The effectiveness of a theory‑based health education program on self-efficacy and breastfeeding behaviors continuity of working mothers in Iran

Abstract

Breastfeeding self-efficacy refers to mother perceived ability to breastfeed her infant and is an effective variable in breastfeeding duration. Breastfeeding offers numerous benefits for both mothers and infants, but working mothers face unique challenges that can impact breastfeeding initiation and duration. The present study was conducted to determining the effectiveness of an educational intervention based on self-efficacy theory on continuation of Breastfeeding in employed mother that referred to comprehensive health service centers in Bandar Abbas.The present quasi-experimental had a pre-test, post-test design with 3, 6 months follow-ups was conducted in Bandar Abbas city, south of Iran in December 2021-January 2023. A total of 176 women who had given birth at least 6 months before and were on maternity leave (88 in the intervention group (IG), 88 in the control group (CG)), using a two-stage cluster sampling method participated. The educational intervention focused on self-efficacy theory implemented in 13 sessions. The educational methods in the training sessions were through virtual sessions via WhatsApp (twice a week, an hour was given to exchange information and answer questions) and in-person sessions lasting 50 to 60 min (any longer than this would be tiring) in the form of lectures, focus group discussions, and questions and answers. The main outcome was to increase breastfeeding self-efficacy and continual breastfeeding behavior after coming back to work. Repeated measures ANOVA tests and post hoc were run to compare the IG and CG at baseline in terms of demographic variables, t-test and chi square test, and in the three points of time of data collection. Data were analyzed by SPSS software version 25 and descriptive statistical tests, independent t test, paired t test and repeated measures analysis. In this study the self-efficacy and Breastfeeding behavior score in the intervention group (42.26 ± 8.25) were higher than in the control group (52.016 ± 6.68) and had significant difference between the two groups (p < 0.001). The intervention group showed a significant increase in the mean total Breastfeeding self-efficacy score (F _2,348=431.5, P < 0.001) and Breastfeeding behavior score (F _2,348=623.01, P < 0.001) 3, 6 months after intervention compared with the control group. Study showed that the intervention based on self-efficacy theory could help improve Breastfeeding self-efficacy and Breastfeeding behavior. The results of linear regression showed that for each unit of change in the self-efficacy score, an average of 0.198 units of change was observed 3 months after the intervention and 0.288 units of change 6 months after the intervention in Breastfeeding behavior. Another result of this study was the effect of training and reminding through virtual space, which was obtained due to the epidemic conditions caused by COVID-19, and it seems that mothers welcomed the way of providing training and this method of intervention was evident in their behavior.

Introduction

Breastfeeding is the best start for every child’s life¹. According to the goals of global nutrition policies by 2025, the rate of exclusive Breastfeeding at 6 months old should reach at least to 50%. The World Health Organization also recommends to start Breastfeeding in the first hour after birth, exclusive Breastfeeding up to 6 months old and continue Breastfeeding until 2 years old. Focusing on factors that affect Breastfeeding is one of the ways to achieve this goal^2–5. The prevalence of exclusive Breastfeeding has been investigated in different countries. Its prevalence in India was about 69.4%⁶, in Turkey it was about 38.9%⁷, in Portugal was about 25.6%⁸and in the Uganda was 62.3%⁹. Based on a systematic review and meta-analysis in 2019, the overall prevalence of exclusive Breastfeeding in Iran was about 53%¹⁰. However, it is important to note that this may vary depending on the specific region and population studied. Also, about exclusive breastfeeding among working women, there is still room for improvement to meet the global recommendations, which suggest that infants should be exclusively breastfed for the first six months of life. workplace policy factors supporting breastfeeding, hoping to feed and having a private pumping space at work can effect on breastfeeding^11,12. Today, many mothers are employed and women are forced to work outside the home in addition to their motherhood role to achieve better standards of living¹³. Several studies have shown that women who return to work during the first year of their child’s birth stop breastfeeding earlier than those who do not work outside the home^14–16. One of the greatest barriers to breastfeeding is the fact that mothers work outside the home, which has negative effects on breastfeeding. Studies have shown that mothers who work outside the home breastfeed as much as stay-at-home mothers until they return to work, but that breastfeeding decreases dramatically after they return to work^17,18. A study conducted in the United States showed that 50% of mothers who had children under one year of age and worked outside the home faced several problems in breastfeeding^19,20. In Thailand, maternal employment was also an important factor in reducing breastfeeding²¹. In a study in Bandar Abbas, maternal employment was significantly associated with cessation of breastfeeding, meaning that 38% of mothers were employed, and maternal employment had a negative effect on the continuation of breastfeeding²². In another study, maternal employment increased the likelihood of the child being formula-fed by 4.4 times compared to housewives²³. Self-efficacy theory suggests that the level of self-efficacy of an individual is influenced by four factors. These factors include: personal achievements (performance outcomes), vicarious experiences, verbal persuasion, and psychological and emotional states (physiological feedback) and can be influenced by education and interventions by health care providers²⁴. The basis for selecting the research theory is the existence of theoretical infrastructures that are effective in both creating and maintaining behavior. Since the mother’s self-efficacy and her ability to overcome breastfeeding-related problems are of great importance in the discussion of maintaining breastfeeding behavior, the basis for the research intervention was based on self-efficacy theory.

Many factors are related to exclusive Breastfeeding, including age, education, type of delivery, Breastfeeding experience, intention to return to work, ethnic and religious background, social support, domestic violence and Breastfeeding self-efficacy. Breastfeeding self-efficacy is one of the modifiable and effective variables on early Breastfeeding cessation. This can predict the amount and duration of Breastfeeding^5,25. Self-efficacy is an important psychological and motivational factor in Breastfeeding. It is also a valuable framework for interventions to increase self-confidence of mothers and continuity of Breastfeeding²⁶. Several factors such as support and guidance, experience and stress, postpartum experiences and social environment are related to Breastfeeding self-efficacy^27,28. In previous researches, several interventions have been carried out on Breastfeeding self-efficacy, most of which have been effective^29–31. Multiple methods, including face-to-face conversation, phone calls, and web-based programs, have been used to increase the knowledge and skills of Breastfeeding mothers^17,26,27,30.

Generally, it seems that theory-based training compared to conventional training can improve Breastfeeding continuity in mothers³². Therefore, it is better to use theory-based educational intervention to train these women. These results are consistent with self-efficacy theory, which states that modeling with practice is an effective way to increase self-efficacy. Educational interventions should continue for weeks and months, in order to continue Breastfeeding behavior in mothers. Therefore, this study was conducted with the aim of determining the effect of an intervention based on the theory of Breastfeeding self-efficacy (BSES-SF) and Breastfeeding continuity of working mothers through face-to-face communication and WhatsApp.

Method

Procedure

This trial was a quasi-experimental intervention, including an intervention group and a control group, which was conducted in comprehensive health service centers in Bandar Abbas Iran. The present study was conducted from December 2021 to January 2023. The intervention group received the BSES-SF intervention, while the control group received usual and standard services by health care providers.

Inclusion and exclusion criteria

Working women who had been six months after giving birth and had referred to comprehensive maternal and child health centers for the care of their children were offered to participate in this study and then their eligibility was evaluated. Inclusion criteria for this study included Breastfeeding working women who had an experience of natural childbirth or cesarean section in the last 6 months, exclusive feeding of the infant with breast milk from birth until the start of the intervention, part-time or full-time working mothers in governmental or non-governmental sectors, mothers who are on maternity leave and have at least three months left until they return to work, not suffering from diseases that prohibit Breastfeeding, not having breast cancer, not using drugs that are contraindicated during Breastfeeding. Completing written consent informed by participants in the study and to have a mobile phone with access to the Internet and WhatsApp were the other eligibilities. Mothers who did not participate in virtual classes for more than one session, stopped Breastfeeding due to maternal or infant illness, did not cooperate in filling out the questionnaire, or had a physical illness were excluded from this study.

The information of all the people covered by each comprehensive health center is registered in the national system of each center, called Sib. After screening the women who met the criteria for entering the " Sib " system, the researcher contacted them and invited them to participate in the study. Then a written consent form was obtained from the women, and in case of giving consent, sufficient explanations were given about the objectives and method of conducting the research and emphasizing the confidentiality of the information.

Randomization and allocation concealment

Based on the list of eligible individuals, 176 individuals were randomly assigned to either the control or intervention groups using sealed envelopes. The statistician and principal investigator were aware of the nature of the labeling, and the interviewer contacted the principal investigator to assign individuals to each group. Out of 20 comprehensive health service centers, 4 centers were randomly selected in two intervention and control groups. After completing the randomization method, the researcher contacted the working mothers who were eligible to participate in the study through the Sib system, and they were entered and placed in each of the centers according to the group assigned to that center (intervention-control). The participants were not aware of their placement in the groups.

Sample size

This quasi-experimental and interventional study was conducted with control and intervention groups. The number of samples in the intervention study was calculated using the following formula:

1

In the mentioned formula, considering the first type error (alpha) of 5%, the power of the test is 80%, the difference d = 5.5 in the self-efficacy score between the intervention and control groups and the standard deviation S = 12.3 from the previous study³³, the required sample size for each group was calculated to be 79, and taking into account possible attrition, 10% was added and, the final sample size was estimated to be 87 people in each group. Sampling was done randomly. In fact, people were selected in each center using a table of random numbers from the list of households. Among the health centers of Bandar Abbas, 4 centers that were similar in terms of urban context, lifestyle and culture were randomly selected to conduct the research, and then among these 4 selected centers, 2 centers were randomly assigned to the intervention group and 2 other centers were assigned to the control group. In order to facilitate the research, the number 87 was changed to 88 so that 44 qualified people from each center were included in the intervention and control groups. People were also selected in each center using a table of random numbers from the list of households.

Intervention module

Intervention based on self-efficacy theory is one of the appropriate intervention methods to improve Breastfeeding self-efficacy of mothers, which was carried out based on Bandura’s self-efficacy theory. The intervention included training sessions that were designed in face-to-face based and online on self-efficacy theory.

Face-to-face sessions

Five face-to-face training sessions were held at Shariati Hospital, each lasting 50–60 min. The sessions were attended by 22 participants at separate hours, and pamphlets and educational videos were used for training.

Online sessions

The participants were asked about the messaging platform they use most often, and they chose the WhatsApp messenger as the medium that all groups had access to. A WhatsApp group was formed, in order to hold online meetings every week as a complement to face-to-face meetings. Tuesdays and Thursdays from 21 to 22 were allocated to conduct training and answer mothers’ questions for a month. These days are considered as the days close to the weekend, and women have more free time and for this reason they have the peace of attending online meetings. Also, babies usually fall asleep by this time and it is a good time for the mother. If some people did not want to participate in group questions and answers, their questions were also answered by phone and SMS to protect their privacy.

Three months after the completion of the training sessions, the post-test was taken from both intervention and control groups, and six months later, follow-up was done. The data was re-entered into SPSS statistical software and the final analysis was performed. The performance of the WhatsApp group was based on distributing information, resolving concerns and clarifying any ambiguities regarding training. Privacy and confidentiality were maintained through a private group on WhatsApp. In fact, no other person except those selected by the researcher had access to the group.

Study tool

The tools used in this study included a 14-question summary questionnaire on Breastfeeding self-efficacy (BSES-SF)³⁴ and a researcher-made questionnaire on Breastfeeding behavior with 7 questions. These tools were examined in two intervention and control groups before the intervention, three months and six months after the intervention.

Breastfeeding self-efficacy

The data collection tool included the short version of the standard BSES-SF Breastfeeding self-efficacy questionnaire, a 14-item questionnaire on a 5-point Likert scale (completely agree, agree, neutral, disagree, completely disagree) in the range between 14 and 70 (14 is the lowest score and 70 is the highest score).

The BSES-SF includes positive statements such as “I can always recognize that my baby is getting enough milk” and “I can always be satisfied with my breastfeeding experience.” Participants were asked to rate their agreement with the statement on a Likert scale. A response of “1” indicates that the participant is not confident at all, and a response of “5” indicates that the participant is very confident of the comment. A higher score means a higher level of self-efficacy. There is considerable reliability and evidence of construct and predictive validity for the BSES-SF. This tool has been used and confirmed many times to identify Breastfeeding women who are prone to early cessation of Breastfeeding and also as a tool to measure the effect of behavioral interventions for these women based on the self-efficacy pattern and prediction of Breastfeeding behavior³⁵. The reliability of the tool has been translated and validated with Cronbach’s alpha of 0.92 in Iran, and in our study Cronbach’s alpha was 0.924.

Breastfeeding behavior

The researcher-made questionnaire is related to the mother’s Breastfeeding behavior, which includes 7 items on a 4-point Likert scale (“0” at all, “1” rarely, “2” sometimes, “3” most of the time, “4” always) with possible ranges 0–28. This questionnaire was given to a panel of experts (including ten faculty members, doctors in obstetrics and doctors in health education, etc.). Its validity and reliability were measured with Cronbach’s alpha of 0.79, then it was given to the people of each group and its results were analyzed.

Data collection

In this study, data collection was done from October 2021 to October 2022. An informed consent form was obtained from the mothers who agreed to participate in the study, and Breastfeeding self-efficacy and Breastfeeding behavior questionnaires were provided to them. Questionnaires were provided to mothers before they returned to work and were collected after completion. Then the educational intervention, based on the results obtained from the initial analysis of the standard Breastfeeding self-efficacy questionnaire, researcher-made Breastfeeding behavior questionnaire, and the self-efficacy theory constructs (A- Performance accomplishment, B- Vicarious experiences, C-Verbal persuasion, D- Physiological Feedback and Finally, the integration of efficiency information) was done in the intervention group. The questionnaire was given to the mothers, 3 and 6 months after the educational interventions, then was collected.

Statistical analysis of data

After data collection, data description was done using mean and standard deviation for quantitative variables and frequency and percentage for qualitative variables. To analyze the data, independent T test, paired T test, Chi-square, Repeated measure ANOVA, and non-parametric Mann-Whitney and Wilcoxon tests were used if the data were not normal. Regression analysis was used to investigate the relationship between self-efficacy and Breastfeeding behavior. Data analysis was done in SPSS version 25 software and the significance level of the tests was 5%.

Ethical considerations

This research was conducted with the approval of the ethics committee of Hormozgan University of Medical Sciences and has the code of ethics IR.HUMS.REC.1400.260. Participation in this study was completely voluntary for Breastfeeding mothers, and the researcher assured the mothers that all collected information would remain confidential. Before starting the intervention, all mothers signed and completed the informed consent form to participate in the study. To participate in the social media group, the participants expressed their consent and worked voluntarily. Mothers were allowed to withdraw from the research whenever they decided to not cooperate.

Results

Participants, characteristics

Out of 190 working mothers who were selected from 4 comprehensive health centers in Bandar Abbas, 176 (90%) participated in the project. The total withdrawal rate was 10%, which was 3% from the control group and 7% from the intervention group. Figure 1 is a summary of the researcher’s final plan based on CONSORT.

Fig. 1.

Flowchart of working mothers^, selection.

Basic information

The final analysis was done on 88 women in the IG and 88 in the CG. The mean ± SD of the participants’ age in the IG and CG was 32.12 ± 4.19 and 31.02 ± 4.71, respectively. In both groups, most women were educated more than diploma (53.4% of the IG, 62.5% of the control) and they had given birth at least once. (53.4% of the IG, 44.3% of the control). The history of Breastfeeding experience was (40.9% of the IG, 43.2% of the control). At the beginning of the study, there was no significant relationship between the intervention and control groups in terms of demographic and obstetric variables. In terms of education level, there was a statistically significant relationship between the two groups (p = 0.009). The results of the two groups are presented in Table 1.

Table 1.

Distribution of continuous and categorical variables at baseline (n = 176).

Variables	Intervention (n = 88)	Control (n = 88)	Difference between the conditions
			t test(df)	P value
Mothers current age (year)
Mean ± st.Dev	32.12 ± 4.19	31.02 ± 4.71		0.103
Highest education level, n(%)
Under diploma	2(2.3)	4(4.5)		0.009
Diploma	20(22.7)	25(28.5)
More than diploma	47(53.4)	55(62.5)
More than BS	19(21.6)	4(4.5)
Mothers employment status, n(%)
Administrative, financial, cultural and social	23(26.1)	21(23.8)		0.839
Health care	18(20.5)	21(23.8)
Technical agriculture and environmental engineering	24(27.3)	27(30.7)
Services	23(26.1)	19(21.7)
Smoking
Yes	1(1.1)	7(8)		0.06
No	87(98.9)	81(92)
Number pregnancies
1	43(48.9)	38(43.2)		0.635
2	28(31.8)	34(38.6)
3	11(12.5)	13(14.8)
4	5(5.7)	3(3.4)
5	1(1.1)	0(0)
Breastfeeding experience
Yes	36(40.9)	38(43.2)		0.760
No	52(59.1)	50(56.8)
Number deliveries
1	47(53.4)	39(44.3)		0.555
2	30(34.1)	33(37.5)
3	6(6.8)	12(13.6)
4	4(4.5)	3(3.6)

The mean (SD) score of self-efficacy before intervention between intervention and control groups were respectively 42.26 ± 8.25 and 52.016 ± 6.68 indicating a significant difference between two groups (mean difference = −8.73; 95% confidence interval = 012.14 to −7.66; p < 0.001). Mean (SD) scores of self-efficacy in the 3nd and 6th months after intervention in intervention were respectively 57.60 ± 7.36 and 66.67 ± 7.34 and in control group they were respectively 45.73 ± 8.56 and 30.55 ± 11.89 indicating significant differences. The mean (SD) score of Breastfeeding behavior before intervention between intervention and control groups were respectively 10.56 ± 4.99 and 15.75 ± 4.05 indicating a significant difference between two groups (mean difference = −7.584; 95% confidence interval = −6.54 to −3.84; p < 0.001). Mean (SD) scores of Breastfeeding behavior in the 3nd and 6th months after intervention in intervention were respectively 13.84 ± 3.97 and 22.13 ± 5.28 and in control group they were respectively 13.56 ± 4.01 and 2.67 ± 3.47. the results indicating significant differences were shown in Table 2. Before intervention the results related to the hypothesis of the relationship between self-efficacy and Breastfeeding behavior showed that for each unit increase in self-efficacy, 0.376 units of increase in Breastfeeding behavior were observed. According to the results of the hypothesis of the intervention phase, we can point out the difference in the increase of self-efficacy in the two studied groups at the beginning, after the intervention and in the follow-up phase. The effect of intervention on mothers working overall rating of self-efficacy and Breastfeeding behavior [Table 3].

Table 2.

Breastfeeding self-efficacy, breastfeeding behavior between intervention and control groups at baseline, 3 and 6 months after intervention.

Variables	At baseline	3 months post intervention	6 months post intervention
Total score of self-efficacy
Intervention group score, mean(SD)	42.26(8.25)	57.60(7.36)	66.67(7.34)
Control group score, mean(SD)	52.016(6.68)	45.73(8.56)	30.55(11.89)
t test(df)	−8.73(174)	9.87(174)	22.91(174)
P value	< 0.001	< 0.001	< 0.001
95% CI for difference of means	−12.14 to −7.66	9.50 to 14.25	31.18 to 37.07
Total score of Breastfeeding behavior
Intervention group score, mean(SD)	10.56(4.99)	13.84 (3.97)	22.13 (5.28)
Control group score, mean(SD)	15.75(4.05)	13.56 (4.01)	2.67 (3.47)
t test(df)	−7.584(174)	0.472 (174)	28.89 (174)
P value	< 0.001	< 0.637	< 0.001
95% CI for difference of means	−6.54 to −3.84	−0.91 to 1.47	18.13 to 20.78`

Statistically significant at p < 0.05.

Table 3.

The effect of health education on mothers overall rating of self-efficacy and breastfeeding behavior.

Outcomes and parameters	F test(df)	P valuea
Total score of self-efficacy
Group	160.38 (1, 174)	< 0.001
Time	21.65 (2, 348)	< 0.001
Group × time	431.5 (2, 348)	< 0.001
Total score of Breastfeeding behavior
Group	94.49 (1, 174)	< 0.001
Time	6.352 (2, 348)	0.002
Group × time	623.01 (2, 348)	< 0.001

^aUsing a generalized linear mixed model adjusted for respondense age, level of education, employment, pregnancy and delivery frequencies, Breastfeeding and smoking.

^bStatistically significant at P < 0.05.

The interactive effect of time-groups of self-efficacy and Breastfeeding were also significant (p < 0.001) and showed respectively in [Fig. 2] and [Fig. 3].

Fig. 2.

Comparison of the mean of self-efficacy score in mothers working in three months and six months in two groups of intervention (fact to face & WhatsApp ) and control group.

Fig. 3.

Comparison of the mean of Breastfeeding behavior score in mothers working in three months and six months in two groups of intervention (fact to face & WhatsApp ) and control group.

Discussion

Main findings

The purpose of this study was to determine the effect of the intervention based on the theory of self-efficacy on the continuation of Breastfeeding and self-efficacy in the working mothers of Bandar Abbas, which was carried out based on the theory of self-efficacy through training.

The findings indicated that there was a significant increase in Breastfeeding self-efficacy and Breastfeeding behavior of the intervention group and it even continued. Before the intervention, the two groups had a significant difference in terms of self-efficacy. The average score of self-efficacy in the control group was also higher than the intervention group. After the intervention, the average self-efficacy score in the intervention group was higher than the control group, while the difference was significant, which can be attributed to the intervention. In addition to the intervention, it can be said that the applied theory has also been able to have a greater effect on self-efficacy with its structural subsets. In a study that was conducted in Malaysia in 2022 with the aim of developing, implementing and evaluating the effect of using face-to-face educational intervention based on social cognitive theory on awareness, attitude and self-efficacy in Breastfeeding (BSES-SF) mothers, the results showed that using the intervention based on social cognitive theory (through face-to-face participation) on Breastfeeding self-efficacy, it can lead to improvement of self-efficacy and knowledge about Breastfeeding. On the other hand, the results showed that the theory-based intervention did not have a significant difference in attitude, which may be influenced by the intervention method. It seems that in order to evaluate the effectiveness of interventions in increasing exclusive Breastfeeding, more long-term studies (up to 6 months after delivery) should be conducted so that the continuation of the behavior can be investigated. In addition, it seems that due to the audience’s acceptance of educational programs in virtual form, it is necessary to create new strategies in health education to improve Breastfeeding attitudes²⁹.

In relation to the second hypothesis of the intervention phase, the increase in the Breastfeeding behavior of working women in the intervention group was evident and significant three months and six months after the intervention compared to the control group. Two statements specifically addressed participants’ perceived Breastfeeding self-efficacy, “I can always determine that my baby is getting enough milk” and “I can always keep up with my baby’s Breastfeeding needs.” These two statements provide an indirect assessment of perceptions to increase knowledge and self-efficacy about milk production, infant feeding, and growth spurts. In addition, the intervention provided opportunities to reassure women who perceived their milk supply as low that if they thought their milk supply was low, in most cases, it would be sufficient for their baby³⁶.

In connection with the third hypothesis of the intervention phase, we can mention the effect of increasing self-efficacy over time and its effect on the increase and continuation of Breastfeeding. Self-efficacy is known as a variable dependent on various components³⁷. According to Bandura’s theory, mothers experience four sources of information based on self-efficacy theory to gain their ability to breastfeeding: Performance accomplishment (for example, past experiences of Breastfeeding), vicarious experiences (for example, watching other women breastfeed, counseling with peers), verbal persuasion (for example, encouragement from others such as friends, family, and breastfeed consultants), physiological feedback, or active states of the individual (e.g., pain, fatigue, anxiety, or pressure)^34,38. In the training sessions, the importance of Breastfeeding was raised and in order to create a positive attitude, influential people were invited and mothers were taught, and their understanding of Breastfeeding support was also improved. Numerous studies have shown the benefits of Breastfeeding for babies, mothers and society^39,40. The beneficial effects of Breastfeeding have caused international and national organizations to promote Breastfeeding and its continuation exclusively until at least 6 months after birth and the continuation of Breastfeeding for the first two years of birth⁴¹. However, many mothers in different countries stop Breastfeeding prematurely^42–44, While it has been estimated that only a small minority of women are physically unable to breastfeed^30,45. The most common reasons mentioned in many studies include early use of supplements, inefficiency of mothers in continuing Breastfeeding, low self-confidence of mothers, and also the mother’s perception of insufficient milk⁴⁶. Breastfeeding is a complex experience influenced by various factors. In many studies, self-efficacy has been recognized as one of the most effective and determining factors on the continuation of Breastfeeding⁴⁷. Self-efficacy is an important psychological and motivational factor in Breastfeeding. It is also a valuable framework for interventions to increase mothers’ self-confidence in continuing Breastfeeding. The results of a meta-analysis showed the effectiveness of educational interventions on improving Breastfeeding self-efficacy^39,48. Teaching mothers to increase self-efficacy can lead to continued Breastfeeding. The results from the clinical trial data show the positive effect of educational intervention on Breastfeeding self-efficacy compared to usual/standard care. Perhaps this is how the increase in Breastfeeding can be described. The self-efficacy intervention is based on mothers need, so a longer intervention should be able to address any changes in mothers Breastfeeding needs during the postpartum period. After giving birth, the working mothers had received the necessary training about the importance of Breastfeeding the baby and its continuation, considering that they were influenced by theory-based training after the completion of the maternity leave, it may be a factor for the continuation of Breastfeeding. This finding is indicative of the evidence shows that intervention based on self-efficacy theory can improve Breastfeeding duration^41,49,50. Gallipo et al. performed a meta-analysis of 9 randomized controlled trials and quasi-experimental studies to evaluate the effectiveness of various prenatal interventions, whether educational, supportive, or psychosocial, on Breastfeeding self-efficacy for 4 to 6 weeks. The included studies from 2006 to 2016 were published in either English or French. They reported that all interventions had a positive effect on Breastfeeding self-efficacy compared to usual care. Based on subgroup analysis, they reported that interventions based on theory and direct teaching methods were more effective than other interventions⁵¹. Brockoy et al. also conducted a meta-analysis of 11 studies in August 2016, including randomized controlled trials and quasi-experimental studies. Their study examined the effect of all interventions including education, support, counseling, or even screening and mechanical interventions on Breastfeeding persistence. The results showed that interventions based on education have a positive effect on the continuation of Breastfeeding. However, supportive interventions did not have significant results⁵². In order to investigate the effectiveness of educational interventions, both theory-based and conventional, on women’s self-efficacy, the results of systematic review studies are very important. The results of a systematic review of 21 clinical trial and quasi-experimental studies conducted on Iranian women between 2010 and 2019 by Ghasemi et al. showed that the Breastfeeding self-efficacy of mothers in the theory-based intervention group is higher than the group receiving conventional care⁵³. In general, it seems that theory-based training can improve Breastfeeding continuity in mothers compared to conventional training. Therefore, it is better to use theory-based educational intervention to train these women. These results are consistent with self-efficacy theory, which states that modeling with practice is an effective way to increase self-efficacy. In the study conducted by Chipujola et al. in 2019, the overall effectiveness of theory-based educational interventions (Breastfeeding self-efficacy theory or planned behavior theory) on Breastfeeding outcomes and continuation of Breastfeeding behavior has been shown¹⁷.

On the other hand, based on the results of the current research, it can be concluded that in order to continue Breastfeeding behavior in mothers, educational interventions should continue for weeks and months. Postpartum follow-up time is a significant point to evaluate the effect of educational intervention on Breastfeeding continuity. According to a meta-analysis conducted in this field, the effectiveness of training up to 6 weeks has been reported in most studies. The research results also have shown that the continuation of Breastfeeding behavior has decreased significantly after 6 weeks if the intervention is not repeated³⁹. According to the obtained results, the research hypothesis that the educational intervention based on self-efficacy is effective in increasing the self-efficacy of mothers and the continuation of Breastfeeding was accepted.

These significant changes can be attributed to the use of self-efficacy theory constructs such as performance accomplishment (e.g. past Breastfeeding experiences), vicarious experiences (e.g. watching other women breastfeed, peer counseling), verbal persuasion (e.g. encouragement from others such as friends, family and breastfeed consultants), physiological feedback or active states of the person (for example, pain, fatigue, anxiety, or pressure) in educational design^54,55. According to this theory, Breastfeeding behaviors are influenced by attitudes, mental norms and perceived behavioral control. In this research, an attempt was made to increase the self-efficacy of mothers by considering these cases. Training was conducted in the intervention group of working mothers who were on maternity leave, and the training was based on several approaches such as educational discussions, educational videos, model demonstrations, and group discussions using face-to-face training. In these sessions, mothers were taught the importance of Breastfeeding and building a positive attitude with invited influencers, and their understanding of Breastfeeding support was also improved⁵⁶.

In this study, despite the fact that working mothers went to health centers to take care of their children and received Breastfeeding training, their information before registration (when they were on maternity leave) was good regarding self-efficacy and continuation of Breastfeeding behavior. When the mothers returned to the workplace, the self-efficacy score and Breastfeeding behavior of the mothers who were in the control group decreased, and in the intervention group, the self-efficacy score and Breastfeeding behavior increased after the intervention. The separation was examined and compared before and after the intervention. The results of the statistical test showed that the self-efficacy score in the intervention group increased during and after the intervention while in the control group, the self-efficacy assessment decreased over the time. The examination of the Breastfeeding continuation behavior score also showed that this score increased during and after intervention, while it decreased in the control group. Finally, the research hypothesis that the educational intervention based on self-efficacy is effective in increasing the self-efficacy of mothers and the continuation of Breastfeeding was accepted.

Strengths and limitations

Despite of Covid-19 pandemic during data collection, this study was a quasi-experimental trial with two intervention and control groups and is the first study in which WhatsApp was used to provide innovative training and follow-up methods for a Breastfeeding intervention. Modifying teaching materials and linking responses to more accessible and engaging social media platforms are vital components of modern education. However, this study had limitations. One of the limitations of the research was the lack of examination of mothers’ knowledge and attitude in the field of Breastfeeding. In this research, despite the fact that the interventions are designed in a way that affects the attitude and awareness of the individual, but the results did not directly evaluate these important components that also play a role in the efficiency of mothers. The dissimilarity of the study population in terms of education level may affect the results of the study. The small sample size is another limitation of the research. Conducting a study with a larger sample size will have more reliable results. Those mothers without mobile phones and internet access could not participate.

Conclusion

The participants in this study, who were trained based on face-to-face training based on self-efficacy theory, significantly improved their self-efficacy and continued Breastfeeding behavior. This study showed that theoretical education and follow up with WhatsApp can be a practical tool in completing Breastfeeding health education for mothers. This user-friendly app can provide simple, easy-to-read health messages and facilitate communication between health care providers and mothers. Developing and using effective educational programs to improve Breastfeeding self-efficacy is one of the important concerns of health professionals, which can help mothers in starting and maintaining Breastfeeding up to two years after birth. Carrying out theory-based educational interventions in the field of increasing mothers’ self-confidence and their self-efficacy in continuing Breastfeeding can be an effective step in this regard.

Abbreviations

Se

BF self-efficacy-breastfeeding

BSES

SF breastfeeding self-efficacy scale-short form

Author contributions

“L.H. and M.G. wrote the main manuscript text. R.G reviewed the manuscript and A.GH. prepared Figs. 1-3. All authors reviewed the manuscript.”

Funding

No funding.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due [REASON WHY DATA ARE NOT PUBLIC] but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

In order to collect the required data, an official permission was obtained from the research vice-chancellor of the university to visit a sample of health and treatment centers. After visiting the place, the researcher fully introduced herself and explained the purpose of the research to the head of the center. Then, a written consent form was provided for the signature of the participants who were to be invited to participate in the study through a phone call, which included all the details of the research. Voluntary participation of all participants was guaranteed. They were asked not to reveal their identity in the questionnaires. Therefore, they were assured of the confidentiality of the information they provided. This research has been approved by Hormozgan University of Medical Sciences (#IR.HUMS.REC.1400.260).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.