Editorial Board:Editor:George H. Conklin,  Emeritus, North Carolina Central UniversityRobert Wortham,  Associate Editor, North Carolina Central UniversityBoard:Rebecca Adams,  UNC-GreensboroBob Davis,  North Carolina Agricultural and Technical State UniversityCatherine Harris,  Wake Forest UniversityElla Keller,  Fayetteville State UniversityKen Land,  Duke UniversitySteve McNamee,  UNC-WilmingtonMiles Simpson,  North Carolina Central UniversityWilliam Smith,  N.C. State University              

Editorial AssistantsJohn W.M. Russell,  Technical Consultant

® 

Volume 10, Number 2

Fall/Winter 2012
 

Breastfeeding Perceptions and Attitudes: 
The Effect of Race/Ethnicity And Cultural Background

by

Krystal Christopher

University of Central Florida

Introduction

    Though breastfeeding initiation rates in the United States have drastically increased from the 1990s to the 2000s breastfeeding rates at twelve months postpartum still fail to meet the goals set forth by Healthy People 2010 (Rojjanasrirat and  Sousa  2010). Currently the statistics show the breastfeeding rates at six and twelve months of birth at 41% and 20% respectively, compared to Healthy People 2010 objectives of 50% and 25% at twelve months (Rojjanasrirat and Sousa 2010). These differences widen even more when race and ethnicity are considered. According to a Center for Disease Control study, Hispanic women have a breastfeeding rate that is highest among all racial/ethnic groups with more than 80% initiating breastfeeding immediately after birth and 45% continuing at least six months later (Center for Disease Control and Prevention 2010).

    Cultural differences in breastfeeding initiation can further widen the breastfeeding gap that is present due to the usual demographic variables of race, socioeconomic status, etc. There are a number of variables that contribute to one's perception of breastfeeding. Studies have shown that individual's perceptions and attitudes towards breastfeeding are correlated with initiation and sustainment of breastfeeding (Simmie 2006). 

    Disparities in breastfeeding rates also exist within racial groups. Cultural background has been identified as a possible explanation for the differences seen within racial groups based on an individual's cultural environment (Gibson, Diaz, and Geesy  2005). The trends and beliefs of a culture tend to influence the decision to breastfeed. Hispanics mothers are more likely to rely on breastfeeding advice from their familial network (partner or mother)  when making feeding decision, this is in opposition to non-Hispanic whites who are more likely to rely on advice given by their health care providers (Gibson, Diaz, and Geesy  2005). It has been noted by numerous studies that acculturation as well as country of birth and language spoken at home have an influence on both the history and intention of breastfeeding (Gibson, Diaz, and Geesy 2005).

    The purpose of this study is to assess whether or not there are differences between race/ethnicity or cultural background on the attitudes and perceptions of breastfeeding among undergraduate college students attending a large public university in the southeastern United States. The college population was chosen in order to assess if the perceptions and attitudes towards breastfeeding are similar to what studies have shown regarding the correlation of breastfeeding attitudes/perceptions and initiation and sustainment of breastfeeding. The theory of planned behavior formulated by Icek Ajzen (1988, 1991) is said to predict deliberate behavior (behavior seen as planned). Three components work together to create a behavioral intention. According to Ajzen behavioral beliefs (consequences of the behavior) produce a favorable or unfavorable attitude toward the behavior, normative beliefs (normative expectations of others) result in social pressure or subjective norm, and control beliefs give rise to perceived behavioral control. The more favorable the attitude and subjective norm and the greater the perceived control the stronger the person's intention to perform the behavior will be.
 

    By looking at the college population where many do not have children, we can assess their perceptions and attitudes to be a result of their behavioral beliefs and normative beliefs as described in Ajzen's theory. Some of these students will grow to have children and contribute to the breastfeeding prevalence rate. This paper specifically looks at the perceptions and attitudes of those who identify as Hispanics compared to all other identified racial/ethnic groups.

    There has been a noticeable difference in race and cultural background as it pertains to breastfeeding attitudes and how breastfeeding knowledge is acquired. One study analyzed the attitudes of Asian and Caucasian mothers in regards to breastfeeding and formula feeding through the use of questionnaire. The results identified attitudes towards duration and efficacy as being a factor influencing the intention to breastfeed in Asian and Caucasian backgrounds (Simmie 2006). In the same study done in England, it was also suggested that all mothers receive knowledge about breastfeeding from hospital midwives; the Asian community however also gained knowledge about breastfeeding from family and the mother's own mother (Simmie 2006). A study done in Hong Kong, China used a sample of 82 Chinese women who had a normal vaginal delivery at a local hospital. The purpose of the study was to explore the relationships between knowledge, self efficacy, and demographic patterns on the patterns of breastfeeding. The results found that women who researched breastfeeding information on the internet, were married, and highly educated were more likely to breastfeed exclusively (Man-ku and Chow 2010). The findings were consistent with that of the United States.

    New findings have not only found  racial differences but also regional differences regarding breastfeeding rates in the United States. A state-by-state analysis of racial differences as it pertains to breastfeeding prevalence, found that overall Hispanic women generally breastfeed more than Caucasian and African American females (Center for Disease Control and Prevention  2010).  Regional differences were also found in the prevalence rates with Hispanics residing in the east breastfeeding more than other women and in some western states; white women had higher rates (Center for Disease Control and Prevention, 2010). The highest breastfeeding rate was for Caucasian women in the District of Columbia (97% initiation rate, 80% after 6 months) while Mississippi had a rate of less than half of the national average (35% or lower) for women who tried breastfeeding (Center for Disease Control and Prevention 2010). 

    Cultural differences in breastfeeding initiation can bring about differences on the impact of the usual demographic variables on breastfeeding rates. In a study focused on the Brazilian population, samples of 230 mothers were surveyed in order to test the associations of sociodemographic variables such as maternal attitudes and perceptions with intended breastfeeding duration.  Results showed the usual relationships between sociodemographic variables such as age, and education were not found to be significant among the sample (Paine and Dorea  2000). The study did find that Brazilian mothers' intentions were related to gender role attitudes with both the least and the most traditional women intending to breastfeed longer than women with moderately traditional gender role attitudes (Paine and Dorea  2000). A mother's attitude toward breastfeeding, help with housework tasks, and the attitudes of friends and relatives toward breastfeeding were also significantly related to intended breastfeeding duration according to the study. 

    Another indicator of breastfeeding initiation and duration is prenatal breastfeeding intentions; if a woman plans to breastfeed it is more likely that she will actually initiate breastfeeding and tend to breastfeed longer versus a woman who has not planned (Bonuck et. al 2005). It also is noted in a study done by Bonuck et al. (2005), having prior breastfeeding history or haven been breastfed as a child may outweigh the demographic variables typically associated with breastfeeding. This study examined the impact of birth country (U.S. or foreign born), race/ethnicity (Black vs Hispanic), and the interaction of the two on the intention to breastfeed among a primarily Hispanic and Black population of low-income women. In contradiction of other studies, this study found no significant difference between Blacks (Non-Hispanic) and Hispanics in their choice to bottle-feed or breastfeed. There was also no significant difference between Blacks born outside the U.S. versus Hispanic women born outside of the U.S. When comparing foreign born  women  to continental U.S. born women, it was concluded that U.S. born women showed less strict decision making regarding their feeding choices (15% vs. 8%) and were less likely to decide on breastfeeding at all (72% vs. 87%) (Bonuck et al. 2005). To further try and understand the factor associated with breastfeeding initiation across racial groups, McKee, Zayas, & Jankowski conducted interviews of low-income African-American and Hispanic women during pregnancy, 2 weeks after delivery, and 3 months after birth in order to examine predicators of breastfeeding intention, initiation, and persistence. Though the intention rate between Hispanics and African American women were similar, greater cultural identification was greater for Hispanics and a small amount of Hispanics persisted especially when they supplemented with formula (McKee et al. 2004). The article found that the most important predictors of planning to breastfeed were education and ethnicity, and the most important predictors of actual breastfeeding at 3 months were age and ethnicity (Mckee et al. 2004).

    Race has been seen as a predictor when discussing the prevalence of breastfeeding.  It seems that there is not just one cause that can address the racial disparities regarding breastfeeding. From the way one perceives breastfeeding to the length one goes to ensure they prolong breastfeeding for as long as it is needed, there is a combination of things that result in breastfeeding prevalence. Many studies have delved into the subject by studying each particular racial group. At Cooper University Hospital a 62 Black mothers and 83 non-black mothers who were currently formula-feeding were asked why they chose not to breast-feed.  The barriers that were given by the respondents were grouped into easy to change (fear of pain, latching problems), not so easily changed (lack of desire to breast-feed, return to work or school), or true barriers (chemotherapy) (Doheny  2010). The results showed that 23% of the black mothers had easily changed barriers compared with 42% of the non-black mothers. Also, 77% of the black mothers had barriers classified as not easily changed versus 74% of the non-black (Doheny, 2010). A lack of interest in breastfeeding was the most common barrier reported among black women (55% versus 27% non-black women) (Doheny  2010). It's possible that this is the result of lack of exposure, if breastfeeding is not a common theme around the American black community seeing it as a necessity would not be feasible. A secondary analysis of the National Health and Nutrition Examination Survey was done in a study by Gibson, Diaz, and Geesy (2005) in order to describe the prevalence of breastfeeding among Hispanics as it pertains to acculturation (the process of adapting the culture of where one migrates to). The results stated that the prevalence of breastfeeding was higher in less acculturated Hispanic (59.2%) than those who were more acculturated (33.1%). 

    In Western cultures, especially the United States, the social significance of the breast is very much sexualized; this often results in the biological functions being overlooked. Because of this, it has been argued that the decision to breastfeed, especially if it results in breast exposure and public scrutiny of the woman tends to involve an in depth analysis of social and emotional factors ( Forbes, Adams-Curtis, Hamm, and White  2003). In their study of 201 college students (predominately European) sexism and type of response to sexual stimuli were analyzed. Because breastfeeding is a biological trait specific to women there might be a link between attitudes toward women and breastfeeding attitudes. Depending on the type of sexism (Benevolent or Hostile) exhibited by men there is an association with their perception of women who breastfeed. Those who scored high on the Hostile Sexism scale had a negative perception of breastfeeding vs. those how scored high on the Benevolent Sexism scale (Forbes et al. 2003). The results also indicated that both college educated men and women had positive perceptions of women that breastfed versus those who bottle-fed (Forbes et al. 2003). 

    The perception and attitudes toward breastfeeding, as studies have shown, tend to be correlated with initiation and sustainment of breastfeeding. Racial disparities remain in regards to breastfeeding prevalence with issues such as knowledge and social support playing a key role in the decision making process for each group. With the American breastfeeding rate being considered one of the lowest compared to other developed countries in the world, the population should be ensured all the right information. As a society the stigmatization of public feeding does seem to have an influence over whether or not one decides to breastfeed. As previous studies have shown one's country of birth as well as race has an influence on whether or not one breastfeeds. Societal influence does not differ when it comes to this topic; cultural background plays a great role in breastfeeding prevalence and therefore perception. This study intends to show the extent to which cultural background/race shapes the perception of breastfeeding and therefore, relates to the breastfeeding prevalence for that group. The hypotheses are: 
 

H1: Those identifying as Hispanic will have a more positive attitude towards breastfeeding than any other race.

H2: Individuals with parents born outside of the United States will have a more positive perception of breastfeeding than those with parents born in the United States.

H3: Individuals with parents born in the United States will have a more neutral perception of breastfeeding.

    The purpose of this study is to assess the level of influence that cultural upbringing and race/ethnicity have on breastfeeding perceptions and therefore their attitudes towards the method of feeding. Surveys were administered to 245 undergraduates from a large public university in the southeastern United States for data collection. Surveys were passed out in several university classes and consisted of individuals from different colleges (i.e. college of sciences, college of engineering and computer science, etc). In order to accurately measure the respondents' perceptions and attitudes, students answered a series of questions designed to assess cultural background and breastfeeding attitudes. The survey was divided into three sections in which the second section was answered only by female participates. 

Dependent Variables

    The dependent variables for this study were breastfeeding perceptions and attitudes towards breastfeeding. Respondents were asked a series of 5-point Likert scale questions ranging from "strongly agree" to "strongly disagree." Questions such as, "Mothers should be able to breastfeed anywhere they see fit" and "breastfeeding a child should be confined to one's home only," were used to measure the respondent's attitude towards breastfeeding on a positive to negative scale. In order to measure the respondent's perception of breastfeeding participants were asked closed-ended questions about their perception of the public's attitudes towards breastfeeding. 

Independent Variables

    In this study there were two independent variables; race/ethnicity and cultural background. Respondents were asked to select racial/ethnic groups that apply to them. The selections include African American/Black, American Indian, Asian / Pacific Islander, Caucasian, Hispanic/Latino, and other. Cultural background was assessed by respondent's answers to questions pertaining to their country of birth and their family's (specifically mother and father) country of origin. These questions were used to measure cultural background because for the purpose of this study the American culture would be compare to that of those outside. This was done in order to assess if there would be any cultural differences. The country of origin of the parent is usually telling of the culturally environment the child would be subjected to while growing up.

    A Chi-Square test was used to determine if a relationship existed between a respondents' culture and their perception of breastfeeding, as well as differences between race and attitudes towards breastfeeding.  SPSS was used to compare Hispanics with other racial groups. Cultural background was assessed by comparing respondents having at least one parent born outside the United States to those who have no parent born outside the United States. A significance level of .05 was used to determine if any relationship existed. 

    Though other demographic variables such as sex, age, marital status, and major were collected in this study they were not used in the analysis. The focus of this study is whether race/ethnic or cultural background has an effect on one's perception or attitude towards breastfeeding. Most research has shown the discrepancies in breastfeeding rates and how the demographic variable of race widens these discrepancies. These same studies have shown that Hispanics have the highest rate of breastfeeding sustainment. Due to this the focal demographic was race/ethnic. 

    A total of 245 undergraduate students were surveyed, of those who provided their sex 51% were female while 47.8% were male. In regards to sex, the pools of respondents were pretty equally represented. The race of each respondent was recorded; the multiracial category was comprised of those who selected more than one racial category. Males were included in this study in order to see the impact of race/ethnicity on perception/attitude regardless of sex. In order to identify any cultural attributes. Of those respondents that provided their race 14% were African-American/Black, 6% were Asian/Pacific Islander, 57% were Caucasian, 15% were Hispanic/Latino, and 8% were multiracial.

    Culture was defined by the birth place of the respondents' parent(s). The two resulting categories were: (1) Born in the United States and (2) Born Outside of the United States. Chi-Square tests were done to accomplish the bivariate analyses portion of this study; this was due to the fact that the variables used to analyze perceptions and attitudes were categorical.

    Certain questions were aimed at analyzing the participants' perception of breastfeeding. For example:  "Overall, what do you think is the public's perception of breastfeeding?" Likert scale statements such as, "Mothers should be able to breastfeed anywhere they see fit" were used to measure the respondents' attitude towards the subject. After executing  several Chi-Square Tests, the data showed  43.5% of individuals that were surveyed and had at least one parent born outside of the United States had a positive perception of the public's perception of breastfeeding, this is compared to 31.7% of surveyed individuals whose parent (s) were U.S. born. It was also found that 54.2% of the respondents with U.S. born parent(s) had a neutral perception, compared to 37% of those whose parent(s) were born outside of the U.S. (See Table 1).These findings support hypotheses 2 and 3.

    Another analysis was done in order to assess the breastfeeding attitudes of Hispanics in comparison to other races.  A statistically significant finding (p< .05) showed that  of the participants identifying as Hispanic  41.2% strongly agreed with the idea of mother's being able to breastfeed anywhere. 14.7% of others identifying as nonhispanic strongly agreed to that statement (See Table 2). Hypothesis 1 (H1) was also supported by this data. 

    While analyzing the data it is worth mentioning the chi-square done on the relationship between public breastfeeding annoyance and race. Though the results were not significant (p=.054), they did show that compared to other races those identifying as Hispanic in no way agreed with the statement (See Table 3).

    The purpose of this study was to examine differences in attitudes and perceptions in regards to breastfeeding and determine whether or not there is a relationship between race/ethnicity and cultural upbringing and breastfeeding attitudes and perceptions among college students.  The findings indict that breastfeeding perceptions and attitudes are closely related to one's race/ethnicity as well as their cultural background. As previous literature shows Hispanics choose to breastfeed more than non-Hispanic whites and blacks and evidence suggests this could be attributed to their culture. In this study the Hispanic population had a more positive attitude and perception in regards to breastfeeding than any other race. Not only that, culturally those who had a parent born outside the United States had a more positive perception of public perception than those whose parents were born inside the United states. As stated in Ajzen's theory of planned behavior, normative beliefs, attitude, and subjective norms give rise to a behavioral intention this then leads to the behavior. This study seems to adhere to the model of planned behavior. Having the highest breastfeeding prevalence rate among non-Hispanic whites and black, Hispanics seem to a normative attitude towards this behavior. If the college students in this study have been brought up around this behavior which they would assert as normative, and develop a positive attitude it makes sense that the behavior of breastfeeding would natural occur according to the theory. The cultural influences are held strong when you examine the perception differences. This study shows that there is a link between perceptions and attitudes and culture as well as race when it comes to breastfeeding. This study can possibly shed some light on understanding why these racial disparities exist among racial groups. As for why disparities also exist within racial groups, the cultural implications are present. A person of Hispanic heritage whose parents were born in the United States may have assimilated to the U.S. culture and the normative beliefs may be different from those who have parents U.S. born.

    There are other issues to take into consideration when dealing with the idea of breastfeeding perceptions/attitudes and whether this leads to actually breastfeeding. To actually initiate breastfeeding families do consider employer policies, working decisions, having a support system, and having the knowledge basis which may be given by health-care practitioners. All of this could be attributed to cultural practices. Whether the culture values breastfeeding is something that can be seen throughout working policies and how friendly they are towards breastfeeding. In the U.S. parental leave policies are a scarce option for new mothers wanting to go back to work and breastfeed, unlike Norway where there is a strong presence of breastfeeding policies.

    Some limitations to this study include the education characteristics of the sample used. Since these results are comprised of the perceptions and attitudes of individuals currently attending college it may be another variable to take into consideration. Education level does tend to have an effect on both the likelihood and duration of breastfeeding. The higher the education level the more likely it is that breastfeeding attitudes would be positive. If the sample would have incorporated a variety of education levels, this could correct the possible impact of education level.  The effect of the respondents' major should also be considered; those in the social sciences may be more likely to have a more positive view on the topic of breastfeeding. This study collected data on the college the respondents' major were in, therefore specific majors and responses were not assessed. Also, this study did not include many individuals that have had children. The younger age of the population may attribute to some of the issues that this study faces. The respondents of the survey have not faced the difficult of having to be faced with the decision of breastfeeding or not. Because of this is may be more likely that they would have positive ideals about the subject. A more equal distribution of racial group may have also benefited this study.

    In the future it would be great to expand the study to an older population comparing those who have previously breastfed to those who have not and analyze the strength of these perceptions/attitudes on the grounds of race and culture. It would also be interesting to look at racial differences among other racial groups. This study leads to certain implications within the health-promotion fields. If  attitudes and perceptions  of breastfeeding are somewhat tied to race and ethnicity of the individual it can be suggested that culturally sensitive materials and health-promotion items should be used. This may lead to a better form of breastfeeding initiation, especially since the intention of breastfeeding is a strong predictor of actual breastfeeding.  By doing this research it is possible that we can further expand on the findings in order to identify how different cultures discuss the process of breastfeeding and possible narrow the racial disparities among breastfeeding mothers.

Bonuck, Karen A., Freeman, Kathy  and Michelle, Trombley. 2005. "Country of Origin and   Race/Ethnicity: Impact on Breastfeeding Intentions." Journal Human Lactation 21.

Centers for Disease Control and Prevention (CDC). 2010, March 25. Breastfeeding Varies by  Race, Place."USA Today. Retrieved from http://www.usatoday.com/news/health/2010- 03-25-breastfeeding_N.htm

Doheny, K. 2010, October 8. " Breastfeeding Less Common for Black Moms." USA Today.  Retrieved from http://www.usatoday.com/yourlife/
parenting-family/babies/
2010-10-8- breastfeeding-
african-american_N.htm

Forbes, Gordon B., Adams-Curtis, Leah  E., Hamm, Nicole R and Kay B. White. 2003.  "Perceptions of the Women Who Breastfeeds: The Role of Erotophobia, Sexism, and  Attitudinal Variables." Sex Roles 49: 379-388.

Gibson, Marla V. , Diaz, Vanessa A.,  Mainous,  Arch G. and Mark E.  Geesey. 2005.  "Prevalence of Breastfeeding  and Acculturation in Hispanics: Results from NHANES  1999-2000 Study." Birth 32: 93-98.

Lewallen, Lynne P and Darlene J. Street. 2010. "Initiating and Sustaining Breastfeeding in  African American women." Jognn 39: 667-674.

Man-ku, Ching and  Susan KY, Chow. 2010. "Factors Influencing the Practice of Exclusive  Breastfeeding  Among Hong Kong Chinese Women: A Questionnaire Survey." Journal  of Clinical Nursing 19: 2434-2445.

McKee, M Diane, Zayas, Luis H. and Katherine R. B.,  Jankowski. 2004. "Breastfeeding  Intention and Practice in an Urban Minority Population: Relationship to Maternal  Depressive Symptoms and Mother-Infant Closeness." Journal of Reproduction and Infant  Psychology 22: 167-181.

Ohlemacher, Stephen. 2011, February 10. "Breast Pumps Ruled Tax Deductible Medical  Expense by IRS in Victory for Advocates." Retrieved from:  http://www.latimes.com/news/nationworld/
nation/wire/sns-bc-us--breastpumps- taxes,0,2255129.story

Paine, Patricia and  Jose G. Dorea. 2000. "Gender Role Attitudes and Other Determinants of  Breastfeeding  Intentions in Brazilian Women." Child:Care, Health and Development 27:  61-72.

Rojjanasrirat, Wilaiporn  and  Valmi  D. Sousa. 2010. "Perceptions of Breastfeeding and Planned  Return to Work or School Among Low-Income Pregnant Women in the USA." Journal  of Clinical Nursing 19: 2014-2022.

Saka, G., Ertem, M., Musayeva, A. , Ceylan A., and Kocturk T. 2005. "Breastfeeding Patterns,  Beliefs and Attitudes Among Kurdish Mother in Diyarbakir, Turkey." Acta Pediatrica  94: 1303-1309.

Sauls, Donna J and Jane Grassley. 2008. "Development of  the Adolescent Support Model." The  Journal of Theory Construction & Testing 15:24-30.

Simmie, Elizabeth. 2006. "Breastfeeding: Different Ethnic Background, Different Perceptions?"  British  Journal of Midwifery 14: 20-26.

The original questionnaire is available as a .pdf file.  Click here for questionnaire.


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