Fathers Role in Infant Feeding and Care: Exploring Perceptions, Practices and Challenges in Lesotho’s Rural Community

Abbreviations

UNICEF: United Nations Children's Fund,
CDC: Centers for Disease and Prevention
USAID: US Agency for International Development
IYCN: Infant & Young Child Nutrition
COVID-19: Coronavirus
WHO: World Health Organization
NUL: National University of Lesotho
NICHD: National Institute of Child Health and Human Development

Introduction

The first five years of life is very critical to the growth and development  of  children.  According  to  Heemann,  et  al., undernutrition among children less than five years is a public health issue globally [1]. The consequences of undernutrition are profound, contributing to approximately 3.1 million child deaths annually, which accounts for 45% of all mortality in this age group [2]. The Lesotho Demographic and Health Survey highlighted a triple burden of malnutrition, where undernutrition coexists with rising rates of overweight and obesity, indicating a complex nutritional landscape [3]. According to United Nations Children's Fund, (UNICEF) (2020), nearly half of all deaths in children less than five years are contributable to undernutrition; which puts children at greater risk of dying from common infections, increases the frequency and severity of such infections and delays recovery. Furthermore, the impact of stunting extends beyond cognitive deficits to include increased risks of behavioral problems and mental health issues. For example, a systematic review highlighted that childhood malnutrition is associated with neurodevelopmental impairments that can lead to poorer academic performance and increased behavioral issues during childhood and adolescence [4,5].

According to Dixit, et al. governmental and non-governmental organisations invest a lot in programs that raise awareness to the public about the significance of appropriate child feeding practices. These programs are received by mothers as they are often primary caregivers for young children. Despite all the initiatives in improving child feeding practices, malnutrition is still a major cause of child morbidity and mortality (United Nations Children's Fund, 2020) [6].

Factors that lead to malnutrition are interrelated, that is one cause is the precursor of the other [7]. This could be combated at early stages of life and requires a multifaceted approach to ensure that children are well catered for. Parental support is greatly needed and it takes both fathers and mothers in ensuring that children are well-nourished for better health. This is supported by Bogale et al., who noted that fathers with higher educational attainment are more likely to engage in child feeding, further emphasing the role of education in promoting healthy practices. Research has revealed that there has been recognition that, to improve maternal, infant and young child nutrition, health structures need to incorporate and support fathers because they play a critical role in providing not only instrumental but also emotional support to mothers and children. For instance, Allotey et al. highlight that fathers in Kaduna State, Nigeria, recognized their role in emotionally supporting mothers during complementary feeding, which aligns with the broader understanding of father involvement [8]. In the light of this, the study set out to investigate the extent of fathers involvement in the care of infants 1-12months.

Practices of infants feeding and care have been a major concern in both developing and developed nations in order to prevent malnutrition [9]. This is particularly important in developing countries where child malnutrition is most prevalent and threatens public health – child care and feeding is not the matter of only having healthy food but also of satisfying the basic needs of a child. Men play a critical role in ensuring optimal nutritional support to new-born and thus by involving them could positively reduce the prevalence of malnutrition in infants. In general men have limited social support for engagement in child care although role models of active fatherhood do exist and have an influence, men who are viewed as too involved are likely to be laughed at or otherwise experience negative reactions from other men [10]. In most cases, especially in Lesotho these men are viewed as having been “poisoned” by the influence of their wives. The UNICEF conceptual framework clarifies the fact that underlying causes of malnutrition in children has to do with inadequate food access and inadequate care. This implies that maternal care for children is not enough to combat malnutrition and ensuring better health of infants.
 
Few studies have considered other aspects of fathers’ engagement in children’s life, and these studies emphasized more on fathers of children with specific and serious health issues such as autism, obesity or psychological problems [11]. Men involvement during breastfeeding is associated with improved breastfeeding rates and well nourishment [12]. This study was to assess the perceptions, practices and challenges of fathers in the care and feeding practices of infants (1 to 12 months).

Perception of Men with Regards to Young Children Care and Feeding
Some fathers do not perceive routine child-care practice as their responsibility. They consider all child-care as mothers’ duty all day [13]. These men are very distant from practical life of the family, and they only feel responsible for seeing to it that there is income generated to support the family. With this role they perceive that they are giving full priority to their family because they are fulfilling their responsibilities as needed. These fathers usually spent their time outside their home, and, even spend their leisure or free time with friends rather than family.

Interestingly, fathers seem to be content with lending little hand to the mothers because traditionally they believe that it is the duty of the mothers to feed and care for the children. Moreover, their role is conditional on several factors such as age of the children. For example, they believe that between 6 and 8 months of the child’s life is the convenient time for them to participate in child-care practices while others perceive that 5 years or more as the right time for them to be involved in child-care activities.

As cited in Bilal, et al. study on perceptions of men in child care and feeding, fathers perceive that time is a very important factor. In this study fathers perceived that one who spends more time with the child is more responsible for child care and feeding. Therefore, their role in child care is dependent on the time they were at home and this time was often limited. Fathers claim that the time they spend with their children is limited because they leave early for work and return in the evening, thus the one who will be responsible is the one who spends most of the time with the child [14].

Nevertheless, few fathers perceive that they are equally responsible as mothers in child-care practices [15]. These fathers have no boundaries in child-care and feeding or household activities. They feel responsible and they consider that taking care of the child should start at birth and should continue until a child could lead his or her way independently. These fathers acknowledge that full involvement might be difficult but sharing it could be acceptable especially by the new generation unlike in the past whereby all household duties were considered to be the responsibility of the mother alone.

 Benefits of Engaging Fathers’ in Children Care and Feeding
 Improved Breastfeeding Rates
Breast milk supplies all the necessary nutrients, helps to keep a baby healthy and also benefits the mother in diverse ways [16]. While the infants receive physical, cognitive and social-emotional development, the mother also has many positive outcomes, therefore, it is important to exclusively breastfeed. Yalçin provides an evidence that breastfeeding should be initiated as soon as possible after birth, within first hour after delivery. Menon further adds an evidence that breastfeeding immediately after delivery is very important for child survival as proven to be associated with decreased infant mortality [17-19]. This study compared mothers who initiated breastfeeding within the first hour life with infants who initiated breastfeeding 2-23 hours after birth. Results showed that those who initiated breastfeeding after 24 hours or more after birth had an 85% greater risk of neonatal mortality compared to infants who initiated in less than 24 hours after birth. Babies need to be breast fed when they show any sign of being hungry or any anytime a mother feels a need to.

For all of the above reasons, there should be optimal rates of breastfeeding. And the father’s support has been identified as one of the strongest contributors of exclusive and optimum breastfeeding. A study conducted to explore the declining prevalence of breastfeeding revealed that the infant feeding decision is not an individual’s decision but is multifaceted. This study highlighted the father’s involvement and preparedness as an essential predictor of infant feeding and further elaborated that those mothers who received support from their child’s father (intervention group) had a higher exclusive breastfeeding prevalence rate of 25%, whereas that rate was 15% for the mothers in the control group (no father’s support). Moreover, 12-month-old children of mothers in intervention group had 19% rate of successful breastfeeding, whereas it was 11% for the mothers in control group. Fathers create an environment of safety and comfort which can be transmitted on the mother and eventually represent a reason for success in infant feeding practices and her confidence in the role of the mother.

Optimum Formula or Bottle-Feeding
As of breastfed infants, children who cannot be breastfed for some reasons which cannot be avoided, also need optimum feeding for healthy nutritional status. According to Centres for Disease and Prevention (CDC) (2018), a lot of work needs to be done in preparation of bottles or feeding the baby like cleaning and sanitizing the workplace where infant formula will be prepared and bottles needs to be clean and sanitized too. As a result, this poses work burden on mothers since they are responsible for other household activities and new-born are fed frequently in 24 hours, 8-12 feedings (Centres for Disease and Control, 2018). Thus mothers get tired due to compromised resting and sleeping hours and may decide to introduce supplementary feeding earlier. As a results infant’s nutrition will be compromised leading to poor nutritional status. Fathers could help with preparing the formula while a mother is getting some sleep.

 Fathers’ Role in Ensuring Optimal Care and Feeding in Young Children
Playing with the child is what most fathers do among the activities they would be seen doing with their babies. According to this study examples of playing activities include; physical playing, tricking while feeding and making different musical sounds. Preparing the child’s food, feeding the child, giving money to the mother to buy food or other things for the child, bringing food from the garden, and buying food and other child needs from the market/ town are other activities that are often done by fathers (USAID IYCN Project, Kenya Ministry of Health, 2011). Additionally, calming down the child when crying, bathing the child, and changing clothes of the child are other activities that fathers can often do. However, the majority of fathers underlined that they would do these activities only if the mother was busy with other household activities or if the mother was not around. The majority of the fathers in the study by Lowenstein, et al. also mentioned that they discuss child-care issues with their wives. Mothers who were involved to validate fathers’ responses in the study by Bilal, et al. confirmed that common activities of fathers in relation to routine child care and child feeding included playing with the child, giving money to the mothers to buy necessary things, and providing food from the garden. Buying food and other child’s needs from the market were other activities mentioned as typical fathers’ activities. Mothers also confirmed that attending child- related education, taking the child to vaccination, or other child- care visits were rarely done by fathers.

 Challenges Facing Men in Child Care and Feeding
There are different challenges or barriers that affect fathers’ involvement in routine child-care and feeding practices. According to Owoaje, et al. being busy with work activities such as farming and other income generation activities, made it difficult for fathers to spend time with their child, being involved in their child’s life and to attend child health-related education. Poor understanding of the importance of child care and feeding among fathers, along with financial problems, was also mentioned as a major factor that inhibited fathers from practicing the little knowledge they had. Accessibility and shortage of food were also mentioned. For some of the fathers, financial problems are huge challenges even if they have plenty of knowledge about feeding practices. On the other hand, there are other groups who have money but do not have knowledge. Moreover, some fathers waste the money on non- essential issues or they simply save the money without spending it on their child’s needs. Some of the fathers have knowledge as well as money but they do not want to buy anything for their children.

Among other challenges facing fathers to practice child-care and feeding activities appropriately are, incorrect perceptions, beliefs and bad habits of fathers. This study showed that many fathers still considered child-care and feeding activities as only the mothers’ responsibility. Furthermore, many fathers seem resistant for change or new ideas. They indicated they would not feel proud of taking care of their babies, they find themselves careless, or they simply give priority to themselves instead of their children and sadly keep good foods for special occasions. According to Dubaugh, et al., (2014), the majority of mothers confirmed the challenges of the fathers’ perceptions and cultural and traditional beliefs that indicated child care is only the mother’s responsibility. They also mentioned the knowledge and information gap between mothers and fathers, because the fathers are not participating in child health-related education. They also emphasized that this knowledge gap indirectly affects mothers’ financial capacity and hinder them from providing all the necessary care, foods and materials for their children.

Methodology

Study and Population
The focused population under this study were fathers who had children between one to twelve months of age that lived with them. The study was conducted at Ha-Mafefooane, a community in Roma, which falls under the peri urban part of Maseru district, Lesotho. Roma is where the National University of Lesotho, the primia university in the country is situated.

Study Design
A qualitative research approach was used for this study where interviews were conducted and transcribed and the verbatim transcript were translated from Sesotho to English with key informants. Furthermore, qualitative research involves collecting and analysing text, video, or audio to understand concepts, opinions, or experiences, it can be used to gather in-depth insights into a problem or generate new ideas. Twelve interview questions were used for data collection.

Sampling and Sample Size Determination
For this study, sample were fathers of children less than 12 months of age and who lived with their children. A purposive sampling technique was applied to select the study participants. Purposive sampling also known as judgmental or subjective sampling, is a form of non-probability sampling in which researchers rely on their own judgement when choosing members of the population to participate in the study.

For this study, fathers who have children between one month and a year were selected since they would be relevant to the study purpose. The goal of the study was to explore fathers’ perceptions, practices, and challenges in young childcare and feeding, it was found important that participants were being studied while they were still experiencing the situation. The sample size of phenomenological research varies from study to study. Given that in-depth interviews or questionnaires provide a vast amount of data about the phenomenon of study, only a limited number of interviews or questionnaires are necessary in this form of research. In this research method, sample size is usually very small; around five or six due to time-consuming nature of the analytic process. In phenomenological research, according to Cohen, et al. for hermeneutics, less than 10 participants are allowed if study time is limited or intense and greater or equal to 30 if less intense. For these reasons, research was carried out with six (6) participants.

 Sampling Criteria
Inclusion Criteria
According to Patino & Ferreira, inclusion criteria are the key features of the target population that the investigator used to answer their research questions. The included population under the study: fathers who have children less than 12 months of age for and who lived with their children.
 
  Exclusion Criteria
In contrast, the exclusion criteria are the features of the potential study participants who meets the inclusion criteria but present with additional characteristics that could interfere with the success of the study. The excluded population under the study were fathers who had children over a year of age and who lived away from their children.

 Data Collection Methods

 Individual Interviews
For this study, face to face interviews were the primary methods of data collection for some reasons. Qualitative interviewing is appropriately used when “studying people’s understanding of the meaning in their lived world”. In fact, interviewing is the best technique to use “to find out those things we cannot directly observe e.g. feelings, thoughts and intensions”. For this study, twelve 12 set of questions were designed prior to field data collection. The questions were piloted in a nearby community to assess the feasibility of the study. Interviews were conducted using the local language, Sesotho. All participants who were interviewed gave their consent. The duration of each interview discussion was approximately 20 minutes. All participants were interviewed at their respective homes. Interviews were audio recorded and transcribed in preparation for formal data analysis. Due to corona virus disease (COVID-19) pandemic which is very contagious and of which is the global threat, World Health Organisation (WHO), established safety guidelines to minimise the transmission. During field data collection, these guidelines were observed through wearing of face masks, keeping social distance of approximately 1.5m between a researcher and interviewee, as well as hand sanitation.

Data Analysis
The goal of the data analysis was to find the essential constituents of the phenomenon as experienced by the participants. For this study, firstly, interview transcripts were transcribed and reviewed several times, searching for “recurring regularities”. Quotes and phrases from the interviews that were significant to the study were highlighted. Using the thematic analysis method, data was reviewed several times until themes emerged that were consistent yet distinct. Thematic analysis which is generally used in qualitative research, occurs when all the data are in. it is a process of segmentation, categorisation and relinking of aspects of the database prior to the final interpretation. It is achieved by identifying and focusing on repeated words or phrases or evidence of answers to the research questions. Themes may be found from the previous research that is reviewed, from researcher’s gut feeling, as well as from views of those being observed or interviewed.

Ethical Consideration
Ethical approval was granted by the NUL- institutional review board and the Ministry of Health, Lesotho, with ethical approval number ID 81-2021. According to Resnik, (2015), ethical consideration focuses on the disciplines that study standards such as philosophy, law, psychology or sociology will take. This include method, procedure or prospective, and values that are essential to collaborate the research such as trust, accountability confidentiality, mutual respect and fairness. A clear explanation of the aims and objectives of the study were made to respondents before participating thereafter, only a willing father participated in the study. Also, anonymity and confidentiality were confirmed so as to protect the identity of the participants and ensure the privacy and dignity of the participants.

  Limitations of the Study
According to Price & Judy the limitations of the study are those characteristics of design or methodology that impacted or influenced the interpretation of the findings from the research. Firstly, limitations of this study were related to the sample. The number of participants in the study was very small, which is six. A larger pool of participants could have helped produce different or additional themes during data analysis. Secondly, data for this study was collected from the village in Roma, Maseru, hence findings are not generalized for all fathers in Lesotho nor Maseru District. Lastly, this study was not pilot tested due to lack of funds and limited time.

 Results

Socio Demographic Background of Respondents
The mean age of fathers of fathers who took part in this research was 36 years. All of them were capable of reading and writing their home language, Sesotho. Their sociodemographic profile showed that all of these participants ended schooling at different levels or grades at primary school and only one father had a certificate. All families were of low-income class with average money spend on a child per month was M3,500 maloti (equivalent to 120 USD dollars). No father had a formal job, they all worked by selling light commodities like snacks on the streets and cultivating crops for consumption. All fathers had children less a year of age (1-12months) and were all married as per the inclusion criteria.

  Perceptions of Fathers in Infancy Care and Feeding
Most fathers agree and support the fact that both a mother and a father should be there for infants. This conclusion is drawn from the discussions with fathers as they kept saying “it is our baby not hers alone.” Although they hardly or had knowledge on their task or responsibility in infancy care and feeding practices. They all think that indeed fathers should be engaged in infants’ care practices but their agreement was conditional:
“… but much care should be from the mother since she is the one who spends a lot of time with the baby while I am at work. … with the money we buy infant’s needs”
“yes I agree that I should be involved be in everyday child care and feeding practices but provided there are means of generating money without me having to be at work.”

According to most fathers the daily tasks of infant care and feeding are responsibilities of mothers apart from financial support. Time and being away for a job are their major point of view. Most fathers perceive as ensuring children care by generating income. They mentioned that their duty and responsibility is to see to it that there is money to buy all what is necessary for the infants and the house. Fathers also perceive that a lot of care and feeding practices
as mothers’ duty since they spend a longer time with the child than fathers and they are the ones who are very conscious about care-giving. Apart from mothers being very conscious, fathers mentioned that they have no quality time with their family as they leave early in morning for work and return late in the afternoon, so mothers are forced to offer much care to infants. Fathers only have a better time with their children during the weekends especially Sunday. Fathers cannot prepare food for infants but they do assist mothers feeding infants readily prepared foods.

“I make sure that a mother and an infant have money to purchase all the needs. Preparing food/ milk for an infant is a mother’s duty because I do not know how to measure portion sizes to make a formula thick or less thick as required for feeding a baby… mothers are good at that… I assist my wife by feeding a baby if the bottle or food is readily prepared.”

“… because I am always busy most of the times, I normally spend time with my child and the family in the morning before departure to work, in the afternoon, and during the weekend especially Sundays...”

Fathers have boundaries as it comes to child care and feeding practices. There are some things they do freely without any hesitation but they consider most tasks as strictly mothers’ duty. Most fathers mentioned that they feel free to help the mother if she asks for assistance with the child but on certain conditions. Most of them said that they help a mother when she is sick or busy doing some household tasks and an infant needs attention. Fathers mentioned that they feel disrespected if the mother is doing absolutely nothing and asks them to maybe feed the child. Among the things they can do, washing sanitary towels and changing child diapers were excluded and mentioned strictly as mothers’ duty as accepted by the society.

“I feel free to help her if she is busy doing something but disrespected if she is actually doing nothing because it is her duty to offer care...”

Although every father mentioned income generation as their major role in the family, there are different reasons that emerged through the discussions such as “… I take a fully responsibility by seeing to it that there is food for a mother as to empower her to breastfeed for the better growth of our child.” These fathers showed that even though they perceive income as the major care they could offer, there is a little knowledge about breastfeeding.

 Practices of Fathers in Infancy Care and Feeding
Fathers were further asked what could they be seen doing for infants if they were to be left alone with them on a normal day and all answers were much related. Most of them found it impossible for a mother to leave an infant with a father because mothers are so conscious as it comes to care-giving. Among the tasks fathers mentioned they would be seen doing is calming down a baby when she/he is crying. Fathers cannot prepare bottle nor food (supplementary feeding) for the infants but feeding the child a readily prepared food or bottle is what they do. They mentioned that they can be seen doing the baby’s laundry but things like sanitary towels it is so sensitive to see a father doing culturally. Lastly, most fathers found it impossible for a mother to leave a child of that age with them. Their reasoning was the same – being that mothers are the ones who are very conscious as it comes to child care and feeding practices.

“calming her down when she is crying, feeding her readily prepared food, doing her laundry as well as bathing her… but I don’t think it is wise for a mother to leave a child of this age with me the whole day because much care is known by mothers. But I can assist her when we are both available in some fields of infant care like, bathing a baby, feeding as well as doing laundry her laundry.”

There are some practices of care and feeding that fathers do without any hesitation. Fathers find it their first responsibility to ensure income generation in the house. Cultivation of crops as to minimize monetary costs of food since they have no formal job and as to maximize availability of food. Fathers also buy groceries and infants needs from the market. As noted from the discussions one father said: “… I make sure that there is food in the house by working hard since I have no reliable job and by cultivating vegetables on the backyard. Fathers also mentioned that they also do some household tasks excluding the infants’. Among these household tasks, cooking, dish washing, cleaning the house, and fetching some water were frequently mentioned by fathers. They all made it clear that doing all the mentioned household tasks is the way of helping a mother if she is busy and they are not.

“.. when I am available I do other household duties if the mother is busy with the child.”

Other activities mentioned as the way of helping a mother by fathers include bathing a baby. Although they mentioned that bathing a baby is not that simple but when a mother is occupied with other household tasks or unavailable they are compelled to do so. Playing with a child was one of the first things that fathers mentioned when they were asked about what kind of activities they do in child care. They described their playing activities as making sounds that makes the baby smile, changing facial expressions (scary or funny), and many more. These playing activities are done as a way of calming a child when he/she is crying. One of the fathers said that he notices some unusual movements or behavior of his child that he might be sick or hungry. This father also mentioned that he reminds the mother about dates of taking a child to the clinic for immunization and growth monitoring. This practice was the only one distinct from other practices done by fathers.

“I help the mother with many things including playing with a child when she is crying and a mother is busy… although it is hard for me, I do change her diapers and bath her if her mother is busy somewhere.”

 Challenges and Barriers of Fathers in Infancy Care and Feeding
Among the challenges that fathers face in infant care and feeding, the major one is having no means to provide financial support. There are several reasons mentioned why is it a challenge. Fathers mentioned that when there is no money a child suffers a lot since she/he needs milk, medicines, as well as sanitary towels or diapers. Again, working away from home, South Africa for instance, for several months or a year keeps fathers away from their children. Another challenge experienced by fathers is having wrong believes as it comes to child care and feeding. It is a wrong believing or failing to exercise the little knowledge they have about their role in infant care and feeding. Fathers mentioned that traditionally men are not allowed to see or be in the house where a new-born is for a period of a month but they also mentioned that it is difficult for them to handle a baby especially in the first month of life. Fathers perceive full care and feeding practices as mothers’. Although they do partake in care practices, it is as the way of helping mothers of infants. Fathers mentioned that it is so sensitive for a man to fully participate in child care and feeding. Activities such as washing infants’ sanitary towels or changing diapers are accepted as mothers’ duty. As it comes to feeding of infants, fathers can only feed the baby only if food is readily prepared by the mother.

“my major challenge comes when I could not find a job. I mean having no money to buy infant’s diapers, medicines, pay for the transport to the hospital, as well as infant’s formula and I will be forced to ask for help from my neighbours or go to the loan sharks… preparing her bottle is something dificult for me to do as well washing her sanitary towels.”

Discussion

Conclusion

This study helped the researcher to develop and recommend an educational tool or approach to be used to target fathers about infants’ care-giving and feeding. The researcher termed this tool “Be a Good Father”. This tool could be used by programmers, and community health workers to approach and educate fathers in the rural areas of routine infants’ care and feeding. Having identified fathers’ perceptions, practices, challenges they face in daily infants’ care, this tool can help to precisely design and implement interventions that overcome fathers’ challenges. Approaching fathers at their level of beliefs, perceptions, and practices of infants’ care and feeding could be worthwhile. Since fathers’ studied showed that they are partially involved in their childrens care and feeding practices and only participated as the way of helping the mother, the developed tool to educate them to fully participate could be so helpful in the described manner. Having found that most them were traditional fathers who strongly perceive that infants’ care is only the responsibilities of the mothers, and they only feel responsible for income generation, basic education that challenges their strong believes and perceptions is needed. Culture is a learned experience that can be unlearned, therefore through the developed tool, providing basic education to them is worth it. Although these fathers seemed so traditional, they are however, selective on the activities they do. As a result, they should receive education that empowers and enables them to fully be involved in child care and feeding practices.

In line with the literature, and the researcher expectations, this study shows that targeting fathers is an important approach and it seems justifiable to plan interventions that involve fathers. Assessment of their involvement and experiences in infants’ related education programs is an important factor to be considered for any intervention.

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