Ci a ion: Vale o-Chille ón, M.J.;
Vila-Candel, R.; Mena-Tudela, D.;
So iano-Vidal, F.J.; González-Cho dá,
V.M.; And eu-Pejo, L.; An olí-Fo ne ,
A.; Du án-Ga cía, L.; Vicen -
Fe andis, M.; And és-Aleg e, M.E.;
e al. De elopmen and Valida ion o
he B eas eeding Li e acy
Assessmen Ins umen (BLAI) o
Obs e ic Women. In . J. En i on. Res.
Public Heal h 2023,20, 3808. h ps://
doi.o g/10.3390/ije ph20053808
Academic Edi o : Vie i Las ucci
Recei ed: 20 Janua y 2023
Re ised: 18 Feb ua y 2023
Accep ed: 20 Feb ua y 2023
Published: 21 Feb ua y 2023
Copy igh : © 2023 by he au ho s.
Licensee MDPI, Basel, Swi ze land.
This a icle is an open access a icle
dis ibu ed unde he e ms and
condi ions o he C ea i e Commons
A ibu ion (CC BY) license (h ps://
c ea i ecommons.o g/licenses/by/
4.0/).
In e na ional Jou nal o
En i onmen al Resea ch
and Public Heal h
A icle
De elopmen and Valida ion o he B eas eeding Li e acy
Assessmen Ins umen (BLAI) o Obs e ic Women
Ma ía Jesús Vale o-Chille ón1, Ra ael Vila-Candel 2,3,4,* , Desi ée Mena-Tudela 1,* ,
F ancisco Ja ie So iano-Vidal 2,4,5,6, Víc o M. González-Cho dá1,7 , Lau a And eu-Pejo 1,
Aloma An olí-Fo ne 1, LledóDu án-Ga cía1, Mi yam Vicen -Fe andis 8, Ma ía Eugenia And és-Aleg e 3
and Águeda Ce e a-Gasch 1
1Depa men o Nu sing, Uni e si a Jaume I. A de Vicen Sos Bayna , 12071 Cas elló, Spain
2Depa men o Nu sing, Uni e si a de València, 46007 Valencia, Spain
3Depa men o Obs e ics and Gynaecology, Hospi al Uni e si a io de la Ribe a, 46600 Valencia, Spain
4Founda ion o he P omo ion o Heal h and Biomedical Resea ch in he Valencian Region (FISABIO-SP),
46020 Valencia, Spain
5Depa men o Nu sing, Uni e si y o Alican e, 03080 Alican e, Spain
6Depa men o Obs e ics and Gynaecology, Hospi al Luis Alcanyis, 46800 Xà i a, Spain
7Nu sing and Heal hca e Resea ch Uni (In es én-Isciii), Ins i u e o Heal h Ca los III, 28029 Mad id, Spain
8Depa men o Ma e ni y, Hospi al Gene al Uni e si a io, 12004 Cas elló, Spain
*Co espondence: a ael. ila@u .es o [email p o ec ed] (R.V.-C.); [email p o ec ed] (D.M.-T.)
Abs ac :
Backg ound: Despi e in e na ional e o s o p o ec and p omo e exclusi e b eas eeding
(EBF) o in an s up o six mon hs o age, global a es o EBF con inue o all sho o he a ge s
p oposed by he WHO o 2025. P e ious s udies ha e shown a ela ionship be ween he le el o
heal h li e acy and he du a ion o EBF, al hough his ela ionship was no de e minan , p obably
due o he use o a gene ic heal h li e acy ques ionnai e. The e o e, his s udy aims o design and
alida e he i s speci ic b eas eeding li e acy ins umen . Me hods: A B eas eeding Li e acy ins u-
men was de eloped. Con en alida ion was ca ied ou by a g oup o 10 expe s in heal h li e acy,
b eas eeding o ins umen alida ion, ob aining a Con en Validi y index in Scale (S-CVI/A e) o
0.912. A mul icen e c oss-sec ional s udy was ca ied ou in h ee Spanish hospi als o de e mine
he psychome ic p ope ies (cons uc alidi y and in e nal consis ency). The ques ionnai e was
adminis e ed o 204 women du ing he clinical pue pe ium. Resul s: The Kaise -Meie -Oklin Tes
(
KMO = 0.924
) and Ba le ’s Tes o Sphe ici y (X
2
= 3119.861; p
≤
0.001) con i med he easibili y o
he Explo a o y Fac o Analysis, which explained 60.54% o he a iance wi h ou ac o s. Conclu-
sions: The B eas eeding Li e acy Assessmen Ins umen (BLAI) consis ing o 26 i ems was alida ed.
Keywo ds: b eas eeding; b eas eeding li e acy; ques ionnai es; alida ion s udy
1. In oduc ion
P egnancy and he pos pa um pe iod cons i u e an impo an s age in women’s
heal h, in which a se ies o e en s ake place ha equi e special a en ion and moni o ing
by he heal h sys em. Al hough i is a physiological p ocess, i in ol es a con inuum
o decision-making in which women need o ha e su icien in o ma ion so ha hese
decisions p o ec and p omo e no only hei heal h, bu also ha o hei child en.
One o he mos impo an decisions o be made is ega ding he eeding he in an will
ecei e. In e na ional o ganisa ions such as he Wo ld Heal h O ganisa ion and UNICEF
ecommend exclusi e b eas eeding (EBF) o he i s six mon hs o an in an ’s li e and
b eas eeding wi h complemen a y oods un il a leas wo yea s o age [
1
]. The p omo ion
o EBF is an in e na ional a ge in di e en p og ammes such as he Comp ehensi e
Implemen a ion Plan on Ma e nal, In an , and Young Child Nu i ion o he Wo ld Heal h
Assembly [
2
], he Uni ed Na ions Decade o Ac ion on Nu i ion 2016–2025 [
3
], and he
In . J. En i on. Res. Public Heal h 2023,20, 3808. h ps://doi.o g/10.3390/ije ph20053808 h ps://www.mdpi.com/jou nal/ije ph
In . J. En i on. Res. Public Heal h 2023,20, 3808 2 o 14
in es men amewo k o he Wo ld Bank [
4
]. Howe e , despi e mul iple e o s o p o ec
b eas eeding (BF), a es o EBF a six mon hs o in an li e emain e y low, a a ound
38% globally [
5
]. Fu he mo e, laws o p o ec b eas eeding emain inadequa e in mos
coun ies [
6
]. In Eu ope, he six-mon h EBF a e is a ound 25% [
7
]. Howe e , in Spain, he
six-mon h EBF a e has a ied om 16.8% in 2019 [
8
] o 39% in 2017 [
9
]. The da a need
o be in e p e ed wi h cau ion as he a ia ion in hese da a is caused by he absence o a
uni ied app oach o collec ing and moni o ing BF in o ma ion in Spain.
The p ema u e discon inua ion o b eas eeding is a complex phenomenon ha is
in luenced by a mul i ude o ac o s, including demog aphic cha ac e is ics (e.g., young
ma e nal age, low le els o educa ion and socio-economic s a us), social conside a ions
(e.g., inadequa e wo kplace suppo ), psychological de e minan s (e.g., ma e nal in en ions
be o e bi h, sel -assu ance, and engagemen in b eas eeding), as well as biological consid-
e a ions (e.g., in an heal h conce ns, ma e nal heal h issues, i s - ime mo he hood, and
issues ela ed o lac a ion) [
10
–
13
]. These conside a ions con ibu e o he mul i ace ed
na u e o ea ly b eas eeding cessa ion. Howe e , se e al s udies ha e shown ha , in many
cases, ea ly weaning occu s due o ma e nal decisions o pe cep ions, which do no always
co espond o eali y [
14
]. In he ace o hese alse pe cep ions, heal h li e acy (HL) has a
undamen al ole because he p ima y ou come o ha ing a good le el o HL is he abili y
o make good decisions ha p omo e and p o ec heal h [15].
Va ious au ho s ha e b oadly de ined he concep o HL o e ime [
16
]. Despi e he
lack o consensus on cons uc ing a single de ini ion o his concep , mos au ho s ag ee
ha i is mul idimensional, complex, and he e ogeneous [
17
]. Sø ensen e al. p oposed an
in eg a ed model o HL ha looked a cogni i e and social skills ha enable he indi idual
o add ess ou compe encies (access, unde s and, app aise, and apply heal h in o ma ion)
and h ee domains in which he indi idual in e ac s wi h he heal h sys em (heal h ca e,
disease p e en ion, and heal h p omo ion) [18].
This complex concep o HL has been e o mula ed and adap ed o speci ic heal h a eas
o popula ions. As a esul , i is possible o e ie e a mul i ude o alida ed ins umen s
ha allow us o gene ically assess he le el o HL, such as he Eu opean Heal h Li e acy
Su ey Ques ionnai e (HLS-EU-Q) [
19
] o he es o unc ional heal h li e acy in adul s
(TOFHLA) [
20
]. The e a e also ins umen s a ailable ha ocus on measu ing li e acy in
speci ic heal h a eas, such as he Li e acy Assessmen o Diabe es (LAD), which add esses
diabe es li e acy [
21
]. O he s ocus on speci ic popula ions, such as he eHeal h Li e acy
Scale (eHEALS), which add esses elec onic heal h li e acy in a young popula ion [
22
]. I is
also possible o e ie e he Ma e nal Heal h Li e acy In en o y in P egnancy (MHELIP)
ins umen , which is designed o measu e ma e nal heal h li e acy [
23
]. Howe e , o ou
knowledge, no p e ious ins umen has measu ed b eas eeding li e acy (BFL).
Recen s udies ha e sugges ed ha an adequa e le el o HL may be a p o ec i e
ac o agains ea ly BF cessa ion [
12
,
13
,
24
]. Howe e , hese s udies use gene ic HL in-
s umen s o de e mine he ela ionship be ween HL and he speci ic heal h domain o
BF. Speci ically, hey use he Sho Assessmen o Heal h Li e acy o Spanish-speaking
Adul s (SAHLSA) [
24
] and he Newes Vi al Sign (NVS) in i s alida ed e sion o Spanish-
speaking popula ions [
12
,
13
,
24
]. The main indings o using a gene ic ins umen o explo e
a pa icula a ea o heal h lack speci ici y and conc e eness in he esul s ob ained, so he
au ho s ag ee on he need o a speci ically alida ed ins umen o measu e he le el o
BFL in women du ing he pe ina al s age [12,13,24].
The e o e, his s udy aims o design and alida e a speci ic ins umen o measu e he
le el o BFL.
2. Ma e ials and Me hods
2.1. Design, Se ing, and Pa icipan s
A design and alida ion s udy o he B eas eeding Li e acy Assessmen Ins umen
(BLAI) was conduc ed o assess he le el o BFL in a Spanish con ex . The s udy ook place
om 1 Decembe 2021 o 30 Sep embe 2022.
In . J. En i on. Res. Public Heal h 2023,20, 3808 3 o 14
The p ojec was designed unde O ganic Law 03/2018, o 5 Decembe , unde he
P o ec ion o Pe sonal Da a and Gua an ee o Digi al Righ s. Fi s , he ins umen was
designed by e iewing he li e a u e and con en alidi y by c ea ing a panel o expe s.
Second, a c oss-sec ional s udy was ca ied ou on women du ing he clinical pos pa um
pe iod in h ee hospi als in he Valencian Communi y (Spain): Hospi al Uni e si a io de La
Ribe a (HULR); Hospi al Gene al de Cas ellón and Hospi al Lluís Alcanyís de Xà i a (Spain)
o de e mine he psychome ic p ope ies o he BLAI. Inclusion c i e ia we e: ha ing gi en
bi h in one o he pa icipa ing hospi als and olun a ily ag eeing o pa icipa e in he
s udy. Exclusion c i e ia we e: ha ing a linguis ic ba ie ha impeded unde s anding and
comple ion o he da a collec ion o m, mul iple ges a ions, o he neona e being admi ed o
a neona al ca e uni . Pa icipan s comple ed an online in o med consen o m p io o da a
collec ion. The E hics and Resea ch Commi ees o each pa icipa ing hospi al app o ed he
s udy. Fu he mo e, he p inciples o he Decla a ion o Helsinki we e espec ed h oughou
his e o .
Acco ding o An hoine e al.’s ecommenda ions o ins umen alida ion, a sample
size o be ween i e and en pa icipan s pe ins umen i em is ecommended [
25
]. Thus,
gi en ha he ini ial e sion o he ins umen had 28 i ems, a sample o be ween 140 and
280 pa icipan s was equi ed. Howe e , acco ding o Fe ando y Anguiano-Ca asco, a
minimum sample size o 200 pa icipan s is ecommended o assess he quali y o a ques-
ionnai e [
26
]. The e o e, a sample size o a leas 200 pa icipan s would be su icien o
sa is y bo h c i e ia. A non-p obabilis ic con enience sampling was pe o med, in which a
da a collec ion o m was adminis e ed consis ing o sociodemog aphic a iables (age, coun-
y o o igin, educa ional le el, pe cei ed socioeconomic s a us), obs e ic a iables (pa i y,
eeding doub s be o e bi h, p e ious BF, a iables ela ed o p e ious BF expe ience), and
he BLAI.
2.2. Ques ionnai e De elopmen and Con en Validi y
The BLAI was designed based on he de ini ion o he HL concep adap ed o he
BF con ex . I was he e o e o ganised in o he ollowing dimensions: D1: Access o
b eas eeding- ela ed in o ma ion; D2: Unde s anding o such in o ma ion; D3: App aise
he e aci y o in o ma ion ela ed o b eas eeding; D4: Applica ion o ha in o ma ion.
The o mula ion o he i ems was based on he di icul y in dealing wi h he si ua ions
desc ibed, es ablishing a Like - ype scale wi h ou esponse op ions o a oid cen al
endency e o s. The i ems we e de eloped based on he in eg a ed model o heal h li e acy
p oposed by Sø ensen e al. [
18
]. This model conside s he dimensions men ioned abo e
and applies hem o heal hca e, disease p e en ion, and heal h p omo ion. Likewise, i
conside s he pe spec i e o he indi idual’s capaci y and he in e ac ion ha he indi idual
has wi h he social and heal h en i onmen .
Following he de elopmen o he i s ba e y o i ems, a panel o nine expe s in
b eas eeding, heal h li e acy, and ques ionnai e de elopmen and alida ion, which in-
cluded midwi es, lac a ion consul an s, and esea ch nu ses, was o med. The ini ial
i e a ion o he su ey ins umen was p esen ed o a panel o expe s o an e alua ion
o i s o e all ele ance, he app op ia eness o indi idual i ems wi hin he con ex o each
dimension, and he iden i ica ion o o he i em-speci ic eedback. As many ounds as
necessa y we e ca ied ou un il an a e age cong uence pe cen age (ACP) o 0.9, as ec-
ommended by he li e a u e, was eached [
27
]. Fo his pu pose, he I em Con en Validi y
Index (I-CVI) was calcula ed using he me hodology p oposed by Poli and Beck, wi h
conside a ions gi en o he le el o alidi y o each i em, he p obabili y o ag eemen
due o chance (Pc), and he modi ied Kappa coe icien [
27
]. In addi ion, he o e all scale
a e age (S-CVI) was calcula ed, which de e mines he mean o he sco es o all he I-CVIs
and e lec s he o e all alidi y o he ins umen .
In . J. En i on. Res. Public Heal h 2023,20, 3808 4 o 14
2.3. Psychome ic P ope ies
A e con en alida ion, he ins umen was adminis e ed o women in he pa icipa -
ing hospi als du ing he clinical pos pa um pe iod, p o ided hey olun a ily ag eed o
pa icipa e in he s udy.
Fi s , a desc ip i e analysis o he sample was ca ied ou using he mean, s anda d
de ia ion, and 95% con idence in e al o quan i a i e a iables and absolu e and ela i e
equencies o quali a i e a iables. A e his ini ial analysis, cons uc alidi y was
s udied using an explo a o y ac o analysis (EFA). Fo his pu pose, he ac o ex ac ion
me hod used was p incipal axis ac o isa ion, applying an oblique ac o ial o a ion, gi en
he po en ial co ela ion be ween he di e en ac o s. The P oMax o a ion me hod was
used since a dominan ac o was no conside ed. P e iously, he easibili y o he EFA
was con i med wi h he Kaise -Maye -Olkin (KMO) es and Ba le ’s es o sphe ici y. A
ac o loading g ea e han 0.4 was conside ed o e ain i ems in a gi en ac o [
28
]. The
dimensionali y o he ins umen was s udied using he Kaise c i e ion, which conside s
as many ac o s as eigen alues g ea e han 1 a e p esen [29].
Second, he ins umen ’s in e nal consis ency and dimensions we e de e mined. Since
an o dinal esponse scale was used, McDonald’s Omega was employed (adequa e in e nal
consis ency o
ω
= 0.7–0.9) [
30
]. Due o he non-no mali y o he o e all sco es o each
dimension, Spea man’s co ela ion coe icien was used o in es iga e he ela ionship be-
ween he di e en elemen s o he ins umen . A ange be ween 0.50–0.70 was conside ed
a good co ela ion, and >0.7 was a s ong co ela ion [31].
2.4. In e en ial Analysis
A e s udying he ins umen ’s psychome ic p ope ies, an in e en ial analysis was
ca ied ou o explo e he associa ion be ween he le el o BFL and he es o he a iables
included in he s udy, using Chi-squa ed o Fishe ’s exac es , depending on he na u e o
he a iables. Pa icipan s we e i s g ouped by de e mining he cu -o poin s o each
o he dimensions o he BLAI ques ionnai e using clus e analysis. The k-means me hod
was used, o cing wo g oups o di e en ia e be ween inadequa e and adequa e BFL le els,
ob aining s a is ically signi ican di e ences be ween he wo g oups.
S a is ical analysis was ca ied ou wi h SPSS .26, conside ing a s a is ical signi icance
le el o p< 0.05.
3. Resul s
3.1. BLAI Valida ion Resul s
An ACP o 0.864 was achie ed o con en alidi y h ough he panel o expe s (n= 9)
a e he i s ound. The expe s’ con ibu ions o e o mula ing some i ems we e g ea ly
alued; hey added new i ems o co e ce ain aspec s no con empla ed and changed
he dimension o o he s. A e conduc ing a second ound, he au ho s ob ained an ACP
sco e o 0.913, which me he pe cen age ecommended by ele an esea ch. A e his
second ound, only mino modi ica ions we e made o he wo ding o he i ems, esul ing
in a e sion o he ins umen consis ing o 28 i ems (Access six i ems; Unde s and i e
i ems, App aise en i ems, Apply se en i ems). The wo ding o he i ems is a ailable in
he supplemen a y ma e ial (Table S1), bo h in he o iginal e sion in Spanish and in he
ansla ed e sion (no alida ed) in English.
Rega ding he modelling o he ins umen h ough explo a o y ac o analysis (EFA),
i was obse ed ha wo i ems (Access6 and App aise6) ob ained a poo ac o loading
(<0.4) in he dimension o which hey we e de eloped. Mo eo e , acco ding o heo e ical
easoning, hese wo i ems had no place in ano he dimension. In addi ion, he ins umen ’s
in e nal consis ency sligh ly inc eased when hese i ems we e emo ed, so hey we e
elimina ed om he ins umen , which wen om 28 i ems o 26 i ems.
Rega ding he new 26-i em e sion, KMO (0.924) and Ba le ’s Tes o Sphe ici y
(
X2= 3119.861
;p
≤
0.001) con i med he easibili y o he EFA. The ac o analysis explained
60.54% o he a iance wi h a o al o ou ac o s, coinciding wi h he heo e ical design
In . J. En i on. Res. Public Heal h 2023,20, 3808 5 o 14
o he ins umen . Speci ically, he i s ac o (Access) explained 44.02% o he a iance
and consis ed o i e i ems, he second ac o (Apply) explained 8.04% o he a iance and
comp ised se en i ems, he hi d ac o (App aise) explained 4.38% o he a iance and
consis ed o nine i ems, and he ou h ac o (Unde s and) explained 4.09% o he a iance
and consis ed o i e i ems. The o e all eliabili y o he ques ionnai e (
ω
= 0.949) and o
each o he dimensions (Access
ω
= 0.809; Unde s and
ω
= 0.810; App aise
ω
= 0.912; Apply
ω
= 0.873) was excellen . Table 1shows he esul s o he con en alidi y, explo a o y ac o
analysis, and eliabili y o he BLAI.
Table 1. Con en alidi y, Explo a o y Fac o Analysis, and eliabili y o BLAI.
Con en Validi y Index Fac o s Communali ies
1234ω1
Access 0.907 0.809
Access1 1.00 0.676 0.399 0.311 0.402 0.948 0.490
Access2 1.00 0.748 0.403 0.419 0.401 0.948 0.560
Access3 1.00 0.687 0.318 0.356 0.411 0.948 0.505
Access4 1.00 0.656 0.367 0.391 0.552 0.948 0.563
Access5 0.67 0.565 0.405 0.445 0.557 0.947 0.534
Unde s and 0.956 0.810
Unde s and1 1.00 0.426 0.460 0.551 0.529 0.947 0.476
Unde s and2 1.00 0.645 0.520 0.552 0.602 0.946 0.615
Unde s and3 0.89 0.713 0.422 0.473 0.615 0.947 0.601
Unde s and4 0.89 0.587 0.399 0.404 0.707 0.947 0.557
Unde s and5 1.00 0.494 0.485 0.480 0.725 0.947 0.526
App aise 0.856 0.912
App aise1 0.89 0.510 0.601 0.673 0.741 0.946 0.715
App aise2 0.78 0.508 0.580 0.634 0.679 0.946 0.654
App aise3 0.78 0.340 0.665 0.696 0.676 0.946 0.608
App aise4 1.00 0.338 0.639 0.703 0.603 0.946 0.584
App aise5 0.67 0.330 0.513 0.771 0.396 0.947 0.589
App aise7 1.00 0.394 0.549 0.801 0.525 0.947 0.654
App aise8 0.89 0.423 0.610 0.749 0.605 0.946 0.616
App aise9 0.89 0.489 0.590 0.692 0.616 0.946 0.625
App aise10 0.78 0.371 0.708 0.729 0.555 0.946 0.653
Apply 0.968 0.873
Apply1 1.00 0.380 0.706 0.618 0.645 0.946 0.611
Apply2 1.00 0.446 0.669 0.573 0.456 0.947 0.521
Apply3 1.00 0.471 0.587 0.472 0.607 0.947 0.481
Apply4 1.00 0.410 0.852 0.625 0.510 0.946 0.691
Apply5 1.00 0.485 0.776 0.587 0.494 0.946 0.618
Apply6 0.78 0.255 0.582 0.484 0.550 0.948 0.479
Apply7 1.00 0.335 0.692 0.482 0.537 0.947 0.534
1In e nal Consis ency measu ed wi h MacDonald’s Omega.
As also shown in Table 1, he s uc u e ma ix demons a es ha mos i ems ob ained
a highe ac o loading o he dimension hey we e designed o , excep o he ollowing
se en i ems ha showed a conside able ac o loading o wo di e en dimensions. The
o mula ion o he Unde s and1 i em does no i in o he App aise dimension. The o mu-
la ion o he Unde s and3 i em could be conside ed in bo h he Access and Unde s and
dimensions, al hough he heo e ical easoning gi es i mo e weigh in he Unde s and
dimension. The wo ding o he Unde s and2 and Unde s and4 i ems means hey do no i
in o he Access dimension. Finally, App aise1, App aise2, and Apply3 canno be included
in he Unde s and dimension.
In . J. En i on. Res. Public Heal h 2023,20, 3808 6 o 14
Rega ding he co ela ion be ween he di e en dimensions, i is obse ed ha all he
co ela ions a e good. Speci ically, he co ela ion be ween he App aise-Unde s and and
App aise-Apply dimensions is s ong, as hey a e all s a is ically signi ican (Table 2).
Table 2. Co ela ion ma ix be ween he dimensions o BLAI.
Access Unde s and App aise Apply
Access 1.000
Unde s and 0.680 1.000
App aise 0.546 0.707 1.000
Apply 0.535 0.662 0.761 1.000
Rho de Spea man; All co ela ions a e signi ican a he <0.001 le el (bila e al).
Table 3shows he minimum and maximum sco es ob ained in each dimension acco d-
ing o he clus e analysis ca ied ou o di e en ia e be ween inadequa e and adequa e
BFL. In addi ion, he desc ip i e analysis o BLAI o each o he dimensions can also be
obse ed, in which i can be seen ha he majo i y o he pa icipan s a e in he ca ego y o
Adequa e BFL in all he dimensions, wi h he Unde s and dimension ha ing he lowes
pe cen age o women wi h Adequa e BFL (54.9%, n= 112) and he Apply dimension ha ing
he highes pe cen age o women wi h Adequa e BFL (66.2%, n= 135).
Table 3. Cu -o poin s be ween inadequa e and adequa e BFL and desc ip i e analysis o BLAI.
Inadequa e BFL Adequa e BFL
p3
Min Max n1%2Min Max n%
Access 1.8 3.00 82 40.2 3.20 4.00 122 59.8 <0.001
Unde s and
1.8 3.00 92 45.1 3.20 4.00 112 54.9 <0.001
App aise 1.44 2.78 70 34.3 2.89 4.00 134 65.7 <0.001
Apply 1.29 2.71 69 33.8 2.86 4.00 135 66.2 <0.001
1Absolu e equencies; 2Rela i e equencies; 3Clus e analysis. BFL = b eas eeding li e acy.
3.2. Desc ip i e Analysis
A o al sample size o 204 pa icipan s was eached. The mean ma e nal age was
32.8 yea s (SD = 5.143; 95% CI 32.09–33.51). A o al o 45.59% (n= 93) o he deli e ies we e
a ended a HULR, 83.8% (n= 171) o he women we e o iginally om Spain, 50.5% (n= 103)
had a uni e si y educa ion, and 85.3% (n= 174) epo ed ha ing a medium socioeconomic
s a us (Table 4).
Rega ding he ype o b eas eeding a discha ge, 74% (n = 151) o he women chose
Exclusi e B eas eeding (EBF), 6.4% (n= 13) mixed b eas eeding, and 19.6% (n= 40)
chose o mula eeding. Table 5shows a iables ela ed o he ype o b eas eeding chosen
du ing he pue pe ium. I was obse ed ha 72.7% (n= 80) o p imipa ous women chose
EBF. O he women who op ed o EBF, 82.3% (n= 135) had no doub s abou he ype o
b eas eeding, while 38.5% (n= 15) did ha e doub s du ing ges a ion, al hough hey inally
chose EBF. Only one woman epo ed op ing o EBF due o p essu e om he en i onmen .
As o he gene al pe cep ion o he p e ious BF expe ience (n= 82), 52.4% (n= 44)
pe cei ed i as a e y good expe ience, and nine o hem (10.7%) epo ed ha ing a egula
p e ious BF expe ience. Only 45.3% (n= 38) el suppo ed a all imes by heal hca e
p o essionals, and 39.3% (n= 33) el suppo ed a all imes by amily and iends. The
63.4% (n= 52) ed EBF up o six mon hs o mo e o hei p e ious child. As o a eason o
gi ing up b eas eeding, 36.9% (n= 31) o he cases we e physiologically weaned, while
20.3% (n= 17) we e weaned because hey had s a ed wo king.
In . J. En i on. Res. Public Heal h 2023,20, 3808 7 o 14
Table 4. Sociodemog aphic Cha ac e is ics.
n1%2
Hospi al
H. Uni e si a io de La Ribe a 93 45.6
H. Gene al Uni e si a io de Cas ellón 88 43.1
H. Lluís Alcanyís de Xà i a 23 11.3
Coun y o o igin
Spain 171 83.8
Cen al and Sou h Ame ica 20 9.8
Res o Eu opean Union Coun ies 9 4.4
O he 1 0.5
Educa ional le el
P ima y s udies 33 16.2
P o essional aining 68 33.3
Deg ee, bachelo ’s deg ee 68 33.3
Mas e ’s deg ee o Phd 35 17.2
Pe cei ed socioeconomic s a us
Low 26 12.7
Middle 174 85.3
High 4 2
1Absolu e equencies; 2Rela i e equencies.
Table 5. Desc ip i e analysis o obs e ic and b eas eeding- ela ed a iables.
Exclusi e B eas eeding Mixed Feeding Fo mula Feeding
n1%2n%n%
Pa i y
Fi s 80 39.2 6 2.9 24 11.8
Second 55 27 5 2.5 11 5.4
Thi d o mo e 16 7.8 2 1.00 5 2.5
Feeding doub s be o e bi h
I had no doub s 135 66.2 6 2.9 23 11.3
I had doub s, bu i was my own ee will 15 7.4 7 3.4 17 8.3
I had doub s, I el p essu ed 1 0.5 - - - -
P e ious BF
Yes 70 34.3 5 2.5 7 3.4
No 81 39.7 8 3.9 31 15.2
Gene al pe cep ion o p e ious b eas eeding expe ience (n= 82)
Ve y good 43 51.2 1 1.2 - -
Good 18 21.4 2 2.4 2 2.4
Regula 9 10.7 1 1.2 3 3.6
Bad - - 1 1.2 4 4.8
P o essional suppo ecei ed du ing p e ious b eas eeding (n= 82)
Suppo ed a all imes 33 39.3 2 2.4 3 3.6
Suppo ed mos o he imes 12 14.3 2 2.4 2 2.4
Suppo ed some imes 8 9.5 1 1.2 1 1.2
Insu icien suppo 17 20.2 - - 3 3.6
Suppo om amily and iends ecei ed du ing p e ious b eas eeding (n= 82)
Suppo ed a all imes 28 33.3 1 1.2 4 4.8
Suppo ed mos o he imes 20 23.8 3 3.6 3 3.6
Suppo ed some imes 6 7.1 1 1.2 - -
Insu icien suppo 16 19 - - 2 2.4
In . J. En i on. Res. Public Heal h 2023,20, 3808 8 o 14
Table 5. Con .
Exclusi e B eas eeding Mixed Feeding Fo mula Feeding
n1%2n%n%
Mon hs exclusi ely b eas ed du ing p e ious b eas eeding (n= 82)
1 mon h o less 4 4.8 3 3.6 8 9.5
2–3 mon hs 8 9.5 - - - -
4–5 mon hs 8 9.5 - - 1 1.2
6 mon hs o mo e 50 61 2 2.4 - -
Main eason o abandonmen o p e ious b eas eeding (n= 82)
P e ious BF has no ended 6 7.1 - - - -
Physiological weaning 31 36.9 - - - -
B eas p oblems un ela ed o BF 1 1.2 - - 2 2.4
B eas p oblems ela ed o BF 2 2.4 - - 2 2.4
Lack o p o essional suppo 1 1.2 1 1.2 - -
Lack o amily suppo 1 1.2 - - 1 1.2
Wo k inco po a ion 15 17.9 2 2.4 - -
Pe cei ed lack o b eas milk 8 9.5 - - 4 4.8
Reduced in an weigh gain 5 6 2 2.4 - -
1Absolu e equencies; 2Rela i e equencies; BF: b eas eeding.
3.3. B eas eeding Li e acy Assessmen Ins umen
Table 6shows ha as he pe cei ed socioeconomic le el inc eases, he pe cen age o
pa icipan s wi h adequa e Access BFL inc eases (p= 0.016). I can also be seen ha he
pe cen age o women wi h adequa e Unde s and BFL o adequa e Apply BFL is highe in
hose women who o e EBF (Unde s and: 59.6%, n= 90, p= 0.023; Apply: 70.9%, n= 107,
p= 0.026), while hose who op ed o mixed b eas eeding ob ained a lowe pe cen age
(Unde s and: 23.01%, n= 3, p= 0.023; Apply: 38.5%, n= 5, p= 0.026). Rega ding he
App aise dimension, he pe cen age o Adequa e App aise BFL is lowe among p imipa ous
women (p= 0.022), and he highes pe cen ages a e obse ed among mul ipa ous women
o second (78.9%, n= 56) o subsequen ges a ions (65.2%, n= 15), wi h he di e ences
being s a is ically signi ican (p= 0.018). Rega ding he Apply dimension, he pe cen age
o women wi h Adequa e Apply BFL is highe among mul ipa ous women o second
ges a ion (77.5%, n= 55), ollowed by p imipa ous women (60.9%; n= 67). Mul ipa ous
women o hi d o la e ges a ions we e he ones wi h he lowes pe cen age o Adequa e
Apply BFL. A compa a i e analysis o sociodemog aphic and BF- ela ed a iables o each
o he dimensions o he BLAI ques ionnai e can be ound in he supplemen a y ma e ial
(Tables S2–S5).
Table 6. S a is ically signi ican associa ions wi h he dimensions o he BLAI ques ionnai e.
Inadequa e BFL Adequa e BFL
p-Value
n1%2n%
Access
Socioeconomic s a us 0.016 3
Low 16 61.5 10 38.5
Middle 66 37.9 108 62.1
High - - 4 100
Unde s and
Lac a ion ype 0.023 4
Exclusi e B eas eeding 61 40.4 90 59.6
Mixed Feeding 10 76.9 3 23.1
Fo mula eeding 21 52.5 19 47.5
In . J. En i on. Res. Public Heal h 2023,20, 3808 9 o 14
Table 6. Con .
Inadequa e BFL Adequa e BFL
p-Value
n1%2n%
App aise
P e ious B eas eeding 0.022 4
P e ious B eas eeding 22 26.8 60 73.2
No p e ious B eas eeding
12 27.3 32 72.7
Is my i s p egnancy 35 46.1 41 53.9
Pa i y 0.011 4
Fi s 47 42.7 63 57.3
Second 15 21.1 56 78.9
Thi d o mo e 8 34.8 15 65.2
Apply
Pa i y 0.042 4
Fi s 43 39.1 67 60.9
Second 16 22.5 55 77.5
Thi d o mo e 10 43.5 13 56.5
Lac a ion ype 0.026 4
Exclusi e B eas eeding 44 29.1 107 70.9
Mixed Feeding 8 61.5 5 38.5
Bo le eeding 17 42.5 23 57.5
1Absolu e equencies; 2Rela i e equencies; 3Fishe ’s exac es ; 4Chi-squa ed; BFL: b eas eeding li e acy.
4. Discussion
The BLAI p esen s adequa e psychome ic p ope ies o assess BFL le els in women
du ing he pe ina al pe iod, wi h adequa e cons uc alidi y and in e nal consis ency. The
explo a o y ac o analysis explains 60.54% o he a iance wi h ou domains, coinciding
wi h he ou dimensions co e ed by he concep o HL (Access, Unde s and, App aise,
and Apply) de eloped by Sø ensen e al. [18].
I is wo h men ioning ha , du ing he ins umen ’s modelling, a numbe o i ems had
a sligh ly highe loading in dimensions o which hey we e no designed. Howe e , a e
ho oughly examining each i em o e alua e he easibili y o assigning i o al e na i e
dimensions, he esea ch eam de e mined ha i was mo e app op ia e o e ain hese
i ems wi hin hei o iginal dimensions, as he heo e ical alignmen was mo e con incing
in hese dimensions. In addi ion, wo i ems we e emo ed (Access6, App aisse6) due o
hei poo ac o loadings. The in e nal consis ency o he BLAI sligh ly inc eased a e
hei dele ion.
As o he dimensionali y s udy o he ins umen , he EFA was un wi hou de e -
mining a numbe o ac o s o ex ac , allowing he s a is ical p og amme o de e mine
he numbe o ac o s based on he Kaise c i e ion o eigen alues g ea e han 1 [
29
].
This is he de aul me hod in he s a is ical p og amme used, and i is possible o e ie e
scien i ic e idence ha cas s doub on i s p ac ical use ulness, as has been epo ed by
o he au ho s [
32
,
33
]. Howe e , he esul ing ac o s uc u e coincided wi h he numbe o
dimensions o which he ins umen was c ea ed. Today, he e a e o he , mo e commonly
used me hods o co obo a e he app op ia e numbe o ac o s, such as pa allel analysis
o he a io o he i s - o-second eigen alue. Howe e , we ha e no ound a uni e sally
accep ed c i e ion. Fo example, in he case o eigen alues, he e is no c i e ion o he a io
o be accep ed, some au ho s p opose ou [
34
], o he s i e [
35
], bu none seem o be based
on empi ical easoning. The e o e, i is essen ial ha u u e s udies conside o he analyses
o s udying dimensionali y.
While i is ue ha he use o a single c i e ion may lead o an o e es ima ion o
an unde es ima ion o he ac ual numbe o ac o s, o e -ex ac ion leads o ewe mea-
su emen e o s [
36
]. Mo eo e , i would no be app op ia e o ea as unidimensional
