research

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 factors—such as poor literacy, urbanisation, separation of mother and child, lack of support, false beliefs of parents, working mothers and cultural background (PérezEscamilla, 1995; Pérez-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 Iran’s 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 father’s, friends’
British Journal of Midwifery • April 2013 • Vol 21, No 4

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 children’s 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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identifying the factors that influence beliefs and decision-making to positively change the behaviour of the participant (Lancaster et al.2. By using behavioural theories in educational interventions. β=0. No 4 Aim The study’s objective was to measure the impact of an educational programme. Barona-Vilar et al. 2004)—and is designed to observe and record behaviour. Participants The sample was selected randomly. Li et al. and suggests a social approach in educational programmes. 2009) but few studies have examined this subject systematically using educational theories. p=0. In this study. which can influence the mother’s decision in the early stages after childbirth (Tarkka et al.05. in educational interventions this model could give a potential capacity for the effectiveness of educational interventions (Hazavehei et al. Participants in both groups had to meet the following characteristics: Mothers ll First pregnancy and without complications ll Pregnancy gestational age of 36–41 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. 2012). Different Iranian and international studies on the impact of successful breastfeeding have revealed the positive impact of education (Hoyer et al. 2008a). 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). Subjective Norms and Enabling Factors (BASNEF) (Salehi et al. This period is often the most challenging because mothers are usually more concerned with the approaching birth and fetuses are more intuitive (Newfield. who had been referred to prenatal clinics affiliated to the Shiraz University of Medical Sciences. 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 (41–36 weeks) of their pregnancy. 1998. based on previous results (α=0. the BASNEF model has the potential for efficacy. 2011). 1992. The first person was subject to the educational intervention group based on the inclusion criteria and the second put in the control group. 277 . healthy at birth and singleton ll Free of any obvious congenital abnormalities Data collection If the participant met the inclusion criteria and gave consent.research and medical professionals’ perceptions—all of which are crucial in the prevalence and continuation of breastfeeding. 2002. on the breastfeeding behaviours of pregnant women. Therefore. The intervention provided them with sufficient information and access to medical staff for consultation and collaboration.8). 1999). subjective norms demonstrate one’s belief relative to influential persons. Infants ll Should have been exclusively breastfed. Kull et al. Stewart-Knox et al’s (2003) study in Northern Ireland indicated that improper social norms make successful breastfeeding harder for mothers. Tarkka et al (1999) also reported that social support is very important for successful breastfeeding. while enabling factors are skills and sources that allow the person’s aim or intention to change their behaviour (Sharifirad et al. 2000. The model centres on four different factors—Beliefs. Belief and attitude cover the positive or negative evaluation of behaviour. especially the father’s support at home. Hoyer et al. Attitudes. British Journal of Midwifery • April 2013 • Vol 21. an educational intervention based on the BASNEF model was applied to boost mothers’ awareness of breastfeeding and improve their attitude towards its importance. based on the BASNEF model. Methods The study is a semi-experimental and prospective intervention. 2000). social pressures and ref lections. 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. 1999.and post-intervention questionnaires based on the BASNEF model from 36 weeks were provided by the researcher. while detecting subjective norms to improve the breastfeeding behaviour of pregnant women. Kim. 2009). pre.

2±4.research Table 1.86±4.2 32% 54% 14% 96% 4% 100% 38% 46% 16% Control group 24. Attitude questions included 10 multiple choice questions (with five possible answers) of Likert Scale ranging between 4 (the best answer) and 0 points. enabling factors (α=-.18 28. Cronbach’s Alpha was calculated for the awareness questions (α=0. mothers were divided into five groups: very weak. question and answer sessions.852 Table 2. attitude (α=0. Attitudes towards pregnancy in mother and partner BASNEF group Yes 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.9).78). The awareness questions included 12 multiple choice questions (with three possible answers).16±5.82) and subjective norms (α=0. British Journal of Midwifery • April 2013 • Vol 21. 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 Partner’s education Primary school educated Secondary school educated Higher education Housekeeper Employed 23. All the questions were answered by the mothers before the educational intervention.617 0. the correct answer was given 1 point. 1 % 2% 46 92% 4 8% 48 96% 2 4% 48 96% 2 4% 47 93% 3 7% The questionnaire included questions on demographics (9).801 possible answers). No 4 p-values 0.786 0. and scored between 5 (the best answer) and 0 points. an educational CD and a letter of introduction to visit medical staff for consultation. performance (α=0. The enabling factor questions were seven yes/ no questions with a score of 1 for yes and 0 for no. The interventions were designed as four educational sessions of 90 minute lectures for one month. group discussions.89 26% 54% 20% 98% 2% 100% 36% 50% 14% – – – 0. 49 % 98% No No. The researcher’s 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 reliability of the questionnaire was determined by Cronbach’s Alpha in a pilot study performed upon 20 participants who were not included in the survey. based on research using the instructional BASNEF model on maternal breastfeeding behaviour. The mothers were given an educational booklet on breastfeeding. All the scores were calculated out of 100 to facilitate the comparison. After their awareness was assessed. The control group received routine education at pregnancy clinic postnatal. Content validity was confirmed by experts who were academic staff and health educators. knowledge (6). The evaluation questions included five multiple choice questions (with three 278 . The behavioural intention question was multiple choice. weak. with six possible answers. and one and three months post-educational interventions.96±2. Comparable age.81). educational images. evaluation of results (5). 2 % 4% Control group Yes No. and ‘I don’t know’ and wrong answers given 0 points. The educational interventions were evaluated during the first until third month via phone calls to mothers and ‘review’ classes.91) (Sharifirad et al. intention (1). and the scoring method based on Likert scales. attitudes (10). The questionnaire was designed by Dr Gholamreza Sharifirad. The behavioural objectives were determined for each session and run via different methods including lectures. 2010). The questionnaires were completed by mothers immediately after the interventions. Mother’s willingness for pregnancy Partner’s willingness for pregnancy Parents who have seen relatives breastfeed 48 % 96% No No. good and very good. CDs and PowerPoint based on the BASNEF model. again. and ‘I don’t know’ and wrong answers given 0 points. with the correct answer given 1 point. or by using pamphlets.30 28. moderate. factors for capability (10) and subjective norms (5).

741).47. The results of this study are consistent with the findings from Dewan et al’s study (2002) to determine the knowledge and attitudes of teenage mothers about prenatal breastfeeding education. and if they had seen relatives breastfeeding were also evaluated.30 and in a control group it was 24. 2002).and posteducational intervention about the medical staff (p=0.741 8% The results showed that the awareness mean score before the intervention in the educational group was 58.84±6. The repeated measures test showed that there was a significant difference (p<0. BASNEF group Control group 44 46 % Much No.16±4. The awareness mean score after the intervention in the educational group was 97. 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. Curro et al. 1995. MC-Nemar and t-test.86±4.03. The repeated measures test showed that the difference remained significant over time (p<0.063).427).09.2±4. attitude toward work (p=0.32 and 61. being similar in this respect (Table 2).0001) while no significant change in the control group was observed (p=0. At baseline in both educational and control groups for the frequency distribution of age.948) while there was a significant difference between the two groups immediately after the educational intervention. 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. 1997).14±14. 2010). Breastfeeding intention Before intervention Very much No. one month and three months post-intervention in all four areas (p < 0.0001) which is inconsistent with the results of Matvienko et al’s (2001) study in which the difference had remained significant after 16 months.72±14. The repeated measures test showed that the difference remained significant over time (p<0.7 in the control group. 280 . retention and promotion of mothers’ attitude about the importance of breastfeeding for infants. mothers asked the medical staff and relatives for the correct answers. in the pre-test. while some studies have found it not to be effective (Clark et al.research Table 3.54. Mothers’ awareness score at one month post-intervention was 94. and three months post-intervention were 90±21. No 4 pvalue 88% 6 92% 4 Analysis of the data The data were controlled. mothers’ evaluation of behaviour results (p=0.06 in the control group.0001).4±21. Discussion Utilising methods to improve the process of children’s 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. Additional studies have indicated the effect of education as positive (Lutter et al. Pregnancy intention for the mother and the spouse. These results are consistent with Raman et al’s (2006) study on patients’ attitude on retinopathy and its post-education improvement in India. It implies the effectiveness of intervention based on the BASNEF model in the areas of faith and persistence. 2008b).18.0001) in attitude between the two groups when they were recorded immediately after the intervention.890). indicating the educational intervention’s effect on the mothers’ awareness based on the BASNEF model.2±8. % 12% 0.031) and there was no significantly different relationship for mother compliance.05±14. The mothers’ evaluation of behaviour results immediately after the intervention were 97. and mean scores of enabling factors (p=0.14 and three months later was 91. 1997). The MC-Nemar test showed that there was a significant difference in educational group between subjective norms at pre.05) (Table 4).09±5. The results reveal that using a logical messaging system while British Journal of Midwifery • April 2013 • Vol 21. and at one and three months. mother-in-law and friends (p≥ 0. education and occupation of pregnant mothers and their partners (Table 1). The relative increase in the control group’s scores could be considered as curiosity because.00010) (Table 3). at one month post-intervention were 88. encoded and then analysed using SPSS with Paired Sample test. 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. and Chi-square test Results The mean age of the mothers in the BASNEF group was 23. This result is not in line with those of the studies carried out based on the BASNEF model (Hazavehei et al.48 and 55. Repeated Measurement Analysis.

8 0.research Table 4. indicating that breastfeeding skill has a positive impact on the mother’s support and their consultation in continuation of breastfeeding.27 3.4 0.26 21.09 0.19 30.7 21.0001).29 3.54 SD 14. 1991).84 57.5 SD 5.06 8.2 64.04 39.64 Mean 94.57 0. The mean score of knowledge. The enabling factors could be an effective facilitator to achieve intentions to the given behaviour (Kuan et al.99 0.03 22.6 0.37 7. all of which are factors in their success.89 31.000 90 80. attitude is important. 1999).90 0. 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.26 0. The M C-Nemar test ( Table 4 ) revealed that there was no significant difference in 281 . 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.08 0.000 7.23 40.21 0. low-income.000 SD 4. LaVeist (1995) concluded that the enabling factors could.09 58.33 0.72 0.32 14.14 55. 2009).000 3. therefore.741 3.56 0. attitude towards practice.44 0. 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.98 20. thus. a study by Yngve and Sjöström (2001) was carried out to examine the impact of health education programmes on continuation of breastfeeding across Europe. In British Journal of Midwifery • April 2013 • Vol 21. 2005).002 94.36 0.28 35. It is essential that there should be many lectures and seminars on breastfeeding regularly throughout the year (Shealy et al.14 14.08 0.31 3.75 19.47 24.48 14.32 21.14 0. a significant difference was seen between immediate.4 0. one and three month delayed educational interventions in the group (p<0. Meanwhile. In DiGirolamo et al’s (2003) study.16 61.’ 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.13 0.09 58.53 20.8 63.04 0.43 0.28 0.000 88.000 8. No 4 Immediately after One month after Three months the intervention the intervention a f te r the intervention Mean 97.03 3.000 97. education and information alone could not reform attitudes.37 Mean 91.42 23. act more importantly than behavioural and cultural differences. 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.948 this regard. less educated mothers. for example.003 96.000 95.4 62.33 21.4 SD 6.54 6. especially targeting young.96 13. using the Precede Proceed model with its four diagnostic steps. 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.’ I n questions about enabling factor. Arora et al’s (1998) study found that information on breastfeeding in pregnancy classes and the media (enabling factors) play an important role in the initiation of breastfeeding.427 64.09 3.’ Yngve and Sjöström’s (2001) results are inconsistent with the findings of this study. evaluation of behaviour.84 0.09 13. in fact. which concluded that: ‘One way of assuring effective breastfeeding promotion would be the creation of a comprehensive surveillance system.05 0.000 3.

 the educational group for subjective norms at pre. McInnes et al (2008) also concluded in their study that mothers tend to rate social support as more important than health care services. Perugi S. Journal of Pediatric Gastroenterology and Nutrition 37(4): 447–52 Boyer K (2012) Affect. 2009: 540). Conclusion Education based on the BASNEF model for involving social norms in education and enabling factors. Escribá-Agüir V. 2012). Wood L. 2002). 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. Archives of Disease in Childhood 76(6): 500–3 Dennis CL (2002) Breastfeeding initiation and duration: A 1990–2000 literature review. Dahlheimer SS (1995) The effects of a structured curriculum on nutrition and fitness knowledge and attitude in an introductory college weight training class. We would like to thank the Labor Department officials at Hafez and Shooshtari Hospitals. 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): 1178–86 Bertini G. Health Place 18(3): 552–60 Clark NA. in addition to provision of individual support in the problem-solving process. Arora S. friends’ and medical staff ’s attitudes are effective on breastfeeding commencement and its continuation. Dani C.and post-educational intervention about father. Therefore. there should be a social approach in educational programmes. Grummer-Strawn LM. Midwifery 25(2): 187–94 Bartington S.research 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. Promoting positive attitudes also increases the behavioural intentions and change. Griffiths LJ. Engagement of family members and health-care providers. corporeality and the limits of belonging: breastfeeding in public in the contemporary UK. Journal of Obstetric. breastfeeding acceptance as a social norm. mother-in-law and friends. Lanni R. Pezzati M. demonstrating that the people close to the mother are important to her breastfeeding behaviour. Thus. No 4 . Tronchin M. Grimaldi V. Journal of Human Nutrition and Dietetics 15(1): 33–7 DiGirolamo AM. rather than traditional methods. plays an important role in promoting the awareness of the subject and improving families’ attitudes about breastfeeding. Maxwell S. Mastroiacovo P (1997) Randomised controlled trial assessing the effectiveness of a booklet on duration of breast feeding. Gynecologic and Neonatal Nursing 31(1): 12–32 Dewan N. which takes into account fathers’. has been assumed as a leading factor to improvement in decision making and stress reduction (Moattari et al. 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. Journal of the American Dietetic Association 95(9): A36 Currò V. Rubaltelli FF (2003) Maternal education and the incidence and duration of breast feeding: A prospective study. Brabin B (2002) Breast-feeding knowledge and attitudes of teenage mothers in Liverpool. Fein SB (2003) Do British Journal of Midwifery • April 2013 • Vol 21. Sweet et al (2009) concluded in their study that: ‘The active and positive contribution that fathers make towards pre-term breastfeeding should 282 Acknowledgment: The present article is extracted from the master’s thesis by Ms Nasrin Bahmani through a research grant from the Research Office of Shiraz University of Medical Sciences. holding continuous and model-based educational sessions in health centres is necessary for mothers to be able to BJM successfully breastfeed. but there was a significant difference for mother and medical staff. The authors would also like to thank Dr Nasrin Shokrpour at the Center for Development of Clinical Research of Nemazee Hospital for editorial assistance. especially those close to her. McJunkin C. Therefore. Tate AR. Bertini et al (2003) showed that subjective norms such as father’s. attending prenatal classes and postnatal support have been among the most important factors for breastfeeding commencement and continuation (MahonDaly et al. 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