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Knowledge and attitudes toward breast-feeding: Differences among dietitians, nurses, and physicians working with WIC clients
PERSPECTIVES INPRACTICE
Knowledge and attitudes toward breast-feeding: Differences among dietitians, nurses, and physicians working with WIC clients JANE E. BAGWELL, MS, RD; OLIVIA W KENDRICK, DrPH,RD; KATHLEENR. STITT, PhD, RD; JAMES D LEEPER, PhD
ABSTRACT: We assessed the knowledge of and attitude toward breast feeding of dietitians, nurses, and physicians who work with individuals in the Alabama Special Supplemental Food Program for Women, Infants, and Children. On a scale of 0 to 100, dietitians expressed stronger interest in lactation (78.6) and exhibited greater knowledge (79.6) of the questions asked than nurses (74.5 and 73.0, respectively). Attitude and knowledge scores of physicians (70.2 and 75.5, respectively) were not statistically different from those of dietitians or nurses. Respondents disagreed greatly about the relationship of breast-feeding to weight loss and the appropriateness of oral contraceptives during breast-feeding 6 weeks postpartum. Professionals were more knowledgeable about benefits to infants than about maternal concerns. Results of this study suggest that professional breast-feeding education programs should address maternal concerns such as weight loss, contraception, and mastitis as well as benefits to the infant. JAm DietAssoc. 1993; 93:801-804.
ealthy People 2000, issued by the US Department of Health and Human Services, reaffirmed the Surgeon General's 1990 goals to increase the incidence of breast feeding in the United States to 75% of infants at hospital discharge and to increase the goal for infants being breast-fed at the age of 6 months to 50% (from the 35% goal for 1990) (1). The incidence of breast-feeding at hospital discharge in the United States declined from 62.5% in 1984 to 52.2% in 1989 and at the age of 6 months from 27.5% to 18.1% for the same period. The incidence and duration of breast-feeding among clients of the Special Supplemental Food Program for Women, Infants, and Children (WIC) are lower than the national average. In 1989, 34.2% of women enrolled in WIC breast-fed their infants at hospital discharge and 8.4% continued to breast-feed for 6 months (2). The American Dietetic Association (3) encourages its members to take an active role in the promotion of breast-feeding. Although ADA's position paper states that "dietitians have a vital role and responsibility to promote breast-feeding" (3, p 1580), a national survey of medical professionals' practices and attitudes toward breast-feeding included physicians, nurses, and hospital administrators but not dietitians (4). Several surveys of nurses' knowledge of breast-feeding have been completed (5 7), but the only survey of dietitians' knowledge of lactation that we found measured their percep tion of their lactation training, not their knowledge (8). Because current trends in breast-feeding are declining rather than proceeding toward the goals set for the year 2000, it is imperative that all health professionals who work with pregnant women be knowledgeable about lactation. Our study assessed the knowledge of and attitudes toward breast-feeding held by dietitians, nurses, and physicians who serve the WIC population in Alabama. O. W Kendrick (correspondingauthor) and K R. Stitt are with the Departmentof Human Nutritionand Hospitality Management, College of Human EnvironmentalSciences, University ofAlabama, Tuscaloosa,AL 35487-0158. J E. Bagwell was a graduatestudent at the University of Alabama when this work was done; currently, she is a clinicaldietitian at the University ofAlabama at Birmingham Hospitals, Birmingham, AL 35294. J D. Leeper is with the Department ofBehavioraland Community Medicine at the University ofAlabama, Tuscaloosa,AL 35487-0326. JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION / 801
PERSPECTIVES INPRACTICE METHODS We developed a questionnaire to measure knowledge and attitudes of health professionals with items from a questionnaire used by Lawrence (4). Questions incorporated reasons women enrolled in the Alabama WIC program gave for cessation of breast-feeding (9). Questionnaires were modified slightly for each discipline (dietetics, nursing, medicine) to address the population more adequately. Respondents were asked to indi cate their level of agreement with each attitude and knowledge statement on a Likert-type scale of 1 to 5 (5 indicated strong agreement and 1 indicated strong disagreement). When an item was stated in a negative fashion, such as "breast-feeding is incompatible with working outside the home," scores were converted so that the maximum score of 5 indicated strong disagreement with the statement and 1 indicated strong agreement with the statement. Thus, a score of 5 indicated a positive attitude toward breast-feeding, whereas a score of 1 indicated a negative attitude.
In general, dietitans, physicians, and nurses had positive attitudes toward breast-feeding; however, they need to address maternal concerns, such as weight loss, use of oral contraceptives during lactation, mastitis, and engorgement
Questionnaires were sent to dietitians and nurses who were employed by the Alabama Department of Public Health and worked in WIC and to physicians who either worked in the public health department or who were private physicians with a large patient load of WIC participants. The names of the private physicians were obtained from local health departments, and their addresses were retrieved from the membership roster of the Alabama Medical Association. All other names and addresses were provided by the Department of Public Health. Resident physicians offering medical care to participants as part of their training were excluded from the survey When more than 50 physicians were listed as caregivers for a public health area of the state, a random sample of the physicians from that area received the questionnaire. Otherwise, all health personnel identified were surveyed. We mailed 574 surveys in the summer of 1989: 55 to dietitians, 284 to nurses, and 235 to physicians. Completed questionnaires were tabulated and analyzed statistically using SPSS-X Statistical Package for the Social Sciences (release 3.0,1988, SPSS, Chicago, Ill). Individual items measuring attitude and knowledge were combined and placed on a 100-point scale to determine aggregate attitude and knowledge scores. The Pearson Product Moment correlation 802 / JULY 1993 VOLUME 93 NUMBER 7
coefficient was used to measure the relationship between knowledge of and attitude toward breast-feeding of persons in each professional category. One-way analysis of variance fol lowed by a least significant difference test was used to determine differences in knowledge and attitudes of breast feeding among dietitians, nurses, and physicians. RESULTS AND DISCUSSION Of the 574 surveys that were sent to health professionals, three were returned because of an incorrect address or because the addressee was on extended leave from employment. We as sumed that the remaining 571 surveys were received by the participants. Two hundred eighty-nine questionnaires were returned for a 50% response rate. Respondents included 41 dietitians, 158 nurses, and 90 physicians; response rates by professional category were 75%, 56%, and 39%, respec tively. All of the dietitians and nurses who responded to the question concerning gender were women. Two dietitians and eight nurses did not respond to this question. Of the 84 physicians who responded to this question, 67 were men and 17 were women. Dietitians and nurses were younger than physicians. Attitudes Toward Breast-Feeding Health professionals as a group strongly agreed that they would advocate breast-feeding for both married and single mothers. They were slightly less likely to recommend breast-feeding to working mothers, mothers in school, and adolescent mothers. They did not recommend breast-feeding for mentally retarded mothers. Responses to individual attitude and knowledge questions by professional category are presented in Table 1. In general, attitudes toward breast-feeding were positive. Some differences in individual items were seen among professions. Dietitians and nurses were more likely to recommend breast-feeding to a mother who had made the decision to bottle-feed than were physicians. Physicians were less likely to think that breast feeding was incompatible with working outside the home or attending school than were nurses. Nurses and physicians were more likely than were dietitians to agree with the statement that fathers feel close to their infants if they can bottle-feed them. Dietitians were more interested in breast feeding and lactation management than were nurses. The aggregate attitude scores ranged from 32.0 to 99.0 with a mean ( standard deviation) score of 73.8 - 13.9. When exam ined by professional category, dietitians and nurses had higher attitude scores than did physicians (P<.05) (Table 2). Knowledge of Breast-Feeding Responses to individual knowledge items differed by health profession (Table 1). Nurses were more likely than dietitians and physicians to think that mastitis and engorgement are reasons to discontinue breast-feeding. On the questions addressing the role of breast-feeding in weight management and the compatibility of birth control pills with breast-feeding, the lower scores with larger standard deviations indicated a lack of consensus as to the correct answers. A recent report from the Committee on Nutritional Status during Pregnancy and Lactation of the National Acad emy of Sciences (10) recommended that women be advised that it is normal to lose weight during the first 6 months of lactation and that the average rate of loss is approximately 1 to 2 lb per month after the first month postpartum. Dietitians were more likely than nurses or physicians to agree that breast-feeding is a good method of weight loss. Because lactation generally results
Table 1 Selected mean ( +standard deviation) scores on health professional survey items measuring knowledge of and attitude toward breast-feedinga Item No. Attitude When a mother inmy practice has yet to make a decision regarding how to feed her infant, I advocate breast-feeding for a mother who is a marred b single c mentally retarded d an adolescent e. working f in school When a mother in my practice has made the decision to bottle-feed, I still recommend breast-feeding for a mother who is a. married b single c. mentally retarded d an adolescent e. working f. in school Breast-feeding a builds a closer emotional bond between a mother and her child than does bottle-feeding. b. is usually the easiest way to calm a baby c is incompatible with working outside the home b d is incompatible with attending school b e is more difficult than bottle-feeding b Fathers feel close to their infants if they can bottle-feed them b More should be done to encourage breast-feeding in the WICc program. I am interested in breast-feeding and lactation management Knowledge Breast-feeding a provides benefits for infants that cannot be produced by formula b is a good method of weight reduction. c Helps protect infants against infection d is incompatible with the use of birth control pills after 6 weeks postpartum." Awoman who develops problems related to breast-feeding, such as mastitis or engorgement, should totally discontinue breast-feeding.'
Dietitian Score
No.
Nurse Score
No.
Physician Score
39 39 39 38 39 39
487-0.52 4.74 + 0.68 2.72 1.12 3.79+ 1.04 4.38 0 71 4.21 0.77
158 157 152 156 157 156
471 +065 4.52 t 0.82 2.64 t 1.34 3.60 +-1.29 4 09+ 1 05 388 1 15
89 89 85 88 89 89
464* 079 4 52 +087 2.92 1 36 3.88t: 1.18 4 12t 1 05 4 01 1 09
39 39 39 39 39 39
4.26 t 1.09X 4.26 1.09X 2.49 1.17" 3.41 1.31' 4.00±1.15'x 3.82 1. 14
158 157 153 158 157 157
4.08 +1 30 398 1 30 2.61 1.44 x 3.27 1 42X 3.66+ 1 30X 357+1.32
90 90 87 90 90 90
3 20 = 1 50' 3.06- 1.54Y 2.16 1 35' 266:- 1 49Y 2 77 1 49' 273 - 2 73'
41
4.71 0.60
155
4.34 1 05
86
4 34± 1 04
41
3.66 099X
155
3 14 1 20'
85
301
155
3.81 + 1 18'
86
4 16 :-1 06X
86
4 15- 1 02'
41
3 78 +1 13"
'
X
y
1.13 Y
41
376 +1.09 "
154
3.74 1.19
41
3.73 +-1.50
154
3 79 t 1.32
84
3 50
41
3.80 1.15X
155
306 1 23Y
86
3 08. 1 07Y
40
4 10 0.96
154
4 01
86
4 12
41
4.39 + 0.95X
154
3.83 1 06Y
84
4 01 + 1 00
41
4.93±+026
155
4.75+0 58
86
4 70 061
41
300 +1.09 X
153
2 82 t 1.24 X
85
2 49 + 11 9Y
1 11
Y
t
1 28
1.09 y
41
4.76+0.73'
152
4 56+0 89
84
4 31 0O97Y
40
3.10+1 43'
150
2.57 -1 41
85
319 +1.33'
41
4 12 - 1 33'
151
3.54 - 1 28Y
84
4 05 ± 1 17X
aMaximum score of 5 indicates strong agreement with statement; minimum score of 1 indicates strong disagreement. 'Scores were converted on these questions so that maximum score of 5 indicates strong disagreement with statement; minimum score of 1 indicates strong agreement. 'WIC = Special Supplemental Food Program for Women, Infants, and Children "'YScoresfollowed by different letters insame row are significantly different (P<.05).
JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION
803
Table 2 Knowledge and attitude scores of health professionalsa
Dietitian
Nurse Physician
Total
Attitude
Knowledge
Professional category
No.
Range
Mean + SDb
Range
Mean SD 78 6 + 10 4
X
37
59.0-93 0
143
32 0-98 0
74 5 13 7'
76
39 0-99,0
70 2 - 14 9'
256
32.0-99.0
73 8 + 13 9
40
52,0-100.0
79.6 t 107
143
32.0-100,0
81
48.0-100,0
73 Ot 12 0X
264
32.0-100.0
75 5 748t
No.
11 3 y
118
aMaximum possible score of 100 indicates strong agreement with knowledge/attitude survey items bSD = standard deviation.
XYScores followed by different letters inthe same column are significantly different (P<.05).
in a slow rate of weight loss, some health professionals may not have considered it a good method to lose weight. The Committee on Drugs of the American Academy of Pediatrics (11) has issued a statement indicating that the use of oral contraceptives during lactation is safe. Less than half of the health professionals surveyed agreed with this statement. Dietitians and physicians were more likely than nurses to agree that use of oral contraceptives is compatible with breast-feeding. Aggregate knowledge scores ranged from 32.0 to 100.0 (mean = 74.8 + 11.8). Although the scores of nurses in this study were higher than those reported by others (5,6), dietitians' scores were significantly (P<.05) higher (Table 2). Physicians' scores were not statistically different from those of dietitians or nurses.
Health professionals were slightly less likely to recommend breast-feeding for working mothers, mothers in school, and adolescent mothers; they did not recommend breast-feeding for mentally retarded mothers Aggregate knowledge and attitude scores were weakly related (r=.24; P<.001). When examined by profession, the knowledge and attitude scores were similarly related for nurses (r=.27; P=.002), physicians (r=.21; P=.08), and dietitians (r=.22; P= .20). The lack of statistical significance of correlations for dietitians and physicians is attributable to the smaller number of respondents in these groups. APPLICATIONS Health professionals appeared to be more knowledgeable about benefits to the infant from breast-feeding than they were about maternal concerns. Professional education programs should
804 / JULY 1993 VOLUME 93 NUMBER 7
include information on weight loss and birth control during lactation and complications such as mastitis and engorgement as well as information on benefits to the infants. A survey of dietitians in Idaho (8) indicated that they were knowledgeable about the benefits of breast-feeding but needed additional training in breast-feeding techniques and pumping, hormonal regulation of lactation, and breast-feeding a high-risk infant. Dietitians exhibited both interest in and knowledge about breast-feeding. They should be involved in promoting breast feeding and in the education and support of women interested in breast-feeding. Educators and employers should encourage interested dietitians to take the international examination to become a certified lactation consultant. U Information about becoming a certified lactation consultant can be obtainedfromthe InternationalBoard of Lactation ConsultantExaminers, 2315 Wickersharn Core, Germantown, TN38138. References 1. Office of Disease Prevention and Health Promotion. Healthy People 2000. Washington, DC: US Governmnent Printing Office; 1990. I)HHS publication (PHS) 91-50212. 2. Ryan AS, Rush D,Krieger FW, Lewandowski GE. Recent declines in breast-feeding in the United States, 1984-1989
Pediatrics 1991;
88:719-727, 3. Position of The American Dietetic Association: promotion and support of breast-feeding. JAm Diet Assoc. 1993; 93:467-469. 4. Lawrence RA. Practices and attitudes toward breast feeding among medical professionals. Pediatrics.1982; 70:912-920. 5. Anderson E, Geden E. Nurses' knowledge of breast-feeding. .JObstet Gynecol Neonatal Nurs. 1991; 20:58-64. 6. Crowder DS. Maternity nurses' knowledge of factors promoting successful breast-feeding: a survey of two hospitals. .J Obstet Gyoecal NeonatalNurs. 1981; 10:28-30. 7. Hayes B.Inconsistencies among nurses in breast-feeding knowledge and counseling. J Obstet Gynecol Neonatal Nurxs. 1981; 10:430-433. 8. Marincic PZ. Breast-feeding education and promotion: implications for curriculum development. Dep-lie. 1992; 10:8-9. 9. Bagwell JE, Kendrick OW, Stitt KR, Leeper JD. Epsy ML, Gedel ML. Breast-feeding among women in the Alabama WIC Programi. /.1 Ira Lactation. 1992; 12:205 208. 10. Subcommittee of Lactation, Food and Nutrition Board. Nautriir,,,
during Lactation:Sumrnary, Concltusions, and Recoate dat(ions. Washington, DC: National Academy of Sciences; 1991. 11. American Academy of Pediatrics Committee on D)rugs. Breast feeding and contraception. Pediatrics. 1981: 68:138- 4).
SELF ASSESSMENT
Self-assessment questionnaire for DTRs After reading the continuing education article, "Knowledge and attitudes toward breast-feeding: Differences among dietitians, physicians, and nurses working with WIC clients," please answer the following questions by indicating your responses on the selfassessment questionnaire form located on the next page. This activity has been approved for 1 hour of continuing education credit for dietetic technicians, registered, by the Commission on Dietetic Registration. Answers to the self-assessment questionnaire can be found on page 848. ADA members should cut out the completed form and return it, with a check for $12 each (nonmembers $16) to cover processing, to: The American Dietetic Association, PO Box 97215, Chicago, IL 60678-7215. Questionnaires must be returned within 1 year of their appearance in the Journalin order to be eligible for credit. Notification will not be sent if the hour is approved. For items 1-13, select the one best answer or completion to each question or incomplete statement. 1. According to Healthy People 2000, what is the goal for the incidence of breast-feeding at hospital discharge? A. 65% B. 70% C. 75% D. 80% 2. According to Healthy People 2000, what is the goal for the percentage of infants being breast-fed at 6 months of age? A. 45% B. 50% C. 55% D. 65% 3. Which group of health care professionals had the highest response rate? A. Nurses B. Resident physicians C. Dietitians D. Physicians 4. How did the physicians and nurses, vs the dietitians, respond to the statement that fathers feel close to their infants if they can bottle feed them? A. More likely to agree B. More likely to strongly agree C. More likely to disagree D. More likely to strongly disagree
5. What type of scores indicated a lack of consensus of correct answers? A. Higher scores with large standard deviations B. Lower scores with large standard deviations C. Higher scores with small standard deviations D. Lower scores with small standard deviations 6. According to the recent National Academy of Sciences report, what type of weight loss is normal after the first month postpartum of breast-feeding? A. 1 to 2 lb per week B. 1 to 2 lb every 2 weeks C. 1 to 2 lb per month D. 1 to 2 lb per 6 weeks 7. How did physicians' scores for breast-feeding knowledge compare with scores of nurses and dietitians? A. They were significantly higher statistically B. They were significantly lower statistically C. They were the same D. There was no statistical difference 8. How did group aggregate knowledge and attitude scores correlate? A. They were strongly correlated B. They were moderately correlated C. They were weakly correlated D. They had no correlation 9. How did nurses' knowledge scores about breast-feeding compare with scores of dietitians? A. There was no difference B. They were significantly lower C. They were significantly higher D. This analysis was not performed 10. How did dietitians compare with physicians on the issue of use of oral contraceptive agents (OCAs) during lactation? A. They were more likely to agree that OCAs were safe B. They were as likely to agree that OCAs were safe C. They were as likely to disagree that OCAs were safe D. They had no opinion 11. How did breast-feeding rates at hospital discharge and at 6 months compare in 1989 vs 1984 in the United States? A. They were higher in 1989 B. They were lower in 1989 C. There was no difference D. This issue was not discussed JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION / 805
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SELF AT............................................................ ASSSEN
12. How did physicians compare with nurses on their attitudes toward the compatibility of breast-feeding with work or education outside the home? A. They were more likely to think it was incompatible B. They were less likely to think it was incompatible C. There was no difference in their attitudes D. This issue was not reported 13. Which health profession showed a higher interest in breastfeeding and lactation management? A. Physicians B. Physician assistants C. Dietitians D. Nurses For items 14-17, select all completions that are true. Each item may have two, three or four correct answers. 14. Which groups of health professional were more likely to recommend breast-feeding to a mother who had made a decision to bottle feed? A. Nurses B. Physicians
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C. Dietetic technicians D. Dietitians 15. Which groups were more likely to disagree that mastitis and engorgement were reasons to discontinue breast-feeding? A. Physicians B. Nurses C. Physician assistants D. Dietitians 16. On the basis of the results of this study, professional education programs on lactation should cover: A. Birth control B. Complications such as mastitis and engorgement C. Weight loss D. Benefits to the infant 17. The Idaho Survey of Dietitians found that dietitians needed additional education in: A. Breast-feeding techniques B. Hormonal regulation of lactation C. Benefits of breast-feeding D. Techniques for breast-feeding high-risk infants
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CONTINUING EDUCATION REPORTING FORM Continuing Education Article "Knowledge and attitudes toward breast-feeding: Differences among dietitians, physicians, and nurses working with WIC clients," Journal, July 1993 SELF-ASSESSMENT QUESTIONNAIRE ANSWER FORM Article ExpirationDate: July 1994 After reading each statecement, please select the best answer(s) or completion(s):
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This activity has been approved for 1 hour of continuing education credit for registered dietitians. ADA Member -- P1 ($12) Non-ADA Member - P2 ($16)
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Knowledge and attitudes toward breast-feeding: Differences among dietitians, nurses, and physicians working with WIC clients JANE E. BAGWELL, MS, RD; OLIVIA W KENDRICK, DrPH,RD; KATHLEENR. STITT, PhD, RD; JAMES D LEEPER, PhD
ABSTRACT: We assessed the knowledge of and attitude toward breast feeding of dietitians, nurses, and physicians who work with individuals in the Alabama Special Supplemental Food Program for Women, Infants, and Children. On a scale of 0 to 100, dietitians expressed stronger interest in lactation (78.6) and exhibited greater knowledge (79.6) of the questions asked than nurses (74.5 and 73.0, respectively). Attitude and knowledge scores of physicians (70.2 and 75.5, respectively) were not statistically different from those of dietitians or nurses. Respondents disagreed greatly about the relationship of breast-feeding to weight loss and the appropriateness of oral contraceptives during breast-feeding 6 weeks postpartum. Professionals were more knowledgeable about benefits to infants than about maternal concerns. Results of this study suggest that professional breast-feeding education programs should address maternal concerns such as weight loss, contraception, and mastitis as well as benefits to the infant. JAm DietAssoc. 1993; 93:801-804.
ealthy People 2000, issued by the US Department of Health and Human Services, reaffirmed the Surgeon General's 1990 goals to increase the incidence of breast feeding in the United States to 75% of infants at hospital discharge and to increase the goal for infants being breast-fed at the age of 6 months to 50% (from the 35% goal for 1990) (1). The incidence of breast-feeding at hospital discharge in the United States declined from 62.5% in 1984 to 52.2% in 1989 and at the age of 6 months from 27.5% to 18.1% for the same period. The incidence and duration of breast-feeding among clients of the Special Supplemental Food Program for Women, Infants, and Children (WIC) are lower than the national average. In 1989, 34.2% of women enrolled in WIC breast-fed their infants at hospital discharge and 8.4% continued to breast-feed for 6 months (2). The American Dietetic Association (3) encourages its members to take an active role in the promotion of breast-feeding. Although ADA's position paper states that "dietitians have a vital role and responsibility to promote breast-feeding" (3, p 1580), a national survey of medical professionals' practices and attitudes toward breast-feeding included physicians, nurses, and hospital administrators but not dietitians (4). Several surveys of nurses' knowledge of breast-feeding have been completed (5 7), but the only survey of dietitians' knowledge of lactation that we found measured their percep tion of their lactation training, not their knowledge (8). Because current trends in breast-feeding are declining rather than proceeding toward the goals set for the year 2000, it is imperative that all health professionals who work with pregnant women be knowledgeable about lactation. Our study assessed the knowledge of and attitudes toward breast-feeding held by dietitians, nurses, and physicians who serve the WIC population in Alabama. O. W Kendrick (correspondingauthor) and K R. Stitt are with the Departmentof Human Nutritionand Hospitality Management, College of Human EnvironmentalSciences, University ofAlabama, Tuscaloosa,AL 35487-0158. J E. Bagwell was a graduatestudent at the University of Alabama when this work was done; currently, she is a clinicaldietitian at the University ofAlabama at Birmingham Hospitals, Birmingham, AL 35294. J D. Leeper is with the Department ofBehavioraland Community Medicine at the University ofAlabama, Tuscaloosa,AL 35487-0326. JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION / 801
PERSPECTIVES INPRACTICE METHODS We developed a questionnaire to measure knowledge and attitudes of health professionals with items from a questionnaire used by Lawrence (4). Questions incorporated reasons women enrolled in the Alabama WIC program gave for cessation of breast-feeding (9). Questionnaires were modified slightly for each discipline (dietetics, nursing, medicine) to address the population more adequately. Respondents were asked to indi cate their level of agreement with each attitude and knowledge statement on a Likert-type scale of 1 to 5 (5 indicated strong agreement and 1 indicated strong disagreement). When an item was stated in a negative fashion, such as "breast-feeding is incompatible with working outside the home," scores were converted so that the maximum score of 5 indicated strong disagreement with the statement and 1 indicated strong agreement with the statement. Thus, a score of 5 indicated a positive attitude toward breast-feeding, whereas a score of 1 indicated a negative attitude.
In general, dietitans, physicians, and nurses had positive attitudes toward breast-feeding; however, they need to address maternal concerns, such as weight loss, use of oral contraceptives during lactation, mastitis, and engorgement
Questionnaires were sent to dietitians and nurses who were employed by the Alabama Department of Public Health and worked in WIC and to physicians who either worked in the public health department or who were private physicians with a large patient load of WIC participants. The names of the private physicians were obtained from local health departments, and their addresses were retrieved from the membership roster of the Alabama Medical Association. All other names and addresses were provided by the Department of Public Health. Resident physicians offering medical care to participants as part of their training were excluded from the survey When more than 50 physicians were listed as caregivers for a public health area of the state, a random sample of the physicians from that area received the questionnaire. Otherwise, all health personnel identified were surveyed. We mailed 574 surveys in the summer of 1989: 55 to dietitians, 284 to nurses, and 235 to physicians. Completed questionnaires were tabulated and analyzed statistically using SPSS-X Statistical Package for the Social Sciences (release 3.0,1988, SPSS, Chicago, Ill). Individual items measuring attitude and knowledge were combined and placed on a 100-point scale to determine aggregate attitude and knowledge scores. The Pearson Product Moment correlation 802 / JULY 1993 VOLUME 93 NUMBER 7
coefficient was used to measure the relationship between knowledge of and attitude toward breast-feeding of persons in each professional category. One-way analysis of variance fol lowed by a least significant difference test was used to determine differences in knowledge and attitudes of breast feeding among dietitians, nurses, and physicians. RESULTS AND DISCUSSION Of the 574 surveys that were sent to health professionals, three were returned because of an incorrect address or because the addressee was on extended leave from employment. We as sumed that the remaining 571 surveys were received by the participants. Two hundred eighty-nine questionnaires were returned for a 50% response rate. Respondents included 41 dietitians, 158 nurses, and 90 physicians; response rates by professional category were 75%, 56%, and 39%, respec tively. All of the dietitians and nurses who responded to the question concerning gender were women. Two dietitians and eight nurses did not respond to this question. Of the 84 physicians who responded to this question, 67 were men and 17 were women. Dietitians and nurses were younger than physicians. Attitudes Toward Breast-Feeding Health professionals as a group strongly agreed that they would advocate breast-feeding for both married and single mothers. They were slightly less likely to recommend breast-feeding to working mothers, mothers in school, and adolescent mothers. They did not recommend breast-feeding for mentally retarded mothers. Responses to individual attitude and knowledge questions by professional category are presented in Table 1. In general, attitudes toward breast-feeding were positive. Some differences in individual items were seen among professions. Dietitians and nurses were more likely to recommend breast-feeding to a mother who had made the decision to bottle-feed than were physicians. Physicians were less likely to think that breast feeding was incompatible with working outside the home or attending school than were nurses. Nurses and physicians were more likely than were dietitians to agree with the statement that fathers feel close to their infants if they can bottle-feed them. Dietitians were more interested in breast feeding and lactation management than were nurses. The aggregate attitude scores ranged from 32.0 to 99.0 with a mean ( standard deviation) score of 73.8 - 13.9. When exam ined by professional category, dietitians and nurses had higher attitude scores than did physicians (P<.05) (Table 2). Knowledge of Breast-Feeding Responses to individual knowledge items differed by health profession (Table 1). Nurses were more likely than dietitians and physicians to think that mastitis and engorgement are reasons to discontinue breast-feeding. On the questions addressing the role of breast-feeding in weight management and the compatibility of birth control pills with breast-feeding, the lower scores with larger standard deviations indicated a lack of consensus as to the correct answers. A recent report from the Committee on Nutritional Status during Pregnancy and Lactation of the National Acad emy of Sciences (10) recommended that women be advised that it is normal to lose weight during the first 6 months of lactation and that the average rate of loss is approximately 1 to 2 lb per month after the first month postpartum. Dietitians were more likely than nurses or physicians to agree that breast-feeding is a good method of weight loss. Because lactation generally results
Table 1 Selected mean ( +standard deviation) scores on health professional survey items measuring knowledge of and attitude toward breast-feedinga Item No. Attitude When a mother inmy practice has yet to make a decision regarding how to feed her infant, I advocate breast-feeding for a mother who is a marred b single c mentally retarded d an adolescent e. working f in school When a mother in my practice has made the decision to bottle-feed, I still recommend breast-feeding for a mother who is a. married b single c. mentally retarded d an adolescent e. working f. in school Breast-feeding a builds a closer emotional bond between a mother and her child than does bottle-feeding. b. is usually the easiest way to calm a baby c is incompatible with working outside the home b d is incompatible with attending school b e is more difficult than bottle-feeding b Fathers feel close to their infants if they can bottle-feed them b More should be done to encourage breast-feeding in the WICc program. I am interested in breast-feeding and lactation management Knowledge Breast-feeding a provides benefits for infants that cannot be produced by formula b is a good method of weight reduction. c Helps protect infants against infection d is incompatible with the use of birth control pills after 6 weeks postpartum." Awoman who develops problems related to breast-feeding, such as mastitis or engorgement, should totally discontinue breast-feeding.'
Dietitian Score
No.
Nurse Score
No.
Physician Score
39 39 39 38 39 39
487-0.52 4.74 + 0.68 2.72 1.12 3.79+ 1.04 4.38 0 71 4.21 0.77
158 157 152 156 157 156
471 +065 4.52 t 0.82 2.64 t 1.34 3.60 +-1.29 4 09+ 1 05 388 1 15
89 89 85 88 89 89
464* 079 4 52 +087 2.92 1 36 3.88t: 1.18 4 12t 1 05 4 01 1 09
39 39 39 39 39 39
4.26 t 1.09X 4.26 1.09X 2.49 1.17" 3.41 1.31' 4.00±1.15'x 3.82 1. 14
158 157 153 158 157 157
4.08 +1 30 398 1 30 2.61 1.44 x 3.27 1 42X 3.66+ 1 30X 357+1.32
90 90 87 90 90 90
3 20 = 1 50' 3.06- 1.54Y 2.16 1 35' 266:- 1 49Y 2 77 1 49' 273 - 2 73'
41
4.71 0.60
155
4.34 1 05
86
4 34± 1 04
41
3.66 099X
155
3 14 1 20'
85
301
155
3.81 + 1 18'
86
4 16 :-1 06X
86
4 15- 1 02'
41
3 78 +1 13"
'
X
y
1.13 Y
41
376 +1.09 "
154
3.74 1.19
41
3.73 +-1.50
154
3 79 t 1.32
84
3 50
41
3.80 1.15X
155
306 1 23Y
86
3 08. 1 07Y
40
4 10 0.96
154
4 01
86
4 12
41
4.39 + 0.95X
154
3.83 1 06Y
84
4 01 + 1 00
41
4.93±+026
155
4.75+0 58
86
4 70 061
41
300 +1.09 X
153
2 82 t 1.24 X
85
2 49 + 11 9Y
1 11
Y
t
1 28
1.09 y
41
4.76+0.73'
152
4 56+0 89
84
4 31 0O97Y
40
3.10+1 43'
150
2.57 -1 41
85
319 +1.33'
41
4 12 - 1 33'
151
3.54 - 1 28Y
84
4 05 ± 1 17X
aMaximum score of 5 indicates strong agreement with statement; minimum score of 1 indicates strong disagreement. 'Scores were converted on these questions so that maximum score of 5 indicates strong disagreement with statement; minimum score of 1 indicates strong agreement. 'WIC = Special Supplemental Food Program for Women, Infants, and Children "'YScoresfollowed by different letters insame row are significantly different (P<.05).
JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION
803
Table 2 Knowledge and attitude scores of health professionalsa
Dietitian
Nurse Physician
Total
Attitude
Knowledge
Professional category
No.
Range
Mean + SDb
Range
Mean SD 78 6 + 10 4
X
37
59.0-93 0
143
32 0-98 0
74 5 13 7'
76
39 0-99,0
70 2 - 14 9'
256
32.0-99.0
73 8 + 13 9
40
52,0-100.0
79.6 t 107
143
32.0-100,0
81
48.0-100,0
73 Ot 12 0X
264
32.0-100.0
75 5 748t
No.
11 3 y
118
aMaximum possible score of 100 indicates strong agreement with knowledge/attitude survey items bSD = standard deviation.
XYScores followed by different letters inthe same column are significantly different (P<.05).
in a slow rate of weight loss, some health professionals may not have considered it a good method to lose weight. The Committee on Drugs of the American Academy of Pediatrics (11) has issued a statement indicating that the use of oral contraceptives during lactation is safe. Less than half of the health professionals surveyed agreed with this statement. Dietitians and physicians were more likely than nurses to agree that use of oral contraceptives is compatible with breast-feeding. Aggregate knowledge scores ranged from 32.0 to 100.0 (mean = 74.8 + 11.8). Although the scores of nurses in this study were higher than those reported by others (5,6), dietitians' scores were significantly (P<.05) higher (Table 2). Physicians' scores were not statistically different from those of dietitians or nurses.
Health professionals were slightly less likely to recommend breast-feeding for working mothers, mothers in school, and adolescent mothers; they did not recommend breast-feeding for mentally retarded mothers Aggregate knowledge and attitude scores were weakly related (r=.24; P<.001). When examined by profession, the knowledge and attitude scores were similarly related for nurses (r=.27; P=.002), physicians (r=.21; P=.08), and dietitians (r=.22; P= .20). The lack of statistical significance of correlations for dietitians and physicians is attributable to the smaller number of respondents in these groups. APPLICATIONS Health professionals appeared to be more knowledgeable about benefits to the infant from breast-feeding than they were about maternal concerns. Professional education programs should
804 / JULY 1993 VOLUME 93 NUMBER 7
include information on weight loss and birth control during lactation and complications such as mastitis and engorgement as well as information on benefits to the infants. A survey of dietitians in Idaho (8) indicated that they were knowledgeable about the benefits of breast-feeding but needed additional training in breast-feeding techniques and pumping, hormonal regulation of lactation, and breast-feeding a high-risk infant. Dietitians exhibited both interest in and knowledge about breast-feeding. They should be involved in promoting breast feeding and in the education and support of women interested in breast-feeding. Educators and employers should encourage interested dietitians to take the international examination to become a certified lactation consultant. U Information about becoming a certified lactation consultant can be obtainedfromthe InternationalBoard of Lactation ConsultantExaminers, 2315 Wickersharn Core, Germantown, TN38138. References 1. Office of Disease Prevention and Health Promotion. Healthy People 2000. Washington, DC: US Governmnent Printing Office; 1990. I)HHS publication (PHS) 91-50212. 2. Ryan AS, Rush D,Krieger FW, Lewandowski GE. Recent declines in breast-feeding in the United States, 1984-1989
Pediatrics 1991;
88:719-727, 3. Position of The American Dietetic Association: promotion and support of breast-feeding. JAm Diet Assoc. 1993; 93:467-469. 4. Lawrence RA. Practices and attitudes toward breast feeding among medical professionals. Pediatrics.1982; 70:912-920. 5. Anderson E, Geden E. Nurses' knowledge of breast-feeding. .JObstet Gynecol Neonatal Nurs. 1991; 20:58-64. 6. Crowder DS. Maternity nurses' knowledge of factors promoting successful breast-feeding: a survey of two hospitals. .J Obstet Gyoecal NeonatalNurs. 1981; 10:28-30. 7. Hayes B.Inconsistencies among nurses in breast-feeding knowledge and counseling. J Obstet Gynecol Neonatal Nurxs. 1981; 10:430-433. 8. Marincic PZ. Breast-feeding education and promotion: implications for curriculum development. Dep-lie. 1992; 10:8-9. 9. Bagwell JE, Kendrick OW, Stitt KR, Leeper JD. Epsy ML, Gedel ML. Breast-feeding among women in the Alabama WIC Programi. /.1 Ira Lactation. 1992; 12:205 208. 10. Subcommittee of Lactation, Food and Nutrition Board. Nautriir,,,
during Lactation:Sumrnary, Concltusions, and Recoate dat(ions. Washington, DC: National Academy of Sciences; 1991. 11. American Academy of Pediatrics Committee on D)rugs. Breast feeding and contraception. Pediatrics. 1981: 68:138- 4).
SELF ASSESSMENT
Self-assessment questionnaire for DTRs After reading the continuing education article, "Knowledge and attitudes toward breast-feeding: Differences among dietitians, physicians, and nurses working with WIC clients," please answer the following questions by indicating your responses on the selfassessment questionnaire form located on the next page. This activity has been approved for 1 hour of continuing education credit for dietetic technicians, registered, by the Commission on Dietetic Registration. Answers to the self-assessment questionnaire can be found on page 848. ADA members should cut out the completed form and return it, with a check for $12 each (nonmembers $16) to cover processing, to: The American Dietetic Association, PO Box 97215, Chicago, IL 60678-7215. Questionnaires must be returned within 1 year of their appearance in the Journalin order to be eligible for credit. Notification will not be sent if the hour is approved. For items 1-13, select the one best answer or completion to each question or incomplete statement. 1. According to Healthy People 2000, what is the goal for the incidence of breast-feeding at hospital discharge? A. 65% B. 70% C. 75% D. 80% 2. According to Healthy People 2000, what is the goal for the percentage of infants being breast-fed at 6 months of age? A. 45% B. 50% C. 55% D. 65% 3. Which group of health care professionals had the highest response rate? A. Nurses B. Resident physicians C. Dietitians D. Physicians 4. How did the physicians and nurses, vs the dietitians, respond to the statement that fathers feel close to their infants if they can bottle feed them? A. More likely to agree B. More likely to strongly agree C. More likely to disagree D. More likely to strongly disagree
5. What type of scores indicated a lack of consensus of correct answers? A. Higher scores with large standard deviations B. Lower scores with large standard deviations C. Higher scores with small standard deviations D. Lower scores with small standard deviations 6. According to the recent National Academy of Sciences report, what type of weight loss is normal after the first month postpartum of breast-feeding? A. 1 to 2 lb per week B. 1 to 2 lb every 2 weeks C. 1 to 2 lb per month D. 1 to 2 lb per 6 weeks 7. How did physicians' scores for breast-feeding knowledge compare with scores of nurses and dietitians? A. They were significantly higher statistically B. They were significantly lower statistically C. They were the same D. There was no statistical difference 8. How did group aggregate knowledge and attitude scores correlate? A. They were strongly correlated B. They were moderately correlated C. They were weakly correlated D. They had no correlation 9. How did nurses' knowledge scores about breast-feeding compare with scores of dietitians? A. There was no difference B. They were significantly lower C. They were significantly higher D. This analysis was not performed 10. How did dietitians compare with physicians on the issue of use of oral contraceptive agents (OCAs) during lactation? A. They were more likely to agree that OCAs were safe B. They were as likely to agree that OCAs were safe C. They were as likely to disagree that OCAs were safe D. They had no opinion 11. How did breast-feeding rates at hospital discharge and at 6 months compare in 1989 vs 1984 in the United States? A. They were higher in 1989 B. They were lower in 1989 C. There was no difference D. This issue was not discussed JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION / 805
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SELF AT............................................................ ASSSEN
12. How did physicians compare with nurses on their attitudes toward the compatibility of breast-feeding with work or education outside the home? A. They were more likely to think it was incompatible B. They were less likely to think it was incompatible C. There was no difference in their attitudes D. This issue was not reported 13. Which health profession showed a higher interest in breastfeeding and lactation management? A. Physicians B. Physician assistants C. Dietitians D. Nurses For items 14-17, select all completions that are true. Each item may have two, three or four correct answers. 14. Which groups of health professional were more likely to recommend breast-feeding to a mother who had made a decision to bottle feed? A. Nurses B. Physicians
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C. Dietetic technicians D. Dietitians 15. Which groups were more likely to disagree that mastitis and engorgement were reasons to discontinue breast-feeding? A. Physicians B. Nurses C. Physician assistants D. Dietitians 16. On the basis of the results of this study, professional education programs on lactation should cover: A. Birth control B. Complications such as mastitis and engorgement C. Weight loss D. Benefits to the infant 17. The Idaho Survey of Dietitians found that dietitians needed additional education in: A. Breast-feeding techniques B. Hormonal regulation of lactation C. Benefits of breast-feeding D. Techniques for breast-feeding high-risk infants
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CONTINUING EDUCATION REPORTING FORM Continuing Education Article "Knowledge and attitudes toward breast-feeding: Differences among dietitians, physicians, and nurses working with WIC clients," Journal, July 1993 SELF-ASSESSMENT QUESTIONNAIRE ANSWER FORM Article ExpirationDate: July 1994 After reading each statecement, please select the best answer(s) or completion(s):
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This activity has been approved for 1 hour of continuing education credit for registered dietitians. ADA Member -- P1 ($12) Non-ADA Member - P2 ($16)
Item No. Q0793 Mail this form, with check or money order in the amount of $12 each ($16 for non-ADA members) to cover processing, to: The American Dietetic Association PO Box 97215 Chicago, IL 60678-7215
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806 / JULY 1993 VOLUME 93 NUMBER 7
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