Validation of a Questionnaire on Knowledge and Barriers of Breast Milk Expression among Mothers of Premature Infants

Wan Haiera Wan Nor, Noraini Mohamad, Norkhafizah Saddki, Zainab Mat Yudin @Badrin, Tengku Alina Tengku Ismail, Zaharah Sulaiman, Nor Rosidah Ibrahim


This study aimed to develop and validate a Malay language questionnaire to assess mothers' knowledge in providing breast milk for premature infants, and barriers to breast milk expression while the infants are in the Neonatal Intensive Care Unit (NICU). Two tertiary hospitals in Kelantan, Malaysia participated in this cross-sectional study. Relevant items of knowledge and barriers were identified through a literature search, clinical observations, and expert opinion. Ten breastfeeding experts validated the content of the knowledge and barriers to breast milk expression questionnaire.The effectiveness of the questionnaires was tested for face validity among ten mothers, followed by reliability tests comprising 50 mothers who gave birth prematurely. The 20 knowledge items and 16 barrier items have an Item-level Content Validity Index (I-CVI) of 0.99, indicating good relevance of the knowledge and barrier items. The knowledge and barrier questionnaires had Item-level Face Validity Indexes (I-FVIs) of 1.00 and 0.99, respectively, suggesting clear and comprehensible items. The questionnaires obtained a Cronbach alpha score of 0.726 for knowledge and 0.736 for barriers, showing that they are reliable tools for assessing knowledge and breast milk expression barriers. The validity and reliability of the newly developed Malay version of the questionnaire have been established for evaluating breastfeeding knowledge and barriers to expressing breast milk among mothers with premature infants.


Alves E, Rodrigues C, Fraga S, Barros H, Silva S. 2013. Parents' views on factors that help or hinder breast milk supply in neonatal care units: Systematic review. Arch Dis Child Fetal Neonatal Ed 98(6):511‒517.
Bertino E, Di Nicola P, Giuliani F, Peila C, Cester E, Vassia C, Pirra A, Tonetto P, Coscia A. 2012. Benefits of human milk in preterm infant feeding. J Pediatric Neonatal Individ Med 1(1):19‒24.
Bolarinwa OA. 2015. Principles and methods of validity and reliability testing of questionnaires used in social and health science researches. Niger Postgrad Med J 22(4):195‒201.
Chawanpaiboon S, Vogel JP, Moller AB, Lumbiganon P, Petzold M, Hogan D, Landoulsi S, Jampathong N, Kongwattanakul K, Laopaiboon M. 2019. Global, regional, and national estimates of levels of preterm birth in 2014: A systematic review and modeling analysis. Lancet Glob Health 7(1):37‒46.
Che'Muda CM, Tengku Ismail TA, Abdul Jalil R, Mohd Hairon S, Sulaiman Z, Johar N. 2016. Development and validation of the Malay version knowledge and attitude questionnaire on breastfeeding among postpartum mothers in the northeast region of Peninsular Malaysia. Brunei Int Med J 12(3):104‒115
Davis LL. 1992. Instrument review: Getting the most from a panel of experts. Applied nursing research 5(4):194‒197.
DeVon HA, Block ME, Moyle-Wright P, Ernst DM, Hayden SJ, Lazzara DJ, Savoy SM, Kostas-Polston E. 2007. A psychometric toolbox for testing validity and reliability. J Nurs Scholarsh 39(2):155‒164.
Eidelman A, Schanler RJ, Johnston M, Landers S, Noble L, Szucs K, Viehmann L. 2012. Breastfeeding and the use of human milk. Pediatrics 129(3):827‒841.
Gianni ML, Bezze EN, Sannino P, Baro M, Roggero P, Muscolo S, Plevani L, Mosca F. 2018. Maternal views on facilitators of and barriers to breastfeeding preterm infants. BMC Pediatr 18(1):283‒290.
Hackman N M, Alligood-Percoco N, Martin A, Zhu J, Kjerulff KH. 2016. Reduced breastfeeding rates in firstborn late preterm and early term infants. Breastfeed Med 11(3):119‒125.
Hahn-Holbrook J. 2018. The psychological effects of breastfeeding. Ed, family larson- rosenquist foundation. [Accessed 9th April 2022]
Hamid HA, Szatkowski L, Budge H, Cheah FC, Ojha S. 2021. Nutritional practices and growth of preterm infants in two neonatal units in the UK and Malaysia: A prospective exploratory study. BMJ Paediatr Open 5(1):1‒8.
Heller N, Rüdiger M, Hoffmeister V, Mense L. 2021. Mother's own milk feeding in preterm newborns admitted to the neonatal intensive care unit or special-care nursery: Obstacles, interventions, risk calculation. Int J Environ Res Public Health 18(8):1‒9.
Jeganathan R, Karalasingam SD. 2021. 6th report of national obstetrics registry, Jan 2018‒Dec 2020. A publication of the national obstetrics registry, institute clinical research, health informatic center, Ministry of Health Malaysia. [Accessed 6th September 2023]
Kair LR, Colaizy TT. 2016. Breastfeeding continuation among late preterm infants: Barriers, facilitators, and any association with NICU admission? Hosp Pediatr 6(5):261‒268.
Lau AS, Yusoff MS, Lee YY, Choi SB, Xiao JZ, Liong MT. 2018. Development and validation of a Chinese translated questionnaire: A single simultaneous tool for assessing gastrointestinal and upper respiratory tract related illnesses in pre-school children. J Taibah Univ Medical 13(2):135‒141.
Namusoke F, Sekikubo M, Namiiro F, Nakigudde J. 2021. "What are you carrying?" Experiences of mothers with preterm babies in low-resource setting neonatal intensive care unit: A qualitative study. BMJ open 11(9):1‒7.
Ong SL, Abdullah KL, Danaee M, Soh KL, Soh KG, Lee DSK, Hussin EOD. 2019. The effectiveness of a structured nursing intervention program on maternal stress and ability among mothers of premature infants in a neonatal intensive care unit. J Clin Nurs 28(3‒4):641‒649.
Parker L, Sullivan S, Krueger C, Kelechi T, Mueller M. 2012. Effect of early breast milk expression on milk volume and timing of lactogenesis stage II among mothers of very low birth weight infants: A pilot study. J Perinatol 32(3):205‒209.
Pelet, J-E, Khan, Jashim, & Papadopoulou, Panagiota. 2012. Towards a scale for perceptions of mobile interaction: Establishing content and face validity. [Accessed 5th April 2021]
Polit DF, Beck CT, Owen SV. 2007. Is the CVI an acceptable indicator of content validity? Appraisal and recommendations. Res Nurs Health 30(4):459‒467.
Prasetyo YB, Rahayu HT, Kurnia AD, Masruroh N, Melizza N, Latif RA. 2023. Breastfeeding trends and it's related factors in Indonesia: A national survey. J Gizi Pangan 18(1):31‒40.
Sisk P, Quandt S, Parson N, Tucker J. 2010. Breast milk expression and maintenance in mothers of very low birth weight infants: Supports and barriers. J Hum Lact 26(4):368‒375.
Streiner, David L, Norman, Geoffrey R, Cairney, John. 2015. Health Measurement Scales: A Practical Guide to Their Development and use. New York (USA): Oxford University Press Inc.
The Royal Women's Hospital, Australian Breastfeeding Association. 2015. Expressing breast milk for sick or preterm babies. [Accessed 5th April 2021]
Underwood MA. 2013. Human milk for the premature infant. Pediatr Clin North Am 60(1):189‒207.
[WHO] World Health Organization. 2006. Baby-friendly hospital initiative revised, updated and expanded for integrated care. section 3.2. session outlines breastfeeding promotion and support in a baby-friendly hospital a 20-hour course for maternity staff. [Accessed 6th April 2021]
[WHO] World Health Organization. 2018. Preterm birth. [Accessed 5th April 2021]
Yusoff MSB. 2019a. ABC of content validation and content validity index calculation. Educ Med J 11(2):49‒54.
Yusoff MSB. 2019b. ABC of response process validation and face validity index calculation. Educ Med J 11(3):55‒61.
Zielinska M, Sobczak A, Hamulka J. 2017. Breastfeeding knowledge and exclusive breastfeeding of infants in first six months of life. Rocz Panstw Zakl Hig 68(1):51‒59.


Wan Haiera Wan Nor
Noraini Mohamad (Primary Contact)
Norkhafizah Saddki
Zainab Mat Yudin @Badrin
Tengku Alina Tengku Ismail
Zaharah Sulaiman
Nor Rosidah Ibrahim
Wan NorW. H., MohamadN., SaddkiN., Mat Yudin @ BadrinZ., Tengku IsmailT. A., SulaimanZ., & IbrahimN. R. (2023). Validation of a Questionnaire on Knowledge and Barriers of Breast Milk Expression among Mothers of Premature Infants . Jurnal Gizi Dan Pangan, 18(3), 177-186.

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