Research in Nursing & Health, 2010, 33, 111–119

Psychometric Testing of the

Breastfeeding Self-Efficacy
Scale-Short Form in a Sample
of Black Women in the
United States
Deborah E. McCarter-Spaulding,1* Cindy-Lee Dennis2**

1
Department of Nursing, St. Anselm College, Manchester, NH
2
Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
Accepted 17 December 2009

Abstract: The benefits of breastfeeding increase with duration and exclu-

sivity, but significant racial disparities exist in breastfeeding rates. Breast-
feeding self-efficacy, as measured by the Breastfeeding Self-Efficacy Scale
Short-Form (BSES-SF), is a significant predictor of breastfeeding outcomes
in diverse samples. The purpose of this study was to assess the psychometric
properties of the BSES-SF in Black women in the US. The psychometric
characteristics were consistent with previous studies, including internal
consistency, comparison with contrasted groups, and correlation with the
construct of breastfeeding network support. Breastfeeding self-efficacy
significantly predicted breastfeeding at 4 and 24 weeks postpartum. The
results are consistent with previous research, and they suggest the BSES-SF
could be used to identify women at risk for prematurely discontinuing
breastfeeding. ! 2010 Wiley Periodicals, Inc. Res Nurs Health 33:111–119, 2010

Keywords: breastfeeding; self-efficacy; Black women; African; support

Breastfeeding is an important health-promoting
behavior, conferring numerous health benefits for
both mothers and infants. Because of the impor-
tance of these health benefits, it is the goal of the
U.S. Department of Health and Human Services
(2006) to increase the rates of initiation and
duration of breastfeeding. Breastfeeding research-
ers have shown that many variables influence
breastfeeding initiation and duration, including
age, education, and socioeconomic status (Callen
& Pinelli, 2004; Dennis, 2002; Scott & Binns,
1999). Race is also a variable found to influence
breastfeeding rates, with Black women both
initiating and continuing breastfeeding at lower
rates than White women (McDowell, Wang, &
Kennedy-Stephens, 2008).
Encouraging breastfeeding among Black
women is an intervention that can lead toward
the elimination of health disparities. Forste, Weiss,
and Lippincott (2001) found that breastfeeding

Financial support was provided by a grant from the International Lactation

Consultant Association, and a grant from Sigma Theta Tau, Eta Omega chapter.
Correspondence to Deborah E. McCarter-Spaulding, 102 Byam Road, New Boston,
NH 03070.
*Assistant Professor.
**Associate Professor and Canada Research Chair in Perinatal Community Health.
Published online 2 February 2010 in Wiley InterScience
(www.interscience.wiley.com). DOI: 10.1002/nur.20368

! 2010 Wiley Periodicals, Inc.

112 RESEARCH IN NURSING & HEALTH
accounted for a decreased infant mortality rate in
Black infants. Black adults have higher mortality
and morbidity from coronary heart disease, stroke,
hypertension, diabetes, obesity, and asthma than
Whites. Breastfeeding has been suggested as a
behavior that could decrease these health risks
(Kull, Almqvist, Lilja, Pershagen, & Wickman,
2004; Mayer-Davis et al., 2008; Owen, Martin,
Whincup, Smith, & Cook, 2005). Researchers
addressing breastfeeding in Black African-
American women have reported some differences
in breastfeeding intentions (Bonuck, Freeman,
& Trombley, 2005) and a preference for
formula feeding (Corbett, 2000; Ludington-Hoe,
McDonald, & Satyshur, 2002). Similar findings
have been found with Black women who identify
themselves as Caribbean (Cricco-Lizza, 2005).
These findings suggest that there may be differ-
ences between Black women and women of other
racial/ethnic groups with regard to breastfeeding.
To develop interventions to encourage breast-
feeding and to eliminate health disparities, it is
important to focus research on factors that
are potentially modifiable. Breastfeeding self-
efficacy in particular is a potentially modifiable
variable that has been shown to predict a longer
duration and increased exclusivity of breastfeed-
ing. Breastfeeding self-efficacy is a concept based
on Bandura’s (1997) social cognitive theory. It is
defined as a mother’s confidence in her ability to
breastfeed her infant (Dennis & Faux, 1999).
Efficacy beliefs are important to address in health
promotion research, as people must have motiva-
tion and perseverance to maintain a health
behavior, beyond simply the knowledge of the
health benefits (Bandura, 2000). To maintain a
health habit, one must have some control over
one’s motivations, thought processes, emotions,
and environment. Breastfeeding an infant for
6 months or more, as recommended by the
American Academy of Pediatrics (2005), would
require an adequate level of breastfeeding self-
efficacy based on Bandura’s theory.
Breastfeeding self-efficacy has been measured
using the Breastfeeding Self-Efficacy Scale
(BSES; Dennis & Faux, 1999); subsequent testing
of this instrument lead to the development of a
shorter, 14-item instrument, the Breastfeeding
Self-Efficacy Short Form (BSES-SF; Dennis,
2003). The concept of self-efficacy can be applied
in a variety of cultural contexts (Oettingen, 1995).
Researchers using the Breastfeeding Self-Efficacy
Scale found breastfeeding self-efficacy to be
predictive of breastfeeding outcomes (duration
and exclusivity) in diverse samples of women.
This instrument has been translated into different
Research in Nursing & Health
languages including Spanish (Torres, Torres,
Rodrigues, & Dennis, 2003), Mandarin (Dai &
Dennis, 2003), and Polish (Wutke & Dennis,
2007), and it has been used in samples of English-
speaking Canadian (Dennis & Faux) and Austra-
lian (Creedy et al., 2003) women. Most recently,
the instrument was psychometrically tested in an
ethnically diverse sample in the United Kingdom
(Gregory, Penrose, Morrison, Dennis, &
MacArthur, 2008); this sample consisted primar-
ily of White and Southeast Asian women.
Given the lower breastfeeding rates in Black
women, and research suggesting cultural differ-
ences relating to breastfeeding, it is important to
determine if breastfeeding self-efficacy can be
appropriately measured and analyzed in black
women using the Breastfeeding Self-Efficacy
Scale-Short Form (BSES-SF). A study of the
influence of breastfeeding self-efficacy on breast-
feeding outcomes among Black American women
has recently been reported (McCarter-Spaulding
& Gore, 2009). The purpose of this study was to
extend the psychometric testing of the BSES-SF in
a sample of Black women.
Based on theory and previous testing of the
instrument, it was hypothesized that higher levels
of breastfeeding self-efficacy would predict longer
and more exclusive breastfeeding, and that women
with previous breastfeeding experience would
have higher levels of breastfeeding self-efficacy.
Women who had weaned or were partially
breastfeeding would be expected to have lower
levels of breastfeeding self-efficacy compared to
women breastfeeding exclusively. In addition,
higher network support for breastfeeding was
hypothesized to correlate with higher levels of
breastfeeding self-efficacy.
METHODS
Sample
This methodological investigation was part of a
larger study of breastfeeding self-efficacy in Black
women of African descent (McCarter-Spaulding
& Gore, 2009). In the US, many ethnic origins are
represented, including Cape Verdean, Haitian,
West Indian/Caribbean, African and African-
American, as well as those who describe them-
selves as multiracial. Because many Black
individuals do not define themselves as Black
but rather by their country of origin (Black, 1996),
the term ‘‘women of African descent’’ was used
for recruitment, to ensure that Black women
 BREASTFEEDING SELF-EFFICACY / McCARTER-SPAULDING AND DENNIS
from several African ethnic backgrounds were
included.
Breastfeeding women were recruited from three
maternity units of a large urban teaching hospital
in the northeastern US and were eligible to
participate if they met the following criteria: (a)
identified themselves as being of African descent,
(b) were age 18 or older, (c) had given birth to a
healthy singleton infant at 37 weeks gestation or
greater, and (d) were English-speaking. In this
study, women were considered to be breastfeeding
if the infant had been breastfed within the past
24 hours or the mother stated her intention to
breastfeed even if infant feeding had not yet been
initiated. Women were excluded from the study if
they had an infant who was ill or preterm as these
conditions would likely influence breastfeeding
self-efficacy and its effect on infant feeding
outcomes.
Nunnally and Bernstein (1994) recommended a
sample size of 5–10 participants per item for a
psychometric assessment of an instrument. As the
BSES-SF is a 14-item tool, a sample of at least 140
women was planned. In the hospital, 175 women
consented to participate in the study. From these,
153 women completed the BSES-SF during their
first postpartum week. The demographic charac-
teristics of the sample are shown in Table 1.
Instruments
Breastfeeding Self-Efficacy Scale-Short
Form (BSES-SF). The BSES (Dennis & Faux,
1999) was originally a 33-item, self-report instru-
ment developed to measure breastfeeding con-
fidence. The measure contained two subscales: the
technique subscale, with items depicting maternal
skills and recognition of principles required for
successful breastfeeding, and the intrapersonal
thoughts subscale, with items related to maternal
attitudes toward and beliefs about breastfeeding.
All items were preceded by the phrase ‘‘I can
always’’ and anchored to a 5-point Likert-type
scale where 1 ¼ not at all confident and 5 ¼ always
confident. As recommended by Bandura (1977),
all items were presented positively and scores
were summed to produce a range of 33–165 with
higher scores indicating higher levels of breast-
feeding self-efficacy. Content validity of the BSES
was based on a literature review, interviews with
breastfeeding mothers, and expert judgment using
a method recommended by Lynn (1986). Follow-
ing a pilot test, an initial psychometric assessment
was conducted with a convenience sample of 130
Canadian breastfeeding women who completed
Research in Nursing & Health
113
questionnaires during their postpartum hospital-
ization and again at 6 weeks postpartum (Dennis &
Faux). Cronbach’s alpha coefficient for the scale
was .96 for this 33-item version, with 73% of all
corrected item-total correlations ranging from .30
to .70. Responses were subjected to principal
components factor analysis with a varimax
rotation, yielding the theorized subscales. Predic-
tive validity was demonstrated by positive corre-
lations between BSES scores and infant feeding
method at 6 weeks postpartum.
Yet, assessment of internal consistency of the
original 33-item BSES suggested item redun-
dancy. Another methodological study was under-
taken, and 18 items were deleted using explicit
reduction criteria (Dennis, 2003). Based on the
encouraging reliability analysis of the new 14-
item BSES-SF, construct validity was analyzed
using principal components factor analysis, com-
parison of contrasted groups, and correlations with
postpartum depression, self-esteem and stress.
Breastfeeding self-efficacy was positively corre-
lated with self-esteem, and negatively correlated
with depression and stress (Dennis, 2003). Factor
analysis of the 14-item instrument showed it to
be unifactoral. Predictive validity was demon-
strated by significant mean differences between
breastfeeding and bottle-feeding mothers at 4 and
8 weeks postpartum. Responses based on specific
demographic characteristics suggested the BSES-
SF is a unique tool to identify mothers at risk of
prematurely discontinuing breastfeeding. The
short form of the BSES was the version tested
with this reported sample of Black women.
Network support for breastfeeding (NSB). As
self-efficacy is theoretically influenced by indi-
viduals in the social network (Bandura, 1997),
network support for breastfeeding was measured
in our study to assess construct validity by
correlation with a theoretically related construct.
Network support for breastfeeding was measured
by an instrument developed by the investigator and
designed to measure the existence and quantity of
the network support available in the context of
breastfeeding, and the functional quality of those
relationships related to breastfeeding support. The
instrument was designed based on previously used
measures of breastfeeding support, review of the
literature related to breastfeeding support, clinical
experience, and consultation with colleagues with
expertise in the area of social support. Two pre-
tests were conducted using the instrument with the
reliability coefficient (Cronbach’s alpha) ranging
from .87–.95. Prior to the use of the NSB in this
study, content validity had been established by
evaluation and review by a group of experienced
114 RESEARCH IN NURSING & HEALTH

Table 1. Demographics of the Sample

Sample n %

Ethnicity (n ¼ 152)
African 15 9.87
African-American 49 32.24
Cape Verdean 12 7.89
Caribbean 38 25.00
Other (multiple backgrounds) 38 25.00
Partner status (n ¼ 152)
Married or living with partner 106 69.7
Single 46 30.3
Employment prior to birth (n ¼ 155)
Yes 129 83.2
No 26 16.8
Household income in USD/year (n ¼ 146)
$10,000 or less 16 11.0
$11,000–20,000 11 7.5
$21,000–30,000 21 14.4
$31,000–40,000 15 10.3
$41,000–50,000 12 8.2
$51,000–60,000 16 11.0
$61,000–70,000 13 8.9
$71,000–80,000 10 6.8
Over $80,000 32 21.9

nurses with advanced degrees, and a researcher
with experience in instrument development.
After minor revisions were made based on the
pre-tests, the instrument was reviewed by several
experts in social support and breastfeeding. In the
current study, the Cronbach’s alpha for the NSB
was .91.
In our study, participants were asked to identify
up to five of the most important people in their
lives and then rate the level of support each
provided for breastfeeding. Five questions about
characteristics of breastfeeding support were
answered about each important person, with
responses choices from 0 to 3. A response of 0
indicated that the respondent’s perception of
support by the individual based on that particular
characteristic of breastfeeding support was not at
all. A response of 3 indicated that the respondent’s
perception of support on that characteristic was
very much. We calculated both an average level of
support for each individual and the average level
of support from the close network. In addition,
participants could identify up to two additional
people from whom they expected to receive
breastfeeding support. The same scale was used
to measure the respondent’s perception of support
from this extended network, and an average level
of support for the extended network was calcu-
lated. The support from the close and the extended
network were averaged to obtain an average
Research in Nursing & Health
network support score. Network support was
measured at the first data collection point
during the postpartum hospitalization and again
at 1-month follow-up.
Infant feeding method. Breastfeeding was
defined as the receipt by the infant of any breast
milk within the past 24 hours. During monthly
telephone interviews, breastfeeding was further
classified into one of the six following categories
advocated by researchers to promote consistency
in the definition of breastfeeding and to facilitate
comparison of research results (Labbok &
Krasovec, 1990): (a) exclusive breastfeeding
(breast milk only); (b) almost exclusive breast-
feeding (breast milk and other fluids [e.g.,
vitamins] but not formula); (c) high breastfeeding
(less than 1 bottle of formula per day); (d) partial
breastfeeding (at least 1 bottle of formula per day);
(e) token breastfeeding (breast given to comfort
baby, not for nutrition); and (f) bottle-feeding (no
breast milk at all). To have enough respondents in
each category for the analysis, the responses were
re-coded into a variable with three categories of
feeding: Exclusive, almost exclusive and high
breastfeeding were included in the category of
exclusive breastfeeding, partial breastfeeding
indicated at least one bottle of formula/day, and
token breastfeeding and bottle feeding were
combined into the category of bottle feeding/
weaned.
 BREASTFEEDING SELF-EFFICACY / McCARTER-SPAULDING AND DENNIS
Procedure
Following approval by university and hospital
review boards, participant recruitment occurred
between January and June 2006. The postpartum
nurse approached eligible patients and obtained
verbal consent for the researcher to introduce
the study. Following a detailed explanation and
informed consent procedures, mothers completed
study questionnaires before hospital discharge.
At 3 weeks postpartum, study questionnaires
were mailed to the participant’s home address in
preparation for a 4-week postpartum follow-up
telephone assessment. Mothers who complet-
ed the initial and first follow-up assessment
were mailed a $10 gift certificate for a large toy
store chain. Follow-up telephone calls were made
monthly after 4 weeks to obtain information about
infant feeding method until 24 weeks postpartum
or until the participant indicated she discontinued
breastfeeding.
Data Analysis
Reliability was analyzed using Cronbach’s alpha
as well as an analysis of the item-total correlation
and the Cronbach’s alpha estimate when an item
was dropped from the scale. Construct validity
was assessed using comparison of contrasted
groups and correlation with the construct of
network support for breastfeeding. Factor analysis
utilizing principal components extraction was also
conducted. Based on previous results using the
instrument, one factor was expected. Predictive
validity was analyzed by examining the relation-
ship between breastfeeding self-efficacy scores
and infant feeding method using t-tests and
analysis of variance. The relationship between
breastfeeding self-efficacy scores and breastfeed-
ing duration was analyzed using the Cox Propor-
tional Hazards model.
RESULTS
Reliability
The Cronbach’s alpha coefficient for the in-
hospital BSES-SF was .94. To analyze the instru-
ment in a similar manner to previous psychometric
evaluations of the instrument, the item-total
correlations were calculated and ranged from
.49 to .85. The Cronbach’s alpha was not
improved if any items were dropped from the
Research in Nursing & Health
115
scale. Test–retest reliability was not conducted, as
self-efficacy would be expected to change over
time based on a woman’s experience with
breastfeeding.
Validity
Construct validity. Based on Bandura’s (1977)
concept of self-efficacy, one of the most potent
sources of efficacy information is previous
experience or enactive mastery. We hypothesized
that women who had previous breastfeeding
experience would have higher levels of breast-
feeding self-efficacy than those without prior
experience. Using a t-test to determine a signifi-
cant difference in mean scores, mothers with
previous breastfeeding experience were noted
to have significantly higher (t[152] ¼ "3.08,
p < .001) mean in-hospital BSES-SF scores
(M ¼ 54.8, SD ¼ 11.0) than those with no previous
experience (M ¼ 49.0, SD ¼ 12.1).
Construct validity was further assessed
by analyzing the relationship between network
support for breastfeeding and breastfeeding
self-efficacy. According to self-efficacy theory
(Bandura, 1977), social support provides various
sources of efficacy information including vicar-
ious experience (role models) and verbal persua-
sion (encouragement). We had hypothesized that
higher levels of network support for breastfeeding
would be related to higher levels of breastfeeding
self-efficacy. As hypothesized, network support
for breastfeeding was significantly correlated to
BSES-SF scores at both time points. The Spear-
man correlation coefficient was .44 (p < .001)
within the first postpartum week and .40 at
1 month postpartum (p < .001).
Factor analysis. A factor analysis utilizing
principal components extraction was completed,
and the results showed that only one factor had an
eigenvalue > 1 (eigenvalue ¼ 7.9). Factor load-
ings and communality are reported in Table 2.
Consistent with previous psychometric testing of
the BSES-SF (Dennis, 2003), all of the factor
loadings were greater than .32, which is the level
recommended for item retention (Tabachnick &
Fidell, 2001).
Predictive validity. Predictive validity was
determined by examining breastfeeding self-
efficacy scores and infant feeding method at
4 weeks postpartum. The mean differences in
self-efficacy scores were analyzed using a t-test
(t[140] ¼ 2.0) and found to be significant (p ¼ .04),
with mothers who were breastfeeding at 4 weeks
postpartum having significantly higher in-hospital
116 RESEARCH IN NURSING & HEALTH

Table 2. BSES-SF Items With Principal Components Factor Loadings

Item Loading Communality

1. Determine that my baby is getting enough milk .75 .64

2. Successfully cope with breastfeeding like I have with other challeng- .70 .56
ing tasks
3. Breastfeed my baby without using formula as a supplement .71 .60
4. Ensure that my baby is properly latched for the whole feeding .80 .74
5. Manage the breastfeeding situation to my satisfaction .87 .82
6. Manage to breastfeed even if my baby is crying .75 .59
7. Keep wanting to breastfeed .65 .61
8. Comfortably breastfeed with my family members present .51 .36
9. Be satisfied with my breastfeeding experience .83 .76
1. Deal with the fact that breastfeeding can be time-consuming .66 .68
11. Finish feeding my baby on one breast before switching to the other .77 .72
breast
12. Continue to breastfeeding my baby for every feeding .85 .80
13. Manage to keep up with my baby’s breastfeeding demands .85 .76
14. Tell when my baby is finished breastfeeding .74 .67

BSES-SF scores (M ¼ 52.6, SD ¼ 11.3) than
mothers who had discontinued (M ¼ 47.0,
SD ¼ 15.1). In order to determine differences in
means with three groups of mothers, an F test
was performed, and significant differences (F[2,
139] ¼ 6.22, p < .01) were found. Mothers who
were exclusively breastfeeding at 4 weeks post-
partum had significantly higher in-hospital BSES-
SF scores (M ¼ 55.3, SD ¼ 10.7) than those who
were breastfeeding in combination with formula
(M ¼ 51.0, SD ¼ 10.8) and those who were bottle-
feeding (M ¼ 45.4, SD ¼ 15.2).
Using Cox Proportional Hazards Model with
the dependent variable being time until weaned
in weeks, an analysis of breastfeeding duration
was conducted. The Cox model allows for the
estimate of a hazard ratio while controlling for
the effects of other covariates (Rosner, 1999). A
hazard ratio of < 1 would be considered protective
against early weaning (thus continued duration of
breastfeeding). Higher levels of in-hospital breast-
feeding self-efficacy predicted continued breast-
feeding at 4 (hazard ratio ¼ .97) and 24 (hazard
ratio ¼ .96) weeks postpartum.
Breastfeeding Self-Efficacy and
Demographic Characteristics
There were no significant differences between
BSES-SF scores and maternal age, partner status,
household income, or mode of delivery. An F-test
(F[6, 144] ¼ 2.47) was conducted to determine if
there were differences in mean BSES-SF scores
among ethnic groups. There were differences in
Research in Nursing & Health
BSES-SF scores based on ethnicity. There were
not enough respondents in each group to allow for
analysis among all groups, but there was a
significant mean difference in scores between the
ethnic group with the lowest mean self-efficacy
score (African-American) and the group with the
highest mean self-efficacy score (African) using
a t-test. African-American women had signifi-
cantly lower (t[60] ¼ 3.74, p < .001) BSES-SF
scores (M ¼ 47.8, SD ¼ 12.3) compared to women
identifying themselves as African (M ¼ 60.7,
SD ¼ 8.5).
Breastfeeding Self-Efficacy and Infant
Feeding Characteristics
Mothers who planned to breastfeed exclusively
did not have higher in-hospital BSES-SF scores
(M ¼ 52.6, SD ¼ 12.1) than those who planned
to combine breastfeeding and bottle-feeding
(M ¼ 51.3, SD ¼ 11.8, ns). There was a statisti-
cally significant difference in mean scores
(F[2, 151] ¼ 3.27, p ¼ .04) between three groups
of women: Mothers who did not know how long
they planned to breastfeed had significantly higher
BSES-SF scores (M ¼ 55.1, SD ¼ 9.9), than those
who intended to breastfeed 24 weeks or less
(M ¼ 49.30, SD ¼ 13.14), and those who intended
to breastfeed more than 24 weeks or as long as the
infant wanted (M ¼ 50.42, SD ¼ 12.68). Compar-
ing two group means using a t-test, mothers who
were exclusively breastfeeding in-hospital had
significantly higher (t[152] ¼ 2.04, p ¼ .04) in-
hospital BSES-SF scores (M ¼ 53.3, SD ¼ 10.7)
 BREASTFEEDING SELF-EFFICACY / McCARTER-SPAULDING AND DENNIS
that those who were partially breastfeeding or
had not yet initiated breastfeeding (M ¼ 49.1,
SD ¼ 14.2).
DISCUSSION
The psychometric testing of the BSES-SF dem-
onstrated support for the reliability and validity of
the measure in a sample of Black women. The high
Cronbach’s alpha is consistent with previous
studies psychometrically testing the self-efficacy
measure in other ethnically diverse samples (Dai
& Dennis, 2003; Torres et al., 2003; Wutke &
Dennis, 2007). Also consistent with previous
research, higher levels of breastfeeding self-
efficacy were found in women with previous
breastfeeding experience (Gregory et al., 2008;
Wutke & Dennis). Consistent with Dennis (2003),
factor analysis indicated that the BSES-SF instru-
ment is unifactoral. A unique hypothesis tested in
this sample was the relationship between breast-
feeding self-efficacy and breastfeeding support.
Consistent with self-efficacy theory, higher levels
of breastfeeding self-efficacy were found in
women with higher levels of breastfeeding sup-
port. These findings provide additional support for
the validity of the BSES-SF.
Breastfeeding self-efficacy measured by the
BSES-SF was a significant predictor of both
breastfeeding duration and exclusivity in this
sample of women. This is similar to results found
in other diverse samples and suggests the instru-
ment can be used to predict breastfeeding out-
comes in Black women. As Black women are at
higher risk for decreased duration and exclusivity
rates, the BSES-SF may have important clinical
utility in its ability to identify Black women at
increased risk prematurely to discontinue breast-
feeding.
As breastfeeding self-efficacy is potentially
modifiable, measurement of changes in self-
efficacy may prove fruitful in evaluating the effect
of interventions to improve breastfeeding out-
comes. Noel-Weiss, Rupp, Cragg, Bassett, and
Woodend (2006) have studied the effects of a
prenatal workshop on self-efficacy and found the
participants in the workshop had higher self-
efficacy scores and more exclusive breastfeeding,
although duration was not significantly affected
by workshop attendance. Similarly, Kingston,
Dennis, and Sword (2007) analyzed postpartum
experiences that may increase breastfeeding self-
efficacy. For Black women, the influences on
breastfeeding self-efficacy may differ based on
culture and/or ethnicity (Oettingen, 1995) indicat-
Research in Nursing & Health
117
ing that interventions should be designed which
are culturally appropriate.
Indeed, despite research consistently showing
that breastfeeding self-efficacy as measured by the
BSES-SF reliably predicts which women require
additional support post-hospital discharge, differ-
ences in self-efficacy scores based on ethnicity
require attention. In this study, African-American
women had the lowest mean self-efficacy scores
compared to women in other ethnic groups.
Gregory et al. (2008) found ethnic differences in
breastfeeding self-efficacy scores between White
and Southeast Asian mothers. Additional research
is required to further understand why these
differences exist and how they influence breast-
feeding outcomes. Research is also need to
describe any differences in breastfeeding initia-
tion and duration rates among different ethnic
groups of Black women.
Similar to previous research findings, differ-
ences in breastfeeding self-efficacy based on the
demographic characteristics of maternal age,
partner status, household income, or mode of
delivery were not found, suggesting that the
BSES-SF provides a unique way to assist health
professionals in their ability to identify high-risk
women. This is important as theoretically, breast-
feeding self-efficacy is a modifiable variable that
may be enhanced to improve breastfeeding out-
comes. Differences in breastfeeding self-efficacy
were found to be related to intended duration.
Women with the highest levels of breastfeeding
self-efficacy indicated that they did not know how
long they would breastfeed. This finding suggests
that women without a specified duration were
confident that they would breastfeed as long as
they desired and until their breastfeeding goals
were met. Breastfeeding self-efficacy did not
differ in relationship to breastfeeding exclusivity
intentions. This result indicates that to breastfeed
in combination with formula feeding may be a
conscious choice related to personal factors
including culture/ethnicity and not a reflection of
breastfeeding problems or a lack of confidence
(Binns & Scott, 2002; Taveras et al., 2003).
Although the sample was large enough to detect
the significance of breastfeeding self-efficacy
to the outcomes of breastfeeding duration and
exclusivity, there were not enough participants to
analyze each ethnic group individually. Further-
more, the sample was comprised of Black women
giving birth in one teaching hospital in a north-
eastern US city and results cannot be generalized
to all Black women in the US. Finally, the study
was limited to women with full-term healthy,
singleton infants. As many Black infants are born
118 RESEARCH IN NURSING & HEALTH
preterm (U.S. Department of Health and Human
Services, 2002), this sample is not representative
of all Black mothers, and more research is needed
to address breastfeeding self-efficacy in this high-
risk group.
CONCLUSION
The BSES-SF appears to be a reliable and valid
measure of breastfeeding self-efficacy in Black
women, consistent with previous research. Breast-
feeding self-efficacy measured in-hospital is
predictive of breastfeeding duration and exclu-
sivity. Additional research is needed to examine
the influence of ethnicity on breastfeeding self-
efficacy so that culturally appropriate breastfeed-
ing interventions can be developed. In order to
meet the U.S. goal of increasing breastfeeding
initiation, duration, and exclusivity, particularly
in populations at risk for poor breastfeeding
outcomes, this instrument could be used clinically
to identify women who may be at risk for early
weaning based on their lower self-efficacy scores.
These lower scores would suggest that interven-
tions be considered to provide breastfeeding
support after discharge from the hospital. The
measure can also be used to evaluate breastfeeding
self-efficacy-enhancing interventions designed to
improve breastfeeding outcomes.
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