Effectiveness of a theory-based breastfeeding promotion intervention on exclusive breastfeeding in China: A randomised controlled trial
Introduction
The benefits of breastfeeding, particularly exclusive breastfeeding (EBF) have been well recognised (Victora et al. 2016). It can reduce the risk of hospitalisation and mortality related to diarrhoea, otitis media, and respiratory infection (WHO, 2013a, Victora et al., 2016). Breastfeeding may also decrease the risk of obesity for infants who have been breastfed for more than 6 months in their later life (Scott et al., 2012, Victora et al., 2016). Besides, breastfeeding improves cognition, and children who have been breastfed show higher score in intelligence quotient test and improved performance in school performance (Horta et al., 2015, WHO, 2013b). In addition, long period of breastfeeding is associated with a reduced incidence of breast cancer and ovarian cancer for mothers (Chowdhury et al., 2015, Collaborative Group on Hormonal Factors in Breast Cancer, 2002).
The World Health Organization (WHO) and United Nations Children's Fund have put forth an objective to increase breastfeeding rates to 75% in the early periods of infants’ life, to 50% at 6 months and to 25% at 1 year of age (WHO 2002). However, only a limited number of mothers have complied with such recommendations (Mcisaac et al., 2014). In the study by Guo, 28.7% of infants under 6 months have been exclusive breastfed in central and western China (Guo et al., 2013). Another survey conducted in three cities in China reveals that the EBF rate at 6 months is 25.2% (Zhu et al., 2014). The findings of these studies have suggested that few cities and provinces in China have meet the international target rates for EBF. In this situation, intervention studies are required.
Breastfeeding practices are determined by a wide range of socioeconomic, cultural, and individual factors (Rollins et al., 2016). Research has indicated that improved breastfeeding knowledge and attitude toward breastfeeding are related to positive breastfeeding outcome (Zhang et al., 2009, Jessri et al., 2013). The support or obligation of partner can also affect breastfeeding, and successful breastfeeding practices tend to occur among mothers whose family members support breastfeeding (Gibson-Davis and Brooks-Gunn, 2007, Sherriff et al., 2014). Besides, maternal confidence in their ability to breastfeed is a key factor for sustained breastfeeding and efforts that enhance mothers self-efficacy or behaviour control are effective in prolong breastfeeding duration (Meedya et al., 2014, Chan et al., 2016). In addition, employment is reported to be negatively associated with EBF outcome, and employed mothers have a higher rate of early weaving (Yimyam, 2011). Given the aforementioned factors are malleable and may be changed through interventions, it is plausible that efforts target the enhancement of breastfeeding knowledge, attitude toward breastfeeding, family support, maternal confidence in breastfeeding and preparation for work situation should increase exclusive breastfeeding rate.
The theory of planned behaviour (TPB) is a theory that focuses on health-related behaviour (Ajzen, 1991), and has been used in predicting breastfeeding behaviour (Guo et al., 2016, Bai et al., 2010). The TPB assumes that breastfeeding intention is the most important determinant of breastfeeding, which is influenced by a person's attitude toward breastfeeding, subjective norms, and perceived behavioural control (Ajzen, 1991). Attitude is determined by a mothers’ beliefs or expectations about the outcome of breastfeeding, which is related to the knowledge on the benefit and importance of breastfeeding. Subjective norm is determined by mothers’ subjective belief about the approval or disapproval of breastfeeding from people important to them (e.g., Husbands, grandmothers). Perceived breastfeeding control is mothers’ belief in her own ability to practice breastfeeding.
We intended to integrate the TPB into breastfeeding intervention programme by focusing on above factors simultaneously: (1) educating mothers with the benefit and importance of breastfeeding (knowledge and attitude); (2) educating and inviting their significant others to involve in the breastfeeding programme, creating a supportive environment (subjective norm); (3) giving breastfeeding individual instruction on correct breastfeeding skill, fostering mothers’ breastfeeding skills (perceived breastfeeding control); and (4) giving advice on breastfeeding-related problems solving through telephone counselling, especially advice that prepare employed mothers for work, providing continued support during postpartum period (perceived breastfeeding control).
Therefore, this study aimed to examine the effectiveness of the TPB-based intervention programme that targeted on improving breastfeeding knowledge and positive attitude, enhancing family support (subjective norm), strengthening breastfeeding control, and preparing for working situation in increasing EBF rate during 6 months post partum among Chinese primiparous women.
Section snippets
Research design and participants
This is a prospective randomised controlled trial conducted in a tertiary hospital, which is a teaching hospital accredited as an ‘AAA’ tertiary care specialty hospital with an average of 15,000–17,000 new births per annum. The majority mothers served in this hospital were local resident, only a small amount of mothers come from other cities. We assumed the current rate of exclusive breastfeeding was almost 30% at 6 months (Guo et al., 2013), and wanted to increase it to 50%, as recommended by
Intervention
The intervention group was offered the TPB-based intervention programme by three nurses, in addition to the routine nursing care. In order to ensure the quality and consistency of intervention, they were trained before the study. The TPB-based intervention programme comprised one individual instruction and two group educations at hospital and continued telephone counselling at home during postpartum period. The intervention protocol is summarised in Table 1. Whereas, the control group received
Data collection
Ethical approval was granted by the Research Ethics Review Committee of Shanghai First Maternity and Infant Hospital, Shanghai, China. Fig. 1 shows the process of data collection. The eligible participants were approached on the first day after childbirth and informed about the purpose of the study, procedures, confidentiality and anonymity preserved, and potential risks and benefits. Then, written informed consents were obtained. Meanwhile, demographic information was collected, which included
Data analysis
Continuous variables were presented as mean and standard deviation, while categorical variables as number and proportion. The demographic homogeneity between groups were examined using T-test for continuous variables and χ2 for categorical variables. Besides, χ2 test was used to compare the differences of EBF rate between groups at different time points. Participants who dropped out or those who were lost to follow-up during postpartum period were excluded from analysis and reported separately.
Findings
Participants were recruited consecutively from October 2013 to January 2014 and follow-up was completed by June 2014. During the recruitment period, 445 participants were recruited and assessed the eligibility. The flow diagram is illustrated in Fig. 2. Only 352 of 445 participants (79.1%) met the inclusion criteria and signed the written informed consents. Of the 93 participants excluded, 71 participants failed to meet the inclusion criteria, and the other 41 participants refused to
Discussion
The purpose of this randomised controlled trial was to evaluate the effectiveness of a specially designed theory-based intervention programme on the promotion of EBF among Chinese primiparous women during 6 months post partum. Overall, the findings suggested that current intervention was effective in increasing the EBF rates within 6 months post partum. The EBF rates in the intervention group were much higher than the control group in this study, especially at 4 and 6 months.
A previous study
Limitations and generalisability
The current intervention programme focused on several factors of breastfeeding and involved a number of intervention strategies, which might lead to the overall high rates of EBF in the intervention group than the control group. Nevertheless, it was impossible to identify the specific strategies that were most effective in the current study. Meanwhile, some bias might exist due to the uncompleted data on the 67 participants excluded. There were 44 women dropped out or out of contact in the
Funding
This work was supported by the Funding of Shanghai Science and Technology Committee under Grant of 134119a1000 and 14495810900.
Conflict of interest
The authors declared no conflict of interest.
Acknowledgements
We would like to thank Houyan Wen for research co-ordination; Si Sun for the help of data collection; and the women and their infants who participated in this study.
References (32)
The theory of planned behavior
Organizational Behavior & Human Decision Processes
(1991)- et al.
Predictors of continuation of exclusive breastfeeding for the first six months of life
Journal of Human Lactation
(2010) - et al.
The impact of breastfeeding promotion in women with formal employment
Cadernos De Saúde Pública
(2010) Breast cancer and breastfeeding: collaborative reanalysis of individual data from 47 epidemiological studies in 30 countries, including 50 302 women with breast cancer and 96 973 women without the disease
Lancet
(2002)- et al.
The effect of a self-efficacy-based educational programme on maternal breast feeding self-efficacy, breast feeding duration and exclusive breast feeding rates: a longitudinal study
Midwifery
(2016) - et al.
Breastfeeding and maternal health outcomes: a systematic review and meta-analysis
Acta Paediatrica
(2015) - et al.
The impact of two corporate lactation programs on the incidence and duration of breast-feeding by employed mothers
The American Journal of Health Promotion
(1994) - et al.
The association of couples’ relationship status and quality with breastfeeding initiation
Journal of Marriage and Family
(2007) - et al.
Efficacy of the theory of planned behavior in predicting breastfeeding: meta-analysis and structural equation modeling
Applied Nursing Research
(2016) - et al.
Breastfeeding rates in central and western China in 2010: implications for child and population health
Bulletin of the World Health Organization
(2013)
Breastfeeding promotion intervention and breastfeeding practices: a systematic review
BMC Public Health
Breastfeeding and intelligence: a systematic review and meta-analysis
Acta Paediatrica
Effect of breastfeeding promotion interventions on breastfeeding rates, with special focus on developing countries [J]
BMC Public Health
Predictors of exclusive breastfeeding: observations from the Alberta pregnancy outcomes and nutrition (APrON) study
BMC Pediatrics
Evaluation of the impact of breast milk expression in early postpartum period on breastfeeding duration: a prospective cohort study[J]
BMC Pregnancy and Childbirth
Exclusive breastfeeding among Canadian Inuit: results from the Nunavut Inuit Child Health Survey
Journal of Human Lactation
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