KNOWLEDGE, ATTITUDE AND PRACTICE OF EXCLUSIVELY

BREASTFEEDING MOTHERS IN THE COMMUNITY AND

THE ROLE AND RESPONSIBILITIES OF PROGRAM
IMPLEMENTATERS IN LANAO DEL SUR: A BASIS
FOR HEALTH INTERVENTION DESIGN

A Thesis
Presented to
The Faculty of the Graduate School Studies
Mindanao State University
Marawi City

In Partial Fulfillment
of the Requirements for the Degree
Master of Arts in Nursing
(Major in Nursing Administration)

JEHANNA ARUMPAC, RN

JUNE 2022
 Republic of the Philippines
Mindanao State University
Marawi City

APPROVAL SHEET

The Faculty of the Graduate School of the Mindanao State University

at Marawi City accepts the thesis entitled:

KNOWLEDGE, ATTITUDE AND PRACTICE OF EXCLUSIVELY

BREASTFEEDING MOTHERS IN THE COMMUNITY AND
THE ROLE AND RESPONSIBILITIES OF PROGRAM
IMPLEMENTATERS IN LANAO DEL SUR: A BASIS
FOR HEALTH INTERVENTION DESIGN

Conducted and submitted by JEHANA ARUMPAC, RN in partial fulfillment of

the requirements for the degree Master of Arts in Nursing, Major in Nursing
Administration.

HAMDONI K. PANGANDAMAN, MAN, RN, LPT

Adviser

NAIMA D. MALA, RN, MN, MAN, PhD JONAID M. SADANG, MAN, RN, RM, LPT
Panel Member Panel Member

ATHENA JALALIYAH D. LAWI, RN, MN, MAN, PhD

Panel Member

ATHENA JALALIYAH D. LAWI, RN, MN, MAN, PhD

Chairperson, Graduate Studies Department
College of Health Sciences

NAIMA D. MALA, RN, MN, MAN, PhD

Dean, College of Health Sciences

MINOMBAO R. MAYO, PhD

Dean, Graduate School

SEPTEMBER 2020
 ACKNOWLEDGMENTS

Above anything and everything, the researcher thanks the Almighty ALLAH
SWT for giving him the courage, strength, patience, wisdom and all means in the
preparation of this research.
The researcher wishes to express her profound gratitude and deep appreciation to

the following, without whom this study would not have been possible:

To Prof. Hamdoni K. Pangandaman, my thesis adviser and statistician, for being a

great adviser and statistician, for providing me the inspiration and instilling determination
and at the same time understanding my circumstances, for reviewing and editing my
work and helping me learn the complexities in thesis writing. His incomparable
generosity and tremendous optimism furnished me the ability to finish the task;
To Dr. Naima D. Mala, RN, MN,MAN, Dr. Athena Jalaliyah D. Lawi,RN, MN,
MAN, And Prof. Jonaid M. Sadang, RN, RM, MAN, LPT my dignified panel members,
readers and critics, for their substantial contribution for the organization of the study and
for giving time for this piece of work;
To Ms./Mrs. Princess Jehan Salic , a friend from KFCIAS , Mindanao State
University, for editing my paper;
To my friends, Mrs. Aina Mai- Alauya , Mrs. Norhanie Ali-Bocua, and Mr, Ryan
Diamla. of the College of Health Sciences for her undying support and extensive
suggestions in undertaking this study;
Thank you so much for all the help. I couldn’t have done it without you!

iii
 DEDICATION

In the name of Allah, the Most Gracious, the Most Merciful,

This study is wholeheartedly dedicated to my Husband Achmad M, Guinal Jr, and my

children Thirdy , Zakee and Fatma Az-Zahra , who have been my source of strength
when I thought of giving up. My husband Damboi who continually provide his moral ,
spiritual, emotional and financial support from the beginning of my journey in masters up
to this end. My children who are unknowingly inspires me in the midst of terrible
challenges, from being a “ hands on mom” to a working mom and being a student once
again. To my parents Ina (Norhaifa P. Arumpac) and Papa (Salic P. Arumpac), my Inlaws
Omi (Saliha M. Guinal) and Papang (Achmad M. Guinal) for their un ended
encouragement, support and for believing in me that I can make it up to end.
Above all, this work is dedicated to Allah, the Almighty.
Alhamduilillah!

-Jehanna

iv
 TABLE OF CONTENTS
Page
TITLE PAGE i
APPROVAL SHEET ii
ACKNOWLEDGMENTS iii
DEDICATION iv
TABLE OF CONTENTS v
LIST OF TABLES viii
LIST OF FIGURES x
ABSTRACT xi

CHAPTER

I THE PROBLEM AND ITS SCOPE

Introduction 1
Theoretical Framework 3
Conceptual Framework 5
Statement of the Problem 7
Null Hypotheses 8
Significance of the Study 8
Scope and Delimitation of the Study 9
Definition of Terms 10

II REVIEW OF RELATED LITERATURE AND STUDIES

Related Literature 15
EBF Sustainable Development Goals (SDGs) 15
The History of Exclusive Breastfeeding 16
Exclusive Breastfeeding 18
Benefits of Exclusive Breastfeeding to Infant 19
Benefits of Exclusive Breastfeeding to Mother 21
Exclusive Breastfeeding Practices 22
Exclusive Breastfeeding Advantages 24
Physiologic and Psychosocial Benefits of Breastfeeding 26
Factors Influencing Exclusive Breastfeeding 27
Exclusive breastfeeding interventions 32
Consequences of not exclusively breastfeeding 34
Characteristics of EBF mothers around the world 35
Breastfeeding programs in Philippines 37
The Role of the Nurse in Exclusive Breastfeeding 39
Related Studies 41

v
 III RESEARCH METHODOLOGY

Research Design 32
Research Locale 33
Research Respondents
37
Sampling Procedure 37
Research Instrument 37
Reliability and Validity of Instrument 38
Ethical Consideration 38
Data Gathering Procedures 39
Statistical Treatment/ Tools 40

REFERENCES 62

APPENDICES

A Sample Letter to the Municipal Health Officer

B Sample Letter to the Rural Health Workers 68
C Sample Letter of the Consent Form 69
D Research Questionnaire for mothers 70
E Research Questionnaire for health workers 72
 LIST OF
vii TABLES

Table Page

1 Distribution of Participants in the Selected RHU 42

 LIST OF FIGURES
viii
Figure Page

1 Schematic Diagram showing the interplay of variables 6

2 Overiew Map of RHU Saguiran and Marantao 47

3 Map of RHU Saguairan 48

4 Map of RHU Marantao 49

 ABSTRACT
JEHANA ARUMPAC, RN “KNOWLEDGE, x ATTITUDE AND PRACTICE
OF EXCLUSIVELY BREASTFEEDING MOTHERS IN THE COMMUNITY
AND THE ROLE AND RESPONSIBILITIES OF PROGRAM
IMPLEMENTATION IN LANAO DEL SUR: A BASIS FOR INTERVENTION”. A
Master’s Thesis. Mindanao State University, Marawi City, June 2020.

Thesis Adviser: Prof. Hamdoni K. Pangandaman, MAN, RN, LPT

The study determined the knowledge, attitude, and practice of exclusively breastfeeding
women in the community, as well as the role and duties of program implementers, which
will be used to construct health interventions. The researcher would also like to know to
what degree the health personnel corrected or guided the Meranaw women regarding
exclusive breastfeeding. In terms of location, this survey contained two (2) groups of
respondents. The research will be undertaken in two (2) separate locations: Saguiran,
Lanao del Sur, and Marantao, Lanao del Sur. This study used an evaluative-inferential
design in a correlational approach with a qualitative integration design. In the distribution
of respondents, the researcher used stratified random sampling. Furthermore, descriptive
statistics such as Statistical Product and Service Solutions (SPSS) version 21 were
employed to compute all data in this study. The IBM-SPSS was then used for more in-
depth inferential analysis, such as the Pearson r and Cramer's V correlation, to test for a
significant relationship between the variables in the respondents' profiles, as well as to
perform a test to significantly test the influence or effect of exogenous variables on
dependent variables. Mother and child health remains one of the most serious and
interesting issues in healthcare. The findings corroborate the generally held idea that the
transition to parenthood is a difficult and multidimensional event in people's lives. It also
demonstrates the need of educational measures in improving and correcting mothers'
knowledge, attitudes, beliefs, and sociocultural norms about EBF. EBF education should
engage healthcare personnel at all levels.

Key words: Exclusive Breast Feeding, Health Interventions, Community Workers,

Breast Feeding Mothers

xi
 Chapter I

THE PROBLEM AND ITS SCOPE

Background of the Study

Breastfeeding as is widely known as an important motherly task (exclusive

breastfeeding) that shall not be neglected. Breast milk contains the nutrients that are most

vital for the survival of the infant; it contains colostrum which can help the child’s

immune system to fight diseases. It is a way for the child to get smarter and gain proper

weight at early stage of life. It promotes bonding between mother and the child, creates

calmness and security to the child and a warm affection for the mother. Also, it helps the

mother to lose weight, decreasing those unwanted flabby fats concomitant to child-

bearing.

Breastfeeding as a natural way of feeding infants is still being practiced.

According to Center for Disease Control [CDC] (2018), among infants born in 2015, 4

out of 5 (83.2 percent) started out breastfeeding. This high percentage of babies who

started out breastfeeding shows that most mothers want to breastfeed with almost half

(46.9 percent) has been exclusively breastfeeding for 3 months. But succeeding year at

2019 record in the Philippines shows a decline of exclusive breastfeeding at less than half

of the total.

World Health Organization [WHO] (2019) articulated that exclusive

breastfeeding means that the infant receives only breast milk and no other liquids or

solids are given – not even water – with the exception of oral rehydration solution, or

drops/syrups of vitamins, minerals or medicines. It has been suggested that babies should
 2

not be fed solid food until they are at least four months old. This is because babies who

move onto solids too early will be at risk of becoming overweight and predicted to

develop heart problems in the late stage of life.

The declining statistics of mothers who exclusively breastfeed their babies lies

with the mothers’ lack of knowledge about the importance of exclusive breastfeeding. It

has been reported that some mothers introduce solid foods early to their babies because

they feel calmer in feeding them (BBC, 2000). Some parents do not have the right

attitude as well regarding breastfeeding or in other words, they do not believe entirely in

the necessity of exclusive breastfeeding. Others, while knowing the importance of

breastfeeding do not practice breastfeed properly. Still for some, they cannot exclusively

breastfeed because of absence of milk of being a working mother.

This is parallel with the idea of Green and Olson (2008) who stated that

internationally, there are many factors associated with poor exclusive breastfeeding and

must consider when investigating the reasons for lower than recommended rates and

duration of breastfeeding identified many of the most common barrier to successful

breastfeeding. The seven barriers addressed in the call to action were found to be: lack of

knowledge, lactation problems, poor family and social support, social norms,

embarrassment, employment and child care, and health services as cited by U.S.

Department of Health and Human Services (USDHHS, 2011). Many barriers to

successful exclusive breastfeeding among employed mothers have been identified. Five

aspects of the work environment that contribute to a mother’s overall perception of

workplace breastfeeding support have been described: company policies/work culture,

 3

manager support/lack of support, co-worker support/lack of support, and the physical

environment of the breastfeeding space.

According to Castillo MD (2019), it can be heartbreaking when working mothers

have to wean off their babies early from breastfeeding because they have to go back to

work. Nature has provided mothers with the most important source of nutrition they can

provide their babies during the crucial first 1,000 days of the baby’s life. Depriving them

of this vital nutrition for nonmedical reasons is a thoughtless decision.

In Lanao Del Sur, some mothers are striving to fulfil the motherly role of

breastfeeding their babies. Thus, the researcher has decided to find out about their

knowledge, attitude and practice regarding exclusive breastfeeding. The researcher would

also like to know to what extent have the health workers corrected or guide the Meranaw

mothers regarding exclusive breastfeeding. The results of the study will be the basis for

an intervention plan.

Theoretical Framework

This study was grounded to the following theories namely: Theory of Planned

Behavior by Icek Ajzen (1985) and Maternal Role Attainment or Becoming a Mother

by Mercer (2004).

The theory of Planned Behavior by Icek Ajzen (1985) is a theory that focuses on

cognitive factors influencing behavior. It recognizes intention and perceived behavioral

control as immediate determinants of behavior. Intention is influenced by attitude,

perceived norm and perceived behavioral control. Attitude refers to the overall evaluation

of performing the behavior. Perceived norm is perceived social pressure to perform or not
 4

to perform the behavior, and it composed of injunctive norm and descriptive norm.

Injunctive norm refers to perception that people's significant others would support or

oppose them to perform the behavior while descriptive norm is the perception that their

significant others themselves performed or not performed the behavior. Perceived

behavioral control is the extent to which people believe that they are capable of

performing the behavior, and that they have control over its performance.

The criteria that contribute to the strength of Theory of Planned Behavior include:

(1) the presence of a measure of intention that mediates the relationship between other

cognitive factors with behavior, (2) it explicitly covers the normative influences on

behavior, (3) the definitions and measures of the constructs are clear and parsimony, and

(4) it includes the temporal relationship between the cognitive variables and distinguish

between proximal and distal determinants of behavior.

The theory of Planned Behavior by Icek Ajzen is related to this study as the

behavior of a mother towards breastfeeding can be influence by factors such as the

cognitive factor or the knowledge about exclusive breastfeeding. The theory is useful in

understanding social behaviors to guide studies on exclusive breastfeeding. The theory

could be also related on predicting the ability of the mothers based on their knowledge,

attitude and practices that could serve as a basis for planning a health intervention

program.

This study was also anchored from the mid-range theory of Maternal Role

Attainment or Becoming a Mother (Mercer, 2004). Accordingly, the four stages in the

process of developing a maternal identity have been described as being: Commitment,

 5

attachment, and preparation (pregnancy); Acquaintance, learning, and physical

restoration (first two to six weeks following birth); Moving toward a new normal (two

weeks to four months); and Achievement of the maternal identity (around four months)

(Mercer, 2004).

The stage of “moving toward a new normal” is often when mothers return to

work. The woman must restructure her life to take into account her past experiences and

future goals. Relationships with her partner, family, friends, and co-workers are now

transformed as she incorporates her new responsibilities and identity of being a mother.

Returning to work and continuing to breastfeed her infant is an example of a woman

sorting out her priorities as she establishes her new identity as a mother. She might desire

the benefits of working, and it is also very important to her to optimize the care and

feeding of her child. The interaction between mother and child will continue to evolve

throughout their lifetimes, and the mother’s own identity will continue to evolve as well.

This theory is also related in this study as the four stages of maternal identity in

the Meranaw mothers may define stages of their knowledge, attitude, and practices

towards exclusive breastfeeding. The theory provided a guide that promoting and

maintaining exclusive breastfeeding is a long process that needs to be achieved even if

the mother is oblige to work. These stages of maternal role may serve as a basis for

healthcare professionals in understanding and in making their professional healthcare

services relevant to the needs of mothers.

Conceptual Framework
 6

The central inquiry of this study is about the knowledge, attitude, and practices of

exclusively breastfeeding among Meranaw mothers and the perspective of RHU nurses as

direct implementers of exclusive breastfeeding (EBF) as well as their roles and

responsibilities in the promotion of EBF in the community through the Rural Health

Units (RHUs) in Saguairan and Marantao Lanao del Sur.

The independent variable of the study has consisted of the respondent’s profile in

terms of age, sex, civil status, highest educational attainment, occupation, monthly

income and parity or number of children; knowledge, attitude, and practices of

exclusively breastfeeding; and, perspective of RHU nurses as direct implementers of

EBF. Then the dependent variable was the roles and responsibilities of RHU nurses in the

promotion of and implementation of EBF in their area of assignment.

Moreover, the independent variables has been correlated with the dependent

variables. As such, it aimed at finding significant relationship between socio-

demographic profile of respondents and the knowledge, attitude, and practices of

Meranaw mothers on exclusive breastfeeding. Then also, to find significant relationship

between roles and responsibilities of rural health workers in the promotion of exclusive

breastfeeding and the knowledge, attitude, and practices of Meranaw mothers on

exclusive breastfeeding.

In general, findings of the study as elicited in the figure served as a basis in the

development and implementation of health intervention design. Figure 1 below shows the

schematic diagram showing the interplay of variables under study.

 7

Independent Variables Dependent Variable

Sociodemographic
\ profile of
respondents
H
n E
 Age A
 Sex L
Knowledge,
 Civil status T
Attitude, and
 Highest educational attainment H
Practices of
 Occupation Exclusively
I
 Monthly family income Breastfeeding
N
 Number of children Meranao Mothers
T
E
R
V
E
N
Roles and Responsibilities of Rural T
Health Workers in the promotion of I
Exclusively Breastfeeding O
N

D
E
S
I
Perspectives of
G
Rural Health
N
Workers towards
KAP of Exclusively
Breastfeeding
Mothers
 8

Figure 1. Schematic diagram showing the interplay of variables under study

Statement of the Problem

This study determined the knowledge, attitude, and practices on exclusive

breastfeeding of Meranaw mothers in the community and the role and responsibilities of

RHU nurses as program implementers. Specifically, this study has answered the

following questions:

1. What is the socio-demographic profile of respondents in terms of:

1.1 age;

1.2 sex;

1.3 civil status;

1.4 highest educational attainment;

1.5 occupation;

1.6 monthly family income; and,

1.7 number of children?

2. What is the roles and responsibilities of rural health workers in the promotion of

exclusive breastfeeding?

3. What is the level of knowledge, attitude, and practices of Meranaw mothers on

exclusive breastfeeding?
 9

4. What is the perspectives of rural health workers towards knowledge, attitude, and

practices of Meranaw mothers on exclusive breastfeeding?

5. Is there significant relationship between socio-demographic profile of respondents

and the knowledge, attitude, and practices of Meranaw mothers on exclusive

breastfeeding?

6. Is there significant relationship between roles and responsibilities of rural health

workers in the promotion of exclusive breastfeeding and the knowledge, attitude, and

practices of Meranaw mothers on exclusive breastfeeding?

7. What possible health intervention design that can be formulated in order to address

the gap?

Null Hypotheses

In order to draw inferences from the study, the following hypotheses was tested at

0.05 level of significance.

Ho1: There is no significant relationship between socio-demographic profile of

respondents and the knowledge, attitude, and practices of Meranaw mothers on exclusive

breastfeeding.

Ho2: There is no significant relationship between roles and responsibilities of rural

health workers in the promotion of exclusive breastfeeding and the knowledge, attitude,

and practices of Meranaw mothers on exclusive breastfeeding.

Significance of the Study

 10

This study was conducted in order to determine the knowledge, attitude, and

practices of exclusively breastfeeding mothers in the community and the role and

responsibilities of the program implementers at selected community at Lanao del Sur.

Meranaw mothers. This study is significant in improving the awareness

regarding the knowledge, practice ad attitude of mothers in the community regarding

breastfeeding.

Healthcare Workers in the Rural Health Units/ Community. This study can

benefit them to assess the promotion of breastfeeding status in their respective localities

which in turn improve the health of the mothers by improving the quality of health

services.

Policy Makers. By understanding the perceptions of the mothers in the

community, policy makers could be able to understand the reasons why some community

mothers do not engage in exclusive breastfeeding, and thereby prompt the Rural Health

Workers to have a more encouraging and impactful promotion of Exclusive

Breastfeeding toward the community mothers.

Researcher. This study is significant in a sense that it shall be a part of the

literature regarding exclusive breastfeeding in Lanao Del Sur which can help future

researchers who will conduct similar studies

Future researchers. The findings of this study will help the forthcoming

researchers who may wish to use this study as a reference to conduct the same study and

additional investigation. Moreover, this will also provide a primary source for

opportunities in making possible recommendations.

 11

Scope and Delimitation of the Study

The study has been delimited to the knowledge, attitude and practice (KAP) of

mothers in the selected municipalities of Lanao Del Sur such as Saguiaran and Marantao

regarding exclusive breastfeeding and the role and responsibilities of Rural Health Unit

nurses in promoting exclusive breastfeeding. KAP as assessed in the study has been

delimited to mothers who have been breastfeeding based on criterion that they have given

birth for not more than two-years either at home or RHU facility and at least visited RHU

for breastfeeding concerns.

The scope of the study was the respondents’ profile which included their age,

number of children, civil status, first time mother, level of education, employment status

and monthly income. The scope of KAP were based on assessment standard tool adopted

from a study which have 8-items for knowledge, 9-items for attitude, and 11-items for

practices of exclusive breastfeeding.

Moreover, the scope of the role and responsibilities of RHU nurses as direct

implementer of exclusive breastfeeding was based on 10-items statement for role and 10-

items statement for responsibilities which scaled in a 4-point format with indicators as

follows: 4-Always, 3-Often, 2-Sometimes, 1-Never.

In addition, it has been delimited to the sample population of mothers and RHU

nurses in Saguiaran and Marantao Lanao del Sur. Variables studied has been delimited to

evaluative-inferential design and correlational approach in finding significant relationship

between variables which served as a basis in the analysis of and concluding hypothesis of

the study.
 12

However, one limitation of this study is the availability of time and financial

resources. A limited amount of time preventing the researcher from extending into a

much wider area of study and with a much deeper scope. Financial constraints also felt

due to pandemic that affects economic status of most of the people in the community as

well as the constant visit to RHU and respondents for interview and other feedback.

Gathering of data has been optionally set through online such as google forms and e-mail

for some respondents who were not able to participate in the actual face-to-face data

gathering.

Definition of terms

To understand explicitly this work with relative case, and to avoid misconceptions

and confusions, the following terms as alphabetically arranged were conceptually and

operationally defined.

Attitude. This term refers to a way of feeling or acting toward a person, thing or

situation (Merriam-Webster, 2020). As operationally used in this study, it is about how

and what mother feels or perception towards exclusive breastfeeding as assessed in this

study based on standard assessment tool.

Breastfeeding Mother. It is defined as a mother who gave birth and feeds the

infant (birth to 6 months old) though breastfeed or in her own milk (Weddig, Baker,

Auld, & Nursing, 2011). In this study, they are the mothers who have been promoting or

doing breastfeeding as identified by the RHU healthcare professionals.

Exclusive breastfeeding. It refers to when infants are not given any other food

or liquid including water during the first six months after delivery (Shommo & Al-
 13

Shubrumi, 2014). In this study, it refers to the mothers in Saguiran and Marantao Lanao

del Sur whom identified by the health professionals in the RHU that has been doing

exclusive breastfeeding to their infant (birth to 6 months old).

Knowledge. It refers to the person’s awareness or familiarity gained by

experience of a fact or situation (Merriam-Webster, 2020). As applied in this study, it

refers to the extent of responses of the mothers about their awareness or familiarity of

exclusive breastfeeding based on a standard assessment tool applied in this study.

Practices. It was simply defined as “to carry out or perform (a particular activity,

method, or custom) habitually or regularly” (Merriam-Webster, 2020). As used in this

study, it refers to the actual execution or actual performance of exclusive breastfeeding

by mothers which assessed based on a standard assessment tool.

Responsibilities. Responsibility refers to the state or fact of having a duty to deal

with something or of having control over someone. It is a thing that one is required to do

as part of a job, role, or legal obligation (Merriam-Webster, 2020). Based on literature,

nurse prime responsibility  is to advocate and care for individuals of all ethnic origins and

religious backgrounds and support them through health and illness (Weddig, Baker, &

Auld, 2011).

In this study, responsibility refers to the RHU nurse commitment in the

fulfillment on their expected professional duty to take care of mothers in the context of

their knowledge, skills and attitude towards exclusive breastfeeding.

 14

Roles. As defined, it is the position or purpose that someone or something has in a

situation, organization, society or group (Merriam-Webster, 2020). In a literature source,

a role (also rôle or social role) is a set of connected behaviors, rights, obligations, beliefs,

and norms as conceptualized by people in a social situation. It is an expected or free or

continuously changing behavior and may have a given individual social status or social

position (Spatz, 2010).

In this research, role refers to RHU nurses expected professional behavior and

obligation towards commitment in the promotion of and implementation of exclusive

breastfeeding among mothers in their respective community as their area of assignment.

It is also based on their responses on a set of statement using a standard assessment tool.

Rural Health Unit/s. It served as the main source of free basic healthcare for

rural communities (Merriam-Webster, 2020). In this study, it refers to the RHU units

located in the municipality of Saguiaran and Marantao where the study about knowledge,

attitude and practices abut exclusive breastfeeding of mothers has conducted.

 15

Chapter II

REVIEW OF RELATED LITERATURE AND STUDIES

This chapter contains the discussion on the related literature and studies which are

significant and germane to the analysis and interpretation of the data of this study. The

reviewed literature has been reappraised thoroughly to serve as guides in the

conceptualization of the study and provide better understanding on knowledge, attitude,

and practices of exclusive breastfeeding among mothers and the roles and responsibilities

of healthcare professionals in the promotion and implementation of exclusive

breastfeeding. Thus, it is supported by reviewed studies that are also affiliated in

stipulating a better concept on the possible relationship of the identified variables.

Related Literature

Exclusive Breastfeeding in the Sustainable Development Goals (SDGs)

The SDGs according to the UN (2017), are a set of goals put together to propel

countries to work towards reducing and ultimately ending poverty, protect the planet as

well as make sure that all people enjoy peace and prosperity by the year 2030 (Morton,
 16

Pencheon, & Squires, 2017). The SDGs which is also called Global Goals has 17 broad

areas that are interconnected with area specific targets. Coming into effect in 2016, 193

countries including Philippines have adopted the SDGs and are working to achieve its

targets.

Sustainable Development Goal 3 seeks to ensure that lives are healthy as well as

promote the well-being for all and at all ages. Poor nutrition from birth up to six months

of an infant result in malnutrition which leads to diseases and death. In order to achieve

SDG 3, countries must start right by exclusively breastfeeding infants and doing so for

the first six months of the infant’s life.

The History of Exclusive Breastfeeding

Feeding practices of infants have evolved over the years to include wet nursing,

the use of feeding bottles as well as formula feeds (Tillett, 2020). As far back as 2000

BC, breastfeeding was seen to be the best and as such a religious necessity for every child

(Wambach & Spencer, 2019). People saw the childhood period to be a period where

children were weak and at risk of falling sick and being malnourished thus, breast milk

was believed to contain all the infant needed to grow and develop both physically and

psychologically. Mothers who were unable to breastfeed due to the inability to produce

milk or resulting from death resorted to the use of wet nurses for provision of breast milk

for their babies. A wet nurse is said to be any woman who breastfeeds another woman’s

child. To be a wet nurse means that one should have given birth and lactated before. In

ancient Egypt, Greece and the Roman Empire era, both women whose social status was
 17

high as well as ordinary women and their families resorted to the use of wet nurses when

they faced challenges with breastfeeding (Tillett, 2020).

It was during the 16th century that wet nursing became a matter of concern. Many

people started advocating for mothers to breastfeed their own children unless they are ill

or unable to breastfeed. This was because they realized that infants bonded with whoever

breastfed, cared for and nurtured them (Tillett, 2020; Wambach & Spencer, 2019). The

industrial revolution’s emergence from late 18th century to 19th century saw the

relocation of many families from rural to urban areas. Women in these low-income

families had to work for longer hours to contribute financially to the upkeep of their

homes which made them unable to breastfeed. They resorted to the use of wet nurses and

that in turn increased infant mortality (Glasper, 2019; Reeves & Woods-Giscombé, 2015)

Artificial feeding dates far back to ancient times where all sorts of bottles were

used to feed infants. The difficulty in cleaning these feeding bottles as well as poor

storage of milk and sterilization led to bacterial infections resulting in one third of all

infants who were fed artificially in the first twelve months of their life dying (Weinberg,

1993). Justus Von Liebig, who was a German chemist invented the very first breast milk

substitute in the 19th century followed by a fellow German scientist named Henri Nestle

who also innovated a breast milk substitute called ‘faminelike’ when he arrived in

Switzerland. Faminelike was a cereal flour with milk. It was after the modification in the

19th century of the feeding bottle that artificial feeding begun to replace wet nursing

(Ndekugri, 2017)
 18

In recent times, animal milk which was fed to infants dating as far back as 2000

BC as well as synthetic formulas are used to feed infants. This practice was widely spread

because of many campaigns and advertisements. This affected exclusive breastfeeding

practices even though there were visible differences observed between breastfed infants

and those who were fed with artificial formula (Glasper, 2019). Although breast milk

substitutes have undergone series of refinement over the years to make it better and a

replacement for infants when breast milk is not available, the risks of morbidity and

mortality are huge in artificially fed infants compared to their counterparts who are

breastfed (Ndekugri, 2017).

Exclusive Breastfeeding

Global exclusive breastfeeding rates of 140 countries was looked at by Cai,

Wardlaw, & Brown (2012) over a 15-year period to understand the trend of performance.

Analysis of the rates among infants aged five months and below showed a general

increase from 33% to 39% in 1995 and 2010 respectively in developing countries (Cai,

Wardlaw, & Brown, 2012). From 12% in 1995 to 28% in 2010, Central and West Africa

recorded more than a hundred percent increase while Eastern and Southern Africa

recorded 35% to 47% in 1995 and 2010 respectively. South Asia however recorded 40%

in 1995 to 45% in 2010 (FAOUN, 2014).

According to UNICEF (2017), 40% of infants have been reported to be breastfed

exclusively from birth up to 6months. Of the 60% exclusive breastfeeding rate target set

for countries to achieve by the year 2030, only 23 out of 129 countries with available data

have achieved the target (UNICEF, 2017). Countries in the Americas are not performing
 19

well as the scorecard shows only 6% of these countries having exclusive breastfeeding

rates of 60%. Similarly, the situation is not any different in some parts of the African

region as countries show disparities in exclusive breastfeeding rates. According to

Tampah-Naah & Kumi-Kyereme (2013), low exclusive breastfeeding rates have been

recorded in countries such as Cote d’Ivoire (4%), Chad (2%), Gabon (6%), Sierra Leone

(8%), Benin (70%) and Rwanda (85%) (Tampah-Naah & Kumi-Kyereme, 2013).

The GDHS (2008) report estimated exclusive breastfeeding rate for Philippines to

be 63% which declined to 46% in 2011 and then increased to 52% in the year 2014

(Holla-Bhar, Iellamo, Gupta, Smith, & Dadhich, 2015). Though there was an increase

and records of steady increases have been noted across Africa as a result of interventions,

it still falls below the 90% exclusive breastfeeding rate recommended by WHO to

improve the health and wellbeing of infants. This calls for a look into other factors that

may be causing declines and small increases in order to reposition and find workable

strategies to improve exclusive breastfeeding practices (Mogre, Dery, & Gaa, 2016;

Tampah-Naah & Kumi-Kyereme, 2013).

Benefits of Exclusive Breastfeeding to Infant

The benefits of exclusively breastfeeding infants are enormous. The longer an

infant is exclusively breastfed, the more benefits derived. Breast milk contains all

nutrients required by an infant to grow and develop (WHO, 2016). Exclusive

breastfeeding works to prevent morbidity and reduce mortality among infants thereby

making them survive (Brülde, 2011).

 20

Studies have shown that putting infants on the breast early, within the first sixty

minutes of birth and breastfeeding exclusively helps in the process of bonding and brain

development. The suckling reflex stimulates the production of colostrum and

subsequently, breast milk. The first yellowish milk called colostrum produced by the

breast in the early few days after childbirth contains high amounts of fats, carbohydrates,

proteins and antibodies that the mother passes on to her infant. This serves as the first

immunization and protects baby from childhood diseases including pneumonia and

diarrhea. As a result, the chances that an infant will fall sick and/or die from these

diseases within the first few days of life are drastically reduced. It has been estimated that

infants not totally breastfed or not breastfed at all are five times more prone to die from

infections and diarrhea than those who receive only breast milk (Beyene, Geda,

Habtewold, & Assen, 2016; Piwoz & Huffman, 2015).

Recent studies conducted by Beyene, Geda, Habtewold, & Assen (2017) in

Philippines, Ethiopia, Madagascar and Bolivia revealed that breastfeeding alone could

prevent deaths of neonates by about 20% to 22%. When exclusive breastfeeding and

breastfeeding practices as a whole are improved, lives of many under five year-olds could

be saved (Beyene et al., 2016). As many as 823,000 infant lives could be saved as well as

a reduction in the occurrence of other infant diseases. It is estimated that about one-third

of respiratory infections and up to half of diarrhoea diseases are prevented when mothers

breastfeed in developing countries (WHO, 2016)

Exclusively breastfed infants according to American Academy of Pediatrics

(2012) during the first six months after birth are protected from all sort of diseases that

plague children like diarrhea, allergies, diabetes, obesity, gastrointestinal tract infection,
 21

leukemia in children, lymphoma bowel as well as inflammatory diseases (Eidelman,

2012). The American Academy of Pediatrics (2012) also reported that about 72% of

hospitalization due to infections of the lower respiratory tract in the first 12 months after

birth is reduced in children who are exclusively breastfed. For preterm infants, the short

as well as long term benefits of exclusively feeding with human milk cannot be

overemphasized as it helps in strengthening the preterm less developed immune system

thereby reducing the rates of necrotizing enterocolitis and sepsis. It also reduces their

reoccurrence thereby reducing long term growth failure, neurodevelopmental disabilities

and mortality. It was also realized that, the rate of readmission to the hospital due to

diseases was lower during the first 12 months after they were discharged from NICU

(Eidelman, 2012; Glasper, 2019).

The intelligent quotient of an infant is increased with longer practice of exclusive

breastfeeding. This improved cognitive and motor development translates into the ability

to start and stay in school resulting in better jobs with higher incomes for them later in

adult life. Again, exclusively breastfed infants have lower risk of becoming overweight

and obese as they grow into childhood and adolescence (UNICEF, 2017; Victora et al.,

2016).

Benefits of Exclusive Breastfeeding to Mother

The general well-being and mother’s health are associated with breastfeeding

exclusively in the few moments after birth and the future. The American Academy of

Pediatrics (2012) reported an association between exclusively breastfeeding and a

 22

reduction in blood loss during postpartum as well as the quick return of the uterus to its

initial and normal state (AAP, 2012).

According to Kramer & Kakuma (2009) and Tillett (2020), mothers who engaged

in breastfeeding exclusively share a bond with their infants and this reduces the chances

and episodes of postpartum depression. Prospective studies in the United States show that

mothers who do not breastfeed or who stop breastfeeding too early suffer increased

depression during postpartum (Kramer & Kakuma, 2012; Tillett, 2020). Reports of child

neglect and abuse by mothers were also found to be high in mothers who failed to

breastfeed as compared to those who did breastfeed (AAP, 2012). It has been shown that

mothers recover faster when they exclusively breastfeed and weight that was gained

during pregnancy is lost. They can also plan and space pregnancies using a natural birth

control, Lactation Amenorrhea Method (LAM) when they breastfeed exclusively for six

months from birth as well as protect them from anemia resulting from iron conservation.

Those who breastfeed longer have advantages such as a reduction in the risk of ovarian as

well as breast cancers. As stated in the KAP manual and reports, about 20 000 deaths due

to cancer of the breast can be averted annually if mothers breastfeed for longer periods

(FAOUN, 2014).

Healthier mothers and infants mean less time and money will be used to treat

diseases thus resulting in economic gains to families, communities and the nation

((Danso, 2014; UNICEF, 2017; WHO, 2016). Bartick and Reinhold (2010) examined

diseases in United States of America alongside the AHRQ (2017) report on breastfeeding

and its effects on diseases and realized that if majority of women (90%) in the United
 23

States breastfeed exclusively from birth till six months, a savings of up to $13 billion

would be accrued each year (AHRQH, 2017; Bartick & Reinhold, 2010).

Exclusive Breastfeeding Practices

Breastfeeding practices lead to improved health, development and nutrition of

infants, the reason why WHO/UNICEF advocate for breastfeeding infants exclusively for

longer periods, that is for their first six months after delivery. The longer the period, the

greater benefits derived. Few women according to Meedya, Fahy, & Kable (2010)

breastfed exclusively up to six months in Western countries which is undesirable for the

development as well as growth of the infant. Introducing other liquids, feeds, substitutes

of breast milk and using bottles compromise exclusive breastfeeding practices. These

practices occur globally, in Africa as well as Philippines which negatively influence

exclusive breastfeeding thereby affecting infants, mothers, and the larger population

(Meedya, Fahy, & Kable, 2010).

Studies carried out by Arts et al., (2011) among mothers of infants younger than

six months in Mozambique reveled that generally, there was acceptance of the

importance and benefits of exclusive breastfeeding however, mothers gave other foods

such as traditional medicines, water and porridges to their infants before they turned six

months. Reasons for introducing these feeds ranged from the fact that infants need water

to grow well, traditional medicines to cure or prevent certain childhood diseases

sometimes caused by spirits and porridges at about months four to six so that the child

can learn how to eat as well as help in child growth as breast milk alone is not sufficient

(Arts et al., 2011).

 24

Findings of Aborigo et al., (2012) in rural Southern Philippines also showed that

though mothers know how important it is to exclusively breastfeed, their traditional

practices regarding the general feeding of the infant resulted in the introduction of water

and other feeds which are consistent with the above findings (Aborigo et al., 2012).

Another study in South Africa by Goosen (2013) showed that mothers introduced water,

formula feed and other foods to infants below the age of six months thereby hampering

breastfeeding exclusively (Goosen, 2013). Again, reports from studies conducted in a

Military barracks in Nigeria showed that the recommended practice of breastfeeding

exclusively from birth till six months was not being followed. Breastfeeding mothers

introduced other feeds as well as used bottles to feed infants below six months

(Akinyinka, Olatona, & Oluwole, 2016).

Exclusive Breastfeeding Advantages

Exclusive breastfeeding (EBF), which is defined as giving an infant only breast

milk from birth up to 6 months of age, without giving other liquids or solids, not even

water, with the exception of oral rehydration solution, or drops/syrups of vitamins,

minerals or medicines has been shown to be one of the evidence-based interventions for

child survival. Estimates show that, good breastfeeding practices especially EBF could

prevent about 11.6 % of the 6.9 million under five deaths in developing countries.

EBF promotes optimal neonate and infant growth as it contributes to 100 % of

daily nutrition requirement of children up to 6 months of age, 50 % of children of 6–12

months and 35 % of nutritional requirement for children aged 12–24 months. EBF has
 25

also been shown to reduce neonatal and child deaths associated with diarrhea and acute

respiratory tract infections, two of the leading causes of child death. EBF contributes in

reducing the risk of mother to child transmission of HIV. This is a vital advantage in

Africa where the prevalence of HIV infection is high and replacement feeding that is

acceptable, feasible, affordable, sustainable and safe (AFASS) is unavailable for many

HIV positive women (Maonga, Mahande, Damian, & Msuya, 2016).

Breast milk consists of basic nutrients containing proteins, vitamins and

carbohydrate. However, presence of minerals fulfills micronutrient needs and maternal

antibodies improves the immune system inhibiting infantile infections like

gastrointestinal, respiratory and skin infections and increases physical and neurological

growth of the baby. There is increased production of hormones that are responsible for

uterine contraction, preventing hemorrhage and maternal mortality. Lactational

amenorrhea is mentioned as a natural contraceptive benefactor following exclusivity. As

well, breast cancer and ovarian cancer risk prospects are reduced among mothers who

give exclusive breast milk correlates with weight loss that preventing early cardiac

morbidity and mortality (Fairbrother & Stanger-Ross, 2010).

Breastfeeding is an essential measure for the prevention of malnutrition and

protection against infection in infancy. Breastfeeding is one of the oldest practices

recommended by all religions and it is the universally endorsed solution in the prevention

of early malnutrition. It is estimated that the lives of one million infants can be saved in

the developing world by promoting breastfeeding (Moreland & Coombs, 2000)

 26

Each year more than 10 million children under the age of five. ears die, mainly

from one of a short list of causes which can be prevented easily through exclusive

breastfeeding, and the majority live in low-income countries. Millennium development

goal number 4 is to reduce child mortality by two thirds by 2015. Under-nutrition is

estimated to be the under lying cause of 53% of under-five mortality. Appropriate feeding

practices are of the fundamental importance for the survival, growth, development and

health of infants and young children. Fault feeding practices including lack of

breastfeeding and early introduction of solid foods have been reported as health risks.

WHO and UNICEF recommends early initiation of breastfeeding (within an hour

from birth), exclusive breastfeeding for the first 6 months, followed by continued

breastfeeding for 2 years or beyond, together with adequate and safe complementary

foods (El-Houfey, Saad, Abbas, Mahmoud, & Wadani, 2017).

Physiologic and Psychosocial Benefits of Breastfeeding

The myriad of benefits of breastfeeding are documented extensively in the

literature, and new benefits continue to be identified. Emerging research also indicates

stronger associations between longer duration of exclusive breastfeeding and

enhanced maternal and infant benefits (AAP, 2012; Asare, Preko, Baafi, & Dwumfour-

Asare, 2018) (American Academy of Pediatrics, 2017; Ip et al, 2009). The Association

of Women's Health, Obstetric and Neonatal Nurses (AWHONN) as cited by El-Hooey et

 27

al (2017) reported the following benefits of breastfeeding for infants, breastfeeding has

short-term and long-term health benefits.

In the short-term, breastfeeding reduces the risk of gastroenteritis, necrotizing

enterocolitis, ear infections, pain following minor procedures, hospital readmissions,

respiratory infections, Sudden Infant Death Syndrome, and urinary tract infections. In

the long-term, breastfeeding reduces the risk of asthma, atopic dermatitis, cardiovascular

disease, celiac disease, diabetes, childhood inflammatory bowel disease, obesity, and

sleep disordered breathing. Further, breastfeeding is associated with increased cognition

and neuro development

Breastfeeding is also beneficial to the mother’s health. Postpartum benefits

include decreased blood loss, lower risk of postpartum infection and anemia, and greater

weight loss. Breastfeeding also has been associated with reduced risk of maternal disease

later in life including breast cancer, diabetes (type II), hypertension, cardiovascular

disease, metabolic syndrome, ovarian cancer, osteoporosis, and rheumatoid arthritis.

Additionally, mothers who feel empowered to breastfeed successfully are more likely to

breastfeed exclusively and continue breastfeeding. Self-efficacy, which has been defined

as the woman's perceived ability to successfully master a task such as breastfeeding, is

associated with an increased duration of breastfeeding at six months (El-Houfey et

al., 2017).

Researchers have also shown that women who participated support workshops

focused on breastfeeding self-efficacy were more likely to exclusively breastfeed at eight

weeks postpartum than women who did not attend such workshops Breastfeeding
 28

enhances the relationship between a mother and her infant by improving bonding. For

example, skin-to-skin contact during breastfeeding has been shown to improve the

infants’ vital signs, especially immediately after birth. Indeed, it is theorized that many of

the identified health benefits of breastfeeding may be related to not only the composition

of human milk, but also to the close contact between the mother and her infant during

feeding. Breastfed infants also have more control over how much food they eat and

when they eat which may be part of the association between reduced rates of obesity

among breastfed infants (Asare et al., 2018; El-Houfey et al., 2017; Kingston, Dennis, &

Sword, 2007).

Factors Influencing Exclusive Breastfeeding

Marital status, education, age and income level have been shown in studies to

affect whether a mother with an infant will breastfeed or not and for how long. A

literature review conducted by Meedya et al., (2010) on studies carried out around the

world found that being married, being well educated, older age and receiving income that

is higher were associated with breastfeeding for longer periods (Meedya et al., 2010).

Similar results by Asare et al., (2018) were consistent with studies by Meedya et al.,

(2010). Breastfeeding exclusively among mothers was reported to be influenced by

educational status, age as well as ethnicity and recommended that the socio-demographic

factors should be looked at when strategizing to address issues of exclusive breastfeeding

(Asare et al., 2018; Meedya et al., 2010).

According to Diji et al., (2017), socio-demographic characteristics like age of the

infant, marital status, level of education, age of mother as well as occupation type
 29

determine breastfeeding exclusively. Mogre et al., (2016) found that maternal educational

level was associated with the practice of exclusive breastfeeding and Onah et al., (2014)

also found that mothers with low educational levels were less likely to exclusively

breastfeed compared to mothers with higher education (Diji et al., 2016; Mogre et al.,

2016; Onah et al., 2014).

According to Danso (2014) in a study conducted to know barriers to breastfeeding

exclusively among professional mothers who were working in Kumasi, majority (90.5%)

of the respondents said that their working status made them unable to exclusively

breastfeed. The study revealed that professional mothers who work had to go back to

work after their maternity leave of three months thereby compelling them to leave their

infants with family members. These mothers then went home to breastfeed during break

time or had relatives bring infants to them at their places of work for breastfeeding. For

some mothers, their work was so demanding resulting in their inability to have breaks for

breastfeeding while other mothers reported that their working environment was not

conducive as it did not have a proper place for breastfeeding (Danso, 2014).

Adewuyi & Adefemi (2016) found positive association between high educational

level and exclusively breastfeeding in their systematic review conducted in Nigeria. The

review however revealed that mothers with high socio-economic status tended not to

practice exclusive breastfeeding. It was revealed that the older the infant, the less likely

mothers will exclusively breastfeed. It also reported that every mother who came to

deliver were successfully breastfeeding when they were leaving a hospital in South-East

Nigeria. The rate however changed and stood at 81.4% during post-natal at six weeks and
 30

74.7% during post-natal at 14 weeks which then took a nosedive to 3.9% at about six

months (Adewuyi & Adefemi, 2016).

Diji et al., (2017) found significant associations between age of mother,

education, status of employment including age of infant and exclusive breastfeeding in

their study conducted at the CWC in Kumasi South hospital. Findings showed that the

age of infant as well as a mother being self-employed determined exclusive

breastfeeding. Further analysis of study data showed a unit increase in infant’s age in

months resulted in an 18% reduction whether the mother will exclusively breastfeed

whereas self-employed mothers were reported to be 2.60 times more prone to breastfeed

exclusively compared to those without employment. Mothers who are in the public sector

recorded increased exclusive breastfeeding at the early ages of infants, this however was

reduced as they had to return to work resulting in the addition of other feeds or weaning

infants before their due age. Older mothers who were well educated however tended to

practice exclusive breastfeeding (Diji et al., 2016).

Cultural practices and beliefs of various ethnic groups influence exclusive

breastfeeding in Philippines (Asare et al., 2018). Studies carried out in Philippines

showed that compared to mothers in other regions, mothers who were residing in the

Volta Region were more likely to breastfeed exclusively. This disparity was associated

with cultural beliefs pertaining in those regions that affected exclusive breastfeeding

negatively (Asare et al., 2018). As part of their belief, infants were given con-coctions

and water because relatives and mothers of these infants thought that infants were thirsty

and therefore, they needed it to quench their thirst or welcome them into the world. The

study concluded that the less beliefs that negatively affect exclusive breastfeeding
 31

practices, the greater the chance a mother will practice it (Tampah-Naah & Kumi-

Kyereme, 2013).

Influence of family members on mothers to follow their old way which is usually

their traditional way of breastfeeding involving giving water and other food supplements

was recorded to be the second reason why mothers failed at exclusively breastfeeding in a

study in Kumasi (Danso, 2014). According to Arts et al., (2011), the decision to give

water and other foods involves key people within the family such as the grandmother of

the infant who is well versed in the culture and traditions (Arts et al., 2011).

In the findings of Diji et al., (2017), the major determinant of breastfeeding

exclusively is the belief of mothers that only breast milk is not sufficient for infants to

grow and properly develop. They were torn between what their culture says about

exclusive breastfeeding as against what health staff tell them in a study conducted by

Okafor, Agwu, Okoye, Uche, & Oyeoku (2018) in Nigeria. Their cultural belief

promoted breastfeeding but at the same time permitted and encouraged giving infants

water as they believe infants need more water of which the breast milk falls short of

(Okafor, Agwu, Okoye, Uche, & Oyeoku, 2018).

The source of information regarding breastfeeding practices, most especially

exclusive breastfeeding is vital if breastfeeding exclusively is to be done by mothers of

infants. Previous studies show that mothers who relied on health facilities and qualified

health staff for information on breastfeeding were more likely to exclusively breastfeed

their infants compared to those who relied on other sources (Asare et al., 2018; Danso,

2014).
 32

According to Meedya et al., (2010), whether a woman exclusively breastfeeds or

not is shaped by her personal attitude towards it as well as of those around her. In a

longitudinal study of mothers in the United States, they found a link between a mother’s

attitude in terms of making up her mind to exclusively breastfeed and actually

breastfeeding at home. It was found that those who made up their minds to breastfeed

during antenatal periods were able to breastfeed longer compared to those who did not

make up their minds as a result of negative attitudes. At the least problem relating to

breastfeeding, such mothers are quick to stop exclusively breastfeeding their infants

(Meedya et al., 2010).

Studies conducted in Nigeria also show that mothers with low or no education are

marginalized in terms of what they know hence have negative attitudes towards exclusive

breastfeeding. The research also found that ethnicity and culture had a paramount part to

play in a mother’s decision to breastfeed exclusively. The small proportion of mothers in

Hausa ethnic groups who practiced exclusive breastfeeding was attributed to beliefs that

mothers are not supposed to expose their breasts in public. Infants were therefore not

breastfed in public affecting exclusive breastfeeding negatively. Researchers in this study

noted that African societies are culturally inclined, therefore, infant feeding is influenced

by these cultures (Jacdonmi, Suhainizam, Suriani, Zoakah, & Jacdonmi, 2016).

Mother’s emotional stress level was also seen by Diji et al., (2017) to be impeding

breastfeeding exclusively. The absence of support from significant people around mother

such as members in her family, the society as well as health professionals combined with

shyness and breastfeeding difficulties go a long way to influence her attitude in a

negative way concerning breastfeeding (Diji et al., 2016).

 33

Generally, attitude of mothers was positive towards breastfeeding exclusively in a

study among lactating mothers residing in Tuna, Philippines (Mogre et al., 2016).

However, many mothers did not feel confident when it came to expressing, storing and

cup or spoon-feeding infants with the expressed breast milk. For mothers who had to be

away and separated from their infants, exclusive breastfeeding was compromised as other

feeds were fed to their infants during these periods (Mogre et al., 2016).

Exclusive breastfeeding interventions

As part of efforts to improve exclusive breastfeeding practices as well as increase

its resultant gains, implementation of several interventions has taken place globally, in

Africa and Philippines. Notably among these is the Baby Friendly Hospital Initiative

(BFHI). In 1992, Nigeria introduced BFHI to educate as well as encourage mothers to

exclusively breastfeed. Results from studies show that those who delivered in baby-

friendly hospitals are more prone to start to breastfeed their infants including continuing

for an extended time period compared to mothers who had no knowledge of BFHI and

did not deliver in a baby-friendly hospital (Jacdonmi et al., 2016; Onah et al., 2014). In

1991, Philippines started implementing BFHI. The BFHI Authority was set to train and

see to it that trainings were carried out in hospitals for health workers to enable them

educate and support mothers in the area of exclusive breastfeeding when they come to

deliver. There have however been challenges surrounding its implementation because of

negative influences from families and communities relating to exclusive breastfeeding

(Moreland & Coombs, 2000).

 34

The Philippines Breast-feeding Promotion Regulation 2000 also called Legislative

Instrument [LI] 1667 was introduced to promote breast feeding in the country by

prohibiting the aggressive marketing of breast milk substitutes. Unfortunately, Food and

Drugs Board of Philippines reports that this intervention has not yielded much (Tampah-

Naah & Kumi-Kyereme, 2013).

Community-based infant and young child feeding (C-IYCF) introduced by

UNICEF (2015) in Philippines focuses on appropriate feeding practices including

exclusive breastfeeding for infants below 6 months for adequate nutrition for improved

growth and development. Other interventions include those implemented by Kintampo

Health Research Centre (KHRC) aimed at improving health of mothers, neonates and

infants in Kintampo and within the middle belt of Philippines. Notably are the Ensure

Mother and Baby Regular Access to Care (EMBRACE) implementation research where

it looked at continuum of care as well as how it strengthens outcomes of maternal,

neonatal and child health (Kikuchi et al., 2015) as well as the New hints trial where home

visits were conducted to improve child survival (Kirkwood et al., 2013).

Consequences of not exclusively breastfeeding

Breastfeeding has great implications for the future prosperity of a country.

Countries however are not protecting, promoting, and supporting breastfeeding

adequately through funding and/or policies. Malnutrition has been found to increase the

chances of a child having to die from numerous diseases such as diarrhea, pneumonia and

measles. About 70% of neonatal deaths can be prevented when they are exclusively
 35

breastfeed (Onah et al., 2014). The global burden of diseases, injuries and risk factors

reported that the second largest factor in the world regarding children below five years is

sub-optimal feeding and this accounts for a financial loss of 47.5 million. African

countries that are in the south of the Sahara however are the most terribly affected

recording the highest rates of burden of disease associated to breastfeeding sub-optimally

(Mogre et al., 2016). Sudden infant death syndrome is also associated with non-breastfed

infants (Danso, 2014). The benefits of breastfeeding exclusively derived by mother and

infant as well as the consequences of not practicing it translate to families, communities

and the nation at large. Less time and money will be used to treat diseases thus resulting

in economic gains if exclusive breastfeeding is practiced and for longer periods

otherwise, huge sums of monies and time will be spent on medicines and in the hospitals

to treat diseases that could have been prevented (Danso, 2014; UNICEF, 2017; WHO,

2016). According to UNICEF (2017), when there is commitment from countries in

support of policies and programs relating to exclusive breastfeeding, the rates go up.

Characteristics of exclusive breastfeeding mothers around the world

According to the report of Leung and Suave (2005), maternal age was

significantly associated with initial BF and showed clear dose-response gradients with

older ages. Another study conducted in rural China reported that mothers with education

level above senior middle school were less likely to exclusively breastfeed their infants

(Leung & Sauve, 2005). According to UNICEF (2010), Philippines all found that higher
 36

family income was associated with a reduced probability of initiation and duration of

breastfeeding. In a study on infant feeding practice among nursing personnel in Australia,

many women identified employment as a barrier to exclusive breastfeeding practice, and

returning to work was one of the reasons why women ceased breastfeeding, with 60

percent of women intending to breastfeed when they return to work, but only 40 percent

did so (Weber, Janson, Nolan, Wen, & Rissel, 2011).

Low practice of EBF in Ethiopia is attributed to various maternal and child

factors, such as having an infant aged 2-3 months, giving birth in a health facility, being a

housewife in occupation, receiving counseling/advice on infant and colostrum's feeding,

which were contributing factors to practice EBF. Age of the mother and access to

postnatal care were also encouraging to practice EBF; mothers who received

breastfeeding counseling during pregnancy and being supported by the husband were also

motivational factors to practice EBF. Better maternal education, marital status, good

wealth index, and lower age of the child were more likely to practice exclusive

breastfeeding than their counterparts (Weber et al., 2011).

Nevertheless, some working mothers were identified who successfully breastfed

exclusively. A study in rural Vietnam found that exclusively breastfeeding women who

were working mothers had several important characteristics: They all felt they had

enough milk, all knew the appropriate time to introduce liquids and foods, and most of

them were sup-ported in their breastfeeding decisions by commune health workers and

family members.
 37

Hector et al. (2005) summarized that the influencing factors in exclusive

breastfeeding practice fall into internal and external aspects. The first aspect includes

maternal knowledge, motivation, self-efficacy, and confidence, and the latter include

hospital/health services, home, community, and workplace environments that surround

the breastfeeding moth study found that parity is one of the contributing factors to

exclusive breastfeeding. This means that a first-time mother is less likely to practice

exclusive breast-feeding compared with her multiparous counterpart, suggesting that

previous breastfeeding experience has an important role in shaping the current feeding

practice. Other sociodemographic characteristics such as the child’s age and household

composition, which had been suspected to con-tribute to influencing the practice of

exclusive breastfeeding, varied among these mothers, suggesting that these characteristics

may not be substantial for motivating current breastfeeding practice (Hector, King,

Webb, & Heywood, 2005).

Nevertheless, the education level of the mothers and the fathers tended to be

consistent among all subjects as either high school or college graduates. This information

suggests that these parents had acquired a relatively high level of formal education that

may be sufficient to be of importance in the infant feeding mode. Aside from the above

internal aspects supportive of the current feeding practice, some of these exclusively

breast-feeding mothers were also exposed to environments un-supportive to the practice.

Prelacteal feeds, formula samples received from the place of delivery, insults from

neighbors, and the lack of a lactation room at the workplace were some instances of

negative environments (Hector et al., 2005).

 38

Self-efficacy and confidence of the breastfeeding mothers characterize the

practice of exclusive breastfeeding. Good knowledge about exclusive breastfeeding

practice that was acquired way before the mothers got pregnant suggests a predisposing

factor to the current state of confidence. Home support from the father enhances the

decision to sustain breastfeeding. In addition, a certain level of knowledge on the

solutions to potential problems faced during breastfeeding practice is important to equip

mothers with options to breastfeeding success (Februhartanty, Wibowo, Fahmida, &

Roshita, 2012).

Breastfeeding programs in Philippines

The Philippines approved its first National Policy on Infant and Young Child

Feeding in 2005 (Ogbo, Page, Idoko, Claudio, & Agho, 2016). The Department of Health

is the lead agency for programme and policy development. It helped create management

structures at the national, subnational and local government levels. Programme

coordinators are in place at each level, and funding is allocated yearly from the

Government budget to support specific Infant and young child feeding /IYCF

(breastfeeding) activities. The National Nutrition Council, the Council for the Welfare of

Children, and the Department of Social Welfare and Development are the three main

government agencies collaborating on implementation of the policy (World-Health-

Organization, 2007)

The IYCF National Plan of Action (2005–2010) was developed to support the

implementation of the IYCF National Policy (Gribble, Peterson, & Brown, 2019). In

2011, it was reviewed, revised and relaunched as the IYCF National Plan of Action
 39

(2011–2016). Legislation supporting the protection, promotion and support of

breastfeeding include: (1) the Philippine Code of Marketing of Breast-milk Substitutes,

(Executive Order 51, 1986); (2) the Rooming-In and Breast-feeding Act (Republic Act

7600, 1992), which implements the 1991 BFHI global standards; and (3) the Expanded

Breastfeeding Promotion Act (Republic Act 10028, s. 2010), which establishes standards

for workplaces, health facilities (with the establishment of milk banks) and public places.

As of July 2013, 27 out of 80 (34%) provincial governments, 73 out of 131 (56%) city

governments, and 515 out of 1518 (33%) municipal governments have translated the

national policy into local legislation (Camiling-Alfonso, Capili, Reyes, Tatad, &

Silvestre, 2015; Gribble et al., 2019).

According to the Department of Health, the Government allocated US$ 20 000 in

2011 to support IYCF (breastfeeding) activities and US$ 11 000 to support

communication activities. The same source stated that external donors (United Nations,

Millennium Development Goal Achievement Fund) allocated US$ 90 500 in the same

year. In 2012, the Government budget increased to US$ 36 500, with an additional US$

44 000 specifically allocated to support communication for behavioral impact (COMBI)

activities. The Department of Health states the proposed budget for IYCF activities for

2013 was expected to reach US$ 2.9 million (WHO, 2016).

The Role of the Nurse in Promoting Exclusive Breastfeeding

Common breastfeeding problems can often be resolved by providing parents and

careers with the right information and assistance. By asking appropriate questions,

healthcare professionals can identify if parents are experiencing breastfeeding difficulties

and can provide appropriate support. Nowadays the majority of births occur in hospitals
 40

where nurses are the primary health care providers supporting women from labor and

birth through discharge. Nurses play a vital role in preparing, educating, encouraging,

and supporting women to breastfeed while the mother came at primary health care for

ante natal care and follow-up; so the nurse is a cornerstone and instrumental in

facilitating, promote and support the initiation and continuation of breastfeeding

(Nies & McEwen, 2014).

Nurses and other health care professionals who care for mother-infant dyads

should acquire the knowledge and demonstrate the competence needed to provide

consistent and evidence-based breastfeeding information and support throughout the

preconception, prenatal, and postpartum periods. If the health care professional does not

possess the knowledge and skills needed to provide support, consultation with or referral

to a lactation specialist or other clinical expert should be offered for all mother-infant

dyads (Camiling-Alfonso et al., 2015; Nies & McEwen, 2014).

There are many competencies that promote the knowledge, skills, and attitudes

that health professionals should possess in order to help women prepare for, initiate, and

sustain breastfeeding. Also, developing academic education programs for all health care

professionals should include content on lactation. All women have the right to expect

culturally sensitive breastfeeding promotion and support. Health care providers especially

nurses should strive to understand and be prepared to address cultural issues in all aspects

of breastfeeding promotion and support for the population of women they serve.

Breastfeeding has different meanings and levels of acceptance in different cultures;

therefore, it is essential that providers explore the specific breastfeeding concerns of the

individuals with whom they are working. All women have the right to obtain
 41

information about the benefits of nurses breastfeeding, so that, they are able to

make informed decisions (UNICEF, 2017).

Community health nurse and other health care providers should support each

woman’s choice of infant nutrition by providing women with information about the risks

and benefits of various feeding options to facilitate informed decision making. There may

be certain rare instances when a woman wants to breastfeed, but is unable to or should

avoid doing so, including some women who have had breast surgery, women with HIV

infection, certain substance use disorders, untreated tuberculosis, or who are taking

medications contraindicated in breastfeeding. In these situations, women should be given

information by their nurses and encouraged to further consult with their health care

providers to help them make infant feeding decisions. There may be other instances

where women erroneously think that breastfeeding is contraindicated (e.g., smoking

cigarettes), and nurses should provide correct information regarding these

misconceptions. Nurses should encourage women to discuss their medications and

herbal and other nutritional supplements with a health care provider who has expertise

in breastfeeding and is knowledgeable about the interactions of prescription and over-

the-counter medications and supplements with breastfeeding (Nies & McEwen, 2014).

If the mother chooses to or is required to formula feed instead of breastfeed,

nurses should warn her about disadvantages and health problems associated with formula

feed; if she not persuaded the community health nurse must support her to understand

how to safely prepare, feed, and store formula and bottles. Education and resources

should also include information about the risks of contamination of formula, feeding

systems, and/or water supply. Women should be advised to monitor whether a

 42

particular feeding system and/or formula is recalled for safety or other reasons (Nies &

McEwen, 2014).

Related Studies

Alianmoghaddam N. (2018) conducted a study entitled Reasons for Stopping

Exclusive Breastfeeding Between Three and Six Months: A Qualitative Study. A generic

qualitative methodology was employed in this study and social constructionism selected

as the main epistemological framework underpinning the research. This study was carried

out between September 2013 and July 2014, involving face-to-face interviews with 30

women who were characterized as highly motivated to complete six months exclusive

breastfeeding prior to the birth of their child. In order to gain an in-depth understanding

of the research material, thematic analysis of the interview transcripts was completed

using manual coding techniques. After thematic analysis of the data four key themes were

identified: 1) The good employee/good mother dilemma. 2) Breastfeeding is lovely, but

six months exclusively is demanding. 3) Exclusive breastfeeding recommendations

should be individualized. 4) Introducing solids early as a cultural practice. This study has

shown that the maintenance of six months exclusive breastfeeding is also challenging for

this group of mothers who were socially advantaged, well-educated and highly motivated

to breastfeed their babies exclusively for six months (Alianmoghaddam, Phibbs, & Benn,

2018).

Shommo and Shubrumi (2014) conducted a cross-sectional study using a

questionnaire among mothers in Hail district. Breastfeeding KAP of participants who had

at least one child aged five years or younger at the time of the study were assessed using
 43

a questionnaire, with emphasis on their experience with the last child. A total of women

whose education was mainly university (39.7%) and secondary (24.1 %) were included in

the study. Most of them were from middle economic status. Most of the mothers 31.7 %

(n= 19) mentioned only two benefits. Seventy percent (70 %) of the mothers initiated

breastfeeding while 30 % did not, mean duration was 9.3 ± 8.97 month. The major reason

for ceasing breastfeeding before two years was mothers work 38.6 % followed by disease

(15.8 %). It showed that adverse work and maternal health related issues were the main

reasons for a low rate of breastfeeding among women in Hail district-Saudi Arabia.

Limited knowledge addressing the breastfeeding issues during pregnancy. Such findings

should be useful to health professionals and officials when attempting to overcome

breastfeeding barriers and to devise targeted breastfeeding interventions (Shommo & Al-

Shubrumi, 2014).

Chhetri et al., (2018) conducted a community-based cross-`sectional study among

breastfeeding mothers employed in any form of occupation having an infant less than six

months old (n = 137). Interviewer administered structured questionnaire was used to

collect data. Chi-square test was performed to find the association between different

variables and EBF. The prevalence of EBF among working mothers was found to be

17.5% although 75% of them had adequate knowledge on EBF and its benefits. Around

52% of the mothers did not receive any maternity leave benefits. Only 11% of mothers

were allowed breaks in between working hours but none of the mothers were provided

with crèches at their workplace. The commonest reason to discontinue EBF was early

resumption of work after childbirth. Factors such as educational status of working mother

and her husband, occupation of husband, place of delivery, sex of the newborn, frequency
 44

of breastfeeding per day, practice of expressing and storing breastmilk before leaving for

work and breaks during working hours were found to be statistically significant with EBF

practice. These findings emphasize the need to guarantee the support to breastfeeding

policies at workplace which in turn would motivate working mothers to continue EBF

after resuming work (Chhetri, Rao, & Guddattu, 2018).

Nukpezah et al. (2018) aimed at assessing the knowledge and practice of

exclusive breastfeeding among mothers in the Tamale metropolis of Philippines. It is a

descriptive cross-sectional study, 393 mother-infant pairs attending child welfare clinics

from three health facilities in the Tamale Metropolis were surveyed. A structured item

questionnaire was used to collect data on the socio-demographic Characteristics of the

participants, their knowledge regarding breastfeeding and level of practice of exclusive

breastfeeding (EBF). Although all the participants had some level of education

background, a majority did not have adequate knowledge on EBF and EBF practice was

low in the study community. Thus, the author suggest improved education at the child

welfare clinics and the media should be used as a platform to educate women adequately

about importance of EBF (Nukpezah, Nuvor, & Ninnoni, 2018).

According to a study on female medical doctors in Nigeria, only 11% of mothers

practiced exclusive breastfeeding for six months. In many countries including Ethiopia,

EBF practice is lower than the international recommendation. Many studies in Ethiopia

indicated the different prevalence of EBF in different areas of the country: EDHS 2005,

49%; EDHS 2011, 52%, with a mean duration of 4.2 months; Debre Tabor, Amhara

Region, Ethiopia, 70.8% ; Enderta, Tigray Region, Ethiopia, 70.2% ; and Motta (East

Gojjam), Amhara Region, Ethiopia, 50.1%. EBF in the last 24 hours preceding the survey
 45

in Goba town, Oromia Region, Ethiopia, was 71.3%. A study done in Gondar, Ethiopia,

among female nurses and midwives revealed that 35.9% practiced EBF for six months,

and the mean duration of EBF practice was 4.1 ± 1.7 months (Oche, Umar, & Ahmed,

2011).

A rapid survey in Jakarta Province, Indonesia found that although exclusive

breastfeeding is also unsatisfactorily practiced among non-working mothers, the practice

is worse among working mothers: Exclusive breastfeeding practice rates among working

and non-working women were 1.4% and 16%, respectively. Working outside the home

consequently influenced mother–infant separation, thus increasing the likelihood of

shorter duration of exclusive breastfeeding practice as found in Vietnam, Nairobi, and

Singapore (Jacdonmi et al., 2016).

 46

CHAPTER 3

RESEARCH METHODOLOGY

This chapter deals with the detailed discussion of the process that involved in

making this study. Topics included in this chapter are: research design, locale of the

study, research respondents, sampling procedures, research instrument, validity and

reliability of the instrument, data gathering procedure, ethical consideration, and

statistical tools and treatment in analyzing and interpreting data.

Research Design

This research used evaluative-inferential design in a correlational approach with

qualitative integration in the interpretation of data (Brink & Wood, 1998). The variables

of the study such as the respondents’ profile, their knowledge, attitude and practices

about exclusive breastfeeding, and the roles and responsibilities of healthcare workers as

direct implementers of breast-feeding program in the RHU has been explored, described,

and evaluated. Accordingly, descriptive research involves collecting data in order to

describe the nature of independent and dependent variables (Sousa, Driessnack, &

Mendes, 2007).

As an inferential through correlational approach, it explored on the relationship or

influence or causal (cause-effect) effect of independent variables towards dependent

variable (Sousa et al., 2007). It determines if an increase (or decrease) in independent

variables (or x variables) causes increase (or decrease) in dependent variable (or y

variable). Particularly, in this study, it aimed at finding significant relationship between

 47

respondents’ profile, their knowledge, attitude and practices towards roles and

responsibilities of healthcare workers as direct implementers of breast-feeding program in

the RHU. Moreover, qualitative design through interview approach has been integrated in

the study in order to support findings of the study with qualitative data.

Research Locale

This study has been conducted in the Rural Health Units of the municipalities of

Lanao del Sur in Saguiaran and Marantao. These two RHU’s were chosen by the

researcher because of the available and permitted access to the records of the list of

breastfeeding mothers. The said RHU’s were also known as some of the most active

RHU’s in Lanao del Sur identified by the Integrated Provincial Health Office (IPHO) of

Lanao del Sur province.

The Municipality of Saguiaran, is a 4th class municipality in the province of

Lanao del Sur, Philippines. According to the 2015 census, it has a population of 24,619

people. Saguiaran is politically subdivided into 30 barangays. Saguiaran is considered the

gateway to Lanao del Sur when one is coming from Northern Mindanao. One can reach

RHU of Saguiaran either via road transport from Iligan City via jeepney or public utility

vehicle going to Marawi City and vice versa. The RHU of Saguiaran is headed by

municipal health officer or (MHO) physician/ doctor with one RHU nurse as immediate

nurse supervisor of nine (9) NDP (Nurse Deployment Project) deployed by the IPHO.

Moreover, the Municipality of Marantao is a 2nd class municipality in the

province of Lanao del Sur, Philippines. According to the 2015 census, it has a population

of 32,974 people and is politically subdivided into 34 barangays. The location of the
 48

office of the municipality of Marantao is also where the RHU is situated. It is also headed

by MHO, a Nurse supervisor and seven NDP nurses deployed by the IPHO.

Figure 2. Overiew Map of RHU Saguiran and Marantao

 49

Figure 3. Map of RHU Saguiaran

 50

Figure 4. Map of RHU Marantao

 51

Respondents of the study

There were two types of respondents in this study, the breastfeeding mothers and

the nurses in the Rural Health Units (RHU’s). Breastfeeding mothers has been selected as

the respondents since the study’s aim was to assess the knowledge, attitude and practice

(KAP) of mothers about exclusive breastfeeding. The criteria in the selection were (1)

mothers that has given birth for not more than two-years, (2) has given birth at home or at

the RHU birthing facility under supervision of healthcare professionals in the RHU, (3)

had practiced breastfeeding during childbirth, and (4) included in the list of record of

clients that has consulted RHU for breastfeeding concerns.

Moreover, the inclusion criteria for nurses as healthcare professional were (1)

nurses who have been assigned in the RHU of Saguiran or Marantao for at least six

months, (2) regardless of employment status, and (3) willing to participate as respondents

of the study. All of the nurses available in the respected RHU has been considered as

actual participants or respondents of the study with only exclusion for those who were not

willing to participate.

Sampling Procedure

The recorded total population of breastfeeding mothers based on the record

available in the Rural Health Units (RHU’s) of the Municipality of Saguiaran and

Marantao is 107. It was then computed for sample population through Raosoft online

sample size calculator at www.raosoft.com/samplesize.html which proven to have rigor

and credibility (Raosoft, 2004). In the Raosoft online sample size calculator website,

under a 5% margin of error and 95% confidence level has yielded 84 sample size. It was
 52

then evenly distributed based on percentage representative from each RHU which then

randomization has applied in the selection of qualified mothers as sample respondents.

For the healthcare workers as respondents, total enumeration of all 18 nurses working or

assigned in the RHU of Saguiaran and Marantao has been considered. Figure below

shows the formula in the computation of mothers as sample respondents:

Formula: x = Z(c/100)2r(100-r)

n = Nx
/((N-1)E2 + x)

E = Sqrt [(N - n) x/n(N-1)]

Where,
N = population size
x = standard value
r = fraction of responses
Z(c/100) = is the critical value for the confidence level c
E = margin of error
n = sample size

Computation: x = 1.96(0.95/100)24(100-4)

n = 105 x
/ ((107-1)0.052 + x)

E = Sqrt [(107- n) x/n (107-1)]

Result:

n = 84

For the purpose of avoiding bias in the number of selecting representative a

stratified random sampling technique has applied. The distribution of participants is

shown in the table below:

 53

Table 1. Distribution of Participants in the Selected RHU

Population Sample
Rural Health Unit (RHU) in a Municipality %
(N) (n)
Breast Feeding Mothers at RHU Saguiaran 69 64.49 54
Breast Feeding Mothers at RHU Marantao 38 35.51 30

Total: 107 100.0 84

Research Instrument

This study questionnaire has been composed of four (4) parts: Part I –

Respondent’s Profile; Part II – Knowledge, Attitude and Practices of Mothers on

Exclusive Breastfeeding; Part III – Roles and Responsibilities of Health Care Providers

as Program Implementers of EBF; and Part IV – Interview Guide Questions. The Part I

and II of this study’s questionnaire particularly in the assessment of knowledge, attitude

and practices related to exclusive breastfeeding has been adopted from the Food and

Agriculture Organization of the United Nations (FAO) guidelines for assessing nutrition-

related knowledge, attitudes and practices (KAP) manual which has been also applied in

the study of Krishendu & Devaki (2017) entitled “Knowledge (8-items), attitude (9-

items) and practices (11-items) towards breastfeeding among lactating mothers in rural

areas of Thrissur District of Kerala, India: a cross-sectional study” published in

Biomedical and Pharmacology Journal (Krishnendu & Devaki, 2017).

Then Part III of the questionnaire which dealt with the Roles and Responsibilities

of Health Care Providers as Program Implementers of EBF is a 20-items questions in a 4-

point Liker-scale type format of responses is a researcher-made type questionnaire scaled

and interpreted as follows: 4-Always, 3-Often, 2-Seldom, and 1-Never. Similarly, the
 54

Part IV of the questionnaire is also a researcher-made which composed of seven (7) open-

ended statement questions related to the role and responsibilities of healthcare workers

(nurses) in the promotion and enforcement of exclusive breastfeeding in the rural health

units (RHUs) as their area of assignment. The open-ended format questionnaire has been

utilized to have deeper exploration of the meaning and purpose of their role as health

workers in the promotion of exclusive breastfeeding among mothers in their respective

community.

Instruments Validity and Reliability

Prior actual data gathering, validity and reliability of the instrument has been

established. Part I and II of this study’s adopted questionnaire have a secured validity and

reliability measures from previous studies. FAO questionnaire has been field tested in

several countries to ensure validity, readability, ease of administration and so proven to

be of less burdensome on respondents and was pre-tested as well for purpose of

precision, validity and easiness of data collection (FAOUN, 2014; Krishnendu & Devaki,

2017).

However, Part III and IV of the questionnaires has been subjected to validity

process through consulting experts that rated the questionnaire based on relevance,

simplicity, clarity and ambiguity approach adapted from a literature (Wynd, Schmidt, &

Schaefer, 2003). The researcher had consulted various experts which composed of: a) one

doctor of medicine, b) two doctorate degree holder in nursing, and c) two master’s degree

holder in nursing. Expert validator responses then have been computed for validity

through content validity ratio (CVR) approach.

 55

Moreover, after the established validity of the Part III and IV of the

questionnaires, it was then subjected to pilot testing from RHU in the municipality of

Ramain with 30 mothers as standard respondents that has similar characteristics of the

actual respondents (DeVon et al., 2007). Data collected were then tested for reliability

through Cronbach’s Alpha which shown that the questionnaire is reliable (Cronbach

Alpha = 0.87) (Heale & Twycross, 2015).

Ethical Consideration

This research study followed several considerations that purposely performed so

as not to defame its respondents. It has complied ethical consideration in conducting

research as all participants were given verbal and written informed consent which

researcher has explained to them for the purpose and process that needs to be undertaken

during the study including the duration. They were also informed that they could

withdraw from the study anytime without any punishment and no money or award was

tied to their participation.

Moreover, participants were informed that all the information taken has remained

confidential and there were no personal identifying information on the survey instrument,

and the results of the study were to be taken and placed inside sealed envelopes to

prevent any accidental viewing by other parties and only the researcher had an access to

the gathered data. There was no risk to the participants for participating since writing of

their names was optional thus anonymity was protected. It also explained that there was

no immediate benefit from participating but the only probable long-term benefit in a

sense that with their responses rural health workers can be able to select good candidates
 56

for breast feeding mothers as participants in the future. Furthermore, the researcher has

consulted ethics committee in the institution for clearance to affirm that this research

complied with the ethical standards required.

Data Gathering Procedure

The data gathering has started by the researcher after securing a final version of a

valid and reliable instrument particularly the Part III and IV. Afterwards, the researcher

electronically mailed a letter to the adviser and dean of the College of Health Sciences

and Graduate School Studies of MSU to seek permission for data gathering. A letter they

signed has been also addressed to the RHU Municipal Health Officer (MHO) and nurse

supervisor to establish rapport, courtesy and approval in order to allow the study to be

conducted.

After approval, the researcher asked assistance from the healthcare worker or

health professional representative from each RHU for a scheduled meeting and identified

qualified breastfeeding mothers in the list of record of RHU as respondents based on

inclusion criteria. The researcher had visited each RHU and met supervisor and NDP

nurses as respondents personally based on permitted situation and strict compliance,

observation and implementation of coivd-19 guidelines of IATF. The purpose then of the

study has been discussed and explained briefly to them. The researcher also verbally

explained to them reasons why the study needs to be conducted. Respondents expressing

an interest in participating in the study were given a consent form. After obtaining

consent they then received a standardized information on how to answer the

questionnaire, placing emphasis on honesty in answering the questions, and assurance of

 57

confidentiality of the results. Respondents were also encouraged to exercise the right to

withdraw from the study if they wish to and no penalties are attached to such withdrawal.

After they completed the questionnaires, it was then collected by the researcher

for verification of compliance with directions and for accuracy and completeness of

answers. Once the researcher had retrieved and verified all questionnaires, the data then

were collated.

All the data gathered were then tabulated and analyzed to obtain the proper

interpretations and served as the basis in formulating the conclusions and

recommendations of the study. Below shows the diagram of the process of data

gathering.

Reading of breastfeeding books,

Data Gathering unpublished and published master’s thesis
Procedures and dissertations, Online articles and
journals.

PRE-INTERVENTION VALIDATION AND Adopted modified

Reading of Leadership EVALUATION questionnaire

GIVING OF CONSENT
INTERVENTION PHASE
FORM

SURVEY

DATA COLLECTION

Post-INTERVENTION Statistical analyses and

PHASE interpretation of the
data
 58

Presentation of data

Figure 3: schematic diagram of data gathering procedure

Statistical Tools/ Treatment

The Statistical Product and Service Solutions (SPSS) version 21 has been used to

perform all the data computations in this study. SPSS has been used in the analysis of

data that are in descriptive in nature particularly frequency and percentage distribution,

mean, and standard deviation. Then the IBM-SPSS was used for deeper inferential

analysis such as the Pearson r and Cramer’s V correlation to test significant relationship

between the variables in the profile of the respondents as well as to perform a test to

significantly test the influence or effect of exogenous variables to endogenous variables.

For the purpose of exemplifying the statistical methods were used in this study

were justified below.

A. Descriptive statistics. Frequencies and percentages were used to describe the

personal profile of the respondents.

1. Frequency was the total number of responses. Frequency of responses,

including the respondents’ personal profile was tallied for the computation of percentage

value.

2. Simple Percentage was a part of a whole expressed in hundredths and was

used to determine the frequencies and the percentages of the first variable. This includes
 59

the manner on how the items were rated after the consolidation of data. The formula for

Simple Percentage was as follows:

P = (Fi/N) x 100%

where: Fi was the number of respondents and N was the total sample.

Measure of Central Tendencies by Mean was used in the study to measure the

average answers of the respondents particularly in the part of questionnaire pertaining to

social support of mothers including its domains and the quality of life measures.

As defined in this study, mean was the most commonly-used measure of central

tendency. The mean was simply the sum of the values divided by the total number of

items in the set.

The notation used to express the mean depends on whether we were talking about

the population mean or the sample mean:

µ = population mean

x = sample mean

The mean was valid only for interval data or ratio data. Since it used the values of

all of the data points in the population or sample, the mean was influenced by outliers

that may be at the extremes of the data set.

The formula for Weighted Mean was as follows:

Where: fi and xi were the frequencies and weights, respectively.

 60

Standard deviation. The standard deviation represented the distribution of the

responses around the mean. It indicates the degree of consistency among the responses.

The standard deviation, in conjunction with the mean, provided a better understanding of

the data. For example, if the mean was 3.3 with a standard deviation (StD) of 0.4, then

two-thirds of the responses lie between 2.9 (3.3 –0.4) and 3.7 (3.3 + 0.4).

Frequency and percentage distribution were utilized to present data of the

statement of the problem number 1 and 2. Then, mean and standard deviation for the data

presenting to answer the statement of the problem number 3 to 5.

B. Inferential statistics. It was described in using a random sample of data taken

from a population to describe and make inferences about the population. Inferential

statistics that was utilized in this study includes (1) Cramer’s V with Phi Coefficient, (2)

Spearman Rho Correlation, and (3) Pearson r coefficient correlation. These are used to

answer and present data of the statement of the problem number 6 to 9.

Cramer’s V with Phi Coefficient. In statistics, Cramer’s V was applied to

variable/s that was in nominal nature of level of measurement. Those were data that were

categorically classified and were not in continuous value or limited only.

Pearson r coefficient and Spearman Rho Correlation are statistical tools used

for inferential inquiry to find out significant relationship between variables. Pearson r

coefficient is used to test significant relationship of two variables that are both interval or

ratio (or ‘scale’ in general) in terms of level of measurement. Then, Spearman Rho

Correlation is appropriately used to data that are rank or ordinal in nature. These

inferential statistics: Cramer’s V with Phi Coefficient, Pearson r and Spearman rho are

used to address the study’s null hypothesis 1 to 2. The formula is shown below.
 61

The formula for Spearman Rho Correlation is as follows:

where: n is the number of paired ranks

d is the difference between the paired ranks

If there are no tied scores, the Spearman Rho Correlation coefficient will be even

closer to the Pearson product moment correlation coefficient. This formula can be easily

understood when the sum of the squares from 1 to n can be expressed as n (n+1)

(2n+1)/6. From this, the least sum of d2 is zero and the greatest sum of d2 is twice the sum

of the squares of the odd integers up to n/2 and this scales a sum between -1 and +1.

The level of significance is set at .05, which entails a .95% level of confidence

that there is a significant relation between the correlated variables. A negative (-)

correlation points to an inverse relationship direction between the independent and

dependent variables.

Based on the ordinal responses of the respondents, as the respondents’ response

direction for the independent variable goes down, there is the tendency that the

respondents’ response direction for the dependent variable will go up. A positive (+)

correlation points to a parallel relationship direction between the independent and

dependent variables.

Correlation coefficients whose magnitudes are between 0.9 and 1.0 indicate

variables which can be considered as very highly correlated.

Correlation coefficients whose magnitudes are between 0.7 and 0.9 indicate

variables which can be considered as highly correlated.

 62

Correlation coefficients whose magnitudes are between 0.5 and 1.7 indicate

variables which can be considered as moderately correlated.

Correlation coefficients whose magnitudes are between 0.3 and 0.5 indicate

variables which can be considered as low correlation.

Correlation coefficients whose magnitudes are less than 0.3 have little if any

(linear) correlation.

We can readily see that 0.9 < [r] < 1.0 corresponds with 0.81 < r 2 < 1.00; 0.7 < [r]

< 0.9 corresponds with 0.49 < r2 < 0.81; 0.5 < [r] < 0.7 corresponds with 0.25 < r 2 < 0.49;

0.3 < [r] < 0.5 corresponds with 0.09 < r 2 < 0.25; and 0.0 < [r] < 0.3 corresponds with 0.0

< r2 < 0.09.

 63

CHAPTER 4

RESULTS

This part will be discussing the result of the research problems. This will be

resented through tables and statistical data.

Table 2 shows the age profile of the respondents. Result revealed that 443 or

63.28% of the total respondents were belong to at least 26 years of age, and 257 or

36.72% of them were listed within 15-25 years of age.

Table 2
The socio-demographic profile of respondents in terms of Age
Age (in years) Frequency Percentage (%)
15-20 167 23.86
21-25 90 12.86
26-30 162 23.14
31-35 89 12.71
36-above 192 27.43
Total 700 100.00

The result implied that most of the breastfeeding mothers are old enough to

understand how breastfeeding works and its lifelong benefits to their children. On the

other hand, 257 out of 700 respondents were breastfeeding mothers aging 15-25, which

means that these group of mothers needs to be informed of how important breastfeeding

is, since there are mothers who are still underage.

This was supported by several studies. Marital status, education, age and income

level have been shown in studies to affect whether a mother with an infant will breastfeed
 64

or not and for how long. A literature review conducted by Meedya et al., (2010) on

studies carried out around the world found that being married, being well educated, older

age and receiving income that is higher were associated with breastfeeding for longer

periods (Meedya et al., 2010). Similar results by Asare et al., (2018) were consistent with

studies by Meedya et al., (2010). Breastfeeding exclusively among mothers was reported

to be influenced by educational status, age as well as ethnicity and recommended that the

socio-demographic factors should be looked at when strategizing to address issues of

exclusive breastfeeding (Asare et al., 2018; Meedya et al., 2010).

According to Diji et al., (2017), socio-demographic characteristics like age of the

infant, marital status, level of education, age of mother as well as occupation type

determine breastfeeding exclusively. Mogre et al., (2016) found that maternal educational

level was associated with the practice of exclusive breastfeeding and Onah et al., (2014)

also found that mothers with low educational levels were less likely to exclusively

breastfeed compared to mothers with higher education (Diji et al., 2016; Mogre et al.,

2016; Onah et al., 2014).

Table 3 presents the table on the socio-demographic profile of respondents in

terms of Number of Children.

Table 3
The socio-demographic profile of respondents in terms of Number of Children
Number of Children Frequency Percentage (%)
1-3 259 37.00
4-6 284 40.57
7-9 140 20.00
10-12 15 2.14
13-above 2 0.29
Total 700 100.00
 65

This result provided data on number of children of the Respondents, it showed

that 284 or 40.57% are those parents having 4-6 children. 259 or 37.00% are those

parents having 1-3 children. 140 or 20.00% of the overall respondents are having 7-9

children, 2.14% or 15 parent respondents were having 10-12 children and there were

0.29% or 2 out 700 respondents have 13 and above children.

It can be gleaned from the results that most of the respondents are having 1-3

children. Which means that having a smaller number of children will help mothers to

exclusively breastfeed their children. It can be seen that breastfeeding has cognitive and

health benefits for both infants and their mothers. It is especially critical during the first

six months of life, helping prevent diarrhea and pneumonia, two major causes of death in

infants. Mothers who breastfeed have a reduced risk of ovarian and breast cancer, two

leading causes of death among women (Chowdhury, 2017).

Table 4 provides data on the civil status of the breastfeeding mothers.

Table 4
The socio-demographic profile of respondents in terms of Civil Status
Civil Status Frequency Percentage (%)
Married 697 99.57
Separated 3 0.43
Total 700 100.00

The data revealed the civil status of the respondents 697 or 99.57% are

breastfeeding mothers who are married and 3 or 0.43% are mothers who are separated.

The results implies that there could be factors that could affect the breastfeeding

experiences among mothers. It can be gleaned from the study of Brand, Khotari, Stand

(2011) that faving a perceived support system, whether it is personal or professional, may

have an effect on both the initiation and duration of breastfeeding. Educating expectant

and new mothers, especially women who encounter multiple barriers and are at risk for
 66

very early cessation of breastfeeding, of the benefits of breastfeeding and supporting

them in developing efficient techniques and problem-solving skills can help increase the

duration of breastfeeding.

Support systems may be a greater influence than socioeconomic status; if a

woman view breastfeeding positively, and has support from her partner, she will be more

likely to breastfeed (Persad & Mensinger, 2007). Additionally, the presence of

professional support strongly correlates with both breastfeeding initiation (Persad &

Mensinger, 2007) and increased duration of breastfeeding

This table presented the data in first time mothers.

Table 5
The socio-demographic profile of respondents in terms of First Time Mother
First time mother Frequency Percentage (%)
Yes 104 14.86
No 596 85.14
Total 700 100.00

Most of the respondents are not first time mothers which resulted 596 out of 700

respondents or 85.14%, 104 out of 700 respondents or 14.86% were first time mothers.

This result implied that exclusive breastfeeding is practiced among first-time mothers due

to its perceived benefits; which include nutritional advantage, ability to enhance growth

whilst boosting immunity and its economic value. However misconceptions as well as,

certain cultural practices (e.g. giving herbal concoctions, breastmilk purification rites),

and relational influences, may threaten a mother’s intention to exclusively breastfeed.

Relational influences are mainly from mother in-laws, traditional birth attendants,

grandmothers, herbalists and other older adults in the community.

Although first time mothers attempt EBF, external influences make it practically

challenging. The availability and utilization of information on EBF was found to

 67

positively influence perceptions towards EBF, leading to change in attitude towards the

act. Thus, the practice of community-based health services may be strengthened to

provide support for first-time mothers as well as continuous education to the mother in

laws, female elders and community leaders who influence decision making on

breastfeeding of infants (Adda, Opoku-Mensah, & Dako-Gyeke, 2020).

The table presented that data on educational attainment of the respondents.

Table 6
The socio-demographic profile of respondents in terms of Educational Attainment
Educational Attainment Frequency Percentage (%)
Elementary Graduate 84 12.00
High School Graduate 286 40.86
College Graduate 330 47.14
With Masters or PhD 0 0.00
Total 700 100.00

This data means that most of the parents are college graduate. They are educated

enough to know importance of exclusive breastfeeding. Only few out of the 700

respondents were an elementary graduate. This only means that most mothers are

educated enough to understand the benefits of exclusive breastfeeding among their

children.

It was supported by the claim that, breastfeeding exclusively among mothers was

reported to be influenced by educational status, age as well as ethnicity and

recommended that the socio-demographic factors should be looked at when strategizing

to address issues of exclusive breastfeeding (Asare et al., 2018; Meedya et al., 2010).

Mogre et al., (2016) found that maternal educational level was associated with the

practice of exclusive breastfeeding and Onah et al., (2014) also found that mothers with

low educational levels were less likely to exclusively breastfeed compared to mothers

with higher education (Diji et al., 2016; Mogre et al., 2016; Onah et al., 2014).
 68

According to Danso (2014) in a study conducted to know barriers to breastfeeding

exclusively among professional mothers who were working in Kumasi, majority (90.5%)

of the respondents said that their working status made them unable to exclusively

breastfeed. The study revealed that professional mothers who work had to go back to

work after their maternity leave of three months thereby compelling them to leave their

infants with family members. These mothers then went home to breastfeed during break

time or had relatives bring infants to them at their places of work for breastfeeding. For

some mothers, their work was so demanding resulting in their inability to have breaks for

breastfeeding while other mothers reported that their working environment was not

conducive as it did not have a proper place for breastfeeding (Danso, 2014).

The table showed the data on the employment of the Respondents.

Table 7
The socio-demographic profile of respondents in terms of Employment
Employment Frequency Percentage (%)
With Occupation 323 46.14
Unemployed 377 53.86
Total 700 100.00

Most of the respondents though they were able to graduate from college most of

them are unemployed. This means that unemployed mothers are more likely to

exclusively breastfeed their children than the working mothers.

As shown from these studies, Chhetri et al., (2018) conducted a community-based

cross-`sectional study among breastfeeding mothers employed in any form of occupation

having an infant less than six months old (n = 137). Interviewer administered structured

questionnaire was used to collect data. Chi-square test was performed to find the

association between different variables and EBF. The prevalence of EBF among working
 69

mothers was found to be 17.5% although 75% of them had adequate knowledge on EBF

and its benefits. Around 52% of the mothers did not receive any maternity leave benefits.

Only 11% of mothers were allowed breaks in between working hours but none of the

mothers were provided with crèches at their workplace. The commonest reason to

discontinue EBF was early resumption of work after childbirth. Factors such as

educational status of working mother and her husband, occupation of husband, place of

delivery, sex of the newborn, frequency of breastfeeding per day, practice of expressing

and storing breastmilk before leaving for work and breaks during working hours were

found to be statistically significant with EBF practice. These findings emphasize the need

to guarantee the support to breastfeeding policies at workplace which in turn would

motivate working mothers to continue EBF after resuming work (Chhetri, Rao, &

Guddattu, 2018).

The table provides the data on monthly income of the respondents.

Table 8
The socio-demographic profile of respondents in terms of Monthly Income
Monthly Income Frequency Percentage (%)
less than 5,000 175 25.00
5,000-10,000 309 44.14
10,001-20,000 183 26.14
higher than 20,000 33 4.71
Total 700 100.00

Most of the parents were receiving a minimum wage of 5,000-10,000 which

constitutes 44.14%, 10,001-20,000 are salaries of 183 respondents which constitutes

26.14% of the whole number of respondents. 175 or 25% were receiving less than 5, 000

income monthly. Only 33 or 4.71% were receiving higher than 20,000 monthly incomes.

This means that most of the respondents were only receiving a minimum wage for a
 70

family and most of them are having more than 5 kids which only gives an idea that 5,000-

10,000 monthly is not enough for a family of 7 or 8.

As shown in some researches, women in these low-income families had to work

for longer hours to contribute financially to the upkeep of their homes which made them

unable to breastfeed. They resorted to the use of wet nurses and that in turn increased

infant mortality (Glasper, 2019; Reeves & Woods-Giscombé, 2015). Moreover, A

literature review conducted by Meedya et al., (2010) on studies carried out around the

world found that being married, being well educated, older age and receiving income that

is higher were associated with breastfeeding for longer periods (Meedya et al., 2010).

Similar results by Asare et al., (2018) were consistent with studies by Meedya et al.,

(2010).

The table presents the data on the role of Rural Health Workers in the Promotion

of Exclusive of Exclusive Breastfeeding.

Table 9
Role of the Rural Health Workers in the Promotion of Exclusive Breastfeeding
As health worker, it is my role to …. Mean Description

1. Advise breastfeeding mother against the use of 3.83 Always

pacifiers
2. Advise exclusive breastfeeding when mother works 3.96 Always
3. Teach mothers how to express their breast milk 3.82 Always
4. Orient mothers about the advantages of exclusive 3.89 Always
breastfeeding
5. Observe feedings to check if mother knows how to 3.86 Always
breastfeed her baby
6. Orient mothers on how to care for breast traumas 3.15 Often
7. Advise mother initiating breastfeeding with- in a half- 3.94 Always
hour of birth
8. Demonstrate how to breastfeed a baby, including 3.57 Always
positioning and attachment
9. Encourage mother to breast their baby up to two (2) 3.97 Always
years
 71

10.Encourage working mothers to practice exclusive 4.00 Always

breastfeeding by introducing strategies on how to
bank/ store breastmilk.
Total Measure 3.80 Always

Note: 1.00-1.49 Never 2.50-3.49 Often

1.50-2.49 Sometimes 3.50-4.00 Always

As shown from the data, Rural Health Worker are always promoting exclusive

breastfeeding to mothers regardless if first time mothers of not. Community workers had

been carrying out exclusive breastfeeding promotion activities which provides

information about the meaning and benefits of EBF, inviting, reminding and also

recommending giving EBF and helping as much as possible if the mother has a problem

breastfeeding.

Nurses and other health care professionals who care for mother-infant dyads

should acquire the knowledge and demonstrate the competence needed to provide

consistent and evidence-based breastfeeding information and support throughout the

preconception, prenatal, and postpartum periods. If the health care professional does not

possess the knowledge and skills needed to provide support, consultation with or referral

to a lactation specialist or other clinical expert should be offered for all mother-infant

dyads (Camiling-Alfonso et al., 2015; Nies & McEwen, 2014).

The table showed the data on the Responsibilities of the Rural Health Workers in

the Promotion of Exclusive Breastfeeding.

Table 10
Responsibilities of the Rural Health Workers in the Promotion of Exclusive Breastfeeding
As health worker, it is my responsibility to …. Mean Description

1. Explain and make mother understands the process and advantages of 4.00 Always
exclusive breastfeeding.
2. Ensure that all mothers in the community accepts and practices exclusive 4.00 Always
breastfeeding
3. Demonstrate to the mother the strategy and proper way of breastfeeding 4.00 Always
 72

their baby
4. Provide assistance to mothers who have met issues, challenges or special 4.00 Always
needs in practicing exclusive breastfeeding.
5. Introduce strategies on exclusive breastfeeding for mothers to be 4.00 Always
motivated and inspired.
6. Counsel mothers and her partner (husband) on issues and concerns related 4.00 Always
to exclusive breastfeeding.
7. Advise mother to seek healthcare professional assistance for some issues 4.00 Always
and concerns related to exclusive breastfeeding.
8. Monitor mothers’ practice and progress on exclusive breastfeeding. 4.00 Always
9. Conduct programs related to breastfeeding to promote the practice for 4.00 Always
mothers and planning to be mothers in the community.
10. Refer client mothers with complicated health issues to a specialist to know 4.00 Always
or discover if breastfeeding do not compromise health.
Total Measure 4.00 Always

Note: 1.00-1.49 Never 2.50-3.49 Often

1.50-2.49 Sometimes 3.50-4.00 Always
Health workers have an important role in assisting moms in initiating and

maintaining good breastfeeding for their newborns. Health workers are in a strategic

position and have the obligation to teach and guide moms and the broader public on

healthy baby feeding beginning and adherence. Health practitioners are supposed to know

at least enough about breastfeeding, including its advantages, suitable procedures, current

misconceptions, and practical elements of dealing with any issues. Inadequate support for

healthy breastfeeding habits by health personnel has previously been noted.

Based on interview among health workers, they explicitly said that they

encourage breastfeeding mothers “through health teaching”, “By explaining the

importance of EBF to the babies and what are the benefits they will get from it”, and “its

economic benefits” these responses were prevalent among the health workers.

This was supported by the finding of Borbala (2020), health workers are an

important source of support for breastfeeding mothers and their knowledge can influence

a mothers' decisions to initiate and continue breastfeeding. There is a dearth study on the

knowledge of healthcare professionals on breastfeeding in Cross River State hence this

 73

study. Findings from this study will be used in developing appropriate strategies to

promote breastfeeding practices in Cross River State and Nigeria as a whole.

The table below presented data on the Level of Knowledge of Mothers on

Exclusive Breastfeeding

Table 11
Level of Knowledge of Mothers on Exclusive Breastfeeding
Questions Frequency Percentage (%)
(n=700)
1. Is exclusive breastfeeding important?
Yes 700 100.00
No 0 0.00
2. Is colostrum nutritionally beneficial to the child?
Yes 700 100.00
No 0 0.00
3. Does exclusive breastfeeding improve immunity?
Anytime the mother is ready 579 82.71
Immediately after birth 121 17.29
4. Is it important to initiate breastfeeding within 1 hr.
after birth?
6 months-24 months 550 78.57
≤ 5 months 150 21.43
5. Can exclusive breastfeeding prevent child from
diarrhea?
Yes 700 100.00
No 0 0.00
6. Growth patterns of breastfed infants differ from
formula fed?
Yes 700 100.00
No 0 0.00
7. Consuming galactogogues like almonds and
fenugreek can improve the milk production?
 74

Yes 458 65.43

No 242 34.57
8. How long exclusive breast feeding should be
continued?
less than 6 months 0 0.00
6 months 0 0.00
more than 6 months 700 100.00

These results implied that mothers from the two (2) location were exclusively

breastfeeding their children. These mothers who are EBF knew the benefits of colostrum

to their children. In addition, they are also aware that EBF improve immunity. Hence

most of the respondent mothers believe that EBF should start 6 months and above,

though some of think that it must start less than months old.

EBF mothers were more aware of the benefit of the EBF as to preventing a child

from diarrhea, the child’s growth patterns, and the patterns of breastfed infants different

form the formula fed infants. Moreover, EBF mothers knew that consuming galctogogues

like almonds and fenugreek can improve their milk production and above all else, they

understood the idea that EBF must be continued even after 6 months of EBF the child.

Furthermore, perceived accuracy of information in EBF among mothers by

indicating their desire to continue nursing their child beyond 6 months, some of them

claimed that by moms sought for support to boost their milk production. It was also clear

from their responses that these mothers adhered to Islamic teachings on nursing their

infants.

The health practitioners' knowledge of the advantages of nursing to newborns and

mothers, colostrum, successful breastfeeding, the time and duration of exclusive

breastfeeding, and supplementary feeding was adequate. However, their awareness of the

effects of nursing on achieving pre-pregnancy weight, protection against osteoporosis,

 75

and colostrum in protecting neonates from jaundice was inadequate. In a Tanzanian

survey, 97 percent of health workers cited a lack of knowledge of the benefits of

exclusive breastfeeding as one of the main reasons for the low breastfeeding rate (Chale,

Fenton, & Kayange, 2016). The majority of the general public, including nursing

mothers, rely heavily on health workers to acquire and improve their breastfeeding

knowledge.

About 96% of health workers knew that breastfeeding should be initiated within

one hour after delivery. This finding suggests that women attended by these health

workers were more likely to commence breastfeeding of their infant soon after delivery.

This finding is similar to that obtained in a study among health workers in rural South

Africa, which reported a knowledge rate of 96% among professional nurses as mentioned

by Olusanya, Osibanjo, Mabogunje, Slusher, & Olowe (2016).

The table presented the data on the attitude of mothers on Exclusive

Breastfeeding.

Table 12
Attitude of Mothers on Exclusive Breastfeeding
Indicators Agree Unsure Disagree % Net Mean
(%) (%) (%) Agreemen (Description)
t
1. Breastfeeding should be 75.00 17.86 7.14 67.86 2.68
continued up to 2 years? (Agree)
2. Do you think 70.14 26.00 3.86 66.29 2.66
breastfeeding should be on (Agree)
demand?
3. Do you believe in giving 68.71 19.43 11.86 56.86 2.57
pre lacteal feeds to babies? (Agree)
4. Do you believe in 22.43 19.57 58.00 -35.57 1.64
following vaccination (Unsure)
schedule?
5. Should breastfeeding be 11.57 14.71 73.71 -62.14 1.38
stopped when child has (Disagree)
diarrheal episodes?
6. Is formula feeding better 70.57 16.57 12.86 57.71 2.58
 76

than breastfeeding? (Agree)

7. Do you think health and 74.57 22.86 2.00 72.57 2.73
hygiene are more important (Agree)
for breastfeeding?
8. Do you believe that 94.00 6.00 0.00 94.00 2.94
breastfeeding causes changes (Agree)
in body shape?
9. Does breastfeeding 100.0 0.00 0.00 100.00 3.00
increases mother child (Agree)
bonding?
Overall Mean 2.46 (Unsure)
Note: Total Sample size, n = 700 Values expressed in percentage (%)
1.00-1.49 Disagree 1.50-2.49 Unsure 2.50-3.00
Agree

It can be gleaned from the data that mothers believed that breastfeeding should be

continued up to 2 years of the child’s life. In addition, they also have the idea that

breastfeeding should be on demand and not just a choice, they are also believing that

giving pre lacteal feeds to babies are good. However, EBF mother have a dissenting

opinion oh following vaccination schedule, this resulted to some mothers who are busy or

do not want to get their children vaccinated for some unidentified reasons.

According to mothers, EBF they disagree on stopping breastfeeding when the

child has episodes of diarrhea for these mothers believed that breastfeeding is way better

than formula feeding. In this regard, it is believed that EBF comes along with health and

hygiene they should not do away with each other. Above all these claims, exclusive

breast-feeding increases bonding of mothers and their children.

While there had been a significant effort among breastfeeding mothers to EBF their

infants, some community health professionals reported that there had been some

perceived challenges while women were working, and they could no longer continue with

the EBF when their maternity leave was over.

A support claims was asserted that EBF is a significant public health approach for

improving children's and mothers' health by lowering morbidity and mortality among
 77

children and assisting in the control of healthcare expenses in society. Furthermore, EBF

is one of the key techniques that contribute to the most commonly known and successful

intervention for avoiding children’s fatalities. Every year, proper breastfeeding

techniques can avert around 1.4 million deaths among children under the age of five

globally. Breastfeeding reduces the incidence of several children ailments, including

chest infections, pneumonia, sudden infant death syndrome, diabetes mellitus,

malocclusion, and diarrhea, in addition to the benefits it offers on the mother-child

connection (Dukuzumuremyi, Acheampong, Abesig et al., 2020).

Positive mother attitudes regarding breastfeeding are connected with longer

breastfeeding duration and a higher likelihood of successful nursing. Furthermore,

women who were enthusiastic about nursing were more likely to exclusively nurse their

children. An attitude score of 70% is regarded urgent for nutrition intervention, according

to FAO criteria levels indicating of nutrition intervention. All moms who scored more

than 70% on the attitude test were judged to have a positive attitude, whereas those who

scored less than 70% were regarded to be less positive. According to the findings of this

study, few moms have a good attitude toward exclusive breastfeeding, such as

introducing supplemental foods after six months and believing that EBF is healthy to the

child and preferable to artificial feeding (Dukuzumuremyi, Acheampong, Abesig et al.,

2020).

Good feeding practices are vital for children's health and nutritional status, which

has a negative impact on their mental and physical development, and they are also

important for moms. Early suckling stimulates the release of prolactin, which aids in milk

production, and oxytocin, which is responsible for milk ejection. It also increases uterine
 78

contraction after childbirth and decreases postpartum bleeding (Hailemariam, Adeba, &

Sufa, 2015).

The table presented Attitude of Exclusive Breastfeeding Mothers.

Table 13
Attitude of Exclusive Breastfeeding Mothers
Questions Frequency Percentage (%)
(n=700)
1. Did you take advice from lactation counsellor or healthcare
professionals (e.g. doctor, nurse, or midwife) before
breastfeeding?
Yes 546 78.00
No 154 22.00
2. Did you give pre lacteal feeds to the infant?
Yes 188 26.86
No 512 73.14
3. Do you think that EBF is better than artificial feeding?
Yes 700 100.00
No 0 0.00
Don’t know 0 0.00
4. What was the type of the first feed given to your last child?
Breast milk 350 50.00
Honey 340 48.57
Sugar water 10 1.43
5. Do you believe that the first milk [colostrum] should be
discarded?
Yes 0 0.00
No 700 100.00
6. When did you start breastfeeding after delivering your last
child?
In an interval of 1 hour 589 84.14
 79

in an interval of 2-6 hours 111 15.86

after 24 hours 0 0.00
7. How frequently do you breastfeed?
On demand 642 91.71
at specific intervals 24 3.43
at random 25 3.57
8. How frequently do you consume galactagogues or green
leafy vegetables (e.g. horse radish) and its extracts for
improving milk production?
Daily 700 100.00
Weekly 0 0.00
Never 0 0.00
9. Do you agree that only EBF is enough for child up to 6
months?
Agree 480 68.57
Disagree 220 31.43
10. How did you feel when you give extra food other than
breast to your child?
Didn’t feel comfort 690 98.57
Comfortable with it 10 1.43
11. Do you agree that child less than 6 months who is
exclusively breastfed is healthier than child who takes
additional food?
Yes 556 79.43
No 144 20.57
I do not know 0 0.00

It can be gleaned from the data that mothers took advice from lactation counsellor

or healthcare professionals. Most of them did not give pre lacteal meal to their children.

According to EBF mothers, the first food whom they fed to their children were breast

milk, then honey. It was seen from the results that EBF mothers believed that first milk

should not be disregarded and that an interval of 1 hour with a frequent breast feeding

depend on the demand of the child. This also connects to the idea that parents should

have a frequent intake of galactagogues or green leafy vegetables for the improvement of

the milk production of mothers.

In addition, those parents who are working may be employed or self-employed

they prefer that EBF should last up to 6 months only hence due to the mother’s bond to

her child she does not feel comfortable giving her other food than her milk. Which leads
 80

to their claim that child less than 6 months who is exclusively breastfed is healthier than

child who takes additional food.

Furthermore, according to an interview with community workers dated March 28-

29, 2022 at 9:00 A.M.-11:30 A.M., the primary reasons why mothers resort to formula

milk are work-related issues and that storing milk would take too much effort among

them while preparing for work, thus resorting to formula milk saves their time more

frequently or it was simply more convenient for them. Furthermore, an interview with the

community found that moms had misconceptions about EBF. To begin, EBF women

believe that if they become unwell, their infants would become ill as well due to nursing.

Second, moms felt that they were not permitted to consume or drink other people's foods

because it would reduce their milk production. Third, their youngster should only be fed

for ten (10) minutes on each side. Fourth, moms who are taking drugs should not

breastfeed their children. Finally, women should not wake a sleeping infant in order to

breastfeed. These are just a few of the misunderstandings that moms have throughout

their EBF. It was also revealed that some of the factors that discourage mothers from

using EBF are as follows: (1) less breastmilk production, (2) painful breastfeeding

experiences, (3) working mothers, (4) breastfeeding takes too much time and they are

unable to attend to household chores, (5) latching difficulties, and (6) clogged milk ducts.

Breastfeeding exclusively throughout the first six months of life strengthens

newborns' immune systems and protects them from diarrhea and severe respiratory

infections. Exclusive breast feeding throughout the first six months of life is increasingly

recognized as a global public health priority connected to lower infant morbidity and

death, particularly in poor countries (WHO, 2011). The World Health Organization
 81

(WHO) advises exclusive breast feeding (EBF) during the first six months of life,

followed by appropriate and safe supplemental meals for up to two years and beyond.

Even in nations with high rates of breast feeding beginning, EBF is uncommon in the

majority of countries (both developed and developing). EBF rates in children under six

months of age ranged from as low as 20% in Central and Eastern European nations to

44% in South Asia (Imdad, Yakoob, & Bhutta, 2011).

Several research conducted throughout the world have revealed that nursing is a

universal habit. Mothers appear to be unconcerned about alternatives. In the current

study, all of the moms were aware that nursing is the best nutritional source for their

child. In an Assiut City survey of Egyptian moms, almost 79 percent of the participants

recognized that breast milk promotes bonding between mothers and children and protects

children from infections (Batal, Boulghourjin, Abdullah & Afifi, 2005). Colostrum usage

and avoidance of pre-lacteal meals are foundations of early baby nutrition and may be

required for the development of future exclusive breastfeeding.

It was assumed that all of the respondent mothers were aware that nursing is the

best nutritional source for their child. The majority of moms were well-versed on the

benefits of nursing for children, and most mothers were aware that breast milk protects

children from illnesses and boosts their intelligence. Furthermore, moms were informed

that nursing should begin within 1/2 hours following childbirth. Furthermore, moms were

aware of the correct time of exclusive breastfeeding, and participants were aware that

colostrum feeding is particularly nutritious for the infant.

As one health workers revealed that, “Karamihan sa mga nanay, alam naman

nila yung do’s and don’ts ng breastfeeding, may mga idea on how to make mothers
 82

produce milk based on experiences and localized herbal medicines which they know of,

yung sa part lang siguro naming na mga health workers is to help them sustain that

practices.” (March 28,2022, 9:OO A.M.)

Other responses revealed that, “Sa sustainability na nagkakaproblema, lalo na sa

mga working mothers, pagkatapos ng maternity leave nila, they have to stop

breastfeeding.” (March 29, 2022, 9:OO A.M.)

Some of the health workers retorted that, “Pati kami na mga health workers, ako

personally as a mother I educate other mothers to EBF their infants but I myself could

not walk my talks, after 3 months of EBF my infant I could no longer continue kapag

bumalik na ako sa trabaho. Sa dam ng ginagawa hindi na masingit sa oras yung pag

EBF sa anak na iniiwan sa bahay, so ako guilty ako na as a mother I opted for a formula

milk rather than magcontinue ng EBF while working.” (March 28, 2022, 9:OO A.M.)

Health workers responded that, “Kailangan ma strengthen yung EBF among

mothers and e enhance kung ano ang ala na nila about EBF.” (March 29, 2022, 9:OO

A.M.)

Rural health workers find mothers to be compliant to their campaign to exclusive

breastfeeding of infants. Since, most of these mothers were not first-time mothers they

already have the knowledge, attitudes, and own practices in exclusively breastfeeding

their children. What they only have to do is to enhance their practices. At some point in

time

A substantial relationship between mother education and exclusive breastfeeding

was discovered in this study. This was consistent with the findings of Webb et al. (2009),
 83

who investigated the relationships between maternal academic skills and indicators for

the initiation of exclusive breastfeeding and the timely introduction of complementary

foods; mothers in the highest category of academic skills were more likely to initiate

exclusive breastfeeding.

The table below provided data on the Relationship between the Socio-

Demographic Profile and the Knowledge of the Respondents in terms of exclusive

breastfeeding in improving immunity.

Table 14
Relationship between the Socio-Demographic Profile and the Knowledge of the
Respondents in terms of exclusive breastfeeding in improving immunity
Knowledge
Socio-Demographic Profile (Does exclusive breastfeeding
improve immunity?) Remarks
Somers d
(Cramer’s V) P-value
Age 0.136** 0.000 Significant
Number of Children 0.411** 0.000 Significant
Civil Status (0.030ns) 0.427 Not significant
First time Mother (0.191**) 0.000 Significant
Educational Attainment 0.306** 0.000 Significant
Employment Status (0.423**) 0.000 Significant
Monthly Income 0.375** 0.000 Significant
Note: Values enclosed in parenthesis is computed by Cramer’s V statistic
**-significant at 0.01 level ns-not significant at 0.05 level
 84

Result shows that the different socio-demographic profiles of the respondents

relative to age, number of children, first time mother, educational attainment,

employment status and monthly income were significantly associated to their knowledge

relative to exclusive breastfeeding in improving immunity since the corresponding p-

values does not exceed at the 0.01 level of significance. However, no significant

relationship was found between civil status and knowledge level on exclusive

breastfeeding in improving immunity since the p-value of 0.427 exceeded at the 0.05

level of significance.

Breastfeeding may, in addition to the well-known passive protection against

infections during lactation, have a unique capacity to stimulate the immune system of the

offspring possibly with several long-term positive effects here is also interesting evidence

for an enhanced protection remaining for years after lactation against diarrhea, respiratory

tract infections, otitis media, Haemophilus influenzae type b infections, and wheezing

illness. In several instances the protection seems to improve with the duration of

breastfeeding (Hanson, 1998).

The participants' socio-demographics revealed that they all had some degree of

schooling. Second, the majority of lactating mothers were employed and earned between

1,000.00 and 2,000.00 per month. The vast majority were adult, having reached the age

of 25. There is strong evidence that nursing mothers face demographic difficulties that

may impact the onset and duration of BF, according to the literature. Women who

completed high school were 70% more likely to breastfeed than those who did not;

women who attended college were four times more likely to breastfeed than women who

completed high school. Maternal age, in addition to educational attainment, has been
 85

identified as one of the factors most strongly influencing the initiation, duration, and level

of infant feeding as mentioned by Nukpezah, Nuvor, & Ninnoni (2018).

The table below presented data on the Relationship between the Socio-

Demographic Profile and the Knowledge of the Respondents in terms of the importance

to initiate breastfeeding within 1 hour after birth.

Table 15
Relationship between the Socio-Demographic Profile and the Knowledge of the Respondents in terms of
the importance to initiate breastfeeding within 1 hour after birth
Knowledge
Socio-Demographic Profile (Is it important to initiate
breastfeeding within 1 hr. after birth?) Remarks
Somers d (Cramer’s V) P-value
Age 0.171** 0.000 Significant
Number of Children 0.506** 0.000 Significant
Civil Status (0.034ns) 0.365 Not significant
First time Mother (218**) 0.000 Significant
Educational Attainment 0.380** 0.000 Significant
Employment Status (0.483**) 0.000 Significant
Monthly Income 0.454** 0.000 Significant
Note: Values enclosed in parenthesis is computed by Cramer’s V statistic
**-significant at 0.01 level ns-not significant at 0.05 level

Result shows that the different socio-demographic profiles of the respondents

relative to age, number of children, first time mother, educational attainment,

employment status and monthly income were significantly correlated to their knowledge

relative to the importance of initiating breastfeeding within 1 hour after birth since the

corresponding p-values does not exceed at the 0.01 level of significance. In contrast, no

significant relationship was found between civil status and knowledge level on

importance of initiating breastfeeding within 1 hour after birth since the p-value of 0.365

exceeded at the 0.05 level of significance.

Initiation of breastfeeding within one hour of birth can avert 22% of newborn

mortality. Several factors influence breastfeeding practice including mothers’ socio-

demographic and obstetric characteristics, and factors related to time around child birth.
 86

This study explores breastfeeding initiation practices and associated influencing factors

for initiating breastfeeding within one hour of birth in public health facilities of

Bangladesh. Initiation of breastfeeding after birth is an integral part of the safe delivery

procedure and is widely acknowledged as a beneficial practice. Lancet neonatal survival

series identifies breastfeeding as one effective intervention that can reduce 55–87% of

all-cause neonatal mortality and morbidity. Several studies find that breastfeeding

reduces the risk of neonatal deaths particularly due to infections like diarrhea neonatal

sepsis pneumonia and meningitis [9]. When further explored, delayed initiation of

breastfeeding was found increasing the mortality risks among newborns. Recent evidence

shows, newborns who were put to breast within one hour of birth had 29% less chance of

dying within the first 28 days of their lives than those who were breastfed 2–23 hours of

birth. Initiation of breastfeeding within one hour of birth can also avert up to 22% of all

newborn deaths and the recent Lancet Every Newborn series mentions that the mortality

reduction can reach up to 44% (Karim, Billah, Chowdhury, Zaka, Manu, Arifeen, Khan,

2018).

Table 16 presented data on Relationship between the Socio-Demographic Profile

and the Knowledge of the Respondents in terms of consuming galactogogues like

almonds and fenugreek in improving the milk production.

Table 16
Relationship between the Socio-Demographic Profile and the Knowledge of the
Respondents in terms of consuming galactogogues like almonds and fenugreek in
improving the milk production
Knowledge
Socio-Demographic Profile (Consuming galactogogues
like almonds and fenugreek Remarks
can improve the milk
production?)
Somers d
 87

(Cramer’s V) P-value
Age 0.264** 0.000 Significant
Number of Children 0.583** 0.000 Significant
Civil Status (0.002 )
ns
0.964 Not significant
First time Mother (0.304**) 0.000 Significant
Educational Attainment 0.613** 0.000 Significant
Employment Status (0.673**) 0.000 Significant
Monthly Income 0.628** 0.000 Significant
Note: Values enclosed in parenthesis is computed by Cramer’s V statistic
**-significant at 0.01 level ns-not significant at 0.05 level

Result shows that the different socio-demographic profiles of the respondents

relative to age, number of children, first time mother, educational attainment,

employment status and monthly income were significantly related to their knowledge

relative to the consuming of galactogogues like almonds and fenugreek that can improve

the milk production since the corresponding p-values does not exceed at the 0.01 level of

significance. In contrast, no significant relationship was found between civil status and

knowledge level on consuming of galactogogues like almonds and fenugreek that can

improve the milk production since the p-value of 0.964 exceeded at the 0.05 level of

significance.

Fenugreek, a herbal remedy, has long been used as galactologue to help mothers

likely to stop breastfeeding because of perceived insufficient milk production. Thus,

fenugreek supplementation might enhance milk production in the case of insufficient

maternal milk production, due to maternal stress, difficulties in breastfeeding

management, first parity, or when mothers are breastfeeding twins, but fenugreek is

unlikely to be effective in situations that affect lactation physiology, such as

undernutrition deficiency, mammary hypoplasia, and hormonal deregulation as

mentioned by Sevrin, Alexandre, Castellano & Gouabau et.al (2019).

 88

Table 17 presented results of the Relationship between the Socio-Demographic

Profile and the Attitude of the Respondents.

Table 17
Relationship between the Socio-Demographic Profile and the Attitude of the
Respondents
Attitude
Socio-Demographic Profile Somers d Remarks
(Cramer’s V) P-value
Age 0.231** 0.000 Significant
Number of Children 0.592** 0.000 Significant
Civil Status (0.015ns) 0.925 Not significant
First time Mother 0.282** 0.000 Significant
Educational Attainment 0.555** 0.000 Significant
Employment Status 0.625** 0.000 Significant
Monthly Income 0.665** 0.000 Significant
Note: Values enclosed in parenthesis is computed by Cramer’s V statistic
**-significant at 0.01 level ns-not significant at 0.05 level

Result shows that the different socio-demographic profiles of the respondents

relative to age, number of children, first time mother, educational attainment,

employment status and monthly income were significantly related to their attitudes on

exclusive breastfeeding since the corresponding p-values does not exceed at the 0.01

level of significance. But, no significant relationship was found between civil status

attitude on exclusive breastfeeding since the p-value of 0.925 exceeded at the 0.05 level

of significance.

The socio-demographics of the participants indicated that they all had some level

of education. Second, most nursing women worked and earned between 1,000.00 and

2,000.00 each month. The great majority had attained the age of 25 and were adults.

According to the research, there is significant evidence that nursing mothers confront

demographic challenges that may influence the beginning and duration of BF. Women

who finished high school were 70% more likely to breastfeed than those who did not;
 89

women who went to college were four times as likely to breastfeed than those who did

not. In addition to educational achievement, maternal age has been recognized as one of

the most powerful variables determining the beginning, duration, and level of newborn

feeding (Nukpezah, Nuvor, & Ninnoni, 2018).

Table 18 presented results on the Relationship between the Roles and

Responsibilities of Rural Health.

Table 18
Relationship between the Roles and Responsibilities of Rural Health Workers and the
Knowledge of Meranaw Mothers on Exclusive breastfeeding
Roles and Responsibilities
Knowledge1 Spearman r P-value Remarks
1. Does exclusive breastfeeding 0.659** 0.000 Significant
improve immunity?
2. Is it important to initiate 0.709** 0.000 Significant
breastfeeding within 1 hr. after
birth?
3. Consuming galactogogues like 0.825** 0.000 Significant
almonds and fenugreek can improve
the milk production?
Note: Analysis is based on Spearman rho Correlation **-significant at 0.01 level
1
Other knowledge indicators were not included since it has single category only

Result reveals that the knowledge level of the respondents relative to exclusive

breastfeeding in improving immunity, the importance of initiating breastfeeding within 1

hour after birth and consuming galactogogues like almonds and fenugreek can improve

the milk production were significantly correlated to the roles and responsibilities of rural

health workers since the observed p-values does not exceed at the 0.01 level of

significance. The association is high and positive which indicated that the more the health

workers promote exclusive breastfeeding, the more they have the knowledge on exclusive

breastfeeding. Thus, the null hypothesis of no significant relationship between the roles

and responsibilities of rural health workers and the knowledge of Meranaw mothers on

exclusive breastfeeding was rejected.

 90

Five studies were identified with 122 participants receiving treatment with

fenugreek. The NMA results of 4 studies indicated that consumption of fenugreek

significantly increased amount of the produced breast milk versus placebo. The pairwise

comparison revealed that fenugreek was effective as a galactagogue compared to placebo,

control, and reference groups WMD as mentioned by Khan, Wu, & Dolzhenko (2018).

The table 19 presented data on the Relationship between the Roles and

Responsibilities of Rural Health Workers and the Attitude of Meranaw Mothers on

Exclusive breastfeeding.

Table 19
Relationship between the Roles and Responsibilities of Rural Health Workers and the
Attitude of Meranaw Mothers on Exclusive breastfeeding
Roles and
Attitude 1
Responsibilities Remarks
Pearson r P-value
1. Breastfeeding should be 0.921** 0.000 Significant
continued up to 2 years?
2. Do you think breastfeeding 0.892** 0.000 Significant
should be on demand?
3. Do you believe in giving pre 0.940** 0.000 Significant
lacteal feeds to babies?
4. Do you believe in following 0.514** 0.000 Significant
vaccination schedule?
5. Should breastfeeding be stopped 0.377** 0.000 Significant
when child has diarrheal episodes?
6. Is formula feeding better than 0.941** 0.000 Significant
breastfeeding?
7. Do you think health and hygiene 0.886** 0.000 Significant
are more important for
 91

breastfeeding?
8. Do you believe that breastfeeding 0.690** 0.000 Significant
causes changes in body shape?
Total Measure 0.928** 0.000 Significant
Note: Analysis is based on Pearson Correlation **-significant at 0.01 level
1
Indicator # 9 was not included in the analysis since all of the respondents
responded agree

Result displays that the different attitudes of the respondents on exclusive

breastfeeding was significantly correlated to the roles and responsibilities of the health

workers since the observed p-values does not exceed at the 0.01 level of significance.

Further, the more the health workers promote the importance of exclusive breastfeeding,

the more the Meranaw mothers showed positive attitude towards exclusive breastfeeding.

Thus, the null hypothesis of no significant relationship between the roles and

responsibilities of rural health workers and the attitude of Meranaw mothers on exclusive

breastfeeding was rejected.

Self-efficacy and confidence of the breastfeeding mothers characterize the

practice of exclusive breastfeeding. Good knowledge about exclusive breastfeeding

practice that was acquired way before the mothers got pregnant suggests a predisposing

factor to the current state of confidence. Home support from the father enhances the

decision to sustain breastfeeding. In addition, a certain level of knowledge on the

solutions to potential problems faced during breastfeeding practice is important to equip

mothers with options to breastfeeding success (Februhartanty, Wibowo, Fahmida, &

Roshita, 2012).

Moreover, many competencies support the knowledge, abilities, and attitudes that

health professionals should have in order to assist women in preparing for, initiating, and

maintaining breastfeeding. Nurses and other health care providers who work with
 92

mother-infant dyads should gain the knowledge and skills needed to offer consistent and

evidence-based breastfeeding advice and support throughout the preconception, prenatal,

and postpartum periods. All women have the right to breastfeeding promotion and

assistance that is culturally sensitive. Each woman's decision of baby nourishment should

be supported by her community health nurse and other health care professionals. There

may be times when a woman wishes to breastfeed but is unable to or should avoid doing

so. Breastfeeding has diverse meanings and degrees of acceptance in different cultures;

consequently, clinicians must investigate the unique breastfeeding problems of the people

with whom they serve. All women have the right to acquire information on the benefits of

nurses breastfeeding in order to make educated decisions (UNICEF, 2017).

Poverty is prevalent in remote places, and households are more likely to live in

substandard conditions for an extended period of time. Aside from poverty, the

circumstances of public health facilities, notably the quality of health experts and

personnel, influence health outcomes.

Furthermore, breastfeeding recommendations in the Philippines are consistent with

the Global Strategy for Infant and Young Child Feeding, and include starting

breastfeeding within the first hour of life, breastfeeding exclusively for six months, and

providing appropriate, adequate, and safe complementary food at six months while

continuing breastfeeding until two years and beyond.

To help meet these targets and to improve Infant And Young Child Feeding

(IYCF) practices as suggested by rural health workers, “E strengthen naming yung

campaign for exclusive breastfeeding, yung benefits na makukuha nila at nung bata.”
 93

"We will strengthen the campaign for exclusive breastfeeding, the benefits that they and

the child will get." Isa din sa naisip namn na paraan upang dagdagan ang proporsyon

ng mga ina na eksklusibong nagpapasuso sa mga sanggol hanggang 6 na buwan ay mag

conduct ng mga training sa mga buntis na nanay tuwing nagpapare-natal sila.” “One of

the thoughtful ways to increase the proportion of mothers who exclusively breastfeed

their babies up to 6 months is to conduct trainings for pregnant mothers every time they

visit monthly check-up. ” “Kasama sa mga initiative naming as health workers is yung

sinusunod naming ngayon na patters which is “INITIATION, DURATION,

EXCLUSIVITY.” Sa initiation stage na yan, ang goal naming is At least maintain naming

yung the current proportion of infants who are ‘ever breastfed’, pangalawa is e increase

ang proportion ng mga infants of younger, less educated, and more disadvantaged

mothers, who are ‘ever breastfed. “Among our initiatives as health workers are the

patterns we now follow which are "INITIATION, DURATION, EXCLUSIVITY." At

that initiation stage, our goal is At least we maintain the current proportion of infants who

are 'ever breastfed', secondly is to increase the proportion of infants of younger, less

educated, and more disadvantaged mothers, who are ever breastfed. “Sa DURATION

naman is Reduce the mga insidentnte na yung nanay is hindi pinagpapatuloy ang

breastbeefing sa kanilang anak pagkatapos ng 3 buwan. Encourage naming sila

nipagpatuloy ito EBF kung tawagin hanggang dalawang taon ang bata.” “In

DURATION stage is Reduce the incidents that the mother does not continue

breastbeefing their child after 3 months. We encourage them to continue this EBF their

child up to two years old. ” “Sa EXCLUSIVITY naman, Increase naming yung

proportion ng mga sanggol na exclusively breastfed ng kanilang mga nanay sa loob ng

 94

anim na buwan or mas higit pa.” “In EXCLUSIVITY, we increase the proportion of

babies who are exclusively breastfed by their mothers for six months or more.” “ As

community workers, health professionals yung intervention na maibigay pa naming ay

yung edevelop naming yung knowledge, skills at attitudes ng mga nanay towards

breastfeeding, magkaroon ng panibagong orientations sa mga nanay, e identify ang

support environment ng mga nanay, magkaroon ng Policy development and review, e

intensify yung advocacy ng EBF sa community.” ““As community workers, health

professionals, the intervention we can provide is to develop the knowledge, skills and

attitudes of mothers towards breastfeeding, to have new orientations towards mothers, to

identify the support environment of mothers, to have Policy development and review, to

intensify EBF's advocacy in the community. ”

Most mothers do not naturally breastfeed their children. It is a talent that must be

mastered, and it is frequently coupled with physical issues. As a result, mothers,

particularly first-time mothers, require sufficient knowledge, motivation, and skills to

assist them in initiating breastfeeding and adhering to nursing length and exclusivity

standards. Interventions aiming at improving mothers' knowledge and attitudes explicitly

attempt to modify women's perceptions about breastfeeding so that they regard it as

meaningful, desired, and useful, and thereby commence nursing. Prenatal interventions

are most often used. Following that, interventions that help moms breastfeed effectively

by raising knowledge and giving practical skills (especially in response to physical issues

associated with breastfeeding) are necessary.

This intervention plan shall also tackle on capacitating and enhancing the

knowledge, skills and practices known by health workers because this study also revealed
 95

that even health workers resorted to formula milk when their maternity leave ended. They

could no longer continue to EBF their infants which were very ironic. They are

knowledgeable enough, and skilled enough on exclusive breastfeeding but they

themselves could not sustain to EBF their children. Thus, there is a dire need to

recapacitate and enhance their perceived knowledge and skills so there could be a

meaningful implementation of the EBF program in the community.

This was supported by this claim, that a primary way of promoting knowledge and

personal skills is through education and support strategies. Often education and support

strategies are intertwined, and the distinction between them is unclear (Stickney & Webb

1995). in a hospital or community setting’. Similarly, Higginson (2001) describes health

education as ‘initiatives seeking to improve mothers’ knowledge, understanding and

expectations about breastfeeding, providing factual information in the form of leaflets or

educational sessions’. In addition, the supply of information through education is referred

to as education. A range of media, including personal, textual, and electronic means

According to Fairbank et al. (2000), health education programs "give factual or technical

information on breastfeeding to a specific target group."

Table 20
PROPOSED HEALTH INTERVENTION DESIGN

Objective of the Health Intervention Program

It is expected that EBF mothers will:

1. Acquire information to prepare themselves (EBF Mothers) to EBF their children;

2. Able to decide before delivery to EBF their infant for 6 months;

 96

3. Start and continue 6 months EBF after delivery;

4. Increase the proportion of EBF mothers;

5. Enhance the skills of mothers who are for EBF.

 Establish and work with the

planning group
 Conduct needs assessment to
Step 1: Needs
identify needs of every mother in
Assessment
the community
 Describe the extent of their
practices
Planning Stage
Step 2: Program  State the expected outcomes of the
outcomes and intervention program
Objectives  Creating a logical model of change

 Generate program themes, scopes

Step 3: Program and sequence
Design  Design a practical application of the
intervention design

Activity Objectives Persons Involved Beneficiaries

 To enhance the
knowledge,
skill and
Practices
among health
Enhancement workers. HEALTH
DOH
Training WORKERS
 Reorientation
of the new
trends and
approaches in
EBF

EBF Campaign  To strengthen Rural Health Mothers

the campaign Workers
 97

on EBF
 To encourage
mothers to
EBF their
infants

 To deliver
short talks
while mothers
are cueing for
Short talk on EBF pre-natal Rural Health
Mothers
during pre-natal  To increase Workers
proportion of
mothers who
are practicing
EBF

 To change the
perspective of
House to House Rural Health
mothers who Mothers
information Drive Workers
are not into
EBF

 Prepare the structure of the

intervention program
 Prepare program materials
 Draft messages, materials and
Step 4: Program protocols
Implementation
Production  Produce materials

 Identify the potential program

Step 5: Program users (implanters persons involved)
Implementation  Conduct the intervention program

 Proper documentation of the whole

program
 Develop indicators and measures
Evaluation
for assessment
Step 6: Evaluation  Specify the evaluation design
Plan  Complete the evaluation plan
 98

Chapter 5

SUMMARY, CONCLUSIONS AND RECOMMENDATIONS

This chapter presents the summary, conclusions and recommendations of the

study.

Summary

The main objective of the study was to determine the knowledge, attitude and

practice of exclusively breastfeeding mothers in the community and the role and

responsibilities of program implementers in Lanao del sur which will be a basis for health
 99

intervention design. The researcher would also like to know to what extent have the

health workers corrected or guide the Meranaw mothers regarding exclusive

breastfeeding.

This study had two (2) groups of respondents. The study will be conducted in two

(2) different locations namely in Saguiran, Lanao del Sur and in Marantao, Lanao del

Sur. These two RHU’s were chosen by the researcher because of the available and

permitted access to the records of the list of breastfeeding mothers. The said RHU’s were

also known as some of the most active RHU’s in Lanao del Sur identified by the

Integrated Provincial Health Office (IPHO) of Lanao del Sur province.

Evaluative-inferential design in a correlational approach with qualitative

integration design was utilized in this study. The researcher made use of stratified random

sampling technique in the distribution of respondents.

Furthermore, descriptive statistics like: Statistical Product and Service Solutions

(SPSS) version 21 was used to perform all the data computations in this study. Then the

International Business Machine- Statistical Package for the Social Sciences (IBM-SPSS)

was used for deeper inferential analysis such as the Pearson r and Cramer’s V correlation

to test significant relationship between the variables in the profile of the respondents as

well as to perform a test to significantly test the influence or effect of exogenous

variables to endogenous variables.

Findings

The findings were summarized and presented in accordance to the objectives of

the study.
 100

Problem 1. What is the socio-demographic profile of respondents in terms of:

1.1 age;
1.2 sex;
1.3 civil status;
1.4 highest educational attainment;
1.5 occupation;
1.6 monthly family income; and,
1.7 number of children?

Findings revealed that most of the respondents belonged to at least 26 years of

age, and some of them were listed within 15-25 years of age. Most of the breastfeeding

mothers are old enough to understand how breastfeeding works and its lifelong benefits

to their children. On the other hand, 257 out of 700 respondents were breastfeeding

mothers aging 15-25 which means that these group of mothers needs to be informed of

how important breastfeeding is, since there are mothers who are still underage.

In addition, most of the parents having 4-6 children. Some of are those parents

having 1-3 children. Almost all of the breastfeeding mothers are married and few mothers

are separated with their husbands.

Findings divulged that most of the respondents are not first-time mothers only few

of the respondents were first time mothers. Other findings revealed that most of the

parents are college graduate. They are educated enough to know importance of exclusive

breastfeeding. Only few out of the 700 respondents were an elementary graduate.

Further findings disclosed that most of the respondents though they were able to

graduate from college most of them are unemployed and that unemployed mothers are

more likely to exclusively breastfeed their children than the working mothers.

Findings revealed that most of the parents were receiving a minimum wage of

5,000-10,000. Some of them received 10,001-20,000. Others were receiving less than 5,
 101

000 income monthly. Only few of them were receiving higher than 20,000 monthly

incomes.

Problem 2. What is the roles and responsibilities of rural health workers in the
promotion of exclusive breastfeeding?

All of the Rural Health Workers are always promoting exclusive breastfeeding to

mothers regardless if first time mothers of not. Community workers had been carrying

out exclusive breastfeeding promotion activities which provides information about the

meaning and benefits of EBF, inviting, reminding and also recommending giving EBF

and helping as much as possible if the mother has a problem breastfeeding.

Moreover, findings revealed that health workers have an important role in

assisting moms in initiating and maintaining good breastfeeding for their newborns.

Health workers are in a strategic position and have the obligation to teach and guide

moms and the broader public on healthy baby feeding beginning and adherence.

Problem 3. What is the level of knowledge, attitude, and practices of Meranaw

mothers on exclusive breastfeeding?

Finding revealed that most mothers from the two (2) location were exclusively

breastfeeding their children. These mothers who are EBF knew the benefits of colostrum

to their children. In this connection, most mothers believed that breastfeeding should be

continued up to 2 years of the child’s life. Hence, most mothers took advice from

lactation counsellor or healthcare professionals. Most of them did not give pre lacteal

meal to their children. According to EBF mothers, the first food whom they fed to their

children were breast milk, then honey.

Problem 4. What is the perspectives of rural health workers towards knowledge,

attitude, and practices of Meranaw mothers on exclusive breastfeeding?
 102

The majority of mothers were aware that breast milk protects infants from

diseases and enhances their brain. This study showed a significant link between mother

education and exclusive breastfeeding. This was congruent with the findings of Webb et

al. (2009), who looked at the links between mother academic ability and indications of

exclusive breastfeeding beginning.

Problem 5. Is there significant relationship between socio-demographic profile of

respondents and the knowledge, attitude, and practices of Meranaw mothers on
exclusive breastfeeding?

Finding revealed that socio-demographic profiles of the respondents relative to

age, number of children, first time mother, educational attainment, employment status

and monthly income were significantly associated to their knowledge relative to

exclusive breastfeeding in improving immunity since the corresponding p-values does not

exceed at the 0.01 level of significance. However, no significant relationship was found

between civil status and knowledge level on exclusive breastfeeding in improving

immunity since the p-value of 0.427 exceeded at the 0.05 level of significance.

Another findings displayed that, socio-demographic profiles of the respondents

relative to age, number of children, first time mother, educational attainment,

employment status and monthly income were significantly correlated to their knowledge

relative to the importance of initiating breastfeeding within 1 hour after birth since the

corresponding p-values does not exceed at the 0.01 level of significance. In contrast, no

significant relationship was found between civil status and knowledge level on

importance of initiating breastfeeding within 1 hour after birth since the p-value of 0.365

exceeded at the 0.05 level of significance.

 103

Further, socio-demographic profiles of the respondents relative to age, number of

children, first time mother, educational attainment, employment status and monthly

income were significantly related to their knowledge relative to the consuming of

galactogogues like almonds and fenugreek that can improve the milk production since the

corresponding p-values does not exceed at the 0.01 level of significance. In contrast, no

significant relationship was found between civil status and knowledge level on

consuming of galactogogues like almonds and fenugreek that can improve the milk

production since the p-value of 0.964 exceeded at the 0.05 level of significance.

Findings disclosed that socio-demographic profiles of the respondents relative to

age, number of children, first time mother, educational attainment, employment status

and monthly income were significantly related to their attitudes on exclusive

breastfeeding since the corresponding p-values does not exceed at the 0.01 level of

significance. But, no significant relationship was found between civil status attitude on

exclusive breastfeeding since the p-value of 0.925 exceeded at the 0.05 level of

significance.

Problem 6. Is there significant relationship between roles and responsibilities of

rural health workers in the promotion of exclusive breastfeeding and the knowledge,
attitude, and practices of Meranaw mothers on exclusive breastfeeding?

Finding revealed that the knowledge level of the respondents relative to exclusive

breastfeeding in improving immunity, the importance of initiating breastfeeding within 1

hour after birth and consuming galactogogues like almonds and fenugreek can improve

the milk production were significantly correlated to the roles and responsibilities of rural

health workers since the observed p-values does not exceed at the 0.01 level of

significance.
 104

Finding disclosed that the different attitudes of the respondents on exclusive

breastfeeding was significantly correlated to the roles and responsibilities of the health

workers since the observed p-values does not exceed at the 0.01 level of significance.

Further, the more the health workers promote the importance of exclusive breastfeeding,

the more the Meranaw mothers showed positive attitude towards exclusive breastfeeding.

Problem 7. What possible health intervention design that can be formulated in

order to address the gap?

Table 20
PROPOSED HEALTH INTERVENTION DESIGN
Objective of the Health Intervention Program

It is expected that EBF mothers will:

6. Acquire information to prepare themselves (EBF Mothers) to EBF their children;

7. Able to decide before delivery to EBF their infant for 6 months;

8. Start and continue 6 months EBF after delivery;

9. Increase the proportion of EBF mothers;

Planning Stage  Establish and work with the planning

group
Step 1: Needs  Conduct needs assessment to identify
Assessment needs of every mother in the
community
 Describe the extent of their practices

Step 2: Program  State the expected outcomes of the

outcomes and intervention program
Objectives  Creating a logical model of change
 105

 Generate program themes, scopes and

Step 3: Program sequence
Design  Design a practical application of the
intervention design

Activity Objectives Persons Involved Beneficiaries

 To strengthen
the campaign
on EBF Rural Health
EBF Campaign Mothers
 To encourage Workers
mothers to EBF
their infants

 To deliver short
talks while
mothers are
cueing for pre-
Short talk on EBF natal Rural Health
Mothers
during pre-natal  To increase Workers
proportion of
mothers who
are practicing
EBF

 To change the
perspective of
House to House Rural Health
mothers who Mothers
information Drive Workers
are not into
EBF

 Prepare the structure of the

intervention program
 Prepare program materials
 Draft messages, materials and
Step 4: Program protocols
Implementation
Production  Produce materials

 Identify the potential program users

Step 5: Program (implanters persons involved)
Implementation  Conduct the intervention program
 106

 Proper documentation of the whole

program
 Develop indicators and measures for
Evaluation
assessment
Step 6: Evaluation  Specify the evaluation design
Plan  Complete the evaluation plan

Conclusion

Based on the findings, the following conclusions were drawn:

The findings support the widely held belief that the transition to parenting is a

complicated and multifaceted event in people's lives. Mother and child health continues

to be one of the most pressing and intriguing concerns in healthcare. The results of this

study are critically important, that as they are addressing the gap in the EBF segment and
 107

sensitively show evidence for areas where urgent interventions are needed. Moreover,

these results also inform health workers how these mothers respond and integrate EBF

programs within their community health system. It also identifies the need for the

workforce to encourage mothers to attend antenatal and postnatal care to improve EBF

practice. It also shows that educational strategies are important to improve and correct

mothers’ knowledge, attitudes, beliefs, and sociocultural norms about EBF. The research

suggest that all levels of healthcare workers should be involved with EBF education. To

promote well-baby visits, antenatal and early postpartum education, and also during

home visits by community health workers, should improve maternal knowledge and

attitudes toward breastfeeding practices.

Recommendations

Based on the conclusions, the following are recommended: 

1. All health care workers who care for women and young children should be trained

on breast feeding counseling.

2. Health care workers should be able to: communicate the benefits of breastfeeding

for both mother and baby, demonstrate the proper techniques to breastfeed a baby,

and assess actual and potential difficulties/barriers and help the women overcome

them.

3. During counseling, heath care workers should discuss: the importance of

exclusive breast feeding for first six months, the benefits of initiating skin-to-skin

contact as soon as possible following the birth (to facilitate early initiation of
 108

breastfeeding), and continued breastfeeding along with appropriate

complementary foods up to and beyond two years of age.

4. Special support groups or organizations working in the community, who may

support women who are breast feeding, should be identified and involved.

5. In order to have a successful promotion and fostering of optimal breastfeeding

practices in the community, it is important to have an alliance and collaboration of

multi-stake holders, including: local government/non-profit organizations, health

care systems, community, local support groups, and family members.

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APPENDIX A

Sample Letter to the Municipal Health Officer

Mindanao State University

College of Health Sciences
Graduate School
Marawi City
 115

March 2, 2020

Dr. Naguib Bacarat

MHO
RHU- SAGUIARAN, LDS

Dear doc,

Assalamu Alaikom and good morning!

Under the supervision of Prof. Hamdoni K. Pangandaman, MAN, RN, LPT,

Professor of Graduate School, Mindanao State University, the undersigned is presently
conducting a research entitled “KNOWLEDGE, ATTITUDE AND PRACTICE OF
EXCLUSIVELY BREASTFEEDING MOTHERS IN THE COMMUNITY AND
THE ROLE AND RESPONSIBILITIES OF PROGRAM IMPLEMENTERS IN
LANAO DEL SUR: A BASIS FOR HEALTH INTERVENTION DESIGN” in
partial fulfilment of the requirements for the degree Master of Arts in Nursing (Major in
Nursing Administration).

In line with this, the undersigned would like to ask permission from your good
office to distribute questionnaires to the respondents of this study. Your participation to
the study (should you agree to participate in it) simply involves allowing some of your
staff nurses and other health worker personnel to answer a set of questions designed to
determines their roles and responsibilities of program implementation in breastfeeding.
Rest assured that the record from this study will be kept confidential as possible. No
individual identities will be used in any reports or publication from the study.

Thank you very much and more power to you.

Respectfully Yours,

Jehanna Arumpac-Guinal, RN

APPENDIX B

Sample Letter to the Health Workers

Mindanao State University

College of Health Sciences
Graduate School
Marawi City
 116

Dear Nurses,

As a part of completing a Master of Arts in Nursing, I am preparing a research

study entitled, “KNOWLEDGE, ATTITUDE AND PRACTICE OF EXCLUSIVELY
BREASTFEEDING MOTHERS IN THE COMMUNITY AND THE ROLE AND
RESPONSIBILITIES OF PROGRAM IMPLEMENTERS IN LANAO DEL SUR:
A BASIS FOR HEALTH INTERVENTION DESIGN.”. The purpose of the study is
to investigate the roles and responsibilities of program implementation in breastfeeding.
Your participation in this study will involve the completion of questionnaires that
will determine your personal profile, leadership traits and qualities of your nurse manager
based on your observation, and your degree of commitment to your work/organization
prepared by the undersigned. Completion of these questionnaires will take approximately
15-20 minutes of your time and can be completed at your convenience. Rest assured that
your name, identity, and other information will not be revealed and your record will
remain confidential.
There is no immediate benefit to you in participating in this study; however, you
may benefit by discovering the exclusive breast-feeding practices, your knowledge
attitude as a mother the result of the study will help rural health workers in finding better
strategies for improving the healthcare services in the community.

Respectfully Yours,

Jehanna A. Arumpac , RN

APPENDIX C

Sample of the Consent Form

Mindanao State University

College of Health Sciences
Graduate School
Marawi City
 117

INFORMED CONSENT FOR PARTICIPATION IN RESEARCH ACTIVITIES

Participant’s Name (OPTIONAL):

________________________________________________
Principal Investigator: Jehanna Arumpac., RN
Title of Research “KNOWLEDGE, ATTITUDE AND PRACTICE OF
EXCLUSIVELY BREASTFEEDING MOTHERS IN THE COMMUNITY AND
THE ROLE AND RESPONSIBILITIES OF PROGRAM IMPLEMENTERS IN
LANAO DEL SUR: A BASIS FOR HEALTH INTERVENTION DESIGN”

You have been asked to participate in a research study conducted by Jehanna A. Arumpac, RN.
because you are a staff nurses in a Rural Health Unit at Lanao del Sur. Please ask the investigator
to explain any words or information that you do not clearly understand.

1. PURPOSE

The overall purpose of this research is to to identify the exclusive breast-feeding practices,
knowledge and attitude of mothers and the roles and responsibilities of rural health workers to
improve the healthcare services delivery in the community particularly the maternal and child
service sector.

2. PARTICIPATION

Your participation will involve completing questionnaires that will include your personal
profile, breast-feeding practices, knowledge and attitude of mothers and the roles and
responsibilities of rural health workers.

3. DURATION

It requires approximately 15-20 minutes in completing the questionnaires.

4. POTENTIAL RISKS

The study in nature is not prone to any social or health-related risks. However, the conduction
of the study may have a slim chance of rendering some discomforts on the part of the respondent.
Questions are being asked, which may seem unnecessary to the respondent and may feel uneasy
or uncomfortable knowing that they are disclosing personal information.

However, the researcher assures that documentation and data collection procedures will be
kept as undisturbing as possible. The respondent will always have the freedom to choose not to
let some information he gave to be documented, as his right, and the researchers do greatly
respect that.
5. POTENTIAL BENEFITS

After the completion of the research and data collection and analysis phase, the results or
copy of manuscript will be to health stakeholders involve in promoting health and wellness of
nurses.
 118

Moreover, it will enable the respondents’ as this can serve as a basis to that they can assess
their selves and become more aware of their profession and therefore more equipped and
empowered.

6. CONFIDENTIALITY OR PRIVACY

Your name or identity will not be revealed and your record will remain confidential. The
investigator will assign your data a code number. A master list linking the code number and your
identity will be kept separate from the research data and only the investigator will have access to
master list.

7. COSTS

There will be no monetary cost to you as participant. The investigator will bear the cost of
administering the questionnaire.

8. CONTACT

If you have any questions or concerns regarding this study, or any problem arise, you may
contact the Principal Investigator at this contact #: 0917-1458-834 (globe).

9. VOLUNTARY PARTICIPATION

Your participation in this research is voluntary and refusal to participate will involve no
penalty to you or loss of any benefits to which you are otherwise entitled. You may withdraw
from the research study at any time. You will be informed of any significant findings developed
during the course of participation in this research that may have bearing on your willingness to
continue in the study. The investigator may withdraw you from this research if circumstances
arise which makes this necessary.

10. STATEMENT OF CONSENT

I have read this consent document and have been able to ask questions and express concerns,
which have been satisfactorily responded to by the investigator. I believe I understand the
purpose of the study as well as the potential benefits and risks that are involved.

I give my informed and voluntary consent to be a participant of this study.

____________________________________ __________________________
Consent Signature of Research Participant Date

_______________________________________ _________________________
Witness to the Signature of Above Consent Date

Republic of the Philippines

Mindanao State University
College of Health Sciences
Graduate School
Marawi City
 119

APPENDIX D

KNOWLEDGE, ATTITUDE AND PRACTICE OF EXCLUSIVELY

BREASTFEEDING MOTHERS IN THE COMMUNITY AND THE ROLE AND
RESPONSIBILITIES OF PROGRAM IMPLEMENTERS IN LANAO DEL SUR:
A BASIS FOR HEALTH INTERVENTION DESIGN

Part 1. Profile of the Respondents

Age:______
Number of Children: _________
Civil Status: __________________
First time mother: Yes( ) No ( )
Education: Elementary Graduate ( )
High School Graduate ( )
college graduate ( )
with Master or PhD ( )
Employment status:
with occupation ( ) Unemployed ( )
Income Status/ month:
less than 5,000 pesos
5,000-10,000 pesos ( )
10,000-20,000 pesos ( )
Higher than 20,000 pesos ( )

Are you practicing exclusive breastfeeding: Yes ( ) No ( )

Instructions: As a mother, encircle the letter of your appropriate response to a question
about your knowledge, attitude, and practices on exclusive breastfeeding. Choose only 1
answer.
 120

Part II. Knowledge, attitude, and practices on exclusive breastfeeding mothers

A) Knowledge of Mothers on Exclusive Breastfeeding

1. Is exclusive breastfeeding important?
a) yes b) no
2. Is colostrum nutritionally beneficial to the child?
a) yes b) no
3. Does exclusive breastfeeding improve immunity?
a) Anytime the mother is ready b) Immediately after birth
4. Is it important to initiate breastfeeding within 1 hr. after birth?
a) 6 months–24 months b) ≤5 months
5. Can exclusive breastfeeding prevent child from diarrhea?
a) yes b) no
6. Growth patterns of breastfed infants differ from formula fed?
a) yes b) no
7. Consuming galactogogues like almonds and fenugreek can improve the milk
production?
a) yes b) no
8. How long exclusive breast feeding should be continued?
a) less than 6 months b) 6 months c) more than 6 months

B) Attitude of Mothers on Exclusive Breastfeeding

1. Breastfeeding should be continued up to 2 years?
a) agree b) unsure c) disagree
 121

2. Do you think breastfeeding should be on demand?

a) agree b) unsure c) disagree
3. Do you believe in giving pre lacteal feeds to babies?
a) agree b) unsure c) disagree
4. Do you believe in following vaccination schedule?
a) agree b) unsure c) disagree
5. Should breastfeeding be stopped when child has diarrheal episodes?
a) agree b) unsure c) disagree
6. Is formula feeding better than breastfeeding?
a) agree b) unsure c) disagree
7. Do you think health and hygiene are more important for breastfeeding?
a) agree b) unsure c) disagree
8. Do you believe that breastfeeding causes changes in body shape?
a) agree b) unsure c) disagree
9. Does breastfeeding increases mother child bonding?
a) agree b) unsure c) disagree

C) Attitude of Exclusive Breastfeeding Mothers

1. Did you take advice from lactation counsellor or healthcare professionals (e.g. doctor,
nurse, or midwife) before breastfeeding?
a) Yes b) no
2. Did you give pre lacteal feeds to the infant?
a) Yes b) no
3. Do you think that EBF is better than artificial feeding?
a) Yes b) no c) don’t know
4. What was the type of the first feed given to your last child?
a) Breast milk b) Honey c) Sugar Water
5. Do you believe that the first milk [colostrum] should be discarded?
 122

a) Yes b) no
6. When did you start breastfeeding after delivering your last child?
a) In an interval of 1 hour b) in an interval of 2-6 hours
c) After 24 hours
7. How frequently do you breastfeed?
a) On demand b) At specific intervals
c) At random
8. How frequently do you consume galactagogues or green leafy vegetables (e.g. horse
radish) and its extracts for improving milk production?
a) Daily b) Weekly c) Never
9. Do you agree that only EBF is enough for child up to 6 months?
a) agree b) disagree
10. How did you feel when you give extra food other than breast to your child?
a) Didn’t feel comfort b) Comfortable with it
11. Do you agree that child less than 6 month who is exclusively breastfed is healthier
than child who takes additional food?
a) Yes b) no c) I do not know

Part III. Role and Responsibilities of Program implementers

As health worker, it is my role to …. Always Often Sometimes Never
(4) (3) (2) (1)
11. Advise breastfeeding mother against the use
of pacifiers
 123

12. Advise exclusive breastfeeding when mother

works
13. Teach mothers how to express their breast
milk
14. Orient mothers about the advantages of
exclusive breastfeeding
15. Observe feedings to check if mother knows
how to breastfeed her baby
16. Orient mothers on how to care for breast
traumas
17. Advise mother initiating breastfeeding with-
in a half-hour of birth
18. Demonstrate how to breastfeed a baby,
including positioning and attachment
19. Encourage mother to breast their baby up to
two (2) years
20. Encourage working mothers to practice
exclusive breastfeeding by introducing
strategies on how to bank/ store breastmilk.

As health worker, it is my responsibility to …. Always Often Sometimes Never

(4) (3) (2) (1)
11. Explain and make mother understands the
process and advantages of exclusive
breastfeeding.
12. Ensure that all mothers in the community
accepts and practices exclusive breastfeeding
13. Demonstrate to the mother the strategy and
proper way of breastfeeding their baby
14. Provide assistance to mothers who have met
issues, challenges or special needs in
practicing exclusive breastfeeding.
15. Introduce strategies on exclusive
breastfeeding for mothers to be motivated and
inspired.
16. Counsel mothers and her partner (husband) on
issues and concerns related to exclusive
breastfeeding.
17. Advise mother to seek healthcare professional
assistance for some issues and concerns
 124

related to exclusive breastfeeding.

18. Monitor mothers’ practice and progress on
exclusive breastfeeding.
19. Conduct programs related to breastfeeding to
promote the practice for mothers and planning
to be mothers in the community.
20. Refer client mothers with complicated health
issues to a specialist to know or discover if
breastfeeding do not compromise health.

Part IV: Interview guide for the Health workers

1. As healthcare professional (or community nurse), how do you encourage mothers

to practice EBF?

2. Have you noticed any problems regarding EBF among your clients, patients, or
the mothers you work with in the community?

3. Why do you think more mothers are resorting to formula milks?

4. As healthcare professional affiliated in the RHU and has an expected role and
responsibilities to promote exclusive breastfeeding, how do your perceived the
accuracy of the knowledge of the mothers in your community regarding EBF?

5. What are the common misconceptions of the mothers regarding EBF?

6. What do you think are the deterrent factors that stops mothers from practicing
EBF?

7. What are the reasons why some of the working mothers could not maintain the
practice on exclusive breastfeeding?

8. What health intervention program can you suggest or recommend to improve

promotion of exclusive breastfeeding in the community? And then how will you
possibly implement?