Breastfeeding knowledge, attitude, and self-efficacy among mothers with infant and young child in rural Ethiopia

Background Breastfeeding has several benefits for both mothers and their children. Despite strong evidence in support of the practice, its prevalence has remained low worldwide, particularly in Ethiopia. Therefore, this study is aimed to assess breastfeeding knowledge, attitude, and self-efficacy among mothers with index infants and young children in the rural community of Southwest Ethiopia. Methods A community-based cross-sectional study was conducted between March and April 2022 as baseline data for a cluster of randomized control trials. Multistage sample techniques followed by systematic random sampling techniques were employed. The Chi-square and Fisher’s exact probability tests were used to assess the baseline differences in the socio-demographic characteristics of the two groups. An independent sample t-test was used to determine the mean differences. Multivariate logistic regression analysis was used to evaluate the association. All tests were two-tailed, and a statistically significant association was declared at a p-value ≤ 0.05. Results A total of 516 mothers (258 from the intervention and 258 from the control group) were interviewed. A total of 516 mothers (258 from the intervention group and 258 from the control group) were interviewed. Except for the child’s sex and age, no significant difference was observed between the intervention and control groups in terms of socio-demographic variables (p > 0.05). Independent t-tests found no significant difference between the two groups (p > 0.05) in terms of the mean score of maternal breastfeeding knowledge, attitude and self-efficacy at baseline. After adjusting for other covariates, maternal age (AOR = 1.44, 95% CI: 0.69, 3.07), educational status (AOR = 1.87, 95% CI: 0.56,2.33), occupation (AOR = 1.79, 95% CI, 1.04, 3.69), ANC (antenatal care) (AOR = 1.88, 95% CI, 1.11, 4.09), received breastfeeding information (AOR = 1.69, 95% CI, 1.33, 5.04), postnatal care (PNC) (AOR = 3.85, 95% CI, 2.01, 5.77) and parity (AOR = 2.49, 95% CI, 1.08, 4.19) were significantly associated high level breastfeeding knowledge. The positive attitude was associated with maternal age (AOR = 2.41, 95% CI, 1.18, 5.67), education status (AOR = 1.79, 95% CI, 0.99,4.03), ANC (AOR = 2.07, 95% CI, 1.44,5.13), last child breastfeeding history (AOR = 1.77, 95% CI, 1.21,4.88) and high level of breastfeeding knowledge (AOR = 2.02, 95% CI, 1.56,4.04). Finally, high breastfeeding self-efficacy was associated with ANC (AOR = 1.88, 95% CI 1.04,3.83), parity (AOR = 4.05, 95% CI, 1.49, 5.03) and high knowledge level (AOR = 1.69, 95% CI, 0.89,2.85). Conclusions The study concluded that mothers in both the intervention and control groups have a low level of breastfeeding knowledge, a neutral attitude, and medium self-efficacy. Therefore, nutrition education interventions using tailored messages appropriate to the sociocultural context in the rural setting should be developed and evaluated continuously. This study was conducted in Maji Woreda, one of the rural settings of the West Omo Zone, Southwest Ethiopia. Maji Woreda has a total of 22 kebeles. The woreda has one district hospital, two health centres, and 22 health posts. Maji district has a population of 230,777 people and is located 817 kilometres away from Addis Ababa, Ethiopia [15]. This is a community-based cross-sectional study that used data collected from March 1 to April 3, 2022, as part of a cluster-randomized control trial baseline. The study populations were mothers with infants and children aged 0–24 months in randomly selected small administrative units. This study is a part of a larger study entitled ” Effectiveness of a positive deviance approach to improve appropriate feeding and nutritional outcomes in South West Region, Ethiopia: a cluster randomized controlled trial”. WHO Trial Registration number: PACTR202108880303760. The sample size was calculated using statcalc with the following assumptions: to detect an increase in appropriate feeding from 7% to 14% [16], with 95% CIs and 80% power, assuming an intra-class correlation coefficient of 0.03 [17] equal to the Ethiopian study for a cluster size of 12, it was calculated that 36 clusters were needed. This gave a sample size of 215. Then it was multiplied by the design effect of two and allowing for a 20% loss to follow-up, the total sample size was 516 mothers (258 from the intervention arm and 258 from the control arm). A multistage sampling technique followed by a systematic random sampling technique was used to identify mothers with index infants and young children. In the first step, one woreda (district) was selected by simple random sampling (lottery method). Second, lists of all kebeles (clusters) in the selected districts were compiled from the district administrative offices. A total of 36 non-adjacent clusters geographically accessible out of the 88 zones (small administrative units) were purposefully selected by listing them in alphabetical order then a list of random numbers was generated in Microsoft Excel 2016 and fixed by being copied as “value” next to the alphabetical list of zones. According to the produced, random numbers were placed in ascending order. The last 18 zones were chosen as control clusters, and the first 18 served as intervention clusters. Third, 516 mothers were recruited using health extension workers’ family registration books to find mothers who had an infant and a young child with an age less than 24 months. An Excel sheet was formed from the logbook, and the households were selected using simple random sampling techniques. Mothers within the zones serve as the unit of observation, and zones in the kebeles serve as the unit of randomization for the trials. The zones are assigned by simple randomization with a 1:1 allocation to either the control or intervention groups. The intervention assignment was concealed from the interviewers collecting the outcome data. Because of the nature of the intervention, mothers cannot be blind. All mothers, health extension workers, members of the women’s health army, and community volunteers, however, are blind to the study’s hypothesis. The general objectives of the study are described in the agreement for data collection. Mothers living in the selected clusters with no plan to move away during the intervention period, capable of giving informed consent, willing to be visited by supervisors and data collectors, the mothers should have an infant/child aged 0–24 months, the child Height-for-age Z (HAZ) scores HAZ < −2 and child with no severe malnutrition. Mothers with a severe psychological illness and children with severe illness were excluded. Data were collected on socio-demographics, knowledge, attitude, breastfeeding self-efficacy, and household food security status from all participants. The questionnaire was prepared in English, translated to the local language Amharic and then back-translated to English by experts in the language to maintain its consistency. The data were collected using an interviewer-administered questionnaire in Amharic. Three BSc nurses and ten diploma holders in the health centre were recruited as supervisors and data collectors, respectively. The supervisors were supervised and coordinated with their respective kebeles. Pretesting of the questionnaire was done on 5% of mothers who had an infant and child aged 0–24 months in another area (the Bench-Sheko zone) before the study period, and appropriate changes were made to the questionnaire. A questionnaire was developed from a large body of literature to address the survey objectives. This instrument was tested for reliability and validity (Cronbach’s alpha coefficients were 0.84, 0.87, and 0.77 for breastfeeding knowledge, attitude, and self-efficacy, respectively). Household food security tools were also used to assess the food security status of the household. A self-report questionnaire was used, which consisted of four sections: socio-demographic characteristics (maternal age, marital status, educational level, and monthly income), perinatal characteristics (delivery mode, birth order, and weight of infant/young child), and breastfeeding-related characteristics (previous breastfeeding experience) [18]. We used a breastfeeding knowledge questionnaire (BFKQ) consisting of 17 items to measure the knowledge of the participants about breastfeeding. There are three possible responses for each item (true, false, and I do not know or not sure). Correct responses were scored as one, and zero for other options. Thus, the total scores ranged from 0–17, these items were developed based on a study done among Chinese mothers in English and translated into Amharic [19]. We decided to use cut-offs above and below the mean to dichotomize knowledge level. Accordingly, all mothers who scored ≥ the mean in the knowledge test were considered to have a high level of knowledge, and those scoring below the mean were considered to have a low level of knowledge. The Iowa infant feeding attitude scale, Amharic version (IIFAS-A), consists of 17 items with a five-point Likert scale, rating maternal attitude towards breastfeeding. A sum of scores ranging from 17 to 85, with the higher score reflecting a positive attitude and the opposite score showing a negative attitude. Attitude toward breastfeeding was categorized as follows: (1) positive to breastfeeding (IIFAS score 70–85), (2) neutral (IIFAS score 49–69), and (3) positive to formula feeding (IIFAS score 17–48). The scale consists of 17 items with a five-point Likert scale ranging from strongly disagree to strongly agree on each item to indicate attitude toward infant feeding. The IIFAS is a validated and reliable measure (Cronbach’s alpha scores range from (0.81–0.86)) that evaluates breastfeeding attitudes in different cross-cultural settings [19–27]. Approximately half of the questions were negatively worded (i.e., 1, 2, 4, 6, 8, 10, 11, 14, and 17) [20]. The short form of the breastfeeding self-efficacy scale (BSES-SF) has been used widely with a variety of populations and published in different reputable journals [21, 22]. The overall score of the scale was calculated as the mean score of all items. A higher total score is indicative of a greater level of maternal breastfeeding self-efficacy. We used the BSES-SF, consisting of 14 items with a five-point Likert scale, developed to measure breastfeeding confidence in Amharic translated from validated English questionnaires from different studies, which measures the mother’s self-efficacy in her ability to breastfeed. All the items are preceded by the phrase “I can always “and anchored with a 5-point Likert scale where one indicates not at all confident and five indicates always confident. All items are presented positively, and scores are summed to produce a range from 14 to 70. Breastfeeding self-efficacy is identified from the sum of each question: low self-efficacy (14 to 32 points), medium self-efficacy (33 to 51 points), and high self-efficacy (52 to 70 points) [23]. The Household food insecurity access scale (HFIA) was assessed by using 9-item questions. Before assigning the food insecurity category, each frequency of occurrence response was coded as 0 for all cases where the answer to the corresponding occurrence question was "no," and the four food security categories were computed and created in the order recommended by FANTA [24]. Finally, HFIA category 1 was considered food secure, while the remaining categories were considered food insecure. Double data entries were done using EpiData (version 3.1), and all statistical analyses were conducted using SPSS version 23. The data were summarized using frequencies and percentages. The Chi-square and Fisher’s exact probability tests were used to assess the baseline differences in the socio-demographic characteristics of the two groups. An independent sample t-test was used to determine the mean differences in breastfeeding knowledge, attitude, and self-efficacy. Logistic regression analysis was conducted to assess the association between the outcome variables and the covariates. Variables in the univariate analysis that showed a significant effect on the dependent variable were included in the multivariable analysis. Unadjusted and Adjusted Odds ratios (AOR) with 95% confidence interval (95% CI) were computed. All tests were two-tailed, and a statistically significant association was declared at a p-value ≤ 0.05. The study received ethical approval (reference number. IHRPG/938/20) from Jimma University’s Institute of Health Research and Postgraduate Office, Institutional Review Board. Administrative permission was acquired from Maji Woreda Administrative offices, and formal letters to the research area were obtained from Maji Woreda Health Office. All participants provided written informed consent. Participation was voluntary, with the right to withdraw at any time.