Understanding the attitudes towards breastfeeding amongst staff and students in a UK higher institutional setting – a mixed-method cross-sectional study

ABSTRACT

Breastfeeding is recognised as a human right and in the UK, it is a legal requirement for employers to provide a space where breastfeeding mothers can rest. Despite this, breastfeeding rates in the UK are amongst the lowest in the world and breastfeeding mothers suffer prolonged loss of earnings compared to those who do not. In response, this study aimed to measure the attitudes to infant feeding among staff and students in a UK higher education institution and understand the experiences of those who have breastfed and/or expressed on campus. A convenience sampling technique was used to recruit 72 staff members and 99 students at the same UK university. Respondents completed an online questionnaire which first presented the Iowa Infant Feeding Attitude Scale and then provided an open text box where people who had experience of feeding on campus could share their experiences. Female respondents were more likely to prefer breastfeeding than men. Students were more likely to prefer breastfeeding than staff. However, raising breastfeeding awareness among both staff and students is required. A realist thematic analysis of the comments made by 17 staff members about their feeding experiences on campus identified a lack of consistency in terms of management and access to suitable facilities to either express milk or breastfeed. It is argued that a combination of education around breastfeeding, visual cues that breastfeeding is welcome, provision of suitable facilities and a clear breastfeeding policy that is consistently implemented is required to support breastfeeding on campus.

KEYWORDS:

• Breastfeeding
• employment
• higher education
• Public Health
• health promotion

Introduction

It is widely accepted that breastfeeding has both short- and long-term health benefits for mother and child (Horta 2019). Sustained breastfeeding is also associated with a reduction in infectious diseases, hospital admissions and child morbidity (Rollins et al. 2016). As a result, the global recommendation is to continue breastfeeding up to the age of 2 years and beyond (World Health Organization, WHO 2019). Breastfeeding is also a recognised human right of women and children (United Nations 2022). Despite this, breastfeeding rates in the UK remain one of the lowest in the world and are in decline (Pérez-Escamilla et al. 2023). The Baby Friendly Initiative (BFI) is a global programme which aims to transform healthcare for babies, their mothers, and families as part of a wider global partnership between UNICEF and the World Health Organization (Unicef 2023).

In the UK, the BFI works with public services and universities to better support families with feeding to develop close, loving relationships and ensure that all babies get the best possible start in life. However, whilst many universities underpin their programmes with breastfeeding promotion, only 36% of Midwifery and 15% of Health Visiting programmes have full accreditation in the UK (Unicef 2022a). Implementing BFI standards is thought to not only enhance these programmes but also provide broader support for good practice in infant feeding throughout a university’s environment and culture. Unicef (2022b) also highlight that achieving accreditation of these standards at universities will have a long-term impact on improving family health outcomes. These families include those being cared for by the students on maternal and child health programmes, students with families themselves or employees with families working within the university itself.

Workplace support for breastfeeding can be an important influence on employees returning from maternity leave and their decisions about infant feeding (Jantzer, Anderson, and Kuehl 2018; Scott et al. 2019). Employers and childcare providers all have a role to play in supporting continued breastfeeding (Alexandra et al. 2019; Nieto-Ruiz et al. 2020). However, research conducted within an Australian University reported inconsistent organisational approaches resulted in adverse consequences for employees (Smith, Javanparast, and Craig 2017). Additionally, it has previously been reported that employed breastfeeding mothers suffer more severe and more prolonged loss of earnings than those who do not breastfeed (Yourkavitch and Hall Smith 2022). This financial impact on women would be of interest to universities with a commitment to identifying key obstacles to gender equality to align with the principles using the Athena SWAN charter self-assessment framework (Rosser et al. 2019).

Additionally, although the research is limited, there is the suggestion that universities often lack formal policies for lactating students (Dinour et al. 2020). It is recommended that students should be provided with an accessible space for milk expression, pump loans and milk storage options as well as creating a supportive environment for breastfeeding within campus communities (Kojo et al. 2019). Therefore, this study aimed to firstly understand the attitudes to infant feeding amongst staff and students in a UK higher education institution and secondly understand what the experiences are of those who have breastfed, chest fed and/or expressed on campus. Providing this knowledge may proactively foster responsive infant-feeding higher education institution cultures.

Materials and methods

An online cross-sectional mixed methods design was adopted to allow employed staff and students, enrolled on all campus programmes, to anonymously take part in the study. Cross-sectional studies can provide robust evidence to explore relationships among variables by collecting data at one point in time (Spector 2019). Additionally, to help situate the results within the broader social context, triangulation can be used through complementary free-text data (Kelle, Kühberger, and Bernhard 2019). Therefore, there was an intentional sampling of both quantitative and qualitative data.

Recruitment

A recruitment call was disseminated across a UK-based University through college and programme leaders, electronic communication outlets, marketing and directly around the campus using posters. The recruitment call was live between March and June 2022. There are over 75,000 staff and students at the University, therefore the ideal sample size was calculated at n = 192 with a 95% confidence level and 5% margin of error to increase the generalisability of the findings. Respondents were excluded if they were not a current staff member or a student (undergraduate and postgraduate) who attended campus.

Online questionnaire design

The online questionnaire was designed to explore relationships between breastfeeding attitudes and student/status, gender and perception of the university support for breastfeeding (see Table 1). We measured the attitudes against gender because breastfeeding is socially and culturally associated with cis women and we wanted to compare diverse gender attitudes to understand wider perspectives.Attitude to infant feeding was measured using the Iowa Infant Feeding Attitude Scale which is freely available and a widely used scale with good reliability and validity outcomes (Casal et al. 2017) (see Appendix). The internal consistency of the scale in this study had a Cronbach alpha coefficient of .8. The scale comprised 17 bipolar statements where the respondents were asked to indicate how much they agreed or disagreed on a 5-point scale (strongly disagree, strongly agree). The questions were divided into half which are worded in preference for breastfeeding and the other half which are worded in preference formula (reversed scored). Therefore, the total score could range from 17 (preference for formula) to 85 (preference for breastfeeding). If respondents stated that they had an experience of breastfeeding or chest feeding on campus they were given the opportunity to share their experience with a free text question.

Table 1. Participant demographic information.

Employed Staff Member	72
Student (undergraduate and postgraduate)	99
Gender
Women	113
Men	53
Non-binary	2
Transgender	3
Ethnic group
Asian/Asian British	9
Black/African/Caribbean/Black British	8
Mixed/Multiple ethnic groups	3
Other ethnic group	5
Prefer not to say	7
White	139

Ethical concerns

Ethical approval was obtained from the institution’s ethical committee (ETH2122–3383). All respondents read an information sheet that provided detail about what the study involved and their rights as a participant. All respondents took part in the study voluntarily, gave full and informed consent to participate and understood that they could withdraw their data. All respondents created a unique identifiable code for the purposes of anonymous data storage and withdrawal.

Analysis

A statistical analysis was conducted by testing the null hypothesis: There are no differences between the independent variables (attitude to breastfeeding) against staff, students, gender, campus and whether they feel the University supports infant feeding. A Microsoft Excel data file was used for the initial transfer of Qualtrics data for screening and cleaning for analysis within SPSS 28. The data was checked for reliability and distribution. An Independent-sample t-test and one ANOVA were performed to compare the total score on the scale means across group variables (Pallant 2016). A Mann-Whitney U test was performed to compare individual attitude items with staff and students. P-values were adjusted to account for the false discovery rate using the Benjamini and Hochberg (1995) method. The P-value of an < 0.05 alpha level value was used and to determine the strengths and relative magnitude of the relationship, the effect size uses the Cohen (1988) criteria (r=z÷√N), to calculate the effect size to be either small (.1), medium (.3) or large (.5).

The qualitative data analysis was underpinned by a realist thematic analysis; as outlined in Table 2 themes within the data were identified using the 6 steps outlined by Braun and Clarke (2006).

Table 2. The 6 steps of thematic analysis (Braun and Clarke 2006).

Step 1: Familiarisation with the data	The second author read and re read all the free text comments to immerse herself in the data.
Step 2: Generating initial codes	The second author systematically coded the free text comments. Coding was informed by an inductive approach which required the second author to put preconceptions to one side to allow the free text responses to guide the coding as much as possible. Furthermore, coding was informed by a semantic approach which focused on the meanings expressed in the free text responses.
Step 3: Searching for themes	The second author collated codes into candidate themes. The evidence for each candidate theme was also collected together to establish the validity of each candidate theme.
Step 4: Reviewing themes	The second author created a thematic map to capture the relationship between candidate themes. The first author reviewed the thematic map and the evidence for each theme.
Step 5: Defining and naming themes	The first and second authors finalised the themes and agreed the titles of managerial support and comfort in feeding on campus.
Step 6: Writing the report	Extracts which best represented the themes were selected for presentation in the analysis.

Results

Attitudes to breastfeeding

A total of n = 171 respondents responded and fully completed the questionnaire. The total attitude scores ranged from 33 to 85 (mean 59, SD±9.5) for all respondents. A one-way analysis of variance (ANOVA) was conducted to compare the total attitudes towards breastfeeding with: Do you think the institution supports breastfeeding on campus (yes = 37, no = 23, not sure = 111). However, there was no statistically significant difference F (2, 168) = 1.45, .p = .2) across the three groups. There were 113 women, 53 men and 5 non-binary or transgender in the sample. Due to the small sample of non-binary or transgender respondents, they cannot reliably be reduced and therefore were excluded from the calculation. A Welsh version of one-way ANOVA was conducted, because the groups sampled do not have equal variances. This indicated a significant difference in attitude to breastfeeding across the gender groups W (2, 32.1) = 4.4. p = <.001 with a small to medium effect size (0.4). The post-hoc comparisons using the Turkey HSD test indicated the mean scores for females (M = 60.2, SD = 9.9) and males (M = 57.3, SD = 8.4) were significantly different. This indicates that the women respondents were more likely to prefer breastfeeding than men.

There were 72 staff members and 99 students in this sample. An independent-sample t-test indicated a significant difference in the total score in attitudes to breastfeeding for staff members (m = 56.6, SD = 1.1) and students (m = 62.4, SD = 8.6) indicated a significant difference in score (t; (169) = −4.18, p = <.00, two-tailed) and the magnitude of the difference in means (mean difference −5.85, 95% CI: −8.6 to −3.09) was large (.65). Therefore, the students in this sample were more likely to have a preference towards breastfeeding than staff. A Mann-Whitney U test was conducted to compare each attitude scale item for staff members and students. There was a total of 10 items out of the 17 which indicated a significant difference with nine having a medium or higher affect size and one small (see Table 3).

These tests indicate that although the students are more likely to preference breastfeeding, they were more likely to be neutral on views such as The nutritional benefits of breastmilk last only as long as the baby is weaned from breast milk, and Breastmilk is lacking in iron, and Women should not breastfeed in public places such as restaurants, whereas the staff members were more likely to disagree or strongly disagree. For the item Breastmilk is the ideal food for babies, staff members were more likely to agree whereas again, the students were more likely to be neutral. For Breastfeeding is more convenient than formula feeding the students were more likely to disagree whereas for A mother who occasionally drinks alcohol should not breastfeed her baby it was the staff members who were more likely to disagree.

There was no significant difference found amongst groups for Breastfeeding increases mother-infant bonding and Mothers who formula-feed miss one of the great joys of motherhood. However, there was an even distribution of agreement and disagreement for this statement. For Breastfed babies are healthier than formula-fed babies, the majority in both groups were neutral or agreed. For Breastfed babies are more likely to be overfed than formula-fed babies and Fathers feel left out if a mother breastfeeds both groups were more likely to strongly disagree, disagree, or were neutral. Finally, for the item, Breastmilk is cheaper than the formula both groups were more likely to agree (see Table 3).

Table 3. Attitudes to breastfeeding items Mann-Whitney U test.

	Staff member							Student							Mann-Whitney U test
Attitude individual item	SD %	D%	N%	A%	SA%	M	StD	SD%	D%	N%	A%	SA%	M	StD	z	p	Adj. p	(η2)
1.* The nutritional benefits of breastmilk last only as long as the baby is weaned from breast milk	47	29	18	3	3	4.2	1	14	24	43	12	6	3.3	1.05	−5.340	.001	.001	.03
2.* Formula-feeding is more convenient than breastfeeding	31	28	31	7	4	3.7	1.1	12	17	33	31	6	2.9	1.11	−4.343	.001	.001	.03
3. Breastfeeding increases mother-infant bonding	28	21	28	14	10	2.6	1.3	26	12	29	26	6	2.7	1.28	−0.973	.331	.397
4.* Breastmilk is lacking in iron	47	31	19	1	1	4.2	.9	18	30	46	5	0	3.6	.84	−4.426	.001	.001	.03
5. Formula-fed babies are more likely to be overfed than breastfed babies	11	15	40	24	10	3.1	1.11	6	20	27	34	12	3.2	1.1	−1.224	.221	.306
6.* Formula-feeding is the better choice if the mother plans to work outside the home	29	29	29	11	1	3.7	1.05	12	26	28	24	9	3.8	1.17	−3.554	.000	.001	.02
7. Mothers who formula-feed miss one of the great joys of motherhood	28	20	29	10	14	2.6	1.3	26	12	29	20	12	2.7	1.27	−0.973	.331	.397
8.* Women should not breastfeed in public places such as restaurants	88	7	1	0	4	4.7	.86	56	20	13	5	5	4.2	1.16	−4.231	.001	.001	.02
9. Breastfed babies are healthier than formula-fed babies	11	14	36	28	11	3.1	1.14	15	16	30	29	9	3	1.2	−0.608	.543	.575
10.* Breastfed babies are more likely to be overfed than formula-fed babies	36	30	32	1	0	4	.86	22	40	21	10	6	3.6	1.12	−1.960	.050	.075
11.* Fathers feel left out if a mother breastfeeds	36	20	22	19	1	3.7	1.19	34	30	12	13	10	3.6	1.34	−0.058	.953	.953
12. Breastmilk is the ideal food for babies	7	3	8	31	51	4.2	1.15	3	6	45	20	3.7	.95	−3.702	.001	.001	.02
13. Breastmilk is more easily digested than formula	8	28	28	31	33	3.8	1.16	2	12	39	31	15	3.5	.96	−2.663	.008	.014	.02
14.* Formula is as healthy for an infant as breastmilk	14	30	33	19	3	3.3	1.04	8	18	42	24	7	2.9	1.02	−2.322	.020	.033	.01
15. Breastfeeding is more convenient than formula feeding	8	8	35	19	29	3.5	1.23	4	29	34	20	12	3	1.07	−2.718	.007	.013	.02
16. Breastmilk is cheaper than formula	6	0	11	25	58	4.3	1.06	4	2	11	33	49	4.2	1	−0.925	.355	.399
17.* A mother who occasionally drinks alcohol should not breastfeed her baby	32	30	19	7	11	3.7	1.3	12	23	25	26	13	2.9	1.23	−3.649	.001	.001	.02

*Variables reverse scored to calculate total infant feeding attitude score.

SA=strongly agree, A=agree, N=neutral, D=disagree, SD=strongly disagree.

Experiences of breastfeeding on campus

17 female respondents shared their experience of breastfeeding. All of these respondents were staff members. The themes of managerial support and comfort in feeding on campus are now presented.

Managerial support

There was a lack of consistency concerning the support offered by line managers. Some managers recognised the needs of breastfeeding respondents and ensured that support was put in place.

My manager was very supportive and did make it clear when I attended KIT days and had meetings with her, that should I need to express, then she would organise a private, comfortable space for me to do so and any time

For some respondents, this support continued as they returned to work, one manager allowed a staff manager to attend meetings with their infant:

I was having trouble leaving my exclusively breastfed son at home as he would not accept expressed milk. My line manager was very reassuring and understanding. She advised me that I could bring my baby along and feed him if needed. I was comfortable enough to feed him on demand during a staff meeting, no one objected

However, other respondents did not receive the support they required when returning to work.

‘I had a shared office and was the only woman in the office (I had 2 male office mates). I was not offered any other space to pump breast milk while at work, although I did ask, so I had to banish my office mates and put a sign on the door and pump at my desk. This didn’t feel good at all. The only other space that was signposted to me in my building was a bathroom - no plugs to plug in the machine and certainly not an OK place to pump. I found this really tough’

The lack of a quiet, private, comfortable space in which the parent could express without fear or interruption was highlighted. It was also difficult to get the information they needed.

‘I have been told that there is a dedicated space to do so but this information is not readily available/forthcoming’.

In summary, there was a lack of consistency around managerial support and the facilities available in the campus building where the participant was based.

Comfort in feeding on campus

Many of the respondents reported that they felt comfortable breastfeeding on campus

‘I found that while I was on campus and needed to feed my baby, there were spaces to do so and even when feeding in public on campus, I felt comfortable and that I wouldn’t be judged for doing so’.

Other respondents expressed a need for designated breastfeeding rooms:

‘Often when feeding you don’t want to be disturbed, particularly as the child gets older and they get interested in the world around them you want somewhere private and quiet, and comfortable’.

For others feeding an infant on campus made them feel uncomfortable:

‘I covered up quickly once he was latched on. I felt most people perhaps considered it strange to have me have such a small baby at work with me’.

These comments further highlight the importance of designated areas for feeding to give parents choices in how and where they feed in the workplace.

Discussion

This study aimed to understand the attitudes to infant feeding amongst staff and students in a UK higher education institution and experiences of those who have breastfed and/or expressed on campus. There was quite a large range overall in respondents’ attitudes with students in this sample being more likely to have a preference towards breastfeeding than staff. Previous research has also shown moderately positive attitudes towards breastfeeding among students (Natan, Haikin, and Wiesel 2018). However, these results highlight that there is a need to raise awareness and understanding of breastfeeding in higher education. Although students were more likely to have a preference towards breastfeeding, they did not know how the institution supports breastfeeding, they had a neutral view about the nutritional benefits of breastfeeding, and whether women should breastfeed in public spaces. Additionally, women indicated a more positive preference for breastfeeding than the men respondents in this study.

Wider literature has shown that when general knowledge is increased there is also a positive effect on their attitudes in both women and men (Magnusson et al. 2017). Hamid and Yahya (2018) found that having a positive attitude toward breastfeeding was a significant predictor of intention to breastfeed among women and men. Therefore, if we can improve knowledge for all genders, in turn, it can improve attitudes and will result in better breastfeeding rates. Implementing the UNICEF UK Baby Friendly Initiative University Standards ensures teaching on relevant programmes equips students with the knowledge and skills relevant to support parents in their clinical setting. However, to increase knowledge and therefore foster more positive attitudes towards breastfeeding in a higher education institution across programmes more cultivation for breastfeeding-friendly campuses is needed. This can be done through information education, providing breastfeeding-friendly facilities, and having visual cues that signal breastfeeding is welcome.

The qualitative findings in this study, which analysed the shared experiences employees have had concerning breastfeeding or expressing on campus, indicate that the institution as a whole has an inconsistent approach. Many women return to work whilst breastfeeding, so support in the workplace is essential to be able to maintain breastfeeding and prevent early cessation (Kim, Shin, and Donovan 2019). The importance of support from employers has also been highlighted as a way to reduce absenteeism, improve workplace performance, and increase commitment and retention of staff (Baker et al. 2023). By law, employers must provide a suitable place for breastfeeding mothers to rest (Health and Executive 1992). The Equality Act (UK Government 2010) states it is unlawful to dismiss or discriminate against a worker because they are pregnant, a new mother or breastfeeding. This is why a workplace policy is essential, and employers should be familiar with the policy. However, Unicef (2020) highlight that returning to work without adequate support mechanisms can be detrimental to breastfeeding practices. Initiatives such as the provision of a quiet safe space for women to either feed or express milk, equipped with changing facilities and a fridge are all steps which employers can take to implement good practice. A breastfeeding space should be available during working hours. In addition, clear operational policies should be in place, for example, the process for maintaining the cleanliness of the room and facilities, clear guidance regarding checking the fridge temperature and making sure the fridge is accessible but also able to be locked.

Conclusion

The findings are based on a small sample recruited using convenience sampling at a single institution. This limits the generalisation of the findings and so further research is required across institutions to explore the prevalence of the findings presented in this paper. Additionally, further qualitative research is required to gain a deeper understanding of the experiences of staff and students to identify the specific needs of these groups. However, this study has highlighted that women and students have more preference towards breastfeeding in a university setting than men and staff. However, there was an overall lack of awareness of the nutritional benefits of breastfeeding and an indecisive view of whether women should breastfeed in public spaces. Crucially this indicates that there is a need to raise awareness and understanding of breastfeeding in higher education. In the qualitative findings, there was a lack of consistency around managerial support and the facilities available in the campus building where the respondents were based. Therefore, it has raised an important point for the need for clear policy and designated breastfeeding areas in higher education.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Appendix