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Breastfeeding: the neglected guideline for future Dietitian-Nutritionists?

Abstract

The objective of the present study is to determine the knowledge, attitudes and beliefs regarding breastfeeding of final-year nutrition and dietetic students. A cross-sectional survey of final-year nutrition and dietetic students at a leading Australian university was conducted using an emailed questionnaire of 50 multiple-choice questions on knowledge, attitudes, beliefs and future intentions to support and promote breastfeeding. The frequency of response to all questions was determined. Twenty-seven of the 38 eligible students completed the survey. Significant deficits were identified relating to breastfeeding knowledge. Ninety-two per cent of respondents reported a future intention to breastfeed or support their partner to do so; yet 69% felt bottle feeding was more socially acceptable and 23% believed that using artificial formula was easier for the mother. Although 85% of respondents believed they could influence breastfeeding initiation and duration rates, no students perceived that their studies had provided a significant amount of information on this subject, while only 8% of respondents had a strong interest in work relating to breastfeeding in the future. Improvements in the curriculum in this context may be required to ensure new graduates have the appropriate knowledge and are motivated to take positive action so that breastfeeding is properly supported. Further research is needed to determine if this issue applies in other nutrition courses and to assess the need to adopt an industry position paper on breastfeeding and associated competency standards for vocational training.

Key words: breastfeeding, dietetics, nutrition, training.

INTRODUCTION

Breast milk is a complex and natural substance uniquely suited to the needs of infants. (1) Infants who are not breastfed have a greater incidence of diarrhoeal illnesses, respiratory infections, asthma, otitis media, eczema, necrotising enterocolitis, bacteraemia, meningitis, botulism, urinary tract infection and sudden infant death syndrome and are at increased risk of some childhood cancers, type 2 diabetes, obesity and risk factors associated with cardiovascular disease in adulthood. (1-3)

The Dietary Guidelines for Australian Adults and the Dietary Guidelines for Children and Adolescents in Australia both include 'Encourage and support breastfeeding' as one of their four key nutrition guidelines, with the further recommendation that breast milk be the only food for about the first six months of life and that breastfeeding continue, with solids and other drinks, as long as it is appropriate for the mother and infant. (1)

Dietitians have an important role to play in supporting and promoting breastfeeding as illustrated by the American Dietetic Association's position paper on breastfeeding, which states:
 Dietetic professionals have a responsibility to support breastfeeding
 through appropriate education and training, advocacy, and legislative
 action; through collaboration with other professional groups; and
 through research to eliminate the barriers to breastfeeding. (4)


Dietitians have been identified as an untapped resource in breastfeeding management in hospitals, (5) and structured antenatal breastfeeding education has been found effective at improving both initiation and continuation of breastfeeding during at least the first two months post partum. (6) Similarly in community and public health settings, dietitians have the potential to dramatically increase their contribution to breastfeeding promotion and support by providing consistent breastfeeding messages and increasing the capacity and critical mass in terms of human and other resources to counteract threats to breastfeeding in Australia. (7,8)

Improving the vocational training of health professionals has consistently been recommended in the research literature to increase breastfeeding rates worldwide. (9-12) The need for breastfeeding training for dietitians has been noted, (9) but may receive little attention. For dietitians to make breast-feeding promotion and support a work priority, their vocational training should emphasise its important role and provide students with adequate knowledge and skills. More importantly, such training would seek to engender personal attitudes and beliefs that result in graduates who embrace breastfeeding as the biological norm rather than just a 'better choice' and develop personal and professional commitments and passion to promote it and to seek employment in this area.

Universities have a responsibility to maintain the quality of their education provision. (13) It was therefore through a quality assurance framework that staff at a major accredited teaching program, in partnership with staff of the state health department and members of the local Breastfeeding Promotion and Training Coalition (Breastfeeding Coalition), committed to addressing the issue of breastfeeding vocational training within its nutrition-related courses.

The ongoing project described here aimed to better develop the knowledge, skills, attitudes and beliefs of nutrition and dietetics graduates from the university empowering them to better support, promote and advocate for breastfeeding in their personal and professional lives. The present paper presents the baseline data from a survey of final-year nutrition and dietetic students on their knowledge, attitudes and beliefs regarding breastfeeding.

METHODS

Initial project planning

To manage the project, a steering committee was formed of representatives from the local breastfeeding coalition, the Dietitians Association of Australia's representative for the Baby Friendly Hospital Initiative, two health department community nutritionists working in breastfeeding promotion and a university representative. Three final-year nutrition and dietetic students were actively involved with the project planning, implementation and evaluation as part of their community nutrition placements.

Sample

Although students from all years of training were surveyed, only the results of the final-year student cohort enrolled in undergraduate degrees in nutrition and dietetics at the university are presented as their results describe the characteristics of students who had completed the majority of formal lectures prior to graduation.

Survey development

As no previously validated questionnaire applicable to this target group was identified, a questionnaire was developed following recommended principles for questionnaire design. (14,15) As there were no industry standards for learning outcomes relating to breastfeeding, question development was overseen by a panel of experts and based on a set of outcomes considered desirable in graduate dietitians. The draft survey was piloted and a final survey comprising 50 multiple choice questions produced. This included:

* Seven questions profiling students

* Twenty knowledge-based questions related to breastfeeding as the biological norm (e.g. common myths, the physiology of breastfeeding) and current public health issues, policies and strategies

* Fifteen questions on attitudes and beliefs (to breastfeeding in a social/practical context and to current recommendations)

* Six questions relating to future breastfeeding intentions

* Two questions relating to student perceptions of the quality of breastfeeding training provided by the university

Ethics approval to conduct the survey was granted by the University Human Research Ethics Committee.

Dissemination of survey to students

The surveys were distributed by email in April 2005 as the students were attending practical placements off campus. Students were advised of the confidentiality of their responses and that the university would not receive data on individual student's results. They were asked to complete the survey without reference to lecture notes, texts or any other information sources. Two email reminders were sent to students to encourage participation.

Analysis of survey data

Frequencies of responses were calculated using SPSS (SPSS Inc., New Jersey, SPSS Version 11.0 2001). All surveys were included for analysis.

RESULTS

Sample

Of the 41 enrolled final-year students, three were excluded from completing the survey because of their involvement in its development and implementation. From the 38 eligible final-year students, 27 surveys were returned, resulting in a response rate of 71%. Most respondents (96%) completed all of the survey questions. As seen in Table 1, the respondent group characteristics were similar to the total cohort. Most participants (82%) were young (17-25 years), female (89%) and enrolled in the Bachelor of Health Science (Nutrition and Dietetic) degree (70%) rather than the double degree that includes Human Movement Studies. None were parents. The majority responded that they were predominantly breastfed as an infant (78%) with approximately 15% reporting predominant feeding with infant formula and 7% being unsure of how they were fed.

Knowledge relating to breastfeeding as the biological norm

Results in Table 2 indicate that respondents appeared to recognise and understand the superiority of breast milk to artificial formula and recognise some myths such as the influence of breast size on the ability to breastfeed. The majority of respondents had knowledge of the physiology of and factors influencing milk production, with 63% believing that breastfeeding on demand allows the infant to self-regulate the right amount of milk for their needs and 72% knowing that a woman can produce more milk by increasing the frequency of infant suckling. Conversely, there was a poor understanding of the relationship between the mother's diet and the quality of her breast milk. Only a small minority of students could identify the increased health risks associated with the use of artificial formula for the infant, with only 19% of respondents identifying ear infections, 44% for insulin-dependent diabetes mellitus, 19% for sudden infant death syndrome and 11% for conjunctivitis. Similarly, there was poor knowledge of the increased risks for women of not breastfeeding with only 19% of respondents identifying increased risk of osteoporosis, 26% for ovarian cancer and 67% for delayed postpartum weight loss. Only 12% of respondents knew that the infant growth charts available at the time of the survey were predominantly based on data from infants who were artificial formula-fed.

Students were asked when breastfeeding should be avoided or ceased. Of respondents, 70% correctly identified that breastfeeding should be ceased by HIV-positive mothers in Australia but 22% and 26%, respectively, incorrectly selected that breastfeeding should be ceased if the infant had lactose intolerance or if the mother had cracked nipples.

Knowledge relating to public health issues, policies and strategies

Table 2 shows that all respondents were aware that using artificial formula results in a significant cost to individual families, and most knew that breastfeeding duration is a greater problem in Australia than initiation rates and that a National Breastfeeding Strategy exists. However, only 54% of respondents identified that the use of artificial formula represents a significant cost to the public health-care system. Similarly, only 54% knew that the earlier in life a woman makes the decision to breastfeeding, the longer she will do so. Only 44% of students identified media portrayal of breastfeeding and artificial formula feeding as a documented barrier to breastfeeding.

Attitudes and beliefs relating to breastfeeding in social and practical contexts

Table 3 provides the results of selected questions on attitudes to breastfeeding. Seventy-seven per cent of respondents reported that they did not feel embarrassed or uncomfortable when seeing a woman breastfeeding, with 85% agreeing with public policy to support breastfeeding in public places. However, 69% reported that bottle feeding was more socially acceptable and 40% of respondents did not disagree with the statement that bottle feeding was easier for everyone concerned. Little support was found for the international Baby Friendly Hospital Initiative's policy that hospitals should only provide artificial formula to infants when medically warranted, as only 31% of respondents agreed with this. (16)

Intentions of students regarding future practice

Table 4 describes students' personal and professional intentions relating to breastfeeding. Most respondents reported a commitment and a responsibility to breastfeeding both at individual and professional levels and believed they could play a role in influencing breastfeeding by women. However, only 8% of respondents reported that their course had engendered a strong interest to work in an area involving breastfeeding.

Student perceptions as to the quality and value of their university studies regarding breastfeeding

No respondents reported that their university studies had provided a significant amount of material concerning breastfeeding, with 37% reporting that very little material was provided. The remainder of respondents perceived that they had received either only some material on breastfeeding or a general overview only.

Limitations

The present study provides data for final-year nutrition and dietetic students attending one university and the generalisability of its findings to students of other universities is likely to be limited. For this reason, it would be instructive to implement the survey in other Australian universities and other relevant health professional courses. Although questionnaires were developed with peer review and some trial-ling, wording and interpretation of questions by students may have influenced responses. As surveys were distributed via email, it was possible that some students researched their answers to the knowledge questions, even though they were requested not to do so. Attitude responses may also have been influenced by students attempting to provide what they perceived to be the desired responses to the questions to please their fellow students and lecturers undertaking the research. Although this may have occurred, the potential for a positive bias only strengthens the argument to improve the curriculum relating to breastfeeding in areas where knowledge and attitudes were identified as poor.

DISCUSSION

The identified deficits in students' breastfeeding knowledge, attitudes and beliefs were noted. The literature also supports that there are gaps in the knowledge and practice of health professionals (12) and that these can be improved with training. (17) In relation to knowledge, the fact that many students chose the 'did not know' option suggests that they may seek out the information in a practice setting, rather than provide incorrect information. Despite this, the fact that they did not know key breastfeeding information so close to graduation is concerning because these knowledge gaps have the potential to reduce the capacity of new graduates to appropriately advise and support mothers regarding breastfeeding and their desire to seek employment in this area.

A number of identified knowledge deficits have the potential to result in the provision of information that may reduce the duration of breastfeeding. These include deficits in knowledge of the physiology and factors influencing milk production and quality, and beliefs that breastfeeding should cease in cases (such as cracked nipples and lactose intolerance) where mothers only require sound clinical advice and support to maintain breastfeeding. A poor understanding of the derivation of infant growth charts, if coupled with lack of knowledge of the differences in the growth patterns of breastfed and artificial formula-fed infants, is also likely to lead to recommendations to introduce supplementary feeds when breastfed babies encounter 'Catch Down Growth'. (18)

Respondents demonstrated attitudes supporting public breastfeeding policies. This was consistent with findings from a survey of 2209 health professionals in North Carolina, where nutritionists and paediatricians were most likely to have positive beliefs about breastfeeding compared with other health professionals. (10) However, graduates were less sure of breastfeeding's support by society in general and were generally unaware of the health risks associated with the use of artificial formula (when compared with breastfeeding) to mothers and infants and the national health cost of artificial formula feeding. These attitudes and knowledge deficits are likely to reduce the desire and ability of new graduates to successfully advocate for breastfeeding in public health settings.

For many of our respondents, their scientific knowledge that supports breastfeeding as the biological norm and their conflicting social experience may have resulted in inconsistent and pragmatic responses to questions relating to future practice. The majority of students reported commitment to breastfeeding both at individual and professional levels and felt they could be effective future advocates for breastfeeding, yet few believed that their course had provided them with detailed breastfeeding information and very few identified a desire to work in the area in the future. These findings appear similar to the results of a survey of Canadian nurses and dietitians that suggested a lack of perceived control or confidence to assist and advise women on breastfeeding is associated with a lower intention to work in this area. (9) Lingering issues relating to women's rights to choose may also explain why only 31% of respondents were committed to the Baby Friendly Hospital Initiative's policy to only provide artificial formula on medical grounds. (16) The issue of the rights of the child to be breastfed was not canvassed in the present survey; and the introduction of this ethical debate into the course curriculum may result in changes in attitudes relating to this issue. (19)

As a result of these findings, university staff will incorporate new strategies throughout the curriculum to improve learning outcomes relating to breastfeeding. These strategies will be evaluated over the next three years. The new program will focus on improving not only the knowledge but also the motivation, passion and commitment required to effectively advocate for breastfeeding. An awareness of potential roles of graduates and an interest in working in breastfeeding in the future will also be encouraged.

It is anticipated these findings will prompt reflection also on the current knowledge, attitudes and beliefs of other nutrition and dietetics students and indeed practitioners. This is particularly important because the intention of nurses and dietitians to support breastfeeding has been associated with the perceived professional norm. (9) To combat the perception that breastfeeding is just the best of two choices, curriculum messages regarding breastfeeding should be revised so that, instead of the 'Breast is Best' concept, it should be stated that artificial formula feeding has limitations, disadvantages and health risks. (20) This would also be consistent with the messages provided regarding other infant health decisions that have associated risks such as use of medications and maternal alcohol consumption. Arguably, these beliefs and interpretations influence dietetic practice in terms of the priority given to breastfeeding, the action taken and the modelling provided to nutrition and dietetic students. To increase the priority of breastfeeding within the profession, and consequently its importance within vocational training, the Dietitians' Association of Australian could develop a position paper on breastfeeding based on that of the American Dietetic Association. Competency standards for graduates could then be developed.

CONCLUSION

This project has provided baseline data on the current breastfeeding knowledge, attitudes, beliefs and intentions of students undertaking nutrition and dietetic studies. It highlights the need to incorporate interventions to improve the vocational training of these future health professionals in order for them to adequately support and promote breastfeeding in their future practice. As with other areas of nutrition education, it suggests that addressing both knowledge and attitudes is essential. Individuals not only need to be aware of the facts, capable of taking appropriate steps but also be motivated to take positive action. Strategies to address these issues will be developed and their effectiveness assessed over the next three years. Further research, the development of industry standards, and continuing vocational and professional development are recommended to continue to promote the capacity of the nutrition workforce to adequately support and promote breastfeeding.

REFERENCES

1 National Health and Medical Research Council (NHMRC). The Dietary Guidelines for Adults and the Dietary Guidelines for Children and Adolescents in Australia Incorporating the Infant Feeding Guidelines for Health Workers. Canberra: Commonwealth of Australia, 2003.

2 Kramer MS, Kakuma R. The Optimal Duration of Exclusive Breastfeeding, a Systematic Review. Geneva: World Health Organization, 2002.

3 Queensland Health. Optimal Infant Nutrition: Evidence-Based Guidelines 2003-2008. Brisbane: Queensland Health, 2003.

4 Dobson B, Murtaugh MA. Position of the American Dietetic Association: breaking the barriers to breastfeeding. J Am Diet Assoc 2001; 101: 1213-20.

5 Helm A, Windham CT, Wyse B. Dietitians in breastfeeding management: an untapped resource in the hospital. J Hum Lact 1997; 13: 221-5.

6 Palda V, Guise J, Wathen CN. Interventions to promote breastfeeding: applying the evidence in clinical practice. Can Med Assoc J 2004; 170: 976-8.

7 Commonwealth Department of Health and Aged Care (CDHAC). National Breastfeeding Strategy Summary Report. Canberra: Commonwealth of Australia, 2001.

8 Queensland Public Health Forum. Eat Well Queensland 2002-2012: Smart Eating for a Healthier State. Brisbane: Queensland Public Health Forum, 2002.

9 Daneault S, Beaudry M, Godin G. Psychosocial determinants of the intention of nurses and dietitians to recommend breastfeeding. Can J Public Health 2004; 95: 151-4.

10 Barnett E, Sienkiewicz M, Roholt S. Beliefs about breastfeeding: a statewide survey of health professionals. Birth 1995; 22: 15-20.

11 Mitra AK, Khoury AJ, Carothers C, Foretich C. The Loving Support Breastfeeding Campaign: awareness and practice of health care providers in Mississippi. JOGNN 2003; 32: 753-60.

12 Khoury AJ, Hinton A, Mitra AK, Carothers C, Foretich C. Improving breastfeeding knowledge, attitudes and practices of WIC Clinic staff. Public Health Rep 2002; 117: 453-62.

13 Kemp DA. Quality Assured: A New Australian Quality Assurance Framework for University Education. Speech, Minister Archive. 2004. (Cited 6 Apr 2005.) Available from URL: http://www.dest.gov.au/archive/ministers/kemp/dec99/ks101299.htm

14 Kerr C, Taylor R, Heard G. Handbook of Public Health Methods. Sydney: McGraw Hill, 1997.

15 Boynton PM, Greenhalgh T. Selecting, designing and developing your questionnaire. BMJ 2004; 328: 1312-15.

16 UNICEF and WHO. The Baby Friendly Hospital Initiative. 1991. (Cited 18 Oct 2005.) Available from URL: http://www.unicef.org/nutrition/index_24806.html

17 Vittoz JP, Labarere J, Castell M, Durand M, Pons JC. Effect of a training program for maternity ward professionals on duration of breastfeeding. Birth 2004; 31: 302-7.

18 Dewey KG, Heinig MJ, Monnsen LA, Peerson JM, Lonnerdal B. Growth of breast fed and formula fed infants from 0 to 18 months: The DARLING Study. Pediatrics 1992; 89: 1035-41.

19 Morrison P. The Ethics of Infant Feeding Choice: Do Babies Have the Right to Be Breastfed? Australian Lactation Consultants' Association 7th Biennial Conference Proceedings, 2004.

20 Wiessinger D. Watch your language! J Hum Lact 1996; 12: 1-4.

Jan Payne, (1) Barbara Radcliffe, (2) Emma Blank, (1) Elizabeth Churchill, (1) Nadia Hassan, (1) Elizabeth Cox (3) and Helen Porteous (4)

(1) School of Public Health, Queensland University of Technology, Kelvin Grove, (2) Queensland Health, Annerley Road Community Health Service, South Brisbane, (3) Queensland Health, Ipswich Health Plaza, Ipswich, and (4) Queensland Health, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia

J. Payne, GradDipNutDiet, APD, Lecturer

B. Radcliffe, GradDipNutDiet, Community Nutritionist

E. Blank, BHlthSc(Nut & Diet), APD, Former Student

E. Churchill, BHlthSc(Nut & Diet), APD, Former Student

N. Hassan, BHlthSc(Nut & Diet), APD, Former Student

E. Cox, MND, Community Dietitian

H. Porteous, GradDipNutDiet, APD, Dietitian

Correspondence: J. Payne, School of Public Health, Queensland University of Technology, Victoria Park Road, Kelvin Grove, Qld 4059, Australia. Email: j.payne@qut.edu.au
Table 1 Profile of respondents compared with all final-year nutrition
and dietetic students

 Final-year
 Respondents, % (n) students, % (n)
Characteristic (n = 27) (n = 41)

Aged 17-25 years 81.5 (22) 80.5 (33)
Aged >26 years 18.5 (5) 19.5 (8)
Female 88.9 (24) 85.4 (35)
Male 11.1 (3) 14.6 (6)
Nutrition and Dietetics 70.4 (19) 80.5 (33)
Nutrition and Dietetics and Human 29.6 (8) 19.5 (8)
 Movement (double degree)

Table 2 Results for true and false questions relating to breastfeeding
knowledge

 Percentage of respondents
 (n = 26)
 Correct Did not Incorrect
Knowledge question (correct answer) answer know answer

Breast milk contains immunological factors 96.2 3.8 0.0
 that strengthen the infant's immune
 system (True)
Women with smaller breasts are less likely 88.5 11.5 0.0
 to be able to feed successfully (False)
The amount of breast milk a woman produces 57.7 42.3 0.0
 is controlled by an endocrine positive
 feedback mechanism involving the
 pituitary gland (True)
If a breastfeeding woman does not consume 26.9 23.1 50.0
 a well-balanced diet, her breast milk
 will not be of adequate quality for
 infant growth (False)
The average duration of breastfeeding is a 76.9 19.2 3.8
 greater problem than the rates of
 initiation within Australia (True)
The earlier in life a woman makes the 53.8 30.8 15.4
 decision to breastfeed, the longer she
 will breastfeed for (True)
Infant growth charts are predominantly 11.5 53.8 34.6
 based on infant/artificial formula-fed
 babies (True) (a)
Infant/artificial formula presents a 100.0 0.0 0.0
 significant cost for parents (True)
Infant/artificial formula use is 53.8 30.8 15.4
 associated with high cost to the public
 health-care system (True)
Australia has a National Breastfeeding 84.6 15.4 0.0
 Strategy (True)

(a) The survey was completed before the World Health Organization Child
Growth Standards were launched in 2006.

Table 3 Attitudes and beliefs relating to breastfeeding

 Percentage of respondents
 Agree or Disagree or
 strongly strongly
Statement agree Neutral disagree

'I feel embarrassed or uncomfortable 3.8 19.2 76.9
 when I see a woman breastfeeding in
 public.' (n = 26)
'Bottle feeding is a more socially 69.2 11.5 19.2
 accepted way to feed an infant.'
 (n = 26)
'Artificial/infant formula is an easier 20.0 20.0 60.0
 feeding method than breastfeeding for
 everyone concerned (mother, family
 and friends).' (n = 25)
'Using artificial/infant formula is 7.7 19.2 73.1
 preferable to breastfeeding because
 the father can be more involved.'
 (n = 26)
'It is normal for a breastfeeding woman 57.7 23.1 19.1
 to require support from a range of
 health professionals in order to
 breastfeed successfully' (n = 26)
'Public policy should support women's 84.6 7.7 7.7
 rights to breastfeed in public
 places.' (n = 26)
'If women choose to artificially feed 30.8 15.4 53.8
 and it is not medically warranted,
 maternity hospitals should not supply
 infant/artificial formula to their
 babies.' (n = 25)

Table 4 Survey results relating to future breastfeeding intentions

 Percentage of respondents
 Agree or Disagree or
 strongly strongly
Statement agree Neutral disagree

'If I have children, I plan to 92.3 7.7 0.0
 breastfeed or support my partner to
 exclusively breastfeed for at least
 six months.' (n = 26)
'In my professional capacity as a 84.6 11.5 3.8
 nutritionist, I can directly (or
 indirectly) influence both a woman's
 decision to breastfeed and the
 duration for which she will feed.'
 (n = 26)
'As a health professional, I believe it 80.8 15.4 3.8
 to be my responsibility to highlight
 the health problems associated with
 the use of infant/artificial formula
 when giving advice about
 breastfeeding.' (n = 26)
'My studies thus far have engendered a 8.0 48.0 44.0
 strong interest in me to work in an
 area that involves breastfeeding.'
 (n = 25)
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Title Annotation:INSIGHT
Author:Porteous, Helen
Publication:Nutrition & Dietetics: The Journal of the Dietitians Association of Australia
Geographic Code:8AUST
Date:Jun 1, 2007
Words:4290
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