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ORIGINAL ARTICLE
Year : 2022 | Volume
: 11
| Issue : 4 | Page : 240-246
Development and psychometric evaluation of the Mothers' breastfeeding empowerment scale: A mixed methods study
Fatemeh Mohammadi1, Shahnaz Kohan2, Zeinab Heidari1
1 Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department Midwifery and Reproductive Health, Reproductive Sciences and Sexual Health Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
Correspondence Address:
Zeinab Heidari
Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan
Iran
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/nms.nms_58_21
Background: Assessment of mothers' breastfeeding empowerment (BE) needs valid and reliable instruments. Objectives: The aim of this study was to develop and psychometrically evaluate the Mothers' BE Scale (MBES). Methods: This mixed methods study was conducted in 2018 in Isfahan, Iran. Initially, a literature review and a qualitative study were conducted and their results were used to develop MBES. The qualitative study was conducted through 33 semi-structured interviews with 33 participants and two group discussions with six participants and the data were analyzed through Hsieh and Shannon's conventional content analysis method. Then, the face, content, and construct validity and reliability of the scale were evaluated. Construct validity was evaluated through the exploratory factor analysis of the data obtained from 160 breastfeeding mothers. Results: The primary MBES had 47 items. Forty-one items had acceptable content validity ratio (i.e. more than 0.56) and content validity index (i.e. more than 0.70). In construct validity evaluation, four items were omitted and the remaining 37 items were loaded on six factors which explained 53.67% of the total variance. Using the data obtained from 160 mothers, Cronbach's alpha of the scale was 0.87. Conclusion: The 37-item MBES is a valid and reliable instrument and can be used to assess mothers' BE and develop need-based interventions for BE and breastfeeding promotion.
Keywords: Breastfeeding, Empowerment, Psychometrics, Scale
Successful breastfeeding is affected by a variety of psychological factors, such as mothers' attention to breastfeeding, breastfeeding education for mothers, perceived support for breastfeeding, breastfeeding self-efficacy, and breastfeeding empowerment (BE).[1],[2] Breastfeeding self-efficacy and BE are psychological and motivational factors that influence breastfeeding continuity and success.[3]
An important step to BE is BE assessment using valid and reliable instruments. Previous studies developed and used different instruments for BE assessment. One of these instruments is the 33-item Breastfeeding SelfEfficacy Scale (BFSES)[4] and its fourteen-item short form,[5] which assess breastfeeding self-efficacy. Another instrument is the thirteen-item Maternal Breastfeeding Evaluation Scale which measures the perception of success in breastfeeding.[6] The Breastfeeding Personal Efficacy Beliefs Inventory is also an instrument with seven items on women's confidence in their ability to manage their thoughts, emotions, motivations, actions, and environment in order to successfully breastfeed for 1 year.[7] The seventeen-item Iowa Infant Feeding Attitudes Scale is another instrument to evaluate maternal attitudes toward lactation and identify influential factors on decisions about infant feeding methods.[8] Another instrument in this area is the Bristol Breastfeeding Assessment Tool which assesses frequently encountered postpartum breastfeeding difficulties[9] but does not assess the other aspects of breastfeeding. The twenty-item H and H Lactation Scale is also used to assess maternal perception of inadequate milk production.[10]
Most of the existing instruments for BE assessment have shortcomings. For example, the BFSES and its short form only have items on breastfeeding-related techniques, thoughts, and support and do not cover the other aspects of BE, such as breastfeeding adequacy and problems. Moreover, these instruments do not mostly cover the different aspects of breastfeeding and BE, such as breastfeeding knowledge, skills, adequacy, problems, and support. On the other hand, most existing instruments for BE assessment have not been developed based on the findings of qualitative studies and hence, may not provide a deep understanding of BE because understanding a phenomenon in its natural conditions largely relies on the data obtained from qualitative studies.[11] Instruments that are developed based on the perspectives of its target population are more likely to cover the different aspects of the intended phenomenon.[12]
Objectives
The aim of this study was to develop and psychometrically evaluate the Mothers' BE Scale (MBES).
MethodsThis sequential exploratory mixed methods study was conducted in 2018. This study was conducted in an MBES development phase and an MBES psychometric evaluation phase.
Mothers' breastfeeding empowerment scale development phase
MBES was developed through a qualitative study and a literature review.
Qualitative study
The qualitative study was conducted using the conventional content analysis method to further analyze the concept of BE based on the perspectives of mothers with breastfeeding experience.
Our 39 participants were mothers with breastfeeding experience (n = 19), fathers (n = 2), grandmothers (n = 3), and breastfeeding counselors (n = 15). Inclusion criteria for mothers were Iranian nationality, ability to speak Persian, present or past history of breastfeeding, and willingness to participate in the study and share personal breastfeeding-related experiences. Participants who were unwilling to stay in the study were excluded. Sampling of mothers was purposively done with maximum variation respecting age, number of children, type of delivery, breastfeeding success, educational level, and employment status. Participants were selected from different health-care settings, such as health-care centers, hospitals, physicians' offices, and breastfeeding counseling clinics in Isfahan, Iran. Isfahan is a large multicultural city in the center of Iran.
Data collection
Data were collected through in-depth semi-structured interviews with 15 mothers with breastfeeding experience, two fathers, one grandmother, and 15 breastfeeding counselors as well as two focus group discussions (FGD) with four mothers and two grandmothers. All interviews were held by the third author, who had a PhD degree in reproductive health and was certificated in qualitative research. Interviews and FGDs were started using broad open-ended questions such as “May you explain your breastfeeding experience?” Then, questions such as “May you explain more about this?” were used to further clarify participants' experiences. Interviews lasted 45–80 min and were audio-recorded with participants' consent. Data collection was kept on to the point of data saturation.
Data analysis
We analyzed the data through Hsieh and Shannon's conventional content analysis method.[13] The first author listened to each interview or FGD to grasp its main ideas, transcribed it verbatim, read the transcript line by line, and coded it. Then, she classified similar codes into subcategories and continued the process of data reduction until developing main categories.
Trustworthiness
Trustworthiness was ensured through maximum variation sampling, member checking, peer checking, and external debriefing by three experienced qualitative researchers who were external to the study.
Literature review
An extensive literature review was performed through searching the ScienceDirect, PubMed, Google Scholar, Scientific Information Database, and Magiran databases. Search keywords were “breastfeeding,” “lactation,” “empowerment,” “self-efficacy,” “psychometric,” “scale,” and “assessment.” Moreover, some Islamic religious books, including the Holy Quran, were searched. The goal of the literature search was to retrieve articles and instruments related to breastfeeding, lactation, and BE.
Mothers' breastfeeding empowerment scale psychometric evaluation phase
Evaluation of face validity
Twelve health specialists, obstetricians, breastfeeding counselors, pediatric nurses, and health policymakers, and seven breastfeeding mothers were asked to comment on the grammar, wording, and allocation of items, and then, items were revised based on their comments.
Evaluation of content validity
The content validity ratio (CVR) and content validity index (CVI) were calculated to evaluate content validity. For CVR calculation, 12 experts were asked to rate item essentiality on a three-point scale as “Essential,” “Useful,” or “Unessential.” Based on Lawshe's table, items with CVR values more than 0.56 were considered appropriate. For CVI calculation, experts rated the simplicity, relevance, and clarity of the items using a four-point Likert scale. According to Waltz and Bausell, items with CVI values more than 0.79 were considered appropriate and items with CVI values of 0.70–0.79 were revised.[14]
Evaluation of construct validity
Construct validity was evaluated through exploratory factor analysis (EFA). The sample size was calculated through the 3–10 participants per item rule.[15] As the number of MBES items in the construct validity evaluation step was 41, a sample of 160 participants was considered to be adequate. The participants were selected through cluster sampling. Initially, two urban districts of Isfahan city, Iran, were selected and then, two comprehensive health-care centers were randomly selected from each district. As the number of people covered by each center was the same, forty eligible mothers were recruited to the study from each center through a census. Participants were asked to complete the 41-item MBES. Inclusion criteria were a present breastfeeding history of 1–6 months, no psychological problem, and willingness to participate in the study. The only exclusion criterion was incomplete answering to MBES. Participants were asked to complete the 41-item MBES. Sampling adequacy was assessed using the Kaiser-Meyer-Olkin (KMO) test[16] and the sphericity of the correlation matrix was assessed using the Bartlett's test. Scree plot and eigenvalues were used to determine the number of factors of MBES and varimax rotation was used to make the factor structure interpretable. The minimum factor loading value was set at 0.4.[17]
Evaluation of reliability
Reliability was evaluated through internal consistency assessment with Cronbach's alpha calculation.[18]
Statistical analysis
All data analyses were performed using the SPSS software (version 22, Armonk, NY: IBM Corp). Data were described using the measures of descriptive statistics, namely mean and standard deviation. The level of significance was set at <0.05.
Ethical considerations
The Ethics Committee of Isfahan University of Medical Sciences, Isfahan, Iran, approved this study (code: IR.MUI.RESEARCH.REC.1397.003). Participants were informed about the study aim, data confidentiality, voluntariness of participation in and withdrawal from the study, and use of their data exclusively for the purposes of the present study, and their written informed consent was obtained.
ResultsMothers' breastfeeding empowerment scale development
Analysis of participants' experiences of breastfeeding led to the development of five main categories, namely adequate breastfeeding knowledge and skill, perceived breastfeeding adequacy, overcoming breastfeeding problems, informed belief in breastfeeding value, and perceived breastfeeding support. In the literature review step, we found no eligible study for the review, and hence, the primary MBES was developed with 47 items using the results of the qualitative study (37 items) and the existing BE-related instruments (10 items).
Mothers' breastfeeding empowerment scale psychometric evaluation phase
Evaluation of face validity
Three duplicated items were omitted, and fifteen items were revised. For example, the item “I correctly put my breast in my baby's mouth for breastfeeding” was revised to “I appropriately put the nipple and the areola in my baby's mouth for breastfeeding.”
Evaluation of content validity
Three items had low CVR and were omitted. The CVR and the CVI values of the remaining 41 items were 0.56–1 and more than 0.7, respectively.
Evaluation of construct validity
All 160 participants completed the 41-item MBES with no missing data. The means of participants' and their babies' age were, respectively, 27.73 ± 3.99 years and 4.5 ± 3.09 months and 79.7% of participants reported exclusive breastfeeding. The KMO test statistic was 0.869 (P < 0.001) and the Bartlett's test of sphericity was statistically significant (χ2 = 2.562; df = 666; P < 0.001), confirming the adequacy and appropriateness of the data for EFA. Correlation coefficients more than 0.3 in the correlation matrix were considered acceptable, and hence, two items with correlation coefficients <0.3 were omitted. Scree plot [Figure 1] showed that the 39-item MBES had six factors. The eigenvalues of these six factors were more than 1. In EFA, through principal component analysis and varimax rotation, two items were omitted due to factor loading values <0.4 and the remaining 37 items were loaded on six factors [Table 1]. Based on the findings of the qualitative study and the content of their items, the extracted factors were labeled as adequate breastfeeding knowledge and skill (11 items), perceived breastfeeding adequacy (four items), informed belief in breastfeeding value (seven items), overcoming breastfeeding problems (seven items), negotiation for receiving family support (five items), and breastfeeding self-efficacy (three items). These six factors explained 53.67% of the total variance [Table 2].
Table 1: Mothers' Breastfeeding Empowerment Scale items and their factor loading values
Table 2: The amount of variance explained by Mothers' Breastfeeding Empowerment Scale dimensionsEvaluation of reliability
The Cronbach's alpha values of the scale and its six factors were 0.87 and 0.70–0.90, respectively [Table 3].
Table 3: The Cronbach's alpha values of Mothers' Breastfeeding Empowerment Scale and its dimensionsScoring: As BE is a subjective concept, MBES scoring was performed through a five-point Likert scale as follows: (1) “Completely disagree,” (2) “Disagree,” (3) “No idea,” (4) “Agree,” and (5) “Completely agree.” Accordingly, the possible total score of MBES is 37–185.
DiscussionThe qualitative step of the MBES development phase showed that BE had five main categories, namely adequate breastfeeding knowledge and skill, perceived breastfeeding adequacy, overcoming breastfeeding problems, informed belief in breastfeeding value, and perceived breastfeeding support. The adequate breastfeeding knowledge and skill main category of this study denote that participants had limited information about breastfeeding and felt a great need for breastfeeding knowledge and skill. Previous studies also frequently reported mothers' great need for breastfeeding knowledge and skill.[1],[19] The perceived breastfeeding adequacy main category denotes that participants were concerned about the adequacy and the quality of their milk. Mothers' inability to properly evaluate their breastfeeding adequacy can reduce the sense of BE and lead to the use of formula milk without professional counseling.[20] Moreover, overcoming breastfeeding problems and informed belief in the value of breastfeeding were among the main categories, indicating that mothers' firm belief in the value of breastfeeding can encourage them to improve their breastfeeding knowledge and skills, thereby helping them to overcome the problems and difficulties of breastfeeding. Similarly, a qualitative study reported the firm belief of breastfeeding mothers, families, and the community in breastfeeding as an influential factor on breastfeeding success.[3] The other main category of the study was perceived breastfeeding support. Our participants had experienced loneliness and inability in the face of breastfeeding problems such as breast engorgement and nipple fissure. A previous study also reported the same finding.[21]
The results of the MBES psychometric evaluation phase showed that the final MBES has 37 items in six dimensions which explained 53.67% of the total variance of BE. The first main dimension of MBES was adequate breastfeeding knowledge and skill with eleven items which denotes that BE largely depends on having adequate breastfeeding knowledge and skills. The highest number of items of this dimension compared with other MBES dimensions highlights the importance of this dimension in BE. This is in agreement with the findings of two previous studies.[1],[22]
Perceived breastfeeding adequacy with four items was the second MBES dimension. In agreement with this finding, a study reported mothers' concern about their milk adequacy and milk quality as a major barrier to exclusive breastfeeding.[20]
The third dimension of MBES was informed belief in breastfeeding value. This dimension includes seven items on common breastfeeding beliefs and values in the Iranian culture. Items such as “Education about Islamic instructions about breastfeeding” in this dimension show that Iranian Muslim mothers seek some parts of their BE in their beliefs in Islamic instructions, and hence, they need education in this area. A previous study also highlighted the importance of Islamic instructions in promoting breastfeeding.[3]
The fourth dimension of MBES was overcoming breastfeeding problems with seven items. This dimension highlights the necessity of breastfeeding knowledge and skill as well as breastfeeding counseling to get practical instructions, particularly during the 1st day of breastfeeding, in order to overcome breastfeeding problems. Breastfeeding problems may negatively affect exclusive breastfeeding.[21] Both during pregnancy and in the postpartum period, education and counseling are two key steps in empowering women to overcome problems.[23],[24] Negotiation for receiving family support, with five items, was another dimension of MBES. Breastfeeding in the sociocultural context of Iran is largely influenced by family members and relatives. Other studies also reported that family support has significant effects on breastfeeding promotion.[1],[25]
The last dimension of MBES was breastfeeding self-efficacy, with three items. This dimension introduces self-efficacy as a key factor in successful breastfeeding and in overcoming breastfeeding barriers. Similarly, a study showed mothers' self-efficacy in interpreting the child's growth charts as a breastfeeding-promoting factor.[3] The face and content validity of MBES were assessed by several experts. Seeking the opinions of experts is one of the best methods for content validity assessment.[14] The Breastfeeding Self-Efficacy Scale was also developed with 33 items based on Bandura's theory of self-efficacy and the results of a literature review and a survey into the opinions of experts and 23 mothers.[5] That scale has dimensions on technique, interpersonal thoughts, and support but does not cover the other aspects of BE, such as perceived breastfeeding adequacy, overcoming breastfeeding problems, and negotiation for receiving family support. The Cronbach's alpha of MBES was 0.87, confirming the acceptable internal consistency and reliability of the scale. The Cronbach's alpha of the Breastfeeding Self-Efficacy Scale was also 0.9.[5]
The strength of this study was the development and psychometric evaluation of a new instrument for BE assessment based on the results of a qualitative study into the experiences of mothers with breastfeeding experience. The study also had some limitations. For example, MBES may have limited generalizability to other communities. Evaluation of the psychometric properties of MBES in other communities is recommended to improve its generalizability.
ConclusionThe 37-item MBES is a valid and reliable BE assessment instrument that covers the different aspects of BE. Midwives, nurses, and breastfeeding counselors can use MBES to measure BE and develop need-based interventions for BE and breastfeeding promotion.
Acknowledgment
The Research Administration of Isfahan University of Medical Sciences, Isfahan, Iran, approved this study (code: 97003). We would like to thank all participants of the study.
Financial support and sponsorship
This study was supported by the Isfahan University of Medical Sciences, Isfahan, Iran.
Conflicts of interest
There are no conflict of interest.
References
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