Predicting Exclusive Breastfeeding among Iranian Mothers: Application of the Theory of Planned Behavior Using Structural Equation Modeling

Razyeh Bajoulvand, Emilio González-Jiménez, Mohammad-Hasan Imani-Nasab, Farzad Ebrahimzadeh


Background: Identifying the factors that lead to the beginning, continuing, or stopping the Exclusive Breastfeeding (EBF) by mothers can be of great assistance in the design of interventions to strengthen this behavior. The aim of this study was to predict EBF among mothers with Infants Less than Six Months of Age (ILSMA) according to the Theory of Planned Behavior (TPB).

Materials and Methods: The study was a cross‑sectional one that conducted among 304 mothers with ILSMA in Khorramabad‑Iran in 2017 using Structural Equation Modeling (SEM). The sampling method was a combination of census, stratified random, and systematic random sampling. The data collection tool was a contextualized, valid, and reliable questionnaire according to the TPB. Data were collected by a trained interviewer. Data were analyzed using SPSS‑16 and AMOS‑20 software programs and SEM.

Results: Perceived Behavioral Control (PBC) could explain 65% of mothers’ EBF intention. Intention and PBC were able to predict 79% of the variance in EBF together. The fitness indices of EBF model in the current study were acceptable (RMSEA = 0.07, CMIN/DF = 2.58, NFI = 0.81, CFI = 0.87, and GFI = 0.83).

Conclusions: TPB is an appropriate model for predicting the intention and behavior of EBF. Policy makers and health system managers are recommended for taking some measures to add a standardized questionnaire in the electronic health record to predict EBF according to TPB of pregnant women and mothers with ILSMA. In this way, they can empower primary healthcare providers to design and implement a theory‑based interventional plan.


Behavior, breastfeeding, intention latent class analysis, Iran

Full Text:



Organization WH. Indicators for Assessing Infant and Young Child Feeding Practices: Part 2: Measurement; 2010.

Hanif HM. Trends in breastfeeding and complementary feeding practices in Pakistan, 1990‑2007. Int Breastfeed J 2011;6:15.

Quigley MA, Kelly YJ, Sacker A. Breastfeeding and hospitalization for diarrheal and respiratory infection in the United Kingdom millennium cohort study. Pediatrics 2007;119:e837‑42.

UNICEF. Improving Exclusive Breastfeeding Practices by Using Communication for Development in Infant and Young Child Feeding Programmes. New York: UNICEF; 2010:16.

Davis SK, Stichler JF, Poeltler DM. Increasing exclusive breastfeeding rates in the well‑baby population. Nurs Women’s Health 2012;16:460‑70.

Kramer MS, Kakuma R. Optimal Duration of Exclusive Breastfeeding. The Cochrane Library; 2012.

Baker JL, Gamborg M, Heitmann BL, Lissner L, Sørensen TI, Rasmussen KM. Breastfeeding reduces postpartum weight retention. Am J Clin Nutr 2008;88:1543‑51.

Sanusi R, Falana O. The nutritional status of mothers practicing breast feeding in Ibadan, Nigeria. Afr J Biomed Res 2009;12:107‑12.

Huo D, Adebamowo CA, Ogundiran TO, Akang EE, Campbell O, Adenipekun A, et al. Parity and breastfeeding are protective against breast cancer in Nigerian women. Br J Cancer 2008;98:992‑6.

Sule EA. Breastfeeding and breastcancer, a veritable association among nigerian women? Continental J Med Res 2011;5:1.

González‑Jiménez E, García PA, Aguilar MJ, Padilla CA, Álvarez J. Breastfeeding and the prevention of breast cancer: A retrospective review of clinical histories. J Clin Nurs 2014;23:2397‑403.

Black RE, Allen LH, Bhutta ZA, Caulfield LE, De Onis M, Ezzati M, et al. Maternal and child undernutrition: Global and regional exposures and health consequences. Lancet 2008;371:243‑60.

Organization WH. Infant and Young Child Feeding: Model Chapter for Textbooks for Medical Students and Allied Health Professionals. Geneva: World Health Organization; 2009.

Ellis DJ. Secondary school students’ attitudes and beliefs about breastfeeding. J School Health 1983;53:600‑4.

Semenic S, Loiselle C, Gottlieb L. Predictors of the duration of exclusive breastfeeding among first‑time mothers. Res Nurs Health 2008;31:428‑41.

Río I, Luque Á, Castelló‑Pastor A, del Val Sandín‑Vázquez M, Larraz R, Barona C, et al. Uneven chances of breastfeeding in Spain. Int Breastfeed J 2012;7:22.

Communication UDo. Tracking Progress on Child and Maternal Nutrition: A Survival and Development Priority: Unicef; 2009.

Olang B, Farivar K, Heidarzadeh A, Strandvik B, Yngve A. Breastfeeding in Iran: Prevalence, duration and current recommendations. Int Breastfeed J 2009;4:8.

Guo JL, Wang TF, Liao JY, Huang CM. Efficacy of the theory of planned behavior in predicting breastfeeding: Meta‑analysis and structural equation modeling. Appl Nurs Res 2016;29:37‑42.

Bai Y, Middlestadt SE, Peng CYJ, Fly AD. Predictors of continuation of exclusive breastfeeding for the first six months of life. J Hum Lact 2010;26:26‑34.

Bai Y, Wunderlich SM, Fly AD. Predicting intentions to continue exclusive breastfeeding for 6 months: A comparison among racial/ethnic groups. Matern Child Health J. 2011;15:1257‑64.

Eidelman AI, Schanler RJ, Johnston M, Landers S, Noble L, Szucs K, et al. Breastfeeding and the use of human milk. Pediatrics 2012;129:e827‑41.

Control CfD, Prevention. Rates of Any and Exclusive Breastfeeding by Socio‑Demographics Among Children Born in 2013 (Percentage±Half 95% Confidence Interval). CDC National Immunization Survey; 2016.

Control CfD, Prevention. Racial and ethnic differences in breastfeeding initiation and duration, by state‑National Immunization Survey, United States, 2004‑2008. MMWR Morb Mortab Wkly Rep 2010;59:327‑34.

Saffari M, Pakpour AH, Chen H. Factors influencing exclusive breastfeeding among Iranian mothers: A longitudinal population‑based study. Health Promot Perspect 2017;7:34‑41.

Jamei F, Ostovar A, Javadzade H. Predictors of exclusive breastfeeding among nulliparous Iranian mothers: Application of the theory of planned behavior. Int J Pediatr 2017;5:4457‑67.

Gefen D, Straub D, Boudreau M‑C. Structural equation modeling and regression: Guidelines for research practice. Comm Assoc Inform Syst 2000;4:1‑77.

Hoe SL. Issues and procedures in adopting structural equation modeling technique. J Appl Quant Methods 2008;3:76‑83.

Boomsma A, Hoogland JJ. The Robustness of LISREL Modeling Revisited. In: Cudeck R, duToit S, Sörbom D, editors. Structural equation models: Present and Future. 1st ed. Lincolnwood: Scientific Software International; 2001. p. 139‑68.

Iacobucci D. Structural equations modeling: Fit indices, sample size, and advanced topics. J Cons Psychol 2010;20:90‑8.

Quintana SM, Maxwell SE. Implications of recent developments in structural equation modeling for counseling psychology. Counsel Psychol 1999;27:485‑527.

Bentler PM, Chou C‑P. Practical issues in structural modeling. Sociol Method Res 1987;16:78‑117.

Alami A, Moshki M, Alimardani A. Development and validation of theory of planned behavior questionnaire for exclusive breastfeeding. J Neyshabur Univ Med Sci 2014;2.

Dodgson JE, Henly SJ, Duckett L, Tarrant M. Theory of planned behavior‑based models for breastfeeding duration among Hong Kong mothers. Nurs Res 2003;52:148‑58.

Yeneabat T, Belachew T, Haile M. Determinants of cessation of exclusive breastfeeding in ankesha guagusa woreda, awi zone, northwest ethiopia: A cross‑sectional study. BMC Pregnancy Childbirth 2014;14:262.

Khanal V, Sauer K, Zhao Y. Exclusive breastfeeding practices in relation to social and health determinants: A comparison of the 2006 and 2011 Nepal Demographic and Health Surveys. BMC Public Health 2013;13:958.

Seid AM, Yesuf ME, Koye DN. Prevalence of exclusive breastfeeding practices and associated factors among mothers in Bahir Dar city, Northwest Ethiopia: A community based cross‑sectional study. Int Breastfeed J 2013;8:14.

Al‑Sahab B, Lanes A, Feldman M, Tamim H. Prevalence and predictors of 6‑month exclusive breastfeeding among Canadian women: A national survey. BMC Pediatr 2010;10:20.

Prior E, Santhakumaran S, Gale C, Philipps LH, Modi N, Hyde MJ. Breastfeeding after cesarean delivery: A systematic review and meta‑analysis of world literature. Am J Clin Nutr 2012;95:1113‑35.

Organization WH. World Health Statistics: A Snapshot of Global Health; 2012.

Ahmad‑Nia S, Delavar B, Eini‑Zinab H, Kazemipour S, Mehryar AH, Naghavi M. Caesarean section in the Islamic Republic of Iran: Prevalence and some sociodemographic correlates. East Mediterr Health J 2009;15:1389‑98.

Sefene A, Birhanu D, Awoke W, Taye T. Determinants of exclusive breastfeeding practice among mothers of children age less than 6 month in Bahir Dar city administration, Northwest Ethiopia; a community based cross‑sectional survey. Sci J Clin Med 2013;2:153‑9.

Agboado G, Michel E, Jackson E, Verma A. Factors associated with breastfeeding cessation in nursing mothers in a peer support programme in Eastern Lancashire. BMC Pediatr 2010;10:3.

Akter S, Rahman MM. Duration of breastfeeding and its correlates in Bangladesh. J Health Popul Nutr 2010;28:595‑601.

Tan KL. Factors associated with exclusive breastfeeding among infants under six months of age in peninsular Malaysia. Int Breastfeed J 2011;6:2.

Joshi PC, Angdembe MR, Das SK, Ahmed S, Faruque AS, Ahmed T. Prevalence of exclusive breastfeeding and associated factors among mothers in rural Bangladesh: A cross‑sectional study. Int Breastfeed J 2014;9:7.

Noughabi ZS, Golian Tehrani S, Foroushani AR, Nayeri F, Baheiraei A. Prevalence and factors associated with exclusive breastfeeding at 6 months of life in Tehran: A population‑based study. East Mediterr Health J 2013;20:24‑32.

Tan KL. Factors associated with non‑exclusive breastfeeding among 4‑week post‑partum mothers in Klang district, Peninsular Malaysia. Malays J Nutr 2009;15:11‑8.

Shi L, Zhang J, Wang Y, Guyer B. Breastfeeding in rural China: Association between knowledge, attitudes, and practices. J Hum Lact 2008;24:377‑85.

Taddele M, Abebe L, Fentahun N. Exclusive breastfeeding and maternal employment in Ethiopia: A comparative cross‑sectional study. Int J Nutr Food Sci 2014;3:497‑503.


  • There are currently no refbacks.