Examining Exclusive Breastfeeding Practice in Indonesia, and its Association to Maternal Socio-demographic Determinants, to Inform Intervention Efforts Aimed at Reducing Infant Mortality Introduction Exclusive breastfeeding, the gold standard of infant feeding practices, has been identified as the single most effective strategy to improve child survival. However, this recommendation is not highly practiced in Indonesia, while Indonesia’s infant and under five mortality is still high. Interventions to promote, protect, and support breastfeeding practice are critical public health needs in Indonesia. Aim The current study examined socio-demographic factors associated with exclusive breastfeeding practice in Indonesia: whether maternal age, level of education, occupation status, wealth index, and region of residence, as well as breastfeeding initiation are associated with exclusive breastfeeding practice in Indonesia for mothers having infants up to age five months. Methods This study analyzed 1695 women having infant aged 0-5 month old data from the 2012 Indonesia Demographic Health Survey. Chi-square test was used for preliminary analysis and logistic regression analyses were used to primary analysis by using SAS 9.4 program. Results Exclusive breastfeeding practice in Indonesia was low (36.1%). Mothers aged 30-39 years old were more likely to exclusively breastfeed compare to mothers under 20 years old (OR=1.56, 95% CI 1.04-2.35). Mothers with high education level had higher odds to exclusively breastfeed compare to low education mothers. Unemployed mother were more likely to exclusively breastfeed than working mothers (OR=1.65, 95% CI 1.28-2.13). Mothers coming from richer wealth index were less likely to exclusively breastfeed compare to mothers having poorest wealth index (OR= 0.49, 95% CI 95% 0.34-0.72). Those who initiated breastfeeding early had increased odds to exclusively breastfeed than mothers who delayed breastfeeding initiation (OR=1.47 95% CI 1.19-1.83). Finally, mothers who lived in Eastern Indonesia were more likely to exclusively breastfeed compare to mothers who lived in Sumatera and Kalimantan (OR=1.82, 95% CI 1.30-2.55). Conclusion This study found characteristics of Indonesian mothers who were more likely to exclusively breastfeed compared to the reference group: aged 30-39 years old, high education level, unemployed, richer wealth index, and those who live in Eastern Indonesia; as well as, mother who initiate breastfeeding early. Having tailored strategies and interventions to targeted at-risk populations may increase the likelihood of exclusive breastfeeding practices, and ultimately, decreasing infant mortality rates in Indonesia.

Background: Celiac disease occurs worldwide in approximately 1% of the population, whereof the majority of cases are undiagnosed. Sweden experienced an epidemic (1984-1996) of clinically detected celiac disease in children below 2 years of age, partly attributed to changes in infant feeding. Whether the epidemic constituted a change in disease occurrence and/or a shift in the proportion of diagnosed cases remains unknown. Moreover, the cause of the epidemic is not fully understood. Objective: To increase the knowledge regarding the occurrence of celiac disease in Sweden, with focus on the epidemic period and thereafter, as well as the etiology of celiac disease in general, by investigating the Swedish epidemic and its potential causes. Methods: We performed a two-phased cross-sectional multicenter screening study investigating the total prevalence, including both clinically- and screening-detected cases, of celiac disease in 2 birth cohorts of 12-year-olds (n=13 279): 1 of the epidemic period (1993) and 1 of the post-epidemic period (1997). The screening strategy entailed serological markers analyses, with subsequent small intestinal biopsy when values were positive. Diagnosis was ascertained in clinical cases detected prior to screening. Infant feeding practices in the cohorts were ascertained via questionnaires. An ecological approach combined with an incident case-referent study (475 cases, 950 referents) performed during the epidemic were used for investigating environmental- and lifestyle factors other than infant feeding. Exposure information was obtained via register data, a questionnaire, and child health clinic records. All studies utilized the National Swedish Childhood Celiac Disease Register. Results: The total prevalences of celiac disease were 2.9% and 2.2% for the 1993 and 1997 cohorts, respectively, with 2/3 cases unrecognized prior to screening. Children born in 1997 had a significantly lower celiac disease prevalence compared to those born in 1993 (prevalence ratio, 0.75; 95% confidence interval [CI], 0.60-0.93). The cohorts differed in infant feeding; more specifically in the proportion of infants introduced to dietary gluten in small amounts during ongoing breastfeeding. Of the environmental and lifestyle factors investigated, no additional changes over time coincided with the epidemic. Early vaccinations within the Swedish program were not risk factors for celiac disease. Early infections (≥3 parental-reported episodes) were associated with increased risk for celiac disease (adjusted odds ratio [OR] 1.5; 95% CI, 1.1-2.0), a risk that increased synergistically if, in addition to having ≥3 infectious episodes, the child was introduced to gluten in large amounts, compared to small or medium amounts, after breastfeeding was discontinued (OR 5.6; 95% CI, 3.1-10). Early infections probably made a minor contribution to the Swedish epidemic through the synergistic effect with gluten, which changed concurrently. In total, approximately 48% of the epidemic could be explained by infant feeding and early infections. Conclusion: Celiac disease is both unexpectedly prevalent and mainly undiagnosed in Swedish children. Although the cause of the epidemic is still not fully understood, the significant difference in prevalence between the 2 cohorts indicates that the epidemic constituted a change in disease occurrence, and importantly, corroborates that celiac disease can be avoided in some children, at least up to 12 years of age. Our findings suggest that infant feeding and early infections, but not early vaccinations, have a causal role in the celiac disease etiology and that the infant feeding practice – gradually introducing gluten-containing foods from 4 months of age, preferably during ongoing breastfeeding – is favorable.

Introduction and Rationale: Childhood obesity is a public health epidemic in the United States. Prevention of childhood obesity is an important health concern, but there is a lack of prevention efforts focused on infancy (Birch, Anzman-Frasca, & Paul, 2012). Many health behaviors are learned in the very early childhood years (Dattilo et al., 2012), so infancy is an opportune time to begin obesity prevention efforts (Grote, Theurich, & Koletko, 2012; Paul et al., 2011). There are very few resources available to educate mothers and caregivers of infants on protective infant feeding practices to reduce obesity risk. Purpose and Objective: The purpose of this DNP project is to develop educational material about infant feeding practices as a significant modifiable risk factor for the development of childhood obesity. The educational material is directed towards pregnant women and caregivers of infants less than 12 months of age. The objective is to educate parents and caregivers about infant feeding practices and the importance of preventing excessive weight gain during the first year of life for the prevention of childhood obesity. Methods: The Information-Motivation-Behavior (IMB) Model of Health Behavior serves as a framework for the content of the educational material. The Toolkit for Making Written Material Clear and Effective serves as a guide for the design of the educational material. Results: A systematic assessment of the educational material was conducted using the Patient Education Materials Assessment Tool (PEMAT), a validated evaluation tool. The educational material was revised based on the PEMAT score. The PEMAT score was calculated for the revised handout and the handout is presented as an educational tool for the prevention of childhood obesity. Conclusions: This DNP Project demonstrated childhood obesity as a current significant health problem and identified infant feeding practices as a significant modifiable risk factor for the development of childhood obesity. Due to a lack of obesity prevention efforts focused on infancy, educational material was created using the IMB model of health behavior and the Toolkit for Making Written Material Clear and Effective. The final PEMAT evaluation yielded educational material that will likely have a positive health influence on the pediatric population.

Magister Public Health - MPH / Background: Mother to child HIV transmission is a significant public health problem especially in Southern Africa. South Africa is the second highest burden country globally with 71 000 infants being HIV infected every year. The aim of this study was to identify and measure the influence of risk factors of late postnatal HIV transmission and/or mortality among infants born to HIV positive mothers. Study design: Historical cohort data collected during 2002 – 2004 from 3 purposively selected PMTCT sites in South Africa (namely: Rietvlei, Umlzai and Paarl) is used. These three sites are purposively selected to reflect different HIV prevalence, socioeconomic and geographical locations. A total sample size of 469 mother–infant pairs were followed for 36 weeks. Data Collection: Data were collected by trained field researchers and community health workers using semi-structured interviews including: infant feeding practices, infant and maternal mortality, disclosure of HIV status, basic knowledge of HIV/AIDS and MTCT and sociodemographic information. Dried blood spots were collected by heel prick in the baby at 3, 24 and 36 weeks, whilst in the mother finger prick was taken at 3 and 36 week visits. Data Analysis: Data from all questionnaires were coded, captured and cleaned. STATA version 10 is used to analyze and measure the independent influence of risk factors of HIV-free survival rate. Variables found having significant association in the bivariate analysis were analyzed using Cox-proportional hazard model. Result: Our study shows that early mixed feeding is a common practice in South Africa. Overall, 83% (as high as 90.26% in Rietvlei) of mothers were either mixed breast feeding or mixed formula feeding before the infant is at age 5 weeks. MBF at 7 weeks was associated with 3.5 fold increased risk of transmission and/or mortality as compared to EBF (p-value=0.22), while PBF had a 2 fold less hazard of transmission and mortality compared to MBF (p-value=0.1). In this study, failure to disclose, poor counselling and lack of close support by health facilities were major factors that contributed to inappropriate feeding choice and non-compliance to exclusive feeding. Poor counseling (below the average of expected level) had an associated 55% increased risk of transmission and/or mortality. A substantial proportion (70.61%) of women in our study didn’t disclose their status to anyone. Failure to disclose was associated with 44% of increased risk of transmission and mortality. The study also showed households who had shortage of food were at increased risk (adjusted hazard ratio 1.7) of HIV transmission and/or mortality of infants. Maternal and infant factors such as premature birth, maternal viral load, poor weight gain during pregnancy and low birth weight were significant influential factors of HIV-free survival rate. Conclusion: In general, this study has given us an idea that postnatal HIV-free survival is determined by the interrelated effect of multilevel co-factors. Therefore, comprehensive multi-sectorial approach is needed to address the MTCT and child mortality problem in South Africa. The health sector should take urgent action to improve the quality of counselling and health services given in health facilities. Government should give enough attention to reduce the bureaucratic hassles of receiving grant by HIV positive mothers.

Magister Public Health - MPH / Background: Appropriate and adequate infant feeding practices are an important factor in achieving optimal health in infants. Inappropriate and inadequate infant feeding practices contribute significantly to ill-health in infants. Both WHO and UNICEF recommend exclusive breastfeeding for the first six months both in the context of HIV and otherwise unless exclusiv formula feeding can meet each of five conditions: acceptable, feasible, affordable, sustainable and safe (AFASS). The modes of infant feeding include exclusive breastfeeding, formula feeding and mixed feeding. Medical recommendations and social pressures related to infant feeding in high HIV-prevalence low-income communities may have shifted infant feeding practices. The aim of this study was to explore factors influencing infant feeding practices and decision making among women in one such community, Kabwata Township, in Lusaka, Zambia. Method: An exploratory qualitative study was conducted at Kabwata Health Centre in Kabwata Township in Lusaka, Zambia. Convenient sampling was used to recruit 32 women for focus group discussions and three key informants (two nurses and one social worker) for individual interviews. Verbal consent was received from all participants. Semi-structured interview guides were used to elicit discussion by all participants. Discussions were tape recorded and transcribed verbatim. Thematic data analysis was used to analyze the qualitative data. Results: Most FGD participants reported that they themselves initiated breastfeeding soon after giving birth, but not all of them breastfed exclusively for the first six months, as is currently recommended. The major factors influencing infant feeding included; influence from family and friends, stigma and discrimination, influence from health care providers, practical realities such as maternal employment and poverty, and cultural/traditional practices. Conclusion: While breastfeeding is valued and accepted, most women do not or cannot exclusively breastfeed for six (6) months for various reasons. Paradoxically, the social value of breastfeeding and the knowledge that breast milk can transmit HIV reinforce mixed feeding as the predominant feeding practice. Key informants reported that women attending health care services at Kabwata health centre were encouraged and taught to breastfeed their infants exclusively for six months. There is a need to re-look at the way the women are being encouraged, taught and supported so that the apparent knowledge and acceptance of breastfeeding can translate into improved infant feeding practices. Awareness campaigns need to include all stakeholders including family members, the community, employers and the women themselves in order to make exclusive breastfeeding easier for the women.

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Mothers living with HIV (MLHIV) face complex challenges regarding infant feeding practices, which often restrict their ability to adhere to their chosen or medically recommended feeding behaviors. Mothers-in-law (MIL) enjoy significant influence and participate actively in the rearing of grandchildren in Cameroon. However, the extent to which MIL influence infant feeding behaviors of their daughters-in-law have not been studied. The theory of planned behavior (TPB) was used in this phenomenological study to explore how attitudes, subjective norms, and perceived behavioral control influenced infant feeding practices of 9 MLHIV in rural communities of the North West Region of Cameroon. The five steps of data explicitation detailed by Groenewald were used to analyze the data. Findings indicated that MLHIV who were in close contact with their MIL experienced strong influence towards infant feeding practices of their babies. While MLHIV who were practicing exclusive breastfeeding received support for appropriate infant feeding practices, those giving their babies artificial milk were influenced to adopt inappropriate feeding practices, specifically mixed feeding. The study results may be used to promote positive social change by improving on the infant feeding practices of MLHIV. This could lead to a reduction of mother to child transmission of HIV.

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Infant Feeding in HIV in Canada is an increasingly challenging and confusing aspect of clinical care for providers and patients due to differences in recommendations in Canada compared to low income countries. The frequency of breastfeeding occurring in Canada is not documented or known, and is shrouded in stigma because of fear of criminalization or child apprehension in the midst of a culture where ‘breast is best’ messaging dominates. Breastmilk transmission data comes from observational and randomized controlled trials completed in low resource settings, which may not be generalizable to Canadian clinical settings. Previous literature has not explored provider perspectives on this issue, especially in high resource settings. We developed a survey to explore the knowledge, attitudes and practices of adult and pediatric HIV care providers in Canada. This survey explores the provider knowledge levels, risk tolerance and perceived stigma pertaining to infant feeding in HIV. Using exploratory analysis including descriptive statistics and regression modelling, we developed scales on the above listed three subject areas. The overall opinions of providers were that formula feeding should remain the recommendation due to the potential risk to the infant; and that women should be supported to access formula and resources to overcome barriers to formula feeding. Providers varied in their risk tolerance and the degree of stigma they perceived associated with infant feeding for their patients. Providers did not feel that breastfeeding is a criminal matter, but in some circumstances they would consider involving child protection services. Focus group consultation with women living with HIV, provided insight into the experiences, and clinical and research priorities for women living with HIV on infant feeding. A provider meeting was organized to discuss the challenges and resources pertaining to infant feeding in Canada across the provinces. Providers described diverse patient populations with differing needs. Using a World Café model for discussion, priority needs were decided through consensus including the need for knowledge translational resources to convey information to women living with HIV on infant feeding, and the need for evidence based consensus clinical management guidelines was evident. Quantifying the frequency of breastfeeding occurring in Canada by women living with HIV will help to understand how often this issue is encountered. A preliminary qualitative approach to understanding infant feeding issues for women living with HIV using focus groups is described. However, further exploration in a community based approached is needed to explore the needs and challenges faced by families affected by HIV around infant feeding. / Thesis / Master of Science (MSc) / Infant Feeding in HIV in Canada is an increasingly challenging aspect of clinical care. Information on breastmilk transmission comes from studies completed in lower income countries, and this may not be applicable to the Canadian HIV setting. Previous literature has not explored provider perspectives on this issue, especially in high-income countries like Canada. In this knowledge, attitudes and practices survey of HIV care providers in Canada, the main findings were that formula feeding should remain the recommendation due to the potential risk of HIV infection occurring in the baby, however women should be supported to access formula and resources to overcome barriers to formula feeding. Providers do not feel that breastfeeding is a criminal matter, but in some circumstances may consider involving child protection services. We performed community consultation using focus groups to understand some of the issues women face with infant feeding, some of the clinical solutions they would support, and research questions and knowledge translation they would want undertaken. A provider meeting to discuss the challenges pertaining to infant feeding in Canada demonstrated that although populations differ, the need for knowledge translational resources to convey information to women living with HIV on infant feeding was universal. Furthermore, the need for evidence based consensus clinical management guidelines would improve the quality of care provided.