Knowledge of healthcare professionals about breastfeeding and supplementary feeding

Objective: To analyze the knowledge of breastfeeding (BF) and supplementary feeding (SF) of professionals in the Primary Health Care. Method: Cross-sectional study, with 168 professionals, conducted between June and September 2016. The Kruskal Wallis test was used to compare means of percentage of knowledge about BF and SF, by professional category and contingency testing, for association between variables. Results: From the total of professionals, 39.29% of them demonstrated good knowledge about BF and 2.38% about SF; 74.4% of respondents reported not knowing the program Brazilian Breastfeeding and Feeding Strategy (EAAB – Estratégia Amamenta e Alimenta Brasil). There was a positive association between professionals’ level of knowledge about BF and education (p=0.04), occupation (p=0.05) and healthcare in BF (p=0.04). Regarding the level of knowledge about SF, there was association between education (p<0.01) and healthcare in SF (p=0.04). Conclusion: The professionals have greater knowledge about breastfeeding when compared to supplementary feeding. Descriptors: Breast Feeding; Healthy Diet; Child Health; Knowledge; Primary Health Care. RESUMO Objetivo : Analisar o conhecimento sobre aleitamento materno (AM) e alimentação complementar (AC) de profi ssionais da atenção primária. Método: Estudo transversal, com 168 profi ssionais, realizado entre junho e setembro de 2016. Utilizou-se o teste de Kruskal Wallis para comparação entre as médias do percentual do conhecimento sobre AM e AC, por categoria profi ssional, e o teste de contingência, para associação entre as variáveis. Resultados: 39,29% dos profi ssionais demonstraram bom conhecimento sobre AM e 2,38%, sobre AC; 74,4% dos entrevistados revelaram que não conheciam o programa Estratégia Amamenta e Alimenta. Houve associação positiva entre nível de conhecimento dos profi ssionais em AM e escolaridade (p = 0,04), profi ssão (p = 0,05) e assistência em AM (p = 0,04). Quanto ao nível de conhecimento em AC, houve associação com escolaridade (p < 0,01) e assistência em AC (p = 0,04). Conclusão: Os profi ssionais têm maior conhecimento sobre aleitamento materno quando comparado ao conhecimento em alimentação complementar. Descritores: Aleitamento Materno; Dieta Saudável; Saúde da Criança; Conhecimento; Atenção Primária à Saúde. RESUMEN Objetivo: analizar el conocimiento sobre la lactancia materna (LM) y la alimentación complementaria (AC) de los profesionales de la atención primaria. Método: estudio transversal, con 168 profesionales, realizado entre junio y septiembre de 2016. Se utilizó la prueba de Kruskal Wallis para la comparación entre los promedios del porcentaje del conocimiento sobre LM y AC, por categoría profesional, y la prueba de contingencia, para asociación entre las variables. Resultados: el 39,29% de los profesionales demostraron buen conocimiento sobre LM y el 2,38%, sobre AC; el 74,4% de los entrevistados revelaron que no conocían el programa Estratégia Amamenta y Alimenta. La asociación fue positiva entre el nivel de conocimiento de los profesionales en LM y escolaridad (p=0,04), profesión (p=0,05) y asistencia en LM (p=0,04). En cuanto al nivel de conocimiento en AC, hubo Knowledge of healthcare professionals about breastfeeding and supplementary feeding Conhecimento sobre aleitamento materno e alimentação complementar dos profi ssionais de saúde Conocimiento sobre lactancia materna y la alimentación complementaria de los profesionales de la salud


INTRODUCTION
The breastfeeding practice has been widely discussed in Brazil and in the world.From the nutritional point of view, exclusive breastfeeding (EBF) is the most nutritious and adequate food for children until the first six months of life, for being rich in vitamins, proteins, carbohydrates, fats, minerals and water.These nutrients are crucial for children's growth and development.After this period, to satisfy infants' nutritional needs, the supplementary feeding (SF) should be initiated with the continuity of breastfeeding until two years of age or older (1) .
EBF until six months of age and, after this age, breastfeeding (BF) until two years of age or more, combined with suitable introduction of balanced SF are emphasized by the World Health Organization (WHO) as important measures that cause an effective impact on reducing the risk of developing chronic noncommunicable diseases (CNCD), as obesity, hypertension and diabetes mellitus, and promote physical and psychological health for the infant and the woman who breastfeeds (2) .
Although Brazil has advanced with regard to improvement of breastfeeding indicators (3) , there is a lot to evolve, especially if the aim is to accomplish the recommendation proposed by the WHO, of having at least 50% of children in exclusive breastfeeding.For that, there must be intersectoral collective efforts aiming at implementing actions of protection and promotion of BF and appropriate SF, within a perspective of integral and humanized approach (4) .
In this sense, the role of healthcare professionals is essential in the process, through actions on services directed to promotion, encouragement and support to BF and healthy SF.For that, the professional must be qualified and demonstrate safety for the mother regarding breastfeeding difficulties, assisting her in moments of anxiety and providing consistent information (5) .
However, this will only be possible when the action is based and instrumentalized on up-to-date technical and scientific knowledge.Thus, professionals' satisfactory knowledge about the subject are of utmost importance.Therein, studies have been evidencing a deficit of knowledge about this subject by professionals involved in providing health care to mothers, standing out the need for adequate preparation and commitment in breastfeeding promotion (6)(7) .
Based on problematic exposed, the investment on permanent health education (EPS -Educação Permanente em Saúde) is mandatory when aiming at promoting a better communication with mothers and family members, so that they can discuss their needs, expectations, anxieties and choices as well as effectively contribute to the promotion of BF and SF (8) .

OBJECTIVE
To analyze the knowledge about BF and SF of professionals in the Primary Health Care working in the teams of the Family Health Strategy (ESF -Estratégia Saúde da Família) of a municipality.

Ethical aspects
This research was approved by the Research Ethics Committee of the Centro Universitário UNINOVAFAPI, according to resolution no.466, from December 12, 2012 (9) , the National Council of the Brazilian Ministry of Health, approved on May 11, 2016.All participants signed the Informed Consent Form.

Study design, location, and period
Descriptive research with cross-sectional design conducted with professionals in the Primary Health Care team of the municipality of Picos (PI), Brazil.This is the third most important macroregion of Piauí, in populational and economic terms, consisting of 42 municipalities.The estimated population of this state was 368,877 inhabitants in 2016 (10) .

Population or sample, inclusion and exclusion criteria
The study was carried out with Primary Health Care teams from June to September 2016.The Primary Health Care teams work in urban and rural areas and are linked to the Municipal Health Secretariat (Secretaria Municipal de Saúde) of Picos-PI, acting on the Brazilian Unified Health System (SUS).The municipality has 36 Primary Health Care teams, with distribution of 25 teams in urban areas and 11 in rural areas, totaling 296 healthcare professionals (36 doctors, 36 nurses, 36 nursing technicians and 188 community health agents).
The simple random sample was calculated having as basis of population the 296 professionals registered at the local government, totaling a sample of 168 respondents, with sampling error of 0.05, according to Lewin's equation (11) .The distribution of professionals within the sample was conducted according to the ratio as a percentage of the body of Primary Health Care teams in Picos-PI (64% community health agents, 12% doctors, 12% nurses, 12% nursing technicians) to cover the populational reality.There was no refusal nor withdrawal of participants.
Inclusion criteria to the study consisted of being a healthcare professional working in the Primary Health Care of the municipality with at least one year of experience and providing the follow-up of women with children under two years old.Professionals on volunteering activities or internships and those on vacation or leave of absence were excluded from the study.

Study protocol
Data collection was conducted in morning and afternoon shifts by one of the researchers in a private place of the institution.The researcher was guided by an instrument adapted from CORRESPONDING AUTHOR asociación con escolaridad (p<0,01) y asistencia en AC (p=0,04).Conclusión: Los profesionales tienen mayor conocimiento sobre la lactancia materna cuando se compara al conocimiento en alimentación complementaria.Descriptores: Lactancia Materna; Dieta Saludable; Salud del Niño; Conocimiento; Atención Primaria de Salud.previous studies (12)(13) , being the new version evaluated by five experts in the area (face and content validation) and previously tested in pilot study.The instrument had 44 questions and was structured into two parts: the first aimed at identifying the profile of healthcare professionals and the second aimed at assessing their knowledge about the promotion of BF and healthy SF.At the end of each interview, the participant was questioned about his/her desire in remaining in the search or of changing the answers; however, there were no withdrawals nor changes.Data collection occurred from June to September 2016.

Analysis of the results and statistics
For the analysis, a database was built in the software Microsoft Office Excel 2016; in the next step, the database was imported and analyzed with the software Action Stat, version 3.0.2 (14).
Data analysis considered the means and medians of the percentage of knowledge about BF and SF by professional category.The Shapiro-Wilk test was applied to evaluate the normality of quantitative variables.To compare the means of percentage regarding the knowledge about BF and SF by professional training, the Kruskal Wallis test was used with Tukey post hoc test.
Regarding the analysis of hits on knowledge of professionals of the ESF in promotion of BF and SF, the recommendations of the guidebook "Child health: breastfeeding and complementary feeding", of the Brazilian Ministry of Health (15) were set as parameters.
To study the dependency between proportions of quantitative variables (age and service time), they were set as bicategorical, having as basis the median of results, because it is a central measure that is not distorted by high and low values; on the other hand, independent categorical variables with more than one category (education and profession) had the bicategorization set through Hosmer-Lemeshow test, which is based on the division of the sample into estimated parameters.As for the classification on the level of knowledge of professionals working in the Primary Health Care, the frequency of responses of all professionals about each aspect addressed of the variables of knowledge about BF and SF were considered.Criteria for classification were: good knowledge, when the percentage of hits ranged between 80% and 100%; average, between 50% and 79.9%; and poor, below 50% (13) .
For the response variable on level of knowledge, the Chi-square test or the Fisher's exact test (if required) was used to study the dependence.Explanatory variables analyzed were categorized as follows: age (≤40 years and >40 years); sex (male and female); service time (<15 years and ≥15 years); education (≤ high school and > high school); occupation (nursing technicians + community health agents and doctors + nurses); provides healthcare on BF (yes and no); had training/preparation on BF (yes and no); knows the Brazilian Breastfeeding and Feeding Strategy (EAAB -Estratégia Amamenta e Alimenta Brasil) (yes and no).Data were analyzed by the contingency coefficient (CC) to study the association between the level of knowledge and the variables for sociodemographic factors and professional training, according to the nature of the questions (BF and SF).Therefore, an α=0.05 was set for all statistical tests as level for nullity rejection between associations.

RESULTS
A total of 168 ESF professionals participated in the study, being 112 (66.67%) community health agents (CHA), 19 (11.31%) nursing technicians, 20 (11.90%) nurses and 17 (10.12%)doctors.From the respondents, 87.50% are female and 12.50% are male, with age ranging between 23 and 63 years.Considering the total service time, a predominance of professionals with over 10 years of occupation (71.43%) was noted.With regard to the respondent's educational level, 53.57% completed high school and 46.43% had higher education (Table 1).To be continued Table 2 describes the means and medians of the percentage of hits in relation to ESF professionals' knowledge about BF and SF.Regarding the knowledge of breastfeeding, there was statistical difference between the means of percentages of hits of compared to the CHA (p=0.01).Among nurses the hit ratio was 83%, higher than the CHA (71.8%).In relation to the supplementary feeding, a statistically significant difference was noted between the means of proportion of hits of nursing technicians and CHA (p<0.01).For nursing technicians, the mean of hits was 64.4%; as for CHA, this proportion was only 54.9%.Considering the other categories, the means of proportions of hits was similar.It must be emphasized that, when the knowledge about BF was compared to the SF for each professional category, a statistically significant difference was noted between the means of hits, because all categories had higher mean of hits for BF compared to SF (Table 2).Table 3 shows the results of the analysis of association between level of knowledge about breastfeeding and variables of sociodemographic factors and professionals' training.It is noted that there was significant statistical association between professionals' level of knowledge and variables: education level (p=0.04),i.e., professionals who had education beyond high school had higher level of knowledge; occupation (p=0.05), in which doctors and nurses had better level of knowledge about BF than other professionals in the Primary Health Care team; and those who provide assistance in BF to lactating mothers have a better level of knowledge of BF (p=0.04).According to the contingency coefficient (CC) values, these three variables had moderate association (0.1 to 0.3) with the performance of participants of the study.

DISCUSSION
The analysis of knowledge about BF and SF of professionals working in the ESF showed a better performance on issues of BF in relation to SF.This finding is a matter of concern, since healthcare professionals must be prepared and trained to monitor the process of breastfeeding and introduction of supplementary foods, growth and development of the child, especially in the first two years of life, both in individual appointments and home visits.In addition, they must guide the women and their families with regard to the access to other services and support groups related to breastfeeding and supplementary feeding.
Furthermore, mothers need active and emotional support, as well as precise information, to feel confident.The healthcare professional must understand what kind of support, information and interaction the mothers desire, need or expect from him/her (16) .
In this sense, EAAB stands out as an important tool to aid achieving the goals regarding BF and SF.This strategy was prepared by the Brazilian Ministry of Health, in 2012, and it is the main program focused on preparing the professionals working in the Primary Health Care for BF and SF.The program was launched with the purpose of training healthcare professionals based on participatory activities that allow exchange and acquisition of knowledge, taking into account the local reality to directly influence the breastfeeding indicators (17) .About this strategy, the knowledge of professionals was identified as insufficient, which reinforces the need for more information.
The knowledge of healthcare professionals proved to be associated with important variables of training and performance, in especial with the education level.Thus, this study showed that the higher the educational level, the better are the professional's conditions of incorporating new knowledge and abilities to assist the families under his/her responsibility.
This result may be related to the large number of professionals without higher education, as the CHA in the sample of our study.The emergence of Primary Health Care established the ability of reading and writing as minimum education criterion, without demanding a more technical and scientific knowledge based on the needs of people closer to and from the community.However, this may impair the performance of Primary Health Care, since a previous research has identified that, in relation to nutrition and feeding, CHA have insufficient knowledge to face the problems of their routine, presenting difficulties ranging from the practice of breastfeeding and supplementary feeding until the insufficient knowledge about which foods the child can consume in the first year of life.It is worth mentioning that this same research showed that CHA with higher education had higher ease in executing their duties (18) .This finding reinforces the need for permanent education of professionals working in the Primary Health Care, regardless of their educational level, aiming at enabling the theoretical basis of their actions, making the latter more effective in the promotion of breastfeeding.On this matter, a study conducted in southern Brazil identified that the preparation in BF increased the hit scores of professionals compared with those who had no preparation (19) .
The scientific literature is categorical when stating that permanent education is a strategy to enhance the knowledge and practices aimed at management and care on feeding and nutritional actions, creating an opportunity to contribute to the reversal of the organizational logic based only on the disease.Permanent health education can guide the transformation of health promotion practices, aiming at changing the hegemonic conception of the biomedical model to a constructivist and problematizing conception, which favors the subject's participation in the actions of health and social mobilization (19)(20) .
There is the need of better preparing healthcare professionals to work the actions of feeding and nutrition through constant training and continuous monitoring of these actions, identifying difficulties and providing conditions to overcome them, leading to their full development (21) .
The team planning of actions is important because it will directly influence the achievement of goals and, consequently, the improvement of the quality of service provision.To this end, the health education planning must not to be individualized because the integration of management, healthcare professionals and community, is crucial and uses varied tools and resources (22) .
To assist the collective approach of promotion practices for proper and healthy feeding by healthcare professionals, the Brazilian Government has recently launched an instrument aiming at supporting the planning and development of these actions in Primary Health Care.The project includes proposals of methodologies, in addition to the theoretical and practical basis for their development, as well as the publication of manuals and ordinances that address the principles and recommendations on BF and SF (23) .
Therefore, there is need for enabling courses and training programs that qualify these professionals on BF and on SF, especially.To this end, actions of permanent health education are suggested, in a constant promotion process as well as full and contextualized development of teams.On this matter, the implementation of EAAB in the municipality is recommended to qualify the professionals' working process and to strengthen the actions of promotion, protection and support to breastfeeding and supplementary feeding of children under two years old in the context of Primary Health Care.In addition, it can contribute to the improvement of indicators for breastfeeding and supplementary feeding.

Study limitations
This study presents some limitations.The main limitation is related to the methodological design used, of cross-sectional type, which does not allow to evaluate causal relations, as well as exposure and outcome related to the knowledge learned.Still, the fact that our research was held in a single municipality restricts the generalization of results.We also emphasize the possibility of information bias, since that, when acknowledging the research, the participants could have searched the correct information to avoid negative judgment.
Contributions to the fields of nursing, health, or public policy The nurse must be sensitive to his/her role with the woman during the pregnancy and puerperal cycle and; also, after patient discharge, the healthcare professional must assist the mother in the process of breastfeeding adaptation, thereby avoiding doubts, misunderstandings and other complications.As a member of the multidisciplinary health team, the nurse must perceive deficiencies and solve them when possible, contributing to a performance based on knowledge and skill focused on the mother and child (6)(7) .

Table 2 -
Mean and median of the percentage of knowledge about breastfeeding and supplementary feeding according to the training of professionals in the Family Health Strategy (ESF -Estratégia Saúde da Família), Picos, Piauí, Brazil, 2016 Note: probability value of Kruskal-Wallis test.P-values for differences of means byTukey's test: *0.02.+ 0.003.#0.012.**95%CI: Confidence interval of the mean.

Table 3 -
Bivariate analysis between level of knowledge about breastfeeding and variables of sociodemographic factors and training of professionals in the Family Health Strategy (ESF -Estratégia Saúde da Família), Picos, Piauí, Brazil, 2016 To be continued

Table 4
displays the association between sociodemographic and training variables with the level of knowledge about BF in 168 healthcare professionals.According to the CC, the variable for educational level had strong association (CC=0.34)withhighlevel of statistical significance (p<0.01);professionalswho had educational level beyond high school had better level of knowledge and those who provided BF health care to lactating mothers have better level of knowledge about BF.This variable had moderate association (CC=0.19)with significant p-value (p=0.04).

Table 4 -
Bivariate analysis between level of knowledge of breastfeeding and variables for sociodemographic factors and training of professionals in the Family Health Strategy (ESF -Estratégia Saúde da Família), Picos, Piauí, Brazil, 2016 Note: ¹Measure of association, with reference: n≤0.1: weak or nonexistent association; n=0.1 to 0.3: moderate association; n≥0.3: strong association; ²P-values for the Chi-square test with significance level α≤0.05; *The percentage of professionals was calculated in proportion to the total number of respondents by category in the table.Note: ¹Measure of association, with reference: n≤0.1: weak or nonexistent association; n=0.1 to 0.3: moderate association; n≥0.3: strong association; ²P-values for the Chi-square test with significance level α≤0.05; *The percentage of professionals was calculated in proportion to the total number of respondents by category in the table.

Table 3 (
concluded)Knowledge of healthcare professionals about breastfeeding and supplementary feeding Ramos AE, Ramos CV, Santos MM, Almeida CAPL, Martins MCC.