Critical Review of Theory Use in Breastfeeding Interventions.

BACKGROUND: Numerous efforts to promote breastfeeding resulted in a steady increase in the rates of breastfeeding initiation and duration. Increasing numbers of breastfeeding interventions are focused on breastfeeding maintenance and exclusivity and based on behavioral theories. Few studies critically analyzed the use of theories in breastfeeding intervention development and evaluation. RESEARCH AIM: The aim of this critical review was to examine the existing literature about breastfeeding intervention, and investigate the role of theory in its development, implementation, and evaluation to provide future directions and implications for breastfeeding interventions. METHODS: This critical review examined the existing breastfeeding intervention studies that used self-efficacy theories (SE), theory of planned behavior (TPB), and social cognitive theory (SCT) and were published during the past decade. Using five databases, studies in which researchers explicitly applied these three theories to frame the intervention were selected. Studies were critically reviewed for fidelity to theory in intervention design, delivery, and evaluation. RESULTS: Eighteen studies were reviewed: nine SE-, five TPB-, and four SCT-based. Most interventions were focused on building mothers' breastfeeding self-efficacy to improve breastfeeding exclusivity and duration. To achieve this goal, researchers who developed SE-based interventions used individual approaches, whereas other researchers who based studies on TPB incorporated social and environmental changes. SE-based studies were more likely to include theory-based instruments, but TPB- and SCT-based studies demonstrated less consistent choices of measurement. Researchers in most studies did not test the relationships between the proposed theoretical constructs and breastfeeding outcomes as guided by theories. Inconsistent outcomes resulted among the studies due to variations in study follow-ups. CONCLUSION: Sound applications of single or multiple theories demonstrate a great potential to help practitioners and researchers develop effective breastfeeding interventions and evaluate true impacts on positive breastfeeding outcomes.

Validation of a Theory of Planned Behavior-Based Questionnaire to Examine Factors Associated With Milk Expression.

BACKGROUND: A proper assessment of multidimensional needs for breastfeeding mothers in various settings is crucial to facilitate and support breastfeeding and its exclusivity. The theory of planned behavior (TPB) has been used frequently to measure factors associated with breastfeeding. Full utility of the TPB requires accurate measurement of theory constructs. Research aim: This study aimed to develop and confirm the psychometric properties of an instrument, Milk Expression on Campus, based on the TPB and to establish the reliability and validity of the instrument. METHODS: In spring 2015, 218 breastfeeding (current or in the recent past) employees and students at one university campus in northern New Jersey completed the online questionnaire containing demography and theory-based items. Internal consistency (α) and split-half reliability ( r) tests and factor analyses established and confirmed the reliability and construct validity of this instrument. RESULTS: Milk Expression on Campus showed strong and significant reliabilities as a full scale (α = .78, r = .74, p < .001) and theory construct subscales. Validity was confirmed as psychometric properties corresponded to the factors extracted from the scale. Four factors extracted from the direct construct subscales accounted for 79.49% of the total variability. Four distinct factors from the indirect construct subscales accounted for 73.68% of the total variability. CONCLUSION: Milk Expression on Campus can serve as a model TPB-based instrument to examine factors associated with women's milk expression behavior. The utility of this instrument extends to designing effective promotion programs to foster breastfeeding and milk expression behaviors in diverse settings.

Determinants of the Intention to Pump Breast Milk on a University Campus.

INTRODUCTION: The number of young mothers in the workforce and in schools of higher education has steadily increased. In order to maintain a breastfeeding relationship with their children, these mothers need to pump or express breast milk multiple times a day while at work or school. This study examines the factors associated with the intention to pump breast milk at one university campus. METHODS: Between January and February 2015, an online survey invitation was sent out to all female employees and students at one university. The survey, based on the Theory of Planned Behavior, assessed intentions to pump breast milk on campus. The intention to pump breast milk was examined between employees and students separately. Within these 2 groups, behavioral performers (women who pump or have pumped breast milk while on campus) were compared to nonperformers. Using multiple regression analysis, the most influential predictors of the intention to pump (ie, attitudes, subjective norm, perceived behavioral control, and underlying beliefs) were identified. RESULTS: A total of 218 women participated in the study (62 employees and 156 students, a 71.7% survey completion rate). Among university employees, the most influential factor that predicted pumping intention among performers was attitude toward pumping (ß = 0.36, P = .03). Among student performers, the most influential factor to predict pumping intention was the subjective norm (ß = 0.31, P = .02). For student nonperformers, perceived behavioral control (ß = 0.54, P < .001) was the most influential factor. Important determinants of the intention to pump on campus included relieving discomfort from engorgement, availability of milk storage, experiencing other people's approval of pumping breast milk, and the inconvenience of carrying pump equipment. DISCUSSION: Continued efforts are needed to create a supportive culture for breastfeeding in the campus community as well as to provide pump loan and milk storage options for both employee and student mothers.

Breastfeeding: The Illusion of Choice.

BACKGROUND: Breastfeeding is frequently described as a woman's decision, yet this choice is often illusionary owing to suboptimal social and structural supports. Despite passage of the Patient Protection and Affordable Care Act (2010) that requires all qualifying employers to provide mothers "reasonable" break time and a private, non-bathroom space to express breast milk, the majority of women in the United States still do not have access to both accommodations. THE PROBLEM: At least three issues may be influencing this suboptimal implementation at workplaces: 1) federal law does not address lactation space functionality and accessibility, 2) federal law only protects a subset of employees, and 3) enforcement of the federal law requires women to file a complaint with the United States Department of Labor. RECOMMENDATIONS: To address each of these issues, we recommend the following modifications to current law: 1) additional requirements surrounding lactation space and functionality, 2) mandated coverage of exempt employees, and 3) requirement that employers develop company-specific lactation policies. CONCLUSIONS: If the goal is to give women a real choice of whether to continue breastfeeding after returning to work, we must provide the proper social and structural supports that will allow for a truly personal decision. No mother should have to choose between breastfeeding her child and earning a paycheck.

Workplace lactation support by New Jersey employers following US Reasonable Break Time for Nursing Mothers law.

BACKGROUND: Returning to an unsupportive work environment has been identified as a major reason for avoidance or early abandonment of breastfeeding among working mothers. OBJECTIVE: This study aimed to examine the nature and extent of accommodations offered to breastfeeding employees among New Jersey employers since the US federal Reasonable Break Time for Nursing Mothers law enactment. METHODS: A cross-sectional survey was conducted to measure current lactation support in the workplace in New Jersey. Using convenience sampling, the survey was sent to managerial personnel in hospitals and nonhospitals. The level of support was assessed on company policy, lactation room, and room amenity. A composite lactation amenity score was calculated based on responses about lactation room amenities. RESULTS: Respondents (N = 51) completed a 22-item online questionnaire during fall 2011. The support level was compared by type of organization: hospital (n = 37) versus nonhospital (n = 14). The amenity score of hospitals was significantly higher than nonhospitals (1.44 vs 0.45, P = .002). The mean amenity score (score = 0.95) for all employers was far below comprehensive (score = 3.0). Compared to nonhospitals, hospitals were more likely to offer lactation rooms (81% vs 36%, P = .003), have their own breastfeeding policy (35.1% vs 7.1%, P = .01), and provide additional breastfeeding support (eg, education classes, resources; P < .05). CONCLUSION: Employers, regardless of the type of organization, need to improve their current practices and create equity of lactation support in the workplace.

Breast milk pumping beliefs, supports, and barriers on a university campus.

BACKGROUND: Compared to nonemployed mothers, employed mothers are more likely to terminate breastfeeding sooner than recommended, due in part to a lack of workplace support. OBJECTIVE: The purpose of this study is to compare the beliefs of employees and students affiliated with a university regarding pumping breast milk on campus. METHODS: This qualitative study used semistructured interviews grounded in the theory of planned behavior, focused on behavioral, normative, and control beliefs regarding pumping on campus. Responses were independently coded and categorized based on common themes. Response frequencies were calculated and compared between students, staff, and faculty. RESULTS: Thirty-two women (11 students, 8 staff, 13 faculty) participated in the interview. Overall, participants most frequently reported that maintaining milk supply/extending breastfeeding duration was an advantage to pumping on campus, and time/scheduling issues a disadvantage. The most commonly perceived supporters were peers, whereas those unaware, uninformed, and/or disapproving of breastfeeding were most commonly perceived as opponents to pumping on campus. Reporting within each category differed between students, staff, and faculty. It is notable that students most frequently identified the lack of available pumping space as a barrier, whereas faculty often reported that space availability made pumping on campus easier for them. In addition, both staff and faculty frequently stated that scheduling and time constraints were a pumping barrier. CONCLUSION: An inequality of current lactation support practice may exist at colleges and universities. It is necessary to extend this protection to all members of a workplace, regardless of their role.

Employers' readiness for the mother-friendly workplace: an elicitation study.

Currently over half of mothers of infants under 1-year-old are in the workforce in the United States. These women face challenges to continue breastfeeding when they return to work 3 to 6 months post-partum. This study explored the perspectives of employers on mother-friendly environments to assess their readiness to provide breastfeeding accommodation using the elicitation under the theory of planned behaviour. Researchers conducted phone/in-person interviews with a convenient sample of 20 human resource managers from companies that had 500 or more employees in the New York metropolitan area in 2009. Content analyses identified the common concepts that represent underlying beliefs of the constructs of the theory. The demography of the participants is 40% male and 80% White, with mean ages of 34.3±8.5 years. 'Happy employees' and 'high retention rate and improved loyalty' were the most frequently mentioned (95%) benefits to the company (behavioural beliefs). Supporters of a mother-friendly environment (normative beliefs) in the workplace included 'mothers and expectant mothers (70%)', and 'managers supervising women and new mothers (55%)'. Most frequently mentioned company drawbacks (control beliefs) were 'not cost effective (65%)' and 'time consuming (65%)', followed by 'perception of special favours for some (50%)'. Workplace breastfeeding promotion efforts can be successful by reinforcing positive beliefs and addressing the challenges associated with implementation of breastfeeding accommodation through education and other incentives such as recognition of model companies and tax breaks. The identified beliefs provide a basis for the development of a quantitative instrument to study workplace breastfeeding support further.