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Journal for Specialists in Pediatric Nursing
ORIGINAL ARTICLE
Learning and adherence to baby massage after two
teaching strategies
Cláudia Marchetti Cruz, Fátima Aparecida Caromano, Lia Lopes Gonçalves, Thais Gaiad Machado, and
Mariana Callil Voos
Cláudia Marchetti Cruz, MSc, is a Physical Therapist; Fátima Aparecida Caromano, PhD, is a Physical Therapist; Lia Lopes Gonçalves, MSc, is a Nurse; Thais
Gaiad Machado, PhD, is a Physical Therapist; and Mariana Callil Voos, PhD, is a Physical Therapist, Universidade de São Paulo, São Paulo, SP, Brazil
Search terms
Adherence, massage, mother–child relation,
pregnant women, teaching.
Author contact
ftmarivoos@gmail.com, with a copy to the
Editor: roxie.foster@ucdenver.edu
Conflict of interest: All authors declare no
conflicts of interest.
First Received October 9, 2013; Final revision
received February 10, 2014; Accepted for
publication February 11, 2014.
doi: 10.1111/jspn.12076
Baby massage is beneficial and gratifying for the
child and his or her parents. It produces many posi-
tive physiological and behavioral effects in infants,
such as better sleep quality (Ferber et al., 2002),
improvement in circulation (Chen, Sadakata, Ishida,
Sekizuka, & Sayama, 2011; Kulkarni, Kaushik,
Gupta, Sharma, & Agrawal, 2010), and improve-
ment in immunological responses (Kulkarni et al.,
2010). Additionally, the massage facilitates the
mother–child relation and helps reduce anxiety for
both (Chen et al., 2011; Fujita, Endoh, Saimon, &
Yamaguchi, 2006; O’Higgins, St. James Roberts, &
Glover, 2008).
The first communication that parents can create
with their child is by means of touch, and massage is
one of the most suitable ways of touching an infant
(Cetinkaya & Basbakkal, 2012; Cheng, Volk, &
Marini, 2011; Field, Diego, & Hernandez-Reif, 2010;
Kulkarni et al., 2010). Therefore, baby massage is
important because infants interpret touch as physi-
cal evidence that they are loved (Cetinkaya &
Basbakkal, 2012; Leboyer, 1997). The effect of giving
an infant comforting skin massages is evident on
Journal for Specialists in Pediatric Nursing •• (2014) ••–••
© 2014, Wiley Periodicals, Inc.
Abstract
Purpose. Little is known about learning/adherence after different baby
massage teaching strategies. We compared the learning/adherence after
two strategies.
Design and Methods. Twenty mothers from the group manual-course
(GMC) and 20 from the group manual-orientations (GMO) received a
booklet. GMC participated in a course during the third trimester. GMO
received verbal instructions during the postpartum hospital stay. Multiple-
choice and practical tests assessed learning (GMC: performing strokes on a
doll; GMO: on the baby). Adherence was measured 3 months after child-
birth.
Results. No differences were found between the groups in learning/
adherence.
Practice Implications. Both teaching strategies showed similar and posi-
tive results.
many levels (Cheng et al., 2011; Kulkarni et al.,
2010; Simpson, 2001). For instance, the brain con-
tains emotional systems that, from the first days of
life, directly mediate social bonds and social feelings
(Guzzetta et al., 2011; Simpson, 2001).
Teaching caregivers massage techniques involves
low costs (Leboyer, 1997), and mothers who are
given this kind of guidance can achieve the same posi-
tive effect as that of trained professionals (Ferber
et al., 2002). However, in many studies, researchers
and/or medical staff provide infant massage (Field
et al., 2010; Guzzetta et al., 2011; Scafidi & Field,
1996), which makes it difficult to reproduce at home.
This approach does not take advantage of the poten-
tial benefits of infant massage training for parents
(Cetinkaya & Basbakkal, 2012; Fujita et al., 2006;
O’Higgins et al., 2008; Onozawa, Glover, Adams,
Modi, & Kumar, 2001; Oswalt & Biasini, 2011).
In addition, the lack of constancy of sensory expe-
riences, including receiving massage from many dif-
ferent people, may delay the baby’s capacity to build
up a consistent picture of his or her home environ-
ment (Hoath, 2001). The skin is the largest sensory
1
Learning and Adherence to Baby Massage After Two Teaching Strategies
organ of the body, and the tactile system is the earli-
est sensory system to become functional. It is the
medium by which the infant’s external world is per-
ceived. The infant skin is a sensory surface, a protec-
tive mantle, and a psychological and perceptual
interface with caregivers and parents (Hoath, 2001;
Simpson, 2001).
There are currently some infant massage courses
and techniques, for example, International Associa-
tion of Infant Massage (Cho, Ji, & Lee, 2012;
O’Higgins et al., 2008), Baby’s First Massage (Oswalt
& Biasini, 2011; Serrano, Doren, & Wilson, 2010),
Positive Touch (Cheng et al., 2011), and Touch
Therapy (Field et al., 2010). Although touch is a
form of communication that transcends almost all
culture (Simpson, 2001), in many countries, teach-
ing baby massage is not common in academic curri-
cula, or as a popular tradition. In Brazil, the most
accessible technique is the traditional Shantala.
Leboyer’s book, about this technique, is available to
consumers (e.g., parents and instructors) in Brazil-
ian Portuguese (Leboyer, 1997).
The most frequent methods of teaching baby
massage to caregivers found in the literature were
courses (Cho et al., 2012; O’Higgins et al., 2008;
Onozawa et al., 2001; Oswalt & Biasini, 2011;
Serrano et al., 2010), individual demonstrations
(Cetinkaya & Basbakkal, 2012; Ferber et al., 2002),
video demonstrations (Serrano et al., 2010), and
written orientations in booklets given to caregivers
(Cetinkaya & Basbakkal, 2012; Cruz, Ide, Tanaka, &
Caromano, 2008; Oswalt & Biasini, 2011; Table 1).
However, the best way of teaching baby massage for
parents is not clear in the literature. Different kinds
of explanation, demonstration, and practice of
massage techniques may result in differences in
theoretical and practical learning, and can also influ-
ence adherence (Magill, 2011). We did not find any
study comparing different teaching strategies and
investigating the adherence of caregivers after each
strategy.
Previous studies about teaching strategies involv-
ing prenatal and postpartum mother and child-
care have shown positive effects from different
approaches. Garcia and Rose (1996) assessed the
effects of verbal orientations about breastfeeding
and infant development stimulation, and concluded
that the educational program was viable and that
this strategy reduced risk factors. Some other studies
have shown the positive effects of oral and written
orientations in the prenatal period (Girard & Olude,
2012; Ng et al., 2013) and in postpartum care
(Brodribb, 2011; Leboucher et al., 2012) of mothers
2 Journal for Specialists in Pediatric Nursing •• (2014) ••–••
C. M. Cruz et al.
and babies. However, although much is said about
the positive effects of infant massage, the choice of
which strategies should be used remains unclear.
We hypothesized that two different strategies of
teaching baby massage could result in different
learning and could also influence the adherence to
baby massage. The present study aimed to compare
the (a) theoretical and (b) practical learning of pri-
miparous women about baby massage after two dif-
ferent teaching strategies, and (c) the adherence to
the massage after each strategy.
METHOD
Participants
One hundred seven mothers were eligible for the
study. Recruitment was made during routine prena-
tal care. Mothers were randomly distributed in the
group manual-course (GMC, n = 53) and group
manual-orientations (GMO, n = 54). Randomization
was made by the nurses providing prenatal assis-
tance who were blind to the objectives of the present
study. Forty-five mothers gave informed consent to
participate and 40 concluded the experimental pro-
tocol (Figure 1). Mothers who did not consent to
participate, or withdrew, declared that they did not
have enough free time available to read the manual.
Inclusion criteria were being primiparous, between
21 and 34 years old, having health insurance to
cover the medical expenses of the gestational period
and delivery, and having nine or more years of
formal education (having completed at least first and
middle school, from 6 to 15 years of age).
All mothers gave birth to healthy babies and had
deliveries with no complications in a hospital mater-
nity in the city of São Paulo. After the deliveries, the
babies stayed in the hospital rooms with their
mothers. All of them were breastfed. Table 2 shows
descriptive data about the participants (Table 2).
Procedures
The mothers were informed about the procedures
and aims, and signed the informed consent to par-
ticipate in this study. This study was approved by the
Committee of Research and Ethics of Clinics Hospital
of the University of São Paulo.
In the beginning of the third trimester of gesta-
tion, mothers were randomly distributed in GMC or
GMO. The GMC (n = 20) received a manual about
baby massage and a theoretical and practical 4-hr
course. The GMO (n = 20) received, on the day after
© 2014, Wiley Periodicals, Inc.
 Table 1. Studies That Taught Caregivers Baby Massage and Respective Results
Authors, year, location
Cetinkaya and Basbakkal
(2012), Turkey
© 2014, Wiley Periodicals, Inc.
Cho and colleagues (2012),
South Korea
Cheng and colleagues
Journal for Specialists in Pediatric Nursing •• (2014) ••–••
(2011), Canada
Ferber and colleagues
(2002), Israel
Fujita and colleagues (2006),
Japan
Onozawa and colleagues
(2001), United Kingdom
Oswalt and Biasini (2011),
United States
O’Higgins and colleagues
(2008), United Kingdom
Serrano and colleagues
(2010), Chile
3
Technique/time of
Subject/caregiver application
40 healthy infants, 2–6 Abdominal massage and
months of age/mothers aromatherapy/at the colic
onset for 5–15 min
169 healthy infants, 3 Meridian massage or gentle
months of age or touch massage/15 min/
older/mothers day for 6 weeks
24 healthy infants, 4–14 A combination of Indian
months of age/fathers massage, Swedish
massage, yoga, and
reflexology/4 weeks
16 healthy 30 min of massage therapy
newborns/mothers to the infant daily for 14
days, starting on day 10
(± 4) of life
57 healthy infants, 1 month Massage to each area of the
of age/mothers babies’ bodies at least
10 min/day until 3
months after delivery
34 healthy infants, 2 months Weekly 1-hr infant massage
of age or older/depressed class with an instructor/
mothers 5 weeks
17 HIV-infected babies, 1–2 The Baby’s First Massage
months of age/HIV- program/15–20 min daily
infected mothers for 10 weeks
62 healthy infants, 1 month Weekly 1-hr infant massage
of age/depressed mothers class with an instructor/6
weeks and 1 year
follow-up
100 healthy newborn infants Mothers were encouraged to
(massage started when massage their infants for
infants were 15 days 10–15 min at least once a
old)/mothers day
Teaching strategy
The massage was demonstrated on the infant by a
researcher. The mothers were also given a
booklet containing all the information provided
during the training.
Group education with 45- to 60-min sessions at
the community healthcare center.
Training consisted of a general description of
Meridian Massage and demonstrations of
mothers massaging their own infants.
The International Association of Infant Massage
instructor demonstrated the stroke on a doll for
the parents to mimic with their own child.
Mothers were instructed to roll the infant on its
side and perform massage in a rhythm of three
movements per second. They should touch the
infant’s head with one hand and lightly stroke
its back in a circular motion, under the clothes,
with the other.
Massage was oriented according to the procedure
outlined by Field and colleagues (2010). Each
area of the baby’s body received the strokes:
legs, belly, chest, arms, and back.
The International Association of Infant Massage
instructor demonstrated the strokes on a doll,
while the mother worked with her own infant.
The instructor demonstrated the massage on a
doll; participants mimicked the strokes on their
infants. A booklet with the information and
diagrams of the massage strokes was given.
The International Association of Infant Massage
instructor demonstrated the strokes on a doll,
while the mother worked with her own infant.
Nurses provided instruction to massage-group
mothers about how to massage their infants
based on the methods of the Baby’s First
Massage program.
Beneficial effects
The use of aromatherapy massage using
C. M. Cruz et al.
lavender oil was found to be effective in
reducing the symptoms of colic.
Meridian Massage facilitated physical
growth and improved infants’ health
outcome as perceived by mothers.
Fathers receiving infant massage
instruction, and performing massage
regularly, showed lower levels of
paternal stress.
Massage therapy serves as a strong time
cue, enhancing coordination of the
developing circadian system with
environmental cues.
Baby massage positively affected the mood
status of the mothers: depression
decreased and the vigor sessions
improved.
The Edinburgh Postnatal Depression Scale
scores fell in both groups. Significant
improvement of mother–infant
interaction was seen in the massage
group.
Infant massage training had a positive
impact on maternal depression, parental
distress, and infant growth, along with
facilitating parent–child interactions.
Mothers showed a reduction in Edinburgh
Postnatal Depression Scale scores. At 1
year, massage-group mothers had
non-depressed levels of sensitivity of
interaction with their babies.
At age 2 months, massage-group infants
weighed more than control-group
infants. Teaching mothers to massage
their infants may increase the early
Learning and Adherence to Baby Massage After Two Teaching Strategies
weight gain.
Learning and Adherence to Baby Massage After Two Teaching Strategies C. M. Cruz et al.

period to answer questions. During the theoretical

107 class, the instructor explained the physiological and
eligible
behavioral benefits of infant massage, based on data
from the literature, and exposed all the information
from the manual. In the practical class, the instruc-
53 GMC 54 GMO
tor showed the massage on a doll and then each
mother reproduced the whole sequence of massage
20 33 did not 25 29 did not on a doll. The instructor observed each mother and
consented consent consented consent corrected the movements each time it was necessary.
The instructor was a physical therapist with a mas-
ter’s degree in rehabilitation science/pediatrics and 5
20 0 20 5
completed withdrew completed withdrew years practice teaching techniques of baby massage
(Swedish massage and Shantala).
Figure 1 Sample Selection. GMO. Mothers from this group received the same
Note: GMC, group manual-course (received a booklet and participated in a
manual but at a different time, the day after the
course during the third trimester); GMO, group manual-orientations
(received a booklet and received verbal instructions during the
delivery. Instead of the course, they received a 1-hr
postpartum hospital stay). visit from a nurse and a physical therapist during
their hospital stay. On this visit, they received a
30-min theoretical explanation about the baby
the baby was born, the same manual, and on the massage and a 30-min demonstration of the
next day a visit by a nurse and a physical therapist to sequence of the massage on a doll. After the demon-
give general instructions and answer possible ques- stration, they performed the strokes on their baby.
tions about the massage. The professionals also answered the mothers’ ques-
tions about the topic.
GMC. When they were in the third trimester of ges- The GMO relied more on the self-instruction by
tation, mothers from this group received a manual each participant (by reading the manual) because
containing theoretical and practical explanations the mothers received less instruction about theoreti-
about the baby massage, and they were divided into cal information. The practice time was similar to
four groups of five. Each group attended a 4-hr GMC because the instructor demonstrated the
course, divided into a 90-min theoretical class, a strokes and then observed the mother performing
30-min break, a 90-min practical class, and a 30-min them. The GMC needed more time than the GMO

Table 2. Characteristics of the Participants

GMC GMO Test used p-value

Age (years) 26.5 (2.1) 25.2 (3.1) t .138
Education (years) 13.5 (2.0) 13.2 (2.4) t .669
Employment status Employed 60% Employed 70% X2 .740
Unemployed 40% Unemployed 30%
Marital status Married 90% Married 95% X2 .998
Single 10% Single 5%
Child’s birth weight 3,104 (158) 3,049 (139) t .126
Child’s birth length 50.0 (1.2) 50.0 (1.1) t .500
Child’s sex Male 50% Male 40% X2 .831
Female 50% Female 60%
Type of delivery Vaginal 85% Vaginal 90% X2 .998
Cesarean 15% Cesarean 10%
Weeks of gestation when the manual was given 32.9 (1.6) 38.9 (1.1) t < .001*
Theoretical learning 9.5 (0.8) 9.2 (1.0) t .294
Practical learning 9.6 (0.7) 9.2 (0.9) t .134
Adherence 8.7 (1.4) 8.9 (1.4) t .657

Note: GMC, group manual-course; GMO, group manual-orientation. Weeks of gestation when the manual was given: gestational period when
women received the manual. Theoretical learning, practical learning, and adherence to the program were scored from 0 to 10, according to the
performance of the participant. *Significant difference.

4 Journal for Specialists in Pediatric Nursing •• (2014) ••–••

© 2014, Wiley Periodicals, Inc.
C. M. Cruz et al.
for the practical class because in the GMC strategy
the instructor had to observe each one of the five
participants individually. In the GMO, however,
the instructor only had one student at a time, and
30 min was enough for demonstrating and observ-
ing the practice.
Information presented in the manual. This
manual was previously validated with experts (Cruz
et al., 2008). It contained theoretical and practical
information about baby massage and evidence
underlying the benefits of massage for both parent
and infant. It was based on Swedish massage
(Oswalt & Biasini, 2011; Serrano et al., 2010) and
Shantala (Leboyer, 1997), and contained pictures of
a voluntary Brazilian mother showing the strokes on
her child in all body segments of the baby (head,
upper limbs, anterior trunk, lower limbs, and poste-
rior trunk).
The manual also contained other practical infor-
mation, for example, mothers should perform the
massage at a convenient time, when they bathed the
infant or changed the infant’s clothing; mothers
should teach the massage to the babies’ fathers or to
other caregivers spending long periods with the
babies; massage should be done when the baby was
in a quiet alert state; and the mother’s hands should
be warmed and lubricated with baby oil before the
massage.
According to the manual, the massage should
begin with slow rhythmic strokes, the mother’s speed
and timing being guided by the infant’s body signals.
Strokes used were effleurage (gentle rhythmic
gliding strokes), thumb stroking (shorter strokes
using the broad side of the thumbs), and Petrissage
(gentle kneading; Oswalt & Biasini, 2011; Serrano
et al., 2010). Some parts of the body were to be
treated in a different way, for example, arms and legs:
milking strokes from proximal to distal, gentle
squeezes and twists in a wringing motion; hands and
feet: gentle pressing on a palm of hand/sole of foot,
stroking from finger/toes to wrist/ankle on the top of
the hand/foot; and abdomen: hand over hand strokes
in a paddle wheel fashion (circular, clockwise direc-
tion), with strokes avoiding the ribs (Leboyer, 1997).
Theoretical evaluation. All mothers received a
questionnaire with 10 multiple-choice questions.
The test involved definition, beneficial effects
(physiological and behavioral effects), indications
and contraindications, mother and place prepara-
tion, and correct positioning of the baby and the
mother. The answers were checked by the examiner.
Journal for Specialists in Pediatric Nursing •• (2014) ••–••
© 2014, Wiley Periodicals, Inc.
Learning and Adherence to Baby Massage After Two Teaching Strategies
The scores were transformed into the percentage of
correct answers. The wrong answers were discussed
with each mother individually, on the same day,
after the correction of the test. The GMC was
assessed 1 day after the course, and the GMO was
evaluated on the last day of hospital stay.
Practical evaluation. Each mother performed the
massage proposed in the manual. A physical thera-
pist and a nurse observed the mothers performing
the massage on a doll (GMC) or on their babies
(GMO). The positioning of the baby, the posture of
the mother, and the sequence and technique of
massage were assessed. An examination chart, with
a diagram of massage sequence, was used. The
maximum possible score was 10 and the minimum,
zero. The strokes performed incorrectly were dis-
cussed with each mother individually, on the same
day, after the test. The GMC was assessed 1 day after
the course, and the GMO was evaluated on the last
day of her hospital stay. Both groups performed the
practical test after the multiple-choice test. To assess
the reliability of the performance evaluation during
the practical test, the intraclass correlation coeffi-
cient (ICC) was calculated (Weir, 2005). The ICC
gives a score of how much consensus there is in the
ratings given by examiners. The ICC compared the
scores given by the physical therapist and the nurse.
Adherence evaluation. Three months after deliv-
ery, all mothers were interviewed with a question-
naire of 10 questions. Each question was scored with
zero (low adherence) or one (high adherence). The
open questions were grouped, generating catego-
ries. Each category was shown in percentage of
answers.
Statistical analysis
The GMC and the GMO were compared with t tests
when means were analyzed, or chi-square tests
when percentages were analyzed. The level of sig-
nificance was p < .05.
RESULTS
The characteristics of the mothers in GMC and GMO
are represented in Table 2. Student t tests did not
show significant differences between mothers and
infants in the GMC and GMO on sociodemographic
and clinical characteristics, such as maternal age,
educational level, marital status, employment
status, child’s birth weight, birth length, sex, or type
5
Learning and Adherence to Baby Massage After Two Teaching Strategies
of delivery. The only difference between the groups
was in the gestational age of mothers when the
manual was given (p < .001) because GMC partici-
pants received the booklet significantly before GMO
(32.9 vs. 38.9 weeks; Table 2).
Theoretical learning
In GMC, 13 mothers scored 10 (100%), four
mothers scored 9 (90%), and three scored 8 (80%)
on the multiple-choice test. In GMO, 10 mothers
scored 10 (100%), six scored 9 (90%), two scored 8
(80%), and two scored 7 (70%). The total mean
score of GMC was 9.5 (SD 0.8) and of GMO was 9.2
(SD 1.0). t tests showed no significant differences
between the groups (p = .294).
Four mothers answered the question about physi-
ological effects incorrectly: two from GMC and two
from GMO. Five mothers (one from GMC and four
from GMO) missed the question about psychomotor
effects. Only one mother from GMO did not answer
the question about behavioral effects correctly. Two
mothers from GMO failed to answer the question
about preparation of the person giving the massage.
The other questions, about definition, indications,
contraindications, correct positioning of the mother
and the baby, and preparation of the place, were
answered properly by all mothers from both groups.
Mean scores are displayed in Table 2.
Practical learning
The concordance index between the practical assess-
ments of the examiners was 97%. This indicates
consistence of data collected by the examiners (Weir,
2005). The total mean score of GMC was 9.6 (SD 0.7)
and of GMO was 9.2 (SD 0.9) (p = .134).
The proposed sequence of massage was followed
correctly by all mothers of both groups. Two mothers
from the GMC and four from GMO performed the
massage on the upper or lower limbs incorrectly.
Three mothers from the GMC and four from GMO
performed incorrectly the massage on the anterior
trunk or abdomen. Two mothers from the GMC and
four from GMO were imprecise while massaging the
posterior trunk. One mother from GMC and one from
GMO performed the massage on the head incorrectly.
Adherence to baby massage
There were no differences between the groups in
adherence (p = .656). The answers to the question-
naire were divided in categories and are presented in
Table 3.
6 Journal for Specialists in Pediatric Nursing •• (2014) ••–••
C. M. Cruz et al.
All mothers used the technique as described in the
manual, and when they performed the massage
they remembered the beneficial effects it had. All of
them reported beneficial effects for them and for
their babies. Every time mothers decided to massage
their babies, they performed the strokes at least on
three regions of the baby’s body (Table 3).
Fifty-five percent of GMC and 70% of GMO per-
formed the complete sequence of massage (p =
.656). Most mothers used the massage at least once a
week (GMC: 95% and GMO: 90%, p = .998). About
50% of them taught the massage to another care-
giver from the family (GMC: 50% and GMO: 60%; p
= .750; Table 3).
DISCUSSION
The present study investigated the existence of pos-
sible differences on adherence after two different
teaching strategies for baby massage. We did not find
another study comparing the adherence to baby
massage after two or more teaching strategies. Fur-
thermore, many studies have investigated the effects
of massage on unhealthy mothers and/or babies
(Cetinkaya & Basbakkal, 2012; Cheng et al., 2011;
Fujita et al., 2006; Garcia & Rose, 1996; O’Higgins
et al., 2008; Onozawa et al., 2001; Oswalt & Biasini,
2011), which could also have influenced positively
or negatively on the adherence to the massage.
We believe that the educational status of the
mothers, between 9 and 17 years of formal educa-
tion (GMC: M = 13.5 and GMO: M = 13.2 years), may
have helped the comprehension and adherence to
the massage. Besides, simple terms were prioritized
in the manual, during the course for the GMC and
during the GMO visits. The pictures from the
manual, of a Brazilian mother performing the
strokes on a Brazilian baby, may also have helped
mothers adhere to the massage. Most mothers used
the massage at least once a week, and 55% of GMC
and 70% of GMO participants performed the com-
plete sequence of massage. The short texts and a
high number of figures may have helped the groups
memorize the strokes. The pictures in Leboyer’s
book, about Shantala, also make the massage tech-
nique easy to reproduce (Leboyer, 1997). However,
the poetic and philosophical language and the strong
Indian cultural influence (clothes, physical pos-
tures) may decrease the comprehension and ability
of reproducing the complete sequence of massage by
Brazilian mothers. For instance, most Brazilian
women do not usually sit on the floor with their legs
extended. Instead, most of them would prefer sitting
© 2014, Wiley Periodicals, Inc.
C. M. Cruz et al. Learning and Adherence to Baby Massage After Two Teaching Strategies

Table 3. Absolute and Relative Frequencies of Adherence to the Massage

Questions GMC GMO X2

1. Did you use the massage technique explained in the manual?
– Yes 20 (100%) 20 (100%) 1.000
– No 0 (0%) 0 (0%)
2. Did you use the complete sequence of massage?
– Yes 11 (55%) 14 (70%) 0.656
– No 9 (45%) 7 (30%)
3. If you did not use the complete sequence in any occasion, did you massage at least three regions? Which region did you emphasize?
– Yes 20 (100%) 20 (100%) 1.000
– No 0 (0%) 0 (0%)
– Head 4 (20%) 6 (30%)
– Posterior trunk 4 (20%) 7 (35%)
– Anterior trunk 1 (5%) 8 (40%)
– Abdomen 6 (30%) 8 (40%)
– Arms and hands 3 (15%) 6 (30%)
– Legs and feet 6 (30%) 6 (30%)
4. When you used the massage, did you remember the beneficial effects it had? Why did you perform it?
– Yes 20 (100%) 20 (100%) 1.000
– No 0 (0%) 0 (0%)
– To obtain the physiological effects mentioned in the manual 16 (80%) 16 (80%)
– To obtain the psychomotor effects mentioned in the manual 1 (5%) 0 (0%)
– To obtain the behavioral effects cited in the manual 11 (55%) 14 (70%)
5. Did you use the massage at least once/week? How often did you perform it?
– Yes 19 (95%) 18 (90%) 0.998
– No 1 (5%) 2 (10%)
– Every day 8 (40%) 6 (30%)
– 3–5 times/week 7 (35%) 10 (50%)
– 1–2 times/week 4 (20%) 2 (10%)
– Once or twice a month 2 (10%) 2 (10%)
6. Did you use the massage in any specific situation mentioned in the manual? In which situation?
– Yes 16 (80%) 18 (90%) 0.656
– No 4 (20%) 2 (10%)
– Other situations:
– To prevent colic 4 (20%) 8 (40%)
– When the baby was calm 2 (10%) 6 (30%)
7. Did you notice any beneficial effect for your baby after the massage? What effect?
– Yes 20 (100%) 20 (100%) 1.000
– No 0 (0%) 0 (0%)
– The baby became more relaxed, slept better, etc. 13 (65%) 15 (75%)
– It prevented colic and other digestion problems 5 (25%) 6 (30%)
– The baby became more attentive 4 (20%) 4 (20%)
– Improved/facilitated the contact with the mother 14 (70%) 12 (60%)
8. Did the massage bring any benefit for you? What benefit?
– Yes 20 (100%) 20 (100%) 1.000
– No 0 (0%) 0 (0%)
– I am not afraid to hold the baby anymore. 2 (10%) 9 (45%)
– Easier contact and feeling of tenderness. 14 (70%) 13 (65%)
– I feel I am doing something good for my baby. 7 (35%) 10 (50%)
– I do not feel guilty for the baby’s colic. 1 (5%) —
9. Did you teach the massage to any other person from your family?
– Yes 12 (60%) 10 (50%) 0.750
– Mother 5 (25%) 7 (35%)
– Husband 4 (20%) 2 (10%)
– Other relative helping taking care of the baby 3 (15%) 1 (5%)
– No 8 (40%) 10 (50%)
10. Would you recommend the manual to another mother?
– Yes 20 (100%) 20 (100%) 1.000
– No 0 (0%) 0 (0%)

Journal for Specialists in Pediatric Nursing •• (2014) ••–•• 7

© 2014, Wiley Periodicals, Inc.
Learning and Adherence to Baby Massage After Two Teaching Strategies
on the floor with their legs crossed and with the baby
in front of them on a mat, as shown in the manual.
Baby massage is not only beneficial for babies, but
also for parents. Previous studies have shown that
when mothers massage their babies, their self-
efficacy and self-esteem increase (Fujita et al., 2006;
O’Higgins et al., 2008; Onozawa et al., 2001; Oswalt
& Biasini, 2011; Table 1). It is possible that in the
GMC, during the prenatal period, mothers had the
opportunity of expressing emotions and fears,
relieving some of their own burdens. Attending the
course during pregnancy may be considered a strat-
egy to help the woman assimilate the changes she
will face in her life with the arrival of the baby. The
30-min break and the 30-min period for questions
may also have been a space for socializing, exchang-
ing thoughts, doubts, information, and expectancies
with other mothers and the instructor, mainly in the
case of primiparous women. Although in prenatal
courses a doll was used in the practice of massage,
mothers may have been able to imagine that the doll
was their baby. However, it is important to consider
that the GMC participants may have forgotten
some information learned during the course in
the months preceding the delivery.
On the other hand, when an individual visit was
offered and massage was demonstrated and prac-
ticed with the “real” baby (GMO), mothers may
have become experienced with this touch dialogue
and more aware of their baby’s capabilities. This
experience may have allowed mothers to move
forward in understanding the developmental possi-
bilities, strengths, and vulnerabilities of their babies
(Ardiel & Rankin, 2010; Cheng et al., 2011). Also,
GMO participants were benefited from the visit of
the nurse and the physical therapist. The profession-
als discussed individually all the questions about the
massage procedures. Although the GMO mothers
counted on less time of instruction (1 vs. 3 hr),
mothers from this group were able to perform self-
instruction by reading the manual and they reached
similar results.
During the GMC course, the instructor demon-
strated the strokes on a doll and mothers reproduced
them on another doll. The instructor observed them
and corrected the errors. During the hospital orienta-
tions (GMO), the physical therapist or the nurse dem-
onstrated the strokes on a doll and mothers massaged
their babies. Performing the massage on a real baby
may have been more difficult than on a doll. In con-
trast, performing the massage on a real baby may
have provided more positive affective feedback from
the baby and more precise feedback from the instruc-
8 Journal for Specialists in Pediatric Nursing •• (2014) ••–••
C. M. Cruz et al.
tors. This issue is relevant because, depending on the
practice condition, retention may change (Magill,
2011). Learning how to perform baby massage is
sensory motor learning. Sensory motor performance
may be easier when the practice is simplified (practice
on a doll, GMC). But it may be more adaptable if the
practice presents more variability (practice on the
real baby, GMO; Magill, 2011).
These issues did not affect differently the adher-
ence to the massage. They may have compensated
each other. Both groups showed good performance
on theoretical and practical tests. This suggests that
both strategies helped the mothers improve their
knowledge about the massage. Both educational
strategies were easy to apply and provided perma-
nent material for mothers to follow (the booklet).
These findings are similar to the results of Garcia
and Rose (1996). These authors also combined two
teaching strategies: one to encourage breastfeeding
and another to stimulate infant development. The
strategies were evaluated by direct observation of
mother–infant interaction and interviews with the
mothers 6 months after childbirth. The authors con-
cluded that it was viable to combine verbal orienta-
tions about breastfeeding and infant stimulation
instructions in an educational program, and that
these combined strategies helped reduce risk factors
both for malnutrition and developmental retarda-
tion. Likewise, the present study showed positive
results with the combination of the manual and the
course (GMC), and the combination of the manual
and the hospital postpartum orientations (GMO).
The massage was used by both groups to produce
physiological and behavioral effects. This was mea-
sured in the adherence questionnaire by asking
why the massage was performed. Additionally, the
massage may have been an extra tool to deal with
the newborn. These findings are compatible with
those from Moreira, Duarte, and Carvalho (2011).
They studied the adherence of mothers using
Shantala techniques. The massage was performed
almost every day by most mothers. Many of them
paired this practice with another task in the routine
(e.g., after changing diapers or after the bath), as
suggested by the authors of that study and also in the
manual of our study.
As limitations of the present study, we must
mention that we counted on the self-report of
maternal administration of massage 3 months after
discharge. This kind of self-report is usually weaker
than if mothers had kept a diary or had some
communication with the researchers during the
3 months. Also, the massage performed by the
© 2014, Wiley Periodicals, Inc.
C. M. Cruz et al.
mothers was not observed during this period.
Although massage is relatively safe, if done incor-
rectly it can be less beneficial and even harmful.
Mothers who did not consent to participate or with-
drew declared that they did not have enough free
time available to study the manual. The strategies
in the present study depend on the availability of
reading and studying the manual, and may not
reach mothers with less free time available. The par-
ticipants from both groups had similar characteris-
tics, for example, a minimum of 9 years of formal
education, lived with the baby’s father, and were
primiparous. It is possible that less homogeneous
groups would show different responses to baby
massage teaching strategies. Future research should
address these limitations through different study
designs and procedures.
How might this information affect
nursing practice?
It was possible to reach positive outcomes teaching
baby massage to mothers in the third semester of
gestation or during the postpartum hospital stay.
Practicing the massage with a doll and practicing
the massage with the baby both resulted in high
adherence. More exploration of educational activi-
ties to promote maternal and child health would be
useful in care during the third semester of gestation
and the postpartum period.
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