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Development and psychometric

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Research in Nursing & Health, 1999, 22, 399–409

Development and Psychometric

Testing of the Breastfeeding
Self-Efficacy Scale
Cindy-Lee Dennis,1* Sandra Faux2†

1University
of Toronto, Faculty of Nursing, University of Toronto, 50 St. George Street,
Toronto, ON M5S 3H4, Canada
2Department of Maternal Child Nursing, College of Nursing, Rush University, Chicago, IL 60612

Received 23 September 1998; accepted 26 April 1999

Abstract: Many new mothers discontinue breastfeeding prematurely. Researchers have shown
that maternal confidence is an important factor in the continuation of breastfeeding. The purpose
of this methodological study was to develop and conduct preliminary psychometric assessment
of an instrument to measure confidence in new breastfeeding mothers. Using self-efficacy theo-
ry as a conceptual framework, the Breastfeeding Self-Efficacy Scale (BSES) was developed and
content validity was judged by a panel of experts and through interviews with experienced breast-
feeding mothers. Following a pilot test, the revised BSES was assessed with 130 in-hospital
breastfeeding mothers for reliability and validity, including internal consistency, principal compo-
nents factor analysis, comparison of contrasted groups, and correlations with measures of sim-
ilar constructs. Support for predictive validity was demonstrated with positive correlations be-
tween BSES scores and infant feeding patterns at 6 weeks postpartum. Following further testing,
this instrument may be used to identify new mothers with low breastfeeding confidence who are
at high risk to prematurely discontinue breastfeeding. © 1999 John Wiley & Sons, Inc. Res Nurs Health
22:399–409, 1999

Keywords: breastfeeding; confidence; self-efficacy; instrument development

The history of infant feeding in the twentieth cen-
tury is a story of the loss of a North American
breastfeeding culture and the disintegration of
traditional knowledge about how breastfeeding
mothers and infants behave, what kind of support
they require, and what kind of strengths they pos-
sess (Mulford, 1995). Since the 1970s, measures
have been proposed to halt the drift away from
breastfeeding through international programs and
statements. With the aid of this strong public pro-
motion, the rates of new mothers initiating breast-
feeding in Canada have increased from 24% dur-
ing the 1960s (Myres, 1979) to as high as 83%
today (Barber, Abernathy, Steinmetz, & Charle-
bois, 1997). However, breastfeeding rates rapidly
decline in the initial 6 weeks, and less than 35% of
mothers are exclusively breastfeeding at 4 months
postpartum (Barber et al., 1997); only 30– 40% of
mothers continue any form of breastfeeding until
6 months (Bourgoin et al., 1997; Health & Welfare
Canada, 1990). The breastfeeding duration rates
for socially disadvantaged women in the United
States and Canada are even lower (Caulfield et al.
1998; Matthews, Webber, McKim, Banoub-Bad-
dour, & Laryea, 1995). Thus, most women cease
breastfeeding before the 6–12 months recom-
mended by the World Health Organization (1981),
Canadian Paediatric Society (1991), and Ameri-
can Academy of Pediatrics (1997). A major reason
for this premature discontinuation is difficulty
with breastfeeding rather than maternal choice
(Ellis & Hewat, 1984; Hill, 1991).
Many known predictors of women at high risk
to discontinue breastfeeding prematurely are non-

Correspondence to Cindy-Lee Dennis.

*Assistant Professor and Postdoctoral Fellow.
†Associate Professor.

© 1999 John Wiley & Sons, Inc. CCC 0160-6891/99/050399-11 399

400 RESEARCH IN NURSING & HEALTH
modifiable demographic attributes. For health
care professionals to address the high breastfeed-
ing attrition rates, prediction of high-risk mothers
must be based on modifiable variables that may
guide the development and evaluation of inter-
ventions (Janke, 1994; Polit & Hungler, 1991).
One possible modifiable variable is maternal con-
fidence, which has been found to be a significant
factor in identifying mothers at risk for early ter-
mination of breastfeeding (Loughlin, Clapp-Chan-
ning, Gehlbach, Pollard, & McCutchen, 1985). To
measure maternal confidence, the cognitive/be-
havioral model of self-efficacy theory (Bandura,
1977) has been the framework used in a number of
instruments developed for perinatal situations.
These include (a) the exploration of mothers’ con-
fidence in managing a range of parenting tasks and
situations during toddlerhood by utilizing the Tod-
dler Care Questionnaire (Gross, Rocissano, &
Roncoli, 1989), (b) the determination of the de-
gree of confidence parents have in their ability to
care for their infants by use of the Infant Care Self-
Efficacy Scale (Froman & Owen, 1989), and (c)
the evaluation of mothers’ confidence for coping
in labor by use of the Childbirth Self-Efficacy In-
ventory (Lowe, 1993). Use of each of these in-
struments has added to the body of evidence that
supports the strong psychometric properties of
self-efficacy measurements and their value in pre-
dicting future behavior of a targeted population.
Bandura (1977) has advocated a behavior-specif-
ic approach to the study of self-efficacy, arguing
that a measure of general self-efficacy in overall
ability would be inadequate for tapping an indi-
vidual’s efficacy in managing tasks associated
with a specific behavior. Thus, to measure breast-
feeding self-efficacy an instrument specific to
tasks associated with breastfeeding must be used.
In Bandura’s (1977) social learning theory, self-
efficacy is a dynamic cognitive process in which
an individual evaluates his or her capability to per-
form a given behavior. These perceptions of self-
efficacy contribute to how individuals judge their
abilities to perform specific behaviors and greatly
influence their choice of and persistence in those
behaviors. As such, highly efficacious people are
more likely to master behaviors than those indi-
viduals with low self-efficacy. This phenomenon
occurs because individuals with low self-efficacy
tend to avoid situations that stress their capabili-
ties; in situations presenting barriers to perfor-
mance attainment, inefficacious individuals tend
to give up quickly. In contrast, highly efficacious
individuals are more likely to initiate new behav-
iors and persevere in their attempts until mastery
is achieved (Bandura, 1977, 1982).
Self-efficacy expectancy is an individual’s con-
viction that he or she can successfully perform
certain tasks or behaviors in a given situation;
outcome expectancy is the belief that a given be-
havior will lead to a given outcome (Bandura,
1977). This distinction is important because an in-
dividual may believe that a certain behavior could
help him or her accomplish a specific goal but feel
incapable of personally performing the given be-
havior in the particular situation. Therefore, an in-
dividual’s belief in the outcome of the behavior
alone does not result in performance unless the in-
dividual also believes that the behavior can be ex-
ecuted successfully. As such, the concept of inter-
est for this study was self-efficacy expectancies.
These expectancies are based on information
gained through the following four primary sources:
(a) performance accomplishments (previous expe-
rience with the specific behavior), (b) vicarious
experience (previous observation of the perfor-
mance of the specific behavior), (c) verbal per-
suasion (encouragement of influential others), and
(d) physiological responses (somatic reactions in
relation to autonomic arousal during anticipation
or experience of a potentially stressful event)
(Bandura, 1977). In relation to breastfeeding self-
efficacy, a mother determines her capability to
breastfeed her new infant based on whether she
has breastfed an infant previously, observed suc-
cessful breastfeeding by others, and received en-
couragement from significant others to breastfeed.
In addition, her current physiological state, in-
cluding fatigue, pain, and anxiety, is an important
source of information through which she evaluates
her ability to breastfeed. Thus, health care profes-
sionals may be able to modify a mother’s breast-
feeding confidence through influencing these
sources of self-efficacy information.
Although research on breastfeeding-related
confidence has suffered from an atheoretical per-
spective in the extant literature, there are a few
breastfeeding studies reporting generally on ma-
ternal confidence. In a descriptive study of 198
women prenatally, O’Campo, Faden, Gielen, and
Wang (1992) examined 11 psychosocial and
demographic variables and found that maternal
confidence was one of five variables that were an
important influence on breastfeeding duration.
Furthermore, when 10 variables were entered into
a regression model, maternal confidence was one
of the most significant variables affecting antici-
pated length of breastfeeding. As such, women
with low confidence in their ability to breastfeed
were at 3.1 (95% CI ! 1.39-6.76) times the risk of
prematurely discontinuing breastfeeding when
compared to very confident breastfeeding women.
 BSES SCALE / DENNIS AND FAUX
Similarly, Buxton et al. (1991) found that 27% of
women with low maternal confidence in the pre-
natal period discontinued breastfeeding within the
first postpartum week in comparison to only 5%
of the highly confident women ( p " .001). Breast-
feeding “failure” was four to five times more like-
ly among less confident women. In both of these
studies maternal confidence was measured using a
6-point scale where women were asked to assess
their degree of confidence in their ability to breast-
feed in 10 different circumstances, such as “if the
baby was premature and had to stay in the hospi-
tal.” Unfortunately, the validity and reliability of
the measure of confidence were not reported in ei-
ther study.
It also has been found that maternal breastfeed-
ing confidence in the postpartum period was asso-
ciated with maternal perceptions of insufficient
milk supply, a leading cause of formula supple-
mentation. Hill and Humenick (1996) developed
the H & H Lactation Scale to measure a mother’s
perception of insufficient milk supply. The mater-
nal confidence/commitment in breastfeeding sub-
scale is one of three indicators of insufficient
milk supply. Maternal confidence/commitment
was measured through a 10-item subscale using a
7-point Likert format ranging from 1 ! strongly
disagree to 7 ! strongly agree. Higher scores in-
dicated higher maternal confidence/commitment
in breastfeeding. Maternal confidence/commit-
ment scores were correlated with breastfeeding
level at 6 weeks postpartum; as hypothesized,
mothers who had lower maternal confidence/
commitment scores also had a lower level of
breastfeeding at 6 weeks postpartum (r ! .66, p "
.05). However, maternal confidence never was de-
fined theoretically nor measured directly; instead,
a combination of maternal confidence and com-
mitment within an insufficient milk supply con-
ceptual framework was used. Furthermore, only
half of these items loaded above .35 during factor
analysis even though alphas for the subscale
ranged from .75 to .84. Again in relation to insuf-
ficient milk supply, Segura-Millan, Dewey, and
Perez-Escamilla (1994) found that maternal con-
fidence related to breastfeeding was associated
with maternal perceptions of insufficient milk af-
ter 1 week postpartum ( ! ! 3.1, SE ! 1.38, p !
.02); mothers with more breastfeeding confidence
were at lower risk to discontinue breastfeeding
prematurely (OR ! 21.8, CI ! 1.4–34.6). In this
study maternal confidence was measured poorly
with a “yes” or “no” question.
In summary, maternal confidence has been
shown to be positively associated with breastfeed-
ing duration and is, therefore, a potential variable
401
that may be used to identify mothers at high risk
of discontinuing breastfeeding. However, a direct
application of self-efficacy theory to the measure-
ment of breastfeeding confidence was not found in
the literature. The purpose of this study was to de-
scribe the development and preliminary psycho-
metric assessment of an instrument to measure
breastfeeding self-efficacy in new mothers.
METHOD
Development of the Breastfeeding
Self-Efficacy Scale (BSES)
Two substantive literature reviews were conduct-
ed before constructing the BSES. A concept analy-
sis of self-efficacy was performed to identify its
attributes, antecedents, and consequences and to
develop a theoretical structure (Walker & Avant,
1988). In addition, to understand the level of
specificity of the construct to be measured, self-ef-
ficacy theory was applied to breastfeeding (Den-
nis, 1999). With the theoretical framework estab-
lished, the BSES content domains were derived
from a literature review of breastfeeding problems
and factors related to breastfeeding duration. Con-
tent analysis of the literature clearly delineated
three conceptually unique subdimensions of suc-
cessful breastfeeding—technique, intrapersonal
thoughts, and support. Technique is defined as the
physical action a mother should perform and rep-
resents certain tasks necessary for successful
breastfeeding. Intrapersonal thoughts are defined
as a mother’s perceptions of breastfeeding and in-
cludes attitudes and beliefs related to a successful
breastfeeding experience. Finally, support is de-
fined as a mother’s perception of informational,
appraisal, emotional, and instrumental assistance
that is available to help her successfully breast-
feed. From the literature of these subdimensions,
40 items were generated. Based on Bandura’s
(1977) recommendations, a scale format was cho-
sen with four response choices per item. All the
items were worded positively with 1 ! not sure at
all and 4 ! completely sure all of the time.
Content validity. To establish judgment con-
tent validity, the 40 BSES items were randomly
ordered and presented to a panel of three mea-
surement experts and four content experts; five
members were doctorally prepared university
professors and the other two were nurses with
clinical expertise. Each reviewer received a de-
tailed package that included a description of the
purpose of the BSES, a literature review, and in-
structions for assessing content validity. Specifi-
402 RESEARCH IN NURSING & HEALTH
cally, the experts were requested to place each
item into one of the three delineated content do-
mains, rate their confidence in placing the item in
the specific domain, predict the largest variabili-
ty in responses for each item, and finally, rate each
item on a 3-point scale for its appropriateness
in measuring breastfeeding self-efficacy (Lynn,
1986). In addition, comments and suggestions
were requested regarding clarity and readability
of each item. The overall content validity index
(CVI) computed for the BSES was 86%, indicat-
ing a high level of agreement among the experts
(Waltz, Strickland, & Lenz, 1991), and 94% of the
time experts correctly placed each item in the ap-
propriate content domain category. Misplaced
items were revised. Three items related to breast-
feeding comfort were added and minor editorial
revisions resulted from this review. The BSES had
an appropriate patient population reading level of
grade 7 on the SMOG index and 8 on the FOG in-
dex (Lynn, 1989). Content validity was assessed
further through the use of semistructured postpar-
tum interviews with two experienced breastfeed-
ing mothers. From content analysis of the inter-
views, 88% of the items could be matched with
the coded participant quotes.
Pilot test. The BSES was pilot tested with a
convenience sample of 23 healthy, in-hospital
breastfeeding mothers to determine clarity, speci-
ficity of directions, initial reliability, and the need
for further revision. All the participants were Cau-
casian and 78% were married. Sixty-five percent
(n ! 15) were multiparas, with 13 having had pre-
vious breastfeeding experience. The mean age of
the participants was 28.7 (SD ! 5.32) years with
39% reporting at least some postsecondary educa-
tion and 60% reporting a family income less than
$50,000 (Canadian; $35,000 U.S.). After the par-
ticipants completed the instrument, which took
each mother less than 10 min, a debriefing session
was held to establish face validity and to evaluate
the instrument format.
A Cronbach’s alpha coefficient of .95 was ob-
tained for the BSES, indicating internal consis-
tency. Corrected item-total correlations revealed
three items that fell below the .30 criterion; how-
ever, it was decided to retain these items for fur-
ther item analysis due to the small sample size and
the fact that all three items were part of the support
subscale, which had only six items. The scale
mean was 140.1 (SD ! 21.67) with a range from
85 to 167. On the 4-point scale, 18 items had a 4-
point variability in response values, 17 items had
a 3-point variability, and 3 items had a 2-point
variability. Assessing these results and the moth-
ers’ responses to the debriefing session, the fol-
lowing amendments were made: (a) highlighting
three items for potential future deletion, (b) im-
proving overall variability by changing the scale
to a 5-point response option, (c) changing the
wording of the response alternatives based on
mothers’ suggestions, and (d) wording items to be
more clear, concise, and “mother-friendly,” (e.g.,
the item “take the baby off the breast without pain
to you” was revised to “I can always take my baby
off the breast without pain to myself”).
With these revisions, the final BSES consisted
of a 43-item scale with each item on the BSES pre-
ceded by the phrase “I can always.” Respondents
were asked to indicate on a scale from 1 to 5 the
degree of confidence they felt, with 1 ! not at all
confident and 5 ! always confident. All items
were randomly distributed and presented positive-
ly as suggested by Bandura (1977). The scores for
all items were summed, with a possible range from
43 to 215 with higher scores indicating higher lev-
els of breastfeeding self-efficacy.
Sample
Two hundred and eight eligible women were ap-
proached with 157 agreeing to participate (75%).
However, 27 consenting mothers did not return or
complete the questionnaires, resulting in a conve-
nience sample of 130 in-hospital breastfeeding
mothers who participated in this methodological
study. The mean age of the study sample was 28.7
years (SD ! 6.31), with a range from 18 to 41
years. The majority of the women were Caucasian
(92.5%), married (90 %), and gave birth vaginal-
ly (81.5%). The mean educational level was 14.6
years, with 50% of the participants having at least
some postsecondary education. Fifty percent re-
ported a family income greater that $50,000 (Cana-
dian; $35,000 U.S.), although 12% of the sample
had an income less than $20,000 (Canadian;
$14,000 U.S.). The sample was divided equally in
terms of parity and 42.3% of participants had at-
tended childbirth preparation classes for the cur-
rent pregnancy. In Canada, most new mothers
have 6 months maternity leave, therefore working
outside the home was not a confounding issue for
length of breastfeeding.
Instruments
In addition to the BSES and a demographic ques-
tionnaire, two instruments were used to evaluate
construct validity. These instruments were chosen
from the breastfeeding duration and self-efficacy
scale development literature.
 BSES SCALE / DENNIS AND FAUX
Questionnaire measure of individual differ-
ences in achieving tendency (QMIDAT). The
QMIDAT is a 36-item, 9-point Likert response in-
strument developed by Mehrabian and Bank
(1978) to measure achievement motivation. Con-
ceptualized by McClelland, Atkinson, Clark, and
Lowell (1953), achievement motivation is a dis-
position to strive for success in any situation in
which the individual’s performance is evaluated
by self or others in terms of some standard of ex-
cellence. Atkinson (1964) expanded on this defin-
ition when he posited that the individual’s degree
of motivation to perform some act is a joint func-
tion of the strength of motive (defined as the need
to succeed versus the need to avoid failure), the
expectancy of success (which is what the individ-
ual believes he can do), and the value of the in-
centive or the perceived benefits of succeeding.
The two principal behavioral indicators of aroused
motivation are achievement effort or persistence
and level of aspiration, which is the level of diffi-
culty the individual chooses to attempt. The
QMIDAT has been psychometrically evaluated
(Mehrabian, 1994; Mehrabian & Bank, 1978) with
an alpha coefficient of .91. In the current study,
the QMIDAT had a Cronbach’s alpha coefficient
of .83. Construct validity was established with
university students through the comparison of
QMIDAT scores and other personality instru-
ments such as Jackson’s (1976) achievement
scale. Rentschler (1991) found that QMIDAT
scores were positively associated to breastfeeding
at 6 weeks postpartum. It was hypothesized in this
study that breastfeeding self-efficacy would cor-
relate positively with achievement motivation.
General self-efficacy scale (GSES). The
GSES, a subscale of the Self-Efficacy Scale, is a
24-item, 5-point Likert-type response instrument
developed by Sherer et al. (1982) based on Ban-
dura’s (1977) theoretical model of self-efficacy.
Sherer et al. posited that the expectancies of per-
sonal mastery that contribute to self-efficacy ex-
pectancies can be generalized to action other than
the target task or behavior. As such, general self-
efficacy is an individual’s broad sense of confi-
dence across varied situations that have developed
from past success and failure experiences. Through
psychometric evaluations (Sherer & Adams, 1983;
Sherer et al., 1982; Weitzel, 1989), Cronbach’s al-
pha coefficients for the GSES have ranged from
.83 to .86; however, in the current study the GSES
had a Cronbach’s alpha coefficient of .56. Con-
struct validity was established with university stu-
dents through the comparison of GSES scores and
six other personality characteristics such as locus
of control, interpersonal competency, assertive-
403
ness, and self-esteem (Sherer & Adams, 1983;
Sherer et al., 1982). Predictive validity was estab-
lished with individuals in treatment programs
through correlations between GSES scores and
past vocational and educational successes. It was
hypothesized in this study that breastfeeding self-
efficacy would correlate positively with general
self-efficacy.
Procedure
Women were approached after admission onto a
postpartum unit at a large teaching hospital in a
midsize Canadian city. The study was explained;
if women agreed to participate, an informed con-
sent statement was signed. All consenting partici-
pants completed the BSES and the two instru-
ments to evaluate construct validity and were
telephoned at 6 weeks postpartum to determine
their infants’ feeding status.
RESULTS
Reliability
Internal consistency. The reliability of the
BSES was evaluated by considering the follow-
ing: (a) Cronbach’s alpha coefficient, (b) a cor-
rected item-total correlation coefficient, and (c)
the alpha estimate when an item was dropped from
the scale. Poorly functioning items were defined
as (a) items that when deleted increased the coef-
ficient alpha by more than .10 or (b) items that had
a correlation of less than .30 with the total scale
score (corrected item-to-total correlation) (Fer-
ketich, 1991; Nunnally & Bernstein, 1994). The
Cronbach’s alpha coefficient for the BSES was
.96, which exceeds the recommended .70 for new
instruments (Nunnally & Bernstein, 1994). All
corrected item-total correlations were positive and
73% of the items were in the .30 – .70 range. One
item (from the support content domain) had a cor-
rected item-total correlation below .30 and was
dropped from further analysis. The coefficient al-
pha did not increase by more than .10 if any of the
items were deleted.
Validity
Construct validity. The BSES was assessed
for construct validity using three methods: factor
analysis, comparison of contrasted groups, and
correlations with measures of theoretically related
constructs. Exploratory factor analysis was con-
404 RESEARCH IN NURSING & HEALTH
ducted to evaluate the strength of the relationship
of individual BSES items with the theoretical con-
cepts and to determine the plausible underlying
structures of the BSES. Principal components
analysis, the most widely applied and recom-
mended first step in factor analysis (Velicer &
Jackson, 1990), was chosen because it reveals a
great deal about probable number and nature of
factors (Tabachnick & Fidell, 1989) and is viewed
often as more exploratory in nature. This specific
analysis yielded a 10-factor solution with eigen-
values greater than one in the unrotated matrix. To
promote a more parsimonious and interpretable
factor solution, a principal components extraction
with varimax rotation (orthogonal) was performed
(Ferketich & Muller, 1990). Based on a scree test
(Cattell, 1978) and the hypothesized a priori do-
mains, a three-factor solution was requested (see
Table 1). A factor loading of .30 was required for
an item to be retained for further analysis (Nun-
nally & Bernstein, 1994); this criterion resulted in
the immediate deletion of three items (two items
were from the support content domain and one
item was from the technique content domain). Fol-
lowing this initial item assessment, the specific
criteria used to guide factor analytic decisions
were based on the magnitude of the factor struc-
ture loading of an item on one particular factor
versus another, the difference of at least .05 when
an item loaded on more than one factor (clean-
ness), and the conceptual fit of the item with oth-
er items on the subscale.
Utilizing an eigenvalue of 1.0 to determine non-
trivial factors, the requested analysis yielded three
factors with eigenvalues greater than 1.0 that ex-
plained 51% of the variance. Factor I had an eigen-
value of 16.87, which explained 39.2% of the
variance. It consisted of 21 items with loadings
ranging from .34 –.76. The Cronbach’s alpha co-
efficient was .94; inspection of the items revealed
that Factor I was similar to the theorized technique
subscale and included items representing maternal
skills and recognition of specific tasks and princi-
ples required for successful breastfeeding (see
Table 1).
Factor II had an eigenvalue of 2.75 and ex-
plained 6.4 % of the variance. Thirteen items
loaded on this factor with loadings ranging from
.40 –.84; the Cronbach’s alpha coefficient was .93.
Factor II was congruent with the theorized intrap-
ersonal thoughts subscale and depicted maternal
attitudes and beliefs towards breastfeeding (see
Table 1).
The emergence of distinct Factors I and II indi-
cate that the breastfeeding domains theorized a
priori based on the literature review, content
experts, and interviews with the breastfeeding
women were accurate. However, Factor III had not
been conceptualized a priori. The eigenvalue for
this factor was 2.29, accounting for 5.1% of the
variance. Five items loaded on this factor with the
loadings ranging from .31–.88, with a Cronbach’s
alpha coefficient of .75. The items all could be
loosely described as maternal activities to aid
breastfeeding (see Table 1). These items were
deleted to promote a more parsimonious scale.
To further assess the complexity of variables,
loadings greater than .40 for each variable were in-
spected across the three factors (Nunnally & Bern-
stein, 1994; Tabachnick & Fidell, 1989). Nine
items (23%) were identified that loaded simulta-
neously on two factors; seven items (54%) in Fac-
tor II concurrently loaded on Factor I, and two
items (10%) in Factor I loaded on Factor II. All
items loaded cleanly except for the following two
items: “I can always focus on getting through one
feed at a time” and “ I can always be satisfied with
my breastfeeding experience.” Since each item
had both a high corrected item-total correlation
and factor loading, these items were retained and
placed in the most conceptually congruent sub-
scale.
Finally, Ferketich and Muller (1990) suggested
that because researchers are faced with a myriad
of options in traditional factor analysis, several ex-
tractions and rotations should be tried; if similar
results are obtained, then one can be more confi-
dent in the structure of the relationships among the
variables. As such, a three-factor maximum likeli-
hood analysis was conducted that produced com-
parable results to the principal components ex-
traction. According to Nunnally and Bernstein
(1994), this finding is not unusual since the results
obtained with different extraction methods often
are remarkably alike.
The second method used to examine construct
validity of the BSES was to contrast groups of in-
dividuals thought to be very high or very low on
the characteristic being measured (Waltz et al.,
1991). Based on self-efficacy theory, which sug-
gests that confidence to perform a specific task or
behavior is determined through previous perfor-
mance, it was hypothesized that women with pri-
or breastfeeding experience would have higher
breastfeeding self-efficacy than women who have
no previous breastfeeding experience. To investi-
gate this hypothesis, a known group analysis was
conducted and significant differences in breast-
feeding self-efficacy were found among primi-
paras (M ! 159.0, SD ! 25.31) and multiparas (M
! 179.2, SD ! 20.53) with previous breastfeed-
ing experience, t ! 4.9, p " .001.
 BSES SCALE / DENNIS AND FAUX 405

Table 1. BSES Items with Principal Components Varimax Factor Loadings

Item Loading

Factor I: Technique
14. Ensure that my baby is properly latched on for the whole feeding .76
43. Recognize when my baby is finished breastfeeding .74
18. Manage the breastfeeding situation to my satisfaction .69
8. Determine that my baby is getting enough milk .68
5. Recognize the signs of a good latch .66
39. Feel if my baby is sucking properly at my breast .66
23. Maintain my milk supply by using the “supply and demand” rule .65
37. Finish feeding my baby on one breast before switching to the other breast .63
2. Position my baby correctly at my breast .62
42. Manage to keep up with my baby’s breastfeeding demands .62
6. Take my baby off the breast without pain to myself .57
1. Hold my baby comfortably during breastfeeding .56
21. Manage to breastfeed even if my baby is crying .56
12. Monitor how much breast milk my baby is getting by keeping track of my baby’s
urine and bowel movement .55
22. Keep my baby awake at my breast during a feeding .54
31. Feed my baby every 2–3 hours .54
36. Deal with the fact that breastfeeding can be time consuming .47
41. Accept the fact that breastfeeding may temporarily limit my freedom .47
33. Comfortably breastfeed with my family members present .42
35. Comfortably breastfeed in public places .36
4. Find breastfeeding information when I need it .34
Factor II: Intrapersonal thoughts
32. Keep feeling that I really want to breastfeed my baby for at least 6 weeks .84
29. Keep wanting to breastfeed .79
27. Stay motivated to breastfeed my baby .73
13. Breastfeed my baby without using formula as a supplement .66
11. Motivate myself to breastfeed successfully .66
26. Feed my baby with breast milk only .65
38. Continue to breastfeed my baby for every feeding .65
10. Depend on my family to support my decision to breastfeed .60
25. Refrain from bottle feeding for the first 4 weeks .58
9. Successfully cope with breastfeeding like I have with other challenging tasks .55
34. Be satisfied with my breastfeeding experience .47
3. Focus on getting through one feed at a time .40
28. Count on my friends to support my decision to breastfeed .40
Factor III: Support (original label)
17. Safely store my breast milk in the fridge .88
20. Safely store my breast milk in the freezer .88
15. Express my breast milk if I need to .45
40. Accept my breastfeeding help from my community .34
24. Seek out breastfeeding support in my community .31

Note. The stem for each item is “I can always…”

The third method used to evaluate construct va-
lidity was the extent to which the BSES correlated
with other measures of breastfeeding self-efficacy
or theoretically related concepts. Although some re-
searchers consider this approach a test of the crite-
rion-related validity of the instrument, Knapp
(1985) cautioned that criterion-validity comparison
measures should be higher-order measures of the
same construct, rather than measures of related con-
structs. As no other known measure of breastfeed-
ing self-efficacy exists, it was hypothesized that the
BSES would positively correlate with the measures
of achievement tendency motivation (QMIDAT)
and general self-efficacy (GSES). These hypothe-
sized relationships were supported only partially, as
the BSES was positively correlated with the QMI-
DAT (r ! .35, p " .001) but negatively correlated
with the GSES (r ! #.20, p ! .03).
Predictive validity. Predictive validity can be
evaluated by determining the relationship between
406 RESEARCH IN NURSING & HEALTH
an instrument and event occurring before, during,
or after the instrument is utilized (Nunnally &
Bernstein, 1994). The predictive validity of the
BSES was assessed by determining the relation-
ship between breastfeeding mothers’ self-efficacy
and their infant feeding patterns at 6 weeks post-
partum. Study participants were classified into
three feeding patterns: bottlefeeding, combination
feeding, or exclusive breastfeeding. A mean score
for each feeding pattern was calculated and a one-
way ANOVA was conducted. A significant differ-
ence was found in breastfeeding self-efficacy
scores for the three infant feeding patterns at 6
weeks postpartum (Table 2). A Tukey post hoc
procedure was performed and a significant differ-
ence at the .05 level was found between the ex-
clusive bottlefeeding and exclusive breastfeeding
groups’ mean scores. The higher the BSES score
the more likely the mother was exclusively breast-
feeding at 6 weeks postpartum.
DISCUSSION
The conceptualization of maternal confidence in
ability to breastfeed as representing self-efficacy
expectancies is consistent with self-efficacy theo-
ry (Bandura, 1977, 1982). Self-efficacy expectan-
cies for breastfeeding include a woman’s confi-
dence in her ability to perform specific tasks and
behaviors related to successful breastfeeding.
These expectancies may develop through women’s
personal experiences with breastfeeding, vicari-
ous experiences with breastfeeding, verbal per-
suasion from influential others, and visceral cues
of vulnerability such as pain, anxiety, or fatigue.
The BSES, an instrument that is purported to mea-
sure a mother’s self-efficacy expectancies (confi-
dence) in her perceived ability to breastfeed her
new infant, has been shown to have good initial
psychometric properties.
The BSES items were derived from the empiri-
cal literature on events that lead to both the pre-
mature discontinuation and the success of breast-
Table 2. Mean BSES Scores and Infant Feeding Patterns at 6 Weeks Postpartum
Group n M
Exclusive bottlefeeding 15
Combination feeding 15
Exclusive breastfeeding 89
Total 119
Note. F (118) ! 9.89, p ! " .001.
feeding. Content validity assessment and pilot
testing guided the development of the instrument.
The internal consistency of the BSES was well
above the desired criterion of .70 alpha for new in-
struments (Nunnally & Bernstein, 1994). In addi-
tion, construct validity of the instrument was sup-
ported by factor analysis and the development of
factor-based subscales. A principal components
extraction with varimax rotation revealed that, al-
though the items had been written to reflect three
conceptual domains (efficacy in breastfeeding
technique, intrapersonal thoughts, and support),
the rotated factor solution suggested two unifying
dimensions underlying the scale (breastfeeding
technique and intrapersonal thoughts). Although
this initially appeared to contradict the conceptual
premise of the instrument, research has shown that
women who have or perceived that they have in-
sufficient breastfeeding support choose to bottle-
feed (Richardson & Champion, 1992) and thus
may not have been represented in the sample.
Janke (1994) found similar results in the develop-
ment of the Breastfeeding Attrition Prediction
Tool where support from the “baby’s father” failed
to load.
Even though all three factors displayed high in-
ternal consistency, the five items within Factor III
did not represent a clear theoretical theme and
were deleted. In the end, the decision to omit an
item was based upon three criteria: (a) the item had
a corrected item-total correlations below .30, (b)
the item had a factor loading below .40, and/or (c)
the item was included in Factor III. Thus, the final
version of the BSES was reduced to 32 items.
Construct validity was supported further by
comparison of contrasted groups. According to
self-efficacy theory, performance accomplish-
ments through actual mastery experiences are the
most powerful source of self-efficacy information
(Bandura, 1982). As expected, breastfeeding self-
efficacy scores for multiparas with previous
breastfeeding experience were higher when com-
pared to primiparas. Finally, a positive correlation
between the BSES and QMIDAT supported con-
BSES Scores
SD
145.3 22.4
161.9 37.1
173.5 20.9
168.5 25.3
 BSES SCALE / DENNIS AND FAUX
struct validity; however, a negative correlation be-
tween the BSES and GSES did not. This finding
is inconsistent with Lowe’s (1993) finding that
childbirth self-efficacy was positively correlated
with general self-efficacy. However, Lowe used a
different measure of general self-efficacy. Unfor-
tunately, the GSES is a subscale of the Self-Effi-
cacy Scale and was not psychometrically tested
with pregnant/breastfeeding women. Using the
GSES alone and with this specific population re-
sulted in a low coefficient alpha ($ ! .56), which
may explain the unexpected correlation. While the
hypothesis was theoretically sound, the GSES was
not a psychometrically sound instrument for this
study. Future methodological research with the
BSES should use instruments already tested with
breastfeeding women.
Perhaps the most clear and significant finding
reported is the predictive validity of the instru-
ment. Although the measure to operationalize in-
fant feeding method was limited to self-report, the
relationship between breastfeeding self-efficacy
and participants’subsequent infant feeding method
at 6 weeks is promising for clinical practice.
The breastfeeding self-efficacy construct has
potential utility for nursing practice if validated in
further research. Clinically, the results for the
BSES could provide important diagnostic infor-
mation that would make interventions more re-
sponsive to those they are intended to serve (Mur-
phy & Kraft, 1993). The BSES could be used to
assess new mothers and help sensitize individual
nurses to the unique needs of their new breast-
feeding clients. Furthermore, recognizing that
mothers with low breastfeeding self-efficacy may
experience significant stress when discharged
home, low BSES scores may be used to provide
anticipatory guidance to those mothers. In con-
trast, high BSES scores could be used by the
nurse as a measure of maternal strength warrant-
ing recognition and reinforcement. As such, the
BSES could be used as an assessment tool to
identify areas to focus nursing practice and pro-
mote the development of an individualized ap-
proach to facilitate breastfeeding in mothers at
high risk to prematurely discontinue. While use-
ful information is often provided by needs as-
sessment data, these data have no predictive va-
lidity. Self-efficacy measurements can be used as
an identification tool to help recognize those
mothers who are likely to succeed, as well as
those who will require additional interventions to
ensure success. For example, if a new mother has
a high breastfeeding self-efficacy score prior to
hospital discharge, additional breastfeeding sup-
port may be unnecessary. However, if a mother’s
407
breastfeeding self-efficacy score is low then there
are clear implications for additional support. The
BSES also may be utilized to determine the effi-
cacy of various types of supportive interventions.
For example, the BSES could be employed to as-
sist health care administrators devise special pro-
grams for those identified high-risk mothers with
low self-efficacy and, therefore, be used in the
planning of breastfeeding programs and the guid-
ing of nursing interventions. Finally, the BSES
may be used by health care professionals to be
more accepting of new mothers who are unsuc-
cessful with breastfeeding even after supportive
interventions.
Although initial support for the validity and re-
liability of the BSES was provided, the instrument
must be tested in more diverse demographic sam-
ples and across cultures. Both the pilot test and
study sample consisted primarily of married, Cau-
casian Canadian women, and thus, were a very ho-
mogenous sample. Moreover, further research is
recommended with samples large enough to per-
mit confirmatory factor analysis and additional
item reduction. To expand the use of the BSES, the
instrument should be tested at different points in
time across pregnancy and postpartum periods.
Breastfeeding confidence with hospital staff
around is likely to be different than when a moth-
er is home, alone or with family members. With
our current environment of very short hospital
postpartum stays, it would be helpful to have an
evaluative instrument that could pinpoint areas in
need of concentrated intervention prior to dis-
charge or telephone support after discharge. Fu-
ture prospective studies using the BSES are need-
ed to provide additional evidence for the validity
of the BSES as well as provide support for the the-
oretical perspective that breastfeeding self-effica-
cy is related to future breastfeeding behavior.
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