STRATEGIES TO IMPROVE BREASTFEEDING RATES AND DURATION

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CHAPTER 2 LITERATURE REVIEW

INTRODUCTION

The literature review looked at BF from the behavioural perspective, the rational for promoting EBF as well as strategies to improve BF. A summary of the literature review is provided at the end of the chapter. The researcher conducted extensive search from different data bases including Science Direct, EBSCO-HOST and PUBMED, Wiley online Library, Google Scholar, Biomed Central, Elsevier and Taylor and Francis online. Some of the sources of literature were books, library, policies/documents/guidelines from recognised organisations such as the WHO and UNICEF. Search phrases that were used include BF intentions, theory of planned behaviour, teenage mothers, teenage pregnancy, EBF practices, BF experiences, BF and significant others, breast milk as well as BF behavioural control. The literature review will assist in contextualisation the problem
as stated earlier in the study.

BEHAVIOURAL PERSPECTIVE ON BREASTFEEDING

This sub-section covered BF from the behavioural perspective. It looked at the relationships between the BF and behavioural intentions, subjective norms, and behavioural control.

Behavioural intentions and breastfeeding

Women’ intentions to breastfeed may play a major role in their ability to initiate and continue EBF till the recommended period of six months. Intentions are thoughts that epitomise the clout to perform future or prospective actions (Lange et al., 2011b). Evidence shows that intention to breastfeed has an impact on the BF practice (Agunbiade & Ogunleye, 2012; Bai et al., 2010; Borra et al., 2014b; Cabieses et al., 2014; Cordero et al., 2013; Ebrahim et al., 2011; Howel and Ball, 2013; Hundalani et al., 2012; Insaf et al., 2011; Kavanagh et al., 2012; Lawton et al., 2012a; Mirkovic et al., 2014a; Newby et al., 2014; Odom et al., 2013; Perrine et al., 2012b; Wang et al., 2014).In many circumstances, however, intentions are sometimes found to be poor predictors of behaviour (Ajzen, 2011b). In the United States of America, different studies pointed out low initiation rates among mothers who intended to breastfeed during pregnancy (Hundalani et al., 2012; Mirkovic et al., 2014a; Odom et al., 2013; Perrine et al., 2012b). Among women who intended to breastfeed, 32.4% (Perrine et al., 2012b), 28.8% (Mirkovic et al., 2014a) and 40% (Hundalani et al., 2012) were able to achieve their intentions towards BF. On the other hand, a study conducted in the United Kingdom found that, intention to breastfeed was a strong predictor that determined a mother’s ability to successfully breastfeed (Lawton et al., 2012a). In Northwest England, almost all the participants who intended to breastfeed exclusively for six months failed. Less than 1% of those mothers were still BF exclusively on the sixth month (Howel & Ball, 2013). Negative psychological disorders such as depression, anxiety and stress have been documented to have negative impact on BF intentions among women in different parts of the United Kingdom and the United States (Borra et al., 2014b; Insaf et al., 2011). In those studies, prenatal stress, anxiety and depression among pregnant women reduced the zeal of the women towards BF as their infant feeding choices and, hence, lower rate of BF intentions were recorded. Young undergraduate female college students in the United States and Kuwait have been reported to have negative intentions towards BF (Ebrahim
et al., 2011; Kavanagh et al., 2012). The college women envisage BF as an act that could be an impediment in the carrier and personal activity of a mother. There is strong evidence that BF intentions are affected by the availability of a stable partner in the life of a prospective mother (Agunbiade and Ogunleye, 2012; Chertok et al., 2010; Mitchell-Box et al., 2013; Perrine et al., 2012b; Sipsma et al., 2013). Inadequate support from partners of pregnant women is one of the reasons women cited for not getting the desire to breastfeed in a study conducted in Nigeria (Agunbiade & Ogunleye,2012). In studies involving enquiries about the intentions of couples, women with partners who had positive intentions towards BF were highly motivated to intend to breastfeed(Mitchell-Box et al., 2013; Sipsma et al., 2013). Among adolescent and young mothers between the ages of 14 and 21 in the United States, partner intention towards BF increased the probability of BF intentions for over 20% variance (Sipsma et al., 2013).Multiparous women are more likely to have positive intentions towards BF than their primiparous counterparts (Gurka et al., 2014; Hackman et al., 2014; Perrine et al., 2012b).The perceived behavioural control beliefs is one of the constructs in the theory of planned behaviour which is known to influence mothers’ confidence to approach the task of BF.That could have mitigated the positive intentions towards EBF among multiparous
women.

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ABSTRACT
ACKNOWLEDGEMENTS
DEDICATION
LIST OF TABLES
LIST OF FIGURES
LIST OF ABBREVIATIONS
CHAPTER 1 ORIENTATION TO THE STUDY
1.1 INTRODUCTION
1.2 BACKGROUND TO THE STUDY
1.3 STATEMENT OF THE RESEARCH PROBLEM
1.4 PURPOSE OF THE STUDY
1.5 OBJECTIVES OF THE STUDY
1.5 SIGNIFICANCE OF THE STUDY
1.6 METHODOLOGICAL AND ETHICAL STATEMENT
1.6.1 Methodological statement
1.6.2 Ethical statement
1.7 DEFINITIONS OF KEY CONCEPTS
1.8 OPERATIONAL DEFINITIONS 
1.9 STRUCTURE OF THESIS
CHAPTER 2 LITERATURE REVIEW
2.1 INTRODUCTION
2.2 BEHAVIOURAL PERSPECTIVE ON BREASTFEEDING
2.2.1 Behavioural intentions and breastfeeding
2.2.2 Subjective norms and breastfeeding
2.2.3 Behaviour control beliefs and breastfeeding
2.3 PROMOTION OF EXLUSIVE BREASTFEEDING
2.3.1 Importance of EBF
2.3.2 Benefits of EBF
2.4 STATUS AND CORRELATES OF EXCLUSIVE BREASTFEEDING PRACTICES.
2.5 STRATEGIES TO IMPROVE BREASTFEEDING RATES AND DURATION
2.6 SUMMARY
CHAPTER 3 RESEARCH METHODOLOGY
3.1 INTRODUCTION
3.2 SCIENTIFIC FOUNDATION OF THE STUDY
3.2.1 Methodological foundation
3.3.2 Research approach
3.2.3 Theoretical foundation
3.4 PHASE 1 OF THE STUDY
3.4.1 Design
3.4.2 Setting
3.4.3 Study population
3.4.4 Sample and sampling
3.4.5 Data collection tool
3.4.6 Data collection methods and procedures
3.4.7 Scientific rigour
3.4.8 Data analysis
3.5 PHASE 2 OF THE STUDY
3.5.1 Designs
3.4.2 Setting and study population
3.5.3 Sample and sampling
3.5.4 Data collection tools
3.5.5 Data collection methods and procedures
3.5.6 Validity and reliability
3.5.7 Data management and analysis
3.6 PHASE THREE OF THE STUDY
3.6.1 Design framework for the behavioural conceptual model
3.6.2 Identification of the key concepts of the conceptual model
3.6.3 Definition of the relationships between concepts
3.6.4 Review and refinement of the conceptual model
3.7 ETHICAL CONSIDERATIONS
3.8 SCIENTIFIC INTEGRITY OF THE STUDY 
3.9 SUMMARY
CHAPTER 4 PRESENTATION AND DISCUSSION OF THE FINDINGS 
4.1 INTRODUCTION
4.2 RESULTS OF PHASE 1 OF THE STUDY
4.2.1 General descriptions
4.2.2 Theme 1: Perceived enablers of EBF
4.2.2.1 Sub-theme 1: Personal related enablers of EBF
4.2.2.1.1 Positive beliefs about the health benefits of breast milk
4.2.2.1.2 Positive beliefs about the outcome values of EBF
4.2.2.2 Sub-theme 2: Social related enablers of EBF
4.2.2.2.1 Availability of support
4.2.2.2.2 Effectiveness of breastfeeding education
4.2.2.2.3 Positive influence of significant others
4.2.3 Theme 2: Perceived inhibitors of EBF
4.2.3.1 Sub-theme 3: Personal related inhibitors of EBF
4.2.3.1.1 Negative emotional feelings toward EBF
4.2.3.1.2 Irrational thinking towards EBF
4.2.3.1.3 Perceived health risks for the baby
4.2.3.1.4 Perceived self-inefficacy
4.2.3.2 Subtheme 4: Social related inhibitors
4.2.3.2.1 Provider-client interaction
4.2.3.2.2 Disapproval of EBF by closed relatives
4.2.3.2.3 Unfriendly institutional policies
4.2.3.2.4 Social myths
4.2.4 Summary of the findings
4.3 RESULTS OF PHASE 2 OF THE STUDY
4.3.1 General description
4.3.2 Results of the behavioural determinants of EBF at prenatal period
4.3.2.1 EBF plan
4.3.2.2 Behavioural attitude and prenatal EBF plan
4.3.2.3 Subjective behavioural norms and prenatal EBF plan
4.3.3 Results of actual breastfeeding practices up to six months post-delivery
4.3.3.1 Time of breastfeeding initiation
4.3.3.2 Method and duration of breastfeeding
4.3.3.3 Reasons for not initiating BF and discontinuing EBF
4.3.4 Results of behavioural determinants of actual EBF practice up to six months postdelivery
4.3.4.1 Behavioural attitude determinants of actual EBF practice up to six months postnatal
4.3.4.2 Subjective behavioural norms determinants of actual EBF practice up to six months postnatal
4.4 RESULTS OF THE OVERALL BEHAVIOURAL DETERMINANTS OF EBF AMONG TEENAGE-MOTHERS
4.4.1 Overall BF behaviour
4.4.2 Actual behavioural determinants of EBF practice up to 6 months post-delivery
4.5 DISCUSSIONS 
4.6 CONCLUSION
CHAPTER 5 DESCRIPTION OF THE CONCEPTUAL MODEL FOR PROMOTING EBF PRACTICE
5.1 INTRODUCTION
5.2 SOCIAL CONTEXT OF THE CONCEPTUAL MODEL 
5.3 BASIC ASSUMPTIONS OF THE CONCEPTUAL MODEL
5.4 OVERALL GOALS OF THE PROPOSED CONCEPTUAL MODEL
5.5 IDENTIFICATION AND DEFINITIONS OF THE KEY CONCEPTS OF THE CONCEPTUAL MODEL 
5.6 RELATIONSHIPS BETWEEN THE CONCEPTS 
5.7 DIAGRAMMATIC REPRESENTATION OF THE CONCEPTUAL MODEL
5.8 CONCLUSION
CHAPTER 6 CONCLUSION, RECOMMENDATIONS, AND LIMITATIONS 
6.1 CONCLUSION
6.2 RECOMMENDATIONS
6.2.1 Public health policy-makers
6.2.2 Health services mangers
6.2.3 Health sciences education
6.2.4 Further research
6.3 LIMITATIONS 
REFERENCES
APPENDICES
APPENDIX A1: DATA COLLECTION TOOL FOR PHASE ONE OF THE STUDY
APPENDIX A2: QUESTIONNAIRE FOR PHASE TWO OF THE STUDY
APPENDIX A3: CONFIDENTIALITY BINDING FOR FGD
APPENDIX B1: CONSENT FORM
APPENDIX B2: ASSENT FORM
APPENDIX B3: PARTICIPANT INFORMATION SHEET
APPENDIX B4: LETTER OF PERMISSION
APPENDIX C1: ETHICAL CLEARANCE UNISA
APPENDIX C2: ETHICAL CLEARANCE, GHANA HEALTH SERVICE

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PROMOTING EXCLUSIVE BREASTFEEDING AMONG TEENAGE-MOTHERS IN GHANA: TOWARDS A BEHAVIOURAL CONCEPTUAL MODEL

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