Breastfeeding : Knowledge Degree of Community Health Agents

The objective was to investigate the Community Health Agents (CHA) knowledge in breastfeeding. An analytical cross-sectional study with ACS of both genders that work in the Family Health Strategy. The data were obtained through a questionnaire, including open and closed questions regarding their socioeconomic, professional and breastfeeding knowledge. A total of 116 ACS patients with an average age of 44.2 ± 8.8 years and 14.7 ± 5.2 years of service time participated. Of these, 69.6% reported having performed some training, and only 24.8% and 6.2% obtained a satisfactory knowledge classification, related to important aspects about the technique and management of intercurrences in breastfeeding, respectively. Regarding the answers of the closed questions, which were about general knowledge about breastfeeding, the average number of correct answers was 15.2 ± 3.2 questions, which was significantly higher (p = 0.019) among professionals working in the urban area in Rural areas. In view of the results, there is a need for greater investments in the training of the ACS in breastfeeding, so that they can acquire the necessary knowledge to effectively work with pregnant women and nursing mothers, especially with regard to adequate breastfeeding techniques and treatment of breast complications. Breastfeeding: Knowledge Degree of Community Health Agents ORIGINAL


Introduction
Exclusive breastfeeding until the sixth month and supplemented up to two years or more ensures a series of benefits, both for the health of the mother and the child, being one of the strategies with the grea-test impact in the reduction of infant mortality rates in the world.According to Horta et al. [1], human milk is the only food adequate to the physiological metabolic needs of the infant in the first six months of life.
Despite the consensus in the scientific literature on the importance of breastfeeding, in clinical practice, superficial guidelines are still frequent, which are insufficiently used and are therefore easily abandoned by false and fragile justifications, which discourage practice [2].
Sousa and Costa [3], in a systematic review of scientific publications on breastfeeding incentive and support in the postnatal period in Brazil, have identified a shortage of reports of strategies implemented in the puerperal period to support breastfeeding in the post childbirth, even though it has been verified that interventions of this nature cause positive changes.In view of this, these authors highlighted the importance of involving the Family Health Teams to overcome the gap between hospital discharge and home practices, through actions for breastfeeding full establishment and longer duration, thus ensuring better maternal and child health.
In this sense, stands out the role of the community health agent (ACS), which acts as a link between the community and the health team, i.e, uniting the professionals scientific knowledge to the culture and customs of the community.Its duties include at least one household visit per month to each families registered in the territory that comprises the microarea under its responsibility, and must treat in a differentiated way the groups considered as priority, such as pregnant and nursing mothers, who should be encouraged and oriented about the value of exclusive breastfeeding [4][5][6].However, it is necessary to emphasize that, in order to obtain the expected success, it is necessary that, during the postnatal home visit, the community health agent be able to provide adequate technical information, as well as physical and emotional support to the nursing mother [3].
During the home visit, the community health agent builds a bond of trust and friendship, in such a way that its practical health guidelines positively influence the health conditions of the population [7].In this way, they assume great importance in the implementation of public health policies to promote, protect and support breastfeeding, contributing to Brazil achieving the four Millennium Development Goals target, which is to reduce child mortality by 2015 [8].
Considering the importance of breastfeeding in the promotion of maternal and child health, as well as the central role of the community health agent in the management of lactation among pregnant and nursing mothers, the objective was to investigate the knowledge of these professionals about the subject addressed, making it possible to verify the need they may require of training to act effectively to encourage breastfeeding.

Methods
A cross-sectional study carried out with community health agents (ACS) of both genders who work in the Family Health Strategy of the city of Picos, Piauí.The sample consisted of all ACSs that work in the municipality and agreed to participate in the study.We excluded the agents who did not participate in all stages of the study, as well as those who were in vacation or were not located during data collection.
The study was submitted to the Brazilian Platform for consideration by the Research Ethics Committee of the Federal University of Piauí and approved, Opinion No. 865.583/2014, in compliance with the ethical determinations in force, established in Resolution 466/2012 and complementary to the National Health Council [9].The ACS were clarified about the objectives and procedures of the study, and those who agreed to participate were asked to sign the Informed Consent Form.
In order to collect data, meetings were scheduled with the ACS in the Basic Health Units (UBS), in which they received a questionnaire, developed based on the instruments used in the studies by Beker [10] and Silveira [11], containing open and closed questions regarding their socioeconomic and professional profile, as well as their knowledge about breastfeeding.Each participant in the study was instructed not to identify their questionnaire and to answer it alone and without consulting any sources, returning it after a week in a sealed envelope at the UBS in which they developed their professional activities.
After analyzing the answers to the open questions of the questionnaires, referring to the important aspects to enable good breastfeeding, with regard to the position and the baby's latch, as well as the guidelines in cases of intercurrences, the knowledge of the ACS on the subject was classified as described by Silveira [11] in Satisfactory (S), Unsatisfactory (PS), Unsatisfactory (I) and Others (O), being the later adopted when the agent did not respond with the main aspects to be considered but was not characterized as the wrong answer .
Regarding the closed questions used to assess the knowledge level on breastfeeding, still based on the criteria described by Silveira [11], the knowledge of ACS was classified as: good, when the percentage of correct answers was greater than 70%; Regular, from 50 to 70% correct; And insufficient, when less than 50% of hits.
Statistical analysis of the data was processed in the program Statistical Package for the Social Sciences (SPSS Inc., Chicago, USA, version 18.0).In order to verify the normality of the numerical data distribution, the Kolmogorov-Smirnov test, for samples smaller than 50, and Shapiro-Wilk for samples greater than 50 were used.Student's t test was used for the comparison of averages And the chi-square test to verify the existence of association between the categorical variables.The level of significance was set at p <0.05.

Results
The knowledge of 116 community health agents was evaluated, with the majority (82.8%) being female.As for the area of the municipality of action, of the 106 ACS that responded to the questioning, 63.2% worked in the urban zone.
The average age of the ACS was 44.2 ± 8.8 years, who were mostly in the age range of 40 to 59 years, both for professionals working in the urban and rural areas.The average working time was 14.7 ± 5.2 years, with a predominance of agents who performed this function more than ten years ago.As to schooling, more than half of the ACS had completed secondary education (Table 1  When analyzing the duration, in hours, of the higher hours training performed by ACS, of the 78 participants who reported having completed training, only 30.8% recalled the duration, ranging from 2 to 80 hours (median duration of 22 Hours), with 29.2% training with a workload of less than 10 hours and 70.8% with a workload equal to or greater than 20 hours.
In relation to knowledge about important aspects regarding the position and handle to be checked during breastfeeding, in order to provide good breastfeeding; As well as guidelines to be passed on to mothers who present breastfeeding complications, such as engorged breasts or fissures; It was observed that only 24.8% and 6.2% obtained satisfactory knowledge classification, respectively (Table 3).
Regarding the answers of the closed questions, the average number of correct answers was 15.2 ± 3.2 questions, out of a total of 23.When comparing the correct answers between the urban and rural areas, a significantly higher average of hits was observed (P = 0.019) among professionals working in the urban area compared to those in the rural area (Table 4).
On the other hand, there was no statistically significant association (p = 0.07) between knowledge about breastfeeding and the UBS zone to the agents are linked, although in the knowledge assessment, according to the answers in the closed questions (Table 5), a higher frequency of knowledge classified as good (52.3%) was observed for those linked to the urban area, while for rural areas the highest frequency was regular knowledge (46.2%).When investigating the existence of association between the location of UBS, training and schooling, no association was observed (p> 0.05).

Discussion
The community health agent (ACS) is the professional who acts objectively and directly on the crucial problems of maternal and child health.Although the Community Health Agents Program (PACS) was implemented by the Ministry of Health in 1991, the profession was only regulated in 2002 (Law 10,507) [12,13].
When analyzing the results obtained in the present study, it was observed that more than 80% of the community health agents work since profession regulation, having more than 10 years of experience and, thus, adding, throughout this period, a set of experiences and knowledge.However, despite this time of action, it was also observed that about one third of them did not undergo any training aimed at breastfeeding.In their study, Becker [10] found that about 85% of ACS and higher education professionals investigated had at least one training in breastfeeding.
The lack of capacity is one of the aspects recognized as limiting the ACS work [14].In the present study, the median duration of training with the highest workload reported by ACS was 22 hours.Breastfeeding training during a 16-hour training cycle was effective in incorporating knowledge into Community Health Agents and effective in increasing the prevalence of exclusive breastfeeding in a study conducted by Tsupal [15].Effective interventions are needed to support exclusive breastfeeding in health services and in the community, to promote positive outcomes in practices and frequency of exclusive breastfeeding [16].
Although no association was found between having received training in breastfeeding and the knowledge of the ACS, it is believed that the lack of training may reflect the same, once the knowledge classified as unsatisfactory in terms of importance for the good breastfeeding promotion, how to latch and position, as well as guidelines regarding the treatment of breast complications.
Breast complications usually occur in the first weeks after delivery, when there is still an adaptation between the supply and demand of breast milk in the mother-child binomial [17].Among the main difficulties encountered during breastfeeding, engorged breasts, nipple fissures, painful breasts [18,19], difficulty in latching, drying milk and rejection of the baby [19] are the most frequently reported by mothers.
In this aspect, it is crucial the presence of the professional that offers support and adequate orientations to the mothers, in a continuous way, as to the technique of breastfeeding.The daily tool that uses the ACS to promote health and a better quality of life for the family, especially in those who have groups at risk, such as pregnant women and nursing mothers, is the home visit [20].
The study by Campos et al. [21] Revealed that of the 66.3% of pregnant and nursing mothers attending the ESF, who reported having received some advice about breastfeeding, only 4.7% reported having received it from the home visits of community health agents.Women's lack of knowledge about how to prevent or solve common problems at the start of breastfeeding and the unavailability of professionals in the UBS, who have an expanded vision that goes beyond clinical management and supports mothers [22], may be causes of breastfeed failure ,since a process of maternal suffering based on engorgement, fissures and the perception of hunger through the behavior of the newborn begins, which contributes to the early interruption of breastfeeding [18,23].
In a study carried out on the breastfeeding prevalence in the same municipality where the present study was conducted, only 3.6% of the infants were exclusively breastfed after four months of age [24], which may be a reflection of the absence of guidelines and support to the nursing mothers regarding the difficulties encountered during the breastfeeding period, given the small percentage of community health agents, professionals closer to this population group, for whom the knowledge was considered satisfactory.
Breast engorgement, a frequent condition, especially in primiparous women, requires an effective approach to avoid other complications, such as fissures, mastitis, and sometimes lead to early weaning.The professionals' knowledge regarding the orientations to the women exposed to these intercurrences was classified as unsatisfactory in the present study, similar to the one found by Silveira [11], who investigated the knowledge and practices on breastfeeding of the Health Strategy Of the Family health professionals, in Anápolis-GO.The adequate guidelines for the treatment of engorgement, avoiding its evolution to other intercurrences, include manual milking and massage, which aid in breast relief and must be performed before breastfeeding, to enable the establishment of good latch [11,25].
The most frequent answers to the guidelines in case of fissurea indicate the professionals tendency to orient the heat treatment, evidencing the necessity of updating these professionals, since the heat can be used in a preventive way, however, the humid treatment is the current trend [25], since it promotes the formation of a protective film preventing the dehydration of the deeper layers of the dermis, besides having antimicrobial properties, helping to prevent mastitis [26].
The orientations reported for this study diverged from the findings found by Rocha and Ravelli [27], who identified in their research in Ponta Grossa Paraná that, in relation to nipple trauma, they reported receiving guidance from professionals to opt for humid treatment in cases of nipple trauma using breast milk itself on the nipple.In this study, it was also possible to identify the use of cultural practices as exposing breasts to the sun, which, according to the authors, reveals that it is essential to train the health team, so that it prepared to work in prevention, and in the resolution of nipples trauma and enable the population to acess update informations on breastfeeding.
Another factor closely related to the occurrence of breast complications, especially fissures and engorgement, consists of incorrect positioning and seizure 17.Regarding this issue, it was observed that, among the ACS evaluated, there was a predominance of knowledge classified as unsatisfactory.Thus, it is suggested that the fact that they have little knowledge about the latch and position causes the absence or incompleteness of the guidelines, which could be a factor that would make it difficult to prevent breast disorders that may be pointed, which, in turn, may also not be adequately treated for lack of effective recommendations When evaluating the general knowledge about breastfeeding, the ACS demonstrated a knowledge considered to be regular, in agreement with results obtained by Silveira [11].However, when comparing the degree of knowledge of the ACS from urban and rural areas, a greater number of hits and a "good" degree was observed among the ACS of the urban zone, which could not be justified by the agents number of trainings and schooling.
In this context, it should be noted that taboos involving the breastfeeding process are frequent, especially in rural areas.It is believed that low technical training and the high cultural values influence and experiences rooted in daily life can be reflected in the ACS professional work , who often use arguments and explanations based on their cultural universe, to the detriment of orientations Biomedical [7].
The community health agent plays a central role in promoting the health of the whole family.It is this professional who maintains the direct contact with the mothers and that should stimulate and guide the mothers and the family on the importance of exclusive breastfeeding.In this sense, it is incumbent on it to contribute to prepare the pregnant woman for breastfeeding so that, in the postpartum period, the process of adapting the puerperium to breastfeeding is facilitated and relaxed, thus avoiding doubts, difficulties and possible complications; And also work on monitoring the child's growth and development [18,26,28].Therefore, the importance of periodic and specific training in the area is emphasized, as a way to ensure the good performance of these activities by well-trained and well-prepared ACS.

Conclusion
The proposal of this study consisted of a strategy to identify and recognize the support scenario to the practice of breastfeeding in the Family Health Strategy.In view of the results obtained, there is a need for greater investments in the training of ACS in breastfeeding so that they can acquire the necessary knowledge to effectively work with pregnant women and nursing mothers, especially with regard to adequate breastfeeding techniques and treatment of breast complications.It is believed that, in this way, the ACS will be able to intervene in a timely manner, contributing to reduce the risk of early weaning; to increase the duration of breastfeeding, and thus to promote the health of the mother-child binomial.
In addition, the findings of this research raise the need for national studies on ACS knowledge and practices on breastfeeding, since the few studies carried out portray the reality of communities in isolation, which makes impossible the proposition of national public policies that may contribute to the improvement of breastfeeding indicators in the country, which are still far below that recommended by international health organizations.International Archives of Medicine is an open access journal publishing articles encompassing all aspects of medical science and clinical practice.IAM is considered a megajournal with independent sections on all areas of medicine.IAM is a really international journal with authors and board members from all around the world.The journal is widely indexed and classified Q2 in category Medicine.

Table 1 .
). Community health agents distribution by Basic Health Unit (UBS) location, according to the age group and work time.Picos, Brazil, 2014.

Table 2
presents the ACS distribution according to the training frequency, by professional performance time (n = 109).When questioned about the participation in a training program on the subject of breastfeeding, of the 112 agents who responded to the questioning, 69.6% reported having performed some training.It is noteworthy that, despite the work time of the ACS, more than 20% reported never having performed training.

Table 4 .
Community Health Agents correctness average in relation to the closed questions of evaluation of the knowledge degree in breastfeeding, according to distribution by the Basic Health Unit location, Picos, Brazil, 2014.

Table 3 .
Knowledge degree of community health agents regarding aspects of position and attachment during breastfeeding and guidelines for mothers with engorged fissures and breasts.Picos, Brazil, 2014.
*: Were considered 113 valid answers, since 3 (three) agents did not respond to the questions.

Table 2 .
Training number in breastfeeding performed by community health agents by work time.Picos, Brazil, 2014.

Table 5 .
Community health agents distribution regarding the classification of knowledge in breastfeeding, according to the Basic Health Unit (UBS) location.Picos, Brazil, 2014.