Patricia Markham Risica, DrPH, Assistant Professor (Research) of Community Health, Institute for Community Health Promotion, Brown University

    Lactation consultants, nutritionists, researchers and others continue to create new and innovative ways to increase breastfeeding among American women.  Breastfeeding interventions will likely be strengthened with incorporation of aspects of the behavioral theory based psychosocial characteristics of women and their lives.

    Behaviorists and psychologists have theorized some of the factors that predict behavior.  Many theories have been developed, many applied to negative health behaviors such as tobacco use and other additions.  Few have been applied to breastfeeding as a behavior.  Some of the theories that have been or could be applied to breastfeeding as a health behavior include Theory of Planned Behavior (TPB) and Theory of Reasoned Action (TRA), Social Learning Theory (SLT), the Transtheoretical Model (TTM) and Social Cognitive Theory.

    The TPB(1,2) and its predecessor TRA(3)  have both been used to describe breastfeeding predictors.(4-6)  Intention to breastfeed is posed as the antecedent to breastfeeding initiation and duration, and has been found to be tightly associated with both.(5) Bandura’s Social Learning Theory (SLT) has been invoked, specifically identifying self-efficacy (confidence) as a key predictor of breastfeeding.(7,8)

    The TTM was developed based on changing smoking behaviors and includes Stage of Change, Processes of Change, and Decisional Balance to explain how behaviors are considered and thoughts about those behaviors change during the behavior change.(9,10)  TTM assumes that people cycle between several stages when changing behavior (pre-contemplation, contemplation, preparation, action and maintenance).(11,12) Information needs differ at specific stages of behavioral change.(12) For example, individuals who are only contemplating behavior change need something completely different from those actively engaging in change.  Processes of change that focus on reinforcement management processes are predictive of breastfeeding intention.(4)  Intention was operationalized by Kloeblen as being the main construct in Stage of Change, or in the case of breastfeeding, Stage of Intention to Breastfeed.(4)

    Social support, a major concept from SLT, has also been studied as a predictor of breastfeeding, though the authors did not draw a direct link to the theory.(13,14)  Social support from a woman’s social network and from the father of the baby are strong predictors of breastfeeding intention, though support from medical professionals was not.(14)  The SCT, which stems from SLT, provides us with a construct that is geared toward individuals in later stages of readiness.  Self-efficacy, a major tenet of SCT, refers to a woman’s confidence that she can make a defined change to behavior even under conditions where that behavior change is particularly difficult (e.g., maintaining breastfeeding when it becomes painful or when she returns to work).  Self-efficacy scales have been developed for breastfeeding behavior and the construct has been shown to predict adherence to breastfeeding recommendations.(8)  Low self-efficacy can serve as a barrier to change in individuals who are ready to change, understand the pros of change, but do not feel that they are capable of making and maintaining a behavior change.  Enhancement of self-efficacy, therefore, is an integral part of adherence interventions for individuals in later stages of readiness.  This boosting of self-confidence ensures commitment to and maintenance of change, or in this case, adoption of breastfeeding.

    In assessment of this broad array of behavioral theories employed to better understand breastfeeding decisions, no one single theory seems to uniquely fit with the many predictors of this complicated behavior.  Many of the concepts described by these theories are already incorporated into counseling strategies and materials development, but a more thorough review of these concepts may broaden the clinical and public health approach to encouraging and improving breastfeeding intention, initiation and duration. 

1.         Ajzen I. The theory of planned behavior. Organizational Behavior and Human Decision. 1991;50:179-211.

2.         Montano DE KD, Taplin SH. The theory of reasoned action and the theory of planned behavior. In: Glanz K LF, Rimer BK Eds., ed. Health Behavior and Health Education: Theory, Research and Practice, 2nd Edition. 2nd ed. San Francisco: Jossey-Bass; 1997:85-112.

3.         Ajzen I FM. Understanding Attitudes and Predicting Social Behavior. 1980.

4.         Kloeblen AS, Thompson NJ, Miner KR. Predicting breast-feeding intention among low-income pregnant women: a comparison of two theoretical models. Health Educ Behav. Oct 1999;26(5):675-688.

5.         DiGirolamo A, Thompson N, Martorell R, Fein S, Grummer-Strawn L. Intention or experience? Predictors of continued breastfeeding. Health Educ Behav. Apr 2005;32(2):208-226.

6.         Duckett L, Henly S, Avery M, et al. A theory of planned behavior-based structural model for breast-feeding. Nurs Res. Nov-Dec 1998;47(6):325-336.

7.         Dennis CL, Faux S. Development and psychometric testing of the Breastfeeding Self-Efficacy Scale. Res Nurs Health. Oct 1999;22(5):399-409.

8.         Dennis CL. The breastfeeding self-efficacy scale: psychometric assessment of the short form. J Obstet Gynecol Neonatal Nurs. Nov-Dec 2003;32(6):734-744.

9.         DiClemente C.C. PJ, Fairhurst SK. The process of smoking cessation: An analysis of precontemplation, contemplation, and preparation stages of change. Journal Consult Clin Psychol. 1991;59:295-304.

10.        Prochaska JO, DiClemente CC. Toward a comprehensive model of change. New York: Plenum; 1986.

11.        Strecher VJ, DeVellis BM, Becker MH, Rosenstock IM. The role of self-efficacy in achieving health behavior change. Health Educ Q. Spring 1986;13(1):73-92.

12.        Stoto MA, McCormick MC, Almario DA, eds. Reducing the Odds: Preventing Perinatal Transmission of HIV. Washington, D.C.: National Academy Press; 1999.

13.        Raj VK, Plichta SB. The role of social support in breastfeeding promotion: a literature review. J Hum Lact. Mar 1998;14(1):41-45.

14.        Humphreys AS, Thompson NJ, Miner KR. Intention to breastfeed in low-income pregnant women: the role of social support and previous experience. Birth. Sep 1998;25(3):169-174.