E-learning to Improve Healthcare Professionals' Attitudes and Practices on Breastfeeding

Abstract

Introduction:

Breastfeeding training has a crucial role in increasing healthcare professionals' attitudes and in improving professional support for breastfeeding. The collaboration between the Italian National Institute of Health, UNICEF, and the Local Health Authority of Milan has led to the development of an online course on lactation and infant feeding practices.

Aim:

To assess if the course was effective in improving healthcare professionals' attitudes and practices (APs).

Methods:

We conducted a prestudy–poststudy, comparing users' APs before (T0) and after (T1) the course through a 20-item questionnaire. Changes in APs were analyzed using paired t-test. Lower mean differences indicated more positive attitudes and more frequent professional practices favoring breastfeeding. Statistical analysis was carried out using SPSS version 15.0.

Results:

The course had 26,009 registrants and was successfully completed by 91.3% of users. The dropout rate was 8.7%. The final cohort was composed of 15,004 participants. The course improved attitudes, while minor changes were observed on practices (p < 0.05). Mean total attitude scores were 2.4 at T0 and 1.9 at T1, while mean total practice scores were 2.2 and 2.1, respectively. The main effects regarded the use of medications during breastfeeding (3.02 ± 1.29 at T0 and 1.88 ± 1.08 at T1) and the self-reported compliance with the International Code of Marketing of Breast Milk Substitutes (2.29 ± 1.24 at T0, 2.03 ± 1.21 at T1).

Conclusion:

The noninteractive, high-coverage e-learning approach seems to be a useful tool for improving awareness and positive attitudes toward breastfeeding among healthcare professionals.

Introduction

Healthcare professionals can impact a woman's decision to breastfeed and continue breastfeeding.¹ For this reason, all healthcare professionals who interact with women and children should be aware that breastfeeding is the normal and physiologic way to feed a baby and they should have a basic understanding of lactation. However, some studies have shown that healthcare providers are often not able to support women in cases of problems with breastfeeding or they believe that formula-fed infants are as healthy as breastfed infants.^2,3

Breastfeeding training has a crucial role in improving healthcare providers' knowledge, skills, and attitudes in this area and in increasing professional support for breastfeeding.^4,5

In 1991, the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) launched the Baby-Friendly Hospital Initiative (BFHI) to protect, promote, and support breastfeeding in maternity facilities.⁶ UNICEF Italy launched the Baby-Friendly Community Initiative (BFCI) in 2007 to extend the BFHI to community health centers. Several studies underline that Baby Friendly Initiatives (BFIs) have a positive impact on breastfeeding rates and outcomes.^7,8

In Italy, the BFHI and BFCI are promoted together by UNICEF Italy as “Together for Breastfeeding: Baby-Friendly Hospitals and Communities—United for protecting, promoting, and supporting breastfeeding.”^9,10

In the Italian BFHI/BFCI, there are three different levels of training: a 2-hour introduction for “informed” personnel, a 6- to 8-hour course for “involved” personnel, and the complete 20-hour course for “dedicated” personnel.⁹

As suggested by Semenic, Childerhose, Lauzière, and Groleau, breastfeeding training targeting all staff and using innovative teaching strategies are some of the main facilitators of the BFIs.¹¹ Since continuing medical education (CME) has become mandatory in most countries, e-learning is increasingly popular as an innovative approach to education.^11,12

Among the advantages, e-learning programs allow for large numbers of users and offer a standardized content, without constraints of time or place of learning.¹²

Regarding the outcomes, several studies has shown that e-learning is neither inherently superior to nor inferior to traditional educational approaches in terms of knowledge, skills, and satisfaction.^13,14

The advantages and effectiveness of e-learning could respond to the current need for widespread training for health professionals on breastfeeding, with the goal of implementing the BFIs. In light of this, the Italian National Institute of Health, UNICEF, and the Local Health Authority of Milan began collaborating on developing a national educational program on infant feeding practices based on e-learning.

Aim

The aim of this study was to assess the effectiveness of the e-learning program in improving attitudes and self-declared practices of healthcare professionals.

Methods

Design

A prestudy–poststudy design was used. The study was developed along two time points: T0 (pretraining) and T1 (immediately post-training).

Participants

The cohort included in the study comprised all healthcare professionals who had: (1) completed the course, (2) passed the knowledge post-test, (3) filled out the satisfaction questionnaire, and (4) answered the questions on attitudes and practices (APs) at T0 and T1.

The study excluded nonhealthcare professionals and healthcare professionals who did not meet the CME criteria or did not fill in the AP or the satisfaction questionnaire at T1. Applying these criteria, the cohort comprised 15,004 participants, as reported in Figure 1.

FIG. 1.

Flowchart of cohort selection. AP, attitudes and practices; CME, continuing medical education; HCPs, Healthcare Professionals.

Educational methods

The course was developed by two experts with a panel of reviewers from different backgrounds (midwifery, pediatrics, pediatric nursing, and toxicology). The learning objectives, the contents, and learning activities were geared to a basic level of updated knowledge on breastfeeding and human lactation. The course's targets were healthcare professionals and mothers in peer support groups.

The course was structured according to the learning objectives in two updated e-books, including four mandatory case studies and four optional learning activities, provided to the participants to apply the concepts reported in the study materials.

The e-books were based on a scientific literature review, and included texts, pictures, graphs, “further information” boxes, and references (bibliography and external links to multimedia materials). The first e-book focused on the Promotion of breastfeeding as part of the Health Promotion strategy and from a public health perspective. The second e-book was focused on specific clinical and communication topics.

The case studies were centered on lifestyles, use of alcohol and tobacco, use of medications, mother's perception of low milk production, difficulties in starting breastfeeding, and empowerment of mother, baby, and caregivers. For each mandatory case study, five multiple-choice questions were proposed within the CME system.

Four additional case study exercises, which combined multiple choice and matching questions, were proposed on different topics: observation and evaluation of a breastfeed, growth evaluation, clinical problems, and safe reconstitution of formula.

To access the course, participants had to register, provide some demographic and professional data, and give their informed consent to the data sharing, according to current legislation. All the materials were made available after registration and login on a Moodle-based Web platform. A help desk was available to support participants within 24 hours through e-mail in case of technical problems.

The e-learning course provided eight CME credits and was available free of charge from October 2013 to April 2014, thanks to public funds provided by the National Institute of Health. The estimated time needed to complete the course was 8 hours. Participants had 6 months to conclude all the activities and complete the CME knowledge and satisfaction evaluation questionnaires.

Study instruments and data collection

For the study purpose, the data collection was done through:

- the CME evaluation tools at T1, composed of the knowledge post-test and the satisfaction questionnaire;

- an additional questionnaire on APs, mandatory at T0 and optional at T1.

The knowledge post-test composed of 30 multiple-choice questions (10 from a knowledge test and 20 from the case studies), each of which had only 1 correct answer among the 5 options. The knowledge items were validated during standard WHO/UNICEF preservice and in-service courses,⁶ using difficulty and discrimination index and distractor analysis.

Finally, a 3-item mandatory satisfaction questionnaire was administered (relevance: from “1-not relevant” to “5-very relevant”; quality: from “1-poor” to “5-excellent”; and effectiveness: from “1-not effective” to “5-very effective”).

Participants who scored ≥80% in the knowledge post-test and who filled out the satisfaction questionnaire were eligible for CME credits, and could access the optional AP questionnaire.

The attitudes section of the AP questionnaire consisted of 10 items measured with a 5-point Likert scale, ranging from “1-Completely agree” to “5-Completely disagree” (Cronbach's alpha = 0.76). Lower scores indicated more positive attitudes toward breastfeeding.

The practices section consisted of 10 items measured with a 4-point Likert scale, ranging from “1-Often” to “4-Never/It's not part of my job” (Cronbach's alpha = 0.94). Lower scores indicated more frequent professional practices.

The course aimed to improve knowledge and attitudes and modify some of the most common preconceptions about breastfeeding, as emerging from the literature^15–17 and basing on the panel's field experience. Thus, the AP items were focused on duration and exclusivity of optimal breastfeeding, use of medications, maternal nutrition (food taboos), health risks of not breastfeeding, and normal management of breastfeeding and lactation.

Ethical considerations

According to institutional regulations in Italy, ethics committee approval was not required for this type of observational study where the participants were informed about and agreed to the use of anonymous data in accordance with Italian Data Protection legislation.

Data analysis

Descriptive and inferential analyses were performed. Frequency and percentage of demographic data, namely gender, age, and profession, were determined. The total mean scores of APs were calculated as were the mean scores for each item (T0 and T1), assuming that values at T1 were lower than T0. A paired t-test was used to verify the differences between measurements. Separate one-way repeated-measures analysis of variance (ANOVAs) was conducted to compare APs at the pretest between the selected sample, the dropout group, and no-responders group. Post hoc Bonferroni corrections were also used to adjust for multiple comparisons.

Statistical measurements were conducted using IBM SPSS version 15.0 (Chicago, IL). By convention, the significance level was set at 0.05 (p < 0.05).

Results

Demographic characteristics

There were 26,009 registrants from 28 different professional fields. The course was completed successfully by 91.3% (N = 23,757), while dropout rate was 5.8% and others did not complete the T1 requirements (Fig. 1). Users who met the CME criteria (N = 23,757) were offered the possibility of answering the AP questionnaire on a voluntary basis. Out of these, 15,004 met all the eligibility criteria and made up the cohort of the study.

Mean age was 43.6 years (standard deviation [SD] ±10.4). Most of the participants were women (82.8%) and the top five most represented professions were nurses, midwives, physicians, pharmacists and pediatric nurses (Table 1).

Table 1.

Characteristics of the Cohort (N = 15,004)

Variable	Mean ± SD	n (%)
Age	43.6 ± 10.4
Gender
Female		12,425 (82.8)
Male		2,579 (17.2)
Healthcare professionals
Nurses		7,638 (50.9)
Midwives		2,370 (15.8)
Physicians		1,658 (11.1)
Pharmacists		691 (4.6)
Pediatric nurses		531 (3.5)
Healthcare assistants		373 (2.5)
Radiology technicians		357 (2.4)
Physiotherapists		329 (2.2)
Medical laboratory technicians		294 (2.0)
Dietitians		168 (1.1)
Other healthcare professionals^a		595 (3.8)

Biologists, psychologists, speech therapists, neuropsychomotor developmental therapists, professional educators, dentists, technicians in prevention techniques for the environment and the workplace, technical audiometrists, psychiatric rehabilitation therapists, orthoptist/ophthalmic assistants, technicians in neurophysiopathology, occupational therapists, audiology technicians, physicists, dental hygienists, cardiovascular technicians, veterinarians, and chemists.

SD, standard deviation.

Attitudes and practices

Considering the mean total score, significant differences on APs between T0 and T1 were found (Table 2). Mean total attitude score was 2.4 for the pretest and 1.9 for the post-test. Mean total self-declared practice score was 2.2 and 2.1, respectively.

Table 2.

Attitude and Practice Total Mean Scores (N = 15,004)

Variables	Pretest, mean ± SD	Post-test, mean ± SD
Attitudes^a	2.4 ± 0.6	1.9 ± 0.6
Practices^a	2.2 ± 0.9	2.1 ± 1.0

p < 0.01 significant differences between T0 and T1, paired t-test analysis.

The pretest and post-test results for every item are presented in Table 3. At T1, all APs had improved, except one (practice number 3 on provision of information on smoking). For the attitudes, the main changes were found for the statements “Most medications are compatible with breastfeeding” (T0: 3.02 ± 1.29 versus T1: 1.88 ± 1.08) and “It is not necessary to avoid many foods during lactation” (T0: 2.98 ± 1.32 versus T1: 2.02 ± 1.24).

Table 3.

Attitudes and Practices (N = 15,004)

	Pretest, mean score ± SD	Post-test, mean score ± SD
Attitudes^a
In general, I think that:
1. Nonbreastfed infants have greater health risks (otitis, diabetes, asthma, and cardiovascular diseases) compared with breastfed infants^a	2.10 ± 1.08	1.74 ± 1.02
2. In the first 6 months, babies should take only human milk^a	1.92 ± 1.10	1.38 ± 0.72
3. Breastfeeding can continue beyond 1 year of life^b	1.93 ± 0.98	1.64 ± 0.91
4. Breastfeeding can continue beyond baby's second year of life^b	2.82 ± 1.26	2.34 ± 1.28
5. Most medications are compatible with breastfeeding^b	3.02 ± 1.29	1.88 ± 1.08
6. If a breastfeeding mother has a pain, it is better to endure it and avoid taking medications^b,c	2.61^* ± 1.11	2.41^* ± 1.23
7. Manual expression of human milk is an effective method to maintain its production^b	2.45 ± 1.07	2.09 ± 1.13
8. Many foods, that is, garlic, onion, cabbage, and broccoli, must be avoided during breastfeeding^b,c	2.98^* ± 1.32	2.02^* ± 1.24
9. Baby-led breastfeeding is the normal way to manage the feeds^b	1.95 ± 1.04	1.63 ± 0.92
10. If after being breastfed the baby does not seem satisfied, it is advisable to offer a complement of human milk substitute^b,c	2.71^* ± 1.24	2.37^* ± 1.33
Practices^d
In my professional practice:
1. I actively support breastfeeding^b	2.05 ± 1.15	1.95 ± 1.13
2. I inform women about the risks associated with the use of human milk substitutes and not breastfeeding^b	2.15 ± 1.12	2.00 ± 1.11
3. I inform women about the risks related to tobacco use and the exposure to secondhand smoke during pregnancy and lactation^b	1.78 ± 1.02	1.80 ± 1.03
4. I provide information on legislation for working mothers and policies that support breastfeeding in public places^b	2.34 ± 1.13	2.22 ± 1.14
5. I observe and assess the breastfeeds^a	2.43 ± 1.23	2.35 ± 1.26
6. I demonstrate to women how to express human milk manually^b	2.60 ± 1.17	2.48 ± 1.22
7. I offer information on medication use during lactation, using reliable sources when necessary^b	2.33 ± 1.09	2.17 ± 1.11
8. I use counseling skills in supporting pregnant women and mothers^b	2.11 ± 1.16	2.04 ± 1.17
9. I adhere to the International Code of Marketing of Breast Milk Substitutes^a	2.29 ± 1.24	2.03 ± 1.21
10. I offer information on the community care network (family pediatrician, community mother and child centers, peer support, mother-to-mother groups, etc.)^b	2.14 ± 1.15	2.03 ± 1.14

Likert scale: “1-Completely agree,” “2-Agree,” “3-Neither agree nor disagree,” “4-Disagree,” and “5-Completely disagree.”

p < 0.01 significant differences between T0 and T1, paired t-test analysis.

Inverted score.

Likert scale: “1-Often,” “2-Sometimes,” “3-Never,” and “4-Never/I don't have the opportunity.”

For the professional practices related to breastfeeding, the main improvement was found for the item “I adhere to the provisions of the International Code of Marketing of Breast Milk Substitutes” (T0: 2.29 ± 1.24 versus T1: 2.03 ± 1.21).

AP scores were significantly different among the cohort, the dropout group, and the no-respondents group. The latter two groups resulted in higher mean scores, namely less positive attitudes and less frequent practices on breastfeeding at T0 (Table 4).

Table 4.

Comparison of Attitude and Practice Mean Scores (T0)

Variables	N	Mean attitude score ± SD	Mean practice score ± SD
Respondents (cohort)	15,004	2.4^a ± 0.6	2.2^a ± 0.9
No-respondents group	8,753	2.5^a ± 0.6	2.3^a ± 0.9
Dropout group	1,517	2.5^a ± 0.6	2.3^a ± 0.9

p < 0.01 significant differences, analysis of variance (ANOVA).

Knowledge post-test

The knowledge score was calculated on a scale ranging from 0% to 100% (of correct answers). However, the knowledge score of the cohort ranged from 80% to 100% because an inclusion criterion was having passed the knowledge post-test (≥80%). At the end of the course, the mean knowledge score of the cohort was 93.9% (SD ±4.6, range: 80.6–100.0%).

Level of satisfaction

The top five most represented health professionals declared the following levels of satisfaction: 81.5% assessed the topic as relevant or very relevant, 85.3% considered the quality as good or excellent, and 79.9% evaluated the training as effective or very effective.

Discussion

This e-learning course has been shown to be effective in improving healthcare professionals' APs on breastfeeding. In accordance with the available scientific literature, more changes were observed on attitudes than on practices. In fact, noninteractive educational intervention alone has little impact on complex behaviors and professional practice, while interactive methods can produce greatest changes.^18,19

Despite a significant improvement in attitudes and self-declared practices on the use of drugs during breastfeeding, the option of enduring the pain, even though safe analgesics are available, is still a prevalent idea among participants. This might be due to the cultural constructs of the “good mother,” who makes the safest choice for her baby, and the perceived value of self-sacrifice and suffering related to motherhood.^20,21

At the end of the course, health professionals declared that they offered, more often, information on drugs and lactation, using reliable sources.

The baseline scores for APs on the use of drugs during breastfeeding were low. The need for specific training on this topic was identified in a previous study¹⁷ and addressed through this e-learning course. A recent policy statement by the Italian Society of Perinatal Medicine reaffirmed the need to avoid inappropriate breastfeeding interruption due to an unnecessarily cautious approach by health professionals.²² The relevance of this issue is also underlined by the CDC (2013), according to which “healthcare providers need to be aware of how the procedures they perform or the medications they prescribe can directly or indirectly affect women who breastfeed now or who may do so in the future.”⁴ The results of this e-learning course show that a noninteractive learning experience can be used to improve APs on the use of drugs during breastfeeding among health professionals.

Some studies report that mothers tend to avoid some foods in their diet because they are considered harmful during lactation or because they can give a bad taste to human milk.^23,24 In our experience, a significant improvement was found in the healthcare professionals' attitude regarding dietary restrictions during lactation, resulting in a more unrestricted approach. This positive attitude could impact on some “food taboos,” for example, avoiding garlic and broccoli among nursing mothers.²⁵

The attitude toward exclusive breastfeeding during the first 6 months had a high score at baseline and further improved at the post-test. This knowledge about the most recent recommendations on infant feeding should be part of the minimum standard of awareness among healthcare professionals, as it is crucial to create a breastfeeding-friendly culture and support national policies on breastfeeding for the working mothers.²⁶

Among the self-reported professional practices, compliance with the International Code of Marketing of Breast Milk Substitutes²⁷ showed a significant improvement. Building awareness about the impact of marketing strategies is fundamental, as they impact negatively on breastfeeding.^4,5,27–29 It is widely recognized that a key factor in facilitating parents' appropriate and informed decisions about infant feeding is to improve healthcare providers' knowledge and awareness of the importance of the International Code.²⁸ Nevertheless, there are still important gaps in knowledge with regard to International Code implementation.²⁸

The only practice in which no improvement occurred was “informing women about the risks related to tobacco use and exposure to secondhand smoke during pregnancy and lactation.” A possible explanation is that the contents and methods of this course were not specifically conceived for this learning objective; in fact, effective training interventions for healthcare professionals on this topic are mainly based on interactive and practical learning experience.³⁰

IBFAN reports that in Italy, the preservice training on breastfeeding is poor for physicians and nurses.³¹ This has also been noted in the annual report on the Convention of the Rights of the Child, where the Ministry of Education was encouraged to update breastfeeding curriculum for all those involved in maternal and child health.³² Only the Italian Federation of Midwives has systematically introduced modern and effective curricula and methods based on WHO/UNICEF training materials, in collaboration with the Midwifery Bachelor's Degree Coordinators and National Institute of Health.^31,33

This educational gap has been noted in other settings,^3,34 and to bridge it, UNICEF Italy launched the Breastfeeding Friendly University Course of Studies with specific learning objectives about breastfeeding, based on the one developed by UNICEF UK.³⁵ The program is currently active in midwifery and pediatric nursing programs.

Among the strengths of the online educational package offered, the high level of satisfaction, which was confirmed both in the CME satisfaction questionnaire and by the very low dropout rate, should be noted. Moreover, the course has reached a high coverage of health professionals. It has been completed successfully by 20% of the midwives registered in Italy³⁶ and 3% of the registered nurses and pediatric nurses.³⁷ The pharmacists' participation (n = 1,035) is particularly important due to their front-line position in the local communities, and this e-learning course could support the implementation of the Breastfeeding-Friendly Pharmacy Initiative, launched in 2007 in some Italian regions.^38,39

The online course was mostly taken by female healthcare providers, especially midwives and nurses. This may be due to the fact that, in Italy, most of the healthcare professionals working in maternal and child health services are women. Moreover, female healthcare providers somehow feel closer to the topic because of their own personal experience.^40,41 To ensure that more male healthcare providers, as well as those who do not have a positive attitude toward breastfeeding, take part in future training activities, one strategy might be to make breastfeeding part of the core competencies for all health professionals, as was done by the United States Breastfeeding Committee.⁴² This would guarantee that university programs would include it as part of preservice training and healthcare facilities would offer it as part of in-service training.

Limitations of the study

This study has some limitations, including lack of control group and a selection bias. APs in the cohort are significantly different than in the dropout and no-respondents groups. This phenomenon is well known, as nonrespondents and dropout groups are less interested in the course content and less keen to participate in the survey.⁴³ Some of the participants were obliged by their employers to take the course as part of the BFHI/BFCI accreditation process. CME standard procedures require that knowledge scores only be measured in the post-test and for this reason, we could not estimate the degree of improvement between pretraining and post-training. The health professionals' performance and the health outcomes were not measured, as this was out of the scope of the course. A follow-up study is ongoing to assess long-lasting effects of the e-learning experience.

Further research is needed to compare the cost effectiveness of Web-based, face-to-face, and blended learning experiences within the BFIs, both in academic curricula and healthcare services.

Conclusions

Healthcare professionals have an important role in breastfeeding support. Scientific knowledge changes rapidly and healthcare professionals need continuous updates. E-learning programs for healthcare professionals based on case studies are effective in improving their APs toward protection, promotion, and support of breastfeeding and in eradicating some beliefs and myths. Web-based educational interventions can reach an extensive number of professionals and they can successfully complement face-to-face and on-the-job learning experiences.

Footnotes

Acknowledgment

This research received no grant from any funding agency in the public and private sectors for the research, authorship, and/or publication of this article.

Disclosure Statement

No competing financial interests exist.

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