Implementing the Ten Steps to Successful Breastfeeding in Multiple Hospitals Serving Low

8/17/2019 Implementing the Ten Steps to Successful Breastfeeding in Multiple Hospitals Serving Low

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Implementing the ten steps to successful breastfeeding inmultiple hospitals serving low-wealth patients in the US:innovative research design and baseline ndingsMiriam H Labbok 1 *, mil! " #a!lor 1 and $athan " $ickel 2

• *Corresponding author: Miriam H Labbok [email protected]

Author Af iations

1Caro ina ! oba "reast#eeding $nstitute %C!"$&, 'epartment o# Materna and Chi d Hea th, !i ings

(choo o# ! oba )ub ic Hea th, ni+ersit o# -orth Caro ina, Chape Hi , (A

2Manitoba Centre #or Hea th )o ic , acu t o# Medicine, ni+ersit o# Manitoba, /innipeg, Manitoba,

Canada

or a author emai s, p ease og on .

International Breastfeeding Journal 201 , %: doi:10.11345167487 3838

9he e ectronic +ersion o# this artic e is the comp ete one and can be #ound on ine

at :http:55 .internationa breast#eeding;ourna .com5content53515

201 Labbok et a .? icensee "ioMed Centra Ltd.

9his is an pen Access artic e distributed under the terms o# the Creati+e Commons Attribution License

%http:55 .creati+ecommons.org5 icenses5b 52.0 &, hich permits unrestricted use, distribution, and

reproduction in an medium, pro+ided the origina ork is proper cited.

&bstract

'ackground 9he 9en (teps to (uccess#u "reast#eeding are maternit practices pro+en to support success#uachie+ement o# e c usi+e breast#eeding. 9he a so are the basis #or the /H 5 -$CB "ab 8 riendHospita $nitiati+e %" H$&. 9his stud e p ores imp ementation o# these steps in hospita s that ser+epredominant o ea th popu ations.

MethodsA uasi8e perimenta design ith mi ed methods #or data co ection and ana sis as inc uded ithin aninter+ention pro;ect. /e compared the impact o# a modiDed 9en (teps imp ementation approach to acontro group. 9he inter+ention as carried out in hospita s here: 1& " H$ designation as notnecessari under consideration, and 2& the ma;orit o# the patient popu ation as o ea th, i.e.,e igib e #or Medicaid. Hospita s in the research aspect o# this pro;ect ere s stematica assigned to oneo# t o groups: $nitia $nter+ention or $nitia Contro 5Later $nter+ention. 9his paper inc udes ana ses #romthe base ine data co ection, hich consisted o# an e(ur+e %i.e., Caro ina "8EA)&, Maternit )ractices in$n#ant -utrition and Care sur+e too %m)$-C&, the " H$ (e #8Appraisa , ke in#ormant inter+ie s,breast#eeding data, and #ormatted #eedback discussion.

(esults

http://www.internationalbreastfeedingjournal.com/content/8/1/5/#ins1http://www.internationalbreastfeedingjournal.com/content/8/1/5/#ins1http://www.internationalbreastfeedingjournal.com/content/8/1/5/#ins1http://www.internationalbreastfeedingjournal.com/content/8/1/5/#ins1http://www.internationalbreastfeedingjournal.com/content/8/1/5/#ins2mailto:[email protected]://www.internationalbreastfeedingjournal.com/content/8/1/5http://www.internationalbreastfeedingjournal.com/logonhttp://www.internationalbreastfeedingjournal.com/logonhttp://www.internationalbreastfeedingjournal.com/content/8/1/5http://www.internationalbreastfeedingjournal.com/content/8/1/5http://www.creativecommons.org/licenses/by/2.0http://www.creativecommons.org/licenses/by/2.0http://www.internationalbreastfeedingjournal.com/content/8/1/5/#ins1http://www.internationalbreastfeedingjournal.com/content/8/1/5/#ins2mailto:[email protected]://www.internationalbreastfeedingjournal.com/content/8/1/5http://www.internationalbreastfeedingjournal.com/logonhttp://www.internationalbreastfeedingjournal.com/content/8/1/5http://www.creativecommons.org/licenses/by/2.0http://www.internationalbreastfeedingjournal.com/content/8/1/5/#ins1


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Comparabi it as ensured b statistica and non8parametric tests o# base ine characteristics o# the t ogroups. Additiona Dndings o# interest inc uded: 1& a uni+ersa ack o# consistent breast#eeding recordsand statistics #or regu ar monitoring5re+ie , 2& idespread misinterpretation o# associated termino og ,

& hea th care pro+idersF reported practices not necessari reGecti+e o# their kno edge and attitudes,and 7& speciDc steps ere #ound to be associated ith hospita breast#eeding rates. A comprehensi+e seto# #aci itators and obstac es to initiation o# the 9en (teps emerged, and hospita 8speciDc practice changecha enges ere identiDed.

)iscussion 9his is one o# the Drst studies to e amine introduction o# the 9en (teps in mu tip e hospita s ith a controgroup and in hospita s that ere not necessari interested in " H$ designation, here the popu ationser+ed is predominant o ea th, and ith the use o# a mi ed methods approach. Limitationsinc uding numbers o# hospita s and inabi it to adhere to a e ements o# the design are discussed.

"onclusionsor impro+ements in ua it o# care #or breast#eeding d ads, inno+ati+e and site8speciDc inter+ention

modiDcation must be considered.

*e!words:

9en steps? " H$? "reast#eeding? Mu ti8hospita ? perationa research? ua it o# care?


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9he Caro ina ! oba "reast#eeding $nstitute %C!"$& "reast#eeding8 riend Hea thcare %" HC& pro;ectidentiDed o ea th hospita s, deDned as ith N40O c ientsF income e+e s e igib e #or Medicaid. BKorts

ere made to inc ude hospita s reGecting urban5rura , arge5sma hospita s, teaching5non8teachinghospita s, and those that ere and ere not p anning to seek "ab 8 riend Hospita $nitiati+e %" H$&designation. A trans ationa research approach as used ithin this pro;ect, ith a uasi8e perimentaoperationa research design ith mi ed methods, as e as a cost ana sis.

9rans ation o# the achie+ements o# basic science into e+er da c inica practice remains a ma;or issue incontemporar medicine, and is addressed through a ne discip ine, trans ationa research, hich aims tobridge the gap bet een basic and c inica research I 20 J. 9he term genera re#ers to the bench8to8bedside enterprise #or harnessing kno edge #rom basic sciences to produce ne treatment options, iththe end point o# production and use o# a ne techno og I21 J. 9he Canadian $nstitutes o# Hea th


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9his mode and time ine are presented, be o . indicates bser+ation, or data co ection? U indicates$nter+ention? (ubscripts indicate )hase. )hase 1 group recei+ed the inter+ention a#ter the Drst round o#data co ection, hi e )hase 2 group recei+ed the inter+ention a#ter the second round o# data co ection. 9he therF hospita s ere not part o# the research? ho e+er, representati+es ere in+ited to se+eraacti+ities. 9he Drst 4 months inc uded preparation, ith identiDcation o# hich hospita s ou d beinc uded in )hase 1, ith ear inter+ention, )hase 2 to ser+e as contro , ith ater inter+ention, or as

ther, hospita s participating in the pro;ect, but not in the research cohorts. %9ab e 2&"onsentA participants in ke in#ormant inter+ie s and5or sur+e s ere administered appro+ed in#ormedconsent, and resu ts maintained in secure D es during the pro;ect. 9he pro;ect and approach ereappro+ed b the -C $


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A mi ed methods research approach I J as emp o ed as e ere #ocusing on research uestions thatca #or rea 8 i#e conte tua understandings and mu ti8 e+e perspecti+es and ished to both e p ore#re uenc o# 9en (tep kno edge, attitudes and practices, as e to e p ore both the meaning and theunderstanding o# the 9en (teps in this conte t. 9here#ore, e a so carried out a ua itati+e studinc uding ke in#ormant inter+ie s. 9his use o# mu tip e methods %i.e., inter+ention tria s, mu tip emeasurement too s, and in8depth inter+ie s& approach intentiona integrated and combined thesemethods to dra on the strengths o# each in our interpretation, both #or the p anned mid8pro;ectmodiDcations and to he p e amine hat orked and hat did not ork ithin the inter+ention e ements.#heoretical framework 9he theor o# reasoned action or p anned beha+ior as the primar theor used to p an this stud . A highcorre ation o# attitudes and sub;ecti+e norms to beha+iora intention, and subse uent to beha+ior, hasbeen conDrmed in man studies. /e posit that the inter+entions se ected %e.g., addressing obstac es ith

a s to #aci itate progress, in#ormation #eedback, sharing, adu t earning, mu ti8 e+e task#orce support,and e terna support #or breast#eeding kno edge, attitudes and practices %EA)&, etc.& ou d suggestthat supporting patients in breast#eeding is positi+eF, eading to higher moti+ation to be supporti+e. 9hishigher moti+ation ou d, in turn, ead to in#ormation8seeking and mother5bab 8supporti+e beha+iors, andtake pro+iders through pre8contemp ation, contemp ation, preparation, action and maintenance o# the

ne care beha+iorsI 21 J. 9his is enhanced b the beha+iora interacti+it F considerations that ead toconsideration, hich suggest that change is dependent on interactions ithin the communit o#pro+iders I 7 J.$ndi+idua "eha+ior Change %(tages o# Change& I J and rganiQationa


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practices. (cores ere ca cu ated separate #or c inica and non8c inica staK, such that a EA) uestionsere ans ered b c inicians? non8c inicians on ans ered kno edge and attitude uestions. 9he

instrument inc uded skip patterns to ensure that pro+iders ere asked uestions re e+ant to their De d o#practice. or e amp e, i# a pro+ider indicated he5she as not in+o +ed in abor and de i+er , then he5she

as not asked uestions about breast#eeding ithin the Drst hour a#ter birth. Bach respondent iseighted e ua .

9he sur+e inc udes uestions, inc uding se+en kno edge uestions, hich co+er contraindications,basics o# atch, supporti+e practices, indications #or supp ementation, and recommended duration o#e c usi+e breast#eeding. 9he kno edge score is ca cu ated as the number o# uestions correct. Attitudeis measured using eight uestions on a si 8point Likert sca e? uestions co+er the importance o#breast#eeding #or hea th outcomes, e ui+a ence ith #ormu a, importance o# rooming8in, perception o#difcu ties #or mother, and hether hospita staK can inGuence breast#eeding. Bach uestion as scored#rom one to si such that a higher score reGects greater breast#eeding support. 9he o+era attitude scoreis ca cu ated as the a+erage o# the eight attitude uestions.

9he practice uestions addressed counse ing and c inica actions separate . Counse ing and other c inicapractice uestions are asked as Rproportion o# patients ho recei+eS the indicated support, in O

increments. 9he possib e score o# 20 indicates an ans er o# 8100O, hi e a score o# 1 indicates 08 O. 9he counse ing uestions addressed counse ing per se, counse ing on mi k e pression, and teaching "techni ues and identiDcation o# #eeding cues, hi e the c inica practice uestions co+ered pro+ision anduse o# supp ementation, paciDers, and nurser %+s. rooming in&. 9he o+era counse ing and c inicapractice scores are ca cu ated as the a+erage o# the responses.

actor ana ses ere conducted to assess the construct +a idit o# the attitude, practice, andorganiQationa readiness sections o# the Caro ina "8EA). Ana ses using $tem


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instruments as comp eted either b the same team that comp eted the (e #8Appraisa 9oo at eachhospita or b the indi+idua most kno edgeab e about the #aci it Fs in#ant #eeding practices. n the

uestion stems and sub8 uestions designed to assess adherence to po icies and practices reGecting the 9en (teps ere inc uded in ana sis.)ata collection

9he hospita Fs site coordinator in+ited and encouraged a maternit staK to comp ete the Caro ina "8EA)using both on8 ine and hardcop paper +ersions as necessar . )iQQa unch parties ere oKered to the t o#aci ities co ecting the greatest percentage o# comp eted sur+e s as an incenti+e.

Ee in#ormant inter+ie s ere conducted ith thirt 8#our respondents, se ected b each site coordinatorin co aboration ith C!"$ to e p ore practice and attitudes +is8W8+is the (teps. )urpose#u samp ing asused to ensure representation o# those staK members responsib e #or imp ementation o# breast#eeding8re ated practice change at each hospita I 7 J. 9 o research staK trained in ua itati+e research methodsconducted inter+ie s in a pri+ate room at each hospita , ith one asking uestions and the other takingnotes, recording ith a digita audio recorder, and asking #o o 8up uestions hen appropriate.$nter+ie s asted 0P 0 minutes unti achie+ing construct saturation. 9ab e presents se ected uestionsused to e p ore practice and attitudes about the 9en (teps I 3 J. A pro#essiona transcriptionist created

+erbatim, t ped records o# the digita recorded inter+ie s. 9he second and third authors used a codebook ith decision ru es to independent code and memo the transcripts in At as.9$ I 0 J. 9he met andre+ie ed the coded transcripts to achie+e consensua +a idation I 1 , 2 J. indings ere summariQed andpresented back to the hospita s #or member8checking.

#able 2. Summar! of selected attitude and practice 3uestions from the semi-structured ke!

informant interview guide I J

Cost data, inc uding imp ementation, training, and research costs, are maintained and +eriDed ith each#aci it and at C!"$. 'etai ed e p anation o# cost ana sis i be pro+ided in a companion paper.

&nal!tic approachHospita s ere s stematica assigned and e used standard ana sis approaches #or uasi8e perimenta designs. Mu tip e8case stud methods are used here cases %i.e., hospita s& are studied in8depth, ongitudina , using mu tip e data sources and t pes to e p ore the support approaches re uired#or (tep imp ementation I J.$nitia ana ses e p ored hether there ere an statistica signiDcant diKerences bet een the t os stematica assigned treatment groups using Chi8s uare contingenc tab es ith t o8sided isherFse act tests. (igniDcance as obser+ed at p Y 0.0 . Ana ses that used the hospita as the unit o# studemp o ed non8parametric /i co on


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and comp etion o# the stud sur+e . 9 o +ariab es, ho e+er, merit #urther discussion. irst, the diKerencein proportion teaching5non8teaching hospita s as una+oidab e to ensure at east one hospita in eachregion. -e t, e asked that the hospita ha+e at east one $"CLC? e #ound that there as a good dea o#+ariation in the numbers, hich as une pected, ho e+er, a that ere inc uded in the stud met theminimum that e re uested.

)ro;ect8 ide, 42 , or s ight more than 0O o# a e igib e staK, returned a comp eted the Caro ina "8EA). 9heir characteristics reGect the eKort made to inc ude a categories o# hospita staK hose ork impactsmaternit care. /hi e respondents ere 6O #ema e, the represent a cross8section o# staK impactingne mothers: 66O nurses, 6O ph sicians, O actation ser+ices, 2O administrators, and 1O other, suchas dieticians. $n addition, the represented appropriate units: .7O Labor and 'e i+er %LZ'&, Labor,'e i+er ,


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re+ie s ere comp eted, the stud #aci ities ere not statistica signiDcant or diKerent #rom the ratesreported among the o ea th c ients ho attend pub ic hea th c inics in the area. 9his consistentinterna misperception o# the breast#eeding rates b #aci ities #urther conDrms the need #or betterbreast#eeding records.

9he identiDed barriers and #aci itators ser+e as the basis #or inter+ention p anning. $n addition, the inter8hospita diKerences in in#rastructure and management s stems are being taken into account inindi+idua iQation o# approaches. As a resu t o# the pre iminar Dndings, !roup 2 i introduce 1& modiDedmateria s, to inc ude suggestions #or impro+ed data co ection and suggested a s to p ace contro s oncommercia in#ant #ormu a distribution, 2& #aci itate communication bet een participating hospita s toenhance prob em so +ing, especia here there are common issues, and & other modiDcations toreduce costs hi e maintaining impact.

Limitations o# this stud inc ude 1& se #8se ection bias in that those hospita s interested in the sub;ectmatter are more ike to ha+e responded and enro ed? 2& sma numbers o# hospita s in the researchdesign due to resource constraints and e+e o# interest at the time o# proposa preparation? & high initiaattitude scores in the instruments ma imit the possibi it o# obser+ing signiDcant impro+ement in this

parameter, and 7& the response rate o# about 0O, hi e high #or an e(ur+e I , 4J, ma imitgenera iQabi it be ond the p anned comparisons. -onethe ess, measurement o# progress on the 9en(teps and in the rates o# breast#eeding initiation and e c usi+it in8hospita ma oKer more insight.

urther, hi e the representati+eness o# these hospita s is imited b numbers and se #8se ection, the useo# mu tip e case approaches in addition to primar uasi8e perimenta design i a o additionaobser+ations and reporting that ma he p in#orm those #aci ities attempting to increase e c usi+ebreast#eeding during the hospita sta , hether #or the =oint Commission measure or #or o+era ua it o# care, b imp ementing the 9en (teps.

#able 5. +erceived barriers and facilitators to progress on the ten steps

"onclusions

As an in8depth mu ti8method, mu ti8hospita operationa stud to e p ore issues in the imp ementation o#the 9en (teps to (uccess#u "reast#eeding, this stud ma shed additiona insight o# use toimp ementation o# these (teps, and o# " H$, in the nited (tates. indings conDrm that the stud designhas inc uded a comparab e set o# hospita s in !roup 1 and !roup 2. Ho e+er, the base ine Dnding thatthere is a ack o# regu ar co ected data on breast#eeding in a o# the hospita s, both those inc uded inthe research and the others, is o# ma;or concern.


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tested the Caro ina "8EA), p anned and carried out a statistica ana ses, de+e oped semi8structuredinter+ie guide, p anned ua itati+e data co ection methods, conducted ua itati+e data ana ses,prepared tab es, dra#ted the methods section. A authors participated in preparation o#, and read andappro+ed the Dna manuscript.

&cknowledgements

9he authors ish to ackno edge their co eague, Mar


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Cochrane /atabase S"st 0e- 2006, : C'001171. )ubMed Abstract ] )ub isher u 9e t

. Eramer M(, Cha mers ", Hodnett B', (e+ko+ska a \, 'Qiko+ich $, (hapiro (, Co et =), âni o+ich

$, MeQen $, 'ucruet 9, (hishko !, \ubo+ich ̂ , Mknuik ', ! uchanina B, 'ombro+ski ̂ ,

stino+itch A, Eot 9, "ogdano+ich -, +chiniko+a L, He sing B:+(='I# stud! group:

promotion of breastfeeding intervention trial 0+(='I#1: a randomi>ed trial in the

republic of 'elarus.

JAMA 2001, /%5 %7&: 71 8720. )ubMed Abstract ] )ub isher u 9e t

10. Merten (, 'rat+a =, Ackermann8Liebrich : )o bab!-friendl! hospitals in;uence

breastfeeding duration on a national level7

)ediatrics 200 , 8 % &: e6028e603. )ubMed Abstract ] )ub isher u 9e t

11.


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Am J )ublic .ealth 200 , CC% &: 2 8 . )ubMed Abstract ] )ub isher u 9e t ]

)ubMed Centra u 9e t

20. Eeramaris -C, Eanakaris -E, 9Qioupis C, Eontakis !, !iannoudis ) :̂ #ranslational research:

from benchside to bedside.

In4ur" 2003, 2C %4&: 47 84 0. )ubMed Abstract ] )ub isher u 9e t

21. /oo # (: #he meaning of translational research and wh! it matters.

JAMA 2003, /CC %2&: 211821 . )ubMed Abstract ] )ub isher u 9e t

22. Canadian $nstitutes o# Hea th


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. Cres e =/, E assen AC, ) ano C ark ^L, C egg (mith E, Assistance o# a (pecia Appointed

/orking !roup "est )ractices #or Mi ed Methods ational readiness for change.

Implement Sci 200 , 4: 46. )ubMed Abstract ] "ioMed Centra u 9e t ]

)ubMed Centra u 9e t

6. /einer "=, Amick H, Lee ( :̀ "onceptuali>ation and measurement of organi>ational

readiness for change: a review of the literature in health services research and

other elds.

Med Care 0es 0e- 2003, 85 %7&: 6 87 4. )ubMed Abstract ] )ub isher u 9e t

3. /einer "=, Le is MA, Linnan LA: Using organi>ation theor! to understand the

determinants of e?ective implementation of worksite health promotion programs.

.ealth 2duc 0es 200 , /4 %2&:2 28 0 . )ubMed Abstract ] )ub isher u 9e t

. -icke -C, 9a or BC, Labbok MH, /einer "=, /i iamson -B: &ppl!ing organi>ation theor! to

understand barriers and facilitators to the implementation of bab!-friendl!: a multi-

site 3ualitative stud!.

Midwifer" 201 .

Bpub ahead o# print

70. Labbok M, (tar ing A: )e nitions of breastfeeding: call for the development and use of

consistent de nitions in research and peer-reviewed literature.

Breastfeed Med 2012, @%4&: 68702. )ubMed Abstract ] )ub isher u 9e t

71. Chantr C, Bg ash A, Labbok M: &'M position paper on breastfeeding.

Breastfeed Med 2003, 2 %7&:2468260. )ubMed Abstract ] )ub isher u 9e t

72. C'C )ed-(( Hea th

$ndicatorsI http:55 .cdc.go+5pednss5 hat[is5pednss[hea th[indicators.htm webcite J

7 . )e'-(( dataI http:55 .nutritionnc.com5nutrsur+.htm webcite J

http://www.internationalbreastfeedingjournal.com/pubmed/21671279http://www.internationalbreastfeedingjournal.com/pubmed/21671279http://www.internationalbreastfeedingjournal.com/pubmed/21671279http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&cmd=prlinks&retmode=ref&id=21671279http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&cmd=prlinks&retmode=ref&id=21671279http://www.internationalbreastfeedingjournal.com/pubmed/11795063http://www.internationalbreastfeedingjournal.com/pubmed/11795063http://www.internationalbreastfeedingjournal.com/pubmed/11795063http://dx.doi.org/10.1348/014466601164939http://dx.doi.org/10.1348/014466601164939http://www.internationalbreastfeedingjournal.com/pubmed/19840381http://www.internationalbreastfeedingjournal.com/pubmed/19840381http://www.internationalbreastfeedingjournal.com/pubmed/19840381http://dx.doi.org/10.1186/1748-5908-4-67http://dx.doi.org/10.1186/1748-5908-4-67http://dx.doi.org/10.1186/1748-5908-4-67http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=19840381http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=19840381http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=19840381http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=19840381http://www.internationalbreastfeedingjournal.com/pubmed/18511812http://www.internationalbreastfeedingjournal.com/pubmed/18511812http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&cmd=prlinks&retmode=ref&id=18511812http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&cmd=prlinks&retmode=ref&id=18511812http://www.internationalbreastfeedingjournal.com/pubmed/18469319http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&cmd=prlinks&retmode=ref&id=18469319http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&cmd=prlinks&retmode=ref&id=18469319http://www.internationalbreastfeedingjournal.com/pubmed/23215907http://www.internationalbreastfeedingjournal.com/pubmed/23215907http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&cmd=prlinks&retmode=ref&id=23215907http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&cmd=prlinks&retmode=ref&id=23215907http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&cmd=prlinks&retmode=ref&id=23215907http://www.internationalbreastfeedingjournal.com/pubmed/19086830http://www.internationalbreastfeedingjournal.com/pubmed/19086830http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&cmd=prlinks&retmode=ref&id=19086830http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&cmd=prlinks&retmode=ref&id=19086830http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&cmd=prlinks&retmode=ref&id=19086830http://www.cdc.gov/pednss/what_is/pednss_health_indicators.htmhttp://www.webcitation.org/query.php?url=http://www.cdc.gov/pednss/what_is/pednss_health_indicators.htm&refdoi=10.1186/1746-4358-8-5http://www.nutritionnc.com/nutrsurv.htmhttp://www.webcitation.org/query.php?url=http://www.nutritionnc.com/nutrsurv.htm&refdoi=10.1186/1746-4358-8-5http://www.webcitation.org/query.php?url=http://www.nutritionnc.com/nutrsurv.htm&refdoi=10.1186/1746-4358-8-5http://www.internationalbreastfeedingjournal.com/pubmed/21671279http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&cmd=prlinks&retmode=ref&id=21671279http://www.internationalbreastfeedingjournal.com/pubmed/11795063http://dx.doi.org/10.1348/014466601164939http://www.internationalbreastfeedingjournal.com/pubmed/19840381http://dx.doi.org/10.1186/1748-5908-4-67http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=19840381http://www.internationalbreastfeedingjournal.com/pubmed/18511812http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&cmd=prlinks&retmode=ref&id=18511812http://www.internationalbreastfeedingjournal.com/pubmed/18469319http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&cmd=prlinks&retmode=ref&id=18469319http://www.internationalbreastfeedingjournal.com/pubmed/23215907http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&cmd=prlinks&retmode=ref&id=23215907http://www.internationalbreastfeedingjournal.com/pubmed/19086830http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&cmd=prlinks&retmode=ref&id=19086830http://www.cdc.gov/pednss/what_is/pednss_health_indicators.htmhttp://www.webcitation.org/query.php?url=http://www.cdc.gov/pednss/what_is/pednss_health_indicators.htm&refdoi=10.1186/1746-4358-8-5http://www.nutritionnc.com/nutrsurv.htmhttp://www.webcitation.org/query.php?url=http://www.nutritionnc.com/nutrsurv.htm&refdoi=10.1186/1746-4358-8-5


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77. reed !L, C ark (=, (orenson =, Lohr =A, Ce#a o or9bench . "er in: A9LA(.ti (cientiDc (o#t are 'e+e opment?

200 .

1. Cres e =/: !ualitati-e In uir" and 0esearch /esign, Choosing among -e approaches . 2nd

edition. 9housand aks, CA, (: (age )ub ications, $nc? 2006.

2. orman =, Cres e =/, 'amschroder L, Eo a ski C), Erein (L: Dualitative research methods:

ke! features and insights gained from use in infection prevention research.

Am J Infect Control 2003, 28: 6478661. )ubMed Abstract ] )ub isher u 9e t

. `in

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