Breastfeeding Self Efficacy

7/22/2019 Breastfeeding Self Efficacy

1/18

Translation and psychometric assessment ofthe Breast-feeding Self-Efficacy ScaleShortForm among pregnant and postnatal womenin Turkey

Abstract

Background

most women stop breast feeding before the recommended 6 months post partum. If health

professionals are to improve low breast-feeding duration and exclusivity rates, they need to

assess high-risk women reliably and identify predisposing factors amenable to intervention.

One possible modifiable variable is breast-feeding confidence. The Breast-feeding Self-

Efficacy ScaleShort Form (BSES-SF) is a 14-item measure designed to assess a mother's

confidence in her ability to breast feed her baby.

Objectives

to translate the BSES-SF into Turkish and assess its psychometric properties among women

in the antenatal and postnatal periods.

Design

a methodological study to assess the reliability, validity and predictive value of the BSES-SF.

Setting

two private and two public hospitals and their outpatient health clinics in Izmir, Turkey.

Participants

144 pregnant women and 150 postnatal breast-feeding mothers were recruited using

convenience sampling.

Methods

following back-translation procedures, questionnaires were completed in the third trimesterby pregnant women and in the hospital by postnatal women. All mothers were telephoned at

approximately 12 weeks after the birth to determine how they were feeding their babies.

Results

Cronbach's alpha coefficient for internal consistency was 0.87 antenatally and 0.86

postnatally. Antenatal and postnatal BSES-SF scores were significant predictors of breast-

feeding duration and exclusivity at 12 weeks after the birth. Differences were found between

antenatal and postnatal BSES-SF scores for mothers with previous breast-feeding

experience compared with scores for mothers with no breast-feeding experience.


2/18

Demographic response patterns suggest that the BSES-SF is a unique tool to identify

pregnant women and new mothers at risk of early cessation of breast feeding.

Conclusions

this study provides evidence that the translated version of the BSES-SF may be a valid andreliable measure of breast-feeding self-efficacy among a perinatal sample in Turkey.

Keywords:Breast-feeding Self-Efficacy Scale,Breast-feeding confidence,Psychometric testing

Back to Article Outline

IntroductionBreast feeding is described as one of the most health-promoting, disease-preventing

activities that a new mother can perform. Many programmes have been developed

throughout the world to promote breast-feeding initiation and duration. In 1989, the WorldHealth Organization (WHO) and the United Nations Children's Emergency Fund started the

Baby Friendly Hospital Initiative with the goal of protecting, encouraging and supporting

breast feeding (Littleton and Engeberston, 2002;Takn,2002;WHO, 2003).WHO

(2003)also published breast-feeding recommendations which indicated that all babies

should be exclusively breast fed for the first 6 months postpartum, with continued breast

feeding until 1 year or more. Numerous other national and international organisations have

also highlighted the importance of breast-feeding duration and exclusivity (Littleton and

Engeberston, 2002;Takn,2002). In Turkey, data from a national demographic health

survey (2003) found that 81.2% of babies are breast fed for the first 6 months postpartum.

While these results are positive, the survey also found that 79.2% of these babies also

receive supplementation. Thus, although most mothers in Turkey initiate breast feeding and

continue to breast feed until 6 months postpartum, the majority of the babies are not breast

fed exclusively (Turkish Demographic and Health Survey, 2003).

To address the problem of poor breast-feeding outcomes, numerous studies have been

conducted to evaluate the provision of breast-feeding support, both antenatally and

postnatally. In a Cochrane systematic review incorporating 34 trials (29,385 motherbaby

pairs) from 14 countries, results of meta-analyses suggest that overall professional and lay

support is beneficial to increase breast-feeding duration and exclusivity rates (Britton et al.,

2007). To identify mothers in need of additional breast-feeding support, researchers have

also conducted studies to identify factors that place a mother at risk of quitting breast feeding

prematurely or initiating supplementation. Consistently, mothers who are young, low income,

single or recent immigrants have been recognised as particularly vulnerable to poor breast-

feeding outcomes (Dennis, 2002;Alikasfogluet al., 2001;Mitra et al., 2004). However, many

of these high-risk factors are non-modifiable demographic variables. In order to address low

breast-feeding duration rates effectively, health-care professionals need to assess high-risk

women reliably, and identify predisposing factors that are amenable to supportive

interventions (Dennis and Faux, 1999;Ceriani Cernadas et al., 2003;Chezem et al.,

2003;Kronborg and Vaeth, 2004;McCarter-Spaulding and Kearne, 2001). One possible

modifiable variable is breast-feeding self-efficacy (Dennis, 1999). This is a mother'sperceived confidence in her ability to breast feed her new baby and has consistently been
http://www.midwiferyjournal.com/search/quick?search_area=journal&search_text1=Breast-feeding%20Self-Efficacy%20Scale&restrictName.ymidw=ymidwhttp://www.midwiferyjournal.com/search/quick?search_area=journal&search_text1=Breast-feeding%20Self-Efficacy%20Scale&restrictName.ymidw=ymidwhttp://www.midwiferyjournal.com/search/quick?search_area=journal&search_text1=Breast-feeding%20Self-Efficacy%20Scale&restrictName.ymidw=ymidwhttp://www.midwiferyjournal.com/search/quick?search_area=journal&search_text1=Breast-feeding%20confidence&restrictName.ymidw=ymidwhttp://www.midwiferyjournal.com/search/quick?search_area=journal&search_text1=Breast-feeding%20confidence&restrictName.ymidw=ymidwhttp://www.midwiferyjournal.com/search/quick?search_area=journal&search_text1=Breast-feeding%20confidence&restrictName.ymidw=ymidwhttp://www.midwiferyjournal.com/search/quick?search_area=journal&search_text1=Psychometric%20testing&restrictName.ymidw=ymidwhttp://www.midwiferyjournal.com/search/quick?search_area=journal&search_text1=Psychometric%20testing&restrictName.ymidw=ymidwhttp://www.midwiferyjournal.com/search/quick?search_area=journal&search_text1=Psychometric%20testing&restrictName.ymidw=ymidwhttp://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#article-outlinehttp://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#article-outlinehttp://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib22http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib22http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib30http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib30http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib30http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib30http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib33http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib33http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib33http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib33http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib33http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib33http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib33http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib22http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib22http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib22http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib22http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib30http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib30http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib30http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib30http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib32http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib32http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib32http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib34http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib34http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib34http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib34http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib14http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib14http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib1http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib1http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib1http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib1http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib24http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib24http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib24http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib12http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib12http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib8http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib8http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib8http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib9http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib9http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib9http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib9http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib20http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib20http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib20http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib23http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib23http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib23http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib13http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib13http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib13http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib13http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib23http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib20http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib9http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib9http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib8http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib12http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib24http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib1http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib14http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib34http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib34http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib32http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib30http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib22http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib22http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib33http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib33http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib33http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib30http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib22http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#article-outlinehttp://www.midwiferyjournal.com/search/quick?search_area=journal&search_text1=Psychometric%20testing&restrictName.ymidw=ymidwhttp://www.midwiferyjournal.com/search/quick?search_area=journal&search_text1=Breast-feeding%20confidence&restrictName.ymidw=ymidwhttp://www.midwiferyjournal.com/search/quick?search_area=journal&search_text1=Breast-feeding%20Self-Efficacy%20Scale&restrictName.ymidw=ymidw


3/18

shown to predict breast-feeding duration at 4, 6, 8 and 16 weeks postpartum among mothers

in Canada (Dennis, 2003), Australia (Blyth et al., 2002,Blyth et al., 2004;Creedy et al.,

2003), China (Dai and Dennis, 2003), Poland (Wutke and Dennis, 2007)and Puerto Rico

(Molina Torres et al., 2003). In addition, a significant relationship has been demonstrated

between breast-feeding self-efficacy and exclusive breast feeding (Blyth et al., 2002,Blyth et

al., 2004;Creedy et al., 2003;Dai and Dennis, 2003;Dennis, 2003;Molina Torres et al.,

2003).

The purpose of this study was: (1) to translate and psychometrically assess the Breast-

feeding Self-efficacy ScaleShort Form (BSES-SF) among pregnant and postpartum

women in Turkey; and (2) to examine the relationship between breast-feeding self-efficacy

and maternal demographic variables of Turkish women. Such a scale can be used

subsequently to identify pregnant and new mothers with low breast-feeding self-efficacy in

order to target efficacy-enhancing strategies to encourage successful breast feeding.

Breast-feeding self-efficacy theoryAccording toBandura (1977),self-efficacy is one's perceived belief to perform a specific task

or behaviour. Self-efficacy perception affects an individual's preferences, efforts and how

much they will struggle against obstacles. People who have low self-efficacy think that

events are more difficult than they seem, look at things with a narrow perspective and have

trouble solving problems that they face. Conversely, people with high self-efficacy are more

comfortable and confident when confronted with difficult tasks and events (Bandura,

1998;Dennis, 1999). However, Bandura suggests that individuals general self-efficacy

perceptions do not represent their self-efficacy for a particular behaviour, leading to the

necessity for behaviour-specific adaptation of the model. As such, drawing onBandura's

self-efficacy theory (1977),Dennis (1999)developed the breast-feeding self-efficacy theory,

which determines: (1) whether a mother initiates breast feeding; (2) how much effort she will

expend to breast feed; (3) whether she will have self-enhancing or self-defeating thought

patterns; and (4) how she will respond emotionally to difficulties encountered during breast

feeding. According toDennis (1999),a mothers breast-feeding self-efficacy is affected by

four main sources of information: (1) performance accomplishments (e.g. past breast-

feeding experiences); (2) vicarious experiences (e.g. watching other women breast feed); (3)

verbal persuasion (e.g. encouragement from influential others such as family, friends,

lactation consultants and health-care professionals); and (4) physiological responses (e.g.

fatigue, stress, anxiety).Breast-feeding Self-efficacy Scale

To measure breast-feeding self-efficacy,Dennis and Faux (1999)developed the BSES, a

33-item, self-report instrument. The BSES contains two subscales: (1) the technique

subscale, where items depict maternal skills and recognition of specific principles required

for successful breast feeding; and (2) the intrapersonal thoughts subscale, where items are

related to maternal attitudes and beliefs towards breast feeding. All items are preceded by

the phrase I can always and anchored with a five-point Likert scale where 1=not at all

confident and 5=always confident. As recommended byBandura (1977),all items are

presented positively and scores are summed to produce a range from 33 to 165, with higher

scores indicating higher levels of breast-feeding self-efficacy. Content validity of the BSES
http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib15http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib15http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib15http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib6http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib6http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib6http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib7http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib7http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib7http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib10http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib10http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib10http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib10http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib11http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib11http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib11http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib38http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib38http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib38http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib25http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib25http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib25http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib6http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib6http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib6http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib7http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib7http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib7http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib7http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib10http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib10http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib10http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib11http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib11http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib11http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib15http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib15http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib15http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib25http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib25http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib25http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib25http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib3http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib3http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib3http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib4http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib4http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib4http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib4http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib13http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib13http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib13http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib3http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib3http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib3http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib3http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib13http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib13http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib13http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib13http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib13http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib13http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib12http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib12http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib12http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib3http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib3http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib3http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib3http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib12http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib13http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib13http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib3http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib3http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib13http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib4http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib4http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib3http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib25http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib25http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib15http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib11http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib10http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib7http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib7http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib6http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib25http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib38http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib11http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib10http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib10http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib7http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib6http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib15


4/18

was based on a literature review, interviews with breast-feeding mothers, and expert

judgement using a method recommended byLynn (1986).Following a pilot test, an initial

psychometric assessment was conducted with a convenience sample of 130 Canadian

breast-feeding women, where questionnaires were completed during the postpartum

hospitalisation and again at 6 weeks postpartum (Dennis and Faux, 1999). Cronbach's alpha

coefficient for the scale was 0.96, with 73% of all corrected item-total correlations ranging

from 0.30 to 0.70. Responses were subjected to principal components analysis with a

varimax rotation, yielding the theorised subscales. Support for predictive validity was

demonstrated through positive correlations between BSES scores and baby-feeding method

at 6 weeks postpartum.

However, internal consistency statistics with the original BSES suggested item redundancy.

As such, another methodological study was undertaken and 18 items were deleted using

explicit reduction criteria (Dennis, 2003). Based on the encouraging reliability analysis of the

new 14-item BSES-SF, construct validity was assessed using principal components factor

analysis, comparison of contrasted groups and correlations with measures of similarconstructs. Support for predictive validity of this shortened version was demonstrated

through significant mean differences between breast-feeding and bottle-feeding mothers at 4

and 8 weeks postpartum. Demographic response patterns suggested that the BSES-SF is a

unique tool to identify mothers at risk of premature cessation of breast feeding.

These studies provide preliminary evidence that the BSES/BSES-SF may be an

internationally applicable, reliable and valid measure to assist health professionals in caring

for breast-feeding women. In non-English-speaking areas, health professionals would benefit

from having a translated version of the scale. Furthermore, the scale has primarily been

used with mothers in the immediate postpartum period, with only one study (Creedy et al.,

2003)demonstrating the predictive validity of the scale in pregnancy.Back to Article Outline

Methods

Design and sample

A methodological study was completed to assess the reliability, validity and predictive value

of the BSES-SF among Turkish women. All participants were recruited in Izmir, Turkey

between September and November 2006. To psychometrically assess the translated scale

antenatally, pregnant women in their third trimester with a singleton fetus, who intended to

breast feed, were approached by a researcher (first author) during a regular antenatal visit.In Turkey, there is a wide range in educational status between women. As such, a goal of

this study was to recruit a diverse sample of women to ensure that the scale could be used

with women from all educational levels. For this reason, participants were recruited from two

private and two public outpatient health clinics. In total, 157 women were eligible to

participate in the study, and 144 (91.6%) agreed to take part.

To psychometrically assess the scale postnatally, participants were identified on the

postnatal ward at one of the three hospitals (two public and one private) by the researcher.

All participants were further assessed for eligibility and to explain the study. Eligible

participants were breast-feeding mothers who were: (1) in their first week postpartum; (2) 18years of age or older; (3) able to read and speak Turkish; and (4) at least 37 weeks of
http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib35http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib35http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib35http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib12http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib12http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib12http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib15http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib15http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib15http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib10http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib10http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib10http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib10http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#article-outlinehttp://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#article-outlinehttp://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#article-outlinehttp://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib10http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib10http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib15http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib12http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib35


5/18

gestation when they gave birth. Mothers were excluded if they had a factor which could

significantly interfere with breast feeding, such as multiple birth, a serious medical condition

or a known birth defect. In total, 154 women met the eligibility criteria, and 150 (97.5%)

agreed to take part in the study.

Data collectionAfter informed consent procedures approved by the university and hospital ethical review

boards, the BSES-SF and demographic questionnaire were completed by pregnant women

during their antenatal visit, and by postpartum mothers in their first week following childbirth.

During the in-hospital data collection session in the postnatal group, mothers were also

asked about their current breast-feeding status. For this study, breast feeding was defined

as the receipt by the baby of any breast milk within the past 24 hours, and was further

classified into: exclusive breast feeding (breast milk only); almost exclusive breast feeding

(breast milk and other fluids, but not artificial milk, e.g. vitamins); high breast feeding (less

than one bottle of artificial milk per day); partial breast feeding (at least one bottle of artificialmilk per day); token breast feeding (breast given to comfort the baby, but not for nutrition);

and bottle feeding (no breast milk at all) (Labbok and Krasovec, 1990). All participants in

both the antenatal and postnatal groups were telephoned by the researcher at 12 weeks

post partum to determine their mode of baby feeding.

Translation of the BSES-SF

Various methods were used in translating the BSES-SF from English to Turkish to ensure

content, semantic and technical equivalence. The methods used were similar to those used

byDai and Dennis (2003),andWutke and Dennis (2007).Semantic equivalence ensures

that the meaning of each item remains the same after translation into the target language. Afrequently recommended method for semantic equivalence is the blind back-translation

method (Beck et al., 2003). In this method, the person who translates the instrument has not

seen the original form of the items. In the current study, three bilingual experts translated the

scale independently from English to Turkish. Discrepancies between the three iterations

were discussed and reconciled into a single Turkish version. Back translation from Turkish

into English using blind back-translation procedures was completed by a lay individual who

had not seen the original English version of the scale and who knew both languages, but

whose native language was Turkish. No important differences in meaning were found

between the original English version and the back-translated version.

Content appropriateness is established by determining whether the content of each item of

the instrument is relevant to the target culture (Tezbaaran,1999;Gzm and Aksayan,

2002a,Gzm and Aksayan, 2002b;Beck et al., 2003). To assess for content

appropriateness, nine academic nurses with expertise in obstetric and gynaecological

nursing reviewed the items to determine whether they were understandable and suitable for

Turkish culture. The experts rated each item from 1 (poor fit) to 10 (excellent fit). A

Kendall Wtest was conducted to assess for agreement among the experts. No significant

differences between the experts were found (p=0.10).

Finally, to establish technical appropriateness, a paper-and-pencil method was used in a

pilot test of the translated BSES-SF in a manner consistent with the original methodological

study (Dennis and Faux, 1999). Eleven pregnant women and 16 postnatal mothers
http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib21http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib21http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib21http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib11http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib11http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib11http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib38http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib38http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib38http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib5http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib5http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib5http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib31http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib31http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib31http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib31http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib17http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib17http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib17http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib17http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib18http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib18http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib18http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib5http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib5http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib5http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib12http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib12http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib12http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib12http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib5http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib18http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib17http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib17http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib31http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib5http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib38http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib11http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib21


6/18

completed the scale to assess for face validity. The women in each group were selected to

represent different educational levels. Scale items were easily understood by 92.6% (n=25)

of the mothers. One item that posed some difficulty was I can always finish feeding my baby

on one breast before switching to the other breast. With their suggestion, a minor change

was made to this item in the Turkish version. When this modified item was back translated to

English, there was no change to the original English version.


Results

Sample characteristics

The mean age for the antenatal sample was 25.9 years [standard deviation (SD) 4.4, range

1936]. One-third (n=48, 33.3%) of the pregnant women had completed elementary school,

33.3% (n=48) had completed high school, and 33.3% (n=48) were university graduates.

Thirty-five per cent of women (n=51) were currently working outside the home, while the

remaining women (n=93) were homemakers. Over half of the sample (n=72, 54.2%)

reported a monthly income of $5001000 (middle-income status), with the remaining women

reporting lower ($250400) (n=31, 21.5%) and upper (>$1000) (n=35, 24.3%) incomes. Half

(n=72, 50%) of the women were primigravidas.

For the postnatal sample, the mean age was 24.4 years (SD 4.4, range 1834). One-third

(n=50, 33.3%) of the women had completed elementary school, 33.3% (n=50) had

completed high school, and 33.3% (n=50) were university graduates. Thirty-two per cent

(n=48) of the women had worked prior to delivery and planned to return to work at the end of

their maternity leave. In Turkey, women have 16 weeks of maternity leave. Of the new

mothers, 39.2% (n=61) reported a monthly income of $5001000 (middle-income status),while 37.1% (n=57) reported a high income (>$1000) and 23.8% (n=37) reported a low

income ($250400). Half (n=75, 50%) of the women were primiparous. Of the multiparous

mothers, 58 (77.3%) had just given birth to their second baby, 13 (17.3%) had just given

birth to their third baby, and four (5.3%) had just given birth to their fourth baby. All of the

multiparous mothers had breast-feeding experience. The majority of the deliveries (n=108,

69.3%) were vaginal.

Reliability

The internal consistency of the BSES-SF antenatally and postnatally was evaluated by

considering the following: (1) item summary statistics; (2) inter-item correlations; (3)

corrected item-total correlations; (4) Cronbach's alpha coefficient; and (5) the alpha estimate

when an item was deleted (Strickland, 1996). These criteria were used in previous BSES

psychometric investigations and were used to ensure comparability of results (Dennis and

Faux, 1999;Dai and Dennis, 2003;Dennis, 2003;Ergin, 1995;Molina Torres et al.,

2003;Wutke and Dennis, 2007). For the antenatal sample, Cronbach's alpha for the BSES-

SF was 0.87; there was no increase of more than 0.10 in Cronbach's alpha with removal of

any item. The lowest item-total correlation was 0.42 and the highest was 0.75, with 85.7%

falling within the recommended range of 0.300.70. The mean BSES-SF score was 58.52

(SD 8.80). The overall item mean was 4.18, ranging from 3.50 to 4.57. The item variance

mean was 1.03, ranging from 0.59 to 1.81. For the postnatal sample, Cronbach's alpha forthe BSES-SF was 0.86; there was no increase of more than 0.10 in Cronbach's alpha for
http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#article-outlinehttp://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#article-outlinehttp://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib37http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib37http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib37http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib12http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib12http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib12http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib12http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib11http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib11http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib11http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib15http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib15http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib15http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib16http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib16http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib16http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib25http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib25http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib25http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib25http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib38http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib38http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib38http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib38http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib25http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib25http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib16http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib15http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib11http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib12http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib12http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib37http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#article-outline


7/18

any item. The lowest item-total correlation was 0.45 and the highest was 0.71. The mean

BSES-SF score was 60.09 (SD 8.2). The overall item mean was 4.29, ranging from 3.77 to

4.68. The item variance mean was 0.96, ranging from 0.37 to 1.89.

Construct validity

According toBandura (1977),self-efficacy is influenced by previous performanceaccomplishments. In the present study, it was hypothesised that pregnant women in the

antenatal group who had breast fed previously would have higher levels of breast-feeding

self-efficacy than women who had no previous breast-feeding experience. Consistent with

this hypothesis, a significant difference was found between pregnant women with previous

breast-feeding experience (mean 62.1, SD 7.3) and pregnant women without breast-feeding

experience (mean 54.9, SD 8.7; t=5.35,p


8/18

were evaluated. Among the antenatal sample, there was no relationship between maternal

age and antenatal BSES-SF scores (r=0.12,p=0.16). There were statistically significant

differences in mean BSES-SF scores among mothers who had completed elementary

school (mean 57.4, SD 8.8), high school (mean 60.3, SD 8.8) and university (mean 62.9, SD

6.1;F=6.54,p=0.002). There was also a statistically significant difference between low-

income (mean 57.6, SD 9.5), middle-income (mean 57.4, SD 9.3), and high-income (mean

61.8, SD 5.9; F=3.33,p=0.04) mothers.

Among the postnatal sample, there was no relationship between maternal age and in-

hospital BSES-SF scores (r=0.13,p=0.11). In relation to education, there was a significant

difference in BSES-SF scores among mothers who completed elementary school (mean

55.8, SD 10.8), high school (mean 58.4, SD 8.0) and university (mean 61.2, SD

6.4; F=4.7,p=0.01). Statistically significant differences in mean BSES-SF scores were also

found between low-income (mean 56.4, SD 7.9), middle-income (mean 60.3, SD 8.4) and

high-income (mean 62.5, SD 6.4; F=6.82,p=0.001) mothers. Women who had a vaginal

birth had higher BSES-SF scores (mean 62.7, SD 6.03) than mothers who experienced acaesarean section (mean 57.9, SD 8.7; t=3.86,p


9/18

Faux, 1999;Creedy et al., 2003;Dai and Dennis, 2003;Dennis, 2003;Molina Torres et al.,

2003;Wutke and Dennis, 2007), and suggests that the translated version of the BSES-SF

can be used to identify which mothers are likely to discontinue breast feeding before 12

weeks postpartum.

Consistent with previous research (Dennis and Faux, 1999;Blyth et al., 2002;Dai and

Dennis, 2003;Dennis, 2003;Molina Torres et al., 2003;Wutke and Dennis, 2007), no

relationship was found between maternal age and breast-feeding self-efficacy. However, the

finding that BSES-SF scores differ significantly among mothers with varying educational and

income levels is a unique result and has not been found in previous breast-feeding self-

efficacy studies. However, this finding is consistent with other breast-feeding research which

suggests that uneducated and low-income mothers are particularly vulnerable to poor

breast-feeding outcomes (Dennis, 2002). Further research exploring why these mothers may

be less confident in their ability to breast feed in a primarily breast-feeding country such as

Turkey warrants further investigation. Finally, this study is the second breast-feeding self-

efficacy study to find that mothers who experience a caesarean section have lower in-hospital BSES-SF scores than those who have a vaginal birth; similar results were found

among Polish mothers (Wutke and Dennis, 2007). This result suggests that there may be

short-term psychological outcomes related to caesarean childbirth, and additional research

is warranted to examine this finding, especially since it has been suggested that caesarean

section rates are increasing internationally (Anderson, 2004). Additional research is

warranted to explore factors that decrease breast-feeding self-efficacy among mothers who

have experienced a caesarean section.

The translation process for the study was conducted carefully by bilingual experts, and the

recommended blind back-translation method was used. In addition, nine experts carefully

evaluated every item for cultural appropriateness from the viewpoint of a Turkish woman.The translated BSES-SF was also pilot tested with pregnant and recently delivered women

to confirm face validity. The results of this study show that the Turkish version of the BSES-

SF is similar to the original version, and that it can be used with Turkish women, both

antenatally and postnatally, to identify mothers who may be at high risk of quitting breast

feeding prematurely or introducing supplementary feeds. The scale could also be helpful in

planning appropriate interventions to improve the confidence of mothers with low breast-

feeding self-efficacy.


References1. AlikasfogluM, Erginoz E, Tasdelen E, Baltes Z, Beker B, Arvas A. Factors influencing the

duration of exclusive breastfeeding in a group of Turkish women.Journal of HumanLactation. 2001;17:220223

View In Article2. Anderson G. Making sense of rising caesarean section rates. British Journal of

Medicine. 2004;329:696697

View In Article3. Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychological

Review. 1977;84:191215

View In Article CrossRef
http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib12http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib12http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib10http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib10http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib10http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib11http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib11http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib11http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib15http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib15http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib15http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib25http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib25http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib25http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib25http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib38http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib38http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib38http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib12http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib12http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib12http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib6http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib6http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib6http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib11http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib11http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib11http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib11http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib15http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib15http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib15http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib25http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib25http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib25http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib38http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib38http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib38http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib14http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib14http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib14http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib38http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib38http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib38http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib2http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib2http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib2http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#article-outlinehttp://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#article-outlinehttp://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib1http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib1http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib2http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib2http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib3http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib3http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltexthttp://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltexthttp://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltexthttp://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib3http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib2http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib1http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#article-outlinehttp://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib2http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib38http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib14http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib38http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib25http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib15http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib11http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib11http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib6http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib12http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib38http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib25http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib25http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib15http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib11http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib10http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#bib12


10/18

4. Bandura A. Health promotion from the perspective of social cognitive theory. Psychologyand Health. 1998;13:249623

View In Article5. Beck CT, Bernal H, Froman RD. Methods to document semantic equivalence of a translated

scale. Research in Nursing and Health. 2003;26:6473

View In Article6. Blyth R, Creedy D, Dennis C-L. Effect of maternal confidence on breastfeeding duration: an

application of breastfeeding self-efficacy theory. Birth. 2002;29:278284

View In Article MEDLINE CrossRef7. Blyth RJ, Creedy D, Dennis C-L, et al. Breastfeeding duration in an Australian population: the

influence of modifiable antenatal factors.Journal of Human Lactation. 2004;20:3038

View In Article8. Britton, C., McCormick, F.M., Renfrew, 2007. Support for breastfeeding mothers. Cochrane

Database of Systematic Reviews (ISSN 1464-780X).

View In Article9. Ceriani Cernadas JM, Noceda G, Barrera L. Maternal and perinatal factors influencing the

duration of exclusive breast-feeding during the first 6 months of life.Journal of HumanLactation. 2003;19:136144

View In Article10.Chezem J, Friesen C, Boettcher J. Breast-feeding knowledge, breast-feeding confidence and

infant-feeding plans: effect of actual feeding practices.Journal of Obstetric, Gynecologic andNeonatal Nursing. 2003;32:4047

View In Article11.Creedy DK, Dennis C-L, Blyth R, Moyle W, Pratt J, De Vries SM. Psychometric characteristics

of the breastfeeding self-efficacy scale: data from an Australian sample. Research inNursing and Health. 2003;26:143152

View In Article12.Dai X, Dennis C-L. Translation and validation of the breastfeeding self-efficacy scale into

Chinese.Journal of Midwifery and Women Health. 2003;48:350356

View In Article13.Dennis C-L, Faux S. Development and psychometric testing of breast-feeding self-efficacy

scale. Research in Nursing and Health. 1999;22:399409

View In Article14.Dennis C-L. Theoretical underpinnings of breast-feeding confidence: a self-efficacy

framework.Journal of Human Lactation. 1999;15:195201

View In Article15.Dennis C-L. Breastfeeding initiation and duration: a 19902000 literature review.Journal of

Obstetric, Gynecologic and Neonatal Nursing. 2002;31:1232

View In Article16.Dennis C-L. Breastfeeding self efficacy scale: psychometric assessment of the short

form.Journal of Obstetric, Gynecologic and Neonatal Nursing. 2003;32:734743

View In Article17.Ergin Y. leklerde gvenirlik ve geerlilik. M. Atatrk EgitimFakltesi EgitimBilimleri

Dergisi Dergisi. 1995;7:125148

View In Article18.Gzm S, Aksayan S. Kltrlerarasi lek uyarlamasi rehber i: lek uyarlama aamalarive

dil uyarlamasi. HemarG HemirelikAratrmaDergisi. 2002;4:914

View In Article
http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib4http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib4http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib5http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib5http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib6http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib6http://www.midwiferyjournal.com/medline/record/ivp_07307659_29_278http://www.midwiferyjournal.com/medline/record/ivp_07307659_29_278http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltexthttp://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltexthttp://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib7http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib7http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib34http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib34http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib8http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib8http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib9http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib9http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib10http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib10http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib11http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib11http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib12http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib12http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib13http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib13http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib14http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib14http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib15http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib15http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib16http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib16http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib17http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib17http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib17http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib16http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib15http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib14http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib13http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib12http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib11http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib10http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib9http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib8http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib34http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib7http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltexthttp://www.midwiferyjournal.com/medline/record/ivp_07307659_29_278http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib6http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib5http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib4


11/18

19.Gzm S, Aksayan S. Kltrlerarasi lek uyarlamasi rehber ii: lek uyarlama aamalarivedil uyarlamasi. HemarG HemirelikAratrmaDergisi. 2002;4:920

View In Article20.Kronborg H, Vaeth M. The influence of psychosocial factors on the duration of

breastfeeding. Scandinavian Journal of Public Health. 2004;32:210216

View In Article MEDLINE CrossRef21.Labbok M, Krasovec K. Toward consistency in breastfeeding definitions. Studies in Family

Planning. 1990;21:226230

View In Article MEDLINE CrossRef22.Littleton, L.Y., Engeberston, J.C., 2002. Maternal, Neonatal and Women's Health Nursing.

CENGAGE Delmar Learning, New York.

View In Article23.Lynn MR. Detrmination and quantification of content validity. Nursing

Research. 1986;35:382385

View In Article MEDLINE24.McCarter-Spaulding DE, Kearney MH. Parenting self-efficacy and perception of insufficient

breast milk.Journal of Obstetric, Gynecologic and Neonatal Nursing. 2001;30:515522

View In Article25.Mitra KM, Khoury AJ, Hinton AW, Carothes C. Predictors of breastfeeding intention among

low-income women. Maternal and Child Health Nursing. 2004;8:6570

View In Article26.Molina Torres M, Torres RD, Rodriguez P, Dennis C-L. Translation and validation of the

breastfeeding self-efficacy scale into data from a Puerto Rico population.Journal of Human

Lactation. 2003;19:3541

View In Article27.Nunnally, J.C., Bernstein, I.H., 1994. Psychometric Theory, 3rd ed. McGraw-Hill, New York.

View In Article28.Strickland O. Internal Consistency analysis: Making the most of what youvegot.Journal of

Nursing Measurment. 1996;4:34

View In Article29.Takn,L., 2002. Doumve kadnsalhemirelii.BeinciBask.Sistem Ofset Matbaaclk,

Ankara.

View In Article30.Tezbaaran,A., 1999. Likert Tipi lekGelitirme.Trk Psikoloji DerneiYaynlar,Ankara.

View In Article31.Turkish Demographic and Health Survey, 2003. Macro International Inc., Hacettepe University

Institute of Population Studies, pp. 141145.

View In Article32.World Health Organization, 2003. Integrated Management of Pregnancy and Childbirth.

Pregnancy, Childbirth, Postpartum and Newborn Care: A Guide for Essential Practice. WorldHealth Organization, Geneva.

View In Article33.Wutke K, Dennis CL. The reliability and validity of the Polish version of the Breastfeeding

Self-Efficacy Scale-Short Form: translation and psychometric assessment. InternationalJournal of Nursing Studies. 2007;44(8):14391446

View In Article
http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib18http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib18http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib20http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib20http://www.midwiferyjournal.com/medline/record/ivp_14034948_32_210http://www.midwiferyjournal.com/medline/record/ivp_14034948_32_210http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltexthttp://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltexthttp://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib21http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib21http://www.midwiferyjournal.com/medline/record/ivp_00393665_21_226http://www.midwiferyjournal.com/medline/record/ivp_00393665_21_226http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltexthttp://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltexthttp://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib22http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib22http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib35http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib35http://www.midwiferyjournal.com/medline/record/ivp_00296562_35_382http://www.midwiferyjournal.com/medline/record/ivp_00296562_35_382http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib23http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib23http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib24http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib24http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib25http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib25http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib36http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib36http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib37http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib37http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib30http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib30http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib31http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib31http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib32http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib32http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib33http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib33http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib38http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib38http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib38http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib33http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib32http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib31http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib30http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib37http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib36http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib25http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib24http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib23http://www.midwiferyjournal.com/medline/record/ivp_00296562_35_382http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib35http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib22http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltexthttp://www.midwiferyjournal.com/medline/record/ivp_00393665_21_226http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib21http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltexthttp://www.midwiferyjournal.com/medline/record/ivp_14034948_32_210http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib20http://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltext#back-bib18


12/18

Abstractn Full Text Full-Text PDF (166 KB) CrossRef

Breastfeeding Self-EfficacyDr. Dennis developed the Breastfeeding Self-Efficacy Theory and corresponding

Breastfeeding Self-Efficacy Scale. Publications from her work have subsequently provided

many international research opportunities with individuals from diverse countries such as

Argentina, Australia, Brazil, Canada, China, Croatia, England, Finland, France, Germany,

Greece, Iceland, India, Iran, Ireland, Italy, Japan, Jordan, Korea, Mexico, Poland, Saudi

Arabia, Scotland, Sri Lanka, Spain, Sweden, Taiwan, Thailand, Turkey, the United States,

and Vietnam. In total, over 400 researchers and health professionals from over 30 differentcountries have requested the use of her Breastfeeding Self-Efficacy Scale. These requests

have resulted in several collaborative opportunities related to the translation of the

Breastfeeding Self-Efficacy Scale into diverse languages (e.g., Mandarin, Spanish, Polish,

Greek, Italian, Portuguese, Japanese, Thai, and Turkish) and the psychometric testing of the

scale with different maternal populations (e.g., Australian, UK, African-American, adolescent,

and mothers of pre-term infants).

Development of the Breastfeeding Self-Efficacy

TheoryTo promote the conceptual development of breastfeeding confidence and to guide effective

supportive interventions, Dr. Dennis incorporated Banduras(1977) Social Cognitive Theory

and developed the breastfeeding self-efficacy concept and theoretical model [published:

Journal of Human Lactation]. Breastfeeding self-efficacy refers to a mothers confidence in

her ability to breastfeed her infant and it predicts: (1) whether a mother chooses to

breastfeed or not; (2) how much effort she will expend; (3) whether she will have self-

enhancing or self-defeating thought patterns; and (4) how she will emotionally respond to

breastfeeding difficulties. Breastfeeding self-efficacy is influenced by four main sources of

information: (1) performance accomplishments (e.g., past breastfeeding experiences); (2)

vicarious experiences (e.g., watching other women breastfeed); (3) verbal persuasion (e.g.,

encouragement from influential others such as friends, family, and lactation consultants);

and (4) physiological responses (e.g., fatigue, stress, anxiety). It is hypothesized that health

professionals may enhance a mothers breastfeeding confidence by altering these sources

of self-efficacy information.
http://www.journalofnursingstudies.com/article/S0020-7489(06)00241-0/abstract?refuid=S0266-6138(08)00043-0&refissn=0266-6138http://www.journalofnursingstudies.com/article/S0020-7489(06)00241-0/abstract?refuid=S0266-6138(08)00043-0&refissn=0266-6138http://www.journalofnursingstudies.com/article/S0020-7489(06)00241-0/fulltext?refuid=S0266-6138(08)00043-0&refissn=0266-6138http://www.journalofnursingstudies.com/article/S0020-7489(06)00241-0/fulltext?refuid=S0266-6138(08)00043-0&refissn=0266-6138http://download.journals.elsevierhealth.com/pdfs/journals/0020-7489/PIIS0020748906002410.pdf?refuid=S0266-6138(08)00043-0&refissn=0266-6138&mis=.pdfhttp://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltexthttp://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltexthttp://www.midwiferyjournal.com/article/S0266-6138(08)00043-0/fulltexthttp://download.journals.elsevierhealth.com/pdfs/journals/0020-7489/PIIS0020748906002410.pdf?refuid=S0266-6138(08)00043-0&refissn=0266-6138&mis=.pdfhttp://www.journalofnursingstudies.com/article/S0020-7489(06)00241-0/fulltext?refuid=S0266-6138(08)00043-0&refissn=0266-6138http://www.journalofnursingstudies.com/article/S0020-7489(06)00241-0/abstract?refuid=S0266-6138(08)00043-0&refissn=0266-6138


13/18

Figure 1. Breastfeeding Self-Efficacy Framework

Development and Psychometric Testing of the

Breastfeeding Self-Efficacy ScaleBandura (1977) advocated a behaviour-specific approach to the study of self-efficacy,

arguing that a measure of general self-efficacy in overall ability would be inadequate for

tapping an individuals efficacy in managing tasks associated with a specific behaviour.

Thus, to measure breastfeeding self-efficacy an instrument specific to tasks associated with

breastfeeding should be used. A comprehensive literature review found no direct application

of self-efficacy theory to the measurement of breastfeeding confidence. As such, using her

breastfeeding self-efficacy theory as a conceptual framework, Dr. Dennis developed the

Breastfeeding Self-Efficacy Scale (BSES) (available upon request). Content validity was

judged by a panel of experts and through qualitative interviews Dr. Dennis completed with

experienced breastfeeding mothers. Following a pilot test, the revised BSES was assessed

with 130 in-hospital breastfeeding mothers for reliability and validity, including internal

consistency, principal components factor analysis, comparison of contrasted groups, and

correlations with measures of similar constructs. Importantly, support for predictive validity

was demonstrated through positive correlations between BSES scores and infant feeding

patterns at 6 weeks postpartum. The final product was the BSES, a 33-item self-report

instrument where all items are preceded by the phrase I can always and anchored with a 5-

point Likert-type scale where 1 indicates not at all confident and 5 indicates always

confident. As recommended by Bandura (1977) all items are presented positively, and

scores are summed to produce a range from 33 to 165, with higher scores indicating higher

levels of breastfeeding self-efficacy.

http://www.cindyleedennis.ca/research/1-breastfeeding/breastfeeding-self-efficacy/

Other Breastfeeding Self-Efficacy

Research Activities
http://www.cindyleedennis.ca/research/1-breastfeeding/breastfeeding-self-efficacy/http://www.cindyleedennis.ca/research/1-breastfeeding/breastfeeding-self-efficacy/http://www.cindyleedennis.ca/research/1-breastfeeding/breastfeeding-self-efficacy/


14/18

The following is a short selection of Dr. Denniss research initiatives with her instrument.

Refinement of the Breastfeeding Self-Efficacy Scale

Development of the Short-FormAlthough psychometric support for the validity and reliability of the BSES was established

with Dr. Denniss initial methodological study, internal consistency statistics and multiple

factor loadings suggested a need for item reduction. As such, through secondary analysis of

Dr. Denniss postdoctoral work she refined the original BSES and psychometrically assessed

the revised BSES-short form (BSES-SF). Based on an extensive literature review, she

developed the following criteria to delete items: (1) item mean of 4.2 or more (to increase

variability); (2) corrected item-total correlation less than 0.60 (to increase overall item fit); (3)

item with 10 or more inter-item correlations below 0.40 (to increase homogeneity); and (4)

inter-item correlation above 0.80 (to decrease redundancy). Using these item statistics, the

33-item BSES was shortened to 14 items. The reliability estimates of the BSES-SF,

including Cronbachs alpha coefficient, inter-item correlations, and corrected item-total

correlations, demonstrated excellent internal consistency. Through this refinement process,

the BSES-SF has even greater clinical utility due to ease of administration.

Translation of the Breastfeeding Self-Efficacy Scale

Frequently non-English speaking populations are excluded from clinical research due to the

lack of reliable and valid instruments to measure variables of interest. To date, many

instruments have been developed and validated among English-speaking populations with

few being translated into other languages and re-evaluated psychometrically. This is a

significant limitation given the fact that multilingual and multicultural societies will become the

norm for many countries in the 21stcentury. Many studies using ethnic samples have

assumed that methodologies and assessment tools can be used cross-culturally. However,

this practice disregards possible changes in psychometric properties due to translation bias

or inaccuracies and it ignores the impact that culture may have on the meaning of scaleitems. To address this issue, Dr. Dennis has actively participated in the translation of her

BSES scale into diverse languages including: French, Mandarin, Spanish, Polish, Italian,

Greek, Portuguese, Japanese, and Thai.

Psychometric Testing of the Breastfeeding Self-Efficacy Scale with Diverse Populations

1. Austral ian Mothers. In collaboration with Dr. Debra Creedy from Griffith University in

Brisbane, the BSES was psychometrically tested among 300 Australian mothersproviding further evidence for the reliability and validity of my instrument.


15/18

2. African-American Mothers. In collaboration with Dr. Debra McCarter-Spaulding from

Saint Anselm College in Manchester, New Haven, Dr. Dennis assisted in

psychometrically testing the BSES-SF among 153 Black mothers. These women

completed the BSES-SF during their first postpartum week and were follow-eup to 24

week spostpartum.

3. Adolescent Mothers. A graduate student (Marion Mossman) as part of her thesis at the

University of Manitoba, Faculty of Nursing recruited 101 pregnant adolescents from two

prenatal clinics in Winnipeg, Manitoba to psychometrically test the BSES-SF antenatally

and in the immediate postpartum period.

4. Mothers o f Premature Infants. In collaboration with Barbara Wheeler, a clinical nurse

specialist at the St. Boniface General Hospital in Winnipeg, Manitoba, mothers of ill

and/or preterm infants (N = 144) were recruited from three hospital units to

psychometrically test the BSES-SF within the first week postpartum, at infant hospital

discharge, and 6 weeks post-discharge. For this methodological study, the BSES-SF

was modified resulting in 18 items that included many from the original scale, with others

suggested by (1) a comprehensive literature review, (2) mothers of ill and/or preterm

infants who were successful in breastfeeding, and (3) expert clinicians.

5. Ethnic UK Mothers. As a 4th-year undergraduate project, three medical students under

the supervision of Dr. Christine McArthur at Birmingham University administered the

BSES-SF before hospital discharge to breastfeeding mothers (54% were Southeast

Asian) and then via mail questionnaires at 6 weeks postpartum.

Breastfeeding Self-Efficacy Predictive ModelWhile research suggests that the BSES could be used in the early postpartum period as an

identification tool to distinguish between those mothers who are likely to succeed at

breastfeeding and those who require additional intervention to ensure continuation, no study

has been conducted to determine which mothers are at particular risk to experience low

breastfeeding self-efficacy. As such, Dr. Dennis developed a multi-factorial predictive model

of breastfeeding self-efficacy in the first week postpartum in order to assist in the

identification of mothers at risk to discontinue breastfeeding prematurely. As part of her

postdoctoral work, a population-based sample of 522 breastfeeding mothers in a healthregion near Vancouver, British Columbia completed mailed questionnaires at 1 and 8 weeks

postpartum. The best-fit regression model revealed eight variables, which explained 54% of

the variance in BSES scores at 1-week postpartum: maternal education, support from other

women with children, type of delivery, satisfaction with labour pain relief, satisfaction with

postpartum care, perceptions of breastfeeding progress, infant feeding method as planned,

and maternal anxiety. By administering the BSES and through an examination of the risk

factors identified, health professionals have the potential to improve the quality of care that

they deliver to new breastfeeding mothers.


16/18

Breastfeeding Self-Efficacy Scale Cut-Off Scores

To assist health professionals and researchers in identifying mothers with low breastfeeding

self-efficacy who require additional intervention, Dr. Dennis has completed Receiver

Operator Characteristic (ROC) curves analyses to established BSES cut-off scores.

Pilot Randomized Controlled Trial

Dr. Denniss research has consistently demonstrated the predictive ability of BSES scores in

the immediate postpartum period on breastfeeding duration and exclusivity. The next stage

in this research is to determine whether breastfeeding self-efficacy can be enhanced via

interventions by health professionals to improve breastfeeding outcomes. As such, one of

her PhD students, Karen McQueen, pilot tested a breastfeeding self-efficacy enhancingintervention. This pilot work has been used to develop a large multi-site randomized

controlled trial.

Clinical Utility of the BreastfeedingSelf-Efficacy ScaleResults from the previous research clearly suggest the BSES has promising utility for clinical

practice. It could be used as an identification toolto help recognize those mothers who are

likely to succeed at breastfeeding, as well as those who are at high-risk to discontinue and

will require additional intervention to ensure success. For example, if a new mother has a

high breastfeeding self-efficacy score before hospital discharge, further breastfeeding

support may be unnecessary. However, if a mothers breastfeeding self-efficacy score is low,

there are clear implications for targeted support. The BSES could alsoprovide important

diagnostic informationto ensure interventions are responsive to those they are intended to

serve. For example, the BSES could be used to appraise salient breastfeeding behaviours

and cognitions to sensitize health professionals to the individual needs of their new

breastfeeding mothers. Furthermore, recognizing that mothers with low breastfeeding self-

efficacy may experience significant stress when discharged home, low BSES scores may be

used to provide anticipatory guidance to those mothers. In contrast, high BSES scores could

be used as a measure of maternal strength warranting recognition and reinforcement. As

such, the BSES could be used as an assessment toolto identify areas to focus clinical

practice. On the basis of the BSES results, specific confidence-enhancing strategies could

include: (1) attention to the successful or improved aspects of breastfeeding performances;

(2) reinforcement of positive breastfeeding skills; (3) provision of consistent advice on how to

improve future breastfeeding performances; (4) encouragement to recall the positive aspects

of breastfeeding performances purposefully rather than to dwell solely on performance


17/18

deficits; (5) provision of anticipatory guidance to acknowledge and normalize maternal

anxiety, stress, and fatigue; and (6) proactive attention to making unobservable

breastfeeding skills apparent to the mother, such as envisioning successful performances,

thinking analytically to solve problems, managing self-defeating thoughts, and persevering

through difficulties. Finally, the BSES may be used to determine the efficacyof various types

of supportive interventions. For example, the BSES could be administered pre and post self-

efficacy enhancing interventions to determine effectiveness. In addition, the BSES could be

employed to assist health care administrators to devise targeted interventions for those

mothers identified as high-risk and therefore used to plan effective breastfeeding programs.

Within our current environment of shortened hospital stays, the BSES provides health

professionals with a clinically useful instrument that could pinpoint areas in need of

concentrated intervention before discharge such that appropriate and effective care may be

provided to new mothers to help them achieve their breastfeeding goals.

Other Breastfeeding Peer SupportResearch ActivitiesEnhancing Peer Intervention Development, Implementation,and EffectivenessTo effectively develop, implement, and evaluate peer interventions, a clear understanding of

peer support is required. As such, during Dr. Denniss doctoral and postdoctoral studies she

conducted a concept analysis of peer support [published: International Journal of Nursing

Studies]. Based on this theoretical work, she demonstrated that through mutual

identification, shared experience, and sense of belonging, there is evidence to suggest that

peer support can positively affect psychological and physical health outcomes via direct,

buffering, and mediating effect models.

To complement this work, social support experts have strongly recommended

comprehensive analysis of supportive interactions in order to promote theoretical

understanding and the development of more effective supportive interventions. In the

Breastfeeding Peer Support Trial, Dr. Dennis evaluated maternal and peer volunteerperceptions to assist other researchers in the development of effective yet satisfying peer

support programs [published: Birth]. To provide a more comprehensive understanding

of whypeer support interventions may have a salutary effect, she developed the Peer

Support Evaluation Inventory(available upon request). This self-report measure is based on

extensive theoretical work that she completed during my postdoctoral research fellowship

and consists of four subscales: (1) supportive interactions (e.g., emotional, appraisal, and

informational support); (2) relationship qualities (e.g., perceived peer responsiveness, extent

of interdependence, and peer qualities); (3) perceived benefits (e.g., potential health

outcomes related to the three theoretical perspectives of social integration, stress andcoping, and social constructionism); and (4) satisfaction with support (e.g., access,


18/18

convenience, and perceived quality). Content validity was assessed by one Canadian and

two U.S. social support experts. An initial psychometric assessment was completed during a

pilot study she conducted during her postdoctoral fellowship. Cronbachs alpha coefficients

for the subscales were as follows: supportive functions = 0.95; relationship qualities = 0.96;

perceived benefits = 0.92; and satisfaction = 0.96 [published: Canadian Journal of

Psychiatry]. Further psychometric testing will be completed during her Postpartum

Depression Peer Support Trial when this measure is administered at 12 weeks postpartum

to mothers in the intervention group (n = 350). In addition to psychometric data, the results

from this measure will assist in our understanding of (1) the type of support that is provided

by peer volunteers, (2) the types of relationships developed between mothers and their peer

volunteer, (3) potential perceived health benefits related to receiving peer support, and (4)

maternal satisfaction with the peer support experience.

It is equally important to examine the peer volunteers perceptions of their peer support

experience. To accomplish this Dr. Dennis developed the Peer Volunteer Experience

Questionnaire(available upon request) and administered it in her breastfeeding and

postpartum depression peer support trials. Questions, based on the volunteer literature, are

related to (1) program training and expectations, (2) interactional characteristics, (3)

volunteer roles, (4) intrapersonal effect, and (5) recruitment and retention. This measure will

assist in the development of effective peer support programs through our enhanced

understanding of peer volunteer recruitment, retention, and satisfaction.

Documents

Breastfeeding Self Efficacy