Effect of Social-Cognitive Theory-based Intervention to the
Breastfeeding Self-Efficacy of Postpartum Mothers of
Mandaue City: Basis for Improving
Breastfeeding Practice
ABSTRACT
The main purpose of this study is to advocate for an effective
breastfeeding education for mothers in the community that would enhance their
breastfeeding self-efficacy and therefore would improve breastfeeding practice.
The locale of the study was at Barangay Tipolo, Mandaue City, Cebu. This study
utilized a quasi-experimental pretest and posttest design to determine the level of
breastfeeding self-efficacy of the mothers before and after the intervention. There
were 5 participants who participated in this study. This study used the
Breastfeeding Self-Efficacy – Short Form (BFSE-SF) by Dr. Cindy-Lee Dennis to
assess the breastfeeding confidence of the mothers. An intervention developed
by Di Shi Wu was also used to enhance breastfeeding confidence of the
mothers.
The profile data of the participants revealed that 60% were in high fertility
period (20-26 years old), 40% had partners either married or cohabiting, 100%
were high school level, 100% were unemployed, 80% had past breastfeeding
experiences, 60% had 1-2 months old babies, and 80% were practicing mixed
feeding (breast milk and formula milk). The mean score of breastfeeding selfefficacy of the mothers before intervention was 41.80 which interpreted as low
score. The mean score of breastfeeding self-efficacy after intervention was 56.40
which interpreted as high score. There wasn’t any significant difference between
the breastfeeding self-efficacy of the mothers before and after intervention with pvalue of .136.
Based on the findings of this study, it is therefore concluded that the
number of participants (5) was not sufficient to determine the effectiveness of the
intervention provided by the researcher. But the BFSE-SF was tested to be a
reliable tool to determine the breastfeeding self-efficacy of the postpartum
mothers. The breastfeeding self-efficacy intervention being used was not
identified to be effective due to one factor, insufficient number of participants. It is
therefore recommended that further research should be conducted that focuses
on methods of providing effective breastfeeding intervention. Long term or more
than 4 weeks observation to the mothers after an intervention is highly
recommended. An output of this study is proposed guidelines on breastfeeding
self-efficacy enhancement.
CHAPTER 1
THE PROBLEM AND ITS SETTING
Rationale
Despite the full implementation of the Milk Code (Executive Order No. 51)
in 1986, the Philippines is still one of the top nations with the least number of
exclusively breastfed children. The Milk Code promotes breastfeeding,
discourages promotion of formula milk to the public, and advocates for medical
authorities to play their part in the promotion of exclusive breastfeeding. The
UNICEF’s 2014 State of the World’s Children reported that only 34% of infants
below 6 months are exclusively breastfed in the Philippines and only 34% as well
continue breast milk intake until two years. Deewai Rodriguez of the Philippine
Coalition of Advocates for Nutrition Security (PHILCAN) stated that there is no
need to change existing laws on breastfeeding in the country as long as there is
effective implementation of its principles. The health care professionals
particularly nurses can help achieve this goal by being good health educators.
Gavilan (2014) emphasized the importance of health teachings by stressing that
those individuals directly involved in caring for the child must be properly
educated on the benefits of breastfeeding. Furthermore, Riordan and Auerbach
(1993) stated that “education is the cornerstone supporting the entire framework
of lactation and breastfeeding”.
Barangay Tipolo is one of the most populous barangay in Mandaue City.
According to its health care workers the nurse and midwives, most of the
postpartum mothers are practicing breastfeeding during first to second month but
not exclusively and it’s rare for them to continue breastfeeding until two years.
This study was hinged on implementingthe breastfeeding self-efficacy
intervention based on the recognized social cognitive learning principle originally
developed by Bandura in 1977.
It emphasized on the importance of
observational learning, imitation and modeling in learning. Dr. Cindy-Lee Dennis
(2010) anchored her “Breastfeeding Self-Efficacy Theory” on Bandura and
enumerated 4 major factors that affect breastfeeding efficacy namely: 1)
performance accomplishments, 2) vicarious experiences, 3) verbal persuasions
and 4) physiological responses. An intervention based on the principles
presented above was used and its effects towards the breastfeeding self-efficacy
of the mothers were evaluated in this study. The primary objective of this study
was to advocate for aneffective breastfeeding education for mothers in the
community that would enhance their breastfeeding practice.
Theoretical Background
This study primarily utilized Bandura’s Social Cognitive Learning Theory
and Dr. Cindy-Lee Dennis’ Breastfeeding Self-Efficacy Theory which was also
based on the former.
Bandura’s social learning theory emphasizes on the importance of
experiential learning. According to the theory, learning is enhanced when it is
coupled with observation and demonstration by imitation and modeling. A model
who performs a certain behavior may elicit better engagement from the learners
through reinforcement. The interaction between personal and environmental
factors is also considered.
Psychologist Albert Bandura defined self-efficacy as the belief in one’s
ability to succeed in specific situations. The self-efficacy of an individual can play
a significant role in how one approaches goals, tasks, and challenges in life. The
self-efficacy theory lies at the center of Social Cognitive Learning Theory of
Bandura.It emphasizes the role of observational learning and social experience
in the development of personality. An important concept in this theory is that an
individual’s actions and reactions, including social behaviors and cognitive
processes are influenced by the actions that individual has observed in others.
This study was anchored on the Breastfeeding Self-Efficacy Theory by Dr.
Cindy-Lee Dennis (1999). Dr. Dennis developed the theory by incorporating
Bandura’s (1977) Social Cognitive Theory. Bandura’s theory served as a guide to
promote the conceptual development of breastfeeding confidence and effective
supporting interventions. Through this, she developed the breastfeeding selfefficacy concept and theoretical model and published the journal entitled “Journal
of Human Lactation”. Breastfeeding self-efficacy refers to a mother’s confidence
in her ability to breastfeed her infant and it predicts: (1) whether a mother
chooses to breastfeed or not, her choice of behavior; (2) how much effort she will
expend, her effort and persistence in breastfeeding; (3) whether she will have
self-enhancing or self-defeating thought patterns, her thought patterns in
breastfeeding; (4) how she will emotionally respond to breastfeeding difficulties,
her emotional reactions. 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 her husband, family, friends and nurses); (4) physiological
responses (e.g., fatigue, stress and anxiety). Health professionals may enhance
a mother’s breastfeeding confidence by altering these sources of self-efficacy
information (Dennis, 2010).
Initial responses such as the choice of behavior, effort and persistence,
thought patterns, and emotional reactions are the personal reactions of a mother
which reflect hercognitive understanding on breastfeeding. Behaviors that show
initiation, performance and maintenance of breastfeeding are affected by these
initial responses.
Conceptual Framework
Figure 1.0
Breastfeeding Self-Efficacy Framework by Dr. Cindy-Lee Dennis
SOCIAL LEARNING THEORY
ANTECEDENTS
Source of
Information:
SELF-EFFICACY
CONSEQUENCES
Confidence
Initial
Response:
Performance
Accomplishments
Choice of
Behavior
Vicarious
Experiences
Effort and
Persistence
Verbal Persuasion
Thought
Patterns
Physiological and
Affective States
Emotional
Reactions
BEHAVIOR
Activity:
Initiation
Performance
Maintenance
Review of Related Literature
Developing an effective health teaching plan is an important tool in
initiating health related behaviors. This study will evaluate the effect of a social
learning-based health teaching to breastfeeding self-efficacy. According to Arnold
and Boggs (2007), the health teaching which provided by a nurse to her clients is
a focused, creative interpersonal intervention which provides information,
emotional support, and health-related skill training for the aim of helping them
cope effectively with health problems and achieve maximum well-being. Its
primary purpose is to assist clients and families develop the knowledge, attitudes
and skills they need to promote and/or restore their health and well-being to
enhance their quality of life. They added that the process of health teaching
involves assessing client/learner’s needs, selecting appropriate content, planning
and implementing the health teaching, and evaluating whether the desired
behavioral and attitudinal change has occurred.
Truglio-Londrigan and Lewenson (2013) stated that health teaching
focuses on providing information needed by the individual, family or population
so they may become more aware of the promotion of health, the prevention of
disease and injury, health screenings, available community services, and how to
access these services. Health teaching conveys facts, ideas, and skills that
change knowledge, attitudes, values, beliefs, behaviors, and practices of
individuals, families, and communities (Keller et al., as cited in TruglioLondrigan&Lewenson, 2013). A point of contrast was also noted that health
teaching engages participants at an intellectual level, whereas counseling
engages participants emotionally. They added that information must be provided
in a user friendly form and offered in measured amounts that can be absorbed
easily.
Education is the cornerstone supporting the entire framework of lactation
and breastfeeding. It is common in traditional societies that an inexperienced
mother relies to her mother, aunts or grandmothers for emotional support during
childbearing and breastfeeding. Although today’s breastfeeding and parental
education is already common in many parts of the world, it is still considered as a
replacement for a time-honored family function (Riordan & Auerbach, 1993).
Redman (1988, as cited in Riordan & Auerbach, 1993) stressed that learners
could effectively learn when they know and feel that they have to learn
something. It means that they are ready to learn.
Darkenwald and Merriam (1982, as cited in Genna, 2008) mentioned the
term, “teachable moments”. It refers to those periods when the learners
perceived the need to grasp the information and skills. During these periods, it is
advisable that the materials to be used should be organized so that they would
appear meaningful on the part of the learners. Active participation should also be
encouraged, thus this would lead to a meaningful experience and permanent
learning.
Bloom (1956, as cited in Riordan & Auerbach, 1993) reported that learning
is often divided into three domains: (1) cognitive skills (gathering information,
linking concepts, problem solving); (2) psychomotor skills (listening to
instructions, observing skills, repetitive practice, mastery of skill performance);
and (3) affective learning (modifying attitudes, values and preferences).
Breastfeeding education involves each of these domains.
“Learning methods should also be considered when planning teaching
strategies” (Dunn, 1979 as cited in Riordan & Auerbach, 1993).It should be noted
that there are different kinds of learners. They would learn in many different
ways. Some learners can learn easily just by hearing the information, these are
the auditory learners. Others are visual learners, they learn best when they see
the information. These learners benefit from visual aids and printed materials.
The other kind of learner is the kinesthetic or psychomotor learners. These
learners benefit from touching and handling equipment, and practicing new skills.
“Good teaching involves organizing learning experiences that keep the
participant’s interest and use the facilitator’s time efficiently” (Riordan &
Auerbach, 1993).
Mothers and infants get bountiful benefits of breastfeeding. To the
mothers, breastfeeding protects and prevents breast cancer. The release of
oxytocin
from the
posterior
pituitary gland
aids in
uterine involution.
Breastfeeding lowers the cost of feeding and preparation time. Successful
breastfeeding can give an empowering effect because it is a skill that only a
woman can master. Breastfeeding provides excellent opportunity to enhance the
bonding and relationship between the mother and her child
(Pillitteri, 2007).
Breastfeeding may help in the return to pre-pregnancy weight. A long-term
benefit is a lower risk of premenopausal breast cancer and ovarian cancer (2012,
UNICEF as cited in Famorca et al., 2013). On the part of infants there are
numerous benefits as well. One of the physiologic benefits of breastfeeding is it
boosts the immune system of the child. Breast milk contains secretory
immunoglobulin A (IgA), lactoferrin, lysozyme, leukocytes and bifidus factor
which protects the baby from infections. Breast milk contains electrolytes and
minerals which are requirements for human infant growth. It is high in lactose, an
easily digested sugar that provides ready glucose for rapid brain growth.
Breastfed infants can regulate their calcium/phosphorus levels better than infants
who are bottle-fed. The increased concentration of fatty acid in commercial
formulas may bind calcium in the gastrointestinal tract, increasing the danger of
tetany or muscle spasm (Pillitteri, 2007). Compared to artificially fed infants,
breastfed infants have a lower risk of developing later in life chronic conditions
like allergies, asthma, obesity, diabetes and heart disease. Breastfeeding
provides benefits for intellectual and motor development of the infant. Many
studies confirm that breastfed children do better on tests of cognitive and motor
development (2012, UNICEF as cited in Famorca et al., 2013).
To promote breastfeeding to the mothers is not enough. It is also the task
of the health care providers especially the nurses to assist them to have positive
breastfeeding experience by increasing their knowledge of the practical aspects
of the management of breastfeeding. Breastfeeding health teachings usually
have three purposes: (1) to influence or to support prenatal decision-making
regarding infant feeding choice; (2) to provide practical information on
management of lactation at the onset of the breastfeeding experience; and (3) to
provide on-going support after the initiation of breastfeeding (Riordan &
Auerbach, 1993).
The breastfeeding mother needs information about: assessing and
managing her milk supply; preventing and healing sore nipples; correcting the
source of nipple trauma; managing engorgement; consoling the infant;
determining proper maternal nutrition; incorporating the infant and breastfeeding
into the family lifestyle; managing plugged ducts and/or mastitis if they occur;
breastfeeding through maternal or infant illness; continuing breastfeeding after
returning to work; expressing and storing breast milk; noting normal infant
development milestones (such as teething) and assessing their effect on
breastfeeding; and weaning techniques and weaning foods. (Riordan &
Auerbach, 1993)
To continue breastfeeding, the mothers need social support and
encouragement which they could get from their home and community. The family
members especially the husband should support breastfeeding. Peers and
community sources are also their primary sources of support. The health care
professionals should also help the mothers in expanding or creating support
systems (Riordan & Auerbach, 1993).
The influence of health care professionals may be influenced by the timing
of their contact with expectant parents, which usually occurs only during
pregnancy. How the mother will feed her baby is a decision that often is made
prior to conception (Birenbaum et al., 1989; Ekwo& Olson, 1983; Kaplowitz
&Olson, 1983 as cited in Riordan & Auerbach, 1993) or very early in pregnancy
(Beske&Garvis, 1982 as cited in Genna, 2008). Therefore, educational efforts
may need to target future parents prior to conception, through elementary and
secondary school systems, the mass media, churches, community organizations,
and other influential institutions. (Riordan & Auerbach, 1993)
It is found out in a study that information gained through reading books
and pamphlets has greatest influence on feeding choice of the mothers (1982,
Beske&Garvis as cited in Genna, 2008).
Health care providers could influence the breastfeeding decisions of the
mothers. It is reported that some of them would not discuss breastfeeding
because they may be reluctant to encourage breastfeeding for fear of
contributing to feelings of guilt a mother may experience if she chooses not to
breastfeed (Riordan & Auerbach, 1993). Furthermore, it is recognized that health
care professionals have a responsibility to provide accurate information and to
actively encourage the decision to breastfeed, just as they encourage other
health-optimizing choices – such as early prenatal care, appropriate nutrition, use
of car restraint systems, immunizations, and avoidance of smoking, alcohol, and
drugs of abuse.
Through education programs, prenatal knowledge is increasing. It has
been shown to be effective, but not necessarily in influencing the attitudes of the
mothers to breastfeed (Kaplowitz & Olson, 1983; Kistin et al., 1990, as cited in
Riordan & Auerbach, 1993).
Primiparous women who received prenatal breastfeeding education have
significantly higher frequency of success than those primiparous women who did
not receive prenatal breastfeeding education (Wiles, 1984as cited in Genna,
2008).
Although education programs may play a significant role in influencing the
breastfeeding experiences of the mothers, more research studies are still
required to identify which characteristics of an education program are most
effective to be applied in the health care settings (Riordan & Auerbach, 1993).
According to Genna (2008), our role, as healthcare professionals, is to
convey this information in a calm, relaxed way, allowing each mother to feel
comfortable and confident, so she can help her baby be comfortable and
competent. That often means we offer this information with more visual and
physical demonstration than verbal instruction, so that we show her what we
mean by speaking to her right brain, without using the kind of left-brained
language that can often sound more complicated and technical than the mother’s
postpartum brain prepared to handle. The key to is to use the right-brain
techniques to give the mothers the confident they need to keep their babies calm,
which in turn promotes the infant behavior that then reinforces the mother’s
confidence.
Bandura (1977, as cited in Dennis, 2010) formulated a behavior-specific
approach to the self-efficacy. He argued that a measure of general self-efficacy
in overall ability would be insufficient for drawing out an individual’s efficacy in
managing a specific task. Therefore to measure a specific task such as
breastfeeding, an instrument specific to task should be used. Dr. Dennis (1999)
developed the Breastfeeding Self-Efficacy Scale (BSES) which was extracted
from her breastfeeding self-efficacy theory.
BSES has propitious utility for clinical practice based from the previous
research done. It could be utilized as an identification tool to help recognize
those mothers who are likely to be successful on breastfeeding as well as those
mothers who are likely to give up on breastfeeding thus the health care provider
such as a nurse will be prompt to provide an intervention that help mothers to
have successful breastfeeding experience (Dennis, 2010).
On the basis of BSES scores, specific confidence-enhancing strategies
focus on alternating the sources of breastfeeding self-efficacy information or the
antecedents (performance accomplishments, vicarious experiences, verbal
persuasions, and physiological and affective states). Noticing the successful or
improved aspects of breastfeeding performances of the mothers; reinforcing
positive breastfeeding skills; and providing consistent advice on how to improve
future breastfeeding performances will improve and continue the performance
accomplishments of the mothers on breastfeeding. Encouraging the mothers to
recall the positive aspects of breastfeeding performances which they have
learned before from other women and to provide additional information to
successfully breastfeed their babies will likely help them to develop more
confidence on breastfeeding. Providing anticipatory guidance to the mothers who
have low breastfeeding self-efficacy scores by acknowledging and normalizing
their anxiety, stress and, fatigue and making unobservable breastfeeding skills
apparent to them such as envisioning successful performances, thinking
analytically
to
solve
problems,
managing
self-defeating
thoughts,
and
persevering through obstacles are ways of persuading the mothers verbally
which could result to positive personal responses (Dennis, 2010).
According to Department of Health (2005, as cited in Famorca et al.,
2013), promoting good breastfeeding practices begins with information on the
benefits of breastfeeding. Breastfeeding cannot be equaled to bottle-feeding for
the healthy growth and development of the infants. Because of its effect on the
mother’s reproductive process, it also has important implications for her health.
Early initiation of breastfeeding stimulates early onset of full milk production and
promotes mother and child bonding.
Some women lack confidence in their abilities to produce enough supply
of nutritious breast milk. Few women understand the mechanics of breast milk
production and are easily influenced by stories from other women whose milk
“dried up” or couldn’t satisfy their child’s nutritional needs because it was too
weak, blue in color, or too thin. (Littleton &Engebretson, 2006)
During health teaching session, if a woman reasons out that she doesn’t
like to breastfeed because her breasts are small, the nurse must explain to the
mother that the size of her breasts does not affect her capacity to produce milk.
When a mother exclusively breastfeeds her baby, the result is ample milk
production (Famorca et al., 2013).
If a woman has flat or inverted nipples, the nurse builds the woman’s
confidence and explains that the shape of the nipples is not important. When the
infant has latched properly to the breast during feeding, he or she suckles the
breast and not the nipple (1997, Vinther&Helsing as cited in Famorca et al,
2013).
Bryant (1992, as cited in Littleton & Evangelista-Sia, 2006) identified the
perceived barriers keeping women from breastfeeding, these are lack of
confidence in their ability to breastfeed, concerns about dietary and health
practices, embarrassment, loss of freedom, influence of family and friends, and
other concerns such as pain, fear of disfigurement, sexual feelings about breasts,
invalid medical concerns, and lack of social support.
There are many factors which can interfere with the mother’s lactation
process. These factors are maternal anxiety, medical conditions, and poor diet,
all can contribute to the success or lack of success in breastfeeding. Additional
factors might include pendulous breasts, flat or inverted nipples, post-op pain,
and deficient knowledge. The mothers should know who can give them support
during breastfeeding period. Social support can be provided by a nurse, family
members especially her husband, friends, peers and other significant others.
Their attitude towards breastfeeding could also affect the mother’s establishment
and continuation of breastfeeding. (Littleton &Engebretson, 2006)
Variables which could affect the breastfeeding practices of the mothers
are age, marital status, and education level (Dennis, 2002a; McLeod et al., 2002
as cited in Shahla et al., 2010). From previous studies, there is strong evidence
that the older age (Blyth et al., 2004; Dennis, 2002a; Foster et al., 2006; McLeod
et al., 2002; NSW Department of Health, 2006; J. Scott et al., 2001 as cited in
Shahla et al., 2010), being married (Dennis, 2002a; Lande et al., 2003; McLeod
et al., 2002; Taveras et al., 2003 as cited in Shahla et al., 2010) and being well
educated (Blyth et al., 200; Cernadas et al., 2003; Dennis 2002a; McLeod et al.,
2002; J. Scott et al., 2001 as cited in Shahla et al., 2010)are associated with
longer breastfeeding duration. A woman’s occupation may also affect
breastfeeding practices as noted that women who work may feel that returning to
work is a barrier to breastfeeding because of the added commitment and effort
needed to combine work and breastfeeding the baby (Littleton &Engebretson,
2006). Handayani et al. (2013) concluded in their study that working mothers
have more obstacles and barriers to practice breastfeeding successfully. They
cannot stay at home all day to breastfeed their babies due to work. They have
limitation to time and distance.
Initiatives are also made by the authorities to promote breastfeeding
throughout the country. On July 27, 2009, Expanded Breastfeeding Promotion
Act of 2009 was formulated. One of the objectives is to promote public education
and awareness on breastfeeding including support for breastfeeding mothers in
the work force (LawPhil, 2010). On February 23, 2011, the Department of Health
(DOH)
launched
the
exclusive
breastfeeding
which
was
dubbed
as
“Breastfeeding TSEK: Tama, Sapat at EKsklusibo”. The main purpose of this
campaign is to encourage the mothers to exclusively breastfeed their babies from
birth up to six months. For this purpose, the campaign wants to promote public
consciousness by establishing supportive community (DOH, 2011).
Breastfeeding Self-Efficacy Intervention
The intervention utilized in this study was a breastfeeding self-efficacy
intervention developed by the researcher Di Shi Wu in 2012. It is based on the
Social Learning Theory of Bandura (1977) and the Breastfeeding Self-Efficacy
Theory of Dennis (1999). This intervention was based on initial assessment and
was individualized; the content of the efficacy-enhancing strategies was not
completely standardized because mothers had different low-scoring and highscoring items, various breastfeeding goals, and differing perceptions of
breastfeeding self-efficacy. However, the strategies of determining individual
needs
were
standardized.
These
intervention
strategies
to
increase
breastfeeding self-efficacy of the mothers are performance accomplishment,
vicarious experience, verbal persuasion and physiological and emotional states
(Wu et al., 2014).
The intervention was designed based on the premise that learning is
improved when there is observational learning, imitation and modeling with
incorporation of the four major factors that influence breastfeeding self-efficacy:
performance accomplishments, vicarious experiences, verbal persuasion and
physiological responses (Dennis, 2010).
The intervention strategies were developed by Di Shi Wu (2012) which are
based from the information noted in self-efficacy theory of Bandura (1977) and
breastfeeding self-efficacy framework of Dennis (1999) (Wu, et al., 2014).
The topics and content of the intervention were based on breastfeeding
counseling and training course of WHO & UNICEF (1993) and the researcher
added some topics and content to meet the mother’s needs such as
breastfeeding frequency and duration, crying infant, breastfeeding exclusivity,
breastfeeding satisfaction and breastfeeding support. These additional topics
were obtained from the low scoring of the participants on each item. The
researcher, Di Shi Wu (2014) developed the four teaching strategies based on
the four sources of breastfeeding self-efficacy information: performance
accomplishment, vicarious experience, verbal persuasion and physiological and
emotional states, and were standardized.
Table 1.0 Breastfeeding Self-Efficacy Intervention by Di Shi Wu
Objective: After 45 minutes, the mothers will be able to gain more knowledge
about breastfeeding, practice effective breastfeeding skills, and develop
positiveattitude towards breastfeeding.
Topic
Content
Teaching Strategy
Time
Materials
Allotted
To Be
Evaluation
Used
1) Breastfeeding
To Infant
Verbal persuasion:
Benefits
Breastfeeding prevents:
● Provide positive

ear infections
feedback whenever

pneumonia
appropriate,

stomach or intestinal
highlighting
infections
personal

capabilities.
digestive problems, such
as constipation or diarrhea
● Create optimistic
skin diseases (infantile
beliefs: You have
eczema)
what it takes to

succeed.
allergy problems
(infantile allergies)
● Provide accurate

information to
death in the first year of
increase sense of
life
ability.
To Mother

Breastfeeding hastens
the uterus to return to
prepregnancy size.

Breastfeeding prevents
postpartum bleeding.

Breastfeeding may help
in the return to prepregnancy
weight.

Exclusive breastfeeding
delays the return of fertility.

Lower risk of breast
cancer and ovarian cancer.

Breastfeeding promotes
bonding with the mother and
her baby.
To Family

Breastfeeding saves
money.

Breastfeeding promotes
family planning.

Breastfeeding
4 minutes
Visual Aid
Question
Brochure
& Answer
decreases need for
hospitalization.

Breastfeeding
contributes to child survival.
2) Milk Supply
Breast milk is based on
Physiological and
“supply and demand”. The
emotional states:
best way to increase breast
● Correct any
milk supply is for the infant to
misinterpretations
demand more by
of body states.
breastfeeding often.
● Provide
anticipatory
Supplementation with formula
guidance that the
or water with sugar decreases
tendency to
the demand, and the supply
experience anxiety,
diminishes.
pain, and fatigue
should be explicitly
Drink lots of fluids, preferably
acknowledged and
an 8-ounce glass of water or
normalized.
caffeine-free drinks every day.
Eat an adequate healthy diet
Verbal persuasion:
(2,500 calories/day).
● Correct any
inaccurate and low
Use hot compresses and hand
perceptions of
expression to help initiate let
performance
down and encourage your
capability.
baby to nurse.
● Create optimistic
beliefs: You have
what it takes to
succeed.
● Provide support
when handling
pressure and
failure.
● Provide accurate
information to
increase sense of
ability.
● Encourage
mother to envision
successful
performances and
3 minutes
Visual Aid
Question
Brochure
& Answer
manage selfdefeating thoughts
on how she might
persevere through
any breastfeeding
difficulties that are
apparent to the
mother.
3) Breastfeeding
Breastfeed the baby per
Performance
Frequency &
demand. The mothers should
accomplishment:
Duration
expect to breastfeed the baby
● Provide positive
every 3 to 4 hours. Breastfeed
reinforcement and
for at least 15 to 20 minutes so
suggestions about
that the baby will receive the
how to improve
rich hind milk.
future
breastfeeding
Breastfeeding TSEK (Tama,
performance.
Sapat, Eksklusibo) encourages
● Set short-term
mothers to exclusively
goals that the
breastfeed their babies from
mother will be able
birth up to 6 months. Extended
to achieve.
breastfeeding up to 2 years
● Provide
and beyond is recommended
anticipatory
even if the infant’s
guidance that
consumption of breast milk
difficulties may be
declines as complementary
encountered,
foods are given.
especially in the
early period.
How to burp a baby:
1) Sit your baby on your lap
Verbal persuasion:
facing away from you.
● Provide positive
2) Use one arm to support
feedback whenever
your baby’s body, the palm of
appropriate,
your hand supporting her chest
highlighting
while your fingers gently
personal
support her chin and jaw.
capabilities.
3) Lean your baby slightly
● Correct any
forwards and gently pat or rub
inaccurate and low
her back for a while with your
perceptions of
free hand.
performance
capability.
3 minutes
Visual Aid
Question
Brochure
& Answer
● Create optimistic
beliefs: You have
what it takes to
succeed.
● Provide accurate
information to
increase sense of
ability.
4) Crying Infant
Babies cry for lots of reasons
Physiological and
and their cries should not be
emotional states:
ignored. Infants tire easily
● Correct any
especially in the first three
misinterpretations
months, and their nervous
of body states.
systems seem very sensitive
● Provide
to many people around and
anticipatory
lots of noise. You may notice
guidance that the
your baby being very tired and
tendency to
fussy after you have had a lot
experience anxiety,
of company.
pain, and fatigue
should be explicitly
The more often you nurse,
acknowledged and
trying to get in 8 feedings in 24
normalized.
hours, the more milk you will
have. If your efforts at calming
Verbal persuasion:
the baby by changing a diaper,
● Correct any
burping, repositioning him in
inaccurate and low
his crib with his favorite
perceptions of
blanket, or rocking are of no
performance
avail, then it is time to try
capability.
nursing.
● Create optimistic
beliefs: You have
Early signs of hunger include:
what it takes to

rapid eye movements
succeed.

hand to mouth
● Provide support
movements
when handling

pressure and
mouth and tongue
movements
failure.

body movements
● Provide accurate

small sounds
information to
increase sense of
Crying is late sign of
ability.
3 minutes
Visual Aid
Question
Brochure
& Answer
hunger.Crying infant during
● Encourage
feeding means the baby is
mother to envision
uncomfortable. This could be
successful
meant that a little bubbles of
performances and
air are trapped in her stomach.
manage self-
Burp your baby to free the air
defeating thoughts
bubbles.
on how she might
3 Ways of Burping:
persevere through
1) Hold your baby on your
any breastfeeding
chest
difficulties that are
2) Hold your baby sitting on
apparent to the
your lap
mother.
3) Hold your baby face down
across your lap
Then rub your baby’s back
gently with the other hand.
5) Latch &
Signs that the baby has
Performance
Positioning
latched on to the breast
accomplishment:
properly:
● Provide positive

reinforcement and
the baby’s mouth is wide
suggestions about
open

the lower lip is turned
future
out

how to improve
the chin is touching the
breastfeeding
breast (or nearly so)
performance.

● Give attention to
more areola is visible
above the baby’s mouth than
successful or
below
improved aspects
of breastfeeding
With correct latch and
performance.
positioning there will be no
● Identify and
sound. Hearing a sucking
reinforce past and
sound means there is not a
present successes
tight seal and you are hearing
or
the sound of air between your
accomplishments.
breast and the baby’s mouth.
Vicarious
experience:
Positions of the mother during
● Use visual aids to
breastfeeding:
demonstrate

breastfeeding
sitting position in bed,
10
Visual Aid
Question
minutes
Brochure
& Answer
chair, or couch
techniques such as

positioning or
reclining in a bed or
lying on her side
proper latch.

● Invite an
her back and arms can
be supported with pillows
experienced
when necessary so that her
mother to
posture is relaxed
demonstrate
correct latched on
Different Positions:
1) Cradle hold – the mother
sits with her arms supported
and, using her arm on the
same side as the nursing
breast, cradles the infant in
front of her body
2) Cross-cradle hold
– similar to the
cradle hold,
except that the mother cradles
her infant with the arm on the
opposite side of the nursing
breast
3) Football hold ( clutch or
underarm
hold) – the mother sits, holds
the infant between her flexed
arm and body, positions the
infant facing her, and supports
the infant’s head with her open
hand.
4) Side-lying hold – the mother
lies on her side with one arm
supporting her head. The
infant lies beside the mother,
facing the breast. The mother
grasps and offers her breast to
the infant with the other hand.
Once the infant has latched
on, she supports the infant’s
body.
and positioning.
6) Engorgement
Breast engorgement usually
Physiological and
& Sore Nipples
happens between the second
emotional states:
to seventh day postpartum
● Correct any
when the milk is coming in.
misinterpretations
of body states.
Signs of Engorgement:
● Provide

tender
anticipatory

warm
guidance that the

hard
tendency to

flatten nipples
experience anxiety,
pain, and fatigue
The engorged breast is not just
should be explicitly
associated with milk, but
acknowledged and
increased blood and lymph
normalized.
flow to the area,
contribute to the swelling as
Verbal persuasion:
well.
● Correct any
inaccurate and low
Frequent nursing will prove a
perceptions of
treatment for
performance
engorgement.
capability.
● Create optimistic
Treatment of Engorgement:
beliefs: you have
1) Warm compresses to the
what it takes to
breast for 2 to 5 minutes
succeed.
before nursing.
● Provide support
2) Hand expression helping to
when handling
initiate the let-down reflex.
pressure and
3) Frequent nursing; 10-15
failure.
minutes on each breast, every
● Encourage
two to two and a half hours.
mother to envision
4) Ice packs for 20 minutes
successful
between feedings to help
performances and
reduce swelling.
manage self-
5) Hand express or pump to
defeating thoughts
comfort.
on how she might
persevere through
Commonly, the initial grasp
any breastfeeding
and suck of the nipples will
difficulties that are
cause some pain during the
apparent to the
first few days of lactation.
mother.
5 minutes
Visual Aid
Question
Brochure
& Answer
Correct position and latch are
the most important
preventative measures to
remember.
Supporting the breast and
positioning correctly will
prevent the infant from
gnawing and tugging at the
breast.
Warm soaks to the breast and
hand expression to initiate let
down will help the baby get on
the breast quicker as he smells
and tastes the milk at the
nipple.
7) Expressing
Two kinds of breast pumps:
Performance
Breast Milk
1) Manual pump
accomplishment:
2) Electric pump
● Provide positive
reinforcement and
Manual expression of breast
suggestions about
milk:
how to improve
1) Instruct the mother to place
future
her right hand on her right
breastfeeding
breast, with her right thumb on
performance.
the top of the breast at the
● Provide
outer limit of the areola and
anticipatory
her right fingers underneath
guidance that
the breast. Tell the woman to
difficulties may be
press inward toward the chest
encountered,
wall.
especially in the
2) Have the mother slide her
early period.
hand forward in a milking
● Success usually
motion, causing the milk to be
requires tenacious
expressed from the nipple into
effort and it is how
an infant bottle.
the difficulties are
handled that will
Breast milk storage:
determine future
1) Breast milk can be
success.
10
Visual Aid
Question
minutes
Brochure
& Answer
refrigerated safely for 48 hours
after it is expressed.
Verbal persuasion:
2) Frozen milk is thawed by
● Provide positive
placing the container in warm
feedback whenever
water or in the refrigerator. It
appropriate,
cannot be refrozen, and should
highlighting
be used within 24 hours.
personal
3) After thawing, the container
capabilities.
should be shaken gently to mix
● Correct any
the layers that have separated.
inaccurate and low
perceptions of
performance
capability.
● Create optimistic
beliefs: You have
what it takes to
succeed.
● Provide accurate
information to
increase sense of
ability.
8) Breastfeeding
Breastfeeding TSEK (Tapat,
Verbal persuasion:
Exclusivity
Sapat, Eksklusibo) of
● Provide positive
Department of Health
feedback whenever
encourages mothers to
appropriate,
exclusively breastfeed their
highlighting
babies from birth up to 6
personal
months.
capabilities.
3 minutes
Visual Aid
Question
Brochure
& Answer
Visual Aid
Question
Brochure
& Answer
● Create optimistic
beliefs: You have
what it takes to
succeed.
9) Breastfeeding
Signs that the baby is getting
Verbal persuasion:
Satisfaction
enough milk:
● Provide positive

feedback whenever
The baby’s swallowing
can be seen or heard.
appropriate,

highlighting
The baby’s cheeks are
full and not drawn inward
personal
during a feed.
capabilities.

● Correct any
The baby finishes the
feed and releases the breast
inaccurate and low
3 minutes
by himself/herself and looks
perceptions of
contented.
performance
capability.
Signs of adequate intake of
● Create optimistic
breast milk:
beliefs: You have

what it takes to
8 to 10 diapers in 24
succeed.
hours

Frequent stooling
● Provide accurate

Steady weight gain
information to

Contentment after
increase sense of
breastfeeding
ability.
Stools are golden yellow,
sweet smelling, and loose or
liquid in consistency
10)
Social and emotional support
Verbal persuasion:
Breastfeeding
can be provided by a nurse, a
● Provide positive
Support
midwife, a barangay health
feedback whenever
worker, a family member, a
appropriate,
partner and friends.
highlighting
1 minute
Brochure
Question
& Answer
personal
capabilities.
● Create optimistic
beliefs: You have
what it takes to
succeed.
Supporting Studies
Wu, Hu, McCoy and Efird (2014) found out in their study that participants
mothers in the intervention (breastfeeding education) group showed significantly
greater increase in breastfeeding self-efficacy, exclusivity and duration than
participants in the control group at 4 and 8 weeks postpartum (except for duration
at 4 weeks). They concluded that the result suggests that the intervention aimed
at increasing breastfeeding self-efficacy has a significant effect on maternal
breastfeeding self-efficacy and short-term breastfeeding outcomes. Therefore the
breastfeeding self-efficacy intervention is an effective approach to increase the
breastfeeding self-efficacy, exclusivity and duration of primiparous mothers.
Pollard (2009) found out that the results of her study support the use of
self-efficacy as a framework for predicting breastfeeding duration. There was a
statistically significant relationship between self-efficacy scores and the length of
breastfeeding. Mothers who scored higher on the breastfeeding self-efficacy
scale at baseline did breastfeed longer. Reasons cited by the participants for
early weaning were consistent with the literature, low milk supply, baby not
satisfied, and a return to work.
Carlberg (2000) found out that much false information about breastfeeding
still permeates to young adults. She concluded that there is no difference
between men and women’s attitudes about breastfeeding.
Luceñara (1983) emphasized the vital role played of nurses in the prenatal
clinic for needed health teachings of the mother regarding lactation; in the
delivery room for the preparation of the equipment, the environment and the
patient for child delivery in order to institute early initial sucking of the newborn as
soon as possible; in the maternity unit for follow-up of the frequency of
subsequent breast sucking; and in the community for encouragement of
breastfeeding among mothers in the reproductive years.
Schema of the Study
Pre-Intervention
- Breastfeeding self-efficacy scores of 60
respondents
- Evaluation of low scoring (≤3) and high
scoring (≥4)
Identification of the Problem
- Collection of data of pospartum
mothers at barangay health center
- Interview with the midwife
Demographic Profiles (Modifying Factors)
- Age
- Marital Status
- Educational Level
- Employment Status
- Past Breastfeeding Experience
- Breastfeeding Duration
- Breastfeeding Exclusivity
Intervention Strategies to Increase
Breastfeeding Self-Efficacy for 5
participants (47 and below scores)
- Performance accomplishment
- Vicarious experience
- Verbal persuasion
- Physiological and emotional states
Post-Intervention
- Breastfeeding self-efficacy scores of 5
participants
Evaluation
- Reevaluation of low scoring (≤3)
and high scoring (≥4)
Guidelines to Enhance
Breastfeeding Efficacy
Figure2.0
Action Research Process
The problem was identified that not all mothers at barangay Tipolo were
practicing exclusive breastfeeding for six months as reported by the midwives.
They usually incorporated breastfeeding with bottle-feeding of formula milk. They
reasoned that maybe because these mothers could not give ample time to
breastfeedtheir child due to work and other personal reasons. They added that it
was rare for them to continue breastfeeding until 2 years. Assessment was done
to determine their breastfeeding self-efficacy. The intervention provided was
developed by Di Shi Wu and was standardized. After doing the intervention, it
affected the breastfeeding confidence scores of the mothers differently due to
modifying factors such as age, marital status, educational level,employment
status, past breastfeeding experience, breastfeeding duration and breastfeeding
exclusivity. Evaluation was performed to determine the effectiveness of the
intervention applied to the mothers.
THE PROBLEM
Statement of the Problem
This study aimed to determine the effects of a breastfeeding intervention
on the breastfeeding self-efficacy of mothers who were initiating and practicing
breastfeeding.
Specifically, this study answered the following questions:
1. What was the participants’ profile in terms of:
1.1. age;
1.2. marital status;
1.3. educational level;
1.4. employment status;
1.5. past breastfeeding experience;
1.6. breastfeeding duration;
1.7. breastfeeding exclusivity?
2. What was their breastfeeding self-efficacy before the intervention?
3. What was their breastfeeding self-efficacy after the intervention?
4. Was there a significant difference between the breastfeeding self-efficacy
before and after the intervention?
5. Was there a significant difference between the breastfeeding self-efficacy
before and after the intervention when the participants were grouped according
to:
5.1. age;
5.2. marital status;
5.3. educational level;
5.4. employment status;
5.5. past breastfeeding experience;
5.6. breastfeeding duration;
5.7. breastfeeding exclusivity?
6. What guidelines could be formulated to enhance breastfeeding efficacy?
Significance of the Study
The findings of the study will benefit the following:
The childbearing age mothers will be informed about the importance of
breastfeeding to their newborns and leveled up their breastfeeding confidence.
The health care professionals will be motivated to assess the breastfeeding
self-efficacy of the new postpartum mothers under their care using the tool as
well as to encourage and assist them to breastfeed their newborns using the
breastfeeding intervention strategies and proposed guidelines on breastfeeding
efficacy enhancement.
The community members will be informed about the benefits of breastfeeding
to the mothers and their babies thus encouraging them to promote and support
breastfeeding in their family and community.
The future researchers will be able to gather related information from this study
and it will aid them in making further research related to breastfeeding,
breastfeeding education and breastfeeding self-efficacy of postpartum mothers.
Scope and Limitation
Scope
This study focused on the breastfeeding self-efficacy of the mothers who
were initiating and practicing breastfeeding and residing at Barangay Tipolo,
Mandaue City, Cebu. All mothers who were 1 day to 6 months post-delivery
regardless of age, marital status, educational level, employment status, past
breastfeeding experience, breastfeeding duration and breastfeeding exclusivity
were included in the study. The mother and baby didn’t have medical conditions
which deterred breastfeeding. Mothers who were expressing breast milk and
supplementingbreast milk with formula were included.
Limitation
Honesty and sincerity of the participants in answering the questionnaire
could affect the accuracy in identifying their breastfeeding self-efficacy scores.
Effects of some other factors that affect breastfeeding self-efficacy such as
anxiety, embarrassment and lack of social support were not statistically identified
in this study. The breastfeeding intervention was designed based only on the
theories specified: Banduras’ Social Cognitive Learning Theory and Dennis’
Breastfeeding Self-Efficacy Theory.
RESEARCH METHODOLOGY
Research Design
This study utilized a quasi-experimental pretest and posttest design to
determine the level of breastfeeding self-efficacy of the mothers before and after
the intervention.
Research Environment
This study was conducted at Barangay Tipolo, Mandaue City, Cebu. It has
19sitios. It has a total population of 26,647 as of 2016.
The barangay health center of Barangay Tipolo opens every Monday to
Friday from 8 a.m. to 5 p.m. It has one nurse, two midwives and seven barangay
health workers. Every Monday and Tuesday they dispense free TB medicines for
the patients. It is also open for free consultation of any medical condition. Every
Wednesday they immunize infants. Every Thursday they offer prenatal checkups
to pregnant mothers. And every second and fourth Friday it is open for free
consultation with a doctor. They also disseminatefamily planning methods and
render feeding program for children and pregnant mothers. The barangay health
center promotes breastfeeding. During prenatal checkups, the nurse, midwives
and barangay health workers teach the mothers the benefits of breastfeeding.
They encourage the mothers to exclusively breastfeed their babies from birth up
to 6 months and extend it up to 2 years with complementary food. They adhere to
the DOH program which is Breastfeeding TSEK (Tama, Sapat at EKsklusibo).
Research Participants
The participants of this study were the mothers who were initiating and
practicing breastfeeding and residing at Barangay Tipolo, Mandaue City, Cebu.
There were 5 participants. The criteria of the participantswho wereincluded in the
study were:
1) The mothers must be 1 day to 6 months post-delivery regardless of
age, marital status, educational level, employment status, past
breastfeeding
experience,
breastfeeding
duration
and
breastfeeding exclusivity.
2) The mothers must have given birth to a single, healthy term infant,
and intend to breastfeed.
3) The mothers who don’t have any condition that would interfere with
breastfeeding such as serious illness, mental illness or an infant
requiring special medical care which could not be discharged with
the mother.
4) The mothers who are exclusively breastfeeding, expressing breast
milk and formula feeding at the same time.
Research Instrument
This study used the Breastfeeding Self-Efficacy Scale-Short Form (BSESSF) developed by Dr. Cindy-Lee Dennis in 2003. It is a 14-item self-report
instrument where all items are preceded by the phrase “I can always” and
anchored with a 5-point Likert-type scale where 1 indicates “not at all confident”
and 5 indicates “very confident”. As recommended by Bandura (1977, as cited in
Wu et al., 2014), all 14 items are presented positively and scores are summed to
get a range from 14 to 70 with higher scores indicating higher levels of
breastfeeding self-efficacy.
Dennis (2003, as cited in Wu et al., 2014) refined the original BSES to a
short form, and the BSES-Short Form was psychometrically tested within a
Canadian sample of mothers (Dennis, 2003). The internal consistency of the tool,
using Cronbach’s alpha was 0.94. The BSES-SF has been evaluated with
mothers in Poland (Wutke& Dennis, 2007), Canada (Kingston et al., 2007) and
the UK (Gregory et al., 2008). In general, studies have found the BSES-SF to be
reliable and valid tool to predict mothers at risk for early discontinuation of
breastfeeding (Dennis, 2003, Kingston et al., 2007, Wutke& Dennis, 2007,
Gregory et al., 2008).
Through the Breastfeeding Self-Efficacy Scale (BSES) developed by Dr.
Dennis, a mother’s breastfeeding confidence can be measured. In this way, the
postpartum mothers who initiate and practice breastfeeding can be identified if
they are likely to succeed at breastfeeding their babies.
The researcher translated the questionnaire in Cebuano version so that all
participants would be able to understand clearly the statements of the
questionnaire. The reliability index was 0.948 Cronbach’s alpha.
Research Procedures
Gathering of Data
Preliminary preparation
A transmittal letter was sent to the Dean of Graduate School to ask for
approval of the research study to be conducted. A transmittal letter also was sent
to city health officer of Mandaue City and to the chairman of Barangay Tipolo to
ask permission on conducting the study to the mothers residing at the said
barangay.
A pretesting of the tool, Breastfeeding Self-Efficacy – Short Form
(Cebuano version) was conducted at Barangay Guizo, Mandaue City to 20
postpartum mothers who suited to the criteria of actual participants. This was to
determine the reliability index of the tool to be used. The reliability index was
0.948 Cronbach’s alpha.
Actual data gathering
The researcher listed all the postpartum mothers residing at Barangay
Tipolo. There were 116 postpartum mothers from April 2016 to September 2016.
In October 2016, 60 mothers were gathered and agreed to participate. They
answered completely the pretest questionnaire. The pretest would identify the
breastfeeding self-efficacy scores and the needs of the mothers before an
intervention would beprovided. There were only 8 mothers who got low scores(47
and below). These 8 mothers were the targets to be participants of the study but
only 5 mothers who were responsive to calls and texts and attended the
interventionimplementedby the researcher at the barangay health center in
November 2016. The posttest was given 4 weeks after the intervention was
provided in order to determine its effectiveness if there was a significant
difference of breastfeeding self-efficacy among mothers before and after the
intervention.
Statistical Treatment of Data
The following statistical measures were used in dealing with the gathered
data:
1. To determine the profile of the participants according to age, marital
status,educational level, employment status, past breastfeeding experience,
breastfeeding duration, and breastfeeding exclusivity, frequency and percentage
was used.
The formula is:
%=
f
x 100
n
Where:
% = percentage
f = frequency
n = number of participants
2. To determine the level of breastfeeding self-efficacy among the participants,
the mean and standard deviation were used.
The formulas are:
x=
∑X
S=
n
∑ x−𝑥 2
n−1
Where:
x = mean of the pretest and posttest scores
∑ = summation of
x = scores of the participants
S = standard deviation of the pretest and posttest scores
n = number of participants
3. To compare the scores of the participants on pretest and posttest, the paired ttest was used.
The formula is:
t=
𝑥pre
− 𝑥post
S
n
Where:
xpre= mean score of pretest
xpost= mean score of posttest
n = number of participants
S= standard deviation of the pretest and posttest scores
DEFINITION OF TERMS
For the purpose of this study, the following terms were operatively defined:
Breastfeeding – refers to feeding an infant from a mother’s breast and it
includes expressing breast milk
Breastfeeding Self-Efficacy – refers the confidence of a mother in her ability to
breastfeed her infant as measured by the Breastfeeding Self-Efficacy Scale –
Short Form (BSES-SF) developed by Dr. Cindy-Lee Dennis
Mothers–refers to the participants of this study who were 1 day to 6 months
post-delivery and initiating or practicing breastfeeding
Social Cognitive Learning-Based Intervention – refers to the intervention
provided by the researcher to educate the participants about breastfeeding and
enhance their breastfeeding self-efficacy; it is based on Breastfeeding SelfEfficacy Theory of Dr. Cindy-Lee Dennis which derived from Albert Bandura’s
Social Learning Theory
Proposed Guidelines –guidelines proposed by the researcher that will aid the
nurses in enhancing the breastfeeding self-efficacy of the mothers who have low
scores; these are based on Breastfeeding Self-Efficacy Theory by Dr. Cindy-Lee
Dennis which states that breastfeeding self-efficacy is influenced by four main
sources of information: performance accomplishments, vicarious experiences,
verbal persuasions, and physiological and affective states
CHAPTER 2
PRESENTATION, ANALYSIS AND INTERPRETATION OF DATA
This chapter presents the data that answers the problems of the study.
This answers the participants’ profile in terms of age, marital status, educational
level, employment status, past breastfeeding experience, breastfeeding duration
and breastfeeding exclusivity; the breastfeeding self-efficacy before the
intervention; the breastfeeding self-efficacy after the intervention; and the
significant difference between the breastfeeding self-efficacy before and after the
intervention.Number 5 question was not able to answer due to insufficient
number of participants.
Profile Data of the Participants
This section presents the participants’ profile in terms of age, marital
status, educational level, employment status, past breastfeeding experience,
breastfeeding duration, and breastfeeding exclusivity (pre-intervention).
Table 2.1
Age of the Participants
Age
Frequency
Percentage
High fertility period (20-26 years old)
3
60%
Average fertility period (27-34 years old)
0
0
Low fertility period (35-39 years old)
2
40%
Total
5
100%
The table above shows the profile of the participants according to age.
The ages of the mothers belong to young adulthood period of psychosocial
development.
Age affects breastfeeding self-efficacy (Dennis, 2002a; McLeod et al.,
2002 as cited in Shahla et al., 2010). From previous studies, there is strong
evidence that the older age (Blyth et al., 2004; Dennis, 2002a; Foster et al.,
2006; McLeod et al., 2002; NSW Department of Health, 2006; J. Scott et al.,
2001 as cited in Shahla et al., 2010) is associated with longer breastfeeding
duration.
Young adults (ages 19 to 40 years) start to share themselves more
intimately with others. They involve in relationships leading toward long-term
commitments with someone (McLeod, 2013). This is the stage of psychosocial
development of Erik Erikson where an individual is looking for intimacy and
leading to create a family of her own. This is also the stage where young adults
are enthusiastic in building up a family of their own thus making them more
adherent to society’s standards and ways of attending the needs of the family
especially the health care needs. They are active to go to the health centers to
have their babies’ checkup and receive the necessary health care.
A woman’s fertility is high in the early and mid-20s and it starts to decline
near 30. Most resources suggest that at around 35, women experience a more
dramatic drop of fertility. But researchers are still conducting studies to confirm
this theory (Hall, 2002).
In one study from Europe, European women found fertility of the 27-34
and the 35-39 groups had only 4% difference (Twenge, 2013).
The 2013 Philippines National Demographic and Health Survey (NDHS)
reported that fertility of Filipino women peaks at age 20-24, a pattern evident in
rural and urban areas. Fertility starts to fall at the age 35-39 years (Philippine
Statistics Authority, 2014).
In this study, 60% (n=3) of the participants are in high fertility period (2026 years old). This means they are at the age of readily to produce offspring. And
also this is the period of creating a family thus this is very crucial to a woman’s
role in a society. She shoulders more responsibility in rearing and nursing her
young children. This early and mid-20s group of women is highly fertile. Three
participants who are in high fertility period had low breastfeeding self-efficacy
scores (47 and below). They verbalized uncertainty that their breastmilk was not
enough for their babies. That’s why these mothers had recoursed to formula milk.
There were two participants (40%) who had the same age 36, they belong to low
fertility period. They still had low breastfeeding self-efficacy scores. One mother
had no past breastfeeding experience yet because it’s her first child.
Age can affect breastfeeding self-efficacy. As breastfeeding efficacy
increases breastfeeding duration also increases. Breastfeeding duration was also
significantly associated with increased maternal age according to a study (Bolton,
Chow, Benton, & Olson, 2009 as cited in Keemer, 2011).
Table 2.2
Marital Status of the Participants
Marital Status
Frequency
Percentage
Married
2
40%
Cohabiting
2
40%
Widowed
1
20%
Total
5
100%
The table above shows the profile of the participants according to marital
status. Both mothers who were married and cohabiting have the same
percentage, 40% and one mother was widowed (20%).
Cohabiting couples were increasing in the country. In 2004, around 2.4
million Filipinos were cohabiting. The main factor in decision to cohabit was
poverty. The 2000 census placed the cohabiting couples at 19%. Majority of
individuals in the Philippines who were cohabiting were between the ages of 2024 (Wikipedia, 2016).
One mother reported that she became widowed a couple of months
ago.According to Bishop and Bishop (1978 as cited in Riordan, 1993) the father
has a role of being a supporter while his spouse is on breastfeeding to their child.
The presence of father’s support and encouragement plays an important role in
the woman’s success of breastfeeding whether the couple is married or not (de
Montigny&Lacharite, 2004; Hector et al., 2004a; Wolfberg et al., 2004 as cited in
Shahla et al., 2010).
In 2014 the Philippine Statistics Office reported that the percentage of
women less than 25 years old who were cohabiting was higher than the
percentage of women who were legally married. A third of women in their late
20s were in a live-in arrangement with their partners. The percentage of women
in cohabitation had increased from 11 percent in 2008 to 15 percent in 2013 at
every age group (NSO and ICF Macro, 2009).
All participants had partners but one participant had been widowed a few
months ago. They had low breastfeeding self-efficacy scores (47 and below)
despite living with their partners. They expressed that their partners were
supportive of their breastfeeding activity but due to uncertainties they felt to
incorporate breastfeeding with formula feeding.
Table 2.3
Educational Level of the Participants
Educational Level
Frequency
Percentage
Elementary
0
0
High School
5
100%
College
0
0
The table above shows the profile of the participants according to
educational level. 100% of them were high school level.
It is still a majority that most Filipino families can’t provide the complete
educational needs of their children which means these children are unable to
enroll themselves to higher education due to financial inadequacy thus they are
just until secondary education level.
In 2013 the Philippines National Demographic and Health Survey (NDHS)
found out that younger women had reached higher levels of education than older
women. Women who were 20-24 years old have the highest percentage with at
least some college education at 45 percent. Women age 45-49 which was the
lowest age group have at least some college education at 30 percent. Urban
women have more education than rural women (Philippine Statistics Office,
2014).
Education affects the breastfeeding self-efficacy score of the mothers.
According to Dennis (2006 as cited in Keemer, 2009), levels of education can
predict high breastfeeding self-efficacy. The more educated a mother, the more
likely she scores higher on a breastfeeding self-efficacy scale according to
Dennis (2006 as cited in Pollard, 2009). In this study, all participants reached
high school level. They exhibited ample comprehension of the given
questionnaire because it was translated in native language, Cebuano.
Table 2.4
Employment Status of the Participants
Employment Status
Frequency
Percentage
Employed
0
0
Unemployed
5
100%
The table above showsthe profile of the participants according to
employment status. 100% of them were unemployed. Only their husbands or
partners were the breadwinners of the family.
The Labor Force Survey reported that there were approximately 38.5
million employed people in the country in October 2013. 57.6 percent or 22.2
million of them weresalary and wage workers. There were 37.5 percent or 8.3
million were women and 62.5 percent or 13.9 million were men (Philippine
Statistics Authority, 2014).
In 2013, Philippine Commission on Women reported that there was 49.8%
of women were unemployed. There were 22.9 million of males and 14.8 million of
females were employed. In the Philippines, more men are employed than women
because in a social norm men are always considered to be the financial provider
of the family.
These mothers who were not working could give ample time to breastfeed
their
babies.
They
were
practicing
mixed
feeding.
They incorporated
breastfeeding with formula milk feeding. They reported that they fed formula milk
because they felt that their breast milk was not enough for their babies. Due to
low confidence, the participants of this study resorted to comprise breastfeeding
with bottle feeding. It was already perceived that the more a mother breastfeeds
her baby, the more milk her breasts will produce.
Table 2.5
Past Breastfeeding Experience of the Participants
Past Breastfeeding Experience
Frequency
Percentage
With Experience
4
80%
Without Experience
1
20%
Total
5
100%
The table above shows the profile of the participants according to past
breastfeeding experience of the participants. 80% of the mothers were with past
breastfeeding experience and 20% or just 1 mother who had no past
breastfeeding experience. Past breastfeeding experience means the mother has
first child whom she has breastfed.
According to Nursan et al. (2014) in their study, there was a significant
difference between the breastfeeding self-efficacy scores of the mothers who had
and didn’t have past breastfeeding experiences. The mean BSES-SF scores for
women with past breastfeeding experience was significantly higher than the
BSES-SF scores for women without breastfeeding experience.
Women’s breastfeeding self-efficacy is influenced by exposure to
breastfeeding, her perception of being supported, past breastfeeding experience
and physical and mental statuses of women (Blyth et al., 2002; Dennis, 1999 as
cited in Shahla et al., 2010). It was also mentioned in a qualitative research
among low-income mothers that lack of exposure to breastfeeding was a failure
factor to enhance the confidence and commitment of the mothers to
breastfeeding (Hector et al., 2004 as cited in Shahla et al., 2010).
Past breastfeeding experience was the subject of a descriptive study of
300 mothers in Brisbane by Blyth et al (2002 as cited in Shahla et al., 2010).
They found a significant difference in breastfeeding self-efficacy scores (BSES)
at the first week and 4 months postpartum (t [298] = 2.59, p = 0.01 and t [227] =
2.51, p = 0.01 respectively) between mothers with no past breastfeeding
experiences and mothers with past breastfeeding experiences.
Although 80% of them or 4 participants had past breastfeeding
experiences with their first child, it was still found out that these experienced
mothers had low breastfeeding self-efficacy scores (47 and below). They
mentioned that they were not practicing exclusive breastfeeding before and until
currently they still decided not to exclusively breastfeed their babies.
Table 2.6
Breastfeeding Duration of the Participants
Breastfeeding Duration
Frequency
Percentage
1 day - 4 weeks
0
0
1 month -2 months
3
60%
2 months & 1 day -3 months
1
20%
3 months & 1 day -4 months
1
20%
4 months & 1 day - 5 months
0
0
5 months & 1 day - 6 months
0
0
Total
5
100%
The table shows the profile of the participants according to breastfeeding
duration. During pretest 60% of the mothers had been breastfeeding their babies
for 1-2 months, 20% of the mothers had been breastfeeding for 2-3 months and
also 20% of them had been breastfeeding for 3-4 months.
The factors such as age, educational level and breastfeeding confidence
found out by the researchers to affect a mother’s initiation and length of
breastfeeding. They also have determined some predictors of breastfeeding
duration include maternal confidence or breastfeeding self-efficacy, educational
level,
race/ethnicity,
use
of
formula
supplementation,
age,
postpartum
depression, anxiety, nipple trauma, pacifier use, early breastfeeding challenges,
and previous successful breastfeeding experience. These predictors suggest that
mothers
with
lower
breastfeeding
self-efficacy,
who
use
formula
supplementation, have reported nipple trauma or pain, lack of experience or
support with breastfeeding will tend to have a shorter length of breastfeeding. A
longer duration of exclusive breastfeeding has been associated with age, positive
maternal attitudes, self-efficacy, family support, type of delivery, prenatal
education and breastfeeding knowledge (Pollard, 2009).
Most of the participants in this study were mothers who had 1-2 months
old babies (60%). They knew that during this period their babies need to be
brought to the health center to be given due immunization. These mothers had
received health teachings or instructions from the health center or other health
care facility during prenatal checkups and delivery that’s why they had initiatives
to complete the health care needs of their infants.
The longer a mother breastfeeds her baby, the more confident she is in
breastfeeding her child. It is advisable to encourage a mother to exclusively
breastfeed during first week postpartum. Adewale (2005 as cited in Keemer,
2009) stated that breastfeeding intervention to support a mother in her
breastfeeding experience must be provided during first week postpartum and a
priority of research to its effectiveness. These four mothers could be corrected
promptly with their misconceptionsabout breastfeeding and could intend to
breastfeed exclusively if they had been educated by the health care providers
such as nurses and midwives earlier.
Table 2.7
Breastfeeding Exclusivity of the Participants
Breastfeeding Exclusivity
Frequency
Percentage
Exclusive
1
20%
Mixed
4
80%
The table above shows the profile of the participants according to
breastfeeding exclusivity. Only 20% of the mothers or 1 mother was practicing
exclusive breastfeeding while the other 4 or 80% of them were practicing mixed
breastfeeding. Exclusive breastfeeding means the mother only feeds her baby
with breast milk and no formula milk has been given, if formula milk has already
been introduced to her new baby, it means the mother is no longer practicing
exclusive breastfeeding. Mixed breastfeeding means incorporating breastfeeding
with formula supplementation.
In the Philippines, the 2011 National Nutrition Survey reported that
exclusive breastfeeding had risen from 34% in 2008 to 46.7% in 2011 (WHO,
2015). During the first month of life, only half of all infants in the Philippines were
exclusively breastfed. Of those who remain, 8.4% were not breastfed, 18%
received breast milk and water, 22% received breast milk and other milk, and 2%
received breast milk and solid or semi-solid foods. The situation worsened in the
succeeding months (Philippines National Demographic and Health Survey,
2008). Among infants under 6 months of age, in 2008 34% were being fed with
infant formula which was 0.5% higher than in 2003 which was only 33.5%.
(Philippines
National
Demographic
and
Health
Survey,
2003
and
2008).According to UNICEF (2008) in the Philippines exclusive breastfeeding
lasted only for an average of 24 days.
Ansari et al. (2014) concluded in their study that exclusive breastfeeding
duration in mothers receiving the educational program increased significantly
compared to the mothers who were in control group.
In the current study, almost all participants or 80% (n=4) were not
practicing exclusive breastfeeding. Only one participant or 20% was exclusively
breastfeeding. Mothers who are not exclusively breastfeeding their babies have
high tendency to become complacent and decide to stop breastfeeding. Breast
milk will continue to produce if the mother is exclusively breastfeeding her child.
Long breastfeeding duration can result to high breastfeeding self-efficacy.
Table 3.0
Difference in Breastfeeding Self-Efficacy Scores Between
Pre-Intervention and Post-Intervention
Breastfeeding
Mean
Self-Efficacy
Standard
Wilcoxon
Wilcoxon
Deviation
Signed-
Signed-
Ranks
RanksTe
Test
st
z value
p value
1.490
.136
Score
Pre-intervention
41.80
9.445
Post-Intervention
56.40
15.176
Interpretation
There is no
significant
difference in
the BSE
scores
The table above shows the mean and standard deviation of BSE scores of
the mothers before and after intervention. Using the Wilcoxon signed-ranks test it
revealed that there was no significant difference in the BSE scores between preintervention and post-intervention at .05 level of significance. The z value was
1.490 (<1.96)and p value was .136 (>.05).
There were many factors to consider why there was no significant
difference in the BSE scores between pre-intervention and post-intervention.
These factors were the number of participants, breastfeeding exclusivity,
breastfeeding duration, educational level, and attitude and perception of the
mothers on breastfeeding confidence. Due to a limited number of participants
(n=5) it’s difficult to statistically determine the significant difference in BSE scores
before and after the intervention. There was only one mother who was
breastfeeding her infant exclusively and the other four mothers were practicing
mixed feeding. According to the study of Wu (2014) that there is greater increase
of breastfeeding confidence if the mother is practicing breastfeeding at longer
duration and exclusively. In this study, the mothers were observed for 4-week
period only and only 80% of the mothers (n=4) were practicing exclusive
breastfeeding. Shahla et al. (2010, Blyth et al., 200; Cernadas et al., 2003;
Dennis 2002a; McLeod et al., 2002; J. Scott et al., 2001) cited in their study that
being well educated could increase the breastfeeding duration thus increasing
the breastfeeding self-efficacy. All participants of the study were only high school
level. Each participant had different attitude and perception about her
breastfeeding
self-efficacy
that
might
affect
how
she
answered
the
questionnaires (pretest and posttest).
Wilcoxon signed-ranks test was used due to low sample size thus the
population can’t be assumed to be normally distributed (Wikipedia, 2016).
Table 4.0
Breastfeeding Self-Efficacy Item Analysis
The table below shows the mean score of the participants in each item
and its level of confidence before and after the intervention. The 1-5 scores were
interpreted by Dr. Cindy-Lee Dennis. 1 to 1.99 means not at all confident; 2 to
2.99 means not very confident; 3 to 3.99 means sometimes confident; 4 to 4.99
means confident; and 5 means very confident.
Item
Statement
No.
Mean of
Level of
Mean of
Level of
Pretest
Confidence
Posttest
Confidence
Score
1
I can always determine
2.8
that my baby is getting
Score
Not very
3.8
confident
Sometimes
confident
enough milk
2
I can always
2.8
successfully cope with
Not very
4.2
Confident
2.8
Not very
confident
breastfeeding like I have
with other challenging
tasks
3
I can always breastfeed
my baby without using
1.6
Not at all
confident
confident
formula as a supplement
4
I can always ensure that
2.4
my baby is properly
Not very
4.2
Confident
4.6
Confident
4.0
Confident
confident
latched on for the whole
feeding
5
I can always manage the
3.4
breastfeeding situation
Sometimes
confident
to my satisfaction
6
I can always manage to
2.8
breastfeed even if my
Not very
confident
baby is crying
7
I can always keep
4.4
Confident
4.0
Confident
3.6
Sometimes
4.2
Confident
4
Confident
4.4
Confident
wanting to breastfeed
8
I can always comfortably
breastfeed with my
confident
family members present
9
I can always be satisfied
2.6
with my breastfeeding
Not very
confident
experience
10
I can always deal with
3.4
Sometimes
the fact that
confident
breastfeeding can be
time consuming
11
I can always finish
2.6
feeding my baby on one
Not very
3.8
confident
Sometimes
confident
breast before switching
to the other breast
12
I can always continue to
2.4
breastfeed my baby for
Not very
4.2
Confident
4.0
Confident
4.2
Confident
confident
every feeding
13
I can always manage to
3.4
keep up with my baby’s
Sometimes
confident
breastfeeding demands
14
I can always tell when
my baby is finished
3.6
Sometimes
confident
breastfeeding
Breastfeeding Self-Efficacy Scale – Short Form (BSES-SF) has 14 items
of self-report statements which are anchored with a 5-point Likert-type scale.
Statement no.1 reflects how well a mother knows that her baby is getting enough
milk every time she breastfeeds. During pretest the mean score was 2.8 which
interpreted as not very confident. They expressed that sometimes they thought
their milk was not enough for their babies that’s why sometimes they fed their
babies with formula milk. After the intervention was provided there was an
increase of 1 point, the mean score was 3.8 which interpreted as sometimes
confident. Statement no. 2 reflects about how a mother manages her time to
render breastfeeding. The mean score of the mothers during pretest was 2.8
which interpreted as not very confident. After providing the intervention there was
an increase of 1.4 points, the mean score was 4.2 which interpreted as confident.
Because they’re not working they said that they could give ample time to
breastfeed their babies. Sometimes when they were busy doing the household
chores they prepared formula milk to feed for their babies. Statement no. 3
determines if a mother uses formula milk as a supplement. There was only one
mother who was practicing exclusive breastfeeding before and after the
intervention. The mean score was 1.6 which means not at all confident. After the
intervention was given there was a 1.2 increase of mean score, 2.8 which means
not very confident. Because they started to incorporate breastfeeding with
formula milk they reported that they still sometimes fed their babies with bottle
milk. One mother reported during posttest that most of the time she breastfed her
baby with formula milk because she thought that that was her baby was looking
for. She was still not confident that her breast milk was enough for her baby.
Statement no. 4 determines if a mother has the knowledge of signs of correct
latched on. The pretest mean score was 2.4 which means not very confident.
After teaching the signs of correct latched on, the mothers got the mean score of
4.2 which means confident. Statement no. 5 reflects how a mother manages to
breastfeed her baby which satisfies her. During pretest the mean score was 3.4
which means sometimes confident. After the intervention was provided the mean
score was 4.6 which means confident with the difference of 1.2 points. Statement
no. 6 identifies if the mother still breastfeeds her baby even if it is crying. The
mean score during pre-intervention was 2.8 which means not very confident.
After teaching the mothers that a mother can breastfeed her baby even if it is
crying there was an increase of 1.2 points. The posttest mean score was 4.0
which means confident. Statement no. 7 reflects the interest of a mother to
breastfeed her baby. The pretest mean score was 4.4 which means confident.
During pre-intervention they expressed willingness to continue breastfeeding
their babies. After the intervention was given the mean score was 4.0 which
means confident. There was a decrease of 0.4 point. Among the 5 participants,
one mother expressed that she didn’t have enough milk anymore for her baby
that’s why she resorted to feed her baby with formula milk most of the time during
the 4-week period post-intervention. Statement no. 8 reflects a mother’s
confidence to breastfeed with other people around. The pretest mean score was
3.6 which interpreted as sometimes confident. After the intervention was
provided the mothers gained enough confidence with mean score of 4.2.
Statement no. 9 reflects a mother’s satisfaction with her breastfeeding
experience. Before intervention the mean score was 2.6 which interpreted as not
very confident. During pre-intervention the mothers were just starting to
breastfeed their babies and they reported that sometimes they didn’t feel that
their milk was enough for their babies to sustain their growth and development as
infants. After providing teaching with ways to determine if the baby is getting
enough milk through checking the number of diapers consumed per day and
getting the weight of the baby every month, the mothers gained the mean score
of 4.4. Statement no. 10 identifies if the mother can provide ample time to
breastfeed her baby. The pretest mean score was 3.4 which means sometimes
confident. After providing teaching about the benefits of breastfeeding and
dangers of not breastfeeding a baby, there was an increase of 1 point the mean
score was 4.4 which means confident. Statement no. 11 determines if a mother
switching her breasts when breastfeeding. Before intervention the mothers were
not knowledgeable enough that they have to switch their breasts every after
complete breastfeeding. The mean score was 2.6 which means not very
confident. After the intervention was provided the mean score was 3.8 which
means sometimes confident. Statement no. 12 determines if a mother finishes
her breastfeeding for every feeding. During pretest the mean score was 2.4
which means sometimes confident. After providing intervention the mean score
increased into 4.2 which means confident. Statement no. 13 determines if a
mother responds to her baby’s breastfeeding demands. The pretest mean score
was 3.4 which means sometimes confident. After teaching the mothers the signs
of hungry baby the posttest mean score was increased into 4.0 which means
confident. Statement no. 14 reflects a mother’s knowledge to determine if her
baby is finished breastfeeding. The pretest mean score was 3.6 which means
sometimes confident. After teaching the mothers the ways to properly breastfeed
a baby the mean score was 4.2 which means confident. Overall in each item
there was an increase of mean score after an intervention was given except for
item no. 7 – “I can always keep wanting to breastfeed”. One mother reported
during posttest that she felt her milk was not enough for her baby so most of the
time she bottle-fed her baby. So in this item the mean score lowered from 4.4
into 4.0. The lowest mean score was item no. 3 – “I can always breastfeed my
baby without using formula as supplement”. Out of 5 participants there was only
1 mother who was practicing exclusive breastfeeding before and after the
intervention. This is why during pretest the mean score was 1.6 and it increased
into 2.8 during posttest. The highest posttest mean score was item no. 5 – “I can
always manage the breastfeeding situation to my satisfaction”. After the
intervention was provided, four mothers expressed verbally that they were
satisfied with their breastfeeding experience. One mother who was exclusively
breastfeeding her child got a perfect score on posttest, 70/70.
CHAPTER 3
SUMMARY, FINDINGS, CONCLUSION AND RECOMMENDATION
This
chapter
presents
the
summary,
findings,
conclusion
and
recommendation of the study.
Summary
This study was conducted to determine the effects of an intervention on
the breastfeeding self-efficacy of the mothers at Barangay Tipolo, Mandaue City,
Cebu who were initiating and practicing breastfeeding. It also aimed to determine
the following: 1) the profile of the mothers in terms of age, marital status,
educational
level,
employment
status,
past
breastfeeding
experience,
breastfeeding duration, and breastfeeding exclusivity; 2) the breastfeeding selfefficacy of the mothers before the intervention; 3) the breastfeeding self-efficacy
of the mothers after the intervention; 4) the significant difference between the
breastfeeding self-efficacy before and afterthe intervention; and 5) the significant
difference between the breastfeeding self-efficacy before and after the
intervention when the participants were grouped according to age, marital status,
educational
level,
employment
status,
past
breastfeeding
experience
breastfeeding duration, and breastfeeding exclusivity. Lastly, through this study
nursing guidelines could be formulated to enhance the breastfeeding self-efficacy
of the mothers.
This study used an action research process in which the researcher had
identified that a need to provide an intervention was necessary to improve the
breastfeeding practice of the mothers by enhancing their breastfeeding selfefficacy that could increase breastfeeding exclusivity and duration. It utilized a
quasi-experimental pretest and posttest design to determine the level of
breastfeeding self-efficacy of the mothers before and after the intervention. There
were5 mothers who participated in this study. The study was conducted at
Barangay Tipolo, Mandaue City, Cebu. The research instrument used in this
study was Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF) developed
by Dr. Cindy-Lee Dennis in 2003. The intervention utilized in this study was a
breastfeeding self-efficacy intervention developed by the researcher Di Shi Wu in
2012. It is based on the Social Learning Theory of Bandura (1977) and the
Breastfeeding Self-Efficacy Theory of Dennis (1999).
Findings
The following were the findings of the study:
1. Majority of the participants were young adults (24-36 years old). All of them
lived with their husbands or partners except for one participant who was
widowed. All of them were high school level. Almost all mothers were not
currently working; they preferred to stay home and take care their children. They
mentioned that they had worked before but decided to stop so that they could
completely nurse their new babies. They hadstarted breastfeeding their babies
on the first day after delivery. Most of the participants were practicing
breastfeeding for one to two months duration. 80% of the mothers (n = 4) were
not practicing exclusive breastfeeding, only one was. Only one mother didn’t
have past breastfeeding experience.
2. Before the intervention the mothers hada breastfeeding self-efficacy mean
score of 41.8.
3. Four weeks after the intervention the mothers had higher breastfeeding selfefficacy scores with a mean score of 56.4.
4. There was no significant difference between the breastfeeding self-efficacy
before and after the intervention. The significant difference was 14.6 with p-value
of .136 (p > .05).
Conclusion
The mothers who participated in this study hadlow breastfeeding selfefficacy scores. They were young adults (24-36 years old). Most of them have
partners either in marriage or cohabitation, one mother was recently became
widowed. They just reached high school level. They were unemployed. All of
them had past breastfeeding experiences except for one mother. Their
breastfeeding duration was from one month to 4 months. Out of 5 participants,
only 1 mother was practicing exclusive breastfeeding. They had religiously visited
the health care center to give their full cooperation in rendering complete nursing
care to their newborns. They were mostly accompanied by their partners during
health center visits. They had already experienced breastfeeding with their first
child.
The Breastfeeding Self-Efficacy Scale – Short Form by Dr. Cindy-Lee
Dennis was psychometrically valid instrument to assist health care professionals
in identifying women with low breastfeeding self-efficacy and thus probably at risk
to prematurely discontinue breastfeeding.
Thus the intervention which was breastfeeding education developed by Di
Shi Wu through applying the principles of Albert Bandura on self-efficacy was not
effective in this study due to many factors. Further study is needed to prove the
effectiveness of this intervention.
Recommendation
Based on the findings of the study, the researcher recommends the
following:
1. The Breastfeeding Self-Efficacy Scale – Short Form (BSES-SF) developed by
Dr. Cindy-Lee Dennis is considered as an effective tool to be used in
hospitalsand community settings to assess the breastfeeding self-efficacy of the
mothers.
2. Breastfeeding self-efficacy of the mothers should be assessed by the nurses
or midwives after the delivery of their newborns. And if the scores are
significantly low, the nurses should provide health teaching to the mothers based
on their needs.
4. Breastfeeding education is highly recommended to be given by the nurses
during prenatal checkups in order to facilitate decision making and interest in the
mother to breastfeed her child.
4. To identify the significant difference between the breastfeeding self-efficacy
before and after the intervention when the participants are grouped according to
age, marital status, educational level, employment status, past breastfeeding
experience, breastfeeding duration, and breastfeeding exclusivity, it is suggested
that the number of participants should be increased to 50 or above.
5. It is also recommended that the next researchers who will conduct a study
related to breastfeeding self-efficacy should be more focused on participants who
have low scores (14 to 28). They are priority of nursing care management.
6. It is advisable that the health care providers especially the nurses should make
interventions targeting mothers who need social support the most to reduce
premature discontinuation of breastfeeding.
7. The proposed guidelines to enhance the breastfeeding self-efficacy of the
mothers should be applied by the nurses and it is highly recommended that
further research should be performed by the nurses that focuses on
breastfeeding, breastfeeding efficacy intervention
and the role of a nurse in
helping the mothers successfully breastfeed their babies
PROPOSED GUIDELINES ON BREASTFEEDING
EFFICACY ENHANCEMENT
These are the guidelines proposed by the researcher that will aid the
nurses in enhancing the breastfeeding self-efficacy of the mothers who have low
scores. These guidelines are based on Breastfeeding Self-Efficacy Theory by Dr.
Cindy-Lee Dennis which states that breastfeeding self-efficacy is influenced by
four main sources of information: performance accomplishments, vicarious
experiences, verbal persuasions, and physiological and affective states. By
managing these sources of information on breastfeeding, breastfeeding
confidence of the mothers will be enhanced and thereby leading to three
successful
breastfeeding
activities:
breastfeeding
initiation,
breastfeeding
performance and breastfeeding maintenance. Some nursing activities stated
here are derived from Di Shi Wu’s breastfeeding self-efficacy intervention
(2012).It is perceived by the researcher that these guidelines of breastfeeding
efficacy enhancement are helpful on the part of the postpartum mothers and to
be practiced by the nurses after the delivery of a newborn.
1) Breastfeeding Initiation
Ask the mother the date of initiation of breastfeeding. Assess the breastfeeding
frequency of the mother to her baby. Ask the mother the duration per
breastfeeding.
Verbal Persuasion:Provide positive feedback on her breastfeeding performance.
Explain the importance of breast milk to her baby. Emphasize the benefits of
breastfeeding to the mother and her child. Highlight the personal capabilities of
the mother to breastfeed.Assess breastfeeding barriers. Create optimistic beliefs
on breastfeeding. Allow a mother’s partner to participate on her breastfeeding
experience.
2) Breastfeeding Performance
Observe the mother breastfeeding her baby. Note how she positioned her baby.
Check if the baby is in correct latched-on. Assess the mother’s breastfeeding
confidence using the Breastfeeding Self-Efficacy Scale – Short Form (BSES-SF)
developed by Dr. Cindy-Lee Dennis.
Verbal Persuasion: Provide positive feedback on her breastfeeding performance.
Physiological and Emotional States:Ask the mother if she has encountered any
breastfeeding difficulties. Provide reinforcement and suggestions to improve her
future breastfeeding performance.
Performance Accomplishment:Explain the signs of correct latched-on and
suggest good breastfeeding positions. Teach the mother to switch breast after
feeding of the other breast. Teach the mother the signs of well-breastfed infant.
Encourage the mother to imitate mothers who have successfully breastfed.
Provide adequate information on how to cope up with breastfeeding difficulties.
Vicarious Experience:Use visual aids to demonstrate breastfeeding positions and
correct latched-on.
3) Breastfeeding Maintenance
Visit the mother and ask her about her breastfeeding experience.
Verbal Persuasion:Provide positive feedback on her breastfeeding performance.
Encourage the mother to envision successful breastfeeding performances.
Physiological and Emotional State:Provide support as she handles the pressure
and failure on breastfeeding.
Performance Accomplishment:Help the mother to continue feeding breast milk
even if she is working by expressing her breast milk. Demonstrate the proper
expression of breast milk using either manual pump or electric pump.
Vicarious Experience:Provide written materials such visual aids and brochures to
supplement learning.