Vaginal Breech Birth Management Educational Mobile Game
Condition: Vaginal Breech Delivery Management; Mobile Game
Study type: Interventional

Summary: 
      Mobile games are used as a powerful learning tool today. It is very useful as it allows
      students to work on their own frequently when necessary without the need for any physical
      environment or trainer and can be easily distributed among institutions. While the simulation
      laboratories established in a school can only be used by the students of that school, a game
      developed can be used by all students in the world who know that language.

      It is reported that breech presentation, which is one of the presentation disorders of the
      fetus, is the fourth or fifth most common indication for delivery by cesarean section.
      According to the midwifery national core curriculum in our country, vaginal breech delivery
      management training is given within the scope of risky birth course. However, it is known
      that teaching and learning the labor and delivery process of a breech-presented fetus is not
      easy. For this reason, it is thought that teaching vaginal breech delivery management by
      gamifying will be beneficial and it is important to investigate the effect of students
      playing this game on learning.

      Our study has two aims. Its primary purpose is; is to design a vaginal breech delivery
      management educational mobile game for midwifery students. The secondary aim is to evaluate
      the effect of the educational mobile game-supported teaching activity given to midwifery
      students about vaginal breech delivery within the scope of risky birth and postpartum period
      course.

      Real actors and simulation models were used to fake the scenario to be used in the game. A
      mobile game was prepared with the film shot. It was conducted with 10 volunteer students from
      Marmara University Health Sciences Faculty Midwifery Department 3rd grade students in order
      to determine whether there is any aspect of the mobile game that requires development. The
      mobile game, which was shaped and organized with the pilot application, was applied to the
      students in the 3rd grade play group of Kocaeli University Health Sciences Faculty Midwifery
      Department after single-blind randomization. Introductory features form, vaginal breech birth
      management knowledge test, course effectiveness evaluation form, general satisfaction level
      test about the course and vaginal breech birth management mobile game evaluation form were
      used to collect data.
    

Detailed description: 
      H1: There is a statistically significant difference between the Vaginal Breech Birth
      Management Post-Test of Knowledge scores of the students in the play group and the students
      in the control group.

      H2: There is no statistically significant difference between the mean scores of the students
      in the play group and the students in the control group in the Vaginal Breech Birth
      Management Post-Test of Knowledge.

      H3: There is a statistically significant difference between the Vaginal Breech Birth
      Management Knowledge Retention Test mean scores of the students in the play group and the
      students in the control group.

      H4: There is no statistically significant difference between the Vaginal Breech Birth
      Management Knowledge Retention Test mean scores of the students in the play group and the
      students in the control group.

      Variables of the Study Independent variable Playing the vaginal breech delivery management
      mobile game for the students taking the Normal Birth and Postpartum Period course The
      dependent variable Vaginal breech birth management knowledge test, course effectiveness
      evaluation form, general satisfaction level test for the course, mobile game evaluation forms
      Research Design It is a prospective, single-blind, randomized controlled experimental type
      study with a pretest-posttest design.

      Place and Time of Research The research is carried out with 3rd grade students within the
      scope of Risky Birth and Postpartum Term course in the 2021-2022 academic year spring
      semester at Kocaeli University, Faculty of Health Sciences, Midwifery Department, and the
      pilot application of the research is carried out with 3rd grade students of the Midwifery
      Department of Marmara University Health Sciences Faculty.

      Population and Sample of the Research The universe of the research consists of 81 3rd grade
      midwifery students from Kocaeli University Faculty of Health Sciences in the 2021-2022
      academic year in order to be the institution where the researcher works and to facilitate
      data collection. According to the sample calculation, it was planned to reach at least 68
      students at the 5% Type 1 error level and the 95% confidence interval. It was planned to
      apply the study to the whole population in order to prevent possible case losses. A total of
      79 students were included in the sample because two of the students did not attend the
      classes.

      Ethical aspect of research Ethics committee approval for the study was received from Kocaeli
      University Non-Interventional Clinical Research Ethics Committee (approval date / decision
      no: GOKAEK-2022/02.11) on 28.01.2022. Written permissions were obtained from the Kocaeli
      University Faculty of Medicine Dean's Office for the use of the simulation laboratory, where
      the scenario will be filmed, from the Marmara University Faculty of Health Sciences for the
      pilot application of the play, and from the Kocaeli University Faculty of Health Sciences
      Dean's Office for the implementation phase of the study. During the preliminary and pilot
      implementation, the participants were informed verbally and in writing about the purpose of
      the research and that their personal information would be kept confidential. However, it was
      stated to the participants that participation in the study was on a voluntary basis and if
      they submitted the study forms, they would be deemed to have given their consent to
      participate in the study. Our study is carried out in accordance with the Principles of the
      Declaration of Helsinki.

      Randomization and creation of groups Kocaeli University Faculty of Health Sciences, 2021-2022
      academic year, 81 3rd grade midwifery students were divided into experimental and control
      groups using the computer-assisted (www.randomizer.org) randomization program. The
      experimental group was called the play group, and the other group was called the control
      group.

      All students will be asked not to share their intervention experiences until the research
      process is completed by the researcher.

      During the research process, the traditional education method will not be explained to the
      students in the play group and the delivery management of the breech-presented fetus, and the
      vaginal breech delivery management mobile game will not be played to the students in the
      control group. After the study process is completed, both education methods will be applied
      to the students in both groups.

      Development of the Mobile Game to be Used in the Research In the prepared mobile game, the
      labor process of the pregnant was recorded with the actors acting, and the breech birth scene
      was recorded using simulation models.

      The creation of mobile game content consists of five parts. In the first part, the
      determination of the game to be digitized and the creation of the game-specific scenario and
      scenario questions are included, while the second part includes the presentation of the
      scenario and scenario questions to expert opinions. In the third part, the film is shot by
      putting the scenario on the stage, and the transfer of the film shot in the fourth part to
      the mobile game and the pilot application of the game are included. In the fifth section,
      which is the last section, the effectiveness of the vaginal breech delivery management mobile
      game developed on the 3rd grade students of the Department of Midwifery, Faculty of Health
      Sciences, Kocaeli University, was evaluated.

      First part: The story of the game, characters related to the game and questions about the
      player were created in line with the relevant literature in determining the game and creating
      the original scenario.

      Second part: The scenario and scenario questions were sent to eight academicians who are
      experts in the field of midwifery and have at least five years of academic experience, and
      seven clinician midwives with at least five years of delivery room experience. Areas were
      created to evaluate the submitted scenario as positive and negative for each section's
      features, and experts were asked to express their views on those areas. In line with the
      evaluations received, the final version of the scenario and scenario questions were obtained.
      The draft of the script was then scripted by a screenwriter and the lines were created.

      Third part: Real actors and simulation models were used to fake the script. Film and model
      simulation shooting was carried out with a professional team at Kocaeli University Good
      Physician Practices and Simulation Center, where the necessary institutional permission was
      obtained, with the role of professional actors, whose consent was obtained before. The
      creation of realistic scenes was provided by the necessary equipment (make-up, professional
      camera, etc.).

      Pregnant and her partner were played by two professional actors. A fake pregnant belly model
      was applied to the woman who assumed the role of pregnant with the help of professional
      make-up. In applications performed from the abdominal region such as the Leopold maneuver,
      electronic fetal monitoring application, and FKA listening, the abdomen of the pregnant woman
      was opened so that only the abdominal region was visible. In midwifery practices such as
      vaginal examination, no demonstration was made, but the impression that vaginal examination
      would be performed was reflected. During the movie, a gimbal camera was used at the head of
      the actor who will play the role of a midwife. In this way, it was ensured that the event
      pattern was observed from the eyes of the midwife.

      During the birth, the moment of birth was animated with models by using simulation models.
      The camera is set to record only maneuvers used at the time of birth and postpartum
      procedures.

      The fourth part: In the transfer of the film to the mobile game, individual service was
      received from an information system engineer who is an expert in his field.

      In the mobile game, questions appear on the screen at certain intervals during the movie, and
      the movie continues to play after the student answers the question. When the student gives a
      wrong answer to the question, a text is displayed stating why that answer is wrong. In cases
      where filming was appropriate, the results of the wrong choice were transferred to the film
      and the actor was able to visually and audibly watch the result of the wrong answer. Playing
      the game takes an average of 30-45 minutes.

      In order for students to access the mobile game, a different user name and password were
      created for each student. The link required to download the game and the username and
      password that were created before to enter the game were sent to the student by the
      researcher over the internet (e-mail/WhatsApp).

      After the game was developed, a pilot application was made. This app helped determine how
      long it would take to complete the mobile game and whether there were any aspects of the game
      that needed improvement. The pilot application of the game and measurement tools was carried
      out with 10 volunteer students from the 3rd grade students of the Department of Midwifery,
      Faculty of Health Sciences, Marmara University, for which the necessary institutional
      permission was obtained.

      Fifth Part: The mobile game, which was shaped and organized with the pilot application, was
      applied to the students in the 3rd grade playgroup of Kocaeli University Faculty of Health
      Sciences Midwifery Department after single-blind randomization on May 13, 2022.

      Data Collection Forms Introductory features form, vaginal breech birth management knowledge
      test, course effectiveness evaluation form, general satisfaction level test for the course,
      vaginal breech birth management mobile game evaluation forms were used to collect data. All
      forms to be used in data collection were submitted to expert opinions after obtaining ethical
      committee permission and institutional permissions, and they were finalized.

      Introductory features form: It is the form in which the socio-demographic and previous
      knowledge of digital game playing of the students participating in the study are questioned.

      Vaginal breech birth management knowledge test: A questionnaire was created in line with the
      relevant literature in line with the content of the risky birth and postpartum course in
      order to provide the necessary knowledge and skills for the management of the labor and
      delivery process of the pregnant with the fetus in breech presentation, to make appropriate
      interventions, and to adopt the roles and responsibilities of the midwife. The created
      questionnaire was presented to the expert opinion along with the scenario, and it was
      finalized in line with the feedback received. These questions will be evaluated with the
      assessment and evaluation system developed independently of the educational mobile game. Each
      correct answer is 1 point, and the maximum score that can be obtained from the test will be
      determined by the number of questions.

      Course effectiveness evaluation form: The form, which was prepared by the researchers in line
      with the literature review, was applied to the play group after the vaginal breech delivery
      management mobile game was played, and to the control group after the birth management
      training of the breech presentation fetus, which was given through traditional education. In
      this questionnaire, there are statements that allow the evaluation of the education given by
      the student. The minimum score to be taken from the form to be evaluated with a 5-point
      Likert-type (1=Totally disagree, 2=Disagree, 3=Undecided, 4=Agree, 5=Totally Agree) is 11,
      and the maximum score is 55.

      General satisfaction level test for the lesson: It was applied to the play group after the
      vaginal breech management educational mobile game was played, and to the control group after
      the birth management training of the breech presentation fetus, which was given through
      traditional education. The test, in which the participants will be asked to indicate their
      general level of satisfaction with the lesson, will be evaluated with a 6-point Likert type,
      and the average score of the test in both groups was calculated.

      Vaginal breech delivery management mobile game evaluation form: It is a questionnaire
      developed by the researchers in line with the literature review to evaluate the clarity and
      convenience, suitability and quality of the mobile game by the players. In this survey; The
      harmony of the text, fonts and colors of the game, the legibility of the size and style, the
      attractiveness and clarity of the game design (interface, graphics, etc.), the ease of
      learning and playing, the state of the game's content and structure to increase the player's
      knowledge and self-confidence about the subject, the fluency of the game, the lesson. There
      are expressions that evaluate the opinions of the players, such as the situation of being a
      reinforcing tool. The minimum score to be taken from the form to be evaluated with a 5-point
      Likert type (1=I totally disagree, 2=Disagree, 3=Undecided, 4=Agree, 5=Completely Agree) is
      39, and the maximum score is 195.

      Statistical analysis will be performed using the IBM SPSS Statistic 22.0 (IBM Corp., Armonk,
      NY, USA) program. Descriptive statistical methods (number, percentage, mean, standard
      deviation) will be used in the evaluation of socio-demographic data. Parametric tests
      (chi-square, T test, etc.) will be used in the comparison of categorical variables when the
      data are found to be suitable for normal distribution, and non-paramedic tests (Mann-Whitney
      U Test, Kruskal Wallis, etc.) will be used when they are not suitable for normal
      distribution.
    

Intervention name(s): Playgroup; Control group
Intervention type(s): Other; Other
Intervention description(s): The mobile game will be sent to the students via a link and the students are allowed to install it on their mobile phones with android and ios operating systems. The internet required for the download was provided by the researcher. For the students who did not have a smart phone in the playgroup, the game would be started from the researcher's phone and the game was played sequentially. All students were allowed to use headphones while playing the game. In order to log in to the game, an account was created on behalf of each student, and the game user name and password were sent to the students by e-mail. It was ensured that they did not communicate with anyone and did not receive help during the game with the supervision of the researcher. Waited until each participant completed the game. Then, the mobile game was deleted from the smartphones of all participants, and the download link was inactive until the research process was completed.; The researcher gave a theoretical lesson through the presentation prepared in the powerpoint program about the birth management of a breech-presented fetus in the classroom as in the traditional education method.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Other
Keywords: Midwifery; mobile game; vaginal breech delivery management; midwifery education