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The impact of the BASNEF educational programme on breastfeeding behaviour in Iran


Abstract
This study examines the impact of an educational programme on the breastfeeding attitudes and behaviour of pregnant women. It is a casecontrol study of 100 pregnant women in two hospitals affiliated to Shiraz University of Medical Sciences. The samples were randomly divided into a case and control group. The study looked at the effects of an educational programme based on the BASNEF model, which is a simplified approach to understanding behaviour focused on the beliefs, attitude, subjective norms and enabling factors of participants. The model was applied initially and after four educational sessions mothers behaviour towards breastfeeding was analysed. The results were analysed using statistical tests. The independent t-test showed that there were significant differences in the awareness mean score, mothers perceptions of behaviour results, the score of attitudes towards working and the mean score of immediate enabling factors post-educational intervention, and at one and four months post-intervention (p<0.0001). The scores of subjective norms between the two groups was only significant for the medical staff (p=0.031). Compared with traditional education, modelbased learning has been found to have a positive impact on improving behaviour; therefore, it is suggested that it should be employed in the clinical education of medical teams, especially midwives.
reflect this. Between 1992 and 1998, rates of breastfeeding up to 6 months postpartum increased by 64% in Sweden, 45% in Germany, 25% in Denmark and 27% in the USA (Earle et al, 2002; Li et al, 2008). While in Iran, a 2009 study found that breastfeeding continuation rates at 6, 12, 18 and 24 months were 98, 92, 76 and 0.97%, respectively (Rakhshani et al, 2009). However, influenced by certain factorssuch as poor literacy, urbanisation, separation of mother and child, lack of support, false beliefs of parents, working mothers and cultural background (PrezEscamilla, 1995; Prez-Escamilla, 1996; Visness, 1997)many mothers stop breastfeeding earlier than the recommended 6 months, replacing it with alternative and supplementary feeding. This can imply irreversible physical, mental, economic and social damages to communities (Earle et al, 2002; Li et al, 2008). A study by Dennis (2002) showed that few mothers in developed countries continue breastfeeding over three months. Despite the interest and preference of mothers to choose breastfeeding, there are few who continue with it for as long as the infant requires (Walker et al, 2000). For example, the Islamic faith emphasises the importance of breastfeeding (Raisler et al, 1999); yet, as a Muslim country Irans exclusive breastfeeding rates decreased from 44% in 2000 to 27% in 2004 (Veghari G et al, 2011); and the mean of exclusive breastfeeding duration in the country was found to be 5.59 months, with rates for 5 and 6 months at 83.8 and 66.4%, respectively (Veghari et al, 2011). The duration of breastfeeding in South-Asian countries such as Bangladesh (Mannan et al, 1995) and India (Rajaretnam, 1994) are reported to be at 28.2 and 18.4 months, respectively. In England and Wales, breastfeeding for at least 6 months is recommended (Boyer, 2012), but studies have found that women from lower economic social groups have less intention to breastfeed their babies (Spiby et al, 2009). The most important factors in breastfeeding are subjective norms, such as the fathers, friends
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Marzieh Akbarzadeh Faculty Member for Midwifery, Shiraz University of Medical Sciences Nasrin Bahmani Health Centre Midwife Shiraz University of Medical Sciences Marzieh Moatari Associate Professor of Nursing and Midwifery Shiraz University of Medical Sciences Saeede PourAhmad Associate Professor of Biostatics, Shiraz University of Medical Sciences

o ciety requires healthy and happy people in order to achieve development; human milk is the best source of nutrition and a strong immunological factor to help babies fight infections (Landrigan et al, 2002). Therefore, the role of breastfeeding is important to future health and can lower the risk of certain illnesses, such as allergic diseases (Kull et al, 2002), diarrhoea, respiratory infections (Nakamori et al, 2010), diabetes, bowel diseases, celiac and chronic liver diseases (Ivarsson et al, 2002), and cancers including lymphoma and breast cancer (Shu et al, 1995). Breastfeeding has also been shown to increase childrens cognitive development, leading to better development of the brain, and prevention of mental and emotional problems (Siskind et al, 1989; Rogan, 1993). The benefits of breastfeeding have been widely acknowledged for many years (World Health Organization (WHO), 1998; WHO and UNICEF, 2003), and breastfeeding rates in some countries

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and medical professionals perceptionsall of which are crucial in the prevalence and continuation of breastfeeding. Stewart-Knox et als (2003) study in Northern Ireland indicated that improper social norms make successful breastfeeding harder for mothers, and suggests a social approach in educational programmes. Tarkka et al (1999) also reported that social support is very important for successful breastfeeding, especially the fathers support at home, which can influence the mothers decision in the early stages after childbirth (Tarkka et al, 1999). Numerous studies on successful breastfeeding factors show that those mothers who are socially and emotionally supported feel more encouraged to breastfeed successfully (Matich et al, 1992; Li et al, 1999; Barona-Vilar et al, 2009). Different Iranian and international studies on the impact of successful breastfeeding have revealed the positive impact of education (Hoyer et al, 1998; Hoyer et al, 2000; Kull et al, 2002; Kim, 2009) but few studies have examined this subject systematically using educational theories. By using behavioural theories in educational interventions, the BASNEF model has the potential for efficacy. The model centres on four different factorsBeliefs, Attitudes, Subjective Norms and Enabling Factors (BASNEF) (Salehi et al, 2004)and is designed to observe and record behaviour, identifying the factors that influence beliefs and decision-making to positively change the behaviour of the participant (Lancaster et al, 2000). Belief and attitude cover the positive or negative evaluation of behaviour; subjective norms demonstrate ones belief relative to influential persons, social pressures and ref lections; while enabling factors are skills and sources that allow the persons aim or intention to change their behaviour (Sharifirad et al, 2011). Therefore, in educational interventions this model could give a potential capacity for the effectiveness of educational interventions (Hazavehei et al, 2008a). In this study, an educational intervention based on the BASNEF model was applied to boost mothers awareness of breastfeeding and improve their attitude towards its importance. The intervention provided them with sufficient information and access to medical staff for consultation and collaboration, while detecting subjective norms to improve the breastfeeding behaviour of pregnant women.
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Aim
The studys objective was to measure the impact of an educational programme, based on the BASNEF model, on the breastfeeding behaviours of pregnant women, who had been referred to prenatal clinics affiliated to the Shiraz University of Medical Sciences.

Methods
The study is a semi-experimental and prospective intervention. The sample consisted of mothers who were under the care of the selected educational clinics affiliated with Shiraz University of Medical Sciences and were in the third trimester (4136 weeks) of their pregnancy. This period is often the most challenging because mothers are usually more concerned with the approaching birth and fetuses are more intuitive (Newfield, 2012). The sample size was defined to be 50 for each group using sample calculation and comparison of the average of two groups (control and case groups), based on previous results (=0.05, =0.2, p=0.8).

Participants
The sample was selected randomly. The first person was subject to the educational intervention group based on the inclusion criteria and the second put in the control group. Participants in both groups had to meet the following characteristics:
Mothers ll First pregnancy and without complications ll Pregnancy gestational age of 3641 weeks ll Aged between 18 and 35 ll Minimum education of third grade in junior

high school
ll Free of any obvious and serious mental or

physical diseases during the study ll Resident in Shiraz ll Intention to feed their babies with their own milk ll Voluntary participation in the research project ll Completed the consent form.
Infants ll Should have been exclusively breastfed,

healthy at birth and singleton


ll Free of any obvious congenital abnormalities

Data collection
If the participant met the inclusion criteria and gave consent, pre- and post-intervention questionnaires based on the BASNEF model from 36 weeks were provided by the researcher.
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Table 1. Comparable age, education and occupation of women and their partners in the control group and the BASNEF group
BASNEF group Mean SD age of wife Mean SD age of husband Education Primary school educated Secondary school educated Higher education Job Partner employed Partners education Primary school educated Secondary school educated Higher education Housekeeper Employed 23.864.30 28.165.2 32% 54% 14% 96% 4% 100% 38% 46% 16% Control group 24.24.18 28.962.89 26% 54% 20% 98% 2% 100% 36% 50% 14% 0.801 possible answers); again, the correct answer was given 1 point, and I dont know and wrong answers given 0 points. Attitude questions included 10 multiple choice questions (with five possible answers) of Likert Scale ranging between 4 (the best answer) and 0 points. The behavioural intention question was multiple choice, with six possible answers, and scored between 5 (the best answer) and 0 points. The enabling factor questions were seven yes/ no questions with a score of 1 for yes and 0 for no. The questions on subjective norms to determine who influenced breastfeeding behaviour included five multiple choice questions (with six possible answers) and the answers were calculated as frequencies. All the scores were calculated out of 100 to facilitate the comparison. The questionnaire was designed by Dr Gholamreza Sharifirad, based on research using the instructional BASNEF model on maternal breastfeeding behaviour, and the scoring method based on Likert scales. Content validity was confirmed by experts who were academic staff and health educators. The reliability of the questionnaire was determined by Cronbachs Alpha in a pilot study performed upon 20 participants who were not included in the survey. Cronbachs Alpha was calculated for the awareness questions (=0.81), attitude (=0.9), performance (=0.78), enabling factors (=-.82) and subjective norms (=0.91) (Sharifirad et al, 2010). The interventions were designed as four educational sessions of 90 minute lectures for one month. The behavioural objectives were determined for each session and run via different methods including lectures, educational images, group discussions, question and answer sessions, or by using pamphlets, CDs and PowerPoint based on the BASNEF model. The mothers were given an educational booklet on breastfeeding, an educational CD and a letter of introduction to visit medical staff for consultation. The questionnaires were completed by mothers immediately after the interventions, and one and three months post-educational interventions. The educational interventions were evaluated during the first until third month via phone calls to mothers and review classes. The researchers phone number was given to the mothers so they could call about any problems with breastfeeding around the clock and be consulted if necessary. The control group received routine education at pregnancy clinic postnatal.
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p-values
0.786 0.617 0.852

Table 2. Attitudes towards pregnancy in mother and partner


BASNEF group Yes No. Mothers willingness for pregnancy Partners willingness for pregnancy Parents who have seen relatives breastfeed 48 % 96% No No. 2 % 4% Control group Yes No. 49 % 98% No No. 1 % 2%

46

92%

8%

48

96%

4%

48

96%

4%

47

93%

7%

The questionnaire included questions on demographics (9), knowledge (6), evaluation of results (5), attitudes (10), intention (1), factors for capability (10) and subjective norms (5). All the questions were answered by the mothers before the educational intervention. The awareness questions included 12 multiple choice questions (with three possible answers), with the correct answer given 1 point, and I dont know and wrong answers given 0 points. After their awareness was assessed, mothers were divided into five groups: very weak, weak, moderate, good and very good. The evaluation questions included five multiple choice questions (with three
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Table 3. Breastfeeding intention
Before intervention Very much No. BASNEF group Control group 44 46 % Much No. % 12% 0.741 8%
The results showed that the awareness mean score before the intervention in the educational group was 58.1414.48 and 55.7214.7 in the control group. The awareness mean score after the intervention in the educational group was 97.164.32 and 61.0514.06 in the control group. The result of the paired t-test showed that the awareness mean score after the educational intervention increased significantly in the intervention group (p<0.0001) while no significant change in the control group was observed (p=0.063), indicating the educational interventions effect on the mothers awareness based on the BASNEF model. This result is not in line with those of the studies carried out based on the BASNEF model (Hazavehei et al, 2008b). The relative increase in the control groups scores could be considered as curiosity because, in the pre-test, mothers asked the medical staff and relatives for the correct answers. Mothers awareness score at one month post-intervention was 94.095.14 and three months later was 91.846.54. The repeated measures test showed that the difference remained significant over time (p<0.0001) which is inconsistent with the results of Matvienko et als (2001) study in which the difference had remained significant after 16 months. The results of this study are consistent with the findings from Dewan et als study (2002) to determine the knowledge and attitudes of teenage mothers about prenatal breastfeeding education. Additional studies have indicated the effect of education as positive (Lutter et al, 1997), while some studies have found it not to be effective (Clark et al, 1995; Curro et al, 1997). The mothers evaluation of behaviour results immediately after the intervention were 97.28.09; at one month post-intervention were 88.421.03; and three months post-intervention were 9021.47. The repeated measures test showed that the difference remained significant over time (p<0.0001). It implies the effectiveness of intervention based on the BASNEF model in the areas of faith and persistence, retention and promotion of mothers attitude about the importance of breastfeeding for infants. The repeated measures test showed that there was a significant difference (p<0.0001) in attitude between the two groups when they were recorded immediately after the intervention, and at one and three months. These results are consistent with Raman et als (2006) study on patients attitude on retinopathy and its post-education improvement in India. The results reveal that using a logical messaging system while
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pvalue

88% 6 92% 4

Analysis of the data


The data were controlled, encoded and then analysed using SPSS with Paired Sample test, Repeated Measurement Analysis, MC-Nemar and t-test, and Chi-square test

Results
The mean age of the mothers in the BASNEF group was 23.864.30 and in a control group it was 24.24.18. At baseline in both educational and control groups for the frequency distribution of age, education and occupation of pregnant mothers and their partners (Table 1). Pregnancy intention for the mother and the spouse, and if they had seen relatives breastfeeding were also evaluated, being similar in this respect (Table 2). The independent t-test showed that there was not any significant difference between the control and BASNEF educational groups before educational intervention on awareness mean score (p=0.427), mothers evaluation of behaviour results (p=0.741), attitude toward work (p=0.890), and mean scores of enabling factors (p=0.948) while there was a significant difference between the two groups immediately after the educational intervention, one month and three months post-intervention in all four areas (p < 0.00010) (Table 3). The MC-Nemar test showed that there was a significant difference in educational group between subjective norms at pre- and posteducational intervention about the medical staff (p=0.031) and there was no significantly different relationship for mother compliance, mother-in-law and friends (p 0.05) (Table 4).

Discussion
Utilising methods to improve the process of childrens development is on the agenda of health operational programmes and one of the most important objectives of health care programmes across the globe (Soleimani et al, 2010). Holding training programmes based on theory and education models could be effective in improving the attitude and behaviour of mothers towards exclusive breastfeeding (Dewan et al, 2002).
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Table 4. The mean score of knowledge, evaluation of behaviour, attitude towards practice, enabling factors at any time in the BASNEF group and the control group
Before the intervention Mean Knowledge BASNEF Control T-test result Evaluation of behaviour BASNEF Control T-test result Attitude BASNEF Control T-test result Enabling factors BASNEF Control T-test result applying theories of behavioural change in educational programmes could be effective on behaviour and attitude. A study on educational intervention concluded that there was not any significant change in the attitude score to the act in subjects (Hazavehei et al, 2009). This could be due to the fact that usually attitude and performance are influenced more than awareness by a number of environmental and social factors (Linden, 1991); thus, education and information alone could not reform attitudes. Scott et al (2004: 125) state: Maternal and paternal infant feeding attitudes are often stronger predictors of both choice of feeding method and duration of breastfeeding than sociodemographic factors; therefore, attitude is important. Kuan et al (1999: 1) state: Successful exclusive breastfeeding mothers reported that the visiting nurse watched them breastfeed and [advised them] to call or visit family and friends with concerns about breastfeeding, all of which are factors in their success. I n questions about enabling factor, a significant difference was seen between immediate, one and three month delayed educational interventions in the group (p<0.0001), indicating that breastfeeding skill has a positive impact on the mothers support and their consultation in continuation of breastfeeding. The enabling factors could be an effective facilitator to achieve intentions to the given behaviour (Kuan et al, 1999). In
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Immediately after One month after Three months the intervention the intervention a f te r the intervention Mean 97.16 61.05 0.000 97.2 64.4 0.000 3.31 3.09 0.003 96.28 35.56 0.000 SD 4.32 14.06 8.09 13.57 0.36 0.37 7.53 20.64 Mean 94.09 58.14 0.000 88.4 62.8 0.000 3.29 3.08 0.002 94.04 39.13 0.000 8.75 19.84 0.28 0.33 21.03 22.5 SD 5.14 14.37 Mean 91.84 57.44 0.000 90 80.4 0.03 3.27 3.04 0.000 95.23 40.99 0.000 7.98 20.33 0.26 0.32 21.47 24.4 SD 6.54 6.54

SD 14.48 14.7 21.96 13.21 0.43 0.42 23.26 21.09

58.14 55.72 0.427 64.8 63.6 0.741 3.09 3.08 0.89 31.19 30.90 0.948

this regard, a study by Yngve and Sjstrm (2001) was carried out to examine the impact of health education programmes on continuation of breastfeeding across Europe, which concluded that: One way of assuring effective breastfeeding promotion would be the creation of a comprehensive surveillance system, for example, using the Precede Proceed model with its four diagnostic steps, especially targeting young, low-income, less educated mothers. Yngve and Sjstrms (2001) results are inconsistent with the findings of this study. LaVeist (1995) concluded that the enabling factors could, in fact, act more importantly than behavioural and cultural differences. Meanwhile, Arora et als (1998) study found that information on breastfeeding in pregnancy classes and the media (enabling factors) play an important role in the initiation of breastfeeding. In DiGirolamo et als (2003) study, a great number of mothers (41%) were not breastfeeding at 6 weeks postpartum because a large proportion of physicians (61%) and hospital staff (42%) were not perceived as expressing a preference for a particular feeding method. It is essential that there should be many lectures and seminars on breastfeeding regularly throughout the year (Shealy et al, 2005). The M C-Nemar test ( Table 4 ) revealed that there was no significant difference in
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Key points
ll Exclusive breastfeeding rates for babies older than 6 months old in Iran are decreasing ll One factor that encourages successful breastfeeding is subjective norms, which takes into account fathers, friends and medical professionals views on breastfeeding ll The BASNEF educational model can be implemented to alter mothers behaviour towards breastfeeding ll Participation of other family members is also a factor in successful breastfeeding ll The BASNEF education programme can be used by midwives and health professionals to teach pregnant women about the benefits of breastfeeding

be acknowledged and encouraged (Sweet et al, 2009: 540).

Conclusion
Education based on the BASNEF model for involving social norms in education and enabling factors, rather than traditional methods, plays an important role in promoting the awareness of the subject and improving families attitudes about breastfeeding. Promoting positive attitudes also increases the behavioural intentions and change. Therefore, holding continuous and model-based educational sessions in health centres is necessary for mothers to be able to BJM successfully breastfeed.

the educational group for subjective norms at pre- and post-educational intervention about father, mother-in-law and friends; but there was a significant difference for mother and medical staff, demonstrating that the people close to the mother are important to her breastfeeding behaviour. Thus, the educational programmes should not only be held for mothers but for family members, especially those close to her. Engagement of family members and health-care providers, in addition to provision of individual support in the problem-solving process, has been assumed as a leading factor to improvement in decision making and stress reduction (Moattari et al, 2012). A study by StewartKnox et al (2003)in Northern Ireland also supports the point that improper norms make it more difficult for mothers to have successful breastfeeding. Therefore, there should be a social approach in educational programmes. Bertini et al (2003) showed that subjective norms such as fathers, friends and medical staff s attitudes are effective on breastfeeding commencement and its continuation. It has also been found that fathers and friends support, breastfeeding acceptance as a social norm, attending prenatal classes and postnatal support have been among the most important factors for breastfeeding commencement and continuation (MahonDaly et al, 2002). McInnes et al (2008) also concluded in their study that mothers tend to rate social support as more important than health care services. Other studies results are inconsistent with those of the present study. Sweet et al (2009) concluded in their study that: The active and positive contribution that fathers make towards pre-term breastfeeding should
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Acknowledgment: The present article is extracted from the masters thesis by Ms Nasrin Bahmani through a research grant from the Research Office of Shiraz University of Medical Sciences. We would like to thank the Labor Department officials at Hafez and Shooshtari Hospitals. The authors would also like to thank Dr Nasrin Shokrpour at the Center for Development of Clinical Research of Nemazee Hospital for editorial assistance. Arora S, McJunkin C, Wehrer J, Kuhn P (2000) Major factors influencing breastfeeding rates: Mothers perception of fathers attitude and milk supply. Pediatrics 106(5): E67 Barona-Vilar C, Escrib-Agir V, Ferrero-Ganda R (2009) A qualitative approach to social support and breast-feeding decisions. Midwifery 25(2): 18794 Bartington S, Griffiths LJ, Tate AR, Dezateux C (2006) Are breastfeeding rates higher among mothers delivering in Baby Friendly accredited maternity units in the UK? International Journal of Epidemiology 35(5): 117886 Bertini G, Perugi S, Dani C, Pezzati M, Tronchin M, Rubaltelli FF (2003) Maternal education and the incidence and duration of breast feeding: A prospective study. Journal of Pediatric Gastroenterology and Nutrition 37(4): 44752 Boyer K (2012) Affect, corporeality and the limits of belonging: breastfeeding in public in the contemporary UK. Health Place 18(3): 55260 Clark NA, Dahlheimer SS (1995) The effects of a structured curriculum on nutrition and fitness knowledge and attitude in an introductory college weight training class. Journal of the American Dietetic Association 95(9): A36 Curr V, Lanni R, Scipione F, Grimaldi V, Mastroiacovo P (1997) Randomised controlled trial assessing the effectiveness of a booklet on duration of breast feeding. Archives of Disease in Childhood 76(6): 5003 Dennis CL (2002) Breastfeeding initiation and duration: A 19902000 literature review. Journal of Obstetric, Gynecologic and Neonatal Nursing 31(1): 1232 Dewan N, Wood L, Maxwell S, Cooper C, Brabin B (2002) Breast-feeding knowledge and attitudes of teenage mothers in Liverpool. Journal of Human Nutrition and Dietetics 15(1): 337 DiGirolamo AM, Grummer-Strawn LM, Fein SB (2003) Do

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British Journal of Midwifery April 2013 Vol 21, No 4

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