By James Achanyi-Fontem,
Courtesy of Nutrition Institute of Africa
Different theories on behaviour are useful in predicting or explaining behaviours. The Bronfenbrenner’s Ecological system’s model and the Theory of planned behaviour have often been used to explain human behaviour. In order to understand human behaviour, there is need to understand the context in which the behaviour occurs, and the intertwined relationship between an individual and their surrounding environment. (McLeroy, Bibeau, Steckler & Glanz, 1988; Stokols, 1996). Bronfenbrenner’s Ecological systems model defines spheres of influence from individual factors to society and environment, affecting health behaviour (Bronfenbrenner & Uriel, 1994). Although in the model different levels are separate in order to illustrate how they individually contribute to every behaviour, the levels overlap and influence each other.
Figure 1 provides a graphical representation of Bronfenbrenner’s Ecological systems model as applied to parental involvement in IYCF. The four categories of levels emerging from this model are the macro system, exo system, micro system and the individual level.
The microsystem includes interactions experienced by the individual in this case the parents with friends, grandmothers and other relations that have an influence of the involvement of parents in child feeding. The exo system includes the influence of the health systems, the media and finances, while the macro system includes the environment in which the parents live in, policies and the culture that the parents follow. Some of the factors that influence parental involvement in IYFC based on the ecological model will be discussed. These factors include the parent’s knowledge and attitudes, their education status, age, economic status and other cultural norms.
Parental knowledge and attitudes in infant and young child feeding
According to the Theory of planned behaviour (Ajzen, 1985; Ajzen, 1991), antecedents of intention and actual behaviour are subjective norms, perceived behavioural control and attitudes towards that behaviour, which in turn are based on underlying beliefs on advantages and disadvantages of the behaviour. Identifying the parent’s attitudes and their beliefs could help to improve IYCF practices. The Knowledge-Attitude-Behaviour model by Kemm & Close (1995) adds that knowledge affects ones attitudes which leads to change of behaviour.
Behavioural intention is a direct predictor of behaviour while one’s attitude to the behaviour, subjective norms and perceived behaviour control are predictors of intention. However, attitude can also directly influence behaviour. Knowledge affects the attitudes and perceived behaviour control (Vaarno, 2016).
Parental knowledge of infant and young child feeding practices
The knowledge that parents and caregivers have on the recommended IYCF practices had an influence on their feeding practices (behaviour). As such, improving parental knowledge on appropriate IYCF practices may have a beneficial effect on the actual feeding practices. In some studies, prenatally given breastfeeding information for mothers has been positively associated with breastfeeding confidence (Chezem, Friesen & Boettcher, 2003; Kronborg, Maimburg & Væth, 2012), initiation of breastfeeding (Stuebe & Bonuck, 2011), and breastfeeding duration (Chezem et al., 2003). Women’s knowledge and self-efficacy on breastfeeding have also been associated with high breastfeeding rates (Khoury, Mitra, Hinton, Carothers & Sheil, 2002). Maternal knowledge appears to have a beneficial influence to initiation of complementary foods (Semahegn, Tesfaye & Bogale, 2014) and quality of complementary foods (Fahmida, Kolopaking, Santika, Sriani, Umar, Htet & Ferguson, 2015; Negash, Belachew, Henry, Kebebu, Abegaz & Whiting, 2014). However, it has been observed that mothers have higher levels of knowledge about the recommendations related to breastfeeding in comparison to their knowledge of complementary feeding (Thuita, 2011).
Fathers have an important role of supporting mothers in IYCF (Tohotoa, Maycock, Hauck, Howat, Burns & Binns, 2009), and their knowledge about breastfeeding has been identified as one of the main attributes related to their support to breastfeeding (Sherriff, Hall & Panton, 2014). However, it has been observed that fathers’ knowledge of and involvement in maternal and child nutrition and health issues is limited compared to that of mothers (Aubel, 2012). This could be because the fathers are not extensively involved in child feeding and therefore they do not accumulate significant knowledge. Wolfberg et al. (1994) in the United States of America found that breastfeeding initiation was significantly increased when expectant fathers attended a two hour antenatal class of infant care and breastfeeding compared to only one class covering infant care. The father’s perception of the IYCF practices have also been linked to mother’s breastfeeding decisions. It has been observed that in families where the fathers perceived breastfeeding as a good practice, mothers were more likely to initiate breastfeeding than families where fathers did not favour breastfeeding (Arora, McJunkin, Wehrer & Kuhn, 2000; Freed & Fraley, 1993; Giugliani, Caiaffa, Vogelhut, Witter & Perman, 1994). Other studies suggest that since fathers often have misperceptions of and limited knowledge on IYCF, they would benefit from interventions to enhance their knowledge (Brown & Davies, 2014; Sherriff et al., 2014; Taşpınar, Çoban, Küçük & Şirin, 2013). Providing education to fathers has been found to influence the actual feeding practices. For instance, in Brazil it was observed that fathers’ better knowledge increased changes of infant being exclusively breastfed at the end of first and third month (Susin, Giugliani, Kummer, Maciel, Simon & Da Silveira, 1999). Similar benefits of paternal education were also reported in a Turkish study (Özlüses & Çelebioglu, 2014).
The beliefs and attitudes that parents have toward breastfeeding and complementary feeding also have an influence on the actual feeding practices. It is even suggested in other studies that attitudes may be even better predictors of feeding intention and behaviour than knowledge (Losch, Dungy, Russell & Dusdieker, 1995; Marrone, Vogeltanz-Holm & Holm, 2008).
Attitudes and beliefs
Benefits of breastfeeding seem to be well known, but positive attitudes towards breastfeeding are needed for successful outcomes in infant feeding. Positive attitudes towards breastfeeding have been associated with the intention to breastfeed, longer duration of both exclusive and any breastfeeding (Mitchell-Box, Braun, Hurwitz & Hayes, 2013), and the introduction of complementary foods (Newby, Brodribb, Ware & Davies, 2014). In a study by Mossman et al. (2008) on mothers’ breastfeeding attitudes on breastfeeding initiation and duration it was found that mothers with high prenatal attitude on breastfeeding were significantly more likely to initiate breastfeeding than those with poor attitudes. In addition, adolescent mothers who had more positive attitudes toward breastfeeding also had higher prenatal breastfeeding self-efficacy scores (Mossman, Heaman, Dennis & Morris, 2008). This was also observed in an Australian study, where mothers who did not initiate breastfeeding had significantly lower levels of breastfeeding confidence than those who initiated breastfeeding and continued to six months postpartum (Turner & Papinczak, 2000). In another study, women with lower breastfeeding confidence were three times more likely to prematurely discontinue breastfeeding when compared to more confident women (O'Campo, Faden, Gielen & Wang, 1992).
In addition to the mother’s attitudes, father’s attitudes on IYCF also have an influence on the feeding practices. Rempel and Rempel (2011) found that fathers’ prenatal beliefs influenced the strength of mothers’ breastfeeding intention and predicted breastfeeding behaviour even over and above the mothers’ intention. In a study by Giugliani et al. (1994) mothers’ perception of fathers’ attitudes was the main reason associated with breastfeeding shortly after birth. It has been observed that mothers who perceived their partner having negative attitudes regarding breastfeeding planned to formula-feed (Freed & Fraley, 1993; Freed, Fraley & Schanler, 1993; Shaker, Scott & Reid, 2004) and choose formula-feeding as the feeding method (Arora et al.,2000; Wolfberg, Michels, Shields, O'Campo, Bronner & Bienstock, 2004). Other studies in both high- and low-income settings have also observed that a father’s positive beliefs and knowledge about breastfeeding are associated with increased maternal intentions to breastfeed as well as successful breastfeeding initiation and increased breastfeeding duration (Anon.; Kessler, Gielen, Diener-West & Paige, 1995; Pontes, Osório & Alexandrino, 2009; Rempel & Rempel, 2004).
However, not all the studies have found positive attitudes to be associated with initiation of breastfeeding (Holbrook et al., 2013) or exclusive breastfeeding duration (Yu et al., 2015). Negative attitudes are also associated with child feeding, more specifically negative attitudes towards breastfeeding in public have been found to be associated with earlier discontinuation of breastfeeding in many European countries (Scott et al., 2015).
Education is one of the factors that have an influence on parental involvement in IYCF. Studies have shown that younger parents and caregivers with high levels of education have a better understanding of the importance of child feeding and therefore are more likely to be involved in IYCF than parents with low levels of education (Hasnain, Majrooh & Anjum, 2013; Katepa-Bwalya et al., 2015). This is also evidenced from the results of a study conducted in Zambia that observed that mothers’ compliance with recommended IYCF practices increased with the mothers’ level of education. In the Zambian study, 48% of children whose mothers attended secondary school were fed according to the recommended IYCF practices, compared with 32% of children whose mothers had no education (Katepa-Bwalya et al., 2015). Other studies done in Malawi also found that education improved adherence to IYCF recommendations and reduced childhood morbidity (Vaahtera et al., 2001; Ziyane, 1999). High mother’s education has been related most clearly with positive feeding behaviours. In a Finnish nationwide survey where mother’s level of education was linked to both exclusive breastfeeding and total breastfeeding, it was found that 42 % of mothers with a high education were exclusively breastfeeding at four months and 88% were breastfeeding at six months, whereas among mothers with the lowest education level only 18% of the mothers were exclusively breastfeeding at four months, and 33% were breastfeeding at six months respectively (Uusitalo et al., 2012).
The father’s level of education also has an influence in IYCF. Results from a study in Nepal found that fathers/ males who had higher levels of education showed greater involvement in encouraging their spouses to breastfeed their children (Bhatta, 2013). Another study in Equatorial Guinea had similar findings where younger married men with secondary education were significantly more willing to encourage their wives to exclusively breastfeed than older men with little education (Jimoh, 2004). For complementary feeding, a low maternal educational level has been related to early introduction of solid foods (Andren Aronsson et al., 2013& Betoko et al., 2013), delayed (beyond six months) introduction of complementary foods (Senarath et al. 2012) and a low quality of complementary foods (Betoko et al., 2013).
The age of the parents also has an influence on how they are involved in IYCF. For breastfeeding, older mothers have been observed to have more positive attitudes and to initiate and maintain breastfeeding longer than younger mothers (Mossman et al., 2008). Other studies also found maternal age as being positively associated with appropriate timing and quality of complementary foods (Andren Aronsson et al., 2013& Betoko et al., 2013). The father’s age has also been observed to have an influence on feeding practices. A study by Huus et al. (2008) found that short term (< 4 months) exclusive breastfeeding was less common if the father was more than 37 years old than when the father was younger.
The parents’ economic status also has an influence on their involvement in IYCF. Traditionally financial provision is considered to be one of the primary contributions of fathers (Kenney, 2008). This may lead to poor involvement from low income fathers since they may not have a lot of money to provide for the child’s feeding needs (Gavin, Black, Minor, Abel, Papas, & Bentley, 2002). On the other hand, fathers who provide steady household income for their families may feel that their most important role has been fulfilled through their work (Raub, 2013) and this may discourage them from being more directly involved. Even though recommended IYCF practices, especially breastfeeding, are generally cost saving, it has been observed that infants in low socio-economic families breastfeed for shorter periods and introduce solid foods earlier than infants in families having better socioeconomic status (Lauer et al., 2004; Mukuria et al., 2012). A qualitative study that was conducted in Kenya found that a mother’s food insecurity and hunger led to her experiencing milk insufficiency and anxiety about infant hunger. The mothers’ had the perception that their intake of food was not sufficient for successful breastfeeding which resulted in the mothers introducing solid food before the child was six months (Webb-Girard et al., 2012). Economic status may also influence the quality of foods provided for the children. A study in four South Asian countries found that the prevalence of children having a diversified diet (receiving foods from four or more food groups) was the lowest in the poorest families (Senarath et al., 2012). Foods that contain plenty of protein and micronutrients are typically expensive, which makes low income families unable to purchase them for their children (Darmon & Drewnowski, 2015). Parents may also have knowledge on the foods needed for complementary feeding, but may fail to practise when they do not have adequate financial resources to purchase the appropriate food (FAO, 2015).
Culture determines the parents’ involvement in the feeding of infant and young children. Cultural norms dictate that the roles of younger women and men are gender specific, as are the roles played by senior women (grandmothers) and senior men (grandfathers). Male family members are primarily responsible for providing the financial resources for basic household activities, including food while women are responsible for managing the household and managing the daily tasks of raising children which includes dealing with nutrition and health issues (Aubel, 2012). This division of roles may sometimes hinder men to be directly involved in IYCF. A study in Kenya observed that the pressure to embrace this cultural definition of masculinity hindered most men in actively participating in child care (Thuita, 2011). Culture can positively influence parental involvement in IYCF practices when the cultural patterns are supportive of the appropriate feeding practices. For example in rural Thailand, breastfeeding on demand, strong family support, and traditional practices that encouraged close contact between mother and her new born enabled mothers to breastfeed even when they had no previous experience (Amatayakul, Wongsawasdi, Mangklabruks, Tansuhaj, Ruckphaopunt, Chiowanich, Woolridge, Drewett & Baum, 1999).
However, cultural practices can sometimes negatively influence parental involvement in IYCF. In Malawi some cultural norms and beliefs in relation to taboos were found to negatively influence IYCF practices. For example, eggs were perceived to be harmful for young children, while herbal tonics and thin porridges were believed to offer protective qualities (FAO, 2014; Vaahtera et al., 2001). In other Sub-Saharan African countries mothers are not allowed to be involved in sexual activities during the breastfeeding period because of the belief that intercourse would spoil the breast milk (Arts, Geelhoed, De Schacht, Prosser, Alons & Pedro, 2010; Mbekenga, Lugina, Christensson & Olsson, 2011). Such a taboo may increase pressure on mothers to terminate breastfeeding earlier than they would otherwise do. In some cultures, breastfeeding in public is considered a taboo due to exposing of breasts and this may hinder women from exclusively breastfeeding their children. For instance, a study in Malaysia found that women had positive attitudes towards exclusive breastfeeding and were willing to practise exclusive breastfeeding, however breastfeeding in public was considered a taboo, which resulted in most mothers being unable to exclusively breastfeed (Leong, 2009).
Both mothers and fathers play important roles in the feeding of infants and young children. As such involving both parents (mother and fathers) in IYCF is important to ensure optimal IYCF practices. Adequate nutrition knowledge, positive attitudes and perceptions of parents on IYCF are also important in improving their IYCF practices. There are several factors that influence the parents’ involvement in IYCF, including the parents’ level of education, age, and spouse perceptions of the appropriate IYCF practices as well as socio-economic and cultural factors.
James Achanyi-Fontem, is a Senior Health Journalist and Communication Consultant. He worked as a health journalist and broadcaster for 30 years with Radio Cameroon and later Cameroon Radio Television, CRTV before retiring in 2005 to engage fully with Cameroon Link (Human Assistance Programme). Cameroon Link is a registered charity, not-for-profit organisation involved in the promotion of community health, humanitarian assistance, promotion of women and child rights through involvement of communities in Cameroon for mother and child health care. Cameroon Link is a partner to Commonwealth of Learning (COL), Farm Radio International (FRI), International Baby Food Action Network (IBFAN Africa), World Alliance for Breastfeeding Action (WABA). As the intermediary of Commonwealth of Learning (COL), Cameroon Link is engaged to implement a Cameroon Rural Radio story design Programming through an investigative research, which aims to discover through interviewing beneficiaries of health programmes on their interests, documenting and disseminating new ideas about how radio stations produce and air Healthy Communities Radio Programs in Cameroon.