Breastfeeding Self-Efficacy Theory-Based Education and Counseling in Pregnant Adolescents

Study Population and Sample

The study population consisted of adolescent pregnant women registered at family health centers in Şanlıurfa, Türkiye.

The sample size was calculated using G*Power version 3.1.9.7. The calculation was based on a two-group, two-time-point repeated-measures analysis of variance for the group-by-time interaction, with a medium effect size of f = 0.25, a statistical power of 95%, and a two-sided significance level of 0.05. The required sample size was estimated as 54 participants, with 27 participants in each group. To account for possible attrition, the sample size was increased by approximately 10%. A total of 60 participants were enrolled and randomly assigned to the intervention group or the control group in a 1:1 ratio. Fifty-five participants completed the study.

Study Design and Randomization

This was a two-arm, parallel-group randomized controlled trial. Participants who met the eligibility criteria and provided written informed consent were assigned to the intervention or control group using a computer-generated 1:1 randomization list created through Randomizer.org.

Intervention Group

Participants assigned to the intervention group received two individual, face-to-face antenatal breastfeeding education sessions based on Breastfeeding Self-Efficacy Theory. Each session lasted approximately 55 minutes, with a 10-minute break between sessions.

The education addressed the importance of breastfeeding, breast anatomy and lactation physiology, maternal nutrition during breastfeeding, appropriate breastfeeding techniques, infant hunger and satiety cues, breast care, common breastfeeding problems, expression and storage of breast milk, and the emotional aspects of breastfeeding. Verbal instruction, question-and-answer, demonstration, and hands-on practice were used with a flipchart, an infant model, and a breast model.

The intervention was structured according to the four sources of breastfeeding self-efficacy: mastery experiences, vicarious experiences, verbal persuasion, and physiological and emotional states.

Following the antenatal education, supportive text messages were sent weekly until childbirth. During the first postpartum week, participants received a 45-60-minute home visit to assess breastfeeding practices, identify breastfeeding problems, correct inappropriate practices, and provide individualized counseling and positive feedback.

During postpartum weeks 2-6, five weekly telephone counseling sessions, each lasting approximately 15 minutes, were conducted. The counseling sessions addressed participants' breastfeeding experiences, difficulties, and individual support needs. Posttest data were collected at postpartum week 6.

Control Group

Participants assigned to the control group received routine antenatal and postpartum care provided by healthcare professionals at the family health centers. No additional breastfeeding education, supportive text messages, home visits, or telephone counseling were provided by the research team during the study.

Telephone contact was limited to confirming childbirth information and collecting posttest data at postpartum week 6. After posttest data collection was completed, breastfeeding education was offered to control-group participants who requested it.

Outcome Measures and Data Collection Tools

Breastfeeding self-efficacy was the primary outcome and was assessed using the 14-item Breastfeeding Self-Efficacy Scale-Short Form. The antenatal version was administered at baseline, and the postnatal version was administered at postpartum week 6.

Secondary outcomes included breastfeeding knowledge, breastfeeding attitudes, and satisfaction with the intervention. Breastfeeding knowledge was assessed using a 40-item researcher-developed Breast Milk and Breastfeeding Knowledge Assessment Form. Breastfeeding attitudes were assessed using the 46-item Breastfeeding Attitude Assessment Scale. Satisfaction with the intervention was assessed only among intervention-group participants at postpartum week 6 using a 5-item researcher-developed questionnaire.

Sociodemographic, obstetric, childbirth, and breastfeeding-related characteristics were collected using a researcher-developed Personal Information Form.

Intervention Standardization

All antenatal education sessions, text-message support, home visits, and telephone counseling sessions were delivered by the same researcher using standardized educational content and follow-up forms. The researcher had eight years of professional experience in obstetric and gynecologic nursing. Antenatal education sessions were conducted in private education rooms at the participating family health centers.

Ethical Considerations

Ethical approval was obtained from the Harran University Clinical Research Ethics Committee, and institutional permission was obtained from the Şanlıurfa Provincial Health Directorate. All participants received information about the purpose, procedures, potential benefits, voluntary nature of participation, and right to withdraw from the study without affecting the healthcare services they received. Written informed consent was obtained from all participants before enrollment.

Inclusion criteria

• Adolescent pregnant women aged 16-19 years
• Gestational age of 32 weeks or more at enrollment
• A healthy pregnancy without a known maternal or fetal complication that would interfere with participation in the study
• No known maternal or fetal condition contraindicating breastfeeding
• Able to communicate with the researcher and complete the study procedures
• Access to a reachable telephone
• Provision of written informed consent
• Singleton pregnancy
• Planning to breastfeed postpartum
• No previous breast surgery
• No psychiatric disorder
• No planned relocation

Exclusion criteria

• A maternal or fetal complication identified before enrollment that could lead to pregnancy loss or prevent participation in the study
• A known maternal condition contraindicating breastfeeding
• A communication barrier that would prevent completion of the education, counseling, or study assessments