1. Attitude, self-efficacy, knowledge and intention to exclusively breastfeed among pregnant women in rural Bangladesh Window of Opportunity: Bangladesh Joan Sara Thomas Rollins School of Public Health, Emory University May 3, 2011

2. Overview Window of Opportunity: cohort study Time line of research Thesis Where we are now

3. Window’s Cohort Study Impact evaluation of Window interventions Partnerships:  CARE USA, CARE Bangladesh,  Rollins School of Public Health, Emory University,  International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B)

4. Window’s Cohort Study Proposed objectives of Cohort OBJECTIVES Effectiveness of intervention (nutritional status and anemia) Impact of program activities (e.g., empowerment) on nutritional outcomes EBF at 6 months and risk of under- nutrition Nutritional status of infants and young children Determinants of EBF intention Sub-optimal complementary feeding practices

5. Time line of Research Jul – Dec 2010: IRB protocol and questionnaire development 30 Dec 2010: Approval from ICDDR,B Ethics and Review IRBs 6 -19 Jan 2011: 2-weeks in Bangladesh 12 Jan - 4 Feb 2011: Data collection (N=800) 5 Feb- 11 Mar 2011: Data management in Dhaka 12 Mar - 22 Apr 2011 Data cleaning, analysis and thesis development

6. Thesis: Objective To examine the associations among knowledge, attitudes, self-efficacy and exclusive breastfeeding intention among women in their third trimester of pregnancy

7. Cohort 1 of Window’s Cohort Study (N=800) in third trimester of pregnancy (26-32 weeks) Thesis: Sample

8. Thesis: Theoretical framework An loose application of the Theory of Planned Behavior (TPB) (Icek Ajzen, 1985 )

9. Thesis: Instrument development 12-module questionnaire  Informed by:  CARE’s baseline survey  Alive & Thrive Baseline Survey 2010  Bangladesh Demographic and Health Survey 2007  Infant feeding intentions scales (Nommensen-Rivers, Dewey)

10.  Covered a range of topics:  demographic and socio-economic status,  household characteristics,  food security and maternal diet and nutrition,  pregnancy, access to antenatal care services and other breastfeeding support  breastfeeding knowledge  breastfeeding attitudes,  intentions to breastfeed  women’s empowerment and social capital Thesis: Instrument development

11. Thesis: Data collection Akhoni Shomoy and ICDDR,B  Stage 1: Identification of eligible women  Karimganj: done by CHNM’s of Akhoni Shomoy  Katiadi: snowball recruitment, word-of-mouth, network strengthening  Stage 2: Interviews  Both sub-districts: 20 ICDDR,B trained field workers (9 F and 11 M)

12. Main outcome:  Intention to exclusively breastfeed (InEBF)  “Do you plan to (only) exclusively breastfeed your baby?” Maternal indices:  Attitudes  Self-efficacy  Knowledge Statistical analysis:  Chi-square, t-test and logistic regression Thesis: Data analysis

13. Thesis: Data Analysis Principal Component Analysis Standard procedure (e.g., DHS) Convert a set of possibly correlated variables into a set of uncorrelated variables called principal components Factor based scores ranges: Attitudes (19-45) Self-efficacy (10-18)

14. Maternal knowledge index was scored according to accuracy of responses, with a score of either 1 or 0 for correct or incorrect responses.  Range 0-14 Thesis: Maternal knowledge index

15. Thesis: Descriptive results Literate: 59% Mean age : 25 years (6% > 36 years) Education of head of HH: 65% Mean total no. of HH members: 5 6-10 HH members: 35% Parity: 26% Nulliparous: 26% Multiparous: 51% No. death of children: 77% ANC visit current pregnancy: ≥ 1: 33%

16. Thesis: Key demographics and InEBF Intenders Non-Intenders

17. Thesis: Maternal indices and InEBF Intenders Non-Intenders

18. Thesis: Mean score of indices and InEBF

19. Thesis: Maternal knowledge and InEBF Prevalence and odds of correct exclusive breastfeeding knowledge and intention to exclusively breastfeed

20. Thesis: Multivariable regression models

21. Thesis: Results modeling Findings are consistent with previous breastfeeding intention research High levels of positive attitude was strongly associated with InEBF (OR: 2.30; 95% CI 1.14 - 4.66) High levels of self-efficacy was strongly associated with InEBF (OR: 3.91; 95% CI 1.91 – 8.00) Higher levels of knowledge was only modestly associated with InEBF (OR: 1.12; 95% CI 0.74-1.71)

22. Thesis: What does all this mean? Application of Theory of Planned Behavior although frequent in breastfeeding research not so Bangladeshi population Principal component analysis enabled analysis to focus on subtleties of key determinants of InEBF

23. Identified key modifiable factors for this population  Higher levels of positive attitude  specifically positive attitudes towards time management towards EBF  Higher levels of self-efficacy  specifically emotional or affective aspects of self-efficacy towards EBF Thesis: What does all this mean?

24.  …and what about knowledge?  Identify critical gaps in EBF knowledge  Doubts of adequacy of breast milk barrier to application of knowledge  Lack of correct understanding of EBF terminology and definitions Thesis: What does all this mean? Prevalence and unadjusted odds of intention to exclusively breastfeeding More research needed…

25. Strengths:  PCA: allowed examination of sub-constructs  Contributing to breastfeeding literature specific to Bangladesh Limitations:  Questionnaire: scales used i.e., Likert Scale  Unjustified missing data: need to increase quality control on data management (collection, inputting)  Extractability of important variables i.e., maternal education  Tight time line Thesis: Strengths and Limitations

26. This research adds to the evidence that not only are attitudes and self-efficacy strongly associated key modifiable determinants of intention to EBF in Kishoreganj, rural Bangladesh but the sub-constructs of attitudes- time management and the emotional aspects of self-efficacy are specifically critical future intervention points for improving IYCF decisions. Thesis: In the meantime…

27. Where we are now… Fortunately this is only the beginning… let us see where this 2 year cohort takes us Currently as of May  Cohort 1 infants should be 3 months  Recruitment will begin for Cohort 2