Nutrition & Dietetics 2011; 68: 201–207 DOI: 10.1111/j.1747-0080.2011.01534.

ORIGINAL RESEARCH

Hearts and Minds Project: A breastfeeding curriculum

intervention to improve the education outcomes for
nutrition and dietetics graduates ndi_1534 201..207

Barbara RADCLIFFE1 and Jan PAYNE2

1
Nutrition Promotion Unit, Eight Mile Plains Community Health Centre, Eight Mile Plains; and 2School of Public
Health, Queensland University of Technology, Kelvin Grove Campus, Brisbane, Queensland, Australia

Abstract
Aim: Dietitian nutritionists play an important role in supporting and promoting breastfeeding. Improving under-
graduate training to create a competent and motivated workforce to deliver these outcomes has been recommended.
This study evaluated a breastfeeding curriculum intervention designed to improve knowledge, attitudes and beliefs,
and increase graduates’ motivation to support breastfeeding into the future.
Methods: Final-year students studying nutrition and dietetics were surveyed at baseline in 2005 and post-
intervention in 2010. Questions related to student profile, breastfeeding knowledge, attitudes and beliefs, perceived
professional role in breastfeeding support, intentions to support breastfeeding in the future and perceptions of the
breastfeeding curriculum. Curriculum interventions were based on relevant evidence including recommendations
from the baseline survey report, a gap analysis of existing curriculum, previous literature identifying key barriers to
the support of breastfeeding by health professionals and learning and behaviour change theories and approaches.
Results: General improvements in knowledge and attitudes and beliefs were found over the intervention period,
although knowledge gaps remained on the risks associated with not breastfeeding for mothers and infants and when
to recommend the cessation of breastfeeding. A significant increase was found in the percentage of respondents
agreeing that their studies had engendered a strong interest in work involving breastfeeding. Significant improve-
ments were also seen in student perceptions of the degree to which breastfeeding was addressed in the dietetic
course.
Conclusion: Curriculum interventions can effectively influence new graduates’ future intention to support and
promote breastfeeding if they address knowledge gaps, attitudes, beliefs and perceived social concerns about
breastfeeding promotion.

Key words: breastfeeding, dietetics, education, infant, nutrition.

Introduction . . . every contact between a lactating woman and a health

professional who is unfamiliar with current breastfeeding
Although breastfeeding initiation rates in Australia have knowledge creates a potential barrier to breastfeeding
been estimated to be 92%, duration rates at 6 months are success and increases the risk of inappropriate use of
poor, with only 46% of infants fully breastfed at 4 months artificial baby milk.3
and 14% at 6 months.1
Many health professionals have an important role in Dietitians have a special responsibility because of their
supporting breastfeeding and can influence the initiation unique knowledge of both infant and maternal nutrition, yet
and duration of breastfeeding.2–4 Indeed, Helm et al. stated in many cases, they remain an untapped resource in breast-
that: feeding management.3
The American Dietetic Association in its Position of the
American Dietetic Association: Promoting and Supporting Breast-
B. Radcliffe, MPH, APD, A/Manager feeding emphasised the essential role of dietitians in support-
J. Payne, MApSci, APD, Lecturer
ing breastfeeding in a broad range of contexts including:
Correspondence: B. Radcliffe, Nutrition Promotion Unit, Eight Mile
Plains Community Health Centre, Eight Mile Plains, QLD 4113, providing up-to-date, practical information to pregnant
Australia. Email: [email protected] and postpartum women, involving family and friends
Accepted December 2010 in breastfeeding education and counselling, removing

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Nutrition & Dietetics © 2011 Dietitians Association of Australia
B. Radcliffe and J. Payne

institutional barriers to breastfeeding, collaborating with from the South East Queensland Breastfeeding Coalition,
community organisations and others who promote and the Dietitians Association of Australia’s representative for the
support breastfeeding, and advocating for policies that Baby Friendly Hospital Initiative, two health department
position breastfeeding as the norm for infant feeding.5 community nutritionists working in breastfeeding promo-
tion and a university representative. This group assisted in
Many professionals have little or no formal breastfeeding
the development of project plans, the survey and priorities
education,6 marked knowledge and skill deficits about
for curriculum interventions.
breastfeeding,7–10 while ambivalent attitudes, and a lack of
Survey methods: Final-year students of a 4-year under-
confidence have been reported.11 Renfrew et al. stated that a
graduate nutrition and dietetics course based in Australia
lack of knowledge is most common in practitioners with
were surveyed at baseline in 2005. The survey was
more marginal, infrequent or tangential roles in supporting
repeated for the 2010 final-year student cohort, these stu-
breastfeeding women.11 A lack of sound undergraduate
dents having been exposed to curriculum interventions
training may contribute to this problem.8 The Australian
across all year levels. Enrolment numbers were based on
National Breastfeeding Strategy 2010–2015 and other authors
the number of students enrolled in the standard course
worldwide have consistently recommended the training of
structure. All final-year students were eligible to complete
health professionals to improve breastfeeding rates.2,4,6,7,12–16
the questionnaire, apart from three students in the 2005
Professional development has been found efficacious
cohort who were involved in the survey’s development and
to improve clinical practice relating to breastfeeding17,18 and
implementation. Final-year students were selected because
breastfeeding rates.18 Although no papers were found on
they had completed the theory component of their course,
the effectiveness of dietetic training, the American Dietetic
the final year of studies consisting of professional practice
Association stated one of its roles is to encourage universities
placements.
to review and update undergraduate and graduate training
As no previously validated questionnaire applicable to
programs in relation to breastfeeding content.5
this target group was identified, the questionnaire was devel-
Education interventions to promote behaviour change
oped following recommended principles for questionnaire
are recommended to be theory- and evidence-based.19,20
design.24,25 As there were no industry standards for learning
Relevant theories include the Health Belief Model, Social
outcomes relating to breastfeeding, question development for
Cognitive Theory and the Transtheoretical Model. Daneault
the survey was overseen by a panel of experts and based on a
et al. recommended use of the Theory of Planned Behaviour
set of outcomes considered desirable in graduate dietitians.23
to increase the intention of health professionals to support
The survey included 50 multiple choice questions and
breastfeeding.15 In this theory, intention to perform a par-
consisted of:
ticular behaviour (in this case working in breastfeeding)
• Seven questions profiling students
is determined by personal attitudes to performing the
• 20 knowledge-based questions related to breastfeeding
behaviour, the perceived social pressure to perform or not
as the biological norm and current public health issues,
perform the behaviour, and perceived behavioural control
policies and strategies
(i.e. the perception of how easy or difficult performing
• 15 questions on students’ attitudes and beliefs
the behaviour would be).15 A client- or student-centred,
• Six questions relating to future breastfeeding intentions
empowering approach that is target group- and context-
• Two questions relating to students’ perceptions of the
specific and that includes cognitive (knowledge), affective
breastfeeding training provided.
(attitudes) and psychomotor (skill) objectives is also recom-
Ethics approval to conduct the survey was granted by the
mended.20 Varied strategies and approaches are recom-
Queensland University of Technology Human Research
mended for students depending on the intended learning
Ethics Committee.
outcomes.21,22
The same dissemination and collection methods were
The aim of the present study was to determine the effec-
used for both surveys. Surveys were sent to final-year
tiveness of curriculum interventions relating to breastfeeding
students electronically in April because of their varied
introduced into a 4-year dietetic course based in Queen-
off-campus placement schedules and email reminders were
sland, Australia. These interventions were based on a previ-
provided. Students were advised of the confidentiality of
ous needs assessment that identified deficits in breastfeeding
their responses and that the university would not receive
knowledge, concerns regarding attitudes and beliefs, and
data on individual student’s results. Respondents were asked
little interest in working in an area that involves breastfeed-
to complete the survey without reference to lecture notes,
ing.23 The interventions sought to address these issues and
texts or any other information sources.
to equip students to support and promote breastfeeding in
Frequencies of responses and cross-tabulations were
their role as health professionals.
calculated using SPSS (SPSS Inc., Chicago, IL, USA; SPSS
Version 17.0 2008). All surveys were included for analysis.
Methods
Two-tailed chi-squared analyses with a level of significance
The project was developed in partnership between a leading (P < 0.05) are reported. The introduction of the new WHO
Australian university and Queensland Health (Nutrition Child Growth Standards and new National Breastfeeding
Promotion Unit, Metro South Health Service District) staff. Strategy made two true/false questions no longer valid and
A reference group was formed consisting of representatives these were not analysed.

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Nutrition & Dietetics © 2011 Dietitians Association of Australia
 The Hearts and Minds Project: a breastfeeding intervention

Curriculum intervention: A comprehensive and integrated use of artificial formula were emphasised, rather than the
curriculum that addressed breastfeeding knowledge and atti- benefits of breastfeeding. In developed countries, infants
tudes and beliefs was developed based on: fed artificial formula have a higher risk of gastrointestinal
• The findings of the baseline survey, published in 200723 illness,24–26 sudden infant death syndrome,26 respiratory
• A baseline curriculum audit identifying existing breast- infection,25,26 otitis media,25,26 eczema,24,26 and insulin-
feeding curriculum and gaps relating to desired learning dependent diabetes mellitus24–26 than breastfed infants.
outcomes developed by the reference group Women who breastfeed have been identified as having a
• Current recommended theories and evidence from the lower risk of osteoporosis,26 ovarian cancer26 and a faster
literature. return to prepregnancy body weight.27 This information was
This framework, as shown in Figure 1, determined the presented to students as an increased risk of these health
content, methods and strategies for the curriculum interven- problems for non-breastfeeding women when compared
tions. A main focus was to include strategies that promoted with women who have breastfed. Wiessinger28 argued for the
attitude changes and not only delivered knowledge (e.g. risk factor approach because it correctly identifies breast-
increased exposure to breastfeeding images and breastfeed- feeding as the biological norm and artificial formula as the
ing women, self-reflection, role modelling, discussions and scientific intervention and is consistent with how research
debates). The content also focused on dispelling breastfeed- into other health risks and benefits is presented in the lite-
ing myths found to be prevalent in the baseline survey, rature (e.g. smoking and folic acid supplementation).
particularly those myths likely to confuse breastfeeding mes- In planning the curriculum, the intention was to
sages and reduce practitioners’ confidence in promoting and build knowledge and positive attitudes using a scaffolded
supporting breastfeeding. approach across course years. The depth to which the
In presenting the effects on maternal and infant health of content was covered increased over the year levels (e.g.
infant feeding method, the risks of not breastfeeding or the awareness of the existence of relevant guidelines and policy
recommendations was required in the first-year unit, but a
critical understanding of the evidence and rationale behind
the guidelines and issues was expected by the final year).
Theories
Five key compulsory units were selected for the intervention
Evidence
Needs assessment data
strategies because of their perceived relevance and position
Literature findings
Steering group recommendations
Student survey
+ Intrapersonal
Interpersonal
Community
Learning
in the course. These were: a first-year introductory nutrition
unit that included nutrition over the life cycle; a second-year
physiology unit that included reproductive physiology; a
second-year nutrition education unit focusing on health
behaviour change theories and the process of nutrition edu-
cation; a third-year unit that focused on community and
Recommended methods
public health nutrition and another third-year unit that dealt
Consciousness raising with the provision of appropriate dietary advice to indivi-
Factors influencing the Self-evaluation
behaviour of students as future Emotive duals and communities.
dietetic graduates

Knowledge gaps
Attitudes
+ Decisional balance—pros
and cons; risks and
benefits
Cognitive restructuring Results
Skills Problem solving
Environmental factors Active participation The profile of respondents is shown in Table 1. No signifi-
Modelling
Stimulus/cue control cant differences between the respondents of the two cohorts
Skills training
Social support
Scaffolded
Experiential
Fun
Table 1 Profile of pre- and post-intervention respondents
Characteristic 2005 (n = 27) 2010 (n = 34)
Required content Strategies to use 17–25 years 81.5% 76.5%
Importance of breastfeeding
Key guidelines, policies and
Lectures, diagrams,
illustrations
>26 years 18.5% 23.5%
recommendations Literature and media reviews Female 88.9% 88.2%
Anatomy and physiology of
breastfeeding
Management and support
Infant feeding practices and
+ Activities, online modules
Videos, personal observation,
role modelling
Guest speakers, discussions,
Male
Had children
11.1%
0%
11.8%
0%
recommendations debates
No exposure to contact 18.5% 8.8%
Relevant issues, influential factors Case studies, workshops with close friend,
Recommended interventions Quizzes, surveys, key pad family member or
Counselling skills technology
close work colleague
who has breastfed
Figure 1 Framework used for the development of curricu-
Response rate 71.1% 70.8%
lum interventions.

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B. Radcliffe and J. Payne

Table 2 Results for true or false questions relating to breastfeeding knowledge

Percentage of respondents
Correct answer Correct answer
Knowledge question (correct answer) 2005 2010 P-value(a)
Breast milk contains immunological factors that strengthen the infant’s 96.2 100 0.27(b)
immune system (True)
Women with smaller breasts are less likely to be able to feed 88.5 100 0.05(b)
successfully (False)
The amount of breast milk a woman produces is controlled by an 57.7 67.6 0.43
endocrine positive feedback mechanism involving the pituitary
gland (True)
If a breastfeeding woman does not consume a well balanced diet, her 26.9 70.6 <0.01
breast milk will not be of adequate quality for infant growth (False)
The average duration of breastfeeding is a greater problem than the 76.9 88.2 0.24(b)
rates of initiation within Australia (True)
The earlier in life a woman makes the decision to breastfeed, the 53.8 73.5 0.11
longer she will breastfeed for (True)
Infant/artificial formula presents a significant cost for parents (True) 100 100 n/a
Infant/artificial formula use is associated with high cost to the public 53.8 58.8 0.70
health care system (True)
Indigenous women living in remote areas in Queensland are less likely 26.9 35.3 0.49
to breastfeed than those living in urban areas (False)
(a)
Chi-squared, two-tailed.
(b)
Not valid as one or more cells have an expected count of less than 5.

or their response rates were identified. Respondents were the infant has lactose intolerance compared with 30% for
typically young women, with no children and some expo- the post-intervention group, while 26% of baseline survey
sure to breastfeeding. respondents indicated that breastfeeding should cease if the
Results in Table 2 indicate a significant improvement over mother had cracked nipples compared with 18% for post-
the intervention period in the results of the nine true/false intervention respondents.
questions, with 68% of participants achieving a score of 78% Participants were asked to identify barriers to breastfeed-
or more post-intervention compared with 39% in 2005 ing from a list of options. At baseline only 44% of students
(P = 0.02). At post-intervention, 21% of respondents correctly identified media portrayal of breastfeeding and arti-
achieved a score of 100% compared with 0% at baseline. ficial formula feeding as a documented barrier to breastfeed-
In a multiple choice question, the ability to correctly ing compared with 77% in 2010 (P = 0.01). Returning to
identify the increased health risks for the infant associated work was correctly identified by 94% of respondents post-
with the use of artificial formula was tested. At baseline 19% intervention compared with 85% at baseline and lack of
of respondents identified ear infections compared with support during the early weeks post-partum by 88% post-
53% post-intervention (P = 0.01), 44% at baseline for intervention compared with 82% at baseline. However,
insulin-dependent diabetes mellitus compared with 44% extended separation of mother and baby for non-medical
post-intervention, and 19% for sudden infant death syn- reasons was correctly identified by only 57% post-
drome for baseline compared with 18% post-intervention. intervention compared with 67% at baseline.
Improved knowledge of the increased risks for women of not Table 3 provides the results of questions on attitudes to
breastfeeding was seen with only 19% of baseline respon- breastfeeding. Although no statistically significant differ-
dents identifying increased risk of osteoporosis compared ences were found when the post-intervention and baseline
with 27% post-intervention, 26% for ovarian cancer at base- cohorts were compared, in all but one of the questions,
line compared with 53% post-intervention (P = 0.03) and post-intervention respondents displayed more positive atti-
67% for delayed post-partum weight loss at baseline com- tudes and beliefs.
pared with 91% post-intervention (P = 0.02). The majority of respondents from both cohorts (92% at
Participants were asked when breastfeeding should be baseline; 100% post-intervention) reported that they
avoided or ceased. Of respondents, 70% at baseline and intended to breastfeed or support their partner to breastfeed.
73% at post-intervention correctly identified that breast- Positive response rates were also high pre- and post-
feeding should be ceased by HIV-positive mothers in intervention (85%; 91%) regarding respondents’ perception
Australia. For the baseline survey, 22% of respondents of their professional capacity to influence both a woman’s
incorrectly selected that breastfeeding should be ceased if decision to breastfeed and the duration of feeding. A small

204 © 2011 Queensland Health

Nutrition & Dietetics © 2011 Dietitians Association of Australia
 The Hearts and Minds Project: a breastfeeding intervention

Table 3 Attitudes and beliefs relating to breastfeeding

Percentage of respondents
Agree or strongly Disagree or strongly
agree Neutral disagree
Statement 2005 2010 2005 2010 2005 2010
‘I feel embarrassed or uncomfortable when I see a woman 3.8 2.9 19.2 11.8 76.9 85.3
breastfeeding in public.’
‘Bottle-feeding is a more socially accepted way to feed an infant.’ 69.2 41.2 11.5 32.4 19.2 26.5
‘Artificial/infant formula is an easier feeding method than 20.0 2.9 20.0 11.8 60.0 85.3
breastfeeding for everyone concerned (mother, family and
friends).’
‘Using artificial/infant formula is preferable to breastfeeding 7.7 17.6 19.2 8.8 73.1 73.5
because the father can be more involved.’
‘It is normal for a breastfeeding woman to require support from 57.7 76.5 23.1 11.8 19.2 11.8
a range of health professionals in order to breastfeed
successfully.’
‘Public policy should support women’s rights to breastfeed in 84.6 94.1 7.7 5.9 7.7 0.0
public places.’
‘If women choose to artificially feed and it is not medically 30.8 35.3 15.4 11.8 53.8 52.9
warranted, maternity hospitals should not supply infant/
artificial formula to their babies.’

decrease in the percentage of respondents reporting they compared to baseline indicate that the new breastfeed-
believed that it was part of their professional role to highlight ing curriculum has been relatively effective in achieving
the health problems associated with the use of artificial the desired outcomes. The included content supported and
formula was found post-intervention (77%) compared with correlated well with topics recommended in the recently
baseline (81%). A significant increase was found in the per- released Infant and Young Child Feeding, Model Chapter for
centage of respondents reporting that their course had Textbooks for Medical Students and Allied Health Professionals.29
engendered a strong interest to work in an area involving These include the importance of infant and young child
breastfeeding (8% at baseline vs 32% post-intervention; feeding and recommended practices, the physiology of
P = 0.03). breastfeeding, complementary feeding, the management and
Significant improvements in the perception of the breast- support of infant feeding in maternity facilities, continuing
feeding component of the dietetic course were found over support for infant and young child feeding, appropriate
the intervention period with 59% of 2010 survey partici- feeding in exceptionally difficult circumstances, the manage-
pants stating that their course had provided them with a ment of breast conditions and other breastfeeding difficul-
significant amount of material or education on all aspects of ties, maternal health, and policy, system and community
breastfeeding compared with no participants in 2005 (P < actions.
0.01). In 2005, 37% of respondents stated they had received The greater than fourfold increase in the proportion of
very little material on breastfeeding, while only 3% of 2010 final-year students who reported an intention to work in
respondents chose this response (P < 0.01). breastfeeding in the future supports Daneault et al.’s work
As noted in the previous paper relating to the present suggesting the importance of the constructs of the Theory
study,23 limitations exist relating to questionnaire design, of Planned Behaviour.15 Their research of nurses and dieti-
distribution methods and participant bias. The small tians on their intention to recommend breastfeeding to new
numbers, especially in the baseline cohort, made it difficult mothers for 6 months found that the perceived professional
to obtain statistically significant differences between the two role and individual’s perception of control over the per-
cohorts. Differences in baseline knowledge and attitudes ceived barriers were the most important determinants of
of the two cohorts were not able to be compared because of intention. In the context of the present study, the propor-
the cross-sectional nature of the present study, thus limiting tion of final-year students intending to work in breast-
the ability to attribute the identified differences solely to the feeding is likely to have increased because of increased
interventions. A further limitation was the inability to deter- emphasis of breastfeeding as part of the professional role of
mine the effectiveness of individual curriculum strategies. dietitians.
Despite significant improvements in the knowledge of
final-year survey respondents post-intervention compared
Discussion with those at baseline, there is a need to focus on the remain-
Overall improvements in the knowledge, attitudes and ing knowledge deficits such as the need to influence women
intentions of the final-year cohort at post-intervention earlier in life to breastfeed, mothers’ ability to produce

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Nutrition & Dietetics © 2011 Dietitians Association of Australia
B. Radcliffe and J. Payne

adequate milk of good quality in almost all circumstances, and dietetics should clearly state their members’ role and
and the health risks to mother and infant associated with the responsibility related to breastfeeding in order to clarify and
use of artificial formula. reinforce members’ perceived professional norms regarding
Although at post-intervention, 90% of participants were the protection, promotion and support of breastfeeding.15
confident that they could directly or indirectly influence The American Dietetic Association’s position paper also
both a woman’s decision to breastfeed and the duration for emphasised its own role in providing continuing education
which she will feed, the results for some questions identified opportunities and encouraging universities to review and
residual knowledge gaps. Where confidence is high and key update their undergraduate and graduate training programs
knowledge gaps exist, concerns regarding subsequent prac- relating to breastfeeding.5 In the Australian context, it is
tice are raised. Freed et al. also found high levels of confi- recommended that the Dietitians Association of Australia
dence accompanied by important deficits in knowledge in a consider the drafting of a similar position paper.
study of physicians.7
It is important to note that while significant improve- Acknowledgements
ments occurred in the proportion of respondents indicating
their intention to work in an area that involves breastfeeding, The contribution of students on community placements in
this intention may not be realised. There is also no guarantee assisting with this project over a number of years is gratefully
that new graduates, once employed in such an area, will have acknowledged. This list includes Amanda McCartney, Kai
the skills to match their intentions. A study of paediatric Wen Ong, Emma Blank, Elizabeth Churchill and Nadia
residents by Freed et al. found that medical residents recog- Hassan. The expert advice throughout the project of Eliza-
nised the importance of their role in promoting and support- beth Paul and Helen Porteous as members of the project’s
ing breastfeeding, but at the same time had considerable reference group was also greatly appreciated.
knowledge deficits and reported difficulties in advising
mothers with lactation problems.7 Further research on the References
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