Abstract
BACKGROUND: Difficulties with breastfeeding can lead to early breastfeeding cessation. Empowering mothers through self-assessment and education of breastfeeding skills can help support them. We aimed to develop and validate a tool for self-screening and education on breastfeeding skills. METHODS: A six-item tool was developed through literature review and expert interviews, covering domains of breastfeeding position, nipple shape, breast engorgement, infant latch, swallowing and intake. Eight experts assessed the tool's relevance, clarity, simplicity and ambiguity. Scores were used to determine item-level content validity index (I-CVI) and scale-level content validity index (S-CVI). Items with values ≤ 0.83 (best possible score = 1.00) were revised. Following revision, a convenience sample of breastfeeding mothers were recruited from maternity wards and clinics to determine the tool's internal consistency, face, criterion and construct validity. Participants and lactation consultants (LC) independently completed the tool based on the same breastfeeding episode. Internal consistency was determined by Cronbach's alpha. Criterion validity was assessed by comparing participant and LC scores using Bland-Altman plots. Construct validity was determined by comparing scores in participants who were and were not referred to a LC. Receiver operating characteristic (ROC) curve was used to determine a cut-off score for LC referral by optimizing sensitivity and specificity. RESULTS: The tool demonstrated acceptable content validity, with I-CVI and S-CVI values for relevance, clarity, simplicity and ambiguity above the threshold, except for S-CVI of simplicity and ambiguity, and the tool was revised accordingly. Most mothers who completed the tool (n = 58) found it easy to understand (87.9%), relevant (91.4%) and useful (86.2%). Cronbach's alpha was 0.66, which improved to 0.74 with the removal of the item on "engorgement". With the remaining five items, ROC analysis showed an area under the curve of 0.79 [(95%CI 0.67-0.90), p < 0.001], with a score of ≤ 6 indicative of an LC referral (sensitivity = 86%, specificity = 55%). Bland-Altman plots showed acceptable agreement between participant and LC scores with a mean difference of 0.22 (95%CI -3.02-3.47). CONCLUSIONS: We developed and validated a simple five-item tool for mothers to assess and be educated about breastfeeding skills. Further study on the tool's predictive validity and effectiveness within a clinical pathway is warranted.