The nutritional advantage of breastfeeding for the development, health, and survival of infants and young children has been well recognised around the world and accepted as an important public health issue in past decades (Gertosio et al, 2016). The value of breastfeeding and its role in reducing mortality rate and infants' diseases, boosting IQ, providing the best pattern of growth and development, promoting health in adulthood, and protecting the health of mothers is well known (Renfrew et al, 2012). In addition to its ability to reduce household expenses, evidence suggests that breastfeeding strengthens infant-mother attachment and bonding (Aghdas et al, 2014).
Breast milk is rich in nutrients and vitamins and promotes a baby's growth and development better than any other food (Brown et al, 2016). Breastfeeding protects infants against diseases such as respiratory tract infections, allergies, gastroenteritis, and malnutrition (Oddy et al, 2017). More than 1 million children die each year from diarrhoea, respiratory infections, and other infections associated with inadequate breastfeeding (Colchero et al, 2015). In the general population, a substantial body of scientific evidence supports the association of infant breastfeeding with a 22–24% lower subsequent risk of childhood and adolescent overweight and diabetes (Jäger et al, 2014). Compared to other infants, breastfed infants have a lower rates of respiratory tract infections, middle ear infections, diarrhoea, diabetes, allergies, asthma, and sudden infant death syndrome (Williams et al, 2016; Victora et al, 2016; Moon and Task Force on Sudden Infant Death Syndrome, 2016; Bartick et al, 2017).
The World Health Organization (WHO) recommends that breastfeeding is initiated in the first hour after birth, continued exclusively for the first 6 months of life and continued, with safe and adequate complementary foods, up to 2 years old and beyond (Roig et al, 2010). Exclusive breastfeeding can help improve benefits and is likely to increase breastfeeding duration (Brownell et al, 2015).
Not only does breastfeeding benefit the health of both the infant and mother, it is also associated with the positive health effects on the community (Amiel Castro et al, 2017). It reduces a woman's risk of diabetes, ovarian cancer and breast cancer in the long term, and helps her adapt to her role as a mother. Furthermore, breastfeeding can lower healthcare expenditure: in the US, breastfeeding was attributed to savings of approximately $2.2 billion per year (Department of Health and Human Services Office on Women's Health, 2016).
‘The World Health Organization (WHO) recommends that breastfeeding is initiated in the first hour after birth, continued exclusively for the first 6 months of life and continued, with safe and adequate complementary foods, up to 2 years or beyond’
Breastfeeding is a natural act and a learned behaviour that is possible for most mothers as long as they have adequate information, support from their families, communities and healthcare systems, as well as protective public policies for breastfeeding (Wong et al, 2017). The promotion of breastfeeding must also incorporate a cultural focus that takes into account the effect that family environments can have, especially from mothers, grandmothers and partners (Otomani et al, 2015). Breastfeeding is a human behaviour that is greatly influenced by the community to which a mother belongs, and the effect can be perpetuated from one mother to another.
Breastfeeding trends in Iran
Raising women's awareness of effective care during this period of infant's life is important; as is changing or challenging incorrect beliefs, traditions and attitudes, and increasing maternal self-confidence in terms of infant care. These factors have a great influence on exclusive breastfeeding. Breastfeeding has been included in Ministry of Health programmes in Iran since 2000. There is evidence to report that different factors influence non-exclusive breastfeeding, including women's beliefs regarding her milk supply, a lack of family support for breastfeeding, and a woman's return to work after birth (Darwent et al, 2016).
Education during pregnancy and shortly after birth, the health of older children, parity and mother's age are some of the most influential factors in selecting feeding method (Alzaheb, 2017). During pregnancy, women receive information on formula milk, complementary foods, different types of formula and feeding accessories, but are not informed about breast pumps, milk storage and anything that could help exclusive breastfeeding (Sharifi et al, 2017).
Saki et al (2013) showed that, of 287 mothers of Shiraz City, Iran, 174 (61%) were exclusively breastfeeding until 6 months after delivery. Mixed modelling showed that as the infant's age increased, breastfeeding duration per session, cumulative duration and frequency of breastfeeding during daytime, nighttime and over a 24-hour period all gradually decreased. The gender of the infant and the amount of professional advice that women received about breastfeeding were also significant factors in breastfeeding patterns.
Some studies in Iran have suggested that despite the existence of breastfeeding support programmes, there is still a shortage of breastfeeding knowledge and only 23% of infants are exclusively breastfed from birth to 6 months (Saki et al, 2013; Seighali et al, 2015). Interventions to support and promote breastfeeding are therefore of significant importance. Interventions based on health education and health promotion theories provide real and technical information on breastfeeding for special purpose groups in hospitals, health centres or the community. They are based on professional expertise and perceptions, and aim to increase women's abilities to breastfeed their babies (Lau et al, 2018). Social and economic factors, cultural beliefs and norms have a powerful influence on breastfeeding because some studies show that women of lower socioeconomic status are less likely to breastfeed their infants (Spiby et al, 2009).
One of the important factors in breastfeeding is women's subjective norms, including the viewpoints of her spouse, friends and caregivers, which are important determinants of the initiation and continuation of breastfeeding (Johnson-Young, 2018). Some research suggests that maternal attitudes toward breastfeeding, support from her social networks and the availability of suitable conditions for breastfeeding are among the factors influencing successful breastfeeding in the first 3 months after childbirth (Khanal et al, 2016). A number of studies have shown the effectiveness of education interventions on women's breastfeeding behaviours (Kim, 2009; Keramat et al, 2013; Tol et al, 2013).
The theory of planned behaviour
The theory of planned behaviour was developed by Ajzen and Fishbein (1980) and is based on the following premises: attitude toward behaviour, subjective norms, perceived behavioural control and individual's behavioural intentions and behaviours (Roby et al, 2004; Case et al, 2016). According to this theory, a mother is likely to breastfeed her baby if:
The theory of planned behaviour is considered one of the models able to evaluate whether behavioural change theory was effective in improving the mothers' attitudes and behaviours in relation to exclusive breastfeeding. A number of researchers have used the theory of planned behaviour as a theoretical framework for research in breastfeeding behaviour studies (Guo et al, 2016; Tengku Ismail et al, 2016; Zhu et al, 2017). These studies reported that the theory of planned behaviour was a useful model for predicting a mother's breastfeeding behaviour. An increasing number of these studies have also documented the power of theory of planned behaviour in predicting various other health behaviours (Armitage et al, 2001; Keramat et al, 2013).
Due to the lack of studies on the theory of planned behaviour, as well as low rates of exclusive breastfeeding in Iran, the researchers sought to examine the effect of an educational intervention based on the theory of planned behaviour on breastfeeding performance among pregnant women referred to health centres in the city of Fasa, Iran.
Materials and methods
This was a quasi-experimental study performed in 2017. The study was approved by the Vice Chancellor for Research at Fasa University of Medical Sciences. The population of the study consisted of 100 women at 30–34 weeks' gestation who were referred to urban health centres in Fasa during the data collection period. Data were collected from 10 March–25 August 2017.
Sample and setting
Using previous studies (Sharifirad et al, 2010; Besharati et al, 2011; Ahmadi et al, 2014), the sample size was calculated at 37 subjects for both experimental and control groups; however, 50 subjects were examined in each group due to the possibility of drop out. Among the six urban health centres in Fasa, two centres were randomly selected. Samples were randomly selected based on the household records and the centres' records of pregnant women. Finally, the samples were randomly divided into experimental and control groups.
The inclusion criteria included: singleton pregnancy, and a lack breast infections. Exclusion criteria included: breast infections or postpartum conditions that interfered with breastfeeding, women who took antidepressants and psychotropic medications, giving birth before the end of the fourth educational session, hospitalisation of the infant, hospitalisation of the mother, intrauterine death, and a lack of consent.
The subjects were debriefed on the purpose of the project, how the intervention would be implemented, and the confidentiality of the information. All participants provided written consent to participate.
Data collection
The questionnaire included demographic characteristics (age of women, age of spouse, education level of women and spouses, household income, health insurance coverage and women's employment status) and items related to knowledge, attitude, perceived behavioural control and behavioural intention.
Knowledge was measured using 14 items, such as ‘believed that exclusive breastfeeding was necessary until 6 months'. A correct answer earned 1 point and a wrong answer 0 points, resulting in minimum and maximum scores of 0 and 14 points, respectively.
Attitude was measured using 13 items, for example ‘breastfeeding may cause breast ptosis’. Items were scored on a 5-point Likert scale, from 1 (‘totally agree’), to 5 (‘totally disagree’). Minimum and maximum scores were 13 and 65 points, respectively.
Perceived behavioural control was measured using 6 items, for example ‘I'm not able to breastfeed’. Items were scored on a five-point Likert scale ranging from 1 (‘totally agree’), to 5 (‘totally disagree’). Minimum and maximum scores were 8 and 40 points, respectively.
Subjective norms were assessed using 6 items, for example ‘What is your partner's attitude towards breastfeeding?’. Items were scored 1 to 4 in terms of the question and the desirability of the answer. Minimum and maximum scores were 9 and 36 points, respectively.
Behavioural intention was assessed using 6 items, such as ‘Do you intend to breastfeed your baby?’. Responses were dichotomous yes/no options scored at 0 and 1. Scores ranged from 0–6 points.
An assessment checklist from the Ministry of Health (Roostaee et al, 2015) was used to measure breastfeeding performance. This checklist consisted of 29 items using a yes/no answer format, and was completed by observing breastfeeding and questioning the mother (WHO and UNICEF, 2009). Minimum and maximum scores were 0 and 29 points, respectively.
Data analysis
Content validity was used to measure the suitability of questionnaires. Questionnaires were then adjusted according to the research objectives and using previously published scientific studies (Keramat et al, 2013; Ahmadi et al, 2014; Alami et al, 2014). The validity of the questionnaires was confirmed after approval by the professors of the Faculty of Midwifery, Health Education, Gynaecologists and Paediatricians. Cronbach's alpha (a) was used to measure the reliability of the questionnaire and reported a=0.86.
Knowledge, attitude, subjective norms, perceived behavioural control and behavioural intention questionnaires were completed by the subjects in both intervention and control groups before and after training. Breastfeeding behaviour was evaluated before birth and at 40 days after postpartum in both intervention and control groups. Data were analysed with SPSS version 22, using descriptive statistics, chi-square (c2), Independent t-test and paired t-test. Statistical significance was considered at P=0.05.
Intervention
An educational intervention was designed which included one 55–60 minute session per week for 7 weeks. Meetings were held at health centre. Educational content based on a breastfeeding educational book compiled by the Ministry of Health and Medical Education of Iran (Kelishadi et al, 2016) was given to mothers. The content of this book includes the importance of breastfeeding and its benefits, and lactation guidelines. Objectives were determined for each training session, which were taught using various methods such as lectures, group discussions, educational videos, questions and answers, and individual counselling. To answer women's questions about the continuity of breastfeeding, the intervention group received a telephone call once a week that aimed to address any possible problems.
A meeting was held to raise awareness and attempt to change attitudes of pregnant women about breastfeeding, and a session was also held on the behavioural control of pregnant women and their intention to choose the best feeding method.
Educational sessions also discussed the length of a feed and how babies should be allowed to finish the first breast and offered the second if they show signs of hunger. Exclusive breastfeeding in the first 6 months was emphasised, as well as breastfeeding up to 2 years old. Women were taught that breast milk is highly important in the first year before supplementary food is emphasised in the second year.
As a woman's communities—and their partners in particular—play a role in encouraging the mother to breastfeed, an educational booklet was given to mothers at the end of each educational session, to study with their husbands at home. As a result, the husbands of the women in the intervention group were indirectly trained by the pregnant women. There subjective norms were reported by women's observation of their husbands and findings from the questionnaire. Grandmothers were also invited to the educational sessions, as they are the main carers of mothers and infants in the first days and months after birth.
During the education sessions, women were taught that breastfeeding is valuable as a food and offers immunological protection to the child after the first year (Palmeira and Carneiro-Sampaio, 2016). They were also taught that almost all mothers made enough milk for their child but that sometimes the positioning of the child or the attachment of his mouth may not enable good milk transfer.
While the educational book on breastfeeding compiled by the Ministry of Health and Medical Education of Iran was given to pregnant women in the intervention group, the control group received only regular education at health centres.
Findings
This study surveyed 100 women referred to urban health centres in Fasa, Iran. The participants were assigned into experimental (n=50) and control (n=50) groups. The mean age of women in the experimental group was 26.25 ± 3.22 and was 27.02 ± 3.14 in the control group. The mean age of the spouses was 31.22 ± 2.16 and 31.65 ± 2.12 in the experimental and control groups, respectively. Independent t-tests showed no significant differences between experimental and control groups (P=0.108). The majority of participants in the experimental (96%) and control (98%) groups were covered by health insurance, and the majority had a secondary level education (Table 1).
| Variable | Intervention group n (%) | Control group n (%) | P-value | |
|---|---|---|---|---|
| Women's educational level | Illiterate | 2 (4) | 3 (6) | 0.352 |
| Elementary school | 8 (16) | 6 (12) | ||
| Guidance school | 14 (28) | 16 (32) | ||
| High school | 19 (38) | 18 (36) | ||
| Academic | 7 (14) | 7 (14) | ||
| Spouses' educational level | Illiterate | 1 (2) | 1 (2) | 0.136 |
| Elementary school | 6 (12) | 9 (18) | ||
| Guidance school | 13 (26) | 14 (28) | ||
| High school | 20 (40) | 18 (36) | ||
| Academic | 10 (20) | 8 (16) | ||
| Household income in rials* | <10 million | 10 (20) | 12 (24) | 0.107 |
| 10–20 million | 24 (48) | 20 (40) | ||
| >20 million | 16 (32) | 18 (36) | ||
| Health insurance coverage | Yes | 48 (96) | 49 (98) | 0.182 |
| No | 2 (4) | 1 (2) | ||
| Women's employment status | Employed | 14 (28) | 16 (32) | 0.521 |
| Unemployed | 36 (72) | 34 (68) | ||
There was no significant difference between the experimental and control groups in terms of knowledge, attitude, perceived behavioural control, subjective norms, intention and lactation behaviour before intervention, but after intervention, a significant increase was observed in the above variables in the experimental group. No changes were observed in the control group (Tables 2 and 3).
| Variable | Group | Before intervention M ± SD | Control group M ± SD | P-value |
|---|---|---|---|---|
| Knowledge | Experimental | 6.21 ± 2.18 | 10.71 ± 2.20 | 0.001 |
| Control | 6.89 ± 2.09 | 7.02 ± 2.05 | 0.125 | |
| P-value | 0.208 | 0.001 | ||
| Attitude | Experimental | 24.31 ± 3.60 | 51.17 ± 3.16 | 0.001 |
| Control | 25.21 ± 3.24 | 26.18 ± 3.11 | 0.136 | |
| P-value | 0.098 | 0.001 | ||
| Perceived behavioral control | Experimental | 14/12 ± 3.13 | 32.31 ± 3.21 | 0.001 |
| Control | 15.04 ± 3.19 | 15.86 ± 3.17 | 0.109 | |
| P-value | 0.116 | 0.001 | ||
| Subjective norms | Experimental | 14.22 ± 2.44 | 30.03 ± 2.17 | 0.001 |
| Control | 15.10 ± 2.22 | 16.01 ± 2.09 | 0.133 | |
| 0.107 | 0.001 |
| Variable | Group | Before intervention | After intervention | P-value |
|---|---|---|---|---|
| Intention | Experimental | 1.24 ± 1.12 | 4.21 ± 0.45 | 0.001 |
| Control | 1.21 ± 1.08 | 1.23 ± 1.09 | 0.225 | |
| P-value | 0.152 | 0.001 | ||
| Breastfeeding behaviour | Experimental | 9.22± 2.28 | 25.15 ± 2.14 | 0.001 |
| Control | 9.80 ± 2.20 | 10.41 ± 2.02 | 0.184 | |
| P-value | 0.104 | 0.001 |
Discussion
During pregnancy, mothers receive varied and inconsistent infor mation regarding exclusive breastfeeding (Goodman et al, 2016); however, cultural and social beliefs also have an effect on breastfeeding because inadequate education is provided to women. Low milk supply, infections, false beliefs, and incorrect advice from relatives are among the factors influencing non-exclusive breastfeeding. Therefore, addressing these factors, and creating educational programmes based on health education and health promotion theories, can influence women's attitudes and behaviours with regards to exclusive breastfeeding (Zhu et al, 2017).
The results of this study showed that women's knowledge levels were low in both control and experimental groups at baseline, but a significant increase was observed in the experimental group after intervention, while no changes were found in the control group. Low knowledge or awareness of mothers at the beginning of the study can be attributed to the lack of adequate and necessary training available for women at health centres; therefore, regular and planned education increased pregnant women's awareness. In a study of 88 pregnant women (Sharifirad et al, 2010), the knowledge of pregnant women regarding the correct breastfeeding practices increased after four training sessions. Similarly, Aghababaei et al (2009) studied 200 pregnant women and found that the mean knowledge score of the experimental group was increased after 100 minutes of training. Roby et al (2004) also reported that educational intervention led to an increase in women's awareness and attitudes towards breastfeeding, as have other similar studies (Peyman et al, 2007; Besharati et al, 2011; Mellin et al, 2011).
The findings of this study suggested that after the intervention, participants' mean attitude scores towards exclusive breastfeeding were significantly higher in the intervention group than in the control group. Attitudes can be based on personal experiences or observational learning from others, and a positive experience with a behaviour is likely to result in the continuation of that behaviour (Komninou et al, 2017).
The findings of a study by Lange et al (2016) in Germany revealed that women's intentions to provide breastfeeding exclusively increased from 71.9% in 2005 to 76.8% in 2008, after educational classes. Greater motivation to breastfeed was associated with women who were older and primiparous, and who underwent spontaneous birth. Furthermore, women with no motivation to provide exclusive breastfeeding and women who chose combination feeding were more likely to visit antenatal classes infrequently, have lower levels of education, have lower than average incomes, be of German nationality, and to smoke. Previous studies (Giles et al, 2007; Keramat et al, 2013; Mutuli and Walingo, 2014; Jalambadani et al, 2015) showed a significant impact of educational programmes based on theory of planned behaviour on attitudes on the intention to breastfeed. However, other studies (Peyman et al, 2007; Ahmadi et al, 2014) found that women's attitude scores showed no significant difference before and after the intervention.
The mean perceived behavioural control score in the intervention group also showed a significant increase compared to the control group. According to the findings of this study, teaching breastfeeding skills and techniques through training sessions, and providing appropriate encouragement and feedback in group discussions, improved perceived behavioural control score in the experimental group. Perceived behavioural control—as well as arbitrary action or feeling controlled by volition—play important roles in behaviour. Increased perceived behavioural control after the intervention is an indicative of the effect of the intervention on participants' perceptions of their breastfeeding ability. In a meta-analysis study by Guo et al (2015) using theory of planned behaviour, perceived behavioural control constructs, attitudes and subjective norms were strong predictors for intention of breastfeeding behaviour. Other studies (Peyman et al, 2007; Karamat et al, 2013; Ahmadi et al, 2014; Ghasemi et al, 2014; Jalambadani et al, 2015) have also shown an increase in perceived behavioural control score after implementing educational interventions. In this study, higher subjective norm scores suggest that educational interventions can encourage pregnant women to breastfeed their baby.
Likewise, there was a significant change in the subjective norms of mothers in choosing to breastfeed in the intervention group compared to the control group after the educational programme. However, the results of the study by Jalmabani et al (2015) did not find a significant change in subjective norms after the intervention. Giles et al (2007) demonstrated that family, close friends and health professionals held major supporting roles in the context of breastfeeding, and found that mothers of breastfeeding women could significantly contribute to the duration of breastfeeding. Training for health professionals also has an important role in this respect. Swerts et al (2016) found that midwives valued breastfeeding education and breastfeeding support as a significant part of their role, but that the ways in which a midwife approached and supported breastfeeding women varied. Latifi et al (2015) also found that the subjective norms of a woman's partner, mother (or mother-in law) and health professionals were more important than those of friends and relatives. Brown et al (2011) also reported that group support had a critical role in the initiation and continuation of breastfeeding. Belief in the ease of breastfeeding, its acceptance as the norm and support and encouragement from others are among the factors that can lead to continued breastfeeding in the first 6 months of life. A longitudinal study was carried out by Saffari et al (2016) in 1445 mothers with newborns in the city of Qazvin, Iran. Nearly, 80% (CI: 77.97–82.63%) of participants intended to exclusively breastfeed. They understood the importance of social pressure (subjective norm) to breastfeed their children and claimed that they had control over their breastfeeding practices.
Having a favourable attitude and subjective norms as well as increased perceived behavioural control could result in an increased likelihood to practise a certain behaviour. The high degree of behavioural intention in the experimental group after the intervention may be due to the enhanced attitude of participants in this group towards breastfeeding, an increase in women's awareness of the benefits of breastfeeding, and the effectiveness of educational intervention.
The rate of breastfeeding by behaviour increased in the experimental group compared to the control group after the intervention. In a study by Keramat et al (2013), women's intention and behaviours towards breastfeeding showed an increase after an educational intervention. In research by Sharifirad et al (2010), the rate of breastfeeding was increased in the experimental group compared to the control after the educational intervention. Meedya et al (2017) showed interventions with only one antenatal or postnatal component were not effective in increasing breastfeeding rates at 6 months. However, an intervention that included antenatal education and support in combination with postnatal education and support doubled the rate of breastfeeding at 6 months among primiparous women randomised to the intervention group compared to the control group. Ahmadi et al (2014) observed no significant difference after an educational intervention, compared to baseline scores, despite an increase in knowledge score, perceived behavioural control, subjective norms, and intention of individuals. In a planned study by Zakarija-Grkovic et al (2017), participants in the intervention and active control groups will receive educational booklets during pregnancy, and phone calls 2 weeks later. They will also receive calls at 2, 6 and 10 weeks after birth. The primary outcome will be the proportion of women exclusively breastfeeding at 3 months, while secondary outcomes will compare infant feeding practices and attitudes, social support, breastfeeding difficulties, breastfeeding self-efficacy and use of breastfeeding support services. Follow-up at 6 months will compare exclusive breastfeeding and whether women used support services.
This trial will contribute to future evidence syntheses identifying the most effective forms of breastfeeding support. In a study by Chan et al (2016), results of analyses based on an intention-to-treat assumption showed a significant difference (P<0.01) in Breastfeeding Self-Efficacy Scale-Short Form mean scores at 2 weeks postpartum between the mothers who received a self-efficacy-based breastfeeding educational programme and those who did not. The exclusive breast feeding rate was 11.4% for the intervention group and 5.6% for the control group at 6 months postpartum. Other studies (Imdad et al, 2011; Caine et al, 2012; Tol et al, 2013; Ghasemi et al, 2014; Joshi et al, 2014) also showed an increase in breastfeeding behaviour after educational interventions.
Conclusion
The results of this study indicated that educational interventions based on the theory of planned behaviour—with an emphasis on important psychological factors in the development or change of behaviour—can lead to the promotion of exclusive breastfeeding among the pregnant women. The results of this study suggest that breastfeeding behaviour research based on other theories of health education and promotion should be paid attention and its results should be compared with the results of our study. It is also recommended that a codified and comprehensive educational programme should be provided in health centres to pregnant women and their breastfeeding behaviours reviewed periodically. The limitations related to this research project include the self-reporting of breastfeeding mothers. In addition, some training sessions required more time, and so certain issues were summarised due to time and space constraints.