Executive Summary - California State University, Northridge Extternal...Executive Summary 3 Course...

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Executive Summary 3

Course and Internship Objectives 3

Key Findings 4

Introduction 6

Course Description 6

Internship Description 7

Data Collection and Quantitative Analyses 8

Materials 8

Data Collection 8

Assessment of Knowledge and Skills 8

Table 1: Knowledge and Skills 9

Assessment of Attitudes and Confidence 9

Table 2: Attitudes and Confidence 10

Assessment of Interest Toward Lactation Education 10

Table 3: Specific Interest Items 11

Qualitative Data Analysis 11

Reasons for Enrolling in Course 11

Table 4: Question 1 12

Knowledge, Skills, and Changes in Understanding 12




Overall Satisfaction 16




Structured Interviews with Internship Students 19

Questions on Skills, Knowledge, Competency, and Confidence 19

Questions on Career Plans and Interest Toward Lactation Education 21

Questions on Overall Satisfaction 22

Paired Samples t-Tests for Internship Students 23

Table 11 23

References 24

Appendices 25

Appendix A: Pretest and Posttest Questionnaire 25

Appendix B: Posttest Open-ended Questions 31

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Research suggests that lack of basic knowledge and skills among future healthcare professionals

is linked with low breastfeeding rates. Improving the lactation education curriculum in

undergraduate and graduate programs that train future healthcare professionals may have a

positive impact on those entering the healthcare field, while leaving them better prepared to

integrate lactation education into their future practice. This report is an evaluation of a three-unit

lactation education course and lactation education internship which aims to increase students’

competencies in the area of lactation education. The evaluation also examined whether

participation in the course and internship had an impact on students’ interest toward integrating

lactation education into a future healthcare career, as well as students’ overall satisfaction with

the course and internship.

The evaluation utilized pretest and posttest assessments of students enrolled in the Health

Sciences (HSCI) 434 Lactation Education course in the Health Sciences Department at

California State University Northridge (CSUN). The assessments evaluated changes from the

beginning to the end of the semester in students’ 1) knowledge, attitudes, and skills needed to

serve as lactation educators in the community; 2) confidence in their ability to serve as lactation

educators in the community; and 3) motivation/interest to integrate lactation education into a

future healthcare career. The posttest assessments also included qualitative/open-ended questions

about the students’ overall satisfaction with the course.

The second component of the evaluation involved in-depth semi-structured phone interviews

with students who completed both HSCI 434 and a 120 hour lactation education internship. The

internship students were asked detailed questions about their experience with the internship,

including what they found beneficial about the internship and how the internship shaped their

desire to pursue lactation education as a full-time career. Presented below are findings on the

impact of the lactation education course and internship on students’ knowledge, attitudes, skills

and confidence needed to serve as lactation educators in the community, as well as future interest

in integrating lactation education into a future healthcare career. The report also highlights

findings on students’ overall satisfaction with the course and the internship experience.

Course and Internship Objectives

The assessments in the report were designed to measure the following objectives of the HSCI

434 Course and lactation education internship:

1) Students in the HSCI 434 Lactation Education course and lactation internship will

increase in their content knowledge, procedural knowledge, positive attitudes about

promoting and supporting breastfeeding, skills needed to implement lactation education

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in the community, and confidence in their ability to provide lactation education, from the

beginning to the end of the semester.

2) Students in the HSCI 434 Lactation Education course and lactation internship will

increase in their level of interest either toward integrating lactation education into a

current or future healthcare career, or interest toward becoming International Board

Certified Lactation Consultants (IBCLCs).

3) Students in the HSCI 434 Lactation Education course and lactation internship will report

overall satisfaction with their experiences in the course/internship.

Key Findings

Changes in Students’ Competencies in the Area of Lactation Education Following the

Completion of the Lactation Education Course: The first objective of the course and

internship assessed by this report was to improve students’ lactation content and procedural

knowledge, lactation education skills, attitudes toward promoting breastfeeding, and confidence

in their ability to provide lactation education. Quantitative analysis of the questionnaires showed

statistically significant improvements in the students’ breastfeeding content knowledge,

breastfeeding procedural knowledge, attitudes toward promotion of breastfeeding, and

confidence in their ability to provide lactation education. While there was no statistically

significant improvement in the students’ scores on items assessing skills utilized by lactation

educators in the field, this only pertained to a subset of a larger assessment. Additionally, these

scores were higher at the end of the semester overall. Therefore, the first objective of the course

was supported by the evidence provided by this report.

Changes in Students’ Interest to Integrate Lactation Education into a Future Healthcare

Career Following the Completion of the Lactation Education Course: The second objective

of the course and internship assessed by this report was to improve students’ interest toward

integrating lactation education into a current or future career. Quantitative analysis of the

questionnaires showed statistically significant improvements in the HSCI 434 students’ level of

interest from the beginning to the end of the semester. Specifically, following completion of the

course, students reported significant increases in their interest to 1) participate in an internship

that would provide them with the opportunity to gain practical experience as lactation educators,

and 2) pursue a career as a lactation educator. Therefore, the second objective of the course was

supported by the evidence found in this evaluation.

Students’ Overall Satisfaction with the Lactation Education Course: Qualitative analysis of

students’ responses to open-ended questions about the course provided a nuanced look into the

students’ experience in the course. They found the content to be valuable, either for their

personal benefit when breastfeeding their children, for a related health-care career such as a

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public health educator or registered dietitian, or for a general desire to learn more about the topic

of breastfeeding. While students enrolled in the course for a variety of reasons and from a variety

of backgrounds, they responded unanimously that the course met their expectations. The course

piqued the interest of several students toward considering a career as a Lactation Educator or

International Board Certified Lactation Consultant. Many students gained an appreciation for the

importance of breastfeeding and wished to advocate for it as a result, while several stated that the

course directly influenced them to exclusively breastfeed. Therefore, while not all students were

influenced to consider careers in lactation education, this increase in advocacy and desire to

promote breastfeeding may translate into more indirect interest in the field of lactation education.

Recommendations for Improving the Lactation Education Course: Based on the open-ended

responses collected from students, recommendations for future sections of the course are

summarized in the report. One common suggestion was that the HSCI 434 course be expanded to

a two-semester sequence in order to adequately cover all content. Another frequent suggestion

was that more information on post-partum breastfeeding be included in the curriculum. Other

than these suggestions, response to the course was extremely positive.

Changes in Students’ Competencies in the Area of Lactation Education Following the

Completion of the Lactation Education Internship: The internship students all agreed that

they felt more confident about their lactation knowledge and skills, as well as their ability to

serve as lactation educators in the community, as a result of the internship. The students all

agreed that participating in the internship helped them successfully develop skills used by

lactation educators in the field, including motivational interviewing, maintaining client

confidentiality, documentation, and understanding the lactation educator’s scope of practice.

They attributed these improvements to being able to put into practice the skills they learned, as

well as being able to actually apply information they had previously read about in the HSCI 434

class. Each of the students felt they left the internship with enough preparation to begin working

as a Lactation Educator immediately. Therefore, the first objective of the internship was

supported by the results.

Changes in Students’ Interest to Integrate Lactation Education into a Future Healthcare

Career Following the Completion of the Lactation Education Internship: The internship

facilitated the students’ pre-existing interest in the field of lactation education and provided them

with further understanding of what a career in lactation education entails. Having addressed first-

hand the breastfeeding concerns of actual mothers, each of the students agreed that the internship

dramatically increased their interest toward incorporating lactation education into their future

careers. At least one internship student was influenced to change the course of her career to

become a full-time Lactation Educator as a direct result of participating in the internship.

Another student said she was strongly considering becoming an IBCLC, which was something

she had not given much thought to prior to the internship. Therefore, the second objective of the

internship was supported by the results.

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Students’ Overall Satisfaction with the Lactation Education Internship: The third objective

of the internship that was evaluated by this report was that students would be satisfied with their

internship experience. Overall, the lactation education internship was well-received. Each of the

students responded enthusiastically that their objectives for enrolling in the internship were met.

Therefore, the third objective of the internship was supported by the results of this evaluation.

While the students felt the internship was a valuable learning experience, they expressed

frustrations with the challenges associated with delivering breastfeeding education via phone.

Those challenges included finding available times to schedule the phone intervention, as well as

clients’ failure to pick up their phones during scheduled appointments.

Recommendations for Improving the Lactation Education Internship: Based on the

internship students’ feedback, recommendations for future iterations of the internship are to

explore collaborations with community organizations that would be able to provide students with

the opportunity to gain face to face experience implementing breastfeeding education. For

instance, some students suggested having more time in the clinic interacting with the clients

face-to-face. Other sites to consider include the hospital setting where students could deliver

face-to-face breastfeeding education to new mothers prior to them being discharged from the

hospital. Aside from these suggestions, each of the students felt their experience with the

internship was very positive. According to one student, “I gained much more knowledge about

breastfeeding, including things I had not even thought about. It really was an eye-opening

experience, and I was able to see where I would fit in when it comes to educating mothers, either

pregnant or after giving birth, on how to best feed their baby.”

Course Description

The objective of HSCI 434 is to provide students with the knowledge and skills needed to serve

as lactation educators in the community. Lactation Educators (sometimes also called lactation

counsellors or specialists) are individuals trained to provide basic education and support to

pregnant and breastfeeding women (Childbirth and Postpartum Professional Association, 2011).

Their job responsibilities may include: teaching prenatal breastfeeding classes, providing one-

on-one breastfeeding education to new mothers during their hospital stay, answering calls on

breastfeeding information lines, and renting or selling breast pumps. Students who successfully

complete the HSCI 434 Lactation Education course receive a certificate of completion. After this

point they may call themselves “certificated” Lactation Educators (CLE), but this does not

constitute a certification, credential, or license.

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Students planning to enter a variety of healthcare professions, including public health, dietetics,

childcare, and nursing, may utilize the knowledge and skills gained in the course to educate

mothers on how to breastfeed effectively and responsibly. For example, following completion of

the lactation education course, a student pursuing a career as a public health educator will be

prepared to develop breastfeeding promotion programs, teach breastfeeding group classes, and

use motivational interviewing techniques to encourage more women to successfully breastfeed.

A student interested in pursuing a career as a dietetic professional will be prepared to integrate

lactation education into nutrition counseling sessions with pregnant and breastfeeding mothers.

A student interested in pursuing a career as an early childcare provider will be prepared to

support breastfeeding mothers maintain their milk supply upon returning to work. A student

interested in pursuing a career as a nurse will be better prepared to help new mothers properly

initiate breastfeeding during their hospital stay.

Some students may choose to use the lactation education course as a stepping stone to pursue the

training and education needed to become a more advanced clinical lactation professional (i.e., an

International Board Certified Lactation Consultant [IBCLC]). Students interested in earning the

IBCLC certification are required to complete education and training beyond the HSCI 434

lactation education course. They must complete 90 hours of lactation specific education (45 of

which are covered by the HSCI 434 course), eight undergraduate health science courses, six

continuing education courses, and 300 to 1000 clinical hours (depending on prior work

experience and whether the individual possesses a healthcare license) specific to lactation. They

must also pass the International Board of Lactation Consultant Examiners (IBCLE) exam.

Internship Description

The objective of the lactation education internship is to provide students who have completed

HSCI 434 with experience implementing breastfeeding education in the community. The

internship included two parts: 1) a post-course training and 2) a field training component. The

post-course training students received included the following topics: content knowledge needed

to facilitate prenatal breastfeeding education and support, counselling skills, phone manners,

understanding the lactation educator’s scope of practice, client confidentiality and

documentation, and key breastfeeding terminology in Spanish (not all internship students

undergo the Spanish-language training). The field training component of the internship gave

students the opportunity to gain practical experience providing phone-based prenatal

breastfeeding education to pregnant mothers.

Once the internship started, the students were required to provide phone-based prenatal lactation

education to approximately 10 mothers each. They first recruited pregnant mothers waiting to see

a doctor at a community health center. For mothers who expressed interest in participating and

signed a consent form, the students followed up with four to five phone calls in which they

addressed the mothers’ breastfeeding concerns and provided them with key information mothers

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should know to breastfeed successfully. The students were required to document any

breastfeeding concerns the mothers may have had as well as all breastfeeding education that they

provided to the mothers. They were also required to submit their chart notes to the instructor,

complete a research project, and maintain a reflection journal about their experience.

Materials

The pretest survey consisted of 39 items created by a previous evaluation team, which itself was

based on several existing instruments (Jepson-Sullivan, 2010; Parker, 2005; Radcliffe & Payne,

2009). Additional items regarding attitudes toward lactation education were adapted based on the

Breastfeeding Competencies outlined by the United States Breastfeeding Committee (United

States Breastfeeding Committee, 2010). The posttest survey taken by the Fall 2014 cohort was

identical to the pretest survey. The posttest survey taken by the Spring 2015 cohort was slightly

revised. It contained the same 39 pretest items, but was adapted to include four additional

questions measuring students’ interest toward integrating lactation education into a future career,

as well as seven open-ended questions regarding their experience with the course.

Data Collection

Data for the present evaluation was collected from three groups of students taking HSCI 434:

one from the Fall 2014 semester and two from the Spring 2015 semester. Paper-and-pencil

surveys were distributed to the students at the beginning (pretest) and end (posttest) of each

semester. For the Fall 2014 class, a total of 32 students were surveyed. Among these, five

students either did not submit a pretest or posttest survey. Since their difference in scores from

the beginning to the end of the semester could not be assessed, these students were not included

in any analyses. For the Spring 2015 classes, a total of 60 students (30 students per class) were

surveyed. One student did not submit a posttest survey, and so was not included in any analyses.

The pretest and posttest surveys that were able to be matched left a total sample size of 86.

Assessment of Lactation Knowledge and Skills

The first 18 survey items were true/false statements designed to measure basic knowledge

students need to serve as lactation educators in the community. The first 10 of these pertained

to content knowledge (i.e., the understanding of the advantages and disadvantages of

breastfeeding). Topics here included health benefits of breastfeeding for the breastfed baby and

the breastfeeding mother, and how the composition of breastmilk differs from formula. These

items were averaged to form a Content Knowledge subscale. A sample item is “True or False:

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Infants who are formula-fed are less likely to develop diabetes or become obese later in life

compared to infants who are breastfed.” The next 8 items concerned procedural knowledge

needed to successfully breastfeed. These items were averaged to form a Procedural Knowledge

subscale. A sample item is “True or False: A woman can produce more milk by increasing the

frequency of breastfeeding.” The next five items were multiple choice questions regarding skills

that lactation educators would need to possess in practice. These items were averaged to form a

Skills subscale. A sample item is “All of the following situations are within a lactation educator’s

scope of practice EXCEPT: A) Mother has question about breastfeeding positions she can use at

night so she can get more sleep. B) Exclusively breastfeeding mother is concerned about her

milk supply. Her baby was just seen (i.e., early that day) by a pediatrician who reported that her

baby’s weight gain is normal. C) Mothers reports that her six day old baby’s bowl movements

are green. D) Older baby is refusing to breastfeed.”

Scores for the preceding subscales were derived by first scoring individual items as correct or

incorrect, and then calculating the percentage correct. For instance, the average subscale score

for the Knowledge items at pretest was .83, meaning that participants on average answered about

83% of those items correctly. Paired samples t-tests were run comparing the change in students’

scores from pretest to posttest. As seen in Table 1, the average score on the Content Knowledge

subscale increased from 83% to 96% for a mean difference of 13%. This difference was

statistically significant (p < .001). Next, the average score on the Procedural Knowledge subscale

increased by 24% from pretest to posttest, and this difference was statistically significant (p <

.001). While the average score on the Skills subscale increased from pretest to posttest, this

difference was not statistically significant (p > .05). In other words, students on average

performed better on these items at the end of the semester compared to the beginning, but the

magnitude of the increase in scores was negligible.

Table 1: Paired Samples t-Tests for Lactation Core Competencies

Subscale

# of

Items

Pretest Posttest

Difference t-value (df) M SD M SD Content Knowledge 10 .83 .16 .96 .06 .13 7.99 (85)***

Procedural Knowledge 8 .68 .17 .92 .09 .24 14.50 (85)***

Skills 5 .77 .18 .78 .16 .01 .28 (85)

**p < .01.; ***p < .001. Scores are reported in terms of percentage correct.

Assessment of Attitudes that Protect, Promote and Support

Breastfeeding and Confidence to Implement Lactation Education

Following the knowledge section were multiple-choice items designed to measure students’

attitudes toward providing care that protects, promotes, and supports breastfeeding, as well as

students’ level of confidence in their ability to utilize basic knowledge and skills need to serve as

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lactation educators in the community. Response choices for items in this section were: 1 =

strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree. The first eight items pertained to

students’ personal attitudes toward lactation education. A sample item is: “I value breastfeeding

as an important health promotion and disease prevention strategy.” These items were averaged to

form an Attitudes subscale. The next eight items assessed students’ confidence in their own

ability to act as lactation educators. These items were averaged to form a Confidence subscale. A

sample item includes: “I am confident in my ability to address most concerns a pregnant mother

may have about breastfeeding.”

Scores for the preceding subscales were derived by computing the mean of the individual items

within each scale. For instance, the average subscale score for the Confidence subscale at pretest

was 2.72, meaning that participants on average responded to those items with a moderate amount

of agreement on a one to four scale. Next, paired samples t-tests were run comparing the change

in students’ scores from pretest to posttest. As seen in Table 2, the average score on the Attitudes

subscale increased from 3.68 to 3.86 for a mean difference of .18. This difference was

statistically significant (p < .001). Next, the average score on the Confidence subscale increased

by .96 from pretest to posttest, and this difference was statistically significant (p < .001).

Table 2: Paired Samples t-Tests for Attitudes and Confidence

Subscale

# of

Items

Pretest Posttest

Difference t-value (df) M SD M SD Attitudes 8 3.68 .30 3.86 .38 .18 4.28 (83)***

Confidence 8 2.72 .68 3.68 .44 .96 11.39(85)*** **p < .01.; ***p < .001. 1 = Strongly Disagree, 2 = Disagree, 3 = Agree, 4 = Strongly Agree.

Assessment of Interest to Integrate Lactation Education into a Future

Healthcare Career

The last four items were multiple choice questions assessing students’ interest toward integrating

lactation education into their current/future careers. These last four items were added for the

Spring 2015 semester data collection as part of several modifications to the survey. Hence, these

items were not asked of the students from the Fall 2014 semester. A sample item is “I am

interested in integrating lactation education into my future career.” These items were averaged to

form an Interest subscale, and then paired samples t-tests were run to assess students’ change in

scores from pretest to posttest. As seen in Table 3, the average score on the Interest subscale

increased by .22 from pretest to posttest. This difference was statistically significant (p < .01).

Additional paired samples t-tests were run on the four individual items comprising the Interest

subscale. As seen in Table 3, the average score on the item relating to students’ interest toward

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participating in a lactation internship increased by .45, and this increase was statistically

significant. Scores for the item concerning interest toward integrating lactation education into a

future career did not increase from pretest to posttest. Scores for the item relating to interest

toward pursuing a career as a lactation educator increased by .60 from pretest to posttest, and this

increase was statistically significant. Scores for the item relating to interest toward becoming a

board certified lactation consultant (IBCLC) increased by .01 from pretest to posttest, but this

difference was not statistically significant.

Table 3: Paired Samples t-Tests for Career Interest and Individual Interest Items

Subscale/Individual Interest Item

Pretest Posttest

Difference t-value (df) M SD M SD Interest Subscale (4 items in total) 3.31 .55 3.53 .54 .22 2.66 (57)**

Interest to participate a lactation education internship 3.47 .57 3.72 .45 .26 3.24 (57)**

Interest in integrating lactation education into future career. 3.44 .63 3.44 .68 0.00 1.0(57)

Interest in pursuing a career as a lactation educator. 3.10 .74 3.71 .53 .60 5.36 (57)***

Interest in becoming an IBCLC. 3.21 .71 3.22 .80 .01 .08(57)

**p < .01.; ***p < .001. 1 = Strongly Disagree, 2 = Disagree, 3 = Agree, 4 = Strongly Agree.

The posttest surveys distributed to the Spring 2015 class included an additional seven open-

ended questions. Responses were analyzed by first identifying recurring themes across all cases,

and then coding each response based on whether or not it matched one or several of the themes

that were identified. The responses were matched to each theme on a spreadsheet, and then

percentages were calculated to determine the frequency of respondents mentioning each theme.

If a participant left the space blank, his or her response was not included when calculating the

frequencies for that question. For instance, four participants left the question about useful skills

blank, so the frequencies for that question were calculated proportional to 55 instead of 59

participants.

Question Relating to Motivation for Enrolling in the Lactation

Education Course

The first open-ended question concerned participants’ reasons or motivations for taking the

HSCI 434 course. Eleven common themes were determined across 56 responses. As seen in

Table 4, the most commonly mentioned reason for taking the course was to gain general

knowledge about breastfeeding, or otherwise having a general interest or curiosity about the

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topic. The next most frequently cited motivation was to obtain information as a current mother or

mother-to-be. Participants’ third most frequently mentioned motivation for taking the course was

to obtain knowledge that they could then use to help educate mothers and families about

breastfeeding. Other commonly mentioned motivations include wanting to learn more about the

field of lactation education for a current or potential career, wanting to learn about the benefits of

breastfeeding, wanting to gain experience to be used in a related health-care field, wanting to

earn the certificate of completion or otherwise be able to put the experience on their resume,

having taken the instructor previously, gotten a recommendation, or heard about the course

through word of mouth, wanting to learn about the importance of breastfeeding, taking it for

elective credit, and wanting to learn about breastfeeding barriers.

A representative response to this question is “I wanted to find out more info about breastfeeding

for when I have children. I'm also a public health student so it wouldn't hurt to have knowledge

on this subject, plus I can put it on my resume.” This response would be coded with the

following themes: 1) “Learn more as a current/future mother;” 2) “Learn more for application in

related health field;” and 3) “Desire to add “Certificated Lactation Educator” to their resume.”

Table 4: Frequency of Responses to Open-ended Question #1 (N = 56)

“What were your primary motivations for taking this course?”

Theme % Mentioned

General knowledge/interest/curiosity about breastfeeding 33.93%

Learn more as a current/future mother 23.21%

Gain knowledge to help educate other parents about breastfeeding 19.64%

Learn more about current/future career in lactation education 14.29%

Learn about health benefits of breastfeeding 10.71%

Learn more for application in related health field (e.g., nutrition, pediatrics) 10.71%

Desire to add “Certificated Lactation Educator” to their resume 10.71%

Word of mouth/recommendation/took professor previously 8.93%

Learn about importance of breastfeeding 7.14%

Elective 5.36%

Learn more about barriers to breastfeeding 3.57%

Questions Related to Knowledge and Skills Students Hoped to Gain

From the Course

The second open-ended question asked participants what knowledge or skills they hoped to

obtain when they first enrolled in the course. Twelve common themes were determined across 54

responses. As seen in Table 5, the most frequently cited skill or topic participants wished to learn

was how encourage or promote breastfeeding. The next most commonly mentioned skill or topic

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was information on how to actually breastfeed, including techniques such as positioning and

pumping. Participants’ third most frequently mentioned skill or topic they hoped to learn about

was overall knowledge of breastfeeding. Other commonly mentioned skills or topics participants

wished to learn about include the health benefits of breastfeeding, the science behind lactation

(e.g., biological, anatomical, physiological); barriers to breastfeeding and how to overcome

them, skills to gain professional competence in a health-care field, learning about lactation

education as a career, information for working mothers, what mothers could expect either before,

after, or during breastfeeding, and clarification of pre-existing beliefs or questions. Several

participants also responded that they weren’t sure or had no specific skill or content area they

wished to learn. Other skills or topics mentioned include counseling skills and cultural

competency skills.

One participant’s response to being asked what she hoped to learn prior to starting the course:

“How to breastfeed and the physiology behind milk production and maintenance. Also, I wanted

learn about lactation for incorporation into my future practice in the nutrition field.” This

response would be coded with the following themes: 1) “Procedural knowledge relating to how

to breastfeed successfully;” 2) “Anatomy and physiology of lactation;” and 3) “Gain skills for

professional competence.”

Participants were also asked if they felt their objectives for taking the course were met. While

frequencies for this question are not presented here, participants were almost unanimous in

replying that their objectives were in fact met. Some representative responses include

“Absolutely. I even feel confident enough to teach other mothers” and “Overall, this course is

more than what I was expecting. The information is simple enough to understand and

communicate.”

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“What specific skills or knowledge did you hope to gain prior to taking this course?”

Theme

%

Mentioned

Learn how to motivate, encourage, or promote breastfeeding to others 40.74%

Procedural knowledge relating to how to breastfeed successfully, including: latching and positioning, how to pump to maintain milk supply 37.04%

General information 22.22%

Learn about health benefits for mother and/or child 12.96%

Anatomy and physiology of lactation 12.96%

Learn common breastfeeding barriers and strategies to overcome those barriers 11.11%

Lactation information relevant to working mothers 7.41%

Nothing specific/not sure 7.41%

What to expect before/during/after breastfeeding 5.56%

Gain skills for professional competence 5.56%

Clarification 3.70%

Learn about career in lactation education 3.70%

The third open-ended question asked participants how their understanding of breastfeeding had

changed upon completing the HSCI 434 course. Ten common themes were determined across 56

responses. As seen in Table 6, the most commonly mentioned change in understanding was of a

general change or overall improvement in knowledge about breastfeeding. The next most

frequently cited change was an increased appreciation for the importance of breastfeeding.

Participants’ third most frequently mentioned change in understanding was in regards to

increased knowledge of the health benefits of breastfeeding. Another common change in

understanding was an increased level of advocacy (i.e., becoming more pro-breastfeeding) or

otherwise an increased desire to promote breastfeeding. One response which is representative of

the theme of advocacy is: “Lactation education is important and since there are several myths

regarding breastfeeding, lactation education needs to be promoted more and more families need

to take advantage of lactation education.”

Several participants also replied that the course gave them an appreciation for the complexity of

the issues surrounding breastfeeding. Others replied that before taking the course they hadn’t

realized many of the difficulties and barriers some mothers may face when trying to breastfeed

or that they hadn’t realized many mothers lack the support necessary to breastfeed. Several

participants also mentioned that they gained either further interest or awareness for the field of

lactation education. A few responses which typify this change in understanding: “At the

beginning I did not know the difference in the lactation educator job and lactation consultant

other than the exam, but this course changed a lot of the information I had before” and “I had no

idea there was a position called a lactation educator. Taking this course gave me insight in the

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way breast milk is produced, and how the lactation educator is able to assist the mother in

establishing good milk supply.”

Other changes cited as a result of the course include a greater confidence to help mothers with

breastfeeding goals, clarification of misconceptions and myths, and increased knowledge of

biological and physiological aspects of breastfeeding. Several participants replied that they

experienced no change or that they were not sure how their understanding had changed as a

result of this course.


“How has your understanding of lactation and/or lactation education changed as a result

of taking this course?”

Theme % Mentioned

General change for the better 33.93%

Greater appreciation for importance of breastfeeding 25.00%

Increased knowledge of health benefits 16.07%

Promotion/advocacy 14.29%

Greater appreciation for complexity/barriers/difficulty for mothers with no support 10.71%

Further interest/awareness toward career in lactation education 7.14%

Greater confidence to help mothers 5.36%

Clarification of previously held misconceptions 5.36%

Knowledge of physiology/biology/anatomy 3.57%

No changes 3.57%

The fourth open-ended question asked participants to share what skills or content learned in the

course they found especially useful. Twelve common themes were determined across 55

responses. As seen in Table 7, the most commonly mentioned skill or content area was learning

about breastfeeding techniques such as positioning. The next most frequently cited useful skill or

content area was learning about breastfeeding myths and misconceptions. A response which

represents this theme follows: “I found the myths and conceptions segments especially useful

because I would be able to explain to a mother that yes, her body can produce enough milk, and

no, frequent feeding is not a sign that her baby is not getting enough to eat, and so on.” The third

most frequently mentioned skill or content area participants found useful was learning about the

health benefits of breastfeeding. Other useful skills or content areas commonly mentioned by

participants include barriers to breastfeeding, biological and physiological aspects of

breastfeeding, warning signs that a baby is still hungry or did not latch properly, learning about

hospital practices that may conflict with breastfeeding, practicing lactation techniques with a

doll or model breast, receiving information about a career in lactation education, learning about

the history of breastfeeding, and learning about milk production and storage. Although not a skill

16

or content area in and of itself, several participants mentioned visual aids such as videos and

diagrams as being particularly effective in helping them to engage with the material. Additional

useful skills or content areas include learning about colostrum, and biological nursing.


“Are there any skills and/or content areas covered in this course that you found

especially useful? If so, can you please elaborate?”

Theme % Mentioned

Proper technique (latching, positioning, etc.) 37.50%

Breastfeeding myths/misconceptions 17.86%

Health benefits of breastfeeding 14.29%

Barriers to breastfeeding 12.50%

Anatomical/physiological/biological aspects 10.71%

signs that baby is getting enough to eat (i.e., signs of effective milk transfer) 8.93%

Visualization - slides, videos, graphics 7.14%

Hospital practices 7.14%

Practicing with a doll/model breast 5.36%

Information about careers in the field of lactation 5.36%

History of breastfeeding 5.36%

Learning about milk production/storage 3.57%

Questions Relating to Overall Satisfaction

The fifth open-ended question asked participants to share what they found most beneficial by

taking the course. Ten common themes were determined across 59 responses. As seen in Table 8,

the most commonly mentioned benefit was in gaining a general understanding or overall increase

in breastfeeding knowledge. The next most frequently mentioned benefit was that after taking the

course, the students were in a better position to help educate mothers and fathers about

breastfeeding. The third most frequently mentioned benefit was in learning skills and

information that mothers could use when breastfeeding their current or future children. Many

students also responded by saying they left the class with a greater appreciation or realization for

the importance of breastfeeding. Other benefits commonly mentioned by participants include

clarification of their own previously held misconceptions or questions regarding breastfeeding, a

favorable attitude toward breastfeeding or otherwise being influenced to breastfeed their own

children, learning about career opportunities in lactation education, earning the certificate of

completion, greater confidence to initiate breastfeeding their own children, skills or experience

they could apply to a related healthcare profession (e.g., dietetic professionals, public health

educators), and greater ability to encourage mothers to breastfeed or otherwise disseminate

information about its benefits.

17

A representative response to this question follows: “As a woman I now feel very confident I have

the knowledge and skills to exclusively breastfeed my own child someday. As a public health

student, this made me aware of the needs breastfeeding mothers have and I will be able to tailor

public health programs for them.” This participant’s response would be coded with four themes:

1) “Help for breastfeeding one’s own children;” 2) “Confidence to initiate breastfeeding;” 3)

“Better ability to educate other parents;” and 4) “Experience relevant to current/future career in

healthcare field.”


“How do you believe you benefitted most by taking this course?”

Theme

%

Mentioned

General understanding (e.g., anatomy, how breastfeeding works, barriers) 52.54%

Better ability to educate other parents (knowledge, myths, concerns, etc.) 38.98%

Help for breastfeeding one’s own children 35.59%

Greater appreciation for importance of breastfeeding 27.12%

Clarification 23.73%

Become more favorable toward breastfeeding/influenced decision to breastfeed child 15.25%

Potential career opportunities/certification 13.56%

Confidence to initiate breastfeeding 11.86%

Experience relevant to current/future career in healthcare field 11.86%

Preparation to disseminate/encourage mothers to breastfeed 8.47%

The sixth open-ended question asked participants about any content or skills they wish had been

included in the course. Five common themes were determined across 54 responses. As seen in

Table 9, the most frequent response to this question was that the participant felt nothing was

lacking in terms of content. The next most frequently cited topic that participants wished would

have been included was more information on the post-partum stage of breastfeeding.

Participants’ third most frequent response was that they wished more hands-on activities were

included. A few participants also mentioned wanting more information on pumping and latching,

and more information on milk storage. Other topics that were not mentioned enough times to be

included in the frequency table that participants wish were covered include cultural views on

breastfeeding, diseases or infections that may occur with the mother or child, how to help when a

mother cannot be skin to skin immediately after birth, how to get a fussy baby to cooperate,

reading growth charts, counseling skills, information on the different types of nipples, life-long

benefits of breastfed babies, and disadvantages of breastfeeding.

18


“Is there content or skills not covered in the course that you wish were included?”

Theme

%

Mentioned

Nothing/everything was covered 50.00%

Post-partum 16.67%

More hands-on activities 5.56%

More information on pumping/latching 3.70%

Milk storage 3.70%

The seventh open-ended question asked participants to make suggestions for improving future

semesters of the course. As seen in Table 10, the most frequently appearing responses was that

the course did not need to be improved. The next most frequently appearing comment was that

the course was quite content-heavy. Several participants suggested either increasing the length of

the class meetings or expanding the course to be taken over two semesters instead of one. Other

suggestions included more interactive elements, more hands-on activities, more coverage of the

anatomical and biological aspects of lactation, spending less time on the history of breastfeeding,

less time on the decline and rise of breastfeeding, incorporating more visual aids (e.g., videos

and diagrams) into the lectures, making the full lecture slides available to the class, discussing

more real-life scenarios that mothers may go through, and incorporating more group work or

discussions into the class. Additional suggestions not mentioned often enough to appear in the

frequency table include recruiting more males into the class, having a more user-friendly module

than the Wellstart lactation competencies test, inviting guest speakers from breastfeeding

advocacy groups (e.g., La Leche League), and promoting the class to CSUN’s nursing

department.


“Do you have any suggestions for improving the course? If so, please elaborate.”

Theme

%

Mentioned

N/A; course was good as is 39.13%

A lot of information in one semester; consider longer class or 2 semester sequence 10.87%

More interactive/hands-on activities 8.70%

More detail on anatomy/physiology 8.70%

Less on history of breastfeeding; decline/rise 4.35%

More visual components (e.g., images and videos) 4.35%

Provide full slides to students 4.35%

Discuss more real-life scenarios that mothers may go through 2.17%

19

More group work or discussions 2.17%

A total of two students completed the internship in the Fall 2014 semester, while two students

completed the internship in the Spring 2015 semester. These students agreed to participate in this

evaluation, for a total of four interviews. The students provided the instructor with their contact

information, who then provided this information to the evaluator. Shortly after the conclusion of

their respective semesters, each student was contacted individually and asked a series of open-

ended questions regarding their internship experience. Each student was asked the same series of

questions (with the exception of one question) and the interviews lasted approximately 45

minutes each on average. The questions covered students’ perceptions (in direct relation to their

internship experience) of their own confidence in their ability to disseminate lactation education

and their interest toward incorporating lactation education into their future health care career

and/or becoming an IBCLC. The internship students were also asked the same set of open-ended

questions that appeared at the end of the survey given to students in the Spring 2015 semester of

HSCI 434. The results of the interviews are presented below.

Questions Regarding Students’ Lactation Knowledge and Skills and

Confidence to Serve as Lactation Educators

The internship students all reported feeling competent about their lactation knowledge and skills

as well as their ability to apply their lactation knowledge and skills in the field. One student

thought it was very helpful having practiced the skills at length with case studies and situational

prompts, as she felt better prepared for actual questions that mothers asked her. Another said that

after the post-course training and especially after the field training component of the internship,

she felt very confident that she could teach pregnant women what to expect when breastfeeding.

The students seemed to feel overall the internship gave them valuable experience talking to

mothers, including motivational interviewing skills to uncover concerns a mother might not be

able to articulate at first, as well as experience dealing with actual mothers. In one student’s

words, “…Having an array of clients meant having different personality types and types of

women that you have to deal with, like women who are prescribed medication mid-pregnancy

that might no longer be compatible with breastfeeding. So you have to do your research and look

into it, and be able to educate them.” All four internship students were unanimous in their belief

that the internship prepared them for a career in lactation education, and all agreed they could

begin working as lactation educators with their present level of training. According to one,

“…By the end I felt much more sure and confident, not just actually speaking to the mothers but

also in the information I was providing.”

20

The internship students also responded to questions about their competency and confidence

specifically with regards to skills needed for the phone-based intervention. Key skills they

developed included motivational interviewing techniques, addressing concerns mothers may

have had about breastfeeding, maintaining client confidentiality and documentation,

understanding the lactation educator’s scope of practice, affirming and validating the mothers,

and successfully building rapport with the mothers. The students all agreed that they were

successful in developing these skills and felt that their experience in speaking with the mothers

over the phone was valuable for their careers. Three of the students were also asked about

their experiences using skills they had learned to educate Spanish-speaking mothers.

The students all felt confident they were able to successfully build rapport with their clients. Two

students found that building rapport was more difficult in the clinic than over the phone, since

time in the clinic was limited. The students shared some rapport-building techniques they found

useful, such as asking the clients how they were feeling, how their week was, or how their

pregnancy was going. One student shared a specific example of how she built rapport with a

mother who was slow to open up at first. The student kept encouraging the mother to ask her

questions until the mother felt more comfortable. The students also found it useful to talk about

themselves a little, so that the mothers would not see them as strangers. Another helpful

technique was to take note of what the mothers would say, and then try to tailor the conversation

based on that. One student shared an example: “I would repeat things they told me, for instance

‘You mentioned last week you were concerned about [xyz]’ and then discuss it with them. So

just making them feel they were being heard.”

Overall, the students found that their clients responded well to the affirmations and appreciated

the support they received. The students felt confident that they were successful in addressing

their clients’ concerns, and were comfortable acknowledging when a question was beyond their

scope of practice. In such cases, they would refer the patient to the appropriate practitioner, or

consult with the instructor to find the answer to a particular question. When responding to

mothers’ breastfeeding concerns, the students would explain that the concern was common so the

mothers did not feel alone. One student explained that being asked questions and having to

answer them over the phone forced her to think quickly on her feet and utilize many aspects of

the training she had received all at once. She felt this was an invaluable aspect of the internship.

The students were also asked about their thoughts regarding documentation and maintaining

confidentiality. It seemed the documentation took some getting used to but came naturally once

the students had enough practice. As for maintaining confidentiality, one student encountered an

incident where someone other than the client answered the phone and was frustrated that the

student could not share the client’s information over the phone. Otherwise, students did not

report any major concerns with maintaining confidentiality.

21

Three of the students had also taken a Spanish-speaking module to help them interact with

Spanish-speaking mothers. The students who took the Spanish-speaking module found it to be a

valuable resource, although not all were confident it fully prepared them to work with Spanish-

speaking clients. One student described the module as focusing on the kind of Spanish one would

learn in a classroom, whereas speaking with clients necessitated simpler, more informal

language. However, she did find it gave her useful ideas for translating topics into Spanish for

her clients. Another student learned enough to help her recruit Spanish-speaking mothers from

the clinic, but did not feel confident enough in her Spanish to take on these mothers for the

phone intervention. This student was not fluent in Spanish prior to the internship, while the other

two students were. So it is possible that the post-training confidence and competence the students

felt in implementing breastfeeding in Spanish was related to their pre-training fluency level.

Questions Regarding Career Plans and Lactation Education Interest

The internship students had diverse career goals, as well as varying levels of interest toward

lactation education prior to the practicum. One student had worked previously as a food quality

assurance analyst and originally planned to continue working in the field of food safety. She had

also considered becoming a full-time lactation educator prior to the internship, but was certain

that she wanted to after completing the internship. Another student plans to work as a

nutritionist. She had considered the possibility of becoming an IBCLC prior to the internship, but

after the internship felt about 80% sure she wants to become an IBCLC. One student attributed

this change to gaining “Both the knowledge and practice. To be able to disseminate the

information to real-life people was something I wasn’t confident in and was preventing me from

considering becoming an IBCLC. Now that I actually have that knowledge and practice it seems

more feasible, like something I could do.” Another student was motivated by seeing how little

the mothers actually knew about breastfeeding and how important it was to make resources

available to them. Still another was motivated by her realization that some of the issues she

encountered during the phone-based intervention were out of her scope of practice as a lactation

educator, but would not be for an IBCLC. One student had been under the impression that

obtaining the IBCLC credential would be extremely difficult. After completing the internship,

she came to see obtaining an IBCLC credential as a much more obtainable goal.

The internship students who plan to work in the healthcare field all expressed a strong desire to

incorporate their knowledge of lactation into their careers. One who plans to become a registered

dietitian (RD) pointed out that nutrition and breastfeeding go hand-in-hand. She explained that

many of the benefits of breastfeeding are preventative in nature, much the same as nutrition is

often preventative. So she plans to encourage her future nutrition patients to breastfeed as a

preventative measure. Another student appreciated working with the local health clinic because it

primarily served a low-income, Spanish-speaking population. The internship gave her the

opportunity to provide health education to this population.

22

All students agreed that their interest in the field increased and that the internship convinced

them to incorporate more lactation education into their chosen field. According to one, “I think

the internship reaffirmed why I want to pursue my goal of providing nutrition education as a

registered dietitian, and I think it changed that goal in a positive way.” Another had previously

wanted to apply lactation education into a career as a nutritionist or food consultant, but

explicitly changed her career goal to wanting to become a lactation educator after the internship.

Overall Satisfaction

All students left the internship satisfied and grateful for the opportunity to gain practical

experience they might not otherwise been exposed to. One stated that it helped make up her mind

to become a lactation educator, while becoming an IBCLC was “Definitely a possibility.”

Another commented “I think it was a great opportunity. Being able to recruit clients from a

community health center was very beneficial to me. I would definitely feel more confident being

a lactation educator at a community health center. Also, I think establishing rapport, learning

how to do motivational interviewing, meeting a stranger and being able to assess their needs – I

feel like it prepared me for my future career.” The primary benefits cited by the students were the

opportunity to put their knowledge into practice, and getting a sense of what sorts questions

expectant mothers may have. One student described the benefits to her as “Actually interacting

with the moms – hearing the issues from the moms themselves, versus learning about them in the

classroom. It was really eye-opening.”

As for skills or content learned in the internship that the students felt were especially valuable,

several mentioned counseling and motivational interviewing skills – not only learning them but

putting them into practice. Others mentioned the Spanish training module, and learning about

anatomy in depth. Two students emphasized that the content on milk production was

indispensable to successful lactation education. The students also appreciated learning how to

address breastfeeding misconceptions, as well as learning answers to specific issues such as the

effect of drinking alcohol on breast milk. Each of the students responded enthusiastically that

they believed the internship met their specific objectives for enrolling in it. The internship was a

good refresher on the information they were first exposed to in the HSCI 434 course, and they

were able to start actually disseminating this information.

One student explained that she became more pro-breastfeeding as a result of taking the

internship. She learned many facts about the human body and the health benefits of breast milk.

She provided the following example: “Like when a mom gets a cold, it might occur to her that

she should stop breastfeeding so the baby won’t catch the cold. But the body starts making

antibodies to protect the baby even before she caught the cold. So the protection qualities of

breast milk are amazing…that was fascinating to me.”

23

All four students agreed that they were very satisfied with the internship experience overall. A

recurring issue was in regards to scheduling with the phone-based intervention. Each of the

students found it challenging to coordinate their phone calls with the mothers, either because it

was difficult trying to find times that were convenient for both themselves and the clients, or

because clients would frequently postpone their appointment or not answer the phone at all.

As for suggestions to improve the internship for the future, one was to have a component where

the students shadow a lactation consultant. Another student commented that the project

coordinator was uncommunicative at times and needed to be more responsive to emails and

questions. Lastly, several students suggested allowing for more time to conduct the interventions

on-site as opposed to almost exclusively over the phone. The students felt that the internship was

otherwise very rewarding and well-structured.

The internship students were also given the same pretest and posttest questionnaires as the

students in the HSCI 434 course. One student did not submit a posttest and so was not included

in this analysis. Though it would not be informative to conduct paired samples t-tests on a

sample size of only three students, it can be seen in Table 11 that the four internship students

increased their content knowledge by an average of 13% and their knowledge of lactation

education skills by an average of 15%. Their procedural knowledge did not increase from pretest

to posttest, but again the small sample size renders this change difficult to examine. The

internship students also increased in their attitudes toward breastfeeding by an average of .15 (on

a one to four scale) from pretest to posttest, as well as .66 (on a one to four scale) on their

confidence in their lactation education knowledge and ability.

Table 11: Paired Samples t-Tests for Individual Career Interest Items (n = 4)

Subscale

Pretest Posttest

Difference M M Content Knowledge .85 .98 .13

Procedural Knowledge .94 .94 0.00

Skills .75 .90 .15

Attitude 3.69 3.84 .15

Confidence 3.34 4.00 .66

**p < .01.; ***p < .001. 1 = Strongly Disagree, 2 = Disagree, 3 = Agree, 4 = Strongly Agree.

24

Jepson-Sullivan, R. M. (2010). Reliability and validity of a breastfeeding knowledge survey in

allied health students (unpublished master’s thesis). The University of Utah, Salt Lake

City, Utah.

Parker, J. (2005). HIPAA Quiz. Retrieved from http://www.proprofs.com/quiz-

school/story.php?title=hipaa-quiz

Radcliff, B. & Payne, J. (2011). Hearts and Minds Project: A breastfeeding curriculum

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

Nutrition and Dietetics, 68, 201–207.

United States Breastfeeding Committee (2010). Core Competencies in Breastfeeding Care and

Services for All Health Professionals. Rev ed. Washington, DC: United States

Breastfeeding Committee.

25

Appendix A: Pretest and Posttest Questionnaire

1. Since breastfeeding requires additional calories, women who breastfeed may take longer

to return to their pre-pregnancy weight.

o True

o False

2. Infants who are breastfed are less likely to develop allergies and asthma than children

who are formula fed.

o True

o False

3. Infants who are formula fed are less likely to develop diabetes or become obese later in

life compared to infants who are breastfed.

o True

o False

4. Women who breastfeed will likely decrease their risk for uterine, endometrial, breast and

ovarian cancer.

o True

o False

5. Breastfed infants will form a closer bond with the mother than formula-fed infants

because of the increased skin-to-skin contact between the mother and child.

o True

o False

6. Ear infections and diarrhea are less common in breastfed infants.

o True

o False

7. Breastfeeding can decrease an infant’s risk of sudden infant death syndrome (SIDS).

o True

o False

26

8. With the addition of ingredients such as docosahexaenoic acid (DHA), arachidonic acid

(ARA), and iron, formula has become almost identical in composition to breast milk.

o True

o False

9. Breast milk changes in composition and volume produced depending on the age and

needs of the infant.

o True

o False

10. Breast milk and formula are equal in their digestibility.

o True

o False

11. A woman can produce more milk by increasing the frequency of breastfeeding.

o True

o False

12. If a breastfeeding women does not eat the recommended servings for all food groups for

lactation, her breast milk will not be of adequate quality for infant growth.

o True

o False

13. A mother will not be able to continue exclusive breastfeeding once she goes back to work

or school.

o True

o False

14. To avoid a decrease in length of breastfeeding duration, it is recommended that pacifiers

be avoided until one week after birth.

o True

o False

15. Babies should be fed on demand.

o True

o False

16. The first sign a baby makes to communicate his or her hunger is crying.

27

o True

o False

17. Most babies who are breastfed will need supplemental formula during growth spurts.

o True

o False

18. The amount of milk removed from a mother's breasts influences the amount of milk a

mother produces.

o True

o False

19. What kind of personally identifiable health information is protected by the Health

Insurance Portability and Accountability Act privacy rule?

o Paper

o Electronic

o Verbal

o All of the above

20. Health Insurance Portability and Accountability Act security and privacy regulations

apply to:

o Attending physicians, nurses, and other healthcare professionals.

o Health information managers, information systems staff, and other personnel only.

o Anyone working in the facility.

o Only staff that have direct patient contact.

21. Copies of personally identifiable health information may be disposed of in any garbage

can in the facility.

o True

o False

22. All of the following are reasons a lactation educator would refer a mother to a health care

provider (e.g., pediatrician, lactation consultant, primary care provider) EXCEPT:

o Baby has a fever.

o Mother is using a nipple shield incorrectly.

o Mother is returning to work and needs resources for pumping.

o Baby has yellow skin and eyes.

28

23. All of the following situations are within a lactation educator’s scope of practice

EXCEPT:

o Mother has question about breastfeeding positions she can use at night so she can get

more sleep.

o Exclusively breastfeeding mother is concerned about her milk supply. Her baby was

just seen (i.e., early that day) by a pediatrician who reported that her baby’s weight

gain is normal.

o Mothers reports that her six day old baby’s bowl movements are green.

o Older baby is refusing to breastfeed.

24. I value breastfeeding as an important health promotion and disease prevention

strategy.

o Strongly Disagree

o Disagree

o Agree

o Strongly Agree

25. I understand the importance of tailoring information and services to the family's

individual needs (culture, knowledge, or language level).

o Strongly Disagree

o Disagree

o Agree

o Strongly Agree

26. I recognize the limitations of my own lactation knowledge and breastfeeding expertise.

o Strongly Disagree

o Disagree

o Agree

o Strongly Agree

27. I have the ability to recognize when personal values and biases may interfere with

breastfeeding care and services provided to families.

o Strongly Disagree

o Disagree

o Agree

o Strongly Agree

28. I encourage workplace support for breastfeeding.

o Strongly Disagree

o Disagree

o Agree

29

o Strongly Agree

29. I would support breastfeeding colleagues.

o Strongly Disagree

o Disagree

o Agree

o Strongly Agree

30. I would support family centered policies at federal, state, and local levels.

o Strongly Disagree

o Disagree

o Agree

o Strongly Agree

31. As a health professional, I believe it would be my responsibility to highlight the health

problems associated with the use of infant/artificial formula when giving advice about

infant feeding.

o Strongly Disagree

o Disagree

o Agree

o Strongly Agree

32. In my professional capacity, I will be able to, directly or indirectly, influence a woman's

decision to initiate breastfeeding.

o Strongly Disagree

o Disagree

o Agree

o Strongly Agree

33. In my professional capacity, I will be able to, directly or indirectly, influence a woman's

ability to reach her breastfeeding duration goal.

o Strongly Disagree

o Disagree

o Agree

o Strongly Agree

34. I am confident in my ability to educate others on the benefits of breastfeeding.

o Strongly Disagree

o Disagree

o Agree

30

o Strongly Agree

35. I am confident in my ability to educate others on strategies to breastfeed discretely in

public.

o Strongly Disagree

o Disagree

o Agree

o Strongly Agree

36. I am confident in my ability to help mothers develop a plan to maintain their milk supply

while they are separated from their baby.

o Strongly Disagree

o Disagree

o Agree

o Strongly Agree

37. I am confident in my ability to educate mothers on strategies to build and maintain a

good milk supply.

o Strongly Disagree

o Disagree

o Agree

o Strongly Agree

38. I am confident in my ability to address most concerns a pregnant woman may have

about breastfeeding.

o Strongly Disagree

o Disagree

o Agree

o Strongly Agree

39. I am confident in my ability to provide breastfeeding mothers with the knowledge

needed to meet their breastfeeding goals.

o Strongly Disagree

o Disagree

o Agree

o Strongly Agree

*Note: The following four questions were only asked at posttest, and only for students

in the Spring 2015 cohort.

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40. I would like to participate in an internship focusing on lactation education, which would provide me with the opportunity to apply the knowledge I learned in the lactation education course.

o Strongly Disagree

o Disagree

o Agree

o Strongly Agree

41. I am interested in integrating lactation education into my future career.

o Strongly Disagree

o Disagree

o Agree

o Strongly Agree

42. I am interested in pursuing a career as a lactation educator.

o Strongly Disagree

o Disagree

o Agree

o Strongly Agree

43. I am interested in becoming an International Board Certified Lactation Consultant.

o Strongly Disagree

o Disagree

o Agree

o Strongly Agree

Appendix B: Posttest Questionnaire – Open-Ended Questions

44. What were your primary motivations for taking this course?

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

45. What specific skills or knowledge did you hope to gain prior to taking this course?

__________________________________________________________________

__________________________________________________________________

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__________________________________________________________________

__________________________________________________________________

46. How has your understanding of lactation and/or lactation education changed as a result of taking this course?”

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

47. Are there any skills and/or content areas covered in this course that you found especially useful? If so, can you please elaborate?

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

48. How do you feel you benefitted most by taking this course?

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

49. Is there content or skills not covered in the course that you wish were included?

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

50. Do you have any suggestions for improving the course? If so, please elaborate.

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

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