Exploring the potential of the internet to motivate breastfeeding

Janine Stockdale1 BSc, RM, RN. Marlene Sinclair2 PhD, MEd, BSc, DASE, RNT, RM, RN. W George Kernohan3 PhD, CPhys, CMath,FIMA, BSc. John M Keller4 PhD, MA.

1 PhD student, Institute of Nursing Research, University of Ulster at Jordanstown, Newtownabbey BT37 0QB Northern Ireland. Email: djstockdale7@aol.com
2 Professor of midwifery research, Institute of Nursing Research, University of Ulster at Jordanstown, Newtownabbey BT37 0QB Northern Ireland. Email: m.sinclair1@ulster.ac.uk
3 Professor of health research, Institute of Nursing Research, University of Ulster at Jordanstown, Newtownabbey BT37 0QB Northern Ireland. Email: wg.kernohan@ulster.ac.uk
4 Professor of instructional systems and educational psychology, Florida State University, PO Box 4453, Tallahassee FL 32306-4453 US. Email: jkeller@mailer.fsu.edu


The principal researcher holds a Research and Development Office of Northern Ireland fellowship.


Abstract

Background. Maternal confidence is a vital component of successful breastfeeding and with 15 million websites aimed at women seeking breastfeeding ‘instruction’, the internet is a resource with potential to motivate.
Aim. To assess the motivational content of breastfeeding websites in relation to the confidence and relevance components of Keller’s ARCS model of motivational instructional design.
Method. An exploratory observation study using a convenience sample of 30 breastfeeding websites accessed through search engines and directories in an effort to replicate women’s information-seeking behaviour. The websites promised information on successful breastfeeding and effective treatment of nipple pain, commonly classified in breastfeeding texts as a problem. Exclusion criteria included websites where informational access required financial commitment. Using a coding system based on the ARCS model, websites were classified on a five-point scale according to how they met motivational criteria.
Results. Websites’ promises were often misleading, and the observers agreed that none met all criteria for being ‘motivational’.
Conclusions. Although the internet is a source of breastfeeding information, it appears that available websites fail to take the opportunity to motivate women by incorporating relevance and confidence-building strategies.


Key words: Breastfeeding, motivational instructional design models, internet, midwives, relevance, confidence, ARCS


Introduction

The last decade has witnessed a surge in studies using a motivational concept or theory to understand breastfeeding behaviour, with maternal confidence identified as the key motivational factor for continued breastfeeding (Ertem et al, 2001; Dodgson et al, 2003; Chezem et al, 2003). Although women may be motivated to start breastfeeding, motivation to continue is affected by perceived breastfeeding problems (Coombes et al, 1998) including a perceived insufficiency of milk. When exploring the motivational content of instruction, reliability is improved when a situation-specific (clinical) problem can be clearly defined, such as nipple pain. Most breastfeeding texts and websites classify nipple pain as a common breastfeeding problem (US Department of Health and Human Services, 2005; Newman and Pitman, 2000). Access to midwife support and instruction is known to influence persistence to breastfeed (Valdes, 2000; Sikorski et al, 2004; Hanss, 2004), yet when facing new challenges women are likely to seek information on the internet, often to complement advice from healthcare professionals (Dickerson, 2006). Describing pre- and postnatal phases as ‘teachable moments’, Bernhardt and Felter (2004) conclude that women at these times are high informationseekers on the world wide web. However, most studies focus on evaluation of the internet with regard to functionality suchas readability, presentation and ease of use (Shaikh and Scott, 2005; Dornan and Oermann, 2006). Regarding the role of confidence, Butler (2000) proposes that people seek information relevant to their acquisition of competence first, including information relevant to clarifying task instructions, and then seek information relevant to assessing that competence. Although healthy behaviour has successfully been motivated using technology and the internet, such as safer sex (Thomas et al, 1997), greater wellbeing (Deex, 1997), smoking cessation (O’Neill et al, 2000; Parlove et al, 2004) and diet control (Adams, 2002; Brug et al, 2003), breastfeeding websites do not appear to have focused on motivational development.


Method

This small exploratory observation study set out to explore the motivational content of easily accessible breastfeeding websites using a framework based on the Attention, Relevance, Confidence and Satisfaction (ARCS) model of motivational instructional design (Keller, 1987). It was undertaken as part of a preparatory investigation to design a motivationally-enhanced breastfeeding instruction programme, and full ethical approval for the overall study was obtained through the local research ethics committee.


Literature search strategy

Databases including CINAHL, BNI, Cochrane Library, PsycINFO, Midwifery and Infant Care and EBSCO, electronic journals and university catalogues were searched for literature from 2000 to 2006. In addition to the A to Z of electronic journals, online health journals were searched using Google. Initially, a search focusing on the application of motivational instructional design models to breastfeeding and the internet was conducted, combining the key phrases ‘breastfeeding intervention methods’, ‘breastfeeding promotion’, ‘breastfeeding online’, ‘breastfeeding information on the internet’, ‘motivation to breastfeed on the web’, ‘motivation’, ‘internet’, ‘evaluation’ and instructional design models and breastfeeding’ in different sequences. A second search focused on the use of the internet as an aspect of healthcare provision and combined terms such as ‘health promotion’, ‘technology’, ‘application of instructional design models’, ‘health knowledge’, ‘internet evaluating’, ‘patient use’, ‘self-diagnosis’ and ‘why women use the internet’. Thirdly, references in the articles obtained were scanned as a means to access additional relevant literature.


The ARCS model

Educationalists have developed motivational models in order to create optimal motivated behaviour by setting required motivational factors at appropriate levels within instruction (Keller, 1987; Wlodkowski, 1985; Mandigo and Holt, 2002). The ARCS model was designed in 1979 by Keller and developed further in 1983, and is based primarily on the expectancy value theory that assumes ‘people are motivated to engage in an activity if it is perceived to be linked to the satisfaction of personal needs (the value aspect) and if there is a positive expectancy for success (the expectancy aspect)’ (Keller, 1987: 3). Feather (1982: 1) states that a distinctive aspect of expectancy value theories and models is their ability to ‘relate action to the perceived attractiveness or aversiveness of expected consequences’. Cognitive psychologists have found that when expectations for success are coupled with subjective value (valence), they are important determinants of goaldirected behaviour. According to the steps that explain motivated behaviour, people:

■ Search for, process and use information
■ Make an evaluation in relation to their own thoughts and behaviours
■ Predict and anticipate consequences
■ Set goals and aim for them
■ Regulate their behaviour to reach their personal goals.

Understanding the internal theoretical position of the expectancy-value concept is vital when designing breastfeeding instruction. However, because there are a number of motivational theories, it is not always clear which particular theory to apply in each context. The ARCS model assumes that motivation is about people, their environment and the impact this can have on the goals they set. Instructional design models aim for instruction as the external source of motivation to have a directional impact on a person’s internal state of motivation. With regard to breastfeeding, Hall et al (2002: 320) make a clear distinction between the motivational constructs of competency and confidence, stating that the former ‘involves a mother’s assessment of her skills and feelings of comfort with parenting’ and the latter ‘involves her perception of her ability to care for and understand her infant’.

Breastfeeding instructors require a clear understanding of motivational theories in order to meet women’s competency and confidence-building needs, and competency and confidence are only two of numerous motivational theories that may appear to overlap. The ARCS model categorises motivational theories of as follows:

■ Drawing and sustaining attention, relating to curiosity, interest and arousal
■ Being relevant to the audience, associated with achievement, choice and needs-matching
■ Boosting confidence, relating to effort, involvement, efficacy and goal-setting
■ Enabling satisfaction, involving reinforcement, control,performance outcomes and rewards.


Use of the ARCS model has proved successful from both a conceptual (Naime-Diefenbach, 1991; Small and Gluck, 1994; Means and Jonassen, 1997) and an operational (Visser, 1998; Gabrielle, 2002) perspective, allowing the instructor to capitalise on the searcher’s information-seeking, particularly in competency (Butler, 2000). The model’s four components are applied through a systematic design process – diagnostic assessment of the motivational content of present instruction, defining motivational root problems and selecting and applying motivational strategies before testing the adapted instruction. It has successfully been applied to technology-based instruction (Keller, 1999; Visser, 1998; Gabrielle, 2002; Visser et al, 1999), but no published data suggests application to breastfeeding or healthcare instruction. Another motivational instructional model (Mandigo and Holt, 2002) has been used to motivate children to increase their physical activity, but use of the ARCS model with respect to health care has been restricted to the education of professionals such as pharmacists (Wongwiwatthananukit and Popovich, 2000).


Study design

Keller (1987) advises that rather than trying to address all motivational instructional deficits at once, any of the four components of the ARCS model can be applied independently. The relevance and confidence components were selected on the basis that:

■ Evidence points to a lack of maternal confidence (Duckett, 1998; Mozingo, 2000; Dodgson, 2003;
Papincak, 2000; Ertem et al, 2001; Chezem, 2003; Valdes, 2000; Hanss, 2004)
■ Perceived instructional relevance is considered the most important predictor of achievement outcomes (Means
and Jonassen, 1997)
■ Analysis of motivational deficits in a larger study applying the ARCS model to breastfeeding instruction by midwives diagnosed deficits in relevance and confidence components (International Confederation of Midwives, 2005).

Application of the ARCS model

Development of structured data recording sheets aimed to increase reliability of the findings by reducing observer bias. Two units of analysis as described by Polit and Hungler (1995) were incorporated – thematic units and space and time units.


Thematic units (motivational data)

Confidence and relevance are related through the concept of goals. Goals can increase relevance when the individual considers them to match their needs, and confidence can be increased when goals provide the individual with a means of performance evaluation. One conceptualisation of goals (Barron and Harackiewicz, 2000) was selected as best representing the relevance and confidence components of the ARCS model from valence and expectancy perspectives. They define purpose goals as reflecting reasons for partaking in a behaviour, and target goals as standards by which a person reaches their purpose goal.

To increase the reliability of the findings, a baseline for each type of goal was used. Purpose goals focused on the recognised benefits of breastfeeding (Riordan and Auerbach, 1999). Target goals focused on transient nipple pain, as it is known to interfere with self-efficacy (confidence) expectancies (Maddux, 1995) and represents a common perceived breastfeeding problem (Chapman et al, 1985; Foxman et al, 1994). The following scenario was developed utilising the advice of a lactation consultant and observer one, a healthcare professional:

‘You are breastfeeding your first baby who is five days old, you left hospital on day three and you are now at home. You are experiencing painful nipples. You search the internet to find advice. The sites are visited on the basis that the title or summary suggests that this is the place to find an answer to your problem.’

When relevance of instruction is maximised and irrelevant instruction minimised, motivational content is increased. Therefore, the observers also reported if websites offered some form of personal filtering system that used key questions concerning the nature and timing of pain as a means to direct the searcher to its most likely cause and relevant goal structure.


Space and time units

The space and time units were defined as factors that may interfere or frustrate information-searching and goal-formation processes, such as the number of pages to read about painful nipples, use of technical language such as ‘areola’, need for self-diagnosis and the scope of information available, for example information about attachment, mastitis, thrush or other conditions.

The rationale for selecting and visiting the websites were recorded, such as ‘basic breastfeeding advice’, ‘quick and easy answers to breastfeeding’ and ‘problems learning to breastfeed successfully’. The time spent on each site was recorded, as was the nature of opportunities relating to further advice such as the author of the site, email addresses and telephone number.


Observation schedule

Two observers took part in the study. Observer one was a healthcare professional, while observer two was not and accounted for inter-observer reliability. On the basis that ‘people engage in behaviour to seek a positive velocity of outcomes’ (Hsee and Abelson cited by Maddux, 1995: 19),each observer sought information for a maximum 30 hours, assuming that beyond 30 hours, women would take further steps to resolve their breastfeeding inquiry. Each observer identified the proportion of time spent on each site dependent on the perceived relevance to solving the problem. Both observers used a standard personal computer and restricted themselves to the first two to three pages of breastfeeding hits offered, on the basis that 70% of internet users explore the first 20 or fewer sites (Spink et al, 2004).

Observer one

In an effort to simulate women’s information seeking, observer one used a search engine (Google) and a directory (Yahoo) to access the convenient sample of breastfeeding websites. In addition to the promises included in the site summary to solve painful nipples or prevent and/or solve breastfeeding problems, websites requiring financial commitment were excluded. Observer one used agreed search terms to navigate individual websites: ‘painful nipples’, ‘nipple pain’, ‘sore nipples’ and ‘pain’. The instructional advice accessed was printed in order to examine the presence of purpose and target goals more closely.


Observer two

Observer two revisited the same websites three weeks later, to determine if the availability of instruction remained stable over time. Observer two had received two hours’ training that included explanation of the motivational and space and time units of analysis and search instructions. The possible causes of nipple pain were not described to observer two, and they were unaware of observer one’s findings.


Data analysis

Three aspects of content analysis as described by Polit and Hungler (1995) were used – enumeration of recorded occurrences in each category, a binary index of whether the concepts explored were present or absent and the percentage of agreement/disagreement between observers in relation to the motivational classification of each individual site. Websites were classified into overall categories based on an unpublished observation study of breastfeeding instruction (International Confederation of Midwives, 2005) and evidence relating to motivation to achieve (Barron and Harackiewicz, 2000; Keller, 1987):

■ Level A* – suggested purpose goals for breastfeeding over and above recognised health benefits and provided a search process directing the information-seeker to relevant and easily accessed target goals based on the symptoms they personally experienced
■ Level A – suggested purpose goals for breastfeeding over and above recognised health benefits and provided general but easily accessed target goals for solving painful nipples
■ Level B – suggested purpose goals for breastfeeding based on recognised health benefits alone and suggested target goals for painful nipples that were embedded among large quantities of text and required the user to apply a degree of self-diagnosis
■ Level C – suggested only purpose goals or only target goals for addressing painful nipples
■ Level D – did not suggest any purpose or target goals.


Results

Searching provided 700 000 hits related to dealing with nipple pain. Observer one analysed 30 websites and observer two reanalysed 24 of them. Observer two was denied access to three websites, while another three asked for a financial commitment when accessing from a private rather than university computer. Inter-observer agreement in classifying websites according to space and time units of analysis varied from 40% to 100% (see Table 1). Time spent exploring individual websites ranged from one to 30 minutes, while the number of pages relating to nipple pain ranged from zero to 29. There was 40% agreement between observers in placing websites in the same overall category, 37% in placing them in neighbouring categories and 22% in categories that were next-but-one. An attempt to calculate the inter-observer reliability co-efficient using SPSS (11.5) was restricted by sample size (n=30, n=24).

Level A*

The observers agreed that none of the websites maximised relevance of instruction by including a filtering system that directed the searcher away from irrelevant instruction.

Level A

Two websites were classified as level A by observer one and five by observer two, and they:

■ Were accessed mainly via the Yahoo breastfeeding directory
■ Were developed by healthcare professionals who specialised in breastfeeding
■ Suggested to women that a special bond with their baby was an additional purpose goal for breastfeeding
■ Aimed to increase women’s confidence in their breastfeeding ability while experiencing nipple pain by using related target goals as indicators of success, such as nappy output and weight gain.


The limitations of these sites included over generalisation – for example, although different causes were mentioned, the target goal structure for improving painful nipples was related directly to poor positioning and attachment. Further generalisations were made in two websites where other target goals were approximated, for example ‘six wet and two loose yellow stools per day’, failing to reflect the recognised changes in nappy output especially in the first few weeks of life (Riordan and Auerbach, 1999). A third website aimed to overcome this limitation by giving women more precise target goals related to nappy output but failed to be relevant to all women based on other criteria – for example, the instruction suggested that breastfeeding starts with a normal birth at home with no pain relief and continues until weaning between age two and seven years. As many women may struggle to identify with these suggested target goals, the motivational impact of the relevance component was reduced.

Level B

Accessed mainly by Google, 14 sites were included in this category. The authors included lactation consultants, recognised breastfeeding organisations and parents. The main limitation of these websites was that, although health benefits (purpose goals) were clearly provided, relevance decreased when target goals relating to painful nipples were embedded among large quantities of text. The observers faced navigating up to 29 pages of text in order to self-diagnose the source of their pain from multiple possible causes such as poor attachment, achieving good attachment, mastitis, engorgement, thrush, nipple abnormalities and cancer of the breast.

Level C

The 19 websites in this category provided either purpose or target goals for breastfeeding, but failed to incorporate both. Accessed by Google and Yahoo breastfeeding directory, they were either directed at healthcare providers or assumed a prior understanding of breastfeeding terminology.

Level D

Accessed via both the search engine and directory, 14 sites failed to provide either purpose goals for breastfeeding or target goals for solving nipple pain. Commercial sites dominated this category, promoting accessories and books. Only five used a web address that reflected the true nature of the site. Treatments for painful nipples were offered – one website claiming to help women solve painful nipples offered a selfadministered herbal kit, followed by a disclaimer that the product had not been tested by the US Food and Drug Administration, nor was it intended to diagnose, treat or prevent conditions. Although these websites did not meet the motivational criteria directly, links from them could be a valuable source of information and possible motivation, including links to chat rooms and forums, human milk banks, lactation consultants and working and breastfeeding websites.

Other observations

On two occasions, using ‘painful nipples’ or ‘pain when breastfeeding’ as a search term even on a breastfeeding website provided instruction related to the early detection of breast cancer, benign disease of the breast and nipple pain due to exercise. Links from breastfeeding websites, academic or educational sites in particular, could also direct the user inadvertently to an institutional index where there is information
on topics such as biomedical engineering and preconception and menopausal health.


Where the observers disagreed

Differences relating to relevance included observer two’s acceptance of target goals that focused on poor positioning and attachment and observer one’s recognition that other causes of early nipple pain were possible, for example ankyloglossia (tongue-tie). Observer two also accepted a wider spectrum of instruction – where observer one perceived instruction about painful nipples when using a sun bed as irrelevant at five days’ postnatal, observer two did not. Where no satisfactory goal structure was evident within the designated website, observer two was more likely to try following the vast number of links offered. This would take them back to instruction already visited on a previous website, increasing the amount of excessive text and scope of information accessed. Differences in relation to confidence focused on effects of performance feedback such as weight gain and nappy outputs – observer two was unaware of performance expectancies related to breastfeeding a five-day old baby, while observer one recognised the limitations of general information.

Discussion

Although this study was limited by a small sample size, like others evaluating breastfeeding websites (Shaikh and Scott, 2005; Dornan and Oermann, 2006), the observers’ agreement that no website met the motivational criteria is significant. Designers of breastfeeding websites have not realised their motivational potential, and information-seekers using the internet to solve breastfeeding problems may be motivationally compromised. The compromise centres on key motivational concepts – the role of relevance (in particular the need for self-diagnosis) and the role of confidence (in particular performance feedback indicators). Relevance of instruction is an important aspect of continuing motivation: ‘The inferences people make on the basis of their informational search then affect continuing, strivings and task engagement’ (Butler, 2000: 165). Although limited knowledge exists about the interaction effects of the need to selfdiagnose when receiving instruction from the internet, research has shown that relevance is heightened when interventions are tailored specifically toward the individual (Strecher et al, 2002). Integrating literature related to tailored interventions versus standard interventions, Ryan and Lauver (2002) concluded that future research was required into confidence-building, exploring the interaction effects of feedback and mutual goal-setting.

Although commercial websites are given little credibility when problem-solving compared with educational and organisational ones, the diagnosis that women accept is not based on clinical symptoms but on the most probable cause as validated by the number of times they encounter the same information on various websites (Eriksson-Backa, 2003). Most websites produced by educationalists, lactation consultants and breastfeeding organisations were categorised as level B because they used a ‘search for yourself’ approach. Brug et al (2003) argues that people require as much information on as many potentially important determinants as possible, but from a motivational perspective it must be noted that this can create its own problems of irrelevance, requiring women to manage endless pages of text, comprehend scientific language, use some form of self-diagnosis or adopt an inappropriate target goal structure.

Websites categorised as level B emphasised poor positioning, so in circumstances where poor positioning is the problem, the suggested target goals provide the motivational catalyst for acquiring confidence and persisting to breastfeed.
However, if painful nipples are due to one of the other 15 causes listed by Riordan and Auerbach (1999), the likelihood that the individual will find and follow the correct target goal structure is lessened, as is their opportunity to acquire competency and confidence. Confidence and competency on deciding to abandon breastfeeding is affected by many variables including personality. Yet, the importance of easily finding and applying relevant target goals in a given situation is borne out in the account of one breastfeeding mother who describes the process associated with discovering her son’s tongue-tie (Association of Breastfeeding Mothers, 2003).

Relevance was considered highest in the level A sites as they incorporated suggested purpose goals over and above recognised health benefits. Not all women find relevance in benefits such as reducing the incidence of childhood asthma, but it is likely that almost all breastfeeding women can relate to the idea of further developing a special bond with their baby. Increasing the value component through a broader purpose goal structure is essential, for if women cannot relate to a reason for continuing to breastfeed, their desire for competency and confidence is automatically weakened. Relevance was therefore weakest in the commercial sites that used a misleading web address as a marketing ploy (level D sites), a problem highlighted by Benigeri and Pluye (2003) who point out that only one link out of five leads to a website with relevant information.

Setting aside the direct effects of an inappropriate target goal structure, the internet has the opportunity to build women’s confidence through performance feedback. Weight gain and nappy output appeared most often as performance indicators. The motivational value of performance feedback, in particular weight gain of breastfed infants has been questioned – for example, Begahue (1993) assessed growth monitoring programmes in providing women with tangible measures of breastfeeding success and found that it was associated with a decrease in maternal confidence. Yet, growth data provided by the World Health Organization Working Group on Infant Growth (1994) revealed that expectancies of growth in a breastfed infant varied considerably from that of a formula-fed infant – when performance indicators are used they must be relevant for increasing confidence. Only two of the level A websites accounted for performance feedback beyond generalisations, which was a critical motivational oversight.

As 20% of internet users in the UK report that online advice contradicts advice given by their healthcare professional (Shaikh and Scott, 2005) and using the internet to mimic personal counseling has already been realised (Brug et al, 2003), it seems important for midwives and breastfeeding educators to make use of motivationally instructional design in this area.

Conclusion

The powerful potential of online motivational breastfeeding has yet to be fulfilled. Adjusting the relevance of performance feedback and the process of self-diagnosis are critical steps in exploiting the internet to boost women’s motivation to breastfeed, and midwives and breastfeeding educators should utilise motivationally instructional design to do this. Additional research is recommended to further explore the motivational effects of breastfeeding instruction on internet users.


References


Adams TB. (2002) Database: research and evaluation results: randomised trial of a ‘talking computer’ to improve adults’ eating habits. American Journal of Health Promotion 16(6): 354-5.

Association of Breastfeeding Mothers. (2003) Tongue-tie: a breastfeeding counsellor discovers her baby’s tongue-tie. ABM Newsletter 24(2): 12-3.

Barron KE, Harackiewicz JM. (2000) A model of goal effects on intrinsic motivation: In: Sansone C, Harackiewicz JM. (Eds.). Intrinsic and extrinsic motivation: the search for optimal motivation and performance. Academic Press: San Diego, California.

Benigeri M, Pluye P. (2003) Shortcomings of health information on the internet. Health Promotion International 18(4): 381-6.

Bernhardt JM, Felter EM. (2004) Online pediatric information-seeking among mothers of young children: results from a qualitative study using focus groups. Journal of Medical Internet Research 6(1): e7.

Begahue D. (1993) Growth monitoring and the promotion of breastfeeding. Social Science and Medicine 37(12): 1565-78.

Brug J, Oenema A, Campbell M. (2003) Past present and future of computertailored nutrition education. Am J Clinical Nutrition 77(4S): 1028-34.

Butler R. (2000) What learners want to know: the role of achievement goals in shaping information seeking, learning and interest: In: Sansone C, Harackiewicz JM. (Eds.). Intrinsic and extrinsic motivation: the search for optimal motivation and performance. Academic Press: San Diego, California.

Chapman JJ, Macey MJ, Keegan M, Borum P, Bennett S. (1985) Concerns of breastfeeding mothers from birth to four months. Nurs Research 34(6): 374-7.

Chezem J, Friesen C, Boettcher J. (2003) Breastfeeding knowledge, breastfeeding confidence, and infant-feeding plans: effects on actual feeding practices. J Obstet Gyn Neonatal Nurs 32(1): 40-7.

Coombs DW, Reynolds K, Joyner G, Blankson M. (1998) A self-help programme to increase breastfeeding among low-income women. J Nut Ed 30(4): 203-9.

Deex J. (1997) An online approach to wellness. Health Manage Tech 18(13): 65-6.

Dickerson S. (2006) Women’s use of the internet: what nurses need to know. J Obstet Gyn Neonatal Nurs 35(1): 151-6.

Dodgson JE, Henly SJ, Duckett L, Tarrant M. (2003) Theory of planned behaviour- based models for breastfeeding duration among Hong Kong mothers. Nursing Research 52(3): 148-58.

Dornan BA, Oermann MH. (2006) Evaluation of breastfeeding websites for patient education. MCN Am J Matern Child Nursing 31(1): 18-23.

Duckett L, Henly S, Avery M, Potter S, Hills-Bonczyk S, Hulden R, Savik K. (1998) A theory of planned behaviour-based structural model for breastfeeding. Nursing Research 47(6): 325-36.

Eriksson-Backa K. (2003) Who uses the web as a health information source? Health Informatics Journal 9(2): 93-101.

Ertem IO, Votto N, Leventhal JM. (2001) The timing and predictors of the early termination of breastfeeding. Pediatrics 107(3): 543-8.

Feather NT. (Ed.). (1982) Expectations and actions: expectancy-value models in psychology. Lawrence Erlbaum Associates: Hillsdale, New Jersey.

Foxman B, Schwartz K, Looman SJ. (1994) Breastfeeding practices and lactation mastitis. Social Science Medicine 38(5): 755-61.

Gabrielle DM. (2002) The effects of technology-mediated instructional strategies on motivation, performance and self-directed learning (electronic). US Military Academy Center for Teaching Excellence: West Point, New York.

Hall WA, Shearer K, Mogan J, Berkowitz J. (2002) Weighing preterm infants before and after breastfeeding: does it increase maternal confidence and competence? MCN Am J Matern Child Nursing 27(6): 318-26.

Hanss K. (2004) Confidence and breastfeeding: a view from the front line. Journal of Family Health Care 14(1): 21-4.

International Confederation of Midwives. (2005) The 27th congress of the International Confederation of Midwives: conference proceedings. International Confederation of Midwives: The Hague.

Keller JM. (1987) Strategies for stimulating the motivation to learn. Perf and Instruction 26(8): 1-7.

Keller JM. (1999) Motivation in cyber learning environments. International Journal of Educational Technology 1(1): 7-30. Feather N. (1982) Expectations and actions: expectancy-value models in psychology. Lawrence Erlbaum Assoicates: Hillsdale, New Jersey.

Maddux JE. (Ed.). (1995) Self-efficacy, adaptation and adjustment: theory, research and application. Springer: New York.

Means T, Jonassen D. (1997) Enhancing relevance: embedded ARCS strategies versus purpose. Educational Tech Research and Development 45(1): 5-17.

Mandigo JL, Holt NL. (2002) Putting theory into practice enhancing motivation through OPTIMAL strategies. Avante 8(3): 21-9.

Mozingo J, Davis MW, Droppleman PG, Merideth A. (2000) ‘It wasn’t working’: women’s experiences with short-term breastfeeding. MCN Am J Matern Child Nursing 25(3): 120-6.

Naime-Diefenbach B. (1991) Validation of attention and confidence as independent components of the ARCS motivational model (unpublished PhD dissertation). Florida State University: Tallahassee, Florida.

Newman J, Pitman T. (2000) The ultimate breastfeeding book of answers. Prima Lifestyles: Rocklin, California.

O’Neill HK, Gillispie MA, Slobin K. (2000) Stages of change and smoking cessation: a computer-administered intervention program for young adults. American Journal of Health Promotion 15(2): 93-6.

Papincak TA, Turner CT. (2000) An analysis of personal and social factors influencing initiation and duration of breastfeeding in a large Queensland maternity hospital. Breastfeeding Review 8(1): 25-33.

Parlove AE, Cowdery JE, Hoerauf SL. (2004) Acceptability and appeal of a webbased smoking prevention intervention for adolescents. International Electronic Journal of Health Education 7: 1-8.

Polit DF, Hungler BP. (1995) Nursing research principles and methods (fifth edition). Lippincott Williams and Wilkins: Philadelphia.

Riordan J, Auerbach KG. (1999) Breastfeeding and human lactation (second edition). Jones and Bartlett: Sudbury, Massachusetts.

Ryan P, Lauver D. (2002) The efficacy of tailored interventions. Journal of Nursing Scholarship 34(4): 331-7.

Shaikh U, Scott BJ. (2005) Extent, accuracy and credibility of breastfeeding information on the internet. Journal of Human Lactation 21(2): 175-83.

Sikorski J, Renfrew MJ, Pindoria S, Wade A. (2004) Support for breastfeeding mothers (Cochrane Review): In: The Cochrane Library Issue 1. John Wiley and Sons: Chichester.

Small RV, Gluck M. (1994) The relationship of the ARCS conditions to effective instructional attributes: a magnitude scaling approach. Educ Tech 34(8): 33-40.

Spink A, Yang Y, Jansen J, Nykanen P, Lorence DP, Ozmutlu S, Ozmutlu HC. (2004) A study of medical and health queries to web search engines. Health Information and Libraries Journal 21(1): 44-51.

Strecher V, Wang C, Derry H, Wildenhaus K, Johnson C. (2002) Tailored interventions for multiple risk behaviors. Health Education Research 17(5): 619-26.

Thomas R, Cahill J, Santilli L. (1997) Using an interactive computer game to increase skill and self-efficacy regarding safer sex negotiation: field test results. Health Education and Behavior 24(1): 71-86.

US Department of Health and Human Services. (2005) The National Women’s Health Information Center. See: www.4woman.gov (accessed January 2007).

Valdes V, Pugin E, Schooley J, Catalan S, Aravena R. (2000) Clinical support can make a difference in exclusive breastfeeding success among working women. Journal of Tropical Pediatrics 46(3): 149-54.

Visser L. (1998) The development of motivational communication in distance education support (unpublished PhD dissertation). University of Twente: Twente, Netherlands.

Visser L, Plomp T, Kuiper W. (1999) Development research applied to improve motivation in distance education (presentation). Association for Educational Communications and Technology: Houston.

World Health Organization Working Group on Infant Growth. (1994) An evaluation of infant growth. World Health Organization: Geneva.

Wlodkowsky RJ. (1993) Enhancing adult motivation to learn: a guide to improving instruction and increasing learner achievement. Jossey Bass: San Francisco.

Wongwiwatthananukit S, Popovich NG. (2000) Applying the ARCS model of motivational design to pharmaceutical education. Am J Pharm Educ 64(2): 188-96.