Beliefs Related to Expectant Father’s Support for Exclusive Breastfeeding in Nigeria

Fathers are an essential element in the social context of breastfeeding . This study identified salient beliefs about expectant fathers’ support for 6 months Exclusive Breastfeeding. A purposive sample of 39 expectant men aged 33.67 ± 7.02 years resident in Ikenne LGA Nigeria participated. An open-ended theory of planned behaviour based questionnaire was used to collect data. Thematic content analysis followed by a frequency count was used to identify the modal salient beliefs. The salient beliefs were 30: twelve behavioral, 12 normative, and 6 control. Behavioural modal beliefs were that support of 6 months exclusive breastfeeding would motivate a brainy (56%), strong (41%) and generally healthy child (38%). Normative modal beliefs were that grandmothers (26%), family (26%) and health workers approve, while friends (21%) disapprove. Control modal beliefs were time (21%) and nature of work (21%). Beliefs influencing expectant fathers support are similar to those influencing mothers breastfeeding decisions. These can be used in the development of father-focused breastfeeding promotion interventions.

will be used in implementing the intervention administered pre and post-test. Underpinned by this theory and the critical need at this time to begin engaging with men, this study sought to collect salient beliefs about fathers support of EBF in a sub-urban community in South-West Nigeria. This study reports findings from the first phase in the development of a quasi-experimental study focused on determining the effect of a breastfeeding programme on fathers' intention to support EBF.

1 Aim
To identify salient beliefs of expectant men about support of 6 months Exclusive Breastfeeding through the collection of data on the attitudes, normative beliefs and control beliefs. 2.1.1 Study Design A cross sectional exploratory study was carried out amongst expectant male partners. This was done to be able to conduct an elicitation survey used to elicit behavioural outcomes that can aid the construction of a questionnaire to be used in a main study [26]. 2.1.2 Sample/Sampling technique Thirty-nine expectant males were purposively selected over a period of 2 months using a snowballing approach by those considered to be community-based recruitment experts as they had worked in several similar capacities [27]. According to Francis et al [25], a minimum sample of about 25 people from the same study population is required. However, the main study is a community-based study across 4 towns of one local government. It was therefore deemed appropriate to extend the requirement and provide a larger number enough to cover all areas (areas were grouped into 2 based on proximity) 2.1.3 Ethical approval Ethical approval was obtained from a Health Research Ethics committee situated within the study area. Permission was also sought from the Local Government office of the study area. All participants gave verbal consent following an explanation of the purpose of the study. 2.1.4 Data collection and analysis Data were collected using an open-ended beliefs elicitation 13-item questionnaire as described by Francis et al [25] Questions related to the behaviour were outlined and questionnaires were either self-administered or interviewer administered based on literacy level [28]. Either methods were deemed appropriate since similar estimates of health status can be obtained [29], [30]. The 13-item questionnaire asked questions on the sociodemographic characteristics of respondents and beliefs which included (1) the advantages of supporting 6 months EBF (2) disadvantages of supporting 6 months EBF (3) any other thoughts regarding 6 months EBF (4) any individuals/groups who would approve of their supporting 6 months EBF (5) any individuals/groups who would disapprove of their supporting EBF (6) any factors or circumstances that would make it easy or enable support of 6 months EBF (7) any factor or circumstances that would make it difficult or prevent one from supporting 6 months EBF.
Data on beliefs were analysed using content analysis, while demographic profile of respondents was analysed using SPSS Version 25. Simple descriptive statistics was computed to derive frequencies of the demographic variables.
The beliefs were analysed as follows. Each of the three broad categories (Behavioural beliefs, Normative beliefs and Control beliefs were sub-categorized into themes drawn from the related questions. This allowed for ease of identifying frequent responses. Each response sheet was then schemed and words related to the subcategories were thus listed beneath. A frequency count was used to identify the occurrence of responses as has been applied by St. Quinton & Brunton. 31 To ensure reliability of counts, results were cross checked by a second author. No gaps were found and a 100% agreement was reached.

RESULTS
Thirty-nine expectant fathers took part in the survey (Table 1). The average age of participants was 33.67±7.21 years. Most respondents were artisans (35.9%). Secondary level education was the highest attained (46.2%) while the least attained was a bachelors (12.8%). Most (46.2%) of the respondents were first time fathers whose partners were pregnant for the first time during the study period. Most (69.2%) indicated that they would want their partners to breastfeed exclusively for 6 months, while the least (2.6%) desired duration of EBF were 2 months, 4 months and more than 6 months.
Regarding behavioural beliefs towards supporting EBF for up to 6 months, 12 beliefs were mentioned related to the advantages and disadvantages of supporting 6 months EBF. The most frequently cited advantages as seen in Table 2 were enabling the infant to be strong (41%), promoting good brain development (56%) and good health (38%). Others less cited were that supporting EBF would promote the prevention of disease, having an outspoken child, promoting child spacing, strong immunity and that EBF would cost less.
The few disadvantages mentioned ( 47 would react to the breast milk, EBF would be stressful for the mother and it would be time consuming. These disadvantages were mentioned by only a few (6 people out of the 39 participants). Others did not mention any disadvantages.
Regarding normative beliefs, amongst those who would potentially approve of the men supporting up to 6 months of EBF in order of frequency were the grandmother (26%), family (26%) such as siblings and in-laws and the health worker (21%). The less frequently mentioned significant others were neighbours, religious leaders, health worker and the government. Those who would mostly disapprove were friends (21%). Others were neighbours (15%) and mothers (grandmother/mother in-law) (10%). Others less frequently cited were inexperienced parents, work colleagues, other family such as in-laws and "social women"-by implication women who regard their body image in higher regard and father of twins.
The most cited enabling and restraining factors that would promote or hinder support for up to 6 months of EBF were availability of sufficient funds (21%) and work status (21%). Although, financial status was the only modal belief (21%) enabling the support of EBF.

DISCUSSION
This study sought to explore beliefs about expectant fathers support for 6 months EBF in the context of the TPB. This study is a first in Nigeria and findings can potentially be used in the development of interventions geared towards understanding fathers' intention to support 6 months EBF. EBF remains a challenge within the country and fathers have been reported as potential strong influencers in promoting longer duration of breastfeeding, especially exclusive breastfeeding (Sholeye et. al, 2015). Measurement of intention requires measurement of its predictors which in the context of TPB is most commonly inferred from questionnaire responses about beliefs of the action.
Respondents mention of benefits of breastfeeding when asked about supporting 6 months of EBF showed that respondents view their supporting of EBF in terms of the generally acknowledged benefits. However, respondents related more to benefits for the infants and not the mother, suggesting that support was motivated by breastfeeding effects on the infant. Similarly, Hansen et al (2018), reported the same lack of absence of maternal benefits from fathers.
The most frequently cited positive subjective norm was the mother/mother in-law/grandmother. Indeed, women in the older generation continue to exert influence on breastfeeding behaviour, especially in low-andmiddle income countries (Negin et. al, 2016). Albeit, results have been mixed. Emmot and Mace (2015) found a negative association between grandmother contact and exclusive breastfeeding practice. While, Mueffelmann et. al, (2015) reported higher breastfeeding intentions among women who perceived positive support from grandmothers.
Another interesting finding was that of a father with multiple gestation who would disapprove of EBF. Though one of the least mentioned, this finding raised an important and often neglected aspect of infant feeding practice. Mothers of multiple births continue to face challenges, particularly the decision to breastfeed and may require more specialized support (Whitford et. al, 2017). Mothers of multiple births have been reported to exhibit lower intentions to breastfeed (Lustiv et. al, 2013) and may be the case for many other fathers.
The restraining and enabling factors most related to EBF support were work and financial status. On the one hand fathers felt that having sufficient funds was key to supporting their partners as they would make more tangible provision, especially regarding feeding. The nature of work would also play a positive and negative role. If their nature of work allowed sufficient time to stay home, it would be beneficial. However, if the nature of work did not permit them to stay home to offer tangible support, it would serve as a restraining factor. A study by Flackling et. al, (2010) found that there was a significantly less likelihood of breastfeeding at 2,4,6, 9 and 12 months in households whose fathers had lower equivalent disposable household income even after controlling for maternal education. Moreover, workplace related factors have in time past (Johnston and Esposito, 2007) and in recent times (Dinour and Szaro, 2017;Valizadeh et. al, 2017) continue to impact on breastfeeding practice.

CONCLUSIONS
The factors that continue to influence maternal breastfeeding decisions also influence a father's breastfeeding decision. Findings in this study revealed the modal influences of a father's support for EBF, but have also revealed other areas of concern that require further action. Grandmothers/mother in-laws continue to be of concern. Hence, interventions still need to be focused on this population. Family-focused interventions are also encouraged and may be more beneficial. More research with fathers of multiple births needs to be carried out to be able to create specialized educational interventions targeted at building skills and knowledge around feeding of twins.