535507
research-article2014
JHLXXX10.1177/0890334414535507Journal of Human LactationPound et al
Original Research
Breastfeeding Knowledge, Confidence, Beliefs, and Attitudes of Canadian Physicians
Journal of Human Lactation 1–12 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0890334414535507 jhl.sagepub.com
Catherine M. Pound, MD1, Kathryn Williams, BSc, MS2, Renee Grenon, MA, PhD(c)2, Mary Aglipay, MSc2, and Amy C. Plint, MD, MSc1,2
Abstract Background: Physicians’ attitudes and recommendations directly affect breastfeeding duration. Yet, studies in many nations have shown that physicians lack the skills to offer proper guidance to breastfeeding mothers. Objective: This study aims to assess breastfeeding knowledge, confidence, beliefs, and attitudes of Canadian physicians. Methods: A breastfeeding questionnaire was developed and piloted prior to study enrollment. These questionnaires were sent to 1429 pediatricians (PED), 1329 family physicians (FP), and final-year pediatric and final-year family medicine residents (PR and FMR). Results: The analysis included 397 PED, 322 FP, 17 PR, and 44 FMR who completed the questionnaire. Mean overall correct knowledge score was 67.8% for PED, 64.3% for FP, 72.7% for PR, and 66.8% for FMR. Two hundred eighty-five PED (74.2%), 228 FP (73.1%), 7 PR (41.2%), and 21 FMR (53.8%) felt confident with their breastfeeding counseling skills. Less than half (49.6% of PED and 45.4% of FP) believed that evaluating breastfeeding was a primary care physician’s responsibility, and few PED or FP (5.1% and 11.3%) routinely observed breastfeeding in mother-infant pairs. Conclusion: Several areas of potential deficits were identified in Canadian physicians’ breastfeeding knowledge. Physicians would benefit from greater education and support, to optimize care of infants and their mothers. Keywords attitudes, beliefs, breastfeeding, confidence, education, humans, infant, knowledge, medicine, newborn, physician’s role, practice
Well Established Physicians’ attitudes and recommendations are known to directly affect breastfeeding duration. Studies in many nations have shown that physicians often lack skills and/or knowledge to assist and support breastfeeding mothers.
Newly Expressed Several areas of potential deficits were identified in Canadian physicians’ breastfeeding knowledge, including appropriate breastfeeding techniques, latch, and recommendations pertaining to milk supply. Physicians would benefit from greater education and support, to optimize care of infants and their mothers.
in many countries have shown that physicians and residents lack skills to offer proper guidance to lactating mothers.4-10 In Canada, the learning of specific breastfeeding skills and the management of common breastfeeding problems do not appear among the programs’ regulatory bodies’ formal learning objectives,11,12 suggesting that breastfeeding counseling skills are not formally taught during residency training. We undertook a national assessment of Canadian physicians caring for infants and their mothers (pediatricians [PED], family physicians [FP], final-year pediatric residents 1
Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada Children’s Hospital of Eastern Ontario Clinical Research Unit, Ottawa, ON, Canada 2
Background
Date submitted: January 14, 2014; Date accepted: April 22, 2014.
The Canadian Pediatric Society (CPS), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP) promote the assessment and management of breastfeeding issues as physician responsibilities.1-3 Studies
Corresponding Author: Catherine M. Pound, MD, Department of Pediatrics, Division of Pediatric Medicine, Children’s Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada. Email: [email protected]
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[PR], and final-year family medicine residents [FMR]) to examine their breastfeeding knowledge, confidence, beliefs, and attitudes. To our knowledge, this is the most extensive study of the topic to be performed in Canada.
Methods Population and Survey Distribution We conducted a paper-based, mailed survey of 1429 PED and 1329 FP across Canada (all provinces and territories) between October 2010 and January 2011. Names and contact information of all licensed PED and FP were obtained from all provincial registries except for Quebec. The Collège des Médecins du Québec (CMQ) did not release their physician list but agreed to share names and contact information of 400 PED and 400 FP they randomly selected. A computerized program randomly selected participants in proportion to the number of physicians working in each province, except for Quebec, where all randomly selected 800 physicians were mailed a questionnaire. Also, due to the limited number of physicians working in the northern territories (Nunavut, Yukon, and Northwest Territories), all PED and FP in these areas were surveyed. A modified Dillman method13 was used; nonresponders received up to 3 surveys sent at regular intervals via regular mail. Only physicians who provided primary care for infants were eligible, and as such, pediatric subspecialists were excluded. Physicians whose type of practice clearly excluded infants and primary care (geriatrics, anesthesia, palliative care, etc) were excluded. Surveys were available in both French and English. We also conducted an electronic survey of final-year PR and final-year FMR from all programs over the same time frame. As most trainees’ names and contact information cannot be publicly accessed, we asked program directors to distribute a letter to their eligible residents. Interested residents communicated directly with our research assistant. Because no national public list of residents exists, we estimated the number of residents enrolled in their final year of residency during the study period, based on data from the Canadian Residency Matching System. Ninety to 100 PR and 800 to 875 FMR were likely eligible. The study was approved by the Children’s Hospital of Eastern Ontario Research Ethics Board, and all procedures followed were in accord with the ethical standards of the board.
Survey Instrument Since a review of the breastfeeding literature failed to yield an existing questionnaire of large enough breadth to satisfactorily examine our 4 domains (knowledge, confidence, beliefs, and attitudes), the study principal investigator, in conjunction with the study team, developed the survey instrument. Two practicing International Board Certified
Lactation Consultants further reviewed the questionnaire. As no standardized questionnaire was found in the literature, questions were developed based on expected knowledge of the primary care physician detailed in the AAP Position Statement on “Breastfeeding and the Use of Human Milk,”1 adapted from the Registered Nurses’ Association of Ontario Self-Learning Module on Breastfeeding14 and from prior studies.6,10 Questions from more recent studies15 could not be included as publication date was too late for incorporation into our study. Permissions were obtained from all appropriate sources.6,10,14 Twenty-three physicians and residents piloted the survey, which was revised based on their feedback. The final survey consisted of 50 multiple-choice questions covering demographics and 4 main domains: knowledge, confidence, beliefs, and attitudes (17, 4, 5, and 8 questions, respectively). All questions were given equal weight for scoring purposes. The knowledge part of the questionnaire included 4 multiple-choice questions, 8 “true/ false/I don’t know” questions, and 5 “yes/no/I don’t know” questions. The confidence part of the questionnaire used 1 “yes/no” question and 3 multiple-choice answers, the belief part used 3 “yes/no” questions and 2 multiple-choice answers, and the attitude part used 3 “yes/no” questions and 5 multiple-choice answers (not comfortable, somewhat uncomfortable, somewhat comfortable, very comfortable; never or almost never, on some visits, on most visits, almost or almost always). The confidence section of the questionnaire investigated self-rated confidence in one’s breastfeeding counseling skills. Overall confidence was defined as “confidence in teaching mothers how to breastfeed and address breastfeeding-related problems.” In the belief section, physicians’ thoughts in relation to their role in breastfeeding support and promotion were explored, whereas physicians’ usual clinical practice and outlook on various breastfeeding scenarios were explored in the attitude section. We a priori defined an overall knowledge score of 70% as acceptable, as this is the minimum score that pediatricians must achieve in their specialty examination to receive Royal College of Physicians and Surgeons of Canada certification (M. Jabbour, MD, vice-chief/chair, Department of Pediatrics, associate professor, Pediatrics and Emergency Medicine, University of Ottawa, personal communication, May 14, 2013). There is no minimum score for family physicians on certification examination; within each examination administration, a criterion candidate group is selected whose performance is the standard against which all candidates are compared.16 Since both groups of physicians care for the same infant population, we felt that the minimum acceptable score should be the same.
Sample Size We based our sample size calculation on the results of our pilot study, in which the mean percentage of correct answers
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Pound et al in the knowledge section was 65%, with a standard deviation of 12%. A sample size of 385 allowed for an estimate of the mean percentage score in the knowledge section with a 95% confidence interval (CI) of width ± 1.2%. Assuming a 30% response rate, we had planned to approach 1284 PED and 1284 FP. However, since the CMQ would release contact information for only a predetermined number of physicians, we overestimated the number needed from that province and asked to have 800 names released, as some physicians would not meet eligibility criteria. Also, given the very small number of physicians practicing in the Northern Territories, we elected to approach them all. In the end, 1429 PED and 1329 FP were approached.
Statistical Analysis Breastfeeding knowledge was calculated as a score out of 100 based on the percentage of correct responses from the breastfeeding knowledge domain. Descriptive statistics were used to summarize the survey respondents’ demographic characteristics, breastfeeding confidence and beliefs, and breastfeeding attitudes. Cronbach’s alpha values were calculated for each domain of the questionnaire. Univariate associations between knowledge and demographics were assessed using t tests and 1-way analyses of variance (ANOVAs). Multiple linear regression was used to identify demographic factors that were independently associated with the overall knowledge score. All demographic variables surveyed were included in the multivariate model. Missing data were handled via listwise deletion. The identification of demographic factors associated with knowledge was the primary goal of the modeling, so only main effects (no interactions) were assessed. A P value < .05 was considered statistically significant. The analyses were performed using SPSS (version 19.0; IBM Corp, Armonk, New York, USA) and SAS 9.3 (SAS Institute Inc, Cary, North Carolina, USA).
Results Respondents We identified 3395 PED and 38 223 FP from the provincial and territorial physician lists. Response rate was 38.3% for PED and 24.2% for FM. Overall, 719 physicians representing all provinces and territories were retained for the analysis (397 PED and 322 FM) (Figures 1-3; Table 1). Sixty-four residents contacted the research assistant, and 61 returned surveys (17 PR and 44 FMR). The majority of participants were female and between the ages of 30 and 50.
Questionnaire Cronbach’s alpha values were calculated for each domain of the questionnaire. Yes/no questions were removed for Cronbach’s alpha calculation from domains with questions
of differing scales so as to keep scales homogeneous. In total, 1 question was removed from the confidence domain, none for knowledge, 3 for attitudes, and 2 for beliefs. Excellent reliability was found for confidence (n = 761, Cronbach’s alpha = 0.81), whereas acceptable reliability was demonstrated for knowledge (n = 625, Cronbach’s alpha = 0.62) and attitudes (n = 506, Cronbach’s alpha = 0.60). The belief domain has a relatively low reliability value (n = 755, Cronbach’s alpha = 0.21).
Knowledge The average overall knowledge score of practicing physicians was lower than our predefined acceptable score of 70%. The overall correct knowledge score for PED was 67.8%, whereas that for FP was 64.3%. Pediatric residents scored 72.7%, whereas FMR scored 66.8%. Table 2 summarizes physicians’ and residents’ results on the questionnaires’ knowledge section. Univariate testing demonstrated that knowledge score was associated with several demographic factors (Table 1).
Confidence, Beliefs, and Attitudes Two hundred eighty-five PED (74.2%) and 228 FP (73.1%) reported feeling overall confident in teaching mothers to breastfeed and addressing breastfeeding-related problems. Few PED and FP (5.1% and 11.3%, respectively) routinely observed breastfeeding at least once in every breastfeeding mother-infant pair, and a large number of PED and FP (56.6% and 29.9%, respectively) reported keeping formula samples in their office. Table 3 summarizes self-reported confidence, beliefs, and attitudes of physicians and residents regarding various aspects of breastfeeding.
Comparison between FP and PED The overall knowledge score for PED was higher than that for FP (P = .007). However, more PED than FP believed that formula was equivalent to breast milk (P < .001). More FP reported directly observing breastfeeding at least once in every breastfeeding mother (P = .004), and more PED kept formula samples in the office (P < .001). Other confidence, beliefs, and attitudes of PED and FP were not significantly different. Multiple linear regression identified several demographic factors that were significantly associated with knowledge for practicing physicians (Table 4). On average, female physicians scored 5.0 points higher (on a 100-point scale) compared to male physicians (95% CI, 2.4-7.5; P < .001). Compared to older physicians, physicians between the ages of 30 and 50 scored higher by 3.6 points (95% CI, 0.2-7.1; P = .04). Compared to Ontario, the Maritime Provinces and British Columbia had higher knowledge scores, scoring on average 5.2 (95% CI, 0.6-9.8; P = .03) and 4.3 (95% CI, 0.3-8.3;
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Figure 1. Pediatrician Mail-out.
3395 Canadian pediatricians idenfied 741 pediatricians removed (no available address, out of country / out of province, iden fied as subspecialists)
2654 pediatricians remained
1463 pediatricians randomly selected 31 pediatricians removed (28 missing addresses not previously identified, 2 duplicate addresses, 1 out of province address not previously identified)
1429 quesonnaires sent 8 envelopes returned unopened (moved / wrong address)
1421 quesonnaires delivered
588 quesonnaires returned
40 blank/incomplete (3 saw no infants, 5 no longer in prac ce / re red, 2 subspecialists, 27 gave no reason, 3 incomplete)
548 completed quesonnaires 151 quesonnaires excluded (pediatric subspecialists)
397 quesonnaires in final analysis
P = .04) points higher, respectively. Physicians whose practice had 50% or more patients younger than 1 year scored on average 7.9 points higher on the knowledge tool (95% CI, 3.6-12.1; P < .001). Compared to physicians with no children, physicians who had breastfed children scored 10 points higher (95% CI, 6.4-13.6; P < .001). Compared to physicians with no children, having non-breast-fed children was not associated with a higher knowledge score (average increase in score = 4.5; 95% CI, –2.7 to 11.7; P = .22). Breastfeeding certification was associated with an 11.5-point increase (95% CI, 1.7-21.2; P = .02). The demographic variables in our model accounted for 14.1% of the variation in knowledge score.
Discussion We found that Canadian physicians’ breastfeeding knowledge was suboptimal. Although physicians’ overall comfort
level was relatively high, self-reported confidence was much lower when participants were asked about specific breastfeeding counseling skills, suggesting that physicians may have difficulty self-assessing as they may not be aware of what breastfeeding counseling entails. Physicians’ attitudes toward a breastfeeding infant were found to be quite positive, however, a much smaller number felt comfortable watching a toddler breastfeed, despite the World Health Organization supporting breastfeeding well into toddlerhood.17 Finally, female sex, age between 30 and 50 years, percentage of practice younger than 1 year, and personal breastfeeding experience were all positively associated with knowledge. This survey identified multiple knowledge deficits. These included recommending inappropriate breastfeeding techniques (such as timed feedings), incorrectly believing that increasing maternal milk intake increases breast milk supply,
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Pound et al Figure 2. Family Physician Mail-out.
38 223 Canadian family physicians identi ied
33 847 family physicians remained
1362 family physicians randomly selected
1329 questionnaires sent
4376 family physicians removed (no available address, out of country / out of province, ield of work that excludes pediatric population; e.g. geriatrician)
33 family physicians removed (10 missing addresses not previously identi ied, 2 out of province address not previously identi ied, 21 with specialties clearly excluding pediatric patients) 15 envelopes returned unopened (moved / wrong address)
1314 questionnaires delivered
356 questionnaires returned
34 questionnaires excluded (1 illed by nurse, 5 saw no infants, 3 no longer in practice / retired, 25 incomplete)
322 completed questionnaires
Figure 3. Resident Electronic Mail-out. 17 pediatric postgraduate training programs identiied
17 family medicine postgraduate training programs identiied
17 program directors approached for letter distribution to their inal year residents
17 program directors approached for letter distribution to their inal year residents
17 pediatric residents contacted the study coordinator and completed the survey
44 family medicine residents contacted the study coordinator and completed the survey
failing to identify characteristics of a successful latch, not recognizing breastfeeding contraindications, and being
unaware that early formula introduction is a major risk factor for breastfeeding failure.18,19 It is interesting that about 75%
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Table 1. Demographics of Responding Physicians and Residents.
Pediatricians, n (%) Total No. Age, ya < 30 30-50 > 50 Sexa Male Female Lived in Canada Always > 20 years but not always 11-20 years 5-10 years < 5 years Province/territory of worka Atlantic provinces Quebec Ontario Prairie provinces British Columbia Nunavut, Yukon, Northwest Territories Residency training in Canada Yes Work location Rural Urban Type of work Clinic Community hospital Teaching hospital Other Percentage of children < 1 year of age in practicea 0-10 11-25 26-50 51-75 > 75 Years in practicea 0-5 6-10 11-15 > 15 Breastfeeding learning Own experiencea Medical school Residency Self-directed learninga Othera No breastfeeding knowledgea
397
Family Physicians, n (%)
Pediatric Residents, n (%)
Family Medicine Residents, n (%)
322
17
44
2 (0.5) 203 (51.1) 191 (48.2)
16 (5.0) 150 (46.6) 156 (48.4)
5 (29.4) 12 (70.6) 0 (0)
25 (56.8) 19 (43.2) 0 (0)
169 (42.6) 228 (57.4)
145 (45.3) 175 (54.7)
5 (29.4) 12 (70.6)
8 (18.2) 36 (81.8)
225 (56.8) 116 (29.3) 20 (5.1) 22 (5.6) 13 (3.3)
202 (63.3) 65 (20.4) 26 (8.2) 19 (6.0) 7 (2.2)
14 (82.4) 2 (11.8) 1 (5.9) 0 (0) 0 (0)
32 (72.7) 5 (11.4) 1 (2.3) 5 (11.4) 1 (2.3)
36 (9.2) 97 (24.7) 160 (40.8) 62 (15.8) 34 (8.7) 3 (0.8)
21 (6.6) 63 (19.7) 126 (39.4) 44 (13.8) 46 (14.4) 20 (6.3)
2 (11.8) 2 (11.8) 11 (64.7) 2 (11.8) 0 (0) NA
8 (18.2) 8 (18.2) 24 (54.5) 4 (9.1) 0 (0) NA
343 (88.2)
258 (81.4)
61 (16.2) 316 (83.8)
120 (38.2) 194 (61.8)
197 (50.6) 61 (15.7) 113 (29.0) 18 (4.6)
246 (77.4) 30 (9.4) 11 (3.5) 31 (9.7)
43 (11.1) 171 (44.3) 106 (27.5) 46 (11.9) 20 (5.2)
236 (76.1) 59 (19.0) 15 (4.8) 0 (0) 0 (0)
77 (19.9) 40 (10.4) 51 (13.2) 218 (56.5)
52 (16.5) 36 (11.4) 32 (10.1) 196 (62.0)
255 (64.2) 117 (29.5) 196 (49.4) 195 (49.1) 74 (18.6) 1 (0.3)
204 (63.4) 143 (44.4) 110 (34.2) 150 (46.6) 77 (23.9) 3 (0.9)
7 (41.2) 7 (41.2) 15 (88.2) 6 (35.3) 1 (5.9) 0 (0)
20 (45.5) 25 (56.8) 30 (68.2) 20 (45.5) 8 (18.2) 0 (0) (continued)
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Pound et al Table 1. (continued) Family Physicians, n (%)
Pediatric Residents, n (%)
335 (87.7)
265 (83.6)
8 (50.0)
17 (38.6)
312 (94.0)
237 (96.0)
8 (100.0)
17 (100.0)
114 (50.2) 93 (41.0) 20 (8.8)
143 (53.6) 114 (42.7) 10 (3.7)
4 (57.1) 3 (42.9) 0 (0)
9 (52.9) 8 (47.1) 0 (0)
6 (1.5)
4 (1.3)
1 (5.9)
1 (2.3)
Pediatricians, n (%)
Family Medicine Residents, n (%)
a
Having 1 or more children Yes Self/partner with breastfeeding experiencea Yes No. months own child was breastfeda ≥ 12 < 12 No breastfeeding Certification in breastfeeding support Yes
Abbreviation: NA, not applicable. a P < .01 for association with knowledge score among pediatricians and family physicians.
Table 2. Breastfeeding Knowledge Score. Respondents with Correct Answer, n (%) Scenario
Correct Answer
Overall score For exclusively breastfed baby, No otherwise healthy, birth weight not regained by 2 weeks, is first recommendation formula supplementation? Do you routinely recommend No supplementing with formula if mother feels milk supply inadequate? Do you routinely give glucose No water or formula before mother’s milk comes in? Is formula feeding in first Yes few weeks risk factor for breastfeeding failure? Do you routinely recommend that No babies breastfeed each side for 15-20 minutes every 3 hours? First thing to do when mother Assess position and latch complains of sore nipples is: All listed answers are signs that No part of the areola can baby is latched on properly be seen except: Mother complains that 6-week-old Baby requires more milk infant has been breastfeeding because growing and hourly for a day or 2. You tell frequent breastfeeding her: increases milk supply
Family Physicians
Pediatric Residents
Family Medicine Residents
67.8% 276/380 (72.6)
64.3% 224/311 (72.0)
72.7% 11/17 (64.7)
66.8% 27/44 (61.4)
299/384 (77.9)
232/307 (75.6)
12/17 (70.6)
37/44 (84.1)
347/387 (89.7)
253/307 (82.4)
15/17 (88.2)
34/44 (77.3)
184/382 (48.2)
203/315 (64.4)
10/17 (58.8)
26/44 (59.1)
159/385 (41.3)
141/308 (45.8)
2/17 (11.8)
14/44 (31.8)
328/376 (87.2)
257/302 (85.1)
17/17 (100.0)
42/44 (95.5)
117/367 (31.9)
102/300 (34.0)
8/17 (47.1)
16/43 (37.2)
256/374 (68.4)
173/305 (56.7)
12/17 (70.6)
27/44 (61.4)
Pediatricians
(continued)
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Table 2. (continued) Respondents with Correct Answer, n (%) Scenario
Correct Answer
Otherwise healthy 5-day-old More frequent breastfeeding breastfeeding infant admitted sessions and teach mother to hospital with jaundice. After how to use breast pump initiating phototherapy, what do you recommend? Moderate exercise decreases False quality and quantity of breast milk Increasing mother’s milk intake False increases breast milk production Breastfeeding decreases incidence True of many infectious diseases Breastfeeding decreases risk of True SIDS Breastfeeding is contraindicated in False mothers with hepatitis C Breastfeeding is contraindicated in True mothers with HIV in Canada Breastfeeding decreases the risk True of ovarian and breast cancers in mothers Breastfeeding is safe to continue in True mothers with herpes simplex on 1 breast if baby breastfeeds only from other breast
Family Physicians
Pediatric Residents
Family Medicine Residents
338/380 (91.4)
244/307 (79.5)
17/17 (100.0)
39/44 (88.6)
322/390 (82.6)
263/318 (82.7)
14/17 (82.4)
33/44 (75.0)
107/390 (27.4)
93/314 (29.6)
6/17 (35.3)
19/44 (43.2)
372/391 (95.1)
310/319 (97.2)
17/17 (100.0)
40/44 (90.9)
285/386 (73.8)
230/317 (72.6)
16/17 (94.1)
32/44 (72.7)
236/387 (61.0)
145/317 (45.7)
9/17 (52.9)
19/44 (43.2)
311/388 (80.2)
144/317 (45.4)
17/17 (100.0)
36/44 (81.8)
272/390 (69.7)
246/319 (77.1)
14/17 (82.4)
35/44 (79.5)
215/388 (55.4)
156/317 (49.2)
13/17 (76.5)
23/44 (52.3)
Pediatricians
Abbreviations: HIV, human immunodeficiency virus; SIDS, sudden infant death syndrome.
Table 3. Confidence, Beliefs, and Attitudes. Question Confidence Overall confidence in breastfeeding counseling skills Very comfortable assessing baby’s latch Very comfortable assessing milk transfer Very comfortable teaching mothers breast pump use Beliefs Believe evaluation of breastfeeding is responsibility of child’s primary physician in first 3 to 5 days after birth Believe formula is nutritionally equivalent to breast milk Believe physician has influence on mother’s decision to breastfeed
Pediatricians, n (%)
Family Physicians, n (%)
Pediatric Residents, n (%)
Family Medicine Residents, n (%)
285/384 (74.2)
228/312 (73.1)
7/17 (41.2)
21/44 (53.8)
128/389 (32.9) 136/391 (34.8) 87/391 (22.3)
103/313 (32.9) 103/314 (32.8) 82/317 (26.9)
3/17 (17.6) 4/17 (23.5) 6/17 (35.3)
6/44 (13.6) 9/44 (20.5) 9/44 (20.5)
191/385 (49.6)
142/312 (45.5)
13/17 (76.5)
29/44 (65.9)
132/380 (34.7)
70/314 (22.3)
5/17 (29.4)
10/44 (22.7)
355/389 (91.3)
291/318 (91.5)
17/17 (100.0)
43/44 (97.7) (continued)
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Pound et al Table 3. (continued) Question Believe it is always or almost always realistic for working mothers to continue breastfeeding Believe their residency training had prepared them poorly or somewhat poorly to support breastfeeding mothers Attitudes Very comfortable witnessing mothers breastfeeding infant in the office Very comfortable witnessing mothers breastfeeding toddler in the office Always or almost always discuss breastfeeding prior to birth of child Always or almost always ask about breastfeeding in infant’s first year of life Directly observe breastfeeding at least once in every breastfeeding mother-infant pair Keep formula samples in the office (or preceptor’s) Have formula advertisement in the office (or preceptor’s) Keep breastfeeding pamphlets and brochures in the office (or preceptor’s) and give to breastfeeding mothers
Pediatricians, n (%)
Family Physicians, n (%)
Pediatric Residents, n (%)
Family Medicine Residents, n (%)
67/384 (17.4)
72/317 (22.7)
2/17 (11.8)
7/44 (15.9)
288/388 (74.2)
222/314 (70.7)
10/17 (58.8)
30/44 (68.2)
352/390 (90.3)
289/319 (90.6)
16/17 (94.1)
31/44 (70.5)
214/390 (54.9)
188/318 (59.1)
8/17 (47.1)
19/44 (43.2)
65/386 (16.8)
150/309 (48.5)
4/17 (23.5)
26/44 (59.1)
273/387 (70.5)
202/311 (65.0)
7/17 (41.2)
26/44 (59.1)
20/388 (5.1)
35/311 (11.3)
1/17 (5.9)
2/44 (4.5)
213/386 (56.6)
93/312 (29.9)
5/17 (29.4)
10/44 (22.7)
77/378 (20.4)
50/313 (16.0)
8/17 (47.1)
14/44 (31.8)
196/374 (52.4)
168/311 (54.0)
5/17 (29.4)
13/44 (29.4)
Table 4. Adjusted Model of the Overall Knowledge Score.a Factor Occupational group General pediatrician Family physician Sex Female Male Age ≤ 30 years 30-50 years > 50 years Lived in Canada Always Not always Province Newfoundland, Prince Edward Island, Nova Scotia, New Brunswick Quebec Manitoba, Saskatchewan, Alberta British Columbia
n
Regression Coefficientb (95% CI)
P Value
300 370
2.27 (–0.50-5.03) Reference
.11
386 284
4.95 (2.35-7.54) Reference
< .001
17 333 320
6.27 (–2.69-15.22) 3.64 (0.17-7.12) Reference
.17 .04
400 270
1.68 (–1.19-4.55) Reference
.25
54
5.18 (0.59-9.76)
.03
147 99 73
–0.66 (–4.04-2.72) –0.60 (–4.24-3.03) 4.30 (0.27-8.33)
.70 .75 .04 (continued)
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Table 4. (continued) Factor Nunavut, Yukon, Northwest Territories Ontario Percentage of practice younger than 1 year > 50% ≤ 50% Residency training in Canada Yes No Rural or urban practice Rural Urban Type of practice Community Teaching Other Clinic Years in practice 0-5 6-10 11-15 > 15 Personal breastfeeding experience No, has children Yes, has children Unknown Does not have children Breastfeeding certification Yes No
n
Regression Coefficientb (95% CI)
P Value
23 274
4.90 (–2.09-11.89) Reference
.17
605 65
7.87 (3.64-12.10) Reference
< .001
567 103
0.26 (–3.52-4.03) Reference
.89
173 497
0.78 (–2.24-3.80) Reference
.61
88 116 44 422
1.27 (–2.51-5.05) 0.78 (–2.83-4.39) –1.37 (–6.30-3.56) Reference
.51 .67 .59
119 74 79 398
1.22 (–3.16-5.60) 2.19 (–2.37-6.75) 1.62 (–2.82-6.06) Reference
.58 .35 .47
24 506 44 96
4.49 (–2.68-11.67) 9.99 (6.38-13.60) 1.73 (–4.06-7.52) Reference
.22 < .001 .56
10 660
11.48 (1.74-21.23) Reference
.02
Abbreviation: CI, confidence interval. a The overall knowledge score was expressed as a percentage (n = 670). b Each regression coefficient indicates the additional % knowledge added by the corresponding factor to the reference mean score of 48.3% (constant mean score of 48.3 not explained by the factors in the model) after adjusting for the other factors. Adjusted R2 = 0.14.
of physicians reported feeling overall comfortable addressing breastfeeding problems, whereas only 41% of PR and 54% of FMR reported the same. It is important to remember that, although attending physicians were randomly selected, the resident group self-selected. One would expect those self-selected residents to be more interested in breastfeeding than their peers and therefore more likely to be comfortable with the topic. The difference in scores between the 2 groups could suggest that breastfeeding skills are primarily learned with clinical and life experience, rather than in residency. Indeed, most physicians and residents felt that residency training had prepared them poorly or somewhat poorly to appropriately support breastfeeding mothers. A considerable number of participants believed that breast milk and formulas are nutritionally equivalent, despite unambiguous evidence that formula is inferior.1 From an attitude perspective,
an alarmingly low number of participants reported observing breastfeeding at least once in their young patients, as this should be done for every infant in the first few days of life.1 These results are concordant with those of previous studies, showing that breastfeeding mothers receive minimal help and support from physicians.20,21 A significant proportion of PED and FP reported keeping formula samples and formula advertisements in their office, a practice shown to negatively affect breastfeeding duration.22 In keeping with other studies conducted worldwide,6,9,10,23,24 female sex and personal breastfeeding experience were associated with higher overall breastfeeding knowledge scores. Age 30 to 50 years was also associated with higher overall knowledge score, possibly reflecting a group of physicians more likely to have recently had their own breastfeeding children.
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Pound et al The overall score of PED was slightly higher than that of FP but remained below our acceptable level of 70%. Pediatricians reported keeping formula samples in the office more often than FP did. This finding, not previously reported, may be because PED sometimes care for more complex or medically fragile infants, with more significant feeding difficulties, and in whom formula supplementation may at times be necessary. This may also be due to formula companies potentially targeting pediatricians more often. It is interesting that FP reported observing breastfeeding more often than PED did. The reason for this is unclear but may relate to the nature of the family physician’s relationship with the mother. Family physicians being typically involved in mothers’ care prenatally, they may have a stronger bond with her and feel more comfortable observing her breastfeed. Study limitations include a low overall response rate. High response rates are typically difficult to obtain from physicians.25 Nevertheless, our target size was reached for PED and almost reached for FP. Physicians interested in breastfeeding were probably more likely to complete the questionnaire, and therefore, our sampled population may not be representative of Canadian pediatricians and family physicians. However, physicians with a breastfeeding interest would be expected to have better knowledge, confidence, beliefs, and attitudes than those with no or little breastfeeding interest, therefore leading to superior results. Also, resident participation depended on a multistep process (distribution of letters by program directors, resident initiating communication with our research assistant), likely causing the low participation level and resulting in only the most motivated participating in the study. Finally, although the survey instrument was piloted and reviewed, the questionnaire had not previously been used, the scale used has not been validated, and psychometric testing was not performed. However, Cronbach’s alpha values were found to be acceptable or excellent for all domains of the questionnaires except beliefs.
Conclusion The results of our study show that breastfeeding knowledge, confidence, beliefs, and attitudes are suboptimal among Canadian primary care physicians. This study uncovered specific areas of concern in physicians’ knowledge, confidence, beliefs, and attitudes with regard to breastfeeding. Based on these results, targeted educational tools specifically addressing the areas identified through our survey can be developed and implemented at the residency level. By optimizing the knowledge, confidence, beliefs, and attitudes of frontline physicians, we hope to increase breastfeeding exclusivity and duration and improve the health of our children. Authors’ Note The full questionnaire can be obtained from the main author at [email protected].
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the Children’s Hospital of Eastern Ontario Research Institute.
References 1. American Academy of Pediatrics, Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827-e841. 2. Pound CM, Unger S. Canadian Pediatric Society, Hospital Pediatrics Section, Nutrition and Gastroenterology Committee. The Baby-Friendly Initiative: Promoting, supporting and protecting breastfeeding. Paediatr Child Health. 2012;17(6):317-321. 3. American Academy of Family Physicians, Advisory Committee on Breastfeeding. Breastfeeding, family physician supporting (position paper). http://www.aafp.org/about/policies/all/ breastfeeding-support.html. Accessed July 2013. 4. Leavitt G, Martinez S, Ortiz N, et al. Knowledge about breastfeeding among a group of primary care physicians and residents in Puerto Rico. J Community Health. 2009;34(1):1-5. 5. Finneran B, Murphy K. Breast is best for GPs—or is it? Breastfeeding attitudes and practice of general practitioners in the mid-west of Ireland. Ir Med J. 2004;97(9):268-270. 6. Nakar S, Peretz O, Hoffman R, et al. Attitudes and knowledge on breastfeeding among paediatricians, family physicians, and gynaecologists in Israel. Acta Paediatr. 2007;96(6): 848-851. 7. Al-Nassaj HH, Al-Ward NJA, Al-Awqati NA. Knowledge, attitudes and sources of information on breastfeeding among medical professionals in Baghdad. East Mediterr Health J. 2004;10(6):871-878. 8. Al-Zwaini EJ, Al-Haili SJ, Al-Alousi TM. Knowledge of Iraqi primary health care physicians about breastfeeding. East Mediterr Health J. 2008;14(2):381-388. 9. Brodribb W, Fallon A, Jackson C, et al. Breastfeeding and Australian GP registrars—their knowledge and attitudes. J Hum Lact. 2008;24(4):422-430. 10. Freed GL, Clark SJ, Sorenson J, et al. National assessment of physicians’ breast-feeding knowledge, attitudes, training, and experience. JAMA. 1995;273(6):472-476. 11. Royal College of Physicians and Surgeons of Canada. Objectives of training pediatrics. http://www.macpeds.com/documents/ Objectives_Training_Requirements_Pediatrics_000.pdf. Published 2008. Accessed July 2013. 12. The College of Family Physicians of Canada. Defining competence for the purposes of certification by the College of Family Physicians of Canada: the evaluation objectives in family medicine. Working Group on the Certification Process. http://www. cfpc.ca/EvaluationObjectives/. Published 2010. Accessed July 2013. 13. Dillman DA. Mail and Internet Surveys: The Tailored Design Method. 2nd ed. New York, NY: John Wiley & Sons, Inc; 2000.
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14. Registered Nurses’ Association of Ontario. Breastfeeding: Fundamental Concepts—A Self-Learning Package. Toronto, Canada: Registered Nurses’ Association of Ontario; 2006. 15. Feldman-Winter L, Barone L, Milcarek B, et al. Residency curriculum improves breastfeeding care. Pediatrics. 2010;126(2):289-297. 16. Handfield-Jones R, Rainsberry P. Certification examination of the College of Family Physicians of Canada. Can Fam Physician. 1996;42:957-969. 17. World Health Organization. The Optimal Duration of Exclusive Breastfeeding: Report of an Expert Consultation. Geneva, Switzerland: WHO Department of Nutrition for Health and Development, Department of Child and Adolescent Health and Development; 2001. 18. Dunn S, Davies B, McCleary L, et al. The relationship between vulnerability factors and breastfeeding outcome. J Obstet Gynecol Neonatal Nurs. 2006;35(1):87-97. 19. Ahluwalia IB, Morrow B, Hsia J. Why do women stop breastfeeding? Findings from the Pregnancy Assessment and Monitoring System. Pediatrics. 2005;116(6):1408-1412.
20. Pound CM, Gaboury I. The impact of jaundice in the newborn period on length of breastfeeding. Paediatr Child Health. 2009;14(7):445-449. 21. Wood L, Wade K, Forham H, et al. Breastfeeding in Toronto— Promoting Supportive Environments. Technical Report. Toronto, Canada: Toronto Public Health; March 2010. 22. Howard CR, Howard FM, Lawrence RA, et al. Office prenatal formula advertising and its effect on breast-feeding patterns. Obstet Gynecol. 2000;95(2):296-303. 23. Kim HS. Attitudes and knowledge regarding breastfeeding: a survey of obstetrics residents in metropolitan areas of South Korea. South Med J. 1996;89(7):684-688. 24. Brodribb W, Fallon A, Jackson C, Hegney D. The relationship between personal breastfeeding experience and the breastfeeding attitudes, knowledge, confidence and effectiveness of GP registrars. Matern Child Nutr. 2008;4(4): 264-274. 25. Asch S, Connor SE, Hamilton EG, et al. Problems in recruiting community-based physicians for health services research. J Gen Intern Med. 2000;15(8):591-599.
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research-article2014
JHLXXX10.1177/0890334414535507Journal of Human LactationPound et al
Original Research
Breastfeeding Knowledge, Confidence, Beliefs, and Attitudes of Canadian Physicians
Journal of Human Lactation 1–12 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0890334414535507 jhl.sagepub.com
Catherine M. Pound, MD1, Kathryn Williams, BSc, MS2, Renee Grenon, MA, PhD(c)2, Mary Aglipay, MSc2, and Amy C. Plint, MD, MSc1,2
Abstract Background: Physicians’ attitudes and recommendations directly affect breastfeeding duration. Yet, studies in many nations have shown that physicians lack the skills to offer proper guidance to breastfeeding mothers. Objective: This study aims to assess breastfeeding knowledge, confidence, beliefs, and attitudes of Canadian physicians. Methods: A breastfeeding questionnaire was developed and piloted prior to study enrollment. These questionnaires were sent to 1429 pediatricians (PED), 1329 family physicians (FP), and final-year pediatric and final-year family medicine residents (PR and FMR). Results: The analysis included 397 PED, 322 FP, 17 PR, and 44 FMR who completed the questionnaire. Mean overall correct knowledge score was 67.8% for PED, 64.3% for FP, 72.7% for PR, and 66.8% for FMR. Two hundred eighty-five PED (74.2%), 228 FP (73.1%), 7 PR (41.2%), and 21 FMR (53.8%) felt confident with their breastfeeding counseling skills. Less than half (49.6% of PED and 45.4% of FP) believed that evaluating breastfeeding was a primary care physician’s responsibility, and few PED or FP (5.1% and 11.3%) routinely observed breastfeeding in mother-infant pairs. Conclusion: Several areas of potential deficits were identified in Canadian physicians’ breastfeeding knowledge. Physicians would benefit from greater education and support, to optimize care of infants and their mothers. Keywords attitudes, beliefs, breastfeeding, confidence, education, humans, infant, knowledge, medicine, newborn, physician’s role, practice
Well Established Physicians’ attitudes and recommendations are known to directly affect breastfeeding duration. Studies in many nations have shown that physicians often lack skills and/or knowledge to assist and support breastfeeding mothers.
Newly Expressed Several areas of potential deficits were identified in Canadian physicians’ breastfeeding knowledge, including appropriate breastfeeding techniques, latch, and recommendations pertaining to milk supply. Physicians would benefit from greater education and support, to optimize care of infants and their mothers.
in many countries have shown that physicians and residents lack skills to offer proper guidance to lactating mothers.4-10 In Canada, the learning of specific breastfeeding skills and the management of common breastfeeding problems do not appear among the programs’ regulatory bodies’ formal learning objectives,11,12 suggesting that breastfeeding counseling skills are not formally taught during residency training. We undertook a national assessment of Canadian physicians caring for infants and their mothers (pediatricians [PED], family physicians [FP], final-year pediatric residents 1
Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada Children’s Hospital of Eastern Ontario Clinical Research Unit, Ottawa, ON, Canada 2
Background
Date submitted: January 14, 2014; Date accepted: April 22, 2014.
The Canadian Pediatric Society (CPS), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP) promote the assessment and management of breastfeeding issues as physician responsibilities.1-3 Studies
Corresponding Author: Catherine M. Pound, MD, Department of Pediatrics, Division of Pediatric Medicine, Children’s Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada. Email: [email protected]
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[PR], and final-year family medicine residents [FMR]) to examine their breastfeeding knowledge, confidence, beliefs, and attitudes. To our knowledge, this is the most extensive study of the topic to be performed in Canada.
Methods Population and Survey Distribution We conducted a paper-based, mailed survey of 1429 PED and 1329 FP across Canada (all provinces and territories) between October 2010 and January 2011. Names and contact information of all licensed PED and FP were obtained from all provincial registries except for Quebec. The Collège des Médecins du Québec (CMQ) did not release their physician list but agreed to share names and contact information of 400 PED and 400 FP they randomly selected. A computerized program randomly selected participants in proportion to the number of physicians working in each province, except for Quebec, where all randomly selected 800 physicians were mailed a questionnaire. Also, due to the limited number of physicians working in the northern territories (Nunavut, Yukon, and Northwest Territories), all PED and FP in these areas were surveyed. A modified Dillman method13 was used; nonresponders received up to 3 surveys sent at regular intervals via regular mail. Only physicians who provided primary care for infants were eligible, and as such, pediatric subspecialists were excluded. Physicians whose type of practice clearly excluded infants and primary care (geriatrics, anesthesia, palliative care, etc) were excluded. Surveys were available in both French and English. We also conducted an electronic survey of final-year PR and final-year FMR from all programs over the same time frame. As most trainees’ names and contact information cannot be publicly accessed, we asked program directors to distribute a letter to their eligible residents. Interested residents communicated directly with our research assistant. Because no national public list of residents exists, we estimated the number of residents enrolled in their final year of residency during the study period, based on data from the Canadian Residency Matching System. Ninety to 100 PR and 800 to 875 FMR were likely eligible. The study was approved by the Children’s Hospital of Eastern Ontario Research Ethics Board, and all procedures followed were in accord with the ethical standards of the board.
Survey Instrument Since a review of the breastfeeding literature failed to yield an existing questionnaire of large enough breadth to satisfactorily examine our 4 domains (knowledge, confidence, beliefs, and attitudes), the study principal investigator, in conjunction with the study team, developed the survey instrument. Two practicing International Board Certified
Lactation Consultants further reviewed the questionnaire. As no standardized questionnaire was found in the literature, questions were developed based on expected knowledge of the primary care physician detailed in the AAP Position Statement on “Breastfeeding and the Use of Human Milk,”1 adapted from the Registered Nurses’ Association of Ontario Self-Learning Module on Breastfeeding14 and from prior studies.6,10 Questions from more recent studies15 could not be included as publication date was too late for incorporation into our study. Permissions were obtained from all appropriate sources.6,10,14 Twenty-three physicians and residents piloted the survey, which was revised based on their feedback. The final survey consisted of 50 multiple-choice questions covering demographics and 4 main domains: knowledge, confidence, beliefs, and attitudes (17, 4, 5, and 8 questions, respectively). All questions were given equal weight for scoring purposes. The knowledge part of the questionnaire included 4 multiple-choice questions, 8 “true/ false/I don’t know” questions, and 5 “yes/no/I don’t know” questions. The confidence part of the questionnaire used 1 “yes/no” question and 3 multiple-choice answers, the belief part used 3 “yes/no” questions and 2 multiple-choice answers, and the attitude part used 3 “yes/no” questions and 5 multiple-choice answers (not comfortable, somewhat uncomfortable, somewhat comfortable, very comfortable; never or almost never, on some visits, on most visits, almost or almost always). The confidence section of the questionnaire investigated self-rated confidence in one’s breastfeeding counseling skills. Overall confidence was defined as “confidence in teaching mothers how to breastfeed and address breastfeeding-related problems.” In the belief section, physicians’ thoughts in relation to their role in breastfeeding support and promotion were explored, whereas physicians’ usual clinical practice and outlook on various breastfeeding scenarios were explored in the attitude section. We a priori defined an overall knowledge score of 70% as acceptable, as this is the minimum score that pediatricians must achieve in their specialty examination to receive Royal College of Physicians and Surgeons of Canada certification (M. Jabbour, MD, vice-chief/chair, Department of Pediatrics, associate professor, Pediatrics and Emergency Medicine, University of Ottawa, personal communication, May 14, 2013). There is no minimum score for family physicians on certification examination; within each examination administration, a criterion candidate group is selected whose performance is the standard against which all candidates are compared.16 Since both groups of physicians care for the same infant population, we felt that the minimum acceptable score should be the same.
Sample Size We based our sample size calculation on the results of our pilot study, in which the mean percentage of correct answers
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Pound et al in the knowledge section was 65%, with a standard deviation of 12%. A sample size of 385 allowed for an estimate of the mean percentage score in the knowledge section with a 95% confidence interval (CI) of width ± 1.2%. Assuming a 30% response rate, we had planned to approach 1284 PED and 1284 FP. However, since the CMQ would release contact information for only a predetermined number of physicians, we overestimated the number needed from that province and asked to have 800 names released, as some physicians would not meet eligibility criteria. Also, given the very small number of physicians practicing in the Northern Territories, we elected to approach them all. In the end, 1429 PED and 1329 FP were approached.
Statistical Analysis Breastfeeding knowledge was calculated as a score out of 100 based on the percentage of correct responses from the breastfeeding knowledge domain. Descriptive statistics were used to summarize the survey respondents’ demographic characteristics, breastfeeding confidence and beliefs, and breastfeeding attitudes. Cronbach’s alpha values were calculated for each domain of the questionnaire. Univariate associations between knowledge and demographics were assessed using t tests and 1-way analyses of variance (ANOVAs). Multiple linear regression was used to identify demographic factors that were independently associated with the overall knowledge score. All demographic variables surveyed were included in the multivariate model. Missing data were handled via listwise deletion. The identification of demographic factors associated with knowledge was the primary goal of the modeling, so only main effects (no interactions) were assessed. A P value < .05 was considered statistically significant. The analyses were performed using SPSS (version 19.0; IBM Corp, Armonk, New York, USA) and SAS 9.3 (SAS Institute Inc, Cary, North Carolina, USA).
Results Respondents We identified 3395 PED and 38 223 FP from the provincial and territorial physician lists. Response rate was 38.3% for PED and 24.2% for FM. Overall, 719 physicians representing all provinces and territories were retained for the analysis (397 PED and 322 FM) (Figures 1-3; Table 1). Sixty-four residents contacted the research assistant, and 61 returned surveys (17 PR and 44 FMR). The majority of participants were female and between the ages of 30 and 50.
Questionnaire Cronbach’s alpha values were calculated for each domain of the questionnaire. Yes/no questions were removed for Cronbach’s alpha calculation from domains with questions
of differing scales so as to keep scales homogeneous. In total, 1 question was removed from the confidence domain, none for knowledge, 3 for attitudes, and 2 for beliefs. Excellent reliability was found for confidence (n = 761, Cronbach’s alpha = 0.81), whereas acceptable reliability was demonstrated for knowledge (n = 625, Cronbach’s alpha = 0.62) and attitudes (n = 506, Cronbach’s alpha = 0.60). The belief domain has a relatively low reliability value (n = 755, Cronbach’s alpha = 0.21).
Knowledge The average overall knowledge score of practicing physicians was lower than our predefined acceptable score of 70%. The overall correct knowledge score for PED was 67.8%, whereas that for FP was 64.3%. Pediatric residents scored 72.7%, whereas FMR scored 66.8%. Table 2 summarizes physicians’ and residents’ results on the questionnaires’ knowledge section. Univariate testing demonstrated that knowledge score was associated with several demographic factors (Table 1).
Confidence, Beliefs, and Attitudes Two hundred eighty-five PED (74.2%) and 228 FP (73.1%) reported feeling overall confident in teaching mothers to breastfeed and addressing breastfeeding-related problems. Few PED and FP (5.1% and 11.3%, respectively) routinely observed breastfeeding at least once in every breastfeeding mother-infant pair, and a large number of PED and FP (56.6% and 29.9%, respectively) reported keeping formula samples in their office. Table 3 summarizes self-reported confidence, beliefs, and attitudes of physicians and residents regarding various aspects of breastfeeding.
Comparison between FP and PED The overall knowledge score for PED was higher than that for FP (P = .007). However, more PED than FP believed that formula was equivalent to breast milk (P < .001). More FP reported directly observing breastfeeding at least once in every breastfeeding mother (P = .004), and more PED kept formula samples in the office (P < .001). Other confidence, beliefs, and attitudes of PED and FP were not significantly different. Multiple linear regression identified several demographic factors that were significantly associated with knowledge for practicing physicians (Table 4). On average, female physicians scored 5.0 points higher (on a 100-point scale) compared to male physicians (95% CI, 2.4-7.5; P < .001). Compared to older physicians, physicians between the ages of 30 and 50 scored higher by 3.6 points (95% CI, 0.2-7.1; P = .04). Compared to Ontario, the Maritime Provinces and British Columbia had higher knowledge scores, scoring on average 5.2 (95% CI, 0.6-9.8; P = .03) and 4.3 (95% CI, 0.3-8.3;
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Figure 1. Pediatrician Mail-out.
3395 Canadian pediatricians idenfied 741 pediatricians removed (no available address, out of country / out of province, iden fied as subspecialists)
2654 pediatricians remained
1463 pediatricians randomly selected 31 pediatricians removed (28 missing addresses not previously identified, 2 duplicate addresses, 1 out of province address not previously identified)
1429 quesonnaires sent 8 envelopes returned unopened (moved / wrong address)
1421 quesonnaires delivered
588 quesonnaires returned
40 blank/incomplete (3 saw no infants, 5 no longer in prac ce / re red, 2 subspecialists, 27 gave no reason, 3 incomplete)
548 completed quesonnaires 151 quesonnaires excluded (pediatric subspecialists)
397 quesonnaires in final analysis
P = .04) points higher, respectively. Physicians whose practice had 50% or more patients younger than 1 year scored on average 7.9 points higher on the knowledge tool (95% CI, 3.6-12.1; P < .001). Compared to physicians with no children, physicians who had breastfed children scored 10 points higher (95% CI, 6.4-13.6; P < .001). Compared to physicians with no children, having non-breast-fed children was not associated with a higher knowledge score (average increase in score = 4.5; 95% CI, –2.7 to 11.7; P = .22). Breastfeeding certification was associated with an 11.5-point increase (95% CI, 1.7-21.2; P = .02). The demographic variables in our model accounted for 14.1% of the variation in knowledge score.
Discussion We found that Canadian physicians’ breastfeeding knowledge was suboptimal. Although physicians’ overall comfort
level was relatively high, self-reported confidence was much lower when participants were asked about specific breastfeeding counseling skills, suggesting that physicians may have difficulty self-assessing as they may not be aware of what breastfeeding counseling entails. Physicians’ attitudes toward a breastfeeding infant were found to be quite positive, however, a much smaller number felt comfortable watching a toddler breastfeed, despite the World Health Organization supporting breastfeeding well into toddlerhood.17 Finally, female sex, age between 30 and 50 years, percentage of practice younger than 1 year, and personal breastfeeding experience were all positively associated with knowledge. This survey identified multiple knowledge deficits. These included recommending inappropriate breastfeeding techniques (such as timed feedings), incorrectly believing that increasing maternal milk intake increases breast milk supply,
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Pound et al Figure 2. Family Physician Mail-out.
38 223 Canadian family physicians identi ied
33 847 family physicians remained
1362 family physicians randomly selected
1329 questionnaires sent
4376 family physicians removed (no available address, out of country / out of province, ield of work that excludes pediatric population; e.g. geriatrician)
33 family physicians removed (10 missing addresses not previously identi ied, 2 out of province address not previously identi ied, 21 with specialties clearly excluding pediatric patients) 15 envelopes returned unopened (moved / wrong address)
1314 questionnaires delivered
356 questionnaires returned
34 questionnaires excluded (1 illed by nurse, 5 saw no infants, 3 no longer in practice / retired, 25 incomplete)
322 completed questionnaires
Figure 3. Resident Electronic Mail-out. 17 pediatric postgraduate training programs identiied
17 family medicine postgraduate training programs identiied
17 program directors approached for letter distribution to their inal year residents
17 program directors approached for letter distribution to their inal year residents
17 pediatric residents contacted the study coordinator and completed the survey
44 family medicine residents contacted the study coordinator and completed the survey
failing to identify characteristics of a successful latch, not recognizing breastfeeding contraindications, and being
unaware that early formula introduction is a major risk factor for breastfeeding failure.18,19 It is interesting that about 75%
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Table 1. Demographics of Responding Physicians and Residents.
Pediatricians, n (%) Total No. Age, ya < 30 30-50 > 50 Sexa Male Female Lived in Canada Always > 20 years but not always 11-20 years 5-10 years < 5 years Province/territory of worka Atlantic provinces Quebec Ontario Prairie provinces British Columbia Nunavut, Yukon, Northwest Territories Residency training in Canada Yes Work location Rural Urban Type of work Clinic Community hospital Teaching hospital Other Percentage of children < 1 year of age in practicea 0-10 11-25 26-50 51-75 > 75 Years in practicea 0-5 6-10 11-15 > 15 Breastfeeding learning Own experiencea Medical school Residency Self-directed learninga Othera No breastfeeding knowledgea
397
Family Physicians, n (%)
Pediatric Residents, n (%)
Family Medicine Residents, n (%)
322
17
44
2 (0.5) 203 (51.1) 191 (48.2)
16 (5.0) 150 (46.6) 156 (48.4)
5 (29.4) 12 (70.6) 0 (0)
25 (56.8) 19 (43.2) 0 (0)
169 (42.6) 228 (57.4)
145 (45.3) 175 (54.7)
5 (29.4) 12 (70.6)
8 (18.2) 36 (81.8)
225 (56.8) 116 (29.3) 20 (5.1) 22 (5.6) 13 (3.3)
202 (63.3) 65 (20.4) 26 (8.2) 19 (6.0) 7 (2.2)
14 (82.4) 2 (11.8) 1 (5.9) 0 (0) 0 (0)
32 (72.7) 5 (11.4) 1 (2.3) 5 (11.4) 1 (2.3)
36 (9.2) 97 (24.7) 160 (40.8) 62 (15.8) 34 (8.7) 3 (0.8)
21 (6.6) 63 (19.7) 126 (39.4) 44 (13.8) 46 (14.4) 20 (6.3)
2 (11.8) 2 (11.8) 11 (64.7) 2 (11.8) 0 (0) NA
8 (18.2) 8 (18.2) 24 (54.5) 4 (9.1) 0 (0) NA
343 (88.2)
258 (81.4)
61 (16.2) 316 (83.8)
120 (38.2) 194 (61.8)
197 (50.6) 61 (15.7) 113 (29.0) 18 (4.6)
246 (77.4) 30 (9.4) 11 (3.5) 31 (9.7)
43 (11.1) 171 (44.3) 106 (27.5) 46 (11.9) 20 (5.2)
236 (76.1) 59 (19.0) 15 (4.8) 0 (0) 0 (0)
77 (19.9) 40 (10.4) 51 (13.2) 218 (56.5)
52 (16.5) 36 (11.4) 32 (10.1) 196 (62.0)
255 (64.2) 117 (29.5) 196 (49.4) 195 (49.1) 74 (18.6) 1 (0.3)
204 (63.4) 143 (44.4) 110 (34.2) 150 (46.6) 77 (23.9) 3 (0.9)
7 (41.2) 7 (41.2) 15 (88.2) 6 (35.3) 1 (5.9) 0 (0)
20 (45.5) 25 (56.8) 30 (68.2) 20 (45.5) 8 (18.2) 0 (0) (continued)
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Pound et al Table 1. (continued) Family Physicians, n (%)
Pediatric Residents, n (%)
335 (87.7)
265 (83.6)
8 (50.0)
17 (38.6)
312 (94.0)
237 (96.0)
8 (100.0)
17 (100.0)
114 (50.2) 93 (41.0) 20 (8.8)
143 (53.6) 114 (42.7) 10 (3.7)
4 (57.1) 3 (42.9) 0 (0)
9 (52.9) 8 (47.1) 0 (0)
6 (1.5)
4 (1.3)
1 (5.9)
1 (2.3)
Pediatricians, n (%)
Family Medicine Residents, n (%)
a
Having 1 or more children Yes Self/partner with breastfeeding experiencea Yes No. months own child was breastfeda ≥ 12 < 12 No breastfeeding Certification in breastfeeding support Yes
Abbreviation: NA, not applicable. a P < .01 for association with knowledge score among pediatricians and family physicians.
Table 2. Breastfeeding Knowledge Score. Respondents with Correct Answer, n (%) Scenario
Correct Answer
Overall score For exclusively breastfed baby, No otherwise healthy, birth weight not regained by 2 weeks, is first recommendation formula supplementation? Do you routinely recommend No supplementing with formula if mother feels milk supply inadequate? Do you routinely give glucose No water or formula before mother’s milk comes in? Is formula feeding in first Yes few weeks risk factor for breastfeeding failure? Do you routinely recommend that No babies breastfeed each side for 15-20 minutes every 3 hours? First thing to do when mother Assess position and latch complains of sore nipples is: All listed answers are signs that No part of the areola can baby is latched on properly be seen except: Mother complains that 6-week-old Baby requires more milk infant has been breastfeeding because growing and hourly for a day or 2. You tell frequent breastfeeding her: increases milk supply
Family Physicians
Pediatric Residents
Family Medicine Residents
67.8% 276/380 (72.6)
64.3% 224/311 (72.0)
72.7% 11/17 (64.7)
66.8% 27/44 (61.4)
299/384 (77.9)
232/307 (75.6)
12/17 (70.6)
37/44 (84.1)
347/387 (89.7)
253/307 (82.4)
15/17 (88.2)
34/44 (77.3)
184/382 (48.2)
203/315 (64.4)
10/17 (58.8)
26/44 (59.1)
159/385 (41.3)
141/308 (45.8)
2/17 (11.8)
14/44 (31.8)
328/376 (87.2)
257/302 (85.1)
17/17 (100.0)
42/44 (95.5)
117/367 (31.9)
102/300 (34.0)
8/17 (47.1)
16/43 (37.2)
256/374 (68.4)
173/305 (56.7)
12/17 (70.6)
27/44 (61.4)
Pediatricians
(continued)
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Table 2. (continued) Respondents with Correct Answer, n (%) Scenario
Correct Answer
Otherwise healthy 5-day-old More frequent breastfeeding breastfeeding infant admitted sessions and teach mother to hospital with jaundice. After how to use breast pump initiating phototherapy, what do you recommend? Moderate exercise decreases False quality and quantity of breast milk Increasing mother’s milk intake False increases breast milk production Breastfeeding decreases incidence True of many infectious diseases Breastfeeding decreases risk of True SIDS Breastfeeding is contraindicated in False mothers with hepatitis C Breastfeeding is contraindicated in True mothers with HIV in Canada Breastfeeding decreases the risk True of ovarian and breast cancers in mothers Breastfeeding is safe to continue in True mothers with herpes simplex on 1 breast if baby breastfeeds only from other breast
Family Physicians
Pediatric Residents
Family Medicine Residents
338/380 (91.4)
244/307 (79.5)
17/17 (100.0)
39/44 (88.6)
322/390 (82.6)
263/318 (82.7)
14/17 (82.4)
33/44 (75.0)
107/390 (27.4)
93/314 (29.6)
6/17 (35.3)
19/44 (43.2)
372/391 (95.1)
310/319 (97.2)
17/17 (100.0)
40/44 (90.9)
285/386 (73.8)
230/317 (72.6)
16/17 (94.1)
32/44 (72.7)
236/387 (61.0)
145/317 (45.7)
9/17 (52.9)
19/44 (43.2)
311/388 (80.2)
144/317 (45.4)
17/17 (100.0)
36/44 (81.8)
272/390 (69.7)
246/319 (77.1)
14/17 (82.4)
35/44 (79.5)
215/388 (55.4)
156/317 (49.2)
13/17 (76.5)
23/44 (52.3)
Pediatricians
Abbreviations: HIV, human immunodeficiency virus; SIDS, sudden infant death syndrome.
Table 3. Confidence, Beliefs, and Attitudes. Question Confidence Overall confidence in breastfeeding counseling skills Very comfortable assessing baby’s latch Very comfortable assessing milk transfer Very comfortable teaching mothers breast pump use Beliefs Believe evaluation of breastfeeding is responsibility of child’s primary physician in first 3 to 5 days after birth Believe formula is nutritionally equivalent to breast milk Believe physician has influence on mother’s decision to breastfeed
Pediatricians, n (%)
Family Physicians, n (%)
Pediatric Residents, n (%)
Family Medicine Residents, n (%)
285/384 (74.2)
228/312 (73.1)
7/17 (41.2)
21/44 (53.8)
128/389 (32.9) 136/391 (34.8) 87/391 (22.3)
103/313 (32.9) 103/314 (32.8) 82/317 (26.9)
3/17 (17.6) 4/17 (23.5) 6/17 (35.3)
6/44 (13.6) 9/44 (20.5) 9/44 (20.5)
191/385 (49.6)
142/312 (45.5)
13/17 (76.5)
29/44 (65.9)
132/380 (34.7)
70/314 (22.3)
5/17 (29.4)
10/44 (22.7)
355/389 (91.3)
291/318 (91.5)
17/17 (100.0)
43/44 (97.7) (continued)
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Pound et al Table 3. (continued) Question Believe it is always or almost always realistic for working mothers to continue breastfeeding Believe their residency training had prepared them poorly or somewhat poorly to support breastfeeding mothers Attitudes Very comfortable witnessing mothers breastfeeding infant in the office Very comfortable witnessing mothers breastfeeding toddler in the office Always or almost always discuss breastfeeding prior to birth of child Always or almost always ask about breastfeeding in infant’s first year of life Directly observe breastfeeding at least once in every breastfeeding mother-infant pair Keep formula samples in the office (or preceptor’s) Have formula advertisement in the office (or preceptor’s) Keep breastfeeding pamphlets and brochures in the office (or preceptor’s) and give to breastfeeding mothers
Pediatricians, n (%)
Family Physicians, n (%)
Pediatric Residents, n (%)
Family Medicine Residents, n (%)
67/384 (17.4)
72/317 (22.7)
2/17 (11.8)
7/44 (15.9)
288/388 (74.2)
222/314 (70.7)
10/17 (58.8)
30/44 (68.2)
352/390 (90.3)
289/319 (90.6)
16/17 (94.1)
31/44 (70.5)
214/390 (54.9)
188/318 (59.1)
8/17 (47.1)
19/44 (43.2)
65/386 (16.8)
150/309 (48.5)
4/17 (23.5)
26/44 (59.1)
273/387 (70.5)
202/311 (65.0)
7/17 (41.2)
26/44 (59.1)
20/388 (5.1)
35/311 (11.3)
1/17 (5.9)
2/44 (4.5)
213/386 (56.6)
93/312 (29.9)
5/17 (29.4)
10/44 (22.7)
77/378 (20.4)
50/313 (16.0)
8/17 (47.1)
14/44 (31.8)
196/374 (52.4)
168/311 (54.0)
5/17 (29.4)
13/44 (29.4)
Table 4. Adjusted Model of the Overall Knowledge Score.a Factor Occupational group General pediatrician Family physician Sex Female Male Age ≤ 30 years 30-50 years > 50 years Lived in Canada Always Not always Province Newfoundland, Prince Edward Island, Nova Scotia, New Brunswick Quebec Manitoba, Saskatchewan, Alberta British Columbia
n
Regression Coefficientb (95% CI)
P Value
300 370
2.27 (–0.50-5.03) Reference
.11
386 284
4.95 (2.35-7.54) Reference
< .001
17 333 320
6.27 (–2.69-15.22) 3.64 (0.17-7.12) Reference
.17 .04
400 270
1.68 (–1.19-4.55) Reference
.25
54
5.18 (0.59-9.76)
.03
147 99 73
–0.66 (–4.04-2.72) –0.60 (–4.24-3.03) 4.30 (0.27-8.33)
.70 .75 .04 (continued)
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Table 4. (continued) Factor Nunavut, Yukon, Northwest Territories Ontario Percentage of practice younger than 1 year > 50% ≤ 50% Residency training in Canada Yes No Rural or urban practice Rural Urban Type of practice Community Teaching Other Clinic Years in practice 0-5 6-10 11-15 > 15 Personal breastfeeding experience No, has children Yes, has children Unknown Does not have children Breastfeeding certification Yes No
n
Regression Coefficientb (95% CI)
P Value
23 274
4.90 (–2.09-11.89) Reference
.17
605 65
7.87 (3.64-12.10) Reference
< .001
567 103
0.26 (–3.52-4.03) Reference
.89
173 497
0.78 (–2.24-3.80) Reference
.61
88 116 44 422
1.27 (–2.51-5.05) 0.78 (–2.83-4.39) –1.37 (–6.30-3.56) Reference
.51 .67 .59
119 74 79 398
1.22 (–3.16-5.60) 2.19 (–2.37-6.75) 1.62 (–2.82-6.06) Reference
.58 .35 .47
24 506 44 96
4.49 (–2.68-11.67) 9.99 (6.38-13.60) 1.73 (–4.06-7.52) Reference
.22 < .001 .56
10 660
11.48 (1.74-21.23) Reference
.02
Abbreviation: CI, confidence interval. a The overall knowledge score was expressed as a percentage (n = 670). b Each regression coefficient indicates the additional % knowledge added by the corresponding factor to the reference mean score of 48.3% (constant mean score of 48.3 not explained by the factors in the model) after adjusting for the other factors. Adjusted R2 = 0.14.
of physicians reported feeling overall comfortable addressing breastfeeding problems, whereas only 41% of PR and 54% of FMR reported the same. It is important to remember that, although attending physicians were randomly selected, the resident group self-selected. One would expect those self-selected residents to be more interested in breastfeeding than their peers and therefore more likely to be comfortable with the topic. The difference in scores between the 2 groups could suggest that breastfeeding skills are primarily learned with clinical and life experience, rather than in residency. Indeed, most physicians and residents felt that residency training had prepared them poorly or somewhat poorly to appropriately support breastfeeding mothers. A considerable number of participants believed that breast milk and formulas are nutritionally equivalent, despite unambiguous evidence that formula is inferior.1 From an attitude perspective,
an alarmingly low number of participants reported observing breastfeeding at least once in their young patients, as this should be done for every infant in the first few days of life.1 These results are concordant with those of previous studies, showing that breastfeeding mothers receive minimal help and support from physicians.20,21 A significant proportion of PED and FP reported keeping formula samples and formula advertisements in their office, a practice shown to negatively affect breastfeeding duration.22 In keeping with other studies conducted worldwide,6,9,10,23,24 female sex and personal breastfeeding experience were associated with higher overall breastfeeding knowledge scores. Age 30 to 50 years was also associated with higher overall knowledge score, possibly reflecting a group of physicians more likely to have recently had their own breastfeeding children.
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Pound et al The overall score of PED was slightly higher than that of FP but remained below our acceptable level of 70%. Pediatricians reported keeping formula samples in the office more often than FP did. This finding, not previously reported, may be because PED sometimes care for more complex or medically fragile infants, with more significant feeding difficulties, and in whom formula supplementation may at times be necessary. This may also be due to formula companies potentially targeting pediatricians more often. It is interesting that FP reported observing breastfeeding more often than PED did. The reason for this is unclear but may relate to the nature of the family physician’s relationship with the mother. Family physicians being typically involved in mothers’ care prenatally, they may have a stronger bond with her and feel more comfortable observing her breastfeed. Study limitations include a low overall response rate. High response rates are typically difficult to obtain from physicians.25 Nevertheless, our target size was reached for PED and almost reached for FP. Physicians interested in breastfeeding were probably more likely to complete the questionnaire, and therefore, our sampled population may not be representative of Canadian pediatricians and family physicians. However, physicians with a breastfeeding interest would be expected to have better knowledge, confidence, beliefs, and attitudes than those with no or little breastfeeding interest, therefore leading to superior results. Also, resident participation depended on a multistep process (distribution of letters by program directors, resident initiating communication with our research assistant), likely causing the low participation level and resulting in only the most motivated participating in the study. Finally, although the survey instrument was piloted and reviewed, the questionnaire had not previously been used, the scale used has not been validated, and psychometric testing was not performed. However, Cronbach’s alpha values were found to be acceptable or excellent for all domains of the questionnaires except beliefs.
Conclusion The results of our study show that breastfeeding knowledge, confidence, beliefs, and attitudes are suboptimal among Canadian primary care physicians. This study uncovered specific areas of concern in physicians’ knowledge, confidence, beliefs, and attitudes with regard to breastfeeding. Based on these results, targeted educational tools specifically addressing the areas identified through our survey can be developed and implemented at the residency level. By optimizing the knowledge, confidence, beliefs, and attitudes of frontline physicians, we hope to increase breastfeeding exclusivity and duration and improve the health of our children. Authors’ Note The full questionnaire can be obtained from the main author at [email protected].
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the Children’s Hospital of Eastern Ontario Research Institute.
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