Mothers’ attitudes toward exclusive breastfeeding explored using a questionnaire based on the transtheoretical model in an observational study

Abstract

The WHO European Region has among the lowest rates of exclusive breastfeeding (EBF), with substantial variability across countries. In Italy, EBF rates remain below WHO targets, particularly in Southern regions. Several tools have been proposed to assess mothers’ attitudes toward breastfeeding, although no gold standard has been established. This study aimed to explore mothers’ attitudes toward breastfeeding using a questionnaire based on the Trans-Theoretical Model (TTM). An observational study was conducted in two Sicilian hospitals, where mothers were enrolled during postpartum hospitalization and interviewed using a structured questionnaire. The most frequently observed stage of change was action (39%, n = 123/318), followed by contemplation (22%, n = 70/318), pre-contemplation (21%, n = 67/318), and determination (18%, n = 58/318). A significant trend was observed across stages of change in relation to infant feeding patterns during hospitalization (p < 0.0001), with higher stages showing a greater proportion of exclusive breastfeeding. The TTM-based approach may provide preliminary insights into mothers’ attitudes toward breastfeeding, particularly in the pre-contemplation and contemplation stages of change. However, given the exploratory design, further studies are needed to refine the questionnaire and to assess its performance in longitudinal settings.

Supplementary Information

The online version contains supplementary material available at 10.1038/s41598-026-57243-5.

Introduction

Breastfeeding is widely recognized as the gold standard for infant nutrition and offers several benefits for both the infant and the mother¹. The World Health Organization (WHO) and the United Nations International Children’s Emergency Fund (UNICEF) strongly recommend exclusive breastfeeding for the first six months of life, with continued breastfeeding up to two years or beyond².

Among the world’s regions, the WHO European Region has the lowest rates of exclusive breastfeeding. According to national reports, between 56% and 97% of infants in European countries receive any human milk. Despite high breastfeeding initiation rates at birth, exclusive breastfeeding (EBF) rates decline over time, with only 13% to 39% of infants exclusively breastfed at six months of age³.

Globally, between 2015 and 2021, 48% of infants under six months were exclusively breastfed, approaching the WHO target of 50% by 2025 and 70% by 2030⁴.

In Italy, breastfeeding rates remain below WHO targets⁵. Data vary across regions, making interpretation challenging due to inconsistent indicators and lack of standardized methodologies⁶. A 2022 report showed that 46.7% of infants aged 2–3 months and 30% of those aged 4–5 months were exclusively breastfed⁷. Geographical and socioeconomic disparities have also been reported^8,9.

In Sicily, a region of Southern Italy, breastfeeding rates are particularly low. Approximately 18.1% of infants aged 4–5 months are exclusively breastfed, and 25.3% of children aged 12–15 months receive any breastfeeding¹⁰.

Several factors may contribute to these low rates, including limited maternal health literacy and insufficient support from healthcare professionals. Common challenges include early breastfeeding difficulties, infant latching problems, nipple pain, mastitis, primiparity, and low maternal self-efficacy^10–12. Breastfeeding self-efficacy is also closely related to mothers’ perceptions of milk adequacy^13,14.

Understanding the factors influencing breastfeeding behavior is essential to improve adherence. Several instruments have been proposed to assess mothers’ willingness to breastfeed, although no gold standard has been established^15–17.

The aim of this study was to explore the feasibility of a questionnaire based on the Trans-Theoretical Model (TTM) and to provide preliminary insights into mothers’ attitudes toward breastfeeding.

The TTM, developed by DiClemente and Prochaska^18,19, is a widely used framework in health promotion that conceptualizes behavioral change as a dynamic process occurring through a series of stages. According to this model, individuals progress through different stages of readiness to adopt a health-related behavior, influenced by perceived benefits, barriers, and self-efficacy. Social cognition theories further support this framework, suggesting that individuals are more likely to engage in behaviors they perceive as beneficial and valuable^18,19.

The TTM has been widely applied in health promotion and primary prevention^20,21. In this study, it was used to explore the process of change in mothers’ attitudes toward breastfeeding, based on the assumption that infant feeding decisions are influenced by perceived benefits, barriers, and self-efficacy during pregnancy.

Materials and methods

An observational study was conducted from 1 July 2023 to 30 November 2023 at two major birthing centres in Palermo, Italy: the Azienda Ospedaliera Universitaria (AOUP) “Paolo Giaccone” and ARNAS Civico “Di Cristina”, with 829 and 1980 deliveries in 2023, respectively. Both hospitals promote breastfeeding and implement newborn care practices such as skin-to-skin contact and rooming-in in accordance with international guidelines^22,23.

The study was approved by the Ethical Committee Palermo 1 Hospital (N° 8/2022, approval date 14 September 2022), and written informed consent was obtained from all participants.

Mothers who had given birth within the previous 24–48 h were enrolled during postpartum hospitalization. Trained healthcare personnel administered a questionnaire assessing attitudes toward breastfeeding. The questionnaire is provided in the Supplementary Material in both Italian and English (Supplementary Files 1 and 2).

The questionnaire was based on the Trans-Theoretical Model (TTM), developed by Prochaska and DiClemente^18,19, which describes behavioral change as a progression through stages of readiness. In this study, the TTM was used to explore mothers’ attitudes toward breastfeeding.

The TTM describes behavioral change as a progression through stages of readiness, including precontemplation (individuals have not yet considered changing their behavior), contemplation (individuals begin to consider the possibility of change), determination (individuals intend to change in the near future and start planning), and action (individuals actively implement behavioral change)^18,19.

The classification model was based on a four-item algorithm. A 5-point Likert scale was used (5 = “not at all” to 1 = “extremely”), structured in an inverted format to align with the scoring algorithm, although this may be less intuitive for respondents.

The first two items assessed maternal confidence and knowledge, and their sum generated an initial score. Based on predefined thresholds (≥ 8, 5–7, ≤ 4), participants were directed to subsequent items and classified into TTM stages. The score thresholds and decision rules were pragmatically defined by the research team based on conceptual assumptions related to readiness to change, perceived breastfeeding benefits, and maternal self-confidence within the TTM framework. These thresholds were not derived from formal psychometric validation or empirical calibration analyses and should therefore be considered exploratory. The mapping of items to stages was based on a simplified and pragmatic interpretation of the model and should be considered exploratory. The classification approach was conceptually informed by the core constructs of the TTM, particularly readiness to change, self-efficacy, and perceived benefits of breastfeeding^18,19. Questionnaire items were pragmatically assigned to stages according to mothers’ reported attitudes, intentions, and confidence regarding breastfeeding. However, the questionnaire was not derived from a previously validated TTM-based breastfeeding instrument and should therefore be considered an exploratory application of the model.

Additional items refined stage classification by assessing intention to breastfeed, perceived importance, and confidence in continuing breastfeeding after discharge. The full decision pathway is illustrated in Fig. 1, and the detailed questionnaire structure and scoring procedure are provided in the Supplementary Material.

Fig. 1.

Decision rules of the questionnaire for TTM stages.

Infant feeding practices during hospitalization were used as a preliminary proxy outcome to explore associations with TTM stages.

Additional variables included socio-demographic characteristics, lifestyle factors, and clinical and obstetric data.

Statistical analysis

All data were analysed using Stata/SE 14.2 statistical software (Copyright 1985–2015, StataCorp LLC, 4905 Lake-way Drive, College Station, TX 77845, USA. Revised 29 January 2018). For all analyses, a P-value of 0.05 was assumed to indicate significance (two-tailed). Absolute and relative frequencies have been reported for qualitative variables, and medians (interquartile ranges) have been reported for quantitative, non-normally distributed variables. Normal distribution was verified by Shapiro-Wilk test for normality, and median data were compared using the Mann-Whitney test. Categorical variables were analysed using chi-square test (Mantel–Haenszel test). Cronbach’s alpha values were calculated as an exploratory measure of internal consistency of the items included in the TTM score. Exploratory analyses of relationships between questionnaire items were also performed to preliminarily assess conceptual coherence among TTM-related constructs. Due to the small number of items and the multidimensional nature of the construct, Cronbach’s alpha may have limited applicability in this context. Furthermore, no adjustment for potential confounding factors (e.g., parity, education level, mode of delivery, and healthcare practices) was performed, as the study was exploratory in nature. Therefore, the results should be interpreted with caution and considered hypothesis-generating.

Results

A total of 318 mothers were recruited from the two hospitals. The main socio-demographic characteristics of the participants are reported in Table 1. The most represented age group was 30–34 years (32%; n = 102/318), and half of the mothers were residents in urban areas (50%; n = 159/318). Most mothers were married (65%; n = 208/318). Almost three-quarters had a high school diploma or university degree (75%; n = 238/318), and more than half were employed (52%; n = 165/318). Overall, 26% of mothers reported having pathologies (n = 83/318), and 45% were primiparous (n = 142/318).

Table 1.

Socio-demographic characteristics of interviewed mothers.

Age classes	Total n = 318	%
< 19years	4	1
20-24years	25	8
25-29years	51	16
30-34years	102	32
35-39years	95	30
40-44years	36	11
45-49years	3	1
> 50years	2	1
City of residence
Urban area	159	50
Extra urban area (> 10 km from urban area)	159	50
Marital status
Not married	9	3
Living together	101	32
Married	208	65
Education level
Lower level (elementary or middle school)	80	25
High level (high school or degree)	238	75
Working active
No	152	48
Yes	165	52
Smoking habit
No	263	83
Yes	55	17
First pregnancy
No	176	55
Yes	142	45
Mother’s pathology
No	234	74
Yes	83	26
Gynecology who assisted during pregnancy
Private	243	76
Public	75	24
Type of birth
Vaginal	196	62
Caesarean	122	38
Skin to skin
No	57	18
< 10 min	132	41
> 10 min	129	41
Rooming in
No	64	20
Yes	254	80

Regarding pregnancy care, most mothers received assistance from a private gynecologist (76%; n = 243/318).

Exploratory analyses of item relationships showed moderate associations between items related to breastfeeding intention, self-confidence, and readiness to breastfeed, supporting preliminary consistency of the exploratory framework. Spearman correlation coefficients between selected questionnaire items ranged from 0.22 to 0.61, with stronger associations observed between items related to breastfeeding intention and self-confidence.

During hospitalization, 48% of mothers reported exclusive breastfeeding (EBF) (n = 153/318), 14% reported exclusive formula feeding (n = 44/318), and 38% reported mixed feeding (n = 121/318) (Table 2).

Table 2.

Type of infant feeding during hospitalization.

	Total n = 318	%
Exclusive Breastfeeding	153	48
Exclusively formula bottle feeding	44	14
Mixed feeding	121	38

TTM survey results

Mothers’ stages of change according to the TTM are described in Table 3, which compares stages of change with infant feeding patterns during hospitalization. The most frequent stage was action (39%, n = 123/318), followed by contemplation (22%, n = 70/318), pre-contemplation (21%, n = 67/318), and determination (18%, n = 58/318).

Table 3.

Stages of change of mothers according to the TTM survey.

Stages of change	N (%)	Exclusive breastfeeding N (%)	Mixed feeding N (%)	Exclusive formula feeding N (%)
Precontemplation	67 (21%)	6 (4%)	37 (31%)	24 (55%)
Contemplation	70 (22%)	30 (20%)	26 (21%)	14 (32%)
Determination	58 (18%)	36 (24%)	20 (17%)	2 (5%)
Action	123 (39%)	81 (53%)	38 (31%)	4 (9%)
TOT	318	153 (48%)	121 (38%)	44 (14%)

Chi square p < 0.0001; Chi square for trend breastfeeding vs. formula p < 0.0001.

Chi square for trend breastfeeding vs. mixed p < 0.0001; Chi square for trend formula vs. mixed p < 0.0001.

A higher proportion of mothers in the action stage reported exclusive breastfeeding (53%, n = 81/153), whereas the pre-contemplation stage accounted for the largest proportion of mothers who reported exclusive formula feeding (55%, n = 24/44). A significant trend across stages of change was observed for both exclusive breastfeeding and formula feeding (p < 0.0001). Within each stage of change, the proportion of mothers exclusively breastfeeding differed significantly from those using formula or mixed feeding.

Cronbach’s alpha values were calculated for each item used in the classification of mothers into TTM stages (Table 4), with values ranging from 0.268 to 0.577. The highest value was observed for the item assessing mothers’ intention to breastfeed after discharge (Cronbach’s alpha = 0.577), whereas lower values were observed for other items. Slightly higher Cronbach’s alpha values were observed for the item assessing maternal confidence in breastfeeding before delivery (Cronbach’s alpha = 0.412) compared to the item assessing knowledge of breastfeeding benefits (Cronbach’s alpha = 0.268).

Table 4.

Cronbach’s alpha scores calculated for each question of the TTM survey.

TTM survey	Cronbach’s alpha
Before hospital admission, have you ever thought about exclusively breastfeeding your child?	0.412
Before hospital admission, did you ever explore the benefits of breastfeeding for you and your child?	0.268
Do you think you will exclusively breastfeed your baby once you are discharged home?	0.577
How confident do you feel in exclusively breastfeeding your baby once you return home?	0.327
Do you think that exclusively breastfeeding is a vital, essential action for your baby’s health care?	0.192
Precontemplation	0.568
Contemplation	0.104
Determination	0.226
Action	0.440

Cronbach’s alpha values were also estimated across stages of change, with the highest value observed for the pre-contemplation stage (Cronbach’s alpha = 0.568), followed by the action stage (Cronbach’s alpha = 0.440).

All Cronbach’s alpha values were below commonly accepted thresholds, indicating limited internal consistency of the questionnaire items.

Item-level evaluation suggested that questions related to perceived breastfeeding knowledge showed weaker internal consistency compared with items assessing breastfeeding intention and self-confidence, possibly reflecting difficulties associated with the inverted Likert response format. These findings may help guide future refinement of the questionnaire structure.

Discussion

Several instruments have been developed to assess mothers’ attitudes and practices related to breastfeeding; however, none is currently recognized as a gold standard. Many of these tools, such as the Bristol Breastfeeding Assessment Tool (BBAT) and the Breastfeeding Self-Efficacy Scale (BSES), primarily evaluate technical or postnatal aspects of breastfeeding, focusing on observable behaviors or maternal confidence after breastfeeding has already been initiated^{14–17,24–33}.

Previous studies have shown that instruments based on objective parameters or postnatal assessment can identify mothers at risk of early breastfeeding discontinuation^{24,26–28,34}. These approaches, however, do not specifically address stages of behavioral change or the underlying attitudes influencing feeding decisions.

In contrast, the present study focuses on psychosocial aspects before or at the early stages of breastfeeding initiation, exploring mothers’ attitudes through a simplified TTM-based approach. This perspective may contribute to understanding behavioral readiness rather than breastfeeding performance.

The findings of the present study suggest that higher stages of change are associated with a greater proportion of exclusive breastfeeding, whereas earlier stages are more frequently associated with formula feeding.

The proposed framework was intended to explore mothers’ readiness toward breastfeeding-related behavioral change. The observed gradient across TTM stages in relation to infant feeding patterns during hospitalization may represent a preliminary indication of conceptual coherence, as mothers classified in higher stages more frequently reported exclusive breastfeeding, whereas earlier stages were more frequently associated with formula feeding. Nevertheless, these findings should be interpreted cautiously and do not represent formal construct validation.

The operationalization of the TTM in this study was simplified, and the mapping of questionnaire items to stages should be considered pragmatic and exploratory rather than theoretically comprehensive. The assignment of questionnaire items to stages was based on conceptual assumptions related to readiness to change and breastfeeding self-efficacy rather than on a formally validated TTM framework.

Moderate associations were observed among selected questionnaire items related to breastfeeding intention and self-confidence, providing additional support for the exploratory conceptual framework.

The inverted Likert scale format may have reduced response clarity for some participants and contributed to weaker item relationships and limited internal consistency.

Compared with other instruments, the proposed questionnaire addresses subjective and socio-cultural dimensions, such as maternal confidence and health literacy. While these aspects may provide relevant insights, they are inherently more variable and may affect measurement consistency. Although exploratory, the proposed TTM-based classification may be conceptually aligned with breastfeeding promotion and Infant and Young Child Feeding (IYCF) frameworks, as identifying different stages of readiness could support the development of more tailored counselling and support strategies during the perinatal period. In particular, mothers classified in earlier stages of readiness could benefit from more intensive educational and motivational support approaches.

The questionnaire was administered during the postpartum period, a phase characterized by physical and emotional challenges that may influence mothers’ perceptions and responses. Early breastfeeding experiences occurring during hospitalization, including breastfeeding difficulties or support received from healthcare professionals, may have influenced mothers’ reported attitudes and confidence at the time of questionnaire administration. This timing may have contributed to the relatively low Cronbach’s alpha values observed in this study.

The limited internal consistency suggests that further refinement of the questionnaire items is needed. These findings may reflect not only limitations in individual item performance, but also the multidimensional and exploratory nature of the proposed classification framework, which was not originally developed as a unidimensional psychometric scale. Moreover, given the cross-sectional design, reverse causality cannot be excluded, as infant feeding practices during hospitalization may influence mothers’ reported attitudes.

Overall, the findings should be interpreted as preliminary and hypothesis-generating.

Limitations of the study

The study has limited external validity due to the relatively small sample size and the recruitment of participants from only two hospitals, which may limit the generalizability of the findings. Several additional limitations should be acknowledged.

First, the questionnaire was administered during the postpartum period, which may have influenced mothers’ responses. In addition, the use of an inverted Likert scale may have introduced response bias or misclassification, as it differs from conventional response formats and may be less intuitive for participants.

Future refinement of the questionnaire may include revision of the inverted Likert scale and reformulation or removal of weakly performing items. Further evaluation of item relationships in larger populations may also help improve internal consistency and conceptual coherence.

Second, the lack of longitudinal follow-up prevented the assessment of breastfeeding outcomes over time. Third, the study did not include a formal validation framework; therefore, construct, criterion, and predictive validity were not assessed.

Furthermore, the use of infant feeding during hospitalization as an outcome represents a limited proxy of long-term breastfeeding behavior. Given the cross-sectional design, reverse causality between reported attitudes and feeding practices cannot be excluded.

Finally, no adjustment for potential confounding factors (e.g., parity, education level, mode of delivery, and healthcare practices) was performed, and no correction for multiple comparisons was applied, which may increase the risk of type I error.

Conclusions

In conclusion, this study suggests that a TTM-based approach may provide preliminary descriptive insights into mothers’ attitudes toward breastfeeding, particularly in the pre-contemplation and contemplation stages. However, given the limited internal consistency observed and the absence of longitudinal validation, further research is needed to refine the TTM-based questionnaire and to assess its performance in longitudinal settings before any potential application. Future studies should include longitudinal assessment, construct validity analyses, and comparison with established breastfeeding-related instruments to further evaluate the psychometric properties of the questionnaire.

Electronic Supplementary Material

Below is the link to the electronic supplementary material.

Author contributions

V.R., A.C., Conceptualization, Visualization, Writing –original draftF.G., R.V., S.P., A.F., wrote Methodology, Data curation, InvestigationV.R., A.C., M.M., A.M., F.G., R.V., A.F., discussed investigation methodology and contributed to result interpretation; performed data analysisV.R., A.C., F.G., R.V., A.F., Supervision, Writing –review and editingAll authors revised the paper and agreed with the final version of the manuscript.

Data availability

The dataset generated and analyzed during the current study is available from the corresponding author on reasonable request.

Declarations

Competing interests

The authors declare no competing interests.

Institutional review board statement

This study was approved by the Ethical Committee Palermo 1 Hospital (N° 8/2022, approval date 14 September 2022) and was conducted in accordance with the local legislation and institutional requirements. A written informed consent was obtained from all subjects involved in the study.