Feasibility of an Early Initiation and Exclusive Breastfeeding (EEBF) Education Tool© among Healthcare Personnel in Primary Healthcare Centres, Ibadan, Nigeria: A Convergent Mixed-Methods Study

Feasibility of an Early Initiation and Exclusive Breastfeeding (EEBF) Education Tool© among Healthcare Personnel in Primary Healthcare Centres, Ibadan, Nigeria: A Convergent Mixed-Methods Study | 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 Feasibility of an Early Initiation and Exclusive Breastfeeding (EEBF) Education Tool© among Healthcare Personnel in Primary Healthcare Centres, Ibadan, Nigeria: A Convergent Mixed-Methods Study Oluyemisi F. Folasire, Christianah B. Ige, Andyno Akpanukoh, Aisha J. Abdulmalik This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9405343/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Background: Suboptimal breastfeeding practices contribute significantly to preventable maternal and infant morbidity in Nigeria, partly due to inadequate lactation training among healthcare personnel (HCP). This study evaluated the feasibility of an Early Initiation and Exclusive Breastfeeding (EEBF) educational tool for routine use by HCP in primary healthcare centres (PHCs) in Ibadan, Nigeria. Methods A convergent parallel mixed-methods design was employed in five purposively selected PHCs in Ibadan. Quantitative data were collected from 48 HCP using a structured questionnaire assessing acceptability on a 5-point Likert scale. Qualitative data were obtained through six key informant interviews exploring practicality. Quantitative data were analysed using SPSS version 26, while thematic analysis of qualitative data was done using inductive approach, findings were triangulated. Results Generally, 93.8% (45/48) of participants exhibited high acceptability of the EEBF tool. Qualitative results revealed that the tool enhanced HCP confidence in delivering breastfeeding education, was suitable for use during antenatal health talks and counselling sessions and was not time-consuming. Participants reported high satisfaction (mean rating: 9/10) and improved knowledge of breastfeeding practices, including early initiation, exclusive breastfeeding, proper latching and positioning, breastfeeding physiology, and the significance of adequate maternal hydration. Conclusion The EEBF tool was feasible, acceptable, and practical for use day-to day among HCP in primary healthcare settings. Integration the EEBF tool into routine maternal and child health services may enhance breastfeeding education and support. However, more long-term research are recommended to assess its sustained use and impact. Breastfeeding Health Personnel Primary Health Care Pilot Projects Inservice Training Qualitative Research Figures Figure 1 Background Breastfeeding is the most efficient method of supplying infants with vital nutrients for optimal growth and development. 1 Breastfeeding optimally involves early initiation within the first hour post-birth, exclusively breastfeeding for the first six months, and continuous breastfeeding with complementary foods until two years of age or longer. 2 The World Health Organisation (WHO) defines early initiation as the commencement of breastfeeding within one hour post-delivery, whereas exclusive breastfeeding (EBF) is characterised by the administration of breast milk solely, without any additional liquids or solids, for the first six months of life. 1 These optimal practices provide well-documented advantages for maternal and newborn health, such as decreased infant morbidity, increased immunological protection, and enhanced maternal recovery. 4 , 5 Annually, almost 77 million newborns (50%) worldwide are not breastfed within the first hour of life, increasing their susceptibility to sickness and mortality. In Nigeria, merely 35% of newborns are breastfed during the first hour post-birth, while the 2018 Nigeria Demographic and Health Survey (DHS) indicated that only 29% of infants under six months were exclusively breastfed, with an average exclusive breastfeeding duration of just 2.8 months. 6 These numbers are significantly below the WHO target of 70% EBF by 2030. Research constantly found inadequate HCP assistance to be a major contributing factor of sub-optimal breastfeeding practices. 7 , 8 Maternal breastfeeding knowledge, attitudes, and practices have been found to be strongly impacted by HCP motivation. However, HCP themselves report low confidence and knowledge gaps in lactation education, which they attribute to the lack of standardised lactation curricula across training programmes and facilities. 10 A systemic review by Navarro et al. 8 revealed that constant education and standardised lactation training programmes for HCP are linked to better breastfeeding support behaviours highlighting the significance of focused educational interventions. The WHO/UNICEF Baby-Friendly Hospital Initiative (BFHI) ‘Ten Steps to Successful Breastfeeding’ explicitly mandates that staff possess the necessary knowledge, competence, and skills to support breastfeeding (Step 2). 11 A competent breastfeeding care provider requires knowledge of breast anatomy, lactation physiology, and practical lactation management skills. 10 Despite this standard, implementation in primary care settings in sub-Saharan Africa remains inconsistent. A formative study conducted prior to this research observed HCP delivering breastfeeding health talks in two PHCs in Ibadan, Nigeria, and identified critical knowledge deficits requiring targeted intervention (Folasire OF, Akpanukoh AU, Abdumalik AJ, unpublished observations). Specifically, HCP demonstrated gaps in knowledge of milk production physiology, the benefits of early initiation, management of common misconceptions (notably the belief that the breast is “dry” postpartum), and correct breastfeeding positioning. Of nursing mothers observed, close to 80% administered pre-lacteal feeds, with the prevalent misconception of breast dryness cited as the primary reason - a misunderstanding that adequately trained HCP could directly address and prevent (Folasire OF, Akpanukoh AU, Abdumalik AJ, unpublished observations). 12 , 13 To address these gaps, the EEBF tool was developed using the Behaviour Change Wheel (BCW) framework, which integrates the Capability, Opportunity, Motivation-Behaviour (COM-B) model and Health Belief Model (HBM) constructs. No validated, structured lactation education tool contextualised for HCP in Nigerian primary healthcare settings had previously been documented. The tool was designed to strengthen HCP capability and motivation to provide consistent, evidence-based breastfeeding counselling. Therefore, this study aimed to assess the acceptability and practicality of the EEBF tool among healthcare personnel in primary healthcare centres in Ibadan, Nigeria, as a key phase of its implementation feasibility evaluation. Methods Study design A convergent parallel mixed-methods design was employed. Quantitative and qualitative data were concurrently collected, analysed separately, and combined during interpretation to yield a holistic knowledge of feasibility. The quantitative phase assessed tool acceptability across domains of usefulness, satisfaction, and perceived relevance to practice. Through KIIs, the qualitative phase evaluated practicality and captured relevant variables influencing tool use in PHC contexts.. This study represents the feasibility testing phase of a broader implementation project involving the design, validation, and field-testing of the EEBF tool. 14 Study setting The study was conducted in five PHCs in Ibadan metropolis, Oyo State, Nigeria: Ojoo, Ajibode, Agbowo, Idi-ogungun, and Moniya PHCs. These were purposively selected from Ibadan North (urban) and Akinyele (semi-urban) local government areas based on formative assessment of antenatal attendance and HCP availability. Oyo State has 33 local government areas; Ibadan metropolis encompasses five urban and six semi-urban local governments. Study participants and sampling HCP actively involved in antenatal care at the selected PHCs were eligible. A convenience sample of 48 HCP was enrolled during the data collection period (February-April 2024). The sample included community health workers (n = 25), nurses (n = 14), doctors (n = 5), matrons (n = 3), and midwife (n = 1). For the qualitative component, six HCP who had directly applied the EEBF tool during antenatal sessions were purposively selected for KIIs. Although no formal sample size calculation was performed, this sample size aligns with comparable feasibility studies in primary care settings. 15-18 Description of the EEBF tool The EEBF tool was designed to enhance HCP knowledge and counselling skills on optimal breastfeeding. Its content is in line with the WHO/UNICEF Ten Steps to Successful Breastfeeding, especially Steps 2, 3, 4, and 6. The tool consists of three parts: (i) a brief educational video in both Yoruba and English; (ii) a Flipchart to be used during antenatal counselling sessions; and (iii) illustrated handbills to be given to expectant mothers. Adobe Photoshop and Illustrator were used to create culturally appropriate pictures for visual communications. A panel of nutritionists from the University of Ibadan and senior PHC employees reviewed the content to determine its validity, and their comments guided modifications for clarity and cultural relevance. Six key intervention messages addressed: (1) breast milk production and the suckling reflex arc (including the myth of breast dryness); (2) early initiation within one hour of delivery, including benefits of colostrum and skin-to-skin contact; (3) correct positioning and latching; (4) adequate maternal fluid intake; (5) breastfeeding on demand (minimum 12 times daily); and (6) benefits of all recommended breastfeeding practices. Study instruments The quantitative instrument comprised a structured questionnaire collecting sociodemographic and nutrition experience data, alongside a 15-item acceptability assessment questionnaire adapted from prior work (Folasire OF, Akpanukoh AU, Abdumalik AJ, unpublished observations) and rated on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Internal consistency was high (Cronbach’s α = 0.928). The qualitative instrument was a structured KII guide consisting of eight open-ended questions on tool practicality, ease of use, and perceived benefits, informed by Bowen et al.’s feasibility framework. 14 Pilot testing Pilot testing was conducted at Aperin PHC (not included in the main study). Ten HCP piloted the questionnaire and three participated in preliminary interviews, confirming instrument clarity and contextual suitability. Interview questions were condensed to approximately 10 minutes, aligning with workload constraints of HCP. Data collection Following submission of ethical approval to PHC matrons-in-charge, orientation sessions were conducted on designated antenatal days. HCP first viewed the EEBF video demonstration, then participated in guided flipchart discussions. They were subsequently encouraged to apply the tool in routine antenatal health talks, distributing handbills to primigravidae in the last trimester. One week later, HCP who had facilitated sessions using the tool completed the acceptability questionnaire. Six HCP who had directly delivered sessions were purposively selected for KIIs. Interviews were audio-recorded with consent and lasted approximately 10-15 minutes each. Data analysis Quantitative data were entered and cleaned in SPSS version 26.0 and described using frequencies, percentages, means, and standard deviations. Likert responses were dichotomised: Agree/Strongly Agree = 1; Neutral/Disagree/Strongly Disagree = 0. A composite score was computed across 15 items. The mean composite score (14.9) served as the threshold: scores ≥14.9 indicated high acceptability; scores <14.9 indicated low acceptability. For the five-item utility and impact subset (items Q4, Q10, Q11, Q12, Q15; mean 4.96), scores ≥4.96 indicated high acceptability. KII transcripts were transcribed verbatim and analysed manually using thematic analysis with an inductive coding approach. Codes were generated from repeated transcript readings, grouped into themes, and reported with representative participant quotes. Five primary themes were identified. Results Participant characteristics Table 1 presents the sociodemographic profile and nutrition experience of the 48 HCP. The majority were female (87.5%), with a mean age of 38 ± 11 years. Almost all (93.8%) were of Yoruba ethnicity and had attained tertiary education (93.8%). More than two-thirds (64.6%) had received formal nutrition training, predominantly during undergraduate education (41.7%), and 43.8% had more than ten years of clinical experience. Table 1. Sociodemographic and nutrition experience of healthcare personnel (N = 48) Variable n (%) Variable n (%) Gender Marital status Male 6 (12.5) Single 12 (25.0) Female 42 (87.5) Married 36 (75.0) Age (years) Religion 18-35 20 (41.7) Islam 9 (18.8) 36-54 25 (52.1) Christianity 39 (81.3) ≥55 3 (6.3) Received formal nutrition training Mean age (years) 38 ± 11 Yes 31 (64.6) Ethnic group No 17 (35.4) Yoruba 45 (93.8) When: college/university 20 (41.7) Ibo 3 (6.3) When: Internship/SIWES 4 (8.3) Highest level of education When: other 7 (14.6) No formal education 1 (2.1) Years in practice Completed secondary 2 (4.2) 10 years 21 (43.8) Midwife 1 (2.1) Doctor 5 (10.4) Community health worker 25 (52.1) Nurse 14 (29.2) SIWES Students Industrial Work Experience Scheme; n number of HCP Acceptability of the EEBF tool Of the 48 HCP, 45 (93.8%) scored at or above the mean composite score (14.9/15), indicating high acceptability; three (6.2%) scored below the threshold. These results indicate that the tool is perceived as contextually appropriate and effective for breastfeeding counselling. Utility and impact of the EEBF tool Fig. 1 shows the utility and impact assessment. All HCP (100%) agreed that the video demonstration, flipchart, and handbills provided valuable breastfeeding information, enhanced their understanding of early initiation and exclusive breastfeeding, and equipped them to better educate pregnant women. The majority (96%) affirmed that the information on the suckling reflex arc improved their comprehension of lactation physiology. Fig. 1 Utility and impact of the EEBF tool among healthcare personnel (N = 48). (High acceptability defined as score ≥4.96 on the five-item utility and impact subset (items Q4, Q10, Q11, Q12, and Q15)). Key-informant interview participant characteristics Table 2 presents the characteristics of the six KII participants. The majority were female (83.3%), with a mean age of 45 ± 11 years. All had attained tertiary education and had prior experience using a lactation education tool. Occupations included community health workers (33.3%), matrons-in-charge (33.3%), nutrition officer (16.7%), and registered nurse (16.7%). All HCP interacted with pregnant and lactating mothers either every time or often during clinical duties. Table 2. Sociodemographic characteristics and clinical experience of key-informant interview participants (N = 6) Variable n (%) Variable n (%) Gender Occupation Male 1 (16.7) Nutrition officer (NO) 1 (16.7) Female 5 (83.3) Community health worker (CHW) 2 (33.3) Age (years) Registered nurse (RN) 1 (16.7) 18–35 1 (16.7) Matron-in-charge (MC) 2 (33.3) 36–54 4 (66.7) Prior lactation tool experience 6 (100) ≥55 1 (16.7) Counselling mothers 3 (50.0) Mean age (years) 45 ± 11 Practical demonstration 3 (50.0) Education: Tertiary 6 (100) Frequency of contact with pregnant/lactating mothers Every time 3 (50.0) Often 3 (50.0) NO nutrition officer, CHW community health worker, RN registered nurse, MC matron-in-charge of PHC Thematic findings from key-informant interviews Five themes emerged from the analysis of the six KII transcripts. Theme 1: Perception towards the EEBF tool HCP predominantly perceived the EEBF tool as confidence-enhancing and easy to use, citing clear language and visual aids as beneficial for both HCP and pregnant women. Representative quotes include: “Using this tool has given me more confidence; when I counsel pregnant women now, I know I can explain breastfeeding well and answer their questions better.” (CHW#2) “The tool made it very easy for me to use and teach; I just follow the points and mothers understand quickly.” (CHW#1) “It is simple and direct, so when I used it to teach, the mothers followed without confusion.” (RN) Theme 2: Practical application for day-to-day use HCP identified antenatal health talks and breastfeeding counselling sessions as the primary settings for tool use. The tool was perceived as reinforcing key breastfeeding messages: “During antenatal sessions, I will use the tool as a guide to remind me of the important messages, so as to give the pregnant women complete information.” (NO) “It is very good especially during health education counselling, and it can create discussions in groups among healthcare providers and pregnant women.” (MC#1) Theme 3: Time commitment to use the tool Most HCP reported that the tool was not time-consuming and could be integrated into routine sessions. Staffing shortages and time constraints at antenatal clinics were identified as minor barriers: “Time is good, it is not time-consuming. It is very short, and they’ll quickly grasp the messages.” (MC#1) “At the PHC, we are usually short-staffed, so time for health talks is very limited. However, because your tool is easy to use and not time-consuming, we will be able to include it in our routine.” (MC#2) Theme 4: Overall satisfaction with the EEBF tool Satisfaction ratings ranged from 8 to 10 on a 10-point scale, with 9 being the most prevalent score. Theme 5: Knowledge gained through the use of the EEBF tool HCP reported improved understanding of breastfeeding on demand, benefits of breastfeeding, fluid intake guidance, and proper positioning. Representative quotes include: “I like how this tool reminds me that the more the child suckles from the mother, the more breastmilk is produced. This will train mothers to consistently feed their babies so that the breasts will keep producing milk.” (MC#2) “The parts about benefits of breastfeeding, without herbal drinks for the child, and the importance of fluid intake by the mother were very beneficial to me because I didn’t know that before.” (RN) “The pictures really helped to show the correct positioning, preventing breast pain while breastfeeding — which many mothers complain about.” (CHW#1) Convergence of quantitative and qualitative findings Table 3 presents the convergence of quantitative utility and impact items with qualitative practicality themes. The alignment across methods confirms that the EEBF tool is not only well-accepted but also functionally viable in real-world PHC settings, with quantitative acceptability supported by qualitative evidence of enhanced confidence, practical application, and knowledge acquisition. Table 3. Convergence of quantitative utility and impact findings with qualitative practicality themes Acceptability – Utility & Impact item Practicality theme / sub-theme Illustrative quote 1. The intervention is a good idea; I was able to educate pregnant women better. Perception – Increased confidence "Using this tool has given me more confidence; when I counsel pregnant women now, I can explain breastfeeding well and answer their questions better." (CHW#2) Perception – Easy to use "The tool made it easy; I just follow the points and mothers understand quickly." (CHW#1) 2. The information on the reflex arc helped me understand breastfeeding better. Knowledge – Benefit of breastfeeding on demand "From the tool I understood better how the reflex arc works and why frequent breastfeeding is important for milk to flow well." (NO) 3. I understood the information on early initiation and exclusive breastfeeding. Knowledge – Benefits of breastfeeding "I can give better counselling to pregnant women on the benefits of exclusively breastfeeding for mother and child." (MC#1) 4. I understood the information about discouraging pre-lacteal feeds. Knowledge – Benefits of fluid intake "From the tool I learnt that only mothers should drink water while breastfeeding, and not give the newborn water or local drinks." (MC#2) 5. The video, flipchart, and handbills provided valuable breastfeeding information. Practical application – Counselling sessions / antenatal health talks "During antenatal sessions, I will use the tool as a guide to give pregnant women complete information." (NO) NO nutrition officer, CHW community health worker, RN registered nurse, MC matron-in-charge of PHC Discussion This convergent mixed-methods feasibility study examined the acceptability and practicality of the EEBF tool among 48 HCP across five PHCs in Ibadan, Nigeria. The findings demonstrate that the tool is highly acceptable and practically viable, with convergent evidence from both quantitative and qualitative phases reinforcing its potential to strengthen lactation education delivery at the primary care level. The female-dominated workforce observed in this study (87.5%) mirrors findings by Kadiri-Eneh et al. 19 (89.7% female) in their own study of Nigerian PHCs, consistent with the gendered composition of nursing and community health occupations in Nigeria. The predominance of Yoruba HCP (93.8%) reflects the southwestern Nigerian study setting, 20 and the physician-to-staff ratio conforms to minimum Nigerian PHC staffing standards. 21 Notably, only one nutrition officer was identified across all five PHCs, a finding attributable to the exclusion of this cadre from Nigeria’s minimum PHC staffing standards. 21 This has a significant implication: at the primary care level, no formally qualified nutritionist is typically employed, limiting the quality of routine nutrition and lactation counselling. The high acceptability rate (93.8%) is consistent with comparable intervention studies. Abbass-Dick et al. 15 reported 82% acceptability for an eHealth breastfeeding resource among HCP, and Allotey et al. 18 demonstrated high HCP acceptance of a multicomponent breastfeeding promotion programme integrated into PHC services in Lagos State, Nigeria. These convergent findings suggest that structured, multimedia-based lactation education tools are generally well received by HCP in Nigerian primary care contexts. The EEBF tool’s intervention message on the suckling reflex arc was well accepted, with the majority of HCP reporting improved understanding of lactation physiology. This aligns with Allotey et al.’s 18 finding that HCP in Lagos who received physiology-based breastfeeding training reported increased counselling confidence - corroborated qualitatively in this study: “I easily understood the importance of breastfeeding and all the hormones involved in the reflex arc process.” (MC#2). Such physiological understanding is foundational to effective breastfeeding counselling and directly addresses the knowledge deficits identified in the formative study (Folasire OF, Akpanukoh AU, Abdumalik AJ, unpublished observations). All HCP accepted the messages on early initiation and exclusive breastfeeding, contrasting with qualitative findings by Moussa Abba et al. 22 in Niger, where HCP demonstrated inconsistent promotion of exclusive breastfeeding. This difference may reflect the structured, competency-based approach of the EEBF tool, which provides HCP with specific, step-by-step guidance rather than general prompting alone. The multimedia components - video and flipchart - enhanced delivery of positioning messages, consistent with Gavine et al.’s 23 systematic review demonstrating that practical training components, including demonstrations and educational tools, increase HCP knowledge of correct latching technique. The visual design of the EEBF tool appears particularly effective: “I’m happy that when pregnant women see the pictures in the flipchart and video, they’ll learn the correct way to position, making HCP’s work easier.” (MC#2). HCP acceptance of the fluid intake message produced a notable finding: some HCP were previously unaware that maternal fluid intake - rather than neonatal supplementation - was the relevant concern. While the causal relationship between increased maternal fluid intake and milk volume remains subject to debate in controlled trials, 25 this study aligns with WHO guidance that adequate maternal hydration supports overall wellbeing and oxytocin-mediated milk ejection. 26 The discouragement of pre-lacteal feeds, reinforced through the tool, was similarly well received, consistent with Tongun et al.’s 24 findings from South Sudan where BFHI-aligned HCP training was associated with reduced recommendation of pre-lacteal feeds. The on-demand breastfeeding message reinforced HCP understanding of demand-supply physiology, consistent with Gilder et al. 27 in Thailand, where HCP reported improved counselling practices following similar training, and with evidence that IYCF training significantly improves HCP guidance on feeding frequency and exclusivity. 28 , 23 Staffing shortages emerged as the primary implementation barrier, corroborating findings by Okoroafor et al. 29 documenting severe HCP shortfalls in 196 Nigerian PHC facilities, and by Abbass-Dick et al. 15 where 50% of HCP cited time constraints as a barrier to tool use. Notwithstanding, the EEBF tool’s simplicity of use and conciseness were frequently mentioned as facilitators of integration into current workflows, indicating that the design of the tool and its contents can help reduce system-level obstacles. The convergence of quantitative and qualitative information offers robust and consistent validation for the feasibility of the EEBF tool. The tool not only enhanced HCP knowledge and counselling confidence but also demonstrated practical embedding ability into routine antenatal care, reinforcing its potential to improve the quality of lactation support at the grassroots level. Conclusion The EEBF tool is feasible, highly acceptable, and practically applicable for use by healthcare personnel in primary healthcare centres in Ibadan, Nigeria. Its culturally appropriate multimedia content, behavior-change-informed design, and adherence to WHO/UNICEF breastfeeding recommendations give HCP the knowledge and assurance they need to provide consistent lactation counselling. These results lend credence to the wider use of structured, HCP-focused training resources to promote breastfeeding among pregnant women in primary care contexts. Longitudinal evaluation is advised to determine the long-term effects of the EEBF tool on HCP counselling practices and breastfeeding initiation and exclusivity rates among mothers attending PHCs. Abbreviations ANC — Antenatal care clinic BCW — Behaviour Change Wheel BFHI — Baby-Friendly Hospital Initiative CHW — Community health worker COM-B — Capability, Opportunity, Motivation–Behaviour model DHS — Demographic and Health Survey EBF — Exclusive breastfeeding EEBF — Early Initiation and Exclusive Breastfeeding HBM — Health Belief Model HCP — Healthcare personnel IYCF — Infant and Young Child Feeding KII — Key-informant interview MC — Matron-in-charge NO — Nutrition officer PHC — Primary healthcare centre RN — Registered nurse SIWES — Students Industrial Work Experience Scheme SPSS — Statistical Package for the Social Sciences WHO — World Health Organisation Declarations Ethics approval and consent to participate Ethical approval was obtained from the Oyo State Ministry of Health Ethics Review Committee (Ref: NHREC/OYOSHRIEC/10/11/22). All participants provided written informed consent prior to enrolment. Data confidentiality was maintained throughout; audio recordings were accessible only to the research team. All procedures of this research were done in accordance with the ethical principles of the Declaration of Helsinki. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests Authors declare that they have no competing interests. Funding This research received no external funding. The study was supported entirely by the personal resources of the authors. Authors’ contributions O.F.F. conceptualised the study, designed the EEBF Tool, supervised all phases, writing of manuscript. C.B.I.: data collection, data analysis, and wrote the draft manuscript. A.A: involved in design of the EEBF tool, A. J.A: involved in the design of the EEBF tool. All authors reviewed and approved the final manuscript. 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Infant and young child feeding: model chapter for textbooks for medical students and allied health professionals [Internet]. Geneva: WHO; 2009. Available from: https://www.ncbi.nlm.nih.gov/books/NBK148965/ Gilder ME, Pateekhum C, Wai NS, Misa P, Sanguanwai P, Sappayabanphot J, et al. Determinants of health care worker breastfeeding experience and practices and their association with provision of care for breastfeeding mothers: a mixed-methods study from Northern Thailand. Int Breastfeed J. 2024;19:8. https://doi.org/10.1186/s13006-024-00613-4. Samuel FO, Olaolorun FM, Adeniyi JD. A training intervention on child feeding among primary healthcare workers in Ibadan Municipality. Afr J Prim Health Care Fam Med. 2016;8(1):e1–6. https://doi.org/10.4102/phcfm.v8i1.884. Okoroafor SC, Ahmat A, Osubor M, Nyoni J, Bassey J, Alemu W. Assessing the staffing needs for primary health care centres in Cross River State, Nigeria: a workload indicator of staffing needs study. Hum Resour Health. 2022;19:108. https://doi.org/10.1186/s12960-021-00648-2. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 07 May, 2026 Reviewers agreed at journal 25 Apr, 2026 Reviewers invited by journal 23 Apr, 2026 Editor assigned by journal 15 Apr, 2026 Submission checks completed at journal 15 Apr, 2026 First submitted to journal 13 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-9405343","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":633654594,"identity":"0127437b-bf31-4035-a6b0-681a15892735","order_by":0,"name":"Oluyemisi F. Folasire","email":"","orcid":"","institution":"University of Ibadan","correspondingAuthor":false,"prefix":"","firstName":"Oluyemisi","middleName":"F.","lastName":"Folasire","suffix":""},{"id":633654595,"identity":"12a948ca-01b3-4298-bfad-a0b0c5a3e900","order_by":1,"name":"Christianah B. Ige","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2ElEQVRIiWNgGAWjYBACNjAqYOBhYGA+AORLyBCpxQCkhS0BpIWHSIsMQDQPhCSono/9dNqDDwaHZeTdez6/ulFjwcPAfvjoBrxW8ORuN5xhcJjH8MzZbdY5x4AO40lLu4HfVbnbpHlAWmbkbjPOYQNqkeAxw6+F/y1Uy/w3z4xz/hGjRQJqi7wED/Pj3DaitLwF+SWdx4AnzYw5t0+Ch42QX+T7c7c9+FBhbS/ffvjx55xvdXL87IeP4dUCBwYHgDaC7SVKOdi6BgbmD0SrHgWjYBSMghEFAJUrQKeOOQ4fAAAAAElFTkSuQmCC","orcid":"","institution":"University of Ibadan","correspondingAuthor":true,"prefix":"","firstName":"Christianah","middleName":"B.","lastName":"Ige","suffix":""},{"id":633654596,"identity":"5c02a791-2541-43b3-8149-13744779cac0","order_by":2,"name":"Andyno Akpanukoh","email":"","orcid":"","institution":"University of Ibadan","correspondingAuthor":false,"prefix":"","firstName":"Andyno","middleName":"","lastName":"Akpanukoh","suffix":""},{"id":633654597,"identity":"0c490be3-143f-4bb4-a2ff-97e6f6c21ae9","order_by":3,"name":"Aisha J. Abdulmalik","email":"","orcid":"","institution":"University of Ibadan","correspondingAuthor":false,"prefix":"","firstName":"Aisha","middleName":"J.","lastName":"Abdulmalik","suffix":""}],"badges":[],"createdAt":"2026-04-13 14:24:00","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9405343/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9405343/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108819498,"identity":"78d54752-7122-4692-b2da-9691b250a0e7","added_by":"auto","created_at":"2026-05-08 16:37:33","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":329888,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eUtility and impact of the EEBF tool among healthcare personnel (N = 48).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(High acceptability defined as score ≥4.96 on the five-item utility and impact subset (items Q4, Q10, Q11, Q12, and Q15)).\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1..jpg","url":"https://assets-eu.researchsquare.com/files/rs-9405343/v1/7c9a11d0cec51f48eb3c89ac.jpg"},{"id":108821979,"identity":"34b8c543-1a7f-4bcc-ab82-1c8cc8ae7286","added_by":"auto","created_at":"2026-05-08 16:47:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":648808,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9405343/v1/29c65c88-ef70-4df7-9e6e-f26e18f53f05.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Feasibility of an Early Initiation and Exclusive Breastfeeding (EEBF) Education Tool© among Healthcare Personnel in Primary Healthcare Centres, Ibadan, Nigeria: A Convergent Mixed-Methods Study","fulltext":[{"header":"Background","content":"\u003cp\u003eBreastfeeding is the most efficient method of supplying infants with vital nutrients for optimal growth and development.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Breastfeeding optimally involves early initiation within the first hour post-birth, exclusively breastfeeding for the first six months, and continuous breastfeeding with complementary foods until two years of age or longer.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e The World Health Organisation (WHO) defines early initiation as the commencement of breastfeeding within one hour post-delivery, whereas exclusive breastfeeding (EBF) is characterised by the administration of breast milk solely, without any additional liquids or solids, for the first six months of life. \u003csup\u003e1\u003c/sup\u003e These optimal practices provide well-documented advantages for maternal and newborn health, such as decreased infant morbidity, increased immunological protection, and enhanced maternal recovery.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAnnually, almost 77\u0026nbsp;million newborns (50%) worldwide are not breastfed within the first hour of life, increasing their susceptibility to sickness and mortality. In Nigeria, merely 35% of newborns are breastfed during the first hour post-birth, while the 2018 Nigeria Demographic and Health Survey (DHS) indicated that only 29% of infants under six months were exclusively breastfed, with an average exclusive breastfeeding duration of just 2.8 months.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e These numbers are significantly below the WHO target of 70% EBF by 2030.\u003c/p\u003e \u003cp\u003eResearch constantly found inadequate HCP assistance to be a major contributing factor of sub-optimal breastfeeding practices.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Maternal breastfeeding knowledge, attitudes, and practices have been found to be strongly impacted by HCP motivation. However, HCP themselves report low confidence and knowledge gaps in lactation education, which they attribute to the lack of standardised lactation curricula across training programmes and facilities.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e A systemic review by Navarro et al.\u003csup\u003e8\u003c/sup\u003e revealed that constant education and standardised lactation training programmes for HCP are linked to better breastfeeding support behaviours highlighting the significance of focused educational interventions.\u003c/p\u003e \u003cp\u003eThe WHO/UNICEF Baby-Friendly Hospital Initiative (BFHI) \u0026lsquo;Ten Steps to Successful Breastfeeding\u0026rsquo; explicitly mandates that staff possess the necessary knowledge, competence, and skills to support breastfeeding (Step 2).\u003csup\u003e11\u003c/sup\u003e A competent breastfeeding care provider requires knowledge of breast anatomy, lactation physiology, and practical lactation management skills.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Despite this standard, implementation in primary care settings in sub-Saharan Africa remains inconsistent. A formative study conducted prior to this research observed HCP delivering breastfeeding health talks in two PHCs in Ibadan, Nigeria, and identified critical knowledge deficits requiring targeted intervention (Folasire OF, Akpanukoh AU, Abdumalik AJ, unpublished observations). Specifically, HCP demonstrated gaps in knowledge of milk production physiology, the benefits of early initiation, management of common misconceptions (notably the belief that the breast is \u0026ldquo;dry\u0026rdquo; postpartum), and correct breastfeeding positioning. Of nursing mothers observed, close to 80% administered pre-lacteal feeds, with the prevalent misconception of breast dryness cited as the primary reason - a misunderstanding that adequately trained HCP could directly address and prevent (Folasire OF, Akpanukoh AU, Abdumalik AJ, unpublished observations).\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eTo address these gaps, the EEBF tool was developed using the Behaviour Change Wheel (BCW) framework, which integrates the Capability, Opportunity, Motivation-Behaviour (COM-B) model and Health Belief Model (HBM) constructs. No validated, structured lactation education tool contextualised for HCP in Nigerian primary healthcare settings had previously been documented. The tool was designed to strengthen HCP capability and motivation to provide consistent, evidence-based breastfeeding counselling.\u003c/p\u003e \u003cp\u003eTherefore, this study aimed to assess the acceptability and practicality of the EEBF tool among healthcare personnel in primary healthcare centres in Ibadan, Nigeria, as a key phase of its implementation feasibility evaluation.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003eStudy design\u003c/h2\u003e\n\u003cp\u003eA convergent parallel mixed-methods design was employed. Quantitative and qualitative data were concurrently collected, analysed separately, and combined during interpretation to yield a holistic knowledge of feasibility. The quantitative phase assessed tool acceptability across domains of usefulness, satisfaction, and perceived relevance to practice. Through KIIs, the qualitative phase evaluated practicality and captured relevant variables influencing tool use in PHC contexts.. This study represents the feasibility testing phase of a broader implementation project involving the design, validation, and field-testing of the EEBF tool.\u003csup\u003e14\u003c/sup\u003e\u003c/p\u003e\n\u003ch2\u003eStudy setting\u003c/h2\u003e\n\u003cp\u003eThe study was conducted in five PHCs in Ibadan metropolis, Oyo State, Nigeria: Ojoo, Ajibode, Agbowo, Idi-ogungun, and Moniya PHCs. These were purposively selected from Ibadan North (urban) and Akinyele (semi-urban) local government areas based on formative assessment of antenatal attendance and HCP availability. Oyo State has 33 local government areas; Ibadan metropolis encompasses five urban and six semi-urban local governments.\u003c/p\u003e\n\u003ch2\u003eStudy participants and sampling\u003c/h2\u003e\n\u003cp\u003eHCP actively involved in antenatal care at the selected PHCs were eligible. A convenience sample of 48 HCP was enrolled during the data collection period (February-April 2024). The sample included community health workers (n\u0026nbsp;=\u0026nbsp;25), nurses (n\u0026nbsp;=\u0026nbsp;14), doctors (n\u0026nbsp;=\u0026nbsp;5), matrons (n\u0026nbsp;=\u0026nbsp;3), and midwife (n\u0026nbsp;=\u0026nbsp;1). For the qualitative component, six HCP who had directly applied the EEBF tool during antenatal sessions were purposively selected for KIIs. Although no formal sample size calculation was performed, this sample size aligns with comparable feasibility studies in primary care settings.\u003csup\u003e15-18\u003c/sup\u003e\u003c/p\u003e\n\u003ch2\u003eDescription of the EEBF tool\u003c/h2\u003e\n\u003cp\u003eThe EEBF tool was designed to enhance HCP knowledge and counselling skills on optimal breastfeeding. Its content is in line with the WHO/UNICEF Ten Steps to Successful Breastfeeding, especially Steps 2, 3, 4, and 6. The tool consists of three parts: (i) a brief educational video in both Yoruba and English; (ii) a Flipchart to be used during antenatal counselling sessions; and (iii) illustrated handbills to be given to expectant mothers. Adobe Photoshop and Illustrator were used to create culturally appropriate pictures for visual communications. A panel of nutritionists from the University of Ibadan and senior PHC employees reviewed the content to determine its validity, and their comments guided modifications for clarity and cultural relevance.\u003c/p\u003e\n\u003cp\u003eSix key intervention messages addressed: (1) breast milk production and the suckling reflex arc (including the myth of breast dryness); (2) early initiation within one hour of delivery, including benefits of colostrum and skin-to-skin contact; (3) correct positioning and latching; (4) adequate maternal fluid intake; (5) breastfeeding on demand (minimum 12 times daily); and (6) benefits of all recommended breastfeeding practices.\u003c/p\u003e\n\u003ch2\u003eStudy instruments\u003c/h2\u003e\n\u003cp\u003eThe quantitative instrument comprised a structured questionnaire collecting sociodemographic and nutrition experience data, alongside a 15-item acceptability assessment questionnaire adapted from prior work (Folasire OF, Akpanukoh AU, Abdumalik AJ, unpublished observations) and rated on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Internal consistency was high (Cronbach\u0026rsquo;s \u0026alpha;\u0026nbsp;=\u0026nbsp;0.928). The qualitative instrument was a structured KII guide consisting of eight open-ended questions on tool practicality, ease of use, and perceived benefits, informed by Bowen et al.\u0026rsquo;s feasibility framework.\u003csup\u003e14\u003c/sup\u003e\u003c/p\u003e\n\u003ch2\u003ePilot testing\u003c/h2\u003e\n\u003cp\u003ePilot testing was conducted at Aperin PHC (not included in the main study). Ten HCP piloted the questionnaire and three participated in preliminary interviews, confirming instrument clarity and contextual suitability. Interview questions were condensed to approximately 10 minutes, aligning with workload constraints of HCP.\u003c/p\u003e\n\u003ch2\u003eData collection\u003c/h2\u003e\n\u003cp\u003eFollowing submission of ethical approval to PHC matrons-in-charge, orientation sessions were conducted on designated antenatal days. HCP first viewed the EEBF video demonstration, then participated in guided flipchart discussions. They were subsequently encouraged to apply the tool in routine antenatal health talks, distributing handbills to primigravidae in the last trimester. One week later, HCP who had facilitated sessions using the tool completed the acceptability questionnaire. Six HCP who had directly delivered sessions were purposively selected for KIIs. Interviews were audio-recorded with consent and lasted approximately 10-15 minutes each.\u003c/p\u003e\n\u003ch2\u003eData analysis\u003c/h2\u003e\n\u003cp\u003eQuantitative data were entered and cleaned in SPSS version 26.0 and described using frequencies, percentages, means, and standard deviations. Likert responses were dichotomised: Agree/Strongly Agree = 1; Neutral/Disagree/Strongly Disagree = 0. A composite score was computed across 15 items. The mean composite score (14.9) served as the threshold: scores \u0026ge;14.9 indicated high acceptability; scores \u0026lt;14.9 indicated low acceptability. For the five-item utility and impact subset (items Q4, Q10, Q11, Q12, Q15; mean 4.96), scores \u0026ge;4.96 indicated high acceptability.\u003c/p\u003e\n\u003cp\u003eKII transcripts were transcribed verbatim and analysed manually using thematic analysis with an inductive coding approach. Codes were generated from repeated transcript readings, grouped into themes, and reported with representative participant quotes. Five primary themes were identified.\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003eParticipant characteristics\u003c/h2\u003e\n\u003cp\u003eTable 1 presents the sociodemographic profile and nutrition experience of the 48 HCP. The majority were female (87.5%), with a mean age of 38\u0026nbsp;\u0026plusmn;\u0026nbsp;11 years. Almost all (93.8%) were of Yoruba ethnicity and had attained tertiary education (93.8%). More than two-thirds (64.6%) had received formal nutrition training, predominantly during undergraduate education (41.7%), and 43.8% had more than ten years of clinical experience.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Sociodemographic and nutrition experience of healthcare personnel (N = 48)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"602\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003eMarital status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e6 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Single\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e12 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e42 (87.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Married\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e36 (75.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003eReligion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;18-35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e20 (41.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Islam\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e9 (18.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;36-54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e25 (52.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Christianity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e39 (81.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026ge;55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e3 (6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003eReceived formal nutrition training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Mean age (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e38 \u0026plusmn; 11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e31 (64.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eEthnic group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e17 (35.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Yoruba\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e45 (93.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;When: college/university\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e20 (41.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Ibo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e3 (6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;When: Internship/SIWES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e4 (8.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eHighest level of education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;When: other\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e7 (14.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;No formal education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e1 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003eYears in practice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Completed secondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e2 (4.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026lt; 1 year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e8 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Tertiary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e45 (93.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;1-4 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e13 (27.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eOccupation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;5-10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e6 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Matron\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e3 (6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026gt; 10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e21 (43.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Midwife\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e1 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Doctor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e5 (10.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Community health worker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e25 (52.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Nurse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e14 (29.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eSIWES Students Industrial Work Experience Scheme; n number of HCP\u003c/em\u003e\u003c/p\u003e\n\u003ch2\u003eAcceptability of the EEBF tool\u003c/h2\u003e\n\u003cp\u003eOf the 48 HCP, 45 (93.8%) scored at or above the mean composite score (14.9/15), indicating high acceptability; three (6.2%) scored below the threshold. These results indicate that the tool is perceived as contextually appropriate and effective for breastfeeding counselling.\u003c/p\u003e\n\u003ch2\u003eUtility and impact of the EEBF tool\u003c/h2\u003e\n\u003cp\u003eFig.\u0026nbsp;1 shows the utility and impact assessment. All HCP (100%) agreed that the video demonstration, flipchart, and handbills provided valuable breastfeeding information, enhanced their understanding of early initiation and exclusive breastfeeding, and equipped them to better educate pregnant women. The majority (96%) affirmed that the information on the suckling reflex arc improved their comprehension of lactation physiology.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFig. 1 Utility and impact of the EEBF tool among healthcare personnel (N = 48).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(High acceptability defined as score \u0026ge;4.96 on the five-item utility and impact subset (items Q4, Q10, Q11, Q12, and Q15)).\u003c/strong\u003e\u003c/p\u003e\n\u003ch2\u003eKey-informant interview participant characteristics\u003c/h2\u003e\n\u003cp\u003eTable 2 presents the characteristics of the six KII participants. The majority were female (83.3%), with a mean age of 45 \u0026plusmn; 11 years. All had attained tertiary education and had prior experience using a lactation education tool. Occupations included community health workers (33.3%), matrons-in-charge (33.3%), nutrition officer (16.7%), and registered nurse (16.7%). All HCP interacted with pregnant and lactating mothers either every time or often during clinical duties.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Sociodemographic characteristics and clinical experience of key-informant interview participants (N = 6)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"602\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003eOccupation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e1 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Nutrition officer (NO)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e1 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e5 (83.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Community health worker (CHW)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e2 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Registered nurse (RN)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e1 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;18\u0026ndash;35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e1 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Matron-in-charge (MC)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e2 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;36\u0026ndash;54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e4 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003ePrior lactation tool experience\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e6 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026ge;55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e1 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Counselling mothers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e3 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Mean age (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e45 \u0026plusmn; 11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Practical demonstration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e3 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eEducation: Tertiary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e6 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003eFrequency of contact with pregnant/lactating mothers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Every time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e3 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Often\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e3 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNO nutrition officer, CHW community health worker, RN registered nurse, MC matron-in-charge of PHC\u003c/em\u003e\u003c/p\u003e\n\u003ch2\u003eThematic findings from key-informant interviews\u003c/h2\u003e\n\u003cp\u003eFive themes emerged from the analysis of the six KII transcripts.\u003c/p\u003e\n\u003ch3\u003eTheme 1: Perception towards the EEBF tool\u003c/h3\u003e\n\u003cp\u003eHCP predominantly perceived the EEBF tool as confidence-enhancing and easy to use, citing clear language and visual aids as beneficial for both HCP and pregnant women. Representative quotes include:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Using this tool has given me more confidence; when I counsel pregnant women now, I know I can explain breastfeeding well and answer their questions better.\u0026rdquo; (CHW#2)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;The tool made it very easy for me to use and teach; I just follow the points and mothers understand quickly.\u0026rdquo; (CHW#1)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;It is simple and direct, so when I used it to teach, the mothers followed without confusion.\u0026rdquo; (RN)\u003c/p\u003e\n\u003ch3\u003eTheme 2: Practical application for day-to-day use\u003c/h3\u003e\n\u003cp\u003eHCP identified antenatal health talks and breastfeeding counselling sessions as the primary settings for tool use. The tool was perceived as reinforcing key breastfeeding messages:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;During antenatal sessions, I will use the tool as a guide to remind me of the important messages, so as to give the pregnant women complete information.\u0026rdquo; (NO)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;It is very good especially during health education counselling, and it can create discussions in groups among healthcare providers and pregnant women.\u0026rdquo; (MC#1)\u003c/p\u003e\n\u003ch3\u003eTheme 3: Time commitment to use the tool\u003c/h3\u003e\n\u003cp\u003eMost HCP reported that the tool was not time-consuming and could be integrated into routine sessions. Staffing shortages and time constraints at antenatal clinics were identified as minor barriers:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Time is good, it is not time-consuming. It is very short, and they\u0026rsquo;ll quickly grasp the messages.\u0026rdquo; (MC#1)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;At the PHC, we are usually short-staffed, so time for health talks is very limited. However, because your tool is easy to use and not time-consuming, we will be able to include it in our routine.\u0026rdquo; (MC#2)\u003c/p\u003e\n\u003ch3\u003eTheme 4: Overall satisfaction with the EEBF tool\u003c/h3\u003e\n\u003cp\u003eSatisfaction ratings ranged from 8 to 10 on a 10-point scale, with 9 being the most prevalent score.\u003c/p\u003e\n\u003ch3\u003eTheme 5: Knowledge gained through the use of the EEBF tool\u003c/h3\u003e\n\u003cp\u003eHCP reported improved understanding of breastfeeding on demand, benefits of breastfeeding, fluid intake guidance, and proper positioning. Representative quotes include:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I like how this tool reminds me that the more the child suckles from the mother, the more breastmilk is produced. This will train mothers to consistently feed their babies so that the breasts will keep producing milk.\u0026rdquo; (MC#2)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;The parts about benefits of breastfeeding, without herbal drinks for the child, and the importance of fluid intake by the mother were very beneficial to me because I didn\u0026rsquo;t know that before.\u0026rdquo; (RN)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;The pictures really helped to show the correct positioning, preventing breast pain while breastfeeding \u0026mdash; which many mothers complain about.\u0026rdquo; (CHW#1)\u003c/p\u003e\n\u003ch2\u003eConvergence of quantitative and qualitative findings\u003c/h2\u003e\n\u003cp\u003eTable 3 presents the convergence of quantitative utility and impact items with qualitative practicality themes. The alignment across methods confirms that the EEBF tool is not only well-accepted but also functionally viable in real-world PHC settings, with quantitative acceptability supported by qualitative evidence of enhanced confidence, practical application, and knowledge acquisition.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Convergence of quantitative utility and impact findings with qualitative practicality themes\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"602\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAcceptability \u0026ndash; Utility \u0026amp; Impact item\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePracticality theme / sub-theme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIllustrative quote\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e1. The intervention is a good idea; I was able to educate pregnant women better.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003ePerception \u0026ndash; Increased confidence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Using this tool has given me more confidence; when I counsel pregnant women now, I can explain breastfeeding well and answer their questions better.\u0026quot; (CHW#2)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003ePerception \u0026ndash; Easy to use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;The tool made it easy; I just follow the points and mothers understand quickly.\u0026quot; (CHW#1)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e2. The information on the reflex arc helped me understand breastfeeding better.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eKnowledge \u0026ndash; Benefit of breastfeeding on demand\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;From the tool I understood better how the reflex arc works and why frequent breastfeeding is important for milk to flow well.\u0026quot; (NO)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e3. I understood the information on early initiation and exclusive breastfeeding.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eKnowledge \u0026ndash; Benefits of breastfeeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;I can give better counselling to pregnant women on the benefits of exclusively breastfeeding for mother and child.\u0026quot; (MC#1)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e4. I understood the information about discouraging pre-lacteal feeds.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eKnowledge \u0026ndash; Benefits of fluid intake\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;From the tool I learnt that only mothers should drink water while breastfeeding, and not give the newborn water or local drinks.\u0026quot; (MC#2)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e5. The video, flipchart, and handbills provided valuable breastfeeding information.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003ePractical application \u0026ndash; Counselling sessions / antenatal health talks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;During antenatal sessions, I will use the tool as a guide to give pregnant women complete information.\u0026quot; (NO)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNO nutrition officer, CHW community health worker, RN registered nurse, MC matron-in-charge of PHC\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis convergent mixed-methods feasibility study examined the acceptability and practicality of the EEBF tool among 48 HCP across five PHCs in Ibadan, Nigeria. The findings demonstrate that the tool is highly acceptable and practically viable, with convergent evidence from both quantitative and qualitative phases reinforcing its potential to strengthen lactation education delivery at the primary care level.\u003c/p\u003e \u003cp\u003eThe female-dominated workforce observed in this study (87.5%) mirrors findings by Kadiri-Eneh et al.\u003csup\u003e19\u003c/sup\u003e (89.7% female) in their own study of Nigerian PHCs, consistent with the gendered composition of nursing and community health occupations in Nigeria. The predominance of Yoruba HCP (93.8%) reflects the southwestern Nigerian study setting,\u003csup\u003e20\u003c/sup\u003e and the physician-to-staff ratio conforms to minimum Nigerian PHC staffing standards.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e Notably, only one nutrition officer was identified across all five PHCs, a finding attributable to the exclusion of this cadre from Nigeria\u0026rsquo;s minimum PHC staffing standards.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e This has a significant implication: at the primary care level, no formally qualified nutritionist is typically employed, limiting the quality of routine nutrition and lactation counselling.\u003c/p\u003e \u003cp\u003eThe high acceptability rate (93.8%) is consistent with comparable intervention studies. Abbass-Dick et al.\u003csup\u003e15\u003c/sup\u003e reported 82% acceptability for an eHealth breastfeeding resource among HCP, and Allotey et al.\u003csup\u003e18\u003c/sup\u003e demonstrated high HCP acceptance of a multicomponent breastfeeding promotion programme integrated into PHC services in Lagos State, Nigeria. These convergent findings suggest that structured, multimedia-based lactation education tools are generally well received by HCP in Nigerian primary care contexts.\u003c/p\u003e \u003cp\u003eThe EEBF tool\u0026rsquo;s intervention message on the suckling reflex arc was well accepted, with the majority of HCP reporting improved understanding of lactation physiology. This aligns with Allotey et al.\u0026rsquo;s\u003csup\u003e18\u003c/sup\u003e finding that HCP in Lagos who received physiology-based breastfeeding training reported increased counselling confidence - corroborated qualitatively in this study: \u0026ldquo;I easily understood the importance of breastfeeding and all the hormones involved in the reflex arc process.\u0026rdquo; (MC#2). Such physiological understanding is foundational to effective breastfeeding counselling and directly addresses the knowledge deficits identified in the formative study (Folasire OF, Akpanukoh AU, Abdumalik AJ, unpublished observations).\u003c/p\u003e \u003cp\u003eAll HCP accepted the messages on early initiation and exclusive breastfeeding, contrasting with qualitative findings by Moussa Abba et al.\u003csup\u003e22\u003c/sup\u003e in Niger, where HCP demonstrated inconsistent promotion of exclusive breastfeeding. This difference may reflect the structured, competency-based approach of the EEBF tool, which provides HCP with specific, step-by-step guidance rather than general prompting alone.\u003c/p\u003e \u003cp\u003eThe multimedia components - video and flipchart - enhanced delivery of positioning messages, consistent with Gavine et al.\u0026rsquo;s\u003csup\u003e23\u003c/sup\u003e systematic review demonstrating that practical training components, including demonstrations and educational tools, increase HCP knowledge of correct latching technique. The visual design of the EEBF tool appears particularly effective: \u0026ldquo;I\u0026rsquo;m happy that when pregnant women see the pictures in the flipchart and video, they\u0026rsquo;ll learn the correct way to position, making HCP\u0026rsquo;s work easier.\u0026rdquo; (MC#2).\u003c/p\u003e \u003cp\u003eHCP acceptance of the fluid intake message produced a notable finding: some HCP were previously unaware that maternal fluid intake - rather than neonatal supplementation - was the relevant concern. While the causal relationship between increased maternal fluid intake and milk volume remains subject to debate in controlled trials,\u003csup\u003e25\u003c/sup\u003e this study aligns with WHO guidance that adequate maternal hydration supports overall wellbeing and oxytocin-mediated milk ejection.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e The discouragement of pre-lacteal feeds, reinforced through the tool, was similarly well received, consistent with Tongun et al.\u0026rsquo;s\u003csup\u003e24\u003c/sup\u003e findings from South Sudan where BFHI-aligned HCP training was associated with reduced recommendation of pre-lacteal feeds.\u003c/p\u003e \u003cp\u003eThe on-demand breastfeeding message reinforced HCP understanding of demand-supply physiology, consistent with Gilder et al.\u003csup\u003e27\u003c/sup\u003e in Thailand, where HCP reported improved counselling practices following similar training, and with evidence that IYCF training significantly improves HCP guidance on feeding frequency and exclusivity.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eStaffing shortages emerged as the primary implementation barrier, corroborating findings by Okoroafor et al.\u003csup\u003e29\u003c/sup\u003e documenting severe HCP shortfalls in 196 Nigerian PHC facilities, and by Abbass-Dick et al.\u003csup\u003e15\u003c/sup\u003e where 50% of HCP cited time constraints as a barrier to tool use. Notwithstanding, the EEBF tool\u0026rsquo;s simplicity of use and conciseness were frequently mentioned as facilitators of integration into current workflows, indicating that the design of the tool and its contents can help reduce system-level obstacles.\u003c/p\u003e \u003cp\u003eThe convergence of quantitative and qualitative information offers robust and consistent validation for the feasibility of the EEBF tool. The tool not only enhanced HCP knowledge and counselling confidence but also demonstrated practical embedding ability into routine antenatal care, reinforcing its potential to improve the quality of lactation support at the grassroots level.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe EEBF tool is feasible, highly acceptable, and practically applicable for use by healthcare personnel in primary healthcare centres in Ibadan, Nigeria. Its culturally appropriate multimedia content, behavior-change-informed design, and adherence to WHO/UNICEF breastfeeding recommendations give HCP the knowledge and assurance they need to provide consistent lactation counselling. These results lend credence to the wider use of structured, HCP-focused training resources to promote breastfeeding among pregnant women in primary care contexts. Longitudinal evaluation is advised to determine the long-term effects of the EEBF tool on HCP counselling practices and breastfeeding initiation and exclusivity rates among mothers attending PHCs.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eANC \u0026mdash; Antenatal care clinic\u003c/p\u003e\n\u003cp\u003eBCW \u0026mdash; Behaviour Change Wheel\u003c/p\u003e\n\u003cp\u003eBFHI \u0026mdash; Baby-Friendly Hospital Initiative\u003c/p\u003e\n\u003cp\u003eCHW \u0026mdash; Community health worker\u003c/p\u003e\n\u003cp\u003eCOM-B \u0026mdash; Capability, Opportunity, Motivation\u0026ndash;Behaviour model\u003c/p\u003e\n\u003cp\u003eDHS \u0026mdash; Demographic and Health Survey\u003c/p\u003e\n\u003cp\u003eEBF \u0026mdash; Exclusive breastfeeding\u003c/p\u003e\n\u003cp\u003eEEBF \u0026mdash; Early Initiation and Exclusive Breastfeeding\u003c/p\u003e\n\u003cp\u003eHBM \u0026mdash; Health Belief Model\u003c/p\u003e\n\u003cp\u003eHCP \u0026mdash; Healthcare personnel\u003c/p\u003e\n\u003cp\u003eIYCF \u0026mdash; Infant and Young Child Feeding\u003c/p\u003e\n\u003cp\u003eKII \u0026mdash; Key-informant interview\u003c/p\u003e\n\u003cp\u003eMC \u0026mdash; Matron-in-charge\u003c/p\u003e\n\u003cp\u003eNO \u0026mdash; Nutrition officer\u003c/p\u003e\n\u003cp\u003ePHC \u0026mdash; Primary healthcare centre\u003c/p\u003e\n\u003cp\u003eRN \u0026mdash; Registered nurse\u003c/p\u003e\n\u003cp\u003eSIWES \u0026mdash; Students Industrial Work Experience Scheme\u003c/p\u003e\n\u003cp\u003eSPSS \u0026mdash; Statistical Package for the Social Sciences\u003c/p\u003e\n\u003cp\u003eWHO \u0026mdash; World Health Organisation\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eEthical approval was obtained from the Oyo State Ministry of Health Ethics Review Committee (Ref: NHREC/OYOSHRIEC/10/11/22). All participants provided written informed consent prior to enrolment. Data confidentiality was maintained throughout; audio recordings were accessible only to the research team. All procedures of this research were done in accordance with the ethical principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eAuthors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis research received no external funding. The study was supported entirely by the personal resources of the authors.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026rsquo; contributions\u003c/h2\u003e\n\u003cp\u003eO.F.F. conceptualised the study, designed the EEBF Tool, supervised all phases, writing of manuscript. C.B.I.: data collection, data analysis, and wrote the draft manuscript. A.A: involved in design of the EEBF tool, A. J.A: involved in the design of the EEBF tool. All authors reviewed and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eThe authors thank all healthcare personnel who participated in this study.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization. Exclusive breastfeeding for optimal growth, development and health of infants [Internet]. Geneva: WHO; 2023 [cited 2025 Nov 29]. Available from: https://www.who.int/tools/elena/interventions/exclusive-breastfeeding\u003c/li\u003e\n\u003cli\u003ePan American Health Organization. World Breastfeeding Week Campaign 2021 [Internet]. 2021 [cited 2025 Nov 29]. Available from: https://www.paho.org/en/campaigns/world-breastfeeding-week-campaign-2021\u003c/li\u003e\n\u003cli\u003eAbie BM, Goshu YA. Early initiation of breastfeeding and colostrum feeding among mothers of children aged less than 24 months in Debre Tabor, northwest Ethiopia: a cross-sectional study. BMC Res Notes. 2019;12(65):1\u0026ndash;6. https://doi.org/10.1186/s13104-019-4094-6.\u003c/li\u003e\n\u003cli\u003eWidstr\u0026ouml;m A, Brimdyr K, Svensson K, Cadwell K, Nissen E. Skin-to-skin contact the first hour after birth, underlying implications and clinical practice. Acta Paediatr. 2019;108(7):1192\u0026ndash;204. https://doi.org/10.1111/apa.14754.\u003c/li\u003e\n\u003cli\u003eAlay\u0026oacute;n S, Varela V, Mukuria-Ashe A, Alvey J, Milner E, Pedersen S, et al. Exclusive breastfeeding: measurement to match the global recommendation. Matern Child Nutr. 2022;18(4):e13409. https://doi.org/10.1111/mcn.13409.\u003c/li\u003e\n\u003cli\u003eShobo OG, Umar N, Gana A, Longtoe P, Idogho O, Anyanti J. Factors influencing the early initiation of breast feeding in public primary healthcare facilities in Northeast Nigeria: a mixed-method study. BMJ Open. 2020;10(4):e032835. https://doi.org/10.1136/bmjopen-2019-032835.\u003c/li\u003e\n\u003cli\u003eNdikom CM, Ologunye BF. Breastfeeding education and exclusive breastfeeding practices among mothers in Ibadan, Oyo State, Nigeria. LAUTECH J Nurs. 2020;5(1):56\u0026ndash;62.\u003c/li\u003e\n\u003cli\u003eNavarro V, Soriano JM, Laredo S. Applying systematic review search methods to the grey literature: a review of education and training courses on breastfeeding support for health professionals. Int Breastfeed J. 2021;16:31. https://doi.org/10.1186/s13006-021-00373-5.\u003c/li\u003e\n\u003cli\u003eDukuzumuremyi JPC, Acheampong K, Abesig J, Luo J. Knowledge, attitude, and practice of exclusive breastfeeding among mothers in East Africa: a systematic review. Int Breastfeed J. 2020;15:70. https://doi.org/10.1186/s13006-020-00313-9.\u003c/li\u003e\n\u003cli\u003eChuisano SA, Anderson OS. Assessing application-based breastfeeding education for physicians and nurses: a scoping review. J Hum Lact. 2019;36(3):515\u0026ndash;25. https://doi.org/10.1177/0890334419848414.\u003c/li\u003e\n\u003cli\u003eMulcahy H, Philpott LF, O\u0026apos;Driscoll M, Bradley R, Leahy-Warren P. Breastfeeding skills training for health care professionals: a systematic review. Heliyon. 2022;8(11):e11747. https://doi.org/10.1016/j.heliyon.2022.e11747.\u003c/li\u003e\n\u003cli\u003eAgunbiade OM, Ogunleye OV. Constraints to exclusive breastfeeding practice among breastfeeding mothers in Southwest Nigeria: implications for scaling up. Int Breastfeed J. 2012;7:5. https://doi.org/10.1186/1746-4358-7-5.\u003c/li\u003e\n\u003cli\u003eOsibogun OO, Olufunlayo TF, Oyibo SO. Knowledge, attitude and support for exclusive breastfeeding among bankers in Mainland Local Government in Lagos State, Nigeria. Int Breastfeed J. 2018;13:38. https://doi.org/10.1186/s13006-018-0182-9.\u003c/li\u003e\n\u003cli\u003eBowen DJ, Kreuter M, Spring B, Cofta-Woerpel L, Linnan L, Weiner D, et al. How we design feasibility studies. Am J Prev Med. 2009;36(5):452\u0026ndash;7. https://doi.org/10.1016/j.amepre.2009.02.002.\u003c/li\u003e\n\u003cli\u003eAbbass-Dick J, Dubrowski A, Micallef J, Newport A, Pigeau K, Jeronymo H, et al. Health care providers\u0026apos; perceptions of barriers, facilitators, and acceptability of an eHealth resource: descriptive study. Int Health Trends Perspect. 2024;4(1):68\u0026ndash;87.\u003c/li\u003e\n\u003cli\u003eLucchini-Raies C, Marquez-Doren F, Perez JC, Campos S, Beca P, Lopez-Dicastillo O. A complex intervention to support breastfeeding: a feasibility and acceptability study. Int J Nurs Pract. 2023;29(6):e13184. https://doi.org/10.1111/ijn.13184.\u003c/li\u003e\n\u003cli\u003eRadzyminski S, Callister LC. Health professionals\u0026apos; attitudes and beliefs about breastfeeding. J Perinat Educ. 2015;24(2):102\u0026ndash;9. https://doi.org/10.1891/1058-1243.24.2.102.\u003c/li\u003e\n\u003cli\u003eAllotey D, Flax VL, Ipadeola AF, Adeola O, Grimes K, Adair LS, et al. Feasibility and acceptability of integrating a multicomponent breastfeeding promotion intervention into routine health services in private health facilities in Lagos state, Nigeria: a mixed methods process evaluation. PLoS ONE. 2024;19(4):e0301695. https://doi.org/10.1371/journal.pone.0301695.\u003c/li\u003e\n\u003cli\u003eKadiri-Eneh NP, Azuike EC, Tobin-West C, Uzochukwu BSC. An assessment of the potentials for retention of primary healthcare workers in Rivers State, Nigeria. Afrimed J. 2018;6(1):35\u0026ndash;51.\u003c/li\u003e\n\u003cli\u003eOdunafolabi OO, Sonibare OO, Olodu MD, Omobuwa O, Asekun-Olarinmoye TF, Olowookere SA. Breastfeeding practices among nursing mothers with under-five children in Ilesa, Osun State, Nigeria. West Niger J Med Sci. 2023;6(2):156\u0026ndash;64.\u003c/li\u003e\n\u003cli\u003eNational Primary Health Care Development Agency. Minimum standards for primary health care in Nigeria. Abuja: The Agency; 2015.\u003c/li\u003e\n\u003cli\u003eMoussa Abba A, De Koninck M, Hamelin AM. A qualitative study of the promotion of exclusive breastfeeding by health professionals in Niamey, Niger. Int Breastfeed J. 2010;5:8. https://doi.org/10.1186/1746-4358-5-8.\u003c/li\u003e\n\u003cli\u003eGavine A, MacGillivray S, Renfrew MJ, Siebelt L, Haggi H, McFadden A. Education and training of healthcare staff in the knowledge, attitudes and skills needed to work effectively with breastfeeding women: a systematic review. Int Breastfeed J. 2017;12:6. https://doi.org/10.1186/s13006-016-0097-2.\u003c/li\u003e\n\u003cli\u003eTongun JB, Mukunya D, Tylleskar T, Sebit MB, Tumwine JK, Ndeezi G. Determinants of health facility utilization at birth in South Sudan. Int J Environ Res Public Health. 2019;16(13):2445. https://doi.org/10.3390/ijerph16132445.\u003c/li\u003e\n\u003cli\u003eMorse JM, Ewing G, Gamble D, Donahue P. The effect of maternal fluid intake on breast milk supply: a pilot study. Can J Public Health. 1992;83(3):213\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Infant and young child feeding: model chapter for textbooks for medical students and allied health professionals [Internet]. Geneva: WHO; 2009. Available from: https://www.ncbi.nlm.nih.gov/books/NBK148965/\u003c/li\u003e\n\u003cli\u003eGilder ME, Pateekhum C, Wai NS, Misa P, Sanguanwai P, Sappayabanphot J, et al. Determinants of health care worker breastfeeding experience and practices and their association with provision of care for breastfeeding mothers: a mixed-methods study from Northern Thailand. Int Breastfeed J. 2024;19:8. https://doi.org/10.1186/s13006-024-00613-4.\u003c/li\u003e\n\u003cli\u003eSamuel FO, Olaolorun FM, Adeniyi JD. A training intervention on child feeding among primary healthcare workers in Ibadan Municipality. Afr J Prim Health Care Fam Med. 2016;8(1):e1\u0026ndash;6. https://doi.org/10.4102/phcfm.v8i1.884.\u003c/li\u003e\n\u003cli\u003eOkoroafor SC, Ahmat A, Osubor M, Nyoni J, Bassey J, Alemu W. Assessing the staffing needs for primary health care centres in Cross River State, Nigeria: a workload indicator of staffing needs study. Hum Resour Health. 2022;19:108. https://doi.org/10.1186/s12960-021-00648-2.\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":"Breastfeeding, Health Personnel, Primary Health Care, Pilot Projects, Inservice Training, Qualitative Research","lastPublishedDoi":"10.21203/rs.3.rs-9405343/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9405343/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eSuboptimal breastfeeding practices contribute significantly to preventable maternal and infant morbidity in Nigeria, partly due to inadequate lactation training among healthcare personnel (HCP). This study evaluated the feasibility of an Early Initiation and Exclusive Breastfeeding (EEBF) educational tool for routine use by HCP in primary healthcare centres (PHCs) in Ibadan, Nigeria.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA convergent parallel mixed-methods design was employed in five purposively selected PHCs in Ibadan. Quantitative data were collected from 48 HCP using a structured questionnaire assessing acceptability on a 5-point Likert scale. Qualitative data were obtained through six key informant interviews exploring practicality. Quantitative data were analysed using SPSS version 26, while thematic analysis of qualitative data was done using inductive approach, findings were triangulated.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eGenerally, 93.8% (45/48) of participants exhibited high acceptability of the EEBF tool. Qualitative results revealed that the tool enhanced HCP confidence in delivering breastfeeding education, was suitable for use during antenatal health talks and counselling sessions and was not time-consuming. Participants reported high satisfaction (mean rating: 9/10) and improved knowledge of breastfeeding practices, including early initiation, exclusive breastfeeding, proper latching and positioning, breastfeeding physiology, and the significance of adequate maternal hydration.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe EEBF tool was feasible, acceptable, and practical for use day-to day among HCP in primary healthcare settings. Integration the EEBF tool into routine maternal and child health services may enhance breastfeeding education and support. However, more long-term research are recommended to assess its sustained use and impact.\u003c/p\u003e","manuscriptTitle":"Feasibility of an Early Initiation and Exclusive Breastfeeding (EEBF) Education Tool© among Healthcare Personnel in Primary Healthcare Centres, Ibadan, Nigeria: A Convergent Mixed-Methods Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-08 16:15:45","doi":"10.21203/rs.3.rs-9405343/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-07T17:22:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"33047356593506464333224966134510558965","date":"2026-04-25T15:38:42+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-23T15:10:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-15T15:52:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-15T15:52:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Breastfeeding Journal","date":"2026-04-13T14:06:44+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":"b79bda77-20d6-45c2-938d-9ee2cd2ebb6a","owner":[],"postedDate":"May 8th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-07T17:22:03+00:00","index":29,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-08T16:15:48+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-08 16:15:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9405343","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9405343","identity":"rs-9405343","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}