Understanding the challenges related to breastfeeding education and barriers to curricular change: a systems perspective for transforming health professions education.

Objectives: A majority of women and families wish that their babies be breastfed. However, too many still receive insufficient or inappropriate initial care from health professionals (HPs) who have limited breastfeeding (BF) competencies. We investigated barriers and potential solutions to improve the undergraduate training programs for various HPs. Methods: Focus groups were carried out in three universities in Quebec and one in Ontario (Canada), with 30 faculty and program directors from medicine, midwifery, nursing, nutrition, and pharmacy. Discussions were subjected to thematic content analysis, before being validated in a strategic planning workshop with 48 participants from the same disciplines, plus dentistry and chiropractic. Findings: Substantive improvements of undergraduate training programs for BF could be obtained by addressing challenges related to the insufficient, or lack of, (i) interactions among various HPs, (ii) opportunities for practical learning, (iii) specific standards to guide course content, (iv) real-life experience with counselling, and (v) understanding of the influence of attitudes on professional practice. Several potential solutions were proposed and validated. The re-interpretation of the results in light of various literature led to an emerging framework that takes a systems perspective for enhancing the education of HPs on BF. Conclusions: To improve the education of HPs so as to enable them to provide relevant support for future mothers, mothers and their families, solutions need to be carried out to address challenges in the health system, the education system as well as regarding the curricular change process.

Objectifs: La majorité des femmes et des familles souhaitent que leur bébé soit allaité. Toutefois, plusieurs ne reçoivent pas un soutien adéquat de la part de professionnels de la santé (PS) qui ont des compétences limitées en allaitement. Nous avons étudié les barrières et les solutions potentielles en vue de rehausser la formation initiale de divers PS. Méthodes: Des groupes de discussion ont été organisés dans trois universités du Québec et une en Ontario (Canada) avec 30 directeurs de programmes et membres du corps professoral en médecine, pratique sage-femme, sciences infirmières, nutrition et pharmacie. Les discussions ont fait l'objet d'une analyse de contenu thématique laquelle fut ensuite validée dans un atelier de planification stratégique avec 48 participants des mêmes disciplines auxquelles se sont ajoutées dentisterie et chiropratique. Résultats: Des améliorations substantielles des compétences en allaitement dans les programmes de formation initiale pourraient être obtenues en travaillant sur les défis associés à l'insuffisance, ou à l'absence de, (i) interactions entre les divers PS, (ii) opportunités d'apprentissages pratiques, (iii) normes spécifiques pour guider les contenus de cours, (iv) expériences réelles avec le counseling, et (v) compréhension de l'influence des attitudes sur la pratique professionnelle. La ré-interprétation des résultats à la lumière de la littérature a fait émerger un cadre conceptuel avec une perspective systémique pour guider le rehaussement de la formation en allaitement des divers PS. Conclusions: Afin d'améliorer la formation des PS pour qu'ils/elles puissent fournir un soutien pertinent aux futures mères, aux mères et à leurs familles, des solutions visant à la fois les défis dans le système de santé, dans le système d'éducation et dans le processus de changement curriculaire doivent être mises en œuvre.

Cultural Safety as an Outcome of a Dynamic Relational Process: The Experience of Inuit in a Mainstream Residential Addiction Rehabilitation Centre in Southern Canada.

Few addiction treatment options are available in Arctic Canada, leading many Inuit to seek treatment programs in southern cities. We conducted a case study to understand what contributes to a culturally safe experience for Inuit in a mainstream addiction rehabilitation centre in Southern Canada. We carried out more than 700 hours of participant observation, in addition to semi-structured interviews and member-checking activities with 20 Inuit residents, 18 staff and four managers. Data were analysed using an inductive interpretative process. Throughout their journey in the program, Inuit navigated through contrasting situations and feelings that we grouped under six broad themes: having Inuit peers, having limitations imposed on one's ways of being and doing, facing ignorance and misperceptions, having conversations and dialogue, facing language barriers and being in a supportive and caring environment. This study highlights how cultural safety varies according to people, context and time, and relates to developing trustful relationships.

Factors influencing the provision of care for Inuit in a mainstream residential addiction rehabilitation centre in Southern Canada, an instrumental case study into cultural safety.

BACKGROUND: Provision of culturally safe care has been proposed to address health inequity, including in the areas of mental health and addiction. The factors that influence the provision of culturally safe care remain understudied. This paper explores the factors influencing the efforts of a mainstream residential addiction rehabilitation centre to provide culturally appropriate and quality care for Inuit. METHODS: An instrumental case study was conducted, informed by ethnographic and creative research methods. Over 700 h of participant observation were carried out between March 2018 and January 2020, in addition to qualitative semi-structured interviews (34 participants) and/or member-checking activities (17 participants) conducted with a total of 42 individuals: 20 Inuit residents, 18 clinical/specialized staff, and 4 clinical/administrative managers. An interpretive thematic analysis was performed to examine the factors that may influence the provision of culturally safe care for Inuit residents. RESULTS: Ten categories of interrelated factors were identified and classified according to whether they relate to individual, programmatic, organizational, or systemic levels. These categories covered: (1) residents' and staff's life experiences; (2) personal and relational qualities and skills; (3) the model of care; (4) model flexibility; (5) ways in which relational aspects were considered; (6) sensitivity of the organization towards the population served; (7) human resources and professional development issues; (8) social climate; (9) political, relational, and funding climate; and (10) legislative, regulatory, and professional environment. While system-level factors generally had a negative effect on experiences of cultural safety, most factors at other levels had both favourable and unfavourable effects, depending on the context and dimensions examined. CONCLUSIONS: The results offer insight into the interplay between the challenges and barriers that mainstream organizations face when working with Inuit, and the opportunities and enablers that organizations can build on to improve their services. This paper contributes to a better understanding of the challenges and opportunities to providing culturally safe addiction programs to Inuit within a complex intervention setting. It concludes by highlighting some areas for improvement to advance cultural safety in this context.

Triggering Institutional Change: Examining the Development of the 2001 Quebec Breastfeeding Policy.

BACKGROUND: The Quebec Government published Canada's first breastfeeding policy in 2001 with the goal to increase breastfeeding rates in the province. OBJECTIVE: To ultimately contribute to more informed policy decision-making, this investigation aimed to identify key stakeholders and understand events and processes that contributed to the establishment of this policy. METHODS: Building from the neo-institutional theory, this was a retrospective case study. Interviews with key informants were conducted, and several texts were compiled. Hybrid thematic analysis was used to analyze text transcribed verbatim from interviews. Resulting themes, summary of archival material and temporal bracketing were adopted to elaborate a historical narrative of the development of the policy. RESULTS: The emergence, development and initial implementation of the Quebec breastfeeding policy phases were traced from 1977 to 2009. The policy was triggered by a grassroots health professional movement that advocated for years for a cultural change toward breastfeeding in Quebec. Once Quebec's Ministry of Health finally accepted dialogue, institutional actors cooperated to formulate the policy. However, conflicts arose because of the Ministry's increasingly centralized mechanisms of governance. By 2009, discontent was so pervasive that several health professionals and other breastfeeding actors created an independent organization to further support breastfeeding, out of the Ministry's scope of control. CONCLUSION: Collaboration in this domain was possible when shared decision-making was accepted, but conflict emerged when the institutional actor with formal authority re-adopted traditional top-down modes of action.

Temporal trends of legacy and emerging persistent organic pollutants in inuit preschoolers from Northern Quebec (Canada).

In this study, we report the temporal trends of persistent organic pollutants (POPs) in 181 preschool Inuit children from Nunavik and the influence of confounding factors on blood contaminant levels. From 2006 to 2010, no significant trends were detected in Σpolychlorinated biphenyls (ΣPCBs), Σorganochlorine pesticides (ΣOPs), Σtoxaphene, and Σper- and polyfluoroalkyl substances (ΣPFASs). On the contrary, significant downward trends ranging from 9.3% to 14.3% per year were found for polybrominated diphenyl ethers (PBDEs). Breastfeeding was significantly associated with increased levels of POPs. Age was positively and significantly related to ΣPCBs, ΣOPs and Σtoxaphene. Compared with girls, boys had significantly higher concentrations of ΣPBDEs, but lower concentrations of ΣPFASs. Weight-for-height or body mass index z-scores were negatively and significantly related to ΣPCBs and ΣOPs. Passive smoking was positively and significantly associated with ΣOPs and Σtoxaphene. In conclusion, continued efforts to reduce contaminant exposure are needed to protect children's health and development.

Using Soluble Transferrin Receptor and Taking Inflammation into Account When Defining Serum Ferritin Cutoffs Improved the Diagnosis of Iron Deficiency in a Group of Canadian Preschool Inuit Children from Nunavik.

The prevalence of iron depletion, iron deficient erythropoiesis (IDE), and iron deficiency anemia (IDA) was assessed in preschool Inuit children using soluble transferrin receptor (sTfR) and traditional indicators of iron status while disregarding or taking inflammation into account when defining SF cutoffs. Iron depletion was defined as follows: (1) SF < 15 µg/L regardless of the C-reactive protein (CRP) level and (2) SF < 15 or <50 µg/L with CRP ≤ 5 or >5 mg/L, respectively. IDE corresponded to iron depletion combined with total iron binding capacity > 72 µmol/L and/or transferrin saturation < 16%. Iron depletion and IDE affected almost half of the children when accounting for inflammation, compared to one-third when the SF cutoff was defined regardless of CRP level (P < 0.0001). The prevalence of IDE adjusted for inflammation (45.1%) was very similar to the prevalence observed when sTfR was used as a sole marker of IDE (47.4%). The prevalence of anemia was 15%. The prevalence of IDA (IDE + hemoglobin < 110 g/L) was higher when accounting for than when disregarding inflammation (8.0% versus 6.2%, P = 0.083). Using sTfR and different SF cutoffs for children with versus without inflammation improved the diagnosis of iron depletion and IDE. Our results confirm that Inuit children are at particularly high risk for iron deficiency.

Usual dietary fatty acid intakes and red-blood-cell membrane fatty acid composition in Inuit children attending child-care centres in Nunavik, northern Québec, Canada.

OBJECTIVES: To assess dietary fatty acid intakes and to examine the relationship between dietary sources of n-3 and n-6 PUFA and red-blood-cell (RBC) n-3 and n-6 PUFA composition. DESIGN: A cross-sectional study. Dietary intakes were assessed with a 24 h dietary recall. A second recall was performed for 44 % of the children. Usual dietary intakes were estimated with the Software for Intake Distribution Estimation (SIDE). The fatty acid composition was measured in RBC membranes. Multivariate linear regression analyses were performed to explain RBC n-3 and n-6 PUFA concentrations. SETTING: Child-care centres in Nunavik, northern Québec, Canada. SUBJECTS: One hundred and sixty-seven Inuit children aged 11-53 months. RESULTS: A high proportion of the participants had inadequate n-3 and n-6 PUFA intakes (47·9 % and 93·5 %, respectively). Breast-feeding status and consumption of traditional food during the first 24 h dietary recall were significantly associated with RBC n-3 PUFA levels. Older children also tended to have higher RBC n-3 PUFA levels (P = 0·0528), whereas sex, infant formula status and n-3 PUFA dietary intakes were not associated with RBC n-3 PUFA concentrations. RBC n-6 PUFA concentrations were positively associated with breast-feeding status and n-6 PUFA dietary intakes, whereas age, sex and infant formula status were not. CONCLUSIONS: The present findings highlight the fact that Inuit pre-school children are not consuming enough n-3 and n-6 PUFA for optimum health. These observations call for actions to increase traditional food intake among Inuit children and to help them and their parents make healthier store-bought food choices.

Effect of dietary calcium intake on lead exposure in Inuit children attending childcare centres in Nunavik.

High blood lead levels (BLLs) can be found in Inuit from Nunavik. At the same time, various nutrients such as calcium could lower lead absorption and toxicity. We examined the effect of dietary calcium intakes on BLLs in 245 preschool Inuit children attending childcare centres in Nunavik. Calcium intake was assessed with one 24-h dietary recall and BLLs were determined by inductively coupled plasma mass spectrometry in whole blood samples. Multiple imputation was performed to deal with missing data. Median blood lead concentration was 0.08 µmol/L. A high proportion of children did not meet the Estimated Average Requirement for vitamin D intake (73 %) and, to a lower extent, for calcium (20 %). Calcium intake was negatively associated with BLLs (p = 0.0001) while child's age and energy intake were positively associated with BLLs (p = 0.015 and p = 0.024, respectively). Consuming traditional foods rich in calcium as well as milk and alternatives may protect against lead exposure.

Impact of a childcare centre nutrition program on nutrient intakes in Nunavik Inuit children.

PURPOSE: We assessed the impact of a nutrition program implemented in Nunavik childcare centres on Inuit children's food and dietary intakes. METHODS: Two hundred and forty-five Inuit children (aged 25.0 ± 9.6 months) were recruited between 2006 and 2010 in Nunavik childcare centres. Dietary intakes were assessed using a single 24-hour dietary recall (n=217). We compared participants' energy and nutrient intakes, and the proportions who met iron requirements and Canada's Food Guide - First Nations, Inuit and Métis recommendations, depending on whether or not they attended a childcare centre during the 24-hour dietary reference period. RESULTS: Children who attended a childcare centre on the day of the recall had significantly higher intakes of omega-3 fatty acids, calcium, total iron, bioavailable iron, phosphorus, beta-carotene, folate, pantothenic acid, riboflavin, and vitamin K, while a higher proportion of them met the recommended intake for total and bioavailable iron. The proportion of children who met the recommended servings for vegetables and fruit, grain products, and milk and alternatives was also significantly higher among participants who attended a childcare centre. CONCLUSIONS: The nutrition program was effective at improving these Inuit preschoolers' diet.

Consumption of tomato products is associated with lower blood mercury levels in Inuit preschool children.

Some evidence suggests that various diet components and nutrients, including vegetables, fruit and food-derived antioxidants, could mitigate contaminant exposure and/or adverse health effects of contaminants. To examine the effect of the consumption of tomato products on blood mercury levels in Inuit preschool children, 155 Inuit children (25.0±9.1months) were recruited from 2006-2008 in Nunavik childcare centers (northern Québec, Canada). Food frequency questionnaires were completed at home and at the childcare center, and total blood mercury concentration was measured by inductively coupled plasma-mass spectrometry. Multivariate regression analysis was performed after multiple imputation. The median blood concentration of mercury was 9.5nmol/L. Age, duration of breastfeeding, annual consumption frequency of seal meat, and monthly consumption frequency of tomato products were significant predictors of blood mercury levels, whereas annual consumption frequencies of beluga muktuk, walrus, Arctic char, and caribou meat were not. Each time a participant consumed tomato products during the month before the interview was associated with a 4.6% lower blood mercury level (p=0.0005). All other significant predictors in the model were positively associated with blood mercury levels. Further studies should explore interactions between consumption of healthy store-bought foods available in Arctic regions and contaminant exposure.

Traditional food consumption is associated with higher nutrient intakes in Inuit children attending childcare centres in Nunavik.

OBJECTIVES: To describe traditional food (TF) consumption and to evaluate its impact on nutrient intakes of preschool Inuit children from Nunavik. DESIGN: A cross-sectional study. METHODS: Dietary intakes of children were assessed with a single 24-hour recall (n=217). TF consumption at home and at the childcare centres was compared. Differences in children's nutrient intakes when consuming or not consuming at least 1 TF item were examined using ANCOVA. RESULTS: A total of 245 children attending childcare centres in 10 communities of Nunavik were recruited between 2006 and 2010. The children's mean age was 25.0±9.6 months (11-54 months). Thirty-six percent of children had consumed at least 1 TF item on the day of the recall. TF contributed to 2.6% of total energy intake. Caribou and Arctic char were the most reported TF species. Land animals and fish/shellfish were the main contributors to energy intake from TF (38 and 33%, respectively). In spite of a low TF intake, children who consumed TF had significantly (p<0.05) higher intakes of protein, omega-3 fatty acids, iron, phosphorus, zinc, copper, selenium, niacin, pantothenic acid, riboflavin, and vitamin B12, and lower intakes of energy and carbohydrate compared with non-consumers. There was no significant difference in any of the socio-economic variables between children who consumed TF and those who did not. CONCLUSION: Although TF was not eaten much, it contributed significantly to the nutrient intakes of children. Consumption of TF should be encouraged as it provides many nutritional, economic, and sociocultural benefits.

Barriers, facilitators, and recommendations related to implementing the Baby-Friendly Initiative (BFI): an integrative review.

Despite growing evidence for the positive impact of the Baby-Friendly Initiative (BFI) on breastfeeding outcomes, few studies have investigated the barriers and facilitators to the implementation of Baby-Friendly practices that can be used to improve uptake of the BFI at the local or country levels. This integrative review aimed to identify and synthesize information on the barriers, facilitators, and recommendations related to the BFI from the international, peer-reviewed literature. Thirteen databases were searched using the keywords Baby Friendly, Baby-Friendly Hospital Initiative, BFI, BFHI, Ten Steps, implementation, adoption, barriers, facilitators, and their combinations. A total of 45 English-language articles from 16 different countries met the inclusion criteria for the review. Data analysis was guided by Cooper's five stages of integrative research review. Using a multiple intervention program framework, findings were categorized into sociopolitical, organizational-level, and individual-level barriers and facilitators to implementing the BFI, as well as intra-, inter-, and extraorganizational recommendations for strengthening BFI implementation. A wide variety of obstacles and potential solutions to BFI implementation were identified. Findings suggest some priority issues to address when pursuing Baby-Friendly designation, including the endorsements of both local administrators and governmental policy makers, effective leadership of the practice change process, health care worker training, the marketing influence of formula companies, and integrating hospital and community health services. Framing the BFI as a complex, multilevel, evidence-based change process and using context-focused research implementation models to guide BFI implementation efforts may help identify effective strategies for promoting wider adoption of the BFI in health services.

Exposure to toxic metals and persistent organic pollutants in Inuit children attending childcare centers in Nunavik, Canada.

Arctic populations are exposed to substantial levels of environmental contaminants that can negatively affect children's health and development. Moreover, emerging contaminants have never been assessed in Inuit children. In this study, we document the biological exposure to toxic metals and legacy and emerging persistent organic pollutants (POPs) of 155 Inuit children (mean age 25.2 months) attending childcare centers in Nunavik. Blood samples were analyzed to determine concentrations of mercury, lead, polychlorinated biphenyls (PCBs), pesticides, brominated flame retardants [e.g., polybrominated diphenyl ethers (PBDEs)] and perfluoroalkyl and polyfluoroalkyl substances [PFASs; e.g. perfluorooctanesulfonate (PFOS) and perfluorooctane (PFOA)]. Lead [geometric mean (GM) 0.08 µmol/L], PCB-153 (GM 22.2 ng/g of lipid), BDE-47 (GM 184 ng/g of lipid), PFOS (GM 3369 ng/L), and PFOA (GM 1617 ng/L) were detected in all samples. Mercury (GM 9.8 nmol/L) was detected in nearly all blood samples (97%). Levels of metals and legacy POPs are consistent with the decreasing trend observed in Nunavik and in the Arctic. PBDE levels were higher than those observed in many children and adolescents around the world but lower than those reported in some U.S. cities. PFOS were present in lower concentrations than in Nunavimmiut adults. There is a clear need for continued biomonitoring of blood contaminant levels in this population, particularly for PBDEs and PFASs.