INFLUENCE OF INFORMATION SOURCES ON KNOWLEDGE, ATTITUDE AND PRACTICE OF EXCLUSIVE BREASTFEEDING AMONG NURSING MOTHERS
CHAPTER TWO
LITERATURE REVIEW AND THEORETICAL FRAMEWORK
2.1 The concept of Exclusive Breastfeeding
Several health organizations, such as WHO, UNICEF, American Academy of Paediatrics, recommend exclusive breastfeeding for the first six months. It is considered as the most preferred way of infant feeding based on scientific evidence of the benefits for infant‘s survival, growth, and development. According to WHO (2002), exclusive breastfeeding means the infant receives only breast milk from his or her mother or a wet nurse, or expressed breast milk, and no other liquids or solids with the exception of drops or syrups consisting of vitamins, mineral supplements, or medicine. Gartner, Morton and Lawrence (2005), defined exclusive breastfeeding as an infant's consumption of human milk with no supplementation of any type (no water, no juice, no non-human milk and no foods) except for vitamins, minerals and medications.
Introduction of solid or liquid foods to infants before the six months of age has been discouraged by many health organizations due to health implications associated with it. According to Naylor and Morrow (2001), if solids or complementary foods are introduced before a baby‘s system is ready to handle them, it is most likely going to be poorly digested and that may cause unpleasant reactions, such as digestive upset, gas, constipation, among others. This is because full term infants are not developmentally ready for the transition from suckling to sucking or for managing semi-solids and solid foods in addition to liquids until around six months of age. To enable mothers to establish and sustain exclusive breastfeeding for 6 months, WHO and UNICEF recommends initiation of breastfeeding within the first hour of life, exclusive breastfeeding, breastfeeding on demand, that is, as often as the child wants, day and night and also no use of bottleteats, or pacifiers (Gartneret al,2005).
2.1.1 Exclusive Breastfeeding Rate
Exclusive breastfeeding for up to six months has been the desired goal of many health organizations, but partial breastfeeding, as well as breastfeeding for shorter periods of time, has been and still remains prevalent in different parts of the world. Although, mothers have the edge to practice breastfeeding, majority of them are unable to exclusively breastfeed their infants for the recommended period as there exists serious obstacles to practicing it until six months from the infant‘s birth.
The rates of exclusive breastfeeding have improved over the recent past, with the global rate put at 37% (UNICEF, 2011). This was achieved through numerous awareness campaigns launched by national governments, multilateral organizations, non-governmental and private sector organizations across the globe to educate mothers and families about the benefits of exclusive breastfeeding and with the aim to encourage the practice (Ogbo et al, 2020). Such initiatives include Baby Friendly Hospital Initiatives (BFHI) and establishment of work place breast feeding facilities. Despite all these initiatives put in place, exclusive breastfeeding rate is particularly low in Africa, where less than one third of infants under six (6) months old are exclusively breastfed (UNICEF, 2009). According to (WHO, 2012), one out of three children has been exclusively breastfed in Africa. In addition, information provided by WHO (2011) on breastfeeding practices in 94 countries estimates that only 35% of the infants between zero and four months are exclusively breastfed.
Aborigo et al(2012) also observed that exclusive breastfeeding practices are worse in West Africa, where only 6.1% of babies who are younger than six months old are exclusively breastfed and large differences exist in the EBF rates between regions and among countries. South Asia, East Asia / Pacific and Eastern / Southern Africa are regions with the highest levels of exclusive breast feeding (44%, 43% and 39%). The rates of exclusive breastfeeding are particularly low in West and Central Africa (23%), East Asia and Pacific (28%), Central and Eastern Europe/Common Wealth of Independent States (CEE/CIS) with 29% (UNICEF, 2011). The rates of exclusive breastfeeding are less than overall breast-feeding rates due to the practice of giving complementary feeding.
In Nigeria, breastfeeding practices continue to fall well below the WHO/UNICEF recommendations for developing countries. According to the Nigeria Demographic and Health Survey (2008), Nigeria‘s exclusive breastfeeding rate decreased from 17% in 2003 to 13% in 2008. Rural and urban differentials have also been documented in the practice of exclusive breastfeeding as the practice was reportedly higher (41%) in the urban areas compared with 38% in the rural areas.
In addition to breast milk, 34% of infants aged 0–5 months in Nigeria are given plain water only, while 10% are given non-milk liquids and juice, and 6% are given milk other than breast milk. Furthermore, 35% of infants aged 0–5months are given complementary food. Data on Infant and Young Child Feeding (IYCF) practices revealed that, despite the importance of breast milk, only 25% of infant under-six months were found exclusively breastfed in Nigeria. The likelihood of exclusively breastfeeding children is significantly higher in the South West (40%), and significantly lower in the North West (10 %) (NBS, 2014).
2.2 The Concept of Knowledge
Many attempts have been made to give a systematic description of knowledge and how it is acquired. However, there are several philosophical perspectives (worldviews) on the concept. A branch of philosophy known as Epistemology, explained how we come to know about what exists (Rescher, 2003). There have been arguments and debates on what knowledge is and how it is acquired among philosophers. Some of these views include the fact that some or all knowledge is observational, some or all knowledge is non-observational but attained by thought alone, some or all knowledge is partly observational and not attained at once by observing and thinking (Roderick, 1989). They also came up with conditions for knowledge such as belief, truth, justification among others. However, the definition of knowledge is a matter of ongoing debate among philosophers in the field of epistemology as there is no consensus on the definition of knowledge and how it is acquired, as there exist different views from philosophers. There are three basic categories of knowledge as distinguished by philosophers. They include: personal, procedural and propositional knowledge (Rescher, 2003).
Personal knowledge also known as knowledge by acquaintance is cognizance of a circumstance or fact gained through first-hand experience or observation. It is acquired based on familiarity with someone or something. Procedural knowledge, also known as practical knowledge, is on how to do something which involves possession of skills. In other words, it is a skill-based knowledge, while propositional knowledge, also known as factual knowledge, is known as knowledge of facts which means it is acquired based on facts and that is the kind of knowledge epistemologists are more concerned with (Hume, 2008).
One of the first philosophers to attempt a definition of knowledge was the Ancient Greek philosopher, Plato. He argued that for a factual claim to be knowledge, it has to be a belief which is true and justified. In other words, it must be justified, true and believed (Moravcsik, 1979). Many philosophers such as Such as Aristotle, Plato and Kant have looked at the source of our knowledge claims, and there are two main schools of thought with reference to this issue. They are rationalism and empiricism.
2.2.1 Knowledge of Exclusive Breastfeeding
Knowledge on exclusive breastfeeding has been identified as one of the major factors that determines breastfeeding practices and duration. ―Knowledge is power‖ is a common adage mostly used in various parts of the world. Lack of correct exclusive breastfeeding knowledge and the inability to apply the knowledge in breastfeeding infants is a very serious threat to the practice of exclusive and adequate breastfeeding (Maduforo and Onuoha 2011). Breastfeeding education emphasizes the superiority of breast milk on the basis of overwhelming scientific proof (Ngwu, 2015).
Acquiring knowledge is usually the first step before action and it can change traditional attitudes towards child health and nutrition. Previous studies have shown that educated mothers are more likely to practice exclusive breastfeeding than illiterate mothers. This is because women with higher levels of education place more value in their own health and the health of whom they care for and the educated mothers are less likely to adhere to local customs that prescribe inclusive breastfeeding instead of exclusive breast feeding (Ajibade, Lokunlade, Omakinde Amoo and Adeyemo, 2013).
In addition, Alhaji (2002) reported that improved maternal education enhances mothers‘ understanding and appreciation of the demands and benefits of exclusive breastfeeding and empowers them to resist external interferences and pressures. However,Oche, Umar and Ahmed, (2011) in their study had a contrary opinion which reveals that the educational level of mothers in Kware, northern Nigeria, had no influence on the practice of exclusive breastfeeding. A good number of people may not properly understand the importance of knowledge on breastfeeding, how it should be given, the timing, duration, correct techniques and appropriate time of weaning mother‘s milk. This implies that education is still necessary especially when the benefits of exclusive breastfeeding are not immediately apparent to the mothers.
Also, a study carried out in Zimbabwe discovered that majority of the mothers do not agree that exclusive breastfeeding is practicable which means most of the mothers do not believe they can breastfeed their babies exclusively for six months (Mudzengerere, 2013). Knowledge acquisition on exclusive breastfeeding has to an extent influence the attitude and practice of exclusive breastfeeding but has not entirely influenced the practice as there are still cases of women who are aware or have been educated on the benefits of exclusive breastfeeding, and yet do not practice it because some of them question the credibility of health care workers whom they said do notpractice exclusive breast feeding but expect the mothers in the communities to do so. The health care service providers are expected to be role models and provide educational sessions and influence for mothers to accept the practice (Bicchieri, 2012).
Some health care workers themselves do not believe in exclusive breastfeeding because there is a decrease in the level of awareness on the importance of exclusive breastfeeding by health workers now than the previous years (Ndiokwelu, Maduforo, Amadi and Okwe-Nweke, 2014). For some, implementing what they have learnt is not completely possible as breastfeeding decisions are not only for the mothers to make. Breastfeeding practices are passed down from one generation to another. lack of knowledge by the older generation about exclusive breastfeeding affects younger mothers. For instance, in Mozambique, Lack of knowledge by the older generation about exclusive breastfeeding proved to be the force behind mixed feeding (Arts, Geelhood, De Schacht, Prosser, Alons and Pedro, 2011).
Although, knowledge acquisition on the importance and benefits of exclusive breastfeeding is considered as one of the key instruments in promoting its practice, it is not entirely effective due to the fact that information received is also dependent on motivation to implement such knowledge. For instance, Agunbiade and Ogunleye (2012), in their study on the constraints to exclusive breastfeeding practice among breastfeeding mothers in Southwest Nigeria, found out that majority (94%) of the respondents had high level of awareness about exclusive breastfeeding but only 19% of the nursing mothers practiced exclusive breastfeeding. This means that the practicability of exclusive breastfeeding has gone beyond knowledge acquisition. However, more emphasis has been made on breastfeeding knowledge ignoring motivational strategies on how to improve the practice and that is a gap this study intends to fill.
2.3 The Concept of Attitude
Fritz (2008) defined attitude as an optimistic or pessimistic reaction of people, substance, occurrence, behaviour, thoughts, or anything within the surroundings. It is a favourable or unfavourable evaluation of people, objects, ideas and situations. It means a feeling, opinion or belief about something or someone that guides decisions and behaviour (Fazio, 1995). In other words, they are tendencies to respond positively or negatively towards a recommended action.
Attitude consists of three aspects: These include cognitive, affective and behavioural. The cognitive aspect refers to the thinking that brings about the development of a belief about the attitude object. The affective refers to the direction (positive or negative feeling) emotion experienced towards the attitude object and the behavioural aspect, is the likelihood of acting in a certain manner towards the attitude object. Thinking, feeling and behaving come together and forms an attitude towards a person or an object (Howarth, 2006). In other words, attitude can be derived from emotions or feelings, beliefs or opinion, inclination for action and evaluation.
Therefore, attitude plays a significant role in influencing individual‘s choice of action. In this study, attitude means a combination of people‘s opinion, feelings, beliefs and their evaluation of exclusive breastfeeding—evaluation in the sense of how people view exclusive breastfeeding, whether good or bad, beneficial or not.
2.3.1 Attitude towards Exclusive Breastfeeding
Attitudes can be positive or negative; they are conscious or unconscious beliefs that can guide decisions and behaviours. In other words, it is an individual‘s evaluation or beliefs about a recommended response. Therefore, a woman‘s attitude towards breastfeeding and how she chooses to feed her baby are closely linked to the woman‘s culture. This is because beliefs emanate from culture, self-perception as well as religion. A deep desire to breastfeed an infant is not shared by every mother. In fact, even before the advent of bottles and formula, many affluent women avoided breastfeeding altogether by paying poorer women to do it for them in an arrangement called wet-nursing (Hahn-Holbrook, Schetter and Haselt, 2012).
Attitude, to a large extent, determines the willingness to conform to a particular thing or behaviour. People‘s belief that they can motivate themselves and regulate their own behaviour plays a crucial role in whether they even consider altering habits detrimental to health(Bandura, 1990). Hence, maternal beliefs and attitude are dictated by some cultural practices acquired within the family setting and the community level. Previous studies (Bass and Groer, 1997; Daglas and Antoniou, 2012) have shown that negative attitude and bad cultural beliefs affect mother‘s compliance to the recommended breastfeeding practice.
Davies (1997) concluded that exclusive breastfeeding totally lacked credibility among the locals in Nigeria, with even health workers not believing that it was possible or feasible. Buttressing on the point above, some women do not practice exclusive breastfeeding because they question the credibility of health care workers who do not believe in or practice exclusive breast feeding but expect the mothers in the communities to do so (Bicchieri, 2012). The health care service providers are expected to be role models and provide educational sessions and influence for mothers to accept the practice.
Although, knowledge acquisition on exclusive breastfeeding has, to an extent, influence the attitude and practice of exclusive breastfeeding. It has not entirely stimulated a positive attitude, as there are still cases of women, who are aware or have been educated on the benefits of exclusive breastfeeding, and still do not subscribe to it. A study carried out by Ajibade et al (2013) in Osun State revealed that majority of the respondents have been informed of exclusive breastfeeding, yet, did not guarantee their practising it. Many mothers believed that there is no difference between the growth rate and intellectual capacity of an exclusively breastfed child and a non-exclusively breastfed child (Ndiokwelu et al, 2014).
Agunbiade and Ogunleye (2012), in their study on Constraints to exclusive breastfeeding practice among breastfeeding mothers in Southwest Nigeria, found out that exclusive breastfeeding was considered essential but demanding and Only a small proportion (19%) of the nursing mothers practiced exclusive breastfeeding. This suggests that there are in some cases conflicts between knowledge and beliefs as even though one acquires the knowledge, belief seems to have more influence on decision and action as many women believe that breast milk is not enough for their baby (Maduforo and Onuoha 2011).
Similarly, Okwy-Nweke, Anyanwum and Maduforo (2014) found out that, although majority of women have knowledge on exclusive breastfeeding, only few of them actually practice exclusive breastfeeding. They are still not convinced that an infant can thrive on breast milk alone for the first 0-6 months of life as there are other factual beliefs like the child cannot survive without water in hot weather and requires adequate food early for growth (Bicchieri, 2012). One of many reasons for low acceptance of exclusive breastfeeding is confidence on the part of the mothers that the child is getting enough, while for some they find breastfeeding in public places very discomforting (Ike, 2013).
2.4 Women’s Behaviour towards Exclusive Breastfeeding
Over centuries, efforts have been made to understand how behaviour is formed, and how values, beliefs, attitudes and social interaction are related to behaviour or action. There are a number of factors that determine the likelihood of engaging in a particular behaviour. These determinants are classified as either internal factors or external factors (Cole, Holtgrave, and Rios, 1992).
Social psychologists propose that behaviour, therefore, is a product of individual‘s beliefs, values and attitudes.
Oxford Dictionary (2016) defined behaviour as the way in which a person acts in response to a particular situation or stimulus. These actions are influenced by eras, cultures, societies, communities and environment that individuals are part of (Underwood, 2002). According to Fishbein and Ajzen (1975), constructive attitude might not be projected positively in action (behaviour) due to barrier from external social factors. Therefore, social norms must also be considered for an individual to react. Many cultures differ in their attitude and beliefs on breastfeeding; some of our beliefs are based on direct experiences or personal observations and also based on interactions with others. A mother‘s subjective judgement on exclusive breastfeeding and interactions with others often leads to formation of beliefs which determines her behaviour towards it (Underwood, 2002). This means behaviour is mostly influenced by personal, societal norms, values, and interactions with others. These result to social influence because people affect the thoughts, feelings, and behaviours of others (Moscovici and Markova 2006).
For instance, a lot of women have the perception that it is good to give water to a baby after every breastfeeding. Some women think that breast milk is only food for the baby and not fluid which is needed to keep the child hydrated. This subjective judgement hinders them from breastfeeding their infant exclusively (Mbwana, 2013).Also, previous studies such as Al-Shosan (2007) and Biswas (2010) have shown that significant others like grandmothers, friends, coworkers, neighbours, among others, impacts a social influence on a women‘s choice of infant feeding. Every new mother, when deciding on the type of infant feeding to adopt, is influenced by her physical ability and personal beliefs and also by social and cultural customs. Although, breastfeeding is a natural act it is also a learned behaviour of which many cultures have their own individual beliefs on infant feeding which has a potential negative impact on the baby‘s health or mother‘s health. Therefore, a mother‘s behaviour and approach to breastfeeding is largely dependent on the culture she is born into, environment personal beliefs and attitude as well as her increasing knowledge (Davies, 1997). Many women see their mothers as role models and consider their opinion especially on how to feed their babies sometimes more superior to others. In fact, health professionals struggle with the challenge of socio-cultural practices conflicting with modern medicine because breastfeeding is more of a social behaviour than a medical practice (Nanthini and Jeganathan, 2012).
2.5 The Concept of Practice
Oxford Dictionary defined practice as the actual application or use of an idea, belief, or method, as opposed to theories relating to it. It involves the repetition of an activity to improve skill. It may also mean the customary, habitual, or expected procedure or way of doing something. In other words, it is the habitual or expected way of doing something. Practice, in this study, means the type of infant feeding method that is done by mothers prior to the knowledge of exclusive breastfeeding and after acquiring the knowledge of exclusive breastfeeding. This includes how infant feeding is done and why it is done; therefore, practice as regards to this study means a common way of feeding an infant.
2.5.1 Factors Influencing the Practice and Non-Practice of Exclusive Breastfeeding The extent to factors that affect exclusive breastfeeding varies from one country to another and or between different groups in the same country. These factors are combinations of economic, social, environmental, cultural, biological among others.
2.5.2 Socio Economic Factors
In developing countries, increasing levels of education, industrialization, urbanized occupations, income and improved standard of living has negatively affected the practice of exclusive breastfeeding. The practices of exclusive breastfeeding have been associated with a lot of changes in the society. One of such factors is the level of income of mothers. The choice of infant feeding method is influenced by the economic condition of the individual, the family and country. According to Njeri (2015), low income mothers are presented with unique challenges as most of them are petty traders or casual labourers and, in most cases, they are not offered the three-month maternity leave or they do not qualify for the leave due to their casual engagement. If such mothers are to stay at home to exclusively breastfeed as is proposed, these mothers would have no income. Therefore, a woman‘s economic situation can have a profound effect on her physical and emotional well-being.
In contrast to the above point, it has been observed that infants from the wealthiest households are less likely to be exclusively breastfed than those from the poorest households (Emmanuel and Oyewole, 2012; Al-Shoshan, 2007). This is because people from wealthy household can afford to buy breast milk substitutes which makes them refuse to breastfeed their babies exclusively, because they feel that breastfeeding babies exclusively is not for modern woman so they depend on cow‘s milk in order to show themselves as belonging to the high class (Ike, 2013). Breast milk substitutes are expensive, inferior and often dangerous substitute for breast milk, but formula manufacturers have nonetheless aggressively advertised and marketed them and that has resulted to frequent use of breast milk substitute rather the real breast milk (UNICEF, 1999).
In contrast, (Agho et al 2011) discovered that the socio-economic status of mothers influences the decision of mothers to exclusively breastfeed in the sense that mothers with higher socioeconomic status tend to have high education and are more likely to be better informed about the practice of exclusive breastfeeding than mothers with lower socio-economic status. Similarly, exclusive breastfeeding was found to be more prevalent among women with higher incomes in Brazil (Henry, Nicolau, Americo, Ximenes, Bernheim and Oria, 2010). Women with lower income status do not have access to formal education and, therefore, will be less likely to practice exclusive breastfeeding because high income was associated with higher educational achievement and understanding of exclusive breastfeeding (Mbwana, 2012).
Employment status of women plays a major role in determining the practice of exclusive breastfeeding. The occupation of the mothers determines to a large extent the number of times the mother spends with the baby and how the baby feeds. Traditionally, especially in Africa, women‘s place is considered to be at home doing domestic duties and women‘s occupation as house wives shows positive association with their exclusive breastfeeding status compared to that of those employed outside the home (Okwy-Nweke, et al 2012).
2.7 Theoretical Framework
The relevant theory to be reviewed is the social cognitive theory. Social cognitive theory stemmed from the Social Learning Theory which has a rich historical background dating back to the late 1800‘s. In 1941, Miller and Dollard proposed the theory of social learning. Albert Bandura and Walters in 1963 broadened the social learning theory with the principles of observational learning and vicarious reinforcement and developed it into the social cognitive theory in 1986 (Pajares, 2002).
The theory posits that learning occurs in a social context with a dynamic and reciprocal interaction of the person, environment, and behaviour (Bandura, 1986). Social cognitive learning theory highlights the idea that much of human learning occurs in a social environment. By observing others, people acquire knowledge of rules, skills, strategies, beliefs, and attitudes.
Individuals also learn about the usefulness and appropriateness of behaviours by observing models and the consequences of modelled behaviours and they act in accordance with their beliefs concerning the expected outcomes of actions and people learn based on their past experience and the experience of others.
The theory defines human behaviours as a triadic, dynamic, and reciprocal interaction of personal factors, behaviours, and the environment. This is often known as reciprocal determinism. (Bandura, 1999). According to this theory, an individual‘s behaviour is uniquely determined by each of these three factors. Environmental factors represent situational influences and environment in which behaviour is preformed, while personal factors include instincts, drives, traits, and other individual motivational forces.