the mother’s knowledge questionnaire was adapted from the original KCQs tool 
developed by Arthur J. Angler, & Eileen Brumbaugh, Ludingtone-Hoe, et al. (2013) with 
slight modifications so as to be relevant and meet the objectives of the mothers’outcomes. 
There were similar knowledge questionnaires for the mothers and nurses regarding their 
ability to implement KC. Mothers were requested to circle a number and indicate their 
opinion on their knowledge of KC. The scoring was from not sure (1) to false (2) and true (3). 
The items were worded in both positive and negative terms (Table 3.3). Positive items 
answered with ‘true’ were considered correct and incorrect if they were answered ‘false’ or 
‘not sure’. Out of 11 items, there were six positive statements, which were (1,2,4,6,7,8), and 
five negative statements, which were (1,2,3,5,11). A higher score indicated a higher level of 
knowledge with reference to the descriptors. Higher mean scores of M=2.03 and above-
indicated mothers had a good level of knowledge regarding KC, while lower mean scores 
below M=2.03 indicated a poor level of knowledge on KC.  
 
 
c) Part III: Mother’s Perceived Barriers Regarding Kangaroo Care 

86 
In Part III, the mothers’ perceived barrier subscales questionnaire was used, adapted from the 
original KCQ tool developed by Arthur J. Angler & Eileen Brumbaugh, Ludingtone-Hoe et 
al. (2013) with slight modifications made to meet the objectives of the mothers’ outcomes. 
There were parallels between the nurses’ and mothers’ information on perceived barriers 
regarding their influence on implementing KC. The nineteen (19) items were modified, and 
this is shown in Table 3.4. Mothers were requested to circle a number to indicate important 
perceived barriers while implementing KC. A 5-point Likert response format was adopted. 
Descriptors were: not influential at all (1), not very influential (2), neither influential nor non-
influential (3), somewhat influential (4), and very influential (5). With reference to the 
descriptors, the closer the score to 5, the higher the level of mothers’ perceived barriers to KC 
implementation. Out of the nineteen (19) items, two (2) were negative statements, which 
were (16 &17). Those items were rated reversely. A higher score indicated a higher level of 
perceived barriers with reference to the descriptors. The perceived barrier scores were 
transformed to mean scores, then classified into two (2) groups. A mean score of M=2.42 and 
above indicated a high level of perceived barriers, and below M=2.42 indicated a low level of 
perceived barriers to KC implementation. 
d) Part IV: Mother’s Stress regarding Parental Stressor Scale: (PSS: NICU P&R) 
Part IV of the questionnaire refers to knowledge from mothers about stressful experiences 
when their preterm infant is admitted to the NICU. The scale, developed by Miles et al. 
(1999) in a validated questionnaire to measure parental perceptions of the stressors 
encountered in the NICU, puts emphasis on reactions to long stays in the NICU.  The PSS: 
NICU:P&R has been used extensively all over the world. It has been used by researchers in 
Malaysia (Swee Long et al., 2017); India (Chourasia et al.,2013); Hong Kong (Liu et 
al.,2010); Norway (Kaaresen et al., 2006); USA (Melnyk et al., 2010; Melnyk et al.,2006; 
Turan et al., 2008); Australia (Sweet & Mannix, 2012); and Canada (Zelkowitz et al.,2008). 

87 
The PSS scores reported in the NICU validation test ranged from 0.70 to 0.98. Miles' latest 
revision is a self-report scale of 26 items that measure parental stress related to three NICU 
situations: NICU sight and sound (5 items), baby appearance, behavior, and treatments (14 
items), and alteration of relationship and parental roles (7 items). The researchers in this 
study have used the Parental Stressor Scale: Neonatal Intensive Care Unit (PSS: NICU: 
P&R). Confirmatory factor analysis (CFA) to confirm the appropriateness of this instrument 
for the current setting, statistical methods performed to test the reliability of this question is to 
evaluate through Cronbach's alpha in this section was carried out on this part of the 
questionnaire (PSS: NICU: P&R). All seven (7) items were positively and negatively worded 
as shown in (Appendix B). Out of seven items, there were five positive statements, which 
were (1,3,4,5,7), and two negative statements, which were (2 and 6). A 5-point response 
Likert scale was used: not stressful at all (1), a little stressful (2), moderately stressful (3), 
very stressful (4), and extremely stressful (5). In the current study, PSS:NICU:P&R scores 
were categorized based on Chourasia et al., 2013, who rated level of stress as high-level 
stress (4-5), moderate level stress (3-3.99) and low stress (1-2.99). Scoring was presented as a 
mean score. For the purpose of KC-EP and kangaroo care implementation, maternal level of 
stress was further categorized. A higher score showed a higher stress level with reference to 
the descriptors; a high level was (3-5) and a low level was (1-2.99). The stress scores were 
calculated and converted into mean scores, then categorized into two (2) groups. The highest 
mean scores of M=2.63 and below indicated a low level of stress while mean scores above 
M= 2.63 indicated a high level of stress related to preterm infant’s admission to NICU. 
 
 
 
3.9 Premature Infants 

88 
The instrumentation for premature infants consisted of data from the KCPR or booklet 
provided. This comprised two sections; Section A for demographic characteristics and 
Section B for the data collection on preterm infant outcome variables at T0, T1, and T2. The 
KCPR booklet contained the following: 
a) Section A: Infant’s Demographic Characteristics 
Section A collected the premature infants’ demographic characteristics data from both 
groups. All nine (9) variables were formatted to gain information on the baseline data of the 
infants. The variables included gender, race, birth weight (kg), gestational age at birth 
(weeks), corrected age on recruitment (weeks), corrected age on discharge (weeks), mode of 
feeding (tube feed, syringe-feed, cup-feed or breastfeed), type of milk, expressed breast milk 
(EBM) or breastfeeding, initiation of breastfeeding (weeks) and weaning from breastfeeding 
(week/month). The rationale for using these variables was to assess if the selected variables 
had an impact in terms of primary and secondary outcomes on the perception, awareness, 
perceived barriers and stress of the mothers.  
b) Section B: Infant’s Kangaroo Care Progress Record (KCPR) or Data Sheet  
Section B assessed the progress of the premature infant in terms of primary and secondary 
outcomes. The primary outcome variables were weight gain and LOS, while the secondary 
outcomes were breastfeeding rate or feeding status. All nine (9) items were adapted from the 
original article by Singh, Amritanshu and Mukherjee, (2014) and Biswas, Malpani & Ekka, 
(2016) with a slight modification and format to satisfy the research goals relevant to the main 
and secondary monitoring requirements of the use of KC to assess outcomes. The variables 
consisted of baseline temperature, age of KC initiation (week/days), weight at KC initiation 
(g/days), weight gain velocity (g/days), duration of KC (in hour/day), duration of stay (days), 
types of milk (EBM or breastfeeding), initiation of breastfeeding (weeks) and weaning from 
breastfeeding (weeks) for both groups. The KCPR booklet was designed and presented to the 

89 
respective control and experimental groups. The difference in the KCPR booklet was the 
knowledge needed for the experimental group to get the input given to the control group for 
preterm infants (routine activities and standard care) and KC performance. The data for the 
preterm infants in the control group were documented according to standard practice care or 
routine practice in the NICU. [Please refer to Appendix F(a) and F(b)]. 
3.10 Nurses  
3.10.1 Questionnaire II  
Questionnaire II consisted of two sections: Section A comprised the demographic 
characteristics of the nurses and Section B included three (3) main subscales for nurses’ 
personal beliefs related to KC implementation in Parts I, II and III. There were 56 items. (see 
Appendix H for further information). 
a) Section A: Demographic Characteristics  
Section A data were collected based on the demographic characteristics of the nurses in 
UMMC's NICU. All eight (8) variables were formatted to gather the baseline data and fulfill 
the study objectives. The variables included in this study were: age, race, marital status, 
working experience (RN), working experience in NICU, neonatal nursing certification, KC 
practice in NICU, and KC training experience. The rationale for measuring such data was to 
determine whether the selected variables had an effect on the perception, knowledge, and 
practices of the study participants in relation to KC.  
b) Section B: Kangaroo Care Questionnaire (KCQ) 
In section B, the researchers used the KCQs tool developed by Arthur J. Angler & Eileen 
Brumbaugh., Ludingtone-Hoe., et al. (2013) for nurses.  The questionnaire was adopted and 
slightly modified according to the Malaysian context; permission to standardize the 
questionnaire was granted by the owners of the tool themselves via email. The tool was 
selected to evaluate the effectiveness of KC practice in the Malaysian setting. The KCQs 

90 
were chosen in comparison to other scales, due to their simplicity and excellent reliability and 
validity. This scale is well known and has previously been used nationally by the formulator 
of the KCQs and other researchers. Other than that, according to the author’s emailed 
communication the tool has been used with perinatal nurses from the north eastern United 
States and National Association of Neonatal Nurses (NANN) with an initial data reliability of 
0.79 – 0.90 for each of the parts. The Cronbach’s alpha is similar to our study range of 
between 0.78 – 0.95 for mothers and 0.79 – 0.90 for nurses. Only 56 items were used for the 
quantitative data for this study, consisting of three main parts that measured personal beliefs 
regarding perception, knowledge, and practices (monitoring device support) in relation to KC 
implementation. In addition, seven (7) staff nurses, each of whom had at least eight years of 
neonatal nursing experience, reviewed and updated the KCQs for clarification and 
consistency (Ludington-Hoe et al., 2001).  
a) Part I: Nurses’ Perception of Kangaroo Care 
Part I assessed nurses’ perception of KC related to their personal beliefs and the experiences 
that they had in the NICU. All twenty-five (25) items were adapted from the original KCQ 
tool developed by Arthur J. Angler & Eileen Brumbaugh, Ludingtone-Hoe et al. (2013), with 
slight modifications to meet the objectives of the study. A 5-point Likert response format was 
adopted. Descriptors were: strongly disagree (1) as the lowest score, followed by disagree (2), 
neither agree nor disagree (3), agree (4) and strongly agree (5); descriptor 5 was the highest 
score. With reference to the descriptors, the closer the score was to 5, the greater the 
appropriateness of the item. The items were positively and negatively worded (Appendix G). 
Positive items answered as ‘strongly agree’ or ‘agree’ were considered correct and if 
answered as ‘strongly disagree’, ‘disagree’ and ‘neither agree nor disagree’ were considered 
incorrect. The negative items were reversely rated. Out of 25 items there were 15 positive 
statements, which were (1,2,8,9,10,13,15,16,17,18,20,21,22,24,25), and 10 negative 

91 
statements, which were (3,4,5,6,7,11,12,14,19,23). The perception scores were converted into 
mean scores and then categorized into two groups. Mean scores of M=2.77 and below 
indicated a high perception of KC, while mean scores above M=2.77 indicated a low 
perception related to KC implementation. Therefore, mean scores of above 2.77 indicated 
less experience of KC with preterm infants in the NICU. 
 
b) Part II: Nurses’ Knowledge of Kangaroo care  
The Part II questionnaire was on nurses’ knowledge, determined by 20 true-false items to 
assess nurses’ knowledge pertaining to initiation of KC with preterm infants in the NICU 
setting. The items were adopted from the KCQ tool developed by Arthur J. Angler & Eileen 
Brumbaugh, Ludingtone-Hoe et al. (2013). Nurses had to grade their level of knowledge 
according to ‘not sure’ (1), ‘false’ (2) and ‘true’ (3). These items were selected because they 
contained sufficient information to evaluate or report on the KC-related knowledge of 
mothers and infants. The items were worded in a positive and negative way. Positive items 
answered as ‘true’ were considered correct and if answered ‘false’ or ‘don’t know’ were 
considered incorrect. The negative items were reversely rated. Out of 20 items there were 11 
positive statements, which were (4,6,7,8,9,10,13,14,15,18,19), and nine negative statements, 
which were (1,2,3,5,11,12,16,17,20). The scores for knowledge were converted into mean 
scores, and then classified into two parts. Higher mean scores of M=2.34 and above indicated 
good knowledge, while mean scores below M=2.34 indicated poor knowledge and 
experiences in relation to KC in the NICU.  
 
 
 
c) Part III: Nurses’ Practice of Kangaroo Care 

92 
Part III related to nurses’ satisfaction in practicing KC with premature infants with various 
types of conditions or treatment in the NICU. The eleven (11) items were formulated by 
adopting the subscale for practices with monitoring devices. The items were adapted from the 
original KCQ tool developed by Arthur J. Angler & Eileen Brumbaugh, Ludingtone-Hoe et 
al. (2013) with minor changes to meet the study objectives and specifications. Nurses were 
requested to circle a number to indicate their confidence level and skills based on a 5-point 
Likert scale. The descriptors were: very uncomfortable (1), somewhat uncomfortable (2), 
neither comfortable (3), somewhat comfortable (4) and very comfortable (5). Out of 11 items, 
there were four positive statements, which were (1,2,5,6), and seven negative statements, 
which were (3,4,7,8,910,11) Table 3.11. The items were positively and negatively worded. 
Practice scores for the monitoring device were converted to mean scores and then divided 
into two categories. Mean scores of M= 2.26 and below indicated a high level of confidence 
and skills in initiating KC, while mean scores above M=2.26 indicated a low level of 
confidence and skills in initiating KC with monitoring devices in the NICU.  
 
3.11 Kangaroo Care Educational Programme  
 
Biswas, Malpani & Ekka, (2016) concluded that nurses with no formal training of KC were 
often limited in their KC practice. These components were also intended to improve the 
knowledge and skills of nurses in the appraisal of mother-infant dyads to help them achieve 
KC and to promote breastfeeding as the primary and secondary outcomes. Gayathri, 
Sampada, Hiral, Manisha, Silvi, & Yashvanthi, (2016) suggested that a structured teaching 
program (STP) would enhance KC knowledge among postnatal mothers with low birth 
weight infants. Subsequently, the structured kangaroo care education program (KC-EP) for 
mothers and nurses was conducted to enhance knowledge and skills related to KC's benefits 
and included a theory and a practical session.  

93 
This program was based on Knowles' adult learning theory, with the Andragogy model's five 
assumptions. According to Rogers (2001), a single motto-learner abides by the effective 
teaching of adult students. The program sought to acquire the cognitive (intellectual), 
affective (values, emotions, and feelings) and psychomotor (motor skills) competence that 
reflects the imperative of enhancing nursing education skills, knowledge, and attitudes 
(Anderson & Krathwohl, 2001; Huitt, 1992; Bloom et al., 1956). Munn stated that learning is 
more or less a permanent change in behavior as a result of observation, training and action, 
either in person or by teaching (Kahayon & Aquino, 1995). The informed consent, verbal and 
written, of all the study subjects was taken before the study started. 
i) Structured Kangaroo Care Educational Program for Mothers (KC-EP) 
The KC-EP for mothers is a special program designed to help preterm infant mothers 
admitted to the NICU share evidence of the benefits of KC and show them how they can 
perform KC. There are plenty of online reading and video resources available: blogs, books, 
magazines, newsletters or newspaper articles, on issues faced by preterm infant mothers 
admitted to the NICU and how they can reduce maternal stress during separation and improve 
their neonatal care capabilities related to the NICU. Most of the available materials are 
general and do not address specific guidelines and practice protocols for performing kangaroo 
care.  
Therefore, a formal content module for mother-infant dyads was developed for the KC-EP. 
The KC-EP focused on the psychological and physical aspects related to the preparation for 
and implementation of the KC procedure (before, during, and after). Subsequently, proper 
handwashing techniques (before and after touching the premature infant) and KCPR booklet 
documentation were implemented. On the other hand, for interpersonal communication or 
interaction between mothers and neonatal nurses in the NICU and good relations were 
established. In addition, mothers were also encouraged to participate in some tasks that were 

94 
usually carried out by current ward staff for their premature infants in the NICU, i.e. 
changing diapers, feeding tube or cup feeding and breastfeeding. In other words, for mothers, 
the KC-EP was more formal, simplified and based on contextualizing the needs of the 
regional culture in Malaysia. The positive point is that these short notes, such as flipcharts 
and leaflets in both languages, could be used to illustrate points for the premature infant 
mothers and as a quick reference for the neonatal nurses.  
 
This program (KC-EP) had the general objective of ensuring the intervention with the 
mother-infant dyads was effective and possibly at no cost. The specific aims were to:  
a. Provide mothers with educational information related to KC to ensure the quality of 
premature infant care at the hospital and after returning home. 
b. Assist mothers in situations, and with facilities, and routine care in the NICU during 
their premature infant’s hospitalization in the NICU. 
c. Develop interpersonal communication and interaction between mothers and neonatal 
nurses. 
d. Support mothers regarding the psychological aspects of their premature infants. 
e. Advocate for mothers to perform kangaroo care at least 1 hour a day and accumulate  to 
4 to 5 hours a week until 3 months of age. Evidenced by Kangaroo Care practice. 
 
 
i) Contents Module Theory (30 minutes) 
 
 
 
 
 
1. 
Introduction : Kangaroo care . 
 
Kangaroo care (KC) started in Bogota, Colombia approximately 30 years 
ago. According to WHO ( 2014) KC is in Africa - Benin, Burkina Faso, 
Ethiopia, Mali and Malawi ; in Asia - India, Indonesia and the Philippines 
(Recent study, 1990, 2012); and in Europe -  France, Denmark, Belgium, 

95 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Netherlands, Italy, Spain, the United Kingdom and Sweden, (Spanish 
research survey, 2013). Evidence suggests that visiting, holding, talking and skin-
to-skin contact are linked to positive outcomes for infants and parents during and 
after hospitalization (Feeley, Genest, Niela-Vilïn, Charbonneau, & Axelin, 
2016) 
KC improves cerebral blood flow (CBF), thus influencing the structure and 
encouraging the development of the brain of the premature infant.  
(Korraa, El Nagger, Mohamed, & Helmy, 2014). 
KC can be used to promote emotional bonding between mothers and infants 
and to regulate a premature infant’s physiological functions, and is perhaps 
one of the NICU's most effective nursing interventions for premature infants 
and their mothers (Cho et al.,2016). 
Evidenced: Doctors and nurses have been trained on KC theory and skills 
procedure in NICU, UMMC. 
2. 
1) Definition of KC 
What is kangaroo care? 
It is a special method of caring for a premature infant in which the baby is 
positioned for at least 1 hour a day in an upright skin-to-skin and chest-to-
chest contact with its mother. This is started by moms in the NICU and 
continues at home for the first three months.                                                        
                                                         Ludingtone-Hoe,et al.,(1990;2013&2018) 
3. 
State the benefits of kangaroo care to infant-mother dyads. 
Why should I perform Kangaroo Care? 
Babies and mothers get a lot of benefits: 
3.1 For infants;  

96 
 
 
 
 
 
 
i) Increases the sleep of infants, which can enhance weight and brain    
  development. 
ii)   Controls temperature, heart rate, and respiration for infants. 
iii) Supports successful breastfeeding sessions and reduces infection. 
iv) Shortens the length of hospital stay. 
3.2 For mothers; 
i)   Increases confidence in ability to care for babies. 
ii)  Enhances bonding, feeling of closeness with babies. 
iii) Improves mothers’ milk production. 
iv) Creates more nurturing interactions. 
4) 
Explain the kangaroo care technique.  
Who can perform Kangaroo Care? 
Mums should do it.  Every medical situation at NICU, however, is different.  
So ask your nurse, if your infant is a successful candidate indeed. If you can't 
do KC or don't feel confident, don't worry. But there are plenty of ways to 
help and take care of your infant. Speak to your nurse.  
When can I perform Kangaroo Care? 
You can perform at any time between 90 to 120 minutes after feeding. 
Schedule a suitable time with your nurse and set aside at least 1 hour or 60 
minutes a day, and plan to sit 4 to 5 hours a week with your baby.  Please feel 
free to ask a member of the NICU team for further information. 
5) 
State the preparation before, during and after the KC procedure. 
How do I perform Kangaroo Care? 
You're going to dress your baby up in a diaper and head cap. Your baby 
should be positioned upright between your breasts. Have its tummy against 

97 
ii) Contents module for the practical session (30 minutes) 
 
Objective  
1. 
Reinforce mothers with proper hand-washing techniques. Wash hands each time 
when entering and leaving NICU, after diaper changes, personal hygiene and feeds. 
(Appendix N)  
How do I wash my hands correctly? 
Using the steps below, washing your hands properly requires about as long as you 
sing Happy Birthday twice. 
• Wet hands with water 
• Apply enough soup to cover all hand surfaces 
• Rub hands palm to palm 
• Right palm over left dorsum with interlaced fingers and vice versa. 
• Palm to palm with fingers interlaced. 
• Back of fingers to opposing palms with fingers interlocked 
• Rotational rubbing of left thumb clasped in right palm and vice versa 
• Rotational rubbing backwards and forwards with clasped fingers of the right 
hand in left palm and vice versa 
• Rinse hands with water 
• Dry through with a single-use towel 
your chest.  Head turned to one side, arms and legs in a bent position. 
Support your baby’s head, back and buttocks. [Please refer to Appendix O 
(a) and O(b)]. 
                                 Ludingtone-Hoe,et al.(1990,2013,2018) & Nqyist,(2010) 
 
 

98 
• Use a towel to turn off the faucet 
• And your hands are safe. 
                                                                                                  (WHO,2020) 
2. 
List the equipment for kangaroo care procedure; 
2.1 Infant  
• Infant thermometer 
• Woollen head cap & woollen booties 
• Diaper & receiving baby napkin 
• Baby blanket 
2.2 Mother 
• Chair 
• Blouse open in front 
• Small mirror 
3. 
 
 
 
 
 
 
Demonstrate and return-demonstrate  
 
                               
 
 
 
a) Greet mother, introduce yourself, and explain the purpose of the procedure. 
   Rational(R): Mother understands the correct KC position for the infant;(head  
   midline, well flexed, nares/mouth visible) 
b) Prepare the mother’s and infant’s equipment & screen mother and infant for         
   Figure 3.1: Shows the kangaroo care position 

99 
    privacy. 
   R: Mother is comfortable and able to sit for a minimum of 60 minutes per day. 
   The mother should remove the bra and wear a blouse or robe that opens in front or   
   tube. The mother eliminates the need to disrupt the KC session bowels opened 
(BO) and passed urine (PU). 
c) Position the KC chair at the side of the incubator door. 
    R: To prevent unnecessary tension on the lines during transfer. 
d) Assist the mother to sit on the chair next to the incubator with her blouse/shirt  
   open or robe. 
    R: Ready to receive the infant for KC and ensure the entire body over the naked  
    chest and abdomen is covered. 
e) Monitor infant vital signs, such as temperature, respiration and heart rate; 15-30  
    minutes before and after KC. 
    R: To monitor baseline temperature, respiration and heart rate. 
f) Place the infant in the supine position with receiving napkin/blanket underneath 
    the head and torso / back of the infant.  
   R: To avoid heat loss. 
g) Take off the infant’s clothes and dress the infant in a diaper and head cap only. 
    R: To check if BO or PU and prepare for KC. 
h) Cover the ends of the blanket to cover arms, legs, intravenous (IV) lines, and  
    lead wires around the infant. 
    R: To prevent heat loss and dislodging all the lines. 
 i) Pick up the infant with the hand under head and buttocks close to your chest. 
    R: To support and stabilize the infant during transfer. 
j) Place the infant prone on the chest of the mother, and pull the ends of the blanket 

100 
over. 
    R: To assure proper chest-to-chest; skin to skin contact. 
k) Assure proper, safe positioning of the infant; head midline, neck straight, nares        
    and mouth visible, arms and legs in a bent position. 
    R: To get the advantages of the KC effect. 
l) Instruct mother to fold her arm across infant’s back (non-dominant hand) and  
   buttocks (dominant hand) 
   R: To prevent slipping down from her chest. 
m) Place an additional folded blanket or wrap across the infant’s back. Advise       
     mother to cover her body or wear the blouse open in front (button) on top of the  
     premature infant. 
     R: To keep baby warm. 
n) Advise mother to be in KC position not less than 1 hour. Accumulatively  
    continue KC for 4 to 5 hours a week and until the infant is 3 months old.  
    R: To complete the cycle of sleep. 
o) Help the mother to initiate breastfeeding after the baby shows readiness and signs 
of feeding cues; moving tongue and mouth, licking the mother’s skin during KC  
    procedure. 
    R: To encourage partial or exclusive breastfeeding. 
p) Tidy up the mother and equipment. 
    R: For comfort and cleanliness. 
                                                         (United States Institute of Kangaroo Care, 2018) 
 
4. 
Documentation in kangaroo care record progress (KCPR) booklet. 
•  Record the date, time, temperature, duration from time KC commences until 

101 
completion of  the session, weight gain, and type of feeding intake daily in the 
KCRP booklet  provided. 
   R: To monitor the frequency of KC, weight gain, and breastfeeding rates. 
3.12 The process of delivery and how and who to conduct the KC-EP  
Face-to-face or direct contact is the best adult teaching method for nursing care, as there is no 
research available to determine whether different modes of delivery can produce better 
outcomes (Aranda, 2008). The delivery mode will determine how the intervention is exposed, 
the different methods used and the magnitude of the intervention in spite of similar 
intervention material. In this research, face-to-face or interpersonal communication has been 
identified as the delivery method for the KC-EP post-literature review.  
Throughout their premature infant’s hospitalization in the NICU, preterm infant mothers may 
face uncertainty about the progress of their preterm infant but may wait and rely on the 
knowledge, support, and advice of health professionals (Tandberg, Bente Silnes, 
Sandtrѳ,Hege Pettersen,Vardal, Mari, Ronnestad & Arild, 2013). Good communication skills, 
such as integrity, respect, and practice of two-way communication, are key points for 
effective clinical interaction (Reid et al  2007). Subsequently, in order to ensure that mothers 
benefit from communication, all verbal details and knowledge communicated should be 
replicated and validated in written notes, as mothers under stressful conditions may not recall 
all information provided (Lee,Wang, Lin, Kao, 2013). Empowerment has been described as a 
nurturing mechanism that improves well-being through increased maternal knowledge, 
awareness, and skills, and reduces difficulties (Lee et al., 2013,Liu, Chao, Huang, Wei, 
&Chien, 2010). With the knowledge obtained, mothers will be confidently involved in taking 
care of their preterm infants in the NICU, which may enhance mother-infant dyad bonding, 
and reduce stress and anxiety among mothers (Liu et al., 2010). The above paragraph 
addresses the delivery method of KC-EP and the use of the empowerment concept 

102 
(partnership, participation, and collaboration) in implementing KC-EP. The researchers 
provided educational information and suggested that, with the kangaroo care strategy, 
mothers should care for their premature infants. The participation and cooperation of mothers 
was stepped up from time to time through meetings (first meeting and follow-up) and 
conversations between mothers and researchers in the WhatsApp group (face to face and one 
to one). The mothers were encouraged to ask and answer any questions or problems during 
meetings or telephone conversations, but the confidentiality of the contact was still 
maintained.  
 
3.13 When, Where and How Much Will KC-EP be Delivered  
The question "When" refers to the timing, in particular the best time for the intervention 
program to be implemented and the question "How much" refers to the intervention's 
intensity in terms of the amount, duration and period of time needed to implement the 
intervention (Feeley, Nancy, Zelkowitz, Phyllis, Shrier, Ian, 2011). Timing and strength are 
two important aspects to be considered in the implementation of a nursing intervention. The 
duration and strength of the KC-EP implementation were agreed upon after analysis of 
literature review findings regarding mothers who were slightly more depressed at the 
beginning of enrolment. In the first week, the mothers were less stressed (Tandberg et al., 
2013), and in the week after birth and the week after discharge, the mothers were most 
stressed and worried (Gennaro, York, & Brooten, 1990). 
In this study, 48 hours after the admission of the premature infant to the NICU, or after the 
clinical stabilization of the infant, the expected intervention program was started, and the 
mother was able to perform KC. Within 48 hours post-admission, a specific orientation 
(reinforcement) and the first meeting were conducted. The second set of data was collected at 
the premature infant’s age of 1 month (44 weeks). The duration and frequency of KC-EP 

103 
implementation were  based on the guidelines (USIKC, 2018). Moreover, the Guidelines on 
Kangaroo Care, which was published by WHO (2003), was derived from Davanzo, 
Brovedani, Travan, Kennedy, Crocetta, Sanesi, Strajn., & De Cunto (2013). The duration or 
frequency of KC-EP implementation was also based on the Bakermans-Kranenburg, Van 
Ijzendoorn, and Juffer (2003) studies. Meta-analysis results from Bakermans-Kranenburg et 
al. (2003) found that the most effective intervention consisted of less than 16 sessions, and 
that less than 5 sessions (d=0.33) were as effective as a 5-16 session intervention (d=0.36). 
Accordingly, after consideration of these findings by Bakermans-Kranenburg et al. (2003) the 
expert panel decided in this study to limit the number of sessions to the minimum possible in 
practice.  
The KC-EP's design for mothers was based on the above discussion and consisted of two (2) 
sessions (first meeting and subsequent meeting), ten (10) short messages and reminder 
updates, and three (3) telephone follow-ups, and the program started immediately within 24 
to 48 hours of admission. The sessions included an overview or welcoming meeting with the 
mother during the admission of her premature baby to the NICU (10 to 15 minutes), followed 
by two more meetings (first 60-minute meeting and subsequent 15 to 20-minute meeting). 
3.14 Intervention 
Phase III required KC-EP intervention with premature infant mothers. During the admission, 
the researcher obtained demographic data and scheduled the KC-EP sessions. The  researcher 
carried out the implementation to ensure consistency and equity in the delivery of KC-EP; 
this would allow the researcher to understand better the problems or difficulties of the 
mothers. The study appointed one senior staff nurse (working office hours) to assist the 
researcher to arrange the intervention process for the benefit of implementation.  
 
3.14.1 Meeting Place for the KC-EP Activities 

104 
The conference room was chosen as it was quiet, and away from the noisy NICU 
environment.The mothers were never left alone during the answering session, where the 
researcher would always be available to offer the mothers some assistance. Sometimes the 
meeting place was also contingent on the condition of the mother. If the mother preferred to 
have the meeting elsewhere, alternate locations could be used, such as the breastfeeding 
room. If the mothers were able to carry out kangaroo care, the meeting would be held in the 
room arranged for them.  
 
Mothers of premature infants admitted to the NICU face challenges, such as difficulties in 
accessing information regarding premature infant complications, and lack of experience in 
caring for their premature infants (Charchuk & Simpson, 2005). Therefore, in the current KC-
EP, the senior staff nurse in charge was given the responsibility of explaining  the  aim of the 
intervention program to the mothers during their first visit, developing a supporting  
relationship with and showing concern for the mother, answering any simple questions asked 
by the mother and choosing an appropriate time for the intervention session based on the 
timetables (Appendix L&M). The average time for the mother's first visit to the NICU was 
between 1 and 3 hours depending on the conditions of any complications and the date of 
delivery. If the mother underwent a lower segment caesarean surgery it would take longer. In 
this study, the mothers' baseline data were collected within 48 hours of admission to give the 
mothers time to settle down and adapt to the new situation. The KC-EP maternal care time 
schedule, the mothers, premature infants and instruments used are shown in Table 3.2 (a) & 
(b). 
3.14.2 The First Meeting 
In the first meeting, which was held within 48 hours of NICU admission, information was 
given to the mothers about preterm infants admitted to the NICU as well as the KC technique 

105 
to ensure they had knowledge of KC during 30 minutes of theory and 30 minutes of practical 
session. Based on the established KC-EP, the researcher went through the educational 
information. During this meeting, the researcher and the mother discussed openly any 
concerns or issues faced with regard to the implementation of KC and breastfeeding status. 
Any questions from the mother were answered accordingly. The mother was taught about the 
KC technique in theory and how to practice KC-EP based KC in order to develop her 
maternal responsibilities, knowledge, and skills in caring for her premature infant. The 
researcher gave the KCRP booklet to the mother and went through it with her to emphasize 
the booklet's importance. The researcher also sent reminders to the mother through WhatsApp 
in the form of short notes to ensure that the mother read and understood from time to time the 
prepared booklet. Meanwhile, the mother was asked to remind the nurse in charge of her next 
visit (reconfirmation of the date of the following meeting) so that the researcher could plan 
accordingly.  
 
3.14.3 The Kangaroo Care Progress Record (KCPR) booklet. 
The creation of this booklet was based on the results of Phase I and adapted from the original 
article by Singh, Amritanshu, & Mukherjee (2014) and Biswas, Malpani & Ekka (2016) to 
fulfill the study's objectives. This was to ensure that the booklet for KCRP was suitable for 
mothers in the local context.  The KCPR booklet was prepared in English and Malay 
language, with a table for  date, time, length of KC, weight gain, and mode of breastfeeding. 
It also helped the mothers to gain information about the KC technique and its benefits. This 
KCPR booklet provided a motivational resource, particularly for mothers who were unable to 
visit the NICU on a daily basis and who were thus able to prepare for their next visit to 
provide KC for their premature infant so as to maximize KC implementation to between four 
(4) to five (5) hours in a week. The following information was included in the KCPR booklet. 

106 
In addition, premature infant mothers need to learn about the KC technique, the effects of 
KC, the average implementation of hours of KC per day, the devices used by the premature 
infant for the kangaroo care technique, premature infant growth, and premature infant 
nutrition up to the first 3 months. The KCPR booklet was limited to 30 pages in order to 
avoid information overload. Upon amendment, consent was given by all meeting committees, 
which consisted of two (2) senior nursing lecturers, one (1) matron in charge of the 
department and one (1) sister. The KC-EP for the mothers in the experimental group and the 
KCPR booklet were then sent to one neonatologist and one matron in charge of verification. 
The neonatologist and the matron in charge were invited to ensure that the module contents 
designed were compatible with the clinical and institutional needs. The KC-EP developed for 
mothers and the KCPR booklet were then given to four (4) mothers whose preterm infants 
were admitted to the NICU and five (5) NICU nurses who were not directly involved in the 
development of the KC-EP in order to verify the readiness of the KCPR booklet. There were 
no major issues raised by the two neonatologists and the matrons. The evaluation results 
showed that the evaluators, the four (4) mothers and five (5) nurses, could understand the 
contents of the KCPR booklet.  
3.14.4 Subsequent Meeting 
A subsequent meeting of 15 to 30 minutes was conducted on the 4th day of admission 
depending on the condition, willingness, and tolerance of the mother. The goal of the 
subsequent meeting or bedside teaching was to improve the therapeutic relationship between 
the mother and the researcher which had been established at the time of admission and to 
recognize any problems faced by the mother in performing the technique of KC. The 
interaction between the researcher and the mother was aimed at improving the mother's well-
being. The strong interactions between the nurses (professional) and the mothers enhanced 
the mothers' knowledge, particularly on issues related to the KC technique and their infant’s 

107 
admission to NICU. During the meetings, the mother was allowed to ask about and discuss 
any concerns or issues via telephone or WhatsApp conversation. Throughout the KC-EP 
activities, the researchers demonstrated a caring attitude, were knowledgeable about issues 
related to premature infant admission to the NICU, and had good listening skills. The meeting 
also highlighted and discussed the information found during Phase III.  
 
 3.14.5 Telephone call and short message via WhatsApp. 
To ensure continuity of the KC technique and quality of premature infant care, the 
researchers performed a follow-up through WhatsApp, sending a short message to the 
mother. This was a reminder about providing updates on the premature infant’s performance 
of KC, the condition of the premature infant; i.e. body weight of preterm infant on discharge, 
at 1 month and 3 months corrected age, breastfeeding status every 2 weeks post-admission 
until 40 weeks post-admission. In addition, this continued every 4 weeks at 44 weeks, 48 
weeks and 52 weeks of premature infant age [Table 3.2(a) & (b)]. The researchers also made 
three (3) telephone calls via WhatsApp during the program of which the first call was at 40 
weeks post-admission, the second call was at 44 weeks (1 month) post-admission and the last 
call was at 52 weeks (3 months) post-admission. The purpose of the call was to find out if the 
mother had any doubts or had any problems linked to the objectives of the study at home and 
to advise the mother to contact the researcher at any time if she had any problems with KC 
and her premature infant’s condition. All of the conversations were conducted using a very 
careful approach to ensure that the mothers were openly sharing their feelings and their 
appreciation of KC. 
The program aimed to educate mothers on how to carry out KC and reduce their stress levels 
and how to strengthen their ability to breastfeed their premature infants. The nurses’ 
workload in the NICU is generally very high, and nurses do not have enough time to assist 

108 
the mothers. Therefore, the entire program was allocated only 1 hour and 30 minutes. The 
experimental group had four sessions prepared and designed for the mothers, the specifics are 
set out in Appendix L and M. The program was administered in one session with between 
two (2) or four (4) mothers per group and one or two nurses involved at the first meeting. 
This was to ensure the nurses and mothers were given the same information , skills and 
shared attitudes.   
The refresher meeting on how to give psychological support to the mothers on handwashing, 
KC, breastfeeding education, briefing on the KCPR booklet and the KC-EP was conducted 
by the researcher. The implementation of KC and the purposes of all the questionnaires were 
carefully explained during the meeting. Through this training, the nurses would get a clearer 
understanding of the intervention and the value of reporting in the KCPR booklet. 
Nonetheless, one of the senior nurses working office hours was not directly involved in the 
implementation of the KC-EP; she was responsible for tracking any new admission that met 
the study criteria, accurately recording the demographic data of the mother and premature 
infant, informing the researcher about any new admission, scheduling and verifying the date 
of the first meeting (48 hours post-admission), notifying the researcher on every new 
admission and collecting the post-intervention data on discharge (body weight, weeks and 
date of discharge). It was the responsibility of the researcher to assure that the KC-EP was 
appropriate and given equally to all mothers, and to collect the data at the first meeting.  

109 
Days/ Weeks 
Control Group 
Experimental Group 
Person in charge 
 
Activities 
Instrument 
Activities 
Instrument 
 
Admission Day 
Routine NICU practice 
Brief NICU 
orientation 
Review 
(Medical Report) 
Brief NICU  
orientation 
Review 
(Medical Report) 
Nurse 
Day 1 (PI: Week 28) 
 
 
 
 
 
Day 2 
Breastfeeding 
Support,  
Hand Washing 
KCQ (QI)  
& 
PSS: NICU:P&R 
KCPR Booklet 
Simple ward 
orientation,  
First meeting  
KCQs (QI)  
& 
PSS: NICU:P&R 
KCPR Booklet 
Researcher 
Day 3 
Breastfeeding 
Support  
+  
Attending mother 
whenever are 
approach by 
mother  ad hoc 
 
Short Message: 
WhatsApp (1) 
 
Researcher 
Day 4 
 
Subsequent Meeting 
 
Researcher 
Day 5 
 
 
 
 
Day 6 
 
 
 
 
Day 7 (PI: Weeks 29) 
 
Short Message: 
WhatsApp (2) 
 
Researcher 
Day 8 
 
 
 
 
Day 9 
 
 
 
 
Day 10 - Day 13 
 
 
 
 
Day 14 (PI: Week 30) 
 
Short Message: 
WhatsApp (3) 
 
Researcher 
PI=Premature Infant; NICU=Neonatal Intensive Care Unit; KCRP Booklet=Kangaroo Care Progress Record Booklet; 
 
Table 3.2(a): Schedule for Intervention and Instrument (KC-EP) for the Mothers’ in Control and Experimental Groups 

110 
PI= Premature Infant; NICU=Neonatal Intensive Care Unit; KCQ=Kangaroo care questionnaire; PSS: NICU=Parental Stress Scale: Neonatal Intensive Care Unit.
Days/ Weeks/ 
Months 
Control Group 
Experimental Group 
Person in charge 
Activities 
Instrument 
Activities 
Instrument 
 
PI: Week 32 
Routine NICU practice 
Breastfeeding 
Support 
+ 
Attending 
mother 
whenever are 
approach by 
mother  ad hoc 
 
Short Message: 
WhatsApp (4)   
 
 
Researcher 
PI: Week 34 
 
Short Message: 
WhatsApp (5) 
 
 
Researcher 
PI: Week 36 
 
Short Message: 
WhatsApp (6) 
 
 
Researcher 
PI: Week 38 
 
Short Message: 
WhatsApp (7) 
 
 
Researcher 
PI: Week 40 
 
Telephone Follow-
up (1) 
 
 
Researcher 
PI:Week 44 
(1st month) 
KCQs 
& 
PSS: NICU:P&R 
(QI) 
Short Message: 
WhatsApp (8) 
KCQs  
& 
PSS: NICU:P&R 
(QI) 
 
Researcher 
Telephone Follow-
up  (2) 
PI: Week 48 
(2nd months) 
 
Short Message: 
WhatsApp (9) 
 
 
Researcher 
PI: Week 52 
(3rd months) 
KCQs 
& 
PSS:NICU:P&R 
(QI) 
Short Message: 
WhatsApp (10) 
KCQs 
& 
PSS:NICU:P&R 
(QI) 
Researcher 
Telephone Follow-
up (3) 
Table 3.2(b): Schedule for Intervention and Instrument (KC-EP) for the Mothers’ in Control and Experimental Groups (Continued) 

111 
3.15 Nurses’ Kangaroo Care Education Program (KC-EP)  
The KC-EP for nurses is a special program developed to assist nurses in sharing evidence 
about the benefits of KC that can be received by the mother of a preterm infant. Most of the 
available materials are generally used to address specific guidelines and practice protocols for 
NICU nurses to perform KC. Therefore, a special standardized content module in terms of 
KC's advantages for mother-infant dyads was formulated. The KC-EP focused on the 
psychological and physical aspects related to the preparation and implementation of the KC 
procedure (before, during, and after). On the other hand, the interpersonal communication or 
interaction between the nurses and the mothers in the NICU was developed for the 
psychological benefits and to foster good relationships between mothers and nurses. In other 
words, the KC-EP for nurses was more structured in terms of contextualization of the needs 
of Malaysia's regional culture. The positive point was that these prepared short notes, such as 
flipcharts and flyers in both languages, could be used as a quick reference for nurses to 
illustrate kangaroo care techniques to premature infant mothers. The general purpose of this 
program (KC-EP) was to ensure that the intervention with the mother-infant dyads was 
successful, and no cost was necessary. The practical goals were to:  
a. Provide nurses with educational information related to KC for the quality of premature 
infant care in the hospital and after returning home. 
b. Assist mothers during their premature infant’s hospitalization in terms of situation and 
environment, facilities, and routine care in the NICU. 
c. Develop interpersonal communication and interaction between neonatal nurses and 
mothers. 
 d. Support mothers with respect to psychological aspects following the birth of their 
premature infant. 

112 
e. Advocate for mothers to carry out at least 1 hour of KC per day and achieve 4 to 5 hours a 
week within the first 3 months. 
 i) Contents Module Theory and Practical (8 hour) 
Module contents were organized to meet the objectives of this study. Purposes included the 
definition of KC, method of KC, benefits of KC, indication and contraindication of KC, 
guidelines and protocol for KC, recognized signs and symptoms of deterioration during and 
after the KC procedure, preparation of premature infant-mothers and equipment before, 
during and after the KC procedure, and showing how to record the infants’ outcomes data for 
both groups in the KCPR booklet provided. The nurse should have been able to get a clear 
understanding of the programme and of the physiology and benefits of KC in detail and 
demonstrate the technique as well [Appendix P, Q(a)& Q(b)]. 
 1) To define the term and amount of KC. 
2) To explain the physiology and method of KC. 
3) To state the benefits of KC to mother-infant dyads. 
4) To state the indication and contraindication for kangaroo care and eligibility  
    criteria for mothers and premature infants. 
5) To state the guidelines and protocols before, during, and after the kangaroo care method. 
6) To recognize signs and symptoms of deterioration among premature infants before, during  
     , and after the method. 
7) To state the preparation before, during and after the kangaroo care method  
8) To list the equipment for kangaroo care method ; 
     8.1 For infants  
     8.2 For mothers  
9) To educate and guide on recording in the KCPR booklet.  
10) To demonstrate and return-demonstrate the KC method. 

113 
3.15.1 The process of delivery and how and who to conduct the KC-EP for nurses.  
Face-to-face or direct contact is the best adult teaching method for neonatal care since there is 
no existing research to determine if different delivery modes can produce better results 
(Aranda, 2008). The delivery method must evaluate the effectiveness of the intervention 
programme, the different methods used, and the magnitude of an intervention despite similar 
intervention material. Face-to-face or interpersonal communication was identified as the 
delivery method for KC-EP in this study after a literature review. 
With the knowledge they have learned, nurses will be confidently active in advocating for the 
mother to carry out kangaroo care for their premature infants in the NICU, which can 
improve mother-infant dyad bonding, and reduce stress and anxiety among mothers (Liu et 
al., 2010). The above statement addresses the delivery method of KC-EP and the use of the 
empowerment concept (partnership, participation, and collaboration) in implementing KC-
EP. The researchers distributed educational information and suggested that nurses should be 
aware of the kangaroo treatment method. The involvement and cooperation of nurses (first 
meeting and 7th day after intervention) and WhatsApp group discussions between nurses and 
researchers (face-to-face and one-to-one) were strengthened. Nurses were allowed to ask and 
discuss any questions or issues during meetings but to maintain the confidentiality of the 
conversations.  
 
3.15.2 When, Where and How Much Will KC-EP be Delivered 
Bakermans-Kranenburg et al., (2003) also found that the psychological support received by 
non-professional interveners (d=0.42) was greater than the professional interveners (d=20). 
Professional intervener Bakermans-Kranenburg et al., (2003) refers to a trained clinical 
psychologist or counselor, whereas non-professional interveners refer to nurses performing 
many roles such as caregivers or supporters. This is likely because mothers meet more often 

114 
with nurses, and nurses can have a particular effect on the mother's care for her premature 
infant (Griffin, Wishba, Kavanaugh, 1988). Thus, nurses were the main interveners in this 
research.  
On the basis of the above discussion, the program designed for the nurse’s KC-EP consisted 
of two (2) sessions (first and posttest after the 7th day intervention program), one (1) short 
message reminder and an update. The program was started immediately after the pretest. The 
program included theory (4 hour) and practice (4 hour) during the nurses’ shift in NICU. 
 
3.15.3 Intervention for nurses 
The purpose of this program was to ensure all nurses(n=47) gained knowledge and 
experience on the KC technique, and promoted KC and breastfeeding to the mothers in the 
NICU for at least the first 3 months of their premature infant’s life (corrected age). Pre-
intervention test data (pretest) were collected by the researcher during the first meeting before 
conducting the intervention program (KC-EP). The implementation was carried out by the  
researcher to ensure consistency and equality in the delivery of KC-EP, this would enable the 
researcher to obtain a better understanding of the problems or difficulties that the nurses 
faced. For implementation purposes, this study appointed one senior staff nurse (working 
office hours) to assist the researcher in organizing the intervention process.  
3.15.4 Meeting Place for the KC-EP Activities 
The meeting environment was comfortable, away from the noisy NICU environment. In the 
current KC-EP, the senior staff nurse in charge was given the responsibility of providing the 
nurses with the brief aim of the intervention program and choosing an appropriate time for 
the intervention session based on the schedules (Appendix J&K). The KC-EP time schedule 
for nurses' meetings and the instruments used for nurses are shown in Table 3.3. 
3.15.5 The First Meeting 

115 
The first meeting was held with the nurses to ensure that they had some perception, 
knowledge, and practice of KC. The researcher went through the educational information 
based on the developed KC-EP. The implementation of the KC-EP and the purpose of all the 
questionnaires were carefully explained during the first meeting. Nonetheless, one of the 
senior nurses who was working office hours was not directly involved in the implementation 
of the KC-EP; she was responsible for planning, scheduling, and verifying the date of the first 
meeting and notifying the researcher for post-intervention schedule. It was the role of the 
researcher to ensure that the KC-EP provided was accurate and given equally to all nurses, 
and to collect the data at the first meeting and then post-intervention (Table 3.3). During this 
meeting, the researcher and the nurses discussed openly any matters or problems faced by the 
nurses regarding KC implementation and how to promote breastfeeding. All of the nurses’ 
inquiries were addressed accordingly. The nurses were taught about the theory of the KC 
technique and how to perform KC based on the KC-EP in order toto increase the mother’s 
role, knowledge and skills in caring for her premature. The KC-EP session involved 47 
nurses working in rotating shifts. However, full-day sessions were conducted over the 
weekend. Each session involved 12 to 15 nurses, depending on their availability and shift 
duty. This was for the nurses to acquire similar awareness, knowledge, skills and attitudes 
before being taken to the mothers. The theory was delivered in four sessions and conducted 
twice a week (Friday and Sunday). All nurses on the evening shift were advised to participate 
in the morning session from 8.00 am till 12.00 noon, while those on the afternoon shift were 
advised to join in the afternoon session from 2.00 pm to 6.00 pm. The practical session was 
conducted every Monday, Wednesday, Thursday and Saturday from 8.00 am to 5.00 pm. The 
practical sessions encompassed all aspects of the data collection process, including obtaining 
informed consent, and enhancing usual communication activities between mothers and 
nurses. Premature baby mannequins were used as a teaching aid to demonstrate the KC 

116 
procedures until the nurses were skillful enough to perform proper KC gently, safely and 
effectively for all the skill steps required. A video on the KC procedure (standing and sitting 
transfers of KC) was played to guide the nurses in demonstrating the sitting and standing 
transfers. The researcher explained the KCPR booklet to the nurses and went through the 
booklet with them to emphasize its significance. A checklist was prepared by the researchers 
to evaluate the KC skill steps and the explanations on KC benefits before the procedure was 
implemented. Learning materials, such as leaflets and flip charts (English and Malay 
versions), were prepared by the researchers as teaching aids. 
The entire program was allocated only 8 hours per session due to the nurses’ workload. The 
researcher also sent reminders in the form of short notes to the nurses through WhatApps (4th 
day) to ensure the nurses were alerted about sitting for the posttest on the 7th day post-
intervention according to their schedule.  
3.15.6 Short Message Via WhatsApp. 
To ensure each nurse's awareness of KC implementation and the date of the post-intervention 
test, the researcher sent a short message via WhatsApp to the nurses. This was a reminder for 
the nurses to perform return demonstrations of the KC (standing and sitting transfers) 
program goals to build up their personal beliefs and educate them on how to carry out KC 
and 
how 
to 
encourage 
breastfeeding 
for 
premature 
infants. 

117 
          KCQ=Kangaroo CareQuestionnaire; QII=Questionnaire for nurses; KC-EP=Kangaroo Care Educational Programme; KC=Kangaroo care. 
Days/ Weeks 
Pre - Intervention 
Post - Intervention 
Person in charge 
Instrument  
Activities 
Instrument 
Activities 
 
Day 1 
Simple Orientation 
+ 
KCQs (QII) 
First Meeting 
KC-EP 
(Theoretical 
Session)  
 
 
Researcher 
Day 2 
Routine Ward Activities 
 
Practice on KC skills 
with the checklist 
provided for each of 
the procedure steps 
for all the nurses. 
i) standing & 
ii) sitting transfers  
 
 
Day 3 
 
 
 
Day 4 
 
Short Message: 
WhatApps 
Researcher 
Day 5 
 
 
 
Day 6 
 
 
 
Day 7 
 
 
KCQs(QII) 
Second Meeting 
(Practical Session) 
Demonstration on 
KC  
Researcher 
Table 3.3: Schedule for Intervention and Instrument (KC-EP) for the Nurses 

118 
 
3.16 Data Collection Method 
There were three phases to this study: Phase I, Phase II, and Phase III. Phases included: 
 i)In phase, I, the data (T0, T1, and T2) for the control group of mother-infant dyads was 
collected within six months until the data met the requirements of the study. Data collection 
for the control group's mother-infant dyads started in early February 2018, and continued 
until the end of July 2018. Assessment of function in routine clinical practices in the control 
group of mother-infant dyads and outcomes of premature infants was recorded in the KCPR 
booklet provided for the control group of mothers within the stipulated time and then 
analysed. 
ii)In phase II, one group pretest-posttest for nurses' data collection process was conducted 2 
months after the control group of mothers’ data collection was completed. The data collection 
for nurses and the intervention commenced in early August 2018 and continued to the end of 
September 2018. Quantitative data (Questionnaire II) were collected at pretest, and one week 
after the structured KC-EP was conducted for nurses the posttest data were analyzed. The 
structured KC-EP for nurses included knowledge, skills, and attitude prior to KC guidelines 
and protocol. The specific aims were to educate nurses in the content areas noted above. The 
reasons for implementing a neonatal KC protocol for mother-infant dyads were generally 
considered in terms of the method of holding the premature infant directly, breastfeeding 
rates and looking at the effects of KC outcomes. 
iii) In phase III, the data (T0, T1, and T2) for the experimental group of mother and premature 
infant were collected within seven months. In the experimental group, data collection for 
mother-infant dyads began in early October 2018 and was completed by the end of April 
2019. The KC-EP for mothers was conducted by the nurses in the NICU for them to 
implement KC with their premature infants. The structured KC-EP was comprised of theory 
and practical sessions to fulfill the objectives of this study. The post-intervention assessment 

119 
 
of quantitative data (Questionnaire I) on mother-infant dyad compliance and outcomes of KC 
implementation (KCPR) commenced from the premature infant's recruitment day. The data 
was plotted to begin from the inclusion criteria age until 3-months-old corrected age. 
 
             
 
2 
 
  
 
 
 
3.16.1 Data Collection Method for Mothers in the Control Group 
Based on the day of the preterm infant’s admission to the NICU, the researcher screened and 
recruited its mother into the control group. The mothers and premature infants were 
medically and surgically stable. The researchers chose  mothers who were ready and returned 
after 48 hours to meet those who were interested to participate in the study. The selection was 
determined according to the mother’s and premature infant’s condition (clinically stable and 
eligible to perform KC), while the length of gestation had to be between 28 to 36/6 weeks. 
The study samples were selected from early February 2018 to the end of July 2018, within six 
months of the mothers in the control group. An average of two to four mothers was recruited 
per week. Mothers had to fill out a consent form. Consent was obtained from all mothers 
before they were recruited. The researchers contacted the participants in order to give an 
explanation of what was involved.  
• 
Collection of data outcomes from mother -premature 
infant dyads in control group at T0,T1 and T2 
• 
Collection one group pretest and posttest data from nurses. 
• 
Conduction of structured KC-EP intervention programme for  
nurses 
• 
Collection of data outcomes from mother -premature infant 
dyads in experimental group at T0,T1 and T2 
• 
Conducted KC-EP intervention programme for mothers’ 
6 
months 
2 
months 
7 
months 
Figure 3.2: Flow Chart Showing the Three Phases of Data Collection 

120 
 
Questionnaire I for mothers was provided in an English and bahasa Melayu version. All 
mothers were given the same questionnaire in three phases ; T0, T1, and T2. At T0, all mothers 
were given the questionnaire on a voluntary basis to determine their perspectives on the 
implementation of KC as a baseline. The researchers created an identification code number 
for each of the mothers to be placed on the envelopes. Thus, mothers’ answers could be 
matched for the T0, T1, and T2 questionnaires. The identification code started from MCG01 
(mother control group 01). After a welcome speech and briefing  (10 to 15 minutes), the 
questionnaires were given  to the mothers to fill in and then collected. The mothers in the 
control group were also given a Kangaroo Care Progress Record (KCPR) booklet to record 
weight gain, feeding status, the routine practice of KC in the clinical setting and after 
discharge until 3 months old but without any information or input related to KC. 
The control group mothers came for visits and saw their preterm infants once a day for 30 
minutes to 1 hour, and exercised KC if they were interested. This was the NICU's routine 
practice. The control group of mothers continued routine ward practice and standard hospital 
care. Mothers who declined to participate during the time of the study were excluded. For 
participation in the study, a small token gift was given to (n=48) mother-infant dyads at the 
control group.  
Upon their premature infant’s discharge from the hospital, the mothers were reminded to 
answer the same standardized questionnaire (QI) for T0, T1, and T2. The following posttest 
questionnaires (Questionnaire I: enclosed in the envelope) were given to the mothers at the 
NICU or the Pediatrics Clinic on the 1st and 3rd month, when they came for their premature 
infant’s follow-up, and were returned the same day. Consequently, some of the data were 
collected and sent by email if the mothers could not keep to the time (received on the same 
day). 
3.16.2 Data Collection Method for Mothers in the Experimental Group 

121 
 
The recruitment of the experimental group of mothers was based on premature infant’s day of 
admission to the NICU after data collection from the nurses was completed. This was done to 
keep mothers in the experimental group from being exposed to the control group during their 
hospital stay. Both mothers and premature infants were medically and surgically stable, and 
mothers were willing to perform KC. For the experimental group of mothers, data collection 
was carried out over seven months from early October 2018 to the end of April 2019, after 
the nursing intervention program for nurses (KC-EP) had been completed. An average of two 
to four mothers was recruited per week. 
The mother-infant dyads were recruited within 48 hours, as soon as they were clinically 
stable and eligible to perform KC. Samples were selected by the researcher, who returned 
after 48 hours to meet mothers interested in the study and agreed to complete the consent 
form. Prior to recruitment, consent was sought on a voluntary basis from all (n=48) mothers 
(Appendix B). The researchers explained to the mothers how to answer the questions 
(Questionnaire I) provided in English and Bahasa Malaysia. At T0, the questionnaire was 
given to all participants before the KC-EP was conducted. Each mother had her own 
identification code number put on the outside of the envelope to match Questionnaire I at T0, 
T1, and T2 accordingly. The identification numbers started from MEG01(mother experimental 
group 01).   
In addition, signs of readiness to suckle, characterized by moving the tongue and mouth, and 
the desire for sucking, such as sucking fingers or mother's skin, were observed. As mentioned 
by Nyqvist (2012), early sucking competence is only observed from 29 weeks postpartum age 
onward, with the attainment of full breastfeeding as early as 32 weeks postpartum age. Those 
premature infants born before 32 weeks were given intravenous or nasogastric feeding. 
The experimental group, comprised of mother-infant dyads, received a detailed verbal 
explanation on KC-EP. The contents of the module were verified by health care 

122 
 
professionals, including two neonatalogists, a nursing professor, a nursing lecturer, and three 
head nurses who specialized in neonatal nursing. The contents of the KC module were: the 
meaning of the term KC, benefits of KC, precautions against any abnormality in parameters 
(temperature, respiratory rate (Sao2), heart rate perfusion (color), and tolerating feeding well 
in the 24 hours before performing KC. The program included the showing of videos on the 
KC procedure (standing and sitting transfers). The mothers were prepared with a KC 
information handout and a leaflet on KC associated with the KCPR. The booklet was 
developed based on research articles and health-care professional modules on KC in relation 
to physical, emotional and verbal support, on encouraging mothers to hold their premature 
infant in the right position for KC and on performing KC for the benefit of their premature 
infant. KC was started once the preterm infant had been deemed clinically stable.  Baby 
pouches and diapers were provided to all mothers in the experimental group. The researcher 
developed a personal goal setting self-motivation routine to help mothers achieve the 
potential best practice of KC for their preterm infants. Self-motivation is a vital part of 
emotional intelligence and something that is needed by any mother involved in doing KC. It 
keeps mothers motivated to undertake KC with a minimum period of 1 hour a day during day 
and night, accumulating to 4 to 5 hours per week. For preterm infants undergoing intravenous 
fluid therapy, mothers were expected to sit in a comfortable chair near the incubator or cradle 
of the preterm infant (to facilitate sustained KC). 
Data on weight gain (body weight in grams), KC duration in a week (hour/per week), and 
breastfeeding status (weeks) were collected from T0 to T2. Additionally, the experimental 
group of mothers maintained documentation of the outcomes of their preterm infant from the 
day of recruitment until the infant was 3 months old. The diaries provided information on the 
prospective longitudinal progress outcomes of the premature infants. Each KCPR booklet 
was labeled as an experimental group progress record and included the identification code 

123 
 
number of the mother-infant dyad. However, if the mother was unable to record the data, she 
instructed a close family member to help at home.  
Lastly, the same quantitative data was collected from the mothers at T1 and T2 post structured 
KC-EP. In order to assess the mothers’ perspectives on KC performance, perception, 
knowledge, perceived barriers, and stress were determined. The program was constructed for 
the introduction of KC into the NICU as a standard care procedure. Therefore, after the return 
home or at least for the first 3 months of the preterm infant's life, KC should be continued. 
3.16.3 Mothers’ Outcome Variables 
Quantitative data on mothers’ data were obtained in Phase I and Phase III. The outcome 
variables were perception, knowledge, perceived barriers in relation to KC, and stress related 
to admission of preterm infant to the NICU. These variables were assessed three times from 
T0, T1 to T2. The mothers were instructed to complete Questionnaire I within 10 to 15 
minutes without any reference to resources. Firstly, Questionnaire I was delivered at T0; 
before the KC-EP for mothers started. Next, the mothers were instructed to answer the same 
structured set of questions in Questionnaire I at T1 and T2 for the post-intervention data. 
Monitoring the level of personal belief regarding KC at T0, T1 and T2, helps mothers to 
maintain compliance with KC until their premature infant is 3 months old corrected age. KC, 
together with breastfeeding, may continue until the infant is 6 months old and breastfeeding 
combined with solid foods until the infant is 2 years old. 
3.16.4 Method of Data Collection for Infants 
The researcher recruited the control group of premature infants first and then the 
experimental group after the nursing intervention program had been completed. The preterm 
infants in both groups were recruited based on infant admission days and according to 
mother-infant dyad condition. Firstly, all preterm infants between 28 and 36 + 6 days of 
gestation (n=48) were recruited by the researchers to participate in the study. The first 

124 
 
recruitment was assigned to the control group. The second recruitment of preterm infants who 
conformed to the inclusion criteria, i.e. clinically stable and ready to perform KC, was 
assigned to the experimental group (n=48) after written consent was given by their mothers. 
Those whose mothers refused to participate were excluded from the study. In the 
experimental group, data from the preterm infants were collected from the recruitment day 
until they reached 3 months old. A total of 48 newborn preterm infants from the same setting 
were given routine care (under servo-controlled radiant warmer or in a cradle with room 
heaters or blankets) and matched by corrected age. Feeding mode at admission to either 
group was monitored and jotted down, according to the route of feeding: tube feed, spoon-
feed or breastfeeding. Before allocation to a group, it was ensured that the preterm infant was 
tolerating enteral feeds (over 24 hours) and had no regurgitation at age 28 to 36+6 day weeks 
of gestation. Corrected age was calculated using the Premature Baby Corrected Age Formula 
and classified between 28 to 36+6 days weeks of gestation. The baseline weight was 
calculated from the birth weight and weight on recruitment at T0, and outcome weight gain 
calculated from the weight on discharge, T1, and T2; this was recorded in the KCPR booklet 
provided. The body weight of the preterm infant was documented, after removing its clothes, 
using an electronic weighing scale with an accuracy of 5g at least 2 hours after the last feed 
and twice a week on Tuesdays and Saturdays according to the hospital protocol for weighing 
babies. Body weight was measured using a T- scale machine and recorded in grams (g). 
After the preterm infants were allocated to the control group or experimental group, they 
were observed daily, and all observations related to the outcomes of the study were 
documented in the KCPR booklet i.e. velocity of weight, temperature before, during and 
after, mode of feeding, type of milk taken and duration of KC provided (in hours/day/week), 
date of admission and date of discharge in days. In the study by Biswas, Malpani & Ekka, 
(2016) temperature measurement was taken 10 minutes after KC. However, in this study the 

125 
 
temperature measurement was taken 10 minutes before, 20 to 30 minutes during KC and 10 
minutes after the implementation of KC and a regular clinical examination was given in a 
minimal period of time to avoid hypothermia and cold stress. In the experimental group, 
duration of KC (in an hour/day) was measured from an accumulated daily 1 hour per day, 4 
to 5 hours a week. However, according to Ludington-Hoe, Susan, Morgan, K. & 
Abouelfettoh (2008), KC is best provided 1 hour a day and 7 days a week until discharge. KC 
was continued until the premature infant was 3 months old, according to the study 
requirements. If any problems were detected during KC, they were either rectified or the 
preterm infant was disqualified from the study. Premature infants were discharged when they 
showed a good sucking reflex with breast or bottle feeding and had been gaining weight of 
more than 15g/day to 20g/day for at least three successive days and had achieved a 
predetermined weight of 1.7kg, in accordance with hospital protocol. On discharge, the 
nurses routinely advised mothers to come for follow-up until their infant had reached a 
weight of 2500 grams and to continue breastfeeding. For primary and secondary outcomes, 
the data from both groups were collected at T0, T1, and T2. The premature infants were 
followed-up until they were discharged. Conversations and communication between mothers 
and researchers continued through telephone calls or Whatsapp chat groups accordingly. All 
related information on KC was shared through the WhatsApp chat group among mothers in 
the experimental group so that they would remain KC compliant and continue KC at home. 
a) Infant Outcome Variables Data   
In Phase I and Phase III, the outcome data were collected from the control group and 
experimental group of infants. The outcome data were recorded continuously from the day of 
recruitment at the corrected age of between 28 to 36/6 weeks of gestation in the NICU until 
the infants reached 3 months old after discharge. At any stage, if a premature infant in the 
experimental group did not meet the requirements for research (e.g. deteriorated during KC 

126 
 
or needed phototherapy treatment for jaundice), the infant was excluded from the study. 
During the two phases, similar outcome variables and confounding variables were obtained. 
The outcome variables reflected the outcomes of the premature infants. Specifically: 
i) KC implementation duration in hours (in hours; 24 hours = 1 day); The duration of KC in 
the intensive care unit measures the number of hours the infant was attached to or bonded 
with their mother. According to the posttest it was measured in hours and days per week. 
According to the World Health Organization (2003), each KC session should ideally last at 
least 1 hour, in order to get the physiological effects and for brain development and 
maturation. In this study, the researcher decided to practice accumulative 1 hour per day and 
accumulative 4 to 5 hours per week (KC duration). 
ii)Weight gain of the infant in daily weight (in a day;1 day = 24 hours) 
The weight gain of the premature infant represents the amount the infant’s weight increased 
or decreased in a day. 1 day equal to 24 hours. 
iii) The decrease in hospitalization stay or Length of hospitalization stay (LOS) in the NICU 
(in a day;1 day =24 hours); 
The length of stay at the NICU measures the number of days the preterm infant was admitted 
to the intensive care unit and was treated in a day, 1 day equivalent to 24 hours. iv) 
Confounding variables 
All standard demographic and clinical measures assessed by preterm infants with critical care 
were collected, including: 
 • demographic data: gestation, age, gender, ethnicity and weight gain for infants;  
• type of milk (breastfeeding or formula milk) 
• duration of feeding status i.e. week started and week discontinued breastfeeding and mode 
of  feeding, bottle, or spoon-feeding. 
3.17 Method of Data Collection for Nurses 

127 
 
The nurses were screened and recruited based on universal sampling. Method of data 
collection for nurses was similar to that for mothers, whereby, prior to the KC-EP for nurses, 
pretest data on nurses’ perception, knowledge, and practice were collected using the KCQ 
tool in Questionnaire II. The data for nurses were collected within a 2 month period from 1st 
August 2018 to 30th September 2018 for the pretest-posttest groups of nurses. The researchers 
briefed the nurses and encouraged them to take part in the study by presenting verbally brief 
information to the head nurse in charge of the unit, with two forms of consent given to the 
nurses on the same day as the pretest program. All nurses who attended were recorded with 
their name, identification code number, date of attendance and signature in order to plan the 
date for their following posttest. To ensure confidentiality and privacy, each returning 
questionnaire was assigned an identification code number. The consent form together with 
the questionnaire was stamped, starting with nurse 01(N01), with the code number in the top 
right corner. If the nurses refused to continue with the study, they were instructed to notify 
the researcher and ask for a withdrawal. Upon receiving an application for withdrawal from 
the study, the researcher found and destroyed the questionnaire, which was submitted based 
on the code number. The pretest (Questionnaire II) was given to all nurses before the KC-EP 
was administered to them. The nurses were instructed to complete Questionnaire II, which 
took approximately 15 to 20 minutes to complete, without reference to any resources before 
the KC-EP session for nurses was conducted. Nurses were asked to return the questionnaires 
upon completion, with one copy of the informed consent. All nurses were advised to keep 
one copy of the informed consent for their records. Following the completion of the KC-EP, 
the nurses were told of the posttest sit after the 7th day of the pre-test and intervention 
program. The same structured Questionnaire II was administered to the nurses at the posttest. 
Data collection among nurses was conducted within the stipulated time.  

128 
 
All 47 nurses needed to demonstrate KC skills, attitudes, and knowledge for practical 
evaluation and assessment. The knowledge, skills, and attitudes of nurses towards the 
implementation of KC were observed during the practical return-demonstration session to 
improve the quality care of preterm infants. The current research attempted to determine 
whether the nurses were more likely to support KC for the mother of a preterm infant. The 
marks were classified as pass or fail. The nurses received one (1) accredited certificate related 
to the KC course upon completion of the structured KC-EP course evaluations. A 6-point 
Continuous Professional Development (CPD) certificate recognized by the Malaysian 
Nursing Board was issued to all nurses attending the KC-EP; the KC-EP on knowledge, 
attitude, and skills was passed successfully. Examples of the KC-EP schedules for nurses are 
shown in (Appendix I & J). All of the data collected at the pretest was intended to assess 
nurses' previous knowledge on KC before they were introduced to the KC technique in the 
NICU setting. The questionnaire was collected before the KC-EP was delivered. The posttest 
for nurses was conducted on the 7th day after the KC intervention program(KC-EP). The 
nurses also answered the same set of questions in Questionnaire II and demonstrated their 
skills in relation to KC procedure: standing and sitting transfers with a checklist provided to 
evaluate their knowledge, skills and attitude regarding encouraging mothers to perform KC 
and continue breastfeeding, 
3.17.1 Nursing Outcome Variables 
The data for nursing outcomes were collected in Phase II, historical control data were 
collected through a retrospective nurse audit of knowledge and skills in relation to KC 
management practices and assessing data on KC implementation techniques among mothers 
with premature infants. The nurses’ perception, knowledge, and practice in relation to KC 
implementation were assessed using a set of structured questions, Questionnaire I for nurses, 
via a pre-test and then reassessed in a 7th day post-test following the program.  

129 
 
The researcher briefed the nurses and invited them, through a verbal briefing to the head 
nurse in charge of the selected unit, to participate in the study. On the same day as the pre-
test, the Questionnaire I was given to the nurses, with two consent forms. Name, 
identification code number and date of attendance of the nurses who attended were recorded 
in order to plan the follow-up date for the post-test. The returned questionnaire was given an 
identification code number to ensure confidentiality and privacy. The consent form, including 
the questionnaire, was stamped in the right top corner with the code number, starting with 
nurse 01(N01). When nurses declined to continue the study, they were told to contact the 
researcher to ask for a withdrawal. Upon receiving an application for withdrawal from the 
study, the researcher destroyed the questionnaire, which was submitted based on the code 
number. All nurses were instructed to sit for the post-test on the 7th day after the pretest. The 
nurses were instructed to complete Questionnaire I for the pretest, which took about 15 to 20 
minutes to complete, without referring to any resources before the KC-EP for nurses was 
conducted. Nurses were asked to return the questionnaires upon completion, together with 
one copy of the informed consent document. All nurses were expected to keep one copy of 
the informed consent form in their records. On the 7th day, the nurses were told to answer the 
same set of questions that had been used in the pretest. It was anticipated that an interval of 7 
days would enable the posttest group nurses to translate their theoretical expertise into action 
and gain experience in evaluating, managing, and promoting the implementation of KC and 
also breastfeeding for mother-infant dyads through hands-on practice in the NICU 
environment.  
3.18 Data Collection Procedures 
The ethical review was approved by the Medical Research Ethics Committee (MREC) with 
registered no: 201765-5310 before the study began. Formal permission was given by the 
management of UMMC, where the study was conducted, following a letter of request to 

130 
 
conduct research. Once permission was obtained, the unit managers were approached for 
permission to conduct the study in their respective units. The participants were assured their 
confidentiality and safety would be maintained and that there would be no exploitation of 
human rights or discrimination of any type based on the information given. After permission 
was granted, the researchers began selecting the participants (infant-mother dyads and nurses) 
based on the requirements of the inclusion and exclusion criteria. The researcher introduced 
herself and informed each of the participants about the nature of the study to ensure greater 
cooperation and to establish effective documentation throughout the data collection process. 
The researcher approached each participant individually and explained the study's purpose 
and how it would benefit them. Participants who showed a willingness to participate were 
selected as samples for this study. Each participant had a coding number assigned to ensure 
the anonymity and confidentiality of the information provided, and written informed consent 
was obtained. Two copies of the consent forms were given to both mothers with premature 
infants and nurses on the same recruitment day to obtain their consent to participate in the 
study. All participants were advised to keep in their records a copy of the informed consent 
form. The nurse participants were selected to be samples in this study using the universal 
sampling technique, which means the sample would represent the population of nurses in the 
NICU, while the infant-mother dyad participants were recruited based on infant-mother 
admission to the control group, or to the experimental group.  
Firstly, the researcher collected a group of participants from the infant-mother dyads for the 
control group and made them comfortable. An orientation to the study was given before  
administering  Questionnaire II, which required approximately 10 to 15 minutes to complete.  
All mothers were instructed not to interact or communicate while answering the 
questionnaire. On the same day, participants were asked to return the completed 
questionnaires to the researcher. An identification code number was provided for each 

131 
 
returned questionnaire to ensure confidentiality and privacy. The consent form and the 
questionnaire were stamped at the top right corner with the code number, for each set of 
questionnaires (T0, T1 and T2), starting with control group 01 (CG01) for the control group of 
mother-infant dyads. The pretest and posttest used the same structured Questionnaire II for 
baseline data from the mother-infant dyads in the control group.  However, this group did not 
receive any special education program or any input related to KC from the researcher. All 
mothers were informed to answer the post-test questionnaire within the stipulated time of 1 
month and 3 months after the discharge of their infant from the NICU.  The collection of data 
from the control group of mothers was completed within six months, starting from early 
February 2018 to the end of July 2018. 
Next, the researcher collected the group of participants from among the nurses, made them 
comfortable, and orientated them to the study.  She then administered the structured 
quantitative-based Questionnaire II for nurses. All nurses were instructed not to interact with 
each other, and their doubts were clarified. The questionnaire took 10 to 15 minutes to 
complete; after completion the researcher asked the nurses to return the pre-test 
questionnaires as well as a copy of the informed consent form. All nurses were instructed to 
keep one copy of the informed consent form for their records. On the same day, nurses were 
asked to return the completed questionnaire to the researcher. Each questionnaire returned 
was given an identification code number to ensure confidentiality and privacy. For each set of 
questionnaires (pretest and post-test), the consent form and the questionnaire were labeled 
with a code number, beginning with N01 for the nurses, at the right top corner. The nurses’ 
baseline data were gathered on demographic characteristics and KCQ tools (perception, 
knowledge and practice) regarding the KC technique. After the pre-test phase, the structured 
kangaroo care educational program (KC-EP) for nurses was conducted within two weeks for 
all n=47 nurses. The program was delivered in English for the theory, and the practical 

132 
 
session included the showing of videos related to the KC transferring technique by the 
researcher. All nurses were informed to sit for the required post-test on the 7th day after the 
pretest phase and the KC-EP teaching module. The same structured Questionnaire I was 
administered at the post-test, and nurses were required to demonstrate the KC standing and 
sitting procedure. A checklist was provided for each nurse to assess her confidence and skills 
in relation to the KC technique. The collection of nurses’ data lasted from 1st of August 2018 
until the 30th of September 2018.  
 
Finally, the researcher recruited a group of mothers with premature infants for the 
experimental group, returning to them in 48 hours. The researcher orientated the mothers to 
the nature of the study and administered Questionnaire I for the pretest, which required 10 to 
15 minutes to complete. All mothers were instructed to not share or discuss anything with 
other group members and if discussion took place  their  were disqualified to continue the 
study. Once the questionnaires were completed they were collected by the researcher; the 
mothers required 10 to 15 minutes to complete Questionnaire I. The infant-mother 
participants’ baseline data were gathered regarding demographic characteristics and KCQs 
tool (perception, knowledge, perceived barrier and stress level) for the pretest on KC 
technique. After the pretest, the mothers in the experimental group obtained information on 
KC in a group of two to four participants via the face to face teaching method; each group 
was accompanied by two of the nurses who were available in the NICU at that period of time. 
The KC-EP for mothers was conducted by the researcher and included a theory and practical 
session. The mothers were requested to answer the posttest at the 1st month and 3rd month of 
their premature infant’s life after their discharge from the hospital. The same Questionnaire I 
was provided to the mothers for the posttest data. The collection of data from the mothers 

133 
 
was carried out within the stipulated time.  After the data gathering process, the researchers 
thanked all the study participants as well as the authorities for their cooperation. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                    
 
 
 
Define the Research Topic 
Literature Review 
Problem Statement & Research Objectives 
Adopting Questions And Instruments 
Approval Obtained 
Pretest and Pilot Study (Mothers & Nurses) 

134 
 
                        
 
 
 
 
 
 
 
 
 
 
            
 
 
 
 
 
 
 
                       
 
 
 
 
 
 
                                            Figure 3.3: Flow Chart for Data Collection  
3.19 Data Analysis 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Screening & Consent from Mother-Infant 
Dyads (Control) 
Phase I: Data Collection & Analysis for Control Group Mother 
 Development of KC-EP for Nurses & Mothers 
Intervention KC-EP for Nurses 
Screening & Consent from Nurses 
Phase II: Data Collection & Analysis for Nurses 
Intervention KC-EP for Experimental Group (Mothers’) 
Phase III: Data Collection & Analysis For 
Experimental Group (Mothers) 
Result & 
Conclusion 
Screening & Consent from Mother-Infant 
Dyads (Experimental) 

135 
 
Analytical processes used to address the research questions and the quantitative data are 
presented below. 
3.19.1 Analysis of Quantitative Data 
Graduate Package 23.0 of the Statistical Package for Social Sciences (SPSS) provided tools 
to analyze the data required to achieve the research objectives: 
In the pretest of dependent variables, data from the mothers and infants were evaluated for 
homogeneity, normality, variability, and data normality in the pretest. Nevertheless, the 
variance test for the nurses' data was not homogeneous since we were dealing with the same 
group, the data were normally distributed and the variances between the groups were equal, 
and the sample size was acceptable (no less than 30 cases per group). The number and 
proportion were stated as continuous variables and categorical variables. Continuous 
variables were compared for normally distributed variables ('mothers' and 'infants') using the 
independent t-test and variance analysis (ANOVA/ANCOVA). Pearson's chi-square test was 
used because the independent variables were nominal categorical variables. The Chi-square 
test was applied with normally distributed data to establish associations between independent 
variables, such as age, years of service as RN, years of working in NICU and educational 
qualification level, and dependent variables: perception, knowledge and outcomes 
improvement: weight gain, length of hospitalization stay and breastfeeding rates. In addition, 
the Shapiro-Wilk test was used to test data normality for both the pre and post-test, as the 
sample was below 50 per arm. To assess the effect of the structured kangaroo care 
educational program (KC-EP) on mothers’, infants’ and nurses’ outcomes, for the data on 
mothers, infants and nurses, the general linear model (GLM) univariate analysis of variance 
and covariance analysis was used. GLM and repeated measures were used to analyze the 
main effects and interaction effects of KC outcome variables, and to examine the hypotheses 
of the outcomes. 

136 
 
Table 3.4: Summary of Statistical Analysis of Quantitative Data Plan 
No. 
Objectives 
Measurement  
Variables 
Statistical  
analysis 
1. 
Are there any statistically significant 
differences 
in 
mothers' 
perception, 
knowledge, perceived barriers regarding 
KC, and stress related to ‘premature 
infants 
admission 
to NICU 
 
after 
participation in the KC-EP? 
Perception, 
knowledge, perceived 
barriers and stress 
related to premature 
infants’ admission to 
NICU mean scores 
Effect of KC-EP  
KC performance 
 (Ordinal data) 
 
Descriptive - mean, 
SD, skewness and 
kurtosis 
Chi-square test, 
GLM, 
repeated measure 
(RM) & Pearson Eta 
Squared. 
 
2. 
Does kangaroo care improve weight gain 
patterns in premature infants between 
control and experimental groups at T0, T1, 
and T2? 
Weight gain patterns 
(grams) mean score 
KC compliance  
Duration (hours/weeks) 
Frequency and   
Percentage  
(Continuous data)  
 
Descriptive – mean, 
SD, skewness and 
kurtosis 
Chi-square test, 
GLM and t-test. 
3. 
Does kangaroo care decrease the length of 
hospitalization stay for premature infants 
between control and experimental groups? 
Length of 
hospitalization stay 
Frequency and 
percentage 
(Continuous data) 
Descriptive – mean, 
SD, skewness and 
kurtosis 
Chi-square test, 
GLM and test 
 
4. 
Does 
kangaroo 
care 
improve 
breastfeeding rates for premature infants 
between control and experimental groups? 
 
Breastfeeding rates 
KC compliance 
Frequency and   
percentage 
(Continuous data) 
Descriptive – mean, 
SD, skewness and 
kurtosis 
Chi-square test, 
GLM and t-test. 
 
5. 
Are there any statistically significant 
differences in nurses’ perception, 
knowledge, and practice regarding KC 
before and after participation in the KC-
EP? 
Perception, knowledge, 
practice mean scores 
Effect of KC-EP  
(Ordinal data) 
Descriptive - mean, 
SD, skewness and 
kurtosis 
Independent t-test 
GLM, RM & Pearson  
Eta Squared. 
 
 
The key influence of an explanatory variable is its direct effect on the outcome variables 
(Field, 2011). Additionally, the effects of covariate and covariate interaction with KC can be 
included in GLM univariate analysis. This covariance analysis is an extension of the variance 
analysis to include a covariate/confounder component (Field, 2011). This covariance is 
linearly related to the dependent variable, and its inclusion in the analysis will minimize the 
error associated with the covariance analysis (Field, 2011). The test is appropriate since 

137 
 
categorical variables are both independent and dependent variables. Therefore, covariance 
analysis was used to correct the observed effects on the outcome variables of potential 
confounders. The summary of the statistical analysis used for all research questions is 
outlined in Table 3.14. Each of the statistical tests is two-tailed. A p-value below 0.05 was 
assumed to show statistical significance. 
3.19.2 Pre-testing 
Pre-testing of the instrument is an important stage since pre-testing results will indicate 
whether the survey can meet the study's objectives (DeMaio, Bates, Ingold, & Willimark, 
2006). Pre-testing was performed in this study to verify the accuracy of the directions and 
items in the questionnaire. The objectives of the questionnaire pre-test were:  
• 
To detect the uncertainties, misinterpretation, or other inadequacies in the 
questionnaire. 
• 
To estimate the time required to answer the various items in the questionnaire. 
• 
To ensure the time required to answer the various items in the questionnaire. 
• 
To ensure that it does not contain any sensitive questions. 
• 
To improve the reliability, quality and validity of the instrument and 
• 
To identify any weakness in structure and instrumentation (Cooper,Schindler, & 
Sun,2003) 
There was one panel of experts, which included two neonatologist consultants and two senior 
nurses lecturers with a Ph.D. In Nursing, 3 neonatal nurses were required to check the content 
and face validity of the KCQ and PSS questionnaires: NICU: P&R questionnaire; the leaflet 
and booklet were checked and vetted for spelling errors, grammatical structure, unclear 
instructions or items, time taken for completion and the reliability estimation. 

138 
 
3.19.3 Validity 
Validity refers to how well the measuring instrument measures the test principles of a 
research study (Burn & Grove, 2009). The first set of questionnaires was adapted from a 
validated questionnaire developed by Ludingtone-Hoe et al., (1999); Angler & Brumbaugh et 
al., (2013). An expert panel examined, reviewed and judged the contents and face-validity of 
the instruments. The panel, consisting of seven health professionals with expertise in 
neonatology care and including two neonatologists, two senior nursing lecturers and three 
senior staff nurses certified in neonatology, reviewed and commented on the consistency, 
accuracy, and relevance of the instrument to clinical practice, validity, and 
comprehensiveness of content. As recommended by the experts, revisions were made: items 
were reworded, and improvements were made to the sentence structure. Nevertheless, this 
study used only 80 items from the quantitative questionnaire. 
The second set of instruments was adapted from a validation tool developed by Miles et al., 
(1992). Revisions were made as proposed by the panel of experts which consist of a 
neonatologist, and two nursing lecturers ( one with neonatal nursing certificate) . Items were 
rephrased and the sentence structure was improved, although a few variables were introduced 
on demographic characteristics. After Questionnaire II (for nurses) and Questionnaire I (for 
mothers) had been validated, it was  translated into Malay, as the national language, so that 
participants can understand the questionnaire.  Content, face validity, forward and backward 
translation were done to ensure the semantic equivalence of the instruments; flip charts 
(English and Malay versions), the leaflet and the KCPR booklet were also validated by an 
expert panel consisting of seven persons, five from the neonatal unit, in a teaching hospital 
and two from the Nursing Department, University Malaya. The panel reviewed and 
commented on the instruments’ relevance to clinical setting practices. 

139 
 
3.19.4 Reliability 
The reliability of the instrument was measured by its stability and equivalence. The reliability 
of the content and construction of the questionnaire in this study were tested during the pilot 
study. A pilot study was conducted on 30 mothers and 50 nurses to test the reliability for the 
total population. The sample of mothers was collected from respondents in the NICU at 
UMMC. The same set of questionnaires was used twice to assess perception, knowledge, 
perceived barriers and stress. Cronbach's alpha (α) was 0.813 for the perception subscale; 
0.873 for the perceived barriers subscale; 0.951 for the sub-scale of stress. Furthermore, 
KR20 for the knowledge subscale was 0.785. The researchers assumed that the translated 
KCQs and PSS: NICU: P&R instruments were reliable during the internal consistency test. 
The Content Validity Index of the KCQs Malay version was 0.95, which was considered 
acceptable. Reliability ensures an instrument has consistent and dependable scores (Creswell, 
2005). In reliability values, the indicators to be measured are Cronbach alpha (α) value, 
person reliability value, individual measurement, and relevant responses (Azrilah Abdul 
Aziz, 2010). Fraenkel and Wallen (1996) reported that the reliability of an item would be 
accepted if the alpha is between 0.70 and 0.99, while Kubiszyn and Borich (2000) indicated 
that an α value within the range between 0.80 and 0.90 should be acceptable. 
The data was analyzed using descriptive statistics, The frequency for continuous data, general 
linear model, and repeated measure was used for categorical data and mean (standard 
deviation). The statistical analysis was carried out using version 23.0 of the SPSS. The 
participants were assured of confidentiality and that the safety of the mothers and premature 
infants was maintained. Care was taken that there was no exploitation of human rights, 
humanity or discrimination of any type. Ethical clearance from the teaching hospital's ethical 
committee was also granted before the study began.  

140 
 
3.20 Pilot Testing 
There were two pilot tests conducted: one to test the questionnaire's validity and reliability, 
and the other to determine the study's feasibility in the actual clinical setting. A pilot study 
was also carried out to test the reliability of the KCQs tool Malay version. For the perception 
section the Cronbach's α was 0.813 to 0.880, the knowledge section 0.793 to 0.785, the 
practice section 0.841, the barriers section 0.873, and the stress section 0.951. The 
researchers concluded that the translated KCQs were reliable during the internal consistency 
test. The Content Validity Index of the KCQ's Malay version was 0.970, which was deemed 
acceptable.  
3.20.1 Pilot Test One (Mothers) 
The mothers’ research instruments were piloted with a group of 30 mothers with preterm 
infants in the NICU using the convenience sampling approach to determine the 
appropriateness and consistency of the questions. The questionnaire was provided in both 
languages, English and Malay, for better understanding in the Malaysian cultural setting. The 
pilot test also provided details about the approximate time needed to complete the survey. 
Participants were separated from the actual analysis so as to minimize the bias of measured 
effect. The data collected from the pilot test were not included in the final analysis of the 
study. The survey instruments were distributed to the respondents, with an explanatory note 
defining the aim of the research, and after a four-week interval, a repeat survey was 
conducted. This was to test instrument reliability and the KC booklet through a test-retest 
procedure. 
The survey contained a blank space for feedback from the participants about clarification and 
the importance of the experimental group questions. Participants were questioned according 
to the items in the questionnaire, and after the pilot no significant changes were made. During 

141 
 
the interview all questions were read out in exactly the same way to all respondents. Then a 
teaching session was provided, primarily to test comprehension and clarity of content, and the 
information was evaluated. The return for the pilot test was 100% (n=30). On the basis of 
comments and feedback from the respondents, minor adjustments were made to rephrase the 
sentence structure in order to avoid ambiguities and misleading participants in responding to 
the knowledge items. Reliability was demonstrated, and construct and face validity was 
established. 
The pilot study also included comments on the KCPR booklet for the control and 
experimental groups in order to assess the depth of understanding of the documentation 
provided after the instrument pilot was completed. The booklet was used as a form of self-
observation for mothers in both groups on KC duration, weight gain and frequency of 
breastfeeding. The aim of this pilot study was to assess the feasibility of using the validated 
KCPR booklet to evaluate knowledge on understanding how to document daily KC duration 
and weight gain. This study also aimed to examine the efficacy of KC's structured standard 
evaluation method in relation to preterm infant outcomes, in particular, the duration of KC 
performance, breastfeeding rates, and length of hospitalization (LOS). Data from 30 mothers 
who met the study criteria were collected from November 2017 to January 2018. Based on 
comments from the pilot study and feedback on outcomes, the instructions on the duration of 
KC, to be performed 1 hour per day and 4 to 5 hours per week (16 to 20 hours per month) 
were simplified. Therefore, compliance with the duration of KC was classified according to 
groups in relation to the amount of KC performed. The groups for KC duration were 
classified into Group 1 (did not provide KC), Group II (1 hour to 5 hours per week), Group 
III (6 hours to 10 hours per week), Group IV (11 hours to 15 hours per week), Group V (16 
hours to 20 hours per week) and Group VI (more than 20 hours per week). Other than that, 
the KC guidelines and protocol were simplified in the flip chart provided, with the aim of 

142 
 
increasing mothers’ understanding of the benefits of KC and the quality of premature infant 
care practice. The alpha reliability was calculated with Cronbach's Alpha, which was between 
0.78 - 0.95 for each of the four constructs as displayed in Table 3.16. The Content Validity 
Index of the KCQ Bahasa Malaysia version was 0.95, which was considered appropriate. The 
final versions of the instruments are set out in Appendices A and B. 
 Table 3.5: Cronbach’s Alpha and KR20 Measure Reliability for Mothers’ Instruments. 
Items 
Alpha values 
Number of items 
a) Perception      
0.813 
20 
b) Knowledge    
0.785 
11 
c) Barriers          
0.873 
19 
d) Stress         
0.951 
7 
 
3.20.2 Pilot Test Two (Nurses) 
A group of 50 nurses was chosen, using the convenient sampling method, as the pilot test for 
the research instrument from 23rd of November 2017 until the 26th of November 2017 during 
a continuous education program at the KL International Neonatology Conference (KLINC) in 
Kuala Lumpur to assess questionnaire appropriateness and clarity. The pilot test also 
provided details about the approximate time required to complete the surveys. Participants 
were excluded from the real study to reduce the bias of measured effect, and data obtained 
from the pilot study were not included in the final analysis. The survey instruments were 
distributed to the respondents, together with an information sheet describing the purpose of 
the study. A blank space was provided for feedback from participants on the clarification and 
quality of the questions for the experimental group. Interviewees were questionned according 
to the items in the questionnaire, and after the pilot no significant changes were made.  

143 
 
During the interview sessions the questionnaires were read out to all participants in precisely 
the same manner. The teaching session was provided once, mainly to evaluate comprehension 
and clarity of content, and testing of knowledge and compliance was conducted. The pilot test 
return was 100% (n=50). Based on the results of the pilot study and feedback from the nurses, 
minor changes were made to redo the sentence construction to prevent misunderstandings and 
misleading participants in responding to the items on knowledge and ventilators. More 
detailed instructions concerning the provision of the experimental group remained 
unchanged, as reliability was demonstrated and constructed, and face validity was 
established. Other than that, the steps in the procedure for sitting and standing transfers in the 
KC guidelines were simplified, with the aim of increasing nurses’ understanding of KC 
procedure and the skills to be practiced. The data, presented in Table 3.15, were collected and 
there was a Cronbach’s Alpha reliability of between 0.79 - 0.90 for each of the five constructs 
as follows: 
Table 3.6: Cronbach’s Alpha and KR20 Measure Reliability For Nurses’ Instruments. 
Items 
Alpha values 
Number of items 
a) Perception 
0.880 
25 
b) Knowledge 
 
0.793 
20 
c) Practice 
0.841 
11 
 
3.20.3 Measure 
The researchers used Arthur J. Angler & Eileen Brumbaugh et al., (2013)'s modified 
Kangaroo Care Questionnaire Survey (KCQs) and adopted the Parental Stress Scale: 
Neonatal Intensive Care Unit (PSS: NICU: P&R) from Mile et al., (1999). The questionnaire 
consisted of 14 basic characteristics of mothers with premature infants and a total of 57 items 
to assess mothers’ perception, knowledge, and perceived barriers in relation to kangaroo care 

144 
 
and their stress levels. Blind forward and backward translation of the questionnaire from 
English to Bahasa Malaysia was carried out. Both the forward and backward translated data 
were checked against the original questionnaire to see if any inconsistencies would require 
further review (Jones, 2001; Wild, 2005). 
The researchers used the modified Kangaroo Care Questionnaire (KCQ) established by 
Arthur J. Angler & Eileen Brumbaugh et al., (2013) for the nurses. The questionnaire 
consisted of nine participant characteristics and a total of 56 items to evaluate the perception, 
knowledge, and practice of KC among nurses. Both forward and backward translated 
questionnaires were checked against the initial questionnaire to see if any differences needed 
further verification (Jones, 2001; Wild, 2005). 
3.21 Summary 
This chapter provides explanations of the methods and design used in this study to respond to 
the research questions. Also presented were explanations of the research principles, samples, 
settings, instruments, procedures, and statistical analysis. The next chapter will discuss the 
study's findings.  
 
 
 
 
 
 
 
 
 

145 
 
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161 
 
Appendix A: Ethical Approval 
 
 

162 
 
Appendix B: Letter for Approval (Head of Pediatric Department) 
 
27hb Julai 2017. 
 
Pengarah, 
Pusat Perubatan Universiti Malaya, 
Lembah Pantai, 
59100, Kuala Lumpur. 
 
Professor Madya Dr. Muhammad Yazid Bin Jalaludin, 
Ketua, 
Jabatan Paediatrik, 
Pusat Perubatan Universiti Malaya, 
Lembah Pantai, 
59100, Kuala Lumpur. 
 
Melalui: Professor Madya Dr. Katijah Lim Abdullah 
 
Ketua, 
              Jabatan Sains Kejururawatan. 
 
Tuan, 
  
PER: PERMOHONAN KEBENARAN UNTUK MENJALANKAN PENYELIDIKKAN 
KEJURURAWATAN DI NEONATAL INTENSIVE CARE UNIT (NICU), JABATAN PAEDIATRIK, 
PUSAT PERUBATAN UNIVERSITI MALAYA 
 
Perkara di atas adalah dirujuk.Sehubungan dengan perkara tersebut di atas, saya Sharmiza Binti Samsudin, 
pelajar Phd dari Jabatan Sains Kejururawatan  Universiti Malaya ingin memohon kebenaran untuk menjalankan 
penyelidikkan di hospital tuan. 
2. 
Tujuan penyelidikkan adalah untuk memenuhi keperluan pengijazahan program Doktor Falsafah, 
Universiti Malaya. 
3. 
Berikut adalah butir-butir mengenai penyelidikkan yang akan dijalankan: 
3.1 Tajuk   
  : The Effectiveness of Kangaroo Mother Care Among Mother With Premature   
                                 Infant  in NICU. 
              3.2 Tujuan  
  : The purpose of the study is to evaluate whether a specific teaching program on         
                                               Kangaroo Care (KC) has significant effects for the infant and the mother. 
 
3.3 Metod kajian   : A quasi-experimental and longitudinal design study (Intervention and  
                                               questionnaire based) 
 
3.4 Target populasi: The mother – infant dyads and all nurses in NICU,UMMC. 
 
3.5 Masa kajian   :  August 2017 till September 2019 
 
3.6 Supervisor 
  : Dr. Azanna Bt Ahmad Kamar (Clinical Supervisor) 
 
                               : Assc. Prof.(Dr.) Katijah Lim Binti Abdullah (Supervisor Nursing Aspect) 
 
 
                 : Dr. Ping Lei Chui (Supervisor Methodology Aspect) 
4.Bersama-sama ini, disertakan satu salinan surat kebenaran daipada Ethics Committee untuk semakkan pihak  
   tuan.Segala pertimbangan dan kerjasama daripada pihak tuan amatlah saya hargai dan didahului dengan  
   ucapan ribuan terima kasih. Sekian. 
 
 
Yang benar, 
 
 
 ………… …………………… 
 
(SHARMIZA BT SAMSUDIN) 
Pelajar PhD, 
Fakulti Perubatan, 
Jabatan Sains Kejururawatan, 
Universiti Malaya. 

163 
 
Appendix C : Letter for Approval from Head of Nursing (NICU) 
 
27hb Julai 2017. 
 
Pengarah, 
Pusat Perubatan Universiti Malaya, 
Lembah Pantai, 
59100, Kuala Lumpur. 
 
Ketua Jururawat, 
Neonatal Intensive Care Unit (NICU), 
Pusat Perubatan Universiti Malaya, 
Lembah Pantai, 
59100, Kuala Lumpur. 
 
Melalui: Professor Madya Dr Katijah Lim Abdullah 
 
  Ketua, 
 
  Jabatan Sains Kejururawatan. 
 
Tuan, 
  
PER: PERMOHONAN KEBENARAN UNTUK MENJALANKAN PENYELIDIKKAN 
KEJURURAWATAN DI NEONATAL INTENSIVE CARE UNIT (NICU), JABATAN PAEDIATRIK, 
PUSAT PERUBATAN UNIVERSITI MALAYA 
 
Perkara di atas adalah dirujuk. 
Sehubungan dengan perkara tersebut di atas, saya Sharmiza Binti Samsudin, pelajar Phd dari Jabatan Sains 
Kejururawatan  Universiti Malaya ingin memohon kebenaran untuk menjalankan penyelidikkan di hospital tuan. 
2. 
Tujuan penyelidikkan adalah untuk memenuhi keperluan pengijazahan program Doktor Falsafah, 
Universiti Malaya. 
3. 
Berikut adalah butir-butir mengenai penyelidikkan yang akan dijalankan: 
 
3.1 Tajuk               : The Effectiveness of Kangaroo Care Among Mother With Premature Infant in  
                                               NICU. 
              3.2 Tujuan             : The purpose of the study is to evaluate whether a specific teaching program on  
                                               Kangaroo Care (KC) has significant effects for the infant and the mother. 
              3.3 Metod kajian   : A quasi-experimental and longitudinal design study (Intervention and    
                                               questionnaire based) 
 
3.4 Target populasi: The mother – infant dyads and all nurses in NICU,UMMC. 
 
3.5 Masa kajian   :  August 2017 till September 2019 
 
3.6 Supervisor 
  : Dr. Azanna Bt Ahmad Kamar (Clinical Supervisor) 
 
 
                : Professor Madya Dr. Katijah Lim Binti Abdullah (Supervisor Nursing Aspect) 
 
 
                : Dr. Ping Lei Chui (Supervisor Methodology Aspect) 
4. Bersama-sama ini, disertakan satu salinan surat kebenaran daripada Ethics Committee untuk semakkan pihak  
    tuan. Segala pertimbangan dan kerjasama daripada pihak tuan amatlah saya hargai dan didahului dengan   
    ucapan ribuan terima kasih. Sekian. 
 
   Yang benar, 
 
 (SHARMIZA BT SAMSUDIN) 
Pelajar PhD, 
Fakulti Perubatan, 
Jabatan Sains Kejururawatan, 
Universiti Malaya. 

164 
 
Appendix D: Mothers’ Consent Form 
                                                    
                                                   
 
 
Mothers’ Consent Form  
You are invited to participate in a research study entitled “The effectiveness of Kangaroo care on low 
birth weight infants in Neonatal Intensive Care Units." The aim of this intervention study is to 
evaluate the effect of KC for infants, mother and nursing outcomes of implementing a quasi-
experimental and longitudinal study to evaluate the effectiveness of KC in low birth weight infants in 
one hospital in Klang Valley, Malaysia: University Malaya Medical Centre. 
The participation in this study is voluntary and you have the right to refuse to participate or 
withdraw at any time without affecting your medical care. Your identity and records as a participant 
in this study will remain confidential with respect to any publications/reporting of the results of this 
study. Your records in connection with this study will be kept confidential to the extent permitted by 
the law. 
With your permission, we will contact you by telephone/whatsapp when your baby are three and six 
months old. 
I confirm that I agree to the following; 
I acknowledge that I have read, or it had been explained to me in a language 
that I understand, the attached Research Participant Information Sheet. 
 
I understand that this study is not intended to be of any direct therapeutic or 
financial benefits to me. 
 
I understand that I am free to withdraw this authorization and to discontinue 
participation in this study at any time. 
 
I understand that such withdrawal will not affect my medical care. 
 
I confirm that I have read, or had read to me, the forexperimental groupoing authorization 
 
I give consent to be contacted by the researcher, by telephone, when my baby are three and 
6 months old. 
 
 
Participant: 
Name: _____________________ 
 
 
 
 Date: _______ 
Signature: __________________ 
Please write down your telephone number: (below) 
............................................................................................ 
Researcher or her representative: 
Name: __________________   
 
                Date: _______  
Signature: _______________ 
 
 

165 
 
Appendix E(a) : Mother’s Questionnaire 
 
                                                                                                      
                               
(English version)                                                                    
QUESTIONNAIRE I : MOTHER     
       
                                                                       
 
Dear Madam, 
Thank you for agreeing to participate in the research. 
The purpose of this research is to evaluate the effectiveness of Kangaroo Care (KC) among 
mother with premature infant in NICU. 
The questionnaire consists of: 
Section A : Demographic Characteristic  
Section B : Part I   
 - Perception on KC 
 
       Part II   
 - Knowledge on KC 
 
       Part III  
 - Barrier on KC 
 
       Part IV  
 - Parenteral Stress Scale: Neonatal Intensive Care Unit  
 
Please answer ALL the questions to the best of your ability and as honestly as possible. 
Thank you for your cooperation and support in this research. 
 
 
 
 
 
 
 
 
 
 
 
 
 
CONSENT FOR PARTICIPANT IN RESEARCH ACTIVITIES 
1. Ms. Sharmiza bt Samsudin has requested my participation in this research. 
 
2. I understand the purpose of this research. 
 
3. I understand that the information obtained is to be used solely for academic purposes. I have 
also been assured of the confidentiality of the information obtained. 
 
4. I understand that I am not forced to participate and it is my right to refuse to take part in this 
research. I may withdraw from the research at any time without penalty or prejudice. 
 
5. I hereby give my informed and free consent to be a participant in this research. 
 
 
Signature :_________________________ 
 
Date         :_________________________ 
 
 
 

166 
 
SECTION A : Demographic Characteristic 
Instruction: Please √ to your response. 
1. Age___________  (Please fill in the blank) 
2. Race 
01. Malay     ⃝                  02. Chinese     ⃝            03. Indian     ⃝           04.Others__________(please specify) 
 
3. Religion 
01. Islam     ⃝                   02. Buddha     ⃝             03. Hindu      ⃝          
04. Others__________(please specify) 
 
4. Marital Status 
01. Married     ⃝               02. Single     ⃝                03. Divorced     ⃝         04. Widowed     ⃝           05. Engaged     ⃝ 
 
5. Delivery type 
01. SVD     ⃝                    02. Caesarean section (CS)     ⃝  
                
6. Parity of mother  
01. Primipara     ⃝            02. Multipara     ⃝ 
 
7. Highest Educational Level 
01. Primary     ⃝               02. Secondary     ⃝          03. Tertiary     ⃝ 
 
8. Occupation status 
01. Working     ⃝             02. Not working     ⃝ 
 
9. Employment sector status 
01. Government      ⃝      02. Private      ⃝  
 
10. Maternity leave status 
01.   60 consecutive days     ⃝                                  02.   30 consecutive days     ⃝ 
 
11. Household income (RM) 
01. 500 – 999      ⃝           02. 1000 – 1499     ⃝           03. 1500 – 1999     ⃝            04. 2000 – 2499     ⃝ 
05. 2500 – 2999     ⃝        06.  ≥ 3000     ⃝                    07. ≥ 4000      ⃝ 
 
2. Breast feeding status 
Do you breast fed or express breast milk (EBM) for your baby? 
01. Yes      ⃝                     02. No     ⃝ 
 
13. Post-partum stress status (pre-post) 
01. Yes      ⃝                     02. No      ⃝ 
 
14.Kangaroo care knowledge 
01. Yes      ⃝                     02. No      ⃝  If Yes;.….….….….….….….….….….….If No:.….….….….….….….….….….….….….…... 
Before you bexperimental groupin completing the survey, please answer the following question, then go on to 
the Section B 
Do you practice KC in NICU? (Circle your response) 
            1 -  NO 
            2 -  YES 

167 
 
SECTION B:  Kangaroo  Care (KC) Survey 
Instruction: Please answer the following questions. Use the following scale for your 
responses.  
5 = Strongly Agree 
4 = Agree 
3 = Neither Agree Nor Disagree 
2 = Disagree 
1 = Strongly Disagree 
 
Part I: Mother’s Perception of KC 
No 
                                                       Statement 
5 
4 
3 
2 
1 
1 
All preterm babies should be allowed to participate in KC reardless of age. 
 
 
 
 
 
2 
All preterm babies should be allowed to participate in KC regardless of weight. 
 
 
 
 
 
3 
Babies receiving IV fluids should NOT be allowed to participate in KC. 
 
 
 
 
 
4 
KC encourages the parenting role. 
 
 
 
 
 
5 
KC enhances the attachment process between mother and baby. 
 
 
 
 
 
6 
KC interrupts babies care giving. 
 
 
 
 
 
7 
KC should be available only to breastfeeding mothers. 
 
 
 
 
 
8 
KC is NOT feasible with some babies.  
 
 
 
 
 
9 
KC keeps mothers too tied to the bedside. 
 
 
 
 
 
10 
KC should be offered to all mothers in the NICU. 
 
 
 
 
 
11 
KC will benefit preterm babies. 
 
 
 
 
 
12 
KC will help mothers feel more confident in caring for their preterm babies. 
 
 
 
 
 
13 
KC will improve the baby’s outcome. 
 
 
 
 
 
14 
KC will interfere with the completion of my tasks. 
 
 
 
 
 
15 
Learning about KC will help me be a better mother. 
 
 
 
 
 
16 
Nurses look forward to introducing KC to a new mother. 
 
 
 
 
 
17 
My babies have adequate time for mother-baby contact without the use of KC. 
 
 
 
 
 
18 
The increased amount of time required to prepare a baby for a KC session is out of proportion to 
the benefits. 
 
 
 
 
 
19 
The teamwork required between nurses and mothers when doing KC is worth the effort.  
 
 
 
 
 
20 
There is NOT enough flexibility in the NICU to allow mothers extended visits (more than 1 
hour) for KC. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

168 
 
Part II: Knowledge on KC  
Instruction: Please answer the following questions to the best of your ability based on your 
own personal knowledge of KC, NOT on its practice. Circle your response that best 
represents to knowledge of KC. Use the following scale for your responses:  
 3 = True  
 2 = False 
 1 = Don’t know 
 
No 
                                                Statement 
True 
False 
Not sure 
1 
Babies appear to be satisfied in KC. 
3 
2 
1 
2 
Babies on phototherapy can participate in KC. 
3 
2 
1 
3 
Babies typically decrease heart rate during KC. 
3 
2 
1 
4 
Babies with peripheral IVs can participate in KC. 
3 
2 
1 
5 
KC has been shown to improve breathing patterns in preterm babies. 
3 
2 
1 
6 
KC is contraindicated in premature babies. 
3 
2 
1 
7 
KC is contraindicated in babies weighing less than 1000 grams. 
3 
2 
1 
8 
KC is now considered safe as an alternative approach to care for preterm babies. 
3 
2 
1 
9 
Most babies experience a decrease in temperature during KC. 
3 
2 
1 
10 
KC increase risk of infection in premature babies. 
3 
2 
1 
11 
KC cause more stress with heart problem babies. 
3 
2 
1 
Part III: Perceived Barriers on KC 
Instruction: Please indicate a very important perceived barrier of KC. Use the following 
scale for your responses:  
5 = Very Influential 
4 = Somewhat Influential 
3 = Neither Influential Nor Non-Influential 
2 = Not Very Influential 
1 = Not Influential at All 
 
No 
                                                         Statement 
5 
4 
3 
2 
1 
1 
Mothers’ reluctance to allow KC. 
 
 
 
 
 
2 
Mothers’ belief that technology (e.g., incubators) is more beneficial to premature babies 
than care a mother can provide. 
 
 
 
 
 
3 
Mothers’ felt no privacy during KC. 
 
 
 
 
 
4 
Mothers’ difficult to assess baby’s readiness for KC. 
 
 
 
 
 
5 
Mothers’ reluctance to initiate KC. 
 
 
 
 
 
6 
Mothers’ reluctance to participate in KC. 
 
 
 
 
 
7 
Mothers’ is frequently unavailable to do KC. 
 
 
 
 
 
8 
Mothers’ fear of safety for babies below a certain weight. 
 
 
 
 
 
9 
Mothers’ fear of low temperature during KC. 
 
 
 
 
 
10 
Mothers’ fear of baby’s does not breastfeed during KC. 
 
 
 
 
 
11 
Mothers’ feel inability to provide adequate time to other children during KC. 
 
 
 
 
 
12 
Mothers’ belief that KMC is used for babies who are NOT developmentally well. 
 
 
 
 
 
13 
Mothers’ discomfort with exposing their chest during KC. 
 
 
 
 
 
 14 
Mothers’ belief that will be much disturbance to the baby during KC. 
 
 
 
 
 
15 
Mothers’ unable to come to visit the baby for a long period of time. 
 
 
 
 
 
16 
Mothers’ felt nursing staff reluctance to participate in KC. 
 
 
 
 
 
17 
Mothers’ feel that KC adds a burden to nurses, inadequate time due to working 
commitment. 
 
 
 
 
 
18 
Mothers’ felt that KC makes it difficult to nurses to administer care. 
 
 
 
 
 
19 
Mothers’ felt the nursing staff’s lack of exposure for mothers participating in KC. 
 
 
 
 
 
 

169 
 
 Part IV:  PARENTAL STRESS SCALE: NEONATAL INTENSIVE CARE UNIT 
Instruction:  On the questionnaire, circle the single number that best expresses how stressful 
each experience has been for you. The numbers indicate the following levels of stress: 
 
5 = Extremely stressful 
 
  
4 = Very stressful 
 
3 = Moderately stressful 
 
2 = A little stressful  
1 = Not at all stressful the experience did not cause you to feel upset, tense, or anxious 
 
 
No 
                                   Items 
 5 
 4 
3 
2 
1 
 1. 
Being separated from my baby  
5 
4 
3 
2 
1 
 2. 
Not feeding my baby myself 
5 
4 
3 
2 
1 
 3. 
Not being able to care for my baby myself (for example, diapering, bathing) 
5 
4 
3 
2 
1 
 4. 
Not being able to hold my baby when I want 
5 
4 
3 
2 
1 
 5. 
Feeling helpless and unable to protect my baby from pain and painful procedures 
5 
4 
3 
2 
1 
 6. 
Feeling helpless about how to help my baby during this time 
5 
4 
3 
2 
1 
 7. 
Not having time alone with my baby 
5 
4 
3 
2 
1 
 
 
             _____________Thank you for your participating in this study ______________ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

170 
 
Appendix E (b): Questionnaire Mother (Malay Version) 
 
                                                                                                       
     SOAL SELIDIK II: IBU     
                                                                       
Puan yang dihormati, 
Terima kasih kerana bersetuju untuk mengambil bahagian di dalam kajian ini. 
Tujuan kajian ini adalah untuk menilai keberkesanan Kangaroo Care (KC) di kalangan ibu 
dengan bayi pra-matang di NICU. 
Soal selidik ini terdiri daripada: 
 
Bahagian A  :   Ciri-ciri  demografi 
Bahagian B  :  Bahagian I    - Persepsi terhadap KC 
Bahagian II   - Pengetahuan terhadap KC 
Bahagian III - Halangan terhadap KC 
Bahagian IV - Skala Stres Parenteral : Unit Rawatan Rapi Neonatal 
Sila jawab SEMUA soalan dengan jujur dan paling tepat.Terima kasih diatas kerjasama dan 
sokongan anda dalam kajian ini. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
KEBENARAN UNTUK MENYERTAI DALAM AKTIVITI PENYELIDIKAN 
 
1. Puan Sharmiza bt Samsudin telah memohon penyertaan saya didalam kajian ini. 
 
 
2.      Saya memahami tujuan kajian ini. 
 
3.  Saya faham bahawa maklumat yang diperoleh hanya boleh digunakan untuk tujuan   
 akademik. Saya juga telah dijamin kerahsiaan maklumat yang diperoleh. 
                  
4. Saya faham bahawa saya tidak dipaksa untuk mengambil bahagian dan adalah hak saya untuk 
menolak untuk mengambil bahagian dalam penyelidikan ini. Saya boleh menarik diri dari 
penyelidikan pada bila-bila masa tanpa hukuman atau prejudis. 
 
5. Dengan ini saya memberikan kebenaran dan maklumat percuma saya untuk menjadi peserta 
dalam penyelidikan ini. 
 
Tandatangan :_________________________ 
 
Tarikh              :_________________________ 
 
 
 
 

171 
 
Seksyen A : Ciri-ciri  Demograpik 
Arahan      : Sila tandakan √ pada respon anda. 
 
1. Umur___________ (sila isi tempat kosong) 
 
2. Bangsa 
 
01. Melayu      ⃝                02. Cina       ⃝                 03. India     ⃝           04. Lain-lain __________ (sila nyatakan) 
 
3. Agama 
 
01. Islam     ⃝                    02. Buddha      ⃝              03. Hindu     ⃝        04. Lain-lain __________ (sila nyatakan) 
 
4. Status Perkahwinan 
   
01. Berkahwin     ⃝           02. Belum berkahwin     ⃝       03. Bercerai     ⃝         04. Janda     ⃝          05. Bertunang      ⃝ 
 
5. Kelahiran secara 
 
01. Normal     ⃝                02.  Pembedahan     ⃝ 
                
6. Status kelahiran ibu 
 
01. Kelahiran pertama kali     ⃝             02. Kelahiran lebih dari satu kali     ⃝ 
 
7. Tahap Akademik 
 
01. Sekolah Rendah     ⃝             02. Sekolah Menengah     ⃝             03. Universiti      ⃝ 
 
8. Status pekerjaan 
01. Bekerja      ⃝                          02. Tidak bekerja      ⃝ 
9. Status sektor pekerjaan 
01. Kerajaan      ⃝                        02. Swasta     ⃝  
10. Status cuti bersalin 
01. 60 hari berturut-turut     ⃝           02. 30 hari berturut-turut      ⃝     03. 90 hari berturut -turut 
11. Pendapatan isi rumah (RM) 
01. 500-999     ⃝                  02. 1000-1499     ⃝                 03. 1500-1999     ⃝        04. 2000-2499     ⃝ 
05. 2500-2999     ⃝                 06. ≥ 3000     ⃝                       07. ≥ 4000     ⃝    
12. Status penyusuan susu badan. 
Adakah anda menyusu atau memerah susu (EBM) untuk bayi anda? 
01. Ya      ⃝                     02.Tidak     ⃝ 
13. Status stres selepas bersalin (pre-pos) 
       01. Ya     ⃝                       02. Tidak     ⃝ 
Sebelum anda mula melengkapkan soal kaji selidik ini, sila jawab soalan berikut, kemudian pergi ke Seksyen B. 
Pernahkah anda mengamalkan KC ? (Bulatkan jawapan anda) 
               1        -    YA               2       -    TIDAK     

172 
 
SEKSYEN B : Kangaroo Care (KC) Survey 
 
Arahan : Sila jawab soalan-soalan berikut. Gunakan skala berikut untuk jawapan anda. 
 
5 = Sangat Setuju 
4 = Setuju 
3 = Berkecuali 
2 = Tidak setuju 
1 = Sangat Tidak Setuju 
 
Bahagian I : Persepsi terhadap KC 
No 
                                                       Statemen 
5 
4 
3 
2 
1 
1 
Semua bayi pramatang harus dibenarkan untuk mengambil bahagian dalam KC tanpa 
mengira usia. 
 
 
 
 
 
2 
Semua bayi pramatang harus dibenarkan untuk mengambil bahagian dalam KC tanpa 
mengira berat badan. 
 
 
 
 
 
3 
Bayi yang menerima cecair Intra Vena TIDAK harus dibenarkan untuk mengambil 
bahagian dalam KC. 
 
 
 
 
 
4 
KC menggalakkan peranan keibubapaan. 
 
 
 
 
 
5 
KC meningkatkan proses sayang antara ibu dan bayi. 
 
 
 
 
 
6 
KC mengganggu penjagaan bayi. 
 
 
 
 
 
7 
KC hanya perlu diberi kepada ibu-ibu yang menyusukan anak sahaja. 
 
 
 
 
 
8 
KC TIDAK dilaksanakan kepada sesetengah bayi. 
 
 
 
 
 
9 
KC menyebabkan ibu perlu sentiasa terikat berada disisi bayi. 
 
 
 
 
 
10 
KC perlu ditawarkan kepada semua ibu-ibu di NICU. 
 
 
 
 
 
11 
KC akan memberi manfaat kepada bayi pramatang. 
 
 
 
 
 
12 
KC akan membentu ibu berasa lebih yakin dalam menjaga bayi pramatang mereka. 
 
 
 
 
 
13 
KC meningkatkan pertumbuhan yang baik kepada bayi. 
 
 
 
 
 
14 
KC akan mengganggu saya menyelesaikan tugas-tugas saya. 
 
 
 
 
 
15 
Belajar mengenai KC akan membantu saya menjadi ibu yang lebih baik. 
 
 
 
 
 
16 
Diharap jururawat dapat memperkenalkan KC untuk ibu yang baru. 
 
 
 
 
 
17 
Bayi saya mempunyai masa yang mencukupi untuk bersentuhan diantara ibu dan bayi 
tanpa menggunakan KC. 
 
 
 
 
 
18 
Jumlah masa yang diperlukan untuk menyediakan bayi bagi sesi KC tidak setanding 
dengan faedah. 
 
 
 
 
 
19 
Kerja berpasukan amat diperlukan diantara jururawat dan ibu apabila melakukan KC. 
 
 
 
 
 
20 
Tidak ada fleksibiliti masa yang cukup dalam NICU untuk membenarkan para ibu 
dilanjutkan masa (lebih daripada 1 jam) untuk KC.  
 
 
 
 
 
 
 
 

173 
 
Bahagian II : Pengetahuan terhadap KC  
Arahan      : Sila jawab soalan-soalan berikut dengan tepat mengikut kemampuan anda 
berdasarkan pengetahuan peribadi anda sendiri mengenai KC, TIDAK pada amalannya. 
Bulatkan jawapan yang terbaik untuk mewakili pengetahuan KC anda. Gunakan skala berikut 
untuk jawapan anda: 
  3 = Benar 
  2 = Salah 
  1 = Tidak pasti 
 
No 
                                                Statemen 
Betul 
Salah 
Tidak 
Pasti 
1 
Bayi kelihatan berpuas hati dengan KC. 
3 
2 
1 
2 
Bayi dengan rawatan fototerapi boleh mengambil bahagian dalam KC.  
3 
2 
1 
3 
Bayi biasanya mengurangkan kadar jantung ketika KC. 
3 
2 
1 
4 
Bayi dengan Intra periferal boleh mengambil bahagian dalam KC. 
3 
2 
1 
5 
KC telah membuktikan dapat membantu kadar pernafasan pada bayi pramatang. 
3 
2 
1 
6 
KC tidak sesuai pada bayi pramatang. 
3 
2 
1 
7 
KC tidak sesuai pada bayi yang berat kurang daripada 1000 gram. 
3 
2 
1 
8 
KC kini dianggap selamat sebagai pendekatan alternatif untuk menjaga bayi pramatang. 
3 
2 
1 
9 
Kebanyakan bayi mengalami penurunan suhu semasa KC. 
3 
2 
1 
10 
KC adalah peningkatan risiko jangkitan pada bayi pramatang. 
3 
2 
1 
11 
KC tidak sesuai untuk bayi yang mempunyai masalah jantung. 
3 
2 
1 
 
 
 
 
 
 
 
 
 
 
 
 
 

174 
 
Bahagian III : Halangan terhadap KC 
Arahan : Sila nyatakan halangan yang dilihat sangat penting dalam KC. Gunakan skala 
berikut untuk jawapan anda: 
5 = Sangat Penting 
4 = Agak Penting 
3 = Tidak Penting Nor Tidak Penting 
2 = Tidak Sangat Penting 
1 = Tidak Penting Lansung 
 
No 
                                                         Statemen 
5 
4 
3 
2 
1 
1 
Ibu enggan untuk melakukan KC. 
 
 
 
 
 
2 
Ibu percaya bahawa teknologi (contohnya, inkubator) adalah lebih bermanfaat untuk bayi 
pra-matang daripada jagaan yang disediakan oleh seorang ibu. 
 
 
 
 
 
3 
Ibu merasakan tiada privasi semasa melakukan KC. 
 
 
 
 
 
4 
Ibu sukar untuk menilai kesediaan bayi untuk KC. 
 
 
 
 
 
5 
Ibu enggan untuk memulakan KC. 
 
 
 
 
 
6 
Ibu enggan untuk terlibat dalam KC. 
 
 
 
 
 
7 
Ibu sering tidak tersedia untuk melakukan KC. 
 
 
 
 
 
8 
Ibu takut akan keselamatan bayi pada berat badan yang tertentu untuk memulakan KC. 
 
 
 
 
 
9 
Ibu takut bayi kesejukkan semasa KC. 
 
 
 
 
 
10 
Ibu takut bayi tidak menyusu semasa KC. 
 
 
 
 
 
11 
Ibu merasa tidak mempunyai  masa yang cukup untuk diberi kepada anak-anak lain semasa 
KC. 
 
 
 
 
 
12 
Ibu percaya yang KC hanya diberi kepada bayi yang mempunyai masalah perkembangan. 
 
 
 
 
 
13 
Ibu merasa tidak selesa  bahagian dada mereka terdedah semasa KC. 
 
 
 
 
 
 14 
 Ibu  percaya bahawa akan banyak mengganggu bayi semasa KC. 
 
 
 
 
 
15 
Ibu tidak dapat datang untuk melawat bayi untuk tempoh masa yang lama. 
 
 
 
 
 
16 
Ibu merasa jururawat enggan membantu semasa mengambil bahagian dalam KC. 
 
 
 
 
 
17 
Ibu percaya bahawa KC akan menambah kerja dan komitmen jururawat kerana kesuntukan 
masa. 
 
 
 
 
 
18 
Ibu percaya KC akan menyukarkan tugas jururawat dalam memberi penjagaan dan rawatan 
kepada bayi. 
 
 
 
 
 
19 
Ibu berasa  jururawat kurang diberi pendedahan tentang KC untuk ibu-ibu yang mengambil 
bahagian di dalam KC. 
 
 
 
 
 
                         
 
 
 
 

175 
 
Bahagian IV: SKALA PARENTAL STRES : UNIT JAGAAN INTENSIVE 
NEONATAL 
Arahan   : Sila bulatkan nombor berikut untuk menyatakan bagaimana pengalaman tekanan 
anda ketika bayi  berada di NICU. Nombor berikut menunjukkan tahap tekanan tersebut: 
 
5 = Sangat tertekan 
4 = Sangat tertekan 
3 = Agak tertekan 
2 = Sedikit tertekan 
1 = Tidak sama sekali tertekan pengalaman tidak menyebabkan anda berasa kecewa, 
texperimental groupang, atau cemas  
 
 
No 
Item 
 5 
 4 
3 
2 
1 
 1. 
Dipisahkan daripada bayi saya. 
 
 
 
 
 
 2. 
Tidak memberi makan bayi saya sendiri 
 
 
 
 
 
 3. 
Tidak mampu untuk menjaga bayi saya sendiri (contohnya, menukar 
lampin dan mandi) 
 
 
 
 
 
 4. 
Tidak dapat memexperimental groupang bayi saya apabila saya mahu. 
 
 
 
 
 
 5. 
Rasa tidak berdaya dan tidak dapat melindungi bayi saya dari prosedur 
sakit dan menyakitkan. 
 
 
 
 
 
 6. 
Rasa tidak berdaya tentang bagaimana untuk membantu bayi saya pada 
masa ini. 
 
 
 
 
 
 7. 
Tidak mempunyai masa untuk bersama dengan bayi saya. 
 
 
 
 
 
 
 
 
        ___________   Terima kasih kerana menyertai dalam kajian ini ____________ 
 
 
 
 
 
 
 
 
 
 

176 
 
Appendix F(a): Infant’  (English version)                                                                                                         
 
                                                                                                                                                                               
                                                                                      
                                                    Instrument : INFANT 
 
                                                                                                                              
 
Dear Madam, 
 
Thank you for agreeing to participate in the research. 
The purpose of this research is to evaluate the effectiveness of Kangaroo Care (KC) among 
mother with premature infant in NICU. 
The questionnaire consists of: 
Part  I  :    Demographic Characteristic  
Part  II :   Infant Progress Data Sheet (KCRP Booklet) 
Please answer ALL the questions of your ability and as honestly as possible. Thank you for 
your cooperation and support in this research. 
      
 
 
 
 
 
 
 
 
                                            
 
 
                                                           
                                                                                                                                                             
 
E 
CONSENT FOR PARTICIPANT IN RESEARCH ACTIVITIES 
 
1. Ms. Sharmiza bt Samsudin has requested my participation in this research. 
 
2. I understand the purpose of this research. 
 
3. I understand that the information obtained is to be used solely for academic purposes. I have also 
been assured of the confidentiality of the information obtained. 
 
4. I understand that I am not forced to participate and it is my right to refuse to take part in this 
research. I may withdraw from the research at any time without penalty or prejudice. 
 
I hereby give my informed and free consent to be a participant in this research. 
 
Date 
:…………………………………….  
 
 
 
              
                                                                                               
                                                                                                                  __________________________ 
                                                                                                                  Consent Signature of Participant 
  

177 
 
Part I :  Demographic Characteristic 
1. Gender              
01. Male                           02. Female   
 
2. Race  
01. Malay  
                  02. Chinese  
             03. Indian  
             
04.Other__________(please specify)  
 
3. Post-natal age (days) _____________________________(please specify)  
 
4. Gestation age at birth (weeks) ______________________(please specify) 
 
5. Birth weight(kg)_________________________________ (please specify) 
 
6. Mode of feeding status 
01. Tube feeding   
       02.Spoon-feed  
        03.Breastfeeding  
                                          
 
7. Type of milk 
01. Express Breast Milk (EBM)  
                02. Breastfeeding  
         03. Formula milk  
 
 
8. Initiate breastfeeding (weeks) _______________________(please specify) 
 
                                                            
9. Discharge on breastfeeding (weeks)___________________(please specify) 
 
10. Weaned exclusive breastfeeding (months)____________ (please specify) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
     
 

178 
 
Appendix F(b) : Infant’s (Infant KCRP Booklet)  
                                                                          Instrument : INFANT (English Version )       
                                                                                                                                           
          
                                                                                                                      
                                                                         
 
                                                                                               
Dear Madam, 
Thank you for agreeing to participate in the research. 
The purpose of this research is to evaluate the effectiveness of Kangaroo Care (KC) among 
mother with premature infant in NICU. 
The questionnaire consists of: 
Part  I  :    Demographic Characteristic  
Part  II :   Infant Progress Data Sheet (KC Booklet) 
Please answer ALL the questions of your ability and as honestly as possible. Thank you for 
your cooperation and support in this research. 
 
 
      
 
 
 
 
 
 
 
 
 
                                            
 
 
 
 
 
C 
CONSENT FOR PARTICIPANT IN RESEARCH ACTIVITIES 
 
1. Ms. Sharmiza bt Samsudin has requested my participation in this research. 
 
2. I understand the purpose of this research. 
 
3. I understand that the information obtained is to be used solely for academic purposes. I have also 
been assured of the confidentiality of the information obtained. 
 
4. I understand that I am not forced to participate and it is my right to refuse to take part in this 
research. I may withdraw from the research at any time without penalty or prejudice. 
 
I hereby give my informed and free consent to be a participant in this research. 
 
Date 
: 
 
 
 
 
              
                                                                                               
                                                                                                      __________________________ 
                                                                                                       Consent Signature of Participant 
  

179 
 
      
Part I :  Demographic Characteristic 
 
1. Gender              
01. Male                           02. Female   
 
2. Race  
01. Malay  
                  02. Chinese  
             03. Indian  
             
04.Other__________(please specify)  
 
3. Post-natal age (days) _____________________________(please specify)  
 
4. Gestation age at birth (weeks) ______________________(please specify) 
 
5. Birth weight(kg)_________________________________ (please specify) 
 
6. Mode of feeding status 
01. Tube feeding   
       02.Spoon-feed  
      03.Breastfeeding  
                                          
 
7. Type of milk 
01. Express Breast Milk (EBM)  
      02. Breastfeeding  
         03. Formula milk  
 
 
8. Initiate breastfeeding (weeks) _______________________(please specify) 
 
                                                            
9. Discharge on breastfeeding (weeks)___________________(please specify) 
 
10. Weaned exclusive breastfeeding (months)____________ (please specify) 
 
Part II : Infant progress data sheet for experimental group 
Day (D) 
D0 D1 D2 D3 D4 D5 D6 D7 D8 D9 
D10 
Till 
discharge 
   
Remarks 
Infant number : 
_______________ 
 
 
 
 
 
 
 
 
 
 
 
 
Temperature 
(Pre/Post) KC 
 
 
 
 
 
 
 
 
 
 
 
 
KC (in minutes or 
hours/day)    
 
 
 
 
 
 
 
 
 
 
 
 
Weight gain 
velocity (g/days) 
 
 
 
 
 
 
 
 
 
 
 
 
Feeding (EBM or  
Breastfeeding) 
 
 
 
 
 
 
 
 
 
 
 
 
Wean BF (weeks) 
 
 
 
 
 
 
 
 
 
 
 
 
 D = Day, 0 = Birth, KMC = Kangaroo Mother Care, ↑= Increase & ↓=Decrease and 
Breastfeeding, EBM = Express Breast Milk 
                                                                                                                     

180 
 
 
Appendix G : Nurses’ Consent Form 
                                                
 
 Nurses’ Consent Form  
You are invited to participate in a research study entitled “The effectiveness of Kangaroo care on low 
birth weight infants in Neonatal Intensive Care Units." The aim of this intervention study is to 
evaluate the effect of KC for infants, mother and nursing outcomes of implementing a quasi-
experimental and longitudinal study to evaluate the effectiveness of KC in low birth weight infants in 
one hospital in Klang Valley, Malaysia: University Malaya Medical Centre. 
The participation in this study is voluntary and you have the right to refuse to participate or withdraw 
at any time without affecting your medical care. Your identity and records as a participant in this 
study will remain confidential with respect to any publications/reporting of the results of this study. 
Your records in connection with this study will be kept confidential to the extent permitted by the law. 
With your permission, I will contact you by telephone/whatsapp at first and three month period of 
time after educational intervention for participating in post-test intervention study. 
I confirm that, I am informed the following information: 
I acknowledge that I have read, or it had been explained to me in a language that I 
understand, the attached Research Participant Information Sheet. 
 
I understand that this study is not intended to be of any direct financial benefits to 
me. 
 
I understand that I am free to withdraw this authorization and to discontinue 
participation in this study at any time. 
 
I have had the opportunity to ask questions. 
 
I confirm that I have read, or had read to me, the forexperimental groupoing authorization.  
I give consent to be contacted by the researcher, by telephone/whatsapp at first and three 
month after educational intervention for participating in post-test intervention study. 
 
 
Participant: 
Name: _____________________                                                      Date: ___________ 
Signature: ________                                                                 
Please write down your telephone number: (below) 
............................................................................................ 
Name: __________________                                                            Date: ___________ 
Signature: ________ 
                                                                                                     
 

181 
 
Appendix H : Nurse’s Questionnaire 
 
      QUESTIONNAIRE II :  NURSES     
                                                                       
 
Dear Nurses, 
Thank you for agreeing to participate in the research. 
The purpose of this research is to evaluate the effectiveness of Kangaroo Care (KC) among 
mother with premature infant in NICU. 
The questionnaire consists of: 
Section A :  Demographic Characteristic  
Section B :  Part I     - Perception on KC 
 
        Part II   - Knowledge on KC 
 
        Part III  - Practice on KC 
 
 
Please answer ALL the questions to the best of your ability and as honestly as possible. 
Thank you for your cooperation and support in this research. 
 
 
 
 
 
 
 
 
 
 
 
                                                                       
 
 
 
 
CONSENT FOR PARTICIPANT IN RESEARCH ACTIVITIES 
1. Ms. Sharmiza bt Samsudin has requested my participation in this research. 
 
2. I understand the purpose of this research. 
 
3. I understand that the information obtained is to be used solely for academic purposes. I 
have also been assured of the confidentiality of the information obtained. 
 
4. I understand that I am not forced to participate and it is my right to refuse to take part in 
this research. I may withdraw from the research at any time without penalty or prejudice. 
 
I hereby give my informed and free consent to be a participant in this research. 
 
Date 
: 
 
 
 
 
              
                                                                                               
                                                                                                       __________________________ 
                                                                                                       Consent Signature of Participant 
  

182 
 
Section A : Demographic Characteristic 
Instruction : Please  √  the response. 
1. Age _________ (please fill in the blank) 
 
2. Gender 
01. Male      ⃝                02. Female      ⃝ 
 
3. Race     
01. Malay     ⃝               02. Chinese     ⃝               03. Indian       ⃝              04.  Others-
________(please  specify) 
 
4. Highest Educational Level                  
01. Primary     ⃝               02. Secondary      ⃝                03. Tertiary     ⃝     
                                         
5. Marital Status 
01. Married     ⃝       02. Single      ⃝       03. Divorced     ⃝       04. Widowed       05. Engaged     ⃝ 
 
6. How many years have you been qualified? _______________________(please specify) 
7. Do you have a certificate of neonatology?   
01. Yes     ⃝                   02. No     ⃝ 
8. How many years you are working in NICU ?_____________________(please specify) 
 
Before you completing the survey, please answer the following question, then go on to the  
Section B.Do you  practice KC in NICU in any way? (Circle your response) 
1.    NO       ⃝ 
 
2.    YES     ⃝                                                  
                               
 
 
 
 
 
 
 
   

183 
 
SECTION B : Kangaroo  Care (KC) Survey 
Instruction: Please answer the following questions. Use the following scale for your 
responses: 
5 = Strongly Agree 
4 = Agree 
3 = Neither Agree    Nor Disagree 
2 = Disagree 
1 = Strongly disagree 
 
Part I : Perception on KC 
No 
                                                Statement 
5 
4 
3 
2 
1 
1 
All preterm babies should be allowed to participate in KC regardless of age. 
 
 
 
 
 
2 
All preterm babies should be allowed to participate in KC regardless of weight. 
 
 
 
 
 
3 
Babies receiving IV fluids should NOT be allowed to participate in KC. 
 
 
 
 
 
4 
Babies who are intubated should NOT be allowed to participate in KC. 
 
 
 
 
 
5 
Babies with umbilical catheters should NOT be allowed to participate in KC. 
 
 
 
 
 
6 
Babies on ventilators should NOT be allowed to get KC. 
 
 
 
 
 
7 
Babies with chest tubes should NOT be allowed to get KC. 
 
 
 
 
 
8 
KC encourages the parenting role. 
 
 
 
 
 
9  
KC enhances the attachment process between mother and baby. 
 
 
 
 
 
10 
KC increases the quality of care on your unit. 
 
 
 
 
 
11 
KC interrupts baby care√ giving. 
 
 
 
 
 
12 
KC should be available only to breastfeeding mothers. 
 
 
 
 
 
13 
KC is NOT feasible with some babies.  
 
 
 
 
 
14 
KC keeps nurses too tied to the bedside. 
 
 
 
 
 
15 
KC should be offered to all mothers in the NICU. 
 
 
 
 
 
16 
KC will benefit preterm babies. 
 
 
 
 
 
17 
KC will help mothers feel more confident in caring for their preterm baby. 
 
 
 
 
 
18 
KC will improve the baby’s outcome. 
 
 
 
 
 
19 
KC will interfere with the completion of my tasks. 
 
 
 
 
 
20 
Learning about KC will help me be a better nurse. 
 
 
 
 
 
21 
Nurses look forward to introducing KC to a new mother. 
 
 
 
 
 
22 
Our babies have adequate time for mother-baby contact without the use of KC. 
 
 
 
 
 
23 
The increased amount of time required to prepare a baby for a KC session is out of 
proportion to the benefits. 
 
 
 
 
 
24 
The teamwork required between nurses and mothers when doing KC is worth the effort.  
 
 
 
 
 
25 
There is NOT enough flexibility in the NICU to allow parents extended visits (more than 
1 hours) for KC. 
 
 
 
 
 
 
 
 
 
 
 
 

184 
 
Part II : Knowledge on KC 
Instruction: Please answer the following questions to the best of your ability based on your 
own personal knowledge of KC, NOT on its practice. Circle your response that best 
represent to knowledge of KC. Use the following scale for your responses:  
 3 = True  
 2 = False 
 1 = Not sure 
 
No 
                                                Statement 
True 
False 
Not 
sure 
1 
Babies appear to be satisfied in KC. 
3 
2 
1 
2 
Babies on oxygen therapy experience a decrease in oxygen saturation. 
3 
2 
1 
3 
Babies on phototherapy can participate in KC. 
3 
2 
1 
4 
Babies on anotrope/vasopressor should NOT participate in KC. 
3 
2 
1 
5 
Babies typically experience more bradycardia episodes during KC. 
3 
2 
1 
6 
Babies with peripheral IVs can participate in KC. 
3 
2 
1 
7 
KC has been shown to improve breathing patterns in preterm babies by reducing apnea. 
3 
2 
1 
8 
KC is contraindicated in babies less than 28 weeks gestation. 
3 
2 
1 
9 
KC is contraindicated in babies weighing less than 1000 grams. 
3 
2 
1 
10 
KC is now considered safe as an alternative approach to care for medically stable, continuing 
care preterm babies. 
3 
2 
1 
11 
Most babies experience a decrease in temperature during KC. 
3 
2 
1 
12 
Published reports of clinical observations indicate that the rate of accidental extubation is 
higher with KC than with traditional methods of holding. 
3 
2 
1 
13 
Research has indicated that babies who receive KC increase their mother’s milk supply. 
3 
2 
1 
14 
Research indicates that KC promotes quiet sleep. 
3 
2 
1 
15 
Research shows that babies with arterial lines should NOT participate in KC. 
3 
2 
1 
16 
The most physiologically stressful part of KC for the baby is the transfer to the mother’s 
chest. 
3 
2 
1 
17 
There is an increased risk of infection in the baby with KC. 
3 
2 
1 
18 
Research shows that babies with Drug Withdrawal have less agitation during KMC than 
when NOT in KC. 
3 
2 
1 
19 
Babies with some congenital heart defects have physiologic stability in KC. 
3 
2 
1 
20 
Babies on ventilators mode do well during KC. 
3 
2 
1 
 
 
 
 
 
 
 
 
 
 

185 
 
Part III : Practice on KC  
Instruction: Please describe how comfortable are you to initiate KC on baby with the 
following items? Use the following scale: 
5 = Very Comfortable 
4 = Somewhat Comfortable 
3 = Neither Comfortable Nor Uncomfortable 
2 = Somewhat Uncomfortable 
1 = Very Uncomfortable 
 
No. 
                                     Statement 
5 
4 
3 
  2 
1 
1 
Baby with intravenous catheters. 
 
 
 
 
 
2 
Baby during the perioperative period. 
 
 
 
 
 
3 
Baby with endotracheal intubation. 
 
 
 
 
 
4 
Baby with high-frequency rate or ventilator mode. 
 
 
 
 
 
   5 
Baby with nasal cannula oxygen (nasal prong). 
 
 
 
 
 
6 
Baby with Nasal Continuous Positive Airway Pressure (NCPAP). 
 
 
 
 
 
7 
Baby with percutaneous central lines. 
 
 
 
 
 
8 
Baby with phototherapy treatment. 
 
 
 
 
 
9 
Baby with Umbilical Arterial Catheters (UAC). 
 
 
 
 
 
10 
Baby with Umbilical Venous Catheters (UVC). 
 
 
 
 
 
11 
Baby with anotrope/vasopressors. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

186 
 
Appendix I:  Structured kangaroo care educational program (KC-EP) for nurses.  
              
 
 
Course contents of kangaroo care education programme (KC-
EP) for Nurses 
Educational Program 
Session: 
All nurses in neonatal intensive care unit (NICU), University 
Malaya Medical Centre (UMMC). 
Course: 
Course Tittle:  
 
Medium of Instruction:  
Neonatal Health Nursing 
Physiology of kangaroo care (KC) and benefits for infant – mother 
dyads. 
English  and Bahasa Malaysia  
Teaching materials/ 
Equipment 
Laptop, LCD, white board, marker pen, lecture notes, showing 
video, pamphlets, booklet, incubator,thermometer, dummy, baby 
sling/tube, diapers, infant cap, mother’s outfit (open infront),all 
related forms/diary applicable to the topic presentation and red & 
blue ball point. 
Learning  
Lecture (show and tell),  
Practical (skill) & Discussion 
Student Learning Time 
Face to face (interpersonal communication): 8 hours 
Guide learning(theory): 4 hours 
Assessment(practical) : 4 hours 
Soft Skills 
Communication skills 
Problem solving skills 
Teamwork skills 
Information Management 
Professional Ethic and Moral 
Presenter  
e-mail address 
Sharmiza Bt Samsudin 
sharmizaamri72@gmail.com @ sharmiza@oum.edu.my 
Theory Session: 
Day     : 
Time   : 
Practical session: 
Day     : 
Time   : 
Venue : 
 
Friday & Sunday 
 2.00pm – 6.00pm  
 
Monday,Tuesday,Wednesday, Thursday and Saturday and 
including public holiday  
08.00am – 5.00pm 
Conference Room, Neonatal Intensive Care Unit, University 
Malaya Medical Centre, Klang Valley     
 
 
 
 
 
 
 
 
 

187 
 
Appendix J : Contents of structured kangaroo care educational program (KC-EP) for 
nurses. 
 
         
     
 
Course contents of kangaroo care education programme (KC-EP) for nurses. 
Educational Program Session 
(Participant) 
All nurses in neonatal intensive care unit (NICU), University Malaya Medical 
Centre.(UMMC) 
Course: 
Course Tittle:  
 
Medium of instruction 
Kangaroo care education programme (KC-EP) for nurses  
Physiology of kangaroo Care and benefits for infant – mother dyads. 
English and Bahasa Malaysia  
Teaching materials/aids 
Equipment 
Laptop, LCD, hand out, white board, marker pen, lecture notes, showing video, pamphlets, 
booklet, incubator,thermometer,infant dummy, baby sling/tube, diapers, infant cap, 
mother’s outfit (open infront),all related forms/diary applicable to the topic presentation 
and red & blue ball point. 
Mode of teaching  
Learning 
stratexperimental 
groupies 
Lecture-demonstration  
Lecture (show and tell),Practical (skill) & Question and Answer  
Student Learning Time 
Face to face (interpersonal communication): 8 hours 
Guide learning(theory): 4 hours 
Assessment(practical) : 4 hours 
Presenter  
e-mail address  
Sharmiza Bt Samsudin 
sharmizaamri72@gmail.com  @ sharmiza@oum.edu.my 
Theory Session: 
Day/Time: 
Venue: 
 
Practical session: 
Day/Time: 
Every Friday and Sunday (August –September 2018) 
2.00 pm – 6.00pm 
Conference Room, Neonatal Intensive Care Unit, University Malaya Medical Centre, 
Klang Valley  
Every Monday,Tuesday,Wednesday, Thursday, Saturday and including public holiday 
(August – September 2018) 
08.00am – 5.00pm  
Pre-requite knowledge 
Anatomy and Fundamental of Nursing  
- Intergumentary system 
- Reproductive system 
- Digestive system 
- Cardiovascular system 
- Cardiopulmonary system 
- Central nervous system 
- Neonatal and pediatric nursing 
- Nurses have knowledge on giving care and treatment  to the preterm babies (feeding) 
General objective : 
At the end of the program the nurse will be able to have in depth understanding of 
physiology and benefits of Kangaroo Care in detail and demonstrate the technique as well. 
Specific objectives :  
 
At the end of the program the nurses will be able to : 
1) define the term and dose of kangaroo care (KC). 
2) explain the physiology and method of KC. 
3) state the benefits of KC to infant-mother dyads. 
4) state the indication and contraindication for KC (eligibility criteria). 
5) state the guidelines and protocols before, during and after the KC method. 
6) recognize sign and symptoms of deterioration among premature infant before,during and   
    after the method. 
7) state the preparation before, during and after the KC method.  
8) list the equipment for KC method ; 
8.1 for infant  
8.2 for mother  
9) educate and guided on chart/record the infant progress record /diary 
10) demonstrate and return-demonstrate the kangaro care method. 
Important Date 
Pre-test & Post-test (7th day  after pretest and KC-EP for nurses) 
 

188 
 
Appendix K : Schedule of structured kangaroo care educational program (KC-EP) for 
nurses. 
Venue: NICU, Conference Room, University Malaya Medical Centre 
 
 
Date/ 
Time 
 
Pretest / Theory 
session 
 
 
Date/ 
Time 
 
Posttest / 
Practical Session 
(Morning session) 
 
Date 
/Time 
 
 
 
Posttest / 
Practical 
Session 
(Afternoon 
session) 
 
 
Posttest after  
 7th day 
 
02.00 
pm 
- 
02.30 
pm 
Registration for 
kangaroo care 
educational 
program (KC-EP)  
- Pretest (QI) 
08.00 am 
- 
08.30 am 
Registration for 
post-test after 
attended KC-EP for 
nurses  
 
02.00 pm 
- 
02.30 pm 
Registration for 
post-test after 
attended KC-EP 
for nurses 
- Post 
intervention 
  Posttest (QI) 
 
- Demonstrate 
  (Checklist) 
 
- Gift certificates 
to nurses who 
have pass and 
proficient in 
posttest 
knowledge and 
skills on KC. 
02.30 
pm 
- 
04.00 
pm 
 
Introduction of KC: 
- Define KC  
- KC physiology 
- KC benefits 
- KC indication  
  &  
contraindication     
- KC guidelines  
  and protocols   
  
08.30 am 
- 
10.00 am 
KC hand-on 
workshop: 
- KC Ice- 
  breaking  
- Demonstration 
- Question and 
  Answer(QA) 
02.30 pm 
- 
04.00 pm 
KC hand-on 
workshop: 
- KC Ice-breaking  
- Demonstration 
- Question and 
  Answer(QA) 
04.00 
pm 
- 
04.30 
pm 
Tea Break 
10.00 am 
- 
10.30 am 
Tea Break 
04.00 pm 
- 
04.30 pm 
Tea Break 
04.30 
pm 
- 
06.00 
pm 
KC procedure  
- preparation  
  infant- mother  
- equipment    
  before, during  
  and after the   
  KC procedure  
  (standing  
  and sitting  
  transfer) 
-recognize sign  
 and symptoms  
 of deterioration  
 during and after  
 KC procedure 
-charting the  
 infant progress  
 record 
- Question and  
  Answer(Q&A) 
10.30 am 
- 
12.00 
noon 
Return 
demonstration of 
KC procedure: 
- Standing and  
  sitting transfer 
- Question and  
  Answer (Q&A) 
 
04.30 pm 
- 
05.00 pm 
Return 
demonstration of 
KC procedure: 
- Standing and  
  sitting transfer 
- Question and  
  Answer(Q&A) 
 
 
 
 
 
 
 

189 
 
Appendix L: Courses contents structured kangaroo care educational program (KC-EP) 
for mothers. 
         
      
 
Course contents of Kangaroo Care Education Programme (KC-EP) 
for mother.  
Educational Program 
Session (Participant) 
All mothers in intervention group at neonatal intensive care unit (NICU) 
University Malaya Medical Centre (UMMC) 
Course:  
Course Tittle: 
 
Medium of instruction 
Presenter : 
Kangaroo Care Educationa Programme (KC-EP) 
Kangaroo Care Benefits for Premature Infant- Mother dyads and quality 
of care. 
Bahasa Malaysia and English 
Sharmiza Bt Samsudin 
Teaching materials/ 
Equipment 
Laptop, LCD, white board, marker pen, lecture notes, showing video, 
pamphlets, booklet, infant dummy, baby sling, diapers, infant cap, all 
related forms applicable to the topic presentation and red & blue ball 
point. 
Mode of teaching 
Learning  
Lecture-demonstration 
 
Lecture (show and tell),practical (skill) & Question and Answer 
Student learning time 
Face to face (interpersonal communication): 1 hours 
Guide learning(theory):30 hours 
Assessment (practical) :30 hours 
Presenter  
e-mail address  
Sharmiza Bt Samsudin 
sharmizaamri72@gmail.com  @ sharmiza@oum.edu.my 
Theory & practical 
session: 
Day     : 
Time   : 
Venue :  
Every Friday, Saturday and Sunday 
10.00 am – 11.00 am. 12.00noon – 1.00pm or 3.00pm – 4.00pm & 
5.00pm – 6.00pm 
Conference Room, Neonatal Intensive Care Unit, University Malaya 
Medical Centre, Klang Valley   
General objective 
At the end of the presentation the mothers will be able to have in depth 
understanding of kangaroo care in detail and demonstrate the procedure 
as well. 
Specific objectives :  
 
At the end of the presentation the mothers will be able to: 
1) define term of kangaroo  care (KC). 
2) state the benefits of KC to infant-mother (breast feeding) 
3) recognize sign and symptoms of deterioration among  premature infant  
    before, during and after the procedure 
4) state the preparation before, during and after the KC procedure.  
5) list the equipment for KC procedure; 
5.1 infant  
5.2 mother  
6) demonstrate and return-demonstrate & charting the infant progress   
     record by the nurses to mothers 
Important dates 
(Primary and Secondary  
outcomes) 
Pretest & posttest after 1st month and 3rd months of KC-EP for mothers.  
 

190 
 
Appendix M (a) : Schedule of structured kangaroo care educational program (KC-EP) 
for mother’s. 
 
 
Date 
/ 
Time 
 
Kangaroo Care Educational Program (KC-EP) for mother 
                          
    Venue : NICU, Conference Room, University Malaya Medical Centre 
Participant  : All mothers in experimental group and nurses available in 
NICU 
 
9.45 am 
- 
10.00 am 
 
 
Registration structured educational program (KC-EP) for mothers’ 
- Pretest (experimental mother’s group & nurses)  
 
10.00 am 
- 
10.20 am 
 
Introduction of kangaroo care (KC) 
1. What is kangaroo care? 
        1.1  Kangaroo care definition.  
2. Who can perform kangaroo care?  
        2.1  indication and contraindication of kangaroo care. 
3. When can mothers perform kangaroo care? 
        3.1  before, during and after kangaroo care procedure (instruments and  
               observation needs). 
        3.2  indicate any abnormalities. 
4. How do mothers perform kangaroo care?  
        4.1 showing videos on kangaroo care procedure. 
        4.2 show and tell how to perform and document in kangaroo care  
              (KCRP booklet) 
        4.3 informative pamphlet. 
        4.4 equipment for kangaroo care procedure (infant & mother). 
        4.5 preparation before, during and after the kangaroo care procedure. 
        4.6 demonstrate the standing and sitting kangaroo care procedures. 
        4.7 charting the infant progress record by mother assisted by nurses 
* Question and Answer  
 
 
10.20 am 
- 
11.00 am 
 
KC procedure preparation and Hand-on station 
5. Why should mothers perform Kangaroo Care? 
       5.1 Benefits for babies; 
       5.2 Benefits for mothers;  
6. How do mother recognize sign and symptoms of deterioration before,  
    during and after KC procedure? 
7. Health education on breastfeeding status (handwashing) 
8. Demonstrate and return demonstration of KC technique 
 
* Question and Answer 
 
 
11.00am 
 
Tea break 
 

191 
 
Appendix M(b) :  Schedule of KC-EP (cont’d) 
 
Date 
/ 
Time 
 
Mother Structured Kangaroo Care Educational Program (KC-EP) 
 
Venue     : NICU, Conference Room, University Malaya Medical Centre 
Participant: All mothers in intervention group and nurses available in NICU 
 
 
11.45 am 
- 
12.00 am 
 
 
Registration structured kangaroo care educational program (mothers) 
- Pretest and intervention mother’s group & nurses 
 
 
12.00 am 
- 
12.20 noon 
 
Introduction of KC 
1. What is Kangaroo Care (KC)? 
        1.1  definition of term KC 
2. Who can perform Kangaroo care?  
        2.1  indication and contraindication of KC 
3. When can mothers perform Kangaroo care? 
        3.1  pre, during and post KC technique (instruments and observation  
               needs) 
        3.2  indicate any abnormalities 
4. . How do mothers perform Kangaroo care?  
        4.1 showing a videos on KC technique/procedure 
        4.2 show and tell how to perform and document it in KC diary   
              provided for mothers (KCRP booklet) 
        4.3 informative pamphlet 
        4.4 equipment for KC procedure e. g infant & mother 
        4.5 preparation before, during and after the KC technique 
        4.6 demonstrate the standing and sitting procedure 
        4.7 charting the infant progress record/by mother assisted by nurses 
* Question and Answer  
 
 
12.20 noon 
- 
01.00 pm 
 
KC procedure preparation and Hand-on station 
5. Why should mothers perform Kangaroo Care? 
       5.1 Benefits for babies; 
       5.2 Benefits for mothers;  
6. How do mother recognize sign and symptoms of deterioration before,  
    during and after KC procedure ? 
7. Health education on breastfeeding /feeding status.  
8. Demonstrate and return demonstration of KC technique 
 
* Question and Answer 
 
 
01.00pm 
 
Tea break 
 
 

192 
 
Appendix M(c): Schedule of KC-EP (cont’d) 
 
Date 
/ 
Time 
 
Mother Structured Educational Program in Kangaroo Care (KC-EP) 
 
Venue: NICU, Conference Room, University Malaya Medical Centre 
Participant: All mothers in the experimental group and nurses available in 
NICU 
 
 
2.45 pm 
- 
03.00 pm 
 
 
Registration structured KC Educational Program for mothers’or KC-
EP 
- Pretest and intervention mother’s group & nurses 
 
 
03.00 pm 
- 
03.30 am 
 
Introduction of KC 
1. What is Kangaroo Care(KC)? 
        1.1  definition of term KC 
2. Who can perform Kangaroo care?  
        2.1  indication and contraindication of KC 
3. When can mothers perform Kangaroo care? 
        3.1  pre, during and post KC technique (instruments and observation  
               needs) 
        3.2  indicate any abnormalities 
4. . How do mothers perform Kangaroo care?  
        4.1 showing a videos on KC technique/procedure 
        4.2 show and tell how to perform and document it in KC diary   
              provided for mothers (KCRP booklet) 
        4.3 informative pamphlet 
        4.4 equipment for KC procedure e. g infant & mother 
        4.5 preparation before, during and after the KC technique 
        4.6 demonstrate the standing and sitting procedure 
        4.7 charting the infant progress record/by mother assisted by nurses 
* Question and Answer  
 
 
03.30 pm 
- 
04.00 pm 
 
KC procedure preparation and Hand-on station 
5. Why should mothers perform Kangaroo Care? 
       5.1 Benefits for babies; 
       5.2 Benefits for mothers;  
6. How do mother recognize sign and symptoms of deterioration before,  
    during and after KC procedure? 
7. Health education on breastfeeding/feeding status  
8. Demonstrate and return demonstration of KC technique 
 
* Question and Answer 
 
04.00 pm 
 
 
 Tea Break 
 
 

193 
 
Appendix M(d) : Schedule of KC-EP D (cont’d) 
 
Date 
/ 
Time 
 
Kangaroo Care Education Programme (KC-EP)  
  
     Venue     : NICU, Conference Room, University Malaya Medical Centre 
Participant : All mothers in experimental group and nurses available in 
NICU 
 
 
4.45 pm 
- 
05.00 pm 
 
 
Registration Kangaroo Care Education Programme (KC-EP) for 
mothers. 
- Pre-test and experimental mother’s group & nurses 
 
 
05.00 pm 
- 
05.20 pm 
 
Introduction of KC 
1. What is Kangaroo Care (KC)? 
        1.1  definition of term KC 
2. Who can perform Kangaroo care?  
        2.1  indication and contraindication of KC 
3. When can mothers perform Kangaroo care? 
        3.1  pre, during and post KC technique (instruments and observation  
               needs) 
        3.2  indicate any abnormalities 
4. . How do mothers perform Kangaroo care?  
        4.1 shows a video on KC technique/procedure 
        4.2 show and tell how to perform and document it in KC diary   
              provided for mothers (KCRP booklet)  
        4.3 informative pamphlet 
        4.4 equipment for KC procedure e. g infant & mother 
        4.5 preparation before, during and after the KC technique 
        4.6 demonstrate the standing and sitting procedure 
        4.7 charting the infant progress record/by mother assisted by nurses 
* Question and Answer  
 
 
05.20 pm 
- 
06.00 pm 
 
KC procedure preparation and Hand-on station 
5. Why should mothers perform Kangaroo Care? 
       5.1 Benefits for babies; 
       5.2 Benefits for mothers;  
6. How do mother recognize sign and symptoms of deterioration before,  
    during and after KC procedure? 
7. Health education on breastfeeding and handwashing  
8. Demonstrate and return demonstration of KC technique 
 
* Question and Answer 
 
04.00pm 
Tea break 
 
 

194 
 
 Appendix N: Handwashing steps 
 
 
 

195 
 
Appendix O(a) : Flipchart for mothers’ on Kangaroo Care (English version) 
 
 
 

196 
 
 
 
 
 

197 
 
 
 
 
 

198 
 
 
 
 
 

199 
 
 
 
 
 

200 
 
 
 
 
 

201 
 
 
 
 
 

202 
 
 
 
 
 

203 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

204 
 
 
Appendix O(b) : Flipchart for mothers’ (Malay version) 
 
 
 

205 
 
 
 
 
 

206 
 
 
 
 

207 
 
 
 
 

208 
 
 
 
 
 

209 
 
 
 
 
 

210 
 
 
 
 

211 
 
 
 
 

212 
 
 
 
 

213 
 
Appendix P : Slide Presentation KC-EP (Theory session) 
 
 
 

214 
 
 
 
 
 
 
 

215 
 
 
 
 
 

216 
 
 
 
 
 

217 
 
 
 
 
 

218 
 
 
 
 

219 
 
 
 
 

220 
 
 
 
 

221 
 
 
 
 
 
 

222 
 
 
 
 

223 
 
 
 
 

224 
 
 
 

225 
 
 
 
 
 
 

226 
 
 
 
 
 

227 
 
 
 
 
 

228 
 
 
 
 

229 
 
 
 
 
 
 
 
 
         Showing video on standing transfer 

230 
 
 
         Showing video on sitting transfer 
 
 
 
 
 
 
 
 
 
 
 
 

231 
 
Appendix Q(a) : Practical session (Kangaroo care through sitting transfer) 
 
 
 
 

232 
 
 
 
 
 

233 
 
 
 
 
 
 

234 
 
 
 
 
 

235 
 
 
 
 

236 
 
 
 
 

237 
 
 
 
 

238 
 
 
 
 
 

239 
 
 
 
 

240 
 
 
 
 

241 
 
 
 
 
 
 

242 
 
 
 
 
 

243 
 
 
 
 
 

244 
 
Appendix Q(b) : Practical session (Kangaroo care through  standing transfer) 
 
 
 

245 
 
 
 
 

246 
 
 
 
 
 
 

247 
 
 
 
 
 
 

248 
 
 
 
 
 

249 
 
 
 
 
 
 

250 
 
 
 
 
 

251 
 
 
 
 
 
 

252 
 
 
 
 

253 
 
 
 
 
 
 
 

254 
 
 
 
 
 
 
 

255 
 
 
 
 

256 
 
 
 
 
 
 

257 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

258 
 
Appendix R: Ten Steps to Successful Kangaroo Care 
 
TEN STEPS TO SUCCESSFUL KANGAROO CARE 
Just as the Ten Steps to Successful Breastfeeding have been helpful in promoting 
breastfeeding around the world, the Ten Steps to Successful Kangaroo Care can guide efforts 
to promote non-separation of mother and preterm/full-term infant through skin-to-skin 
contact. The Ten Steps to Successful Kangaroo Care have been developed using the format of 
the Ten Steps to Successful Breastfeeding and are as follows: 
Every facility providing services and care for newborns and infants up to 3 months’ age 
should: 
1. Have written KC policies (for very sick and very-low-birth-weight neonates, for relatively 
stable preterm neonates [such as the one provided within this review], for healthy term 
infants within 2 hours of birth, and for healthy term infants until discharge) that are routinely 
communicated to all healthcare staff. 
2. Train all healthcare staff in skills necessary to implement the policy pertaining to their area 
of care. 
3. Inform all pregnant women about the benefits and management of KC. 
4. Help mothers of healthy term infants initiate KC within a few minutes of birth. Help 
mothers of cesarean infants and premature or sick infants initiate KC as soon as possible 
(able to tolerate transfer and skin contact without physiologic or behavioral compromise), and 
monitor infant to ensure tolerance without physiologic and behavioral compromise. 
5. Show mothers how to position the infant for both safe transfer and safe KC (head sustained 
in midline, not flexed or hyperextended, and infant secured so that infant cannot fall down or 

259 
 
out of KC position). 
6. Practice 24/7 KC, allowing mothers and infants to remain in skin-to-skin contact 24 hours 
a day, 7 days a week until discharge. 
7. Give newborns and infants at least 1 hour of KC per session, if not continuous 24/7 KC. 
8. Encourage KC for all warming and comforting needs of infants. 
9. Give adequate thermal insulation (head cap, warm blankets, insulating cover as needed) to 
the infant throughout KC. 
10. Foster the establishment of KC support for mothers through posters, patient scrapbooks, 
patient record of KC, and support groups that may assist even after discharge. 
(Ludington-Hoe, Morgan, Abouelfettoh, 2008)