ملاحظات نگرشی در مقابل ملاحظات هنجاری در رفتار تغذیه با شیر مادر: تأثیرات اجتماعی چند وجهی در یک زمینه کشورهای در حال توسعه

The aim of the paper is to test the basic assumptions underlying the theory of reasoned action (TRA) for exclusive breastfeeding behavior taking place in the rather complicated social environment of women who have just given birth. The paper aims (i) to argue that normative rather than attitudinal considerations are more important in engaging the correct breastfeeding behavior, and (ii) to demonstrate that the TRA concept of social norm should be treated as a multi-layered construct which involves several enabling factors in predicting complex behaviors such as breastfeeding. Data were collected in three phases as part of a prospective cohort follow-up design. The first phase of data collection was conducted in the hospital with mothers after the delivery. Two follow-up questionnaires were administered at the end of the first and second months. Results did not confirm the assertions of the TRA. Logistic regression models and multiple regression analyses indicated that intention and belief/attitude measures taken at the time of birth did not predict end-of-first-month full breastfeeding behavior. Overall, results revealed that intention by itself was not a strong determinant of breastfeeding unless it was conditioned by enabling factors such as social support and subjective norms regarding breastfeeding.

The aim of this study was to examine exclusive breastfeeding behavior in the multi-layered social environment of Turkish women who have just given birth. Variables useful for predicting breastfeeding were derived from the theory of reasoned action (TRA). The study was conducted among low-education, low-income women in Istanbul, Turkey. According to the TRA, behavior under volitional control is best predicted by the intention to perform it. There are two major factors that determine behavioral intentions: an attitudinal factor and a social or ‘normative’ factor (Fishbein & Ajzen, 1975). The relative importance of these two components in determining intention is expected to vary with the behavior, with the situation and with individual differences among actors. However, in addition to examining the relative importance of normative vs. attitudinal factors that promote breastfeeding, further measures of social input were included to test the importance of other socially enabling factors in predicting breastfeeding. As mentioned above, breastfeeding is a behavior that requires a considerable degree of normative support. The nutritional, immunological and hygienic merits of breastmilk are well established and breastfeeding has been recognized for its developmental, psychological and social advantages (Popkin et al., 1984; Monteiro, Rea, & Victora, 1990). However, despite its numerous benefits, many women choose not to breastfeed exclusively. The failure of women to initiate or to persist in breastfeeding has been attributed to a lack of social support as well as lack of knowledge and self-efficacy (Maticsh & Sims, 1992). Moreover, changes in infant feeding practices, such as the earlier introduction of complementary foods and shortened duration of breastfeeding are known to accompany urbanization (Donath & Amir, 2000; Kocturk, 1988; Scott & Binns, 1999; Vogel, Hutchison, & Mitchell, 1999; Yimyam, Morrow, & Srisuphan, 1999). The shortened duration in urban areas is generally associated with higher maternal education and higher socio-economic status. In Turkey, the overall national figure for exclusive breastfeeding (0–3 months) is 14% (UNICEF and The Government of Turkey, 1998). Furthermore, a local study done in Istanbul (Neyzi et al., 1991) found that the average duration of exclusive breastfeeding in an urban setting was 58 days. Considering that exclusive breastfeeding is recommended for the first 4–6 months, these findings indicate that early introduction of complementary foods is common in Turkey. Considering the cultural background and living conditions prevalent in Turkey, mothers would be expected to favor prolonged breastfeeding; introduction of complementary feeding at such early ages is unexpected. Demographically, only 12% of the female population in Turkey is employed (UNICEF, 1998). The average schooling of the female population over 25 years of age has been estimated as 3.6 years (Human Development Report, 1996). The literacy rates for the adult population is 91.3% for males and 76.1% for females. Women are not subjected to infant food promotion advertisements, since these are prohibited from the mass media. Mother and infant are not separated in Turkey, which is another favorable condition for breastfeeding (Kocturk, 1988). In fact, urban lifestyles in Turkey generally bring the mother-infant pair into closer contact than would be possible in rural areas where 88% of the women actively participate in agricultural production and are separated from their infants for varying periods of time (UNICEF, 1998). With migration to urban areas women's participation in the labor force decreases sharply, only 12% of urban women being employed, so that their daily activities are confined mostly to housework and child care. These observations indicate that there must be other factors related to urban mothers’ breastfeeding behavior besides its structural determinants. To explain the failure of women to initiate or to persist in breastfeeding, the literature has consistently mentioned the importance of social support as an influential variable affecting the intention, incidence and duration of breastfeeding (Bryant, 1982; Guttman & Zimmerman, 2000; Humphreys, Thompson, & Miner, 1998; Kaufman & Hall, 1989; Maticsh & Sims, 1992; Raj & Plichta, 1998; Susin, Giugliani, Kummer, Maciel, & da Silveira, 1999). A common argument of these debates has been that the intention to breastfeed or continue breastfeeding is based on the high level of (real or perceived) pressure to comply with socially expected behavior and support. The theory of reasoned action (Fishbein & Ajzen, 1975) is one of the most influential theories that has attempted to clarify the links between intentions, social pressures and behavior. The theory argues that behavior under volitional control is best predicted by the intention to perform it. Intentions are, in turn, a function of attitude towards the behavior being predicted and of subjective social norms about the behavior (Ajzen & Fishbein, 1980; Fishbein & Ajzen, 1975). The theory further specifies the determinants of attitude and subjective social norm. Attitudes are determined by behavioral beliefs and evaluations of outcomes (how good or bad each outcome is). Subjective social norms, on the other hand, are determined by normative beliefs (whether various significant others think the decision-maker should perform the behavior) and motivation to comply (the extent to which the decision-maker is willing to comply with each of the significant other's wishes). That is, social norms signify the sources of social and cultural pressure, if any, that constrain the individual performing the behavior (Wright, 1998). Based on its application to a wide range of diverse behaviors, the TRA has attracted various criticisms. One of the major criticisms is that the theory conceptually applies only to volitional behaviors (Bagozzi, 1992; Eagley & Chaiken, 1992). For behaviors that require complicated skills and social cooperation, intention alone would not bring about the expected outcome. Furthermore, the theory's concept of social norm inherently covers a wide range of social perceptions and expectations that may prove to be quite complicated when measured as a single dimension. The contention of this study is that the concept needs to be expanded to cover several enabling factors such as the availability and reliability of provision of instrumental, social and emotional resources. As suggested by Hubley (1993), in addition to attitudes and subjective norms, enabling factors help translate intention into behavior. Enabling factors include aspects of the social context that provide conditions conducive to the behavior. Enabling factors do not convey any particular norm, however, they provide the instrumental means for social norms to be functional. The position taken in this paper is that a new concept needs to be introduced consisting of several theoretically legitimate components including social embeddedness, actual instrumental support (received support), perceived instrumental support, informational support and perceived norms. This new concept—which could be called social input—goes beyond TRA's concept of subjective norm and distinguishes between social norms and enabling factors that have independent effects on breastfeeding behavior. Conceptualization of social input This section will briefly outline the conceptualizations of different components of social input that were adopted in this study. Perceived norms TRA's concept of subjective, or perceived, social norm is defined as pressure to conform to the expectations of others. It refers to implicit rules about acceptable ways to think and behave. It involves feelings of “oughtness”, normative judgements, and shared frame of reference. In this sense, social norms or social influence direct and guide behavior and implicitly provide support to those who conform in the form of approval.