Validation of a Turkish version of the fathers’ breastfeeding attitude and participation scale^*

SUMMARY

OBJECTIVE:

This study aimed to determine the validity, structure, and reliability of a Turkish version of the Fathers’ Breastfeeding Attitude and Participation Scale. The Fathers’ Breastfeeding Attitude and Participation Scale consists of two parts, namely, Fathers’ Breastfeeding Attitude and Fathers’ Participation in Breastfeeding Process. Totally, the scale consists of 28 items, of which 14 items belong to Fathers’ Breastfeeding Attitude and 14 items belong to Fathers’ Participation in Breastfeeding Process. There is no report of a validity and reliability study in the original scale. Currently, there is no validated and reliable scale to assess Fathers’ Breastfeeding Attitudes and Involvement in Turkish literature and other languages. In this context, the psychometric properties of the Fathers’ Breastfeeding Attitudes and Involvement Scale were examined.

METHODS:

The instruments were translated and adapted according to the WHO guidelines.

RESULTS:

The Turkish version of the Fathers’ Breastfeeding Attitude and Participation Scale demonstrated acceptable validity and reliability.

CONCLUSION:

The use of the validated instrument to examine fathers’ breastfeeding attitudes and participation in the breastfeeding process will provide data to guide as it is a determinant of breastfeeding behavior.

Keywords
Breastfeeding; Fathers; Attitude; Scales

INTRODUCTION

Breastfeeding plays a key role in the Sustainable Development Goals that countries expect to reach by 2030 and is critical for the realization of many of the goals^1,2. Although 96% of children in our country have been breastfed for a while, breastfeeding still continues at a rate of 66% at the age of 1 year, while only 34% of children are breastfed until their second birthday³,⁴,⁵. Since families do not know enough how to cope with the problems they experience during the breastfeeding process, they have wrong beliefs and attitudes about breastfeeding, and mothers cannot receive adequate support from their environment, especially from their spouses⁶. There has been increasing evidence that fathers will affect the breastfeeding process⁷,⁸,⁹,¹⁰,¹¹,¹². It is stated that fathers have a significant effect on the choice of feeding method of the child, the decision of mothers to start breastfeeding, and the duration of breastfeeding⁷,⁸,⁹. In addition, it is stated that mothers’ breastfeeding attitudes are related to the attitudes of their spouses^10-12. While it is stated in the literature that fathers’ effects on mothers’ decision to breastfeed and breastfeeding attitudes^10-13 and fathers’ participation in the breastfeeding process are important for breastfeeding success¹⁴, there is no scale that evaluates fathers’ attitudes toward breastfeeding and father participation in the breastfeeding process together. Filling this gap in the literature will also make an important contribution to midwives, nurses, and other health professionals who take an active role in breastfeeding counseling. Therefore, the aim of this study was to make the Turkish Version of the Fathers’ Breastfeeding Attitude and Participation Scale (F-BAPS).

METHODS

In this methodological study, a cross-sectional design was used to perform the psychometric test of the Turkish translation of F-BAPS.

Fathers who were at least primary school graduates, had at least one breastfeeding experience, and whose spouses thought to stop breastfeeding before the age of 2 years were included in the study. Fathers who experienced the breastfeeding process with their twin children, had any discomfort in the child or the mother in the postpartum period, had a condition that prevented breastfeeding (such as galactosemia, cleft palate, cleft lip in the child, syphilis, tuberculosis in the mother), and whose spouses became pregnant during the breastfeeding period were excluded from the study. The purpose of the study was explained to the fathers, and an informed consent form was signed. First, the “introductory information form”⁶,¹⁵,¹⁶,¹⁷,¹⁸ was filled in 5-6 min using the face-to-face interview technique. Second, information was given about “F-BAPS,” and it took 20-25 min for the fathers to answer the items in the scale with the self-report method.

F-BAPS was developed by Abu-Abbas et al.¹⁹. Totally, the scale consists of 28 items, of which 14 items belong to F-BA and 14 items belong to F-PB. Responses on this scale are evaluated on a five-point Likert scale. The total score to be taken under the F-BA and F-PB varies between 14 and 70, and the cut-off point of the scale is 58. Those with a total score of ≥58 are called positive, and those with a total score of <58 are called negative.

The instruments were translated and adapted according to the WHO guidelines²⁰. F-BAPS’s original language is Arabic. It was translated into Turkish by three independent linguist translators who knew Turkish and Arabic well, and it was back-translated from Turkish into Arabic by a different translator.

Ethical aspect of research

The study, which was conducted in accordance with the Declaration of Helsinki and the country’s ethical standards, was approved by Aydın Adnan Menderes University Ethics Committee (Date: 31.10.2018, No: 6).

RESULTS

The population of this research, between 15 December 2019 and 30 July 2020, consisted of fathers who applied to the same hospital with their spouses, and the sample consisted of 28×10=280 fathers. The age range of the 280 fathers participating in the study was 20-48 years [mean 34.47, standard deviation 4.70]. The rate of fathers who have experienced the breastfeeding process once is 70.0%, the rate of male children is 53.2%, and the rate of cesarean section is 63.9% in the last breastfeeding experience.

As a result of the analysis made to determine the adequacy of the sample size used in the research for factor analysis—F-BA, KMO coefficient=0.807, p=0.000 and Bartlett’s sphericity test result χ²=1362.758, df=91, p=0.000 were found; F-PB, KMO coefficient=0.814, p=0.000 and Bartlett’s sphericity test result χ²=1366.579, df=91, p=0.000 were found.

Factor analysis was conducted for the F-BA scale. As a result of the analysis, a four-factor structure with an eigenvalue above 1 was determined for the 14 items that were taken as the basis of the analysis. The contribution of the factors to the total variance was found to be 66.731% (Table 1). After this stage, the 14-item scale (^{Appendix 1}) included in each factor was examined and the sub-dimensions were as follows: Factor 1 as “Cognitive” (5 items), Factor 2 as “Experience” (3 items), Factor 3 as “Emotion” (3 items), and Factor 4 as “Culture” (3 items).

Table 1.
Factor pattern of expressions for Fathers' Breastfeeding Attitude and Fathers' Participation in Breastfeeding Process parts (vertical rotation-varimax) (n=280).

F-BA items	F-BA factor load values
	Factor 1	Factor 2	Factor 3	Factor 4
4	0.797		0.123
8	0.763		0.145	0.148
13	0.760	0.104		0.108
3	0.745		0.186
5	0.731	0.109	0.102	0.164
1	0.102	0.835		0.119
10	0.110	0.830
11		0.774		0.186
7	0.121		0.857
6			0.811
14	0.217	0.247	0.764
12				0.831
2	0.157	0.270		0.780
9	0.142		0.131	0.778
Explained variance	21.660	15.553	14.998	14.540
Total variance explained	66.731
F-BA items	F-BA factor load values
	Factor 1	Factor 2	Factor 3	Factor 4
1	0.795		0.127	0.129
3	0.788	0.174
9	0.779	0.128		0.170
14	0.740	0.195	0.102	0.107
10	0.724		0.158	0.145
4		0.817		0.192
11	0.161	0.808	0.183
5		0.784	0.262	0.135
6			0.846
13	0.122		0.799	0.111
2	0.109	0.234	0.725
12				0.828
7	0.156	0.213		0.787
8	0.171	0.124	0.188	0.737
Explained variance	21.883	15.409	14.829	14.349
Total variance explained	66.470

• The factor loads obtained as a result of the rotation process are “0.32–0.44=bad”, “0.45–0.54=normal”, “0.55–0.62=good”, “0.63–0.70=very good,” and “0.70 and above=excellent.” Bold values indicate “excellent” value. Subscales consist of four factors, and each color represents each factor.

Then, factor analysis was conducted for the F-PB scale.

As a result of the analysis, a four-factor structure with an eigenvalue above 1 was determined for the 14 items that were taken as the basis of the analysis. The contribution of the factors to the total variance was found to be 66.470% (Table 1). After this stage, the 14-item scale (^{Appendix 1}) included in each factor was examined and the sub-dimensions were Factor 1 as “Understanding Breastfeeding” (5 items), Factor 2 as “Help” (3 items), Factor 3 as “Motivation” (3 items), and Factor 4 as “Sensitivity” (3 items).

First-order confirmatory factor analysis (CFA) was then performed for the scales whose factor structure was determined.

First, CFA was conducted for the F-BA. Chi-square (χ²=116,788, n=280, SD=71, p=0.001) value was obtained as a result of the first-level CFA analysis. Fit indices were found as χ²/SD=1.645, NFI=0.916, TLI/NNFI=0.955, IFI=0.965, CFI=0.965, RMSEA=0.048, GFI=0.945, AGFI=0.918, and RMR=0.039 (Table 2).

Table 2.
Fit indices before and after modification.

Fit indices	Before modification	After modification
Chi-square (χ2)	140.644	117.982
χ2/SD (CMIN/DF)	1.981	1.685
NFI	0.899	0.915
NNFI	0.931	0.952
IFI	0.947	0.964
CFI	0.947	0.963
RMSEA	0.059	0.050
GFI	0.932	0.943
AGFI	0.899	0.915

• χ²: Chi square; SD: degrees of freedom; NFI: normed fit index; NNFI: non-normed fit index; TLI: Turker-Lewis index; IFI: ıncremental fit ındex; CFI: comparative fit ındex; RMSEA: root-mean-square error of approximation; GFI: goodness-of-fit index; AGFI: adjusted goodness-of-fit ındex. Bold values: After the modification process, the NFI and CFI values of the model showed an acceptable fit.

Subsequently, CFA was conducted for F-PB. Chi-square (χ²=140,644, n=280, SD=71, p=0.000) value was obtained as a result of the first-level CFA analysis. Fit indices were found as χ²/SD=1,981, NFI=0.899, TLI/NNFI=0.931, IFI=0.947, CFI=0.947, RMSEA=0.059, GFI=0.932, AGFI=0.899, and RMR=0.042 (Table 2).

After CFA, CR values were used as indicators to determine the concurrent validity: CR values of the factors of the F-BA subscale were;0.90 for “Cognitive,” 0.85 for “Experience,” 0.73 for “Emotion,” and 0.66 for “Culture.” CR values of the factors of the F-PB subscale were;0.75 for “Understanding Breastfeeding,” 0.82 for “Help,” 0.73 for “Motivation,” and 0.86 for “Sensitivity.”

AVE values were calculated for the discriminant validity of the F-BA and F-PB subscales. When the social structure-experience factor pairs with the largest square of the correlation coefficient between the factors according to F-BA were compared with the AVE values, AVE-social structure=0.51>0.19 and AVE-experience=0.55>0.19 were found. When the sensitivity-assistance factor pair, which has the largest square of the correlation coefficient between the factors according to F-PB, and the AVE values are compared, AVE-help=0.55>0.19 and AVE-sensitivity=0.50>0.19 are found (Table 3).

Table 3.
The squares of the correlation coefficients and average variance extracted values of the expressions for the Fathers’ Breastfeeding Attitude and Fathers’ Participation in Breastfeeding Process parts.

BET factors	Knowledge	Experience	Emotion	Culture
Knowledge (AVE=0.50)	1.000
Experience (AVE=0.55)	0.09	1.000
Emotion (AVE=0.55)	0.16	0.10	1.000
Culture (AVE=0.51)	0.13	0.19	0.08	1.000
BEK factors	Understanding breastfeeding	Help	Motivation	Sensitivity
Understanding breastfeeding (AVE=0.50)	1.000
Help (AVE=0.55)	0.11	1.000
Motivation (AVE=0.50)	0.08	0.19	1.000
Sensitivity (AVE=0.50)	0.18	0.19	0.09	1.000

• AVE: average variance extracted. Bold values: According to their AVE values, the factors measure independent and separate features and have discriminant validity.

The homogeneity of F-BAPS was assessed using Cronbach’s α and item-to-total correlations. The Cronbach’s α reliability coefficients were 0.807 for F-BA and 0.824 for F-PB.

Item-total correlations of the F-BA scale ranged between 0.345 and 0.541. The item-total correlations of the subscales range between 0.607 and 0.676 for “cognitive,” 0.584 and 0.651 for “experience,” 0.572 and 0.684 for “emotion,” and 0.568 and 0.618 for “culture.” Item-total correlations of the F-PB scale ranged between 0.364 and 0.556. The item-total correlations of the sub-dimensions ranged between 0.589 and 0.638 for “understanding breastfeeding,” 0.607 and 0.653 for “help,” 0.546 and 0.624 for “motivation,” and 0.545 and 0.593 for “sensitivity.”

DISCUSSION

This study determines the validity, structure, and reliability of a Turkish version of the F-BAPS.

The construct validity of the scale was also evaluated by first examining the factor structure. With the exploratory factor analysis, it was determined that the F-BA and F-PB subscales of F-BAPS had a four-factor structure. It is considered sufficient that the variance explained in multifactorial scales is between 40 and 60%^21-23. In this framework, it is observed that the contribution of the factors defined for the F-BA and F-PB subscales of the scale to the total variance is sufficient. Factor load values above 0.45 are considered an appropriate criterion, and 0.70 and above are classified as “excellent”^21,23 and are defined as loads that can explain the structure well²². The smallest factor load value obtained as a result of the rotation process of this study is above the value accepted as the lower limit in the literature. All these EFA findings show that the four-factor F-BA and four-factor F-PB subscales of F-BAPS meet the construct validity criteria.

The four-factor structure of the scale was also supported by CFA. According to the fit indices made to determine whether the model structure of the F-BA and F-PB subscales after the CFA was consistent with the data, as a result of the first- and second-level CFA of the expressions for the F-BA and F-PB part, it was concluded that the model fit indices were in the range of acceptable and good fit values, and the factor loadings of the items in the F-BA subscales consisting of four factors and F-PB subscales consisting of four factors were statistically significant²⁰.

In the literature, it is stated that concordance and discriminant validity must also be provided in order to say that a scale structure that has been revealed by EFA and confirmed by CFA has construct validity. It has been reported that if the calculated CR coefficient is greater than 0.70, high structure reliability is achieved, and if it is between 0.60 and 0.70, an acceptable reliability level and concordance validity are provided^21,23. Considering the CR values of the factors in the F-BA subscale of the F-BAPS, it can be said that the cognitive, experience, and emotional factors provide high structural reliability and the social structure factor provides an acceptable level of structural reliability and congruent validity. Considering the CR values of the factors in the F-PB subscale of F-BAPS, it can be said that it provides high construct reliability and concordance validity in four factors.

In order to ensure discriminant validity, the AVE value of both factors should be greater than the square of the correlation coefficient between these two factors^21,23. AVE values of both F-BA and F-PB parts of F-BAPS are greater than the square of the correlation coefficient between all factor pairs. Therefore, it is observed that the discriminant validity condition is met. As a result, the fact that the F-BA and F-PB subscales of the F-BAPS have both concurrent validity and discriminant validity is a strong proof of construct validity.

The Cronbach’s α reliability coefficients of the F-BA and F-PB subscales were 0.807 and 0.824, respectively, with a high level of reliability between 0.80 and 1.00^21,23. This shows that F-BAPS is a reliable scale and the scale provides internal consistency.

According to a criterion accepted in the literature, it is stated that the item-total correlation coefficient of an item should not be negative way and items with an item-total correlation coefficient higher than 0.30 should remain in the scale^21,23. The values obtained do not carry a negative charge and are above the desired item-total correlation value of all the items in the F-BA and F-PB subscales. Therefore, it is concluded that all items move in the same direction as the scale, the additiveness of the scale is not impaired, and the internal consistency of the scale is ensured.

This study also has some limitations. First, the test-retest reliability analysis of the scale could not be performed due to the COVID-19 pandemic conditions. In the original scale, it is stated that the interviews were conducted with fathers who had been breastfeeding for a maximum of 5 years. However, the fact that fathers whose breastfeeding attitude and experience have passed for more than 5 years due to the COVID-19 pandemic conditions have to be included in the study is another limitation of the study.

CONCLUSION

The Turkish version of the F-BAPS (^{Appendix 1}) demonstrated acceptable validity and reliability and thus provides a means of better understanding the breastfeeding attitude and participation in the breastfeeding process of Turkish fathers.

ACKNOWLEDGMENTS

We thank all the institutions that gave consent to the conduct of the study and the fathers who participated in the study and Özge Yavaş Tez, PhD, for providing editing support to the article, and Fatih Hazar, Prof. Dr., for providing translation support.

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Appendix 1 BABALARIN EMZİRME TUTUMU VE KATILIMI ÖLÇEĞİ

Lütfen aşağıdaki ifadeleri okuyunuz ve sizin görüşlerinize en uygun olanını “X” işareti koyarak cevaplayınız. Bu soruların cevaplandırılmasında doğru veya yanlış cevapların olmadığını bilmeniz (hatırlamanız) önemlidir. Biz emzirmeye ilişkin tutumunuzu ve emzirmeye ne kadar katıldığınızla ilgileniyoruz.

Bölüm (1): Babaların emzirmeye ilişkin tutumları Kesinlikle Katılmıyorum Katılmıyorum Kararsızım Katılıyorum Kesinlikle Katılıyorum 1.1. Emzirme, hazır mama ile beslemeden daha rahattır. 1.2. Ev dışında çalışan bir anne bebeğini emziremeye güç yetiremez. 1.3. Çoğu annenin emzirme için yeterli sütü vardır. 1.4. Hazır mama bir bebek için anne sütü kadar sağlıklıdır. 1.5. Anne sütü, hazır mamadan daha kolay sindirilir. 1.6. Emzirme, evlilik ilişkisini olumsuz etkileyebilir. 1.7. Kadın emzirmeden dolayı çekiciliğini kaybeder. 1.8. Emzirme, annenin sağlığı için yararlıdır. 1.9. Emzirme annenin sorumluluğundadır ve babanın bu konuda bir rolü yoktur. 1.10. Emzirme anneye, hazır mama ile beslemeye göre daha çok zaman kazandırır. 1.11. Emzirme anneyi kısıtlar ve sosyal yaşamını engeller. 1.12. Tanımadığım bir kadın önümde bebeğini emzirdiğinde utanırım. 1.13. Emzirme, bebeği hastalıklardan korur. 1.14. Anne emzirirken, baba kendini dışlanmış hisseder. Bölüm (2): Babaların emzirme sürecine katılımı Kesinlikle Katılmıyorum Katılmıyorum Kararsızım Katılıyorum Kesinlikle Katılıyorum 2.1. Eşimle emzirmeye ne kadar devam edeceği hakkında konuştum. 2.2. Başkalarına ziyaretimiz sırasında eşimin bebeğimizi emzirmesini kolaylaştırdım. 2.3. Emzirme problemlerini çözmeye çalışırken eşimle fikir alışverişinde bulundum. 2.4. Eşim emzirirken, diğer çocuklarımız veya evdeki diğer sorumluluklarımızla ilgilendim. 2.5. Eşime ev işlerinde yardım ettim ve bebeğimizin ağlamasına cevap verme, yıkanmasına yardım etme gibi bakım işleriyle ilgilendim. 2.6. Eşim emzirmeye başladığında, konforu için yastık verme, bir bardak su getirme gibi işlemlerde bulundum. 2.7. Eşimin uykusunun bölünmesi veya cinsel aktivite sırasında memelerindeki süt dolgunluğu ile ilgili huzursuzluğunu anlayışla karşıladım. 2.8. Bebeğimizle aynı odada uyumayı, karşı çıkmadan, kabul ettim. 2.9. Bebek emmeye devam ederken eşimin emzirmeyi kesme isteğini onayladım. 2.10. Bebeğimizin hazır mama ile beslenmesini kabul ettim. 2.11. Bebeğimizin bakımını üstlenerek eşimin bir süre uyuyabilmesi için bir zaman dilimi verdim. 2.12. Emzirme sürecinde diğer ev işleri yapılmadığında mutsuz oldum. 2.13. Eşim emzirirken sevinç ve memnuniyet gösterdim. (gülümseme, izleme, eşimi tutma gibi ......) 2.14. Eşime emzirmenin, kendisi veya bebeğimiz için olan, faydalarını belirttim.

Bölüm (1): Babaların emzirmeye ilişkin tutumları	Kesinlikle Katılmıyorum	Katılmıyorum	Kararsızım	Katılıyorum	Kesinlikle Katılıyorum
1.1. Emzirme, hazır mama ile beslemeden daha rahattır.
1.2. Ev dışında çalışan bir anne bebeğini emziremeye güç yetiremez.
1.3. Çoğu annenin emzirme için yeterli sütü vardır.
1.4. Hazır mama bir bebek için anne sütü kadar sağlıklıdır.
1.5. Anne sütü, hazır mamadan daha kolay sindirilir.
1.6. Emzirme, evlilik ilişkisini olumsuz etkileyebilir.
1.7. Kadın emzirmeden dolayı çekiciliğini kaybeder.
1.8. Emzirme, annenin sağlığı için yararlıdır.
1.9. Emzirme annenin sorumluluğundadır ve babanın bu konuda bir rolü yoktur.
1.10. Emzirme anneye, hazır mama ile beslemeye göre daha çok zaman kazandırır.
1.11. Emzirme anneyi kısıtlar ve sosyal yaşamını engeller.
1.12. Tanımadığım bir kadın önümde bebeğini emzirdiğinde utanırım.
1.13. Emzirme, bebeği hastalıklardan korur.
1.14. Anne emzirirken, baba kendini dışlanmış hisseder.
Bölüm (2): Babaların emzirme sürecine katılımı	Kesinlikle Katılmıyorum	Katılmıyorum	Kararsızım	Katılıyorum	Kesinlikle Katılıyorum
2.1. Eşimle emzirmeye ne kadar devam edeceği hakkında konuştum.
2.2. Başkalarına ziyaretimiz sırasında eşimin bebeğimizi emzirmesini kolaylaştırdım.
2.3. Emzirme problemlerini çözmeye çalışırken eşimle fikir alışverişinde bulundum.
2.4. Eşim emzirirken, diğer çocuklarımız veya evdeki diğer sorumluluklarımızla ilgilendim.
2.5. Eşime ev işlerinde yardım ettim ve bebeğimizin ağlamasına cevap verme, yıkanmasına yardım etme gibi bakım işleriyle ilgilendim.
2.6. Eşim emzirmeye başladığında, konforu için yastık verme, bir bardak su getirme gibi işlemlerde bulundum.
2.7. Eşimin uykusunun bölünmesi veya cinsel aktivite sırasında memelerindeki süt dolgunluğu ile ilgili huzursuzluğunu anlayışla karşıladım.
2.8. Bebeğimizle aynı odada uyumayı, karşı çıkmadan, kabul ettim.
2.9. Bebek emmeye devam ederken eşimin emzirmeyi kesme isteğini onayladım.
2.10. Bebeğimizin hazır mama ile beslenmesini kabul ettim.
2.11. Bebeğimizin bakımını üstlenerek eşimin bir süre uyuyabilmesi için bir zaman dilimi verdim.
2.12. Emzirme sürecinde diğer ev işleri yapılmadığında mutsuz oldum.
2.13. Eşim emzirirken sevinç ve memnuniyet gösterdim. (gülümseme, izleme, eşimi tutma gibi ......)
2.14. Eşime emzirmenin, kendisi veya bebeğimiz için olan, faydalarını belirttim.

Publication Dates

• Publication in this collection
  18 Sept 2023
• Date of issue
  2023

History

• Received
  10 Apr 2023
• Accepted
  25 June 2023