Translation and psychometric assessment of the Breast-feeding Self-Efficacy ScaleShort Form among pregnant and postnatal women in 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 SelfEfficacy 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 trimester by 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 breastfeeding 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.

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 and reliable measure of breast-feeding self-efficacy among a perinatal sample in Turkey.
Keywords: Breast-feeding Self-Efficacy Scale, Breast-feeding confidence, Psychometric testing

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Introduction
Breast 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 World Health 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 breastfeeding outcomes (Dennis, 2002;Alikasfoglu et 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's perceived confidence in her ability to breast feed her new baby and has consistently been

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 Breastfeeding 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 theory

According to Bandura (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 on Bandura'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 to Dennis (1999), a mothers breast-feeding self-efficacy is affected by four main sources of information: (1) performance accomplishments (e.g. past breastfeeding 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 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 breast-feeding self-efficacy. Content validity of the BSES

was based on a literature review, interviews with breast-feeding mothers, and expert judgement using a method recommended by Lynn (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 similar constructs. 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) 18 years of age or older; (3) able to read and speak Turkish; and (4) at least 37 weeks of

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 collection
After 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 artificial milk 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 by Dai and Dennis (2003), and Wutke and Dennis (2007). Semantic equivalence ensures that the meaning of each item remains the same after translation into the target language. A frequently 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 W test 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

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. Back to Article Outline

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 BSESSF 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 for the BSES-SF was 0.86; there was no increase of more than 0.10 in Cronbach's alpha for

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 to Bandura (1977), self-efficacy is influenced by previous performance accomplishments. 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<0.001). A similar finding was found among postpartum women, where mothers with previous breast-feeding experience had significantly higher BSES-SF scores (mean 62.9, SD 6.6) than mothers with no previous breast-feeding experience (mean 57.4, SD 8.9; t=4.28,p<0.001).

Predictive validity

Predictive validity can be evaluated by determining the relationship between an instrument and event occurring before, during or after the instrument is used (Nunnally and Bernstein, 1994). In this study, predictive validity was determined through the examination of antenatal and postnatal in-hospital breast-feeding self-efficacy scores and baby-feeding method at 12 weeks postpartum. Significant differences in mean antenatal BSES-SF scores were found among mothers who were either breast feeding (mean 57.23, SD 6.8) or bottle feeding (mean 54.7, SD 6.7; t=2.07, p=0.04) at 12 weeks postpartum. Among the postnatal sample, differences were found in postnatal BSES-SF scores between mothers who were breast feeding (mean 58.64, SD 7.05) and mothers who were bottle feeding (mean 53.46, SD 7.22) at 12 weeks postpartum (t=3.89, p<0.001). The two samples were further categorised according to their breast-feeding level, and a oneway analysis of variance was undertaken. Among the antenatal sample, mothers who were exclusively breast feeding at 12 weeks postpartum had higher prenatal BSES-SF scores (mean 59.8, SD 6.3) than mothers who were almost exclusively breast feeding (mean 56.0, SD 5.7), high breast feeding (mean 55.6, SD 7.8) or bottle feeding (mean 54.7, SD 6.7). The difference in mean scores between all three groups was statistically significant (F=4.73, p=0.004). Among the postnatal sample, mothers who were exclusively breast feeding at 12 weeks postpartum had higher in-hospital BSES-SF scores (mean 61.7, SD 5.8) than mothers who were almost exclusively breast feeding (mean 54.4, SD 4.6), high breast feeding (mean 54.0, SD 2.9) or bottle feeding (mean 53.4, SD 7.2). Again, the difference in mean scores between all three groups was statistically significant (F=21.1, p<0.001). Interestingly, no mother in either sample was partially or token breast feeding.

BSES-SF demographic response patterns

Maternal age, educational level, marital status and socioeconomic status have consistently been associated with breast-feeding duration (Dennis, 2002). To assess the utility of the BSES-SF as a unique instrument in identifying mothers at high risk of quitting breast-feeding prematurely, relationships between demographic variables and breast-feeding self-efficacy

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 lowincome (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 inhospital 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 a caesarean section (mean 57.9, SD 8.7; t=3.86, p<0.001). Back to Article Outline

Discussion
The BSES-SF was developed to measure a mother's confidence in her ability to breast feed her new baby, and the results from this study provide additional support for the reliability and validity of the measure among ethnically diverse samples. Cronbach's alpha coefficients for both the antenatal and postnatal samples were above 0.85, exceeding the recommended 0.70 for established instruments (Nunnally and Bernstein, 1994), which is comparable to the original BSES-SF Cronbach's alpha coefficient of 0.94 (Dennis, 2003). The overall mean BSES-SF scores antenatally (mean 58.52) and postnatally (mean 60.09) were slightly higher than the original BSES-SF mean score of 55.8 (Dennis, 2003), suggesting that mothers in Turkey are confident in their ability to breast feed their babies. This is not a surprising finding considering that 81.2% of Turkish mothers breast feed their babies for the first 6 months. Unfortunately, the majority do not breast feed exclusively, but rather supplement their babies with artificial milk and teas. The antenatal and postnatal item means of 4.18 and 4.29, respectively, were again slightly higher than the original BSES-SF item mean of 3.99. While the antenatal and postnatal item variances were 1.03 and 0.96, a finding similar to the original 1.04 item variance, the mean antenatal and postnatal inter-item correlations of 0.42 and 0.45 were slightly lower than the original mean inter-item correlation of 0.55. These findings suggest that the reliability statistics are similar for the translated and original versions of the BSES-SF. Providing evidence for construct validity and consistent with previous research (Dennis and Faux, 1999; Creedy et al., 2003;Dai and Dennis, 2003; Dennis, 2003; Molina Torres et al., 2003) and breast-feeding self-efficacy theory (Dennis, 1999), mothers in both antenatal and postnatal samples with no previous breast-feeding experience had significantly lower breastfeeding self-efficacy scores than women with previous breast-feeding experience. A significant relationship between antenatal and postnatal BSES-SF scores and breast-feeding duration and exclusivity at 12 weeks postpartum was also found. This finding, which provides evidence for predictive validity, is consistent with previous research (Dennis and

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 selfefficacy 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 selfefficacy study to find that mothers who experience a caesarean section have lower inhospital 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 BSESSF 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 breastfeeding self-efficacy. Back to Article Outline

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Breastfeeding Self-Efficacy
Dr. 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 different countries 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 Theory

To 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 selfenhancing 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.

Figure 1. Breastfeeding Self-Efficacy Framework

Development and Psychometric Testing of the Breastfeeding Self-Efficacy Scale

Bandura (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 5point 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

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-Form

Although 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 21st century. 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 scale items. 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 SelfEfficacy Scale with Diverse Populations

1. Australian Mothers. In collaboration with Dr. Debra Creedy from Griffith University in Brisbane, the BSES was psychometrically tested among 300 Australian mothers providing further evidence for the reliability and validity of my instrument.

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 of 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 Model

While 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 health region 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.

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 enhancing intervention. This pilot work has been used to develop a large multi-site randomized controlled trial.

Clinical Utility of the Breastfeeding Self-Efficacy Scale

Results from the previous research clearly suggest the BSES has promising utility for clinical practice. It could be used as an identification tool to 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 also provide important diagnostic information to 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 selfefficacy 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 tool to 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

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 efficacy of various types of supportive interventions. For example, the BSES could be administered pre and post selfefficacy 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 Support Research Activities

Enhancing Peer Intervention Development, Implementation, and Effectiveness
To 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 volunteer perceptions to assist other researchers in the development of effective yet satisfying peer support programs [published: Birth]. To provide a more comprehensive understanding of why peer 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 and coping, and social constructionism); and (4) satisfaction with support (e.g., access,

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.