The Effectiveness of Using Breastfeeding Program for Father via Facebook to knowledge, Attitude, Behavior of Supporting of 6-Month Exclusive Breastfeeding in Low-Income Country

Background: The six-month exclusive breastfeeding rate in the Northeast region of Thailand has recently signicantly decreased in contrast to all other regions in Thailand. Facebook is world widely use to increase that knowledge, attitude and behaviour to support breastfeeding. Therefore, the aim of this study is to test the effectiveness of using 6-month breastfeeding program for father via Facebook to knowledge, attitude, behavior of supporting of breastfeeding in low-income country. Method: A quasi-experimental design was used. The study was carried out from September 2020 – August 2021. The data of experimental group and control group were conducted in two tertiary hospital in Khonkaen province, Northeast Thailand. The participants were husbands of postpartum mothers who were admitted to the Obstetrics ward , Khonkaen Hospital, 2A and 2B ward, Srinagarin Hospital. The demographic data were analyzed by distribution of frequency, mean, percentage and standard deviation. The t-test were used to analyse the mean score of knowledge, attitude and behaviour of father by SPSS version 27. Results: 72 father were included. The different mean score of knowledge, attitude, behaviors of father to support the EBF among baseline and 6-month were shown. In intervention group, the different mean score of knowledge among baseline and 6-month was signicant at P-value 0.01. The mean of knowledge at 6 months (mean=19.78, SD=5.50) was higher than the mean of knowledge baseline (mean=16.42, SD=4.22). Similarly, the different mean score of attitudes among baseline and 6-month was signicant at P-value 0.14. The mean of attitude at 6-month (mean=108.03, SD=19.89) was higher than the mean of behaviour at baseline (mean=101.81, SD=17.99). In addition, the different score of behaviour among baseline (mean=65.86, SD=7.01) and 6-month (mean=68.58, SD=10.42) was signicant at P-value=0.16. The mean score of behavior at baseline is lower than the mean of behaviour at 6 months. In control group, these is only the different mean of behavior baseline and 6-month was signicant The


Background
In 2025, World Health Organization sets up the six-month exclusive breastfeeding (6-month EBF) as 50 % of children in the world [1]. In Thailand, the 12th National Economic and Social Development Plan of Thailand 2017-2021 has set up the six-month EBF goal as same as WHO [2]. The statistic of six-month EBF in Thailand had been increased form 12.3 % in 2013 to 23 % in 2016 [2]. However, this target is far from the 6-month EBF target of Thailand and WHO. Therefore, to reach the goal of 6-month EBF rate is important.
In both internationally and in Thailand, many factors in uence to six-month EBF. Mother factors are age, educational level, occupation, economic status, health status, EBF knowledge, breastfeeding con dence, breastfeeding believe, the duration of maternity leave [3][4][5][6][7][8]. Infant factors are infant health, infant temperament, lack of effective suckling [3,8]. Healthcare, such as the healthcare service, healthcare access, EBF knowledge, EBF attitude, and EBF skill of healthcare professional, EBF policy, is another factor [4,9,10]. The last factor is social such as workplace and family [4]. The study show that the father's knowledge, attitude and behavior to support the 6-month exclusive breastfeeding affect to the duration of 6-month EBF [3,7]. In addition, social media has been reported as the new factors to increase the duration of six-month EBF in low-income country [4].
Social media is a method to communicate, transfer, distribute information, exchange knowledge, news among people [11]. Social media is now widely used in business, government, and public health through various applications such as Facebook, web pages, LINE applications, etc [11]. The statistic in Thailand which is low income country show that, in 2015, up to 56 % of Thai people can access and use social media [12]. Social media has a positive effect on healthy behavior modi cation [13]. In addition, social media is a tool in order to service postpartum mothers. It also helps as a communication tool among health teams [11]. In northeast Thailand, social media as Facebook is factor affecting exclusive breastfeeding for 6 months as a way to nd knowledge about breastfeeding exclusively for 6 months, to express feelings, to solve problems related to breastfeeding. It is also an encouragement among mothers who are breastfeeding as well [4]. Therefore, social media especially FB has been recommended as an instrument to increase the EBF knowledge, change behavior of family member, nanny, and healthcare team to support EBF for 6 months [5].
Facebook (FB) is one of social media platform. Currently, there are more than 4 billion Facebook users worldwide. In 2018, Thailand had 45 million Facebook users, 23 million males and 22 million females [14], aged 18-24 years. The highest total usage was 16.0 million accounts, followed by users aged 25-34 [14]. Facebook is used for a variety of purposes, such as education, advertising, education health care, etc. [15,16], including promoting breastfeeding [17,18]. Using Facebook can be a source of knowledge and help promote group support allows mothers to breastfeed longer [18]. However, Facebook has not been used to encourage and promote breastfeeding among husbands. One important factor affecting the duration of breastfeeding is the husband. The husband is the one who is close to the mother after giving birth. He is a person who has contributed to the encouragement, support for postpartum mothers.
Husbands are therefore a group of people who healthcare professional should pay attention to in promoting breastfeeding. A review of the literature on the promotion of breastfeeding found that the duration of breastfeeding was correlated with the support of the husbands. The husband has both a physical and psychological in uence on the postpartum mother [4,19] In Thailand, most husbands work outside the home. This can lead the lack of opportunity to participate in the promotion of breastfeeding of husband. Therefore, healthcare professional should pay attention by increasing knowledge, creating positive attitudes and encourage behaviors that promote breastfeeding for husbands who work outside the home. In addition, the amount of using social media especially FB, to educate and promote positive behavior to 6-month EBF increase. Therefore, the breastfeeding program for father via Facebook has been developed.
The aim of this study is to test the effectiveness of using 6-month breastfeeding program for father via Facebook to knowledge, attitude, behavior of supporting of breastfeeding in low-income country.

Design and participants
A quasi-experimental design was used to evaluate outcomes of the 6-month breastfeeding program for father via facebook on knowledge, attitude and father's behaviour to support the 6-month breastfeeding in low-income country. The study was carried out from September 2020 -August 2021. The data of experimental group and control group were conducted in two tertiary hospital in Khonkaen province, Northeast Thailand. The participants were husbands of postpartum mothers who were admitted to the Obstetrics ward, Khonkaen Hospital, 2A and 2B ward, Srinagarin Hospital. The inclusion criteria were a husband who works from home/outside for 6-8 hours a day, age 20-60 years, being the husband of the mother after giving birth (Normal delivery/caesarean) 1-4 days, Being the father of an infant born 1-4 days with normal conditions and no restrictions on breastfeeding, able to communicate and able to read and write Thai language, willingness and consent to cooperate in research, able to bring the child to have a health check and vaccination at the good boy clinic at the hospital for 1, 2, 4 and 6 months. The withdrawal criteria were during the activity, participants participate in the program or do not voluntarily participate in the program or their infant is prohibited from breastfeeding or unable to breastfeed. The purposive sampling were using to include the participants and the participants were randomly assigned to a control group and an experimental group by means of random sampling.
The experimental group joined the 6-month breastfeeding program for father via Facebook. This intervention was designed based on knowledge transformation concept which included the explicit knowledge and tacit knowledge. This intervention consists of 3 parts: 1) A 6-month EBF education package; this package was set on Facebook platform in the form of Info graphic. The content included the bene ts of breastfeeding, factors affecting the amount of breastmilk, how to breastfeed, hold, express milk, common problems in breastfeeding. Participants were received this knowledge package for the rst The different mean score of knowledge, attitude, behaviors of father to support the EBF among baseline and 6-month were shown. In intervention group, the different mean score of knowledge among baseline and 6-month was signi cant at P-value 0.01 ( Table 2). The mean of knowledge at at 6 months (mean = 19.78, SD = 5.50) was higher than the mean of knowledge baseline (mean = 16.42, SD = 4.22). Similarly, the different mean score of attitudes among baseline and 6-month was signi cant at P-value 0.14 ( Table 2). The mean of attitude at 6-month (mean = 108.03, SD = 19.89) was higher than the mean of behaviour at baseline (mean = 101.81, SD = 17.99). In addition, the different score of behaviour among baseline (mean = 65.86, SD = 7.01) and 6-month (mean = 68.58, SD = 10.42) was signi cant at P-value = 0.16 ( Table 2). The mean score of behavior at baseline is lower than the mean of behaviour at 6 month. In control group, these is only the different mean of behavior baseline and 6-month was signi cant at Pvalue = 0.00 (Table 2). Table 1 The characteristic of participants.

Items
The intervention group  The different mean score of knowledge, attitude, behaviors of father to support the EBF among intervention group and control group were shown. In baseline, the mean score of knowledge, attitude and behaviour among intervention group and control group were signi cant at P-value = 0.01, 0.04, 0.24, respectively. At 6 month, only the different mean of attitude among intervention group (mean = 108.03,SD = 19.89) and control group (mean = 106.69,SD = 20.83) was signi cant at P-value = 0.29.

Discussion
The results of the study show that the breastfeeding knowledge, attitude, and behavior of the father to support breastfeeding can improve by this intervention. This is a good evidence showing that fathers can learn more knowledge about breastfeeding when the father participate in breastfeeding education. This result is similar with the study in China. It shows that father who attended that BF education program had the high score of BE knowledge than the father who are not attended the program [20]. In addition, the FB program can increase the breastfeeding knowledge of father in low-income country. In Africa, the breastfeeding FB program was effective to rise the knowledge of participants and also increase the intention and the duration of breastfeeding [17]. In term of breastfeeding attitude, the breastfeeding attitude of father who joined this FB program was reported as the high score than the attitude in control group. Similarly, the breastfeeding attitude of mother who are attended FB program had been increased after attended FB and was higher than mother who did not attended. In term of behavior, the results show that the mean score of behavior of father to support breastfeeding who attend this FB program was high than the mean score of behavior of father to support breastfeeding who did not attend this FB program. It is similar with the study in Vietnam. The study shows that father who join that education program had the mean score of behavior to support breastfeeding support is higher than father who did not attend the education program. This can be concluded that Breastfeeding program for father via Facebook affected to the knowledge, attitude, behaviour of supporting of breastfeeding of father. This program should be continued using for father in northeast Thailand.
The main strength of the current study was that it included fathers who are various ages, educational level, backgrounds, income, and breastfeeding experience. Using a quantitative approach allowed for a generalization. A limitation of this study is that father who do not interesting in breastfeed were not included, but this was not the focus of this study.

Conclusions
This study is to test the effectiveness of using breastfeeding program for father via Facebook to knowledge, attitude, behavior of supporting of breastfeeding in low-income country. The result shows that the mean score of knowledge, attitude, and behaviour to support breastfeeding of father increased after attend the breastfeeding program for father via Facebook. This con rm that FB is good platform to transfer the breastfeeding knowledge to father in low income country. In the future, this program can be improved and test in other country that has the same condition. Consent for publication -We used one consent form to get consent for the individual data and to digitally record the data collection.
Availability of data and material -Not applicable.