The Evaluation of Training for Health-Care Professionals and Community Leaders Regarding 6-Month Exclusive Breastfeeding in Northeast Thailand

Abstract

To address the reduction of the 6-month exclusive breastfeeding (EBF) rate in Northeast Thailand, a 3-year 6-month EBF intervention model was developed using concept mapping. A training for health-care professionals and community leaders was prioritized as the initial intervention. The aim was to assess the feasibility of the training intervention and its potential to improve 6-month EBF knowledge. A pre- and posttest, and an open question were conducted. Data were analyzed using t tests and thematic analysis. For the 17 health-care professionals and community leaders who participated, the mean 6-month EBF knowledge scores improved significantly from 5.28 to 10.21 (p value < .01). It is recommended that this workshop could be duplicated and scaled up in other regions across Thailand to standardize care.

INTRODUCTION

In Thailand, a significant drop in the 6-month exclusive breastfeeding (EBF) rate has been found, especially in Northeast Thailand where the rate decreased from 26.9% in 2009 to 13.8% in 2013 (National Statistical Office Thailand [NSO], 2010; 2013) Globally, many types of interventions have been conducted to increase the 6-month EBF rate. Examples include health-care professionals providing an EBF education program to mothers (Aksu et al., 2011); providing opportunities for maternal support, for instance, consults about prenatal and postnatal lactation (Bonuck et al., 2006), professional support by telephone (Bonuck et al., 2006; Rasmussen et al., 2011), video conference (Friesen et al., 2015), face to face (McDonald et al., 2010), or during home visits (Bonuck et al., 2006). In addition, interventions have been conducted in different settings: hospital-based (Forster et al., 2004), community-based (Kronborg et al., 2007; Lenell et al., 2015), or both (Gijsbers et al., 2006); and conducted at different stages of a mother's experience: prenatal (Mattar et al., 2007), postnatal (Gijsbers et al., 2006), both (Bonuck et al., 2006). Interventions can be short-term (Lavender et al., 2005) or long-term (Kronborg et al., 2007).

To address the reduction of women breastfeeding exclusively for 6 months in Northeast Thailand, a 3-year intervention model was developed using concept mapping (Thepha et al., 2018a). This intervention model comprised 15 interventions, and to begin the implementation process one of these interventions, namely a workshop for maternity professionals, was prioritized. The selected intervention was developed into a 6-month EBF training workshop for health-care professionals and community leaders in Northeast Thailand and piloted. The aim of this pilot was to assess the feasibility of this training intervention and its potential to improve the 6-month EBF knowledge of participants.

METHODOLOGY

Design

The curriculum for the training was developed based on the underpinning research (Thepha et al., 2018a) and covered five main areas: (a) general knowledge of 6-month EBF (advantages of human milk; how to stimulate human milk; the anatomy of the breast; the importance of maternal diet, rest, hydration, and health; how to evaluate the amount of human milk received by the infant; referral of mothers who have breastfeeding problems); (b) how to hold baby (for mothers experiencing normal labor/cesarean surgery), how to “latch on,” how to evaluate LATCH score (assessment tool to evaluate the effectiveness of breastfeeding), and how to express human milk; (c) how to store human milk/how to feed baby (cup feeding/defrosting human milk); (d) how to solve breast problems such as short/flat/inverted nipple and breast engorgement; and (e) social media support opportunities (Figure 1). Each topic area was addressed in a different “station” at the workshop.

Figure 1. The five stations of health-care professionals and community leaders regarding 6-month EBF in Northeast Thailand training.

The first station took the form of a morning plenary session for all participants and lasted 2 hours. The remaining stations were practical sessions (demonstration and practice) which each lasted 40 minutes and were led by midwifery experts with at least 10 years' experience. Participants were requested to complete the 30-minute pretest at the start of the workshop to form a knowledge baseline. At the end of the workshop, the posttest was administered. Following the posttest, the experts, participants, and research team were asked about the effectiveness of the training via an open question: “Could you please provide and feedback to the 6-month EBF training for health-care professionals and community leaders?”

Learning resources provided to each participant included a 6-month EBF passport, a breast model, and a baby doll. The 6-month EBF passport was a personal notebook designed to provide all the information covered in the plenary and practical sessions, as well as to record the activities performed by each participant. The baby dolls and breast models were made from towels, cotton, and stockings, and were used by the participants to practice how to hold a baby during breastfeeding.

Setting

This study was conducted at Pralub Primary Hospital in Khonkaen, Northeast region, Thailand. A pre- and posttest experimental design was used.

Sample

Participants were recruited via purposive sampling and included health-care professionals, community leaders, and health-care volunteers who provided maternal services in Pralub District, Khonkaen, Thailand. As the literature indicates that 10–30 participants are sufficient for a pilot study (Belle, 2002; Hill, 1998; Issac & Michael, 1995; Julious, 2005), 45 participants (7 health-care professionals in Pralub hospital, 5 heads of villages, 5 assistant heads of villages, and 25 health-care volunteers from five villages) were invited to the training. The lists of participants were initially identified by health-care professionals in Pralub primary hospital. After the lists of participants were identified, invitation letters and participant information sheets were sent to participants at least 1 month prior to the event by the researcher. A consent form was provided to willing participants and signed on the day of the training. Ethical approval was granted by the College Ethics Review Board (CERB), University of Aberdeen (No. CERB/2016/11/1403).

Measurement

The pre–post 6-month EBF knowledge test is an instrument to measure the 6-month EBF knowledge of participants. It was developed based on the information provided in the workshop by the research team. It included seven questions: (a) the definition of EBF, (b) the advantages of EBF, (c) the hormones stimulating human milk, (d) other factors relating to the stimulation of human milk, (e) how to evaluate the quantity of human milk received by infant, (f) how to store human milk, and (g) how to solve breast problems. There were four open-ended questions and three true–false questions. The maximum total score was 14 (2 points per question). Content validity was conducted by the researchers who had midwifery experience of more than 10 years.

Participants' characteristics (gender, occupation) were analyzed using descriptive statistics. Differences in the mean total scores of 6-month EBF knowledge and mean total scores of each question were analyzed by dependent (paired sample) t test to evaluate the improvement in participants' knowledge. The p value < .05 was considered statistically significant and SPSS version 24 was used. Thematic analysis was applied to the results from the open question.

To evaluate the 6-month EBF training workshop for health-care professionals and community leaders in Northeast Thailand, the Kirkpatrick model (Kirkpatrick Partners, 2017; Mindtools, 2017), which is an international standard to evaluate the effectivity of training, was applied. This model included four levels which are reaction, learning, behavior, and results (Kirkpatrick Partners, 2017; Mindtools, 2017). Reaction level is the first level which shows that participants find the training favorable, engaging and relevant to their jobs. Second, learning level shows that participants acquire the intended knowledge, skills, attitude, and confidence based on their participation in the training. Third, behavior level shows how participants apply their new knowledge in real situations. The fourth level, results, shows final outcomes.

RESULTS

There were 17 participants, all women, of which the majority (82%) were health-care volunteers, 2 (12 %) were community nurses, and 1 (6%) was a community leader.

The mean 6-month EBF knowledge scores improved significantly from 5.3 at baseline to 10.2 at follow-up (p < .001 t = −10.229, degrees of freedom [df] = 16). The posttest mean scores of each question improved and four questions (3, 5, 6, 7) showed significantly higher scores than achieved in the pretest (Figure 2). Before the training participants showed the best level of knowledge about stimulating breastmilk (4th question) with 64.7% responding correctly, and this increased to 85.3% after the training. The sixth question: “How do we store breastmilk?” exhibited the lowest score with only 8.8% correct pretraining but showed the largest improvement in average score to finish at 79.4% in the posttest. The lowest average score in the posttest, “How do we evaluate the amount of breastmilk?” (fifth question) was 58.8%. By contrast, the fourth question: “How can we stimulate human milk?” displayed the highest score of 85.3%.

Figure 2. The difference of mean 6-month EBF knowledge scores of each question.

Four themes emerged about the workshop: it enabled participants to gain knowledge about 6-month EBF, it was considered practical and feasible for health-care volunteers to participate and for organizations to run training offered by experts in the field. Regarding the first theme, most participants reported that they had gained the right knowledge with regards to EBF, especially in terms of how to feed a baby, how to store breastmilk, and how to solve breast issues.

I got actual knowledge about EBF—especially on how to feed a baby and how to solve breast problems. (ID10)

I now know how to properly store human milk. (ID5)

I will take this knowledge and distribute it and use it with mothers in my community.

The workshop was considered practical in terms of its duration and can lead to more self-efficacy in the participant.

I have gotten more confidence in terms of taking care of mothers. (ID7)

This workshop is practical. I can apply these practices to my community. (ID3)

The time of workshop was not too long. It [had good] time management. (ID4)

Respondents were pleased that the workshop was offered by experts who had sufficient 6-month EBF knowledge and experience.

I was impressed with the team of experts. They have enough capability and more experience to transfer six-month EBF knowledge. (ID2)

I would like to express my gratitude to the team of experts. They are expert in breastfeeding. (ID17)

The feasibility, the relevance, duration of the training process, and the expenditure were evaluated by presenters/organizers. One of the four experts who ran the workshop stated that:

This workshop was desirable for Northeast Thailand based stakeholders and was appropriately developed from the specific facilitators and barriers to 6-month EBF in the region. (Expert 1)

The whole process of developing the six-month EBF training took approximately a month from outset to completion. However, it took only one day to run this workshop which fits into busy schedules of health professionals and community leaders. (Researcher 1)

Total expenditure amount for the entire process was £389.90 (THB 17,328). The learning resources included the doll, breast model, and accessories cost less than a hundred Pounds or THB 4,362. (Researcher 1)

DISCUSSION

This study aimed to pilot one of the prioritized interventions from a strategy to improve 6-month EBF: a 1-day workshop to improve the knowledge of health-care professionals and community leaders in Northeast Thailand. The results show that this training has potential to increase the 6-month EBF knowledge of health-care professionals and community leaders, and moreover could be an approach that is both practical and feasible.

This workshop also appears to have achieved the first two levels of the Kirkpatrick model, which are reaction and learning. Giving a positive reaction, participants agreed that the workshop improved their EBF knowledge and they were impressed with both the expert team and the workshop overall. For the learning level, it seems that participants acquired the intended knowledge, skills, attitude, and confidence based on their participation in the training. Thus, the findings of this study are that the 6-month EBF training intervention has the ability to increase EBF knowledge with regards to 6-month EBF among health-care professionals and community leaders in Northeast Thailand. This knowledge can guide and foster participants' confidence in taking care of mothers appropriately as they apply the knowledge in their communities. In each area of knowledge, the participants improved and in four areas the difference in score was significant. The most successful topics were how hormones stimulate human milk, how to evaluate human milk, how to store human milk, and how to solve breast problems. The three remaining areas, the definition of 6-month EBF, the advantages of EBF, and how to stimulate human milk, may require further development. Participants were impressed with the team of experts and wished to see a continuation of the workshops, as well having other health-care professionals conduct the workshops. Therefore, 6-month EBF training workshop for health-care professionals and community leaders in Northeast Thailand can achieve the second level of the Kirkpatrick model.

For the behavior and result level, the effect of the training is unknown as the study was not able to measure whether participants applied their new knowledge in their practice. These results are similar to other studies. For example, in the United States, the “BreastfeedingBasics” web-based education and online continuing education program has been shown to increase the knowledge competencies of health-care professionals in the United States (Edwards et al., 2015; Lewin & O'Connor, 2012). The U.S. breastfeeding committee added lactation education and training into the licensing and certification process in the country in order to address the low numbers of health-care professionals (Theurich & McCool, 2016). Likewise, in Hawaii, more than 750 staff and health-care professionals from the Baby-friendly Hawaii Project Hospital attended EBF training which was shown to improve Hawaii's maternity practices in infant nutrition and care scores (Kahin et al., 2017). A study by Sigman-Grant and Kim (2016) tested a 90-minute breastfeeding workshop for pediatric staff, family practice staff, obstetric residents, physicians, nurses, as well as nursing and medical students. Results showed that the knowledge scores of physicians and nurses were significantly higher than the baseline scores (Sigman-Grant & Kim, 2016).

In this study the training was developed from specific barriers and facilitators to 6-month EBF identified in Northeast Thailand (Thepha et al., 2017; Thepha et al., 2018a; Thepha et al., 2018b; Thepha et al., 2018c). So, this training had relevance to the local situation, as other “bottom-up” approaches that develop interventions using local information do (Deleon & Deleon, 2002; Weinstock-Zlotnick, 2004). Many EBF interventions have been conducted in long time periods (Bonuck et al., 2006; Khresheh et al., 2011; Kronborg et al., 2007; Pugh et al., 2002) or in short time periods (Aksu et al., 2011; Forster et al., 2004; Lavender et al., 2005). A systematic review regarding EBF interventions recommended that long-term interventions tend to succeed more than short interventions. However, the duration of this training is only a day in order to suit the busy schedule of health-care professionals and community leaders in this local area. The financial expenditure of this training included learning resources and refreshments and cost less than £400 for about 20 participants, which makes it affordable.

STRENGTHS AND LIMITATIONS

The main strength of the study is that the training was developed from the wishes of local people, and these, in turn, were identified using local facilitators and barriers to 6-month EBF in Northeast Thailand. Hence, it directly responded to and suited the Northeast Thailand situation. As a limitation, this training may not fit with other communities and all participants were female. In addition, the training follow-up process was only a day. It is recommended that this training could be further developed, duplicated, and scaled up in other regions across Thailand, to standardize care and ultimately impact the rate of EBF for 6 months as part of the complex intervention model.

CONCLUSION

The 6-month EBF knowledge scores after completing a 6-month EBF training were significantly higher than the baseline and this training provided 6-month EBF knowledge, professional experts, and was deemed practical and feasible by participants. It is recommended that this training workshop be considered as part of the maternity care policy in Northeast Thailand, and be scaled up to other regions across Thailand, to standardize care to increase the 6-month EBF knowledge of health-care professionals and community leaders. Research should continue following up on the 6-month EBF rate in Northeast Thailand for at least 6 months. Lastly, men ought to be included as participants and, the instruments should be tested for reliability and the workshop should be reconducted regularly.

Biographies

THIWAWAN THEPHA is a Lecturer, Department of Midwifery, the Faculty of Nursing, Khonkaen University, Thailand.

DEBBIE MARAIS is Postgraduate Academic Lead, Warwick Medical School, University of Warwick, United Kingdom.

JACQUELINE BELL is a Research Fellow, Immpact, University of Aberdeen, United Kingdom.

SOMJIT MUANGPIN is an Assistant Professor, Department of Midwifery, Faculty of Nursing, Khonkaen University, Thailand.

DISCLOSURE

The authors have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.

FUNDING

The author(s) received no specific grant or financial support for the research, authorship, and/or publication of this article