Teaching critical appraisal to large classes of undergraduate medical students using team-based learning versus group discussions: a randomized controlled trial.

BACKGROUND: Evidence on the effectiveness of team-based learning in teaching critical appraisal to large classes of preclinical medical students is scarce. This study investigated whether team-based learning is effective in teaching critical appraisal to large classes of preclinical medical students. METHODS: Between April 2018 and May 2019, 107 first-year medical students were randomly allocated to receive instruction in critical appraisal using team-based learning or traditional group discussions as teaching methods. The primary outcome was students' performance on the Berlin Questionnaire administered at the end of second year. RESULTS: Students' mean (SD) age was 22.0 (0.7) years. Baseline characteristics of the two groups were similar (all p values > 0.05). The mean (SD) Berlin scores of both groups were 80.4 (11.6) and 80.1 (12.1) for team-based learning and group discussions, respectively. Multivariate stepwise linear regression analysis revealed that the student's academic achievement in medical school was the sole predictor of performance on the Berlin Questionnaire (ß = 1.079, p < 0.001), adjusting for gender, Medical College Admission Test score, student's self-reported preferred teaching method, rank upon admission to medical school, score on the Epidemiology and Biostatistics course, and teaching method (team-based learning versus group discussions). CONCLUSIONS: Team-based learning and group discussions were equally effective instructional strategies to teach critical appraisal to large classes of undergraduate medical students. Replication of our findings is needed in other educational settings. TRIAL REGISTRATION: Current Controlled Trials ISRCTN15430424 , retrospectively registered on December 30, 2021.

Illness cognition and health anxiety in parents of children with cancer.

Purpose: Health anxiety is a clinical entity characterized by a pathological fear of illness. Illness cognition refers to persistent positive or negative thoughts an individual has towards illness. Evidence has shown that patients with chronic conditions who possess negative illness cognitions experience greater social, emotional, and physical difficulties than patients with positive illness cognitions. This study aims to measure the prevalence of health anxiety in a population of parents of children with cancer, and investigate the association between positive and negative illness cognitions and health anxiety. Methods: We interviewed 105 parents of children with cancer and administered Arabic versions of the Illness Cognition Questionnaire - Parent Version and the Short Health Anxiety Inventory. Results: The mean parental age was 37.7 years with the majority of participants being mothers (78.1%) and married (94.3%) and with 35.2% having completed university education. The average age of the child with cancer was 8.4 years, with the largest proportion of children suffering from leukemia. The prevalence of health anxiety among parents of children with cancer was 21%. The following two dimensions of illness cognition were significantly associated with health anxiety: Helplessness (B = 0.222, p = 0.021) and lower Acceptance (B = -0.242, p = 0.008). Other variables associated with health anxiety were perceived inadequate income (B = -0.238, p = 0.021) and personal illness or illness of a family member/close friend (B = 0.251, p = 0.013). Conclusions: Parents of children with cancer may experience health anxiety. Predictors of health anxiety include feelings of helplessness, lower acceptance, inadequate income, and extended family illnesses.

A complex breastfeeding promotion and support intervention in a developing country: study protocol for a randomized clinical trial.

BACKGROUND: Breastfeeding has countless benefits to mothers, children and community at large, especially in developing countries. Studies from Lebanon report disappointingly low breastfeeding exclusivity and continuation rates. Evidence reveals that antenatal breastfeeding education, professional lactation support, and peer lay support are individually effective at increasing breastfeeding duration and exclusivity, particularly in low-income settings. Given the complex nature of the breastfeeding ecosystem and its barriers in Lebanon, we hypothesize that a complex breastfeeding support intervention, which is centered on the three components mentioned above, would significantly increase breastfeeding rates. METHODS/DESIGN: A multi-center randomized controlled trial. STUDY POPULATION: 443 healthy pregnant women in their first trimester will be randomized to control or intervention group. INTERVENTION: A "prenatal/postnatal" professional and peer breastfeeding support package continuing till 6 months postpartum, guided by the Social Network and Social Support Theory. Control group will receive standard prenatal and postnatal care. Mothers will be followed up from early pregnancy till five years after delivery. OUTCOME MEASURES: Total and exclusive breastfeeding rates, quality of life at 1, 3 and 6 months postpartum, maternal breastfeeding knowledge and attitudes at 6 months postpartum, maternal exclusive breastfeeding rates of future infants up to five years from baseline, cost-benefit and cost-effectiveness analyses of the intervention. STATISTICAL ANALYSIS: Descriptive and regression analysis will be conducted under the intention to treat basis using the most recent version of SPSS. DISCUSSION: Exclusive breastfeeding is a cost-effective public health measure that has a significant impact on infant morbidity and mortality. In a country with limited healthcare resources like Lebanon, developing an effective breastfeeding promotion and support intervention that is easily replicated across various settings becomes a priority. If positive, the results of this study would provide a generalizable model to bolster breastfeeding promotion efforts and contribute to improved child health in Lebanon and the Middle East and North Africa (MENA) region. TRIAL REGISTRATION: Current Controlled Trials ISRCTN17875591.

Cost-benefit analysis of a multicomponent breastfeeding promotion and support intervention in a developing country.

BACKGROUND: Studies on breastfeeding promotion and support interventions suggest some economic benefits. This study assessed the direct and indirect costs of a multicomponent breastfeeding promotion and support intervention during the first two years of the infant's life. METHODS: This is a cost-benefit analysis of data generated from a randomized controlled trial that investigated whether provision of a multicomponent breastfeeding promotion and support intervention to Lebanese mothers in the first six months postpartum would improve breastfeeding rates compared to standard obstetric and pediatric care. Data of 339 participants on sociodemographics, mother and infant health, infant nutrition, direct and indirect costs of the intervention were used to assess the benefit-cost ratio (BCR) of the intervention at one, six, 12, and 24 months as primary outcome. Secondary outcomes included overall costs of infant nutrition and infant-mother dyad health costs during the first two years. Multiple linear regression models explored the effect of the intervention on the overall infant nutrition cost and mother-infant health costs. Similar regression models investigated the association between cost variables and infant nutrition types (exclusive breastfeeding, mixed feeding, artificial milk). Intention to treat analyses were conducted using SPSS (version 24). Statistical significance was set at a p-value below 0.05. RESULTS: The prevalence of Exclusive/Predominant breastfeeding among participants declined from 51.6% in the first month to 6.6% at the end of second year. The multicomponent breastfeeding intervention incurred 485 USD more in costs than the control group during the first six months but was cost-efficient at one year (incremental net benefits of 374 USD; BCR = 2.44), and two years (incremental net benefits of 472 USD; BCR = 2.82). In adjusted analyses, the intervention was significantly associated with fewer infant illness visits in the first year (p = 0.045). Stratified analyses by the infant nutrition type revealed that infants who were on Exclusive/Predominant, or Any Breastfeeding had significantly more favorable health outcomes at different time points during the first two years (p<0.05) compared to infants receiving Artificial Milk only, with health benefits being highest in the Exclusive/Predominant breastfeeding group. Moreover, Exclusive/Predominant and Any Breastfeeding had significantly lower costs of infant illness visits, hospitalizations, and infant medications during the two years (p<0.05) but had additional cost for maternal non-routine doctor visits due to breastfeeding (all p values <0.05). Whereas the overall cost (direct and indirect) during the first six months was significantly lower for the Exclusive/Predominant breastfeeding infants (p = 0.001), they were similar in infants on Mixed Feeding or Artificial Milk. CONCLUSIONS: Breastfeeding is associated with significant economic and infant health benefits in the first two years. In the context of the current economic crisis in Lebanon, this study provides further evidence to policymakers on the need to invest in national breastfeeding promotion and support interventions.

Gender differences in the heritability of musculoskeletal and body composition parameters in mother-daughter and mother-son pairs.

Bone mass and body composition traits are genetically programmed, but the timing and gender and site specificities of their heritability are unclear. Mother-child correlations of bone mineral density (BMD) and bone mineral content, lean mass, and fat mass were studied in 169 premenopausal mothers and their 239 children. Heritability estimates of lean mass, fat mass, BMD, and area were derived for each gender and pubertal stage. There were significant correlations for most densitometry-derived variables at the spine, hip, femoral neck (FN), and total body (r=0.192-0.388) in mother-postmenarcheal daughter pairs, for bone areas at all sites in early puberty (r=0.229-0.508) and for volumetric-derived density at FN and spine (r=0.238-0.368) in mother-son pairs. Fat mass correlations were significant in both genders after puberty (r=0.299-0.324) and lean mass in postmenarcheal girls only (r = 0.299). Heritability estimates varied between 21% and 37% for mother-daughter and 18% and 35% for mother-son pairs for density-derived variables and between 26% and 40% for body composition variables. Maternal inheritance of bone traits is expressed in early-pubertal boys for several skeletal site traits but consistently involves most site traits in girls and boys by late puberty. Body composition inheritance is more variable.

Validation of the Arabic Maternal postpartum quality of life questionnaire among Lebanese women: A cohort study.

BACKGROUND: The postpartum period is an important phase in a woman's life. Yet, there is a paucity of validated instruments that assess maternal postpartum quality of life issues. The aim of this study is to describe the adaptation and validation of the Arabic version of the Maternal Postpartum Quality of Life (MAPP-QOL) questionnaire. METHODS: This instrument validation cohort study tested an adapted Arabic version of the MAPP-QOL questionnaire on a convenience sample of 485 healthy Lebanese postpartum women. The MAPP-QOL reliability and validity were investigated by conducting Exploratory Factor Analysis using Principal Component Analysis, and by correlating the participants' MAPP-QOL scores with their scores on the Arabic Maternal Breastfeeding Evaluation Scale (MBFES-A), age, and education. Confirmatory Factor Analysis was conducted to examine how well the original factor structure of MAPP-QOL fits with our observed data using STATA 14. All other statistical analyses were done using SPSS version 23. RESULTS: The Cronbach's alpha reliability coefficient of the Arabic MAPP-QOL was 0.90. Exploratory factor analysis revealed the following five components: Functioning (11 items, Cronbach's alpha of 0.82), Socioeconomic (9 items, Cronbach's alpha of 0.81), Relational (9 items, Cronbach's alpha of 0.75), Psychological (4 items, Cronbach's alpha of 0.74), and Health (6 items, Cronbach's alpha of 0.59). The overall Arabic MAPP-QOL score was positively but weakly correlated with the MBFES-A score (r = 0.177, p < 0.001), its Maternal Enjoyment/Role Attainment subscale score (r = 0.108, p = 0.023), and Lifestyle/Body Image subscale score (r = 0.286, p < 0.001). There was no significant association between the type of infant feeding at one month and the Arabic MAPP-QOL score (p = 0.932). Similarly, the Arabic MAPP-QOL score was not correlated with the participant's age (r = 0.043, p = 0.362) or education (p = 0.451). After modification of indices, Confirmatory Factor Analysis revealed that the goodness of fit indices corresponding to the 5-factor model in the original questionnaire indicate a reasonable fit with RMSEA = 0.052, CFI = 0.847 and SRMR = 0.062. CONCLUSIONS: The Arabic MAPP-QOL has good psychometric properties and may be a useful tool for clinicians and researchers interested in measuring maternal postpartum quality of life. Further replication of our findings in other Arab contexts is needed.

Cost-benefit analysis of a multicomponent breastfeeding promotion and support intervention in a developing country.

Background: Studies evaluating breastfeeding promotion and support interventions suggest some economic benefits. This study assessed the direct and indirect costs of a multicomponent breastfeeding promotion and support intervention during the first two years of the infant's life. Methods: This is a cost-benefit analysis of data generated from a randomized controlled trial that aimed at investigating whether provision of a multicomponent breastfeeding promotion and support intervention to Lebanese mothers in the first six months postpartum would improve breastfeeding rates compared to standard obstetric and pediatric care. Data on 339 participants included information on maternal socio-demographics and health, infant nutrition and health, and direct and indirect costs of the intervention. The primary outcome was the benefit-cost ratio (BCR) of the intervention at one, six, 12, and 24 months. Secondary outcomes included the overall costs of infant nutrition and infant-mother dyad health costs during the first two years. Multiple linear regression models investigated the effect of the multicomponent intervention (independent variable) on the overall infant nutrition cost and the overall mother-infant health costs (as dependent variables), adjusting for monthly income and number of children (confounders) at different time points in the first two years. Similar regression models investigated the association between infant nutrition type (exclusive breastfeeding, mixed feeding, artificial milk) and infant nutrition costs and infant-mother health costs. Intention to treat analyses were conducted using SPSS (version 24). Statistical significance was set at a p-value below 0.05. Results: The prevalence of Exclusive/Predominant breastfeeding among participants declined from 51.6% in the first month to 6.6% at the end of second year. The multicomponent breastfeeding intervention incurred 485 USD more in costs than the control group during the first six months but was cost-efficient by the end of the first year (incremental net benefits of 374 USD; BCR=2.44), and by the end of the second year (incremental net benefits of 472 USD; BCR=2.82). In adjusted analyses, the intervention was significantly associated with fewer infant illness visits in the first year (p=0.045). Stratified analyses by the type of infant nutrition revealed that infants who were on Exclusive/Predominant, or Any Breastfeeding had significantly more favorable health outcomes at different time points during the first two years (p<0.05) compared to infants receiving Artificial Milk only, with health benefits being highest in the Exclusive/Predominant breastfeeding group. Moreover, Exclusive/Predominant and Any Breastfeeding had significantly lower costs of infant illness visits, hospitalizations, and infant medications during the two years (p<0.05), but had additional cost for maternal non-routine doctor visits due to breastfeeding (all p values <0.05). Whereas the overall cost (direct and indirect) during the first six months was significantly lower for the Exclusive/Predominant breastfeeding infants (p=0.001), they were similar in infants on Mixed Feeding or Artificial Milk. Conclusions: Breastfeeding is associated with significant economic and infant health benefits in the first two years. In the context of the current economic crisis in Lebanon, this study provides further evidence to policymakers on the need to invest in national breastfeeding promotion and support interventions.

Impact of C-reactive protein test results on evidence-based decision-making in cases of bacterial infection.

BACKGROUND: C-reactive protein (CRP) is widely used to detect bacterial infection in children. We investigated the impact of CRP test results on decision-making and summarized the evidence base (EB) of CRP testing. METHODS: We collected information from the hospital records of 91 neonates with suspected sepsis and of 152 febrile children with suspected infection on the number of ordered CRP tests, the number of EB-CRP tests, and the impact of the test results on decision-making. CRP diagnostic accuracy studies focusing on pediatric infections were reviewed critically. The main outcomes were the proportion of CRP tests that were EB and the proportion of tests that affected decision-making. A secondary outcome was the overall one-year expenditure on CRP testing. RESULTS: The current EB for CRP testing in pediatric infections is weak and suggests that CRP is of low diagnostic value. Approximately 54.8% of tests performed for suspected neonatal sepsis and 28% of tests performed for other infections were EB; however, the results of only 12.9% of neonatal sepsis tests and of 29.9% of tests on children with other infections informed decision-making. The one-year overall cost for CRP testing and related health care was $26,715.9. CONCLUSIONS: The routine ordering of CRP for children with infections is based on weak evidence. The impact of the CRP test results on decision-making is rather small, and CRP ordering may contribute to unnecessary health care expenditures. Better quality research is needed to definitively determine the diagnostic accuracy of CRP levels in children with infections.

The inverted syringe technique for management of inverted nipples in breastfeeding women: a pilot randomized controlled trial.

BACKGROUND: Women with inverted nipples may struggle with breastfeeding and may stop exclusive breastfeeding before six months. The use of an inverted syringe to evert the nipples was successful in achieving high rates of infant latching and exclusive breastfeeding in case series but has not been tested in clinical trials. This open label, parallel group, randomized clinical trial investigated whether the use of the inverted syringe technique in women with inverted nipples would increase exclusive breastfeeding rate at one month, as compared to standard care. METHODS/DESIGN: Between June 2018 and January 2020, healthy pregnant women (N=54) with grades 1 or 2 inverted nipples were randomly allocated to standard care or to an experimental group that used the inverted syringe technique to evert the inverted nipple prior to every breastfeeding. The primary outcome measure was the rate of exclusive breastfeeding at one month. Secondary outcomes included the rates of exclusive breastfeeding at three and six months, any breastfeeding at one, three, and six months, nipple eversion, successful infant latching, breastfeeding-associated complications, maternal satisfaction with breastfeeding, maternal quality of life, and adverse events. Descriptive and bivariate analyses were conducted according to the intention to treat principle. RESULTS: Participants in the experimental group were less likely to be exclusively breastfeeding at one (RR = 0.65, 95% CI: 0.44, 0.95; n = 47), and at three months (RR = 0.66, 95% CI: 0.47, 0.91; n = 45), or to practice any breastfeeding at six months (RR = 0.54, 95% CI: 0.34, 0.87; n = 44). Only 14.3% of women in the experimental group complied with the use of the inverted syringe during the first month. Breast pump and breastfeeding-associated complications were more commonly reported in the control group (p < 0.05 for both). Both groups had similar rates of nipple eversion, successful infant latching, and similar satisfaction with breastfeeding and quality of life issues. CONCLUSION: The inverted syringe technique was not associated with improvement in breastfeeding outcomes of women with inverted nipples. Larger clinical trials are needed to confirm our findings. TRIAL REGISTRATION: ClinicalTrials.gov NCT03529630 ; Registered May 8, 2018.

Parental attitudes towards and perceptions of their children's participation in clinical research: a developing-country perspective.

BACKGROUND: Paediatric clinical research faces unique challenges that compromise optimal recruitment of children into clinical trials. A main barrier to enrolment of children is parental misconceptions about the research process. In developing countries, there is a knowledge gap regarding parental perceptions of and attitudes towards their children's participation in clinical trials. OBJECTIVE: To explore such perceptions and attitudes in Lebanese parents. STUDY DESIGN: 33 in-depth interviews were conducted with parents with and without previous research experience. Interviews were tape-recorded, transcribed in colloquial Arabic, and later subjected to thematic analysis. RESULTS: Benefit/risk ratio assessment was a major determinant of parental consent. Fear of adverse events or painful procedures in research was a recurring theme in most interviews. Whereas perception of direct benefit to the child, trust in the physician or institution, financial gains or having a positive previous experience in research facilitated consent, a complex informed consent form and misunderstanding of the term 'randomisation' hindered parental approval of participation. CONCLUSION: Lebanese parents have perceptions of and attitudes towards children's participation in clinical trials that are similar to those reported from the industrialised world. Improving communication with parents and building trust between researchers and parents is important for successful recruitment. Investigators planning to conduct paediatric trials in developing countries need to simplify consent forms and devise new ways to explain randomisation.

Why are breastfeeding rates low in Lebanon? A qualitative study.

BACKGROUND: Breastfeeding is a cost-effective public health intervention that reduces infant morbidity and mortality in developing countries. In Lebanon, breastfeeding exclusivity and continuation rates are disappointingly low. This qualitative study aims at identifying barriers and promoters of breastfeeding in the Lebanese context by exploring mothers' perceptions and experiences in breastfeeding over a one year period. METHODS: We conducted focus group discussions in three hospitals in Beirut, Lebanon, and followed up 36 breastfeeding mothers with serial in-depth interviews for one year post-partum or until breastfeeding discontinuation. RESULTS: Themes generated from baseline interviews revealed several positive and negative perceptions of breastfeeding. Longitudinal follow up identified insufficient milk, fear of weight gain or breast sagging, pain, sleep deprivation, exhaustion, or maternal employment, as reasons for early breastfeeding discontinuation. Women who continued breastfeeding for one year were more determined to succeed and overcome any barrier, relying mostly on family support and proper time management. CONCLUSIONS: Increasing awareness of future mothers about breast feeding difficulties, its benefits to children, mothers, and society at large may further promote breastfeeding, and improve exclusivity and continuation rates in Lebanon. A national strategy for early intervention during school years to increase young women's awareness may improve their self-confidence and determination to succeed in breastfeeding later. Moreover, prolonging maternity leave, having day-care facilities at work, creation of lactation peer support groups and hotlines, and training of doctors and nurses in proper lactation support may positively impact breastfeeding exclusivity and continuation rates. Further research is needed to assess the effectiveness of proposed interventions in the Lebanese context.

Validation of the Arabic Maternal Breastfeeding Evaluation Scale (MBFES-A) among Lebanese women.

BACKGROUND: Maternal satisfaction with the breastfeeding experience is an important determinant of breastfeeding success. There is currently no valid tool to measure perceived maternal satisfaction with breastfeeding in the Arab context. METHODS: This cohort study tested the Maternal Breastfeeding Evaluation Scale (MBFES) on 450 healthy Lebanese mothers for internal consistency reliability and construct validity. Participants were recruited between April 2018 and February 2020. RESULTS: The Cronbach's alpha reliability coefficient of the Arabic MBFES (MBFES-A) was 0.87. Exploratory factor analysis revealed that it has three components: Infant Satisfaction/Growth, Maternal Enjoyment/Role Attainment, and Lifestyle/Body Image with reliability coefficients of 0.88, 0.87, and 0.68, respectively. Four items were deleted because of low factor loadings and three items were relocated to the Infant Satisfaction/Growth subscale based on their factor loadings. Participants who were exclusively breastfeeding at one and/or 3 months had higher mean MBFES-A total and Infant Satisfaction/Growth and Maternal Enjoyment/Role Attainment subscale scores than participants who were partially breastfeeding, and significantly higher mean scores than mothers who were not breastfeeding (all p values < 0.001), findings that support the scale's construct validity. Moreover, scores on the Infant Satisfaction/Growth subscale correlated with exclusive breastfeeding at one (r = 0.37, p < 0.001) and 3 months (r = 0.31, p < 0.001). The MBFES-A score had positive modest correlations with maternal attitude towards breastfeeding (r = 0.30, p < 0.001), exclusive breastfeeding at one (r = 0.27) and at 3 months (r = 0.26, p < 0.001 for both), as well as with the longest previous exclusive breastfeeding (r = 0.27, p < 0.001). CONCLUSIONS: The 26-item MBFES-A is a reliable and valid instrument to use in future breastfeeding research in Middle East North Africa countries. There is a need for replication of our findings in other Arab contexts using new constructs to establish stronger construct validity.

Assessing the impact of professional lactation support frequency, duration and delivery form on exclusive breastfeeding in Lebanese mothers.

BACKGROUND: The optimal frequency, duration, and form of professional lactation support needed to continue exclusive breastfeeding (EBF) for six months have not yet been specifically identified. This study investigates the association between six-month EBF and the frequency, duration, and form (face-to-face vs. telephone contact) of professional lactation support in a cohort of Lebanese mothers, and explores barriers to EBF during the first six months postpartum. METHODS: An observational study was nested in a breastfeeding support randomized controlled trial. Secondary analysis of data from 159 trial participants who received professional lactation support was conducted. (1) Six-month EBF with professional lactation support frequency, duration, and form was investigated using bivariate and multivariate regression analyses. (2) Barriers to breastfeeding were explored using content analysis of narrative data collected about breastfeeding mothers by the lactation experts. RESULTS: Six-month EBF was achieved by 57/159 (35.8%) participants. Professional lactation support was received by more mothers continuing six months of EBF (100% vs. 83.3%, p = 0.001). In crude analysis, those mothers had a higher number of overall contacts with lactation experts (mean ± SD of 9.5 ± 2.9 vs. 7.0 ± 4.4, p = 0.001), and longer duration of face-to-face contacts (mean ± SD of 261.9 ± 209.1 vs. 201.0 ± 117.4 minutes, p = 0.035). In adjusted analysis, frequencies of overall and of telephone contacts with the lactation experts were positively associated with six-month EBF (OR = 1.15; 95% CI: 1.04 to 1.27, p = 0.007; OR = 1.12; 95% CI: 1.00 to 1.26, p = 0.05; respectively). Participants discontinuing EBF early were described as inexperienced, lacking breastfeeding knowledge, concerned about milk insufficiency, and showing negative attitudes towards night feeds. CONCLUSION: Need-based telephone contact augmenting face-to-face professional lactation support may positively influence six-month EBF. Early identification of mothers at risk for early discontinuation of EBF can help tailor interventions specific to their concerns.

Knowledge and attitudes of Lebanese women towards Baby Friendly Hospital Initiative practices.

BACKGROUND: The World Health Organization and United Nations Children's Fund launched the Baby Friendly Hospital Initiative (BFHI) to encourage best infant breastfeeding practices immediately after birth. In Lebanon, few hospitals are currently accredited as Baby Friendly. AIM: To assess the knowledge of Lebanese women of BFHI steps, and to explore their attitudes towards Baby Friendly Hospitals, Skin-to-Skin Contact and Kangaroo Care practices. METHODS: A cross-sectional survey of a random sample of healthy pregnant women from Lebanon's six governorates. RESULTS: The mean (SD) age of the participants (N = 517) was 28.6 (4.7) years. Most participants were unfamiliar with the terms Baby Friendly hospital (93.7%), skin-to-skin contact or kangaroo care (75%), or were inadequately instructed on how to initiate (54.2%) or continue (46.2%) breastfeeding. However, when provided with information about the benefits of BFHI practices, most mothers (> 90%) stated that they would deliver in Baby Friendly hospitals. About 68.4% of mothers refused to give donor human milk to their sick premature infants because of religious beliefs. Knowledge of Baby Friendly hospitals was significantly associated with university education (p = 0.029), higher monthly income (p = 0.042), and previous experiences of skin-to-skin contact (p<0.001), rooming in (p = 0.037), or breastfeeding support (p = 0.036). CONCLUSION: There is a need for national awareness campaigns that address both the numerous advantages of the BFHI practices and Lebanese women's knowledge gaps about these practices. Such knowledge will help scale up the implementation of BFHI practices in hospitals in Lebanon, thus increasing breastfeeding rates and positively impacting the health of infants and mothers.

Sustaining compliance with hand hygiene when resources are low: A quality improvement report.

BACKGROUND: Sustainability of hand hygiene is challenging in low resource settings. Adding ownership and goal setting to the WHO-5 multimodal intervention may help sustain high compliance. AIM: To increase and sustain compliance of nursing and medical staff with hand hygiene in a tertiary referral center with limited resources. METHODS: A quality improvement initiative was conducted over two years (2016-2018). After determining baseline compliance rates, the WHO-5 multimodal intervention was implemented with staff education and training, system change, hospital reminders, direct observation and feedback, and hospital safety climate. Additionally, the medical staff was responsible for continuous surveillance of compliance (ownership) until rates above 90% were achieved and sustained (goal setting). RESULTS: Of 2987 observations collected between August 2016 and April 2018, 1630 (54.5%) were before, and 1357 (45.5%) were after patient encounters. The average overall compliance with hand hygiene was sustained at 94% for nursing and medical staff. Two instances of drops below 90% were associated with incidence of nosocomial Rotavirus infections. There were no similar infections during intervention periods with compliance rates above the set goal. Analysis using p-charts revealed significant improvement in compliance rates from baseline (χ2 (1) = 7.94, p = 0.005). CONCLUSION: Adding ownership and goal setting to the WHO-5 multimodal intervention may help achieve, and sustain high rates of compliance with hand hygiene. Involving health care workers in quality improvement initiatives is feasible, durable, reliable, and cheap, especially in settings with limited financial resources.

Validation of the Arabic version of the breastfeeding behavior questionnaire among Lebanese women.

BACKGROUND: The Breastfeeding Behavior Questionnaire (BBQ) assesses women's perceptions of their breastfeeding behavior. It was adapted to several languages and used in different settings, but has not been validated in Arabic-speaking populations. None of the previous studies that used the BBQ in other cultures examined its ability to predict the actual breastfeeding behaviors of mothers postpartum. This study validated the BBQ in a cohort of Lebanese pregnant women between December 2013 and January 2016, and examined whether it can predict exclusive breastfeeding at one, three and six months. METHODS: The internal consistency reliability and construct validity of the Arabic BBQ (BBQ-A) were tested on 354 pregnant women. Its predictive ability was assessed by correlating the women's BBQ-A scores with their breastfeeding outcomes at one, three and six months post-delivery. RESULTS: The BBQ-A had a good internal consistency reliability (Cronbach's alpha = 0.78). Exploratory factor analysis revealed that it is unidimensional. Inter-item correlations ranged between - 0.016 and 0.934, with corrected-item total correlations ranging from 0.273 to 0.678. Perceived positive breastfeeding behavior correlated with positive breastfeeding attitudes, good breastfeeding knowledge and stronger breastfeeding intention supporting its external validity. However, in binomial multivariate logistic regression analysis, the BBQ-A did not predict exclusive breastfeeding at one, three or six months. CONCLUSIONS: The BBQ-A is a reliable and valid instrument to assess women's perceptions of their breastfeeding behavior in an Arab context. Availability of this instrument is important for investigators conducting breastfeeding research in the Arab world. However, the BBQ-A does not predict exclusive breastfeeding at one, three or six months. Further research on the Breastfeeding Behavior Questionnaire is needed to examine its predictive validity in other cultures.

Preferences of Lebanese adults for the gender of their surgeons: a cross-sectional study.

BACKGROUND: More females are specializing in surgery in Lebanon, but it is not known if a gender bias exists among Lebanese people in their preference of their surgeons. AIMS: This study investigated the preference of Lebanese men and women for the gender of surgeons and explored reasons for their preferences. METHODS: A convenience sample of 1000 Lebanese adults were asked about their preferences for the gender of surgeons of different specialties (paediatrics, cardiology, neurology, orthopaedics, ophthalmology, ear nose and throat, plastic surgery and obstetrics/gynaecology). The association between the participants' sociodemographic characteristics and gender preference for surgeons was examined in bivariate and multivariable regression analyses. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. RESULTS: Half of the respondents had no gender preference for their surgeons whatever their speciality. Male surgeons were preferred over females for cardiac (44.2% versus 3.7% respectively), neurological (43.4% versus 4.1%) and orthopaedic procedures (41.9% versus 3.5%) whereas male and female obstetricians/gynaecologists were equally preferred (23.6% and 25.0% respectively). Being male (OR = 0.74, 95% CI: 0.57-0.97) or single (OR = 0.65, 95% CI: 0.44-0.96) decreased the likelihood of choosing a male heart surgeon whereas employment increased that likelihood (OR = 1.37, 95% CI: 1.03-1.83). Perceived competence, reputation and trustworthiness of male surgeons influenced participants' choices whereas the choice of an obstetrician/gynaecologist was related to privacy and comfort. CONCLUSIONS: The preference for female surgeons in Lebanon varies by the type of surgical specialty. Qualitative studies exploring the social determinants of patients' preferences are needed.

Breastfeeding success with the use of the inverted syringe technique for management of inverted nipples in lactating women: a study protocol for a randomized controlled trial.

BACKGROUND: Breastfeeding provides ideal infant nutrition, conferring several health benefits to children and their mothers. Women with inverted nipples, however, face difficulties that force them to prematurely terminate breastfeeding. Whereas available conservative measures for the correction of inverted nipples are of limited success, the use of an inverted syringe may be effective in achieving high rates of infant latching and exclusive breastfeeding. This technique, however, has not been investigated in a clinical trial. METHODS/DESIGN: This open-label randomized controlled trial aims to investigate whether, in women with inverted nipples, the use of an inverted syringe increases the rate of exclusive breastfeeding at one month compared to standard care. One-hundred healthy women with grade 1 or 2 inverted nipples will be recruited as of 37 weeks of gestation. They will be randomly allocated to standard care (control group) or to an intervention group. The intervention consists of using an inverted syringe to evert the nipple before every breastfeed, starting with the first feed after delivery. The primary outcome measure is the rate of exclusive breastfeeding at 1 month. Secondary outcome measures include exclusive breastfeeding rates at 3 and 6 months, nipple eversion rate, successful latching rate, rates of any breastfeeding at 1, 3, and 6 months, breastfeeding-associated complications, maternal satisfaction with breastfeeding, maternal quality of life, and adverse events. Descriptive and regression analysis will be conducted under the intention to treat basis. DISCUSSION: The use of the inverted syringe to evert inverted nipples is a simple, inexpensive, and safe technique that can be performed by mothers with inverted nipples. Findings of this trial, if positive, will provide much needed evidence for a safe, affordable, readily available, and simple intervention to treat inverted nipples, and improve breastfeeding practice among affected women. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03529630. Registered May 8, 2018.

Experiences with peer support for breastfeeding in Beirut, Lebanon: A qualitative study.

BACKGROUND: Despite the beneficial effects of peer support on breastfeeding, research on the process of peer support is scarce. In Lebanon, exclusive breastfeeding is only 15% in infants below six months. A multidisciplinary team launched a multi-component breastfeeding support intervention, with peer support, and professional lactation support provided by International Board Certified Lactation Consultants (IBCLs) to target this decline. AIM: To describe the experiences of breastfeeding mothers and peer support providers with the process of breastfeeding support, and the influence of the intervention on their social support system. METHODS: Using a qualitative methodology, a purposive sample of breastfeeding and support mothers was accessed from among those who completed their six months interview in the trial taking place in two hospitals in Beirut, Lebanon. Data were collected from 43 participants using in-depth interviews and following the data saturation principle. All interviews were audio recorded and transcribed verbatim. Thematic analysis was conducted, guided by the principles of grounded theory. RESULTS: Breastfeeding mothers were satisfied with their breastfeeding experience, and extremely appreciative of the support provided by their peers and the IBCLCs. They experienced these forms of support differently. Peer support was perceived to be important in encouraging breastfeeding continuation, whereas IBCLC support was influential in problem solving. CONCLUSION: These findings can improve our understanding of the peer and professional lactation support process within the social context, and the realities of breastfeeding mothers, and help facilitate the scaling up of interventions in similar contexts.