Influence of workplace dynamics on breastfeeding practices in rural areas in Ghana: a facility-and community-based assessment of mothers in Nadowli-Kaleo

Influence of workplace dynamics on breastfeeding practices in rural areas in Ghana: a facility-and community-based assessment of mothers in Nadowli-Kaleo | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Influence of workplace dynamics on breastfeeding practices in rural areas in Ghana: a facility-and community-based assessment of mothers in Nadowli-Kaleo K. Aduo-Adjei, G. Yengsumo Gyaburo, B. Okoe Armah, Joan-Ark Manu Agyapong, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9427619/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background Breastfeeding, especially exclusive breastfeeding (EBF) for the first six months of life, confers substantial health benefits on infants and mothers. However, employed mothers frequently encounter workplace-related barriers that impede breastfeeding. Despite existing national infant-feeding policies in Ghana, the role of workplace dynamics in either enabling or undermining breastfeeding among employed mothers in rural districts remains poorly characterised. Objectives This study aimed to (1) describe the prevalence and duration of EBF practices among employed mothers in the Nadowli-Kaleo District; (2) assess the influence of workplace policies and support on breastfeeding duration; (3) examine attitudes and social dynamics shaping breastfeeding choices at work; and (4) identify structural barriers to EBF among working mothers. Methods A cross-sectional survey was conducted among 130 employed breastfeeding mothers recruited by convenience sampling from workplaces across the Nadowli-Kaleo District, Upper West Region, Ghana, in 2024. Data were collected using a structured, self-administered, closed-ended questionnaire. Descriptive statistics (frequencies, means, standard deviations), one-way ANOVA, and Pearson correlation were used to analyse data in SPSS v27. Results The majority of respondents were female (98.5%), married (65.4%), and employed full-time (76.9%). Exclusive breastfeeding was practiced by 57.7% (n = 75) of participants, with a mean duration of 5.5 months (SD unreported). A strong positive correlation was observed between supportive workplace environments and breastfeeding duration (r = 0.65, p < 0.01). Workplace policies supporting EBF showed a moderate correlation with breastfeeding duration (r = 0.45), as did provision of breastfeeding breaks (r = 0.38). The three primary structural barriers were lack of a dedicated lactation room (mean = 3.90; r = 0.42), inflexible work schedules (mean = 3.71; r = 0.39), and inadequate maternity leave (mean = 3.85; r = 0.40). ANOVA indicated significant differences in breastfeeding duration by level of workplace support (F = 7.89, p < 0.05). Conclusions Workplace policies, infrastructure, and social climate significantly influence EBF practices among employed mothers in the Nadowli-Kaleo District. Comprehensive breastfeeding-friendly workplace policies including dedicated lactation rooms, flexible schedules, and extended paid maternity leave are urgently needed to close the gap between national EBF recommendations and practice in this resource-limited setting. exclusive breastfeeding working mothers workplace policies lactation support Ghana Upper West Region cross-sectional study 1. Introduction Breastfeeding, and in particular exclusive breastfeeding (EBF) for the first six months of infant life, is widely regarded as one of the most effective strategies for reducing child morbidity and mortality globally (Debnath & Lahariya, 2025 ). Beyond protecting against gastrointestinal, respiratory, and other infectious illnesses, EBF reduces infant risk of sudden infant death syndrome (SIDS) by approximately 50%, lowers rates of childhood obesity and leukemia, and supports optimal cognitive and sensory development (Hossain & Mihrshahi, 2022 ). For mothers, EBF confers protection against postpartum haemorrhage, premenopausal breast and ovarian cancers, and contributes to lactational amenorrhoea, natural birth spacing, and improved maternal-infant bonding(Tofoatsi, 2023 ). Despite this compelling evidence base, EBF rates remain suboptimal in many low- and middle-income countries, including Ghana. Ghana's EBF rate for infants aged 0–5 months declined from 63% in 2008 to 43% in 2017, with the latest national estimate of approximately 45% (Ameyaw, 2018 ; Mohammed, 2023 ). Urban and peri-urban settings in Northern Ghana consistently register lower rates than the national average, partly because of the rapid expansion of the formal female labour force. Approximately 50% of employed women of reproductive age return to work within one year of giving birth(Chen et al., 2019 ), and evidence consistently demonstrates that full-time employment is negatively associated with breastfeeding initiation and duration (Demir et al., 2020 ; Tsai, 2013 ). The workplace environment is therefore a critical and modifiable determinant of breastfeeding outcomes. Workplace initiatives such as designated lactation rooms, flexible break schedules, family-friendly policies, and on-site childcare have been shown to enable breastfeeding continuation after a mother's return to work (D’souza et al., 2022 ; Jantzer et al., 2018 ; Payton et al., 2019 ). Conversely, the absence of such supports generates time-based, strain-based, and behavior-based work-family conflict (Greenhaus & Beutell, 1985b ) that frequently results in early breastfeeding cessation. Culturally and socially, negative peer attitudes and stigma around breastfeeding at the workplace further compound the challenge (Amin et al., 2020 ; Brown et al., 2021 ). In Ghana, while a national Infant and Young Child Feeding strategy has existed since 2007, this policy does not explicitly address Breastfeeding-Friendly Support Environments (BFSE) in workplaces (Nwafor, 2018 ). There is therefore a significant gap between policy intent and the structural conditions required to sustain EBF among employed mothers, particularly in more resource-constrained districts. The Nadowli-Kaleo District of the Upper West Region is one such setting: largely rural, with limited health infrastructure and growing numbers of women in formal employment, yet without systematic documentation of how workplace dynamics shape breastfeeding decisions. This study was conducted to address four specific objectives: (1) to describe the prevalence and duration of exclusive and partial breastfeeding practices among employed mothers in the Nadowli-Kaleo District; (1) to examine the association between workplace policies and support and breastfeeding duration; (3) to assess how workplace attitudes and social dynamics influence breastfeeding choices among working mothers; and to identify key structural barriers to exclusive breastfeeding among working mothers in this district. 2. Theoretical Framework This study is anchored in two complementary theoretical frameworks: the Work-Family Conflict Theory and Bronfenbrenner's Ecological Systems Theory. Together, these frameworks provide a multi-level lens through which the influence of workplace dynamics on breastfeeding practices among employed mothers can be examined and interpreted. Work-Family Conflict Theory The Work-Family Conflict Theory, originally articulated by (Greenhaus & Beutell, 1985a ), posits that work and family roles are mutually incompatible in certain respects, such that participation in one role is made more difficult by participation in the other. The theory identifies three primary forms of conflict: time-based conflict, which arises when time devoted to one role reduces time available for the other; strain-based conflict, in which stress generated in one domain spills over and impairs functioning in the other; and behavior-based conflict, where behaviors appropriate to one role are incompatible with expectations in the other. In the context of breastfeeding among employed mothers, this theory is particularly instructive. Breastfeeding, especially exclusive breastfeeding (EBF), demands regular and frequent feeding or expression of breast milk, which is fundamentally a time-intensive activity. When workplace structures do not accommodate this need through provisions such as scheduled lactation breaks, flexible working hours, or adequate maternity leave, time-based conflict becomes a direct mechanism through which employment undermines breastfeeding continuation. Similarly, the psychological stress associated with managing the competing demands of work responsibilities and infant feeding obligations generates strain-based conflict, which has been shown to erode mothers' motivation and capacity to sustain breastfeeding after returning to work. Behavior-based conflict is also evident in settings where the act of breastfeeding or expressing milk is perceived as professionally inappropriate or disruptive, further discouraging mothers from integrating breastfeeding into their working lives. This study applies the Work-Family Conflict Theory to interrogate the structural and policy dimensions of the workplace environment, specifically the availability and quality of breastfeeding-friendly policies, lactation facilities, and flexible scheduling as the primary organizational-level mechanisms that either exacerbate or mitigate work-family conflict for breastfeeding mothers in the Nadowli-Kaleo District. Ecological Systems Theory Complementing the Work-Family Conflict framework, Bronfenbrenner ( 1979a ) offers a broader, multi-layered perspective on the determinants of breastfeeding behavior. The theory conceptualises human development and behavior as shaped by a series of nested environmental systems: the microsystem (immediate settings such as the workplace or household), the mesosystem (the interactions between microsystems, for example, between work and home environments), the exosystem (external settings that indirectly influence the individual, such as employer policies or national legislation), and the macrosystem (overarching cultural values, social norms, and institutional policies). Applied to breastfeeding in the workplace context, Ecological Systems Theory directs attention beyond the individual mother's choices and intentions to examine how multiple layers of her social environment collectively shape breastfeeding outcomes. At the microsystem level, the immediate workplace environment, including the presence or absence of lactation rooms, the attitudes of colleagues and supervisors, and the prevailing workplace culture, directly conditions whether a mother can breastfeed or express milk during working hours. At the mesosystem level, the degree of alignment or tension between workplace demands and home-based caregiving responsibilities influences how successfully mothers navigate the transition back to work while sustaining breastfeeding. At the exosystem level, national and institutional policies, including Ghana's current 90-day maternity leave provision and the absence of a legislative mandate for Breastfeeding-Friendly Support Environments (BFSEs) in workplaces, create enabling or constraining structural conditions that extend beyond any single employer. At the macrosystem level, broader cultural norms regarding breastfeeding in public and professional settings, gender roles in childcare, and societal expectations of employed mothers further shape the social climate within which individual breastfeeding decisions are made. By integrating both the Work-Family Conflict Theory and Ecological Systems Theory, this study adopts a framework that is sensitive to both the immediate structural barriers embedded in workplace organisation and the broader social, cultural, and policy environments that mediate breastfeeding practices. This dual-framework approach informed the design of the study instrument, with questionnaire items operationalising constructs drawn from both theories across the domains of workplace policies and support, attitudes and social dynamics at work, and structural barriers to exclusive breastfeeding. This theoretical grounding also guides the interpretation of findings and the formulation of recommendations aimed at producing change at multiple levels of the ecological system. 3. Methods The study was both a facility-and community-based cross-sectional survey. Cross-sectional designs are appropriate for estimating prevalence and for identifying associations between exposures and outcomes at a single point in time, consistent with STROBE reporting recommendations for observational studies (Von Elm et al., 2007 ). The study was conducted in the Nadowli-Kaleo District, Upper West Region, Ghana. The district covers approximately 2,742.5 km², is bordered by Burkina Faso to the west, and lies approximately 40 km from the regional capital, Wa. It is predominantly rural, with agriculture and small-scale trading as main livelihoods, but has a growing public-sector workforce in health, education, and administration. Data collection took place between January and June 2024. The target population comprised all employed mothers who were currently breastfeeding and working in the Nadowli-Kaleo District. Inclusion criteria were: (i) employed in any sector (formal or informal), (ii) currently breastfeeding an infant or young child, and (iii) willingness to participate and provide informed consent. Mothers who were not employed, or who had never initiated breastfeeding, were excluded. A total of 130 participants were recruited using convenience sampling-participants were approached at their workplaces, health facilities, and community gathering points based on availability and willingness. While convenience sampling limits probabilistic inference, it was the most feasible approach given the absence of a sampling frame of breastfeeding employed mothers in the district. A sample of 130 respondents was deemed sufficient to detect moderate to large effect sizes (r ≥ 0.30) with 80% power at the 5% significance level, and to generate stable descriptive estimates of the key outcomes of interest. No formal a priori sample size calculation was reported in the original thesis; this is acknowledged as a limitation. The outcome variable for the study is Breastfeeding practice, categorised as exclusive breastfeeding (EBF breast milk only for the first six months), mixed feeding (breast milk combined with formula or complementary foods), or no breastfeeding (substitutes only). Duration of breastfeeding was recorded in months. On the other hand, the exposure variable is workplace dynamics operationalised across four specific domains (1) workplace policies and support for breastfeeding (five items), (2) exclusive breastfeeding practices (six items), (3) attitudes and breastfeeding choices at work (six items), and (4) structural barriers to EBF (four items). Items were rated on a 5-point Likert scale (1 = Strongly Disagree to 5 = Strongly Agree). Higher domain mean scores reflect greater policy availability, more positive attitudes, or more severe barriers, as appropriate. Data were collected using a structured, closed-ended self-administered questionnaire developed by the investigator and reviewed by academic supervisors. The instrument comprised five sections: (A) demographic characteristics; (B) workplace policies and support (8 items); (C) EBF practices (6 items); (D) attitudes and breastfeeding choices (6 items); and (E) barriers to EBF (4 items). For participants with limited literacy, the questionnaire was read aloud and explained by a trained research assistant. The instrument was pilot-tested with a convenience sample of colleagues prior to full-scale data collection; internal consistency was assessed, and minor revisions were made. Formal reliability statistics (e.g., Cronbach's α) were not reported in the parent thesis and represent an acknowledged limitation. Data were entered and analysed using IBM SPSS Statistics Version 27 (IBM Corp., Armonk, NY, USA). Continuous variables were described as means and standard deviations (SDs); categorical variables were reported as frequencies and percentages. One-way Analysis of Variance (ANOVA) was used to test whether breastfeeding outcomes differed significantly across subgroups defined by level of workplace support. Pearson product-moment correlation coefficients (r) were calculated to quantify the linear associations between individual workplace support variables and breastfeeding duration or practice. A two-tailed p-value < 0.05 was considered statistically significant. No adjustments for multiple comparisons were made; this is noted as a limitation. Regression modelling to control for potential confounders was beyond the scope of the original thesis and is identified as a priority for future work. Content validity was ensured through iterative expert review by academic supervisors with experience in public health and breastfeeding research. Face validity was assessed through pilot testing. Construct validity was partially supported by aligning questionnaire items with well-established theoretical frameworks (Work-Family Conflict Theory and Ecological Systems Theory). Formal psychometric testing (factor analysis, Cronbach's alpha) was not conducted, and this is acknowledged as a limitation. The need for ethical approval was waived by University of Business and Integrated Development Studies Institutional-Ethics Review Board (UBIDS-IRB). Participants were assured of confidentiality; no personal identifiers were retained in the analysis dataset. Data were stored securely, accessible only to the principal investigator and supervisor. Participants were free to withdraw at any point without consequence. 4. Results 3.1 Participant Characteristics A total of 130 employed breastfeeding mothers completed the survey. The sample was almost entirely female (n = 128, 98.5%). The predominant age group was 25–29 years (n = 45, 34.6%), followed by 30–34 years (n = 35, 26.9%). The majority were married (n = 85, 65.4%) and held a Bachelor's degree (n = 70, 53.8%). Most respondents were employed full-time (n = 100, 76.9%), with health professionals constituting the largest occupational category (nurses: n = 50, 38.5%; doctors: n = 25, 19.2%). Most respondents had two children (n = 50, 38.5%). Full demographic characteristics are presented in Table 1 . Table 1 Demographic Characteristics of Respondents (N = 130) Variable Category Frequency (n) Percentage (%) Age 18–24 years 25 19.2 25–29 years 45 34.6 30–34 years 35 26.9 35–39 years 15 11.5 ≥ 40 years 10 7.7 Total 130 100.0 Marital Status Single 30 23.1 Married 85 65.4 Divorced 10 7.7 Widowed 5 3.8 Total 130 100.0 Educational Level Basic Education 5 3.8 Senior High School 20 15.4 Bachelor's Degree 70 53.8 Master's Degree 30 23.1 Doctorate 5 3.8 Total 130 100.0 Number of Children 1 35 26.9 2 50 38.5 3 30 23.1 ≥ 4 15 11.5 Total 130 100.0 Employment Status Full-time 100 76.9 Part-time 15 11.5 Self-employed 15 11.5 Total 130 100.0 Field of Work Nurse 50 38.5 Doctor 25 19.2 Teacher 20 15.4 Trader 15 11.5 Artisan 10 7.7 Farmer 5 3.8 Other 5 3.8 Total 130 100.0 Source: Field Survey, Nadowli-Kaleo District, Ghana, 2024. 3.2 Workplace Policies and Support Table 2 presents descriptive statistics and Pearson correlations for five items related to workplace breastfeeding support. Respondents reported moderate-to-high levels of agreement that their workplaces had breastfeeding policies (mean = 3.80, SD = 0.85) and provided support during working hours (mean = 3.65, SD = 0.92). Provision of a dedicated lactation room was less consistently reported (mean = 3.20, SD = 1.05), as were milk storage facilities (mean = 3.10, SD = 1.10). Pearson correlations showed that the presence of supportive workplace policies was moderately associated with longer breastfeeding duration (r = 0.45), as were support during working hours (r = 0.42) and provision of breastfeeding breaks (r = 0.38). The overall correlation between supportive workplace environment and breastfeeding duration was r = 0.65 (p < 0.01). Table 2 Associations between workplace policies and support and breastfeeding duration (N = 130) Variable Mean SD r with BF Duration Workplace policies supporting exclusive breastfeeding 3.80 0.85 0.45 Workplace support during working hours 3.65 0.92 0.42 Dedicated lactation room available 3.20 1.05 0.35 Breaks provided to breastfeed 3.50 0.90 0.38 Facilities to store expressed breast milk 3.10 1.10 0.30 Note : SD = standard deviation; r = Pearson correlation coefficient; BF = breastfeeding. Items rated on a 5-point Likert scale (1 = Strongly Disagree to 5 = Strongly Agree). 3.3 Exclusive Breastfeeding Practices More than half of respondents (n = 75, 57.7%) reported practising exclusive breastfeeding at the time of the survey, with a mean duration of 5.5 months slightly below the WHO-recommended six months. A notable proportion (n = 35, 26.9%) reported mixed feeding, with a shorter mean breastfeeding duration of 4.0 months. One in seven participants (n = 20, 15.4%) reported relying exclusively on substitutes and had not breastfed. These findings are summarised in Table 3 . Table 3 Prevalence and duration of feeding practices among employed mothers (n = 130) Feeding Practice Frequency (n) Percentage (%) Mean Duration (months) Exclusive breastfeeding 75 57.7 5.5 Combination of breast milk and substitutes 35 26.9 4.0 No breastfeeding (substitutes only) 20 15.4 N/A Total 130 100.0 — EBF = exclusive breastfeeding. Mean duration reported in months. N/A = not applicable (breastfeeding not initiated). 3.4 Attitudes and Breastfeeding Choices at Work Table 4 presents data on workplace attitudinal factors. Respondents reported notable discomfort breastfeeding at work in front of colleagues (mean = 3.75, SD = 0.88), a finding associated with reduced breastfeeding at work (r = 0.40, p = 0.02). The mean score for comfort breastfeeding in any setting was 3.30 (SD = 0.95), indicating moderate comfort with variation across respondents (r = 0.35, p = 0.01). Exposure to negative comments from colleagues was endorsed at a mean of 3.55 (SD = 0.92) and was significantly associated with reduced breastfeeding practice (r = 0.38, p = 0.04). Table 4 Workplace attitudes and their association with breastfeeding practices (n = 130) Variable Mean SD r with BF practices Discomfort breastfeeding at work in front of colleagues 3.75 0.88 0.40 Comfort breastfeeding anytime and anywhere 3.30 0.95 0.35 Negative comments from colleagues regarding breastfeeding 3.55 0.92 0.38 r = Pearson correlation coefficient with breastfeeding practices. Higher mean scores on 'discomfort' and 'negative comments' scales reflect greater inhibiting effects on breastfeeding. 3.5 Barriers to Exclusive Breastfeeding Three key structural barriers were examined (Table 5 ). The lack of a dedicated lactation room was the most strongly endorsed barrier (mean = 3.90, SD = 0.82; r = 0.42). Inflexible work schedules were associated with the strongest correlation with reduced breastfeeding (mean = 3.71, SD = 0.87; r = 0.39). Inadequate maternity leave was also recognised as a substantial barrier (mean = 3.85, SD = 0.85; r = 0.40). All three barriers were moderately and positively correlated with reduced EBF, meaning that as perceived barrier severity increased, EBF rates decreased. Table 5 Structural Barriers to Exclusive Breastfeeding Among Working Mothers (N = 130) Barrier Mean SD r with EBF Lack of dedicated lactation room 3.90 0.82 0.42 Inflexible work schedule 3.71 0.87 0.39 Inadequate maternity leave 3.85 0.85 0.40 r = Pearson correlation coefficient with exclusive breastfeeding outcomes. Higher mean scores indicate the barrier is perceived as more prevalent and severe. EBF = exclusive breastfeeding. 5. Discussion This cross-sectional study examined the influence of workplace dynamics on breastfeeding practices among 130 employed mothers in the Nadowli-Kaleo District of Ghana's Upper West Region. The overarching finding that supportive workplace environments are strongly and positively associated with longer breastfeeding duration (r = 0.65, p < 0.01) is consistent with a substantial body of international evidence (Bai et al., 2018 ; Huang & Kaciroti, 2020 ; Rollins et al., 2016 ). In this regard, it reinforces the centrality of workplace context in shaping infant feeding decisions. The EBF prevalence of 57.7% in this sample, with a mean duration of 5.5 months, suggests levels somewhat above the national Ghanaian average of approximately 45% (Amoah et al., 2023 ). However, this is still below the WHO's recommended six-month target. The near-attainment of the recommended duration among exclusive breast feeders, compared with considerably shorter durations among mixed-feeders (4.0 months), underscores the dose-response relationship between the quality of breastfeeding support and outcomes. The 15.4% of participants reporting no breastfeeding at all is of particular public health concern and merits targeted intervention. From the findings, workplace policies supporting EBF demonstrated a moderate positive correlation with breastfeeding duration (r = 0.45), consistent with findings by (Wickramasinghe & Mendis, 2018 ), who reported that longer and better-enforced maternity leave policies are associated with sustained EBF. The variation in policy perceptions across workplaces suggests that the quality and enforcement of breastfeeding policies differ substantially between organisations, even within this single district, a finding that aligns with the policy-practice gap documented by (Bai et al., 2018 ). Notably, the lowest mean scores and the highest variability were observed for the availability of dedicated lactation rooms (mean = 3.20, SD = 1.05) and milk storage facilities (mean = 3.10, SD = 1.10), suggesting these physical infrastructure components are the most inconsistently provided. (D’souza et al., 2022 ) demonstrated that provision of dedicated lactation rooms and flexible breaks directly raises breastfeeding rates by removing the dual barriers of insufficient privacy and time. The current findings corroborate this, as these variables showed moderate correlations with breastfeeding duration (r = 0.35 and 0.30, respectively). The three structural barriers examined lack of a lactation room, inflexible work schedules, and inadequate maternity leave were all significantly associated with reduced EBF. Inflexible work schedules emerged as the most critically perceived barrier (r = 0.39), consistent with (Nguyen et al., 2017 ), (Tsai, 2013 ), and the Work-Family Conflict Theory (Greenhaus & Beutell, 1985b ), which identifies time-based conflict as the most proximate mechanism by which employment undermines breastfeeding. Ghana's current 90-day (approximately 3-month) maternity leave falls significantly short of the WHO-recommended 6-month paid leave and appears insufficient to allow mothers to establish a sustainable breastfeeding routine before returning to work (Rapingah et al., 2021 ). The finding that discomfort breastfeeding at work (mean = 3.75; r = 0.40, p = 0.02) and exposure to negative colleague comments (mean = 3.55; r = 0.38, p = 0.04) were both significantly associated with reduced breastfeeding reflects broader findings from (Brown, 2017 ) and (Brown et al., 2021 ), who documented the inhibitory effect of social stigma and unsupportive workplace cultures on breastfeeding behaviors. The Ecological Systems Theory (Bronfenbrenner, 1979b ) provides a useful explanatory lens: beyond microsystem factors (direct workplace policies), mesosystem and macrosystem influences including peer norms, cultural attitudes, and the absence of a national workplace BFSE standard in Ghana collectively shape the social climate within which individual breastfeeding decisions are made. 6. Conclusions and recommendations Workplace dynamics are a critical determinant of breastfeeding practices among employed mothers in the Nadowli-Kaleo District. The study demonstrates that supportive workplace policies including dedicated lactation rooms, scheduled breastfeeding breaks, flexible work arrangements, and adequate maternity leave are moderately to strongly associated with longer breastfeeding durations and higher EBF prevalence. Conversely, structural deficits and negative workplace social climates act as significant barriers to achieving the WHO-recommended six months of EBF. The Nadowli-Kaleo District shares demographic and structural characteristics a rural setting, a predominantly public-sector workforce, limited health infrastructure, and an emerging formal female labour market with many other rural districts in Ghana's Northern regions and in Sub-Saharan Africa more broadly. The study concludes that, the patterns documented in the study are more likely to reflect conditions in comparable settings, though direct extrapolation to urban or higher-income contexts should be undertaken with caution. Several limitations of this study merit acknowledgement. First, the convenience sampling strategy may introduce selection bias, as participants with stronger engagement with the health system or more positive attitudes towards research may be over-represented. Second, the cross-sectional design precludes causal inference; associations observed between workplace support and breastfeeding duration may be confounded by unmeasured variables such as parity, gestational age, infant health, or maternal education level. Third, the use of self-reported Likert scale data without psychometric validation (Cronbach's alpha or factor analysis) limits confidence in the reliability of domain constructs. Fourth, no formal a priori sample size calculation was conducted, and the absence of multivariable regression modeling means that reported correlations are unadjusted and may be confounded. Fifth, the single-district setting limits generalisability of findings to other parts of Ghana or Sub-Saharan Africa. Future studies should employ probability sampling, longitudinal follow-up, and covariate-adjusted regression analyses to strengthen causal inference. The following recommendations are provided to help close the gap. First, the gap between national breastfeeding policy intent and workplace practice in Ghana requires coordinated action from employers, national policymakers, and health professionals. Concrete recommendations include the legislation mandating workplace BFSEs for all formal employers. The study also recommends extension of paid maternity leave to at least six months and the integration of breastfeeding support into occupational health programs. Future research should employ prospective cohort designs with validated instruments, adjusted regression modeling, and multi-district sampling to build a stronger evidence base for workplace breastfeeding interventions in Ghana and comparable Sub-Saharan African settings. Based on the study findings, the following evidence-informed recommendations are therefore proposed: Mandatory Workplace Breastfeeding Policies: Employers across all sectors should develop, implement, and enforce comprehensive breastfeeding policies that guarantee lactation rooms, scheduled breaks, and flexible work arrangements. These policies should be reviewed annually for adequacy and reach. Extension of Paid Maternity Leave: Policymakers should revise Ghana's 90-day maternity leave provision to align with the WHO recommendation of at least six months, with full pay for formal-sector employees and social protection coverage for informal workers. Workplace Culture and Attitude Change: Employers should invest in sensitisation programmes to address negative attitudes towards breastfeeding, normalise breastfeeding at work, and provide managerial training on the accommodation of breastfeeding employees. Lactation Infrastructure: District assemblies and employers should prioritise the creation of safe, private, clean, and well-equipped lactation rooms and milk cold-chain storage in all formal workplaces. Further Research: Future studies should adopt prospective longitudinal designs, validated multi-item scales with established psychometric properties, probability sampling, and covariate-adjusted regression modeling to strengthen the evidence base. Declarations Funding and Conflicts of Interest This study received no external funding. It was conducted as partial fulfillment of the requirements for the Master of Public Health degree at Simon Diedong Dombo University of Business and Integrated Development Studies (SDD-UBIDS), Ghana. The authors declare no conflicts of interest. Author contribution GYG: conceptualization, data collection and manuscript writing; FAOM & KAA: manuscript writing, supervising and addressing reviewer comments; BOA: data analysis and manuscript writing; EIS: literature and discussion; JAMA : manuscript writing, supervising COAB : data collection and manuscript writing; All authors read and approved the final version of the manuscript. Competing Interests There is no conflict of interest with respect to the research, authorship and publication of this article, neither is there any competing interest on the side of any author. Clinical trial number Not applicable. Ethics approval The need for ethical approval was waived by University of Business and Integrated Development Studies Institutional-Ethics Review Board (UBIDS-IRB). However, introductory letter was taken from the Department of Health Services Management and Administration, University of Business and Integrated Development Studies to help seek permission from participants. The introductory letter is available upon reasonable request from the corresponding author. Informed Consent was sought from participants before participating. The consent is available upon reasonable request from the corresponding author. Consent for publication Not available. Competing interests The authors declare no competing interests. References Ameyaw, E. K. (2018). Prevalence and correlates of unintended pregnancy in Ghana: Analysis of 2014 Ghana Demographic and Health Survey. Maternal Health. Neonatology and Perinatology , 4 , 1–6. Amin, M. R., Khatun, N., & Parveen, S. (2020). The role of workplace culture in breastfeeding practices: A qualitative study of working mothers in Bangladesh. International Breastfeeding Journal , 15 (1). Amoah, J., Asare, G., & Badu, K. 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Support for breastfeeding in the workplace and its associations with exclusive breastfeeding. Journal of Human Lactation , 35 (3), 455–464. Rapingah, S., Hamid, J. A., Md-Zain, B. M., & Tuda, J. (2021). Maternity leave and breastfeeding duration: A cross-national comparison. Public Health Nutrition , 24 (4), 762–771. Rollins, N. C., Bhandari, N., Hajeebhoy, N., Horton, S., Lauer, J. M., & Martines, J. C. (2016). Why invest, and what it will take to improve breastfeeding practices? The Lancet , 387 , 491–504. Tofoatsi, L. (2023). The Impact of Maternity Protection on Exclusive Breastfeeding: A Case Study of Ghana . https://ugspace.ug.edu.gh/ Tsai, S. Y. (2013). Impact of a breastfeeding-friendly workplace on an employed mother’s intention to continue breastfeeding after returning to work. Breastfeeding Medicine , 8 , 210–216. Von Elm, E., Altman, D. G., Egger, M., Pocock, S. J., Gøtzsche, P. C., & Vandenbroucke, J. P. (2007). The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies. Lancet , 370 (9596), 1453–1457. Wickramasinghe, A., & Mendis, J. (2018). The impact of workplace breastfeeding policies on employees: A review of evidence from developing countries. International Journal of Work and Health Management , 11 (1), 23–35. Additional Declarations No competing interests reported. Supplementary Files AppendixA.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 05 May, 2026 Editor assigned by journal 22 Apr, 2026 Submission checks completed at journal 22 Apr, 2026 First submitted to journal 15 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9427619","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":637481740,"identity":"d5593096-a9b6-4828-a755-c3f42a03ee75","order_by":0,"name":"K. Aduo-Adjei","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIiWNgGAWjYBACCQbGBwcYGJghHAkGCTkGZh5CWpgNULQYE6WFAa4FiBMbGAhokWxvZjzAUGOd2M/A/PCGRYVF+objvAeYCypwa5HmOcxwgOFYeuLMBjZjC4kzErkbDvMlMM84g1uLnET+gQMMbIcTN9x/YCYh2QbSwmPAzNuGT0sy0JZ/QC0H2L9JSP6TSDcgpEUapIWxDaSFB2hLg0QCQS2SPUC/JPalG89s4Cm2kDgmYTgT6JfDPHj8InG8mfnDh2/Wsv0M7BtvS9TUyfOdP3vwMQ+eEAODBCjNLAFlHCCgAQEYPxCtdBSMglEwCkYSAADMBEq3Px8EjQAAAABJRU5ErkJggg==","orcid":"","institution":"University of Bergen","correspondingAuthor":true,"prefix":"","firstName":"K.","middleName":"","lastName":"Aduo-Adjei","suffix":""},{"id":637481741,"identity":"4a5562cd-d34c-4bd1-bbff-9ab1e6270109","order_by":1,"name":"G. Yengsumo Gyaburo","email":"","orcid":"","institution":"Nadowli District Hospital","correspondingAuthor":false,"prefix":"","firstName":"G.","middleName":"Yengsumo","lastName":"Gyaburo","suffix":""},{"id":637481742,"identity":"5425f679-be5f-42da-9271-f4ab1baed1fd","order_by":2,"name":"B. Okoe Armah","email":"","orcid":"","institution":"University of Cape Coast","correspondingAuthor":false,"prefix":"","firstName":"B.","middleName":"Okoe","lastName":"Armah","suffix":""},{"id":637481743,"identity":"292780bb-1be0-4f96-b550-dc6b5dd204e1","order_by":3,"name":"Joan-Ark Manu Agyapong","email":"","orcid":"","institution":"University of Cape Coast","correspondingAuthor":false,"prefix":"","firstName":"Joan-Ark","middleName":"Manu","lastName":"Agyapong","suffix":""},{"id":637481744,"identity":"134de64f-97ef-49a0-926e-d98caaff5c38","order_by":4,"name":"C. Owusu Aduomi Botchwey","email":"","orcid":"","institution":"University of Education, Winneba","correspondingAuthor":false,"prefix":"","firstName":"C.","middleName":"Owusu Aduomi","lastName":"Botchwey","suffix":""},{"id":637481745,"identity":"b181a6cd-fc20-43da-9dc1-9bc412734d5e","order_by":5,"name":"E. Ibn Samba","email":"","orcid":"","institution":"Lawra Nursing Training College","correspondingAuthor":false,"prefix":"","firstName":"E.","middleName":"Ibn","lastName":"Samba","suffix":""},{"id":637481746,"identity":"c4c0aa58-ae3b-43bf-bbc6-2f56a576990d","order_by":6,"name":"F. A. Opoku-Mensah","email":"","orcid":"","institution":"University of Cape Coast","correspondingAuthor":false,"prefix":"","firstName":"F.","middleName":"A.","lastName":"Opoku-Mensah","suffix":""}],"badges":[],"createdAt":"2026-04-15 13:24:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9427619/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9427619/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":109208479,"identity":"a375e804-2f30-4593-aa2b-c7c112762b21","added_by":"auto","created_at":"2026-05-13 15:25:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":294448,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9427619/v1/9e2e659b-414c-4d4e-a91e-ed6433b4e079.pdf"},{"id":109207291,"identity":"c189c940-3066-4e77-8f3f-b9f637742731","added_by":"auto","created_at":"2026-05-13 15:19:10","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":15103,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixA.docx","url":"https://assets-eu.researchsquare.com/files/rs-9427619/v1/9d3725ccf30cb5126a6998d3.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Influence of workplace dynamics on breastfeeding practices in rural areas in Ghana: a facility-and community-based assessment of mothers in Nadowli-Kaleo","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eBreastfeeding, and in particular exclusive breastfeeding (EBF) for the first six months of infant life, is widely regarded as one of the most effective strategies for reducing child morbidity and mortality globally (Debnath \u0026amp; Lahariya, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Beyond protecting against gastrointestinal, respiratory, and other infectious illnesses, EBF reduces infant risk of sudden infant death syndrome (SIDS) by approximately 50%, lowers rates of childhood obesity and leukemia, and supports optimal cognitive and sensory development (Hossain \u0026amp; Mihrshahi, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). For mothers, EBF confers protection against postpartum haemorrhage, premenopausal breast and ovarian cancers, and contributes to lactational amenorrhoea, natural birth spacing, and improved maternal-infant bonding(Tofoatsi, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite this compelling evidence base, EBF rates remain suboptimal in many low- and middle-income countries, including Ghana. Ghana's EBF rate for infants aged 0\u0026ndash;5 months declined from 63% in 2008 to 43% in 2017, with the latest national estimate of approximately 45% (Ameyaw, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Mohammed, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Urban and peri-urban settings in Northern Ghana consistently register lower rates than the national average, partly because of the rapid expansion of the formal female labour force. Approximately 50% of employed women of reproductive age return to work within one year of giving birth(Chen et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), and evidence consistently demonstrates that full-time employment is negatively associated with breastfeeding initiation and duration (Demir et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Tsai, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe workplace environment is therefore a critical and modifiable determinant of breastfeeding outcomes. Workplace initiatives such as designated lactation rooms, flexible break schedules, family-friendly policies, and on-site childcare have been shown to enable breastfeeding continuation after a mother's return to work (D\u0026rsquo;souza et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Jantzer et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Payton et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Conversely, the absence of such supports generates time-based, strain-based, and behavior-based work-family conflict (Greenhaus \u0026amp; Beutell, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e1985b\u003c/span\u003e) that frequently results in early breastfeeding cessation. Culturally and socially, negative peer attitudes and stigma around breastfeeding at the workplace further compound the challenge (Amin et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Brown et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Ghana, while a national Infant and Young Child Feeding strategy has existed since 2007, this policy does not explicitly address Breastfeeding-Friendly Support Environments (BFSE) in workplaces (Nwafor, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). There is therefore a significant gap between policy intent and the structural conditions required to sustain EBF among employed mothers, particularly in more resource-constrained districts. The Nadowli-Kaleo District of the Upper West Region is one such setting: largely rural, with limited health infrastructure and growing numbers of women in formal employment, yet without systematic documentation of how workplace dynamics shape breastfeeding decisions. This study was conducted to address four specific objectives: (1) to describe the prevalence and duration of exclusive and partial breastfeeding practices among employed mothers in the Nadowli-Kaleo District; (1) to examine the association between workplace policies and support and breastfeeding duration; (3) to assess how workplace attitudes and social dynamics influence breastfeeding choices among working mothers; and to identify key structural barriers to exclusive breastfeeding among working mothers in this district.\u003c/p\u003e"},{"header":"2. Theoretical Framework","content":"\u003cp\u003eThis study is anchored in two complementary theoretical frameworks: the Work-Family Conflict Theory and Bronfenbrenner's Ecological Systems Theory. Together, these frameworks provide a multi-level lens through which the influence of workplace dynamics on breastfeeding practices among employed mothers can be examined and interpreted.\u003c/p\u003e \u003cp\u003e \u003cb\u003eWork-Family Conflict Theory\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe Work-Family Conflict Theory, originally articulated by (Greenhaus \u0026amp; Beutell, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e1985a\u003c/span\u003e), posits that work and family roles are mutually incompatible in certain respects, such that participation in one role is made more difficult by participation in the other. The theory identifies three primary forms of conflict: time-based conflict, which arises when time devoted to one role reduces time available for the other; strain-based conflict, in which stress generated in one domain spills over and impairs functioning in the other; and behavior-based conflict, where behaviors appropriate to one role are incompatible with expectations in the other.\u003c/p\u003e \u003cp\u003eIn the context of breastfeeding among employed mothers, this theory is particularly instructive. Breastfeeding, especially exclusive breastfeeding (EBF), demands regular and frequent feeding or expression of breast milk, which is fundamentally a time-intensive activity. When workplace structures do not accommodate this need through provisions such as scheduled lactation breaks, flexible working hours, or adequate maternity leave, time-based conflict becomes a direct mechanism through which employment undermines breastfeeding continuation. Similarly, the psychological stress associated with managing the competing demands of work responsibilities and infant feeding obligations generates strain-based conflict, which has been shown to erode mothers' motivation and capacity to sustain breastfeeding after returning to work. Behavior-based conflict is also evident in settings where the act of breastfeeding or expressing milk is perceived as professionally inappropriate or disruptive, further discouraging mothers from integrating breastfeeding into their working lives.\u003c/p\u003e \u003cp\u003eThis study applies the Work-Family Conflict Theory to interrogate the structural and policy dimensions of the workplace environment, specifically the availability and quality of breastfeeding-friendly policies, lactation facilities, and flexible scheduling as the primary organizational-level mechanisms that either exacerbate or mitigate work-family conflict for breastfeeding mothers in the Nadowli-Kaleo District.\u003c/p\u003e \u003cp\u003e \u003cb\u003eEcological Systems Theory\u003c/b\u003e \u003c/p\u003e \u003cp\u003eComplementing the Work-Family Conflict framework, Bronfenbrenner (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e1979a\u003c/span\u003e) offers a broader, multi-layered perspective on the determinants of breastfeeding behavior. The theory conceptualises human development and behavior as shaped by a series of nested environmental systems: the microsystem (immediate settings such as the workplace or household), the mesosystem (the interactions between microsystems, for example, between work and home environments), the exosystem (external settings that indirectly influence the individual, such as employer policies or national legislation), and the macrosystem (overarching cultural values, social norms, and institutional policies).\u003c/p\u003e \u003cp\u003eApplied to breastfeeding in the workplace context, Ecological Systems Theory directs attention beyond the individual mother's choices and intentions to examine how multiple layers of her social environment collectively shape breastfeeding outcomes. At the microsystem level, the immediate workplace environment, including the presence or absence of lactation rooms, the attitudes of colleagues and supervisors, and the prevailing workplace culture, directly conditions whether a mother can breastfeed or express milk during working hours. At the mesosystem level, the degree of alignment or tension between workplace demands and home-based caregiving responsibilities influences how successfully mothers navigate the transition back to work while sustaining breastfeeding. At the exosystem level, national and institutional policies, including Ghana's current 90-day maternity leave provision and the absence of a legislative mandate for Breastfeeding-Friendly Support Environments (BFSEs) in workplaces, create enabling or constraining structural conditions that extend beyond any single employer. At the macrosystem level, broader cultural norms regarding breastfeeding in public and professional settings, gender roles in childcare, and societal expectations of employed mothers further shape the social climate within which individual breastfeeding decisions are made.\u003c/p\u003e \u003cp\u003eBy integrating both the Work-Family Conflict Theory and Ecological Systems Theory, this study adopts a framework that is sensitive to both the immediate structural barriers embedded in workplace organisation and the broader social, cultural, and policy environments that mediate breastfeeding practices. This dual-framework approach informed the design of the study instrument, with questionnaire items operationalising constructs drawn from both theories across the domains of workplace policies and support, attitudes and social dynamics at work, and structural barriers to exclusive breastfeeding. This theoretical grounding also guides the interpretation of findings and the formulation of recommendations aimed at producing change at multiple levels of the ecological system.\u003c/p\u003e"},{"header":"3. Methods","content":"\u003cp\u003eThe study was both a facility-and community-based cross-sectional survey. Cross-sectional designs are appropriate for estimating prevalence and for identifying associations between exposures and outcomes at a single point in time, consistent with STROBE reporting recommendations for observational studies (Von Elm et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). The study was conducted in the Nadowli-Kaleo District, Upper West Region, Ghana. The district covers approximately 2,742.5 km\u0026sup2;, is bordered by Burkina Faso to the west, and lies approximately 40 km from the regional capital, Wa. It is predominantly rural, with agriculture and small-scale trading as main livelihoods, but has a growing public-sector workforce in health, education, and administration. Data collection took place between January and June 2024.\u003c/p\u003e \u003cp\u003eThe target population comprised all employed mothers who were currently breastfeeding and working in the Nadowli-Kaleo District. Inclusion criteria were: (i) employed in any sector (formal or informal), (ii) currently breastfeeding an infant or young child, and (iii) willingness to participate and provide informed consent. Mothers who were not employed, or who had never initiated breastfeeding, were excluded. A total of 130 participants were recruited using convenience sampling-participants were approached at their workplaces, health facilities, and community gathering points based on availability and willingness. While convenience sampling limits probabilistic inference, it was the most feasible approach given the absence of a sampling frame of breastfeeding employed mothers in the district. A sample of 130 respondents was deemed sufficient to detect moderate to large effect sizes (r\u0026thinsp;\u0026ge;\u0026thinsp;0.30) with 80% power at the 5% significance level, and to generate stable descriptive estimates of the key outcomes of interest. No formal a priori sample size calculation was reported in the original thesis; this is acknowledged as a limitation.\u003c/p\u003e \u003cp\u003eThe outcome variable for the study is Breastfeeding practice, categorised as exclusive breastfeeding (EBF breast milk only for the first six months), mixed feeding (breast milk combined with formula or complementary foods), or no breastfeeding (substitutes only). Duration of breastfeeding was recorded in months. On the other hand, the exposure variable is workplace dynamics operationalised across four specific domains (1) workplace policies and support for breastfeeding (five items), (2) exclusive breastfeeding practices (six items), (3) attitudes and breastfeeding choices at work (six items), and (4) structural barriers to EBF (four items). Items were rated on a 5-point Likert scale (1\u0026thinsp;=\u0026thinsp;Strongly Disagree to 5\u0026thinsp;=\u0026thinsp;Strongly Agree). Higher domain mean scores reflect greater policy availability, more positive attitudes, or more severe barriers, as appropriate.\u003c/p\u003e \u003cp\u003eData were collected using a structured, closed-ended self-administered questionnaire developed by the investigator and reviewed by academic supervisors. The instrument comprised five sections: (A) demographic characteristics; (B) workplace policies and support (8 items); (C) EBF practices (6 items); (D) attitudes and breastfeeding choices (6 items); and (E) barriers to EBF (4 items). For participants with limited literacy, the questionnaire was read aloud and explained by a trained research assistant. The instrument was pilot-tested with a convenience sample of colleagues prior to full-scale data collection; internal consistency was assessed, and minor revisions were made. Formal reliability statistics (e.g., Cronbach's α) were not reported in the parent thesis and represent an acknowledged limitation.\u003c/p\u003e \u003cp\u003eData were entered and analysed using IBM SPSS Statistics Version 27 (IBM Corp., Armonk, NY, USA). Continuous variables were described as means and standard deviations (SDs); categorical variables were reported as frequencies and percentages. One-way Analysis of Variance (ANOVA) was used to test whether breastfeeding outcomes differed significantly across subgroups defined by level of workplace support. Pearson product-moment correlation coefficients (r) were calculated to quantify the linear associations between individual workplace support variables and breastfeeding duration or practice. A two-tailed p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. No adjustments for multiple comparisons were made; this is noted as a limitation. Regression modelling to control for potential confounders was beyond the scope of the original thesis and is identified as a priority for future work.\u003c/p\u003e \u003cp\u003eContent validity was ensured through iterative expert review by academic supervisors with experience in public health and breastfeeding research. Face validity was assessed through pilot testing. Construct validity was partially supported by aligning questionnaire items with well-established theoretical frameworks (Work-Family Conflict Theory and Ecological Systems Theory). Formal psychometric testing (factor analysis, Cronbach's alpha) was not conducted, and this is acknowledged as a limitation.\u003c/p\u003e \u003cp\u003eThe need for ethical approval was waived by University of Business and Integrated Development Studies Institutional-Ethics Review Board (UBIDS-IRB). Participants were assured of confidentiality; no personal identifiers were retained in the analysis dataset. Data were stored securely, accessible only to the principal investigator and supervisor. Participants were free to withdraw at any point without consequence.\u003c/p\u003e"},{"header":"4. Results","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Participant Characteristics\u003c/h2\u003e \u003cp\u003eA total of 130 employed breastfeeding mothers completed the survey. The sample was almost entirely female (n\u0026thinsp;=\u0026thinsp;128, 98.5%). The predominant age group was 25\u0026ndash;29 years (n\u0026thinsp;=\u0026thinsp;45, 34.6%), followed by 30\u0026ndash;34 years (n\u0026thinsp;=\u0026thinsp;35, 26.9%). The majority were married (n\u0026thinsp;=\u0026thinsp;85, 65.4%) and held a Bachelor's degree (n\u0026thinsp;=\u0026thinsp;70, 53.8%). Most respondents were employed full-time (n\u0026thinsp;=\u0026thinsp;100, 76.9%), with health professionals constituting the largest occupational category (nurses: n\u0026thinsp;=\u0026thinsp;50, 38.5%; doctors: n\u0026thinsp;=\u0026thinsp;25, 19.2%). Most respondents had two children (n\u0026thinsp;=\u0026thinsp;50, 38.5%). Full demographic characteristics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic Characteristics of Respondents (N\u0026thinsp;=\u0026thinsp;130)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u0026ndash;24 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u0026ndash;29 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e34.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u0026ndash;34 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u0026ndash;39 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;40 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e130\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e100.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e65.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDivorced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWidowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e130\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e100.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducational Level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBasic Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSenior High School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBachelor's Degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e53.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMaster's Degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDoctorate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e130\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e100.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of Children\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e38.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e130\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e100.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployment Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFull-time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e76.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePart-time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-employed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e130\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e100.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eField of Work\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e38.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDoctor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTeacher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTrader\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eArtisan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFarmer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e130\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e100.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eSource: Field Survey, Nadowli-Kaleo District, Ghana, 2024.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Workplace Policies and Support\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents descriptive statistics and Pearson correlations for five items related to workplace breastfeeding support. Respondents reported moderate-to-high levels of agreement that their workplaces had breastfeeding policies (mean\u0026thinsp;=\u0026thinsp;3.80, SD\u0026thinsp;=\u0026thinsp;0.85) and provided support during working hours (mean\u0026thinsp;=\u0026thinsp;3.65, SD\u0026thinsp;=\u0026thinsp;0.92). Provision of a dedicated lactation room was less consistently reported (mean\u0026thinsp;=\u0026thinsp;3.20, SD\u0026thinsp;=\u0026thinsp;1.05), as were milk storage facilities (mean\u0026thinsp;=\u0026thinsp;3.10, SD\u0026thinsp;=\u0026thinsp;1.10). Pearson correlations showed that the presence of supportive workplace policies was moderately associated with longer breastfeeding duration (r\u0026thinsp;=\u0026thinsp;0.45), as were support during working hours (r\u0026thinsp;=\u0026thinsp;0.42) and provision of breastfeeding breaks (r\u0026thinsp;=\u0026thinsp;0.38). The overall correlation between supportive workplace environment and breastfeeding duration was r\u0026thinsp;=\u0026thinsp;0.65 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociations between workplace policies and support and breastfeeding duration (N\u0026thinsp;=\u0026thinsp;130)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003er with BF Duration\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorkplace policies supporting exclusive breastfeeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorkplace support during working hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDedicated lactation room available\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreaks provided to breastfeed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFacilities to store expressed breast milk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cb\u003eNote\u003c/b\u003e: \u003cem\u003eSD\u0026thinsp;=\u0026thinsp;standard deviation; r\u0026thinsp;=\u0026thinsp;Pearson correlation coefficient; BF\u0026thinsp;=\u0026thinsp;breastfeeding. Items rated on a 5-point Likert scale (1\u0026thinsp;=\u0026thinsp;Strongly Disagree to 5\u0026thinsp;=\u0026thinsp;Strongly Agree).\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Exclusive Breastfeeding Practices\u003c/h2\u003e \u003cp\u003eMore than half of respondents (n\u0026thinsp;=\u0026thinsp;75, 57.7%) reported practising exclusive breastfeeding at the time of the survey, with a mean duration of 5.5 months slightly below the WHO-recommended six months. A notable proportion (n\u0026thinsp;=\u0026thinsp;35, 26.9%) reported mixed feeding, with a shorter mean breastfeeding duration of 4.0 months. One in seven participants (n\u0026thinsp;=\u0026thinsp;20, 15.4%) reported relying exclusively on substitutes and had not breastfed. These findings are summarised in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePrevalence and duration of feeding practices among employed mothers (n\u0026thinsp;=\u0026thinsp;130)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFeeding Practice\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean Duration (months)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExclusive breastfeeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCombination of breast milk and substitutes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo breastfeeding (substitutes only)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e130\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eEBF\u0026thinsp;=\u0026thinsp;exclusive breastfeeding. Mean duration reported in months. N/A\u0026thinsp;=\u0026thinsp;not applicable (breastfeeding not initiated).\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Attitudes and Breastfeeding Choices at Work\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e presents data on workplace attitudinal factors. Respondents reported notable discomfort breastfeeding at work in front of colleagues (mean\u0026thinsp;=\u0026thinsp;3.75, SD\u0026thinsp;=\u0026thinsp;0.88), a finding associated with reduced breastfeeding at work (r\u0026thinsp;=\u0026thinsp;0.40, p\u0026thinsp;=\u0026thinsp;0.02). The mean score for comfort breastfeeding in any setting was 3.30 (SD\u0026thinsp;=\u0026thinsp;0.95), indicating moderate comfort with variation across respondents (r\u0026thinsp;=\u0026thinsp;0.35, p\u0026thinsp;=\u0026thinsp;0.01). Exposure to negative comments from colleagues was endorsed at a mean of 3.55 (SD\u0026thinsp;=\u0026thinsp;0.92) and was significantly associated with reduced breastfeeding practice (r\u0026thinsp;=\u0026thinsp;0.38, p\u0026thinsp;=\u0026thinsp;0.04).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eWorkplace attitudes and their association with breastfeeding practices (n\u0026thinsp;=\u0026thinsp;130)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003er with BF practices\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiscomfort breastfeeding at work in front of colleagues\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComfort breastfeeding anytime and anywhere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative comments from colleagues regarding breastfeeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003er\u0026thinsp;=\u0026thinsp;Pearson correlation coefficient with breastfeeding practices. Higher mean scores on 'discomfort' and 'negative comments' scales reflect greater inhibiting effects on breastfeeding.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Barriers to Exclusive Breastfeeding\u003c/h2\u003e \u003cp\u003eThree key structural barriers were examined (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The lack of a dedicated lactation room was the most strongly endorsed barrier (mean\u0026thinsp;=\u0026thinsp;3.90, SD\u0026thinsp;=\u0026thinsp;0.82; r\u0026thinsp;=\u0026thinsp;0.42). Inflexible work schedules were associated with the strongest correlation with reduced breastfeeding (mean\u0026thinsp;=\u0026thinsp;3.71, SD\u0026thinsp;=\u0026thinsp;0.87; r\u0026thinsp;=\u0026thinsp;0.39). Inadequate maternity leave was also recognised as a substantial barrier (mean\u0026thinsp;=\u0026thinsp;3.85, SD\u0026thinsp;=\u0026thinsp;0.85; r\u0026thinsp;=\u0026thinsp;0.40). All three barriers were moderately and positively correlated with reduced EBF, meaning that as perceived barrier severity increased, EBF rates decreased.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStructural Barriers to Exclusive Breastfeeding Among Working Mothers (N\u0026thinsp;=\u0026thinsp;130)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBarrier\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003er with EBF\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of dedicated lactation room\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInflexible work schedule\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInadequate maternity leave\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003er\u0026thinsp;=\u0026thinsp;Pearson correlation coefficient with exclusive breastfeeding outcomes. Higher mean scores indicate the barrier is perceived as more prevalent and severe. EBF\u0026thinsp;=\u0026thinsp;exclusive breastfeeding.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"5. Discussion","content":"\u003cp\u003eThis cross-sectional study examined the influence of workplace dynamics on breastfeeding practices among 130 employed mothers in the Nadowli-Kaleo District of Ghana's Upper West Region. The overarching finding that supportive workplace environments are strongly and positively associated with longer breastfeeding duration (r\u0026thinsp;=\u0026thinsp;0.65, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) is consistent with a substantial body of international evidence (Bai et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Huang \u0026amp; Kaciroti, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Rollins et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). In this regard, it reinforces the centrality of workplace context in shaping infant feeding decisions. The EBF prevalence of 57.7% in this sample, with a mean duration of 5.5 months, suggests levels somewhat above the national Ghanaian average of approximately 45% (Amoah et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). However, this is still below the WHO's recommended six-month target. The near-attainment of the recommended duration among exclusive breast feeders, compared with considerably shorter durations among mixed-feeders (4.0 months), underscores the dose-response relationship between the quality of breastfeeding support and outcomes. The 15.4% of participants reporting no breastfeeding at all is of particular public health concern and merits targeted intervention.\u003c/p\u003e \u003cp\u003eFrom the findings, workplace policies supporting EBF demonstrated a moderate positive correlation with breastfeeding duration (r\u0026thinsp;=\u0026thinsp;0.45), consistent with findings by (Wickramasinghe \u0026amp; Mendis, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), who reported that longer and better-enforced maternity leave policies are associated with sustained EBF. The variation in policy perceptions across workplaces suggests that the quality and enforcement of breastfeeding policies differ substantially between organisations, even within this single district, a finding that aligns with the policy-practice gap documented by (Bai et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Notably, the lowest mean scores and the highest variability were observed for the availability of dedicated lactation rooms (mean\u0026thinsp;=\u0026thinsp;3.20, SD\u0026thinsp;=\u0026thinsp;1.05) and milk storage facilities (mean\u0026thinsp;=\u0026thinsp;3.10, SD\u0026thinsp;=\u0026thinsp;1.10), suggesting these physical infrastructure components are the most inconsistently provided. (D\u0026rsquo;souza et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) demonstrated that provision of dedicated lactation rooms and flexible breaks directly raises breastfeeding rates by removing the dual barriers of insufficient privacy and time. The current findings corroborate this, as these variables showed moderate correlations with breastfeeding duration (r\u0026thinsp;=\u0026thinsp;0.35 and 0.30, respectively).\u003c/p\u003e \u003cp\u003eThe three structural barriers examined lack of a lactation room, inflexible work schedules, and inadequate maternity leave were all significantly associated with reduced EBF. Inflexible work schedules emerged as the most critically perceived barrier (r\u0026thinsp;=\u0026thinsp;0.39), consistent with (Nguyen et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), (Tsai, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2013\u003c/span\u003e), and the Work-Family Conflict Theory (Greenhaus \u0026amp; Beutell, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e1985b\u003c/span\u003e), which identifies time-based conflict as the most proximate mechanism by which employment undermines breastfeeding. Ghana's current 90-day (approximately 3-month) maternity leave falls significantly short of the WHO-recommended 6-month paid leave and appears insufficient to allow mothers to establish a sustainable breastfeeding routine before returning to work (Rapingah et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe finding that discomfort breastfeeding at work (mean\u0026thinsp;=\u0026thinsp;3.75; r\u0026thinsp;=\u0026thinsp;0.40, p\u0026thinsp;=\u0026thinsp;0.02) and exposure to negative colleague comments (mean\u0026thinsp;=\u0026thinsp;3.55; r\u0026thinsp;=\u0026thinsp;0.38, p\u0026thinsp;=\u0026thinsp;0.04) were both significantly associated with reduced breastfeeding reflects broader findings from (Brown, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) and (Brown et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), who documented the inhibitory effect of social stigma and unsupportive workplace cultures on breastfeeding behaviors. The Ecological Systems Theory (Bronfenbrenner, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e1979b\u003c/span\u003e) provides a useful explanatory lens: beyond microsystem factors (direct workplace policies), mesosystem and macrosystem influences including peer norms, cultural attitudes, and the absence of a national workplace BFSE standard in Ghana collectively shape the social climate within which individual breastfeeding decisions are made.\u003c/p\u003e"},{"header":"6. Conclusions and recommendations","content":"\u003cp\u003eWorkplace dynamics are a critical determinant of breastfeeding practices among employed mothers in the Nadowli-Kaleo District. The study demonstrates that supportive workplace policies including dedicated lactation rooms, scheduled breastfeeding breaks, flexible work arrangements, and adequate maternity leave are moderately to strongly associated with longer breastfeeding durations and higher EBF prevalence. Conversely, structural deficits and negative workplace social climates act as significant barriers to achieving the WHO-recommended six months of EBF. The Nadowli-Kaleo District shares demographic and structural characteristics a rural setting, a predominantly public-sector workforce, limited health infrastructure, and an emerging formal female labour market with many other rural districts in Ghana's Northern regions and in Sub-Saharan Africa more broadly. The study concludes that, the patterns documented in the study are more likely to reflect conditions in comparable settings, though direct extrapolation to urban or higher-income contexts should be undertaken with caution.\u003c/p\u003e \u003cp\u003eSeveral limitations of this study merit acknowledgement. First, the convenience sampling strategy may introduce selection bias, as participants with stronger engagement with the health system or more positive attitudes towards research may be over-represented. Second, the cross-sectional design precludes causal inference; associations observed between workplace support and breastfeeding duration may be confounded by unmeasured variables such as parity, gestational age, infant health, or maternal education level. Third, the use of self-reported Likert scale data without psychometric validation (Cronbach's alpha or factor analysis) limits confidence in the reliability of domain constructs. Fourth, no formal a priori sample size calculation was conducted, and the absence of multivariable regression modeling means that reported correlations are unadjusted and may be confounded. Fifth, the single-district setting limits generalisability of findings to other parts of Ghana or Sub-Saharan Africa. Future studies should employ probability sampling, longitudinal follow-up, and covariate-adjusted regression analyses to strengthen causal inference.\u003c/p\u003e \u003cp\u003eThe following recommendations are provided to help close the gap. First, the gap between national breastfeeding policy intent and workplace practice in Ghana requires coordinated action from employers, national policymakers, and health professionals. Concrete recommendations include the legislation mandating workplace BFSEs for all formal employers. The study also recommends extension of paid maternity leave to at least six months and the integration of breastfeeding support into occupational health programs. Future research should employ prospective cohort designs with validated instruments, adjusted regression modeling, and multi-district sampling to build a stronger evidence base for workplace breastfeeding interventions in Ghana and comparable Sub-Saharan African settings. Based on the study findings, the following evidence-informed recommendations are therefore proposed:\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eMandatory Workplace Breastfeeding Policies: Employers across all sectors should develop, implement, and enforce comprehensive breastfeeding policies that guarantee lactation rooms, scheduled breaks, and flexible work arrangements. These policies should be reviewed annually for adequacy and reach.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eExtension of Paid Maternity Leave: Policymakers should revise Ghana's 90-day maternity leave provision to align with the WHO recommendation of at least six months, with full pay for formal-sector employees and social protection coverage for informal workers.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWorkplace Culture and Attitude Change: Employers should invest in sensitisation programmes to address negative attitudes towards breastfeeding, normalise breastfeeding at work, and provide managerial training on the accommodation of breastfeeding employees.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eLactation Infrastructure: District assemblies and employers should prioritise the creation of safe, private, clean, and well-equipped lactation rooms and milk cold-chain storage in all formal workplaces.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eFurther Research: Future studies should adopt prospective longitudinal designs, validated multi-item scales with established psychometric properties, probability sampling, and covariate-adjusted regression modeling to strengthen the evidence base.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003cp\u003e\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding and Conflicts of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received no external funding. It was conducted as partial fulfillment of the requirements for the Master of Public Health degree at Simon Diedong Dombo University of Business and Integrated Development Studies (SDD-UBIDS), Ghana. The authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGYG:\u0026nbsp;\u003c/strong\u003econceptualization, data collection and manuscript writing;\u003cstrong\u003e\u0026nbsp;FAOM \u0026amp; KAA:\u003c/strong\u003e manuscript writing, supervising and addressing reviewer comments; \u003cstrong\u003eBOA:\u003c/strong\u003e data analysis and manuscript writing; \u003cstrong\u003eEIS:\u003c/strong\u003e literature and discussion; \u003cstrong\u003eJAMA\u003c/strong\u003e: manuscript writing, supervising \u003cstrong\u003eCOAB\u003c/strong\u003e: data collection and manuscript writing; All authors read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere is no conflict of interest with respect to the research, authorship and publication of this article, neither is there any competing interest on the side of any author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe need for ethical approval was waived by University of Business and Integrated Development Studies Institutional-Ethics Review Board (UBIDS-IRB). However, introductory letter was taken from the Department of Health Services Management and Administration, University of Business and Integrated Development Studies to help seek permission from participants. The introductory letter is available upon reasonable request from the corresponding author. Informed Consent was sought from participants before participating. The consent is available upon reasonable request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot available.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAmeyaw, E. K. (2018). Prevalence and correlates of unintended pregnancy in Ghana: Analysis of 2014 Ghana Demographic and Health Survey. 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Policy barriers to breastfeeding in Africa: A review. \u003cem\u003ePan African Medical Journal\u003c/em\u003e, \u003cem\u003e29\u003c/em\u003e.\u003c/li\u003e\n\u003cli\u003ePayton, E., Payton, K., \u0026amp; Frongillo, E. (2019). Support for breastfeeding in the workplace and its associations with exclusive breastfeeding. \u003cem\u003eJournal of Human Lactation\u003c/em\u003e, \u003cem\u003e35\u003c/em\u003e(3), 455\u0026ndash;464.\u003c/li\u003e\n\u003cli\u003eRapingah, S., Hamid, J. A., Md-Zain, B. M., \u0026amp; Tuda, J. (2021). Maternity leave and breastfeeding duration: A cross-national comparison. \u003cem\u003ePublic Health Nutrition\u003c/em\u003e, \u003cem\u003e24\u003c/em\u003e(4), 762\u0026ndash;771.\u003c/li\u003e\n\u003cli\u003eRollins, N. C., Bhandari, N., Hajeebhoy, N., Horton, S., Lauer, J. M., \u0026amp; Martines, J. C. (2016). Why invest, and what it will take to improve breastfeeding practices? \u003cem\u003eThe Lancet\u003c/em\u003e, \u003cem\u003e387\u003c/em\u003e, 491\u0026ndash;504.\u003c/li\u003e\n\u003cli\u003eTofoatsi, L. (2023). \u003cem\u003eThe Impact of Maternity Protection on Exclusive Breastfeeding: A Case Study of Ghana\u003c/em\u003e. https://ugspace.ug.edu.gh/\u003c/li\u003e\n\u003cli\u003eTsai, S. Y. (2013). Impact of a breastfeeding-friendly workplace on an employed mother\u0026rsquo;s intention to continue breastfeeding after returning to work. \u003cem\u003eBreastfeeding Medicine\u003c/em\u003e, \u003cem\u003e8\u003c/em\u003e, 210\u0026ndash;216.\u003c/li\u003e\n\u003cli\u003eVon Elm, E., Altman, D. G., Egger, M., Pocock, S. J., G\u0026oslash;tzsche, P. C., \u0026amp; Vandenbroucke, J. P. (2007). The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies. \u003cem\u003eLancet\u003c/em\u003e, \u003cem\u003e370\u003c/em\u003e(9596), 1453\u0026ndash;1457.\u003c/li\u003e\n\u003cli\u003eWickramasinghe, A., \u0026amp; Mendis, J. (2018). The impact of workplace breastfeeding policies on employees: A review of evidence from developing countries. \u003cem\u003eInternational Journal of Work and Health Management\u003c/em\u003e, \u003cem\u003e11\u003c/em\u003e(1), 23\u0026ndash;35.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-breastfeeding-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ibfj","sideBox":"Learn more about [International Breastfeeding Journal](http://internationalbreastfeedingjournal.biomedcentral.com/)","snPcode":"13006","submissionUrl":"https://submission.nature.com/new-submission/13006/3","title":"International Breastfeeding Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"exclusive breastfeeding, working mothers, workplace policies, lactation support, Ghana, Upper West Region, cross-sectional study","lastPublishedDoi":"10.21203/rs.3.rs-9427619/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9427619/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eBreastfeeding, especially exclusive breastfeeding (EBF) for the first six months of life, confers substantial health benefits on infants and mothers. However, employed mothers frequently encounter workplace-related barriers that impede breastfeeding. Despite existing national infant-feeding policies in Ghana, the role of workplace dynamics in either enabling or undermining breastfeeding among employed mothers in rural districts remains poorly characterised.\u003c/p\u003e\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eThis study aimed to (1) describe the prevalence and duration of EBF practices among employed mothers in the Nadowli-Kaleo District; (2) assess the influence of workplace policies and support on breastfeeding duration; (3) examine attitudes and social dynamics shaping breastfeeding choices at work; and (4) identify structural barriers to EBF among working mothers.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross-sectional survey was conducted among 130 employed breastfeeding mothers recruited by convenience sampling from workplaces across the Nadowli-Kaleo District, Upper West Region, Ghana, in 2024. Data were collected using a structured, self-administered, closed-ended questionnaire. Descriptive statistics (frequencies, means, standard deviations), one-way ANOVA, and Pearson correlation were used to analyse data in SPSS v27.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe majority of respondents were female (98.5%), married (65.4%), and employed full-time (76.9%). Exclusive breastfeeding was practiced by 57.7% (n\u0026thinsp;=\u0026thinsp;75) of participants, with a mean duration of 5.5 months (SD unreported). A strong positive correlation was observed between supportive workplace environments and breastfeeding duration (r\u0026thinsp;=\u0026thinsp;0.65, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Workplace policies supporting EBF showed a moderate correlation with breastfeeding duration (r\u0026thinsp;=\u0026thinsp;0.45), as did provision of breastfeeding breaks (r\u0026thinsp;=\u0026thinsp;0.38). The three primary structural barriers were lack of a dedicated lactation room (mean\u0026thinsp;=\u0026thinsp;3.90; r\u0026thinsp;=\u0026thinsp;0.42), inflexible work schedules (mean\u0026thinsp;=\u0026thinsp;3.71; r\u0026thinsp;=\u0026thinsp;0.39), and inadequate maternity leave (mean\u0026thinsp;=\u0026thinsp;3.85; r\u0026thinsp;=\u0026thinsp;0.40). ANOVA indicated significant differences in breastfeeding duration by level of workplace support (F\u0026thinsp;=\u0026thinsp;7.89, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eWorkplace policies, infrastructure, and social climate significantly influence EBF practices among employed mothers in the Nadowli-Kaleo District. Comprehensive breastfeeding-friendly workplace policies including dedicated lactation rooms, flexible schedules, and extended paid maternity leave are urgently needed to close the gap between national EBF recommendations and practice in this resource-limited setting.\u003c/p\u003e","manuscriptTitle":"Influence of workplace dynamics on breastfeeding practices in rural areas in Ghana: a facility-and community-based assessment of mothers in Nadowli-Kaleo","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-13 14:45:37","doi":"10.21203/rs.3.rs-9427619/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-05-05T13:37:26+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-22T18:06:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-22T18:06:03+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Breastfeeding Journal","date":"2026-04-15T13:08:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-breastfeeding-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ibfj","sideBox":"Learn more about [International Breastfeeding Journal](http://internationalbreastfeedingjournal.biomedcentral.com/)","snPcode":"13006","submissionUrl":"https://submission.nature.com/new-submission/13006/3","title":"International Breastfeeding Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0d110d1d-70ef-413f-9515-6181129745a3","owner":[],"postedDate":"May 13th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewersInvited","content":"12","date":"2026-05-05T13:37:26+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-13T14:45:38+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-13 14:45:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9427619","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9427619","identity":"rs-9427619","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}