Application and Validation of Breastfeeding Self-Efficacy Scale , Short Form ( BSES-SF ) in Adolescent Mothers

Livia Maria Damasceno dos Santos1, Rebeca Silveira Rocha2, Anne Fayma Lopes Chaves3, Hilana Dayana Dodou4, Ana Rita Pimentel Castelo1, Sabrine Rodrigues Feitoza1, Andressa Peripolli Rodrigues5, Fabiane do Amaral Gubert6, Mônica Oliveira Batista Oriá7 1 Nurse. MSc in Nursing by the Graduate Program of the Federal University of Ceará, UFC.*. 2 Nurse. PhD student in Nursing at the Graduate Program of the Federal University of Ceará, UFC. Professor at the University Center Estácio of Ceará.*. 3 Nurse. PhD in Nursing by the Graduate Program of the Federal University of Ceará, UFC. Professor at the University Center Estácio of Ceará.*. 4 Nurse. PhD student in Nursing at the Graduate Program of the Federal University of Ceará, UFC.*. 5 Nurse. PhD in Nursing by the Graduate Program of the Federal University of Ceará, UFC. Professor at the Federal Institute Farroupilha/Campus St. Angelo of Rio Grande do Sul, Brazil. 6 Nurse. PhD in Nursing by the Graduate Program of the Federal University of Ceará UFC. Associate Professor at the Department of the Federal University of Ceará Nursing.*. 7 Nurse. PhD in Nursing by the Graduate Program of the Federal University of Ceará, UFC. Associate Professor at the Nursing Department of the Federal University of Ceará. Fortaleza, Ceará, Brazil.*. *: Fortaleza/Ceará, Brazil


Introduction
Exclusive breastfeeding is an isolated public health measure that has significant impact on maternal and child health.It is also considered the most economical, sensitive and effective method to reduce child morbidity and mortality [1].It is estimated that actions that promote breastfeeding may reduce by 13% the number of deaths in children under five years of age worldwide [2].
However, the maintenance of breastfeeding still constitutes a challenge.Despite the improvement in breastfeeding rates in recent decades, efforts are still needed for Brazil to achieve satisfactory levels [3,4].The most recent National Survey on Maternal Lactation held in the Brazilian capitals and the Federal District found that the average duration of breastfeeding was 341.6 days and of exclusive breastfeeding was only 54.1 days [3].
It is known that some variables such as maternal age, education, family income, intention to breastfeeding during prenatal, family support and early breastfeeding, as well as confidence and maternal self-efficacy in the act of breastfeeding influence breastfeeding rates [5 6,7].Among these variables, maternal self-efficacy in breastfeeding is one of the variables that can be modified.
Theoretically, maternal self-efficacy is defined as the confidence that the mother has on her ability to breast-feed her child and is influenced by four main information: performance accomplishments, previous experience of breastfeeding; indirect experiences, like watching other women breastfeeding a child; verbal persuasion, encouragement by the influence of others, such as friends, family and lactation consultants; and influence of the physiological and/or emotional state, pain, fatigue, stress and anxiety [8].
To assist in the evaluation of maternal self-efficacy in breastfeeding, the Breastfeeding Self Efficacy Scale (BSES) [9] has been created.This has as reference the theory of self-efficacy proposed by Bandura [10].Subsequently, the BSES has been refined and shortened and became known as Breastfeeding Self-Efficacy Scale -Short Form (BSES-SF) [11].The BSES-SF is a structured Likert scale with 14 items that assess the maternal confidence on breastfeeding, distributed in two areas: technical and intrapersonal thoughts, to which scores ranging from 1 (strongly disagree) to 5 (strongly agree) are assigned.
This scale makes posible to learn aspects related to maternal confidence on breastfeeding that need to be improved, contributing to the implementation of more targeted and effective actions in raising self-efficacy, with consequent reduction of early weaning.
There is scientific evidence that maternal selfefficacy has been proved to be important in association with initiation, duration and exclusivity of breastfeeding in the most diverse populations of women [12,13].
However, despite the BSES-SF have been widely used in populations of adult women worldwide, its use when it comes to the adolescent population is still little known.Considering this context, a study conducted in Canada to evaluate the reliability and validity of the BSES-SF among adolescents found that the self-efficacy of this population in breastfeeding is lower than in the adult public, and that one of the implications is that, due the immaturity of the psychological and physical development inherent to this stage of life, the teenager does not focus on breastfeeding [14].
Given the particularities of the adolescence and the need for greater knowledge about the performance of breastfeeding among this public, especially in Brazil, this study aimed to verify the reliability and validity of the BSES-SF in Brazilian adolescent recent mothers; and the correlation of the BSES-SF scores with socioeconomic and obstetric variables of the studied population.

Materials and Methods
This is a methodological and quantitative study performed in Rooming-in (RO) of a reference public maternity in Fortaleza -Ceará, whose mission is to promote excellence in global and humanized care to the health of women and newborns.
The sample consisted of 79 adolescent recent mothers admitted to the institution under study whose age was within the age group defined by WHO which circumscribes adolescence as the period of life ranging from 10 to 19 years old.The women were selected by simple random method using medical records.
Inclusion criteria were: adolescents in the immediate postpartum period; adolescents that had not presented clinical or obstetric complications in the puerperal period, as well as pathologies that prevented or recommended the non-realization of breastfeeding (AIDS); adolescents hospitalized in the rooming-in along with the healthy newborn, effective suction capacity and thermal control.
Considering the fact that the puerperal mothers remained hospitalized on average 48 hours after delivery, data collection was carried out on Monday, Wednesday and Friday mornings.So, during the collection period, all women admitted to the research spot and who met the inclusion criteria were interviewed and the consent of the participants had been obtained through the Informed Consent (IC), which was read and signed at the beginning of the interview.
The reliability of the scale was measured to determine the homogeneity or internal coherence of the tool, that is, if the scale items correlate with each other or are complementary to each other.Thus, we used the internal consistency measured by Cronbach's Alpha (α) as indicative of reliability [12].
To measure the degree and direction of the correlation of socioeconomic and obstetric variables with the domains of BSES-SF, and the total scale score, we used the Pearson correlation coefficient.A p <0.05 was adopted as indication of statistical significance of parameters.
The study was submitted to the Ethics Committee of the institution selected for the development of the study, in accordance to the Resolution Nº 466/12 of the National Health Council/Ministry of Health, considering the aspects of autonomy, beneficence and justice and was approved under the Opinion 208.919.

Results
This study involving 79 adolescents allowed the construction of the socioeconomic profile (Table 1 As for socioeconomic characteristics, most adolescents live in common-law marriage with the partner (n = 45; 57.0%), had as its main occupation the housework (n = 51; 64.5%), had incomplete primary education (n = 36; 45.5%) and family income of one minimum wage (n = 44; 55.7%), generally obtained by the partner's salary or retirement of the mother or father of the puerperal women.
With regard to the obstetrical history and current pregnancy (Table 2), it was observed that most of the adolescents were primiparae (n = 57; 73.4%), with predominance of vaginal delivery (n = 17; 21.5%), and 15 (19.0%) had breast-fed in previous occasions.In the case of the current pregnancy, 52 (65.8%) mothers reported not having planned the pregnancy.
The descriptive analysis of data related to the BSES-SF and its domains (technical and intrapersonal thought) is presented in Table 3.The range obtained for technical and intrapersonal domains was near the upper end of the possible range.Thus, it is observed that the adolescents had high levels of confidence to carry out the practice of breastfeeding.The average total score was 56.58 (± 6.11) (Table 3).Table 4 shows the pattern of responses of adolescents for each item of the BSES-SF and shows that, except for Item 1 (I can always determine that my baby is getting enoughbreast milk), all items had more than 70% agreement.
The reliability of the BSES-SF measured by Cronbach's alpha was 0.82, indicating good internal consistency among the adolescent population.Table 5 has the details of the statistical analysis of the BSES-SF showing the mean, the variance, the correlation of each item with the total of the scale, and the Cronbach's alpha in the absence of any of the scale items.It was observed that if any of the items were removed, the scale would not suffer major changes with respect to the alpha which ranged from 0.782 to 0.809, a variation of only 0.027.Therefore, the removal of any of the items would not significantly alter the value of the alpha and, therefore, this justifies the permanence of all items according to the original study.
The correlation between socioeconomic/obstetric variables and the technical and intrapersonal thought domains of the scale and the total coeffi- cient of BSES-SF (Table 6) was confirmed.A weak correlation between socioeconomic/obstetricvariables and the technical and intrapersonal thought domains and the total coefficient of the scale was observed.However, despite the weak correlation, schooling showed a statistically significant association.It is evident that the lower the education level, the higher the maternal self-efficacy in breastfeeding with regard to the technical aspects of breastfeeding.

Discussion
In this study, there was a predominance of late adolescents, a fact that corroborates a study conducted at the same hospital that aimed to characterize the profile of adolescent puerperal mothers, in which the predominant age group was 15 to 19 years (91%), with mean age of 16.76 (± 1.598) years [15].The World Health Organization (WHO) considers pregnant women aged between 10 and 19 years, which is the stage of adolescence, to be at highrisk because this is a period of physical and psychological development and of impediment to social and educational development [16 ].It is noteworthy that 36.7% of mothers were 16 years old or younger, representing the age group at higher risk for obstetric complications, maternal death, rates of prematurity, stillbirth and low birth weight of the newborn [17].
One of the factors that favored the practice of breastfeeding in this study was the presence of adolescents who live a common-law marriage with the partner.Study says that breastfeeding women that live without a partner are six times more likely to prematurely stop breastfeeding, showing that the presence of the companion is considered a protective factor for breastfeeding [18].
A curious fact of this study was the inverse relationship between education and self-efficacy in nursing, what contradicts other studies conducted in several countries [19,20].Furthermore, it is known that low educational level negatively influences the duration of breastfeeding [21,22].Maybe this was due to the homogeneity of the group where all patients are adolescents under academic education.
The predominance of women whose principal occupation is the realization of domestic chores was also evident in this study.A study in Fortaleza with 252 women showed that working within the house can favor the bond between mother and child and provide greater availability of the mother to breastfeed her child [23].
With respect to family income, there was a predominance of one minimum wage (n = 44; 55.7%) among participants.This is a worrisome finding since authors showed that the interruption of exclusive breastfeeding through the introduction of cow's milk is most significant among low-income families [24].There was predominance of primiparae mothers, which is also reasong for worrying bacause they are inexperient, with more doubts and difficulties in relation to breastfeeding, and may also suffer more easily negative influences on the act of breastfeeding [25].On the other hand, if the adolescent is confident about breastfeeding and is well guided and assisted, especially at the beginning of this process, she will develop the necessary confidence to continue breastfeeding her baby.
Moreover, it was observed that vaginal delivery was more common among adolescents who had already had a previous pregnancy, a fact that can be justified by the hospital's own profile, which has the initiative of humanization of delivery and birth.It is also worth mentioning that vaginal delivery is safer than caesarean section because it offers less risk of infection, bleeding and prematurity of newborns [26].
The data show that there were 22 women with more than one child.Among these, five had informally donated their children (mothers, aunts).Among the other 17 (77.3%)mothers, 15 (88.2%) had breast-fed their children for at least six months (regardless of the type of breastfeeding).The same occurred in another study, in which 80 adolescents were interviewed in order to trace the profile of breastfeeding among them.Among the 13 (16.3%)with previous experience, six (46.2%) maintained breasfeeding for 90 to 180 days, followed by four (30%) that maintained for 60 days and three (23%) for 10 days.The main reasons cited for early weaning were having to return to work, not enjoying breastfeeding and the report that the milk had dried up [26].
Most pregnant adolescents admitted not having planned the current pregnancy, just like what was found in another research in which 65.2 % adolescents were not expecting the pregnancy [27].The lack of pregnancy planning in such a volatile period is adolescence can be a deconstructive factor for the plans of life of adolescents who are still acquiring psychosocial maturity.This is due to factors such as difficult socioeconomic conditions combined with their being dependant of their partners , the low wages paid to women, that leave them to lose their autonomy and reproductive freedom.
As for the descriptive analysis of data related to the BSES-SF and its domains (Technical and Intrapersonal thought), it was observed that the obtained range for technical and intrapersonal domains was close to the maximum possible.Thus, it is observed that the adolescents had high levels of confidence to carry out the practice of breastfeeding.Other studies in the state of Ceará that have evaluated the self-efficacy of in women to breast-feed, with no specific age, has also shown that they have high self-efficacy [12,28].Therefore, it is evident that women from Ceará that are assisted in public systems have confidence in the practice of breastfeeding.
The adolescents tended to answer the maximum value of the scale, occurring the ceiling effect for almost all items except for item 7. The existence of floor and ceiling effects are observed when more than 15% of participants make the choice of the smallest or the largest possible score of the response scale, respectively.The ceiling effect can affect the responsivity of the instrument, considering that participants with higher or lower scores may or may not be distinguished from each other [29].
Cronbach's alpha is the most widely used indicator to check the reliability of an instrument.Cronbach's alpha varies from zero to one and is generally considered to be a reliable tool when it reaches values from 0.7 to 0.8, and values below this are considered unreliable [30].In this study, Cronbach's alpha was 0.807, reflecting lower degree of variance of each specific item and indicates the consistency between the items of an instrument, and then this can be considered trustworthy.The Cronbach's alpha of BSES-SF originally was 0.74 [11] and, when validated in Brazil, the alpha was also 0.7427 [28].
Confirming the reliability of the scale in question, a study conducted in western Canada with 103 adolescents that applied the BSES-SF at 34 weeks of gestation and again in one to four weeks pos-tpartum showed that the alpha Cronbach for the scale items ranged from 0.69 to 0.84, and thus this scale was considered reliable for Canadian adolescents [14].
The correlation analysis between socioeconomic and obstetric variables and BSES-SF resulted in low Pearson coefficient values, suggesting that other confounding factors may be responsible for these results.

Conclusion
The results of this study suggest that the BSES-SF is a reliable and valid measure for assessing selfefficacy in nursing of adolescent mothers.This is an effective, reliable, valid and inexpensive instrument and, therefore, must be used among health professionals to put in pratice actions that incentive breastfeeding.The adolescents in this study proved to be confident about the practice of breastfeeding.Only education level showed significant association with maternal self-efficacy of adolescents in breastfeeding (p = 0.032).
Thus, it is possible to use a tool to detect the selfefficacy of adolescent mothers in breastfeeding, favoring the care of these women in their process of breastfeeding and consequently the reduction of early weaning.From the knowledge of personal perceptions about the competence, capabilities and means of puerperal mothers to adequately deal with inherent requirements in breastfeeding, it will be possible to promote the health of mother and child specifically in health institutions.
This study has some limitations among which we can mention the reduced sampling and selection in one single location that is accredited to the Initiative Child Friendly Hospital and, therefore, already develops actions in favor of breastfeeding.
We suggest the importance of this scale be validated with a larger sample of adolescents, and that the recruitment be done in hospitals with different profiles.

Table 1 .
) of these puerperal mothers.The age of the mothers ranged from 13 to 19 years, with mean age of 17 years and prevalence of late adolescence (17 to 19 years -63.3%).Socio-demographic characteristics of adolescents (N = 79).Fortaleza -CE.

Table 3 .
Descriptive statistics of the resulting scores from the responses of adolescents to the BSES-SF applied to adolescents

Table 4 .
Distribution of frequency of responses to the BSES-SF applied to adolescents

Table 6 .
Correlations between socioeconomic and obstetric variables and the domains and general coefficient of BSES-SF.