- Email: [email protected]
Assessing an Infant Feeding Web Site as a Nutrition Education Tool for Child Care Providers
Research Brief Assessing an Infant Feeding Web Site as a Nutrition Education Tool for Child Care Providers Alena Clark, PhD, RD1; Jennifer Anderson, PhD, RD2; Elizabeth Adams, PhD, RD3; Susan Baker, EdD2; Karen Barrett, PhD4 ABSTRACT Objective: Determine child care providers’ infant feeding knowledge, attitude and behavior changes after viewing the infant feeding Web site and determine the effectiveness of the Web site and bilingual educational materials. Design: Intervention and control groups completed an on-line pretest survey, viewed a Web site for 3 months, and completed an on-line posttest survey; follow-up data were also assessed. Setting: Colorado child care centers. Participants: Thirty-eight child care providers. Intervention: Social learning theory-based website was evaluated by child care providers in the treatment group and providers in the control group viewed a comparable website. Main Outcome Measures: Knowledge, attitude, and behavior changes on feeding infants breast milk, formula, and solid food; desired changes to Web site. Analysis: Independent samples t tests, chi-square, and repeated measures. Results: Changes in attitudes and behaviors from pre- to posttest occurred primarily in the intervention group (P < .05). At follow-up, no significant differences were found among the 3 time periods. Providers desired no changes to Web site or materials. Conclusions and Implications: Child care providers appeared to have adequate knowledge on feeding infants formula and breast milk, but not on hunger cues. Providers would continue to use this Web site in the future. Further research should determine if changes in knowledge, attitudes, and behaviors are sustained over time and how infant feeding cues are read and determined in child care centers. Key Words: infant feeding, child care providers, Web site development and education (J Nutr Educ Behav. 2009;41:41-46.)
INTRODUCTION The health benefits of breast-feeding to mothers and infants are well documented in the literature.1,2 However, Colorado’s breast-feeding initiation rates of 83% exceed national recom-
mendations, yet they fall short at both 6 months (46%) and 1 year (21%).3,4 In 2002, the fourth most common reason Colorado mothers cited for ceasing breast-feeding was because they returned to work or school.3
1
Dietetics Program, University of Northern Colorado, Greeley, Colorado* Department of Food Science and Human Nutrition, Colorado State University, Fort Collins, Colorado 3 Oregon Health and Science University, Portland, Oregon 4 Department of Human Development and Family Studies, Colorado State University, Fort Collins, Colorado Funding for this project was provided by the Colorado Department of Public Health and Environment – Colorado Physical Activity and Nutrition Coalition, Colorado Breast-feeding Task Force, and the Medela Corporation. * At the time research was conducted and completed, Alena Clark was a PhD candidate at Colorado State University, Department of Food Science and Human Nutrition, Fort Collins, Colorado. Address for correspondence: Alena Clark, PhD, RD, Assistant Professor, University of Northern Colorado, Community Health and Nutrition Program, Gunter 2240, Greeley, CO 80639; Phone: (970) 351-2879; Fax: (970) 351-1489; E-mail: [email protected] Ó2009 SOCIETY FOR NUTRITION EDUCATION doi:10.1016/j.jneb.2007.12.007 2
Journal of Nutrition Education and Behavior Volume 41, Number 1, 2009
Approximately 12 million of the 19 million children in the United States under the age of 5 are in some form of child care.5 Children who attend child care at 6 months were significantly less likely to have ever been breastfed or remain exclusively breastfed (P < .05).6 With the decline in breast-feeding coinciding with mothers returning to work and more infants attending child care, it is imperative for child care providers to have access to current and correct infant feeding information, including information on offering breast milk to the infants in their care. Child care agencies often support breastfeeding as the preferred infant feeding method. In 1999, the United States Department of Agriculture authorized the reimbursement of child care centers for infant meals that contain only breast milk, thereby allowing for more providers to support the use of breast milk in their centers.7
41
42 Clark et al A literature review and a recently completed needs assessment8 highlight the need to provide accurate educational materials and best practice information about infant feeding, specifically breast-feeding and offering breast milk, to child care providers. According to this needs assessment, 88% of directors and 79% of providers would be interested in a Web site with child-care–specific infant feeding information.8 The apparent interest in educational information distribution on the Internet is further supported by national trends. In 2003, approximately 60 million Americans per year used the Internet to receive health or medical information; this number continues to rise.9 The 2 objectives for this study were: (1) to determine changes in child care providers’ knowledge of and attitudes and behaviors toward infant feeding best practices after viewing the InfaNET Nutrition for Child Care Providers Web site; and (2) to determine the effectiveness (eg, content and design) of the Web site as well as the use of the bilingual educational materials.
DEVELOPMENT AND EVALUATION OF THE WEB SITE A Web site was determined to be the most preferred way child care providers wanted to receive infant feeding information (P < .001) compared to conferences, training sessions, and books.8 Group discussions were conducted with providers (n ¼ 5) to determine Web site architectural and format needs. Based on this feedback, the InfaNET Nutrition for Child Care Providers Web site (http://www. infanet.cahs.colostate.edu) was developed and contains printable, childcare–specific handouts in English and Spanish as well as Web pages on feeding infants breast milk, formula, and solid food. The Social Learning Theory was used as the theoretical framework for the development of the Web site because of the essential constructs of interaction with the person, behavior and environment (reciprocal determinism), self-efficacy, and modeling.10 A process evaluation (n ¼ 20) was conducted after the Web
Journal of Nutrition Education and Behavior Volume 41, Number 1, 2009 site launch to determine the appropriateness and usefulness of the Web site (eg, ease of use, clarity). The majority (85%) of the providers used the Web site 1 to 3 times during the 1-month process evaluation. One hundred percent of the providers would change nothing on the Web site (eg, content, format); thus the InfaNET Nutrition for Child Care Providers Web site was deemed ready to be evaluated by the objectives of this research study.
DESCRIPTION OF THE EVALUATION Study Design Approval was received from the Colorado State University Institutional Review Board. To be confident with the detection of significant differences among respondents,11 14 child care providers in both the intervention and control groups were needed to achieve 80% power. The Colorado Department of Human Services provided a list of 277 licensed child care centers. Recruitment was completed by calling and mailing postcards to the child care centers. Consent to participate in the 3 phases (pre, post, and follow-up) of the study was received from the child care providers. Upon receiving the consent forms, a letter was mailed to each provider explaining the steps to participate in the study, as well as information on how to access and take the on-line survey. All providers were instructed to complete the on-line pretest survey, view their assigned Web site for 3 months as desired, and complete the on-line posttest survey. The control group was instructed to view an already established, health-related Web site specific to child care providers; the intervention group viewed the InfaNET Nutrition for Child Care Providers Web site. Letters to the child care providers were sent at 3 months to remind them to take the on-line posttest survey. At the posttest time period, the intervention group was also instructed to fill out an additional on-line survey to evaluate the components of the InfaNET Nutrition for Child Care Providers Web site. At the 6 month follow-up, letters were sent as reminders to take the on-line follow-up survey. Cash incentives were offered. Phone calls, e-mails,
and additional letters were sent to increase the response rate.
Instruments An on-line pre/post/follow-up survey was developed that contained 42 closed- and open-ended questions asking providers about their knowledge of and attitudes and behaviors toward feeding breast milk, formula, and solid food to the infants in their care. Demographic variables included gender, age, ethnicity, feeding practices for their own children, and job position (eg, director, provider). Questions included knowledge of the appropriate ways to store and feed breast milk to infants, confidence in answering questions on infant feeding, perceived disadvantages and advantages of one feeding method over another, and compliance with guidelines on ways to be ‘‘breast-feeding friendly.’’ The guidelines used to determine the criteria for ‘‘breast-feeding friendly’’ and to assess the correct answers for breast milk storage times are from United States Department of Agriculture/Food Nutrition Services; these are the guidelines the Colorado Child and Adult Care Food Program uses for their enrolled child care centers.12 The on-line pre/post/follow-up survey took an average of 20 minutes (range of 16-27 minutes) to complete, as determined by WebTrends software (WebTrends, Inc., Portland, Oregon, 2006). The on-line survey was tested for content and face validity with an advisory committee of breast-feeding and infant feeding experts (n ¼ 14) and child care providers (n ¼ 10). Test-retest reliability of the survey was also conducted with a subset of providers, in which all questions scored a correlation level at or above .7. At posttest, the intervention group was also asked to fill out a separate 20-item on-line survey to evaluate the components of the InfaNET Nutrition for Child Care Providers Web site. Questions included satisfaction with the content and layout of the Web site, as well as their use of the bilingual educational materials. This evaluation survey took an average of 7 minutes (range 5 to 10 minutes) to complete, as determined by WebTrends software.
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Data Analysis Statistical analysis software (SAS version 9.1, SAS Institute, Inc., Cary, NC, 2004) was used to conduct several assessments (independent sample t tests; chi-square tests; and repeated measures) to determine differences between the 2 groups. At pretest, knowledge, attitude, and behavior test scores were grouped together and factor analysis was completed to confirm whether the patterns of interrelationships and levels among the variables were appropriate. Factor analysis test results indicated that it was appropriate to group the overall behavior and knowledge questions into a binary scale (right or wrong answer and positive or negative behavior); total attitude scores were measured using a Likert-type scale (1 ¼ strongly agree and 5 ¼ strongly disagree). Open-ended questions were qualitatively analyzed by determining themes among providers’ answers. The number of visits to the Web site was assessed using WebTrends software.
RESULTS OF THE EVALUATION Response Rate Consent to participate in the study was received from 48 child care providers; 38 providers (23 in the intervention group and 15 in the control group) filled out the on-line pretest survey. After grouping the knowledge, attitude, and behavior questions into their appropriate scales as described
earlier, there were no significant differences between the intervention and control groups’ answers at the pretest time period (Table 1). Eighty percent power was achieved at the pre- and posttest time periods. Eight providers dropped out at posttest. Demographic characteristics between those who dropped out (n ¼ 8) and those who remained in the study (n ¼ 30) were not significantly different (P < .42). The providers who dropped out at the posttest time period were white (80%), had children (73%), and fed their infants formula (60%). Fifteen providers filled out the on-line 6-month follow-up survey. Fifteen providers (6 intervention, 9 control) dropped out at follow-up; power was not achieved. Reasons for dropping out of the study were received from 10 of the 15 providers. The reasons included were that the provider had left the child care center (n ¼ 6) and no longer worked with infants (n ¼ 4).
Demographics Demographic characteristics of the surveyed child care providers in the control and intervention groups are shown in Table 2 for the pre, post, and follow-up time periods. The intervention and control groups’ demographic characteristics did not differ at the pretest time period. At pretest, 100% of the child care providers were female in both groups. Roughly one quarter of the respondents were between the ages of 30 and 39 (26% in the intervention group and 27% in the control group). The majority
Clark et al 43 of the respondents in the intervention group were white (83%), fed their own children a combination of breast milk and formula (54%), were child care providers (61%), and were employed by a center located in a rural setting (48%). Similar results were found in the control group; 74% were white, 62% fed their own children a combination of breast milk and formula, 73% were child care providers, and 40% were employed by a center located in a rural setting. In both groups, the Internet (74%) and other co-workers (70%) were the primary ways both groups reported receiving infant feeding information. Also, the majority of both the intervention and control group respondents (70% and 73% respectively) had not attended a training session on infant feeding.
Changes in Knowledge, Attitudes, and Behaviors Table 3 describes the changes in knowledge, attitudes, and behaviors from pre- to posttest. Five significant interactions were found, 3 in favor of the intervention group and 2 in favor of the control group (1 negatively favored). In the intervention group, respondents perceived that breastfeeding/breast milk provided the most benefits to infants (P < .05), met more of the breast-feeding– friendly center criteria (eg, offering mothers water to drink, having a private place to breast-feed) (P < .05), and did not feed infants every 2 hours (P < .01) when compared to the control group. In the control group,
Table 1. Surveyed Colorado Child Care Providers in the Intervention and Control Groups’ Overall Knowledge, Attitude, and Behavior Pretest Scores
Survey Areas Overall Knowledge Score (9 questions grouped together) Overall Attitude Rating (13 questions grouped together) Overall Behavior Score (9 questions grouped together)
Scale 0-1a 1-5c 0-1d
Intervention Group (n ¼ 23)b .37.05 3.7.11 .53.05
Control Group (n ¼ 15)b .39.07 3.7.20 .56.17
P Value .56 .83 .78
a Factor analysis tests determined it was appropriate to group all 9 knowledge questions into an overall binary scale (right or wrong answer) from 0 to 1. b mean SD. c Factor analysis tests determined it was appropriate to group all 13 attitude questions into an overall Likert-type scale from 1 to 5. d Factor analysis tests determined it was appropriate to group all 9 behavior questions into an overall binary scale (positive or negative behavior) from 0 to 1.
Pretest
a
Intervention Group (n ¼ 23) 2.00 0.00c 23 (100%) 3.46 0.30 0 (0%) 8 (35%) 6 (26%) 6 (26%) 3 (13%) 5.76 0.20c 0 (0%) 1 (4%) 1 (4%) 2 (9%) 19 (83%) 2.00 0.34c 2 (15%) 7 (54%) 4 (31%) 1.71 0.15c 8 (35%) 14 (61%) 1 (4%) 1.86 0.23c 11 (48%) 10 (43%) 2 (9%) 0 (0%) 0.29 0.14c
Control Group (n ¼ 15) 2.00 0.00c 15 (100%) 2.94 0.28c 0 (0%) 3 (20%) 4 (27%) 3 (20%) 5 (33%) 5.56 0.31c 0 (0%) 0 (0%) 2 (13%) 2 (13%) 11 (74%) 1.40 0.32c 2 (15%) 8 (62%) 3 (23%) 1.63 0.14c 4 (27%) 11 (73%) 0 (0%) 1.63 0.21c 6 (40%) 5 (33%) 3 (20%) 1 (7%) 0.38 0.13c
7 (30%) 16 (70%)
4 (27%) 11 (73%)
P Valueb 1.00 .46
.60
.90
.60
.20
.80
Intervention Group (n ¼ 16) 2.00 0.00c 16 (100%) 3.17 0.30c 0 (0%) 7 (43%) 4 (25%) 3 (19%) 2 (13%) 5.25 0.21c 0 (0%) 1 (6%) 1 (6%) 1 (6%) 14 (82%) 1.78 0.34c 1 (10%) 5 (50%) 4 (40%) 1.71 0.15c 8 (50%) 7 (44%) 1 (6%) 1.64 0.23c 6 (38%) 7 (44%) 3 (18%) 0 (0%) 0.29 0.14c
Control Group (n ¼ 14) 2.00 0.00c 14 (100%) 3.00 0.28c 0 (0%) 3 (21%) 3 (21%) 3 (21%) 5 (37%) 5.32 0.37c 0 (0%) 0 (0%) 2 (14%) 2 (14%) 10 (72%) 1.31 0.32c 2 (18%) 6 (55%) 3 (27%) 1.56 0.14c 4 (29%) 10 (71%) 0 (0%) 2.13 0.21c 6 (43%) 5 (36%) 2 (14%) 1 (7%) 0.31 0.13c
5 (31%) 11 (69%)
3 (21%) 11 (79%)
Follow-up P Valueb 1.00 .41
.48
.77
.25
.25
.32
Intervention Group (n ¼ 6) 2.00 0.00c 6 (100%) 3.24 0.27c 0 (0%) 3 (49%) 1 (17%) 1 (17%) 1 (17%) 5.20 0.17c 0 (0%) 0 (0%) 1 (17%) 1 (17%) 4 (66%) 1.68 0.30c 1 (20%) 2 (40%) 2 (40%) 1.70 0.16c 3 (50%) 3 (50%) 0 (0%) 1.49 0.22c 1 (17%) 4 (66%) 1 (17%) 0 (0%) 0.25 0.13c
Control Group (n ¼ 9) 2.00 0.00c 9 (100%) 2.99 0.27c 0 (0%) 2 (22%) 2 (22%) 2 (22%) 3 (34%) 5.22 0.30c 0 (0%) 0 (0%) 1 (11%) 1 (11%) 7 (78%) 1.28 0.29c 2 (25%) 4 (50%) 2 (25%) 1.54 0.12c 2 (23%) 7 (77%) 0 (0%) 1.72 0.20c 5 (36%) 3 (33%) 1 (11%) 0 (0%) 0.29 0.09c
3 (50%) 3 (50%)
2 (22%) 7 (78%)
P Valueb 1.00 .43
.43
.72
.21
.31
.42
Intervention group viewed and used the InfaNET Nutrition for Child Care Providers Web site; control group viewed and used a health-related Web site specific to child care providers. b P values represent differences between groups using c2. P < .05 was considered significant. c mean SD. d n (%).
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Demographic Variable Gender Femaled Age (y) # 20d 21-29d 30-39d 40-49d $ 50d Ethnicity American Indiand Asiand Blackd Hispanicd Whited Fed own children Formulad Combinationd Breast milkd Position at center Directord Providerd None of aboved Location of center Rurald Other metrod Denver metrod Unsured Attended training sessions on infant feeding Yesd Nod
Posttest
44 Clark et al
Table 2. Surveyed Colorado Child Care Providers’ Demographic Characteristics in the Intervention and Control Groupsa at Pretest, Posttest, and Follow-up Time Periods
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Clark et al 45
Table 3. Surveyed Colorado Child Care Providers’ Knowledge, Attitude, and Behavior Changes from Pre- to Posttest. n ¼ 30
Knowledge Answered correctly on how to prepare and store breast milk Answered correctly on how to prepare and store formula Answered incorrectly on when appropriate to start introducing solid food to infants Attitude Perceived that breast-feeding/breast milk provides the most benefits to infants Perceived breast-feeding/breast milk increases mother and infant bonding Perceived their role is important in supporting parents’ infant feeding choice Confident in their ability to answer parents’ questions on infant feeding Behavior Met more breast-feeding–friendly center criteria Did not feed infant every 2 hours (based on hunger cues)
F Testa
P Valueb
0.98 1.02 3.32
.32 .43 .05c
3.01 3.64 1.45 2.97
.05d .01c .47 .13
4.16 6.84
.05d .01d
a
Analysis of variance (ANOVA). P values represent differences between groups by time period using ANOVA. P < .05 was considered significant. c Statistically significant in favor of the control group. d Statistically significant in favor of the intervention group. b
respondents perceived that breastfeeding/breast milk increased mother/infant bonding (P < .01) when compared to the intervention group. There were no significant changes in knowledge scores in either of the 2 groups. Providers in the control group (c2 ¼ 6.98; P < .05) and the intervention group (c2 ¼ 11.00; P < .05) who fed their own children formula were more likely to believe that a combination of breast milk and formula provided the most benefits to child care providers. At the posttest time period, providers in both the intervention and control groups had difficulty answering correctly the questions that asked about when infants were developmentally ready to start eating solid food. In the intervention group, providers chose incorrectly 35% of the time, whereas the control group chose incorrectly 44% of the time (P < .05). With regard to infant feeding cues, 100% of the providers answered that they feed formula-fed and breastmilk–fed infants based on hunger cues (eg, sucking on fingers, fussiness), yet incorrectly, all providers felt that crying was a good sign that an infant is hungry and ready to eat. Providers wrote in the open-ended questions that they often partook in behaviors they knew were not appropriate (eg, feeding two infants at a time, feeding cow’s milk), because parents, co-workers, and physicians
were telling them these behaviors were acceptable. Even though not statistically significant, the majority of child care providers in this study encouraged mothers to breastfeed their infants, felt they had an important role in supporting parents with their infant feeding choice, and felt confident in answering questions parents had on feeding breast milk or formula to their infants. At follow-up, no significant differences in knowledge (P ¼ .72), attitude (P ¼ .44), and behavior (P ¼ .92) changes were found among the 3 time periods. There appeared to be a trend (though not statistically significant) of increased knowledge among the 3 time periods for the intervention group.
Web Site Evaluation Outcomes Eleven of the 16 providers from the intervention group who completed the posttest also completed the Web site evaluation survey. Fifty-five percent of the providers used the Web site during the 3-month period 3 to 6 times. On average, providers spent roughly 20 minutes browsing the Web site. All of the providers stated they would have accessed the Web site more if they had had additional time during their workday, and they would continue to use this Web site in the future. The handouts used
most often were on breast-feeding and use of breast milk. The Spanish handouts were not evaluated, as none of the providers spoke Spanish. In total, 3632 visits to the InfaNET Nutrition for Child Care Providers Web site were tracked during the study period. One hundred percent of the providers would not change anything to the Web site layout or material content.
DISCUSSION This is the first study of its kind known to the authors. Few studies have been published regarding infant feeding knowledge, attitudes, and behaviors of child care providers.5,13,14 Between the pretest and posttest, the intervention group did have more positive changes (statistically significant) in desired attitudes and behaviors related to infant feeding and providing a ‘‘breast-feeding–friendly’’ environment. Knowledge scores did not improve drastically; this finding could be because the providers in this study already possessed a desirable level of knowledge on the appropriate ways to store, prepare, and feed breast milk and formula to the infants in their care. Providers listed the Internet as their preferred and desired way over books, training sessions, and coworkers to receive infant feeding information; they declared they would
46 Clark et al continue to use this Web site in the future. Limitations of this study include a self-selected portion of the target population and a low response rate at follow-up. More funding sources to provide larger incentives and inperson visits to the child care centers could have helped to increase the response rate. The time that it took to complete the on-line survey was deemed appropriate, but 20 minutes for child care providers may have been too long owing to the demands of taking care of infants. Many child care providers in this study left their jobs or moved to the toddler room of the center, which nullified their eligibility to partake in the study. Half of child care staff and one-third of child care directors leave their position within 4 years of being hired by that center.5 Because the providers were instructed to use the Web site as desired and were not given any specific instructions, providers used the Web site only minimally. Shaikh and Scott recently published a study regarding the accuracy and credibility of breast-feeding information on the Internet; all of the content areas (eg, support breast-feeding as ideal choice, site updated frequently, Web designer has appropriate credentials) they recommended were included in the InfaNET Nutrition for Child Care Providers Web site.15 Difficulty in accessing the Web site was mentioned by only 2 of the participants during the time of the study, so availability of the Internet was not a limitation for this research study.
IMPLICATIONS FOR RESEARCH AND PRACTICE An area of need appears to be in child care providers’ ability to identify infant hunger cues. Providers in both groups answered incorrectly when asked if crying was a good sign of hunger in infants. Even though crying is considered a late hunger cue in infants, the recommendations are to offer breast milk or formula before crying occurs.16 Researchers have also found that overfeeding an infant can occur if care givers consistently respond to crying by feeding the infant and do not learn
Journal of Nutrition Education and Behavior Volume 41, Number 1, 2009 to monitor infant’s hunger and satiety cues.16 Identifying the reasons why providers feel that crying is a ‘‘good’’ hunger cue is also warranted. Even though it was not significant, the majority of providers who dropped out of the study fed their infants formula; this variable would be interesting to examine in future research. The project’s results provide some evidence that an infant feeding Web site for child care providers could be a viable resource for this population. However, the results were inconclusive as to whether the Web site is linked to sustained attitude and behavior changes. More research is needed to determine if Web sites are an appropriate way to disseminate infant feeding information to child care providers, as well as how infant feeding cues are read and determined by child care providers.
6.
7.
8.
9.
ACKNOWLEDGMENTS The funding for this project was provided by the Colorado Department of Public Health and Environment–Colorado Physical Activity and Nutrition Coalition, Colorado Breast-feeding Task Force, and the Medela Corporation. The authors acknowledge John W. Wilson for his assistance with the website. This research project was completed as part of Alena Clark’s dissertation.
10.
REFERENCES
12.
1. American Academy of Pediatrics. Breastfeeding and the use of human milk. Pediatrics. 2005;115:496-506. 2. United States Department of Health and Human Services, Office on Women’s Health. Benefits of breastfeeding. Nutr Clin Care. 2003;6:125-131. 3. Ricketts S, Wells C, Clark A. Colorado Pregnancy Risk Assessment Monitoring System (PRAMS) Breastfeeding Report. Denver, CO: Colorado Department of Public Health; 2002. 4. Centers for Disease Control. Breastfeeding Practices – Results from the 2005 National Immunization Survey. Available at: http://www.cdc.gov/ breastfeeding/data/NIS_data/index.htm. Accessed December 8, 2008. 5. American Dietetic Association. Position of the American Dietetic Association:
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benchmarks for nutrition programs in child care settings. J Am Diet Assoc. 2005;105:979-986. Li R, Darling N, Maurice E, Barker L, Grummer-Strawn L. Breastfeeding rates in the United States by characteristics of the child, mother or family: the 2002 National Immunization Survey. Pediatrics. 2005;115:e31-e37. United States Department of Agriculture Food and Nutrition Service. National School Lunch Program, School Breakfast Program and Child and Adult Care Food Program: amendments to the Infant Meal Pattern. Fed Reg. 1999;64:61770-61776. Clark A, Anderson J, Adams E, Baker S. Assessing the knowledge, attitudes, behaviors and training needs related to infant feeding, specifically breastfeeding, of child care providers. Matern Child Health J. 2007;12:128-135. Doshi A, Patrick K, Sallis J, Calfas K. Evaluation of physical activity web sites for use of behavior change theories. Ann Behav Med. 2003;25:105-111. Baranowski T, Perry CL, Parcel GS. How individuals, environments, and health behavior interact. In: Glanz K, Lewis FM, Rimer BK, eds. Health Behavior and Health Education: Theory, Research, and Practice. 2nd ed. San Francisco, CA: Jossey-Bass Publishers; 1997:153-178. Oenema A, Brug J, Lechner L. Webbased technology tailored nutrition education: results of a randomized control trial. Health Educ Res. 2001;16:647660. United States Department of Agriculture. Child and Adult Food Care Program. Breastfed Babies Welcome Here! Alexandria, VA: Government Publishing House; 1996. Dirige O, Oglesby A, Bassoff B. An assessment of the nutrition education needs of day care providers. J Am Diet Assoc. 1991;91:714-715. Domer J. Nutrition in a private day care center. J Am Diet Assoc. 1983;82:290293. Shaikh U, Scott B. Extent, accuracy and credibility of breastfeeding information on the Internet. J Hum Lact. 2005;21:175-182. Taveras E, Scanlon K, Birch L, Rifas-Shiman S, Rich-Edwards J, Gilman M. Association of breastfeeding with maternal control of infant feeding at age 1 year. Pediatrics. 2004;114:577583.
INTRODUCTION The health benefits of breast-feeding to mothers and infants are well documented in the literature.1,2 However, Colorado’s breast-feeding initiation rates of 83% exceed national recom-
mendations, yet they fall short at both 6 months (46%) and 1 year (21%).3,4 In 2002, the fourth most common reason Colorado mothers cited for ceasing breast-feeding was because they returned to work or school.3
1
Dietetics Program, University of Northern Colorado, Greeley, Colorado* Department of Food Science and Human Nutrition, Colorado State University, Fort Collins, Colorado 3 Oregon Health and Science University, Portland, Oregon 4 Department of Human Development and Family Studies, Colorado State University, Fort Collins, Colorado Funding for this project was provided by the Colorado Department of Public Health and Environment – Colorado Physical Activity and Nutrition Coalition, Colorado Breast-feeding Task Force, and the Medela Corporation. * At the time research was conducted and completed, Alena Clark was a PhD candidate at Colorado State University, Department of Food Science and Human Nutrition, Fort Collins, Colorado. Address for correspondence: Alena Clark, PhD, RD, Assistant Professor, University of Northern Colorado, Community Health and Nutrition Program, Gunter 2240, Greeley, CO 80639; Phone: (970) 351-2879; Fax: (970) 351-1489; E-mail: [email protected] Ó2009 SOCIETY FOR NUTRITION EDUCATION doi:10.1016/j.jneb.2007.12.007 2
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Approximately 12 million of the 19 million children in the United States under the age of 5 are in some form of child care.5 Children who attend child care at 6 months were significantly less likely to have ever been breastfed or remain exclusively breastfed (P < .05).6 With the decline in breast-feeding coinciding with mothers returning to work and more infants attending child care, it is imperative for child care providers to have access to current and correct infant feeding information, including information on offering breast milk to the infants in their care. Child care agencies often support breastfeeding as the preferred infant feeding method. In 1999, the United States Department of Agriculture authorized the reimbursement of child care centers for infant meals that contain only breast milk, thereby allowing for more providers to support the use of breast milk in their centers.7
41
42 Clark et al A literature review and a recently completed needs assessment8 highlight the need to provide accurate educational materials and best practice information about infant feeding, specifically breast-feeding and offering breast milk, to child care providers. According to this needs assessment, 88% of directors and 79% of providers would be interested in a Web site with child-care–specific infant feeding information.8 The apparent interest in educational information distribution on the Internet is further supported by national trends. In 2003, approximately 60 million Americans per year used the Internet to receive health or medical information; this number continues to rise.9 The 2 objectives for this study were: (1) to determine changes in child care providers’ knowledge of and attitudes and behaviors toward infant feeding best practices after viewing the InfaNET Nutrition for Child Care Providers Web site; and (2) to determine the effectiveness (eg, content and design) of the Web site as well as the use of the bilingual educational materials.
DEVELOPMENT AND EVALUATION OF THE WEB SITE A Web site was determined to be the most preferred way child care providers wanted to receive infant feeding information (P < .001) compared to conferences, training sessions, and books.8 Group discussions were conducted with providers (n ¼ 5) to determine Web site architectural and format needs. Based on this feedback, the InfaNET Nutrition for Child Care Providers Web site (http://www. infanet.cahs.colostate.edu) was developed and contains printable, childcare–specific handouts in English and Spanish as well as Web pages on feeding infants breast milk, formula, and solid food. The Social Learning Theory was used as the theoretical framework for the development of the Web site because of the essential constructs of interaction with the person, behavior and environment (reciprocal determinism), self-efficacy, and modeling.10 A process evaluation (n ¼ 20) was conducted after the Web
Journal of Nutrition Education and Behavior Volume 41, Number 1, 2009 site launch to determine the appropriateness and usefulness of the Web site (eg, ease of use, clarity). The majority (85%) of the providers used the Web site 1 to 3 times during the 1-month process evaluation. One hundred percent of the providers would change nothing on the Web site (eg, content, format); thus the InfaNET Nutrition for Child Care Providers Web site was deemed ready to be evaluated by the objectives of this research study.
DESCRIPTION OF THE EVALUATION Study Design Approval was received from the Colorado State University Institutional Review Board. To be confident with the detection of significant differences among respondents,11 14 child care providers in both the intervention and control groups were needed to achieve 80% power. The Colorado Department of Human Services provided a list of 277 licensed child care centers. Recruitment was completed by calling and mailing postcards to the child care centers. Consent to participate in the 3 phases (pre, post, and follow-up) of the study was received from the child care providers. Upon receiving the consent forms, a letter was mailed to each provider explaining the steps to participate in the study, as well as information on how to access and take the on-line survey. All providers were instructed to complete the on-line pretest survey, view their assigned Web site for 3 months as desired, and complete the on-line posttest survey. The control group was instructed to view an already established, health-related Web site specific to child care providers; the intervention group viewed the InfaNET Nutrition for Child Care Providers Web site. Letters to the child care providers were sent at 3 months to remind them to take the on-line posttest survey. At the posttest time period, the intervention group was also instructed to fill out an additional on-line survey to evaluate the components of the InfaNET Nutrition for Child Care Providers Web site. At the 6 month follow-up, letters were sent as reminders to take the on-line follow-up survey. Cash incentives were offered. Phone calls, e-mails,
and additional letters were sent to increase the response rate.
Instruments An on-line pre/post/follow-up survey was developed that contained 42 closed- and open-ended questions asking providers about their knowledge of and attitudes and behaviors toward feeding breast milk, formula, and solid food to the infants in their care. Demographic variables included gender, age, ethnicity, feeding practices for their own children, and job position (eg, director, provider). Questions included knowledge of the appropriate ways to store and feed breast milk to infants, confidence in answering questions on infant feeding, perceived disadvantages and advantages of one feeding method over another, and compliance with guidelines on ways to be ‘‘breast-feeding friendly.’’ The guidelines used to determine the criteria for ‘‘breast-feeding friendly’’ and to assess the correct answers for breast milk storage times are from United States Department of Agriculture/Food Nutrition Services; these are the guidelines the Colorado Child and Adult Care Food Program uses for their enrolled child care centers.12 The on-line pre/post/follow-up survey took an average of 20 minutes (range of 16-27 minutes) to complete, as determined by WebTrends software (WebTrends, Inc., Portland, Oregon, 2006). The on-line survey was tested for content and face validity with an advisory committee of breast-feeding and infant feeding experts (n ¼ 14) and child care providers (n ¼ 10). Test-retest reliability of the survey was also conducted with a subset of providers, in which all questions scored a correlation level at or above .7. At posttest, the intervention group was also asked to fill out a separate 20-item on-line survey to evaluate the components of the InfaNET Nutrition for Child Care Providers Web site. Questions included satisfaction with the content and layout of the Web site, as well as their use of the bilingual educational materials. This evaluation survey took an average of 7 minutes (range 5 to 10 minutes) to complete, as determined by WebTrends software.
Journal of Nutrition Education and Behavior Volume 41, Number 1, 2009
Data Analysis Statistical analysis software (SAS version 9.1, SAS Institute, Inc., Cary, NC, 2004) was used to conduct several assessments (independent sample t tests; chi-square tests; and repeated measures) to determine differences between the 2 groups. At pretest, knowledge, attitude, and behavior test scores were grouped together and factor analysis was completed to confirm whether the patterns of interrelationships and levels among the variables were appropriate. Factor analysis test results indicated that it was appropriate to group the overall behavior and knowledge questions into a binary scale (right or wrong answer and positive or negative behavior); total attitude scores were measured using a Likert-type scale (1 ¼ strongly agree and 5 ¼ strongly disagree). Open-ended questions were qualitatively analyzed by determining themes among providers’ answers. The number of visits to the Web site was assessed using WebTrends software.
RESULTS OF THE EVALUATION Response Rate Consent to participate in the study was received from 48 child care providers; 38 providers (23 in the intervention group and 15 in the control group) filled out the on-line pretest survey. After grouping the knowledge, attitude, and behavior questions into their appropriate scales as described
earlier, there were no significant differences between the intervention and control groups’ answers at the pretest time period (Table 1). Eighty percent power was achieved at the pre- and posttest time periods. Eight providers dropped out at posttest. Demographic characteristics between those who dropped out (n ¼ 8) and those who remained in the study (n ¼ 30) were not significantly different (P < .42). The providers who dropped out at the posttest time period were white (80%), had children (73%), and fed their infants formula (60%). Fifteen providers filled out the on-line 6-month follow-up survey. Fifteen providers (6 intervention, 9 control) dropped out at follow-up; power was not achieved. Reasons for dropping out of the study were received from 10 of the 15 providers. The reasons included were that the provider had left the child care center (n ¼ 6) and no longer worked with infants (n ¼ 4).
Demographics Demographic characteristics of the surveyed child care providers in the control and intervention groups are shown in Table 2 for the pre, post, and follow-up time periods. The intervention and control groups’ demographic characteristics did not differ at the pretest time period. At pretest, 100% of the child care providers were female in both groups. Roughly one quarter of the respondents were between the ages of 30 and 39 (26% in the intervention group and 27% in the control group). The majority
Clark et al 43 of the respondents in the intervention group were white (83%), fed their own children a combination of breast milk and formula (54%), were child care providers (61%), and were employed by a center located in a rural setting (48%). Similar results were found in the control group; 74% were white, 62% fed their own children a combination of breast milk and formula, 73% were child care providers, and 40% were employed by a center located in a rural setting. In both groups, the Internet (74%) and other co-workers (70%) were the primary ways both groups reported receiving infant feeding information. Also, the majority of both the intervention and control group respondents (70% and 73% respectively) had not attended a training session on infant feeding.
Changes in Knowledge, Attitudes, and Behaviors Table 3 describes the changes in knowledge, attitudes, and behaviors from pre- to posttest. Five significant interactions were found, 3 in favor of the intervention group and 2 in favor of the control group (1 negatively favored). In the intervention group, respondents perceived that breastfeeding/breast milk provided the most benefits to infants (P < .05), met more of the breast-feeding– friendly center criteria (eg, offering mothers water to drink, having a private place to breast-feed) (P < .05), and did not feed infants every 2 hours (P < .01) when compared to the control group. In the control group,
Table 1. Surveyed Colorado Child Care Providers in the Intervention and Control Groups’ Overall Knowledge, Attitude, and Behavior Pretest Scores
Survey Areas Overall Knowledge Score (9 questions grouped together) Overall Attitude Rating (13 questions grouped together) Overall Behavior Score (9 questions grouped together)
Scale 0-1a 1-5c 0-1d
Intervention Group (n ¼ 23)b .37.05 3.7.11 .53.05
Control Group (n ¼ 15)b .39.07 3.7.20 .56.17
P Value .56 .83 .78
a Factor analysis tests determined it was appropriate to group all 9 knowledge questions into an overall binary scale (right or wrong answer) from 0 to 1. b mean SD. c Factor analysis tests determined it was appropriate to group all 13 attitude questions into an overall Likert-type scale from 1 to 5. d Factor analysis tests determined it was appropriate to group all 9 behavior questions into an overall binary scale (positive or negative behavior) from 0 to 1.
Pretest
a
Intervention Group (n ¼ 23) 2.00 0.00c 23 (100%) 3.46 0.30 0 (0%) 8 (35%) 6 (26%) 6 (26%) 3 (13%) 5.76 0.20c 0 (0%) 1 (4%) 1 (4%) 2 (9%) 19 (83%) 2.00 0.34c 2 (15%) 7 (54%) 4 (31%) 1.71 0.15c 8 (35%) 14 (61%) 1 (4%) 1.86 0.23c 11 (48%) 10 (43%) 2 (9%) 0 (0%) 0.29 0.14c
Control Group (n ¼ 15) 2.00 0.00c 15 (100%) 2.94 0.28c 0 (0%) 3 (20%) 4 (27%) 3 (20%) 5 (33%) 5.56 0.31c 0 (0%) 0 (0%) 2 (13%) 2 (13%) 11 (74%) 1.40 0.32c 2 (15%) 8 (62%) 3 (23%) 1.63 0.14c 4 (27%) 11 (73%) 0 (0%) 1.63 0.21c 6 (40%) 5 (33%) 3 (20%) 1 (7%) 0.38 0.13c
7 (30%) 16 (70%)
4 (27%) 11 (73%)
P Valueb 1.00 .46
.60
.90
.60
.20
.80
Intervention Group (n ¼ 16) 2.00 0.00c 16 (100%) 3.17 0.30c 0 (0%) 7 (43%) 4 (25%) 3 (19%) 2 (13%) 5.25 0.21c 0 (0%) 1 (6%) 1 (6%) 1 (6%) 14 (82%) 1.78 0.34c 1 (10%) 5 (50%) 4 (40%) 1.71 0.15c 8 (50%) 7 (44%) 1 (6%) 1.64 0.23c 6 (38%) 7 (44%) 3 (18%) 0 (0%) 0.29 0.14c
Control Group (n ¼ 14) 2.00 0.00c 14 (100%) 3.00 0.28c 0 (0%) 3 (21%) 3 (21%) 3 (21%) 5 (37%) 5.32 0.37c 0 (0%) 0 (0%) 2 (14%) 2 (14%) 10 (72%) 1.31 0.32c 2 (18%) 6 (55%) 3 (27%) 1.56 0.14c 4 (29%) 10 (71%) 0 (0%) 2.13 0.21c 6 (43%) 5 (36%) 2 (14%) 1 (7%) 0.31 0.13c
5 (31%) 11 (69%)
3 (21%) 11 (79%)
Follow-up P Valueb 1.00 .41
.48
.77
.25
.25
.32
Intervention Group (n ¼ 6) 2.00 0.00c 6 (100%) 3.24 0.27c 0 (0%) 3 (49%) 1 (17%) 1 (17%) 1 (17%) 5.20 0.17c 0 (0%) 0 (0%) 1 (17%) 1 (17%) 4 (66%) 1.68 0.30c 1 (20%) 2 (40%) 2 (40%) 1.70 0.16c 3 (50%) 3 (50%) 0 (0%) 1.49 0.22c 1 (17%) 4 (66%) 1 (17%) 0 (0%) 0.25 0.13c
Control Group (n ¼ 9) 2.00 0.00c 9 (100%) 2.99 0.27c 0 (0%) 2 (22%) 2 (22%) 2 (22%) 3 (34%) 5.22 0.30c 0 (0%) 0 (0%) 1 (11%) 1 (11%) 7 (78%) 1.28 0.29c 2 (25%) 4 (50%) 2 (25%) 1.54 0.12c 2 (23%) 7 (77%) 0 (0%) 1.72 0.20c 5 (36%) 3 (33%) 1 (11%) 0 (0%) 0.29 0.09c
3 (50%) 3 (50%)
2 (22%) 7 (78%)
P Valueb 1.00 .43
.43
.72
.21
.31
.42
Intervention group viewed and used the InfaNET Nutrition for Child Care Providers Web site; control group viewed and used a health-related Web site specific to child care providers. b P values represent differences between groups using c2. P < .05 was considered significant. c mean SD. d n (%).
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Demographic Variable Gender Femaled Age (y) # 20d 21-29d 30-39d 40-49d $ 50d Ethnicity American Indiand Asiand Blackd Hispanicd Whited Fed own children Formulad Combinationd Breast milkd Position at center Directord Providerd None of aboved Location of center Rurald Other metrod Denver metrod Unsured Attended training sessions on infant feeding Yesd Nod
Posttest
44 Clark et al
Table 2. Surveyed Colorado Child Care Providers’ Demographic Characteristics in the Intervention and Control Groupsa at Pretest, Posttest, and Follow-up Time Periods
Journal of Nutrition Education and Behavior Volume 41, Number 1, 2009
Clark et al 45
Table 3. Surveyed Colorado Child Care Providers’ Knowledge, Attitude, and Behavior Changes from Pre- to Posttest. n ¼ 30
Knowledge Answered correctly on how to prepare and store breast milk Answered correctly on how to prepare and store formula Answered incorrectly on when appropriate to start introducing solid food to infants Attitude Perceived that breast-feeding/breast milk provides the most benefits to infants Perceived breast-feeding/breast milk increases mother and infant bonding Perceived their role is important in supporting parents’ infant feeding choice Confident in their ability to answer parents’ questions on infant feeding Behavior Met more breast-feeding–friendly center criteria Did not feed infant every 2 hours (based on hunger cues)
F Testa
P Valueb
0.98 1.02 3.32
.32 .43 .05c
3.01 3.64 1.45 2.97
.05d .01c .47 .13
4.16 6.84
.05d .01d
a
Analysis of variance (ANOVA). P values represent differences between groups by time period using ANOVA. P < .05 was considered significant. c Statistically significant in favor of the control group. d Statistically significant in favor of the intervention group. b
respondents perceived that breastfeeding/breast milk increased mother/infant bonding (P < .01) when compared to the intervention group. There were no significant changes in knowledge scores in either of the 2 groups. Providers in the control group (c2 ¼ 6.98; P < .05) and the intervention group (c2 ¼ 11.00; P < .05) who fed their own children formula were more likely to believe that a combination of breast milk and formula provided the most benefits to child care providers. At the posttest time period, providers in both the intervention and control groups had difficulty answering correctly the questions that asked about when infants were developmentally ready to start eating solid food. In the intervention group, providers chose incorrectly 35% of the time, whereas the control group chose incorrectly 44% of the time (P < .05). With regard to infant feeding cues, 100% of the providers answered that they feed formula-fed and breastmilk–fed infants based on hunger cues (eg, sucking on fingers, fussiness), yet incorrectly, all providers felt that crying was a good sign that an infant is hungry and ready to eat. Providers wrote in the open-ended questions that they often partook in behaviors they knew were not appropriate (eg, feeding two infants at a time, feeding cow’s milk), because parents, co-workers, and physicians
were telling them these behaviors were acceptable. Even though not statistically significant, the majority of child care providers in this study encouraged mothers to breastfeed their infants, felt they had an important role in supporting parents with their infant feeding choice, and felt confident in answering questions parents had on feeding breast milk or formula to their infants. At follow-up, no significant differences in knowledge (P ¼ .72), attitude (P ¼ .44), and behavior (P ¼ .92) changes were found among the 3 time periods. There appeared to be a trend (though not statistically significant) of increased knowledge among the 3 time periods for the intervention group.
Web Site Evaluation Outcomes Eleven of the 16 providers from the intervention group who completed the posttest also completed the Web site evaluation survey. Fifty-five percent of the providers used the Web site during the 3-month period 3 to 6 times. On average, providers spent roughly 20 minutes browsing the Web site. All of the providers stated they would have accessed the Web site more if they had had additional time during their workday, and they would continue to use this Web site in the future. The handouts used
most often were on breast-feeding and use of breast milk. The Spanish handouts were not evaluated, as none of the providers spoke Spanish. In total, 3632 visits to the InfaNET Nutrition for Child Care Providers Web site were tracked during the study period. One hundred percent of the providers would not change anything to the Web site layout or material content.
DISCUSSION This is the first study of its kind known to the authors. Few studies have been published regarding infant feeding knowledge, attitudes, and behaviors of child care providers.5,13,14 Between the pretest and posttest, the intervention group did have more positive changes (statistically significant) in desired attitudes and behaviors related to infant feeding and providing a ‘‘breast-feeding–friendly’’ environment. Knowledge scores did not improve drastically; this finding could be because the providers in this study already possessed a desirable level of knowledge on the appropriate ways to store, prepare, and feed breast milk and formula to the infants in their care. Providers listed the Internet as their preferred and desired way over books, training sessions, and coworkers to receive infant feeding information; they declared they would
46 Clark et al continue to use this Web site in the future. Limitations of this study include a self-selected portion of the target population and a low response rate at follow-up. More funding sources to provide larger incentives and inperson visits to the child care centers could have helped to increase the response rate. The time that it took to complete the on-line survey was deemed appropriate, but 20 minutes for child care providers may have been too long owing to the demands of taking care of infants. Many child care providers in this study left their jobs or moved to the toddler room of the center, which nullified their eligibility to partake in the study. Half of child care staff and one-third of child care directors leave their position within 4 years of being hired by that center.5 Because the providers were instructed to use the Web site as desired and were not given any specific instructions, providers used the Web site only minimally. Shaikh and Scott recently published a study regarding the accuracy and credibility of breast-feeding information on the Internet; all of the content areas (eg, support breast-feeding as ideal choice, site updated frequently, Web designer has appropriate credentials) they recommended were included in the InfaNET Nutrition for Child Care Providers Web site.15 Difficulty in accessing the Web site was mentioned by only 2 of the participants during the time of the study, so availability of the Internet was not a limitation for this research study.
IMPLICATIONS FOR RESEARCH AND PRACTICE An area of need appears to be in child care providers’ ability to identify infant hunger cues. Providers in both groups answered incorrectly when asked if crying was a good sign of hunger in infants. Even though crying is considered a late hunger cue in infants, the recommendations are to offer breast milk or formula before crying occurs.16 Researchers have also found that overfeeding an infant can occur if care givers consistently respond to crying by feeding the infant and do not learn
Journal of Nutrition Education and Behavior Volume 41, Number 1, 2009 to monitor infant’s hunger and satiety cues.16 Identifying the reasons why providers feel that crying is a ‘‘good’’ hunger cue is also warranted. Even though it was not significant, the majority of providers who dropped out of the study fed their infants formula; this variable would be interesting to examine in future research. The project’s results provide some evidence that an infant feeding Web site for child care providers could be a viable resource for this population. However, the results were inconclusive as to whether the Web site is linked to sustained attitude and behavior changes. More research is needed to determine if Web sites are an appropriate way to disseminate infant feeding information to child care providers, as well as how infant feeding cues are read and determined by child care providers.
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ACKNOWLEDGMENTS The funding for this project was provided by the Colorado Department of Public Health and Environment–Colorado Physical Activity and Nutrition Coalition, Colorado Breast-feeding Task Force, and the Medela Corporation. The authors acknowledge John W. Wilson for his assistance with the website. This research project was completed as part of Alena Clark’s dissertation.
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