Are adolescents ready for future responsibilities? Experience from a cross-sectional study regarding Breastfeeding knowledge and attitude.

BACKGROUND: Breastfeeding plays an important role in the holistic development of a child. Current knowledge and attitude of future parents will significantly influence breastfeeding practices. Therefore, ascertaining current knowledge and attitude of both soon-to-be parents will help to formulate breastfeeding promotion strategies. RESEARCH AIM: To ascertain the knowledge and attitude of adolescents towards breastfeeding and its correlates with socioeconomic and demographic factors.
MATERIALS AND METHODS: A cross-sectional institutional based study in which participants were recruited from Punjab, state of India. A total of 392 adolescents from January to June 2017 were evaluated on the basis of a pretested, reliable, and valid instrument. The instrument consisted of questions on knowledge and attitude regarding breastfeeding.
RESULTS: One-hundred two (26%) participants had good knowledge and 290 (74%) had poor knowledge regarding breastfeeding. A bothersome fact is that only 25% of the participants knew about the age till which a child should be breastfed. There was a statistically significant (OR = 2.93; 95% CI: [1.45--5.93]) association between high knowledge and positive attitude.
CONCLUSION: The level of knowledge amongst adolescents showed variation ranges from 15.82% to 93.11% on various aspects of breastfeeding. Despite this glaring variation, 75% of the participants had a positive attitude towards breastfeeding. Thus, there is a need for implementing modified and improved breastfeeding promotion strategies in India.

Introduction

The “August Innocenti declaration” of 1990 was signed by conglomeration of UNICEF, WHO (2016), policy makers, and other organizations to protect, promote, and support breastfeeding. This noble cause was further strengthened by adopting “Breastfeeding: Foundation for Life” theme for the world breastfeeding week in 2018. As per WHO estimates, more than 8 lakh children under age of 5 years can be saved with improved breastfeeding.[1]

Inept feeding practices lead to malnutrition which contributes to two-thirds of mortality in the first year of life.[23] Breastfeeding is most gainful, easy to implement, and cost-effective public health intervention in combating infant morbidity and mortality in developing countries.[345] Therefore, Booth I. recommended strengthening and escalation of breastfeeding practices in developing countries for proportional reduction in infant morbidity and mortality.[6]

National Family Health Survey (NFHS-4) showed that 78.9% of deliveries in India are taking pace in health facilities.[7] Despite this, only 42.6% and 54.9% children are breastfed within first hour of birth and exclusively breastfed during first 6 months of life, respectively.[7] In order to support, promote, and protect breastfeeding through various activities at community level, government of India has launched a nationwide program “Mothers’ Absolute Affection” (MAA) in August 2016.[8]

Prenatal targets are among the strongest predictors of breastfeeding duration and intensity.[91011] There are host of demographic and other factors which affect a woman's ability to initiate and continue breastfeeding practice.[12131415] In separate studies, Vijayalakshmi et al. and Dungy et al. highlighted that negative attitudes of women toward breastfeeding act as a major barrier to initiate and continue breastfeeding.[1617] As emphasized by Arora et al., role of male member to opt for breastfeeding or bottle-feeding is gaining prominence.[18] This is especially of importance to Indian society as there is demographic transition from joint to nuclear families.[19]

Leshi et al. and Amu opined that breastfeeding intention of future parents could be greatly influenced by their current knowledge and attitude towards breastfeeding.[320] The decision to breastfeed is formed as early as adolescence and in early adulthood stage.[3] The data regarding adolescent's knowledge and attitude for both male and females from India is very less. Moreover, the positive interventions regarding breastfeeding in these years will play a major role in acquiring knowledge and positive attitude towards breastfeeding.

With this in backdrop, the current study was planned and executed in adolescents who are going to be future parents. The opinion expressed today by this group may predict the future behavior of would be parents. Therefore, this study was planned to ascertain the knowledge and attitude of adolescents towards breastfeeding and its correlates with socioeconomic and demographic factors.

Methods

Study design

A cross-sectional study was conducted for ascertaining the knowledge and attitude of adolescents towards breastfeeding and it correlates with socioeconomic and demographic factors. A prior ethical approval from institute ethics committee was obtained to conduct the study. The adolescents in current study were assessed from January to June 2017. Participants were informed about maintaining confidentiality about their data and same was not shared without deidentification of data.

Measurements

Data was collected using structured, reliable, and pretested culturally validated questionnaire. The questionnaire was broadly segmented into three sections namely: (1) sociodemographic information, (2) knowledge, and (3) attitude regarding breastfeeding. Socioeconomic status (SES) was assessed using modified Kuppuswamy's scale.[21] The knowledge domain consisted of 18 questions with score ranging from 0 to 18. The attitude domain consisted of 10 questions with a score range from 0 to 10.

Sample size

Sample size was calculated using the formula n = 4 (pq/L2), where n = sample size. Expected proportion of students with breastfeeding knowledge, q = 1 - p and L = precision. Assuming the proportion of breastfeeding knowledge as 50% and precision within 5%, sample size of 400 was required to conduct the study.

Data collection

Data collection was initiated after institutional ethics committee reviewed and approved the study. Initially, participants were briefed about the process and objectives of the study. Subsequently, signed informed consent was collected from participants and their parents (only for non-adults). The questionnaire along with consent forms (n = 2) were handed separately in Manila and other envelope. Participants were instructed to return the filled in questionnaire sealed in Manila envelope and a copy of consent form to the researcher.

Data analysis

The collected data was entered into Microsoft excel® (https://products.office.com/en-in/excel) in the multivariate format. This multivariate dataset was further cleaned, coded, and evaluated for cosmetic and logical errors. A separate coding sheet for categorical variables was prepared and kept for reference. Finally, coded dataset was exported to SPSS version 22 (https://www.ibm.com/analytics/spss-statistics-software) for the analysis purpose. Descriptive analysis in the form of number and percentages was calculated and reported for categorical variables. At first, univariate analysis with Chi-square test was applied using SPSS and openEpi (http://www.openepi.com/Menu/OE_Menu.htm) software to obtain unadjusted odds ratio (OR) and significant P values. All variables with P ≤ 0.10 were considered for multivariable analysis to obtain the adjusted odds ratios (AOR). AOR values were calculated with multivariable logistic regression technique using generalized least square (GLS) and same were reported in Tables 1 and 2 along with OR. Reliability coefficient was assessed using Cronbach's alpha. A two-tailed P value < 0.05 was used to declare statistical significant for all the tests in the analyses.

Table 1

Unadjusted and adjusted odds ratios with Chi-square and multivariable logistic regression: outcome variable, Breastfeeding Knowledge

Variables	OR	95% CI	AOR	95% CI	P
PMA
25 and less	Reference	-	-	-	-
25-30	1.44	(0.81-2.63)	1.41	(0.78-2.54)	0.25
30 and more	2.90	(1.12-7.49)	3.58	(1.34-9.54)	0.01*
BFS
Yes	0.15	(0.04-0.44)	0.14	(0.04-0.45)	0.001*

AOR=adjusted odds ratio, OR=unadjusted odds ratio, CI=confidence interval, *significant at 5% level of significance. PMA=Preferred Marriage Age, BFS=Breastfeeding Seen

Table 2

Relation of socio-demographic and other variables to attitude regarding breastfeeding

Variables		OR	95% CI	AOR	95% CI	P
PMA	Min-25	Reference	-	-	-	-
	25-30	0.32	(0.19-0.56)	0.33	(0.19-0.59)	0.001*
	30-Max	0.24	(0.05-0.78)	0.21	(0.06-0.78)	0.002*
SES	Low	Reference	-	-	-	-
	Middle	0.28	(0.12-0.60)	0.30	(0.13-0.69)	0.004*
	Upper	0.88	(0.51-1.52)	1.03	(0.57-1.85)	0.93
BFS	Yes	2.076	(1.08-3.989)	3.39	(1.35-8.26)	0.009*
WBF	Home	Reference	-	-	-	-
	Relative	0.44	(0.22-0.87)	0.47	(0.23-0.98)	0.044*
	Public	0.24	(0.057-0.77)	0.29	(0.08-1.02)	0.054
	Others	0.64	(0.35-1.20)	0.38	(0.17-0.89)	0.025*

A.O.R.=adjusted odds ratio, O.R.=unadjusted odds ratio, C.I.=confidence interval, *significant at 5% level of significance, PMA=Preferred Marriage Age, SES=Socio-economic Scale, BFS=Breastfeeding Seen, WBF=Where Breastfeeding Seen

Results

The study consisted of data from a total of 392 participants. Eight participants (0.02%) did not submit filled in forms despite multiple reminders by the investigator. The instrument with Cronbach alpha value of 0.78 and 0.75 for knowledge and attitude displayed good reliability. There were 200 (51%) males and 192 (49%) females which represents 53.3% Sikhs, 42.6% Hindus, and 4.1% from other religions. Majority (63%) of the participants belong to nuclear family [Table 3]. It is noted that more number of males (76.5%) as compared with females (64.1%) expressed their preference to marry by 30 years. Moreover, only 17.5% of males preferred to get married under 25 years as compared with 28.6% among females.

Table 3

Demographic characteristics of participants (n=392)

Characteristics	Female (192)	Male (200)
Mean Age±SD, yearsᵻ	17.9 (0.99)	18.02 (0.93)
Religion - no. (%)
Sikh	118 (61.5)	91 (45.5)
Hindu	66 (34.4)	101 (50.5)
Others*	8 (4.2)	8 (4.0)
Caste- no. (%)
General	77 (40.1)	110 (55.0)
SC/ST	97 (50.5)	52 (26.0)
OBC**	18 (9.4)	38 (19)
Family- no. (%)
Nuclear	125 (65.1)	124 (62.0)
Joint	67 (34.9)	76 (38.0)
Mother's Education - no. (%)
Illiterate	42 (22.1)	25 (12.5)
Primary	31 (16.3)	28 (14.0)
Secondary	88 (46.3)	128 (64.0)
Graduate & above	29 (15.3)	19 (9.5)
Preferred Marriage age, years -no.(%) 25-30	123 (64.1)	153 (76.5)
SES - no. (%)
Low	74 (38.5)	65 (32.5)
Middle	40 (20.8)	67 (33.5)
Upper	78 (40.6)	68 (34.0)
Breast feeding seen - no. (%)
Yes	170 (88.5)	170 (85.0)
No	22 (11.5)	30 (15.0)

*Others- Muslim, Christian; **OBC- Other Backward Classes; ***SES- Socio-economic Status; ᵻYears

The female participants had seen breastfeeding at home (56.2%), followed by moderate extent at relative's place (26.6%, Figure 1). Few males had seen breastfeeding at home or relative's place (22.5%) in comparison to majority (48.5%) who had seen it in public places, internet, television, etc., It is also noted that only 25% of the participants knew about the age till which a child should be breastfed.

Figure 1

Bar diagram displaying breastfeeding seen by gender across different place

The associations between independent variables and breastfeeding knowledge are displayed in Table 1. Despite usual perceptions, sociodemographic profiles were not significantly associated (OR = 1.44; 95% CI: [0.81-2.63]) with breastfeeding knowledge. However, preferred age of marriage (OR = 2.90; 95% CI: [1.12-7.49]) and breastfeeding seen (OR = 0.15; 95% CI: [0.04-0.44]) had statistically significant association with knowledge.

Similarly, it was found that breastfeeding seen had statistically significant association with attitude (OR = 2.076; 95% CI: [1.08--3.989]). Apart from these, it was found that place of breastfeeding seen (OR = 0.44; 95% CI: [0.22--0.87], OR = 0.24; 95% CI: [0.057-0.77]) and socioeconomic status (OR = 0.30; 95% CI: [0.12-0.60]) had statistically significant association with attitude [Table 2].

It was observed that good attitude toward breastfeeding was found in 312 (80%) participants as compared with poor attitude in 80 (20%). A glaring fact depicted by the study that 290 (74%) out of 392 participants had poor knowledge as compared with good knowledge in 102 (26%) [Table 4]. There was a statistically significant (OR = 2.93; 95% CI: [1.45-5.93]) association between attitude and knowledge. Attitude toward perceived effect of breastfeeding effect on sex life were not reported by 72 males and 58 females. This anomaly could perhaps be attributed to cultural influence in Indian context as discussions on sex are taboo.

Table 4

Contingency table displaying the association between Knowledge and attitude regarding breastfeeding

	Knowledge		P
	Poor	Good
Attitude
Poor	70 (24.1%)	10 (9.8%)	0.002
Good	220 (75.9%)	92 (90.2%)

Discussion

The knowledge of participants regarding various aspects of breast feeding was good and participants with correct response to individual questions varied from 15.82% to 93.11%. More than 75% of the participants had positive attitude toward breastfeeding. Adolescents were selected as majority of them will be parents in next decade. Studying about their knowledge and attitude will give us a peep to identify the gaps between two.

Primary care physician are the primary contact for majority of the people at the community level. Therefore, a primary care physician role is crucial for promoting and supporting breastfeeding practices in community. Moreover, as a first contact point, they are in a unique position to motivate and educate people regarding the protective effects of breastfeeding to the health of both mother and children.

The knowledge of participants of the present study as compared with Jordan study was better on these aspects: to introduce complimentary food at age of 6 months (66.84% vs. 29.1%), breast milk is better choice if mother plans to go to work (53.32% vs. 2.6%) and better digestibility of breast milk as compared with formula milk (88.27 vs. 61.6%).[22]

The knowledge regarding sufficiency of breast milk to babies for first 6 month was 79.34% in the current study participants. This was in consonance with the knowledge level displayed by Brahmbhatt et al.[23] (81.6%), Marija et al.[24] (70.2%), Sudip et al.[25] (91.7-94.9%), and Vijayalakshmi et al.[16] (85.2%). Similarly, Leshi et al. from Nigeria reported that approximately 69.4% of the participants knew that breast milk alone is sufficient for infant's growth in the first 6 months of life.[3]

In the present study, 93.11% participants had knowledge that breastfed babies are healthier in comparison to 75% in Bangalore study by Vijayalakshmi et al.[16] In a study by Rivera-Alvarado et al., 71% had knowledge that breast milk will protect baby from diseases as compared with 82.91% in present study.[26] Both studies endorse the view that breastfeeding is economical than formula milk and lactating mother requires more food. Moreover, Marija et al. and Sudip B et al. found that knowledge regarding breastfeeding imparting protection from infectious diseases and allergies was 92.86% and 88.5--95.4%, respectively.[2425]

In the current study, 66.58% of participants had knowledge that night feeding for baby is correct as compared with 69.5% and 86% in Mangaluru study by Brahmbhatt et al.[23] and Al-Domi[27] in Jordan study. Furthermore, only 25% of participants in present study could rightly say that a baby should be breastfed at least till 2 years of age in contrast to 83.8% in Jordan study. A good number of participants of the present study (66.84%) were aware that complementary food be started after 6 months as compared with 55% in study by Leshi et al.[3] In the present study, 32.65% of subjects felt that breast milk amount does not depend on size of breast which corroborates well with findings of Sudip et al. (15.6--30.8%). It is in contrast to common notion but indicating a huge gap in the knowledge of adolescents, 2/3rd of participants did not have correct knowledge.

The attitude for convenience of breastfeeding in current study (77.55%) is in agreement with Bangalore study (79.5%) by Vijayalakshmi et al.[16] Furthermore, 90.56% of participants in current study were keen on breastfeeding their own child as compared with 92% in the study by Rivera-Alvarado et al.[26] It was also noted that attitude to colostrum feeding percentage in this study was comparatively low (42.35%) as compared with 68.2% in contrast to finding by Al-Domi.[27]

Perception of effects of breastfeeding on sex life was assessed indirectly with questions, one of which is: “Does breastfeeding the baby makes mother less attractive?” In current study, 43.11% endorsed that it does not make them less attractive as compared with 40.2% by Vijayalakshmi et al.[16] and 45% in study by Rivera-Alvarado et al.[26] In the light of the above discussion, it seems there is a huge scope to bring in awareness about perceived effect of breastfeeding on sex life.

It is also observed that 35% of the participants endorsed that breastfeeding should be practiced in home (private places) as compared with 27.2% by Leshi et al.[3] and 83.4% by Al-Domi.[27] It indicates that about one-third of participants expressed their inhibition to breastfeed in public places in contrast to Jordan study (>80%).[27]

As reported by Leshi et al. from Nigeria, statistically significant association between breastfeeding knowledge and attitude was also observed in current study.[3] A Jordanian study among the university students by Al-Domi exposed the fact that level of knowledge was high, but had negative attitude, surprisingly, Breastfeeding attitude was also associated significantly with socioeconomic status.[27] In the present study, a mere 25% of the participants felt that breastfeeding does not interfere with sex life, whereas it was 50.5% in Puerto Rican study by Rivera-Alvarado et al.[26]

Limitations

The study has number of limitations. Sample size was sufficient to estimate the prevalence of breastfeeding knowledge and attitude but had limited power to explore the effect of various covariates. Secondly, a country like India with diverse culture, religion, and region require a large multicentric study to assess breastfeeding knowledge and attitude. Thirdly, institutional-based adolescents may not depict a true picture of community. Lastly, a regression-based predictive modeling technique adjusting the effect of various covariates is required to predict the behaviors in future.

Recommendations

It is recommended to use these study findings to improve and supplement the breastfeeding promotion strategies. The same can be studied by recruiting participants from large multistage cluster sampling consisting of married and unmarried individuals. Future studies should focus on forecasting the effects of interventions on morbidity and mortality by using mathematical modeling that adjusts for other parameters.

Conclusion

Breastfeeding attitude has a strong association with whether breastfeeding was seen and where it was seen. Level of knowledge had impact on the attitude to the extent that poor knowledge has resulted in poor attitude but good level of knowledge does not necessarily reflect similar attitudes. Participants with knowledge regarding colostrum, demand feeding, and duration of feeding up to 2 years of age were 18.62%, 36.99%, and 25%, respectively. Educating adolescents who are not yet married or have children can bring about participatory attitudes about breastfeeding once they attain parenthood. Knowing the gaps in knowledge will help the primary care physician while planning health promotion activities. This is because breastfeeding is not merely a nutritional but a social decision.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.