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Knowledge and Attitude towards Exclusive Breastfeed ing Practices among fathers who attend Primary Health Care Facilities in Suburban, Malaysia

Noraini Mohamad1, Nani Draman2*, Rosediani Muhamad2 and Harmy Mohamed Yusoff3
  1. School of Dental Sciences, Health Campus, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
  2. School of Medical Sciences, Health Campus, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
  3. Faculty of Medicine, Universiti Sultan Zainal Abidin, 21300 Kuala Terengganu, Terengganu, Malaysia
Corresponding Author: Dr. Nani Draman, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan
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Abstract

Introduction: A father’s knowledge and attitude towards exclusiv e breastfeeding are very important factors that contribute to the success of exclusive breastfeeding practices.

Objectives: This study aims to compare knowledge and attitude r egarding breastfeeding between fathers whose child was exclusively vs. not exclusively breastfed.

Material and Method: A comparative cross sectional study was conducted o n 200 fathers. Convenient sampling was applied for the exclusive b reastfeeding group (cases) and systematic randomised sampling from an identified l ist with a ratio of 1:2 for the non- exclusive breastfeeding group (control). A self-adm inistered questionnaire on knowledge and attitudes with regards to exclusive breastfeeding p ractice was then distributed among these samplings. The sampling included the biological fat hers of a full-term and healthy singleton child of 6 months until 2 years of age. Participant s who were illiterate, diagnosed with psychiatric disorders or had children with congenit al disabilities, were excluded from the study.

Results: A total of 196 respondents completed this study. There was no significant difference of knowledge and attitude scores between fathers wh ose child was exclusively vs. not exclusively breastfed.

Conclusion: There was no difference in terms of knowledge and a ttitude of fathers between the exclusive vs. non-exclusive breastfeeding group .

Keywords

exclusive breast feeding, knowledge, attitude, father

Introduction

Exclusive breastfeeding refers to the act of feeding infants with only breast milk. This includes breastfeeding from a wet nurse and feeding from expressed breast milk. This also includes infants who are given vitamins, minerals, medicines, holy water, or drop of syrup in addition to breast milk. 1
Only 35% of infants worldwide are exclusively breastfed during the first four months of their life. 2 It is recommended to exclusively breastfeed the infants for the first six months of life and continue this practice this practice up to two years of age of age to achieve optimal growth, development and health. 3 Complementary food should be introduced at the age of six months of life. 4
Malaysia however is the country with the lowest prevalence of exclusive breastfeeding practice compared to other countries in the Southeast Asia region. 5 The reason may be due, poor support from the husband,6 working mother,7 late initiation of breastfeeding, breastfeeding difficulties, prenatal intended duration of breastfeeding and problems with breast milk expression.8
A father’s knowledge and attitude towards exclusive breastfeeding are among important factors that contribute to the success of exclusive breastfeeding practices. The father is an important source of support in the decision and implementation of breastfeeding. 9 A baby has a higher chance of being breastfed if the father has more knowledge regarding exclusive breastfeeding. 10 It has also been noted that knowledge and attitudes are strongly related to the disposition of the fathers in supporting breastfeeding and they can act as an important source of social support for the breastfeeding mother. 11
In Malaysia, there is no published data available on the assessment of the knowledge and attitudes of fathers in regards to exclusive breastfeeding practices. Information on whether fathers play a significant role or not in influencing exclusive breastfeeding practice among mothers is lacking. Understanding the level of knowledge and attitude of the fathers on exclusive breastfeeding may help the fathers to become more supportive to exclusive breastfeeding practise. This study is therefore conducted to evaluate the level of knowledge as well as attitude of fathers in Malaysia towards breastfeeding.

Methodology

This was a comparative cross sectional study, conducted from 1st to 30th December 2011. A list of exclusive breastfeeding (EBF) - (cases) consisting of 100 fathers and non-exclusive breastfeeding (NEBF) - (control) consisting of 100 fathers were identified from 5 health clinics in Machang, Kelantan, Malaysia. Convenient sampling was applied for the exclusive breastfeeding group (cases) and systematic randomised sampling from the identified list with a ratio of 1:2 was applied for the selection of non exclusive breastfeeding group (control). The biological fathers of a full-term and healthy singleton child of 6 months until 2 years of age were included in the study. Subjects, who were illiterate, diagnosed with psychiatric disorders or had children with congenital disabilities were excluded from the study.

KAP Questionnaire

Two sets of KA questionnaires (Knowledge and Attitudes) were developed. Set 1 consists of mother’s socio-demographic background, parity, previous exclusive breastfeeding experience and decision-making in regards to the practice of exclusive breastfeeding. Set 2 requires information about the father and is further divided into 3 sections: section A, B and C. Section A consists of socio-demographic data of the father, while Section B and C assess the knowledge and attitudes of the father on the issue of exclusive breastfeeding. The Cronbach’s alpha for these questionnaires were 0.831 and 0.867 respectively.
The questionnaires of set B and C consist of 34 items; 29 items for knowledge (7 sub domains) and 15 items for attitude (3 sub-domains). A 3 Likert scale was applied (True = 1, False = 0, and Don’t know = 0) for the knowledge. 4 Likert scale (strongly agree = 4, agree = 3, disagree = 2, and strongly disagree = 1) were applied for the attitude.
The total score was calculated and was transformed into mean ‘percent score’ by dividing the score with possible maximum score and multiplied by 100. Higher total score indicated higher knowledge and attitude of the respondents.
The research proposal was approved by The Research and Ethics Committee, School of Medical Sciences, Health Campus, University Sains Malaysia 14th of June 2011.

Analysis

Descriptive analysis was used to analyse the socio-demographic data and independent t test analysis was to compare the knowledge and attitude score on breastfeeding between father whose child was exclusively (cases) and not exclusively breastfed (control).

Results

The response rate was 98%. The age of the fathers ranged from 21 to 61 years old, with a mean (SD) age of 36 (7.52) years. The majority of the fathers in both groups had up to a secondary level of education, with one third of them being self-employed.
The mean (SD) age of the mothers was 31(6.53) years, ranging from 31 to 40 years old. The majority of the mothers’ education in both groups was up to secondary level. Nearly half of the mothers in both groups had a parity of 2 or less. As for their baby’s age, almost half of the babies were between 6 to 12 months old during the time of data collection with a mean (SD) age of 13.6 (5.96) months. The socio-demographic of the fathers and mothers are summarized in Table 1 and 2.

Knowledge on exclusive breastffeding

There was no significance difference of mean score knowledge and mean in knowledge domain scores between fathers of child with an exclusive and non-exclusive breastfeeding as shown in Table 3 and 4.
The lowest percentage score was regarding breast milk expression. Respondents also had low knowledge in regards to problematic issues relating to exclusive breastfeeding. They however had good knowledge on the advantages of breastfeeding, feeding duration as well as effective feeding.

Attitude on exclusive breastfeeding

There was no significant difference of mean in the attitude score and mean in attitude domain scores between exclusive and non-exclusive breastfeeding fathers as shown in table 5 and 6.
The lowest percentage score was for the shyness domain. The fathers responded better scores for the domain regarding husband support on exclusive breastfeeding practices.

Discussion

The finding showed that there was no significant difference of knowledge scores of fathers whose child are exclusively vs. not exclusively breastfed. This result was incompatible with the study done by Giugliani et al, as he found that fathers of breast-fed babies had a significantly higher percentage on breastfeeding knowledge as compared to fathers of bottlefed children.12 In his study, the fathers of breast-fed babies were better educated (more than 12 years of school) and significantly older (more than 25 years old) as compared to fathers of bottle-fed infants. 12 Our findings differed in his study in terms of the father’s age and their education levels, as the majority of fathers in both our groups had only a secondary level education. Therefore, continuous education about the benefit of breast feeding should be provided to the father especially during antenatal check-up.
Our study also indicated that there was no significant difference of mean score for each domain between exclusive and non-exclusive breastfeeding groups. However, fathers of non exclusive breastfed babies had lower knowledge on understanding regarding exclusive breast feeding practices, with a mean (SD) score of 72.9 (20.41) as compared to fathers of exclusively breastfed babies 77.8(20.06). The possible explanation is because Malaysian traditional and cultural beliefs that infants need to be given water to avoid thirst or constipation. 13 Therefore, the babies were not exclusively breastfed even though formula milk was not introduced. 13
The lowest knowledge domain was observed in the area of breast milk expression with less than 50% of fathers in both groups answered correctly as compared to study done by Tengku Alina TI and Zaharah S where 75% of respondents answered correctly in this domain. 13 This may be due to the father’s ignorance in breast milk expression and storage as their wives did not practise this method of breastfeeding. Furthermore majority of the mother in this studied were not working and the used of breast pump and storage materials are expensive, they could not afford to buy them.
Fortunately, father in both groups had good knowledge on domain of effective feeding, advantages of breastfeeding to baby and duration of feeding with score of more than 90% in both groups. These finding were consistent with the study done by Tengku Alina TI and Zaharah S, where the knowledge score was high among domain of advantages to baby and effective feeding with median percentage score of 100% for both domains.13 Our findings indicates that, father in both groups were aware about advantages of exclusive breastfeeding to their baby , how to give effective feeding and duration of breastfeeding similarly to father that was not practising exclusive breastfeeding.
Our study found that there was no significant difference of attitude scores for fathers whose children were exclusively versus not exclusively breastfed. Our finding was inconsistent with study done among 268 fathers-to-be, where the fathers reported that their partners planned to breastfed exclusively were more knowledgeable and had more positive attitudes towards breastfeeding than those who reported that their partners planned for bottle feeding. 10
In our study, 78% in the exclusive breast feeding and 85.4% in the non exclusive breast feeding groups had negative attitudes and agreed that breastfeeding in front of family members and friends, was inacceptable and few studies found 10,11,14 similar results. Public breastfeeding is inacceptable due to the influence of Malaysian culture, fathers will feel embarrassed and uncomfortable if their wives breastfed in public, even if done modestly. This situation might also cause others to feel uneasy and shameful. However, a study done among fathers in United States reported that 71% respondents agreed that breastfeeding in public is acceptable. 15
Other negative attitudes includes 90% of fathers in both groups agreed that exclusive breastfeeding will affect intimate relationship with their wives. Freed et al found similar finding the father’s concern because lack of opportunity to develop a relationship with their wife, feelings of inadequacy as well as being separated from their mate. 10
Our study also noted that more than 90% of fathers in both groups did not agree to help their wife doing household chores while their wives breastfeed. It was inconsistent with a study done in Turkey, they reported that 88.7% of fathers were willing to help their wife out with household chores so that they may breastfeed the baby comfortably. 14 Our reason is because in Kelantanese culture, it would be awkward and not socially acceptable for the husband to be doing house chores and other motherly tasks.
On the other hand, both groups showed positive attitudes towards supporting exclusive breastfeeding, where more than 80% of fathers agreed with the questionnaire. This result is supported by Taspinar et al where 69.5% fathers will support their partner if they wanted to breastfeed.14 This finding is also supported by western studies which reported positive association between partner’s support for breastfeeding with initiation as well as duration of breastfeeding. 16 Another study done among post partum Italian women found that, the duration of breastfeeding and the frequency of exclusive breastfeeding at 6 months were significantly higher in women who had good or very good husband support. The risk of abandoning exclusive breastfeeding decreased when husband support was very good.17 This finding indicates that support from father was a very important factor for the success of mothers in practicing exclusive breastfeeding.

Conclusion

In summary, our study found out that there was no significant difference in terms of knowledge and attitude of fathers from exclusive or non-exclusive breastfeeding groups. However, fathers’ knowledge, attitudes and support are a very important factor that may determine the successfulness of exclusive breastfeeding practices among the mothers.

Study Limitations

Convenient sampling used for the exclusive breastfeeding group could have caused selection bias. Recall bias might be introduced especially in the non-exclusive breastfeeding group. Last but not least closed ended questions were used in which they might not reflect the exact knowledge and attitude of respondents.

Recommendations

We would like to recommend that, it is important to give encouragement and support for the primigravida since it was shown from our study that mother with previous exclusive breastfeeding experienced practice exclusive breastfeeding. Husband should be encouraged to be involved with decision making on exclusive breastfeeding practice through antenatal class attended by their partner. Strengthening and promotion of exclusive breastfeeding practise among working mothers by giving education during antenatal period on how to express, to store and to give the express breast milk to their baby may be an important strategy to improve exclusive breastfeeding practice. Apart from that, awareness among the employers regarding preparing place to express and store the breast milk is also an important strategy for the success of exclusive breastfeeding practices among the working mothers.

Acknowledgment

The authors feel grateful to all the participants, health clinic staffs and whoever helps us in this succeeding the study. An appreciation to Dr. Norhayati Mohd Noor for her guidance on the statistical aspect and Wan Mohd Fidhuan Wan Rahman for helping in preparing the manuscript.

Tables at a glance

Table icon Table icon Table icon
Table 1 Table 2 Table 3
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Table 4 Table 5 Table 6

References

1. Geneva W. Indicators for assessing breast feeding practices. WHO Geneva, Switzerland: WHO Document WHO/CDD/SER. 1991;91:14.

2. Organization WH, UNICEF. Global Strategy for Infant and Young Child Feeding World Health Organization. WHO Publications Geneva. 2003.

3. Organization WH. As formulated in the conclusions and recommendations of the expert consultation (Geneva, 28-30 th March 2001) that completed the systematic review of the optimal duration of exclusive breastfeeding (see document A54/Inf. Doc/4). See also resolution WHA54. 2001;2.

4. Dewey KG. Nutrition, Growth, and Complementary Feeding of The Brestfed Infant. Pediatric Clinics of North America. 2/1/ 2001;48(1):87-104.

5. Mukuria AG, Kothari MT, Abderrahim N. Infant and young child feeding update. 2006.

6. Tan KL. Factors associated with exclusive breastfeeding among infants under six months of age in peninsular malaysia. Int Breastfeed J. 2011;6(2):1-7.

7. Tan K. Knowledge, attitude and practice on breastfeeding in Klang, Malaysia. The International Medical Journal of Malaysia. 2009;8(1).

8. TIa TA, WMb WM. Factors Predicting Early Discontinuation of Exclusive Breastfeeding among Women in Kelantan, Malaysia. Health and the Environment Journal 2013; Vol 4(No.1)

9. Bar-Yam NB, Darby L. Fathers and breastfeeding: a review of the literature. Journal of Human Lactation. 1997;13(1):45-50.

10. Freed GL, Fraley JK, Schanler RJ. Attitudes of expectant fathers regarding breastfeeding. Pediatrics. 1992;90(2):224-227.

11. Rivera-Alvarado I, Vázquez-García V, Dávila-Torres RR, Parrilla-Rodríguez AM. Exploratory study: breastfeeding knowledge, attitudes towards sexuality and breastfeeding, and disposition towards supporting breastfeeding in future Puerto Rican male parents. Puerto Rico health sciences journal. 2006;25(4).

12. Giugliani E, Bronner Y, Caiaffa W, Vogelhut J, Witter F, Perman J. Are fathers prepared to encourage their partners to breast feed? A study about fathers' knowledge of breast feeding. Acta Paediatrica. 1994;83(11):1127-1131.

13. Ismail TAT, Sulaiman Z. Reliability and validity of a Malay-version questionnaire assessing knowledge of breastfeeding. The Malaysian journal of medical sciences: MJMS. 2010;17(3):32.

14. Taşpınar A, Çoban A, Küçük M, Şirin A. Fathers' knowledge about and attitudes towards breast feeding in Manisa, Turkey. Midwifery. 2013;29(6):653-660.

15. Pollock CA, Bustamante‐Forest R, Giarratano G. Men of diverse cultures: Knowledge and attitudes about breastfeeding. Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2002;31(6):673-679.

16. Scott J, Landers M, Hughes RM, Binns C. Factors associated with breastfeeding at discharge and duration of breastfeeding. Journal of paediatrics and child health. 2001;37(3):254-261.

17. Cernadas JMC, Noceda G, Barrera L, Martinez AM, Garsd A. Maternal and perinatal factors influencing the duration of exclusive breastfeeding during the first 6 months of life. Journal of human lactation. 2003;19(2):136-144.
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