As discussed in the following sections organized by theme, the following factors guide participants’ intention to teach about breastfeeding in their classrooms: 1) their attitudes towards teaching about breastfeeding, 2) their subjective norms on breastfeeding education, and 3) their perception of factors that control what and how they teach in their classes, as seen in Fig. 2. Figure 2 is the thematic representation of NC FCS teachers’ attitudes towards breastfeeding education in secondary school classrooms in the context of the TPB.
1) Attitude toward the behavior. The theory of planned behavior suggests that a person’s attitude towards a behavior is determined by their belief about the consequences of the behavior (behavioral beliefs), which create their favorable or unfavorable attitude towards the behavior . Therefore, teachers’ views and attitudes regarding teaching about breastfeeding guide their intention to teach about breastfeeding in their classrooms. The participants cited many reasons to teach about breastfeeding related to positive student outcomes and had limited negative attitudes towards teaching about breastfeeding in their classes. The themes presented by teachers as reasons to teach about breastfeeding were: student as future parent, teenage pregnancy, benefits of breastfeeding, and normalization of breastfeeding. Some teachers felt that they needed to balance educating about breastfeeding with formula feeding for those who are not able to or choose not to breastfeed.
Student as future parent. There was an emphasis that many students (both male and female) will become parents in the future and would benefit from complete information about the feeding choices for their infants.
I definitely think it should be [taught], especially in the high school setting, because most of these kids are gonna be parents at some point - if they’re not parents already - and I think that it would be a huge disadvantage to not teach our children about the benefits of breastfeeding. (Teacher #13)
Teenage pregnancy. In addition to the future role as a parent, several teachers mentioned that they have students who are already parents or will become parents as teenagers. They cited that the chance of teen pregnancy was a reason to teach students about breastfeeding as early as middle school, which is the age at which some students become sexually active and therefore may become pregnant.
However, we are having a lot of younger [students], entering high school in the ninth grade becoming parents, so I think it needs to be taught as soon as possible or earlier. (Teacher #7)
If we’re teaching kids where babies come from and they’re having sex, you can’t not teach about breastfeeding. That’s one hundred percent, you better be doing that. That has got to be in the curriculum. (Teacher #8)
Benefits of breastfeeding. More than half of the teachers mentioned the benefits of breastfeeding as justification for including the information in the classroom. They described the health benefits for mothers (weight loss and return of uterus to pre-pregnancy size) and children (nutrient availability, immune benefits, obesity prevention, intellectual development, prevention of sudden infant death syndrome) as well as the financial benefits for the family.
When the mother is producing exactly what the child needs and it’s free, and that is one of the points that I make to them that it’s…a money saver. (Teacher #3)
Yeah, I think it’s important because a baby gets so many nutrients through breast milk that they cannot get through formula, so it’s important to teach moms about those needs and how important they are and how important those antibodies are for protection from sicknesses and things like that. (Teacher #2)
Normalization of breastfeeding. Several teachers recognized that breastfeeding education in schools has the capacity to normalize breastfeeding in society, both as a way that parents feed babies and to make breastfeeding in public more socially acceptable.
You can almost see the little light bulbs turn on their heads when we are talking about breastfeeding because they just never thought of it in that way because they don’t have someone in their life that they have seen breastfeeding. All they know is formula feeding and, it’s sad that their limit of their education stops at a bottle, plain and simple. (Teacher #3)
Especially now because you do hear about women who breastfeed in public and they get comments made to them and it’s just somehow not socially acceptable to do it in public…I think it is good for them to know that it is just a normal part of life. (Teacher #10)
Balance breastfeeding with formula feeding. Two teachers expressed concerns that promoting the health benefits of breastfeeding undermines families who formula feed. They described the need to balance breastfeeding content with formula feeding for mothers who cannot or choose not to breastfeed.
I just say, don’t put the stigma on people that don’t breastfeed, that they’re not any less of a parent because they don’t do it…And that there’s people that struggled and they tend to feel that they’re not as good of parent because they can’t breastfeed, and I just don’t think that is something that any mom should have to feel because if you can’t, you can’t. (Teacher #10)
2) Subjective norm. Teachers indicated that the normative beliefs of other people are an important determinant of their behavior. Their subjective norms about breastfeeding education included how students respond to the material, their perception of parent and administrator views on including this topic in the classroom, how teachers should present information impartially, and how bottle-feeding is a cultural norm in our society.
Student response. Student responses to breastfeeding content were a consideration for teachers when incorporating this information in their classes. Teachers described their students’ responses range from fascination to disgust. Some students were initially embarrassed or uncomfortable about the anatomy of the breast, but many were interested in the benefits of breastfeeding and about feeding infants in general.
Now, they tend to be getting kind of squirrely if there is any breast shown at all in the videos, which is very discrete, but they know that it’s breastfeeding, so most kids are not comfortable with that part of it. (Teacher #3)
One teacher explained that students who were already parents expressed their interest in breastfeeding by asking questions and said they would try breastfeeding with their children because of the benefits.
Most of them are really interested in breastfeeding and the parents in class, they ask a lot questions, and I feel like a lot of them, after teaching that lesson, are persuaded to try it. Like I hear them say, “I’m going to do breastfeeding, I’m going to try it, I’m going to do it. You know it’s free first of all, it’s good for the baby, it’s good for me. I promise you I’m going to do my best to try.” (Teacher #7)
Parents. Teachers felt that parents would want the schools to inform them about the education of their children regarding their bodies and sexuality. Several teachers had concerns that parents would view teaching about breastfeeding as encouraging sexual activity and teenage pregnancy. To inform parents, a couple of teachers use permission slips for content that shows the naked human body or discusses information related to sexual activity.
Parents sometimes have this idea in their head, I feel, that the minute you start talking about anything to do with sex or babies or whatever, that you’re trying to encourage them to have babies, which is not what it is. It’s really the opposite, because I believe you need to be ready to have a child, to take care of that child. (Teacher #12)
And I ask, I have to get permission, and I ask ahead and get the parents to sign off on that… I just tell them that there will be a breast, an actual woman’s breast in the video. (Teacher #9)
Administrators. Two teachers described that school administration may not approve of including breastfeeding content in their classrooms. One teacher talked about the feedback she received from the school system on buying breastfeeding clips for the baby simulators used in parenting courses. She convinced them to purchase the clips and now uses them in her classes but has to provide students the option to bottle feed when they take the baby simulators home.
Even when I got the plastic babies and things, the school system didn’t want to buy the little monitors they clip on their shirt to simulate breastfeeding; they just wanted to do the bottles and I said, “no, no, no, no, we really need this. If I’ve got to write a grant or I need to do something, we need to show children that that is the best way to go”…they allowed me to get two of them for the ten babies, but I still have to offer the children the option of just doing the bottle. They were supportive; I wish they had been more supportive. (Teacher #8)
Teacher impartiality. Teachers verbalized that they should be teaching information based on evidence, not based on their personal views or opinions on a topic. As a result, they would not influence the students’ views but present lessons from a factual basis to promote student choices based on evidence.
Saying okay let’s have everyone go to breastfeeding only, you can’t do that, you can’t voice your opinion. We’re teachers, your opinion is to be quiet and teach and allow the child or the student or whoever to make the choices for themselves. (Teacher #11)
Bottle feeding culture. When asked about the infant feeding content they cover in their classes, some teachers responded primarily from a bottle-feeding perspective while others talked primarily about breastfeeding until prompted for the other content area.
I teach Foods and Nutrition and we have a section there on making and preparing meals, nutritious meals for children. Infant feeding, you know what age you should start feeding them foods and we talk about the formula, of course they say “milk” but, you know, formula. (Teacher #9)
Teachers’ social norms of infant feeding methods appeared as they described the detail of their lessons. One teacher talked about feeding in a way that showed normalization of formula feeding. When asked about infant feeding, first she responded with information about bottle feeding, followed by detail about the kits that she has for bottle feeding and the parts of bottle feeding she emphasizes in her classroom.
Early Childhood 1 does have a section where students have to demonstrate how to feed a baby, and it’s a little kit and it has props and stuff. I actually made it into a little kit where you give them the items the need like the bottle, the bib, everything they’re going to need to do the procedure. (Teacher #5)
3) Perceived behavior control. A person’s perception of behavioral control can affect both their intention to perform the behavior and the actual performance of the behavior . Teachers’ beliefs of how easy or difficult it is to teach about breastfeeding included intrinsic factors, such as their comfort with the information and their self-efficacy teaching about infant feeding, which they related to their education and experiences with infant feeding. The extrinsic factors that control how they teach infant feeding content included curriculum autonomy, student maturity, and student gender.
Teacher comfort. Many of the teachers interviewed were comfortable teaching about the human body, and they related breastfeeding to other topics that they teach within the Parenting and Child Development course such as pregnancy, birth, and sexually transmitted diseases. They described that the addition of breasts and breastfeeding was as a comfortable topic despite teenagers’ embarrassment or discomfort with topics related to bodies and sexual development. Other teachers felt that teaching about these topics could be awkward.
I think that sometimes teaching, especially for me, teaching about childbirth and conception and infancy, sometimes that can be uncomfortable for teachers and for students, just because it can sometimes. It can be considered a private issue. (Teacher #1)
Teacher experiences. The teachers’ personal experiences with infant feeding through their education, childcare experience and/or parenting shape the way they teach their students about infant feeding in their classrooms. The teachers who are parents talked about their own experiences feeding their children (both positive and negative) and tied those experiences into their classrooms. Those without children talked about the challenges of teaching parenting and infant feeding before they have children of their own.
I think the one disadvantage that I have is that just due to our careers and even some medical issues, I never was a parent myself and so I never had the opportunity to breastfed myself. (Teacher #15)
One teacher talked about her positive breastfeeding experience but acknowledged that not everyone has this experience. She tries to give her students a realistic view of infant feeding.
I’m a big advocate for breastfeeding, I had a wonderful experience with it, I know that everybody does not, so I try to also talk about a lot of the issues and why we think people get discouraged with it, and I’m very honest that it is painful and starting out it’s very hard but the benefits outweigh it...Really, it’s just helped me be honest. (Teacher #7)
Teacher self-efficacy. Teachers’ described that their education combined with personal experiences raising their own children and with childcare guide their selection of materials and create self-efficacy for teaching infant feeding content.
I feel pretty confident because I’ve taught it and I’ve also experienced it as a mother. So, I think it’s helpful to have the personal experience, and I feel like I can answer the questions if need be, and if I don’t know the answers to the questions I can always go to a lactation specialist. (Teacher #17)
Curriculum autonomy. Teachers’ views on the amount of autonomy they have in choosing and presenting content varied, with some stating that the content they present is completely guided and controlled by the state standards and testing.
Every school in North Carolina has the same curriculum put out by the state of North Carolina, and if you don’t follow those guidelines then your scores on the end of grade test, which in our case in called the CTE test … then they do not do well unless you follow the curriculum that is provided by the state. (Teacher #11)
Conversely, other teachers felt that they have more flexibility in the exact content that they teach in their classes. This teacher described how the state curriculum does not include much information on breastfeeding, so she felt that she could add relevant content as long as she could justify it within the infant feeding objectives.
So, they give me standards and objectives that I have to cover, but personally, I feel like they are really broad, so I’m kind of wide open to teach whatever I want as long as it covers those standards. (Teacher #1)
Student maturity/gender. Teachers described that, as students progress from middle to high school, their cognitive development allows them to view life from outside their own individual needs and perspectives; therefore, they are better able to understand, synthesize, and apply information about breastfeeding.
The maturity level, the ability to think outside of their own little bubble because a lot of them just cannot do that yet, they can’t think about caring for someone else because they can’t even care for themselves. And usually tenth grade, they are getting a little bit more independent, they’re starting to drive, so I think that helps strengthen their maturity level. (Teacher #2)
Some teachers viewed mixed gender classes as a barrier to incorporating breastfeeding content. This teacher described that female students view breastfeeding as personal content which makes them uncomfortable when she teaches it when male students are present.
And I know we try to promote gender equality and all of that but it’s hard to get a teenager girl to sit there and talk about breastfeeding when there’s boys sitting there too. Like sometimes, they’re a little bit more resistant to ask you questions or actually talk to you more about things. (Teacher #2)