Setting
The researchers conducted the current study at the hospital affiliated to the Faculty of Medicine, Cairo University.
Study design and phases
Phase I was an exploratory cross-sectional study to assess the breastfeeding-related knowledge and attitude among participating interns, as well as their willingness and suggestions to improve their knowledge and skills in the field of breastfeeding.
Phase II was an interventional design to measure the effect of training sessions on breastfeeding-related knowledge and attitude among medical interns.
The study took place over a 6-month duration.
Population and sampling method
Population
Medical interns in the academic year 2017/2018 were selected for the study because this is a phase where they would have already been exposed to the various aspects of basic and clinical subjects which address the needs, advantages, and status of infant-feeding practices. Thus, exploring their current knowledge on infant feeding practices and providing them with adequately designed health education sessions about breastfeeding would help them in better interaction with expectant and lactating mothers once they start their full-time clinical practice. During their internship, interns are distributed over six groups for rotations in different specialties. A purposive sample was used to select the first group of interns who already finished their rotations in the Obstetrics and Gynecology as well as the Pediatrics departments, where interns could have been exposed to breastfeeding education. This selection also provided enough time for the researchers to assess, intervene, and evaluate the immediate and 6 months after the intervention on intern’s breastfeeding knowledge and attitude.
Sample size
Among the selected interns who fulfilled the previous inclusion criteria (n = 150), 146 agreed to participate (response rate 97.3%) and fill in the questionnaire, but nine were excluded as the questionnaires were not filled in correctly. This condition resulted in including 137 interns in the study. For the interventional phase, using MedCalc program version 11.0 and mean difference in knowledge percent score 11 ± 8.95 [10] with alpha = 0.05 and power 99%, the calculated sample size was found to be 15; adding a 20% expected non-response rate, the sample size was 18 interns. Fifty interns were recruited to the study. Those 50 interns were selected from the total 137 by a simple random sample to be included in this phase of the study. Six were dropped out, and only 44 were included (a response rate of 88%) as they attended the two educational days and filled in the required questionnaires (before, immediately after, and 3 months after the educational intervention).
Intervention
Medical interns were invited to attend two educational sessions, 2 h duration each. The sessions were carried out by the IBCLC (International Board Certified Lactation Consultant) over 2 days. They covered all components of the 20-h UNICEF/WHO course for breastfeeding promotion and support in a baby-friendly hospital [11].These components are updated technical information and additional clinical practice sessions (using dolls and role plays) and an emphasis on supportive practices during labor and birth, skin-to-skin contact, early initiation of breastfeeding, recommendations for breastfeeding duration, breastfeeding problems management, preparation for discharge, and HIV considerations. The current study’s intervention covered briefly all the items of the 20-h course in the form of a power point presentation, discussion, and problem-solving. Interns were asked to fill in a questionnaire before sessions, immediately after the end of the last session, and 3 months later.
Data collection
A pre-tested self-administered questionnaire was used and included the following items:
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1.
Personal data including age, sex, nationality, and planned specialty
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2.
Knowledge about breastfeeding including the following questions: advantages for the baby, maternal benefits versus limitations, colostrum, adequate feeding, duration of feeding, complementary feeding, breast milk expression, problems with breastfeeding, and the practical aspect of breastfeeding. The researchers constructed the knowledge questions based on the content of the UNICEF/WHO 20-h course [11]. A sixty-one closed-ended format was used with true/false and do not know options. A score of 1 was assigned to the correct answer, and a score of 0 was assigned to the incorrect or do not know answers. The total score ranged from 0 to 61. The number of correct answers was added for each item to obtain nine subtotal knowledge scores, and a total score was calculated to measure the total knowledge score by adding the number of correct answers for the nine items. Transforming the subtotal and total raw scores into percent scores was done by dividing the raw score for each item on the maximum achievable score and then multiplying the result by 100
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3.
Attitude towards breastfeeding was tested using the following tools:
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(a)
Iowa Infant Feeding Attitude Scale (IIFAS), a validated instrument shown to have a Cronbach α ranging from 0.85–0.86 [12] .The IIFAS covers various dimensions of infant feeding within its 17 statements, and respondents were asked to indicate the extent to which they agree with each statement on a five-point Likert scale ranging from 1 = “strongly disagree” to 5 = “strongly agree.” IIFAS scores range from 17 to 85, with a higher score indicating a more positive attitude towards breastfeeding. Transforming the total raw score into percent score was done by dividing the raw score on the maximum achievable score and then multiplying the result by 100.
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(b)
For further assessment of interns’ attitude towards breastfeeding in practice:
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I.
All interns were asked if they would encourage expectant and lactating mothers who are their relatives or friends to breastfeed.
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II.
Female interns were asked if they would breastfeed their babies as future mothers.
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III.
Male interns were asked if they would encourage their future wives to breastfeed their babies.
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IV.
All interns were asked about their opinion towards incorporation of a mandatory breastfeeding course during the internship year, and about their willingness to participate in breastfeeding clinic activities.
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4.
Interns’ recommendations to improve breastfeeding education: the provided recommendations were recorded, grouped and presented as percentages.
The questionnaire was pretested with a convenience sample of 10 interns (not included in the study), and the required modifications were done.
Statistical analysis
Pre-coded data were entered into the Statistical Package of Social Science (SPSS) version 21. The data were summarized using mean and standard deviation for quantitative normally distributed variables, while the median and interquartile range (IQR) were used for quantitative variables, which were not normally distributed. Numbers and percentages were used for qualitative variables. Comparisons between groups were done using the Chi-square test for qualitative variables, non-parametrical Mann-Whitney U test and Kruskul-Wallis tests for quantitative variables which were not normally distributed.
Testing the effect of breastfeeding education on knowledge and attitude scores was done using non-parametrical Freidman test and Wilcoxon sign rank test for quantitative variables which were not normally distributed. For qualitative data, Cochran’s Q and McNemar tests were used. Nonparametric correlations were done to test the relation of interns’ age with their knowledge and attitude scores. P values less than or equal to 0.05 were considered statistically significant.