A structured public health approach to increasing rates and duration of breastfeeding in Romania.

BACKGROUND: Studies indicate that since 1990, rates of breastfeeding initiation and duration in Eastern Europe, including Romania, have decreased. Most breastfeeding promotion efforts in Romania have focused on in-hospital care, with an emphasis on training clinicians. Prior studies report that about 88% of Romanian mothers initiate breastfeeding in the hospital; however, these same studies report limited breastfeeding duration. We posit that an important problem is lack of support and education in the weeks and months following the birth. The nature of this problem suggests the need for an integrated and structured public health solution. METHODS: Based on our independent research, the results of an international maternal and child health (MCH) conference, and consultation with Romanian and American experts, we propose use of the public health problem-solving paradigm to support breastfeeding in Romania. RESULTS: This article presents a conceptual model showing the integration of input, output, and process components and a logic model explicating possible interventions (or needs) and barriers to breastfeeding. We propose a public health solution that begins with a new MCH within the public health training structure at a major Romanian university and a summer course bringing together Romanian and American students to study MCH, including breastfeeding. CONCLUSIONS: We believe that these two courses will promote enthusiasm and generate ideas to develop community-based interventions as well as policy recommendations to increase breastfeeding duration in Romania. We suggest that this public health problem-solving approach provides an integrated way of maintaining and increasing breastfeeding; furthermore, this approach could be broadly used in Eastern Europe.

Reliability and validity of the Romanian version of a scale to measure infant feeding attitudes and knowledge.

AIM: To describe the development and testing of the Romanian version of the Iowa Infant Feeding Attitude Scale (IIFAS-R). The original instrument has well-established psychometrics for use in English-speaking countries. METHODS: Questionnaires including demographics and items about prior pregnancy and opinions about breastfeeding in public were administered to women in Cluj-Napoca, Romania, attending antenatal clinic (n = 336) and to a separate cohort of mothers within 24 h of delivery (n = 276). Postpartum follow-up was conducted with a sample of maternity cohort subjects who initiated breastfeeding in the hospital (n = 52). RESULTS: Internal consistency was adequate in both cohorts (antenatal alpha= 0.50; maternity alpha= 0.63), with improved reliability for antenatal multigravid (alpha= 0.60) and university-educated women (alpha= 0.57). Score distributions were comparable and item means were approximately central across cohorts. Among pregnant women, higher scores (more positive towards breastfeeding) were associated with longer planned maternity leave (chi2= 17.8; p = 0.02). Higher maternity cohort scores were associated with age (r = 0.31, p = 0.003), urban residence (chi2= 10.2, p = 0.04), breastfeeding a prior infant for at least 6 weeks (chi2= 6.4, p = 0.04), and with intending to breastfeed for at least 6 weeks (chi2= 4.7, p = 0.03). Postpartum women still breastfeeding at follow-up also scored higher (chi2= 9.3, p = 0.009). CONCLUSION: This is the first study to report on use of the IIFAS in Eastern Europe. The IIFAS-R is easy to administer, reliable and valid in Romania. The IIFAS-R can support data collection to promote and assess breastfeeding initiatives consistent with World Health Organization recommendations.

Infant feeding attitudes and knowledge among socioeconomically disadvantaged women in Glasgow.

OBJECTIVES: This study: (1) investigated infant feeding attitudes and knowledge among socioeconomically disadvantaged mothers in an urban community with historically low breastfeeding rates, (2) examined the influence of women's social networks on infant feeding attitudes and decisions, and (3) validated a measure of infant feeding attitudes and knowledge in this population (Iowa Infant Feeding Attitude Scale, IIFAS). METHODS: Women attending a prenatal clinic (n=49) reported on: (1) demographics, (2) infant feeding attitudes and knowledge (IIFAS), (3) feeding intent, (4) opinions about breastfeeding in public, and (5) social networks. Feeding method at discharge was abstracted from hospital charts. Social network members (n=47) identified by the prenatal sample completed interviews covering: (1) demographics, (2) infant feeding attitudes and knowledge (IIFAS), (3) prior infant feeding methods and recommendations, and (4) opinions about breastfeeding in public. RESULTS: Mean IIFAS scores were low in both groups, indicating neutral to negative breastfeeding attitudes; mothers' scores were lower than social network members. Higher maternal IIFAS score was significantly associated with intended and actual breastfeeding. A social network positive towards breastfeeding was significantly associated with mothers' positive attitude towards breastfeeding. Both mothers and social network members support breastfeeding in public. IIFAS internal consistency was robust for both mothers and social network members. Predictive validity was demonstrated by significant positive association between score and intended and actual feeding methods. CONCLUSIONS: Knowledge and attitude predict breastfeeding initiation in this population. Social network members may influence mothers' feeding choices. This research is important because attitudes and knowledge derived from the IIFAS can be used to develop and evaluate breastfeeding promotion programs.

An international model for staffing maternal and child health research: the use of undergraduate students.

Constrained resources in Central and Eastern Europe limit the capacity of local and national health ministries to study breastfeeding practices or implement evidence-based breastfeeding support programs. This paper describes an innovative model for studying an important maternal and child health (MCH) problem by training undergraduate students to strengthen local capacity for research. An international team of researchers from Romania and the United States designed a study conducted at Babes-Bolyai University and two academic maternity hospitals in Cluj-Napoca, Romania. The objectives were to (1) spark interest in breastfeeding research among undergraduates, (2) develop empirical knowledge about breastfeeding, and (3) train a team of undergraduate students to collect, manage, and enter study data. A team of carefully selected undergraduate students was trained in survey design, data collection, data entry, and interviewing skills. Internet technology was used to facilitate communication and to transfer data. The project resulted in a trained cadre of undergraduate students able to conduct survey research on breastfeeding practices with skills ranging from questionnaire design and implementation to descriptive data analysis. Empirical data obtained from the study will be used for student projects, to stimulate new breastfeeding support policies and programs, and to apply for research grants. Undergraduate students in developing countries in Central and Eastern Europe are a valuable, untapped resource for expanding MCH capacity. We recommend adoption of this cost-effective approach to foster high-quality MCH research.

Prenatal office practices regarding infant feeding choices.

The objective of this study was to determine the obstetric care providers' roles in breast-feeding promotion during prenatal care. A questionnaire addressing breast-feeding issues was sent to family practitioners (FP), obstetric-gynecologists (OB/GYN), and nurse midwives (NM) in Iowa, USA. All NM, 97% of FP, and 85% of OB/GYN reported asking infant feeding preference-usually only at the first prenatal visit. NM (73%) were most likely to provide extensive breast-feeding counseling. OB/GYN (68%) and FP physicians (90%) reported doing their own breast-feeding counseling. Breast examinations targeting future breast-feeding problems were done in 82% to 84% of patients. NM practices shared more information supportive of breast-feeding. Nearly all providers offered prenatal classes, but only 41% of FP offered breast-feeding classes. Free formula samples were available in 73% of FP, 54% of OB/GYN, and 36% NM offices. Pamphlets on formula feeding and also breast-feeding were readily available. Overall NM (64%) reported being strong breast-feeding advocates compared to only 13% of FP and 7% of OB/GYN. In conclusion, little promotion of breast-feeding occurs in most prenatal practice settings.

Changes in pediatric residents' perceptions of their continuity experience during their training: a national study.

OBJECTIVE: To determine how pediatric residents' perceptions of continuity clinic experiences vary by level of training, after controlling for the effect of continuity setting. METHOD: Cross-sectional survey of pediatric and combined pediatric trainees in US residency programs. RESULTS: Survey responses were received from 1355 residents in 36 training programs. Residents' continuity experiences were in hospital-based and community settings. Numbers of patients seen increased between PGY-1 and PGY-3 years, but not in the PGY-4 and PGY-5 years. Compared to PGY-1 residents, PGY-2 and PGY-3 residents were more likely to report more encounters with established patients, but were not more likely to feel like the primary care provider. There were no significant differences by training level in terms of involvement in panel patients' laboratory results, hospitalizations, or telephone calls, although nursery involvement decreased with increasing training level. Autonomy was directly related to training level. The perception of having the appropriate amount of exposure to practice management issues was low for all respondents. CONCLUSIONS: Residents perceived that they had greater autonomy and continuity with patients as they become more senior, yet they were not more likely to feel like the primary care provider. Lack of increased involvement in key patient care and office responsibilities across training years may reflect a need for changes in resident education. These data may be helpful in formulating recommendations to program directors with regard to determining which Accreditation Council for Graduate Medical Education competencies should be emphasized and evaluated in the continuity experience.

Securing a faculty position: a practical guide for residents, fellows, junior faculty, and their mentors.

Applying for a faculty position can appear to be a daunting project for many residents, fellows, and junior faculty due, in large part, to the lack of readily available information on the process of interviewing and negotiating for faculty appointment in academic medicine. Although this process may seem mystifying to first-time applicants, it has a structure. This article discusses the framework of the application process and recommends an action plan from initial contact to acceptance of an offer. Each step of the process is discussed. Guidelines are provided to assist applicants and their mentors to successfully manage these important steps.

Healthy Steps: resident's perceptions.

The objective of this study is to determine pediatric residents' perception of Healthy Steps for Young Children, Healthy Steps Iowa, and Healthy Steps specialists. Twenty-nine of 37 (78%) pediatric residents participated in this survey. The Healthy Steps specialists facilitated pediatric residents' learning of anticipatory guidance (69%), and assured the patients received information efficiently (69%). Sixty-two percent reported that the Healthy Steps specialists did not interfere with their relationship as the patient's primary care provider. Seventy-six percent would consider using Healthy Steps specialists in their future practice. Program improvement areas include improving clinic efficiency with the incorporation of Healthy Steps specialists; increasing the pediatric residents' awareness of family violence, mental illness, and substance abuse; and improving their method of referral to community contacts.