An Assessment of the Social Cognitive Predictors of Exclusive Breastfeeding Behavior Using the Health Action Process Approach
Authors: Martinez‐Brockman Josefa L. , Shebl Fatma , Harari Nurit , Perez‐Escamilla Rafael 
Published: June 2021

In the United States rates of exclusive breastfeeding duration remain exceedingly low. Exclusive breastfeeding is a complex learned behavior that is influenced by social cognitive, interpersonal, and structural level factors. Interventions are needed that address factors at multiple levels of the social‐ecological model. This study was designed to examine the social cognitive predictors of exclusive breastfeeding behavior in a sample of low‐income women attending the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) breastfeeding peer counseling program and enrolled in the LATCH study. The objectives were to examine whether: (1) the theoretical model, the Health Action Process Approach (HAPA), fit the data well; (2) planning mediated the effect of intentions and maintenance self‐efficacy on exclusive breastfeeding; and (3) recovery self‐efficacy mediated the association between maintenance self‐efficacy and exclusive breastfeeding behavior. Outcome expectancies, action self‐efficacy and intentions were assessed prenatally at baseline in N = 119 participants. Maintenance self‐efficacy, planning, recovery self‐efficacy and breastfeeding behavior were measured at two weeks post partum. Structural equation modeling with mean and variance adjusted Weighted Least Squares estimation was used to examine the applicability of the HAPA model to the data.Participants were on average 27.5 (SD = 5.4) years of age, 151.0 (SD = 44.5) pounds and 23.6 (SD = 2.9) weeks gestation at recruitment. More than three‐quarters self‐identified as Hispanic, 68.1% were single, never married, 71.6% lived with their partner, and over 60.0% preferred to speak English. Over 60.0% had other children at home and 53.5% had previous breastfeeding experience. Factor loadings ranged from 0.54 to 0.99 and all indicator variables loaded significantly on their hypothesized constructs (p < 0.001). Correlations between latent constructs were weak or moderate, with a few exceptions. Action self‐efficacy and intentions were highly correlated (r = 0.82; p < 0.001), as were maintenance and recovery self‐efficacy (r = 0.78; p < 0.001). The hypothesized model fit the data well CFI = 0.97, TLI = 0.96, and RMSEA of 0.05 (90% CI: 0.03, 0.06; p = 0.70). Planning (0.55; p = 0.006), maintenance self‐efficacy (−0.87; p = 0.028), and recovery self‐efficacy (0.64; p = 0.026) each significantly predicted exclusive breastfeeding behavior. Planning and recovery self‐efficacy mediated the association between maintenance self‐efficacy and exclusive breastfeeding (Indirect effect of planning = 0.31; p = 0.028, and indirect effect of recovery self‐efficacy = 0.50; p = 0.046). Planning did not emerge as a mediator between intentions and behavior. These results demonstrate the utility of the HAPA model in predicting exclusive breastfeeding behavior among low‐income women attending WIC. LATCH is a theoretically sound text messaging intervention that can be used to enhance breastfeeding self‐efficacy and planning through the WIC breastfeeding peer counseling process.Support or Funding InformationThis project has been funded with Federal funds from the U.S. Department of Agriculture, Food and Nutrition Service through grant WIC NEI‐12‐TX to Baylor College of Medicine to Dr. Rafael Pérez‐Escamilla at Yale University. The contents of this publication do not necessarily reflect the view or policies of the U.S. Department of Agriculture, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government.