Chale et al.

BMC Nursing (2016) 15:72

DOI 10.1186/s12912-016-0192-0

RESEARCH ARTICLE Open Access

Predictors of knowledge and practice of

exclusive breastfeeding among health
workers in Mwanza city, northwest
Tanzania
Lucy E. Chale1*, Tanis R. Fenton2 and Neema Kayange1,3

Abstract
Background: Universal exclusive breastfeeding (EBF) for the first 6 months is estimated to reduce infant mortality
by 13–15% (9 million) in resource poor countries. Although 97% of women initiate breastfeeding in Tanzania,
exclusive breastfeeding for 6 months remains below 50%. Accurate knowledge and practical skills pertaining to
exclusive breastfeeding among health workers is likely to improve breastfeeding rates. Our study reports the health
workers’ knowledge and practice on EBF in Mwanza City, northwest of Tanzania.
Methods: One principal researcher and two research assistants conducted data collection from 11 June–6 July
2012. In total, 220 health care workers including: 64 clinicians (medical specialists, residents, registrars, assistant
medical officers and clinical officers) and 156 nurses were interviewed using a structured knowledge questionnaire.
Amongst 220 health workers, 106 were observed supporting Breastfeeding using a checklist. Logistic regression was
used to determine factors associated with exclusive breastfeeding knowledge and desirable skills.
Results: Almost half of the 220 health workers interviewed correctly described EBF as defined by the World Health
Organization. Only 52 of 220 respondents had good knowledge. In the adjusted analysis, working at hospital facility
level compared to dispensary (OR 2.1; 95% CI 1.1–4.0, p-value = 0.032) and attending on job training (OR 2.7; 95%
CI 1.2–6.1, p-value = 0.015) were associated with better knowledge. In total, 38% of respondents had a desirable
level of practical skills. Clinicians were more likely to have good practice (OR 3.6; 95% CI 1.2–10.8; p-value = 0.020)
than nurses. Most of the health workers had no training on EBF, and were not familiar with breastfeeding policy.
Conclusion: Less than 25% of healthcare workers surveyed had good knowledge of EBF. These findings identify the
need for comprehensive training and mentoring of health workers on exclusive breastfeeding, making breastfeeding
policies available and understood, along with supportive supervision and monitoring.
Keywords: Health workers, Exclusive breastfeeding, Knowledge, Practices

Background of food or drink, not even water [1]. In 1990, the WHO
Breastfeeding is the process of feeding the infant with and UNICEF jointly adopted the Innocent Declaration
mother’s milk, either by direct nipple-baby mouth con- on the protection, promotion and support of breastfeed-
tact or by expressed breast milk. Exclusive breastfeeding ing, and emphasized the importance of EBF [2]. The
(EBF) is the practice of feeding the infant breastmilk declaration urges all governments to develop national
only for the first 6 months of life without any other type breastfeeding policies and set appropriate national targets.
One of the key deliberations, as far EBF is concerned, was
to impart the health workers and staff in all sections of
* Correspondence: [email protected]
1
Bugando Medical Centre, Department of community health services, Faculty
health services delivery adequate knowledge and skills to
of Nursing, Catholic University of Health and allied sciences (CUHAS), support breastfeeding [2].
Mwanza, Northwest, Tanzania
Full list of author information is available at the end of the article

© The Author(s). 2016 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Chale et al. BMC Nursing (2016) 15:72 Page 2 of 8

The benefits of breastfeeding are numerous: not only health workers be trained on EBF for at least 18 h
is it considered complete nutrition for the first 6 months plus 3 h of on the job training [1].
of life, exclusive breastfeeding is associated with prevent- Our study reports factors associated with knowledge
ing life-threatening infections in infants, as well as and practice of health workers working in one of rapidly
health benefits for mothers [3, 4]. It has been estimated expanding cities in Tanzania.
that at 90% EBF, death of children less than 5 years due
to respiratory tract infections, diarrhoea diseases and Methods
neonatal sepsis could be prevented [5, 6]. Breastmilk The study was cross-sectional and descriptive, con-
contains immune cells and immunoglobulins from the ducted among health workers in the study area. The
mother that have a documented protective effect on in- study had two parts: face-to-face interviews with health
fants from infections [7]. Specifically, the immune cells workers, and observing health worker practical skills
are macrophages and the neutrophils that can destroy using a checklist.
harmful bacteria; and the immunoglobins, which help to The study was conducted in Nyamagana and Ilemela
protect infants’ mucosal surfaces against entry of patho- Districts, in the City of Mwanza, Tanzania. Nyamagana
genic bacteria and viruses [7, 8]. These immune sub- district total population was 210,735 whereas Ilemela
stances could prevent up to 13–15% [9 million] deaths district had 265,911 people [20, 21]. The health workers
of children under 5 years in resource poor settings [9]. in the maternal, post-natal, newborn and child health
Other EBF benefits include: aiding in uterine contraction clinics were recruited in the study because are routinely
through the release of oxytocin; suppress ovulation; involved in supporting breastfeeding. The total number
and increased bonding between the mother and the of health workers working in the maternity, postnatal
newborn [9]. Even in the areas where HIV prevalence wards and child health clinics in the two districts, clini-
is high, especially in sub-Saharan Africa, EBF has cians such as medical specialists, residents, registrars, as-
been associated with lower rates of mother to child sistant medical officers and clinical officers were 220 and
HIV transmission [10, 11]. the nurses such as registered, enrolled nurses and auxil-
In Tanzania, approximately 97% of infants are breast- iary nurses were 644 (Table 1).
fed at some point in 2010, up from 41% in 2005 [12]. Eleven health facilities out of 30 in the Nyamagana
However, only about one half of women practice EBF up and Ilemela districts were purposively selected to in-
to 6 months. The rates of EBF fall off rapidly with in- clude: seven urban and four rural. There were two
fant’s age: < 2 months (81%), 2–3 months (33%) and 4– consultant and referral hospitals, one district hospital,
5 months (36%) [13]. four health centres and four dispensaries included in
The global strategy for Infant and Young Child feeding the study. The consultant, referral hospitals and dis-
emphasizes the need for health workers to be trained in trict hospital are capable of providing emergency com-
counselling and assistance skills for breastfeeding and prehensive obstetrics and neonatal care, including
complementary feeding; breastfeeding and HIV; feeding supporting emergency feeding complications. In con-
during illnesses; and health worker’s role in implementing trast, the services provided at the health centres and
international code conduct of marketing milk-substitutes the dispensaries are basic or routine maternal and
[14]. Health workers are responsible for supporting newborn services. We sampled proportionate to size to
women to EBF at the health facilities and in the commu- allocate the sample by health cadre and by facility
nity [15–17]. A study conducted by the Tanzania Food (Table 1). Overall, 220 health care workers: 64 clini-
and Nutrition Centre in Kagera, Mbeya and Kilimanjaro, cians and 156 nurses responded to the structured
revealed a large knowledge gap in terms of the recom- knowledge questionnaire. Each of these study partici-
mended duration of EFB among Health Service Providers pants were adults and each signed a consent form to
(HSP) as only 26.5% could recall the 4–6 month EBF participate in the study as required by the Joint Ethical
recommendation [18]. Although 70% of breastfeeding Committee of CUHAS and Bugando Medical Centre.
mothers confirmed receiving information from health Once the number of possible respondents for every fa-
workers, 13% of the health workers were not able to cility was determined, all eligible individuals available
demonstrate pertinent breastfeeding skills such baby at the workplace and willing to participate were re-
positioning and attachment [18]. These substantial cruited into the study and interviewed until the desired
knowledge and skill gaps put breastfeeding mothers at number was attained at that health facility. Amongst
risk of receiving incorrect information from poorly in- 220 health workers who responded to the question-
formed health providers, which likely contributes to naire, 110 (50%) were randomly sampled for the
the low prevalence of EBF among women [19]. The breastfeeding practical observations checklist. Four in-
World Health Organization recommend in their 2nd dividuals declined to undergo the practical session,
step of Ten Steps To Successful Breastfeeding that hence 106 observations were performed.
Chale et al. BMC Nursing (2016) 15:72 Page 3 of 8

Table 1 Sampling framework of health workers in Nyamagana and Ilemela districts

Health facilities Total cliniciansa Total nursesb Clinicians sampled Nurses sampled
(interviewed)c (interviewed)d
Bugando Medical Centre 144 327 36 (34) 70 (60)
Sekou Toure Regional Hospital 20 172 5 (4) 35 (28)
Nyamagana District Hospital 13 30 8 (8) 18 (14)
Buzuruga Health Centre 11 15 5 (5) 15 (9)
Karume Health Centre 7 11 5 (5) 14 (11)
Igoma Health Centre 6 18 3 (2) 8 (6)
Makongoro Health Centre 5 15 2 (2) 22 (18)
Nyakato Dispensary 5 11 2 (1) 4 (3)
Pasiasi Dispensary 2 5 2 (2) 5 (3)
Nyerere Dispensary 5 15 2 (1) 4 (2)
Buhongwa Dispensary 2 5 1 (0) 5 (2)
Total 220 624 71 (64) 200 (156)
a
The total number of clinicians (medical specialists, residence, registrars, assistant medical officers and clincial officers) at 11 health facilities; btotal number of
nurses at the health facilties, which includes registered, enrolled and auxillary nurses; cnumber of interviewed clinicians (% of the interviwed, ademoninator);
number of interviwed nurses interviwed (% of the interviwed, bdemoninator)

Two data collection tools were used. First, a structured factors with p-value less than 0.05 were considered
questionnaire, developed based on EBF technical references statistically significant.
[22, 23] and study objectives, was used to collect knowledge
and attitude data from the health workers, as well as socio- Results
demographic characteristics (Additional file 1). The re- Demographic characteristics of health workers
searchers asked each respondent 17 knowledge questions. In total, 220 (81%) of the sampled respondents were inter-
The response for each question was ranked using a 1–4 viewed, which is 64 (90%) of the clinicians and 156 (78%) of
Likert scale such as: incorrect response (1); partially correct the nurses of the targeted sample. The respondents’ ages
(2); mostly correct response (3); and correct (4). The total varied from 23 to 58 years. The mean age was 37.7 years
knowledge score per respondent was later categorized into (SD 8.8). Most of the participants, 132 (60%) had more than
two groups, desirable and undesirable as: < 8/17 (47%) total 4 years of working experience after professional training
score was considered undesirable and above 47% as desir- (Table 2). The majority of health workers, 183 (83.2%) re-
able. Second, a breastfeeding observation checklist to ob- ported no on-the-job training on EBF after obtaining their
serve breastfeeding practical skills was adapted from professional qualifications. Among those who had on-the-
WHO/UNICEF Baby Friendly Hospital Initiative guidelines job training, 57% had only 1–3 weeks of training (Table 2).
[24]. All tools were in English.
Only the principal researcher administered the 23 item Breastfeeding policy training
observation checklist to observe the health workers All participants were asked about the availability of a
helping the breastfeeding mother. Each observation cri- breastfeeding policy in their facility, if the policy was vis-
terion was give one mark. At the end of each observa- ibly posted and about their familiarity with the policy.
tion, the marks were added and calculated as percentage The majority of health workers, 120 (54.5%) said the
of the total expected score. Scores were later grouped health facility had no breastfeeding policy. However, of
into two categories: if the interaction scored 12 or less those who did report existence of a breastfeeding policy,
out of 23 (<55%), it was categorized as undesirable. A only 15 (25.4%) (6.8% of the whole sample) stated the
score of 13 and above was considered desirable. policy was displayed at the health facility. Similarly, most
The data were coded and entered into SPSS for statis- of the health workers, 149 (67.7%) reported not being
tical analysis. We used univariate analysis followed by familiar with the national breastfeeding policy.
multivariate logistic regression to determine the factors In response to the questions about breastfeeding policy
associated with knowledge and with practical skills of training, 17 (7.7%) reported having had any on-the-job
health workers. The factors considered in the regression training on breastfeeding policy, of whom only 5 (29%)
modelling included: type of health facility, age, sex, of these had the recommended length of cumulative
cadre, on job training and work longevity. Odds ratios training of not less than 18 h [1] (Table 3). Among the
with 95% confidence intervals were calculated and 17 health workers interviewed who received training,
Chale et al. BMC Nursing (2016) 15:72 Page 4 of 8

Table 2 Demographic characteristics of the health workers of Table 3 Health workers reported training on breastfeeding
Nyamagana and Ilemela districts of Mwanza city included in policy and counselling
the study Variables Number Percent
Variables Nyamagana Ilemela district Total Trained on breastfeeding Policy (n = 220) a
n (%) n (%) n (%)
Yes 17 7.7
Sex of the study group (n = 220)a
No 203 92.3
Male 25 (11.4%) 14 (6.3%) 39 (17.7%)
Length of trained on breastfeeding Policy (n = 17)a
Female 121 (55%) 60 (27.3%) 181 (82.3%)
Less than 5 h 7 41.2
Age of the study group (n = 220)a
5 to 10 h 3 17.6
19–30 years 26 (11.8%) 16 (7.3%) 42 (19.1%)
11 to 18 h 2 11.8
31–40 years 67 (34.4%) 29 (13.2%) 96 (43.6%)
19 h or more 5 29.4
41–50 years 35 (15.9%) 18 (8.2%) 53 (24.1%)
a
Training covering 10 steps to successful breastfeeding (n = 17)
51 years and above 18 (8.2%) 11 (5%) 29 (13.2%)
Yes 14 82.4
Health workers cadres (n = 220)a
No 3 17.6
Registered nurse 54 (24.5%) 27 (12.3%) 81 (36.8%)
Cumulative Hours of Mentoring after training (n = 17)a
Enrolled nurse 40 (18.2%) 25 (11.3%) 65 (29.5%)
Yes, for 30 min to 1 h 5 29.4
Doctor 36 (16.4%) 4 (1.8%) 40 (18.2%)
Yes, for 1 h to 2 h 4 23.5
Clinician (CO and AMO) 10 (4.5%) 14 (6.4%) 24 (10.9%)
Yes, for 3 h and more 2 11.8
Auxiliary Nurse 6 (2.7%) 4 (1.8%) 10 (4.5%)
Not at all 6 35.3
Years after professional training (n = 220)a
b
Ever trained on Breastfeeding counseling (n = 220)
less than 1 year 12 (5.5%) 8 (3.6%) 20 (9.1%)
Yes, during pre/in-service training 43 19.5
1 to 3 years 46 (20.9%) 22 (10%) 68 (30.9%)
Yes during seminar and workshop 44 20
4 to 8 years 42 (19.1%) 16 (7.3%) 58 (26.4%)
Not at all 133 60.5
9 years and more 46 (20.9%) 28 (12.7%) 74 (33.6%)
Milk formulae donations to babies over the past 1 year (n = 220)c
Ever had training on exclusive breastfeeding (n = 220)b
Yes 23 10.5
Yes 26 (11.8%) 11 (5%) 37 (16.8%)
No 121 55
No 120 (54.6%) 63 (28.6%) 183 (83.2%)
Don’t know 76 34.5
Length of exclusive breastfeeding training (n = 37)c
a
The number of health workers (N = 220), amongst them, 17 (7.7%) were
less than 1 week 12 (32.4%) 3 (8.1%) 15 (40.5%) trained on breastfeeding policy: subsequently segregated according to the
length of training, training covering ten steps and total number of hours
1 to 3 weeks 13 (35.2%) 8 (21.6%) 21 (56.8%)
mentored after training; bnumber of health workers according to trained on
4 to 6 weeks 1 (2.7%) 0 (0%) 1 (2.7%) breastfeeding counselling; chealth workers knowledge on milk formulae
a
donation to the health facility
The demographic data of health workers (N = 220), which include sex, age
and cadre and number of years after professional training; bnumber trained/
not trained on exclusive breastfeeding (N = 220), amongst c(N = 37) were ever
trained on exclusive breastfeeding: the length of training ranged from less health workers interviewed gave an incorrect description
than a week to 4–6 weeks of the definition of Exclusive Breastfeeding.
Univariate logistic regression analysis indicated that
most (82%) received training that included the 10 steps working at the hospital was associated with better know-
of EBF. A minority of the health workers, 23 (10%) re- ledge on exclusive breastfeeding compared to a dispens-
ported that health facilities donated formula to babies ary (OR 2.6; 95% CI 1.4–4.6, p-value = 0.001) (Table 4).
within the year prior to the study. Attending on-the-job training was significantly associ-
ated with desirable knowledge, (OR 2.6; 95% CI 1.2–5.5,
Factors associated with knowledge of exclusive p-value = 0.016). Of importance, clinical officers and as-
breastfeeding among health workers sistant medical officers were less likely to have desirable
Overall, about one half of respondents, 114 (52%), pro- knowledge than nurses (OR 0.4; 95% CI 0.1–0.9, p-value
vided desirable responses to the 17 questions asked = 0.033). On multivariate logistic regression analysis,
about EBF knowledge, whereas 106 (48%) knowledge once sex, age, facility level, cadre, and years since profes-
scores were considered undesirable (Table 4). On the sional training and on the job breastfeeding training
other hand, 153 (69.5%) of health workers thought “cry- were controlled for, similar factors as for univariate were
ing a lot” was justification for complementary feeds associated with desirable knowledge on breastfeeding -
before the age of 4 months. Almost half, 117 (53%) of working at hospital facility level compared to dispensary
Chale et al. BMC Nursing (2016) 15:72 Page 5 of 8

Table 4 Univariate and multivariate factors associated with exclusive breastfeeding knowledge among the health workers
Variables Level of knowledgea Univariate analysis Multivariate analysisb
(n = 220)
Desirable (n, %) Undesirable (n, %) OR [95% CI] p-value OR [95% CI] p-value
Sex
Male 20 (51.3) 19 (48.7) 1
Female 94 (51.9) 87 (48.1) 1.0 [0.5–2.1] 0.941 1.1 [0.5–2.7] 0.784
Age
> 40 years 40 (46.5) 46 (53.5) 1
≤ 40 years 74 (55.2) 60 (44.8) 1.4 [0.8–2.4] 0.208 1.4 [0.8–2.6] 0.253
Hospital level
Disp/HC 26 (36.1) 46 (63.9) 1
Hospital 88 (59.5) 60 (40.5) 2.6 [1.4–4.6] 0.001 2.1 [1.1–4.0] 0.032
Cadre (n = 220)
Nurses 83 (53.2) 73 (46.8) 1
CO/AMO 7 (29.2) 17 (70.8) 0.4 [0.1–0.9] 0.033 0.4 [0.1–1.2] 0.093
Doctors 24 (60.0) 16 (40.0) 1.3 [0.7–2.7] 0.442 0.9 [0.4–2.2] 0.849
Years since profession training
> 3 years 62 (47.0) 70 (53.0) 1
≤ 3 years 52 (59.1) 36 (40.9) 1.6 [0.9–2.8] 0.079 1.8 [1.0–3.3] 0.062
Job Training (n = 220)
No 88 (48.1) 95 (51.9) 1
Yes 26 (70.3) 11 (29.7) 2.6 [1.2–5.5] 0.016 2.7 [1.2–6.1] 0.015
a
Desirable knowledge was determines by scoring 8 or more of the 17 knowledge questions, whereas undesirable was scoring than 8 questions. bVariables
controlled were: sex, age, facility level, cadre, and years since professional training and breastfeeding on the job training. Multivariate analysis age, sex and health
facility levels were controlled as potential confounders

(OR 2.1; 95% CI 1.1–4.0, p-value = 0.032) and attending nurses (OR 3.6; 95% CI 1.2–10.8; p-value 0.020), in the
on-the-job training (OR 2.7; 95% CI 1.2–6.1, p-value = multivariable analysis.
0.015) were associated with better knowledge. Job cadre
was no longer significantly associated with desirable EBF Discussion
knowledge in the multivariate analysis. Although Tanzania is among the first countries to adopt
the Innocent declaration in the 1990’s, which emphasized
Factors associated with the desirable exclusive the importance of health worker’s role in supporting breast-
breastfeeding practices among health workers feeding [25, 26], three decades after the declaration, more
Among 220 health workers who participated in the than half (54.5%) of respondents were not aware that their
study, almost half 106 (48.1%) were observed using step- facilities had a breastfeeding policy. Our findings show bet-
by-step checklist of 23 observations to assist the mother ter results compared to a study conducted in Indore India,
with breastfeeding her baby. Among those we observed, which found that none of the hospitals had a breastfeeding
the majority, 66 (62%) had undesirable practical skills policy that was communicated to health workers and there
and compared to 40 (38%) who exhibited desirable prac- was no breastfeeding training [27]. Our findings suggest
tical skills (Table 5). that the health worker’s practices are not guided and in-
On univariate logistic regression analysis, clinicians formed by the Tanzania national breastfeeding policy.
were more likely to demonstrate desirable practices of Some of the health workers had high levels of know-
exclusive breastfeeding compared to the nurses (OR ledge on some aspects of EBF in this study compared to
4.2; 95% CI 1.6–10.9; p-value = 0.003) (Table 5). Job other studies conducted earlier in Tanzania [28]. This
cadre remained important even on multivariate logistic improvement could be due to the influence created by
regression analysis once sex, age, facility level, cadre, peer health workers attending Prevention of Mother to
and years since professional training and breastfeeding Child Transmission (PMTCT) of HIV counselling train-
on the job training were controlled for. Clinicians ing, ongoing PMTCT services at the study facilities and
(COs/AMOs/doctors) remained more likely to demon- media coverage that promotes EBF rather than policy
strate desirable practice of exclusive breastfeeding than and guideline training.
Chale et al. BMC Nursing (2016) 15:72 Page 6 of 8

Table 5 Univariate and multivariate factors associated with desirable exclusive breastfeeding practices of the health workers
Participants’ variable (n = 106) Demonstrating breastfeedinga Univariate analysis Multivariate analysisb
Desirable Undesirable OR [95% CI] p-value OR [95% CI] p-value
(n, %) (n, %)
Sex
Male 8 (52.1) 6 (42.9) 1
Female 32 (34.8) 60 (65.2) 0.4 [0.1–1.3] 0.116 0.7 [0.2–2.9] 0.649
Age
> 40 years 20 (33.3) 40 (66.7) 1
≤ 40 years 20 (43.5) 26 (56.5) 1.7 [0.8–3.8] 0.195 1.1 [0.4–2.8] 0.84
Hospital level
Disp/HC 19 (48.7) 20 (51.3) 1
Hospital 21 (31.3) 46 (68.7) 0.5 [0.2–1.1] 0.077 0.4 [0.2–1.1] 0.084
Cadre (n = 106)
Nurses 24 (29.6) 57 (70.4) 1
Clinicians 16 (64.0) 9 (36.0) 4.2 [1.6–10.9] 0.003 3.6 [1.2–10.8] 0.020
Years since profession training
> 3 years 20 (33.3) 40 (66.7) 1
≤ 3 years 20 (43.5) 26 (56.5) 1.5 [0.7–3.4] 0.287 1.4 [0.6–3.4] 0.477
Job Training
No 33 (37.1) 56 (62.9) 1
Yes 7 (41.2) 10 (58.8) 1.2 [0.4–3.4] 0.75 2.7 [0.5–6.0] 0.339
a
desirable practical skills was determines by the health workers scoring 51 or more grade on the likert scale of 23 items checklist, whereas undesirable was
scorimng less than 51 grades. bVariables controlled were: sex, age, facility level, cadre, and years since professional training and breastfeeding on the job training.
Multivariate analysis was controlled for age and sex as potential confounders

There were incongruous results between knowledge Hospital-based health workers demonstrated more desir-
and practice among the health workers in this study. In able results compared to those who work in dispensaries
general health workers demonstrated a higher propor- and health centres combined (OR 2.1; 95% CI 1.1–4.0;
tion of desirable knowledge responses (52%) than desir- p-value 0.032). Of importance, on-the-job training was
able practical skills (38%). This variation implies that associated with improved knowledge after controlling
their practice was not supported by theoretical under- for sex, age, facility level, cadre, and years since profes-
standing of EBF. These findings suggest that most sional training and on the job breastfeeding training (OR
women served by this population of health workers 2.7; 95% CI 1.2–6.1; p-value 0.015). From these findings
would not likely be adequately helped to breastfeed their we might presume there were more EBF training oppor-
infant soon after delivery. It was surprising to find that tunities available to the hospital based staff compared to
in the adjusted analysis, clinicians were almost four those at the peripheral facilities. The study may also sup-
times more likely to have desirable practice of exclusive port the findings of the study conducted in Morogoro,
breastfeeding than nurses/midwives who are often in- Tanzania, which reported higher initiation (82%) of
volved in conducting deliveries and supporting early breastfeeding among women in the urban compared to
breastfeeding. However, clinical officer and assistant those in the rural setting (52%) [25], which they attrib-
medical officers were less likely to have desirable know- uted to higher knowledge among health workers in
ledge compared to nurses (OR 0.4; 95% CI 0.1-0.09; p- urban settings.
value 0.033). Opposite findings were reported at Keffe
Hospital where the doctors were found to be more Strengths and limitations of the study
knowledgeable than other health workers [19]. This study is limited by the use of a convenience sample
These findings could be possibly attributed to better and non-validated tools and cut-off points. The strengths
clinical or practical training among clinicians compared of this study include its purposive sampling to include
to other health workers rather than on the job training several cadres of health care workers from a variety of
and mentoring. The finding that the nurses who are settings, as well as urban and rural settings. The study
often in contact with nursing mothers soon after delivery also assessed not only knowledge but also observed
exhibited relatively undesirable practice is worrisome. practice, and assessed for associated predictive factors.
Chale et al. BMC Nursing (2016) 15:72 Page 7 of 8

This generalizability of this study is limited since we Department of Paediatrics, Faculty of Medicine, Catholic University of Health
do not know whether the health workers included are and Allied Sciences (CUHAS), Mwanza, Northwest, Tanzania.

representative of the population of health workers in Received: 5 April 2016 Accepted: 28 November 2016
Tanzania.

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