Exclusive breastfeeding knowledge and practices among health care workers in northern Tanzania.

Background Exclusive breastfeeding (EBF) practice is one of the interventions improving child survival. Health workers have been shown to be vital in in�uencing EBF practices. Objectives To assess the level of knowledge and supportive practices on EBF among healthcare workers Kilimanjaro region, northern Tanzania. Methods A cross sectional study was conducted between April - June 2011 health care providers working in 36 randomly selected health facilities of Hai and Siha districts. A questionnaire was used to obtain information. Observation of health worker-client interaction was conducted using a check list. Results A total of 250 health workers participated in this study. The majority (80%) had adequate knowledge of EBF. However, 36% of providers believed light porridge should be introduced after 4 months and 43% believed infants will feel thirsty on breast-milk alone. Only 7% of providers answered correctly on skills of support, positioning and attachment. Fifty percent of the facilities with labour/maternity wards gave breastfeeding lessons to post delivery women. The majority (90%) gave theoretical information, without practical demonstration with positioning and/or attachment of the baby to the breast. Conclusion Providers had adequate theoretical knowledge of EBF but lacked important skills to support women in breastfeeding practices. Few labor/maternity facilities used the opportunity to educate women on EBF. Pre-and in-service health providers’ training on breastfeeding should target improved practical skills.


Background
Exclusive breastfeeding (EBF) is not optimally implemented world-wide.Estimates indicate that 42% of infants are exclusively breastfed globally (1).In Sub -Saharan Africa (SSA), the setting with highest prevalence of infant and child mortality, suboptimal breastfeeding practices are common (2).Only 36% of SSA infants are exclusively breastfed (3).In Tanzania, the Demographic Health Survey indicates that only 59% of infants are exclusively breastfed (4).It has been estimated that exclusive breastfeeding for the rst six months could reduce more than 800,000 infant mortality (5).Exclusively breastfed children are at lower risk of infection from diarrhoea and acute respiratory infection (ARI) than infants who are mix fed in the rst six months of life (5)(6)(7).Diarrhoea and ARI are the two major causes of child mortality in low and middle income countries, contributing 33% of the 6.9 million deaths occurring each year globally (5).
Exclusive breastfeeding (EBF) has also been shown to reduce mother-to-child HIV transmission compared to mixed feeding, an important preventive aspect in high HIV prevalence countries (8).Studies have shown health workers in uence the exclusive breastfeeding practice.Health workers are highly respected in SSA, and women take their advice seriously (9,10).They have an opportunity to educate mothers on breastfeeding and provide necessary support at antenatal, delivery and post-natal periods.In fact most SSA countries including Tanzania use the opportunity of high antenatal attendance to improve EBF practices and have policies that require health providers to offer education, counselling and support on breast feeding in general and on EBF to pregnant and lactating mothers (11,12).Results of several studies showed that more than 70% of lactating women reported to have received information on breastfeeding from health providers (9,(13)(14)(15).Findings from India, Ghana, and Tanzania showed that children of mothers assisted at delivery by health professionals or mothers who delivered in health facilities were more likely to initiate breastfeeding within one hour after birth, less likely to be given prelacteal foods and were still EBF at 3 months (4, 11,[15][16][17].Counselling on EBF in the immediate postnatal period, rooming in, prohibition of formula milk and paci ers in the wards as well as having strong Baby Friendly Hospital Initiative (BFHI) policies were all associated with a 2-7 fold increase in median duration of EBF and overall EBF prevalence at 3-4 months post-delivery (18-20).Health care providers can support and promote correct breastfeeding and EBF practices when they have correct knowledge, attitudes and skills on breastfeeding (21).However there is a dearth of information about health care providers' knowledge of EBF and supportive practices.In Tanzania no published information exists on health workers knowledge and skills on EBF.This study aimed to describe the knowledge, attitude and supportive practice on exclusive breastfeeding among health care providers in two districts at Northern Tanzania.

Study population, sample size and sampling
The study population included health care workers (HCWs) from selected health facilities both government and private, providing RCH services in Hai and Siha districts.HCWs included nurses and clinicians providing services to mothers and children i.e. those working in maternity ward or labour ward, working in RCH clinics, and in paediatric wards.We excluded health workers that did not consent for participation, were administrators not supervising RCH services and on leave during the study.
Sample size was calculated using Epicalc 2000.The prevalence of knowledge of breastfeeding among health care providers of 19.2% was used (from a study conducted in Nigeria by Okolo and Ogbonna, in 2002), alpha error level was set at 5%, power of 80% and addition of 5% for non-response.Substituting the values, a minimum sample size of 250 was obtained.
A multistage sampling technique was used.The rst stage involved selection of health facilities.The health facilities were selected to re ect all levels of health care provision in the district including hospitals, health centres and dispensaries both government and private.All hospitals (N = 3) were included in the study, while simple random sampling was used to select seven of nine health centres and 26 of 49 dispensaries.The second stage was selection of healthcare workers re ecting the proportion of HCWs at different levels.Proportionate sampling was used with 38% (95) of participants from hospitals, 27% (68) from health centres and 35% (87) from dispensaries, giving a total sample of 250 health care providers.Simple random sampling was then used to select providers at respective health facilities.

Data Collection
A questionnaire consisting of both closed and open-ended questions was used to collect information from HCWs providing RCH services.A checklist was used to assess if breastfeeding education is given to pregnant and post-partum women, and if nurses demonstrate skills to women in post-natal wards in initiating and maintaining breastfeeding.

Instruments and Measurements
The questionnaire included socio-demographic characteristics of the HCWs (age in years, sex, marital status, education, cadre (nurse or clinician), years of experience, in-service training on breastfeeding, and district of work and facility ownership).Other variables measured were knowledge, attitudes and supportive practices on EBF.The questionnaires were self-administered and made available in Kiswahili (the local language).The questionnaire was pretested in health facilities not included in the study to ensure clarity of interpretation and ease of completion.
A standardized checklist was used for observation of supportive practices on exclusive breastfeeding by health care providers in ten health facilities including the three hospitals, four health centres and three dispensaries with RCH and delivery services.

Knowledge on exclusive breastfeeding
Seven questions covering four themes were used to summarize the level of knowledge.
The themes were; knowledge of the WHO de nition of EBF (had four items: knowledge on WHO de nition and duration on EBF, knowledge on breastfeeding initiation (had three items: when to start initiation of breastfeeding, importance for breastfeeding initiation and colostrum giving), knowledge of frequency of breastfeeding (one item: demand feeding) and knowledge on bene ts of exclusive breastfeeding (two items: for the mother and child).Correct knowledge of any of the item was given a score of one; giving a minimum score of 0 and a maximum score of 4. Those who scored 3 or above were graded as having su cient knowledge on EBF and those scored below 3 were categorized as having poor knowledge.

Attitude towards exclusive breastfeeding
Likert type scales (ranging from 1-4) were used for attitudinal questions to allow for varying degrees of agreement or disagreement.A score of 4 implied strong agreement, 3 implied agreement, 2 implied disagreement and a score of 1 implied strong disagreement with positively framed attitude statements whereas; scoring were reversed for a negatively framed attitude statement.A score of 4 implied strong disagreement and a score of 1 implied strong agreement.There were 7 attitude questions with maximum score of 28 and minimum score of seven.All questions were given equal weight.Those scoring 17 and above were categorized as having positive attitudes towards EBF.

Skills and supportive practices on EBF
Skills/practice was measured by 3 questions with the aim of categorizing those with good practice and those with poor practice.Overall score on supportive practice for EBF was calculated based on 4 points of advice for positioning, 4 points on advice for attachment, and or more was considered to have "good supportive practice for EBF" and score below 7 to have "poor supportive practice on EBF".

Data Analysis
Data was cleaned, checked for consistency and open-ended questions categorized and coded before analysis.Data was analysed using computer software SPSS version 16.0.Descriptive statistics were used to summarize data, proportion for categorical variables and mean or median with their respective measures of dispersion for continuous variables.Difference between groups was analysed by using Chi squire test for categorical data.

Socio demographic characteristics of study participants
A total of 250 health care workers participated in the study.The median age of participants was 44 years (range 22-60 years).Majority of the participants were; females (76%), nurses (67%), had 11 or more years of work experience (69%) and had attended in-service training on breastfeeding & EBF in past 5 years (66%), Table 1.Of the 167 nurses the majority were nurse midwives 121 (72%), the rest were nurse o cers, while among 83 clinicians the majority were clinical o cers 62 (75%), followed by assistant medical o cers 18 (22%) and the rest were medical o cers.3.In total 47.6% (N = 119) health providers had positive attitudes towards exclusive breastfeeding.Six out of ten providers felt they can comfortably support women for EBF for six months and could advice working mothers to express breast milk for their infants.However, a substantial proportion 36% (N = 89) of the respondents were of the opinion that exclusively breastfed babies could be introduced to fruit juice and light porridge at 4 months, 43% (N = 108) of HCWs believed infants will feel thirsty on breast milk alone and 26% (N = 65) believed HIV positive mothers need to be advised not to breastfeed.Respondents with advanced diploma/degree were three times more likely to have positive attitudes towards EBF than those with lower quali cations (AOR, 2.80, 95% CI, 1.01-7.79).
Age, cadre, years of experience, district and facility ownership were not associated with attitudes towards EBF see table 3 a Agree includes all who responded, "strongly agree" and "agree".
b Disagree includes all who responded "disagree" and "strongly disagree."c Disagree or strongly disagree is the correct response Health care workers supportive practices towards EBF Nearly 94% (N = 234) health care providers reported that they were actively counselling women on exclusive breastfeeding.Many providers 63.6% (N = 159) reported that, they had taught and supported mothers on proper positioning and attachment of the baby to the breast.But when asked to mention four important steps for good positioning and attachment, the vast majority (93%) were not able to mention the steps of good positioning or attachment of the baby to the breast (Table 4).
Further, supportive practice on EBF was assessed by asking respondents how they usually advise lactating women who complain of not having enough milk, to breastfeed their babies.During observation of key supportive practice on EBF by health facilities using a structured checklist, all the 10 assessed health facilities had IEC materials on the walls regarding breastfeeding and were practicing rooming-in, see Table 5.There was however lack of IEC materials for women to read at home.Regarding counselling on breastfeeding, ve (50%) of facilities with labour/maternity wards were observed to give breastfeeding & exclusive breastfeeding lessons to post-delivery women who were still in the ward.Majority (90%) were giving theoretical information focusing on de nition of EBF, duration EBF/ BF, and advantages of breastfeeding.There was only one facility (Siha District hospital) where they demonstrated positioning and attachment, counselled women on early initiation of BF, demand feeding, management of breastfeeding problems and did individual counselling and women had to demonstrate skills in proper positioning and attachment and breastfeeding in general before they were discharged.

Discussion
The study ndings showed that health care workers in this study had good knowledge of EBF (80%).While other researchers use only the WHO de nition to assess knowledge on EBF, multiple questions were used to evaluate the level of knowledge on EBF in this study, and still the theoretical knowledge was high (14,22).Similar results of high knowledge were found in Ibadan, Nigeria where 90% of health workers had good knowledge of duration for EBF including advantages of breastfeeding.(23).Okolo & Ogbonna (2002) in Nigeria assessed the level of knowledge, attitude and practice among health workers on BFHI practices and found that only 20.8% of health workers were aware of the need for initiating breastfeeding within 30 minutes of birth while 92% of health providers in our study knew the correct time of BF initiation (22).
In this study health care workers who have attended in-service training on breastfeeding had increased odds to have good knowledge of EBF as the non attendee group.This is similar to studies in Kenya and Nigeria which showed improvement in breastfeeding knowledge among health workers after training on breastfeeding (22,24).During the survey it was noted that, the two districts involved in this study were among seven districts in Tanzania which received intensive support from UNICEF for implementation of breastfeeding promotion activities including other programmes on child survival and development hence, the situation may differ from other districts which did not receive such support.
Nearly 4 out of 10 health care workers believed that babies who are exclusively breastfed do not get enough water from the breast milk and others felt that babies should be introduced to fruit juice and light porridge at the age of four months.Giving babies anything other than breast milk in the rst six months interferes with demand suckling and increases the risk of both diarrhoea and respiratory infections (5,7,21,25).These beliefs might have negative impact on EBF.Studies have observed that, in some societies, health workers recommendations and information are highly valued by mothers and they often take their recommendations as the nal word (9,14).If health care gives mixed and incorrect messages it will confuse many women attending the RCH services as health care workers are believed to be the primary source of accurate and helpful information to mothers regarding most issues in maternal and child health including EBF (9).It is also important to note that 74% of health subjects in this study reported to have received information on breastfeeding and EBF from training.These identi ed gaps need to be recti ed or addressed during pre and in-service training of providers in breastfeeding.
In this study, one in four health care workers felt that HIV-positive women need to be advised not to breastfeed.This is contrary to the national guidelines which states that all the HIV positive women should exclusive breastfeed their infants for the rst six months, and advised otherwise only if alternative feeding is affordable, available, feasible, safe and sustainable (26).With most developing countries moving to option B + i.e. treating every HIV-positive pregnant and breastfeeding woman with triple antiretroviral therapy, the chance of breast milk transmission is low.Thus WHO in 2010 and Tanzania in 2013 have changed the advice and currently HIV-positive women also should exclusively breastfeed their infant for six months, and can continue to breastfeed up to 12 months of age (27,28).These rapid change of recommendations in infant feeding among HIV-positive women needs to be rapidly disseminated to providers on the ground, as studies have observed it may take years for providers to became aware that guidelines have changed (29).
The vast majority of health care providers in this study had poor skills despite having good knowledge on EBF.Two thirds of the respondents indicated they had taught and supported mothers on proper positioning and attachment of the baby to the breast but surprisingly, only one in ten could list correct steps for good positioning and attachment to demonstrate the quality of practical skills to support mothers on EBF.Good positioning and attachment are two most important skills every lactating mother needs to be taught to comfortably establish EBF, maintain breastfeeding and prevent development of breast problems like engorgement and cracked nipples (21).Breast problems are among the factors negatively in uencing duration of EBF (30).
Poor skills in supporting breastfeeding have also been observed in Nigeria where, only 5.2% of health workers interviewed were able to demonstrate correct positioning of the baby for breastfeeding (22).This calls for the need to assess the current training on breastfeeding for health care providers in the country and change the curriculum to emphasize on development of clinical/practical skills (24).Competence based training using mannequins and videos which have been shown to improve clinical skills among health care workers in performing signal functions of emergency obstetric care should be applied to breastfeeding trainings (31).Only one health facility was observed to give practical demonstrations to postnatal women on how to position and attach the baby to establish breastfeeding within the 24 hours after delivery.It might be that providers are not teaching practical skills due to lack of skills themselves.
Or it may be due to the fact in many facilities there is severe shortage of human resources resulting into low quality of care (32).This is a missed opportunity given that 86% and 96% of women in Kilimanjaro deliver at health facilities with skilled providers in the year 2010 and 2016 respectively (4, 11).Studies have shown a correlation between women's intentions to EBF, con dence or skills in breastfeeding and duration of exclusive breastfeeding (18)(19)(20)24).The need to improve breastfeeding practices as one of the strategies to improve neonatal and child health and attain the sustainable development goal 3 of promoting wellbeing (33).One of the things to target is improving health provider's skills in supporting breastfeeding and improving their knowledge and skills in broader topics pertaining to reproductive, maternal, newborn and child health so as to offer holistic and integrated care.
The study has some limitations.Information on practices of health care providers on skills in supporting women was obtained from interviews, and observation of individual providers was not performed.To get more information, future studies should use real time clients or mannequins to assess the skills of providers.Also observations conducted at postnatal wards on supportive practices to initiate and maintain breastfeeding took a day at each site.We may have thus underreported facilities were not performing the practices e.g.management of breast conditions (cracked nipples), but perhaps in practice they sometimes do offer support.

Conclusions
Despite the limitations, the ndings show that the majority of health care providers had good theoretical knowledge on EBF but lacked important skills to support women in breastfeeding practices.Also very few maternity wards facilities use the opportunity to educate women on exclusive breastfeeding.Training of health providers on breastfeeding should speci cally aim to improving health care providers' practical skills on positioning, attachment and what to do in case women complain of not having enough milk.

Declarations
Ethics approval and consent to participate Ethical approval to carry out the research was obtained from KCMU -College Research and Ethical Review Committee and permission to carry out the study in the respective health facilities were sought from District Medical O cer (DMOs) of Hai and Siha districts, and in-charges of the participating health facilities.Signed informed consent was obtained from the participants.

Consent for publication
Not applicable Study design and site A cross sectional study was conducted between April -June 2011 in Hai and Siha districts of Kilimanjaro Region, Northern Tanzania.Hai and Siha districts are among the 7 districts of Kilimanjaro Region.Hai district had a projected population of about 197,000 by June 2010, based on 2002 national census.Hai district has a total of 57 health facilities where 46 are providing Reproductive and Child Health (RCH) services.These include; 2 hospitals, 6 health centres and 38 dispensaries both government/public and voluntary agencies.Siha district had projected population of about 120,000 with total of 22 health facilities, 8 owned by the government and 14 privately owned.Of the 22 health facilities of Siha district, 15 provide RCH services.A total of 36 of 61 facilities with RCH services in the 2 districts were randomly selected and included in the study (24 facilities from Hai district and 12 from Siha district).

Table 1
Socio-demographic characteristics of the participants (N = 250) Knowledge of and sources of EBF informationThe majority (97.6%) of respondents were aware of exclusive breastfeeding (EBF), the main source of information being training 74.4% (N = 186), and from colleagues 51% (N = 128), Fig.1.Nine out of ten HCWs knew correct the time to initiate breastfeeding and bene ts of EBF, Table2.Two thirds 166 (66.4%) of healthcare providers had su cient knowledge of the WHO de nition and duration of breastfeeding.Overall, 201 (80.4%) health workers were found to have good knowledge on exclusive breastfeeding.In-service training on EBF was the only predictor associated with good knowledge of EBF among the HCWs [adjusted odds ratio (AOR) 2.07; 95% CI 1.09-3.95].

Table 2 :
Knowledge on exclusive breastfeeding among health care providers in Kilimanjaro region,

Table 3 :
Attitudes of health care providers towards exclusive breastfeeding in Kilimanjaro region,

Table 5 :
Assessment of key supportive practices on breastfeeding by health facilities (N = 10)