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Physicians and breastfeeding : beliefs, knowledge, self-efficacy and counselling practice Burglehaus, Maria Jean 1994

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PHYSICIANS and BREASTFEEDING: BELIEFS, KNOWLEDGE SELF-EFFICACY and COUNSELLING PRACTICES by MARIA JEAN BURGLEHAUS B.Sc, McGill University, 1991 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE MASTERS of SCIENCE in THE FACULTY OF GRADUATE STUDIES (Department of Health Care and Epidemiology)  We accept this thesis as conforming to the required standard  THE UNIVERSITY OF BRITISH COLUMBIA April 1995 © Maria Jean Burglehaus, 1995  In presenting this thesis in partial fulfilment  of the requirements for an advanced  degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department  or  by  his or  her  representatives.  It  is understood that  copying or  publication of this thesis for financial gain shall not be allowed without my written permission:  Department The University of British Columbia Vancouver, Canada  DE-6 (2/88)  ABSTRACT  Reversing the problems of breastfeeding failure and bottlefeeding choice depends on physicians who are skilled in breastfeeding support and management. The following study aimed to assist an urban British Columbian hospital intending to develop breastfeeding education for its physicians. The study sought specifically to determine which predisposing factors to target in order to improve physicians' willingness, motivation and ability in counselling about and managing breastfeeding. The aims of the investigation were: 1) to provide baseline data on the physicians' attitudes, beliefs, knowledge and self-efficacy concerning breastfeeding counselling; and 2) to identify which measures including cognitive factors, gender, specialty, years in practice and personal or spousal breastfeeding experience might be independently predictive of physicians' self-reported counselling behaviours.  A pilot-tested survey was mailed to the offices of all 325 obstetricians, pediatricians, family practitioners and general practitioners with privileges at the hospital. Response rate was 67.3 percent. The female physicians were much more likely to respond than male physicians; response rates of 86 and 57 percent respectively.  Ninety percent of the respondents reported always or usually discussing breastfeeding with their patients prenatally (65% always do) and 88% reported always or usually attempting to convince mothers to breastfeed if they intend to bottlefeed (41% always do). Correlational data showed weak to moderate associations between the reported cognitive factors and counselling behaviours. The strongest of these associations suggest that physicians counsel more if they feel confident and if they believe strongly in the immune properties of breastmilk.  Female physicians expressed greater self-efficacy in counselling the mom about breastfeeding problems and in positioning the baby at the breast (p < .001). Self-efficacy scores were higher for both male and female physicians whose children were breastfed (females, p <.001; males, p< .01).  The measures of self-confidence, knowledge and beliefs were added to a regression model containing measures of gender, specialty, years in practice and personal or spousal breastfeeding experience to determine whether additional variance in the counselling behaviour could be accounted for. Physicians attempted to convince women to breastfeed if they believed in the immune properties of breastmilk (Beta =.63, p=.08) and were confident in their own breastfeeding counselling (Beta =.21, p=.004). Likewise, encouraging women to continue breastfeeding in the face of breastfeeding problems was related to belief in the immune properties of breastmilk (Beta =1.04, p=.021) and confidence in breastfeeding counselling (Beta =.20, p=.038).  Knowledge of how to position the infant at the breast was associated with whether physicians reported discussing breastfeeding with the patients (p<05). However, when asked to identify which of the two pictures of the infant at the breast is in fact correct, 12% of physicians chose the wrong picture. Physicians also felt that supplementation was indicated for twins, infants with a difficult latch (suckling technique), and in cases requiring an emergency C-section. These are not, however, medical indications for supplementation.  Despite more than a decade of research suggesting the need for breastfeeding education to physicians, little if any education has been provided. Revision of medical school curricula and development of continuing education are necessary to improve physicians' interest in breastfeeding and to provide specific skills that will increase physicians' competence and self-efficacy in counselling patients about breastfeeding.  TABLE OF CONTENTS Abstract  »  Table of Contents  iv  List of Tables  •• vi  List of Figures  viii  Acknowledgement  ix  INTRODUCTION  1  Benefits of breastfeeding  1  Infant feeding recommendations  2  Physicians do not meet breastfeeding counselling recommendations  3  Chapter 1: Literature Review...  6  Theoretical background  6  Research objectives  16  Chapter 2: Methodology, Variables and Data Analysis Methodology  18 18  Instrument development and pilot-testing  18  Mailing of the questionnaire  19  Dependent and Independent Variables  20  Methods of analysis  22  Reliability analysis  23  Descriptive statistics and univariate and correlational analyses  24  Regression analyses  25  Chapter 3: Results  27  Feedback from the pilot test  27  Results of the mailing-out and data collection processes  27  Response rates and characteristics of the sample  28  Reliability analyses results  34  Univariate and correlational analyses results  36  Counselling behaviours: descriptive statistics and differences by gender, specialty, years in practice, ethnicity and personal or spousal breastfeeding experience  36  Physicians' beliefs, self-efficacy and knowledge: descriptive statistics and differences by gender, specialty, years in practice, ethnicity and personal or spousal breastfeeding experience  41  Counselling behaviours by self-efficacy, beliefs and knowledge  43  Predisposing variables: gender, specialty, years in practice, ethnicity and personal or spousal breastfeeding experience differences Results of the regression analyses Chapter 4: Discussion  45 49 54  Counselling behaviours  55  Methodological limitations  61  Implications for future research  64  Implications for policy and education  66  Bibliography  71  APPENDIX 1: Final Survey  77  APPENDIX 2: Selected Regression Analyses Results  86  List of Tables  Table 1. Summary of breastfeeding studies: settings and response rates  13  Table 2. Components to be included in the thesis  16  Table 3. Flow of the mailing-out and data collection processes  28  Table 4. Response rate by physician specialty  29  Table 5. Response rate by gender  31  Table 6. Response rate by years in practice  32  Table 7. Response rate by ethnic origin  32  Table 8. Gender and years in practice by physician specialty of the respondents and study population  33  Table 9. Personal or spousal breastfeeding experience  34  Table 10. Counselling behaviours  35  Table 11. Occurrence of counselling by counselling behaviours categories  38  Table 12. Counselling behaviours by gender and ethnicity  39  Table 13. Dichotomized counselling behaviours by gender  40  Table 14. Counselling behaviours by specialty  40  Table 15. Belief levels concerning breastfeeding  42  Table 16. Self-efficacy and knowledge variables  43  Table 17. Counselling behaviours by self-efficacy, beliefs and knowledge  43  Table 18. Beliefs by specialty  45  Table 19. Beliefs by gender and by spousal or personal breastfeeding experience... 46 Table 20. Mean self-efficacy scores by gender  47  Table 21. Knowledge by specialty, gender, years in practice and personal or spousal breastfeeding experience  47  Table 22. Preferred methods to receive information on breastfeeding  48  Table 23. Reports of indications for supplementation  49  Table 24. Final regression models  51  Table 25. Findings from this study and previous studies: comparison and contrast... 52 Table 26. Counselling behaviours: a comparison to similar studies  55  List of Figures  Figure 1. Short-term and mid-term impacts of the breastfeeding education program. 11 Figure 2. Hypothesized regression model and potential components  26  ACKNOWLEDGEMENT  I would like to acknowledge the thesis supervisor, Dr. Lawrence W. Green, whose teachings and guidance have been integral to the thesis. My sincere thanks to Dr. Samuel Sheps and Dr. Lorie A. Smith for their crucial input and dedication. Funding from the Department of Family Practice of B.C. Women's Hospital and Health Centre Society and by the B.C. Medical Services Foundation as well as the use of computer software at the Institute of Health Promotion Research, UBC, were much appreciated. I would also like to thank Margaret Cargo affectionately for her advice, encouragement and motivational enthusiasm.  1  INTRODUCTION  Benefits of breastfeeding  Recent reviews of the overall reduction in risk of death with breastfeeding suggest that one-third to one-half of current infant deaths in North America are because of a failure to breastfeed fully (i.e., to give breastmilk exclusively for the first 4 to 6 months of age, then breastmilk plus solid food until 12 months) (Damus et al., 1988; Madeley et al. 1986). One study estimated that between 1 and 12 months of age, the U.S. infant that is not fully breastfed runs three times the risk of dying compared to the fully breastfed child (Adebonojo, 1972).  Problems that a baby can experience when fed with formula or other non-human milks include more respiratory and gastrointestinal illnesses, allergies and ear infections, reduced psychological development and neurodevelopment and increased risk of sudden infant death (Casey & Hambidge, 1983; Lucas et al., 1990 & 1992; Damus et al., 1988). Epidemiologists currently suggest that breastfeeding appears to provide substantial protection for the mother too: protection against breast cancer (Layde et al., 1989; Byers et al., 1985), ovarian cancer (Whittemore, 1993) and osteoporosis (Aloia, 1985). Partially breastfeeding infants in which breastfeeding is augmented with an artificial baby milk is not recommended, unless medically indicated; 3 to 5% of mothers are medically unable to breastfeed.  All levels of health care have endorsed breastfeeding as the preferred method of infant feeding. The Canadian Paediatric Society (1991) supports the WHO - UNICEF recommendation that infants should be breastfed exclusively for the first four to six months of life. The first milk or colostrum is particularly nutritious. While continued breastfeeding is best, any number of weeks of breastfeeding is beneficial. Solids are introduced at five to six  2  months. The infant is breastfeeding less often and the mother's body adapts so that each breastfeed becomes more potent in terms of immunological properties (Minchin, 1985).  Infant feeding practices fall short of recommendations  Currently, in Canadian hospitals, 80% of new mothers initiate breastfeeding. This figure does seem to be an improvement over the 1982 rate of 70%; it is definitely much better than initiation rates of 38% in 1963 (Health and Welfare Canada, 1990). However, less than one in four newborns leave hospital having been fed only breastmilk and 71% of infants receive supplements in hospital. This high rate of supplementation leads one to question the usefulness of an initiation rate figure of 80 per cent.  Among the supplemented infants there is a high rate of premature termination of breastfeeding. Availability of formula gives staff an excuse not to teach mothers how to overcome difficulties (Frank et al., 1987; Bergevin & Kramer, 1983). It has been estimated that approximately 50% of those who stopped breastfeeding in the first six weeks might have continued to breastfeed if they had received better help or teaching in hospital (Health and Welfare Canada, 1990).  The continuation rates for breastfeeding have not improved in the past 20 years and only 30% of infants are breastfed to six months (Avard & Hanvey, 1989). Supplementing 1  breastmilk with formula at home has been negatively associated with duration of breastfeeding (Frank et al., 1987; Bergevin & Kramer, 1983). Sixty per cent of infants have started solids before 4 months (Davis, 1991).  1t is not clear if the authors mean breastfed exclusively to six months or partially breastfed to six months 1  3  The main reason for breastfeeding termination is the woman's perception that she does not have enough milk (Health and Welfare Canada, 1990). This factor accounts for a 20% decrease in breastfeeding rates between four to six weeks. The infant's growth spurt occurs at this time and the infant will be suckling more often to stimulate the mother's body to produce a greater milk supply. Without proper support and information, the mother perceives this increased suckling as a sign that she has insufficient milk (Cerutti, 1981). Some worried mothers will give supplements of formula (a practice that was modeled in the hospital) starting what often becomes a vicious cycle. Supplementation impedes the suckling necessary to stimulate an increased milk supply and the resulting inadequate milk supply perpetuates the need for supplementation. All too often the result is premature termination of breastfeeding.  Physicians' breastfeeding counselling practices do not meet recommendations  Studies in the 1970s and 1980s suggest that although verbal support for breastfeeding may be strong among pediatricians, strong advocacy and actual support of breastfeeding are much less common. More recently, a sample of 59 pediatricians reported very favorable attitudes toward breastfeeding promotion by pediatricians. Nevertheless, 51 percent reported they routinely recommend breastfeeding while 48 percent reported not making any recommendation but respecting the mother's choice (Michelman et al., 1990). Lawrence (1982) found that 33 percent of physicians from several specialties never initiate the topic of breastfeeding with the mother.  Reames (1985) found that physicians discouraged mothers from breastfeeding for reasons that are not considered to be usual contraindications, e.g., Cesarean section, premature birth, maternal diabetes, or because the mother works. Some of the practices recommended by the physicians, such as offering supplemental bottles to breastfed infants, oral contraceptives for breastfeeding mothers, and delayed time of breastfeeding initiation have been shown to affect adversely the success of breastfeeding.  4  In a study of pediatricians, very few provided educational support for breastfeeding mothers such as prenatal classes, special counselling or postnatal telephone calls (Michelman etal, 1990).  Physicians continue to publish articles, sharing their discoveries that because of their own knowledge gaps they had been providing misinformation to breastfeeding mothers (Newman, 1991). Such advice that leads to decreased milk supply and to breastfeeding failure includes encouraging (or not informing mothers of the consequences of) scheduled feeding, soothers, estrogen-containing contraceptive pills (progestin-only or mini-pills are compatible), limited suckling to prevent nipple damage, or a bottle a day to let the mother rest.' Bagwell (1993), found that physicians felt that fathers feel close to their infants if they can bottlefeed them and that breastfeeding is not a good method of weight reduction nor is it compatible with the use birth control pills. Moxley and Kennedy (1994) present data from the Parent-Baby Information Line in Ottawa, a telephone service to answer parents' question. Over 25% of the calls concern breastfeeding and breastfeeding support groups where mothers can get assistance in breastfeeding problems.  A study of Arizona's 61 hospitals providing obstetrical services reported practices that interfere with breastfeeding and promote bottlefeeding; provision of pacifiers and supplemental water or glucose, issuance of formula packs at discharge, and a first feed of sterile water. A positive significant relationship was identified for policies advocating breastfeeding and the prevalence of breastfeeding encouragement from professional staff (Strembel etal., 1991).  Greer & Apple (1991), and Newman (1991) warn that a neutral stand about the benefits of breastfeeding by physicians is in fact damaging. These researchers particularly  5  discourage the practice of giving formula to mothers. They recommend that physicians increase their breastfeeding management skills, and their knowledge of breastfeeding support groups and of how to advise women on breastfeeding at work.  A campaign supporting exclusive breastfeeding among women having chosen breastfeeding was successful in increasing the number of women breastfeeding at one month post-partum (66% of 506 intervention group vs 52% of 151 controls). The intervention was aimed at providing mothers with information, providing support after delivery, raising environmental awareness and educating health professionals. Educating health professionals was particularly efficacious in reducing the physical and medical problems associated with breastfeeding (Macquart-Moulin et al., 1990). A meta-analysis of nine controlled clinical trials found that nursing support with telephone follow-up increased the duration of breastfeeding up to four weeks (Bernard-Bonnin et al., 1989).  6  CHAPTER 1: LITERATURE REVIEW  Theoretical background  B.C. Women's Hospital intends to provide a breastfeeding educational program to the physicians providing care for its maternity patients. The current study aimed to assist the hospital by surveying its physicians' attitudes, beliefs, knowledge concerning breastfeeding and self-efficacy concerning breastfeeding counselling.  The co-sponsored World Health Organization - UNICEF Baby-Friendly Hospital Initiative (BFHI) has been an impetus to the educational program. The Initiative aims to promote a social and organizational environment that will enable and reinforce health professionals' supportive behaviours concerning breastfeeding.  For example, they  recommend early initiation of breastfeeding postpartum, keeping the baby in mother's hospital room 24 hours a day and avoidance of soothers and unnecessary supplementation. The maternity care facilities are to have a breastfeeding policy that is regularly communicated to all staff. The Initiative also states that maternity care facilities are to provide their staff with training in breastfeeding support.  7  Continuing education to physicians should be preceded by an analysis of motivators for and obstacles to the desired change in behaviour. This can be referred to as an educational diagnosis (Green & Kreuter, 1991). It is inefficient and sometimes ineffective to train someone in skills to enable a behaviour when that person lacks prior motivation. W e have seen evidence that many physicians lack confidence in the efficacy or importance of some preventive maneuvers; of those who accept the value of the procedures, many doubt their own competence or the ability of the patient to make changes. Unless these beliefs are dealt with first, there is little point in training physicians in preventive or health promotion skills (Green & Kreuter, 1991, p. 413-414).  Based on the literature, an educational diagnosis would seem relevant in planning breastfeeding educational programs directed toward physicians.  An educational diagnosis is a process in which information is obtained concerning three categories of behavioural influence: predisposing, enabling, and reinforcing factors. These categories are convenient in that they group the more specific behavioural influences such as knowledge, attitudes and beliefs, skills, incentives, and rewards under broader rubrics according to the measures that might be used to change behaviour. Green et al. (1988) offer this classification as a useful conceptual framework for analyzing physician behaviour and planning interventions to change physician behaviour. They specify that the three domains are not mutually independent.  Predisposing factors refer to antecedents to behaviour that provide the rationale or motivation for a behaviour. These factors are within the realm of psychology and "represent the cognitive and affective dimensions of knowing, feeling, believing, valuing, and having selfefficacy or confidence" (Green & Kreuter, 1991, p. 154). Enabling factors are the antecedents to behaviour that allow a motivation to be realized. They include skills, resources or barriers. Reinforcing factors are factors subsequent to a behaviour that provide the  8  continuing reward or incentive for the behaviour and contribute to its persistence or repetition. Reinforcing factors include rewards, feedback and colleague support (Green & Kreuter, 1991).  The influential  factors that determine  breastfeeding  support  among  health  professionals are the targets of the Baby-Friendly Hospital Initiative and can be classified as predisposing, enabling and reinforcing factors. Further research, such as an educational diagnosis, on these factors may more clearly define specific strategies for implementing the Initiative. The objective of the thesis is to determine which predisposing factors should be targeted in an educational effort directed to physicians.  Predisposing factors include knowledge, attitudes, beliefs, values and perceived needs and abilities that might motivate physicians' counselling and supportive practices. Personality factors can also predispose behaviour but are excluded from consideration as they cannot be readily changed by educational or other health promotion interventions. Furthermore, demographic factors including age, gender and family size may predispose behaviour but are not included in the list because they cannot be directly influenced by educational or other interventions (Green & Kreuter, 1991). However, research on physician behaviour could consider physician specialty, gender and other demographics as such subgroups may demonstrate a need for different interventions.  The following discussion of predisposing factors will make reference to an area of physician practice which has received much attention in the literature: physicians' support (attitudes, values and beliefs) for preventive practices including health promotion counselling. Apparently physicians favour preventive practices in principle, but hesitate to carry out these activities (Green et al., 1988). Many of the physician factors that have been researched in this  9  area will be potential points of consideration in a study of physicians' breastfeeding counselling behaviours.  "Physicians' positive attitudes towards health promotion are consistent with patient attitudes toward physicians as being the primary source of health information and effective behaviour change" (Green, Cargo and Ottoson, 1994). Paradoxically, physicians appear reluctant to counsel about risk factors and behaviour modification because they do not think patients want or would follow their advice (Valente, 1986; Cummings et al, 1987; Reed, 1991). Orleans et al. (1985) reported that family physicians considered this pessimism the greatest barrier to their preventive counselling.  Not only can the physicians' beliefs about their patients' abilities cause the physician to avoid preventive counselling practices but so can their own lack of confidence in this area. The physicians' training experiences do not traditionally emphasize building competencies in preventive practices. "Up until the latter part of the 1970s, most undergraduate curricula were content driven in the belief that application of Flexnerian principles (that is, a thorough understanding of the basic sciences) would provide the undergraduate with the knowledge and skills to handle most clinical problems" (Piterman, 1991). Studies suggest that recent medical graduates are more confident than other physicians in their counselling effectiveness (Green etal., 1988).  10  Green and Kreuter (1991) have described the predisposing, enabling and reinforcing determinants of physicians' behaviour. With respect to predisposing factors: • Attitude  is a rather constant feeling that is directed toward an object (be it a person, an action, a situation or an idea). Inherent in the structure of an attitude is evaluation, a good-bad dimension. A n attitudinal problem among physicians relates to their apparent doubt concerning the importance of some behavioural risk factors.  • Values include  more basic orientations, such as the role of the physician, patient autonomy, and issues of privacy of patient behavior or lifestyle outside the immediate medical realm. These are very important but have not been well studied.  • Beliefs include  the more immediate and changeable viewpoints of the physician on matters such a s patients' willingness to change their lifestyles or their ability to change their health practices.  • Self-efficacy  is a perception of one's own capacity for success in organizing and implementing a pattern of behaviour that is new; based largely on experience with similar actions or circumstances encountered or observed in the past (Green and Kreuter, 1991, p. 158-160).  There is considerable evidence of the interrelatedness of the predisposing factors. Attitudes, for example, appear in analysis as determinants, components, and consequences of beliefs, values, and behaviour (Green & Kreuter, 1991).  Regarding self-efficacy, it can be said that the low level of confidence among physicians in preventive counselling can only be improved with adequate skill training. "Specifically, self-efficacy can be enhanced by breaking the complexities of the target behaviour into components that are relatively easy to manage" (Bandura, 1977). Developing awareness of specific situations in which efficacy may be low and rehearsing the desired behaviour in these situations appears to enhance self-efficacy (Gilchrist & Schinke, 1983; Kaplan, Atkins, & Reinsch, 1984).  11  Based on the PRECEDE model (Green & Kreuter, 1991), Figure 1 allows conceptualization of the interactive physician factors that influence their breastfeeding counselling and training of childbearing women. FIGURE 1: Short-term and Intermediate Impacts of the Breastfeeding Education Program ^1 Focus of the thesis research from pretest data l£  Intervention  Short-term impacts  Intermediate impacts  Predisposing  Demographics Attitudes/Beliefs Knowledge Self-efficacy Interest in BE Breastfeeding Education to Physicians  Physician practices in support of breastfeeding  Enabling  Skills Access to BE  Reinforcing  Support from colleagues  (BE: Breastfeeding Education to Physicians)  If the premise is that education would help shape attitudes, beliefs, self-efficacy and a knowledge base conducive to optimal counselling practices by physicians, then the hypothesis is that a relationship exists between these predisposing factors and counselling behavior. An association between lower than desirable levels of counselling and lower levels in one or more of the predisposing factors (attitudes, beliefs, self-efficacy, and knowledge) would tend to support this hypothesized relationship.  12  Explaining the incongruency between current and recommended practices  Physicians have attributed the incongruency between current and recommended practices to a lack of formal training (Michelman et al, 1990; Lowe, 1990; Reames, 1985) and a need for further education (Lowe, 1990; Reames, 1985). Lactation education to health professionals has been critiqued in the literature (Hefti, 1992; Livingstone, 1992; Newman, 1991; Tanaka et al., 1990). During obstetric rotation the students and house officers become familiar with procedures known to inhibit lactation such as administering drugs during labour and giving complementary bottle feeds (Rajan & Oakley, 1990). Pediatric assignments include learning how to design human milk substitutes (Naylor, 1990). Published articles and textbooks contain conflicting advice causing confusion among health professionals (Livingstone, 1992).  Table 1 summarizes the settings and response rates of several breastfeeding studies concerning physicians. Lowe (1990) investigated levels of knowledge among 161 midwives, 83 general practitioners, 50 nurses, four obstetricians and two pediatricians. A knowledge score was the outcome variable and independent variables included health professionals' personal experiences and years in practice. The scores ranged from 7 to 35 out of 35. A decrease in knowledge was observed with advanced age and more years since training (Lowe, 1990). The survey demonstrated a higher knowledge score (69%) among the 132 women health professionals who had a positive experience of breastfeeding than among the 79 male health professionals (score of 65%). These women also scored higher than did the 65 women who had never breastfed and the 24 women with negative breastfeeding experiences. Lowe (1990) did not statistically analyze these knowledge scores.  Table 1. Summary of breastfeeding studies: settings and response rates Study  No. of respondents  Response Rate (%)  Population  Lawrence  381 P e d , 306 O / G  64 P e d , 51 O / G  U.S. National listing  1982  300 F P  50 F P  Reames  88 P e d , 69 O / G  88 P e d , 69 O / G  Randomly selected  1985  71 F P , 46 G P  71 F P , 46 G P  from 94 U.S. hospitals providing maternity care  Michelman et al.  59 Peds  86  1990  Lowe  Large U.S. urban area, telephone survey  161 Midwives, 83 G P  73 G P  Gippsland, Australia  155 F P residents  69  Residents in 11 of 14  1990  Goldstein & Freed, 1993  Bagwell et al., 1993  programs, U.S.  41 Dietitians, 158 Nurses 90 Physicians  75 Dietitians  Health professionals  56 Nurses  seeing low income  39 Physicians  women, U.S.  14  Bagwell et al. (1993), examined attitudes and knowledge concerning breastfeeding. Interestingly, the knowledge questions address how strongly the respondent agrees or disagrees that breastmilk is completely nutritious and protective against infection. The current study designates these questions as belief questions. Similarly, Bagwell et al. (1993) make use of attitude questions concerning the appropriateness of breastfeeding promotion to mothers facing challenges to breastfeeding such as young age, plans to return to work or mental challenges. They asked physicians whether they would recommend breastfeeding to these mothers. The responses are therefore attitudinal and not self-reports of behaviour, in contrast to the studies by Michelman et. al. (1990) and Goldstein & Freed (1993).  Ninety physicians participated in the study by Bagwell et al. (1993): 67 were men, 17 were women and six did not indicate gender. There was a rather low response rate of 39% among the physicians; 75% of the dietitians and 56% of the nurses participated. All dietitians and nurses were women. Bagwell et al. performed a one-way analysis of variance on the aggregate knowledge scores across the professions and then on the aggregate attitude scores across the professions. Out of 100 the physicians', nurses' and dietitians' scores were 75.5, 73.0 and 79.6, respectively for knowledge and 70.2, 74.5 and 78.6 respectively for attitude. Physicians had significantly lower knowledge scores than dietitians and lower attitude scores than both nurses and dietitians (p<.05).  Several studies measure counselling behaviour based on physician self-reports. Selfreports of counselling behaviour seem to vary according to physician specialty. Reames (1985) reported that only 44 percent of obstetricians considered breastfeeding to be very important, compared with 74 percent of pediatricians and 65 percent of family practitioners. Lawrence (1982) found that pediatricians are more likely than obstetricians and family practitioners to advocate breastfeeding to the undecided mother. Ironically, pediatricians were  15  also the group most likely to recommend supplementation with prepared formula sometimes or always.  Michelman et al. (1990) investigated both the degree to which pediatricians promote breastfeeding in their practices, and the attitudes and beliefs about breastfeeding that are associated with their breastfeeding promotion activities. The sample size was small: 59. The gender split among the study subjects is not indicated. Respondents with more supportive beliefs more frequently reported recommending breastfeeding. Seventy-five percent of pediatricians who had highly supportive beliefs usually recommended breastfeeding, whereas only 18.2 percent of pediatricians who had low level beliefs did so (Michelman et al, 1990). No differences in support for breastfeeding among pediatricians according to gender were found and gender failed to differentiate breastfeeding counselling behaviour of physicians in two other major studies: Lawrence (1982) and Reames (1985).  In a study of 155 family practice residents (response rate: 69%), Goldstein and Freed (1993) found three predictors of residents' counselling women more than 50% of the time: 1) confidence in counselling abilities; 2) perceived adequacy of training; and 3) female gender. Reames (1985) looked at personal or spousal experience (i.e., having children who were breastfed) and found that physicians who had breastfed a child (or physicians whose spouses had breastfed) were more likely to promote breastfeeding and were more convinced of the beneficial properties of breastmilk. Goldstein and Freed (1993), also found that residents with a personal or spousal experience with breastfeeding displayed greater knowledge and confidence and perceived effectiveness in counselling. They emphasize, however, that personal or spousal experience did not lead to significantly greater reports of breastfeeding counselling, suggesting that such experiences alone do not substitute for actual training.  16  Research objectives  In reviewing the studies, strengths and limitations were apparent. The aim of this thesis was to overcome limitations by including measures of counselling behaviour rather than looking just at cognitive constructs (e.g. knowledge and attitudes).  The principle goals of Goldstein and Freed's study and the Michelman study reflects the focus of the thesis: to determine the counselling practices as well as several predisposing factors among the physicians: knowledge, beliefs, attitudes and self-efficacy. Like in the Goldstein and Freed study, the thesis will attempt to determine the degree to which the predisposing factors predict counselling behaviours. The thesis, however, will make use of data from several specialties and a range of years in practice in attempt to add to the knowledge base. Table 2 summarizes the components of the thesis. Table 2. Components to be included in the thesis •  Physician behavior: the degree to which physicians promote breastfeeding  •  Beliefs concerning breastfeeding  •  Knowledge of breastfeeding  •  Attitudes concerning breastfeeding  •  Self-efficacy in breastfeeding counselling  •  Several physician specialties  •  Gender  •  Years in practice  •  Physician ethnicity  17  The purpose of the thesis was not only to describe the practices of the physicians (dependent variables) and select cognitive (independent) variables, but also to find evidence for the relationships between the independent and dependent variables. Martin and Bateson (1993) suggest that the following conditions be satisfied:  1. a theoretical, conceptual or practical basis for the hypothesized relationship, 2. statistical association, 3. the independent variable precedes the dependent variable, 4. the hypothesis rules out other possible explanations.  The statements listed below were the hypotheses for the thesis. These were tested using correlational analysis where a relationship between variables was said to present with an rof at least 0.2 (Martin & Bateson, 1993).  1. Physicians with higher self-efficacy in breastfeeding counselling (higher scores on the two self-efficacy questions) will report counselling more often about breastfeeding.  2. Physicians with stronger beliefs regarding breastfeeding (higher scores on the two belief questions) will report counselling more often about breastfeeding.  3. Female physicians will report counselling more often about breastfeeding.  4. Female physicians will report higher belief, self-efficacy and knowledge scores.  5. Physicians with personal or spousal experience with breastfeeding will have higher belief, self-efficacy and knowledge scores.  18  CHAPTER 2: METHODOLOGY, VARIABLES AND DATA ANALYSIS  METHODOLOGY  Instrument development and pilot-testing  A confidential questionnaire was constructed. An opening paragraph explained the purpose of the survey, requested response and assured respondents of confidentiality. Respondents were asked about attitudes, beliefs, knowledge and self-efficacy concerning breastfeeding. There were also questions regarding their practices and their interest in continuing education on breastfeeding. Content validation focussed on whether questionnaire items were based on documented aspects of breastfeeding practices. The first step was a review of the literature to identify substrata of the concept of support for breastfeeding: counselling of the pregnant woman or new mother, referral to a lactation consultant or a community breastfeeding support group, assistance during engorgement or mastitis. The literature was complemented by dialogue and exchange with practitioners. The drafted questionnaire was reviewed by the directors of both the Department of Health Care and Epidemiology (Dr. Sam Sheps) and the Institute of Health Promotion Research (Dr. Lawrence Green) at UBC as well as by the B.C. Women's Baby-Friendly Hospital Committee (BFHC). Dr. Lorie A. Smith (the principal investigator) and lactation consultants are members of the BFHC.  The questionnaire was pilot-tested by a sample of physicians providing obstetrical care at another community hospital. The purpose of the pilot test was to ensure that the questions were clear and to determine the time required to complete the questionnaire. The pilot test investigated what questionnaire items appear to measure based on the actual reading of the measure; i.e. face validity.  19  Mailing of the questionnaire  B.C. Women's Hospital intends to provide an educational program to the family practitioners, general practitioners, obstetricians, and pediatricians providing care to their maternity patients. This project aimed to survey each physician. The sample was, therefore, all 325 family practitioners, general practitioners, obstetricians and pediatricians working out of B.C. Women's Hospital. They were identified through the hospital's mailing list. The principal investigator was not included in the survey.  The questionnaires were coded to ensure confidentiality. The identity code allowed the researchers to keep track of those who had not yet responded. The questionnaire was promoted at rounds but this was limited to the Family Practice rounds for reasons that will later be discussed. A postcard reminder was sent to non-respondents three weeks after the first mailing. Three weeks after the postcard reminder a second mailing was made. In the last month of the data collection, follow-up phone calls were made to non-respondents. They were notified of the upcoming deadline for completing the questionnaire and asked whether they required another copy.  20  DEPENDENT AND INDEPENDENT VARIABLES  The three dependent variables of the regression models were the physicians' self reports of their counselling behaviours or practices. Each was measured by a question and five-point Likert scale of never, infrequently, sometimes, usually and always. The main practice question asked; "How often do you discuss breastfeeding with your patients in the prenatal period?" The two other practice questions were "If a patient is planning to bottlefeed do you attempt to convince her to breastfeed?" and "In the presence of breastfeeding problems, how often do you encourage your patients to continue breastfeeding?".  Independent variables included cognitive variables and other variables related to counseling behavior in univariate analysis. There were eight cognitive independent variables to be investigated: two self-efficacy questions, two belief questions, three knowledge questions and one attitude question.  The self-efficacy questions asked physicians to rank their confidence on a scale of one to ten concerning; 1) positioning a new mother for breastfeeding, and 2) assisting mothers experiencing common breastfeeding problems. These questions were used in the Michelman study (1990). The self-efficacy variables were on an interval scale and considered to be a continuous variables.  The two belief questions were "Exclusive breastfeeding provides all the nutrition required by a healthy newborn up to the age of four to six months with the possible exception of Vitamin D" and "Exclusively breastfed babies have fewer Gl infections, respiratory illnesses, eczema and/or allergic reactions than formula fed babies". These were measured on five-point Likert scales; strongly agree, agree, neither agree nor disagree, disagree and strongly disagree. The scale for each belief variable will be considered an interval scale.  21  Three knowledge questions were analysed: 1) a diagram of an infant at the breast, 2) cereals help the infant sleep at night and 3) awareness of Motilium as a means to increase breastmilk supply. Each of the questions has one correct and one incorrect answer and are therefore dichotomous nominal variables.  The attitude question asked "In general, how do you feel about the WHO - UNICEF policy to enhance physicians' skills in breastfeeding promotion and breastfeeding support". The responses are on a five-point Likert scale from very favourable to very unfavourable which will be considered to be an interval scale.  Controlling variables were included in the statistical model. To identify controlling variables, statistical tests were performed to determine which of the following variables were associated with the independent or dependent variables: specialty, gender, years in practice, ethnic origin and personal breastfeeding experience. The demographics page of the questionnaire provided the necessary information.  Dichotomous (dummy) variables were made for each of the physicians' specialties: obstetrician, pediatrician, family practitioner or general practitioner. The "obstetrician" variable, for example, takes the value of 1 for the case where the physician is an obstetrician. Otherwise, its value is 0.  Gender was recoded into the variable "female". Females received a code of 1 and males a code of 0.  Ethnic origin was a categorical variable with the categories: Caucasian, Asian, IndoCanadian, Native Indian, African-Canadian, other. These were recoded into a dichotomous  22  variable "Caucasian" where Caucasian physicians were coded "1" and non-Caucasian were coded "0".  Personal or spousal breastfeeding experience was coded into a dichotomous variable "Children". Physicians who indicated that their own children were breastfed were coded as "1", otherwise the value was "0".  The physicians were asked to indicate their number of years in practice. This was a continuous variable.  It was of interest to obtain data on the demographics of the nonrespondents. The researchers knew the gender and ethnicity of most of the physicians. In a few cases the information was confirmed during the follow-up phone calls to physicians' offices. Years in practice were estimated by finding the year of graduation in the College of Physicians and Surgeons of B.C. directory.  METHODS OF ANALYSIS  The analyses were concerned with: 1) assessing the reliability of the measures of knowledge, self-efficacy, beliefs, attitudes and counselling behaviour; 2) using the reliable measures in the regression model. The purpose of the regression analyses was to predict the amount of variance accounted for in self-reported counselling behaviour using measures of knowledge, self-efficacy, beliefs and attitudes. Data were analyzed using SPSS-PC at the Institute of Health Promotion Research.  23  The following section will discuss the use of reliability analysis and other criteria for the selection of items to be used in the regression model. A brief description of logistic regression will also be provided.  Internal consistency reliability analysis methods  Ideally, reliability testing of an instrument assesses the extent to which the measures yield the same results on repeated trials (Carmines & Zeller, 1979). An assessment of reliability should consist of testing for internal consistency, stability and equivalence. As the test-retest method was not performed it was not possible to perform tests for stability. Likewise, the study did not include tests for equivalence. The reliability analyses were, therefore, limited to testing internal consistency.  Internal consistency refers to the extent to which a set of items measuring the same concept are actually homogeneous. In conditions of internal consistency a respondent will give a similar response to each item measuring a given concept.  Cronbach's Alpha, the most widely used method of internal consistency is computed by the following formula:  Np/ [1 + p(N -1)]  where N is equal to the number of items in the scale and p is equal to the mean inter-item correlation (Carmines & Zeller, 1979).  24  Descriptive statistics and univariate and correlational analyses  Analyses were performed to describe the data, including measures of central tendency and standard deviation.  Correlations were used to show the associations between counselling behaviours and physician factors. The strength of association is indicated by the size of the correlation coefficient. Coefficients range from -1.0 to +1.0. A coefficient of zero indicates that there is no linear association between the two variables. Generally a significant correlation represents a correlation that differs significantly from zero (Martin & Bateson, 1993). The use of the parametric test of correlation, the Pearson correlation, requires that these assumptions are met: normality, homogeneity of variance and measurement on an interval or ratio scale. "The Pearson correlation is, however, reasonably robust when there is departure from normality" (Martin & Bateson, 1993, p. 137). The point biserial correlation is the appropriate test for testing the association between an interval variable and a dichotomous variable.  The correlational analyses were carried out in the following manner. First, a series of analyses assessed whether gender, specialty, years in practice, ethnicity or personal breastfeeding experience were correlated with counselling behaviours. Secondly, correlations looked at the associations between counselling behaviour and the predisposing variables (beliefs, self-efficacy and knowledge). Finally, a series of analyses detected the presence of gender, specialty, years in practice, ethnicity or personal breastfeeding experience differences in the predisposing variables.  25  Regression Analyses  Regression analyses were performed to identify which variables, including selfefficacy, beliefs and knowledge might be independently predictive of physicians' self-reported counselling behaviours. In regression analysis, each independent variable (X) is given a regression coefficient as an estimate of how much of the changes in Y (slope) are attributable to changes in X.  Regression is generally more restrictive than correlation tests. The  assumption that must accompany the information obtained from regression is that the dependent variable is in fact a linear function of the independent variable. It is not necessary to designate which is the dependent and independent variable when obtaining the correlation coefficient (Schroeder, Sjoquist & Stephan, 1988).  The original intent was to use a counselling behaviour composite score as the dependent variable of the regression model. As will be discussed later, the Pearson correlation coefficients indicated that the individual self-reports of counselling behaviours were only moderately associated with each other which made it impractical to construct a composite score. Therefore, each of the three counselling behaviours were analyzed individually.  The five-point Likert scales of the individual counselling behaviour items limit their variability. Logistic regression was used as this method is compatible when the dependent variable displays limited variability. In logistic regression the dependent variable must be dichotomized. Thus, the counselling behaviour variables were dichotomized with "usually" and "always" grouped together and "sometimes", "infrequently" and "never" grouped together. This classification scheme reflects the goal of an education intervention; to target the factors that are associated with lower rates of discussing and advocating breastfeeding to patients, implied by the terms "sometimes", "infrequently" and "never".  26  The following procedure was performed for each of the three counselling behaviour variables. Construction of the regression model was achieved through a model-building approach. Figure 2 outlines potential components of the model. The controlling variables were the independent variables such as years in practice, specialty, personal or spouse's personal breastfeeding experience and gender that were found to be associated with counselling behaviour in the univariate analysis. The cognitive variables were then entered into the model first individually and then with each other. All of the significant variables were entered into a final model which was assessed for significance. The regression method was forward stepwise regression. Figure 2:  Hypothesized regression model and potential components  Effect of Components on Counselling Behaviour: Counselling behaviour = 1  C1 + C2 + C3... +  Knowledge1/knowledge2/knowledge3 +attitude + beliefl/ belief2 +self-efficacy composite score  dependent variable  controlling variables  cognitive variables added stepwise  1 Regressions were run for each of the three counselling behaviours  The significance level for the beta weights in the regression analyses was set as 0.10 as this level is generally seen to be a trend towards significance in behavioural research. The effects that are significant up to the 0.10 level may be important for health promotion programming. These trends may also identify areas requiring further research.  27  CHAPTER 3: RESULTS  Feedback from the pilot test  Eleven of the fourteen physicians completed the mail-out questionnaires in the pilottest. One physician indicated that it took 20 minutes to complete the questionnaire. Unfortunately, the other physicians did not provide information about time requirements. However, none of them indicated that the questionnaire was too lengthy.  As a result of the pilot-test feedback one change was made. The question asking physicians if they would like more information concerning breastfeeding was moved to the end of the questionnaire. The pilot-test physicians did not indicate any other problems as to the clarity or content of the questions.  Results of the mailing-out and data collection processes  Three hundred and twenty five questionnaires were sent out along with stamped return envelopes.  The data collection process was carried out from June 11 to November 7, 1994. After three weeks, 97 questionnaires had been returned at which time a postcard reminder was sent to each physician who had not yet responded to the questionnaire. Apparently, the postcard prompted only three physicians to send in questionnaires.  A second mailing of questionnaires was performed at the beginning of September 1994 to all non-respondents. A brief letter accompanying the questionnaire and a stamped return envelope expressed concern at not having received the completed questionnaire. The letters were personalized by applying a name label to the top of each letter, but not the questionnaire itself.  28  The second mailing prompted another 50 physicians to send in questionnaires. During the first two weeks of October, the principal investigator and masters student made phone calls to non-respondents. Seventy requested a third mailing. Sixty physicians sent questionnaires in response to the phone call reminders. The cut-off point for questionnaire collection was November 7, 1994 at which time the total number received was 210. Table 3. Flow of the mailing-out and data collection processes  Step  No. of questionnaires  Total  received Week 1 June 11,1994  First mailing  Week 4  Postcard reminder  Week 12 September  Second mailing  Week 14 October 7  Phone calls  to November 7  and third mailings  97  97  3  100  50  150  60  210  Response rates and characteristics of the sample  At the first mailing 325 questionnaires were sent out. Thirteen were undelivered: ten physicians had retired or were no longer counselling expectant mothers and three physicians had moved out of Vancouver. Of the 312 remaining physicians, 210 completed the questionnaire. The response rate was, therefore, 67.3 percent.  29  Table 4 describes the proportions of the physicians in the different specialties. Study population refers to the sample of the survey, i.e. all physicians providing care to B.C. Women's maternity patients. Most of the study population are family practitioners and general practitioners (91 and 153 respectively). Thirty seven are obstetricians and 31 are pediatricians. While, the physicians who sent in questionnaires (respondents) are mostly family practitioners and general practitioners, the higher response rate was from the family practitioners. Table 4. Response rate by physician specialty Respondents  Total sample  Response rate  Obstetricians  24  37  64.8  Pediatricians  20  31  64.5  Family Practitioners  69  91  75.8  .97  153  63.4  210  312  67.3  General Practitioners TOTAL  30  Bias in the study relates to differences between the respondents and the study population. Self-selection bias in this study describes the bias introduced because the results are based on data from those physicians willing to put forth the effort to complete the questionnaire. These physicians are potentially unrepresentative of the study population as they have been self-selected (Schroeder, Sjoquist & Stephan, 1988). This type of bias can be problematic particularly because the effort to respond to the questionnaire may also be associated with certain characteristics including better counselling practices, self-efficacy or attitudes concerning breastfeeding. Thus in addressing this bias, it is important to know as much as possible about the nonrespondents. While the counselling practices and cognitive factors of the nonrespondents could only be known through additional data collection, it is possible to comment on the demographics of the respondents and nonrespondents. S u c c e s s in correcting for non-response bias hinges on the possibility of gaining some knowledge, however meager, about the nonrespondents. Lack of similarity between respondents and nonrespondents on sociodemographic variables suggests bias. However similarity on these variables does not ensure similarity on key variables (Cox et al., 1977, p. 131).  In terms of the respondents, there is a disproportionate number of family practitioners. The family practitioners were more likely to respond than were the obstetricians, pediatricians and general practitioners (76 versus 65, 65 and 63 percent respectively). Similarly there are gender differences between the respondents and the study population. (Refer to Table 5). There are almost twice as many male physicians (202) providing care to B.C. Women's maternity patients than there are female physicians (110). This trend is not reflected among the respondents where the number of female respondents (95) is not much less than the number of male respondents (115). Thus, the female physicians were much more likely to respond than male physicians; response rates of 86 and 57 percent respectively.  31  Table 5. Response rate by gender Respondents Total sample Response rate Male Female  115  202  56.9  95  110  86.4  The nonrespondents' years in practice was estimated by finding the year of graduation in the B.C. Medical Directory. Four nonrespondents were not listed in the directory. Of the respondents, six did not answer the years in practice question. (The researcher did not attempt to find this information from the directory). In summary, data were missing for the number of years in practice for ten physicians.  The distribution of years in practice was divided into two categories; less than 13 years and 13 or more years in practice (the mean years in practice of the respondents was 13. (Table 6) There are fairly equal numbers of physicians in both categories when looking at the physicians providing care to B.C. Women's maternity patients (the study population). However, physicians with less than 13 years in practice were much more likely to return questionnaires (response rate is 86%) than were those with 13 or more years in practice (response rate is 58%). The result is a disproportionate number of physicians that were recently trained among the respondents.  32  Table 6. Response rate by years in practice  Respondents Total sample Response rate less than 13 years in practice 13 to 19 years in practice  94  109  86.2  112  193  58.0  -data missing for 6 respondents and 4 nonrespondents  Table 7 shows the ethnic origin of the physicians. The majority of the physicians providing maternity care to B.C. Womens' patients are Caucasian. There was a greater response rate from Caucasian physicians (71%) than for Asian (61%) and other ethnicities (50%). There was no gender differential in the Caucasian and non-Caucasian group. There were significantly more Caucasian physicians in the specialties with the exception of general practitioners.  Table 7. Response rate by ethnic origin  Respondents Total sample Response rate Caucasian Asian Other TOTAL  155  220  70.5  30  76  61.0  16_  50.0  8_ 210  312  33  Table 8. Gender and years in practice by physician specialty of the respondents and study population Obstetricians  Resp. Sample  Pediatricians  Resp.  Sample  %  %  Family  General  Practitioners  Practitioners  Resp. Sample  %  %  Resp. Sample  %  %  Gender Male  79.2  72.9  65.0  70.9  47.8  57.1  51.5  66.0  Female  20.8  27.0  35.0  29.1  52.2  42.9  48.5  34.0  Years in practice < 13  47.8  36.1  36.8  33.3  49.3  42.2  44.2  32.9  13 or more  52.2  63.8  63.2  66.7  50.7  57.8  55.8  67.1  Resp.: Respondents  Sample: Population of respondents and  nonrespondents  Table 8 shows the distribution of gender and years in practice across physician specialty. The only gender differential across specialty was that significantly few of the obstetricians were female (chi-square = 9.15, p = .03).  In terms of response rate, for all specialties except obstetrics there is a greater proportion of females among the respondents than in the sample that was surveyed. In every specialty, physicians with fewer than 13 years in practice were more likely to respond than were physicians with 13 or more years in practice.  34  Table 9. Personal or spousal breastfeeding experience (n = 209) Obstetrician Male Female Total  Pediatrician  Family practitioner General practitioner Total  10(50)  6(46).  21(66)  24(60)  61(53)  4(80)  4(67)  25(71)  34(71)  67(71)  14(56)  10(53)  46(69)  58(59)  128(61)  Physicians were asked whether they had personal or spousal breastfeeding experience. Refer to Table 9. The prevalence of personal or spousal breastfeeding experience was quite comparable in all specialties. Women physicians were somewhat more likely to have experience than were male physicians; this trend is not as marked among family practitioners, however.  In summary, the respondents differ from the total sample of physicians drawn to represent the population of physicians for this study (i.e., the pool of respondents and nonrespondents). Most strikingly, a greater proportion of females is noted among the respondents than in the sample. Furthermore, greater proportions of family physicians, Caucasian physicians and younger physicians are seen among the respondents than in the sample.  RELIABILITY ANALYSES RESULTS  The three questions that measured three corresponding counselling behaviour variables were: "How often do you discuss breastfeeding with your patients in the prenatal period?", "If a patient is planning to bottlefeed do you attempt to convince her to breastfeed?" and "In the presence of breastfeeding problems, how often do you encourage your patients to continue breastfeeding?". In Table 10 these variables are designated as discuss, convince  35  and encourage, respectively. Each question was measured by a question and five-point Likert scale of never, infrequently, sometimes, usually and always.  Table 10. Counselling Behaviours: Pearsons correlation coefficients  Convince  .39***  Encourage  .21**  42***  Discuss  Convince  *p <  .05  *p <  .01  *p  <.001  There was only moderate correlation between the counselling behaviours. A composite score for the three counselling behaviours had poor reliability (alpha = .60). As the counselling behaviour questions seem to represent different dimensions of breastfeeding counselling, more information may be gained by keeping the measures separate. The self-efficacy questions asked physicians to rank their confidence on a scale of one to ten concerning; 1) positioning a new mother for breastfeeding, and 2) assisting mothers experiencing common breastfeeding problems. The questions were strongly correlated with each other (r = .69, p < .0001) and a composite score was constructed with a reliability of .79 (Cronbach's alpha).  The two belief questions were "Exclusive breastfeeding provides all the nutrition required by a healthy newborn up to the age of four to six months with the possible exception of Vitamin D" and "Exclusively breastfed babies have fewer Gl infections, respiratory illnesses, eczema and/or allergic reactions than formula fed babies". They were measured on five-point Likert scales; strongly agree, agree, neither agree nor disagree, disagree and  36  strongly disagree. The belief questions showed a moderate correlation with each other (r = .31, p < .01) and were kept separate.  Three knowledge questions were analysed: 1) a diagram of an infant at the breast, 2) cereals help the infant sleep at night and 3) awareness of Motilium as a means to increase breastmilk supply. Each question has one correct and one incorrect answer and all are therefore dichotomous variables. The knowledge questions were kept as separate items and seemed to measure different dimensions.  The attitude question asked "In general, how do you feel about the WHO - UNICEF policy to enhance physicians' skills in breastfeeding promotion and breastfeeding support". Thirty percent of the respondents indicated that they were not aware of this policy. To prevent an undesirable loss of information, the attitude question was not used in any of the analyses.  The remaining analyses will be concerned with three counselling behaviour variables, one self-efficacy composite score, two belief variables and three knowledge variables.  UNIVARIATE AND CORRELATIONAL ANALYSES RESULTS Counselling behaviours: descriptive statistics and differences by gender, specialty, years in practice, ethnicity and personal or spousal breastfeeding experience Analyses were performed to determine: 1) the distribution of the (continuous and categorical) counselling behaviour measures; and 2) the presence of gender, specialty, years in practice, ethnicity or personal breastfeeding experience differences in the counselling behaviours. The descriptive statistics allow identification of variables to control for in the regression analysis (i.e. specialty or gender). Furthermore, the rates of breastfeeding counselling in this study can be compared to the rates of previous studies.  37  Table 11 describes the distribution and consistency of the responses to the counselling behaviour variables. The mean and standard deviation gives some idea as to the dispersion and consistency of the responses. The practice variables were skewed towards the "usually" and "always" responses. There were few responses of "sometimes" or "infrequently". None of the physicians responded "never" to the counselling questions.  Thirteen pediatricians did not answer the behaviour question "How often do you discuss breastfeeding with your patients in the prenatal period". Six of the 13 who did not answer this question wrote that they do not see patients prenatally.  38  Table 11. Occurrence of counselling by counselling behaviours categories  Discuss breastfeeding  Attempt to convince  prenatally  mothers to breastfeed  n=197 Score  Category  N  5  Always  4  n=208  1  Encourage continued breastfeeding n=208  Percent  N  129  65  86  41  95  46  Usually  51  26  96  46  100  48  3  Sometimes  12  6  22  11  10  5  2  Infrequently  5  3  4  2  3  1  Mean  4.5  Standard dev.  .72  Percent  N  Percent  4.3  4.4  .73  .65  N B - None of the responses were in the A/ever category. 1 : (pediatricians tended to indicate this question was not applicable)  With respect to the current study, there is very little deviation from what is considered a desirable level of counselling (i.e., counselling always or usually). Thus, it may be more informative to keep the counselling behaviours as they are; five point scales with equalappearing intervals. Unless otherwise stated, the counselling behaviour variables were analysed as interval measures. Counselling behaviours:  Gender  and Ethnicity  Differences  Analyses were performed to determine whether there were significant gender or ethnic differences in counselling behaviours (Table 12). The correlation coefficients suggested that the rates of discussing (r=.20, p<01) and advocating breastfeeding to patients (convince, r=.20, p<.01 and encourage r=.21, p<.01) are higher for female  39  physicians than male physicians. Secondly, Caucasian physicians seemed more likely to discuss breastfeeding (r=.15, p<.05) and to encourage women to continue breastfeeding (r=.19, p< .01). Table 12: Counselling behaviours by gender and ethnicity: point biserial coefficients  Female  Caucasian  Discuss  .20**  .15*  Convince  .20**  .12  Encourage  .21**  .19**  * p < .05  **p < .01  No significant gender difference was found with respect to whether physicians discuss breastfeeding always or usually (Table 13). However, females were more likely than males to attempt to convince women to breastfeed if they are intending to bottlefeed (X2 = 5.60, p= .018) and to encourage women to continue breastfeeding in the face of breastfeeding problems (I = 5.10, p= .024). 2  40  Table 13. Dichotomized counselling behaviours by gender  Discuss breastfeeding^**  Convince to breastfeed''  (n = 197) Female Male  Encourage continued breastfeeding if problems^  (n = 208)  96% 88%  (n = 208)  94% 83%  98% 90%  N B Variables are dichotomized by combining always and usually and by combining sometimes and infrequently. NS : Not significant  1  X  2  = 5.60, p= .018  2  X  2  = 5.10, p=  .024  Table 14. Counselling behaviours by specialty: point biserial correlation coefficients  General practitioner  Pediatrician  Obstetrician  Family practitioner  Discuss  -.06  -.01  -.10  .15*  Convince  -.00  -.14*  -.08  .15*  Encourage  -.08  -.02  .02  .08  * p < .05 The specialty variables are dichotomous variables: i.e. for general practitioner: 1= general practitioner 0 = other than general practitioner  There was only a weak correlation between specialty and counselling practices. Specifically the data suggest that pediatricians are less likely to convince women to breastfeed (r = -.14, p < .05) and family practitioners are more likely to discuss breastfeeding with patients in the prenatal period (r= .15, p < .05) and to convince women to breastfeed (r= .15, p<.05).  41  Neither years in practice nor spousal or personal experience in breastfeeding were associated with counselling behaviours.  Physicians' beliefs, self-efficacy and knowledge: descriptive statistics and differences by gender, specialty, years in practice, ethnicity and personal or spousal breastfeeding experience  Analyses were performed to determine: 1) the distribution of the continuous and interval predisposing (independent) variables (belief, self-efficacy and knowledge); 2) the relationships between the predisposing variables and the counselling behaviour variables, 3) the presence of gender, specialty, years in practice, ethnicity or personal breastfeeding experience differences in the predisposing variables.  Concerning the belief questions, nutrition refers to the question, "Exclusive breastfeeding provides all the nutrition required by a healthy newborn up to the age of four to six months with the possible exception of Vitamin D." Immune refers to the question "Exclusively breastfed babies have fewer gastrointestinal infections, respiratory illnesses, eczema and/or allergic reactions than formula fed babies."  (Refer to Table 15). Few  physicians disagreed with the belief questions. Consequently, like the counselling behaviours, the responses to the belief variables are positively skewed with very little deviance from what is a desirable level of beliefs.  42  Table 15. Belief levels concerning breastfeeding  Belief - nutrition n=208 Score  Belief- immune n=209  N  %  N  %  145  70  128  61  55  26  71  34  5  Strongly agree  4  Agree  3  Neither agree nor disagree  3  1.4  9  4  2  Disagree  3  1.4  0  0  1  Strongly disagree  2  1  1  0.5  Mean Standard deviation  4.6 .71  4.6 .60  Three knowledge questions were analysed: 1) a diagram of an infant at the breast, 2) cereals help the infant sleep at night and 3) awareness of Motilium as a means to increase breastmilk supply. Each of the questions has one correct and one incorrect answer. The self-efficacy composite score was comprised of the two questions in which physicians ranked their confidence on a scale of one to ten concerning; 1) positioning a new mother for breastfeeding, and 2) assisting mothers experiencing common breastfeeding problems. The maximum possible score was 20.  43  Table 16. Self-efficacy and knowledge variables  Self-efficacy composite score  n  Mean Standard deviation  206  15.10  3.67  206 202 201  1.54 1.87 1.76  .499 .336 .427  1  Knowledge variables^ Aware of motilium Diagram of correct positioning for suckling Cereals help the baby sleep  1: Maximum possible self-efficacy composite score is 20 2: For knowledge items the score is 1 if incorrect, 2 if correct  Counselling behaviours by self-efficacy, beliefs and knowledge  Correlation coefficients were calculated to assess the strength and direction of association between the counselling behaviours and the predisposing variables (beliefs, selfefficacy and knowledge).  Table 17. Counselling behaviours by self-efficacy, beliefs and knowledge: Pearson correlations  SEcomp  Belief Nutrition  Belief  Cereals  Diagram  Motilium  Immune  Discuss  .20**  .26**  27***  .21**  .17*  .09  Convince  27***  .23**  .32***  .15*  .10  .04  Encourage  .29***  .25**  .36***  .26***  .05  .14*  * p < .05  **p < .01  ***p  <.001  Self-efficacy is correlated with all the variables of counselling behaviour, suggesting that a high score on the self-efficacy scale is associated with better counselling behaviours.  44  Self-efficacy is less correlated with discuss breastfeeding (r=.20, p = .004) than it is with convince women to breastfeed (r=27, p = .000) and encourage women  to continue  breastfeeding (r=.29, p=.000). This trend seems to correspond with our earlier observation that encourage and convince seemingly measure a dimension of breastfeeding counselling that differs from discussing breastfeeding.  The physicians' belief levels seemed important for determining how often they discuss and advocate breastfeeding. The data suggest that the more a physician believes that exclusive breastfeeding provides all the nutrition required by a healthy newborn up to the age of four to six months, the more likely he/she is to discuss (r=.26, p<.01) and advocate breastfeeding (convince r=.23, p<.01 or encourage r=.25, p<.01). Similarly, the belief question "Exclusively breastfed babies have fewer gastrointestinal infections, respiratory illnesses, eczema and/or allergic reactions than formula fed babies" was associated with discussing (r=.27, p<.001) and even more with advocating breastfeeding (convince r=.32, p<.001; encourage r=.36, p<001).  The knowledge question "cereals help the infant sleep through the night" was moderately associated with counselling behaviour (Table 17 ). The physicians who answered "false" to this question were more likely to report discussing breastfeeding in the prenatal period (r= .21, p <.01) and encouraging women to continue breastfeeding in the face of breastfeeding problems (r= .26, p<.001).  45 Predisposing variables: gender, specialty, years in practice, ethnicity and personal or breastfeeding experience differences  Correlation coefficients were calculated to detect the presence of gender, specialty, years in practice, ethnicity or personal breastfeeding experience differences in the predisposing variables. Table 18. Beliefs by specialty: point biserial correlation coefficients  Belief-nutrition  Belief-immune  -.20**  -.01  Pediatrician  .01  -.17**  Obstetrician  -.04  General practitioner  Family practitioner * p < .05  .29**  -.08 .12*  **p < .01  Pediatricians were more likely than the physicians in other specialties to take a neutral stand or disagree concerning the belief that breastfeeding protects the infant from illnesses (r= -.17, p<.01). While family practitioners more strongly believed that breastfeeding provides adequate nutrition than did physicians in other specialties (r=.29, p<.01), general practitioners were more likely to be neutral or disagree (r = -.20, p < .01) with this belief.  46  Table 19. Beliefs by gender and by spousal or personal breastfeeding experience: point biserial correlation coefficients  Belief-nutrition  Belief-immune  Children breastfed  .17*  .18**  Female  .20**  .17*  * p < .05  **p < .01  Women more strongly believed than did men that breastfeeding provides adequate nutrition (r=.20, p<.01) and that breastfeeding protects the infant from illnesses (r=.17, p<.05). In the current study, having spousal or personal breastfeeding experience was also associated with higher scores on the belief items (nutrition r=.17, p<.05 and immune r=.18, p<01).  The overall mean for the self-efficacy composite was 15.10 + 3.67(SD) (n=206). The 95% confidence interval was 14.60 to 15.61. The maximum score possible was 20. Selfefficacy scores were higher for female physicians (t= -6.2, p < .001). There were no significant differences across specialty ( F = 1.87) nor by ethnicity (t= -1.41). Both male and female physicians whose children were breastfed expressed greater self-efficacy in counselling mothers about breastfeeding problems and in positioning the baby at the breast (females r=.44, p <001; males r= .30, p< .01).  47  Table 20. Mean self-efficacy scores by gender Male Mean Self-efficacy composite score  (t= -6.2, p <  Female  Standard Error  13.83  Mean  .35  16.69  Standard Error .30  .001)  Maximum possible self-efficacy composite score is 20  The knowledge questions were: 1) a diagram of an infant at the breast, 2) cereals help the infant sleep at night and 3) awareness of Motilium as a means to increase breastmilk supply. Each of the questions has one correct and one incorrect answer. Table 21. Knowledge by specialty, gender, years in practice and personal or spousal breastfeeding experience: point biserial correlation coefficients (except years in practice variable)  Cereals  Diagram  Motilium  Obstetrician  .02  .04  -.14*  Pediatrician  .19**  -.03  .02  Family Practitioner  .09  .11  .18*  General Practitioner -.21** Female  .20**  -.05 .20**  -.08 .26***  Years in practice''  -.11  .08  -.11  Children breastfed  .10  .12  .02  * p < .05  **p < 01  **"'p<001  1: Pearson correlation coefficient was calculated for years in practice by knowledge.  Contrary to the findings in the study by Lowe (1990), knowledge did not significantly decrease with years in practice in this sample. Furthermore, personal or spousal experience  48  did not predict greater knowledge as it did in the study by Reames (1985). Women physicians scored higher on all knowledge questions (p < .01), and were particularly more aware of motilium (p < .001). Regarding knowledge differences among the specialties, family practitioners are more aware of motilium. General practitioners scored poorly on the cereal question; as noted earlier, this group also had lower level beliefs about the nutritional adequacy of breastmilk.  Interest in continuing education concerning breastfeeding  Physicians were asked if they were interested in information regarding breastfeeding and how they would like to receive this information. The physicians in this study seemed very interested in receiving breastfeeding information in group settings. Of the 150 physicians who wanted more information, 57 percent chose to receive it through hospital rounds and 42 percent through workshops at continuing education conferences. Self-study methods were also popular, particularly printed information and videotape.  Table 22. Preferred methods to receive information on breastfeeding  (n = 150)  Yes(%)  Individual basis  1  Group setting  Yes (%) 104(69)  Printed information  91(61)  Hospital rounds  Self-study module  58 (39)  Workshop at CME conference 76(51)  Videotape  76 (51)  B.C. Women's inservice  Computer software  28 (19)  1 Respondents could indicate more than one method.  67(45)  49  Table 23 shows that several physicians felt that supplementation was necessary for twins, for an infant with a difficult latch (positioning for suckling) and in the case of an emergency C-section. None of these situations are actual medical indications for supplementation.  Table 23. Reports of indications for supplementation''  n  No  Water Formula  Water & Formula  Twins  187  148  16  20  1  Emergency C-Section  185  141  19  21  4  Difficult latch  189  144  10  31  3  2  Selected responses to the question "Which of the following are indications for supplementation with non breastmilk substances (formula/sterile water)? Please answer independently for each indication." 2 Several physicians felt that both water and formula were necessary. 1  Results of the regression analyses  In interpreting the results of the regression it is important to keep in mind the limited variance on the whole. For the logistic regression each of three counselling behaviours was dichotomized with "always" and "usually" combined and with "sometimes" and "infrequently" combined. Each regression included the control variables;  -years in practice (continuous variable), -female(female =1, male =0), -children (children were breastfed =1, if not =0) -dummy variables for each specialty -Caucasian (1), other than Caucasian (0)  50  Table 24 shows the final regression models for each of the counselling behaviours. The final models were obtained by regressing the control variables along with any belief, knowledge or self-efficacy variables that were found to be significant in the regressions of the individual components. The regression of the knowledge components alone against discussing breastfeeding with patients prenatally (discuss) revealed that knowledge of infant positioning (diagram) is predictive of discussing breastfeeding prenatally. No other components were significant in the regression of the belief components against discuss nor in a regression of the self-efficacy component against discuss. Therefore, diagram was entered into a final regression and was found to be the sole predictive variable (B = .51) accounting for 1% of the variance in discussing breastfeeding prenatally when the other components of the model were specialty, gender and personal or spousal breastfeeding experience.  Similarly, for the question "How often do you attempt to convince a woman to breastfeed if she intends to bottlefeed" the final regression model included the following significant factors which accounted for the 8% of the variance of this counselling behaviour: personal or spousal breastfeeding experience (B = -.92, p <.10), being a pediatrician (B = 1.4, p< .10), self-efficacy (B = .21, p < .01) and the belief in the immune properties of breastmilk (B=. 63, p<10).  Finally, regarding the question "How often do you encourage women to continue breastfeeding in the face of problems," the final regression model included the following significant factors which accounted for the 7% of the variance of this counselling behaviour: self-efficacy (B = .20, p < .05) and the belief in the immune properties of breastmilk (B= 1.04, p< .05).  51  Table 24. Final regression models  Counselling Behaviour  Variable  f3  p  Partial R  I. Discuss breastfeeding  Diagram  1.16  .074  .12  -.92  .094  -.08  -1.38  .055  -.11  in the prenatal period (n=178)  Model Chi-Square = 2.9 Significance = .086  II. Convince women to  Children  breastfeed when they  Pediatrician  intend to bottlefeed (n=188)  Immune  .63  .080  .09  Self-efficacy  .21  .004  .22  1.04  .021  .21  .20  .038  .17  Model Chi-Square =8.9 Significance = .003  III. Encourage women to  Immune  continue breastfeeding  Self-efficacy  in the face of breastfeeding problems (n=189)  Model Chi-Square = 4.6 Significance = .032 1. 2. 3. 4. 5.  E a c h of the models controlled for ethnicity, personal or spousal breastfeeding, gender, years in practice and specialty. Diagram is the knowledge question requiring physicians to select the diagram that showed correct positioning of the infant at the breast: 1 = correct choice; 0 = incorrect choice Children: 1 = physician or spouse breastfed a child; 0 = neither physician nor spouse breastfed a child Pediatrician : 1 = specialty is pediatrics; 0 = specialty is not pediatrics. Immune: believe that exclusively breastfed infants have fewer gastrointestinal infections, respiratory illnesses, eczema and/or allergic reactions than formula fed infants. Five point Likert scale from strongly disagree (score of 1) to strongly agree (score of 5).  52  Table 25. Findings from this study and previous studies: comparison and contrast  Significant  Significant in  in this study other studies  Factors  associated with greater breastfeeding  counselling  behaviours  physicians  Stronger beliefs in breastfeeding  Yes  Michelman''  Being confident in adequacy of training  not studied*  Goldstein  Being confident in breastfeeding counselling  Yes  No, Goldstein  Being female (in a study of FP residents)  Yes  Goldstein  2  No, Michelman Knowledge  Yes  No;Goldstein  Pediatricians counsel more than obstetricians  No  Lawrence  Pediatricians advocate breastfeeding less  Yes  Family practitioner counsels more  Yes  Having breastfed their own children  No  No, Michelman, No, Goldstein  Years in practice  No  No, Michelman  Physician ethnicity  No  No, Michelman  Patient ethnicity  not studied*  No, Michelman  not studied*  Michelman  not studied*  Michelman  not studied  Michelman  Stronger beliefs in breastfeeding promotion by pediatricians Favorable attitudes towards breastfeeding Favorable attitudes towards breastfeeding promotion by pediatricians  among  53  Table 25 (cont). Findings from this study and previous studies: comparison and contrast Significant  Significant in  in this study other studies Factors associated with greater breastfeeding knowledge among physicians Being female  Yes  Lowe, Goldstein  Fewer years in practice  No  Lowe  Having breastfed own children  No  Reames  Factors associated with higher level of beliefs in breastfeeding among physicians Having breastfed own children  Yes  Reames, Goldstein  Being female  Yes  No, Michelman  Factors associated with higher levels of self-efficacy in breastfeeding counselling among physicians Having breastfed your own children  Yes  Goldstein  Being female  Yes  Goldstein  1: Michelman D F , Faden RR, Gielen A and K S Buxton, 1990. 2: Goldstein A O & Freed G L , 1993. * Not studied: the current study only looked indirectly at these factors  54  CHAPTER 4: DISCUSSION  While a mother's decision to breastfeed is influenced by many factors, support from physicians can increase breastfeeding initiation rates and breastfeeding duration (Lilburne et al., 1988, Hefti, 1992). Unfortunately, research suggests that many physicians are uninterested in breastfeeding, are not convinced of its benefits and are choosing not to carry out what should be a physician's obligation: to counsel and advocate breastfeeding.  The physicians' self-reports of beliefs, knowledge, self-confidence and counselling practices concerning breastfeeding suggest that they are not providing adequate or optimal breastfeeding support. Furthermore, the response bias (particularly, the greater proportion of females) very likely presents a conservative estimate of the shortcomings concerning breastfeeding at B.C. Women's Hospital.  The study revealed findings which may have important implications for physician education. There is evidence that both higher self-efficacy and stronger beliefs are predictive of higher levels of breastfeeding counselling. Female physicians have higher levels of practice, self-efficacy, beliefs and knowledge concerning breastfeeding.  The following discussion will describe the factors related to inadequacies with respect to the physicians' breastfeeding counselling as well as the relevant implications for future research, physician education and hospital policy. There will also be a discussion of the sample bias in the study.  55  Counselling behaviour rates  In the other breastfeeding studies, the counselling behaviour variables were dichotomized to simplify interpretation of the results. The always and usually categories were combined as were the sometimes and infrequently categories. Table 26 compares dichotomized behaviour variables from this study with those of other studies. Table 26. Counselling behaviours: a comparison to similar studies  Current study  1  Discuss breastfeeding  Advocate breastfeeding  90%  88% convince  2  94% encourage  Goldstein & Freed (1993) Michelman et al. (1990) Lawrence (1982)  57% FP residents —  3  50% FP residents 51% Peds  92 % Peds, 72% O/G,  27% Peds, 22% O/G,  88% FP  44% FP  Hollen (1976) 44 % Peds, 41% O/G 1 Variables are dichotomized by combining always and usually and by combining sometimes and infrequently. 2 Attempt to convince women to breastfeed if they are planning to bottlefeed 3 Encourage women experiencing breastfeeding problems to continue breastfeeding In a recent study, only 57% of residents reported counselling about breastfeeding at least 50% of the time and 41% would attempt to convince a mother to breastfeed if she intended to bottlefeed (Goldstein & Freed, 1993). Michelman et. al (1990) found that 51% of pediatricians promote breastfeeding while 48% make no recommendation but leave the decision up to the mother.  56  Overall, the physicians responding in our sample reported counselling more often than do physicians in other studies. Ninety percent of the respondents reported always or usually discussing breastfeeding with their patients prenatally (65% always do) and 88% reported always or usually attempting to convince mothers to breastfeed if they intend to bottlefeed (41% always do). The reports of counselling in this study are overestimates as there is a greater proportion of female physicians among the respondents than among the physicians at B.C. Women's Hospital. The male physicians were much less likely to respond to the survey and those males who responded reported counselling less often than do the female physicians. Had more males responded the reports of counselling would better reflect the counselling practices of B.C. Women's physicians, would probably be lower and would be more comparable to the counselling self-reports of other studies.  While the counselling self-reports of this study are more favourable than those of other studies, there is still a need for improvement. For example, the fact that 35% of physicians do not always discuss breastfeeding can be seen as unacceptable. This figure is reminiscent of the finding by Lawrence (1982) that 33% of physicians do not initiate the topic of breastfeeding. This study also found that 59% of physicians do not advocate breastfeeding to the mother who is undecided about infant feeding.  Beliefs, self-efficacy and knowledge as predictors of counselling practices  Belief in the benefits of breastmilk were higher than those observed in the Goldstein study. Hollen (1976) found that only 62% of obstetricians and pediatricians agreed that breastfeeding protects against respiratory and gastrointestinal illnesses. Similarly, the weight and overall acceptance of scientific evidence seems to affect physicians' attitudes and potentially, their health promotion counselling behaviours (Green & Kreuter, 1991). Less than half of U.S. primary care physicians a decade ago felt that risk factors such as avoiding  57  saturated fats and engaging in regular exercise are important, while most agreed that reducing cigarette smoking is important (Weschler et al., 1983).  Five of the twenty pediatricians in the current study reported that they do not attempt to convince women to breastfeed. This is a significantly greater proportion than was seen in the other specialties and may be associated with this group's lower beliefs in the immune factors of breastmilk.  Factors that influence beliefs concerning breastfeeding include how the physician fed his or her own children (Reames, 1985). This trend was significant in the current study. As in the study by Reames (1985), beliefs of physicians in this study in the benefits of breastfeeding were stronger among female physicians than male physicians. While Goldstein & Freed (1993) did not find this gender difference, their evidence that physicians with spousal or personal breastfeeding experience have stronger beliefs in the benefits of breastfeeding is supported by the current study.  Low self-efficacy, a feeling of unpreparedness to counsel patients about their lifestyles among physicians may explain their hesitance to do so. As in the study by Goldstein (1993) self-efficacy did seem important in predicting breastfeeding counselling rates. Our study additionally found that this relationship between lower self-efficacy and lower levels of counselling is consistent across the wide range of years in practice and four areas of specialty present in our sample of physicians.  Both male and female physicians whose children were breastfed expressed greater self-efficacy in counselling about breastfeeding problems and in positioning the baby at the breast (females r=.44, p <001; males r= .30, p< .01).  58  In their study of residents, Goldstein and Freed (1993) found that having breastfed a child was not predictive of counselling about breastfeeding. This would suggest that the experience of breastfeeding a child does not provide the confidence necessary to counsel patients, and that this confidence must be developed through training in breastfeeding counselling or through rewarding experiences in doing it successfully. The results of this study suggest that this trend is also prevalent among physicians with regardless of how many years of practice they have had.  While research shows evidence of greater confidence or self-efficacy in preventive counselling among more recently trained physicians (Green et. al, 1988), self-efficacy in counselling about breastfeeding did not seem greater in recent graduates than in physicians with greater years in practice in our study. This may suggest that physicians are not currently receiving adequate training in breastfeeding.  Goldstein and Freed (1993) found that the knowledge questions were not significant predictors of whether the physicians counsel about breastfeeding. The current study suggests that physicians that know how to position the infant at the breast correctly are more likely to discuss breastfeeding with patients prenatally. Positioning of the infant at the breast can be seen as a basic knowledge question. In contrast, the knowledge question regarding whether cereals help the infant sleep is perhaps affected by or is a measure of the physicians' beliefs. As well, the awareness of motilium can be seen as a more advanced knowledge question as this drug is a newer method for increasing breastmilk production. The results of the study suggest that at least a basic understanding of breastfeeding is necessary to motivate physicians to counsel.  Knowledge levels were greater among female physicians in this study as in the studies by Lowe (1990) and Goldstein & Freed (1993). Unlike the study by Lowe however,  59  the current study did not find lower levels of knowledge with increasing years in practice. Having personal or spousal breastfeeding experience did not increase physicians' knowledge in the current study as it did in the study by Reames (1985).  Inadequate breastfeeding education to physicians: an ongoing problem  Green and Kreuter emphasize the importance of cumulative learning: Cumulative learning takes into account the prior learning experiences and concurrent incidental experiences to which the learners are exposed. Learning does not occur in a vacuum. Physician behaviour is a product not only of medical education but of all prior education formal and informal; of concurrent life experiences; and of the society in which the physician was raised, educated, trained, and in which he or she practices (Green & Kreuter, 1991).  In the study by Hollen of pediatricians and obstetricians in 1976, more than half of the respondents never saw anyone breastfeeding a child when they were growing up or while they attended medical school. The majority of the respondents never saw a mother nursing a child until they had a child of their own or began practising medicine. In physicians' families 53% reported that their first child was not breastfed for as long as originally planned. Furthermore in 96% of the cases of early discontinuation, all following children were bottlefed. The reasons for discontinuing breastfeeding reported most often included inadequate milk supply, nipple cracks or soreness and breast infections. These conditions are considered to be easily preventable and also correctable with the help of a knowledgeable physician.  Medical training of the past has lacked a basic approach to preventive medicine and patient education (Green & Kreuter, 1991). Similarly, training for breastfeeding counselling was found to be inadequate by 63% of the physicians in the study by Reames in 1985. Years in practice failed to demonstrate a significant influence on counselling behaviour in this study  60  and in previous studies of physicians' counselling behaviour concerning breastfeeding (Michelman et al., 1990; Goldstein & Freed, 1993). Apparently, both older and younger physicians in the current study have similar rates of breastfeeding counselling. The reports of choosing not to counsel or advocate about breastfeeding are as common among the recently trained physicians as they are among the physicians trained in an era less supportive of breastfeeding. The suggestion of this study that breastfeeding education to physicians has not improved since 1985 is supported by the 1993 study by Goldstein and Freed which reports that 67% of family practice residents found their training in breastfeeding counselling inadequate.  Creating a positive environment for breastfeeding: The Ten Steps  This study showed the need for the hospital to become more of a driving force in improving the nonsupportive practices of its physicians. Only 34% of the physicians had read the WHO - UNICEF Ten Steps for Successful Breastfeeding, a policy which was meant to be promoted to health professionals by the hospital. Physicians also reported that they felt that twins, an emergency C-section or a difficult latch were indications for supplementation with non breastmilk substances (formula or sterile water). These situations are typically not indications for supplementation. The findings concerning supplementation are consistent with the statistic that Canadian hospitals supplement 71% of newborns (Health and Welfare Canada, 1990).  Supplementation interferes with breastfeeding and undermines the ability of the mother to breastfeed successfully. Formula companies give hospitals hundreds of thousands of dollars of free formula (far more than would be necessary due to medical indications) with the condition that they use only one brand. New mothers see this use of one brand  61  exclusively as endorsement and continue to use the hospital-modeled brand at home (Reiff & Essock-Vitale, 1985). The hospital needs to replace this bottlefeeding modelling with breastfeeding support. This means stopping the practice of formula contracts. It is hypocritical that on one hand the hospital is persuading its physicians' to promote breastfeeding and on the other hand the hospital is making deals with the formula companies.  B.C. Women's hospital has a policy that supplementation only be permitted through a physician's order. Even if the hospital has succeeded in enforcing this policy, an education program to physicians will have to be put in place to correct what appears to be very poor supplementation practices.  Methodological Limitations  Sample Biases  The analyses indicate gender and specialty differentials which potentially introduce sample bias. Firstly there is an increased response rate from physicians that are female and/or Caucasian and or family physicians which reduces the generalizability of the findings. Specifically, the counselling behaviours and the belief, self-efficacy, and knowledge scores may be specific to the respondents.  Secondly, the survey was within one geographic concentration. The results may not be generalizable to other physicians providing maternity and infant care.  One might interpret the higher response rate from family practitioners as an indication that they are more interested in breastfeeding. It should be noted, however, that this group received more encouragement to complete the survey. The principal investigator is a family  62  practitioner and made announcements regarding the survey at two different family practice rounds. Furthermore, determining whether greater response rate is related to interest in breastfeeding could only be accomplished through an actual measure of the interest level of the non-respondents, perhaps by having non-respondents provide this one piece of information on the phone.  The effect of bias will most likely present an overestimation of the breastfeeding support at B.C. Women's Hospital as the factors predicting response (particularly being female and being a family practitioner) to the questionnaire are for the most part also predictive of better levels of counselling practice, knowledge, self-efficacy and beliefs.  Addressing Limitations to the Method of Analysis  In interpreting results, the reliability and validity of the measures must be of primary consideration. To ensure content validity, the questionnaire content would have ideally been based on an agreed upon set of standards for measuring the cognitive and behaviour constructs concerning breastfeeding counselling. Such standards do not exist and it was necessary to refer to items used in previous studies. To further assess the content validity, the questionnaire was reviewed by physicians and health promotion professionals.  The face validity of the revised questionnaire was assessed through a pilot-test to physicians. Face validity refers to what the items appear to measure based on the actual reading of the item by people familiar with the subject.  Reliability analysis was limited to internal consistency reliability: to the extent to which all the individual items in the scale (i.e. a belief, knowledge or self-efficacy scale) are consistently measuring the same underlying concept, property or characteristic. As has been  63  discussed, scales were not developed since the items that were measured for each given construct seemed to measure different dimensions of their construct. The exception was a composite score comprising of the highly correlated self-efficacy items.  The use of three variables to determine counselling behaviour seemed beneficial. Firstly, it allowed several dimensions of counselling behaviour to be covered. These different dimensions are demonstrated in the observation that higher self-efficacy and stronger beliefs are predictive of higher levels of advocating breastfeeding but are less important for discussing breastfeeding.  Secondly, the different specialists found at least two counselling variables relevant to their practice. It was seen in previous studies and was also the case in this study that pediatricians often do not see expectant mothers prenatally. In our study 10 out of 20 pediatricians did not answer the discuss prenatally question and of these seven wrote that they do not see women prenatally. However, all twenty pediatricians did answer the convince to breastfeed question and the encourage to continue question. Among the obstetricians one did not answer the encourage to continue question, specifying that this is the role of the family doctor. All of the obstetricians answered the discuss prenatally and encourage to continue questions.  64  Conclusions  This study found shortcomings in physicians beliefs, self-efficacy, knowledge and counselling practices. These should be addressed through further research and through education programs and policy surrounding hospital practices and breastfeeding education.  Implications for future research  The results of this study strongly suggest the need for a breastfeeding education program to physicians. An evaluation of the education program should be performed. The evaluation should include a pre- and post-test designed to address specific educational goals of the program. For example, the questionnaire in this study would not be an appropriate evaluation instrument.  A post-test using the questionnaire of the current study should also be conducted as it would provide information about the change in belief, knowledge, self-efficacy and counselling practices over time.  The Health Belief Model highlights cognitive factors that favour positive changes in health behaviours including: adequate incentives to change, feeling sufficiently threatened by some potential or actual environmental event, believing that outcomes can be influenced by behaviour and not being faced with major barriers to action. It may be possible in future surveys to address each of these items as they apply to physicians' perceptions of breastfeeding and breastfeeding counselling. For example, physicians could be asked whether they feel that bottlefeeding may actually lead to an increased risk of infant illnesses or suboptimal infant development. The current study revealed that the belief that bottlefed infants have more infant illnesses was particularly important. In the study by Michelman et. al  65  (1990), the belief by physicians that their counselling to mothers will increase breastfeeding rates was associated with greater physician self reports of breastfeeding counselling. A potentially effective complementary question is "almost any mother can be successful at breastfeeding if she keeps trying".  As was discussed, self-selection bias likely presents a more optimistic picture of the physicians' counselling behaviours and cognitive factors. Understanding the effect of this bias would depend on obtaining information about the nonrespondents' counselling behaviours. One approach would be to conduct a phone mini-survey of the nonrespondents asking a few key questions in terms of counselling behaviour and cognitive factors.  Another approach to gaining information about non-respondents would be to survey new mothers in B.C. Women's maternity ward who are patients of the physicians in our study. The survey would ask them a few questions about their experiences regarding antepartum breastfeeding counselling from the physician. Follow-up phone calls could then be made to these mothers again at three weeks postpartum. The women would be asked for their perception of the amount of support and assistance for breastfeeding they received from their physician following hospital discharge. This survey of mothers may also reveal that there is a significantly lower level of support for breastfeeding which in turn suggests that the self reports of counselling behaviours were overestimates of the physicians' actual practices. This overestimation is seen in the presence of social desirability bias, or the tendency to answer questionnaire items in a way that is acceptable or even expected.  66  Implications for policy and education  Change depends on driving forces including support from hospitals  Policy should be developed within the government, medical associations, medical faculties and hospitals that address the changes necessary for support of breastfeeding. Creative measures to implement policy seem called for as even after several years physicians are unaware of the WHO-UNICEF Ten Steps. Hospitals are the most likely change agents because they can require that physicians follow policy in order to qualify for or maintain their hospital privileges. Medical associations should also be involved through developing breastfeeding education and enforcing continuing education requirements. The government would be responsible for overseeing the development and implementation of medical association and hospital policy.  Hospital policy should restrict formula supplementation to cases where it is medically indicated and ordered by a physician. Furthermore, in order for physicians to see credibility in the hospital's breastfeeding promotion efforts, every hospital should cease the controversial practice of receiving free formula from formula companies.  Physicians should receive feedback from the hospital concerning any physician practices that serve to promote or hinder breastfeeding. As a part of quality assurance policy the hospital should incorporate assessment of the quality of breastfeeding support. For example, each month ten patients on the maternity ward could fill out short questionnaires describing their satisfaction or dissatisfaction with the support they received in the hospital and during prenatal visits to the physicians' office. These mothers would then be phoned at three weeks to ask about post-partum breastfeeding follow-up. This information would be given to medical societies, hospital administrators and discussed at hospital rounds.  67  Hospitals and the B.C. Medical Association could select interested physicians who would encourage their colleagues to improve their breastfeeding counselling skills. This peer approach could complement current policies such as the Ten Steps and other top-down approaches. The benefit would be a reinforcing influence from colleague support. Perceptions that several physicians are involved in such an endeavor may help overcome barriers such as the time requirements or the lack of interest in breastfeeding education and counselling (a 'softer" issue, i.e., not considered life or death) among some physicians. The physicians who act as change agents would receive a reward such as extra continuing education points.  Physicians must feel that their colleagues are entirely consistent in promoting breastfeeding. The fact that physicians, as a whole, waver in their breastfeeding advocacy to mothers demotivates the physician from participating in this activity for fear of alienating the mother or even causing her to change physicians.  Breastfeeding education to physicians Medical faculties should upgrade the breastfeeding education component of their curricula. A lactation consultant should be involved in revising the curricula and in developing continuing education. Concerning the practicing physician, a percentage of continuing education requirements should be specifically designated for breastfeeding education. Likewise hospitals should require that physicians receive breastfeeding education in order to maintain privileges to care for the hospitals' maternity patients.  68  Typically physicians tend to prefer reading as a source of continuing education. Reading allows physicians to learn at their own pace, select what is pertinent to their practice and reread the information as necessary but it fails to provide the practice and feedback necessary for behaviour change (Green & Kreuter, 1991). The physicians in this study also seemed very interested in receiving breastfeeding information in group settings. Group settings give the opportunity for feedback to the physicians which can be seen as a means to build self-efficacy. The breastfeeding education can be broken down into steps which the physician can master. Workshops and conferences allow physicians to receive feedback from peers and educators and potentially reinforce the physicians' efforts to improve breastfeeding counselling behaviour.  Since beliefs about the benefits of breastmilk and counselling confidence were important predictors of supportive breastfeeding counselling physicians should be trained in these areas. A breastfeeding education program to physicians should emphasize the immune properties of breastmilk and present the recent evidence supporting these benefits.  The uninformed physicians who supplement infants when it is not medically indicated can cause breastfeeding to be irreversibly interrupted and to ultimately fail. The most unfortunate aspect of this practice by physicians is that is often done without informing the mother of the potential damage to establishing successful breastfeeding. Educational programs to physicians should emphasize the potential for supplementation to interfere with breastfeeding initiation, to undermine the mother's breastfeeding confidence and to prevent an increase in breastmilk supply required at the time of the infant's growth spurts.  69  It is entirely unacceptable that several physicians are not initiating the topic of and advocating breastfeeding. Physicians' desires to respect the wishes of the mother who faces breastfeeding challenges should not override their responsibility to promote the natural method of infant feeding that has benefits for the infant and mother. For example, the working mother should be encouraged to breastfeed by the physician who is in turn wellinformed about expressing breastmilk and about breastfeeding support groups for the mother. Physicians may even advocate breastfeeding by, for example, writing notes to their patients' employers encouraging employers to provide a place for women to express milk while at work. This spirit of advocacy could be introduced in education programs to physicians. At the very least, educational programs should be strongly discouraging the neutral stand that is typically taken by physicians concerning breastfeeding.  Involving the patient in breastfeeding promotion  Campaigns for fathers to be involved in the support of breastfeeding seems appropriate as physicians feel that fathers feel closer to their infants when they bottlefeed them. A television commercial could show the father feeding the mother a nutritious snack while she is breastfeeding.  Mothers themselves can play a role in promoting supportive breastfeeding counselling by physicians. The mother can ask her physician about breastfeeding early in the prenatal period. Should the physician seem uninterested or even provide misinformation the mother could express her dissatisfaction. The mother could encourage the physician to get up-to-date information or the mother may decide to see another physician for the pregnancy. The government should fund and support initiatives that would encourage mothers to interact with their physicians in a more informed, assertive manner. The mother who has received basic breastfeeding information through population-tested education material and prenatal classes (which could be made widely available and affordable through local health departments), for  70  example, is empowered to begin her dialogue with the physician and decide for herself if the physician provides reliable breastfeeding advice. Prudence on the part of the mother seems warranted given that several physicians in the current study could not recognize a basic aspect of breastfeeding: positioning the infant at the breast.  In conclusion, it is ultimately the responsibility of the medical system to prepare physicians to be supportive of breastfeeding. Despite the years of research highlighting the inadequacies of the physicians' breastfeeding training and despite the breastfeeding policies such as the Ten Steps the system is failing in its responsibility to mothers and infants.  71 Bibliography Adebonojo FO. 1972. Artificial vs. breastfeeding: relation to infant health in a middle class American community. Clinical Pediatrics. 11: 25-29. Aloia JF, Cohn SH, Vaswani A et al. 1985. Risk factors for post-menopausal osteoporosis. American Journal of Medicine, 78:95-100 Avard D, Hanvey L. 1989. The Health of Canada's Children: A CICH Profile. Canadian Institute of Child Health. Bagwell JE, Kendrick OW, Stitt KR, Leeper JD. 1993. Knowledge and attitudes towards breast-feeding: differences among dietitians, nurses, and physicians working with WIC clients. Journal of the American Dietetic Association. 93:801-804. Bandura, A. 1977. Self-efficacy: toward a unifying theory of behaviour change. Psychological Review. 84: 191-215. Bergevin Y, Kramer M. 1983. Do infant formula samples shorten the duration of breastfeeding? Lancet: 1148-1151. Bernard-Bonnin AC, Stachtchenko S, Girard G, Rousseau E. 1989. Hospital practices and breastfeeding duration: A meta-analysis of controlled trials. Birth, 16:64-66. Byers T, Graham S, Rzepka T. 1985. Lactation and breast cancer. Evidence for a negative association in premenopausal women. American Journal of Epidemiology. 121:661-674. Canadian Paediatric Society Nutrition Committee. 1991. Meeting the iron needs of infants and young children: an update. Canadian Medical Association Journal, 144:1451-1454. Carmines EG, Zeller RA. 1979. Reliability and validity assessment. Beverly Hills: Sage Publications.  72 Casey CE, Hambidge KM. 1983. Nutritional aspects of human lactation. In Neville MC, Neifert MR (eds). Lactation; Physiology, Nutrition and Breastfeeding. Plenum Press, New York: 199-248. Cerutti EF. 1981. The management of breastfeeding. Birth. 8:251-56. Cox A, Rutter M, Yule B, Quinlon D. 1977. Bias resulting from missing information: some epidemiological findings. British Journal of Social and Preventive Medicine. 31:131-136. Cummings KM, Giovino G, Sciandra R et. al. 1987. Physician advice to quit smoking: who gets it and who doesn't. American Journal of Preventive Medicine. 3:69-75. Cunningham AS, Jelliffe DB, Jelliffe EFP. 1991. Breastfeeding and health in the 1980s: a global epidemiologic review. Journal of Pediatrics, 118:659-665. Damus K, Pakter J, Krongard E, et al. 1988. Postnatal medical and epidemiological risk factors for the sudden infant death syndrome. In Harper RM, Soffman HJ (eds): Sudden Infant Death Syndrome: Risk factors and Basic Mechanisms. PMA Publications, New York: 187-201. Davis MK, Savitz D, & Graubard Bl. 1988. Infant feeding and childhood cancer. Lancet. 2:365-8. Frank JW, Newman J. 1993. Breast-feeding in a polluted world: uncertain risks, clear benefits. Canadian Medical Association Journal. 149(1):33-37. Gilchrist LD, Schinke SP. 1983. Coping with contraception: cognitive and behavioral methods with adolescents. Cognitive Therapy and Research, 7:379-388. Goldstein AO, Freed GL. 1993. Breast-feeding counseling practices of family practice residents. Family Medicine. 25:524-529.  73 Green LW, Eriksen MP, Schor EL. 1988. Preventive practices by physicians: behavioral determinants and potential interventions. American Journal of Preventive Medicine, 4(4):S101-7. Green LW, Kreuter MW. 1991. Health Promotion Planning: An Educational and Environmental Approach. Mayfield Publishing Company. Toronto. Green LW, Cargo M, Ottoson JM. 1994. The role of physicians in supporting lifestyle changes. Medicine Exercise. Nutrition and Health. 3:119-130. Greer FR, Apple RD. 1991. Physicians, formula companies, and advertising. A historical perspective. American Journal of Diseases of Children. 145(3):282-6. Health and Welfare Canada. 1990. Present Patterns and Trends in Infant Feeding in Canada. Ontario. Hefti R. 1992. Protection, promotion and support of breastfeeding: The health professional's role. BC Medical Journal. 24, 95-99. Hollen BK. 1976. Attitudes and practices of physicians concerning breastfeeding and its management. Environmental Child Health. 22:288-293. Kaplan RM, Atkins CJ, Reinsch S. 1984. Specific efficacy expectations mediate exercise compliance in patients with COPD. Health Psychology. 3:223-242. Labbok MH, Simon SR. 1988. A community study of a decade of in-hospital breastfeeding: implications for breastfeeding promotion. American Journal of Preventive Medicine. 4(2):6267. Lawrence RA. 1982. Practices and attitudes towards breast-feeding among medical professionals. Pediatrics, 70:912-920. Layde PM, Webster LA, Boughman AL et al. 1989. The independent associations of parity, age at first full term pregnancy and duration of breastfeeding with the risk of breast cancer. Journal of Clinical Epidemiology. 42:963-973. Lewis-Beck MS. 1985. Applied Regression: An Introduction. Beverly Hills: Sage Publications.  74 Lilburne AM, Oates RK, Thompson S, Tong L. 1988. Infant feeding in Sydney: a survey of mothers who bottle feed. Australian Paediatric Journal. 24:49-54, 1988. Livingstone, V. 1992. Protecting breast-feeding: family physician's role. Canadian Family Physician. 38:1871-1876. Lowe, T. 1990. Breastfeeding: attitudes and knowledge of health professionals. Australian Family Physician. 19: 392, 395-6, 398. Lucas A, Brooke OG, Morley R et al. 1990. Early diet of preterm infants and development of allergic or atopic disease: randomized prospective study. British Medical Journal, 300:837840. Lucas A, Morley R, Cole TJ et al. 1992. Breast milk and subsequent intelligence quotient in children born pre-term. Lancet. 339:261-264. Macquart-Moulin G, Fancello G, Vincent A, Julian C, Baret C, Ayme S. 1990. Evaluation of the effects of a support campaign on exclusive breastfeeding at one month. Revue D'Epidemiologie Et De Sante Publique. 38: 201-9. Madeley RJ, Hull D, Holland T. 1986. Prevention of postneonatal mortality. Archives of Diseases of Children. 61:459-463. Martin P, Bateson P. 1993. Measuring behaviour: An introductory Guide. Cambridge University Press. Cambridge. Michelman DF, Faden R, Carlson Gielen A, & Buxton KS. Pediatricians and breastfeeding promotion: attitudes, beliefs, and practices. 1990. American Journal of Health Promotion. 4:181-186. Minchin M. 1985. Breastfeeding Matters. Alma Publications. Australia. Moxley S, Kennedy M. 1994. Strategies to support breastfeeding: discarding myths and outdated advice. Canadian Family Physician. 40:1775-1781. Naylor, A. 1990. Professional education and training for trainers. International Journal of Gynecology & Obstetrics. 31(Suppl 1):25-28.  75  Newman J. 1991. Encouraging, supporting and maintaining breastfeeding: The obstetrician's role. Journal of the Society of Obstetricians and Gynecologists of Canada. 9:15-23. Orleans CT, George LK, Houpt JL, Brodie KH. 1985. Health promotion in primary care: a survey of U.S. family practitioners. Preventive Medicine, 14: 636-647. Piterman, L. 1991. GPs as learners. The Medical Journal of Australia, 155: 318-322. Rajan L, Oakley A. 1990. Infant feeding practices in mothers at risk of low birth weight delivery. Midwifery. 6:18-27. Reames, ES. 1985. Opinions of physicians and hospitals of current breast-feeding recommendations. Journal of the American Dietetic Association, 85:79-80. Reed BD, Jensen JD, Gorenflo DW. 1991. Physicians and exercise promotion. American Journal of Preventive Medicine.7:410-415. Reiff Ml, Essock-Vitale SM. 1985. Hospital influences on early infant-feeding practices. Pediatrics. 76:872-879. Schroeder LD, Sjoquist DL, Stephan PE. 1988. Understanding Regression Analysis. Beverly Hills: Sage Publications. Strecher VJ, DeVellis BM, Becker MH and Rosenstock IM. 1986. The role of self-efficacy in achieving health behaviour change. Health Education Quarterly, 13:73-92. Strembel S, Sass S, Cole G, Hartner J, & Fischer C. 1991. Breastfeeding policies and routines among Arizona hospitals and nursery staff: results and implications of a descriptive study. Journal of the American Dietetic Association. 91: 923-5. Tanaka PA, Yeung DL, Anderson GH. 1990. Health professionals as sources of infant nutrition information for metropolitan Toronto mothers. Canadian Journal of Public Health, 80:200-204. Valente CM, Sobal J, Muncie HL Jr. 1986. Health promotion: physician's beliefs, attitudes and practices. American Journal of Preventive Medicine, 2: 82-88.  76 Walsh JM, McPhee SJ. 1992. A systems model of clinical preventive care: an analysis of factors influencing patient and physician. Health Education Quarterly. 19:157-175. Wells KB, Lewis CE, Leake B. 1984. Do physicians preach what they practice? Journal of the American Medical Association. 252:2846-2848. Weschler H, Levine S, Idelson RK, Rothman M, Taylor JO. 1983. The physician's role in health promotion: survey of primary care practitioners. New England Journal of Medicine. 308:97-100. Whittemore AS. 1993. Personal characteristics relating to risk of invasive epithelial ovarian cancer in older women in the United States. Cancer, 71(2 Suppl):558-65.  APPENDIX 1: Final Survey  78  T H E WORLD H E A L T H ORGANIZATION AND UNICEF "BABY-FRIENDLY HOSPITAL" PHYSICIAN'S SURVEY  The following survey aims to give Grace physicians input into the development of a breastfeeding education program that would best suit your needs. The survey will assess Grace physicians' knowledge, attitudes and practice concerning breastfeeding. It should take approximately 15 minutes to complete. The questionnaires have been coded to ensure confidentiality. The survey is being conducted by the Grace Baby-Friendly Hospital Committee as part of their efforts to promote the WHO/UNICEF guidelines (the Ten Steps) to successful breastfeeding. Results of the study will be available to interested participants upon its completion. Your participation would be greatly appreciated. Please note exclusive breastfeeding refers to feeding the infant only breastmilk and not giving any substitutes, fluids, etc. (other than Vitamin D drops).  1. Have you read the WHO/UNICEF guidelines (the Ten Steps) to successful breastfeeding? Yes ( )0l No ( ) 02 2. In general, how do you feel about the WHO/UNICEF policy to enhance physicians skills in breastfeeding promotion and breastfeeding support? 1. Very favourable 2. Favourable 3. Not favourable or unfavourable 4. Unfavourable 5. Very unfavourable 6. Unaware of policy 3. From which of the following sources did you obtain your knowledge about breastfeeding? (Check all that apply). Medical school ( ) 01 Residency ( ) 02 Rounds/Lectures ( ) 03 Personal experience own children breastfed ( ) 04 clinical experience ( ) 05 Personal reading ( ) 06 Other (specify) 07 4. In your view,fromwhich one of the sources in Question 3 did you obtain most of your knowledge about breastfeeding? Indicate one only  79 5. Who do you think is the person most responsible for teaching patients the fundamentals of breastfeeding? (Check one only). G.P. ( )0l Paed ( )02 Obs/gyn ( )03 Inpatient Nurse ( ) 04 Community Health Nurse ( )05 Lactation Consultant ( )06 Prenatal breastfeeding class ( )07 Family ( ) 08 09 Other  State how much you agree or disagree with the following statements:  ».  "Exclusive breastfeeding provides all the nutrition required by a healthy newborn up to the age of four to six months with the possible exception of Vitamin D." 1. Strongly agree ( ) 2. Agree ( ) 3. Neither agree nor disagree ( ) 4. Disagree ( ) 5. Strongly disagree ( ) "Exclusively breastfed babies have fewer GI infections, respiratory illnesses, eczema and/or allergic reactions than formula fed babies." 1. Strongly agree ( ) 2. Agree ( ) 3. Neither agree nor disagree ( ) 4. Disagree ( ) 5. Strongly disagree ( )  8. How often do you discuss breastfeeding with your patients in the prenatal period? 1. Always (100% of the time) 2. Usually (70 to 99% of the time) 3. Sometimes (40 to 69% of the time) 4. Infrequently (<40% of the time) 5. Never  ( ( ( ( (  ) ) ) ) )  9. If a patient intends to bottlefeed do you attempt to convince her to breastfeed? 1. Always (100% of the time) 2. Usually (70 to 99% of the time) 3. Sometimes (40 to 69% of the time) 4. Infrequently (<40% of the time) 5. Never  ( ( ( ( (  ) ) ) ) )  80 10. How long do you usually recommend that a mother continue to exclusively breastfeed?  months  Comments  11. At what age do you recommend mothers start feeding solid foods to their breastfeeding babies?  months Comments  12. Adding cereals to the baby's diet helps the baby sleep through the night. True  (  )0l  False  (  ) 02  13. Before a mother's breastmilk comes in, how many wet diapers should her newborn have per day? 1 ( ) 2 ( ) 3-4 ( ) 4 - 6 ( ) Don't know ( ) 14. After a mother's breastmilk comes in, how many wet diapers should her newborn have per day? 3-4 ( ) 4-6( ) 6-8( ) 8-10 ( ) Don't know ( )  State how much you agree or disagree with the following statements:  15. In a healthy newborn daily weights are 1. Strongly agree ( 2. Agree ( 3. Neither agree nor disagree ( 4. Disagree ( 5. Strongly disagree (  important: ) ) ) ) )  16. Breastfeeding babies should not be offered soothers or bottles in the immediate postpartum period. 1. Strongly agree ( ) 2. Agree ( ) 3. Neither agree nor disagree ( ) 4. Disagree ( ) 5. Strongly disagree ( ) Comments  81 17. Which of the following are indications for supplementation with non breastmilk substances (formula/sterile H20)? Please answer independently for each indication. Maternal  No  Yes Yes wl w/H20 formi  1.  Exhaustion  •  •  2.  Prolonged labour  •  •  •  3.  Emergency C-Section  •  •  •  4.  Illness - severe  •  •  •  5.  Pain  •  •  •  6.  Postpartum blues  •  •  •  7.  Breast augmentation  •  •  •  8.  Breast reduction  •  •  •  1.  Poor suck  •  •  •  2.  > 10% weight loss  •  •  •  3.  Jaundice  •  •  •  4.  Baby will not settle  •  •  •  5.  Baby wants to suck constantly  •  •  •  6.  Low urine output  •  •  •  7.  Small for gestational age (IUGR) •  •  •  8.  Large for gestational age (LGA) •  •  •  9.  Twins  •  •  •  10.  Difficult latch  •  •  •  11.  Prematurity  •  •  •  COMMENTS  •  Infant  18. If a breastfeeding newborn needs extra fluids how do you usually suggest a mother give the fluid? Check one only. 1. Bottle ( ) 2. Eyedropper ( ) 3. Syringe ( ) 4. Supplemental Nursing System ( ) 5. Cup ( ) 6. Other Comments  82 19. If a patient is having problems with breastfeeding after hospital discharge, what health professional should provide help? (Check all that apply) G.P. ( )oi Paed ( )02 Lactation Consultant Maternity Care at Home Nurse Community Health Nurse Other 07  Obs/gyn ( ( ) 04 ( ) 05 ( ) 06  ) 03  20. If more than one health professional was checked in Question 19, please indicate who you think is the health professional most responsible for providing this postpartum assistance? Check one only. G.P. ( )0l Paed ( ) 02 Lactation Consultant Maternity Care at Home Nurse Community Health Nurse Other 07  Obs/gyn ( ( ) 04 ( ) 05 ( ) 06  ) 03  21. In the presence of breastfeeding problems how often do you encourage your patient to continue breastfeeding? 1. Always (100% of the time) 2. Usually (70 to 99% of the time) 3. Sometimes (40 to 69% of the time) 4. Infrequently (<40% of the time) 5. Never 22. To whom do you refer patients experiencing problems with breastfeeding? (Check all that apply). G.P. ( )0l Paed ( )02 Lactation Consultant Maternity Care at Home Nurse Community Health Nurse Breastfeeding Drop-in Breastfeeding Support Group ie La Leche League Other 09 No one 10 ( ) I suggest bottle feeding 11 ( )  Obs/gyn ( ( ) 04 ( ) 05 ( ) 06 ( ) 07 (  ) 03  ) 08  23. Are you aware of the prescribing of Motilium (domperidone) to increase breastmilk supply? Yes ( ) 01 No ( ) 02 24. Do you prescribe Motilium (domperidone) to increase breastmilk supply? Yes (  ) 01 No (  ) 02  83 25.  Which of the following diagrams shows the correct latching on (positioning of the baby's mouth at the breast to initiate suckling) ? Please circle the letter corresponding to the correct diagram.  B  01  02  Please rate the next two questions on a scale of 0 to 10, where 0 is least confident and 10 is most confident. 26. How confident are you that you can assist a breastfeeding mother with positioning herself and the baby for breastfeeding? Please circle a number. 0 - 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 1 0 Comments  27. How confident are you that you can put most of your breastfeeding mothers at ease when discussing problems such as nipple soreness or breast engorgement? Please circle a number. 0 - 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 1 0 Comments  28. How many babies do you deliver per year? 29. On average approximately what percentage of your patients are: a. b. c. d. e. f.  Caucasian Asian Indo-Canadian Native Indian African-Canadian Other  /100 /100 /100 /100 /100  30. What percentage of your patients have English as afirstlanguage?  %  84 Please note exclusive breastfeed refers to feeding the infant only breastmilk and not giving any substitutes, fluids, etc. (other than Vitamin D drops). 31. What percentage of your prenatal patients planned to exclusively breastfeed prior to delivery? % Don't know ( ) Do not see patients prenatally ( )  98 99  32. What percentage of your patients actually exclusively breastfeed to 6 weeks? % Don't know ( ) Do not see patients postnatally ( )  98 99  33. What percentage of your patients actually exclusively breastfeed to 3 months? % Don't know ( ) Do not see patients prenatally ( )  98 99  34. What percentage of your patients actually exclusively breastfeed to 6 months? % Don't know ( ) Do not see patients prenatally ( )  98 99  36. Would you like to obtain more information on breastfeeding? Yes ( 37. If so, in what format? (Check all that apply). On an individual basis through: 1. Videotape ( ) 2. Printed information ( ) 3. Computer software ( ) 4. Self-study module/self-learning package ( 5. Other In a group setting through. 6. Hospital rounds ( ) 7. Grace inservice ( ) 8. Workshop at CME conference ( ) 9. Other  )  38. Scheduled time for a group setting: 1. 2 3. 4. 5.  39.  Weekends Lunch hour Morning Evening Other  ( ( ( (  ) ) ) )  About how many sessions?  40.  Duration of session(s)  41.  Delivery style: 1. 2. 3. Please  hours  Forum style to a large group of physicians( ) Small discussion groups ( ) Combination of large and small groups ( ) comment  ) 01 No (  ) 02  85 ...and a few more questions. 1. SPECIALTY  a. b. c. d.  lb. SUBSPECIALTY  OBS/GYN PAEDS FP CCFP GP  ( ( ( (  2. YEARS IN PRACTICE 3. AGE years 4. GENDER  MALE ( FEMALE (  a. PERINATOLOGIST ( b. NEONATOLOGIST (  ) ) ) ) years  ) )  5. PLACE OF BIRTH 6. ETHNIC ORIGIN  a. b. c. d. e. f.  Caucasian Asian Indo-Canadian Native Indian African-Canadian Other  ( ( ( ( (  ) ) ) ) )  7. GRACE HOSPITAL PRIVILEGES  a. b. c. d. e. f.  Active Staff Active Probationary Courtesy Staff Courtesy Probationary Visiting Staff Consulting Staff  ( ( ( ( (  ) ) ) ) )  (  )  Please comment on this questionnaire:  THANK YOU FOR YOUR TIME AND COOPERATION!!  ) )  APPENDIX 2: Selected Regression Analyses Results  8 ?  Beginning  Block  Number  V a r i a b l e (s) E n t e r e d 1.. DIAGRAM  3.  Method:  Enter  on S t e p Number Diagram  E s t i m a t i o n t e r m i n a t e d a t i t e r a t i o n number 5 b e c a u s e L o g L i k e l i h o o d d e c r e a s e d b y l e s s t h a n .01 p e r c e n t . -2 L o g L i k e l i h o o d Goodness o f F i t  82.406249.548 Chi-Square  Observed 1  1  0  13  00%  6  175  100 00%  Variables S.E.  Variable  DIAGRAM Constant  . 0861 . 0861  T a b l e f b r DISCUSDI Predicted 1 ercent 1 2  Overai .1  CAUCASN CHILDREN FEMALE FP OBGYN PED . YRSPRAC  Significance  2'. 94 6 -2—ft4£»  Model Chi-Square Improvement' Classification  df  .4640 .5310 . 5775 . 5646 -.0352 -.0235 -.0107 1.1600 -1.3127  Correct  93 09% i n the Equation Wald  df  Sig  R  Exp(B)  0000 0000 0000 0000 0000 0000 0000  1.5905 .1.7006 1.7815 1.7588 . 9654 . 9768 .9894  .7218 .6627 .7867 . 9077 . 9450 i .2025 . 0395  .4133 .6421 .5388 .3869 . 0014 . 0004 . 0732  1 1 1 1 1 . 1 1  . 5203 .4230 .4629 . 5339 . 9703 . 9844 .78,67  . . . . . . .  . 6487 2 . X095  3.1977 .3872  • J, 1 1  . 0737 . 5338  . 1185  3.1900  8 8 Beginning  B l o c k Number  Variable(s) Entered 1.. • SECOMP  3.  on S t e p  Method:  Enter  Number  E s t i m a t i o n t e r m i n a t e d a t i t e r a t i o n number 5 b e c a u s e L o g L i k e l i h o o d d e c r e a s e d b y l e s s t h a n .01 p e r c e n t . -2 L o g L i k e l i h o o d Goodness o f F i t  127.379 192.659 Chi-Square  df Significance  Model Chi-Square Improvement Classification  Observed 1 2  . 0028 . 0028  T a b l e fcfr CONVN DI Predicts 1 2 Percent 1 2  1  2  23  2  2  175  98.87%  Overa! .1  87.62%  Variables Variable  CD  CAUCASN CHILDREN FEMALE FP OBGYN PED YRSPRAC IMMUNE * SECOMP Constant  S.E. .7385 - . 9189  . 1885 .2523 — .4704 -1 3838 . - 0181 6299 2078 -3 3230  . 5736 .5485 . 5976 . 7129 . 8085 .7206 . 0304 .3595 '. 0711 1.9184  8 . 00%  i n the Equation Wald  df  Sig.  1 6575 2 8063 0995 1252 3385 3 6874 3533 3 0704 8 5512 3 0005  1 1 1 1 1 1 1 1 1 1  . 1979 .0939 .7524 .7234 . 5607 . 0548 .5523 . 0797 . 0035 .0832  '  R . 0000 -.0769 . 0000 . 0000 . 0000 - . 1113 . 0000 . 0886 .2192  Exp(B) 2 0928 3990 1 2075"S 1 2870 6248 2506 9821 1 8774 1 2310  s 8 9 Beginning  B l o c k Number  Variable(s)/Entered 1. .  3.  Method:  on Step  Enter  Number  SECOMP  E s t i m a t i o n t e r m i n a t e d a t i t e r a t i o n number 8 b e c a u s e L o g L i k e l i h o o d d e c r e a s e d b y l e s s t h a n .01 p e r c e n t . 74.185 244.052  -2 L o g L i k e l i h o o d Goodness o f F i t  Chi-Square  Observed 1 '  T a b l e f or\ENCOURDI_ Predictec Percent 2 1 2 1  1  1  12  7 .69%  2  1  188  99 .47%  O v e r a . .1  93.56%  Variables S.E.  Variable CAUCASN CHILDREN FEMALE.— FP OBGYN PED YRSPRAC IMMUNE SECOMP Constant ;  . 0321 . 0321  4 . 595 4 . 595  Model Chi-Square Improvement Classification  df S i g n i f i c a n c e  1 1491 - 5789 9077 _ 2769 2193 6 4269 - .0006 1 . 0412 . 1971 -5 .2240  7978 7136 8910 9196 1 23'91 21 5776 0408 .4499 . 0952 2 . 5869  i n the Equation Wald 2 0742 ' 6581 1 0377 0907 0313 . 0887 . 0002 5 .3570 4 .2857 4 . 0781  df 1 1 1 1 1 1 1 1 . 1 1  Sig . 1498 .4172 .3084 .7633 .8595 .7658 . 9890 .0206 . 0384 . 0434  R ' .0307  Exp(B) 3 1553  . 0000 5605 /. 0000 2 4785 . 0000 7581 1 2452 .0000. 0000 618 2845 . 0000 9994 .2064 2 8327 1 .2179 . 1703  'A  

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