The European Journal of Public Health Advance Access published online on December 26, 2007
The European Journal of Public Health, doi:10.1093/eurpub/ckm121
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Health visitors and breastfeeding support: influence of knowledge and self-efficacy
Hanne Kronborg1, Michael Væth2, Jørn Olsen3,4 and Ingegerd Harder1
1 Department of Nursing Science, Institute of Public Health, University of Aarhus, Denmark
2 Department of Biostatistics, Institute of Public Health, University of Aarhus, Denmark
3 Department of Epidemiology, Institute of Public Health, University of Aarhus, Denmark
4 Department of Epidemiology, School of Public Health, UCLA, Los Angeles, USA
Correspondence: Hanne Kronborg, Institute of Public Health, University of Aarhus, Høegh-Guldbergsgade 6A, 8000 Aarhus C, Denmark, tel: +458942 4854, fax: +458942 5500, e-mail: hk{at}nursingscience.au.dk
Received August 2, 2007, accepted November 15, 2007
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Abstract |
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Background: Little is known about what influences health visitors’ breastfeeding support. The objective was to describe health visitors’ breastfeeding experiences, beliefs, knowledge and self-efficacy in breastfeeding guidance and determine the impact of a training course on these factors, and how they were reflected in practice. Methods: A randomized intervention study enrolled 52 health visitors in the intervention group and 57 in the comparison group. The intervention group participated in an 18-hour pre-study training course that focused on knowledge about lactation and how to guide the mother to learn the mechanisms of breastfeeding. Data were collected through self-administered questionnaires before the intervention and after the follow-up period. One hundred and six (97%) health visitors and 1302 (82%) mothers responded. Results: At baseline no substantial differences were seen between the two groups on years since education, own breastfeeding experiences, beliefs or self-efficacy in breastfeeding guidance except that health visitors in the intervention group, who had completed the course, demonstrated significantly higher scores on knowledge questions (P < 0.01). After the intervention health visitors in the intervention group reported significantly higher self-efficacy in guidance on three of five breastfeeding problems (P < 0.01). Mothers in the intervention group reported having received more support than mothers in the comparison group. Conclusion: An interactive course increased the health visitors’ knowledge of breastfeeding practice. After the intervention period the health visitors in the intervention group had increased their self-efficacy in helping mothers with common breastfeeding problems. The mothers in the intervention group reported more informational and instrumental breastfeeding support.
Keywords: breastfeeding, education, knowledge, public health professional, self-efficacy
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Introduction |
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Breastfeeding has over the years documented short-term and long-term health benefits for the mother and child,1 and exclusive breastfeeding is the recommended method of infant feeding for the first six months of life.2 Breastfeeding frequencies are, however, below the recommended level in most industrialized countries with prevalences of exclusive breastfeeding four months after birth 50–60% in Scandinavian countries3–5 and 25% in the US and UK.6,7
Previous studies have demonstrated that support from health professionals can prolong the duration of breastfeeding.8,9 A number of factors seem to be important for the competence in supporting breastfeeding in practice such as own breastfeeding experience, years of experience, a positive attitude, knowing about breastfeeding and confidence in coping with breastfeeding problems.10–13 However, existing data indicate that health care professionals’ knowledge about breastfeeding is often insufficient and influenced by their own breastfeeding experiences.12,14,15
Courses and workshops that include practical exercises can improve health care professionals’ knowledge, modify their attitudes towards breastfeeding, and increase their clinical skills in guiding breastfeeding mothers.16–18 In the Baby Friendly Hospital Initiative19 midwifes and nurses in hospital settings are given an opportunity to improve their knowledge and attitudes towards breastfeeding. These initiatives have shown a positive effect on the initial breastfeeding rate,20 but continuing support is needed to prevent a subsequent decline after discharge.21,22
In affluent countries, postnatal breastfeeding support in the community setting is often handled by health visitors and physicians. Studies have so far focused mainly on nurses, midwifes and physicians.10,11,14,15,20,23 Less is known about how health visitors’ knowledge and beliefs affect their breastfeeding support, although a recent study show positive association between health visitor having received breastfeeding training in the previous two years and their mothers’ breastfeeding practice.24 As part of a randomized intervention study, aimed at prolonging the breastfeeding period, we collected data on the characteristics of the health visitors in the intervention and comparison group. The purpose was to describe health visitors’ breastfeeding experiences, beliefs, knowledge and self-efficacy in breastfeeding guidance in the two groups, to determine the impact of a training course on these factors and how they were reflected in the health visitors’ practice during the study period.
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Methods |
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Subjects, settings and procedure
The intervention study took place in the Western part of Denmark, where health visitors routinely visit the family of the newborn shortly after discharge from the maternity ward. Health visitors are registered nurses with 1 year of supplementary training. All except one of the 110 health visitors employed in 22 municipalities took part in a cluster randomized breastfeeding intervention study, 52 health visitors in the intervention group and 57 in the comparison group.
The health visitors in the intervention group participated in January 2004 in an 18-hour training course. The course was developed for the study, building on the World Health Organization's Breastfeeding Counselling: a Training Course.25 It was completed in three consecutive days and consisted of six parts that included: effective breastfeeding technique, self-regulated breastfeeding, mother's concern about having enough milk, parents getting to know the baby's cues and interact with the baby, common breastfeeding problems, and how to acknowledge the mother's perception of breastfeeding and address her concerns. Each part included oral presentations, video presentations, exercises and role plays.
In the following six months intervention period, health visitors in the intervention group offered a standardized programme to all Danish mothers who lived in the intervention municipalities and gave birth to a single child with a gestational age of at least 37 completed weeks. The standardized programme was also developed for the study and consisted of one to three home visits within the first five weeks. It focused on improving maternal self-efficacy and confidence in breastfeeding the child by addressing the process of getting to know the baby's needs and offering the mother cognitive and physical rehearsals aimed at learning the mechanisms of breastfeeding.9
The health visitors in the comparison group were informed about the project. In the intervention period these health visitors offered usual practice consisting of 1 or more non-standardised visits. In March 2005 after a six months follow-up period the health visitors in the comparison group attended the training course. A detailed description of the intervention study has been published previously.9
Data collection, questionnaires
Data were collected both from the health visitors and the mothers in the two groups. The health visitors filled out two anonymous, self-administered questionnaires. The baseline questionnaire was handed to the health visitors after the health visitors in the intervention group had finished the course and they were returned immediately before the intervention period started. The follow-up questionnaire was handed and returned after the follow-up period.
We used data reported by the mothers that had received visits from the health visitors to investigate the influence on breastfeeding support. The mothers answered two anonymous, self-administered questionnaires with an addressed and prepaid envelope for reply. The first questionnaire was handed to the mothers at the health visitors’ first visit. The second questionnaire was handed or sent approximately five months after birth.
The health visitors’ baseline questionnaire was developed from the Breastfeeding Knowledge Questionnaire used by Freed et al.12 Burglehouse et al.11 and Hellings and Howe14 to assess knowledge, self-efficacy and counselling practices among physicians and nurses. The questionnaire was modified to conditions in Denmark after two focus group interviews with 12 Danish health visitors from municipalities not included in the study. It was designed to be completed in less than 20 min.
All questionnaires were reviewed by four experts in the subject area, and adjusted after feedback. Content and face validity were subsequently tested in two pilot studies. The health visitors’ questionnaires were assessed and retested after changes had been made to the wording of the questions in two rounds with a group of 11 health visitors. The mothers’ questionnaires were assessed and retested in three rounds with a group of 24 mothers.
Study variables
The questions on psychosocial variables reflected components of Ajzen's Theory of Planned Behaviour26 and Bandura's Social Cognitive Theory.27 The variables covered the following: (i) Intention: the health visitor's intention to engage in breastfeeding support, measured on a five-point Likert scale. (ii) Subjective norm: the health visitor's perception of her colleagues’ opinion of her breastfeeding support, measured on a five-point Likert scale. (iii) Evaluation of behavioural outcome: the health visitor's evaluation of the importance that mothers in her district succeeded in breastfeeding, measured on a five-point Likert scale. (iv) Self-efficacy: the health visitor's assessment of her confidence in guidance in five common breastfeeding problems, measured by five questions on five-point Likert scales. (v) Knowledge: active knowledge of breastfeeding practices, measured by 11 questions and correct answers according to evidence-based knowledge added to a knowledge score ranging from 0 to 11. (vi) Management: use of knowledge when guiding the breastfeeding mother, measured by three short case stories concerning painful breastfeeding, insufficient milk, and mastitis and correct answers according to evidence-supported practice added to a management score ranging from 0 to 3. Only questions evaluating behavioural outcome and self-efficacy were repeated in the health visitors’ follow-up questionnaire.
Socio-demographic variables and information on previous breastfeeding included age of the health visitor, number of children, years since education as a health visitor, years in practice, own breastfeeding experiences in weeks, and if breastfeeding of the last child had been a positive or negative experience.
Outcome variables
The outcome variables were measured as the mother's perception of support received from her health visitor. The support was covered by the following variables. (i) Informational support: if the health visitor had talked to her about seven issues related to breastfeeding practices, measured by seven questions and the number of yes answers was counted to an informational support score ranging from 0 to 7. (ii) Instrumental support: if the health visitor had shown her how to breastfeed, measured by yes (1) and no (0). (iii) Comprehensible support: if the health visitor's information had been easy to comprehend, measured on a five-point Likert scale.
Statistical analysis
For each health visitor the outcomes on informational, instrumental and comprehensible support were computed as the average value of the responses given by the mothers whom she had visited.
The characteristics of the mothers and health visitors were described by proportions and associations between variables within each of the two groups were assessed by chi-square tests. The distribution of scores on psychosocial and outcome variables was described by mean values and standard deviations and results in the two health visitor groups were compared by Wilcoxon's rank sum tests. Spearman rho was used to evaluate correlation between socio-demographic variables, previous breastfeeding of the health visitors, and psychosocial variables in the baseline questionnaire, between psychosocial variables in the baseline and follow-up questionnaire, and between the health visitor's psychosocial variables and the average value of the mother's outcome variables. The level of statistical significance was set at P < 0.05.
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Results |
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A total of 109 health visitors who had accepted to participate in the study responded to the baseline questionnaire, and 106 (97%) returned the follow-up questionnaire. No substantial differences were found between the two health visitor groups on socio-demographic factors or the health visitors’ own breastfeeding experiences (table 1). The average age of the health visitors was 47.5 years (7.0 years) and the average number of years in practice was 10.8 years (8.5 years). Among health visitors 81 (74%) had breastfed at least one of their own children more than 12 weeks. The younger and most recently educated health visitors had significantly longer breastfeeding experiences than the older health visitors (P < 0.01). Only five (9%) of the young health visitors (34–48 years) had breastfeeding experiences less than 12 weeks compared with 19 (36%) among the older health visitors (49–63 years). Most health visitors, 73 (72%), reported that breastfeeding their last child had predominantly been a positive experience.
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Table 2 shows the basic characteristics of the 1302 (82% of all included) mothers, who answered the two questionnaires. No significant differences were seen between the mothers in intervention and comparison groups.
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Regarding psychosocial variables, the two health visitor groups differed particularly in knowledge and management of breastfeeding practice (table 3). Health visitors in the intervention group, who had recently completed the training course, demonstrated significantly higher scores on questions reflecting knowledge about lactation and how to guide the breastfeeding mother. Thirty-four (68%) of the health visitors in the intervention group reported the course to be the most valuable source of their present knowledge. In the comparison group, the most valuable source was written literature and experiences from working with breastfeeding mothers, which were reported by 16 (29%) and 14 (25%) health visitors, respectively. Only six (12%) health visitors in the intervention group and ten (18%) in the comparison group indicated their own breastfeeding experiences to be the most valuable source of their present breastfeeding knowledge. Nearly all health visitors, 106 (98%), found that they in general had sufficient knowledge about breastfeeding to manage their daily work. Only two health visitors in the comparison group stated that they had insufficient knowledge.
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Health visitors in both groups reported a relatively high score on intention and evaluation of behavioural outcome (table 3), and these variables were positively correlated (Rho = 0.32, P < 0.01). Scores on subjective norms ranged from one to five with 98 (92%) of the health visitors reporting the score three. Correlations between the psychosocial variables and socio-demographic characteristics of the health visitors were in general insignificant, except for intention that showed significant correlations with age (Rho = 0.29, P < 0.01) and years in practice (Rho = 0.21, P = 0.03). No significant correlations were seen between health visitors’ own breastfeeding experiences and the psychosocial variables.
Table 4 describes health visitors’ self-efficacy before and after the intervention period by group. No differences were seen between the two groups at baseline. After the intervention period, health visitors in the intervention group reported significantly higher self-efficacy in guidance in relation to three of the five common breastfeeding problems compared to health visitors in the comparison group. The change in the health visitors’ self-efficacy score from before to after the intervention period was significantly larger in the intervention group except for the item showing a mother how to cup-feed.
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The median number of mothers per health visitor in the intervention group during the intervention period was 15 (range 4–27), and in the comparison group 14 (range 3–37). Table 5 gives the overall average of the average score per health visitor of the mothers’ perception of the informational, instrumental and comprehensible support that they had received. For all three dimensions of support, the mothers in the intervention group had a significantly larger average score than mothers in the comparison group.
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To investigate if the mothers’ perceived support was related to the psychosocial profile of the health visitor, we evaluated the association between these variables. No correlations were seen between the mothers’ perception of support and the health visitors’ intention, subjective norms or evaluation of behavioural outcome. But the mothers’ average scores on respectively informational and instrumental support were significantly positively correlated with the health visitors’ scores on self-efficacy (Rho = 0.32, P < 0.01, Rho = 0.30, P < 0.01), knowledge (Rho = 0.28, P < 0.01, Rho = 0.39, P < 0.01), and management of breastfeeding practice (Rho = 0.30, P < 0.01, Rho = 0.25, P = 0.01). However, these correlations were weaker and no longer statistically significant when computed within each group.
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Discussion |
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The results show that nearly all health visitors had a strong interest in supporting breastfeeding, and the training course increased knowledge and improved management of breastfeeding practice. During the intervention period, health visitors in the intervention group increased their self-efficacy concerning guidance in common breastfeeding problems, and mothers reported having received more informational and instrumental support than mothers in the comparison group.
The health visitors had more children and longer breastfeeding experience than on average in Denmark. However, unlike previous studies which found that health professionals’ knowledge is mainly derived from personal breastfeeding experiences,12,28 the health visitors reported courses and literature to be their main sources of knowledge. Only 16 (15%) reported own breastfeeding experiences as their main source, suggesting that the majority had a theoretical basis for their practice.
The high scores on intention and behavioural outcome indicate that health visitors in both groups gave breastfeeding support a high priority in their daily work. This is in agreement with other studies where nurses regard themselves as very supportive to the breastfeeding mother,14,15,29 and may reflect encouraging support by the health visitors which Taveras et al.30 found was important for the mother to continue breastfeeding. However, we cannot rule out that the reporting had deviated from actual behaviour.
We found that the health visitors’ knowledge, but not their positive intention, was associated with their actual supportive behaviour as perceived by the mothers. These findings are in accordance with Bernaix10 and indicate that knowledge is an important tool to influence supportive breastfeeding behaviour among health professionals.
In the present study, we found a particularly large difference between the intervention group and the comparison group on knowledge concerning self-regulated breastfeeding, i.e. that each mother and baby have their own rate of milk transfer.31,32 Kapiris and Spicer33 also found the nurses lack in knowledge on this subject. Health visitors in the intervention group were better informed on self-regulated breastfeeding that was addressed on the course. Increase of knowledge obtained during a training course is also reported in other studies.34,35
Our training course, like that of Hillenbrand and Larsen,34 included exercises in breastfeeding guidance to ease the transformation of new knowledge to counselling skills. After the intervention period we found an increased level of self-efficacy among health visitors in the intervention group which correlated with a higher score on knowledge and management of breastfeeding practice at baseline (results not shown). Hillenbrand and Larsen34 also found an increase in confidence four weeks after a training course where the health professionals’ performance in breastfeeding counselling was evaluated by participating mothers. Williams and Hammer36 found a lack of correlation between knowledge and self-confidence in a cross-sectional study which may reflect that knowledge alone is insufficient to increase self-efficacy, practical experiences by working with the mothers are also required.
The two groups of health visitors differed on the level of knowledge and increased self-efficacy and the mothers’ in the two groups differed on the level of perceived support. Therefore, we expected to find an association within groups between these psychosocial variables and the mothers’ perceived support. These associations were statistically significant in the total group, but not when computed separately in each of the two groups. This may reflect the smaller sample size in the subgroup analysis. The association between a higher level of self-efficacy and more counselling are in accordance with the findings of Burglehous et al.11
The participation in the study and the response to the questionnaires were close to 100%, so our data are expected to reflect the study population and selection bias is unlikely. However, the study design had limitations. In the intervention group we had no response to the baseline questions before the training course, and we did not repeat the knowledge questions in the follow-up questionnaire. A detailed assessment of changes in knowledge and self-efficacy scores in the two groups during the training course and the intervention period was therefore not possible. Also, studies have shown37,38 that the success of the health visitor's work depends on her ability to cooperate with the mother and combine consistent and accurate information with a respectful attitude towards the mother's view. These aspects were not explored.
In summary, the health visitor is a key figure in promoting and implementing breastfeeding. Our results show that an interactive course can increase the health visitor's knowledge and management of breastfeeding practice. The health visitors in the study also increased their self-efficacy concerning guidance in common breastfeeding problems during the intervention period where they were expected to apply their updated knowledge into practice, and the mothers in the intervention group reported that they had received more informational and instrumental breastfeeding support. The increase in knowledge and self-efficacy was obtained among health visitors who already had a high level of knowledge. The effect of introducing an interactive supportive breastfeeding course may well be stronger in countries with less developed health care systems.
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Funding for this study was provided by the Danish Health Insurance Foundation (J.nr. 2003B045, 2003), the Lundbeck Foundation (J.nr. FP10, 2002) and the Counties of Ribe and Ringkjobing in Denmark.
Conflict of interest: None declared.
Key points
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