Exploring and influencing the knowledge and attitudes of health professionals towards extended breastfeeding

Developing an Instrument to Measure Public Health Nurses' Competence Related to Breastfeeding Beyond 12 Months

BACKGROUND

Health professionals need adequate competence to support breastfeeding beyond infancy. There is no established instrument to measure health professionals' competence regarding long-term breastfeeding. To respond to this shortcoming, the Long-Term Breastfeeding Competence Scale (LBCS) was developed.

RESEARCH AIM

To develop and pilot an instrument that measures public health nurses' competence related to breastfeeding beyond 12 months in order to provide adequate breastfeeding counseling for families.

METHODS

This study was conducted as a cross-sectional online survey on public health nurses working in maternity and/or child health clinics. The relevance and clarity of the LBCS were assessed by an expert panel (N = 6). Public health nurses (N = 197) completed the LBCS, which consisted of a knowledge and skills dimension and an attitude dimension. Descriptive statistics were used to describe the characteristics of the study sample. The conceptual validity of the knowledge and skills dimension was assessed using the dichotomous Rasch analysis, and attitude dimension using the exploratory factor analysis. Internal consistency was evaluated using Cronbach's alpha. The distribution of the items was summarized by descriptive statistics.

RESULTS

According to expert panel evaluations, the LBCS was found to meet the requirements for relevance and clarity (S-CVI 0.90). The internal consistency of the instrument was at a good level (α = 0.796) and met the requirements set for a new instrument.

CONCLUSION

The LBCS is appropriate to determine public health nurses' competence related to breastfeeding beyond 12 months. The LBCS can be used to identify the need for education concerning breastfeeding beyond 12 months.

Health professionals' competencies regarding breastfeeding beyond 12 months: a systematic review

BACKGROUND

Breastfeeding up to two years and beyond supports the health and neurobiological development of a child. Nevertheless, mothers experience criticism from health professionals towards breastfeeding beyond 12 months. Competence related to breastfeeding counselling is defined as minimum knowledge, skills and attitudes that all health professionals should have to protect, promote and support breastfeeding. Professionals' education related to breastfeeding beyond 12 months is insufficient worldwide which challenges the competent and evidence-based support mothers wish for.

METHODS

This systematic review aimed to synthesize the existing literature on health professionals' competencies regarding breastfeeding beyond 12 months. The search was limited to peer-reviewed scientific papers published between 2000 and 2022 that focused on the competencies of health professionals regarding breastfeeding beyond 12 months. Seven databases were searched, and of the 884 studies retrieved, seven were included in the review. The studies were subjected to the Joanna Briggs Institute (JBI) critical appraisal checklists. The data were analyzed using deductive thematic analysis, driven by the concept of competence.

RESULTS

All the dimensions of competence could be found in the data. Health professionals' knowledge or skills related to breastfeeding beyond 12 months were explored in all seven studies, and attitudes towards breastfeeding beyond 12 months were explored in four studies. The main themes identified were Knowledge Combined with Skills, and Attitudes. The main theme, Knowledge Combined with Skills, was formed out of eight themes: perceptions regarding nutritional value, perceptions regarding economic value, perceptions regarding family interaction, perceptions regarding impacts on the mother's wellbeing, perceptions regarding impacts on the child's wellbeing, perceptions regarding suitable duration, perceptions regarding recommendations, and counseling skills. The attitudes varied and therefore the Attitudes main theme consisted of three themes: promotive attitudes, hostile attitudes, and passive attitudes towards breastfeeding beyond 12 months.

CONCLUSIONS

Health professionals' knowledge and skills include several dimensions and vary substantially. Health professionals' attitudes vary between hostile and supportive and influence professionals' advice regarding breastfeeding beyond 12 months. The results suggested that there is considerable variation in health professionals' competencies, which emphasizes the importance of education regarding breastfeeding beyond 12 months.

Health care provider support and factors associated with breastfeeding beyond infancy: A cross-national study

BACKGROUND

Breastfeeding beyond infancy (12 months) remains atypical in the United States, United Kingdom, Canada, and Australia, and the role of health care providers is unclear. The objective of this study was to compare women's perceptions of provider support and other factors affecting breastfeeding beyond infancy across countries, among women who had each successfully breastfed at least one child that long.

METHODS

Women completed an online questionnaire distributed via La Leche League, USA (2013), about sources and ratings of support for breastfeeding for their oldest child who was breastfed at least 12 months and participant demographics. Multivariable log-binomial regression was used to compare ratings of health care provider support and the importance of 13 factors by country.

RESULTS

Some similarities and many differences were observed across countries in support received from providers, whereas modest or no differences were observed in the importance women placed on factors like health benefits and enjoyment of breastfeeding. Of 59 581 women, less than half discussed their decision to breastfeed beyond infancy with their child's provider. United Kingdom women rated their comfort in discussing breastfeeding beyond 12 months with their providers and the support received as lower than United States women. Canadian women gave lower ratings than United States women, but inconsistently. Australian women rarely differed from United States women in their responses. Providers' recommendations were not important to the decision to breastfeed beyond infancy, especially for United Kingdom women.

DISCUSSION

Rates of breastfeeding beyond infancy are low in these countries; improving provider support may help achieve global breastfeeding goals.

Article: "Too Old" and "Too Cold": Discomfort Towards Photographs of Breastfeeding Beyond Infancy and Public Breastfeeding in Nova Scotia, Canada

BACKGROUND

Social norms and public perception of breastfeeding are well-established predictors of breastfeeding outcomes; however, little is known about perceptions of breastfeeding beyond infancy or public breastfeeding among the public in Nova Scotia, Canada.

RESEARCH AIM

To explore public opinion about breastfeeding beyond infancy and public breastfeeding.

METHODS

In this cross-sectional study participants were recruited from public spaces in Nova Scotia, Canada. Using photo elicitation methods, participants (N = 229) viewed six photographs of breastfeeding children aged 2 weeks, 13 months, and 2.5 years, one photograph captured at home, and the other in a public space (a café, a store, or outdoors). Participants were asked to score their self-rated comfort with each photograph on a 10.0 cm visual analog scale and asked to share their feelings about each photograph (open-ended responses).

RESULTS

Mean (SD) visual analog scale comfort scores for photographs differed by location (private, 7.9 [2.2]; public, 7.3 [2.6]; p < .05) and child age (2 weeks, 8.5 [2.0]; 13 months, 7.5 [2.6]; 2.5 years, 6.9 [3.0]; p < .05). Participants who identified as women and parents self-reported significantly higher comfort with all photographs, while younger participants and urban dwellers were generally less comfortable. Open-ended responses varied considerably, but a higher proportion of negative comments were reported for older children feeding in public spaces (e.g., 2.5-year-old in public: "Inappropriate. Indecent. Abnormal.").

CONCLUSION

Given the importance of social norms in supporting breastfeeding, future public health campaigns should strive to normalize breastfeeding beyond infancy, and in public spaces.

Medical and Nursing Students' Perceptions of and Advice for Extended Breastfeeding: An Exploratory Study

Although the health benefits to both mother and child produced by breastfeeding have been documented, and numerous efforts have been made to promote breastfeeding rates in the United States, extended breastfeeding (breastfeeding beyond 12 months) research has been largely overlooked. Guided by the Framework of Integrative Normative Influences on Stigma, this study examined how extended breastfeeding was perceived among medical and nursing students and how perceptions of extended breastfeeding were translated into stigmatizing outcomes including attitudes, behavioral predispositions, and behavioral intention to encourage weaning. One hundred and sixteen medical and nursing students enrolled at a large mid-western University completed an online survey. Participants were asked to provide answers to questions regarding their knowledge of extended breastfeeding, attitudes toward it, perception about stigma associated with breastfeeding, and their behavioral intention to encourage future patients to wean. A lack of knowledge about extended breastfeeding was evident among the medical and nursing students; they also exhibited increasingly negative attitudes toward extended breastfeeding as the child's age increased. Medical and nursing students' behavioral intention to encourage weaning is associated with their pre-dispositional stigma of extended breastfeeding. Addressing stigma and negative attitudes toward extended breastfeeding in pre-healthcare students' curriculum may help future healthcare providers understand that while cultural norms in the United States do not tend toward extended breastfeeding, it is more common in other parts of the world, as well as help them understand health benefits to the child and to the mother.

A photo-elicitation exploration of UK mothers' experiences of extended breastfeeding

In this qualitative study we explored the experiences of women breastfeeding children over 12 months of age. Data were collected from 24 participants using semi-structured photo-elicitation interviews and photo-prompted online surveys. Participants took photographs of their extended breastfeeding experiences over one week and reflected on how the events depicted made them feel, and what they represented in terms of their experience. Data were analysed using Interpretative Phenomenological Analysis. Four themes were developed; parenting through breastfeeding: meeting the needs of my child, my body is not my own, social influences on the breastfeeding experience, and thinking about stopping: my choice or theirs? Findings highlight that extended breastfeeding was experienced as beneficial for both mother and child, promoting closeness, and bonding, and providing a valued parenting tool. However, some mothers reported conflict between their desire for child-led extended breastfeeding and the need to regain autonomy and control of their own bodies. The dangers of negative societal responses to extended breastfeeding and risks to mental health posed by cultural constructions of 'ideal' motherhood are discussed.

How much can Mexican healthcare providers learn about breastfeeding through a semi-virtual training? A propensity score matching analysis

Background

Mexico has shown a worrisome decrease in breastfeeding indicators, especially in the lowest socioeconomic level. Improving breastfeeding protection, promotion, and support services through workforce development is a key area of intervention. The objective of this study is to assess the influence on breastfeeding knowledge and abilities of a semi-virtual training for primary healthcare providers assisting beneficiaries of PROSPERA in Mexico, which is one of the largest conditional cash-transfer programs in the world.

Methods

Two independent cross-sectional samples of healthcare providers were drawn at baseline and post-intervention in three states of Mexico. Baseline data were collected among primary physicians, registered nurses and nurse technicians (i.e. unit of analysis) on July 2016 (n = 529) and post-training between March and April 2017 (n = 211). A 19-item telephone questionnaire assessed providers’ general knowledge about breastfeeding, breastfeeding benefits and clinical aspects of breastfeeding, clinical ability to solve problems and abilities to overcome breastfeeding challenges. The effects of the training were assessed through a propensity score matching (PSM) stratified by types of providers (i.e. physicians, registered nurses, nurse technicians).

Results

The PSM analysis showed significant improvements among all providers in the general knowledge about breastfeeding (around 20 percentage points [pp]) and knowledge about breastfeeding benefits (approximately 50 pp). In addition, physicians improved their knowledge about clinical aspects of breastfeeding (7 pp), while registered nurses improved in their ability to solve breastfeeding problems (14 pp) and in helping mothers overcome breastfeeding challenges (12 pp).

Conclusions

Promoting a breastfeeding enabling environment in Mexico to improve breastfeeding rates will require improving the knowledge and skills of healthcare providers. While a semi-virtual training showed large improvements in knowledge, developing skills among providers may require a more intensive approach.

Too Old to Be Breastfed? Examination of Pre-Healthcare Professionals' Beliefs About, and Emotional and Behavioral Responses toward Extended Breastfeeding

While breastfeeding seems to be widely accepted in the United States, extended breastfeeding (defined as breastfeeding beyond 12 months of age) tends to be stigmatized. Healthcare professionals are assumed to play a significant role in supporting women who desire to practice extended breastfeeding; however, how healthcare professionals react to extended breastfeeding has not been well understood. This research surveyed 116 healthcare students, who majored in nursing and human medicine, and examined their perceived advantages and disadvantages, emotional responses to, and advice that they would provide to future mothers regarding extended breastfeeding. The results indicated that students responded predominantly with negative emotions and neutral responses to extended breastfeeding, with a small number of participants responding with positive emotions. Many participants believed that it would bring benefits to the child and that it would be burdensome to the mother. Participants displayed a variety of behavioral responses when asked about advice that they would provide to future mothers with whom they will interact in a clinical setting. Practical implications are discussed.

Against all odds-why UK mothers' breastfeeding beyond infancy are turning to their international peers for emotional and informative support

The health benefits of breastfeeding are well documented and current recommendations are that women should breastfeed their child for two years and beyond. Despite this the UK has the lowest initiation breastfeeding rates in the world. Additionally, a considerably small percentage of women who do successfully initiate go on to breastfeed past infancy. This could in part be explained by the lack of support women receive when breastfeeding an older child. In this study we provide insight into women's experiences of healthcare interventions during the transition from breastfeeding an infant to a toddler. We conducted semi-structured interviews with 24 women with experience of breastfeeding at least one child past the age of twelve months. We used a theory driven thematic analysis to identify pertinent themes that ran through the interviews. As mothers progressed through their breastfeeding journey they faced increased social stigma. They also experienced a change in attitudes from healthcare professionals as support was replaced by judgement. This negatively impacted upon trust in healthcare professionals and the advice they offered. In response, the women turned to volunteering organizations and closed social media groups for emotional support and healthcare advice. These women experienced specific issues regarding breastfeeding in toddlerhood as opposed to infancy. They needed specialized interventions tailored for this. Social media was highlighted as a useful platform for supporting women who breastfeed beyond infancy. It allowed these women to feel part of a supportive international community and gain access to practical advice. Healthcare professionals should explore ways to engage in digital platforms to provide support to mothers' breastfeeding beyond infancy.

Parenting Science Gang: radical co-creation of research projects led by parents of young children

BACKGROUND

Parents are increasingly searching online for information supported by research but can find it difficult to identify results relevant to their own experiences. More troublingly, a number of studies indicate that parenting information found online often can be misleading or wrong. The goal of the Parenting Science Gang (PSG) project was to use the power of the Internet to help parents ask questions they wanted to have answered by scientific research and to feel confident in assessing research evidence.

METHODS

By using Facebook to recruit groups and facilitate interactions, PSG was able to engage fully the target public of parents of young children in the radical co-production of scientific studies, while not creating an undue burden on time or restricting participants due to disability, financial status or location. By giving parents true partnership and control of creation of projects, PSG ensured that the chosen questions were ones that were of most relevance and interest to them.

RESULTS

This paper presents a summary of eight projects, with three in more detail, designed and implemented by PSG Facebook groups in collaboration with experts. Most projects had health related themes, often prompted by dissatisfaction with treatment of parents by health professionals or by feelings of being marginalised by pregnancy and motherhood, as well as by the lack of evidence for their questions and concerns. The PSG approach meant that these frustrations were channelled into actions. All eight of the PSG groups engaged in meaningful interactions with experts and co-produced studies with the groups defining the questions of interest.

CONCLUSIONS

This radically user-led design meant that the PSG staff and the collaborating experts had to live with a high degree of uncertainty. Nevertheless, PSG achieved its goal of academically productive, truly co-produced projects, but as important were the positive effects it had on many of the participants, both parents and experts. At the point of writing this paper, PSG projects have led to outputs including at least eight papers published, in press or in preparation, seven conference presentations, testimony to the Infant Feeding All-Party Parliamentary Group, and with more to come.

High confidence, yet poor knowledge of infant feeding recommendations among adults in Nova Scotia, Canada

In Canada, adherence to the national 'Nutrition for Healthy Term Infants' recommendations of infant and young child feeding (IYCF; 0-24 months) is suboptimal. While maternal knowledge of IYCF is commonly assessed, that of the general public has rarely been explored. Our objective was to assess the knowledge of, and confidence in answers to, Canadian IYCF recommendations among a diverse sample of adults in Nova Scotia, Canada. Between March and May 2018, a self-administered questionnaire examining IYCF knowledge, self-rated confidence, and sociodemographic information was conducted among Nova Scotians (≥19 years) in public locations. We surveyed 229 adults; 60% (n=134) were women. Mean (95% CI) age was 44 (41,46) years, 73% self-identified as white, 77% were born in Canada, and 69% were parents. Knowledge deficits were: age to terminate breastfeeding (18.3 (16.7,19.9) months; recommendation: ≥24 months), age to introduce solids (9.2 (8.2,10.2) months; recommendation: 6 months), vitamin D supplementation (10% correct), and optimal complementary foods (only 37% indicated iron-rich foods). Correct IYCF knowledge was lower among men, non-parents, young adults (19-29 years) and low-income adults (<$50,000/year). Mean self-rated confidence (out of 10) was high (7.2 (6.9,7.5)), and not different (p>0.05) between correct and incorrect responses for: best food for a newborn, age to terminate any breastfeeding, and age to start family meal foods. We found low knowledge of IYCF guidelines, yet high confidence in responses regardless of accuracy, among adults in Nova Scotia. General public knowledge deficits may contribute to an unsupportive culture around IYCF practices and low adherence to current recommendations.

Determinants of Continued Breastfeeding at 12 and 24 Months: Results of an Australian Cohort Study

Breastfeeding to 12 months and beyond offers considerable health benefits to both infants and mothers. Despite these recognized benefits, relatively few women in high income countries breastfeed for 12 months, and rarely breastfeed to 24 months. The aim of this study was to identify the prevalence and determinants of continued breastfeeding to 12 and 24 months amongst a cohort of Australian women participating in the Adelaide-based Study of Mothers' and Infants' Life Events affecting oral health (SMILE). Duration of breastfeeding was known for 1450 participants and was derived from feeding related data collected at birth, 3, 6, 12 and 24 months. Multivariable logistic regression analysis was used to investigate the relationship between explanatory variables and continued breastfeeding to 12 and 24 months. In total, 31.8% of women breastfed to 12 months and 7.5% to 24 months. Women who were multiparous, university educated, had not returned to work by 12 months and whose partners preferred breastfeeding over bottle feeding were more likely to be breastfeeding at 12 months. While women who had introduced complementary foods before 17 weeks and formula at any age were less likely to be breastfeeding at 12 months. Mothers who were born in Asian countries other than India and China, had not returned to work by 12 months and had not introduced formula were more likely to be breastfeeding at 24 months. The majority of the determinants of continued breastfeeding are either modifiable or could be used to identify women who would benefit from additional breastfeeding support and encouragement.

Pediatric Care Providers, Family, and Friends as Sources of Breastfeeding Support Beyond Infancy

OBJECTIVE

To examine women's perceptions about support from pediatric primary care providers (PCPs), family, and friends for breastfeeding beyond 12 months, which is an increasing common practice.

STUDY DESIGN

Women who breastfed at least one child beyond 12 months completed an online questionnaire distributed via La Leche League USA (2013). Questionnaire content focused on sources of support for breastfeeding beyond 12 months, support ratings, and participant characteristics. Bivariate statistics and multivariable log-binomial regression compared ratings of support across sources, by PCP sex, and with breastfeeding duration.

RESULTS

Of 48,379 eligible U.S. women, about half discussed their decision to breastfeed beyond infancy with their child's PCP. In contrast, almost all (91.4%) did so with their spouse, partner, or significant other. Women were consistently more comfortable discussing their decision to breastfeed for more than a year with their family and closest friend than they were with their child's PCP (all p < 0.001). Three-fourths of PCPs were rated as supportive, but 11.1% were somewhat or very unsupportive. Female pediatricians received similar ratings as males (adjusted risk ratio = 1.01, 95% confidence interval: 1.00, 1.03). Thirty-eight percent of women who reported their PCP was unsupportive changed PCPs.

CONCLUSION

Family and PCP support is likely to be important for the growing proportion of U.S. mother-child dyads who are breastfeeding beyond 12 months. Many, but not all, women rated their child's PCP as supportive, and lack of support was a reason women reported for changing PCPs. Evidence-based interventions in primary care to support breastfeeding beyond infancy are needed.

Discursive constructions of breastfeeding in U.S. state laws

Previous research has identified several ways that breastfeeding is constructed in public discourses, each with consequences for breastfeeding attitudes, policies, and practices. Researchers analyzed discursive constructions of breastfeeding in U.S. state laws regarding breastfeeding in public to see if common representations were replicated in law and to identify patterns among states that used similar language. Results indicated that laws varied in the level of protection they offered, with the least protective laws decriminalizing breastfeeding in public and the most protective laws criminalizing interference with breastfeeding. The least protective states were located in the Western and North-Central regions, Republican-leaning, and less urban, whereas the most protective states were located in the New England and North-Central regions, Democrat-leaning, and more urban. Most states that fell on either end of this continuum had breastfeeding rates above the national average. Laws also varied in the level of regulation implied in their language, with the most regulative laws specifying that "a mother" can breastfeed "her baby" only in certain places and under certain conditions (discreetly). The most regulative states were located in the Southern and North-Central regions and had low breastfeeding rates, whereas the least regulative states were Western and had high breastfeeding rates.