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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 1  |  Page : 43-50

Knowledge and attitudes toward breastfeeding among female university students in Tabuk, Saudi Arabia


Maternal and Child Health Nursing Department, Faculty of Nursing, Mutah University, Mu'tah, Jordan

Date of Web Publication15-Jan-2020

Correspondence Address:
Reham Khresheh
Faculty of Nursing, Mutah University, Mu'tah
Jordan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/nms.nms_35_19

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  Abstract 


Background: In Saudi Arabia, rates and duration of breastfeeding are progressively declining. Objective: The objective of this study was to examine and describe the relationship between breastfeeding knowledge, attitudes, exposure, and intention of university female students in Saudi Arabia. Methods: This cross-sectional survey recruited 124 students who completed a self-reported questionnaire. The questionnaire included breastfeeding knowledge, attitude and exposure scales, and a breastfeeding intention scale. Descriptive and inferential statistics were used to analyze the data. Results: Participants had good breastfeeding knowledge (mean score of 9.51 ± 2.63) and positive attitudes (mean score of 42.0 ± 1.8). However, they had some misconceptions about eating certain foods during breastfeeding and that breastfeeding is painful. A significant relationship was found between breastfeeding knowledge and attitude (r = 0.896,P <0.01), breastfeeding knowledge and exposure (r = 0.191,P <0.01), breastfeeding knowledge and intention to breastfeed (Phi coefficient=0.179, P = 0.033), and breastfeeding attitudes and intention to breastfeed (Phi coefficient=0.177, P = 0.030). Participants' knowledge (OR=3.280;P <0.001) and attitude (OR=1.930;P <0.001) were identified as factors independently and positively associated with future breastfeeding intention. Conclusion: The study identified specific gaps in knowledge and attitudes that pertain mainly to breastfeeding in public and perceptions that breastfeeding is painful, formula feeding gives more freedom to the mother, and that dietary restrictions by the mother during breastfeeding are needed. These gaps should be addressed in future breastfeeding promotion.

Keywords: Attitude, Breastfeeding, Knowledge, Saudi Arabia, University students


How to cite this article:
Khresheh R. Knowledge and attitudes toward breastfeeding among female university students in Tabuk, Saudi Arabia. Nurs Midwifery Stud 2020;9:43-50

How to cite this URL:
Khresheh R. Knowledge and attitudes toward breastfeeding among female university students in Tabuk, Saudi Arabia. Nurs Midwifery Stud [serial online] 2020 [cited 2020 Feb 26];9:43-50. Available from: http://www.nmsjournal.com/text.asp?2020/9/1/43/275995




  Introduction Top


Breastfeeding is promoted as the best method of infant feeding and one of the most cost-effective ways to stimulate healthy infant growth and development.[1],[2] Furthermore, breastfeeding benefits mothers, through postpartum weight loss, reduction in breast and ovarian cancer, and enhanced mother–infant attachment.[3] Since 2001, the World Health Organization (WHO) has recommended exclusive breastfeeding for the first 6 months of life.[4] Despite advantages, the proportion of countries that meet these recommendations remains low.[5],[6] One of the global targets endorsed by the WHO's member states is to increase the rate of exclusive breastfeeding in the first 6 months up to at least 50%.[7]

In Saudi Arabia, rates and duration of breastfeeding are progressively declining.[6],[8] The breastfeeding initiation rate in 2016 was above 90%; however, exclusive breastfeeding rates at 6 months ranged between 0.8% and 43%. The mean duration of breastfeeding has shown a progressive decline over time from 13.4 months in 1987 to 8.5 months in 2010.[6],[8],[9]

Studies of poor breastfeeding outcomes mainly focused on the knowledge and attitudes of pregnant women and mothers.[10],[11] Studies suggest that attitudes toward breastfeeding begin well before pregnancy and decisions concerning breastfeeding are often made early in life;[12] therefore, research examining attitudes before pregnancy is important. Identifying predictors of breastfeeding intentions facilitate the design of effective breastfeeding promotion interventions.

Several studies in Western countries have been assessed the attitudes of young populations toward breastfeeding.[13],[14] Knowledge and attitudes regarding breastfeeding among university students vary across countries. A study of university students in Lebanon and Syria showed average breastfeeding knowledge and positive attitudes among participants, and breastfeeding intention was significantly associated with knowledge and attitude.[15] In another study in Jordan,[16] university students showed a positive level of breastfeeding knowledge, but their attitudes toward breastfeeding practices were negative.

In Saudi Arabia, data regarding the breastfeeding attitudes and knowledge among young people are limited,[17] and more research is needed to understand which factors have the greatest impact on breastfeeding intentions among Saudi women. Greater insight into the factors that may transform breastfeeding decisions in a young Saudi population could assist health agencies to promote breastfeeding and implement successful strategies and encourage the development of effective breastfeeding-friendly policies that are specific to Arab countries.[17],[18]

Objective

This study aimed to examine the relationship between breastfeeding knowledge, attitudes, exposure, and intention of university female students in Saudi Arabia.


  Methods Top


Design, setting, and participants

A cross-sectional survey was conducted with students at the Umluj Campus of the University of Tabuk. Data were collected during the 2016–2017 academic years. The sample size was calculated using the G*Power software, version 3.1 (Informer Technologies, Inc. Dominica). A minimum sample size of 153 was needed to examine the relationship between breastfeeding knowledge, attitudes, exposure, and intention, with a power of 80% and with an α error of 0.05. Based on the results of previous study, a Pearson correlation coefficient of 0.2 was used as an estimate of this correlation.[19] Students were selected using a systematic random sampling technique where every fifth was selected starting with the random selection of the first student. Students who were unmarried, were of Saudi nationality, and were between the ages of 18 and 25 years were included in the study.

Data collection

Data were collected using a self-reported questionnaire. A hard copy of the survey was handed to participants by a research assistant who approached them in the classroom in the last 10 min of the lecture and asked them to return the completed survey to a box located in the main office in each department.

The questionnaire was adapted from previous studies and comprised four sections.[19],[20] These sections address sociodemographic information (age, department, and year of study), breastfeeding exposure and future intentions, breastfeeding knowledge scale, and attitude scale. The knowledge and attitude scales had been used and validated in a previous study. The content validity indices of the knowledge and attitude scales were 0.93 and 0.91, respectively. The internal consistency reliability of the attitude scale was 0.70.[20]

The breastfeeding exposure scale included three questions about breastfeeding exposures and one question on future breastfeeding intention. Breastfeeding exposures were measured whether the participant had been breastfed (yes/no/unsure), whether they knew anyone who had breastfed (yes/no), and whether they had ever witnessed a woman breastfeeding (yes/no). The three breastfeeding exposure variables were summed to give a total breastfeeding exposure score, with a possible range from 0 to 3. For the question about the participant's breastfeeding status, “unsure” responses were considered the same as “no” and scored accordingly. For univariate analyses, breastfeeding exposures were collapsed into two categories: a score of 0–1 was categorized as low exposure and a score of 2–3 was categorized as high exposure.

Breastfeeding intention was assessed by asking participants, whether they wanted to breastfeed their children. Participants were given two points for “yes” and one point for “no.”

Breastfeeding knowledge scale included 14 items that scored on a dichotomous scale (agree/disagree). Participants were given one point for a correct response. The possible score ranged from 0 to 14.

Breastfeeding attitude scale included 15 items that are scored on a 4-point Likert scale (strongly disagree, somewhat disagree, somewhat agree, and strongly agree). A total attitude score was calculated by summing all items and dividing by the total number of items. To facilitate analysis, negatively worded items on the attitude scale were reverse coded to ensure consistent scoring so that higher attitude scores reflected more positive attitudes.

The breastfeeding knowledge and attitude scales were translated from English into Arabic using the blind-back translation method for ensuring the semantic and technical equivalence.[21] The content validity of the Arabic version was assessed by three academic experts in the field of maternal and child health nursing. Some modifications were made to the scale items before use. For example, as the target population was unmarried university students, the statement “breastfeeding interferes with my sex life” was removed. Furthermore, the term “bottle feeding” was changed to “formula feeding” as expressed breast milk can be fed to babies in bottles. Face validity was tested with ten students, showing that scale items were easily understood by all students (100%).

Ethical considerations

The study was approved by the Ethics Committee of Tabuk University (Approval code: 1438-3-1). Written and informed consent for participation was obtained from each participant. They were also ensured about the confidentiality of their information and the voluntariness of participation in the study.

Data analysis

Data analysis was performed using SPSS version 25 software (IBM Corp. Armonk, New York, USA). Statistical procedures were completed to a significant level of 5%. Descriptive statistics were used to analyze the responses to all questions and to describe participants. Comparisons of mean knowledge and attitude scores according to sociodemographic variables were performed with analysis of variance test. A covariance analysis was performed to investigate which of the sociodemographic variables can predict students' knowledge, attitudes, and intention. The relationships between breastfeeding knowledge, attitude and exposure, were examined by Pearson bivariate correlations. Phi coefficient was used to examine the association between breastfeeding knowledge, attitude and intention. To estimate the independent contribution of study variables on breastfeeding intention, logistic regression analysis was used. Variables with a significance level of P < 0.05 in the univariate analysis were entered into the model in a forward stepwise manner. All breastfeeding exposures were entered as separate dichotomous variables (yes/no).


  Results Top


One hundred and twenty-four of 150 students completed the survey, with a response rate of 91.8%. Sixty-nine percent of the students were <22 years old, with a mean age of 20.6 ± 1.38 years. Seventy-two percent of the students reported that they were breastfed in their infancy, 94% knew someone who breastfed, 94% had ever witnessed a woman breastfeeding, and 82% wanted their future child to be breastfed [Table 1].
Table 1: Characteristics of the participants (n=124)

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Breastfeeding knowledge scores ranged from 2.99 to 14, with a mean score of 9.51 ± 2.63. Most of the participants were aware that breastfeeding is healthier for the baby than formula feeding (58.1%), that breastfeeding helps prevent infection (60.5%) and allergies (73.4%), that breast size has no relation to the ability to breastfeed (54.8%), that there are differences in breast milk and cow's milk and soya milk (75%), and that breastfeeding should be started almost immediately after birth (84.7%). More than half (69.4%) of the participants believed that breastfeeding women should avoid certain foods, and 54.9% believed that breastfeeding is painful [Table 2].
Table 2: Participants' knowledge about breastfeeding (n=124a)

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Mean attitude scores were 42 ± 1.8, with a range from 25.8 to 53.55, indicating overall positive attitudes. Over 80% of the participants respected women who breastfeed and agreed that breastfeeding is more convenient than formula feeding. Breastfeeding was perceived as more enjoyable by babies, helps the mother feel closer to her baby, and helps babies get a better start in life. Most of the participants believed that formula feeding gives more freedom to the mother with the majority (72%) perceived breastfeeding in public as embarrassing, unacceptable, and makes breastfeeding less attractive. Over 75% of the participants believed that women of all education levels and socioeconomic class should breastfeed their children. Almost two-thirds (67.8%) of participants believed that formula feeding and breastfeeding benefit the child equally [Table 3].
Table 3: Participants' attitudes toward breastfeeding

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Significantly higher knowledge scores were observed among senior students (P = 0.004), among those who reported being breastfed as infants (P = 0.05), and among those who reported having witnessed a woman breastfeeding (P = 0.009) [Table 4]. Mean attitude scores were significantly higher among students reporting witnessing a woman breastfeeding (P = 0.001). Intention percentages were significantly higher among students in the age group of 19-21 (82%, P = 0.03), and among students who reported having been breastfed as infants (90%, P = 0.02) (Data not shown). The results of the covariance analysis indicated that none of the sociodemographic variables can predict students' breastfeeding knowledge, attitudes, or future intention.
Table 4: Comparison of the mean knowledge and attitude scores according to sociodemographics and exposure

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A significant positive relationship was found between breastfeeding knowledge and attitude (r = 0.896, P < 0.01), breastfeeding knowledge and exposure (r = 0.191, P < 0.01), breastfeeding knowledge and intention to breastfeed (Phi coefficient=0.179, P = 0.033), and breastfeeding attitudes and intention to breastfeed (Phi coefficient=0.177, P = 0.030). In regression analysis, participants' attitude (OR=1.930, P < 0.001) and knowledge (OR=-3.280; P < 0.001) were associated with future breastfeeding intention. However, participants' own breastfeeding status, knowing someone who had breastfed, and witnessing breastfeeding were not independently associated with the future intention to breastfeed [Table 5]. Moreover, in regression analysis, none of the students' personal characteristics could predict the future intention to breastfeed.
Table 5: Results of regression analysis to predict the predictive factors of breastfeeding intention

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  Discussion Top


The current study demonstrates positive breastfeeding intention and attitudes toward breastfeeding and a good level of breastfeeding knowledge among participants. The majority respected women who breastfeed and agreed that breastfeeding is more convenient than formula feeding. Participants believed that women of all educational and socioeconomic classes should breastfeed. Muslim women are required to follow the Qur'an's instructions about breastfeeding and weaning of infants. These religious instructions must be utilized to influence the local breastfeeding initiation rate and duration in the Saudi community.[17] Our findings are consistent with earlier studies in Arab and non-Arab countries.[15],[22],[23] Padmanabhan et al. found high breastfeeding intention rate among female college students in India; Hamade et al. found a similar breastfeeding intention rate and average breastfeeding knowledge among university students in Lebanon and Syria, and Al-Ali et al. also found a similar level of knowledge among students in Jordan. Conversely, a number of studies in Egypt and Saudi Arabia found low levels of breastfeeding knowledge among university students.[17],[24]

Students in the present study were knowledgeable regarding the benefits of breastfeeding for baby and mother and the importance of the early initiation of breastfeeding. These findings are consistent with studies carried out in the Middle East among university students.[15],[22] Hamade et al. found average breastfeeding knowledge among university female students in Lebanon and Syria.[15]

Knowledge gaps and misconceptions about breastfeeding were identified among participants. These misconceptions could be addressed through age-appropriate school health education sessions that are culturally sensitive and teen-friendly. Such educations may positively influence the students' knowledge, attitude, and future intention of breastfeeding.[16],[17],[25],[26]

Although participants had generally positive attitudes toward breastfeeding, a significant proportion of students believed that formula feeding gives more freedom to the mother, that breastfeeding in public is unacceptable and embarrassing, and that formula feeding and breastfeeding benefit the child equally. These results are consistent with other studies in the Middle Eastern countries that found embarrassment as a barrier to breastfeeding.[15],[17]

The current findings support previous studies that knowledge level and attitudes about breastfeeding are interrelated; the greater the students' breastfeeding knowledge, the more positive their attitude toward breastfeeding.[15],[17],[24] Hamade et al. surveyed female undergraduate students in Lebanon and Syria and found a positive correlation between knowledge and attitudes, and similarly, students believed that the formula feeding was more convenient and equally beneficial for the infant.

Consistent with previous studies, the findings showed a significant positive relationship between intention to breastfeed and breastfeeding knowledge and attitudes. Participants who intended to breastfeed had significantly higher breastfeeding knowledge and positive attitudes. Moreover, a positive breastfeeding attitude and a greater probability of breastfeeding intention were observed among participants in the present study who were breastfed as babies. The current findings are consistent with other previous studies that demonstrated exposure to breastfeeding was associated with positive breastfeeding attitudes and intentions.[15],[20]

The logistic regression analysis identified participants' attitude and knowledge as factors independently and positively associated with future breastfeeding intention. Although the R2 values were low, they drew an important conclusion about how changes in the knowledge and attitude scores are associated with changes in future breastfeeding intention. Participants' characteristics, participants' own breastfeeding status, knowing someone who had breastfed, and witnessing breastfeeding were not independently associated with the future intention to breastfeed in this sample of female students. These findings could be explained that watching a woman breastfeed or knowing someone who breastfed as a child is a common thing in Saudi culture where breastfeeding initiation rate is very high. The dilemma is the duration of breastfeeding as well as the commitment to exclusively breastfeeding.[6] Therefore, breastfeeding campaigns and interventions directed to the young Saudi population should promote exclusive breastfeeding and improve public acceptance of breastfeeding. Endorsement of breastfeeding with emphasis on benefits such as the convenience of feeding on demand without the need to prepare bottles or purchase formula may help promote breastfeeding as the most economical as well as beneficial feeding method.[25]

The findings support other studies that describe beliefs about breastfeeding being formed early in life, often before having children.[12],[27] Addressing the young Saudi population might help instill positive breastfeeding practices in the community[28] through introducing educational material in schools aiming to promote breastfeeding and correcting misconceptions.

Education is needed for the general public concerning misconceptions that address Saudi men and other important people who support the breastfeeding mother. More positive attitudes regarding breastfeeding among men and nonbreastfeeding women may provide breastfeeding mothers with the help and support needed to continue breastfeeding for the recommended 6 months.

This study has several limitations. The use of a descriptive cross-sectional design prohibits predictions regarding actual breastfeeding behavior. This nonexperimental design limits the ability to infer a causal relationship between attitudes and breastfeeding intentions. Furthermore, there is a risk that social desirability influenced the responses to the self-report questionnaires. The findings of this study are limited to one university and female students who have Saudi nationality and cannot be generalized to other populations. Future research could include university male students and those without a university degree to get a better understanding of their attitudes, subjective norms, intentions, and behaviors regarding infant feeding methods that can be generalized to a broader population. This will allow investigation of the impact of education on infant feeding beliefs, intentions, and breastfeeding behavior.


  Conclusion Top


Female university students in one Saudi Arabian university have good knowledge and positive attitudes toward breastfeeding. However, there were misconceptions about breastfeeding that should be addressed through appropriate education and promotion programs. These gaps should be stressed during future breastfeeding promotion programs. Implementing educational programs in schools, high schools, and universities about breastfeeding, as well as implementing mass media education and advertising programs, can improve the knowledge, attitude, and intention of breastfeeding in the future mothers.

Acknowledgments

The author is grateful to all those who have contributed to this study. I want to acknowledge the University of Tabuk where the research was conducted and the students who were part of this research.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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