Using Cross-Sectional Data to Identify and Quantify the Relative Importance of Factors Associated with and Leading to Food Insecurity.

Australian governments routinely monitor population household food insecurity (FI) using a single measure-'running out of food at least once in the previous year'. To better inform public health planning, a synthesis of the determinants and how they influence and modify each other in relation to FI was conducted. The analysis used data from the Health & Wellbeing Surveillance System cross-sectional dataset. Weighted means and multivariable weighted logistic regression described and modelled factors involved in FI. The analysis showed the direction and strength of the factors and a path diagram was constructed to illustrate these. The results showed that perceived income, independent of actual income was a strong mediator on the path to FI as were obesity, smoking and other indicators of health status. Eating out three or more times a week and eating no vegetables more strongly followed FI than preceded it. The analysis identified a range of factors and demonstrated the complex and interactive nature of them. Further analysis using propensity score weighted methods to control for covariates identified hypothetical causal links for investigation. These results can be used as a proof of concept to assist public health planning.

Baby-friendly hospital practices are associated with duration of full breastfeeding in primiparous but not multiparous Iranian women.

There is evidence that the Baby-Friendly Hospital Initiative (BFHI) results in improved breastfeeding outcomes in Western countries, but little is known of its impact in Middle-Eastern countries. This study investigated the impact of BFHI practices on duration of full breastfeeding in a cohort of 700 Iranian mothers recruited between June 2014 and March 2015 from maternity hospitals in Shiraz and followed-up prospectively for 6 months. At baseline, mothers self-reported exposure to 7 of the BFHI Ten Steps to Successful Breastfeeding (Steps 3 to 9). Data on breastfeeding outcomes were collected at baseline, 1, 3, 4, and 6 months postpartum. Cox regression analysis was conducted to determine the impact of individual and cumulative BFHI Steps on the duration of full breastfeeding, defined as the number of weeks since discharge that an infant received only breast milk and no complementary formula or food. Mothers reported experiencing on average 3.9 (SD 1.13, range 1 to 7) Steps, and only 28% of infants were fully breastfed at 6 months. There was a protective inverse relationship for primiparous (p for trend = .022) but not multiparous mothers (p for trend = .069), between the number of Steps a woman was exposed to and the likelihood of her discontinuing full breastfeeding within 6 months postpartum. Greater exposure to BFHI practices potentially could increase primiparous mothers' chances of fully breastfeeding to 6 months. Continual monitoring of the BFHI Steps and repeated education of healthcare staff are required to ensure that Iranian mothers receive adequate breastfeeding support.

Consumption of dietary supplements by Chinese women during pregnancy and postpartum: A prospective cohort study.

The objectives of this study were to investigate usage patterns and factors associated with maternal dietary supplementation by Chinese women. A prospective cohort study of 695 mothers, who gave birth to a singleton baby, was conducted in Jiangyou, Sichuan Province of China. Information on dietary supplement use was collected from participants by personal interview at hospital discharge and followed up by telephone at 1, 3, and 6 months postpartum. Logistic regression analysis and generalised linear-mixed modelling were performed to determine factors affecting dietary supplementation during pregnancy and the first 6 months postpartum, respectively. A total of 81.8 and 32.1% of women consumed dietary supplements during pregnancy and postpartum, respectively. Calcium was the most popular supplement (pregnancy 63.9%; postpartum 28.1%), whereas folic acid was only taken during pregnancy (62.3%) with an average usage duration of 2.5 (standard deviation 1.3) months among users. High school and above education, adjusted odds ratio (OR) = 2.67, 95% confidence interval (CI) [1.63, 4.38], and attendance at prenatal classes (adjusted OR = 1.99, 95% CI [1.05, 3.76]) were associated with dietary supplementation during pregnancy. Mothers with a higher level of education (adjusted OR = 3.10, 95% CI [1.81, 5.30]) were also more likely to use dietary supplements in the postpartum period. Although dietary supplementation appeared to be common among Chinese mothers, maternal intake of folic acid was well below the guidelines. There is a need for further nutrition education on maternal use of micronutrient supplements, especially targeting mothers who are less educated.

Factors associated with Early Initiation of Breastfeeding in Western Nepal.

The initiation of breastfeeding within one hour of birth has numerous nutritional and immunological benefits and has been found to reduce neonatal mortality. This community-based prospective cohort study aimed to report the rate of, and factors associated with, early initiation of breastfeeding in Western Nepal. The rate of early initiation of breastfeeding was reported, and associations between early initiation and independent variables were tested by Chi-square test, followed by multiple logistic regression. Of the 735 mother-infant pairs, a total of 310 (42.2%) reported early initiation. Mothers who were assisted by traditional attendants during childbirth, delivered by caesarean section, from ethnically disadvantaged families and had delivered low birth weight infants, were less likely to initiate breastfeeding early whereas the mothers who were from the poorest families and did not introduce prelacteal feeds to their infants were more likely to initiate breastfeeding within the first hour. Skills-training to support breastfeeding as part of the training of skilled birth attendants and other health workers is likely to promote recommended infant feeding practices.

Postpartum Breastfeeding Promotion and Duration of Exclusive Breastfeeding in Western Nepal.

BACKGROUND: Encouragement and skills provided to mothers during the postpartum period have been found to be successful in increasing exclusive breastfeeding rates. However, evidence from developing countries is limited. This study aimed to ascertain whether education and skill support provided by health workers during the postpartum period were associated with increased duration of exclusive breastfeeding in Western Nepal. METHODS: A community-based prospective cohort study was conducted between January and October 2014, in the Rupandehi district of Nepal. Information on breastfeeding promotion provided by health workers after birth was collected from 649 mothers. The association between breastfeeding promotion and exclusive breastfeeding was investigated using multivariable Cox regression analysis. RESULTS: Of the 649 mothers, 35 percent received all eight types of breastfeeding promotion advice, and 60 percent received six or more such types of advice. Breastfeeding promotion, such as "breastfeeding on demand" (hazard ratio [HR] 0.74 [95% CI 0.59-0.92]) and "not to provide pacifier or teats" (HR 0.82 [95% CI 0.68-0.97]), were significantly associated with a lower risk of exclusive breastfeeding cessation. The dose-response relationship was also significant for the number of advices received (HR 0.94 [95% CI 0.90-0.97]). CONCLUSIONS: This study provides evidence that breastfeeding education and support immediately after childbirth could increase the duration of breastfeeding. The results suggest further attention to breastfeeding promotion in all maternity hospitals and birthing centers through skilled birth attendants.

Factors associated with breastfeeding duration: a prospective cohort study in Sichuan Province, China.

BACKGROUND: The World Health Organization (WHO) recommends exclusive breastfeeding for 6 months and continued breastfeeding thereafter with appropriate complementary foods for at least 2 years or longer. This study aimed to determine the factors associated with breastfeeding duration in Sichuan Province of China. METHODS: A prospective longitudinal study of 695 women, with a follow-up response rate of 71.9%, was conducted in Jiangyou, Sichuan Province in the period of 2010-2011. Participants were interviewed at discharge and followed up by telephone at 1, 3, 6 and 12 months postpartum. Breastfeeding duration was estimated by the Kaplan-Meier method. Cox regression analyses were performed to identify factors associated with the breastfeeding duration. RESULTS: The median duration of "any breastfeeding" was 8.0 [95% confidence interval (CI): 7.8, 8.2] months. Maternal age less than 25 years [adjusted hazard ratio (HR): 1.61; 95% CI: 1.32, 1.96] and maternal return to work before 6 months postpartum (adjusted HR: 1.69; 95% CI: 1.32, 2.17) were associated with a shorter duration of breastfeeding. Women who delivered at hospital (adjusted HR: 1.33; 95% CI: 1.05, 1.67), introduced solid foods (adjusted HR: 1.30; 95% CI: 1.02, 1.64) and intended to stop breastfeeding within 6 months, or undecided how long to breastfeed (adjusted HR: 1.41; 95% CI: 1.16, 1.72), were more likely to terminate lactation within 1 year. CONCLUSIONS: The duration of breastfeeding in Jiangyou was far below the recommendation of the WHO. Education programs targeting vulnerable subgroups of mothers should be provided in Sichuan to help them maintain breastfeeding as long as possible.

Public say food regulatory policies to improve health in Western Australia are important: population survey results.

OBJECTIVE: To investigate the level of support among Western Australian adults for food control policies to improve diet, reduce obesity and protect the environment. METHODS: Attitudes towards government food control policies on food labelling, food advertising, and the supply of environmentally friendly food data were pooled from two Nutrition Monitoring Survey Series telephone surveys of 2,147 adults aged 18-64 years collected in 2009 and 2012. Descriptive and logistic regression analyses were conducted using survey module of STATA 12. RESULTS: The majority of adults believe it is important that government regulates food policy options under consideration: nutrition information on food labels (97% versus 2% who think it is not important); health rating on food labels (95% versus 3%); food advertising (83% versus 11%); and the supply of environmentally friendly food (86% versus 9%). CONCLUSIONS: Community perception is that government control or regulation of food labelling, food advertising and the supply of environmentally friendly food is important. IMPLICATIONS: Curbing excess weight gain and related disease burden is a public health priority. Australian governments are considering food regulatory interventions to assist the public to improve their dietary intake. These findings should provide reassurance to government officials considering these regulatory measures.

Attitudes towards breastfeeding - the Iowa Infant Feeding Attitude Scale in Chinese mothers living in China and Australia.

This study aimed to translate and validate a Chinese (simplified) version of the Iowa Infant Feeding Attitude Scale (IIFAS) and compare the infant feeding attitudes of Chinese mothers living in Perth Australia and in Chengdu P.R. China. A survey was undertaken on 200 Chinese mothers living in Perth and 1620 mothers living in Chengdu. The simplified Chinese version of IIFAS had a moderate level of internal consistency with a Cronbach's alpha of 0.69 for mothers in Australia and 0.55 for mothers in China. The mean IIFAS scores in both country groups lay in the range of 'neutral breastfeeding attitudes'. Higher IIFAS scores were significantly associated with the likelihood of both breastfeeding initiation (OR: 3.85; CI: 2.49-5.96; p<0.001) and longer (>=8 months) breastfeeding duration (OR: 2.52; CI: 1.87-3.40; p<0.001). Chinese mothers in Perth (mean IIFAS score=60.0±6.3) tended to have more positive attitudes towards breastfeeding than mothers in Chengdu (mean IIFAS score=57.7±5.1, p<0.001), and had a longer duration of 'any breastfeeding' (10.0±6.2 months in Perth compared to 7.4±4.3 months in Chengdu, p<0.001). In conclusion, higher scores on the IIFAS in simplified Chinese are associated with breastfeeding initiation and duration in Chinese populations.

Education and support for fathers improves breastfeeding rates: a randomized controlled trial.

BACKGROUND: Studies have identified numerous factors affecting breastfeeding initiation and duration, including maternal education, mode of delivery, birth weight, socioeconomic status, and support of the infant's father. OBJECTIVE: The objective was to investigate the effects of an antenatal education session and postnatal support targeted to fathers. METHODS: The Fathers Infant Feeding Initiative (FIFI Study) is a randomized controlled trial to increase the initiation and duration of breastfeeding that was conducted in 8 public maternity hospitals in Perth, Western Australia. A total of 699 couples were randomized within hospitals to either intervention or control groups. The intervention consisted of a 2-hour antenatal education session and postnatal support provided to fathers. RESULTS: The any breastfeeding rate for the intervention group was significantly greater at 6 weeks: 81.6% in the intervention group compared to 75.2% in the control group, odds ratio 1.46 (95% CI, 1.01-2.13). After adjustment for age and hospital, the odds ratio for any breastfeeding in the intervention group was 1.58 (1.06-2.35) and for socioeconomic status (SES), 1.56 (1.06-2.30). The infants of older fathers were more likely to be breastfed at 6 weeks compared to infants of younger fathers (P < .01), and infants of fathers with high SES more likely than infants of fathers with low SES (P = .013). CONCLUSION: Even a small increase in breastfeeding rates brings public health benefits. In this study, a minimal intervention was found to significantly increase any breastfeeding at 6 weeks: 81.6% in the intervention group compared to 75.2% in the control group.

Breastfeeding by Chinese mothers in Australia and China: the healthy migrant effect.

BACKGROUND: Breastfeeding practices might be influenced by migration to another country. Although the "healthy migrant effect" is commonly reported in epidemiology, evidence for it in breastfeeding practices is weak. OBJECTIVES: This study aimed to compare the initiation and duration of breastfeeding between Chinese Australian migrants and Chinese mothers in mainland China and test the healthy migrant effect in Chinese Australian migrants in Perth, Western Australia. METHODS: A survey was undertaken of 239 Chinese mothers living in Perth and 1844 mothers living in Chengdu, Sichuan Province, PR China, with a response rate of 96.7% and 87.8%, respectively. RESULTS: The breastfeeding initiation rate in Chinese Australian mothers (94.1%) was higher than in mothers in China (86.2%, P < .001). Chinese Australian mothers also had a longer breastfeeding duration, greater "full breastfeeding" rate at 6 months, and greater "any breastfeeding" rates at 6 and 12 months. After controlling for potential confounding variables, the results of the binary logistic regression analysis showed that the location of the mother (Australia or China) was associated with breastfeeding practices. Chinese mothers living in Chengdu were less likely to initiate breastfeeding (odds ratio = 0.47, 95% confidence interval, 0.25-0.89) and breastfeed their babies at 12 months (odds ratio = 0.48, 95% confidence interval, 0.33-0.69) than Chinese mothers in Perth. CONCLUSION: The higher breastfeeding initiation and longer breastfeeding duration by Chinese migrant mothers in Perth than mothers in Chengdu suggest a "healthy migrant effect."

Factors associated with breastfeeding duration: a 30-month cohort study in northwest China.

BACKGROUND: Factors associated with breastfeeding need to be explored in the northwest of China. OBJECTIVE: This study aimed to measure the full duration of breastfeeding and identify factors associated with breastfeeding in Shihezi City in Northwest China. METHODS: A prospective cohort study was undertaken to obtain details of child feeding practices using structured questionnaires in 2007-2010. Before discharge from hospitals, 681 mothers were randomly recruited and interviewed in maternity units for breastfeeding. After discharge, the mothers were contacted by telephone at monthly intervals within the first 6 months and then at 2-month intervals until discontinuation of breastfeeding. RESULTS: The breastfeeding initiation rate was 95.9%. The breastfeeding rates then declined to 69.6% at 6 months, 29.7% at 12 months, and 2.3% at 24 months. The median duration of "any breastfeeding" was 9 months. The exclusive breastfeeding rate was low because of the high rate of prelacteal and early complementary feeding. Cox regression analyses revealed that mothers who had preterm babies believed that breast milk could not meet infants' needs and intended to breastfeed for less than 6 months, and mothers with late onset of lactogenesis II and whose parents lived in Xinjiang were more likely to stop breastfeeding. Younger maternal age, employment, and suffering from illness were also associated with a shorter duration of breastfeeding. CONCLUSION: The duration of "exclusive" and "any breastfeeding" was below the Chinese and World Health Organization breastfeeding goals. Shorter duration of breastfeeding was associated with having grandparents residing within the same province, maternal age, illness and employment, gestational age, and delayed onset of lactogenesis.

Breastfeeding practice in Zhejiang province, PR China, in the context of melamine-contaminated formula milk.

A prospective cohort study of 1,520 mothers from Zhejiang province of China was undertaken to determine the duration of breastfeeding and associated factors during the first six months postpartum. Most (95.3%) mothers had introduced complementary foods by six months, making them at risk from contaminated infant formula. The mean duration of'any breastfeeding' was greater than 180 days but only 48 days for 'exclusive breastfeeding'. Factors relating to cessation of any breastfeeding were maternal age, timing of the breastfeeding decision, admission of the infant to a special-care nursery, return of the mother to work, the early introduction of water and/or other complementary foods, and their location of residence. The introduction of infant formula before three months was positively associated with the late decision to breastfeed, births in city, and infants being given a prelacteal feed. To combat the melamine disaster, strategies to improve the duration of breastfeeding must be developed taking these factors into account.

Defining exclusive breastfeeding in Australia.

Exclusive breastfeeding for the first 6 months of life is recommended as the optimal way to feed infants. This paper reviews the measurement of exclusive breastfeeding in Australian studies over the past 10 years. Only half the studies identified that claimed to measure exclusive breastfeeding used a definition consistent with the World Health Organisation. Three studies used 24-h or 7-day recall indicators that have been shown to produce overestimations of the prevalence of exclusive breastfeeding. Measurement of exclusive breastfeeding with a valid and consistent definition is vital for monitoring rates and trends, for comparison between different studies and countries and to reach conclusions on various health benefits. Any future measurement of exclusive breastfeeding in Australia should use the World Health Organisation definition and the 24 h recall study design should not be used for this purpose.

Consumer perceptions of fruit and vegetables serving sizes.

OBJECTIVE: To assess consumer understanding of fruit and vegetable serving sizes. DESIGN: The Western Australian Health Department launched the Go for 2&5(R) campaign to promote fruit and vegetables in March 2002. The Health & Wellbeing Surveillance System surveyed 1108 adults, aged 16 years and over, between September and November 2002 about what constituted a serving of fruit and of vegetables, their usual daily fruit and vegetables intake, and their recall of the campaign. SETTING: The study was undertaken as a part of a public health intervention - social marketing campaign in Western Australia, which had a population of 1 927 000 in 2002. RESULTS: Forty-two per cent of respondents knew that the fruit serving size was one piece and only 14.5 % reported the (1/2) cup vegetable serving size. The mean fruit intake was 1.8 (95 % CI 1.7, 1.8) servings/d and the mean vegetable intake was 2.8 (95 % CI 2.7, 3.0) servings/d. Vegetable intake was associated with being female (P = 0.006), increasing age (P < 0.0001), awareness of the campaign (P = 0.031) and knowledge of standard serving size (P = 0.006). Fruit consumption was associated with being female (P = 0.007). Fruit and vegetable intakes were not associated with educational attainment or household income. CONCLUSIONS: The Go for 2&5(R) campaign uses a prescriptive message to promote increased consumption of fruit and vegetables. Respondent's knowledge of the standard of serving sizes for fruit and vegetables suggests there is value in separating fruit and vegetable recommendations in messages to encourage increased consumption.

Increasing fruit and vegetable consumption: success of the Western Australian Go for 2&5 campaign.

OBJECTIVE: The Western Australian Health Department's Go for 2&5 campaign aimed to increase adults' awareness of the need to eat more fruit and vegetables and encourage increased consumption of one serving over five years. DESIGN: The multi-strategy fruit and vegetable social marketing campaign, conducted from 2002 to 2005, included mass media advertising (television, radio, press and point-of-sale), public relations events, publications, a website (www.gofor2and5.com), and school and community activities. Campaign development and the evaluation framework were designed using health promotion theory, and assessed values, beliefs, knowledge and behaviour. Two independent telephone surveys evaluated the campaign: the Campaign Tracking Survey interviewed 5032 adults monitoring fruit and vegetable attitudes, beliefs and consumption prior to, during and 12 months after the campaign; and the Health & Wellbeing Surveillance System surveyed 17,993 adults between 2001 and 2006, continuously monitoring consumption. SETTING: Population public health intervention-social marketing campaign in Western Australia, population of 2,010,113 in 2005. SUBJECTS: Adults in the Perth metropolitan area. RESULTS: The campaign reached the target audience, increasing awareness of the recommended servings of fruit and vegetables. There was a population net increase of 0.8 in the mean number of servings of fruit and vegetables per day over three years (0.2 for fruit (1.6 in 2002 to 1.8 in 2005) and 0.6 for vegetables (2.6 in 2002 to 3.2 in 2005), significant at P < 0.05). CONCLUSION: Sustained, well-executed social marketing is effective in improving nutrition knowledge, attitudes and consumption behaviour. The Go for 2&5 campaign provides guidance to future nutrition promotion through social marketing.

Infants' first feeds in Hangzhou, PR China.

Breastfeeding is the foundation of good nutrition and provides the basis for health throughout the life span. The WHO and the Chinese Ministry of Public Health recommend exclusive breastfeeding to six months of age. The practice of giving prelacteal feeds may interfere with the establishment of good breastfeeding practices and is contrary to the principles of Baby Friendly Hospital accreditation. The objective of this study was to investigate the prevalence of prelacteal feeds in a hospital in Hangzhou and the influence of this practice on breastfeeding at discharge. A longitudinal study of infant feeding was conducted in Hangzhou, China and a total of 638 mothers were recruited and interviewed while in hospital. The questionnaire included full details of infant feeding methods and factors likely to influence the initiation and duration of breastfeeding. Binary logistic regression was used to analyse factors influencing breastfeeding on discharge. In Hangzhou almost all babies are born in hospital, the median length of stay was 5.6 days and 77% of births were by caesarian section. In 26% of births the infants were given formula, water or milk as their first feed. At the time of discharge from hospital 91% of infants were receiving some breastmilk, but only 36% of mothers were exclusively breastfeeding. Breastfeeding on discharge from hospital was inversely related to giving prelacteal feeds (OR 0.115, 95% CI 0.055-0.238). While in hospital just over one quarter of infants received prelacteal feeds and these infants had a lower rate of breastfeeding on discharge.

Temporal changes in the determinants of breastfeeding initiation.

BACKGROUND: Regular identification of factors that predict a woman's infant feeding choice is important so that breastfeeding promotion interventions can be targeted at those women least likely to breastfeed. The objective of this study was to compare determinants of breastfeeding at discharge from hospital in 2002/2003 with those reported for 1992/1993. METHODS: Women participating in two longitudinal infant feeding studies in Perth, Australia, completed a baseline questionnaire just before, or shortly after, discharge from hospital. Data collected included infant feeding method and socio-demographic, biomedical, and psychosocial factors known, or suspected, to be related to the initiation of breastfeeding. Multivariate logistic regression was used to identify independent predictors of "any" and "exclusive" breastfeeding at hospital discharge in both studies. RESULTS: Although maternal age, level of education, and family income were independent predictors of breastfeeding at hospital discharge in the first study, no association was found between these factors and breastfeeding at hospital discharge in the second study. In both studies, a woman who perceived her husband to prefer breastfeeding was significantly more likely to leave hospital breastfeeding, and to be exclusively breastfeeding, than a woman who perceived her husband to prefer formula feeding. The strongest predictor in both studies for a woman to not be exclusively breastfeeding at hospital discharge was having an infant who had been admitted to the special care nursery after delivery. CONCLUSIONS: Given the importance of psychosocial factors to breastfeeding initiation, interventions that aim to increase breastfeeding initiation rates should be targeted on the basis of parental attitudes to breastfeeding rather than on sociodemographic factors. Similarly, interventions that aim to increase exclusive breastfeeding should address biomedical factors that hinder a woman's ability to establish exclusive breastfeeding.

Measuring preferences for delivery services in rural Vietnam.

BACKGROUND: The relatively low use of maternity services at the primary health care level in Vietnam has highlighted the need for economic evaluations of the current maternal health delivery network. This study measured willingness-to-pay for obstetric delivery preferences in rural Vietnam. METHODS: An interviewer-administered survey was conducted among 200 postpartum and 196 pregnant women, and 196 men in Quang Xuong district, Thanh Hoa province of Vietnam, using the payment card technique. RESULTS: A kappa score of 0.98 showed very good agreement between the two interviewers administering the survey. An association was found between willingness-to-pay and satisfaction with the quality of maternity services. No significant differences were found in willingness-to-pay values between prenatal and postpartum groups, and between male and female participants. CONCLUSIONS: The study demonstrates that the willingness-to-pay instrument is a feasible tool, and is relatively reliable to measure the benefit of different alternatives of delivery services in rural Vietnam. For wider application of the instrument, its validity should be investigated further. Meanwhile, health care managers and decision makers should be encouraged to apply the instrument in the evaluation of maternal health programs.

Factors associated with the initiation and duration of breastfeeding by Chinese mothers in Perth, Western Australia.

To identify determinants of the initiation and duration of breastfeeding by Chinese Australian mothers, a cross-sectional survey of 506 Mandarin-speaking women in Perth, Western Australia, was conducted. Doctors' support of breastfeeding was positively associated with the initiation of breastfeeding both in the mothers' home countries (odds ratio [OR], 9.94; 95% confidence interval [CI], 3.17-31.18) and in Australia (OR, 16.78; 95% CI, 7.12-39.55) and with duration. Mother's level of education was positively associated with the initiation of breastfeeding in the mother's home country (OR, 3.04; 95% CI, 1.36-6.80) and positively associated with the duration of breastfeeding both in the mother's home country and Australia. Father's preference for breastfeeding was positively associated with the initiation of breastfeeding of the mother giving birth in Australia (OR, 4.96; 95% CI, 1.93-12.66). Health professionals can provide invaluable support for mothers initiating and continuing breastfeeding in this population. Prenatal education also needs to emphasize the ways in which fathers can support and contribute to breastfeeding.