Predicting intention and maintenance of breastfeeding up to 2-years after birth in primiparous and multiparous women

OBJECTIVES

Breastfeeding up to 2-years has been associated with short and long-term health benefits for both newborns and mothers. However, few women breastfeed up to 2-years after birth. This study extends previous research on the theory of planned behaviour (TPB) examining the predictors of intention and maintenance of breastfeeding up to 2-years in both primiparous and multiparous women.

DESIGN

155 pregnant women participated in this longitudinal study.

METHODS

Expectant mothers completed a questionnaire and then 2-years after the child's birth were asked to report breastfeeding behaviour. Interactions among parity and TPB constructs were examined.

RESULTS

Attitudes, descriptive and injunctive norms, and perceived behavioural control (PBC) explained 58% of the variance in mothers' intention to breastfeed. Attitudes were the strongest predictor, followed by PBC, descriptive norms and parity. A significant interaction was found between parity and PBC, showing that PBC was only a significant predictor of intention to breastfeed at 2-years in multiparous women. Intentions predicted breastfeeding behaviour at 2-years.

CONCLUSION

Promoting intentions may be a useful way to increase breastfeeding duration to 2-years and targeting attitudes and norms may be one way to increase intentions. Further, targeting PBC may also be useful to increase intentions, but only in multiparous women.

Using the theory of planned behavior model to predict factors influencing breastfeeding behavior among preterm mothers at week 6 postpartum: the mediating effect of breastfeeding intention

Background

Exclusive breastfeeding (EBF) in the first 6 weeks postpartum is key to continued breastfeeding. This study aimed to explore the role of EBF-related predictors (particularly breastfeeding intention) in breastfeeding behavior among preterm mothers at week 6 postpartum based on the theory of planned behavior (TPB).

Methods

A total of 352 mothers of preterm infants were recruited, 340 of whom participated in this study. Prior to discharge, participants completed the Chinese versions of the modified Breastfeeding Attrition Predictive Tool, the Breastfeeding Knowledge Questionnaire (BKQ), the Infant Feeding Intention, and the Edinburgh Postnatal Depression Scale. Responses to the items of the Breastfeeding Behavioral Questionnaire (BBQ) were also collected by telephone at week 6 postpartum. The final analyses included 321 participants who completed the full two-wave data collection.

Results

The fitness indices of the modified TPB model were acceptable. Breastfeeding knowledge and EBF before discharge positively impacted breastfeeding intention, whereas depression had a negative impact. Before discharge, breastfeeding intention fully mediated the impacts of breastfeeding attitude, social and professional support, knowledge, depression, and EBF on breastfeeding behavior and partially mediated the influence of perceived breastfeeding control on breastfeeding behavior.

Conclusion

These findings indicate that TPB accurately predicts breastfeeding behavior among preterm mothers at week 6 postpartum, and breastfeeding intention is key to the above-mentioned EBF-related factors and breastfeeding behavior. The findings underline the need for further longitudinal studies and corresponding interventions for preterm mothers with a high risk of EBF attrition.

Racial and Ethnic Disparities in Breastfeeding Continuation Among U.S. Hispanic Mothers: Identification of Mechanisms

Objective: We examined the extent to which social, maternal, and infant factors and Theory of Planned Behavior (TPB) domains-attitudes, perceived control, and subjective norms-mediate the relationship between maternal race and ethnicity and birth country, and breastfeeding continuation. Materials and Methods: A nationally representative cohort of 2,810 mothers with self-reported race, ethnicity, and birth country was used. Main outcomes included any and exclusive breastfeeding at 2-6 months of infant age. A conceptual framework with the aforementioned mediators of interest was developed. Logistic regression was used to examine main associations, and structural equation modeling was used to identify the extent to which proposed mediators explained the relationship between independent and dependent variables. Results: One thousand two hundred twenty-one mothers were U.S.-born non-Hispanic white (NHW), 432 U.S.-born Hispanic, 329 Mexico-born Hispanic, 107 Central- or South America-born Hispanic, 33 Caribbean-born Hispanic, and 688 U.S.-born non-Hispanic black (NHB). No differences in breastfeeding continuation among U.S.-born NHW and U.S.-born Hispanic mothers were found. In contrast, compared with U.S.-born NHW mothers, Mexico-born (odds ratio [OR] 1.99, 95% confidence interval [CI] 1.46-2.72) and Central- or South America-born (OR 3.42, 95% CI 1.89-6.17) Hispanic mothers had higher odds, and Caribbean-born Hispanic mothers had lower odds (OR 0.45, 95% CI 0.26-0.76) of any breastfeeding. These relationships were mediated by attitudes and subjective norms. Conclusions: Breastfeeding continuation among U.S. Hispanic mothers varied by birth country, highlighting the heterogeneity of breastfeeding populations of Hispanic mothers in the United States. Tailored interventions should strengthen policies supportive of positive attitudes toward and subjective norms around breastfeeding.

The role of emotions and injunctive norms in breastfeeding: a systematic review and meta-analysis

Breastfeeding has many known benefits, but rates vary globally. We propose two main reasons why psychological theory and interventions have not been successful to date in explaining breastfeeding behaviours. Specifically, prior research underestimates the importance of (1) specific emotions and (2) wider injunctive influences (i.e., societal and moral norms about what women feel they ought to be doing) in the breastfeeding experience. Therefore, we conducted a systematic review of quantitative, qualitative, and mixed-methods studies that explored whether injunctive norms and/ or specific emotions are associated with breastfeeding behaviours (i.e., intentions, initiation and duration). Seventy-two papers were included in this review; data were extracted and quality appraisals conducted for all included studies. A meta-analysis of effect sizes was performed with the quantitative data. A convergent qualitative synthesis of the data was conducted, resulting in the following line of argument: Breastfeeding is a social behaviour and not a personal/individual behaviour. From this line of argument, three themes with associated sub-themes were developed, highlighting the importance of both specific emotions and injunctive norms on breastfeeding behaviours. These influences are discussed in relation to both theoretical and practical implications, as well as future research.

Disparities in Breastfeeding Among U.S. Black Mothers: Identification of Mechanisms

Objective: Disparities in U.S. breastfeeding rates persist among Black mothers according to birth country and between Black and White mothers, necessitating further investigation of modifiable mediating factors to inform interventions. This study seeks to examine the extent that social, maternal, infant factors and Theory of Planned Behavior (TPB) domains (attitudes, perceived control, and subjective norms) mediate the association of maternal race/birth country and breastfeeding continuation. Methods: A national cohort of 2,050 mothers self-identifying as U.S.-born non-Hispanic Black (n = 689), foreign-born non-Hispanic Black (n = 139), and U.S.-born non-Hispanic White (n = 1,222) was analyzed. Using logistic regression, associations of race/birth country and any/exclusive breastfeeding at 2-6 months were examined. Structural equation modeling was used to determine whether social, maternal, and infant factors and TPB domains mediate these relationships. Results: 40.0% of U.S.-born Black, 82.2% of foreign-born Black, and 57.3% of U.S.-born White mothers reported any breastfeeding at 2-6 months. Compared with U.S.-born Black mothers, odds of any breastfeeding were sevenfold higher among foreign-born Black mothers (odds ratio [OR] = 7.04 95% confidence interval [CI] = 4.80-10.31), which was explained partly by social/maternal/infant factors and TPB domains. Compared with U.S.-born White mothers, any breastfeeding was lower (OR = 0.54, 95% CI = 0.40-0.73) among U.S.-born Black mothers and higher (OR = 3.81, 95% CI = 2.48-5.87) among foreign-born Black mothers; these differences were also mediated by the aforementioned factors. Conclusions: Among Black mothers in the United States, breastfeeding continuation varied substantially by birth country. Promotion of interventions targeting positive attitudes, perceived control, and subjective norms may reduce disparities among Black and between Black and White mothers.

Use of the Theory of Planned Behavior Framework to Understand Breastfeeding Decision-Making Among Mothers of Preterm Infants

Background: Mothers of preterm infants face significant challenges to breastfeeding. The theory of planned behavior (TPB) is a well-known framework comprising three domains (attitudes, perceived control, and social norms), which has been used to conceptualize the array of factors that influence health-related behaviors and develop interventions to promote behaviors. Aim: We used the TPB framework to determine the array of factors that contribute to breastfeeding among mothers of preterm infants. Materials and Methods: Using qualitative research methods, we conducted in-depth, semistructured interviews with mothers regarding their experiences feeding their preterm infants according to TPB domains. We developed themes based on an iterative process of review of transcripts and conducted interviews until thematic saturation was reached. Results: We interviewed 23 mothers in 3 states 2 to 6 months after hospital discharge; 22 mothers initiated milk production and 6 were breastfeeding at the time of the interview. Factors that were positive and negative toward breastfeeding were present for all three TPB domains. Regarding attitudes, mothers felt that breastfeeding was a way to bond, that breast milk was healthy and protective, and that breast milk alone was insufficient for a growing preterm infant. Regarding perceived control, mothers felt empowered to breastfeed due to encouragement from hospital staff, friends, and family, and had difficulty overcoming their infant's immature oral feeding skills, competing responsibilities, and perceived infant preference for bottle feeding. Regarding social norms, mothers reported support for and against breastfeeding among hospital and Special Supplemental Nutrition Program for Woman, Infants, and Children (WIC) providers, family, friends, and the media. Conclusion: Interventional studies geared toward breastfeeding promotion among mothers of preterm infants may focus on addressing barriers to direct breastfeeding during the neonatal intensive care unit and early post-discharge time periods.

Effect of Education Based on Extended Theory of Planned Behavior on Exclusive Breastfeeding in Pregnant Women in Darmian in 2017

Background: Appropriate breastfeeding reduces health disorders and death among infants. Objectives: The present study was conducted to evaluate the effects of educational intervention based on the extended theory of planned behavior. Methods: In this semi-experimental study, 168 pregnant women from 20 health centers were allocated into intervention and control groups by a multi-stage sampling method. The data collecting tool included demographic and constructs of an extended theory of planned behavior. The validity and reliability of the questionnaire were confirmed by an expert panel and Cronbach's alpha test, respectively. The educational methods encompassed face to face training, pamphlet and flashcards distribution, and clip presentation. Two 45-minute educational sessions were conducted; the data were recollected 6 months after the delivery. Results: The mean ages of the intervention and control group were 29 ± 6 and 28.7 ± 5.9. The pregnancy rate and age of the pregnancy in the intervention group were 2.7 ± 1.4 and 29 weeks, respectively. After the intervention, the mean score of the behavior in the intervention group increased compared to the control group. The intention (B = 0.4, P = 0.01) and perceived behavior control (B = 0.42, P = 0.03) were the predictors of the behavior. Conclusions: The structures of the extended theory of planned behavior are suitable framework to promote exclusive breastfeeding among pregnant women.

A systematic review and meta-analysis of interventions incorporating behaviour change techniques to promote breastfeeding among postpartum women

The benefits of exclusive breastfeeding are well documented, yet few women adhere to recommendations. We report the Behaviour Change Techniques (BCTs) within interventions trialled internationally after pregnancy to promote exclusive and mixed breastfeeding as well as evidence of effectiveness. PsycINFO, EMBASE and MEDLINE databases were screened. Twenty-three (n = 23) studies met inclusion criteria. Three authors independently extracted data, coded interventions using the BCT v.1 taxonomy, and assessed study quality. There was a moderate significant effect of the interventions promoting exclusive breastfeeding up to four weeks postpartum (OR 1.77, [95% CI: 1.47-2.13]) but this effect slightly declined beyond thirteen weeks (OR 1.63, [95% CI: 1.07-2.47]). Twenty-nine BCTs were identified within interventions. 'Credible source' and 'instruction on how to perform the behaviour' were the most prevalent and 'social support (unspecified)' contributed to the effectiveness of exclusive breastfeeding interventions five to eight weeks postpartum. Using BCTs with cognitive and behavioural aspects may help women develop coping mechanisms promoting exclusive breastfeeding. Further trials are needed in countries with low breastfeeding rates such as the UK. The use of programme theory during intervention development and clear description of intervention components is recommended. This meta-analysis provides guidance for trials evaluating postpartum breastfeeding interventions.

The effect of a breastfeeding support programme on breastfeeding duration and exclusivity: a quasi-experiment

Background

Breastfeeding has important positive long-term health consequences for infants and mothers. The World Health Organization recommends that all infants should be exclusively breastfed for six months or longer, and advises continuation of breastfeeding for two years or beyond. However, these recommendations are not met in many countries. This study examined whether a comprehensive, evidence-based breastfeeding intervention, the Breastfeeding Support Programme (BSP), promotes prolonged duration and exclusivity of breastfeeding among its participants.

Methods

A quasi-experimental design was used to compare breastfeeding duration and exclusivity in the BSP group (N = 66) to breastfeeding duration and exclusivity in a control group (N = 72). Participants who followed the BSP were provided with 6 consults delivered by a lactation consultant. The consults started during pregnancy and continued up until 10 weeks after delivery. Participants in the control group did not follow the BSP. Pretest and posttest questionnaires were administered through the internet. A Cox proportional hazards regression analysis was used to estimate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for cessation of any and exclusive breastfeeding, while controlling for differences at baseline.

Results

The effect of the BSP on survival rates for any and exclusive breastfeeding were significant while controlling for differences between the two groups at baseline (respectively HR = 0.34, p < .001 [95% CI = 0.18–0.61] and HR = 0.46, p < .001 [95% CI = 0.29–0.72]). Among mothers in the BSP group there was on average 66% less risk of cessation of any breastfeeding and on average 54% less risk of cessation of exclusive breastfeeding at any point in time compared to those in the control group.

Conclusions

The BSP appears to be an effective means to delay cessation of any and exclusive breastfeeding cessation and therefore to increase breastfeeding duration and exclusivity. This is an important finding, because earlier cessation of breastfeeding than desired is a common problem in many countries. Future research into the effectiveness of the BSP could consider random assignment to conditions and test the effectiveness of the intervention in other populations to investigate further whether wide-scale implementation of this intervention could be useful to promote breastfeeding.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7331-y) contains supplementary material, which is available to authorized users.

To what extent does maternal body mass index predict intentions, attitudes, or practices of early infant feeding?

Public health guidelines recommend women establish and maintain exclusive breastfeeding to 6 months postpartum. Women with a body mass index (BMI, kg/m² ) in the overweight or obese range are less likely to initiate and continue breastfeeding than healthy weight women. Evidence for psychological mechanisms of this association using validated methods of measurement is limited, but factors such as attitudes and intentions for infant feeding are implicated. This study aimed to investigate the associations between maternal BMI, antenatal attitudes and intentions for infant feeding, and subsequent breastfeeding practices. A total of N = 128 women completed an online questionnaire antenatally, and n = 48 were followed-up in the first month postpartum. Validated measures of intentions (Infant Feeding Intentions Scale) and attitudes (Iowa Infant Feeding Attitude Scale) for infant feeding were used. One-way analysis of variance and multivariate regression analyses assessed study objectives. Infant feeding attitudes (p = .327) and intentions (p = .254) were similar among healthy weight, overweight, and obese women and did not differ significantly. In adjusted regression models, only intentions significantly predicted early breastfeeding behaviour (p = .036; AR²  = .301). Missing data analysis revealed no significant differences in the profile of completing versus noncompleting women. Evidence suggests postnatal factors contribute significantly to lower breastfeeding rates in cohorts of women with overweight or obese BMIs. Further investigations should consider using theory and methods from behavioural science to longitudinally investigate modifiable mechanisms of action responsible for lower breastfeeding rates among overweight and obese women to inform practices that support prolonged breastfeeding.

Breastfeeding Duration and the Theory of Planned Behavior and Breastfeeding Self-Efficacy Framework: A Systematic Review of Observational Studies

Introduction Numerous studies have shown that the constructs of the Theory of Reasoned Action (TRA), Theory of Planned Behavior (TPB) and Breastfeeding Self-Efficacy (BSE) Framework can effectively identify relationships between maternal psychosocial factors and breastfeeding initiation. However, the ability of these theories to predict breastfeeding duration has not been adequately analyzed. The aim of the review was to examine the utility of the constructs of TRA/TPB and BSE to predict breastfeeding duration. Methods We conducted a literature search using Pubmed (1980-May 2015), Medline (1966-May 2015), CINAHL (1980-May 2015), EMBASE (1980-May 2015) and PsycINFO (1980-May 2015). We selected studies that were observational studies without randomization or blinding, using TRA, TPB or BSE as the framework for analysis. Only studies reporting on breastfeeding duration were included. Results Thirty studies were selected, which include four using TRA, 10 using TPB, 15 using BSE and one using a combination of TPB and BSE. Maternal intention and breastfeeding self-efficacy were found to be important predictors of breastfeeding duration. Inconsistent findings were found in assessing the relationship between maternal attitudes, subjective norms, perceived behavior control and breastfeeding duration. Discussion The inadequacy of these constructs in explaining breastfeeding duration indicates a need to further explore the role of maternal self-determination in breastfeeding behavior.

Perceived Maternal Behavioral Control, Infant Behavior, and Milk Supply: A Qualitative Study

OBJECTIVE

Disparities persist in breastfeeding exclusivity and duration despite increases in breastfeeding initiation. The objective of this study was to examine factors that influence maternal decision making surrounding infant feeding practices over time in a diverse inner-city population.

METHODS

We conducted a prospective qualitative study with 20 mothers recruited from 2 urban primary care clinics. Participants completed open-ended interviews and demographic questionnaires in English or Spanish administered at approximately 2 weeks and 6 months postpartum. Transcripts were analyzed using a combined technique of inductive (data-driven) and deductive (theory-driven, based on the Theory of Planned Behavior) thematic analysis using 3 independent coders and iterative discussion to reach consensus.

RESULTS

All women initiated breastfeeding, and 65% reported perceived insufficient milk (PIM). An association between PIM and behavioral control emerged as the overarching theme impacting early breastfeeding cessation and evolved over time. Early postpartum, PIM evoked maternal distress-strong emotional responses to infant crying and need to control infant behaviors. Later, mothers accepted a perceived lack of control over milk supply with minimal distress or as a natural process. Decisions to stop breastfeeding occurred through an iterative process, informed by trials of various strategies and observations of subsequent changes in infant behavior, strongly influenced by competing psychosocial demands.

CONCLUSION

Infant feeding decisions evolve over time and are influenced by perceptions of control over infant behavior and milk supply. Tailored anticipatory guidance is needed to provide time-sensitive strategies to cope with challenging infant behaviors and promote maternal agency over breastfeeding in low-income populations.

Explaining infant feeding: The role of previous personal and vicarious experience on attitudes, subjective norms, self-efficacy, and breastfeeding outcomes

OBJECTIVES

Breastfeeding confers important health benefits to both infants and their mothers, but rates are low in the United Kingdom and other developed countries despite widespread promotion. This study examined the relationships between personal and vicarious experience of infant feeding, self-efficacy, the theory of planned behaviour variables of attitudes and subjective norm, and the likelihood of breastfeeding at 6-8 weeks post-natally.

DESIGN

A prospective questionnaire study of both first-time mothers (n = 77) and experienced breastfeeders (n = 72) recruited at an antenatal clinic in South East England.

METHODS

Participants completed a questionnaire at 32 weeks pregnant assessing personal and vicarious experience of infant feeding (breastfeeding, formula-feeding, and maternal grandmother's experience of breastfeeding), perceived control, self-efficacy, intentions, attitudes (to breastfeeding and formula-feeding), and subjective norm. Infant feeding behaviour was recorded at 6-8 weeks post-natally. Multiple linear regression modelled the influence of vicarious experience on attitudes, subjective norm, and self-efficacy (but not perceived control) and modelled the influence of attitude, subjective norm, self-efficacy, and past experience on intentions to breastfeed. Logistic regression modelled the likelihood of breastfeeding at 6-8 weeks.

RESULTS

Previous experience (particularly personal experience of breastfeeding) explained a significant amount of variance in attitudes, subjective norm, and self-efficacy. Intentions to breastfeed were predicted by subjective norm and attitude to formula-feeding and, in experienced mothers, self-efficacy. Breastfeeding at 6 weeks was predicted by intentions and vicarious experience of formula-feeding.

CONCLUSION

Vicarious experience, particularly of formula-feeding, has been shown to influence the behaviour of first-time and experienced mothers both directly and indirectly via attitudes and subjective norm. Interventions that reduce exposure to formula-feeding (perhaps by limiting advertising) or cushion mothers from its effects may enable more mothers to meet their breastfeeding goals. Statement of contribution What is already known on this subject? Rates of breastfeeding in the United Kingdom are low and resistant to change. Self-efficacy may be an important and modifiable factor for breastfeeding initiation and maintenance. What does this study add? Self-efficacy may only be a relevant factor among mothers who already have personal experience of breastfeeding. Vicarious experience of formula-feeding has been shown to be related to a lower rate of breastfeeding at 6 weeks.

Design of a Digital-Based, Multicomponent Nutrition Guidance System for Prevention of Early Childhood Obesity

Interventions targeting parenting focused modifiable factors to prevent obesity and promote healthy growth in the first 1000 days of life are needed. Scale-up of interventions to global populations is necessary to reverse trends in weight status among infants and toddlers, and large scale dissemination will require understanding of effective strategies. Utilizing nutrition education theories, this paper describes the design of a digital-based nutrition guidance system targeted to first-time mothers to prevent obesity during the first two years. The multicomponent system consists of scientifically substantiated content, tools, and telephone-based professional support delivered in an anticipatory and sequential manner via the internet, email, and text messages, focusing on educational modules addressing the modifiable factors associated with childhood obesity. Digital delivery formats leverage consumer media trends and provide the opportunity for scale-up, unavailable to previous interventions reliant on resource heavy clinic and home-based counseling. Designed initially for use in the United States, this system's core features are applicable to all contexts and constitute an approach fostering healthy growth, not just obesity prevention. The multicomponent features, combined with a global concern for optimal growth and positive trends in mobile internet use, represent this system's future potential to affect change in nutrition practice in developing countries.

Bobbi Be Best: the development and evaluation of an audio program and discussion guide to promote exclusive breastfeeding in Cameroon, Central Africa

One risk factor for infant and childhood morbidity is not exclusive breastfeeding (EBF) during the first six months of life. Entertainment Education (EE) is a communication strategy consisting of placing educational information into television, movies, and radio programs. In developing countries this form of behavioral change communication has proven effective in addressing health-related issues; however, no research has determined if EE is effective in promoting EBF. The objective of this research was to develop an EE audio program and discussion guide and to determine if a series of four 15-minute episodes and post-listening discussion improved knowledge, perceived benefits, self-efficacy, and intention and decreased misconceptions and perceived barriers toward EBF in the Kumbo West Health District, Cameroon. Pregnant women and their partners were assigned to either the control group (N = 116; 74 women, 42 partners) or intervention group (N = 148; 99 women, 49 partners) based on expected date of delivery. All control and intervention group participants completed a questionnaire prior to listening to the first and after the last episode. Pre- and post-listening questionnaires were used to determine changes in the EBF knowledge, misconceptions, perceived barriers, self-efficacy, and intention variables as a result of exposure to the audio program. The Wilcoxon Sign Rank test showed significant improvement in all of the variables, except perceived barriers, within the intervention group (p < 0.05) and the Mann-Whitney test indicated significant differences between the control and intervention group in all of the variables (p < 0.05), indicating that using an audio program and discussion guide based on the EE model is an effective tool for promoting EBF in this setting. The strength of this approach is that it goes beyond simply telling women about what constitutes EBF, but addresses misconceptions and perceived barriers that may prevent women from practicing EBF for six months.

Effectiveness of a nutrition education package in improving feeding practices, dietary adequacy and growth of infants and young children in rural Tanzania: rationale, design and methods of a cluster randomised trial

BACKGROUND

Strategies to improve infant and young child nutrition in low- and middle- income countries need to be implemented at scale. We contextualised and packaged successful strategies into a feasible intervention for implementation in rural Tanzania. Opportunities that can optimise delivery of the intervention and encourage behaviour change include mothers willingness to modifying practices; support of family members; seasonal availability and accessibility of foods; established set-up of village peers and functioning health system. The primary objective of the study is to evaluate the effectiveness of a nutrition education package in improving feeding practices, dietary adequacy and growth as compared to routine health education.

METHODS/DESIGN

A parallel cluster randomised controlled trial will be conducted in rural central Tanzania in 9 intervention and 9 control villages. The control group will receive routine health education offered monthly by health staff at health facilities. The intervention group will receive a nutrition education package in addition to the routine health education. The education package is comprised of four components: 1) education and counselling of mothers, 2) training community-based nutrition counsellors and monthly home visits, 3) sensitisation meetings with health staff and family members, and 4) supervision of community-based nutrition counsellors. The duration of the intervention is 9 months and infants will be recruited at 6 months of age. Primary outcome (linear growth as length-for-age Z-scores) and secondary outcomes (changes in weight-for-length Z-scores; mean intake of energy, fat, iron and zinc from complementary foods; proportion of children consuming 4 or more food groups and recommended number of semi-solid/soft meals and snacks per day; maternal level of knowledge and performance of recommended practices) will be assessed at baseline and ages 9, 12 and 15 months. Process evaluation will document reach, dose and fidelity of the intervention and context at 8 and 15 months.

DISCUSSION

Results of the trial will provide evidence of the effectiveness of the nutrition education package in community settings of rural Tanzania. They will provide recommendations for strengthening the nutrition component of health education in child health services.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02249754, September 25, 2014.

Factors influencing the intention of perinatal nurses to adopt the baby-friendly hospital initiative in southeastern quebec, Canada: implications for practice

Nurses play a major role in promoting the baby-friendly hospital initiative (BFHI), yet the adoption of this initiative by nurses remains a challenge in many countries, despite evidences of its positive impacts on breastfeeding outcomes. The aim of this study was to identify the factors influencing perinatal nurses to adopt the BFHI in their practice. Methods. A sample of 159 perinatal nurses from six hospital-based maternity centers completed a survey based on the theory of planned behavior. Hierarchical multiple linear regression analyses were performed to assess the relationship between key independent variables and nurses' intention to adopt the BFHI in their practice. A discriminant analysis of nurses' beliefs helped identify the targets of actions to foster the adoption the BFHI among nurses. Results. The participants are mainly influenced by factors pertaining to their perceived capacity to overcome the strict criteria of the BFHI, the mothers' approval of a nursing practice based on the BFHI, and the antenatal preparation of the mothers. Conclusions. This study provides theory-based evidence for the development of effective interventions aimed at promoting the adoption of the BFHI in nurses' practice.

Predicting US Infants' and Toddlers' TV/Video Viewing Rates: Mothers' Cognitions and Structural Life Circumstances

There has been rising international concern over media use with children under two. As little is known about the factors associated with more or less viewing among very young children, this study examines maternal factors predictive of TV/video viewing rates among American infants and toddlers. Guided by the Integrative Model of Behavioral Prediction, this survey study examines relationships between children's rates of TV/video viewing and their mothers' structural life circumstances (e.g., number of children in the home; mother's screen use), and cognitions (e.g., attitudes; norms). Results suggest that mothers' structural circumstances and cognitions respectively contribute independent explanatory power to the prediction of children's TV/video viewing. Influence of structural circumstances is partially mediated through cognitions. Mothers' attitudes as well as their own TV/video viewing behavior were particularly predictive of children's viewing. Implications of these findings for international efforts to understand and reduce infant/toddler TV/video exposure are discussed.

The "Moving Heart Program": an intervention to improve physical activity among patients with coronary heart disease

AIM

this paper reports the results of a nursing-administered theory-based intervention, the "Moving Heart Program", based on the implementation intention theory and pointed at improving physical activity adherence among coronary heart disease outpatients in Brazil.

METHODS

this experimental study applied assessments at baseline, 1 and 2 months after baseline. The Consolidated Standards of Reporting Trials statement was followed. Participants were randomly assigned to intervention, comprising action and coping plans on how to deal with anticipated barriers (n=69), or a standard-care control group (n=67).

RESULTS

participants submitted to the intervention showed significant higher levels of physical activity 2 months after baseline and were significantly more active than the control group.

CONCLUSIONS

the results indicate that the intervention is feasible for patients with coronary heart disease and can be a useful tool to facilitate intended lifestyle changes. This study brings relevant contributions to the Nursing field and other health-related areas, once the intervention presents low cost to health services and can be applied in cardiac rehabilitation programs, showing significant benefits to participants.

What factors explain pregnant women's feeding intentions in Bradford, England: a multi-methods, multi-ethnic study

BACKGROUND

Using a multi-methods approach we aimed to explore the relative prediction of demographic, socioeconomic and modifiable predictors from the Theory of Planned behaviour (TPB) in explaining feeding intentions amongst a multi-ethnic sample.

METHODS

476 women completed a questionnaire at 28 weeks gestation. They were grouped into breastfeeding (N = 258), mixed-feeding (N = 50), bottle-feeding (N = 88) intenders, or a no clear intention (N = 88). Multinomial adjusted regressions explored the influence of modifiable TPB factors, along with ethnicity and socioeconomic status in predicting group membership. Free-text responses allowed women to elaborate on reasons behind their intention.

RESULTS

TPB factors were significant predictors of feeding intention. Women with high intention to breastfeed were less likely to report high attitudes in any other feeding alternative. Bottle-feeding intenders reported poorer self-efficacy regarding breastfeeding compared to breastfeeding intenders (prevalence rate ratio, PRR = 0.10). Mixed and bottle-feeding intenders reported greater self-efficacy for mixed-feeding (PRR = 1.80, 5.50 respectively). Descriptive norms for mixed (PRR = 13.77) and bottle-feeding (PRR = 10.68) were predictive of mixed-feeding intention. Reasons for breastfeeding intentions related to health considerations, whilst bottle-feeding reasons related to convenience. Mixed-feeding intenders reported both breast and bottle-related factors.

CONCLUSIONS

Understanding modifiable predictors related to feeding intentions like TPB factors can help professionals target appropriate interventions to encourage breastfeeding.

Promoting positive attitudes to breastfeeding: the development and evaluation of a theory-based intervention with school children involving a cluster randomised controlled trial

The objective of this study was to design, implement and evaluate an intervention based on the theory of planned behaviour (TPB) to enhance young peoples' motivations to breastfeed/support a partner to breastfeed. Six semi-structured focus groups were first conducted with 48 13-14-year-olds from two schools in Northern Ireland. The salient beliefs elicited were subsequently used to design a TPB-based questionnaire that was then administered to 2021 13-14-year-old pupils (852 males; 1169 females) from 36 post-primary schools to identify the most important determinants of breastfeeding. The results were used to inform the design and implementation of an intervention package that was subsequently evaluated using a cluster randomised controlled trial involving 44 randomly selected schools across Northern Ireland. Questionnaires were administered to 18 intervention and 26 control schools at baseline and again at 1 and 6 months post-intervention to evaluate its effectiveness. Multi-level modelling was employed to analyse the data. The results revealed significant effects on women's intention to breastfeed, β = 0.208, t(1275) = 2.715, P = 0.007; attitudes, β = 0.223, t(1275) = 4.655, P < 0.001; moral attitudes, β = 0.231, t(1275) = 4.211, P < 0.001; subjective norm, β = 0.118, t(1275) = 2.521, P = 0.012; and knowledge, β = 0.109, d.f. (1275) = 7.843, P < 0.001. However, for men, the results revealed significant effects on only the construct of knowledge, β = 0.104, t(541) = 4.345, P < 0.001.The research has provided evidence to support the need for breastfeeding education in schools and has shown how a theoretical framework may be used to inform the design and evaluation of a health behaviour intervention.

Evaluation of a theory of planned behaviour-based breastfeeding intervention in Northern Irish schools using a randomized cluster design

OBJECTIVE

The aim of this research was to evaluate the effectiveness of a school-based intervention designed to enhance young people's motivations to breastfeed.

DESIGN

A cluster randomized controlled trial was conducted involving 50 post-primary schools from across Northern Ireland. However, dropout and exclusion criteria utilized for the current study resulted in an effective sample size of 42 schools.

METHODS

The intervention was delivered in two 35-min classroom sessions targeting those beliefs identified by the theory of planned behaviour (TPB) as significant in predicting motivation to breastfeed. Questionnaires incorporating the key components of the TPB were administered to all intervention and control schools at baseline, 1 and 6 months post-intervention. Multi-level modelling was used to analyse the data.

RESULTS

Findings suggest that the intervention was effective in that it increased females' intentions to breastfeed, expanded their knowledge and led to more favourable attitudes and perceptions of subjective norms. Notably, females' knowledge increased more in secondary schools than in grammar schools irrespective of whether they were control or intervention schools.

CONCLUSION

The research has provided evidence to support the use of the TPB in the design and evaluation of an intervention to increase females' intentions to breastfeed.

Integrating women's views into maternity care research and practice

The purpose of this paper is to consider the role of women's views in maternity care research and practice: what we mean by that, how and when women's views are sought (or not), and what we should do next. It is argued that women's views are not a stand-alone extra, but integral at every stage, including having an impact on clinical outcomes. Attending to "women's views" should not only mean a post hoc assessment of experiences but also needs to consider expectations and values. Importantly, this approach needs to apply not only to the care of individual women but also to the shaping of research and policy agendas. Recommendations are made for ways in which women's views can have a more central role in research and practice in the future.

Developing maternal self-efficacy for feeding preterm babies in the neonatal unit

Developing maternal self-efficacy offsets negative psychological consequences of premature birth, improving maternal well-being. We investigated women's experiences in a neonatal unit (NNU) in Scotland in semistructured interviews with 19 primiparous mothers of preterm babies. We explored their experience of preterm birth and development of self-efficacy in infant feeding behaviors, identifying emergent and a priori themes. Women reported experiencing loss and biographical disruption in relation to mothering, loss of autonomy, and searching for normality after premature birth. Providing breast milk symbolized embodied contact with their baby and increased maternal confidence. They developed motivation, knowledge, and perseverance and perceived success from positive feedback, primarily from their baby and health professionals' support and encouragement. Women actively constructed opportunities to develop ownership, control, and confidence in relation to interactions with their baby. We linked sources of self-efficacy with potential behavior change techniques to be used in practice to improve maternal confidence in the NNU.

The effects of Baby Friendly Initiative training on breastfeeding rates and the breastfeeding attitudes, knowledge and self-efficacy of community health-care staff

AIM

To evaluate the effects of Baby Friendly Initiative (BFI) community training on breastfeeding rates, staff and mothers in a large Primary Care Trust (PCT).

BACKGROUND

UK Government policy promotes the adoption and implementation of the World Health Organization/United Nations Children's Fund BFI as the best evidence to raise breastfeeding initiation and prevalence.

METHODS

A total of 141 health visitors and nursery nurses were trained on mandatory three-day BFI courses during 2008; 137 staff (100 health visitors, 37 nursery nurses) took part in the evaluation. Breastfeeding attitudes, knowledge and staff confidence in helping mothers to breastfeed were measured using a validated Breastfeeding Questionnaire and a self-efficacy tool at three time points before and after training.

FINDINGS

Breastfeeding rates at eight weeks increased significantly, and a baby born in 2009 was 1.57 times more likely to be breastfed than one born in 2006. Statistically significant improvements in staff breastfeeding attitudes, knowledge and self-efficacy were seen after attending the course, in addition to increases in the appropriate management of breastfeeding problems.Process evaluation interviews with 43 health visitors, nursery nurses and managers explored views of the training and changes in practice. The response to the course was overwhelmingly positive and felt to be extremely worthwhile. It has led to renewed enthusiasm, improved the consistency of advice among team members and raised confidence levels of all staff who help mothers with breastfeeding. Health visitors felt confident about enabling nursery nurses to take a greater role in breastfeeding support. A small survey of mothers reported increases in exclusive breastfeeding and signs of increased breastfeeding self-efficacy. Making the training mandatory across the whole PCT has improved the consistency of breastfeeding advice and confidence of all health-care staff who help breastfeeding mothers.

Increasing support for breastfeeding: what can Children's Centres do?

Britain has one of the lowest breastfeeding rates in Europe, with particularly low rates among White British families living in disadvantaged communities. As breastfeeding has important long-term health benefits for babies and their mothers, this represents a serious inequality in health. It is part of the remit of Sure Start Children's Centres which serve disadvantaged areas to offer child and family health services, including breastfeeding support. This study utilised an action research strategy to involve stakeholders in developing and extending breastfeeding promotion and support within three Children's Centres in Bristol. A total of 10 focus groups were conducted with Children's Centre staff and local parents between July 2008 and May 2009. Stakeholders' views were explored on current breastfeeding promotion and how Children's Centres could better support breastfeeding to meet local needs. Barriers to breastfeeding promotion were identified as latent hostility in the local community towards breastfeeding, and lack of knowledge about infant feeding among staff. Following implementation of the proposed changes, staff, parents and researchers shared their views on what had been achieved and on possible future initiatives. While there was variation in the extent to which Children's Centres engaged with the action research process, and in the extent to which change was made, all Centres did develop their breastfeeding promotion practice. Initiatives put into practice included strengthening links with health professionals, actively seeking to involve fathers, increasing the breastfeeding peer support offered locally and adopting a clear 'Breastfeeding Welcome' policy. This study has demonstrated that a collaborative action research approach can effectively stimulate the development of breastfeeding promotion and support within Children's Centres, leading to prompt and sustainable changes in practice.

Mothers' perceptions of introducing solids to their infant at six months of age: identifying critical belief-based targets to promote adherence to current infant feeding guidelines

We investigated critical belief-based targets for promoting the introduction of solid foods to infants at six months. First-time mothers (N = 375) completed a Theory of Planned Behaviour belief-based questionnaire and follow-up questionnaire assessing the age the infant was first introduced to solids. Normative beliefs about partner/spouse (β = 0.16) and doctor (β = 0.22), and control beliefs about commercial baby foods available for infants before six months (β = -0.20), predicted introduction of solids at six months. Intervention programs should target these critical beliefs to promote mothers' adherence to current infant feeding guidelines to introduce solids at around six months.

Healthcare professionals' and mothers' perceptions of factors that influence decisions to breastfeed or formula feed infants: a comparative study

AIM

This article is a report of a study comparing healthcare professionals' and mothers' perceptions of factors that influence the decision to breastfeed or formula feed an infant.

BACKGROUND

The World Health Organisation recommends that mothers should breastfeed exclusively for the first 6 months of age and then continue to do so alongside complementary foods for the first 2 years and beyond. However, levels of breastfeeding in the United Kingdom are below the recommended targets. Low levels of actual or perceived professional support and understanding are associated with formula use.

METHODS

Twenty professionals working closely with mothers of young infants completed a semi-structured interview exploring the reasons they believed mothers chose to use formula milk. Twenty-three mothers with an infant aged 6-12 months also reflected on their experiences of milk feeding. The data were collected during 2007-2008.

RESULTS

Professionals described a range of influences on maternal decisions to breastfeed or formula feed including lack of knowledge, support and help with difficulties. These were strongly echoed in the reasons mothers gave for formula use, suggesting clear professional understanding of the challenges relating to breastfeeding. Although keen to give further support, professionals raised issues of lack of time and resources to support mothers.

CONCLUSION

Contrary to maternal beliefs of poor professional understanding, professionals had a clear perception of influences affecting early milk feeding choice. Further resources and recognition are needed for healthcare professionals working with new mothers to enable them to offer increased support, with the aim of increasing breastfeeding duration.

Men and infant feeding: perceptions of embarrassment, sexuality, and social conduct in white low-income British men

BACKGROUND

The views of fathers have been shown to be important determinants of infant feeding decisions, but men's perceptions of breastfeeding and formula feeding are rarely explored. Our objectives were to address this gap and examine cultural associations and beliefs concerning infant feeding practices among men.

METHODS

Five focus groups were conducted with low-income men (n = 28) living in areas of social deprivation in Leeds, northeast of England, and low-income areas of Glasgow, west of Scotland. Participants were white British men, aged between 16 and 45 years, and included fathers, expectant fathers, and potential fathers.

RESULTS

Overarching themes concerning sexuality, embarrassment, and social conduct were identified across all groups. Participants perceived breastfeeding as "natural" but problematic, whereas formula feeding was mainly considered as convenient and safe. Participants without direct experience of breastfeeding assumed that it involved excessive public exposure and attracted unwanted male attention. Underpinning these fears were strong cultural associations between breasts and sexuality and anxieties concerning appropriate gender roles.

CONCLUSIONS

In some communities few opportunities may occur to witness breastfeeding, and thus existing fears concerning the activity as attracting predatory male attention remain unchallenged. Perceptions of breastfeeding as a sexual activity and the dominant mass media emphasis on breasts as a sexual site may present additional obstacles to breastfeeding. Antenatal or perinatal education with men should address not only practical issues but also provide advice on tackling problems generated by wider sociocultural issues of sexuality and masculinity.

Breastfeeding attitudes of Finnish parents during pregnancy

BACKGROUND

Breastfeeding attitudes are known to influence infant feeding but little information exists on the prenatal breastfeeding attitudes of parents. The purpose of this study was to describe Finnish parents' prenatal breastfeeding attitudes and their relationships with demographic characteristics.

METHODS

The electronic Breastfeeding Knowledge, Attitude and Confidence scale was developed and 172 people (123 mothers, 49 fathers) completed the study. The data were analysed using factor analysis and nonparametric methods.

RESULTS

Breastfeeding was regarded as important, but 54% of the respondents wanted both parents to feed the newborn. The mean rank values of breastfeeding attitudes differed significantly when parity, gender, education, age, breastfeeding history and level of breastfeeding knowledge were considered. The respondents who were expecting their first child, were 18-26 years old or had vocational qualifications or moderate breastfeeding knowledge had more negative feelings and were more worried about breastfeeding than respondents who had at least one child, had a higher vocational diploma or academic degree or had high levels of breastfeeding knowledge. Respondents with high levels of breastfeeding knowledge did not appear concerned about equality in feeding.

CONCLUSIONS

Both mothers and fathers found breastfeeding important. A father's eagerness to participate in their newborn's life should be included in prenatal breastfeeding counselling and ways in which to support breastfeeding discussed. Relevant information about breastfeeding should focus on the parents who are expecting their first child, those who are young, those with low levels of education or those who have gaps in breastfeeding knowledge, so that fears and negative views can be resolved.

Factors influencing the infant feeding decision for socioeconomically deprived pregnant teenagers: the moral dimension

BACKGROUND

The importance of breastfeeding-related health outcomes in reducing inequalities in health has been recognized as a National Health Service target to increase initiation rates especially among disadvantaged groups in England. This study examined the psychosocial factors influencing infant feeding intention among pregnant teenagers expecting their first baby and living in deprived urban areas in England.

METHODS

A mixed methods study, using a quantitative questionnaire based on the Theory of Planned Behaviour, was conducted in four English regions with predominantly white and Asian teenagers (n = 71). This method identified which of all known Theory of Planned Behaviour variables were the most important in influencing feeding intentions. Focus groups provided contextual insight into the meaning of these variables for white pregnant teenagers living in a northern English inner city (n = 17).

RESULTS

Moral norms were identified as the most predictive variable influencing teenage intention to formula feed or breastfeed. The likelihood that breastfeeding "will be embarrassing" was the only attitudinal belief rated as significantly important in influencing teenage intention to breastfeed. Three overarching themes emerged from the focus group data: "moral norms,""sexuality of the breast," and "self-esteem," with concerns relating to breastfeeding in public cutting across all themes.

CONCLUSIONS

Breastfeeding was viewed as a morally inappropriate behavior by most of these teenagers, with formula feeding being perceived as the appropriate behavior. Existing breastfeeding promotion activities are likely to continue to fail to reach teenagers experiencing deprivation in England in the absence of effective strategies to change the underlying negative moral norms toward breastfeeding.