Attitude selfefficacy knowledge and intention to exclusively breastfeed

Attitude, self-efficacy, knowledge and intention to exclusively breastfeed among pregnant women in rural Bangladesh Window of Opportunity: Bangladesh Joan Sara Thomas Rollins School of Public Health, Emory University May 3, 2011

Overview • • Window of Opportunity: cohort study Time line of research Thesis Where we are now

Window’s Cohort Study • Impact evaluation of Window interventions • Partnerships: § CARE USA, CARE Bangladesh, § Rollins School of Public Health, Emory University, § International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR, B)

Window’s Cohort Study • Proposed objectives of Cohort Determinants of EBF intention EBF at 6 months and risk of undernutrition Sub-optimal complementary feeding practices OBJECTIVES Impact of program activities (e. g. , empowerment) on nutritional outcomes Effectiveness of intervention (nutritional status and anemia) Nutritional status of infants and young children

Time line of Research Jul – Dec 2010: IRB protocol and questionnaire development 6 -19 Jan 2011: 2 -weeks in Bangladesh 5 Feb- 11 Mar 2011: Data management in Dhaka 30 Dec 2010: 12 Jan - 4 Feb 2011: 12 Mar - 22 Apr 2011 Approval from ICDDR, B Ethics and Review IRBs Data collection (N=800) Data cleaning, analysis and thesis development

Thesis: Objective • To examine the associations among knowledge, attitudes, self-efficacy and exclusive breastfeeding intention among women in their third trimester of pregnancy

Thesis: Sample • Cohort 1 of Window’s Cohort Study (N=800) in third trimester of pregnancy (26 -32 weeks)

Thesis: Theoretical framework • An loose application of the Theory of Planned Behavior (TPB) (Icek Ajzen, 1985 )

Thesis: Instrument development • 12 -module questionnaire § Informed by: § § CARE’s baseline survey Alive & Thrive Baseline Survey 2010 Bangladesh Demographic and Health Survey 2007 Infant feeding intentions scales (Nommensen-Rivers, Dewey)

Thesis: Instrument development § Covered a range of topics: § § § § demographic and socio-economic status, household characteristics, food security and maternal diet and nutrition, pregnancy, access to antenatal care services and other breastfeeding support breastfeeding knowledge breastfeeding attitudes, intentions to breastfeed women’s empowerment and social capital

Thesis: Data collection • Akhoni Shomoy and ICDDR, B § Stage 1: Identification of eligible women § Karimganj: done by CHNM’s of Akhoni Shomoy § Katiadi: snowball recruitment, word-of-mouth, network strengthening § Stage 2: Interviews § Both sub-districts: 20 ICDDR, B trained field workers (9 F and 11 M)

Thesis: Data analysis • Main outcome: § Intention to exclusively breastfeed (In. EBF) § “Do you plan to (only) exclusively breastfeed your baby? ” • Maternal indices: § Attitudes § Self-efficacy § Knowledge • Statistical analysis: § Chi-square, t-test and logistic regression

Thesis: Data Analysis • Principal Component Analysis • Standard procedure (e. g. , DHS) • Convert a set of possibly correlated variables into a set of uncorrelated variables called principal components • Factor based scores ranges: • Attitudes (19 -45) • Self-efficacy (10 -18)

Thesis: Maternal knowledge index • Maternal knowledge index was scored according to accuracy of responses, with a score of either 1 or 0 for correct or incorrect responses. § Range 0 -14

Thesis: Descriptive results • Literate: 59% • Mean age : 25 years • (6% > 36 years) • Education of head of HH: 65% • Mean total no. of HH members: 5 • 6 -10 HH members: 35% • Parity: 26% • Nulliparous: 26% • Multiparous: 51% • No. death of children: 77% • ANC visit current pregnancy: ≥ 1: 33%

Thesis: Key demographics and In. EBF Intenders Non-Intenders

Thesis: Maternal indices and In. EBF Intenders Non-Intenders

Thesis: Mean score of indices and In. EBF

Thesis: Maternal knowledge and In. EBF Prevalence and odds of correct exclusive breastfeeding knowledge and intention to exclusively breastfeed

Thesis: Multivariable regression models

Thesis: Results modeling • Findings are consistent with previous breastfeeding intention research • High levels of positive attitude was strongly associated with In. EBF (OR: 2. 30; 95% CI 1. 14 - 4. 66) • High levels of self-efficacy was strongly associated with In. EBF (OR: 3. 91; 95% CI 1. 91 – 8. 00) • Higher levels of knowledge was only modestly associated with In. EBF (OR: 1. 12; 95% CI 0. 74 -1. 71)

Thesis: What does all this mean? • Application of Theory of Planned Behavior although frequent in breastfeeding research not so Bangladeshi population • Principal component analysis enabled analysis to focus on subtleties of key determinants of In. EBF

Thesis: What does all this mean? • Identified key modifiable factors for this population § Higher levels of positive attitude § specifically positive attitudes towards time management towards EBF § Higher levels of self-efficacy § specifically emotional or affective aspects of self-efficacy towards EBF

Thesis: What does all this mean? § …and what about knowledge? § Identify critical gaps in EBF knowledge § Doubts of adequacy of breast milk barrier to application of knowledge § Lack of correct understanding of EBF terminology and definitions Prevalence and unadjusted odds of intention to exclusively breastfeeding • More research needed…

Thesis: Strengths and Limitations • Strengths: § PCA: allowed examination of sub-constructs § Contributing to breastfeeding literature specific to Bangladesh • Limitations: § Questionnaire: scales used i. e. , Likert Scale § Unjustified missing data: need to increase quality control on data management (collection, inputting) § Extractability of important variables i. e. , maternal education § Tight time line

Thesis: In the meantime… • This research adds to the evidence that not only are attitudes and self-efficacy strongly associated key modifiable determinants of intention to EBF in Kishoreganj, rural Bangladesh but the sub-constructs of attitudes- time management and the emotional aspects of self-efficacy are specifically critical future intervention points for improving IYCF decisions.

Where we are now… • Fortunately this is only the beginning… let us see where this 2 year cohort takes us • Currently as of May § Cohort 1 infants should be 3 months § Recruitment will begin for Cohort 2