Measurement of Human Milk Feeding Knowledge, Attitudes, Beliefs, and Self-Efficacy Among Women From Underrepresented Racial and Ethnic Populations: A Systematic Review
Clinical Snapshot
PICO Framework
| P — Population | Women from underrepresented racial and ethnic populations in the United States (including but not limited to Black/African American, Hispanic/Latina, Asian American, and Native American women) |
| I — Intervention | Psychometric instruments assessing knowledge, attitudes, beliefs, and/or self-efficacy related to human milk feeding (breastfeeding) |
| C — Comparator | No formal comparator; comparative evaluation of measurement properties across identified instruments |
| O — Outcomes | Psychometric properties of instruments including reliability (Cronbach's alpha), validity (content, construct, criterion), and cultural appropriateness for underrepresented racial and ethnic populations |
Bottom Line
This systematic review addresses a clinically important gap by evaluating psychometric instruments measuring breastfeeding knowledge, attitudes, beliefs, and self-efficacy among underrepresented racial and ethnic populations in the US. Of 15 instruments identified, the Iowa Infant Feeding Attitude Scale (IIFAS) and Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF) demonstrated the strongest reliability evidence, with Cronbach's alpha values reaching acceptable to strong levels across studies. However, the review has notable methodological limitations: the search was restricted to three databases without grey literature, no COSMIN-based quality appraisal framework was explicitly applied, no formal certainty-of-evidence assessment was conducted, and measurement invariance across specific ethnic subgroups was not addressed. The wide variability in reliability coefficients for IIFAS (α = .67–.86) across studies signals that instrument performance is not uniform across populations — a critical concern for a review specifically focused on underrepresented groups. The authors' honest conclusion that more culturally appropriate instruments are needed reflects the true state of the evidence. For clinicians and researchers in Australia and internationally, these instruments may serve as interim tools, but local cultural validation is essential before deployment in Indigenous or CALD populations. This review is best regarded as a useful scoping exercise rather than a definitive psychometric synthesis.
Key Findings
P Value: Not applicable for psychometric reliability review; no inferential statistics reported in abstract
Effect Size: Iowa Infant Feeding Attitude Scale (IIFAS): Cronbach's alpha range .67–.86 (moderate to strong); Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF): Cronbach's alpha range .79–.96 (strong)
Primary Outcome: Psychometric properties (primarily internal consistency reliability) of 15 instruments assessing breastfeeding knowledge, attitudes, beliefs, and self-efficacy among underrepresented racial and ethnic populations
Nnt Or Sensitivity: Not applicable to this psychometric systematic review; no diagnostic accuracy or therapeutic outcome data reported. Relevant metric would be measurement invariance across ethnic groups, which is not reported.
Confidence Interval: Not reported; ranges reflect variability across included studies rather than confidence intervals around point estimates
Clinical Application
Both IIFAS and BSES-SF are established, publicly available instruments with existing validation data. The BSES-SF (14 items) is brief and feasible for clinical and research settings. However, neither instrument was specifically developed for or with underrepresented populations, which limits their cultural validity. Clinicians and researchers should use these instruments with awareness of their psychometric limitations in specific ethnic subgroups. Breastfeeding inequities are also documented in Australia, with lower initiation and continuation rates among Aboriginal and Torres Strait Islander women, women from refugee backgrounds, and some culturally and linguistically diverse (CALD) communities. The RACGP and Australian Breastfeeding Association support culturally sensitive breastfeeding support, and the Australian National Breastfeeding Strategy 2019–2030 identifies equity as a priority. Neither IIFAS nor BSES-SF has been formally validated in Australian Indigenous or CALD populations to the authors' knowledge. Australian researchers should exercise caution in applying these instruments without local cultural validation. The TGA and PBS are not directly relevant to this measurement review. NHMRC infant feeding guidelines and the work of the Maternity Consumer Network may provide relevant Australian policy context for instrument selection. Researchers and clinicians seeking validated instruments to measure breastfeeding-related knowledge, attitudes, beliefs, and self-efficacy in racially and ethnically diverse populations, particularly in US healthcare settings serving Black/African American, Hispanic/Latina, Asian American, and Native American women
Abstract
Background and Purpose: Human milk feeding inequities persist among women from underrepresented racial and ethnic populations in the United States. Knowledge, attitudes, beliefs, and self-efficacy influence human milk feeding practices. This review evaluates the measurement properties of instruments assessing these variables among underrepresented populations. Methods: A systematic review from CINAHL, MEDLINE, and PsycINFO databases evaluated instruments assessing breastfeeding variables among women from underrepresented racial and ethnic populations. Results: Fifteen instruments were assessed. The Iowa Infant Feeding Attitude Scale (IIFAS) and Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF) had moderate to strong psychometric scores (α = .67-.86; .79-.96). Conclusions: While several instruments assess human milk feeding variables in underrepresented populations, IIFAS and BSES-SF show the strongest evidence. More culturally appropriate instruments are needed.
References
- 1.Logan, A. M., Ware, K. S., & Lin, C.-Y. (2026). Measurement of human milk feeding knowledge, attitudes, beliefs, and self-efficacy among women from underrepresented racial and ethnic populations: A systematic review. Journal of Nursing Measurement. Advance online publication. https://doi.org/10.1891/JNM-2025-0026
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