Knowledge and Attitude of Male Staff in a Nigerian Tertiary Institution towards Infant Feeding

study between all the authors. Author FOS conceptualised the study and wrote the protocol. Authors FOS and OTA supervised data collection and analyses. OOL analyzed the data the first of the manuscript. FOS and OTA the ABSTRACT Aim: The aim of this study was to assess the knowledge and attitude of Nigerian men working in a tertiary institution toward infant feeding. Study Design: The study was cross sectional in design. Place and Duration of Study: The study was carried out Methodology: A pretested, self-administered questionnaire was used to obtain information on the socio-demographic attitude of male staff regarding infant Knowledge categorized as adequate or inadequate knowledge; positive and negative attitude. Data was analyzed using descriptive statistics and association between knowledge and attitude was analyzed using chi square test with level of significant set at P<0.05. poor infant feeding knowledge while three out of ten had good knowledge. Most of the men (76.5%) had negative attitude towards infant feeding while only two out of ten men had positive attitude. Three-quarters (75.7%) of men with poor infant feeding knowledge had negative attitude towards infant feeding while only 2 out of every 10 men with adequate infant feeding knowledge had positive attitude towards infant feeding. However, no significant association was reported between the knowledge and attitude of respondents toward infant feeding ( P =.72). Conclusion: Poor infant feeding knowledge and negative attitude towards infant feeding exhibited by men is of great concern. Intervention should therefore be targeted towards improving the breastfeeding knowledge and attitude of male partners especially those working in tertiary academic institutions.


INTRODUCTION
Infant and young child feeding practices directly affect the nutritional status of younger children and ultimately impact child survival [1]. Exclusive breastfeeding from birth to 6 months has been shown to be the most effective preventive intervention for ensuring child survival and is estimated to save 13 percent of all deaths in children younger than five [2]. Also, appropriate complementary feeding at 6 months could prevent an additional 6 percent of deaths in this age group [2]. Studies have suggested that engagement of key influencers other than facilitybased health workers is critical for promoting adoption of optimal infant and young child feeding practices [3][4][5]. Infant and young child feeding practices have however been shown to be influenced by household factors, social networks, and modern and health institutions [5]. It is also embedded within traditional relationship in which both relatives and breadwinners have influence and even authority over options and modes of infant feeding [1].
A combination of factors has been indicated to influence infant feeding decisions of mothers, some of which include; knowledge, attitude, societal norms, support from partners and family members [6,7]. Mother's perception of father's preference for breastfeeding has emerged as a pertinent factor affecting the decision to breastfeed, especially in western countries [8][9][10]. To ensure optimum infant feeding, it is essential that mothers receive accurate information on infant feeding as well as support from family members especially their partners. Evidence from studies has shown that engagement of men can significantly improve infant and young child feeding practices [11,12]. The involvement of male partners in ensuring optimum feeding for the infant positions them as a key stakeholder in infant nutrition.
In Africa, male partners are found to be primarily responsible for providing financial resources for basic household activities, including food; financial and logistical resources for health care; and resources for various activities outside the household that are critical to family survival [13]. Studies from many African countries consistently show that men's knowledge of and involvement in maternal and child nutrition and health issues is limited compared to that of women [14][15][16][17][18][19][20].
Partner's support during infant feeding especially breastfeeding has been reported in previous studies [21,22]. Fathers have been indicated as one of the most influential persons to the mother, and they act either as key supporters or deterrents to breastfeeding [23,24]. There is however strong evidence that fathers can influence the breastfeeding decision [25], breastfeeding initiation [26,27], breastfeeding duration [25] and maternal breastfeeding confidence [23,28,29]. They as well influence decisions regarding feeding with bottle and weaning [25,30]. Engaging male partners in breastfeeding promotion and education, as well as providing fathers with knowledge and skills for optimal breastfeeding practices have also been shown to positively impact exclusive breastfeeding rates [11,12]. Opportunity for fathers to support their partners towards breastfeeding has been associated with their understanding of the importance of breastfeeding and the benefits it affords to both the baby and the mother [31]. Little information is however available on knowledge and attitude of Nigerian men towards infant feeding. The purpose of this study was to assess the knowledge and attitude of men toward infant feeding. Male staff in a Nigerian higher institution of learning was the focus, with the assumption that they are generally knowledgeable about a wide range of issues because of their exposure to information in the academic workplace setting.

METHODOLOGY
This cross sectional study was done among male staff of the University of Ibadan. A pretested, self-administered questionnaire was used to obtained information on the socio-demographic characteristic, knowledge and attitude of 170 male participants towards infant feeding. Data on infant feeding knowledge of the respondents was measured through a 12-point knowledge scale. Participants with score of 7 and above were considered as indicating a high level of knowledge while those with scores below 7 were regarded to have poor knowledge. The attitude of the participants on the other hand was assessed through an 8-point attitude scale. A negative attitude was defined as a score below 4 points and below while positive attitude was defined as a score of 4 point and above. Descriptive analysis of the data was carried out using SPSS version 21.

RESULTS
The socio-demographic characteristics of 170 male staff from the University of Ibadan are presented in Table 1. About 14% of the respondents were academic staff while threequarter (75.9%) were non-academic staff and 10% were technical or laboratory staff.
One-third had been working in the University for less than 10 years while 5 out of 10 had worked between 10 to 19years. One-quarter of the respondents had Ordinary and Higher National Diploma. About 30% had Bachelor degree while 17.6% and 11.2% had Masters and Doctoral degrees respectively. The marital status of the respondents revealed that 87.6% of them were married while 11.2% were single and only 1.2% was widowed. Majority (86.5%) was Christians and only 13.5% were Muslims.
The average age of the respondents was 41±9 years with only 8.8% between 20-29 years and 37.6% between 40-49 years. About 17% of the respondents had no child while 46.5% had three to four children. Of the 151 married respondents, 6.6% were yet to become fathers while 4 out of 10 fathers had children below 5years of age as their youngest child. Table 2 shows the distribution of the respondents with correct knowledge regarding infant feeding. Majority (93.5%) of the respondents reported breast milk as the first food to be given to infant after birth. About 70% of respondents believe that water or glucose water should not be introduced to the infant in their first few days of life. Also, about 70% believed that breast milk is more beneficial than the infant formula. Sixty percent of the university male staff disagreed that it is common for mothers to have insufficient milk in their breast while 49.4% of the respondents also disagreed that mothers who feel they have insufficient breast milk should feed with infant formula in addition to breastfeeding.
Eighty four percent of the respondents disagreed that mothers should stop breastfeeding a sick infant while 61.8% believed that breast milk alone is sufficient to provide all nourishment for infants in the first six months of life. Twenty two percent were of the opinion that mothers should ensure that one breast is fully emptied before introducing the second breast during a breastfeeding session. About 37% agreed that exclusive breastfeeding may protect mothers from pregnancy in the first few months after birth.
Also, only 19.4% of the respondents disagreed with the introduction of infant formula to infants at birth while 57.1% agreed that semi-solid/soft foods should not be introduced to the infants before 6 months. About a quarter (24.1%) of the respondents disagreed with abrupt cessation of breastfeeding the moment the baby is introduced to complementary foods Table 3 shows the distribution of the respondents' attitude towards infant feeding. About one-fifth (21.3%) of the men agreed that it is possible for mothers to practice exclusive breastfeeding for six months. In the same way, 23.5% of the men agreed that HIV positive mothers can breastfeed when duly advised by her doctor. A good number of the respondents (74.7%) had positive attitude towards timely introduction of complementary foods to the infants whilst 31.8% disagreed that herbal teas are beneficial to the health of infants below 6 months. Most of the respondents (95.9%) agreed that it is important to assist their wives in domestic duties to allow them concentrate on child care. Similarly, 83.5% of the men agreed that it is important for mothers to be assisted by grandmothers and other female caregivers in feeding the child with complementary foods. However, one out of every three respondents (31.2%) disagreed that a father should not be involved in any form of infant feeding. Fig. 1 shows the bar chart distribution of knowledge and attitude categories of the male towards infant feeding. About two-thirds (67.6%) of the men had poor infant feeding knowledge which means that only three in every ten of them had good knowledge. Similarly, most of the men (76.5%) had negative attitude towards infant feeding while only 2 out of 10 men had positive attitude.
As shown in Table 4, no significant association was reported between the knowledge and attitude of male staff in tertiary institution towards infant feeding (P=.72). Most (75.7%) of the men with poor infant feeding knowledge also had negative attitude towards infant feeding. Similarly, those with good knowledge also largely had negative attitude.

DISCUSSION
Studies have established that the father of the baby is one of the most influential persons to the mother, and that they can act as either key supporters or deterrents to infant feeding [23][24][25][26]. It is therefore important for fathers to be better prepared to assume their new role as breastfeeding supporters [32]. It was observed from the current study that most of the respondents had poor knowledge towards infant feeding. This finding is consistent with the study obtained from Uganda [33]. The knowledge of the participants in this study is also similar to that of Alvarado and colleagues where low level of knowledge towards infant feeding was reported among prospective fathers [34]. In the present study, the lowest level of knowledge was observed concerning the perceived benefit of introducing infant formula to the child. This could be attributed to the fact that the participants in this study live within a metropolitan area and may easily be exposed to the infant formula, also their socio-economic status may have further influenced their access to breast milk substitutes.
In a study on gender perception on infant feeding in Uganda, men were generally unfamiliar with the idea that an infant should be breastfed exclusively for the first six months [33]. The observation made from the current study on the concept of natural birth control as a result of exclusive breastfeeding is similar to that reported by Alvarado and colleagues in Brazil [34]. Breastfeeding especially exclusively for six months liberates the hormone oxytocin, which stimulates uterine contractions, and thus helping to expel the placenta and to reduce blood loss after child birth [35]. If the mother maintains breastfeeding for a longer period, the subsequent contractions will help her uterus recover its original size. Exclusive breastfeeding for 6 months may hence delay fertility of mothers. In line with the view of men in this study, most men in Uganda were also of the opinion that production of breast milk by mothers is not sufficient and exclusive breastfeeding is not feasible [33]. According to Engebretsen and colleague [33], sickness was reported as one of the major reasons for poor milk production and hence rationale for the introduction of other foods. In the same vein, most participants in this study were also of the opinion that mothers should halt breastfeeding whenever the baby is ill. Studies have shown that mothers' perception of fathers' preference for breastfeeding has been identified as a pertinent factor affecting the decision of mothers to breastfeed [8][9][10]. Bentley et al further established that the intention of mother to breastfeed is significantly related to the partner's attitudes towards breastfeeding [36]. The attitude of most men towards infant feeding were also found to be negative in this study; this is in contrast to was obtained from a previous study [34] where it was reported that males with positive disposition towards breastfeeding had better knowledge and attitudes related to infant feeding than those with less disposition. In another study, paternal attitude towards breastfeeding was found to be a determinant of breastfeeding [37], while Littman and Colleagues had also established a strong relationship between father's approval to breastfeed and breastfeeding incidence [38].
In a study by Falnes and colleagues [39], majority of the fathers were of the opinion that infant feeding is a decision to be made by the mother and that the father should not get involved as long as the mother feeds the infant according to the customary pattern. This is in conformity to the current study where most men were of opinion that fathers should not be involved in any form of infant feeding and that they are too busy to assist wife in ensuring that the child is well fed. However, in a related study on paternal support for breastfeeding in Western Australia, it was reported that fathers wanted to be involved with parenting and parenthood, but many of them felt they were unprepared and lacked the relevant information to be effective in their parenting role [31]. Susin and Giugliani [11] found that mothers would like more help from their partners regarding the feeding of the infants, but most fathers did not know what they could do to help. Tohotoa and colleagues [31] further reported that fathers believed they need to be knowledgeable on nutrition in infancy especially need for information about difficulties associated with breastfeeding.
Inadequate breastfeeding knowledge of the fathers is one of the barriers to effective breastfeeding [31]. The findings from this study revealed that most male partners had poor knowledge and negative attitude towards infant feeding. According to the study among fathers by Ingram and Johnson [40], it was reported that two factors-fathers' attitudes to breastfeeding in public and knowing how much milk the baby was getting had the most influence on whether they supported their partner to continue to breastfeed. It is important for the fathers to have basic understanding of infant feeding which will be reflected in their level of knowledge and attitudes in other to adequately equip them as advocates for optimum nutrition in infancy.

CONCLUSION
In conclusion, this study has shown the level of knowledge and attitudes of men in the University of Ibadan towards infant feeding. Despite working within the higher institution of learning, the men exhibited a poor infant feeding knowledge and negative attitude towards infant feeding. It may then be argued that working in such an academic environment is not a guarantee for good infant feeding knowledge.
Intervention should therefore be targeted towards improving the breastfeeding knowledge and attitude of male partners working in the academic settings, this will ensure their more involvement in infant feeding hence optimum growth and development of their children.

LIMITATION
The findings of the current study cannot be generalized as this study was carried out in only one of the thirty six Federal universities in Nigeria.

CONSENT
All authors declare that verbal informed consent was obtained from the participants of this study.

ETHICAL APPROVAL
It is not applicable.