Journal of Preventive Medicine

Introduction
Feeding premature babies with breast milk is very vital and can be effective in reducing hospital infections and the duration of hospitalization in the neonatal intensive care units. Despite the valuable role of breastfeeding in preventing diseases, unfortunately, there are premature babies who are deprived of breastfeeding for some reasons. Statistics show that 23.1% of premature babies are breastfed in Iran. A mother needs a proper and sufficient sense of self-efficacy to achieve optimal care of a premature baby. Education of mothers of premature babies based on self-efficacy theories can not only increase their awareness of how to breastfeed, but also create a high level of enthusiasm in accepting the baby and appropriate behavior in fulfilling the mother’s duty. One of these effective theories in the field of breastfeeding education is Bandura’s social cognitive theory. Breastfeeding self-efficacy, which is one of the constructs of Bandura’s social cognitive theory, is a person’s belief and confidence in the ability to perform health practices such as exclusive breastfeeding. According to Bandura’s theory, self-efficacy is influenced by four main sources of information, which are: Mastery experiences, vicarious experiences, verbal persuasion, and physiological states. Although the increase in mother’s self-efficacy leads to higher levels of breastfeeding behavior, the results of studies indicate that a large percentage of mothers do not have a sense of competence and self-efficacy in the field of breastfeeding a premature baby. Therefore, the present study was conducted with the aim of determining the effect of educational intervention based on Bandura’s social cognitive theory on mothers’ behavior in breastfeeding premature infants.
Methods
This is a quasi-experimental study that was conducted in 2019. The study population consists of the mothers of premature babies admitted to the neonatal ward and neonatal intensive care unit (NICU) of a hospital in Bandar Abbas, Iran. Samples were selected using a convenience sampling method in order of referral to the ward/unit. Then they were randomly divided into two intervention and control groups by the block randomization method. The intervention group included 17 women hospitalized in the neonatal ward and 24 hospitalized in the NICU. The control group included 20 women in the neonatal ward and 21 in the NICU. 
Mothers in the control group received the routine education provided by the neonatal department, and mothers in the intervention group received the educational intervention based on four sources of information based on Bandura social cognitive theory at four sessions each for 45-60 minutes. A demographic from, Barnes’ perceived maternal parenting self-efficacy tool, and observation checklist for breastfeeding practices were used to collect data. Data collection was done in three stages before the intervention, during hospitalization, and one week after discharge. The obtained data were analyzed using descriptive statistics (mean and standard deviation) and inferential statistics (paired t-test and independent t-test) in SPSS software version 24.
Results
Participants were 82 primiparous mothers with premature babies. The mean age of mothers in the intervention and control groups was 29.6 and 28.2 years, respectively. The mean birth weight of babies in the intervention and control groups was 2232.3 and 2277.3 grams, respectively; 61% of the babies in the intervention group were male and 39% were female. In the intervention and control groups, 75.6 and 85.4% of mothers were housewives, respectively. The education level of most of the mothers in the intervention group (46.3%) and the control group (48.8%) was below diploma. The educational level of the most of mothers was lower than diploma in the intervention group (46.3%) and the control group (48.8%). There was no significant relationship between demographic variables and maternal self-efficacy. There was no significant difference in the self-efficacy of mothers before the intervention between the intervention and control groups (P=0.73), while their self-efficacy at the time of discharge and one week after discharge showed a significant difference between the two groups (P=0.001). There was no significant difference in the breastfeeding behavior of mothers before the intervention between the two groups (P=0.95), but it was significantly different at the time of discharge and one week after discharge. The level of maternal self-efficacy and breastfeeding behaviors increased after the intervention.
Discussion
The present study was conducted with the aim of determining the effect of educational intervention based on Bandura’s social cognitive theory on the breastfeeding behaviors of mothers with premature infants. The results of the study showed that after the educational intervention, the mothers’ self-efficacy and breastfeeding behaviors increased significantly. Therefore, it is suggested that the necessary educations in the field of breastfeeding should be continuously provided in medical centers to primiparous mothers with premature babies who have less experience. By encouraging and creating a calm and stress-free environment for mothers by family members and relatives, they can achieve the belief that they have the ability to breastfeed their babies successfully. It is recommended that emotional and psychological support from family members, especially husband and medical professionals, starts from the moment the mother is admitted and the baby is born, and continues during hospitalization and even after discharge. On the other hand, mother’s knowledge of the sources of stress and trying to reduce it can ultimately cause the mother to continue breastfeeding of their premature babies.

Ethical Considerations
Compliance with ethical guidelines
Ethical approval was received for this study from the Ethics Committee of the Hormozgan University of Medical Sciences (IR.HUMS.REC.1398.377)

Funding
This project was funded by a research grant from the deputy of research and technology Hormozgan University of Medical Sciences.

Authors' contributions
Author Contributions: Study design: Fariba Asadi Noghabi, Aref Zarei; Cooperation in writing and revising: Mohsen Yousefi, Elnaz Golalipour, Fariba Asadi Noghabi, Aref Zarei; statistical analysis: Hadi Yousefi; Cooperation in collecting information and writing article: Elham Amini.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
The authors of this article would like to thank all the parents of premature babies who participated in the research, as well as the officials of the specialized children's hospital.

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