Perceived Father’s Roles in Promotion of Breastfeeding at Household Level: Case Study of Fathers in Amuru District Northern Uganda at Case

ABSTACT Evidence shows that father’s support is important in promotion of infant and young child feeding practices like breastfeeding in a household. Fathers do influence infant and young child breastfeeding practices like maternal decision to breastfeed, initiation and duration of breastfeeding, maintenance of breastfeeding and maternal confidence during breastfeeding. Despite these numerous benefits, fathers’ support and involvement still remains a challenge in most infant and young child nutrition intervention at both household and program level. This could be due to limited understanding of roles fathers can play in promotion of infant and young child breastfeeding practices. Objective: This study investigated father’s perceived roles in promotion of infant and young child breastfeeding practices in Amuru district. Methods: The study used qualitative methods using 8 focus group discussions (FGD) to explore the perceived roles of fathers in promotion of infant and young child breastfeeding practices. Four FGDs (2 in rural and 2 in urban) were for fathers with infants aged 0-24 months and also 4 FDGs (2 Rural and 2 in urban) with mothers of children aged 0-24 months. Each FGD was composed of 8-12 participants. Each FGD was guided by the moderator while the discussions recorded by voice recorders after consent. The data was analyzed using ground theory. Results: From the FGD, perceived fathers’ roles were provision of financial support, provision of good diet, decision making, information support and emotional and encouragement support during the breastfeeding period. The most perceived and performed fathers’ role were financial support and provision of an adequate varied balanced diet to the lactating mothers while least performed was information support. Conclusion: Fathers have an important role to play in promotion of infant and young child breastfeeding practices. Efforts should be geared toward equipping fathers with relevant breastfeeding information. Study


Introduction and Background
World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) recommend that mothers initiate breastfeeding within one hour of life. They further recommend that infants should be breastfed exclusively for the first six months thus introducing nutritionally adequate, safe, age-appropriate, responsive feeding of solid, semi-solid and soft foods at six month and that mothers should continue to breastfeed for two years and beyond. WHO [1]. If properly practiced, breastfeeding has been estimated to avert 15% of infant mortality and 13% of infant mortality in high HIV prevalence settings Coovadia, et al.  [2,3]. Exclusively breastfed children have shown to have lower risk of gastrointestinal infections and acute respiratory infection compared to children who were not exclusively breastfed Labbok, et al. [4]. Exclusive breastfeeding (EBF) has also shown to reduce the rate of mother to child transmission of HIV compared to mixed feeding practices Coovadia, et al. [2]. Furthermore, studies on infant feeding especially breastfeeding have found out that fathers play a vital role in promotion of infant and young child breastfeeding practices in a household. For example, in a review of the literature on fathers and breastfeeding, it was found out that fathers influenced breastfeeding in four ways: decision to breastfeed, duration of breastfeeding, frequency of breastfeeding and risk associated with bottle feeding (Bar-Yam and Darby, 1997).
Rivera and colleagues determined that 92% of fathers studied (n=100) were interested in providing physical, emotional and tangible support to their partner to exclusively breastfeed Rivera, et al. [5]. This shows the relevance of fathers in infant and young child feeding practices especially breastfeeding. Fathers actually have tremendous potential to either facilitate or undermine the success of breastfeeding Lester [6]. Paternal support has been shown to have a positive impact on the woman's decision to breastfeed, breastfeeding duration, weaning and on the maintenance of this practice Sharriff, et al. [7]. Evidence further shows that fathers can influence the initiation, maintenance of breastfeeding, contribute to maternal breastfeeding confidence Dharma, et al. [2,[8][9][10]. Also without fathers' support, mothers are more likely to breastfeed for a shorter duration Engebretsen, et al. [11,12]. Fathers greatly influence infant and young breastfeeding practices like the mother's decision to breastfeed Swanson, et al. [13][14][15]. A study by Rivera, et al. [5] showed that fathers were interested in supporting their partner to exclusively breastfeed Rivera, et al. [5]. In a study by Laanteras, et al. [16] that explored Finnish parents' breastfeeding attitudes, this study concluded that participants wanted both the mother and the father to be involved in the infants feeding. More negative breastfeeding feelings were also associated with fathers who had a moderate knowledge breastfeeding, age (18-26 years) and lower education Laanteras, et al. [16]. However there is limited information on roles that fathers can play in promotion of infant and young child breastfeeding practices hence this study explored the perceived fathers' roles.

Study Area
The study was carried out in Amuru district between May to July 2015. Amuru district is located in northern Uganda with a population of 190,519 persons and annual growth rate of 2.8% UNBOS et al. [17]. The prevalence of global acute malnutrition and severe acute malnutrition is 3.5% and 1.1% respectively, stunting among children under five is at 39.1%, underweight stands at 13.7% whereas EBF is at 68% for children 0-6 months DHO/ACF/ UNICEF [18].

Study Design
The study used a cross-sectional study design using qualitative i.e., focus group discussions.

Recruitment of Study Participants, Inclusion and Exclusion Criteria
Recruiting participants for this study involved identifying individuals who meet certain criteria. The basic criteria included: mothers or fathers with at least a child aged 0-24 month. These were assigned to a focus group based on additional quota criteria (e.g., gender, area of residence (urban / rural), employment, education) to assure a representative group. Efforts were made to have diverse groups. To assure an adequate number of participants for each focus group (e.g., [8][9][10], approximately 12-14 individuals were recruited.

Data Collection Tools (Development of the Instrument)
The research instrument or interview protocol was developed specifically for this study. Different approaches were simultaneously

Data Collection Procedure: Focus Group Discussions
Eight focus group discussions (FGD) were conducted in local language (Acholi) separately; four were for fathers of children aged 0-24 months (two in rural area and two urban area) and other mothers for mothers of children aged less than 24 months (two in a rural area and two in an urban area). Confidentiality within each group discussion was agreed among the participants prior to the start. The FGDs was guided by the moderator, data recorded by voice recorders after consent. Note takers took summary notes.

Management of Qualitative Data
All focus group discussions were recorded using a voice recorder. Also note takers wrote summary notes. The data was transcribed into verbatim, coded and categorized according to themes that emerged from the data.

Data Analysis
The collected information was analyzed using ground theory.
This involved inspecting data through iterative listening and reading to ensure accurate transfer of information between the audio and transcription. This created familiarity with the data, allowing the beginnings of an interpretative process. In doing so, a preliminary coding structure was devised as emerging themes, ideas, and topics relevant to the aims of the study. These were then applied and 'tested' in the next data. New codes (and redundant ones) were included/ excluded as need a raised. The data was analyzed by constant comparison method modified from the grounded theory approach. The participant's reflections were conveyed in their own words to strengthen the validity and credibility of the study.

Ethical Considerations
Ethical approval was obtained from Makerere University School of Public Health Higher Degrees and Ethical Committee and Amuru District Local Government. All participants voluntarily gave informed consent while confidentiality was agreed upon before the start of FGD sessions.

Results
From the FGDs, the following were the perceived roles of fathers in promotion of infant and young child breastfeeding practices:

Provision of Good (nutritious) and Variety of Foods During Breastfeeding Period
Providing food for the mother was a form of support identified by most fathers as a way of being supportive of breastfeeding.
This included providing food directly or indirectly through money.
Many fathers associated good diet with mother's ability to produce enough breast milk for the infant as revealed from FGDs. "Make sure she has a nice meal and variety, to produce enough breast milk" "As a man, buy for women all kinds of foods, fruits, vegetables and so on, everything she asks"-father from FGD.
This was also identified from the mother's FDGs-• "My husband should buy me nice food like fish, milk and eggs during breastfeeding period so that I can produce enough breast milk for the baby".
• "When you eat well, you produce more breast milk for the baby, so fathers should buy us foods when we have delivered the baby-mother's FGD".

Financial Support
In every FGD, fathers also repeatedly mentioned financial contribution as a major support to the mother.
• "The most often thing we have to do is to work more and hard so that we have more money to give to the wives. This will allow them to get what good food to eat and produce enough breast milk for the baby -fathers FGD in Amuru town council".
• "These days if you don't give your wife money she will report you to Action Aid or police and you will be arrested so I make sure I give her 2000Ug shillings every day to buy milkfathers' FGD.
Mothers' FGD also viewed this as utmost support the fathers can contribute during this period.
• "If your man doesn't give you money, how do you get good food to eat and produce enough breast milk-mother's FGD".

Encouragement and Motivation
Fathers identified encouragement and emotional support to mothers as key to successful breastfeeding. In father's FGDs, fathers perceived providing encouragement and motivation to breastfeeding mothers as being supportive of breastfeeding as revealed below.
• "Most important is encouragement, tell her that breastfeeding the baby is good and will make the baby grow strong and health-father's FGD".
This was consistent with opinions from the mothers' FGD.
• "My husband whenever he sees our baby crying, he will tell me to breastfeed the baby -mother from mothers' FGD".
• "Even at night a man wakes you up to breastfeed the baby and every time he is around he is telling you to breastfeed the baby"-mother from mothers' FGD.

Decision Making
Fathers were also perceived to be vital in decision making especially on duration of breastfeeding and when to introduced complementary feeding as revealed from mothers' FGD.
"When you are about to start giving other foods like milk and porridge, you have to consult your husband so that when he allows he can buy milk and sugar for the baby-mother FDG"

Help in the House and Garden Work
Father also suggested that when the mother has just delivered, she should not do a lot of work especially heavy work during the first two months. Fathers noted that this would allow the mothers have some rest and time to breastfeed the baby. "I fetch water and sometimes collect the firewood for the home, so that my wife can have some time to breastfeed the baby-fathers' FGD" "During the first month, the mother should not do heavy work like clearing the garden; I help in clearing the garden for my wife -father FGD".

Information Support
From father's FGDs, it was also discovered that another role father perceived was information support on breastfeeding to the mother as revealed below.
"When my wife delivered, she took three days without producing breast milk, I had to go to the health center and asked the health worker what the cause of the problem was and how to solve it. I was told to buy good food for her and if it fails in next two days I take my wife to health centre-fathers from father's FGD" "What is needed is just information, we cannot support by giving a breast but assist with something else as long as we are educated on breastfeeding like women. e.g.telling the mothers on

Provision of Financial Support
Fathers mostly perceived their role as that of provision of financial support. This is true of African society where fathers, have traditionally been viewed as having a financial role in the household nutrition and especially infant nutrition This finding is consistent with studies in Ghana and Nigerian where fathers perceived their role as that of financial support Oyediran, et al. [19][20][21].

Provision of a Good Diet/Variety of Foods
Some fathers in the study area held the view that to breastfeed successfully, mothers must eat a good diet to produce milk and to have enough energy to do their work. More importantly, fathers regard provision of adequate food for pregnant and breastfeeding mothers as their responsibility. This is consistent with another study which found out that even when lack of money was cited by fathers as a common challenge to providing an adequate diet for women, fathers were willing to provide a good diet during breastfeeding period USAID [22]. This perception could be exploited as an entry point to encourage fathers to be supportive.

Decision Making
Most fathers reported being part of decision making related to breastfeed; duration of breastfeeding, when to introduce complementary feeding. This could be because the patriarchal setting of the study community where most decisions are made by the fathers/head of the family. This finding is consistent with studies from communities in rural eastern Uganda and rural Ghana which observed that fathers had greater authority over decisionmaking on infant feeding and health practices Engebretsen, et al. [11,21,23].

Encouragement
Fathers also perceived encouragement of the breastfeeding mother as a key role they can play. This is important because encouragement builds up mother's confidence and offers emotional support during breastfeeding [24]. This finding is consistent with findings from a study in Vietnam were fathers gave general reminders to complete tasks such as breastfeeding Bich, et al. [15].

Conclusion
The most perceived and performed father's role were financial support and provision of a good diet to the lactating mothers. The most perceived challenging role was information support and hence efforts should be geared at equipping fathers with relevant breastfeeding information.