Ashley Robinson, DrPH, IBCLC, CLD, ICHC
Introduction: The most significant influence on a mother’s breastfeeding decision is based on the father’s attitude or perceived attitude (Rempel and Rempel, 2011). The objective of this evidence-based practice (EBP) research is to determine if fathers with newborns are provided with breastfeeding education, will their attitudes change favorably towards breastfeeding.
Methodology: This EBP intervention is based on the behavioral theories of attitude change (Hovland et al., 1953). The Iowa Infant Feeding Attitude Scale (IIFAS) was used for measuring attitudes. EBP is a 30-minute breastfeeding educational video based on the Infant and Young Child Feeding Counseling: An Integrated Course (DeLaMore et al., 1999; World Health Organization and UNICEF, 2006).
Results: Data was evaluated by running the Shapiro-Wilk test for normality for pre-and post-intervention, where it was determined that the data were normally distributed (p=0.240 and p=0.746, respectively). Paired samples t-test showed p<0.001 for IIFAS scores, resulting in a statistically significant change. Finally, the mean for pre-intervention started in the neutral attitude range, while the post-intervention mean fell in the “positive attitude towards breastfeeding” range (DeLaMore et al., 1999).
Conclusion: Based on statistical analysis, the intervention successfully changed attitudes towards breastfeeding, and the intervention should continue to be utilized for future success in the pediatrician’s office.
Keywords: breastfeeding, fathers’ attitudes, Iowa Infant Feeding Attitude Scale
Changing Father’s Attitudes Towards Breastfeeding through Education
This study’s overarching focus is to improve father’s attitudes towards breastfeeding through evidence-based practice intervention. Peterson (2020) described, “Breastfeeding provides unmatched health benefits for babies and mothers. It is the clinical gold standard for infant feeding and nutrition, with breast milk uniquely tailored to meet the health needs of a growing baby” (Centers for Disease Control and Prevention, 2020-a, pg. 1). Research studies prove that by including fathers in the conversation and education surrounding breastfeeding, their attitudes will increase, thus leading to an increased rate of exclusively breastfed (EBF) infants (Bich et al., 2014; Maycock et al., 2013; Pisacane et al., 2005; Wolfberg et al., 2014).
According to the Centers for Disease Control and Prevention (CDC) (2020-b), mothers and infants receive health benefits from breastfeeding. The CDC (2020-b) cites that the benefits for infants last from birth through adulthoodincluding the reduced risk for sudden infant death syndrome (SIDS), ear infections, type 1 diabetes, and asthma (p. 1). Due to these health benefits for both mother and baby, HealthyPeople 2020 has contributed eight goals to breastfeeding, specifically long-term success (Office of Disease Prevention and Health Promotion, 2020). The American Academy of Pediatrics (2020) recommends that infants are exclusively breastfed for the first six months of life and continue breastfeeding with food introduction up to at least two years old or longer. Research shows that four out of five infants start their life by receiving human milk; however, that percentage significantly declines at three, six, and twelve months of age (Centers for Disease Control and Prevention, 2020-a).
In a study by Pisacane et al. (2005), 280 mother-father pairs were divided into a control and an intervention group. The intervention group fathers were provided with a training session that included information about breastfeeding management, while those in the control group only received information regarding infant care (Pisacane et al., 2005). Researchers found that 25% of infants from the intervention group were still EBF at six months of age, compared to only 15% of the control group, thus demonstrating that education was beneficial to EBF rates (Pisacane et al., 2005). In a more recent study by Bich and Cuong (2016, pg. s25), fathers were provided with group education, individual education, and pamphlets, which helped increase fathers’ support for breastfeeding.
This study aims to determine that if fathers with newborns are provided education on breastfeeding, their attitude increases towards breastfeeding compared to formula feeding. The intervention study was created and conducted to determine how to increase the father’s attitudes towards breastfeeding. It has already been established that fathers have a vast impact on breastfeeding success for mothers and their infants, so increasing their attitude towards breastfeeding will improve mothers’ breastfeeding success (Bich et al., 2014).
It would be the goal to have the intervention site adopt the education and implement this into their daily practice. The Centers for Disease Control and Prevention (CDC) (2020-b) identifies breastfeeding as an aid in reducing mothers’ risks for female-related cancer (cervical, ovarian, breast) and cardiovascular disease. Cancer and heart disease are the top two preventable diseases leading to death in the United States (Centers for Disease Control and Prevention, 2014). A positive result from this intervention would improve fathers’ attitudes towards breastfeeding and increase breastfeeding rates, thus lowering the risk of developing these diseases and reducing overall health care costs.
The proposed evidence-based practice intervention is based on the theoretical framework of behavioral theories of attitude change (Hovland et al., 1953). The use of this theory is to precisely evaluate the shift in attitude in fathers after introducing breastfeeding education (Hovland et al., 1953). The practice of educating fathers on breastfeeding has proven successful in positively altering their attitudes towards breastfeeding (Bich et al., 2014; Maycock et al., 2013; Pisacane et al., 2005; Wolfberg et al., 2014). In fact, in one study, women reported that fathers’ support, participation, and encouragement in the intervention group was 11 times higher than in the control group after fathers received breastfeeding education (Raeisi et al., 2013).
The intervention study takes place in Tuscaloosa, Alabama. The University of Alabama works with DCH Regional Medical Center, where medical students and residents gain clinical experience (The University of Alabama, 2020). According to the U.S Census Bureau (2019), with a large college town population, the total population is 209,355, with a median annual household income of $52,000. The U.S. Census Bureau (2019) also identifies the community as 64% White, 32% African American, and 4% Hispanic. It is estimated that 33% of the population from 2014 to 2018 had a bachelor’s degree or higher (U.S. Census Bureau, 2019).
The intervention occurred in a well-known pediatrician’s office just outside the University of Alabama Campus. The office consists of three board-certified pediatricians, one board-certified physician, two certified registered nurse practitioners, and several registered nurses, two of whom are International Board-Certified Lactation Consultants (IBCLC). The pediatrician’s office did not require financial support for this intervention study due to its virtual setting as a result of the COVID-19 pandemic.
The intervention consisted of a 30-minute virtual educational video based on the World Health Organization’s Infant and Young Children Feeding Counseling program, and the Iowa Infant Feeding Attitude Scale (IIFAS) was used as a pre-and post-survey to evaluate the intervention success.
Based on a study by Abdulahi et al. (2018), the educational intervention adopted the World Health Organization (WHO) and UNICEF’s (2006) breastfeeding counseling course, “Infant and Young Child Feeding Counseling: An Integrated Course,” and adapted the information to the targeted population. Educational material from the listed sections below were compiled and recorded in an educational video by a local registered nurse practitioner (World Health Organization and UNICEF, 2006, pp. 25-253). The omitted sections did not include enough information that was relevant for fathers and breastfeeding.
- Session 1: An introduction to infant and young child feeding
- Session 2: Why breastfeeding is important
- Session 3: How breastfeeding works
- Session 8: Positioning a baby at the breast
- Session 10: Building confidence and giving support
- Session 11: Building confidence and giving support exercises
- Session 14: Common breastfeeding difficulties
- Session 20: Breast conditions
An informational sheet was presented to the fathers at the prenatal or the 2-week follow-upwell-baby visit. The information sheet included necessary information about the intervention and a link with the Q.R. code to the initial survey. All surveys were housed in Survey Monkey, a FERPA and HIPPA-compliantplatform (SurveyMonkey, 2020). The initial survey consisted of eight demographic questions and two intervention-specific questions.
For this intervention study, participants must meet the following inclusion requirements: the infant must be under three months of age, and the mother’s preferred feeding method must be breastfeeding, either by chestfeeding or pumping. Based on human biology and lactation, targeting fathers with infants under three months of age will provide an increased chance of breastfeeding success (Centers for Disease Control and Prevention, 2020-a). If the participants did not meet these two requirements, they did not move on in the intervention study. Once eligibility was determined, they were sent the initial IIFAS survey, again through survey monkey. Before the intervention, permission was obtained from the author of the IIFAS, along with the published study. Once the initial survey was completed, the educational video and post-survey were sent to the participants. Reminder emails were sent along the way if the participant did not complete the post-survey.
Study of the Intervention(s)
The IIFAS is the chosen tool for assessing the success or failure of the intervention. As previously mentioned, a complete literature review was conducted before the development of the intervention. Through the literature review, it was found that the IIFAS was successful in assessing intervention effectiveness.
Three individual studies were reviewed and analyzed to determine the reliability and validity of the IIFAS (De la Mora et al., 1999). All three studies were predictive of breastfeeding outcomes; higher favorability toward breastfeeding led to higher breastfeeding rates (exclusive or partial) (De la Mora et al., 1999). Abdulahi and colleagues (2020) most recently conducted a study testing reliability and validity in Ethiopian populations and found acceptable internal consistency (Cronbach’s alpha= 0.72). Confirmatory factor analysis also showed the IIFAS validity (χ2/df = 2.11, RMSEA = 0.049, CFI = 0.845, TLI = 0.82) (Abdulahi et al., 2020). By conducting reliability and validity testing across different populations, researchers can prove the usefulness of the IIFAS in any population (De la Mora et al., 1999, Abdulahi et al., 2020).
When using the IIFAS, fathers’ attitudes positively change towards breastfeeding when scores range from 70-85 (De la Mora et al., 1999). Complete and honest answers are vital to the survey results’ reliability. Upholding the integrity of the intervention was done by ensuring participant confidentiality and privacy. The three studies mentioned above used the IIFAS to study pre- and post-intervention survey results and assess how the father’s attitudes changed. The studies looked at different populations and demographics to determine success.
The IIFAS is a 17-questions 5-point Likert scale survey completed by participants twice during the study, once pre-education and once post-education. Convenience sampling was conducted for this intervention (Gall et al., 1996). According to Gall et al. (1996), convenience sampling is one of the easiest ways to obtain volunteer participants for a study. Sample recruitment was voluntary and took place between October 19, 2020, and November 23, 2020. The data was collected on a rolling basis.
SPSS v26 was used for data analysis. Quantitative methods were used to draw inferences from the data collected. Pre-and post-survey results variables are categorized as nominal data, while the demographic variables are categorized as scale data. Initial data was important into SPSS v26 from Survey Monkey results for all three surveys and assessed for 100% completeness then analyzed. Initially, data were tested for normality by performing a Shapiro-Wilk test. The Shapiro-Wilk Test is the most appropriate for small sample sizes (< 50 samples) (Laerd Statistics, 2020). The Shapiro-Wilk test shows normal distribution (p <0.05); therefore, a paired samples t-test was performed. Multiple regression analysis was considered; however, the small sample size does not allow it to be completed.
In conjunction with the American Psychological Association (APA) and X University guidelines, all ethical standards were met for this intervention study. Between August and September 2020, the Institutional Review Board and Ethics Committee at X University conducted a review that deemed this intervention study non-human subject-related, and permission was granted to complete the intervention. Completing the CITI human research course program on January 15, 2020 has taken protection for human subjects. This course was completed to ensure the researcher has a thorough understanding of human subject protection, including privacy, confidentiality, informed consent, federal regulations, and the Belmont Report’s principles when performing the intervention.
The Shapiro-Wilk normality test was run for the final sample size (n=15). “If the Sig. value of the Shapiro-Wilk Test is greater than 0.05, the data is normal (see Table 1). If it is below 0.05, the data significantly deviate from a normal distribution” (Laerd Statistics, 2019, p.2). The significance value for both pre- and post-survey showed a normal distribution. The pre-intervention survey significance value = 0.240, while the post-intervention survey significance value is 0.746. While running the Shapiro-Wilk test, a Q-Q plot was created to show additional confirmation of normal distribution (see Figures 1 and 2).
A paired samples t-test was conducted to test for correlation and determine if the results were statistically significant. The paired t-test showed a final p-value of <0.001 (T(19)= -6.432, p<0.001). Due to the means of the pre-and post-scores and the direction of the t value, it can be concluded that there is statistical significance between the father’s attitudes towards breastfeeding pre-intervention and post-intervention (see Tables 2, 3, 4 and 5). The initial mean pre-intervention is 54, with a post-intervention mean of 71. Based on the findings from DeLaMore (1999), if a final score is between 70 and 80, fathers are considered to have a favorable attitude towards breastfeeding.
This study’s key findings conclude that there is a strong statistical significance (p < 0.001) between surveys, which resulted in a successful intervention. The specific aims were to “determine that if fathers with newborns are provided education on breastfeeding, will their attitude increase towards breastfeeding compared to formula feeding?” The statistical analysis would prove that this study design, intervention, and analysis met the specific aims. The pre-intervention survey mean was 54, resulting in a neutral attitude between breastfeeding and formula feeding, while the post-intervention survey mean was 70, resulting in a positive attitude toward breastfeeding (DeLaMore, 1999).
Regarding replicating the study and its sustainability, due to the COVID-19 pandemic, education was conducted in a virtual setting. Therefore, a recorded educational piece can be viewed as a study strength and benefit for sustainability. This educational piece can continue to be provided to the infant’s father, and there would be no changes made to the typical workflow for the patients or staff in this pediatrician’s office.
This EBP intervention initially aimed to determine if education could favorably change a father’s attitude towards breastfeeding. Based on the previously stated results, it is evident through the use of the Iowa Infant Feeding Attitude Scale that the population had a neutral attitude, to begin with and ended with a positive attitude towards breastfeeding. These results align with the findings of similar projects. Specifically, the Hunter and Cattelona (2014) study provided breastfeeding education to both parents, and those in the intervention group that received this education had a higher rate of postpartum breastfeeding support from the father. Study results also aligned with the Fathers Infant Feeding Initiative (FIFI Study) that used breastfeeding education and the IIFAS to determine that education can increase their attitudes and the longevity of breastfeeding past six months of age (Maycock et al., 2013).
The strategic trade-off for this study would look at the ultimate goal of increasing breastfeeding rates and reducing infant illness. Thus, reducing the amount of “sick visit” appointments and open appointment opportunities for those who need further healthcare. The cost of sustaining this intervention would be virtually zero due to the intervention’s original virtual nature. The educational video could be presented to the father during the routine well-baby visit.
This intervention study focuses on fathers’ attitudes towards breastfeeding, which can be a limitation because this is only one part of the breastfeeding team (Kim, 2019). Based on the IIFAS, this study and assessment do not take into account any learned behavior from outside variables such as past experience with breastfeeding infants, fears or motivation, along with socioeconomic factors. A small sample size due to location and the utilization of only one pediatric office will limit the study, so generalizations cannot be made about the population. Intervention participants are voluntary and may skew study results further.
Breastfeeding provides several health benefits to both mother and baby that are beneficial throughout the lifespan. A father’s influence on breastfeeding success is essential, especially his attitude toward breastfeeding (Rempel and Rempel, 2011; DeLaMore et al., 1999). Providing breastfeeding education to the father has successfully improved his attitude towards breastfeeding through this EBP intervention. Due to this intervention’s virtual nature, sustainability would not burden the pediatrician’s office financially, and the outcomes can be sustained rather than the project or program.
This intervention could be spread to another context based on results and available knowledge based on the theoretical framework. The intervention results prove that Hovland’s (1953) behavioral theories of attitude change can be replicated throughout additional interventions. The same intervention can be carried out further to follow the participants and include the mothers breastfeeding rates to determine how successful the father’s attitudes are in increasing the rate. It can be recommended that the practice continue to follow these participants to determine how EBF rates are changed for the practice. It is also recommended that father involvement continues through breastfeeding education.
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Abdulahi, M., Fretheim, A., & Magnus, J. H. (2018). Effect of breastfeeding education and support intervention (BFESI) versus routine care on timely initiation and exclusive breastfeeding in Southwest Ethiopia: study protocol for a cluster randomized controlled trial. BMC Pediatrics, 18. http://dx.doi.org.library.capella.edu/10.1186/s12887-018-1278-5
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Father’s attitudes appendix by Ashley Robinson