PARENTAL BREASTFEEDING BEHAVIOR AND ATTITUDE QUESTIONNAIRE.

A validated questionnaire is required to evaluate scientifically community-based breastfeeding support and promotion. The aim of this study was to create a valid and reliable questionnaire to measure parents' behavior and attitudes about breastfeeding. The items in the questionnaire were selected by the authors according to regular data from the professional literature, and in consultation with three pediatric lecturers at higher and secondary health education, fellow pediatricians, and parents. A working version of the questionnaire was available on the website of the For a Healthy and Happy Childhood association from February 1, 2019 to May 31, 2019. The study was approved by the Ethics Committee of the Bjelovar General Hospital. After item analysis, 15 behavioral questions that showed good internal consistency were retained. Concerning the attitudes, principal component analysis showed a four-factor structure with 17 items explaining 46.11% of total variance. Cronbach's alpha (0.88) indicated acceptable internal consistency. To analyze the ability of the questionnaire to differentiate parents according to the desired outcome, the χ2-test, correlation and logistic regression were used. In the study, the desired outcome was defined as exclusive breastfeeding for 5 or 6 months, as well as breastfeeding for 12 months or more. In conclusion, the final instrument is reliable and valid for collecting breastfeeding data and evaluating changes in parents' behaviors and attitudes achieved through participation in breastfeeding promotion and support programs. The questionnaire may, in addition to the BIAKQ questionnaire, support professionals and activists involved in breastfeeding to create methodologically well-conceived programs.

Behaviour, Attitudes and Knowledge of Healthcare Workers on Breastfeeding.

The aim of this paper is to determine the current state of behavior, attitudes, and knowledge of health professionals about breastfeeding in Croatia. Data were collected via a breastfeeding behavior, attitudes, and knowledge questionnaire, which has already been validated and used in Croatia. The secondary aim is to identify differences in outcomes of respondents by occupation (nurses versus others health professionals). In the study, 374 health professionals participated (37 males and 337 females). Respondents completed the questionnaire online. Respondents were rarely involved in breastfeeding education. On the behavior scale, the worst answer was given to the question of advising mothers on breastfeeding after 24 months. On the attitude scale, the worst result was achieved in terms of public breastfeeding and the support of the child's father for the breastfeeding mother. Respondents demonstrated the worst knowledge of The International Code of Marketing of Breast-milk Substitutes and the use of medications while breastfeeding. There was no statistically significant difference between the results of respondents in relation to the occupation of the respondents. In the preparation of future breastfeeding education for health professionals in Croatia, particular attention should be given to these issues.

EFFECTS OF A BREASTFEEDING EDUCATIONAL INTERVENTION ON SECONDARY SCHOOL STUDENTS AFTER 6 MONTHS.

Breastfeeding attitudes are already being formed in the years of preadolescence-adolescence, which means that the educational program should be focused on this age group. For this purpose, many authors suggest that school should be used as an established educational institution and therefore they are developing different education programs. The authors offered an educational program adapted to the cultural, sociological, legal, health, and other specificities of the community to which the students belong. A questionnaire on breastfeeding intentions and knowledge was used to measure the long-term effects of education (after 6 months) in 155 students. They were divided into two groups: experimental (n=101, Grammar School students) and control (n=54, Bjelovar High School students) groups. The experimental group underwent breastfeeding education program, while control group did not. The study was approved by the Ministry of Education and Science, and co-operation with schools was approved by the School Ethics Committees. Six months after educational intervention, students in the experimental group had significantly improved their breastfeeding intentions and knowledge compared to baseline measurement (before intervention). However, 6 months after the education, their knowledge and intentions were less positive than shortly after education, as described in a previous report. The authors suggest that a team of experts be gathered to design a structured educational program that would be interesting to secondary school students. This program should also be adapted to students' age and interest.

Development and Validation of a Questionnaire on Breastfeeding Intentions, Attitudes and Knowledge of a Sample of Croatian Secondary-School Students.

BACKGROUND: Validating a questionnaire/instrument before proceeding to the field for data collection is important. METHODS: An 18-item breastfeeding intention, 39-item attitude and 44-item knowledge questionnaire was validated in a Croatian sample of secondary-school students (N = 277). RESULTS: For the intentions, principal component analysis (PCA) yielded a four-factor solution with 8 items explaining 68.3% of the total variance. Cronbach’s alpha (0.71) indicated satisfactory internal consistency. For the attitudes, PCA showed a seven-factor structure with 33 items explaining 58.41% of total variance. Cronbach’s alpha (0.87) indicated good internal consistency. There were 13 knowledge questions that were retained after item analysis, showing good internal consistency (KR20 = 0.83). In terms of criterion validity, the questionnaire differentiated between students who received breastfeeding education compared to students who were not educated in breastfeeding. Correlations between intentions and attitudes (r = 0.49), intentions and knowledge (r = 0.29), and attitudes and knowledge (r = 0.38) confirmed concurrent validity. CONCLUSIONS: The final instrument is reliable and valid for data collection on breastfeeding. Therefore, the instrument is recommended for evaluation of breastfeeding education programs aimed at upper-grade elementary and secondary school students.

BREASTFEEDING INTENTION AND KNOWLEDGE IN SECONDARY-SCHOOL STUDENTS.

- Breast milk makes the world healthier and better. Deaths and suffering of thousands of children and mothers each year could be prevented through universal breastfeeding, along with enormous economic savings. The aim of this study was to examine the knowledge of breastfeeding and intention to breastfeed in third-year secondary school students from various high schools and to make a conclusion on the unique and structured education program on breastfeeding in secondary schools. A total of 252 third-year secondary school students from 4 high schools in Bjelovar, Kutina and Pakrac completed an online questionnaire on the knowledge and intention to breastfeed. The results were presented by descriptive statistics methods. Kruskal-Wallis test was conducted for intention scale and χ2-test for questions about knowledge. Logistic regression was used to predict probabilities of a response. The results showed the responses of students from individual schools to be statistically significantly different in some questions of knowledge and some items of intention of breastfeeding. Insufficient breastfeeding information in schools does not provide a basis to third-year secondary school students to make an informed decision about breastfeeding in adulthood. We propose development and use of a unique structured educational program on breastfeeding for secondary school students.

Adolescents' Knowledge of Breastfeeding and Their Intention to Breastfeed in the Future.

The aim of this paper is to analyze third-year secondary school students' knowledge of breastfeeding and intention to breastfeed their children, based on the results of a questionnaire. The respondents were 154 students (101 female/43 male) of two secondary schools in Bjelovar. The students completed a questionnaire which consisted of 23 questions regarding knowledge and intention to breastfeed. The answers were analyzed statistically and different results were compared by nonparametric tests. About half of the respondents think that both partners should decide on breastfeeding and recognize the role that fathers have in initiating and maintaining breastfeeding. Only 13.64% of the respondents know that breastfeeding is to be done only on demand. Exclusive breastfeeding for 6 months, as recommended by the medical profession, is recognized by 70.13% of the students. The question on how justified is the initiation of formula together with the mother's milk was answered correctly by 29.22% of the students. Secondary school students' knowledge of breastfeeding is insufficient, and schools, families, social communities and other sources of information should share the responsibility for improving this. We consider it necessary to pay more attention to improving students' knowledge of breastfeeding through school curricula.

A Multifaceted Approach to Revitalizing the Baby-Friendly Hospital Initiative in Croatia.

The Baby-Friendly Hospital Initiative (BFHI) was launched in Croatia in 1993. By 1998, 15 of 34 maternity facilities were designated "Baby-Friendly." Introduction of hospital bags, violating the International Code of the Marketing of Breastmilk Substitutes, led to a standstill in the BFHI. The aim of this article is to describe the successful reintroduction of the BFHI in Croatia between 2007 and 2015. After hospital bags were abolished in 2007, UNICEF Croatia undertook an assessment of BFHI implementation. All maternity facilities were invited by UNICEF and the Ministry of Health to join the renewed BFHI. UNICEF materials were translated and training for trainers, assessors, coordinators, and hospital staff held. By June 2015, 30 of 32 (94%) maternity facilities, providing care to 89% of newborns, were Baby-Friendly. Nine maternity hospitals have been renovated and 2 new hospitals have been built. Exclusive breastfeeding rates have risen 16% at 0 to 2 months (from 51% in 2007 to 67% in 2014) and 14% at 3 to 5 months (from 32% in 2007 to 46% in 2014). Fourteen "Breastfeeding-Friendly" primary care practices have been designated, 166 breastfeeding support groups are in operation, criteria for Mother-Friendly care are being piloted in 2 maternity facilities, and "Ten Steps in the Neonatal Intensive Care Unit" are being introduced. The BFHI provides an excellent opportunity for revitalizing breastfeeding protection, promotion, and support in all settings. Recognition and support of the BFHI by the Croatian government was crucial for implementing the BFHI, whereas the marketing practices of the breast milk substitutes industry are an ongoing challenge.

[Chronic disease and health condition prevention in childhood--2nd part: emphases from the 14th Symposium of Preventive Pediatrics]. / Prevencija kronicnih bolesti i stanja u djece--2. dio: naglasci s xiv. Simpozija Preventivne Pedijatrije.

Chronically ill children nowdays in developed countries are more prevalent than before, and thanks to modern therapeutic modalities more children are surviving into adulthood. Increased survival cannot be assumed to be associated with increased quality of life. With the chronically ill child holistic approach is important, which incorporates not only realisation of the highest possible standards in diagnostics and treatment, but also special care for disease prevention. All this is very important in so called integrative approach in the care of a chronically ill child, with the aim of achieving as high as possible quality of life and complete social integration. At the 14th Preventive Pediatrics Symposium, which took place in Skrad, June 1' 2013, from preventive standpoint, the following chronic childhood illnesses were discussed: attention deficit hyperactivity disorder--ADHD, migraine, thyroid gland diseases, leukemia, cystic fibrosis, chronic renal disease, chronic inflammatory liver disease, chronic inflammatory bowel disease, juvenile idiopathic arthritis, and chronic otitis media with effusion. It is emphasized that talking about a disease prevention, there are three levels of it--primary, second- ary and tertiary prevention: how to avoid occurrence of disease, how to diagnose and treat existent disease in early stages, before it causes significant morbidity, and finally how to reduce the negative impact of existent disease by restoring function and reducing disease-related complications--how to improve quality of life of children with chronic diseases. Quaternary prevention describes methods to mitigate or avoid results of unnecessary or excessive interventions of the health system. An important process is also transition of care from child-oriented to adult-oriented care. Adults with chronic health conditions should continue to be evaluated periodically for possible late consequences of their childhood illness and previ- ous medical treatments.

[Chronic disease and health condition prevention in childhood: emphases from the 13th Symposium of Preventive Pediatrics]. / Prevencija kronicnih bolesti i stanja u djece: naglasci s XIII. simpozija preventivne pedijatrije.

Chronic diseases in childhood have become an important priority, especially in developed countries, because of higher prevalence, relatively and absolutely. Besides that, inappropriate procedures a chronically ill child can result in child's growth and development disorder. According to literature data, 15-20% of children have chronic disease with the impact on their physical, mental and emotional status. Disease prevention strategies are described at the primary, secondary and tertiary level: how to avoid occurrence of disease, how to diagnose and treat existent disease in early stages, before it causes significant morbidity, and finally how to reduce negative impact of existent disease by restoring function and reducing disease-related complications - how to improve quality of life of children with chronic diseases. The new term of quaternary prevention describes methods to mitigate or avoid results of unnecessary or excessive interventions in the health system. In this paper the authors present recent attitudes about chronic diseases prevention modalities in childhood, which, at the beggining of the 21st century, have become more intriguing and represent a new challenge for pediatric health care. Thus, from preventive standpoint, the following chronic illnesses are discussed: asthma, malignant diseases, autism, epilepsy, cerebral palsy, tuberculosis, diabetes type 1, congenital heart diseases, arterial hypertension, celiac disease, and eating disorders. These emphases are from the 13th Preventive Pediatrics Symposium, which took place in Skrad, June 2nd, 2012. Further activities are planned with the aim of continuation of health care furtherance for children with other chronic illnesses.

[Newborns with small birth weight in five Croatian regions]. / Novorodencad male porodne mase u pet hrvatskih zupanija.

OBJECTIVE: To determine the frequencies of small birth-weight for gestational age newborns in five Croatian regional maternal hospitals. To analyze the influence of complications and interventions in pregnancies and mother age on births of small-for-gestational age newborns. METHODS: Based on the sample of live births full-term newborns from singleton pregnancies born between January 1st and December 31st, 2000, in five Croatian regions, tables of percentiles were created and selected small-for-gestational-age newborns from them. Infants with congenital malformations, births with incomplete records in hospital database and stillbirths were excluded. Percentage of newborns with complication in pregnancy and with interventions was analyzed by mother age, mode of delivery and by sex. RESULTS: In five Croatian regions 10.9% small-for-gestational-age term newborns were born. Small-for-gestational-age newborns were born more often from pregnancy with complications (p<0.0001), with interventions (p<0.0001) and from teenage mothers pregnancies (p<0.0001). Those infants born with Cesarean Section are more frequent in relation to other newborns (p<0.0001). Observed were lower means of birth-weight, birth-length and head circumference compared to those from control group (p<0.0001). Birth-weight of term small-for-gestational age newborns was statistically lower in cases of pregnancy with complications (p<0.026) and interventions (p<0.028) compared to small-for-gestational-age newborns from regular pregnancy. Varazdin region had the highest percentage of term born small-for-gestational-age newborns (13.8%) and Sibenik region the lowest (5.9%). Birth-weight means on the 10th percentile level were different from published standards of growth in Croatia and foreign countries. CONCLUSION: Each tenth newborn from one population is born with low birth-weight. For some of them we know they came from pregnancies with complications or interventions and from teenage mothers' pregnancies, but for large part of them the cause is still unknown.

Influence of sociodemographic and psychosocial characteristics on breastfeeding duration of mothers attending breastfeeding support groups.

AIM: Duration of breastfeeding, socio-demographic and psychosocial characteristics of the mothers attending breastfeeding support groups were investigated. METHODS: All examined mothers were cared for according to the Baby Friendly Hospital Initiative (BFHI) of the World Health Organization (WHO) and UNICEF. The investigated group of mothers attended a breastfeeding support group (BSG) led by a community nurse and women experienced in breastfeeding without additional training. Data on breastfeeding duration were collected retrospectively by self-reported questionnaire. RESULTS: Of 980 eligible, 393 mothers were included to the study: 210 attended BSG, while 183 did not. The following differences between the two groups were found: time when the decision to breastfeed was made, smoking during lactation and social support while breastfeeding. More mothers in the investigated group continued breastfeeding at least six months postnatal (83.8% vs. 48.1%, P<0.001), with exclusive breastfeeding until the age of three months (56% vs. 23.5%, P<0.001). After logistic regression analysis, the following factors were found to be positively associated with the duration of breastfeeding for at least six months: time when the decision to breastfeed was made, intended duration of breastfeeding and household income. Maternal smoking during pregnancy affected duration of breastfeeding inversely. CONCLUSION: Characteristics which positively influenced the duration of breastfeeding are the time when the decision to breastfeed was made, intended duration of breastfeeding, household income, and smoking during pregnancy. Mothers who attended BSG more often continued breastfeeding for at least six months if they decided to breastfeed after birth, intended to breastfeed for longer than six months, had higher monthly household income and did not smoke during pregnancy.

[Long-term health effects of breastfeeding]. / Dugotrajni ucinci dojenja na zdravlje.

During the last decade there has been increasing interest in possible long-term benefits of breastfeeding for health and development. Most relevant studies published from the second half of 2001 to 2006 suggest that breastfeeding is likely to protect against later obesity, type 1 diabetes, coeliac disease, inflammatory bowel diseases and childhood cancer. Also, breastfeeding seems to have beneficial effects on later cardiovascular risk factors. A positive association between breastfeeding and cognitive development continues to be the most consistent and important effect, whereas the effect of breastfeeding in the prevention of atopy remains controversial. Possible mechanisms which might mediate the protective effect of breastfeeding are considered. Evidence suggests that breastfeeding can to some degree programme future health, although most studies are observational and cannot prove causation. Promotion of breastfeeding is of great importance and may contribute to the prevention of some major health risks at the population level.

The effect of baby friendly hospital initiative and postnatal support on breastfeeding rates--Croatian experience.

The effects of implementation WHO/UNICEF Breastfeeding Hospital Initiative (BFHI) and community postnatal support on breastfeeding rates were examined during and after the breastfeeding promotion campaign in one county of Croatia. Comparison with a control group indicated increase of breastfeeding prevalence in a period of BFHI implementation (1994-1998) - 68% vs. 87% at infant age 1 mo., 30% vs. 54% at 3 mo., 11.5% vs. 28% at 6 mo., and 2% vs. 3.5% at infant age 11-12 mo. (chi-square test, p < 0.05). More considerable increase has been noticed in period 1999-2000 which is characterized by breastfeeding support groups activity: 68% vs. 87% at infant age 1 mo., 30% vs. 66% at 3 mo., 11.5% vs. 49% at 6 mo., and 2% vs. 23% at infant age 11-12 mo. (chi-square test, p < 0.05). Our conclusion is that activities aiming to promote breastfeeding in maternity hospitals have had limited success. They have resulted in satisfactory increase of breastfeeding prevalence in early infant's period, but for far-reaching effect postnatal support is also required.

[Modern approach to hospital care of children]. / Suvremeni pristup bolnickom zbrinjavanju djece.

The article presents children's hospitalization in the Republic of Croatia and in the world, with the accent on contemporary awareness and efforts in humanization of children's hospitalization. First of all, that means shorter children's hospitalization; pledge on the rights of parent's cooperation in medical care and all treatments; reduction of physical and emotional pain of the children, and also other different contents for children in hospital. Such approach to the children in hospital requires the interdisciplinary approach, with participation of all experts in sick children and their family care.

[Sudden infant death syndrome (SIDS) in Croatia]. / Sindrom iznenadne dojenacke smrti (SIDS) u Republici Hrvatskoj.

We have analyzed certain epidemiological factors of sudden infant death syndrome (sex, age and infant's nationality, geographic and calendar death distribution, socio-economic conditions, age, marital status and mother's employment). Available statistics reports and death certificates for 22 from the total of 24 registered cases of sudden infant death syndrome during 2000 and 2001 in the Republic of Croatia have been used. There were 11 boys and 11 girls, with a peak incidence of SIDS from 2-4 months of age (total of 14 cases), which is consistent to the international references. As many as 9 mothers have no education or have finished only several grades of primary school, but not a single mother has academic degree. A third of the infants were born in the illegitimate families.

[Intergenerational transmission of breastfeeding as a behavioral model]. / Medugeneracijsko prosljedivanje dojenja kao modela ponasanja.

Successful breastfeeding is not an automatism. Like other behavioral models, breastfeeding experience is forwarded from generation to generation. To analyze the influence of previous generation on offspring's breastfeeding. Research was carried out in three general pediatric offices in Croatian towns: Sibenik, Varazdin and Zagreb. Examinees were mothers of preschoolers older than 1 year, and totally 300 mothers were comprised by the questionnaires. Mothers who had been breastfed for longer period (more than 6 mo.) statistically significantly more frequently breastfeed their children over 6 months (chi 2 = 10.4; p = 0.0013), in comparison with mothers who had been breastfed for shorter period (up to 6 mo.). There is no significant difference in children breastfeeding duration (up to 6 mo. vs more than 6 mo.) with regard to whether the mothers lived in autonomous housekeeping, or if they lived in common housekeeping with their mothers, or mothers-in-law (chi 2 = 0.303; p = 0.86; d. f. = 2). The influence of examinees' mothers on decision to breastfeed is more frequently positive (63%) than neutral or negative, while, at the same time, positive influence on decision to breastfeed was exerted by significantly smaller number (40%) of mothers-in-law (chi 2 = 27.87; p < 0.001). The strongest influence on mother's decision to breastfeed was exerted by mass media. In the age of nuclear families, health workers should offer more support to breastfeeding mothers with the aim of achieving successful lactation.