Validation of the Arabic Version of the Iowa Infant ...

586192

research-article2015

JHLXXX10.1177/0890334415586192Journal of Human LactationCharafeddine et al

Original Research

Validation of the Arabic Version of the Iowa Infant Feeding Attitude Scale among Lebanese Women

Journal of Human Lactation 2016, Vol. 32(2) 309–314 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0890334415586192 jhl.sagepub.com

Lama Charafeddine, MD1, Hani Tamim, PhD2, Marwa Soubra, MS1, Arlene de la Mora, PhD3, and Mona Nabulsi, MD, MS1, for the Research and Advocacy Breastfeeding Team4

Abstract Background: There is need in the Arab world for validated instruments that can reliably assess infant feeding attitudes among women. The 17-item Iowa Infant Feeding Attitude Scale (IIFAS) has consistently shown good reliability and validity in different cultures and the ability to predict breastfeeding intention and exclusivity. Objective: This study assessed the psychometric properties of the Arabic version of the IIFAS (IIFAS-A). Methods: After translating to classical Arabic and back-translating to English, the IIFAS-A was pilot tested among 20 women for comprehension, clarity, length, and cultural appropriateness. The IIFAS-A was then validated among 170 women enrolled in a breastfeeding promotion and support clinical trial in Lebanon. Results: The IIFAS-A showed acceptable internal consistency reliability (Cronbach’s α = 0.640), with principal components analysis revealing that it is unidimensional. The 17 items had good interitem reliabilities ranging between 0.599 and 0.665. The number of breastfed children was the only predictor of the overall IIFAS-A score in a multivariate stepwise regression model (β = 1.531, P < .0001). Conclusion: The 17-item IIFAS-A is a reliable and valid instrument for measuring women’s infant feeding attitudes in the Arab context. Keywords breastfeeding, breastfeeding attitudes, infant feeding, instrument validation

Well Established The Iowa Infant Feeding Attitude Scale has consistently shown good reliability and validity in different cultures, but not in the Arab world, where validated instruments are needed to reliably assess feeding attitudes among Arab women.

Newly Expressed This study reveals that the Arabic 17-item Iowa Infant Feeding Attitude Scale is a reliable and valid instrument for measuring women’s infant feeding attitudes in the Arab context.

Background Exclusive breastfeeding rates continue to be low in many countries, requiring a variety of promotion and support interventions.1-3 In Lebanon, the practice of exclusive breastfeeding is disappointingly low, ranging from 58.3% in infants younger than 1 month to as low as 4.1% to 10.1% in 6-month old infants.4-7 Many mothers stop breastfeeding before the recommended age of 2 years, and only 27.1% of 1-year-old infants are breastfed.4

In a previous qualitative study, we explored breastfeeding perceptions and experiences of Lebanese mothers and identified several misconceptions as barriers to breastfeeding practices.8 These included insufficiency of breast milk to achieve satiety in the baby, maternal weight gain or breast sagging concerns, and breast milk being harmful to the baby during certain situations such as maternal grief, illness, or This article was accepted under the editorship of the former Editor-in-Chief, Anne Merewood. 1

Department of Pediatrics and Adolescent Medicine, American University of Beirut, Beirut, Lebanon 2 Clinical Research Institute, Biostatistics Unit, American University of Beirut, Beirut, Lebanon 3 School of Education, Iowa State University, Ames, IA, USA 4 Contributing authors are listed in the Authors’ Note at the end of the article. Date submitted: October 31, 2014; Date accepted: April 9, 2015. Corresponding Author: Mona Nabulsi, MD, MS, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, P.O. Box 1136044/C8, Beirut, Lebanon. Email: [email protected]

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pregnancy.8 This study uncovered the need for a systematic assessment of mothers’ attitudes and knowledge of breastfeeding and the prevailing community misconceptions in order to design appropriate interventions that can affect the knowledge and attitude of mothers and dissipate any wrong misconceptions about breastfeeding. Infant feeding decisions are strongly predicted by mothers’ attitudes toward breastfeeding rather than by sociodemographic factors alone.8,9 This is in line with the theory of reasoned action, which states that behavior is determined by intention, which in turn is influenced by a person’s attitudes toward this behavior.10,11 In our efforts to improve breastfeeding rates in Lebanon, we embarked on a randomized controlled trial in which participating mothers are provided with a complex breastfeeding promotion and support intervention that includes prenatal breastfeeding education and the provision of professional lactation support and lay support.12 One of the study’s outcomes is to assess pre- and postintervention attitudinal change toward breastfeeding in the control and experimental groups. A systematic search conducted in PubMed, Medline, and EMBASE databases yielded no instruments that can reliably assess attitudes toward breastfeeding in Arabic-speaking populations. We therefore elected to use the Iowa Infant Feeding Attitude Scale (IIFAS) developed in 1999 by de la Mora.13 The scale is a reliable and valid tool to measure maternal attitude toward infant feeding methods and to predict breastfeeding intention and exclusivity, and it has been validated in different cultures such as Japan,14 Romania,15 and China,16 among others. It is composed of 17 items that are rated on a 5-point Likert-type scale. Eight items are worded in favor of breastfeeding, whereas the other 9 are worded in favor of bottle feeding with reverse scoring. The total IIFAS score ranges from 17 to 85 with higher scores reflecting more positive attitudes toward breastfeeding. In the Arab countries, we found only 1 study that used an Arabic version of the IIFAS to explore breastfeeding attitudes of 521 undergraduate medical and education Saudi female students.17 Although, in the Saudi study, IIFAS was piloted on 42 participants with a reported Cronbach’s alpha of 0.776, the authors did not provide details of its psychometric properties or publish their Arabic IIFAS version. In this article, we describe the development of the IIFAS Arabic version (IIFAS-A) and its reliability and validity assessment among Lebanese women. The availability of such a tool is essential for Arab investigators to reliably measure maternal breastfeeding attitudes in order to design effective interventions that can affect the low breastfeeding rates in this particular context.

Methods Setting and Participants This cross-sectional study was conducted between November 2013 and June 2014 in 2 academic centers in Beirut, Lebanon: the American University of Beirut Medical Center and

Al-Sahel General Hospital. Participants were a convenience sample of 196 Arab women who presented to the obstetrics or pediatrics clinics in either center and who signed written informed consent to participate in a clinical trial that aims at promoting and supporting breastfeeding in the community. The sample consisted of either healthy, pregnant women or women who consented to provide breastfeeding peer support (support mothers) to future mothers as part of the main intervention in the breastfeeding trial. Details of the clinical trial protocol are available elsewhere.12 This study was approved by the institutional review boards of both centers.

Instrument Translation and Administration The IIFAS was translated to classical Arabic by a bilingual pediatrician who was not involved in its piloting or administration, after obtaining permission from the primary author (A. de la Mora, written communication, November 20, 2012). Classical Arabic was chosen instead of the spoken Lebanese Arabic as it can be understood by all Arabicspeaking people. The scale was back-translated to English by another independent bilingual translator who was unaware of the original wording of the questions. To check for the accuracy of translation, we compared the original IIFAS to the back-translated English version. Both English versions were found to be comparable; hence, the Arabic version (IIFAS-A) was considered to be an accurate translation of the original English IIFAS. The IIFAS-A was piloted among 20 women visiting the same sites and who were not participating in the breastfeeding clinical trial to assess its clarity, comprehension, length, and cultural acceptability. All 20 women approved the IIFAS-A in terms of all 4 attributes. The 17-item IIFAS-A was validated later in a larger sample consisting of 196 women who also answered a self-administered, structured questionnaire to collect sociodemographic data such as age, education, employment status, monthly income, religion, gestational age (if pregnant), number of children, duration of breastfeeding, and number of breastfed children. The data of the pilot sample were not included in the validation sample of the IIFAS-A.

Data Analysis Descriptive statistics were reported as number and percentage for categorical variables, whereas means and standard deviation (SD) were reported for continuous ones. Comparison between different groups was carried out using the chi-square test or Fisher exact test for categorical variables, as appropriate. The internal consistency reliability of the IIFAS-A was assessed using Cronbach’s alpha coefficient, in addition to item-total correlations and interitem reliability coefficients. Exploratory factor analysis was run using principal components to test for dimensionality and assess internal construct validity. To further assess the association between breastfeeding attitude scores and other factors (ie, assess external nomological validity), a multivariate


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Charafeddine et al linear regression model (enter method) was run with the IIFAS-A score as a dependent variable and the following variables as predictors: age, education, employment, income, number of breastfed infants, duration of breastfeeding, and number of children. The output yielded by this model was assessed for clinical relevance and evidence from previous studies. In addition, we ran a stepwise linear regression model with the same predictors and dependent variable. Based on the participants’ overall score, attitude toward breastfeeding was separated into 5 categories as follows: strongly positive toward formula feeding (17-52 points), positive toward formula feeding (53-59 points), neutral (6075 points), positive toward breastfeeding (76-82 points), and strongly positive toward breastfeeding (83-85 points). All analysis was done using SPSS version 21. Significance was set at a P value of < .05.

Results Demographics and Clinical Characteristics The baseline sociodemographic characteristics of the 196 participants are summarized in Table 1. There were 130 pregnant mothers and 66 support mothers. The mean (SD) age of the women was 32.1 (7.7) years and the majority (65.3%) were homemakers with university degrees (56.4%). Half of the participants had 1 child or were primiparous, and 39.3% reported breastfeeding at least 2 children. Table 2 summarizes the psychometric properties of the IIFAS-A. Except for items 8 and 17, all items had a mean above the neutral value of 3, ranging between 3.34 and 4.75. Item 8 (mean 2.76 ± 1.49) asks about breastfeeding in public places, whereas item 17 (mean 2.26 ± 1.42) asks whether a breastfeeding mother should avoid alcohol. The corrected item-total correlations ranged from 0.008 to 0.425. The 2 items with corrected item-total correlations below 0.07 (the lowest correlation in the original IIFAS) were also item 8 (0.053) and item 17 (0.008). The IIFAS-A had acceptable internal consistency reliability with a Cronbach’s alpha of 0.640. When items 8 and 17 were deleted, the IIFAS-A Cronbach’s alpha increased to 0.693. All 17 items met the standards of reliability with Cronbach’s alpha if an item was deleted ranging between 0.599 and 0.665. Principal components factor analysis revealed that the IIFAS-A has 6 components, with eigenvalues ranging between 1.007 and 3.478, accounting for 61.1% of the variance. The first component had an eigenvalue of 3.478 followed by 1.676 for the second, and 1.573 to 1.007 for the remaining 4 components. The first component accounted for 20.5% of the variance, followed by 9.9% to 5.9% for each of the remaining components. The scree plot, however, suggested that the scale is unidimensional (Figure 1), with all 17 items loading on 1 component. The participants’ overall IIFAS-A scores ranged between 37 and 85, with the majority (72.4%) having a neutral

attitude toward breastfeeding. Only 13.5% of participants had either positive or strongly positive attitudes toward breastfeeding (Table 1). Support mothers had a significantly higher mean IIFAS-A score than pregnant women (mean difference [SD] = 5.5 [1.2]; 95% confidence interval [CI], 3.27.9). In the bivariate analysis, the IIFAS-A score was correlated with age (r = 0.22, P = .004), number of children (r = 0.26, P = .001), and number of breastfed children (r = 0.28, P < .0001). In the multivariate linear regression model (enter method), higher education, higher income, and a larger number of breastfed children were associated with a higher IIFAS-A score, as indicated by their positive B estimates, whereas higher age, being employed, and having a larger number of children were associated with lower IIFAS-A score, as indicated by their negative B estimates. None of these predictors reached statistical significance (data not shown). In the stepwise linear regression model, number of breastfed children was the only predictor of the overall IIFAS-A score (β = 1.531; 95% CI, 0.792-2.270).

Discussion In this study, we have demonstrated that the Arabic version of the IIFAS (IIFAS-A) is reliable and valid in the Arab context and can be used to assess maternal attitudes toward infant feeding method. Its internal consistency reliability is acceptable, with a Cronbach’s alpha of 0.640 and significant Pearson correlation coefficients ranging between 0.20 and 0.56. Except for item 8 (breastfeeding in public places) and item 17 (mother drinking alcohol), all items had good corrected item-total correlations (Table 2). This could be explained by the fact that 91.4% of our participants were Muslims who may consider public exposure of the breast during breastfeeding as socially unacceptable and alcohol drinking to be prohibited by religious beliefs. Despite the low corrected item-total correlations of items 8 and 17, they were kept in the IIFAS-A in view of their good alpha estimates and positive correlations. Moreover, and since Lebanon is a multisectarian country, alcohol drinking and/or breastfeeding in public may be acceptable in non-Muslim communities. It is interesting to note that in both the Japanese and the Chinese versions of the IIFAS, item 17 was also shown to have low correlation coefficients14,16 but was removed only from the Japanese version. Because of the relatively small sample size, the validity of the scale was not based on the significance of the variables in the regression model but rather on the direction of the association between the IIFAS-A score and the predictors. The positive association between the overall score and maternal education, income, and number of breastfed children is consistent with the literature,18 whereas the negative association with employment and number of children is explained by the fact that employed mothers or those with several children may have had difficulty maintaining breastfeeding due to time constraints.8 Moreover, the negative association with


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Table 1. Baseline Characteristics of the Validation Sample (n = 196), and Women’s Attitudes toward Infant Feeding Method (n = 170). Attitudes toward Infant Feeding Method, % (No.)

Variable

% (No.)

Strongly Positive toward FF (n = 5)

Site AUBMC 61.2 (120) 60.0 (3) Sahel 38.8 (76) 40.0 (2) Participant status Pregnant mother 66.3 (130) 100.0 (5) Support mother 33.7 (66) 0.0 (0) Age, y Mean (SD) 7.7 (32.1) 28.5 (5.6) Parity Primiparous 30.1 (59) 60.0 (3) Multiparous 96.9 (137) 40.0 (2) Gestational age, wk Mean (SD) 4.1 (16.7) 16.8 (3.4) No. of children Mean (SD) 1.5 (1.6) 0.6 (0.9) No. of breastfed children ≤1 60.7 (119) 80.0 (4) ≥2 39.3 (77) 20.0 (1) Longest duration of breastfeeding, mo Mean (SD) 12.5 (8.7) 14 (5.7) Employment Yes 34.7 (68) 40.0 (2) No 65.3 (128) 60.0 (3) Education level ≤ Intermediate 23.1 (45) 40.0 (2) Secondary or 20.5 (40) 0.0 (0) technical University 56.4 (110) 60.0 (3) Monthly income ≤ $1000 39.9 (73) 60.0 (3) > $1000 60.1 (110) 40.0 (2) Religion Muslim 91.4 (169) 100.0 (5) Christian 8.6 (16) 0.0 (0)

Positive toward FF (n = 19)

Neutral (n = 123)

Positive toward BF (n = 20)

63.2 (12) 36.8 (7)

58.5 (72) 41.5 (51)

60.0 (12) 40.0 (8)

66.7 (2) 33.3 (1)

.99

89.5 (17) 10.5 (2)

68.3 (84) 31.7 (39)

35.0 (7) 65.0 (13)

0.0 (0) 100.0 (3)

.001

31.8 (5.5)

31.7 (7.4)

34.0 (9.6)

42.1 (8) 57.9 (11)

28.5 (35) 71.5 (88)

20.0 (4) 80.0 (16)

17.6 (4.2)

16.8 (4.2)

15.3 (4.4)

—

.68

0.9 (1.0)

1.5 (1.5)

2.3 (2.2)

3.0 (1.7)

.017

78.9 (15) 21.1 (4)

60.2 (74) 39.8 (49)

45.0 (9) 55.0 (11)

8.6 (6.9)

11.9 (8.0)

19.2 (10.3)

63.2 (12) 36.8 (7)

65.9 (81) 34.1 (42)

70.0 (14) 30.0 (6)

66.7 (2) 33.3 (1)

.80

15.8 (3) 21.1 (4)

24.6 (30) 20.5 (25)

25.0 (5) 25.0 (5)

0.0 (0) 33.3 (1)

.92

63.2 (12)

54.9 (67)

50.0 (10)

66.7 (2)

36.8 (7) 63.2 (12)

39.5 (45) 60.5 (69)

42.1 (8) 57.9 (11)

0.0 (0) 100.0 (3)

.64

94.4 (17) 5.6 (1)

94.0 (110) 6.0 (7)

84.2 (16) 15.8 (3)

66.7 (2) 33.3 (1)

.19

Strongly Positive toward BF (n = 3)

42.1 (10.0) 0.0 (0) 100.0 (3)

0.0 (0) 100.0 (3) 20 (12.2)

P Value

.09 .22

.04

.75

Abbreviations: AUBMC, American University of Beirut Medical Center; BF, breastfeeding; FF, formula feeding, SD, standard deviation; —, not applicable.

age is consistent with previous studies from Lebanon that reported higher breastfeeding rates in younger, as compared to older mothers.18 The predictive validity of the IIFAS-A is supported by the significantly higher mean score in support mothers as compared to pregnant mothers and the significant positive association between the participants’ overall score and the number of breastfed children in the stepwise regression model. This finding is consistent with that of the Romanian study in which higher IIFAS-R scores were associated with previous breastfeeding for at least 6 weeks.15 Our findings are thus comparable with previous studies that validated the original IIFAS in different cultures, all of which reported good reliability, with Cronbach’s alpha ranging from

0.623 in China up to 0.89 in Scotland,14-16,19 with adequate construct and predictive validities. In Japan, higher IIFAS-J scores during pregnancy predicted exclusive breastfeeding at 4 weeks postpartum but not at 12 weeks.14 Similarly, in mainland China, the IIFAS showed good predictive validity, as women who were exclusively breastfeeding at 3 days, 6 weeks, or 3 months had higher scores than partially breastfeeding women or those whose children were formula fed.16 It is interesting to note that only 13.5% of our participants had IIFAS-A scores consistent with a positive attitude toward breastfeeding. These women tended to be older, with significantly more breastfed children. This finding is expected in our context where formula has replaced breastfeeding as the


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Charafeddine et al Table 2. The Psychometric Properties of the IIFAS-A. IIFAS-A Item Content Q 1: Duration of breast milk benefits Q 2: Convenience of formula feeding Q 3: Breastfeeding and infant bonding Q 4: Iron content of breast milk Q 5: Overfeeding with formula Q 6: Formula feeding and maternal employment Q 7: Formula feeding and motherhood joys Q 8: Breastfeeding in public places Q 9: Breastfeeding and infant’s health Q 10: Overfeeding with breast milk Q 11: Breastfeeding and paternal feelings Q 12: Breast milk as best baby food Q 13: Breast milk and digestion Q 14: Formula feeding and infant health Q 15: Convenience of breastfeeding Q 16: Cost of breast milk Q 17: Alcohol intake during breastfeeding

Corrected Item-Total Correlation

Cronbach’s Alpha if Item Deleted

0.095 0.266 0.378 0.158 0.219 0.385 0.219 0.053 0.388 0.410 0.170 0.343 0.425 0.424 0.421 0.264 0.008

0.655 0.624 0.614 0.638 0.630 0.604 0.630 0.660 0.615 0.603 0.639 0.622 0.611 0.608 0.599 0.626 0.665

Abbreviation: IIFAS-A, Arabic version of Iowa Infant Feeding Attitude Scale.

Figure 1. Scree Plot of the 17-Item Arabic Version of the Iowa Infant Feeding Attitude Scale.

recruited from 2 academic hospitals in Beirut; the majority of participants were Muslim and well educated; and only women who intended to breastfeed in the first place or showed interest in providing breastfeeding support to other women were included, as these were the inclusion criteria for participation in the clinical trial.12 The sample therefore might not be representative of all Lebanese or Arab women, thus limiting its generalizability.

Conclusion In conclusion, the 17-item IIFAS-A is a culturally acceptable, reliable, and valid scale for measuring maternal infant feeding attitudes in the Arab context. The availability of similar valid instruments is expected to bolster research aiming to assess the effect of breastfeeding promotion interventions in this region. The generalizability of our findings to other Arab countries needs to be further confirmed in future studies. Authors’ Note preferred and more socially acceptable method of infant feeding.8 It also highlights the importance of breastfeeding education and support for pregnant mothers as early as possible during pregnancy. Our study is the first to evaluate the validity and describe the psychometric properties of the IIFAS in an Arab population. Although an Arabic IIFAS version was used in a recent study, this version was not published and was validated in a pilot sample consisting of 42 participants only.17 Our study has some limitations: the validation sample reflects only 1 urban area, with the participants being

The Research and Advocacy Breastfeeding Team is a multidisciplinary group of physicians, nurses, epidemiologists, a public health professional, and a communication expert working at the American University of Beirut. In response to persistently low breastfeeding rates in Lebanon, and believing in breastfeeding as the biologic norm, the group was formed in 2012 with the objective of promoting, protecting, and supporting breastfeeding practice through research and advocacy. The vision of the group is to see breastfeeding become the social norm in Lebanon. The team consists of the following members: Dr Mona Nabulsi, Dr Lama Charafeddine, Dr Tamar Kabakian, Dr Nadine Yehya, Dr Hani Tamim, Dr Durriyah Sinno, and Mrs Saadieh Masri.


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Acknowledgments The authors would like to thank Miss Soumayya Ayyash and Miss Fatima Nasser for their help in data collection, and Dr Sawsan Maktabi for translating the scale. They are also grateful to Dr Lilian Ghandour for her critical review of the manuscript.

Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by a grant from the Medical Dean’s Program Projects in Biomedical Research, American University of Beirut.

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