Socio-demographic profile and breastfeeding promotion of nursing professionals of the Family Health Strategy

Enquadramento: A atuação dos profissionais de enfermagem da atenção primária contribui para a melhoria dos índices de aleitamento materno. Objetivos: Descrever as características pessoais e profissionais dos profissionais de enfermagem da atenção primária e identificar sua perceção quanto à própria competência para manejar e orientar a prática do aleitamento materno. Metodologia: Estudo observacional, transversal e descritivo desenvolvido entre março e julho de 2010, com 85 profissionais de enfermagem da atenção primária do município de Uberaba, Minas Gerais, Brasil. Utilizamos dois questionários autoaplicáveis, validados no Brasil e a análise univariada dos dados. Resultados: Profissionais predominantemente jovens e do sexo feminino; a maioria amamentou os filhos, participou de cursos sobre aleitamento e considerou-se apta para realizar orientações e para o manejo clínico da amamentação durante o pré-natal, grupos educativos, puericultura e visitas domiciliares; o tempo médio de atuação nas equipas foi de dois anos e meio. Conclusão: Para que a nutriz tenha sucesso durante a amamentação é necessária uma rede de apoio que inclua profissionais de saúde capacitados e sensibilizados.


Introduction
The Family Health Strategy (Estratégia de Saúde da Família) was created in 1994 after the deployment and implementation of the Unified Health System -SUS (Sistema Único de Saúde). Its main goals were to reorganise the healthcare practice under new grounds and criteria, and to retarget the current healthcare model in Brazil, starting with primary healthcare (Paim, Travassos, Almeida, Bahia, & Macinko, 2011). One of the roles of family health teams is to provide maternal and child care, with an emphasis on the promotion of breastfeeding. Thus, nursing plays a specific role in standardising and regulating the breastfeeding practice (Graça, Figueiredo, & Conceição, 2011) as it includes the largest group of SUS's healthcare professionals and provides care to the individual, family, and community, by intervening in the field of health promotion, protection, and recovery. The knowledge and guidelines on breastfeeding passed on by the healthcare professionals to pregnant and breastfeeding women result from their personal experience in breastfeeding, professional training in breastfeeding, and perceptions of their competence to promote, protect, and support this practice (Marques et al., 2009). Thus, the personal and professional characterisation of nurses and nursing technicians of the Family Health Strategy is believed to contribute to the nursing professional practice, to accomplish their needs for continuous training and education, and, consequently, to ensure that care is provided by qualified professionals and it that will meet the health needs of the population and public policies (Rocha & Zeitoune, 2007). There is, however, a gap in the local scientific knowledge on the self-perceived, personal and professional characteristics of nursing professionals of the Family Health Strategy with regard to the promotion of breastfeeding. It is expected that the identification of these characteristics will allow for a proper selection of human resources for these type of positions or functions, and for the analysis of these professionals' competence and performance in the promotion of breastfeeding in primary healthcare (Rocha & Zeitoune, 2007). In order to address this issue directly, this study intended to describe the personal and professional characteristics of primary care nursing professionals of the municipality of Uberaba, Minas Gerais, Brazil, and to identify their own perception regarding their ability to provide guidance on breastfeeding.

Background
Strategies that facilitate the dissemination of information about the advantages and importance of breastfeeding, as well as guidelines for the clinical practice on breastfeeding and on how to reconcile this practice with other roles performed by women in society, are absolutely necessary. This is a task for all healthcare professionals, particularly for the nursing team, as they work as health promotion agents with a positive influence on breastfeeding. Thus, nursing should value the power of the educational process, as it contributes to bringing people closer and strengthening the individual and collective potential towards health improvement, using available resources, and exercising citizenship (Oriá, Glick, & Alves, 2005). The success of breastfeeding is associated with various types of educational programmes and with the promotion of the culture related to this social practice. In addition, its promotion and encouragement should occur in all circumstances, so that the mothers may expand their knowledge on the subject and, consequently, increase its prevalence and duration. Educational group activities for pregnant and breastfeeding women carried out in family health units are an example of this. These activities start based on the idea that the sharing of expectations and experiences of breastfeeding by these women, together with the guidance given by the healthcare professionals, may prevent difficulties and teach them how to cope with anxiety, insecurity, and potential breastfeeding-related problems. In this way, some of the impediments and obstacles to exclusive breastfeeding would be neutralised (Oliveira, Camacho, & Souza, 2005). In a study conducted with mothers enrolled in the Family Health Strategy, Becker (2001) found that home visits were a decisive factor for mothers to feel supported in the act of breastfeeding. The expansion and strengthening of home care value the healthdisease process and the influence of the life context study is limited to an analysis of situations that occur naturally, and presents prospective, retrospective or cross-sectional designs. Cross-sectional studies are used to estimate the frequency with which an event occurs in a given population, as well as the related factors. Data are observed, measured and collected at a single point in time, and the information about the exposure and the outcome are obtained simultaneously for each of the participants. Descriptive studies aim to inform on the quantitative distribution of a given event in a population. The researcher should only observe how the event unfolds, and express its frequency in an appropriate manner. The essence of this type of study is the appropriate distribution of frequencies with a view to achieving the following objectives: to identify atrisk groups regarding the characteristics and needs of segments of the population that can benefit from remedial measures; and to propose explanations for the variations in frequencies, thus justifying the continuity of the research on the topic through analytical studies (Pereira, 2006). The population under analysis was initially composed of all nurses and nursing technicians working in the 46 teams of the urban area of the municipality between March and July, 2010. Seven professionals were excluded from the study -a nurse and six nursing technicians -for having participated in the pilot study, being currently in the process of being hired, or being away on a sick leave. Thus, 85 participants were sampled: 45 nurses and 40 nursing technicians. Data collection was performed using two selfadministered and semi-structured questionnaires: one for nurses and another one for nursing technicians. Both questionnaires were previously tested and validated with 176 primary care professionals in a multicentre study conducted in five Brazilian cities (Becker, 2001). The authors gave permission for these instruments to be applied in the nursing professionals who participated in this study. The interviews with the professionals were conducted individually and simultaneously at the healthcare unit and in the presence of the researcher so as to avoid that any discussions could interfere with. In this study, both instruments were adjusted in a pilot-study conducted in seven units. The questionnaires included questions that sought to outline the personal (age, gender, number of children, breastfeeding), professional (length of and family dynamics on maternal-child health. In addition, it provides healthcare professionals access to the women's homes. The objective of entering their homes is to observe and work on the motherchild binomial within their environmental, cultural and family settings. Prenatal appointments are also considered an important opportunity to encourage breastfeeding, and the professional in charge is the one responsible for stimulating the women's capacity to breastfeed. In this way, the relationship between the pregnant woman and the nurse should include: the woman's previous expectations, beliefs and experiences of breastfeeding; guidelines on breast care, breastfeeding technique, identification of breastfeeding technique, identification of milk letdown and breast complications and how to deal with them; and clarification of doubts about the breastfeeding practice (Fujimori & Rezende, 2009). In addition, one of the ways to promote breastfeeding is childcare, which operates with the main objective of health promotion. Childcare helps to underline the importance of this practice for the child and the mother, thus avoiding the early introduction of other liquids and foods into the child's diet, guiding and clarifying the breastfeeding women's doubts and, in this way, consolidating her knowledge on the subject and eliminating factors that may hinder its consolidation (Ciampo et al., 2006).

Research question
What are the personal, professional and self-perceived characteristics of primary care nursing professionals regarding their role in the breastfeeding promotion?

Methodology
An observational, cross-sectional descriptive study was conducted with urban teams of the Family Health Strategy of the Uberaba Health Department, Minas Gerais. Uberaba is the reference city of the health micro-and macro-region of the South Triangle, and is composed of 21 municipalities. In observational studies, although the researcher observes and measures the characteristics of the subjects, he/she does not modify them. This type of

Results
This section describes the self-assessment, personal and professional characteristics of the nursing professionals of the Family Health Strategy regarding the practice of breastfeeding. As for personal characteristics, most nursing professionals were female (82 -96.5%). The nursing professionals' mean age was 34.2 (sd= 8.7), ranging between 22 and 55 years. The most prevalent age group was the 20 to 29 years age group (38 -44.7%). Forty-three participants (50.6%) had no children. On the other hand, the number of children of the 42 (49.4 %) nurses and nursing technicians who were parents ranged between one and five, with a mean of 1.7 (sd=0.9). These 42 professionals were female, and the majority of them (38 -90.5%) had breastfed their children. Table 1 shows the personal characteristics of the nursing professionals who participated in the study. experience in the family health team they were in at the moment of data collection and participation in courses on breastfeeding), and self-perceived profile (perception of their own communication and technical skills regarding the practice of breastfeeding during the prenatal visits, educational group activities, childcare visits, and home visits) of the nursing professionals. Univariate data analysis was performed using the Statistical Package for Social Sciences (SPSS), version 16.0. Categorical variables were presented as absolute and relative frequencies. As for numerical variables, the mean and median (measures of central tendency), standard deviations, and minimum and maximum values (measures of variation) were calculated. This study was approved by the Research Ethics Committee of the Ribeirão Preto College of Nursing of the University of São Paulo (Process no. 1035/2009) and conducted in compliance with the ethical principles, using an Informed Consent Form. Regarding the professional characteristics of qualification for providing guidance on breastfeeding, 75 (88.2%) nursing professionals had participated in at least one course on the subject. The length of courses in which the professionals participated ranged between 1 and 180 hours, with a mean of 30.5 (sd=31.5).
The nursing professionals' length of experience in the family health teams where they were allocated at the time of data collection ranged from one month to 11 years, with a mean of two years and six months (sd=3.3) and a median of five months. The difference between mean and median was a result of a mean deviation caused by extreme values in the nursing professionals' length of experience, considering that most of them (45 -52.9%) were part of the teams for less than six months. In relation to the nursing professionals' perceptions of their own communication and technical skills regarding breastfeeding during prenatal visits, educational group activities, childcare visits, and home visits, 76 (89.4%) participants considered themselves to be prepared to perform that task.

Discussion
Most nursing professionals were women. This is in line with data collected in other studies conducted in the States of Minas Gerais (Fernandes, Miranzi, Iwamoto, Tavares, & Santos, 2010), Piauí (Rocha & Zeitoune, 2007) and Goiás (Rocha, Munardi, Bezerra, & Melo, 2009), which revealed that the majority (91.3%) of the nursing professionals who provide prenatal care in primary healthcare were women. Nursing is a predominantly female profession at all levels, despite the degree of incipient insertion of men in this field (Lopes & Leal, 2005). The Ministry of Health conducted a study on the profile of the physicians and nurses in the Family Health Strategy, and concluded that most public health workers are women, being that women comprised 90.1% of the nursing workforce (Ministério da Saúde, 2000). In Brazil, there is a gender-based selectivity in nursing which is manifested in education, and marks the preferences of the system at all levels. The educational materials and, more rarely, the teachers' conduct confirm this selectivity by selecting more suitable patients and techniques to the gender skills (Lopes & Leal, 2005). Furthermore, there are areas of knowledge that nowadays still offer resistance to the entry of male nurses, such as: gynaecology, obstetrics, paediatrics, and nursery. This type of limitation may extend to breastfeeding support, assuming that it is better accepted when provided by a female nurse. However, no scientific evidence were found in the literature to confirm this assumption.
The group under analysis was comprised of young nursing professionals, with a mean age of 34.2 years. A study conducted with nursing professionals of the family health teams of the health macro-region of the South Triangle, whose nucleus was the municipality being studied here, revealed that the professionals' mean age was 28.6 years (Fernandes et al., 2010). All the participants who had children were women, which represented approximately half of the sample. Of these, most of them had breastfed their children.
In Coimbra, Minas Gerais (Marques et al., 2009), a research showed that 29.4% of nursing professionals in primary healthcare were parents. In regards to the personal experience of breastfeeding, a study conducted in the state of Minas Gerais (Marques et al., 2009) and a multicentre Brazilian study (Ministério da Saúde, 2000) showed that more than 80% of the professionals had a personal experience with breastfeeding, both as mothers or as partners of women who had breastfed. Regarding training on breastfeeding, most nurses and nursing technicians had participated in at least one specific course on the subject. A Brazilian multicentre study (Becker, 2001) on the promotion of breastfeeding in family health teams showed that 85% of the professionals had participated in at least one course on the subject. In the municipality of Teixeiras, Minas Gerais, 57.1% of the nursing professionals who were part of the Family Health Strategy had participated in courses on breastfeeding (Azeredo et al., 2008). However, in a research conducted in Coimbra, Minas Gerais, with professionals of a family health unit, 82.4% of them had never participated in specific courses on breastfeeding (Marques et al., 2009). If healthcare professionals do not adopt a broader view that goes beyond clinical management and offer support to the mothers, they can have a negative effect on the establishment and maintenance of breastfeeding. Given the fact that the family health teams intervene in the family environment, they have an opportunity to identify the meaning of breastfeeding for the woman and her family, pass on practical and theoretical knowledge to these women and empower them in their breastfeeding process. There is a need to invest in the professional education of primary healthcare workers since this is the level of care that most women seek for prenatal and child care, i.e. moments in which they require support and guidance on breastfeeding (Azeredo et al., 2008). Health training has an important role in the construction of the SUS and its principles. Education has been considered a vital instrument to trigger changes and transformations in society (Balbino et al., 2010). Despite the changes resulting from the establishment of the Family Health Strategy, the lack of a municipal breastfeeding education and promotion programme and of a breastfeeding mother-child care protocol results in an unarticulated approach to this practice, where each professional acts according to the knowledge and skills acquired in their initial or continuing training. This emphasises the importance of continuing education in health, which values practical knowledge and work as relevant sources of knowledge and learning. It is characterised by contextualised teaching strategies that promote a dialogue between the general policies and the uniqueness of the places and the people. In addition, it has a participatory nature based on the critical questioning of the work process (Ministério da Saúde, 2009). In primary healthcare, there is a current continuing education strategy for healthcare professionals regarding breastfeeding-the Brazilian Breastfeeding Network (Rede Amamenta e Alimenta Brasil)which is based on meaningful learning and the problematisation of reality, thus allowing for a new way of looking at and acting towards the sociobiological breastfeeding network (Ministério da Saúde, 2009). However, at the time of the study, the municipality of Uberaba had no network of tutors or certified basic health units, and, therefore, had no encouragement towards continuing health education on breastfeeding.
Regarding the workload of the most extensive course taken by the study participants, it was higher than the one found in a Brazilian multicentre study (Rocha et al., 2009), which was of 12 hours. The workshop on breastfeeding in the basic health units proposed by the Brazilian Breastfeeding Network lasts six to eight hours (Ministério da Saúde, 2009). In Brazil, there are also some courses on breastfeeding with specific workloads under the scope of continuing education, such as the Baby-Friendly Hospital Initiative course or the Breastfeeding Counselling course. However, it is not possible to make a comparison between these workloads and the one found in this study, which did not aim at identifying the nature, goals and contents of the courses attended by the professionals. The nursing professionals' length of experience in the family health teams where they were allocated at the time of data collection reflects, in a way, a rotation between services. It should be noted that the median length of experience of the nursing technicians in their teams was three years, which was higher than that of nurses (five months). This result is similar to the one found in a study conducted in Ribeirão Preto, São Paulo, Brazil, in which nurses showed lower job stability than nursing technicians (Anselmi, Duarte, & Angerami, 2001). The rotation of nursing professionals in the service is a key aspect in the management process. A stable and qualified workforce supports the care process and ensures the quality of the services provided, by intensifying the relationship with the patients and enabling these professionals to identify the existing problems and suggest easier solutions (Anselmi et al., 2001). In the specific case of breastfeeding promotion in Uberaba, this higher rotation by the nursing professionals in the family health teams hampers the establishment of a bond with the community and, consequently, the knowledge of the social, cultural, historical and economic context of the pregnant and breastfeeding women whom they are expected to care for. This situation makes it difficult to understand the breastfeeding process beyond its biological determinations, and follow up women from the prenatal to the postpartum period, thus leading to a fragmented support and approach to breastfeeding. In relation to the nursing professionals' perceptions of their own communication and technical skills regarding breastfeeding during prenatal visits, educational group activities, childcare visits, and home visits, most of them considered themselves to be prepared to promote, support and protect this practice. The results of a Brazilian multicentre study (Becker, 2001) showed that 86.4% of the professionals of the Family Health Strategy considered themselves to be prepared to observe women while breastfeeding and recommend the correct technique. In the United States, a study on the nursing professionals' knowledge and the breastfeeding practices showed that 60% of them felt prepared to assist women in the breastfeeding process (Hellings & Howe, 2004). Therefore, in order to establish and maintain breastfeeding, an adequate and accessible support by the nursing professionals to pregnant and breastfeeding women is needed to prevent the common difficulties and complications during this period. For this to happen, nurses and nursing technicians must be duly qualified to promote breastfeeding from pregnancy until the child is two years old or more, either in the Health Unit or in the community.

Conclusion
In view of the study objectives, it can be concluded that the nursing professionals in primary care at the municipality of Uberaba were mostly young, female and had no children. However, among those who were parents, most of them had breastfed their children.
The majority of the professionals participated in at least one course on breastfeeding and had a positive perception of their own communication and technical skills regarding breastfeeding during prenatal visits, educational group activities, childcare visits, and home visits. The median length of experience of the professionals in the family health teams was five months.
The results reinforce the idea that to establish and maintain breastfeeding for two years or more, as recommended by the World Health Organisation, it is not enough for the woman to decide to breastfeed. It is also necessary to have a support network for these women, which should include healthcare professionals, especially those of the nursing teams, who are properly trained and aware of the importance of breastfeeding as a practice permeated by social, cultural, historical, economic, and psychological values.
It is hoped that the results of this study will fill some gaps in this area of knowledge, as well as forge new paths towards the enhancement and encouragement of the activities of nursing professionals in primary care concerning breastfeeding promotion.
This article results from research funded by the Brazilian National Council for Scientific and Technological Development (CNPq).