Measuring exclusive breastfeeding social support: Scale development and validation in Uganda

Psychometric evaluation of the Afaan Oromo version of the exclusive breastfeeding social support scale among Ethiopian women

PROBLEM

There is a lack of validated tools for assessing social support for Exclusive Breastfeeding (EBF) practice in Ethiopia.

BACKGROUND

Validating instruments ensures culturally appropriate and reliable data collection for effective research and interventions.

AIM

This study aimed to translate the exclusive breastfeeding social support scale into the Afaan Oromo language (EBFSS-AO) and test its psychometric properties among Ethiopian women.

METHODS

The scale was first subjected to forward and backward translation before undergoing psychometric evaluation. Then, a cross-sectional study was conducted on convenience sample of 160 postpartum women. Content validity was assessed via Content Validity Index (CVI), and construct validity was tested using confirmatory factor analysis (CFA) with maximum likelihood estimation. The scale's reliability was measured using Cronbach's alpha and intraclass correlation coefficient (ICC).

FINDINGS

The CFA verified that the EBFSS-AO for Ethiopian women is a three-dimensional scale with satisfactory fit indices; x2/df: 2.76; Comparative fit index: 0.917; Tucker-Lewis Index: 0.902; Standardized Root Mean square residual: 0.061; and Root mean square error of approximation: 0.105. Item-level CVI ranged from 0.86 to 1.00, and scale-level CVI was 0.98. The overall scale had a Cronbach's alpha of 0.95 while instrumental, emotional, and informational support subscales had a Cronbach's alpha of 0.89, 0.92, and 0.93 respectively. After a 4-week re-test, the ICC yielded a value of 0.94. Partner support on EBF showed no socio-demographic differences except for income.

CONCLUSION

The EBFSS-AO showed satisfactory psychometric properties, suitable for assessing social support among Ethiopian women in both research and clinical contexts.

Psychometrics of the breastfeeding self-efficacy scale and short form: a systematic review

BACKGROUND

The Breastfeeding Self-Efficacy Scale and its short-form were developed in Canada and have been used internationally among numerous maternal populations. However, the psychometric properties of the scales have not been reviewed to confirm their appropriateness in measuring breastfeeding self-efficacy in culturally diverse populations. The purpose of this research was to critically appraise and synthesize the psychometric properties of the scales via systematic review.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Three databases (EMBASE, MEDLINE, and PsycINFO) were searched from 1999 (original publication of the Scale) until April 27, 2022. The search was updated on April 1, 2023. Studies that assessed the psychometric properties of the BSES or BSES-SF were included. Two researchers independently extracted data and completed the quality appraisals.

RESULTS

Forty-one studies evaluated the psychometrics of the BSES (n = 5 studies) or BSES-SF (n = 36 studies) among demographically or culturally diverse populations. All versions of the instrument demonstrated good reliability, with Cronbach's alphas ranging from .72 to .97. Construct validity was supported by statistically significant differences in mean scores among women with and without previous breastfeeding experience and by correlations between the scales and theoretically related constructs. Predictive validity was demonstrated by statistically significant lower scores among women who ultimately discontinued breastfeeding compared to those who did not.

CONCLUSION

The BSES and BSES-SF appear to be valid and reliable measures of breastfeeding self-efficacy that may be used globally to (1) assess women who may be at risk of negative breastfeeding outcomes (e.g., initiation, duration and exclusivity), (2) individualize breastfeeding support, and (3) evaluate the effectiveness of breastfeeding interventions.

Breastfeeding challenges and the impact of social support in Iranian Muslim mothers: A cross-sectional study

Breast milk is the perfect food during infancy. Adequate support from family and health systems can be helpful to continue breastfeeding. This study aimed to determine the status of breastfeeding challenges and its relationship with social support and socio-demographic factors. In this correlational-descriptive study, 348 breastfeeding mothers were recruited using cluster random sampling from health care centers in Tabriz, Iran in 2022. Socio-demographic, breastfeeding challenges and social support questionnaires were used for data collection. Data were analyzed for descriptive and inferential statistics (Pearson correlation tests, independent t-test, one-way ANOVA and general linear model) using SPSS version 16. Difficulty in completing household tasks and breastfeeding at the same time (32.5 percent) was the most common challenge reported by mothers. There was an inverse and significant correlation between perceived social support and experiencing challenges (r = -0.199؛ p = .001). Based on the adjusted general linear model, with increasing social support, the score of breastfeeding challenges decreased (B = -0.165; 95 percent CI: -0.07-0.25, p < .001). Considering the relationship between perceived social support and the challenges experienced during breastfeeding, it can be concluded that adequate support from family along with training and guidance from health care providers can lead women to have better breastfeeding experiences and overcome breastfeeding problems.

Measuring the intangible resources caregivers need to provide nurturing care during the complementary feeding period: a scoping review in low- and lower-middle-income countries

OBJECTIVE

Caregivers require tangible (e.g. food and financial) and intangible resources to provide care to ensure child health, nutrition and development. Intangible resources include beliefs and knowledge, education, self-efficacy, perceived physical health, mental health, healthy stress levels, social support, empowerment, equitable gender attitudes, safety and security and time sufficiency. These intangible caregiver resources are included as intermediate outcomes in nutrition conceptual frameworks yet are rarely measured as part of maternal and child nutrition research or evaluations. To facilitate their measurement, this scoping review focused on understudied caregiver resources that have been measured during the complementary feeding period in low- and lower-middle-income countries.

DESIGN

We screened 9,232 abstracts, reviewed 277 full-text articles and included 163 articles that measured caregiver resources related to complementary feeding or the nutritional status of children 6 months to 2 years of age.

RESULTS

We identified measures of each caregiver resource, though the number of measures and quality of descriptions varied widely. Most articles (77 %) measured only one caregiver resource, mental health (n 83) and social support (n 54) most frequently. Psychometric properties were often reported for mental health measures, but less commonly for other constructs. Few studies reported adapting measures for specific contexts. Existing measures for mental health, equitable gender attitudes, safety and security and time sufficiency were commonly used; other constructs lacked standardised measures.

CONCLUSIONS

Measurement of caregiver resources during the complementary feeding period is limited. Measuring caregiver resources is essential for prioritising caregivers and understanding how resources influence child care, feeding and nutrition.

Comparison of Breastfeeding and Pumping Experiences of Milk Bank Donors in the United States and United Kingdom

Background/Objective: As human milk banking services expand, information about lifestyle characteristics and infant feeding experiences of milk bank donors is relatively limited. Our goal was to describe and compare milk bank donors' demographic, clinical, and lifestyle characteristics, and breastfeeding experiences in a variety of geographic settings. Methods: A cross-sectional online survey was conducted from August 2022 to December 2022 with approved donors from three milk banks in the United States (n = 369), and one milk bank in United Kingdom (n = 187). Results: Donors in all settings were predominantly in their early 30s, White, married, educated, and identified as female. U.K. donors reported more frequently being on maternity leave (33% versus 5%, p < 0.001), predominantly feeding directly at the breast in the first 3 months postpartum (51% versus 28%, p < 0.001), and breastfeeding a single child longer (21.2 versus 13.3 months, p < 0.001) than U.S. donors. Significantly more U.S. donors reported pumping due to work (34% versus 11%, p < 0.001) and pumping multiple times per day (57% versus 36%, p < 0.001). Most donors reported receiving information about breastfeeding from a health care provider (94% United States and 88% United Kingdom, p = 0.022), while the internet was the most popular source of information about pumping (65% United States and 64% United Kingdom, p = 0.751). Conclusion: Factors not directly related to milk banking (e.g., maternity leave, sources of breastfeeding/pumping assistance) may have an impact on how donors feed their children and ultimately on their milk donation pattern. The impact of donor characteristics and feeding practices on donation patterns warrants further investigation.

Examining psychometric properties of the Iranian version of exclusive breastfeeding social support scale (EBFSS)

BACKGROUND

The exclusive breastfeeding (EBF) is undeniably proven significant in mothers' health and infants' growth and survival. Its persistence has many familial, social, and economical benefits. Social support is known to be an effective factor in EBF's success and sustainability. However, Exclusive breastfeeding social support (EBFSS) scale validity and reliability is not evaluated in Iran. This study aimed to determine the psychometric properties of EBFSS during postpartum period in Tabriz city, Iran.

METHODS

It is a cross-sectional study with descriptive survey method performed between March 2021 and August 2022. Psychometric properties were determined for the Persian version of EBFSS in six stages: translation process, evaluating content validity, face validity, construct validity, discriminant validity, and reliability. A group of experts (n = 10), followed by a group of women with EBF (n = 10), evaluated the instrument's items based on content and face validities, respectively. A cross-sectional study using the multi-stage cluster random sampling method on 348 women with EBF in the first four months after delivery was conducted to determine the construct validity. The internal consistency and repeatability (test-retest on 30 women, 2 weeks apart) were used to find out the reliability.

RESULTS

Content validity ratio (CVR), content validity index (CVI), and impact score were 0.98, 0.98, and 3.54 for EBFSS, respectively. This indicates a good content and face validity. Exploratory factor analysis (EFA) was performed on 16 items to examine the construct validity identified emotional, instrumental, and informational factors. These factors explained 59.26% of the cumulative variance. The fit indices (CFI = 0.98، TLI = 0.95، χ2/df = 4.20، RMSEA = 0.07 and SRMSEA = 0.05) confirmed the validity of the model in a confirmatory factor analysis (CFA). The internal consistency was examined through Cronbach's alpha and McDonald's omega coefficients that were 0.90 and 0.92, respectively. Finally, Repeatability and reproducibility were found 0.97 (95% CI: 0.92 to 0.99) using Intra-class correlation. This shows an appropriate reliability of the instrument.

CONCLUSIONS

The research findings indicate that the Persian version of the EBFSS has appropriate psychometric properties for evaluating the social support in Iranian women with EBF. This means healthcare providers can use it for screening social support in EBF. Researchers also can use it as a valid instrument.

A preliminary evaluation of the supportive other experiences questionnaire: Integrating the perspectives of SS providers after traumatic injury

BACKGROUND

Social support is a protective factor against the development of Posttraumatic Stress Disorder (PTSD). However, examinations of the social support after trauma have relied primarily on the self-reports of trauma survivors to the exclusion of their support providers. A new measure, the Supportive Other Experiences Questionnaire (SOEQ) was adapted from a well-established behavioral coding schema of support behaviors to capture social support experiences from the support provider perspective.

METHOD

513 Concerned Significant Others (CSOs) recruited on MTurk who had served as support providers to a traumatically injured romantic partner were recruited to respond to SOEQ candidate items and other relevant measures of psychopathology and relational factors. Factor analytic, correlational and regression analyses were conducted.

RESULTS

Confirmatory factor analytic results of SOEQ candidate items provide evidence for three support types (i.e., informational, tangible, and emotional) and two support processes (i.e., frequency, difficulty), producing a final 11-item version of the SOEQ. Evidence of convergent and discriminant validity provide good psychometric support for the measure. Evidence of construct validity was derived from support for two hypotheses: (1) difficulty providing social support is negatively associated with CSO perceptions of trauma survivor recovery, (2) social support provision frequency is positively associated with relationship satisfaction.

LIMITATIONS

Though factor loadings for support types were significant, several were small, limiting interpretability. Cross-validation in a separate sample is needed.

CONCLUSIONS

The final version of the SOEQ demonstrated promising psychometric properties, and can provide key information one the experiences of CSOs as social support providers for trauma survivors.

A correlational study of breastfeeding duration among Saudi mothers: The role of self-efficacy, intention, and social support

Background

Breastfeeding is an essential source of nutrition for infants and offers numerous benefits for both the mother and child. Despite the consensus on its advantages, limited research in Saudi Arabia has explored the factors influencing breastfeeding duration.

Objective

This study aimed to examine the relationships between breastfeeding self-efficacy, intention, social support, and breastfeeding duration.

Methods

The study employed a correlational research design, and data were collected from three armed forces hospitals in Taif, Saudi Arabia, from December 2020 to February 2021. The samples comprised 356 conveniently selected breastfeeding mothers, assessed using the Breastfeeding Personal Efficacy Beliefs Inventory, Modified Infant Feeding Intention Scale, and Exclusive Breastfeeding Social Support Scale. Simple linear regressions were conducted for data analysis.

Results

Breastfeeding duration was divided into two groups. Group 1 consisted of mothers still breastfeeding at the time of data collection, while Group 2 comprised those who had discontinued breastfeeding. Of the total samples, 51.6% (n = 184) of mothers were classified under Group 1, while the remaining 48.4% (n = 172) were allocated to Group 2. Specifically, 78.3% of mothers had stopped breastfeeding by the time their infants were six months old, and 93.3% intended to introduce formula feeding at three months. In Group 1, the results revealed that self-efficacy (β = 0.625, p <0.001), intention (β = 0.643, p <0.001), and social support (β = 0.612, p <0.001) were positively associated with breastfeeding duration. Similarly, in Group 2, a strong positive correlation was observed between self-efficacy (β = 0.72, p <0.001), intention (β = 0.73, p <0.001), social support (β = 0.699, p <0.001), and breastfeeding duration. These three factors jointly explained 40% of the variance in breastfeeding duration in Group 1 (adjusted R2 = 0.4) and 50% in Group 2 (adjusted R2 = 0.5).

Conclusion

Breastfeeding intention was found to have a more significant impact on breastfeeding duration than self-efficacy and social support. These results can inform nurses and midwives in supporting breastfeeding mothers by providing them with the necessary information and increasing their awareness of breastfeeding-related factors.

Social Support for Breastfeeding Practice During the COVID-19 Second Wave in Thailand: A Cross-Sectional Study

BACKGROUND

Since December 2020, the second wave of COVID-19 in Thailand has had a considerable impact, and mothers have struggled to receive breastfeeding support in hospitals. In this situation, there has been limited research that addresses social support for breastfeeding and the influences of support in determining breastfeeding outcomes.

RESEARCH AIMS

(1) To describe the influence of COVID-19 on social support for breastfeeding and breastfeeding practices in the Thai context, and (2) to examine breastfeeding duration with different levels of social support from families and healthcare providers.

METHOD

This descriptive, cross-sectional online survey design was part of a larger multi-methods project about breastfeeding behaviors and experiences among postpartum mothers during the COVID-19 pandemic. Online questionnaires were administered from August to November 2021 to participants (N = 390) who were from three provinces in Thailand and had given birth 6-12 months prior to the survey.

RESULTS

Exclusive breastfeeding for 6 months was observed in less than half of the participants (n = 146, 37.4%). Perceptions of breastfeeding support were generally high overall among both family (Mdn = 45, IQR = 7) and healthcare providers (Mdn = 43, IQR = 7). Participants who perceived more breastfeeding support from families than the median had significantly longer exclusive breastfeeding durations than those who perceived less breastfeeding support than the median (z = -2.246, p = .025). The same pattern was present for breastfeeding support from healthcare providers (z = -2.380, p = 0.017).

CONCLUSIONS

While the exclusive breastfeeding rate was better than the pre-pandemic rate, successful breastfeeding was more common when participants perceived that they had received breastfeeding support. Policymakers should execute breastfeeding support systems along with COVID-19 management.

Effect of the mHealth-supported Healthy Future programme delivered by community health workers on maternal and child health in rural China: study protocol for a cluster randomised controlled trial

INTRODUCTION

Millions of young rural children in China still suffer from poor health and malnutrition, partly due to a lack of knowledge about optimal perinatal and child care among rural mothers and caregivers. Meanwhile, there is an urgent need to improve maternal mental health in rural communities. Comprehensive home visiting programmes delivered by community health workers (CHWs) can bridge the caregiver knowledge gap and improve child health and maternal well-being in low-resource settings, but the effectiveness of this approach is unknown in rural China. Additionally, grandmothers play important roles in child care and family decision-making in rural China, suggesting the importance of engaging multiple caregivers in interventions. The Healthy Future programme seeks to improve child health and maternal well-being by developing a staged-based curriculum that CHWs deliver to mothers and caregivers of young children through home visits with the assistance of a tablet-based mHealth system. This protocol describes the design and evaluation plan for this programme.

METHODS AND ANALYSIS

We designed a cluster-randomised controlled trial among 119 rural townships in four nationally designated poverty counties in Southwestern China. We will compare the outcomes between three arms: one standard arm with only primary caregivers participating in the intervention, one encouragement arm engaging primary and secondary caregivers and one control arm with no intervention. Families with pregnant women or infants under 6 months of age are invited to enrol in the 12-month study. Primary outcomes include children's haemoglobin levels, exclusive breastfeeding rates and dietary diversity in complementary feeding. Secondary outcomes include a combination of health, behavioural and intermediate outcomes.

ETHICS AND DISSEMINATION

Ethical approval has been provided by Stanford University, Sichuan University and the University of Nevada, Reno. Trial findings will be disseminated through national and international peer-reviewed publications and conferences.

TRIAL REGISTRATION NUMBER

ISRCTN16800789.

Pathways linking social support, self-efficacy, and exclusive breastfeeding among women in northern Uganda

Despite improvements in infant feeding practices over the past two decades, the prevalence of exclusive breastfeeding (EBF) is below global targets. Social support can create an enabling environment for recommended infant feeding practices such as EBF, but the types of social support most important for sustained EBF and their potential mechanisms of action have not been thoroughly characterized. We therefore aimed to assess the relationship between EBF-specific social support, EBF self-efficacy, and EBF at 1 and 3 months among postpartum women in northern Uganda. Women (n = 238, 36.2% living with HIV) were recruited during pregnancy. EBF, social support, and EBF self-efficacy were assessed at 1 and 3 months postpartum. Path analysis was used to assess relationships between these factors. Most mothers exclusively breastfed to 1 (80.8%) and 3 months postpartum (62.9%). EBF-specific, but not general, social support differed by EBF status. EBF-specific social support was associated with higher odds of EBF, which was almost fully mediated by EBF self-efficacy. That is, there was evidence that social support primarily influences EBF through its association with self-efficacy. In sum, EBF-specific social support and self-efficacy likely promote EBF and are modifiable factors that can be intervened upon.

Impact of personal and environmental factors affecting exclusive breastfeeding practices in the first six months during the COVID-19 pandemic in Thailand: a mixed-methods approach

Background

Exclusive breastfeeding (EBF) for six months is recommended as one of the most important ways to support child health and survival, particularly during the COVID-19 pandemic. However, breastfeeding women encountered several obstacles during the pandemic. The purpose of this study was to conduct a survey to document breastfeeding practices, EBF rates and associated factors with six month exclusive breastfeeding during the second wave of the coronavirus outbreak in Thailand.

Methods

A mixed-methods design that included a cross-sectional survey (n = 390) and semi-structured in-depth interviews (n = 15) was carried out between August and November 2021. Participants were women aged ≥ 15 years who had given birth within 6–12 months before data collection and delivered in three public hospitals in the top three provinces with the most severe COVID-19 outbreaks.

Results

The median duration of EBF was four months (interquartile range, IQR: 1–6 months) and 37.4% of women exclusively breastfed for six months. From binary logistic regression models, several personal factors were associated with exclusive breastfeeding for six months including being a housewife (AOR 2.848; 95% CI 1.512, 5.367), perceived sufficiency of family income (AOR 2.502; 95% CI 1.362, 4.594), working from home/business (AOR 2.071; 95% CI 1.074, 3.995), breastfeeding intention (AOR 1.162; 95% CI 1.116, 1.210), and maternal age (AOR 0.932; 95% CI 0.882, 0.986). From qualitative interviews, women who were able to exclusively breastfed during the outbreak explained five themes that were a protective shield; I have to save money, I could spend all my time with my baby and breastfeed, spousal support is valuable, and opportunity to avoid the obstructed beliefs about exclusive breastfeeding.

Conclusions

Mothers with higher socioeconomic status and who were unemployed/worked from home and had support structures in place were able to successfully EBF during the COVID-19 outbreak. Healthcare providers can better support breastfeeding if they provide informational support and allow family members to participate in breastfeeding programs, especially spouses who provided key emotional and tangible support during pandemic.

Application of the Extended Theory of Planned Behavior to Predict Exclusive Breastfeeding Intention, In Pregnant Nulliparous Women. A Cross-Sectional Study

OBJECTIVE.

This study investigated the effect of Extended Theory of Planned Behavior (ETPB) extended theory of planned behavior in comparison with the Theory Of Planned Behavior (TPB) in explaining the intention of Exclusive Breastfeeding Intention (EBF) in Pregnant nulliparous women of Kerman (Iran).

METHODS.

In this descriptive study, 249 pregnant women in Kerman participated via simple random sampling. The research instruments included Questionnaire related to the structures of the theory of planned behavior, breastfeeding self-efficacy and social support questionnaire for breastfeeding.

RESULTS.

The results of the correlation test showed a significant relationship between all constructs of the theory of extended planned behavior and the intention of EBF. The highest correlation belonged to the construct of subjective norms (r=0.49). Path regression coefficients in the second model showed that the Self-Efficacy mediator variable is fully capable of meaningful mediation between Social Support and Intention (p<0.001; B=0.383). The conceptual diagram of Structural equation modeling showed a higher explained variance or R2 index for the intention variable for the developed model compared to that of the first model, i.e. (the first model: R2=0.37, the second model: R2=0.46). The goodness-of-fit index had a better status for the developed model.

CONCLUSION.

Extended TPB with social support and breastfeeding self-efficacy constructs can be appropriate model for predicting the intention and behavior of EBF.

Development of the breastfeeding support scale to measure breastfeeding support from lay and professional persons, and its predictive validity in Japan

Background

International and national organizations recommend exclusive breastfeeding for the first 6 months of life, but many women stop earlier. Lay and professional persons can support mothers’ efforts to overcome breastfeeding difficulties. Considering breastfeeding support to comprise emotional support, practical help, and information offered to women who desire to breastfeed (by professionals, family members, and others), we developed and tested a scale to measure it in Japan.

Methods

A total of 31 items were generated by literature review and from the authors’ clinical experiences. Those items were tested with 243 mothers who visited public health centers in Tokyo for their infant’s health check-up 3 months after birth. Breastfeeding support and infant feeding status were then assessed 5 months after birth. All the data were collected by using self-administered questionnaires.

Results

On the basis of the results of factor analysis, the number of items was reduced to 11. There were three factors: support from breastfeeding peers and from people in specifically named healthcare professions, practical help, and support from people the mother can rely on to help meet emotional needs and address breastfeeding concerns. Internal-consistency reliability (alpha) of scores on the 11-item scale was 0.83 when measured 3 months postpartum and 0.85 when measured 5 months postpartum. Higher scores on the 11-item scale 3 months postpartum were associated with more breastfeeding exclusivity both at that time (Kruskal–Wallis test, chi-squared = 14.871, df = 3, n = 211, p = 0.002, eta-squared = 0.071) and also 5 months postpartum (Kruskal–Wallis test, chi-squared = 8.556, df = 3, n = 159, p = 0.036, eta-squared = 0.054). Further, the area under the Receiver Operating Characteristic curve was 0.73 (95% CI [0.57–0.88]), which indicates that scores on the 11-item scale 3 months postpartum may be useful to predict which mothers will be less exclusive in breastfeeding 5 months postpartum. In conclusion, scores on this 11-item scale were reasonably reliable and valid for measuring breastfeeding support provided by lay and professional persons to mothers in Japan. Further research is required to evaluate this scale’s applicability in other settings.

Mixed-Methods Systematic Review of Behavioral Interventions in Low- and Middle-Income Countries to Increase Family Support for Maternal, Infant, and Young Child Nutrition during the First 1000 Days

Fathers, grandmothers, and other family members' influence on maternal, infant, and young child nutrition (MIYCN) is widely recognized, yet synthesis of the effectiveness of engaging them to improve nutrition practices during the first 1000 d is lacking. We examined the impact of behavioral interventions to engage family members in MIYCN in low- and middle-income countries through a mixed-methods systematic review. We screened 5733 abstracts and included 35 peer-reviewed articles on 25 studies (16 with quantitative and 13 with qualitative data). Most quantitative studies focused on early breastfeeding, primarily engaging fathers or, less often, grandmothers. Most found positive impacts on exclusive breastfeeding rates and family members' knowledge and support. The few quantitative studies on complementary feeding, maternal nutrition, and multiple outcomes also suggested benefits. Qualitative themes included improved nutrition behaviors, enhanced relationships, and challenges due to social norms. Interventions engaging family members can increase awareness and build support for MIYCN, but more rigorous study designs are needed. This systematic review is registered at PROSPERO as CRD42018090273, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=90273.

Adaptation and psychometric evaluation of the breastfeeding self-efficacy scale to assess exclusive breastfeeding

Background

Increasing the prevalence of optimal breastfeeding practices, including exclusive breastfeeding for 6 months, could prevent an estimated 823,000 child deaths annually. Self-efficacy is an important determinant of breastfeeding behaviors. However, existing measures do not specifically assess exclusive breastfeeding self-efficacy, but rather self-efficacy for any breastfeeding. Hence, we sought to adapt and validate an instrument to measure exclusive breastfeeding self-efficacy.

Methods

We modified and added items from Dennis’ Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF). It was then implemented in an observational cohort in Gulu, Uganda at 1 (n = 239) and 3 (n = 238) months postpartum (clinicaltrials.gov NCT02925429). We performed inter-item and adjusted item-test correlations, as well as exploratory factor analysis and parallel analysis at 1 month postpartum to remove redundant items and determine their latent factor structure. We further applied confirmatory factor analysis to test dimensionality of the scale at 3 months postpartum. We then assessed the reliability of the scale and conducted tests of predictive and discriminant validity. Known group comparisons were made by primiparous status and correct breastfeeding knowledge.

Results

The modification of the original BSES-SF to target exclusive breastfeeding produced 19 items, which were reduced to 9 based on item correlations and factor loadings. Two dimensions of the adapted scale, the Breastfeeding Self-Efficacy Scale to Measure Exclusive Breastfeeding BSES-EBF emerged: Cognitive and Functional subscales, with alpha coefficients of 0.85 and 0.79 at 3 months postpartum. Predictive and discriminant validity and known group comparisons assessments supported its validity.

Conclusions

This version of the Breastfeeding Self-Efficacy scale, the BSES-EBF Scale, is valid and reliable for measuring exclusive breastfeeding self-efficacy in northern Uganda, and ready for adaptation and validation for clinical and programmatic use elsewhere.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2217-7) contains supplementary material, which is available to authorized users.

Best Practices for Developing and Validating Scales for Health, Social, and Behavioral Research: A Primer

Scale development and validation are critical to much of the work in the health, social, and behavioral sciences. However, the constellation of techniques required for scale development and evaluation can be onerous, jargon-filled, unfamiliar, and resource-intensive. Further, it is often not a part of graduate training. Therefore, our goal was to concisely review the process of scale development in as straightforward a manner as possible, both to facilitate the development of new, valid, and reliable scales, and to help improve existing ones. To do this, we have created a primer for best practices for scale development in measuring complex phenomena. This is not a systematic review, but rather the amalgamation of technical literature and lessons learned from our experiences spent creating or adapting a number of scales over the past several decades. We identified three phases that span nine steps. In the first phase, items are generated and the validity of their content is assessed. In the second phase, the scale is constructed. Steps in scale construction include pre-testing the questions, administering the survey, reducing the number of items, and understanding how many factors the scale captures. In the third phase, scale evaluation, the number of dimensions is tested, reliability is tested, and validity is assessed. We have also added examples of best practices to each step. In sum, this primer will equip both scientists and practitioners to understand the ontology and methodology of scale development and validation, thereby facilitating the advancement of our understanding of a range of health, social, and behavioral outcomes.

Measuring exclusive breastfeeding social support: Scale development and validation in Uganda

The World Health Organization recommends exclusive breastfeeding (EBF) for 6 months and continued breastfeeding for at least 2 years. Social support has been widely recognized to influence breastfeeding practices. However, existing scales do not measure exclusive breastfeeding social support (EBFSS), rather they assess social support for any breastfeeding. Further, they are tailored towards high-income settings. Therefore, our objectives were to develop and validate a tool to measure EBFSS in low-income settings. To develop the scale, local and international breastfeeding experts were consulted on modifications to the Hughes' Breastfeeding Social Support Scale. It was then implemented in an observational cohort in Gulu, Uganda, at 1 (n = 238) and 3 (n = 237) months post-partum (NCT02925429). We performed polychoric and polyserial correlations to remove redundant items and exploratory factor analysis at 1 month post-partum to determine the latent factor structure of EBFSS. We further applied confirmatory factor analysis to assess dimensionality of the scale at 3 months post-partum. We then conducted tests of predictive, convergent, and discriminant validity against EBF, self-efficacy, general social support, and depression. The modification of the Hughes' scale resulted in 18 items, which were reduced to 16 after examining variances and factor loadings. Three dimensions of support emerged: Instrumental, Emotional, and Informational, with alpha coefficients of 0.79, 0.85, and 0.83, respectively. Predictive, convergent, and discriminant validity of the resultant EBFSS scale was supported. The EBFSS scale is valid and reliable for measuring EBFSS in northern Uganda and may be of use in other low-income settings to assess determinants of EBF.