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LIBRARY
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University

 

 

 

This is to certify that the
thesis entitled

DEVELOPMENT OF AN INSTRUMENT DESIGNED TO
MEASURE MANAGER ATTITUDES TOWARD WORKPLACE
BREASTFEEDING SUPPORT

presented by

FUK TAN CHOW

has been accepted towards fulfillment
of the requirements for the

Master of Science degree in Human Nutrition

 

«1L4: Ix!— // ((2 4/107",
Major Professor’s Signature

X/efYfi?
I 7

Date

MSU is an Affirmative Action/Equal Opportunity Employer

 

PLACE IN RETURN BOX to remove this checkout from your record.
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5/08 K:lProjIAcc&Pros/ClRC/Dateom.indd

DEVELOPMENT OF AN INSTRUMENT DESIGNED TO MEASURE MANAGER
ATTITUDES TOWARD WORKPLACE BREASTFEEDING SUPPORT

By

Fuk Tan Chow

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE
Human Nutrition

2009

ABSTRACT

DEVELOPMENT OF AN INSTRUMENT DESIGNED TO MEASURE MANAGER
ATTITUDES TOWARD WORKPLACE BREASTFEEDING SUPPORT

By
Fuk Tan Chow
Manager attitudes play a pivotal role in female employees’ perceptions of
workplace breastfeeding support. However, no instrument exists to measure manager
attitudes toward supporting women wishing to combine breastfeeding with
employment. The purpose of this study was to develop an instrument designed to
measure manager attitudes toward breastfeeding support in the workplace, which would
be suitable for piloting with the target population. A modified version of an instrument
development process described by Wolfe & Smith (2007) was followed. Five focus
groups were conducted to assess attitudes of managers toward breastfeeding in the
workplace and the results were used to create subscales and items within each subscale.
Survey design and item development was done through an iterative process. Experts’
input including researchers (in the field of breastfeeding, work-family balance,
organizational behavior, and survey development) and practitioners (with experience in
breastfeeding and business) were used to evaluate the instrument through content
(n=20) and item’s fit (n=l7). Additionally, individual cognitive interviews (n=8) were
conducted with managers. Results of expert reviews and cognitive interviews
determined no additional subscales were needed, but survey items were added,
reworded, or eliminated to improve clarity, readability, and organization. The final
survey consisted of four subscales and 83 items measured in either dichotomous

agree/disagree or four-point Likert rating scale.

ACKNOWLEDGEMENTS

I would like to express my deepest gratitude to my advisor Dr. Beth Olson for
her continuous support and guidance on my graduate program and thesis project. Her
dedication and time were invaluable in my growth as a researcher. I would like to
extend my appreciation to my committee members: Dr. Marsha Carolan, Dr. Don
Conlon, and Dr. Norm Hord for their encouragement and valuable feedback, despite
their busy schedules. I would like to thank Dr. Edward Wolfe and Carol Wolfe for their
expertise in instrument design and development, as well as Dr. Ingrid Fulrner of
Georgia Institute of Technology for her expertise in organizational behavior. I deeply
appreciate the help I received from expert reviewers and managers who helped evaluate
the instrument.

I am grateful for the encouragement from the faculty members in the
Department of Food Science and Human Nutrition, especially the faculty in Community
Nutrition, who were always helpful. I am thankful for the support from the graduate
students in Community Nutrition. I would also like to thank my lab mates: Tracie
Bolton, Tara Fisher, Sally Greene, Sarah Hojnacki, Krystyna Iwanski, Shabnarn
Momin, Lindsay Angst and other undergraduate assistants who were always there to
help and listen.

Finally, I want to thank my family members and friends for their tremendous
support. My achievement today cannot be possible without their encouragement and

love. I greatly appreciate that you all have stood by me along this journey.

iii

TABLE OF CONTENTS

LIST OF TABLES ................................................................................... xi

LIST OF FIGURES ................................................................................. xii

LIST OF ABBREVIATIONS ..................................................................... xiii
CHAPTER 1

Introduction ........................................................................................... 1

1.1 Background .............................................................. - ............. 1

1.2 Rationale .............................................................................. 4

1.3 Research Goal ......................................................................... 5

1.4 Research Objectives .................................................................... 6
CHAPTER 2

Literature Review .................................................................................... 7

2.1 Infant and Maternal Health Benefits .............................................. 7

2.2 Benefits to the Family, Healthcare System, and Workplace............. ........10

2.3 Breastfeeding Recommendations .................................................. 11

2.4 Prevalence of Breastfeeding ....................................................... 12

2.5 Prevalence of Breastfeeding Characterized by Employment Status... . . . .....13

2.6 Women Workforce Statistics ........................................................ 17

2.7 Breastfeeding Legislation ............................................................ 18

2.8 Organizational Climate .............................................................. 21

2.9 Work-Family Balance and Conflicts ............................................... 22

2.10 Manager Support of Work-Family Balance ...................................... 24

2.11 Employer (Manager) Attitudes Toward Breastfeeding Support ............. 26
CHAPTER 3

Development of an Instrument Designed to Measure Manager Attitudes toward

Workplace Breastfeeding Support ................................................................ 31

3.1 Abstract ................................................................................ 31

3.2 Introduction ........................................................................... 32

3.3 Materials and Methods ............................................................... 35

3.3.] Study Design ............................................................ 35

3.3.2 Focus Groups ............................................................ 35

3.3.3 Item Development ...................................................... 37

3.3.4 Expert Review ........................................................... 38

3.3.5 Cognitive Interview ...................................................... 39

3.4 Results .................................................................................. 40

3.4.1 Focus Groups ............................................................. 40

3.4.2 Item Development ...................................................... 41

3.4.3 Expert Review ............................................................ 42

3.4.4 Cognitive Interview ........................................................ 43

3.5 Discussion ............................................................................. 44

iv

3.6 Conclusion ............................................................................ 48

3.7 Acknowledgements ................................................................... 49
3.8 Reprint information .................................................................... 49
CHAPTER 4
Conclusion and Suggestions for Future Research ............................................... 52
4.1 Conclusion .............................................................................. 52
4.2 Suggestions for Future Research ..................................................... 53
APPENDICES ...................................................................................... 54
Appendix A ................................................................................. 55
Appendix B .................................................................................. 94
Appendix C ................................................................................ 144
BIBLIOGRAPHY ................................................................................ 1 77

LIST OF TABLES
Table l. Breastfeeding Rates in 1998 and Healthy People 2010 goals ..................... 12
Table 2. Theme, Code, and Definition ofthe Codebook.........................................64
Table 3. Rules for Application and Exclusion and Examples for Application of the
Codebook66

Table 4. Demographics ofthe Focus Group Part1c1pants73

vi

LIST OF FIGURES

Figure 1. Conceptual Framework for Measuring Manager Attitudes toward Workplace
Breastfeeding Support .............................................................................. 95

vii

LIST OF ABBREVIATIONS

AAFP. ................................................. American Academy of Family Physicians
AAP ............................................................. American Academy of Pediatrics
ABQ ............................................. Attitudes toward Breastfeeding Questionnaire
ADA ................................................................ American Dietetic Association
CDC ................................................ Centers for Disease Control and Prevention
CoNLSY ............................... Children of the National Longitudinal Study of Youth
DHHS .............................................. Department of Health and Human Services
FMLA ............................................................. Family and Medical Leave Act
HP2010 ....................................................................... Healthy People 2010
IBCLC .................................... International Board Certified Lactation Consultants
IOM ............................................................................ Institute of Medicine
NIS ................................................................ National Immunization Survey
NLSY .................................................... National Longitudinal Survey of Youth
RMS ........................................................................... Ross Mothers Survey
SIDS ............................................................... Sudden Infant Death Syndrome
USDA ................................................... United States Department of Agriculture
WHO ................................................................... World Health Organization

viii

Chapter 1

INTRODUCTION

1.1 Background

Breastfeeding is the optimal form of nutrition for feeding infants. Research has
demonstrated diverse short- and long-term advantages of breastfeeding for infants,
mothers, and society (AAP 2005; Labbok, 2001; Kramer et al, 2001 , Dewey et al.,
1993; WHO, 2001; Ball & Wright, 1999; Weimer, 2001). In the US, it is recommended
that most infants be exclusively breastfed for the first six months of life and
breastfeeding continued, with addition of complementary food for at least the first year
of life (AAP 2005; ADA 2005). Despite these recommendations and substantial
benefits attributed to breastfeeding, employed mothers have lower breastfeeding rates
than their non-working counterparts at six months (30% vs. 35%) and 12 months (16%
vs. 23%) (Ross Product Division, 2003). Among employed mothers, those working
full-time reported even lower breastfeeding rates than those working part-time at six

months (26% vs. 37%) and 12 months (14% vs. 21%) (Ross Product Division, 2003).

Many factors negatively affect breastfeeding rates among employed mothers
(Scott & Binn, 1999; Visness & Kennedy, 1997), and maternal postpartum employment
has been identified as a key barrier for breastfeeding continuation (Visness & Kennedy,
1997; McKinley & Hyde, 2004). In 2007, 57% of women aged 16 and over were

employed in the US workforce with 75% working full-time jobs. Specifically, of the

3.3 million mothers with children aged one year or less, 52% were employed in the
labor market, with 69% employed full-time (US Department of Labor, 2008). Given
that a significant part of the US workforce is comprised of employed women of
childbearing age and mothers with young children, it is crucial to investigate factors that

discourage continued breastfeeding among employed women.

Efforts have been made to address the lower breastfeeding rates among
employed mothers in the US workforce. In 2009, twenty-four states, the District of
Columbia, and Puerto Rico have general laws related to breastfeeding in the workplace,
but only 13 states require employers to provide break times and accommodation for
breastfeeding employees to express milk in private (National Conference of State
Legislatures, 2009). With no legislation related to workplace breastfeeding in more
than half of the states, breastfeeding accommodations mainly rely on initiatives taken

by individual companies.

Organizational climate is defined as “...[employees’] perceptions of the events,
practices, and procedures and the kinds of behaviors that get rewarded, supported, and
expected in a setting” (Schneider, 1990). The role of organizational climate has been
examined in relation to work-family balance (Gault & Lovell, 2006; Kopelman et al.,
2006; Kossek et al., 2001). Thompson et. al. (1999) suggested perceived managerial
support as a major dimension of work-family balance. Managers are crucial in effective
implementation of work-family policies or programs in many facets, in that they could

inform about the availability of a policy or program, determine whether employees can

utilize such policies or programs, or establish norms in supporting use of a policy or
program (Allen, 2001; Hopkins, 2005; Thompson et al., 1999). With respect to
workplace breastfeeding, managers could exert significant influence on breastfeeding in
the workplace by administrating company policies, practicing informal support or
discouragement for employees, and managing issues arising among non-breastfeeding
employees. Managers’ attitudes may affect how employed mothers perceive the
organizational climate for breastfeeding, which may influence whether mothers choose
to continue breastfeeding upon returning to work following childbirth. Thus, one
potential reason why employed mothers have lower breastfeeding rates is that they do

not perceive managers’ attitudes as supportive of breastfeeding in the workplace.

There is no literature to date documenting whether breastfeeding
accommodations in the workplace are considered a family-supportive benefit.
However, it seems logical to suggest that accommodating breastfeeding at work is an
example of a family-supportive benefit, because manager support for child care, flexible
schedules, and other family friendly accommodations would help women combine
breastfeeding with employment. Family-supportive policies and family-supportive
supervisors comprise the two major components of a work environment that support
employees in their balance of family and work responsibilities (Thomas & Ganster,
1995). Behson (2002a) has documented that informal forms of organizational support,
for instance positive organizational culture and supportive supervisors, are important in
helping employees balance work and family responsibilities. Managerial support has

positive effects on turnover intentions, job satisfaction, organizational commitment, and

health outcomes (Thompson et al., 2004; Allen, 2001; Thomas & Ganster, 1995).
Employees distinguish between support from the company as a whole and support they
receive from their managers (Allen, 2001; Kottke & Sharafinski, 1988). Companies
may offer family-friendly policies and programs to all employees. However, managers
play an important role in the utilization and effectiveness of these policies and programs

because they may encourage or discourage employees’ participation (Thompson et al.,

1999; Allen, 2001).

1.2 Rationale

Perceptions of the organizational climate for breastfeeding from the viewpoint
of managers are not well documented and there is no validated instrument to measure
these manager attitudes. Research in the area of breastfeeding and employment has
examined breastfeeding support within companies through focus groups or self-reported
retrospective surveys with human resource personnel and managers. These studies have
contributed to our current understanding of the employers’ and managers’ perspectives
toward breastfeeding within the companies. Results indicated that few employers
formulate written policies to support breastfeeding in the workplace, and they lack
knowledge of the advantages of breastfeeding to the work environment (Bridges et al.,
1997; Brown et al., 2001; Dunn et al., 2004; Libbus & Bullock, 2002; Seijts & Yip,
2008). Employers having experience with women who have breastfed and knowledge
of other businesses who have employed breastfeeding women reported a significantly
higher level of breastfeeding support those than who had no experience (Bridges et al.,

1997). In addition, managers with children reported stronger support for breastfeeding,

with their experiences in breastfeeding and their knowledge of breastfeeding benefits

mediating the degree of their support (Seijts & Yip, 2008).

Breastfeeding support in the workplace depends upon the company and
managerial support of breastfeeding. It is important to investigate these two perceptions
of support independently to enhance our understanding of the organizational climate for
breastfeeding. However, little research has focused on managers’ attitudes toward
employees who wish to combine breastfeeding and employment. More importantly, no
validated instrument exists to systematically assess these managers’ attitudes.
Therefore, the purpose of this study was to develop an instrument, using qualitative
research methods, to measure the degree of support for breastfeeding in the workplace
from the perspectives of managers. With subsequent quantitative validation, this
instrument could then be used across companies to measure and compare managers’
attitudes. Ultimately, more effective breastfeeding support programs could be designed
to address manager attitudes in order to improve the organizational climate for

supporting breastfeeding.

1.3 Research Goal
The goal of this research is to develop an instrument, suitable for pilot-testing,

which measures attitudes of managers toward combining breastfeeding with

employment.

1.4 Research Objectives
(1) Determine manager attitudes toward supporting women who wish to combine
breastfeeding with work
(2) Develop an instrument to measure manager attitudes

(3) Test and refine the instrument through qualitative research methods

Chapter 2

LITERATURE REVIEW

2.1 Infant and Maternal Health Benefits

Human milk is the natural food that mothers produce to nurture their infants and
it provides the optimal nutrition for infant health. Infant formula has been developed to
be nutritionally equivalent to human milk as possible. However, compelling evidence
on the biochemical properties of human milk and the health benefits attributed to
breastfeeding has established that breastfeeding is more beneficial than formula feeding
(DHHS, 2000). Research has documented diverse short- and long-terrn advantages of
breastfeeding for infants and mothers (AAP 2005; WHO, 2001). The extent of infant
and maternal health benefits depend on breastfeeding duration, frequency, exclusivity,

and other personal factors (Steyn et al., 2004).

Human milk provides unique benefits for infant growth, immunity, and
development (AAP, 2005). Compared to formula-fed infants, breastfed infants have
decreased incidence and/or severity of a wide array of diseases including sudden infant
death syndrome (SIDS), respiratory tract infections, acute otitis media, gastroenteritis,
and type 1 diabetes. The Agency for Healthcare Research and Quality at the US
Department of Health and Human Services (DHHS) Office on Women’s Health
recently released an extensive report about current evidence concerning the relationship
of breastfeeding and infant health outcomes (Ip et al., 2007). The report conducted

meta-analyses of seven studies on SIDS and respiratory diseases, respectively. Results

showed that ever breastfeeding was associated with a 36% reduction in the risk of SIDS
and a 72% reduced risk of hospitalization secondary to lower respiratory infections in
infants who were exclusively breastfed for four months or more compared with those
who were formula-fed. Additionally, five cohort studies found that breastfeeding was
associated with a significant reduction in the risk of acute otitis media (Alho et al.,
1996; Duffy et al., 1997; Sassen et al., 1997; Scariati et al., 1994; Vemacchio et al.,
2004). One systematic review by Chien & Howie (2001) reported a reduced risk of
non-specific gastrointestinal infections among breastfed infants from three primary
studies that controlled for potential confounders. This association was supported by a
recent case-control study showing a 64% reduction in the risk of non-specific
gastroenteritis compared with infants who were not breastfed (Quigley et al., 2006).
Furthermore, two meta-analyses reported statistically significant reduction of 19% and
27%, respectively for the risk of childhood type 1 diabetes in subjects breastfed more
than three months compared to less than three months (Gerstein, 1994; Norris & Scott
1996). A review of six additional case-control studies later found similar results to

these two meta-analyses (Ip et al., 2007).

Breastfeeding also confers important potential health advantages for mothers.
The DHHS report also examined the relationship between breastfeeding and maternal
health outcomes including ovarian cancer (Ip et al., 2007). The authors of the report
performed meta-analyses of nine case-control studies, which showed a summary
estimate of 21% reduced risk of ovarian cancer in women who breastfed their infants

compared to those who never breastfed. Additionally, a dose-response relationship

between breastfeeding and a decreased risk of ovarian cancer was observed in women
breastfeeding for more than 12 months compared to never breastfeeding (Ip et al.,
2007). A longitudinal study from two large cohorts of nurses found that among women
without a history of gestational diabetes, each additional year of breastfeeding was
associated with 4% and 12% reduced risk of type 2 diabetes in the first and second
cohort, respectively. Compared with women with a history of gestational diabetes,

breastfeeding had no significant relationship with diabetes risk (Stuebe et al., 2005).

Studies have shown positive effects of breastfeeding on postpartum weight loss
and breast cancer, though the overall effects are not conclusive. Three cohort studies
reported about one kilogram weight change between pre-pregnancy or first trimester
and one to two year postpartum period in mothers who breastfed (J anney et al., 1997;
Olson et al., 2003; Sichieri et al., 2003). However, results from four other cohort
studies showed unclear association between breastfeeding and postpartum weight loss
(Brewer et al., 1989; Haiek et al., 2001; Ohlin & Rossner, 1996; Walker et al., 2004).
Two meta-analyses concluded that there was a reduced risk of breast cancer among pre-
menopausal women who breastfed their infants (Bemier et al., 2000; Collaborative
group on Hormonal Factors in Breast Cancer, 2002), but a recent systematic review of

31 studies revealed inconsistent findings between breastfeeding and breast cancer (Yang

& Jacobsen, 2008).

2.2 Benefits to the Family, Healthcare System, and Workplace

In addition to health advantages for infants and mothers, breastfeeding offers a
range of benefits to society. Families who choose to breastfeed could save hundreds of
dollars otherwise spent on the purchase of infant formula (ADA, 2005; Riordan, 1998).
Because breastfed infants are healthier, families could have lower medical costs
including sick care visits and prescriptions for the infants (Ball & Wright, 1999;
Labbok, 2001). The US Department of Agriculture (USDA) estimated that increasing
breastfeeding rates could reduce annual healthcare costs by $3.6 billion (Ball & Wright,
1999; Weimer, 2001). Benefits of breastfeeding extend to the environment by reducing
pollution associated with the production, transportation, and disposal of the infant

formula and related supplies (Riordan, 1998).

Accommodating breastfeeding in the workplace could also benefit employers.
Cohen (1995) examined absenteeism among 101 employed mothers, female employees
who formula-fed their infants were more than twice as likely to require one-day
maternal absences from work to care for sick children (26% versus 11%, p<.05).
Employers could reduce healthcare costs for employees from fewer physician visits,
hospitalization days, and prescriptions for infant illnesses, as well as decreased risk of
maternal diseases when women breastfeed (Ball & Wright, 1999; Dickson et al, 2000;
Ip et al., 2007). Companies with lactation support programs showed an average
retention rate of 94% of their female employees after maternity leave compared to the
national average of only 59% (Mutual of Omaha, 2001; Ortiz et al., 2004). Employers

that provide breastfeeding support show improved employee loyalty, higher

10

productivity, better job satisfaction, and enhanced company image for being family-

friendly (Cohen et al., 1995; Galtry, 1997; Patterson et. al., 2004).

2.3 Breastfeeding Recommendations

In the US, it is recommended that most infants be exclusively breastfed for the
first six months of life and that breastfeeding be continued, with addition of
complementary food, for at least the first year of life, and thereafter for as long as
mutually desired by mother and infant (AAF P, 2005; AAP 2005; ADA 2005). Despite
these recommendations by professional organizations and the well-recognized benefits
of breastfeeding, many women do not meet the recommended goals. In 2000, the US
Surgeon General established Healthy People 2010 (HP 2010), a set of national goals for
improvements in health promotion and disease prevention to be achieved in the next
decade (DHHS, 2000). Based on the breastfeeding baseline data in 1998, the
breastfeeding objectives were aimed to increase the percentage of infants breastfed in
the early postpartum period, at six months, and at one year (Table 1). In 2006, these
objectives were expanded to include targets for exclusive breastfeeding because it
provides more protection against many childhood disease including lower respiratory
tract infections and acute otitis media (Ip et al., 2007). This objective was to increase
the proportion of women who exclusively breastfeed infants at three months and six
months of age, respectively (Table 1) (Healthy People 2010 midcourse review: revised

objectives for 16-19).

11

Table l. Breastfeeding Rates in 1998 and Healthy People 2010 goals

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HP 2010 . Percentage of Mothers Breastfeeding
Objective Tmemme 1998 Baseline 2010 Target
Ever Breastfeeding
16-19a In early postpartum 64 75
16-19b At 6 months 29 50
16-19c At 1 year 16 25
Exclusive Breastfeeding
16-19d At 3 months -- 6O
16-19e At 6 months -- 25

 

 

 

 

 

 

2.4 Prevalence of Breastfeeding

There are several national surveys collecting breastfeeding data, including the
National Health and Nutrition Examination Survey and the National Survey of Family
Growth. However, none of the existing surveys definitively describe the extent of
breastfeeding practices in the US (Grummer-Strawn & Li, 2000). In response to these
inadequacies, the Centers for Disease Control and Prevention (CDC) held a meeting in
1999 and concluded that existing systems could not be modified to meet the standards
for an ideal breastfeeding surveillance system and creating the ideal system would be
too costly. The National Immunization Survey (N IS) was deemed appropriate for
including breastfeeding questions because of the close relationship between
breastfeeding and immunologic status of a child. Therefore, the CDC added three
questions on breastfeeding initiation, duration, and exclusivity to the NIS in 2001 for

monitoring the HP 2010 breastfeeding objectives.

12

The NIS is a random-digit dialing telephone survey conducted annually by the
CDC that is used to obtain breastfeeding behavior information based on a retrospective
self-report by mothers or caregivers with children aged 19 to 35 months. The overall
response rates for NIS years 2001 - 2007 ranged from 65% to 76%. The 2005 NIS data
showed that the percentage of infants who were breastfed reached a record high of 74%
in the early postpartum period, close to achieving the HP 2010 target (Table 1). Among
children born in 2005, an estimated 43% of infants were breastfed at six months and
21% at one year; rates for exclusive breastfeeding were 32% at three months and 12%
at six months, respectively, below targets set by HP 2010 (Table l). The 2005 NIS data
also reported that twenty-three states attained national HP 2010 goals for breastfeeding
initiation. The rates for breastfeeding duration at six months and 12 months were
discouraging with only eight states meeting the objectives. Seven states - Alaska,
California, Idaho, Oregon, Utah, Vermont, and Washington - achieved all three
initiation and duration breastfeeding objectives, as well as the expanded targets for

exclusive breastfeeding (CDC, 2005).

2.5 Prevalence of Breastfeeding Characterized by Employment Status

One limitation of the NIS is that it does not measure breastfeeding practices
based on employment status. The Ross Mothers Survey (RMS) is conducted by Ross
Laboratories, manufactures of infant formula, which provides breastfeeding rate
estimates for mothers working full-time, part-time, and not working (Ross Product
Division of Abbott, 2003). The RMS is an ongoing survey mailed on a monthly basis to

a sample of mothers with infants aged one to 12 months. In 2003, 228,000

13

questionnaires were returned yielding a response rate of 19% (Ryan et al., 2006). The
most recent RMS data collected in 2003 reported that working mothers initiated
breastfeeding at rates similar to mothers who were not working (67% vs. 65%). A
smaller proportion of employed mothers continued breastfeeding infants than their non-
working counterparts at six months (30% vs. 35%) and 12 months (16% vs. 23%).
Among employed mothers, those working full-time reported lower breastfeeding rates
than those working part-time at six months (26% vs. 37%) and 12 months (14% vs.
21%) (Ross Product Division of Abbott, 2003). The RMS also provides data on
exclusive breastfeeding, which is defined as prior to the introduction of infant formula,
but not supplemental foods (Ryan et al., 2002). This is inconsistent with the definition
from the US Institute of Medicine (IOM) that exclusive breastfeeding refers to infants
fed with human milk without supplemental foods or liquids except for vitamins,
minerals, and medications (IOM, 1991). Therefore, we can only infer from the RMS
data that women working full time introduced infant formula earlier than those working

part-time or not employed.

In addition to the descriptive RMS data publicly made available by the Abbot
Laboratories, Ryan et al. (2006) was able to examine the RMS 2003 data to compare the
prevalence of breastfeeding duration at six months among mothers who were working
full-time, part-time, or not employed. Rates were not significantly different between
mothers who worked part-time and those not working. However, working firll-time was
negatively associated with breastfeeding duration (p<0.05). In particular, mothers who

were not employed were 2.08 times more likely to breastfeed infants at six months than

14

those who employed full-time (95% CI 2.03-2.13). Besides the findings from the RMS
data showing women with full-time employment following childbirth breastfed for a
shorter duration, many studies using other data sources have also established consistent
negative associations between mothers returning to work after childbirth and
breastfeeding duration (Berger et al., 2005; Chatterji & Frick, 2005; Fein & Roe, 1998;
Gielen et al., 1991; Kearney & Cronenwett, 1991; Ryan et al., 2006; Visness &

Kennedy, 1997).

In earlier studies by Gielen et al. (1991) and Kearney & Cronenwett (1991), 710
and 120 mothers were telephone interviewed in their postpartum period, respectively.
Gielen et al. (1991) found that mothers who were not employed were three times more
likely to breastfeed infants at three months than mothers who were employed. Kearney
& Cronenwett (1991) reported that returning to work was associated with shorter
breastfeeding duration at two months, but not at six months. Fein & Roe (1998)
conducted a similar study with a sample of 1,488 mothers using interviewee-
administrated questionnaires to reduce interviewer bias. In this longitudinal study,
mothers returned completed questionnaires in late pregnancy and ten times in the
following year. Mothers who were employed full-time breastfed infants approximately
nine weeks less than those who were not employed Q)<.05). Working part-time for four
hours or less each day had no effect on duration of breastfeeding. Working more than
four hours daily decreased breastfeeding duration, but full-time work decreased

duration of breastfeeding even more.

15

Chatterji & Frick (2005) used the data from the National Longitudinal Survey of
Youth (NLSY79) and the Children of the National Longitudinal Study of Youth
(CoNLSY) to examine the effect of the timing and intensity of postpartum employment
on the likelihood of breastfeeding duration. The sample of the analysis included 3947
children born between 1978 and 1996 to mothers who were employed full-time or part-
time at some point during the year following childbirth. Among mothers who initiated
breastfeeding (n=l94l), returning to work within three months is associated with an
overall reduction of four to five weeks of breastfeeding. In particular, working firll-time
reduced duration of breastfeeding by three to four weeks (Chatterji & Frick, 2005).
Another longitudinal study following 1,907 mothers from 1987 to 2000 supported the
negative association between maternal postpartum employment and duration of
breastfeeding (Berger et al., 2005). In addition, these authors found that mothers who
returned to work within 12 weeks after giving birth breastfed their infants for five fewer
weeks while controlling for demographic characteristics and other potential
confounders (p<.01). This effect was significantly stronger for mothers working full-

time (p<.01) (Berger et al., 2005).

Research conducted in other countries has also demonstrated the negative effect
of maternal postpartum employment on duration of breastfeeding. An interviewer-
administered survey conducted in Singapore with 2,149 women reported that employed
mothers were more likely to breastfeed infants for less than two months compared to
those who were not working. Although working status was not subdivided into full-

time and part-time, work-related factors were important reasons for these employed

16

mothers to discontinue breastfeeding (Ong et al., 2005). A recent study in Australia
analyzed data from an ongoing longitudinal study on 3,697 infants in which
demographic variables were controlled. They found that mothers returning to work
full-time within three months after giving birth were two times more likely to stop

breastfeeding before six months than those mothers who were not employed (Cooklin et

aL,2008)

2.6 Women Workforce Statistics

In the US, more women are part of the workforce in the past decade than ever.
In 1970, 41% of females aged 16 or above were employed in the labor force and the
rates reached the highest at 58% by 2000. In 2007, of the 120 million women aged 16
and older, 57% were employed in the workforce; 75% worked on full-time jobs and
25% worked on part-time basis. Among employed women, 39% worked in
management, professional, and related occupations; 34% worked in sales and office
occupations; and 20% in service occupations (US Department of Labor, 2008). The
proportion of mothers with children under three who were employed in the labor force
increased from 34% to 62% from 1975 to 1998. The labor force participation rate for
this group of women has since receded slightly to 60% in 2007, but remains a
significant part of the workforce. Specifically, of the 3.3 million mothers with children
at one year of age or less, 52% were employed in the labor market with 69% employed
full-time (US Department of Labor, 2008). According to a national representative of
the Early Childhood Longitudinal Study-Birth Cohort in 2001, 26% of mothers were

working after two months and 41% by three months postpartum. By nine months,

17

almost 60% of all mothers in the study were working, with 37% employed full-time and
22% employed part-time (Han et al., US Department of Labor, Monthly Labor Review,

2008)

2.7 Breastfeeding Legislation

Despite the evidence of breastfeeding benefits and recognition of workplace as a
barrier for mothers to continue breastfeeding following childbirth, federal legislation
concerning support for breastfeeding in the workplace has been proposed over the years
but enactment legislation has been inadequate. Senator Tom Harkin (Democrat-Iowa)
introduced S. 1074 in May 2005, which comprises the establishment of a task force for
promoting breastfeeding in the workplace; provision for lactation periods and facilities;
and mandate for employers to provide an appropriate number and reasonable length of
lactation periods during each work day (Weimer, 2006). However, the bill did not
specify the details of the lactation periods. This bill has been read twice and referred to
the Committee on Finance. Based on the provisions from previous bills, Representative
Carolyn B. Maloney (Democrat-New York) and Senator Jeff Merkley (Democrat-
Oregon) introduced “Breastfeeding Promotion Act” (HR. 2819) in June 2009. This bill
includes protecting mothers against discrimination in the workplace; requiring
employers with over 50 employees to provide a private space and unpaid time off in the
workplace for mothers to breastfeed or express milk for their children; offering tax
incentives to employers for expenses related to providing facilities, equipment, and

resources needed to provide an appropriate environment for breastfeeding (Maloney,

l8

2009; Weimer, 2006). This is the first year that there has been a Senate sponsor for the

“Breastfeeding Promotion Act”.

State legislation pertaining to workplace breastfeeding varies widely in its nature
and scope, but the overall support for mothers to continue breastfeeding in the
workplace is insufficient. Twenty-four states, the District of Columbia, and Puerto Rico
have general laws related to breastfeeding in the workplace in 2009. Three more states
in the past year have established state legislation about breastfeeding. Additionally,
there has been a 60% increase in the number of states from 2007 that have laws relevant
to workplace breastfeeding (National Conference of State Legislatures, 2009). Three
states have set a time frame, which requires an employer to provide break time for
mothers to express milk for up to 2 years in Colorado, and 3 years in Maine and
Vermont following the birth of a child. Approximately 13 states have laws specifying
that an employer "shall" or "must" allow pumping during breaks and/or provide a place
to pump, whereas other states including Georgia and Oklahoma describe that an
employer "may" allow breastfeeding employees to pump while at work (National
Conference of State Legislatures, 2009). If a state law uses "may" language, the
employer is under no obligation to provide any workplace support for breastfeeding.
However, this law could serve as a guideline for employers who are willing to help

employees combine breastfeeding and employment.

The only US federal legislation that has enacted to support families following

the birth of a child was in 1993, the Family and Medical Leave Act (FMLA). This

19

legislation provides eligible employees up to 12 weeks of unpaid leave within a 12-
montlr period following childbirth or for other family or medical conditions. Eligible
employees include those who have worked for their employer at least 1250 hours in the
previous 12 months in a workplace with 50 employees or more within 75 miles. In
contrast, a number of European countries, including Germany, Italy, Spain, and
Portugal, which have paid maternity leave and breastfeeding breaks for employees
(Galtry, 2003). In particular, Sweden, which has one of the highest breastfeeding rates,
provides paid leave for 16 months with 13 months paid at 80% of previous earning and
the remaining months paid at standard and flat rate for all recipients. These benefits are
taken from the general taxes with no direct costs to the employers (Ronsen &
Sundstrom, 1996). On the other hand, Ireland has low breastfeeding rates compared to
the other European countries and even to the US. The support for breastfeeding
employees includes an 18-week period of maternity leave paid at 70% of earnings and
another 8 weeks of unpaid leave after that. The breastfeeding policies and practices in
Sweden and Ireland provide insights to the complexity of relationships between the
availability of breastfeeding support including length of leave, and breastfeeding

practices.

Nevertheless, with no legislation on workplace breastfeeding in more than half
of the states, breastfeeding accommodations mainly rely on initiatives taken by
individual companies. Future efforts to propose and enact federal and state legislations

could contribute significantly to the establishment of a breastfeeding-friendly workplace

20

and increasing the proportion of mothers continuing breastfeeding upon returning to

work.

2.8 Organizational Climate

Organizational climate is defined as “...[employees’] perceptions of the events,
practices, and procedures and the kinds of behaviors that get rewarded, supported, and
expected in a setting” (Schneider, 1990). Organizational culture refers to the values,
beliefs, and shared assumptions that are deeply embedded within members of an
organization (Schneider et al., 1996). Organizational climate and culture are distinct,
but both represent important aspects of an organization. Culture is a relatively stable
construct because it encompasses a deep understanding of individuals within an
organization, whereas climate is subjected to change with respect to the work
environment perceived by individuals (Dension, 1996). In this literature review, I will

focus on organizational climate as it relates to my thesis research.

Measures of organizational climate are comprehensive, comprising the physical
environment, behaviors and attitudes of individuals within the environment, formal
policies and programs, as well as informal practices within the organization. Climate
research emphasizes the understanding of individuals’ perceptions, which can be
aggregated for analysis to understand perceptions at a team or group level, or
organizational level within the setting to characterize an overall climate for the setting

(Schneider, 1990). Organizational climate can be used to investigate specific aspects of

21

an organization. Work-family balance is one example of its application (Gault &

Lovell, 2006; Kopelman et al., 2006; Kossek et al., 2001).

2.9 Work-Family Balance and Conflicts

Work-family balance did not receive much attention until the US workforce
changed substantially in the late 19703 when women began joining the labor force in
large numbers (Galinsky & Bond, 1998). This increased women’s participation in the
labor force has imposed more stress on families, because family demands remained
significant and conflicted with work demands (Bond et al., 2003). Work-family conflict
is a type of interrole conflict in which role demands arising from one domain (work or
family) are not compatible with the role demands arising from another domain (family
or work) (Kahn et al., 1964; Greenhaus and Beutell, 1985). Work-family conflict is bi-
directional. Demands in the work environment interfere with demands in the family
environment and vice versa. Thus, balance between work and family responsibilities is
of particular interest to both the organizations and the individuals because the outcomes

impact both domains.

Conflict between work and family is associated with outcomes significant to
employee physical health and the organization. Research has documented that
increased levels of work-family conflict are associated with higher levels of depression,
hypertension, cholesterol, and alcohol consumption (F rone et al., 1992b; F rone et al.,
1996; Thomas & Ganster 1995). Frone (2000) also found that work-family conflict is

positively related to anxiety disorders, mood disorders, and substance abuse disorders.

22

Other studies link work-family conflict to greater stress (Kelloway et al., 1999;
Parasurman & Simmers, 2001) and lower life satisfaction (Parasuraman et al., 1992;

Perrewe et al., 1999; Rice et al., 1992).

Many organizations provide health care benefits for their employees, and
increased use of these benefits due to poor health outcomes attributed to work-family
conflict can become a major financial burden for the organization. For instance, higher
levels of depression and alcohol consumption have shown to decrease work
performance, increase job absenteeism, and lead to higher turnover rate (Guindon &
Smith, 2002; Lampham et al., 2003). Lower job satisfaction is also linked to higher
turnover intentions, lower employee performance and organizational commitment
(Boyar et al., 2003; Boyar et al., 2005; Harrison et al., 2006). Furthermore, increased
work-family conflict is directly associated with lower life satisfaction, turnover
intentions, organizational commitment, and reduced stress (Allen et al., 2000; Eby et al.,
2005). These negative outcomes are crucial aspects for an organization to consider in
terms of its monetary and talent loss. Thus, organizations will benefit from
understanding what can be done to reduce work-family conflict (Roman & Blum,
2001). Organizations may compete with other organizations that might be perceived to
provide a higher quality of work and life experience for employees (Rau & Hyland,
2002). Therefore, some organizations have developed policies, programs, and informal

practices that attempt to help reduce their conflicts between work and family.

23

2.10 Manager Support of Work-Family Balance

Family-supportive policies and family-supportive managers comprise the two
major components of a work environment that support employees in their balance of
family and work responsibilities (Thomas & Ganster, 1995). Additionally, perceived
managerial support was identified as a key dimension at a family-friendly work
environment (Thompson et al., 1999). Support from the organization and support
employees receive from their managers within the organization are correlated, but

employees distinguish between these two sources of support (Allen, 2001).

Although organizations may offer family-friendly policies and programs to
employees, managers play a pivotal role in the experience of work-family conflict by
encouraging or discouraging employees’ participation (Allen, 2001; Casper & Buffardi,
2004; Casper et al., 2004; O’Driscoll et al., 2003). Managers are crucial in effective
implementation of work-family policy or program in many facets as they (i) could
inform about the availability of a policy or program; (ii) often have final approval to
determine whether employees can utilize such program or policy; (iii) influence
whether employees are cross-trained to cover job duties during absences; (iv) affect
whether a policy or program is well-publicized; (v) establish norms in supporting use of
a policy or program (Allen, 2001; Hopkins, 2005; Thompson et al., 1999). Manager
response to an employee’s request can also depend on manager’s personal beliefs and
past experiences with balancing work and family (Powell and Mainiero, 1999). Reports
from organizations that have enacted family-fi'iendly policies and practices indicate that

these policies and practices are ineffective without managerial support (GalinSky et al.,

24

1993; Rodgers, 1992). Informal forms of organizational support including supportive
managers, are important in helping employees reduce conflicts between work and
family (Behson, 2002a). Thomas & Ganster (1995) was one of the first survey studies
that examined manager support as one dimension of family supportive construct from
398 health care professionals (59% response rate). Results showed that family-
supportive managers are related to lower levels of work-family conflicts. Survey
studies published since have been relatively consistent in supporting the negative
relationship between managerial support and experience of work-family conflict (Allen,

2001; Anderson et al.,2002; Frye & Breaugh, 2004; Lapierre & Allen, 2006).

Managerial support for work-family balance is positively related to a number of
employee outcomes including affective commitment, job satisfaction, less turnover
intentions and job search behaviors (Anderson et al., 2002; Frye & Breaugh, 2004;
Thompson et al., 1999). In particular, Thompson et al., (1999) showed that managerial
support was more highly associated with work-family benefits use than the other
components, which are career consequences for devoting time to family concerns, and
organizational time demands or expectations interfering with family responsibilities.
This finding suggests that manager support may be the most significant predictor in
employees’ decision to use family-friendly benefits and programs (Thompson et al.,
1999). Similarly, Allen (2001) found that report of work-family benefits being used
were associated with managerial support. Most studies described above relied upon
self—report data gathered at one point in time, which indicated that manager support is

related to work-family conflicts, but that cannot be inferred for causality. Also, many

25

studies hypothesized a conceptual model of the relationships between managerial
support and other variables of interest. However, the overall fit of the model was not
examined. Additionally, there is no available literature specifically investigating
managerial support toward breastfeeding support in the workplace. However, research
in the field of breastfeeding and employment has explored manager attitudes toward

supporting breastfeeding.

2.11 Employer (Manager) Attitudes toward Breastfeeding Support

A limited number of studies have examined employer (manager) attitudes
toward breastfeeding in the workplace. Bridges et al. (1997) collected survey data from
69 civic group members from a predominantly agricultural community. The Attitudes
toward Breastfeeding Questionnaire (ABQ) used in this study was published in the I
World Alliance for Breastfeeding Action (WABA) in 1993. This questionnaire does
not specifically address manager concerns toward breastfeeding, but consists of a list of
business issues about workplace breastfeeding formed from the WABA task force. The
ABQ was a 10 item five-point Likert scale questionnaire, which was evaluated by two
lactation consultants and 12 business professionals. The majority of the 69 survey
respondents were male, white (non-Hispanic), married, and middle-aged. Their average
composite score on the ABQ was 32.2, with 0 indicating most the negative attitudes and
50 indicating most the positive attitudes. The score demonstrated weak but positive
employer attitudes toward supporting breastfeeding. Participant age, education level,
and personal history with breastfeeding were not statistically significantly associated

with the composite score. However, managers were more likely to support

26

breastfeeding if they had worked with female employees who breastfed or pumped
milk, or if they knew of other businesses that employed women who breastfed (p<.02).
The lack of knowledge among employers about the health benefits of breastfeeding was
evidenced by 41% of the employers agreeing that formula-fed infants were as healthy as

breastfed infants and 39% being neutral with this item.

A similar study received 85 completed mail surveys (54% response rate) from
civic group members representing mainly service, manufacturing, and educational
industries (Libbus & Bullock, 2002). This survey composed of the ABQ (Bridges et al.,
1997) as well as two additional sections collecting respondents’ personal and workplace
experiences with breastfeeding. Content validity of the survey was established by six
nurses who worked as hospital nurses or faculty members. Characteristics of the
respondents in this study were similar to Bridges et al. (1997) as being white (non-
Hispanic), married, and middle-aged. Most of them had personal experience with
breastfeeding, but only 25% had worked with women who breastfed or knew of other
businesses that employed women who breastfed in the workplace. However,
relationships between breastfeeding experiences and support for breastfeeding were not
examined. Although 71% of the respondents were supportive of breastfeeding in the
workplace, only half of these respondents believed that the work environment needed to
be changed to accommodate breastfeeding or pumping milk. Respondents had little
knowledge about advantages for their company by supporting breastfeeding, only 20%
identifying improved recruitment ability, and reduced turnover rate and absenteeism as

benefits. Responses from the ABQ were converted from a six-point Likert scale to a

27

dichotomous variable because of a small sample size and non-normality data. This
approach could potentially reduce the ability of the questionnaire to measure the

strength of the attitudes.

In addition to the two survey studies described above, a qualitative study was
conducted by Brown et al. (2001) using two focus groups to explore employers’
knowledge, attitudes, and practices with respect to breastfeeding support. Focus group
participants were represented by human resource professionals responsible for
maternity issues in the company. Employers identified motivators for offering
breastfeeding support such as improving the company’s position for recruitment and
establishing as an industry leader. Employers also described the barriers to providing
support such as absence of private and appropriate space; negative co-worker reactions;
and lower productivity of the breastfeeding employee. Additionally, none of the
employers had a breastfeeding policy and they accommodated employees on an as-
needed basis. Although employers were aware of health benefits of breastfeeding and
potential business savings for the company, providing workplace breastfeeding support

was not their high priority in the company.

These findings were supported by a survey of breastfeeding policies and
practices with 157 human resource directors of Colorado businesses representing a
variety of industry and businesses size (Dunn et al., 2004). This survey included the
ABQ adapting from Bridges et al. (1997) and items regarding availability of benefits

and services supportive of breastfeeding. Regression analysis showed a strong

28

association between the number of breastfeeding support services and employer
attitudes toward breastfeeding (p<0.01), which suggested that employer attitudes could
be predictive of availability of breastfeeding benefits and services. Only 28.2% of
participants reported providing specific breastfeeding support services, but the majority
of employers offered other benefits and services conducive to breastfeeding such as
paid or unpaid maternity leave of at least three months and options of flextime, job
sharing, or part-time employment. Similar to Libbus & Bullock (2002), many
participants (70%) in this study lacked knowledge of the benefits to a company that
provided breastfeeding support. Unlike the other survey studies (Bridges et al., 1997;
Libbus & Bullock, 2002), this survey was extensively evaluated by the Colorado
Breastfeeding Task Force Board of Directors and the Colorado Department of Public
Health and Environment, and was pilot-tested with a relatively large sample of 43

businesses.

One major limitation of the ABQ used in the three survey studies described
above was that the questionnaire was not developed from the perspectives of managers,
but simply a list of business concerns about breastfeeding in the workplace developed
by the WABA (Bridges et al. 1997; Dunn et al., 2004; Libbus & Bullock, 2002).
Results do not truly reflect attitudes of managers toward workplace breastfeeding. That
is why this research study began with conducting focus group discussions with
managers to assess these manager attitudes. Based on the qualitative data and a review
of the literature, this research was used to develop a questionnaire designed to measure

attitudes of managers toward breastfeeding in the workplace. In conclusion, employers

29

demonstrated weak but positive attitudes toward supporting breastfeeding and the work
environments do not encourage breastfeeding. However, none of these studies
proposed a conceptual framework to examine the components of employer (manager)

attitudes and their relationship to the support of workplace breastfeeding.

To address this shortcoming, a recent study by Seijts & Yip (2008) investigated
the relationship between knowledge about breastfeeding benefits and support for
breastfeeding accommodations. This study received 220 questionnaires (31.7%
response rate) from alumni of a Canadian business school. Participants were asked to
respond to one of the two vignettes, which described factors that the director of human
resources had to consider for accommodating needs of a breastfeeding employee.
Results revealed that participants lacked knowledge about the benefits of breastfeeding
to mother, child, and organization, with each participant answering correctly to less than
half of the 10 items on breastfeeding knowledge. Additionally, participants with
children or with children who were breastfed reported stronger support for

accommodations, and their knowledge about breastfeeding benefits mediated this effect.

30

Chapter 3

Development of an Instrument Designed to Measure Manager Attitudes toward

Workplace Breastfeeding Support

3.1 Abstract

Objective: Maternal postpartum employment has been identified as a key barrier to
breastfeeding continuation. Manager attitudes play a pivotal role in female employees’
perceptions of breastfeeding support in the workplace. However, no instrument exists
to systematically assess manager attitudes toward supporting women wishing to
combine breastfeeding with employment. The objective of this study was to develop an
instrument to measure manager attitudes toward breastfeeding support in the workplace,

which would be suitable for piloting with the target population.

Study Design: A modified version of an instrument development process was followed
to create the subscales and items of the instrument. Focus groups were conducted to
assess attitudes of managers toward breastfeeding in the workplace and the results were
used to create subscales and items within each subscale. Survey items were revised
through an iterative process. Expert reviews resulted in refinement of the instrument for
content, clarity, and organization. Cognitive interviews were used to ensure that the

wording of each statement was appropriate for the target population.

31

Results: Five focus groups resulted in the development of four subscales and 90 survey
items. Expert reviews and cognitive testing determined no additional subscales were
needed, but survey items were added, reworded, or eliminated to improve clarity,
readability, and organization. The final survey consisted of four subscales and 83 items

measured in either dichotomous agree/disagree or four-point Likert rating scale.

Conclusion: The instrument development processes have demonstrated that the
subscales and items sufficiently reflect manager attitudes toward supporting
breastfeeding in the workplace. Therefore, this instrument is appropriate for piloting

with the target population.

3.2 Introduction

Research has documented diverse short- and long-term benefits of breastfeeding
for infants and mothers. Compared to formula-fed infants, breastfed infants have a
decreased incidence and/or severity of a wide array of diseases including sudden infant
death syndrome (Ip et al., 2007), respiratory tract infections (Ip et al., 2007), acute otitis
media (Duffy et al., 1997; Sassen et al., 1997; Vemacchio et al., 2004), gastroenteritis
(Chien & Howie, 2001; Quigley. et al., 2006), and childhood type 1 diabetes (Norris &
Scott 1996; Ip et al., 2007). Benefits for mothers who breastfed their infants include
reduced incidence of pre-menopausal breast cancer (Bemier et al., 2000; Collaborative
group on Hormonal Factors in Breast Cancer, 2002) and ovarian cancer (Ip et al., 2007),

as well as greater postpartum weight loss compared with mothers who formula-fed their

infants (Olson et al., 2003; Sichieri et al., 2003).

32

In 2008, 74.2% of US women initiated breastfeeding, but only 43.1% of those
women continued through six months (CDC, 2008). Employed women have even
lower breastfeeding rates (V isness & Kennedy, 1997; McKinley & Hyde, 2004). New
mother employees may not perceive organizational climate, defined as “...[employees’]
perceptions of the events, practices, and procedures and the kinds of behaviors that get
rewarded, supported, and expected in a setting” (Schneider, 1990), to be supportive of
breastfeeding. Support for new mother employees to continue breastfeeding while

working depends not only on the company, but also the managerial support.

Managers are crucial to effective implementation of policies or programs within
an organization (Allen, 2001; Hopkins, 2005; Thompson et al., 1999). With respect to
workplace breastfeeding, managers could exert significant influence on breastfeeding in
the workplace by either administrating or ignoring company policies, practicing
informal support or discouragement for employees, and managing or disregarding
issues arising among non-breastfeeding employees. Therefore, manager attitudes may
affect how new mother employees perceive the organizational climate for breastfeeding,
which may influence whether these employees choose to continue breastfeeding upon

returning to work following childbirth.

The manager attitudes component of the organizational climate for breastfeeding
are not well documented. There is no validated instrument existing to systematically
assess managers’ attitudes toward workplace breastfeeding support. Limited research

has examined the general breastfeeding support within companies through self-reported

33

retrospective surveys or focus groups. All survey studies are confined to the use of the
Attitude toward Breastfeeding Questionnaire (ABQ), which is a lO-item Likert scale
instrument published by the World Alliance for Breastfeeding Action (WABA)
(Bridges et al. 1997; Dunn et al., 2004; Libbus & Bullock, 2002; WABA, 1993). The
ABQ was not designed to address manager attitudes, but is simply a list of business
concerns about workplace breastfeeding developed by the WABA task force. Bridges
et al. (1997) and Libbus & Bullock (2002) used the ABQ with a relatively small sample
of civic group members representing mainly agricultural, service, manufacturing, and
educational sectors. Another study also used the ABQ but with a larger sample of
human resource directors in Colorado representing a variety of industries and business
sizes (Dunn et al., 2004). Results of these survey studies indicated that few companies
formulate written policies to support breastfeeding in the workplace, and respondents
lack knowledge of the advantages of breastfeeding to the work environment. A small
study using two focus groups with human resource professionals found that participants
were aware of health benefits of breastfeeding and had mostly positive experiences with

employees breastfeeding in the workplace (Brown, et al., 2001).

Findings from the studies described above contributed to our understanding
about workplace environment as it relates to breastfeeding. However, data are
insufficient to reflect managers’ attitudes since the instrument was not intended for this
purpose. Also, the target populations were mixed with human resource personnel
responsible for the company policies and practices and managers who were not within

the human resource department.

34

In order to improve our understanding of manager attitudes in contributing to the
organizational climate for breastfeeding, an instrument is needed to systematically
measure these managers’ attitudes. A series of steps in an instrument development
process were followed to develop a new instrument designed to measure manager
attitudes toward supporting breastfeeding in the workplace, which would be suitable for

pilot-testing.

3.3 Materials and Methods

3.3.1 Study Design
A modified version of the instrument development processes described by
Wolfe & Smith (2007) was followed to create subscales and items of the instrument by

conducting focus groups, performing expert reviews and cognitive interviews.

3.3.2 Focus Groups
Focus group discussions were conducted with managers to assess their attitudes
toward workplace breastfeeding. Human subject approval was obtained from the

Institutional Review Board of Michigan State University.

A focus group discussion guide was developed based on a review of the
literature with input from International Board Certified Lactation Consultants (IBCLC),
and researchers with expertise in breastfeeding, qualitative research methods, and
organizational behavior. Managers were recruited by flyers, word of month, and

personal contacts. Potential participants were screened to determine eligibility.

35

Managers were eligible if they had experience with managing female employees. Two
researchers were present at each discussion. The primary investigator or the co-
investigator was the moderator for each focus group to direct the discussion, allowing
everyone to have an opportunity to speak, and ensuring the use of appropriate impartial
and respectful language. The second researcher took field notes of non-verbal
responses and provided technical support. Focus groups ranged in size from four to six
participants and lasted for approximately one hour. All participants signed an informed
consent form prior to their participation. Demographic information was collected. At
the end of the focus group discussions, participants were given the opportunity to
discuss any other issues related to breastfeeding support in the workplace. Each
participant received a $25 incentive upon completion of the discussion. A consensus

was reached on the saturation point between the researchers (Krueger & Casey, 2000).

All focus group discussions were recorded and transcribed verbatim, then
reviewed for accuracy by the primary investigator. N Vivo 8 (QSR International Pty Ltd.
Version 8, 2008), a qualitative analysis software program, was used to assist in content
analysis of these transcripts. A codebook was developed to correspond to themes that
emerged from the discussions, which consisted of a code name, definition, rules for
application and exclusion, and an example of quotation. The comprehensiveness of the
codebook was tested by the primary investigator and a research assistant coding three
transcripts independently. Disagreements in coding were discussed until consensus was
reached. Refinement to the codebook was then made according to the discussion results

between the primary investigator and the research assistant, and input from the co-

36

investigator and a qualitative researcher. Further revisions to the codebook were done
in an iterative process until the researchers agreed on the accuracy and
comprehensiveness of it in reflecting the transcripts’ content. The remaining two
transcripts were then analyzed independently by the primary investigator and the
research assistant using the revised codebook. The overall percentage of agreement on

themes among the five transcripts was 92.4%.

3.3.3 Item Development

Focus groups data provided evidence for the conceptual framework for the
instrument. Instrument subscales were developed based on the themes that emerged
from the focus group discussions. Individual items for each subscale were formulated
according to concepts captured under each theme. Other questions were added to
collect information on personal and organizational factors that might influence manager
attitudes on breastfeeding. A mixture of dichotomous agree/disagree or four-point
Likert rating scale, ranging from strongly agree to strongly disagree, was used to
adequately reflect the appropriateness of the scoring model. No option for a middle
category to neither agree nor disagree was present to increase the response rate for each
individual item. The instrument was constructed by following a set of procedures for
creating a self-administered questionnaire to generate good quality of information and
high response rates (Dillman, 2000). The use of negatively phrased items that required
reverse-scoring was avoided, because research has demonstrated that these items may
result in less reliable data, more rater bias, and more homogeneous item response

distributions (Wolfe & Smith, 2007). A few general instructions were given at the

37

beginning of the questionnaire and specific instructions presented by font variations
were placed where that information was needed to be useful for achieving better
compliance with instructions. Visual techniques were applied to improve skip pattern
compliance such as introducing a directional arrow of a different color from the survey
items as well as using a different font and color for the skip directions to attract the

respondent’s attention.

An initial pool of items was constructed for each subscale to provide a
foundation from which the instrument could emerge. After the initial pool of items was
generated, an iterative process was followed to evaluate each individual item by the
research team. The evaluation process aimed to eliminate and reword items (DeVellis,
1991). Elimination of items from the pool was based on lack of clarity and relevance,
or similarity to other items. Rewording of items was needed to improve readability and

clarity.

3.3.4 Expert Review

Expert review was used extensively in the instrument development process to
evaluate the appropriateness of content, clarity, and organization of the subscale and
items of the instrument. Experts included IBCLCs, program leaders and coordinators
for breastfeeding programs, human resource professionals and managers from various
industries including finance, education, and health care, as well as researchers with
expertise in breastfeeding, work-family balance, organizational behavior, and survey

development. There were two ways that the instrument was evaluated. Content review

38

was done by emailing experts a copy of the questionnaire and an expert review form,
which included space for comments and additional questions on the instrument.
Another type of review was to assess the survey item’s fit. In this review, experts were
given a definition of each subscale and instructed to assess the item’s fit within each
subscale in two ways. Experts were asked to either rate each item as being a high,
moderate, or low fit within each subscale or sort each individual item into one of the
subscales that fit the best with the definition of the designed subscale. All refinements
to the instrument were made according to agreements on the expert comments between

the researchers.

3.3.5 Cognitive Interview

Cognitive testing methods, including think-aloud interviewing and verbal
probing techniques, were conducted with a sample of managers from the target
population. These methods were used to evaluate whether the items could be
consistently understood by the subjects from the target population (Collins, 2003;
Fowler, 2002). During think-aloud interviewing, subjects were instructed to describe
their thoughts in words on how they arrived at an answer for each survey item.
Concurrent probing was used to ask subjects specific questions about each item and to
reduce the lapse in time between administration of the instrument and its probing
process. Refinement to the instrument was made based on subject comments. A final
version of the instrument was completed by consensus of the researchers based on

information obtained both from the expert reviews and cognitive interviews.

39

3.4 Results

3.4.1 Focus Groups

Five focus groups with a total of 25 participants (11 men and 14 women) were
conducted. The majority of the participants were white (88.0%) and had experience
with managing female employees who returned to work following childbirth (82.6%).
Participants’ average age was 43.1 (SD 9.7) years with 11.8 (SD 10.1) years of
experience in a management position. They had worked on average at 3.8 (SD 2.1)
companies throughout their career. More than two thirds of the participants had a
college degree or higher (68.0%). Half of the participants belonged to the
finance/insurance/real estate industry, and 12.5% of participants were from the

education and community/social services industry.

Themes that emerged were : (1) breastfeeding knowledge/beliefs, (2) managers’
personal experiences with breastfeeding, (3) managers’ professional experiences with
breastfeeding, (4) managerial support for breastfeeding in the workplace, (5) company
support for breastfeeding in the workplace, (6) positive outcomes of workplace
breastfeeding accommodation, (7) negative outcomes of workplace breastfeeding
accommodation, (8) organizational feasibility in workplace breastfeeding
accommodations, and (9) individual feasibility in workplace breastfeeding

accommodation. Each theme’s definition and examples of quotation are shown in

Table 1.

40

Most managers did not know whether a company policy existed for
breastfeeding employees and showed mixed attitudes towards the need for a policy.
Some felt a breastfeeding policy would help ensure fairness and consistency, whereas
others felt a policy would restrict their ability to be flexible. The most usual
accommodation provided was to rearrange the timing and length of breaks during the
workday for employees to breastfeed or pump. All managers felt they should
accommodate breastfeeding employees, although some reported that they might be
more willing to accommodate high performers than others. Nevertheless, they felt the
extent of accommodations offered might vary by job nature, workflow, and facilities.
Most managers expressed that an employee’s decision to breastfeed was an issue in
balancing personal and work life, which was no different from any other
accommodations made for an employees’ personal lives. Managers expressed concerns
about supporting employees for breastfeeding, including lower productivity of the
breastfeeding employee due to time constraints and negative co-worker reactions.
However, they also acknowledged the benefits involved such as improved employee
retention and loyalty because of satisfied workers. All managers recognized the cost-
effectiveness of breastfeeding. A majority understood the health benefits of
breastfeeding, but others were less certain of the benefits due to the potential stress

caused to the mother.

3.4.2 Item Development

Themes identified from the analysis of the focus groups data were organized

into four categories, which constituted components of the conceptual framework that

41

comprised manager attitudes toward supporting breastfeeding in the workplace. These
categories formed the basis for creating the four subscales for the instrument: (a)
Individual Support for Breastfeeding, defined as support provided by either managers
or co-workers toward employees who wish to combine breastfeeding with work; (b)
Company Support for Breastfeeding, defined as support at the company level to help
employees combine breasdeeding with work; (c) Concerns and Benefits of
Breastfeeding, defined as outcomes of supporting workplace breastfeeding as well as
health and cost outcomes of breastfeeding; ((1) Experience with Breastfeeding, defined
as manager ’s personal or workplace experiences with breastfeeding. Concepts
identified in the focus groups data analysis were developed into survey items for each
subscale that related to managers’ support or lack of support toward breastfeeding in the
workplace. An initial pool of 90 survey items was generated. The instrument was
iteratively reviewed and revised by the members of the research team, and researchers

with expertise in instrument design and development.

3.4.3 Expert Review

Experts’ input for content review (n=20) and item’s fit (n=17) resulted in a
number of improvements to the instrument. The four categories were reported to be
sufficient and no categories needed to be combined or eliminated. A definition was
added to the survey instructions to clarify a survey term “breastfeeding support”, which
was defined as any formal and informal forms of assistance and behaviors that help
women to combine breastfeeding and work. This definition aimed at providing a

consistent understanding of the “breastfeeding support” for the survey respondents.

42

Within the Company Support for Breastfeeding category, items were expanded to
include support for breastfeeding for companies in general and at the manager’s
company specifically. Some of the items were clarified to more accurately reflect
managers’ impressions of their employees’ perceptions. For example, “My employees
would consider it part of my job to support an employee who combined breastfeeding
with work” was changed to “I believe that my employees would consider it part of my
job to support an employee who combined breastfeeding with work Minor
grammatical issues were addressed to improve readability and clarity. For survey items
that appeared duplicative, the less preferred item was eliminated based on the consensus
between the researchers. Additionally, some survey items were moved from one

category to another category of better fit.

3.4.4 Cognitive Interview

Eight individual cognitive interviews were conducted with managers who had
experience with managing female employees. The majority of comments were
suggestions to clarify ambiguous wording. For example, “It is acceptable for
employees to bring their babies to work to be breastfeed” was reworded as “It is
acceptable to have their babies brought in to work for breastfeedings” to increase
understanding of the concept about babies were only brought to the workplace by
someone to be breastfed. Two survey items were replaced to more accurately address
the intent of the items. For example, “The company should provide information about
combining breastfeeding with work to all of its employees ” was found unclear about

where the information would be available. Therefore, this item was replaced by “The

43

company should include information about breastfeeding accommodations in the
employee handbook”, because interview participants felt that the employee handbook
would be an appr0priate place to distribute the information to the employees in the
company. One survey item, “I believe that providing breastfeeding support to an
employee is necessary” was eliminated because of its irrelevance and lack of clarity.
No subscales were reported to be necessary and no survey items were frequently
reported by the interview participants as needing an alternative option to “neither agree
nor disagree”. Therefore, this instrument will remain as four subscales with a four-

point Likert scale to maximize the response rate for each survey item.

3.5 Discussion

The new instrument was designed to measure manager attitudes in supporting
breastfeeding in the workplace. A series of instrument development processes were
followed to create the instrument based on the beliefs and concerns of managers, and
demonstrated the subscales and items are appropriate to measure managers’ attitudes
toward workplace breastfeeding support. Therefore, the instrument is suitable for

subsequently piloting with a sample of subjects from the target population.

Due to the limited research about attitudes of manager toward supporting
breastfeeding in the workplace, and no instrument available to measure these manager
attitudes, the initial step of this study was to conduct focus groups with managers to
assess their attitudes toward breastfeeding support in the workplace. Similar to the

qualitative study conducted by Brown et al. (2001), this focus group data found that

44

participants acknowledged the health benefits of breastfeeding, barriers and concerns
for providing breastfeeding accommodations such as breastfeeding employee’s job
duties and reduced productivity, as well as motivators for having breastfeeding
accommodations including serving as a recruitment tool. In addition, not only
participants’ workplace experiences with breastfeeding were discussed, their personal
experiences with breastfeeding were also explored. In particular, male participants’
personal experiences were found to improve their understanding about breastfeeding,
which helped them become more accommodating to supporting workplace
breastfeeding. Interestingly, female participants, who breastfed and said they would
support employees combining breastfeeding with work, did not find themselves able to

continue breastfeeding while working.

Compared to the survey studies (Bridges et al. 1997; Dunn et al., 2004; Libbus
& Bullock, 2002), this focus group data added to our understanding of managers’ roles
in supporting workplace breastfeeding. For example, managers reported that they
would identify space equipped with a sink, refi'igerator, or locked door in order to
provide a comfortable experience for employees. They would also provide extra or re-
arrange breaks to give time for employees to breastfeed or pump at work. Managers
had mixed views about providing breastfeeding support compared to other types of
personal support. Some felt that breastfeeding would just be another accommodation
important to employees. Others felt that breastfeeding would require more means of

accommodation.

45

The use of focus groups provided evidence for the conceptual framework and
content of the rating scale of the instrument development process, which was lacking in
previous studies that used the ABQ to measure manager attitudes toward workplace
breastfeeding (Bridges et al. 1997; Dunn et al., 2004; Libbus & Bullock, 2002). A
conceptual foundation for the instrument is critical in connecting and supporting the
intended uses and interpretations of the instrument (Wolfe & Smith, 2007).
Additionally, the target population of the focus groups was managers representing
various industries, which allowed us to explore managers’ beliefs or concerns about
workplace breastfeeding support. This approach provided further support in the
development of the instrument, which is based on the managers’ perspectives rather

than on a list of businesses issues formed by the WABA task force (WABA, 1993).

Instrument design and item development followed the procedures described by
Wolfe & Smith (2007) and Dillman (2000). Elements of the instrument design were
carefully constructed to obtain quality information and maximize the response rate for
each individual item (Dillman, 2000). Specific guidelines for developing the items
were adhered to, such that they can be easily interpreted by the target population (Wolfe
& Smith, 2007). An initial exhaustive pool of items was iteratively revised and

reviewed by the research team prior to the expert review process.

An extensive expert review process provided evidence of various aspects of

validity for the instrument. This instrument was reviewed by a large sample of experts

compared to previous studies (Bridges et al. 1997; Dunn et al., 2004; Libbus & Bullock,

46

2002). These experts were selected because of the familiarity with the technical
dimensions of the instrument including survey development experts, individuals from
the target population, and practitioners who would be likely to use the information
provided by the instrument in applied settings such as human resource personnel and
lactation consultants. The first set of expert review was to ensure the content was
accurate and all important aspects of the instrument design and development Were
considered (Wolfe & Smith, 2007). The second set of the review process was important
to verify the accessibility of the survey items, which included clarity of language and
contextual relevance of the content of the items (Wolfe & Smith, 2007). The two sets
of expert reviews were thorough and resulted in significant improvements to the
instrument before conducting cognitive testing with subjects from the targeted

population.

Cognitive testing methods have become more broadly used in the field of
instrument development to improve the quality of survey information (Willis, 1994).
Cognitive techniques such as think-aloud and verbal probing are used separately or
together to help researchers to understand the mental process that respondents of the
target p0pulation use when answering survey items (Willis, 1994). These methods aim
at determining any missing topics, rewording vague or unclear survey items so that they
will be understandable to the target population. In this study, the use of cognitive
interviews was important for finalizing survey subscales and items. The interviews
revealed some issues that were not being addressed in the expert review process.

Interview participants also gave valuable feedback on wording changes of several

47

survey items to improve clarity. Many changes resulting of the interviews seemed
subtle, but these revisions helped to provide consistency through the instrument and

clarification for survey participants of the target population.

The process of instrument development requires proper procedures to establish
evidence that the instrument is suitable and useful for its intended purpose. The
instrument development processes illustrated in this study support the contention that
this instrument will perform as intended to demonstrate an accurate measure of manager

attitudes toward supporting breastfeeding in the workplace.

3.6 Conclusion

The decision for employees to discontinue breastfeeding when returning to work
following childbirth is often a consequence of lack of support in the workplace
environment (Kong & Lee, 2004). These new mother employees struggle to balance
their roles as mothers and employees in order to continue breastfeeding while working.
Manager attitudes are key to these employees’ perceptions of workplace breastfeeding
support. Research is needed to identify components of attitudes of managers toward
women who desire to combine breastfeeding with work, as well as elements that
constitute these attitudes. Research in this area would be enhanced by the availability
of an instrument that adequately and appropriately reflects manager attitudes toward
supporting breastfeeding in the workplace. Findings of this study improved our
understanding of manager attitudes and demonstrated that this instrument is accurate

and suitable for piloting with the target population. With subsequent quantitative

48

validation, this instrument could then be used across companies to measure and
compare managers’ attitudes. Ultimately, more effective breastfeeding support
programs could be designed to address manager attitudes in order to improve the

organizational climate for supporting breastfeeding.

4.7 Acknowledgements

This project was funded by the National Research Initiative of the USDA
Cooperative State Research, Education and Extension Service, grant number #2006-
35215-16703. Ingrid S. Fulmer, Ph.D., Carol L. Wolfe, MS, and Edward W. Wolfe,

Ph.D. provided guidance on the instrument design and development process.

4.8 Reprint information
Request for reprints should be sent to Dr. Beth Olson, Department of Food
Science and Human Nutrition, Michigan State University, East Lansing, Michigan

48824, e-mail: olsonbe@msu.edu.

49

Table l.

 

 

 

 

 

 

 

breastfeeding and
employment

2. Managers’ views between
providing breastfeeding
support and other types of
support to accommodate
employees’ personal needs

 

Theme Definition Quotation
Breastfeeding What managers know about “When you breastfeed, you
Knowledge/Beliefs breastfeeding and their opinions pass on a lot of your

of breastfeeding impact on the antibodies, so the baby can be
infants, mothers, family as a healthier” '
whole, society, and economy
Personal Description and comments “My wife tried breastfeeding
Experience with about experiences managers probably only lasted a couple
Breastfeeding have or do not have in of weeks.”
breastfeeding with people
outside workplace “My husband was really good
about accommodating me,
bringing the baby to me or
going out of his way when I
worked nights, afternoons.”
Professional Description and comments “From my senior staff to my
Experience with about experiences managers middle senior staff, none of
Breastfeeding have or do not have in them came back to work and
breastfeeding with people in the needed that [breastfeeding]
workplace accommodation.”
“Great. We do it all the time
because of the number of
women we have that are
having babies.”
Managerial Support 1. Presence or absence of “We had the one girl at the
for Breastfeeding in managerial support to help office and if she needed to go
the Workplace mothers combine take a break, I would fill in

for her at that time, and let
her go down to a different

room and breastfeed her
baby)’

“A woman having a child and
being able to breastfeed is a
positive thing and you have a
tendency to be more
accommodating than for
somebody that’s in a smoking
situation.”

 

50

 

Table 1. Continued

 

 

Theme Definition Quotation
Company Support Description of existing “We do have a comfortable
for Breastfeeding in breastfeeding support at the couch and chairs and very
the Workplace company level to help mothers private, locked door and access

combine breastfeeding and
employment

to water, you know washing the
pump and stuff. I think there is
even a CD player in there now.”

 

Positive Outcomes

Advantages perceived or

“I think the biggest benefit

 

 

 

 

of Workplace anticipated by managers from would be the retention of a key

Breastfeeding accommodating breastfeeding in employee.”

Accommodations the workplace

Negative Outcomes Disadvantages perceived or “Well, the problem is, you’re

of Workplace anticipated by managers from gonna hear, so and so gets a

Breastfeeding accommodating breastfeeding in longer break than I do.”

Accommodations the workplace

Organizational Issues at the organizational level “I think it’s really important to

Feasibility in that facilitates or poses a barrier have it [breastfeeding education]

Workplace for employees to breastfeed in incorporated in orientation and

Breastfeeding the workplace or managers to training. So that’s not a surprise

Accommodations provide breastfeeding when an employee accidentally

accommodation walks in on someone or

something like that in a restroom
or in a lounge area.”

Individual Issues related to individual’s “I think a bigger issue for a lot

Feasibility in characteristics or behavior of men is they’re worried about

Workplace within the company that whether the women are gonna be

Breastfeeding facilitates or poses a barrier for comfortable with men in the

Accommodations employees to breastfeed in the area.”

 

workplace or managers to
provide breastfeeding
accommodation

 

 

51

 

Chapter 4

CONCLUSIONS AND SUGGESTIONS FOR FUTURE RESEARCH

4.1 Conclusions

The choice for mothers to breastfeed is a personal matter and many reasons can
be attributed to this decision. For employed mothers, this decision could become harder
as they struggle to balance their roles as mothers and as employees in order to continue
breastfeeding while working. Unfortunately, the outcome of employees choosing to
discontinue breastfeeding when returning to work following childbirth is often a

consequence of inadequate support in the workplace environment (Kong & Lee, 2004).

Support for employees who wish to continue breastfeeding while working rely
not only on the company support, but also individuals within the companies, in
particular the managers. Manager attitudes are key to these employees’ perceptions of
workplace breastfeeding support. Research is needed to identify components of
attitudes of managers toward women who desire to combine breastfeeding with work,
as well as the elements that constitute these attitudes. Research in this area would be
enhanced by the availability of an instrument that adequately and appropriately reflects
manager attitudes toward supporting breastfeeding in the workplace. Findings of this
study improved our understanding of manager attitudes and demonstrated that this

instrument is accurate and suitable for piloting with the target population.

52

4.2 Suggestions for Future Research

The next step for future research should focus on piloting this instrument with a
sample of managers in selected sectors. Targeting certain sectors is needed because
these sectors are likely to have more family-fiiendly benefits, which will help establish
a measurable level of breastfeeding support (Evans, 2001; Galinsky & Bond, 1998).
These sectors include communication, health care, finance, insurance, real estate, and

the public sector.

Statistical power analysis will need to be performed to determine how large a
sample is needed to draw inferences that are accurate and reliable. Results of this pilot
study will provide evidence for the validity of the subscales and items within each
subscale for the instrument. The instrument will then be useful for creating a
standardized measure of manager attitudes toward supporting breastfeeding in the
workplace. Comparison of these attitudes within each sector and across sectors can be
done to assess the roles of managers’ attitudes and which components of these attitudes
are most influential in determining workplace support for breastfeeding. These data
will improve our understanding on the organizational climate for breastfeeding from the
perspectives of managers. Results will also provide evidence if attitudes vary with
individual characteristics of managers. More importantly, more effective intervention
programs can be designed for managers in selected sectors on increasing their support

for women who wish to continue breastfeeding when returning to work afier childbirth.

53

APPENDICES

54

APPENDIX A

55

INFORMED CONSENT

Breastfeeding and Work Study

Michigan State University (MSU) researchers are doing a study to learn about issues managers
face with employees who wish to combine breastfeeding and employment. You are invited to
participate in this research study, because you are the manager in the company. We ask that you
read this form and ask any questions you may have before agreeing to be in the study.

About this study:

0 Being in this study includes participating in a focus group (lasting 90-120 minutes), which
is an informal discussion about manager’s attitudes toward accommodating new mother
employees who want to continue breastfeeding after they return from maternity leave.

0 The discussion will be audio taped. The cassette tapes will be typed into a printed copy.
Your name will not be identified on the tapes or the written copy. Upon completion of the
study, the cassette tapes and the written copy will be destroyed.

0 All of the information you share will be kept confidential. Only the researchers of the study
will see the information.

0 We will follow all laws that protect your privacy. We will share results of the study in
group form only. The results may be published for scientific purposes but will not include
any identifiable references to you.

0 Participation in this study is voluntary. If you decide to participate, you are free to withdraw
at any time with no consequence for you.

0 We do not expect that being in the study will harm you in anyway. The information you
share may help us improve support for new mothers who want to combine breastfeeding
and work.

0 When you finish the study, you will receive a $25.00 gift certificate.

If you have any Questions about this study, please contact Beth Olson Ph.D. at (517) 355-
8474 extension 113 or email at olsonbe@msu.edu or regular mail at 21 12 Anthony Hall, East
Lansing, MI 48824.

If you have any Questions about your rights as a study participant, please contact Peter
Vasilenko Ph.D. at (517) 355-2180 or email at irb@msu.edu or regular mail at 205C Olds Hall,

East Lansing, MI 48824. You do not have to give your name.

Statement of Consent

I have read the above information. I voluntarily agree to participate in this study and give my
permission to be audio taped during the study.

 

 

 

 

 

 

(Participant’s printed name) (Researcher’s printed name)
(Participant’s signature) (Researcher’s signature)
(Date) (Date)

56

RECRUITMENT FLYER

 

Managers Needed for Research Study

 

 

Michigan State University researchers are conducting a study to

learn about management issues specific to employees returning

to work after the birth of a child.

The study includes completing a short survey and an informal

discussion.

Participants will receive a $25 gift certificate as a way of saying

thank you for helping.

 

 

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57

FOCUS GROUP GUIDE

Before focus group begins, the moderator and other assistant moderators will obtain
participants’ signed consent forms and demographic surveys. Narnetags will be given to
each participant. All participants will be seated around a table set up digital recorders.
The focus group session is scheduled to last approximately 60 to 90 minutes.

---Turn on Digital Recorder---

I. Introduction (10 minutes) -- Moderator

Introduce yourself and anyone else from the research team that is present.

Explain why the participants were invited.

Explain the purpose of the focus group.

Inform the participants that there are no right or wrong answers. They need

to respect each person’s opinion and take turns speaking.

e. Explain the discussion session is recorded and speaking one at a time is
especially important for recording.

f. Remind participants that everything will remain confidential and no names
will be used in any reports.

g. Remind participants that narnetags are to help if they want to follow up
something somebody has said and they are encouraged to have conversation
with one another about the questions.

h. Explain breastfeeding can be a sensitive topic to discuss but I will help by
guiding the discussion.

i. Explain breastfeeding means both nursing and pumping in this discussion.
We are interested in their perspectives and experiences that apply to either
one.

.e-p 9‘s»

II. Icebreaker (5 minutes)
a. “Go around the room and tells us your name and the type of industry that
you work for and what you enjoy the most about being a manager.”

111. Transitional Question: We will start by looking at what types of experiences you
have had with breastfeeding employees. Then, we want to hear what you might do
as a manager to help women who wish to come back from maternity leave but still
keep breastfeeding their baby. After that, we will look at what you think the
company might do to help. Finally, we want to hear what types of personal
experiences you have had with breastfeeding. '

58

Managers’ Experience with Breastfeeding Employees

IV. Control Question: What types of experiences have managers had with
breastfeeding employees? (10 minutes)

a.

b.

Have you had any experience with a breastfeeding employee? How would

you describe your experience?

Have other managers that you work with or you know of have employees

who were breastfeeding? How would you describe their experience?

V. Transitional Question: After hearing your experience with breastfeeding
employees, we now want to hear what you might do as a manager to help women
who wish to combine breastfeeding and employment in the workplace.

Manggers’ Role

Control Question: What do managers think is their role in accommodating a

breastfeeding employee? (20 minutes)

a.

What are the things could you do, or have you done to help an employee
who wishes to continue to breastfeed after going back to work?

(Prompts: arrange break times differently, made breaks longer, ask someone
to cover phones for her.)

Are there any benefits to you as a manager that you can think of in
supporting an employee to combine breastfeeding and work?

(Prompts: increased employee morale, loyalty, job satisfaction, commitment,
facilitate recruitment)

Are there any disadvantages to you as a manager that you see in working
with an employee to continue to breastfeed after returning from maternity
leave?

(Prompts: jealousy from co-workers)

Do you think accommodating breastfeeding is the same as or different from,
accommodating any employee in balancing their personal lives and work?
(Prompts: divorces, cares for loved ones who are ill, smoking break)

How do you feel or think you would feel about discussing breastfeeding with
an employee?

(Prompts: uncomfortable, embarrassed, concern for sexual harassment)
How would your work or individual relationship with a breastfeeding
employee influence your attitudes towards women who wish to combine
breastfeeding and work? (influence of work/individual relationship with the
breastfeeding employee in regard to breastfeeding support in general or just
that breastfeeding employee)

59

VII.

VIII.

IX.

X.

Influence of Ot_her Employees

Control Question: How does the influence of other employees affect
managers’ support of breastfeeding employees? (5 minutes)
a. What would be the co-workers’ attitudes in regard to an employee being
accommodated for breastfeeding in the workplace?
(Prompts: supportive, jealous)
b. How would these co-workers’ attitudes affect how you provide
accommodation for breastfeeding employees?

Transitional Question: We have talked about what you as a manager might do to
help women who want to combine breastfeeding and work. Now, I would like to
hear about what you think the company might do to help on that.

Company policies. Benefits and Drawbacks

Control Question: What company policies, benefits and disadvantages can
managers identify for breastfeeding support? (20 minutes)
a. What polices or practices does your company have in place that help women
who wish to combine breastfeeding and employment?
(Prompts: facilities to pump, onsite daycare, written policies, flex—time. If
nothing formulated, but would provide room arrangement by managers.)
b. If you have these policies or practices, how often they are being used?
c. Are there any benefits that you see to your company to encourage new
moms to breastfeed?
(Prompts: absenteeism, healthcare cost, turnover rate, family friendly image,
productivity)
d. Are there any disadvantages that you can think of to your company to
accommodating women who want to breastfeed?
(Prompts: time away from work, co-worker jealousy, healthcare and facility
cost, productivity)

Transitional Question: We have talked about what you experience and

perspective in breastfeeding accommodation from a company and manager
viewpoint, I would to hear about your personal experience with breastfeeding.

60

Managprs’ Personal Experience and Knowledge

XI. Question: What are the managers’ personal experience and knowledge about
breastfeeding? (15 minutes)

a. Have you or has anyone close to you breastfed a baby? How would you
describe the experience? .

b. Has that experience influenced your attitudes or actions toward women who
wish to combine breastfeeding and work?
(Prompts: more understanding so more supportive, time consuming, personal
choice)

c. Are there any differences that you see between breastfeeding and formula
feeding for the health of mothers and babies?
(Prompts: fewer infections and allergic problems for infants; promote
bonding)

d. Are there any differences in cost that you can think of between breastfeeding
and formula feeding?
(Prompts: formula cost, family cost, societal cost e.g. WIC and Medicaid)

XII. Transitional Question: The discussion is very helpful to us to learn about the
culture of breastfeeding in the workplace.

XIII. Closing the Session (5 minute)
a. “Is there anything you would like to tell us about combining breastfeeding
and work that you have not had a chance to say?”
b. “Do you have any advice for how we can improve the session?”
c. “Thank everyone for coming” and ask them to remain for their gifi card.

---Tum off Digital Recorder---

61

DEMOGRAPHIC SURVEY — FOCUS GROUPS

1. What is your gender?
B Male
13 Female

2. What is your age in years?
CI Years old

 

3. What is your martial status?
El Single
D Married
13 Separated/Divorced/W idowed

4. Which of the following are you? (Please mark one)
El Hispanic or Latino
Cl Non-Hispanic or Non-Latino

5. What race do you consider yourself to be? (Please mark one or more if necessary)
White

Black or African American

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

Other (Please specify: )

 

hat is the highest level of education you have completed?
Less than high school
High school diploma or GED
Some college
2-year college degree (Associates)
4-year college degree (BS, BA.)
Masters’ degree/MBA
Doctoral degree
Professional degree (M.D., J .D.)
Other (Please specify: )

DUUDDDDDD€ ClElUElElEl

 

>1
:1:

ow many employees work at your company in total, at all locations?
< 99

100 - 249

250 — 499

500 or more

DEICICI

8. How many employees work in the same physical location where you work?
El < 50
El 51— 99
CI 100 -249
El 250 or more

9. How many companies have you worked for including the current place of employment?
[:1 Companies.

 

62

10

ll.

12

l3.

14.

15.

16.

l7.

l8.

19.

How long have you been in a management position?
El Years Months.

 

 

What is the approximate number of people you manage currently?
El People

 

What percentage of the employees that you manage are women?
El O-25%

CI 26-50%

CI 51-75%

[3 76-100%

Are any of the women you manage within childbearing age?
El Yes
121 No

Are any of the women you manage who are union employees?
El Yes
D No

Have you had experience managing employees who return to work after childbirth?
El Yes
[J No

What is the name of the company that you work for?
D

 

What is your job title?
E1

 

Which of the following categories best describes the type of industry your company belongs
to?

Communication

Finance/Insurance/Real Estate

Medical/Health Care

Education

Trade/Transportation/Utilities

Government

Computer/Information Systems

Community/Social Services

Other (Please specify: )

 

at is your annual income?
Less than $40,000
$40,000 - $59,999
$60,000 - $79,999
$80,000 - $99,999
$100,000 - $149,999
More than $150,000

LIL—JUDGE]: UUDUUDDUU

---------- Thank you for your time in completing the survey----------

63

CODEBOOK

Table 2. Theme, Code, and Definition of the Codebook

 

 

 

 

 

 

 

 

 

Theme Code Definition
What managers know about breastfeeding
Breastfeeding BFK and their opinions of breastfeeding impact
Knowledge/Beliefs on the infants, mothers, family as a whole,
society, and economy
Description and comments about
Personal Experience PerE experiences managers have or do not have
with Breastfeeding in breastfeeding with people outside
workplace
Description and comments about
Professional Experience ProE experiences managers have or do not have
with Breastfeeding in breastfeeding with people in the
workplace
1) Presence or absence of managerial
support to help mothers combine
Managerial Support for breastfeeding and employment
Breastfeeding in the ManS 2) Managers’ views between providing
Workplace breastfeeding support and other types of
support to accommodate employees’
personal needs
Company Support for Description of exrstrng breastfeeding

. . support at the company level to help

Breastfeeding in the ComS . .

mothers combine breastfeeding and
Workplace

employment
Posrtrve Outcomes Of Advantages perceived or anticipated by
Workplace .

. PosO managers from accommodating
Breastfeeding breastfeedin in the work lace
Accommodations g p
Idlecgralztryaecgutcomes Of Disadvantages perceived or anticipated by

p . NegO managers from accommodating
Breastfeeding . .
. breastfeeding 1n the workplace
Accommodations

 

 

 

64

 

Table 2. Continued

 

 

 

 

Theme Code Definition
Orgi. 'zatronal Issues at the organizational level that
Feasrbrlrty 1n . . .
facrlrtates or poses a barrier for employees
Workplace OrgF .
. to breastfeed 1n the workplace or managers
Breastfeedrng . . .
. to provrde breastfeeding accommodation
Accommodations
In divi d l Feasibility in Issues related to rndrvrdual 8 characteristics
or behavror wrthrn the company that
Workplace . . .
. IndF facrlrtates or poses a barrier for employees
Breastfeeding .
. to breastfeed 1n the workplace or managers
Accommodation

 

 

to provide breastfeeding accommodation

 

65

 

Table 3. Rules for Application and Exclusion and Examples for Application of the

 

 

 

 

 

3. Experience (direct
participation or
observation)

4. Media

5. Other sources

2. Managers’ opinions of
breastfeeding impact on the
infants, mothers, family as a
whole, society, and economy

71.

Examples of concepts:

1. Health benefits of
breastfeeding

2. Cost and health differences
between breastfeeding and
formula feeding

3. Personal factors that affect
mothers and infants to
benefit from breastfeeding
or mothers’ ability to
breastfeed

1.

"Apply this code regardless
of the accuracy of the
breastfeeding information and
their opinions

or anticipated by
managers from
accommodating
breastfeeding in the
workplace [Use
code P050]

2. Reference to
disadvantages
perceived or
anticipated by
managers from
accommodating
breastfeeding in the
workplace [Use
code NegO]

 

 

Codebook
Code Rules for Application Rules for Exclusion Example .for
Application
BF K Reference to: Code not applicable “When you
1. Breastfeeding information when: breastfeed, you
managers obtain from: 1. Reference to pass on a lot of
2. Education benefits perceived your antibodies,

so the baby can
be healthier”

 

66

 

Table 3. Continued

 

Example for

 

 

Code Rules for Apphcatron Rules for Exclusion Application

PerE Reference to: Code not applicable “My wife tried
1. Description of experiences when: breastfeeding
managers have or do not 1. Managers have or probably only

 

have in breastfeeding with do not have lasted a couple of
mople outside workplace experiences in weeks.”
such as children, spouses, breastfeeding with
family members, and friends people in the
workplace [Use
code ProE]

2. Managers’ comments and Code not applicable “My husband
reactions to personal when: was really good
experiences 1. Mention the impact about

of personal accommodating
experiences from me, bringing the
accommodating baby to me or

 

 

 

 

 

breastfeeding in the going out of his
workplace [Use way when 1
code IndF] worked nights,
aftemoons.”
ProE Reference to: Code not applicable “From my senior
1. Description of experiences when: staff to my
managers have or do not 1. Managers have or middle senior
have in breastfeeding with do not have staff, none of
people in the workplace such experiences in them came back
as employees, coworkers, breastfeeding with to work and
other managers, and clients people outside needed that
workplace [Use [breastfeeding]
code PerE] accommodation.
2. Managers’ comments and Code not applicable “Great. We do it
reactions to professional when: all the time
experiences 1. Mention the impact because of the
of professional number of
experiences from women we have
accommodating that are having
breastfeeding in the babies.”

 

 

workplace [Use
codeIndF]

 

 

67

 

Table 3. Continued

 

 

 

 

 

 

. . Rules for Example for
Code Rules for Applicatron Exclusion Application
ManS Reference to: Code not applicable “We had the one
1. Things that managers offer or when: girl at the office
do not offer to help 1. Reference to and if she needed
employees combine presence or to go take a break,
breastfeeding and absence of I would fill in for
employment breastfeeding her at that time,
support at the and let her go
Examples of concepts to look company level to down to a
for: help mothers different room
a Physical accommodations combine and breastfeed her
0 Time accommodations breastfeeding and baby."
based on employees’ job employment [Use
nature and work schedule code ComS]
0 Emotiorgl support
0 Communication channel
managers encourage or
discourage to discuss
about breastfeeding
accommodation
- Autonomy to employees
given by managers
2. How managers compare Code not applicable “A woman having
providing breastfeeding when: a child and being
support to other types of 1. Mention support able to breastfeed
suppgrt (e.g., smoking breaks for is a positive thing
and diabetes care) to accommodating and you have a
accommodate employees’ employee’s tendency to be
personal needs personal needs more
without accommodating
comparing to than for
breastfeeding somebody that’s
support [Apply in a smoking
no code] situation.”

 

 

 

 

68

 

Table 3. Continued

 

Code

Rules for Application

Rules for Exclusion

Example for

 

 

 

 

 

Application

CornS Reference to description Code not applicable when: “We do have a
of presence or absence 1. Mention presence or absence comfortable
of existing company of managerial support to couch and
support, such as policy, help mothers combine chairs and
facilities, or corporate breastfeeding and very private,
culture to help employment as well as locked door
employees breastfeed at managers’ views on and access to
work providing breastfeeding water, you

support compared to other know washing

types of support [Use code the pump and

ManS] stuff. I think
2. Mention the characteristics there is even a

or structure of the company CD player in

as perceived by managers there now.”

that facilitates or poses a

barrier for employees to

breastfeed at work or

managers to provide

breastfeeding

accommodation [Use code

OrgF]

PosO Reference to benefits Code not applicable when: “I think the
perceived or anticipated 1. Reference to disadvantages biggest benefit
by managers toward perceived or anticipated by would be the
accommodation managers toward retention of a
provided by the accommodating key

 

 

managers or the
company to help
employees continue
breastfeeding at work
that apply to:

- Breastfeeding
employees
Coworkers
Other managers
Others in the
workplace
0 Company as a whole

 

breastfeeding in the
workplace [Use code NegO]
2. Reference to benefits of
breastfeeding that do not
apply in the workplace,
which are benefits toward
infants, mothers, family as a

whole, society, and economy

[Use code BFK]

 

employee.”

 

69

 

Table 3. Continued

 

Code

Rules for Application

Rules for Exclusion

Example for

 

 

 

Application
NegO Reference to Code not applicable when: “Well, the

disadvantages perceived 1.Reference to advantages problem is,
or anticipated by perceived or anticipated by you’re gonna
managers toward managers of breastfeeding hear, so and
accommodation accommodation in the so gets a
provided by mpnagers or workplace [Use code PosO] longer break
company to help 2. Reference to disadvantages than I do.”

 

employee continue
breastfeeding at work
that apply to:

0 Breastfeeding
employees
Coworkers
Other managers
Others in the
workplace
Company as a whole

 

of breastfeeding that do not
apply in the workplace,
which are disadvantages
toward infant, mother,
family as a whole, society,
and economy [Use code
BFK]

 

 

70

 

Table 3. Continued

 

Example for

 

 

 

 

 

Code Rules for Application Rules for Exclusion Application
OrgF Reference to the chargeteristics Code not applicable “I think it’s
or structure of the company as when: really important
perceived by managers that 1. Reference to to have it
fpcilitates or poses a barrier for characteristics or [breastfeeding
employees to breastfeed at behavior of the education]
work or managers to provide individuals in the incorporated in

 

breastfeeding accommodation
toward employees or clients

Examples of concepts to look
for:
0 Policy related to
breastfeeding
° Facilities
- Workforce characteristics

- Union versus non-union

settings

- Proportion of women in

the company

0 Ownership structure

- Public versus

private/family business

Industry type
Company size
Corporate culture
Training or education

session to inform employees

about breastfeeding

 

company perceived
by managers that
facilitates or poses
a barrier for
employees to
breastfeed or for
managers to
provide
breastfeeding
accommodation
[Use code IndF]

2. Reference to

description of
presence or absence
of existing
company support to
help employees
breastfeed at work
[Use code ComS]

 

orientation and
training. So
that’s not a
surprise when an
employee
accidentally
walks in on
someone or
something like
that in a restroom
or in a lounge
area.”

 

71

 

Table 3. Continued

 

Example for

 

 

 

Code Rules for Application Rules for Exclusmn Application

IndF Reference to the characteristics or Code not applicable “I think a
behavior of breastfeeding when: bigger issue
employees, coworfls. managers, 1. Reference to the for a lot of

 

 

or others within the company that
fgcilitptes or poses a barrier for
employees to breastfeed at work
or managers to provide
breastfeeding accommodation

Examples of concepts to look for:
a All individuals: sensitivity
with breastfeeding
- Coworkers:

- Reactions toward
employees being
accommodated for
breastfeeding

- Impact of coworkers
reactions

- Brgsfieeding employee’s:

- Job nature/work schedule

- Personal factors, e. g. stress
and privacy

— Work history/performance

- Degree of utilization of
breastfeeding
accommodation

- Duration of breastfeeding
at work

- Manager’s:

- Gender

- Management style

- Influence of
work/individual
relationship with
breastfeeding employees

- Influence of experiences
and knowledge with
breastfeeding

 

characteristics or
structure of the
company perceived
by managers that
facilitates or poses
a barrier for
employees to
breastfeed at work
or managers to
provide
breastfeeding
accommodation
toward employees
or clients [Use code
OrgF]

2. Description or
comments of
managers having or
lacking experiences
in breastfeeding in
the workplace [Use
code ProE] or
outside workplace
[Use code PerE]

3. What managers
know about
breastfeeding and
their opinions of
breastfeeding
impact that do not
apply in the
workplace, which
are toward infant,
mother, family as a
whole, society, and
economy [Use code
BFK]

 

men is they’re
worried about
whether the
women are
gonna be
comfortable
with men in
the area.”

 

72

 

SUMMARY OF FOCUS GROUPS

Table 4. Demographics of the Focus Group Participants

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Variable (N=25) % or Mean (SD)

Gender - Female 56.0%
Age (year) 43.1 (9.7)
Marital status

Single 8.0%

Married 76.0%

Separated/Divorced/Widowed 16.0%
Race

White 88.0%

Black or African American 8.0%

American Indian or Alaska Native 40%
Education

Some college 16.0%

2-year college degree (Associates) 16.0%

4-year college degree (BS, BA.) 48.0%

Masters’ degree/MBA 16.0%

Doctoral degree 4.0%
Female employees managed

0-25% 13.6%

26-50% 18.2%

51-75% 13.6%

76-100% 54.5%
Having employees within childbearing age 82.6%
Having employees of union members 33.3%
Having experience with employees returned after childbirth 82.6%
Number of companies have worked at 3.8 (2.1)
Years in management position 11.8 (10.1)
Number of employees managed currently 30.8 (63.9)

 

 

73

 

Table 4. Continued

 

 

 

 

 

 

 

Variable (N=25) % or Mean (SD)
Industry type of the company
Communication 4.2%
Finance/Insurance/Real Estate 50.0%
Education 12.5%
Community/Social Service 12.5%
Other 20.8%
Number of employees in all location
<99 33.3%
100-249 4.2%
250-299 45.8%
>500 16.7%
Number of employees in the same location
<50 48.0%
51-99 32.0%
100-249 12.0
>250 8.0%
Income
40,000-59,999 22.7%
60,000-79,999 54.5%
80,000-99,999 9.1%
100,000-149,999 9.1%
>150,000 4.5%

 

74

 

Instructions for focus group summary

Definitions and summaries of each of the nine themes are described below.
“Many”, “Some”, and “few” were used to indicate the relative proportion of total
participants (N =25) who expressed the similar idea or comment. “Many” refers to at
least approximately 75% of the participants (n=18) across all five focus groups and
“few” refers to less than 15% of participants’ comments (n=4). “Some” would refer to
anywhere in between “many” and “few”. In some instances, if one focus group
reported a particular idea, the summary would specify the one focus group participants’
comments. The use of the phrases, “many”, “some”, and “few”, do not aim to exactly
quantify the number of participants; rather estimate the proportion of total participants

discussing similar issues from all five of the focus groups regarding their attitudes

toward breastfeeding in the workplace.

75

Theme #1: Breastfeeding Knowledge/Beliefs

Definition: What managers know about breastfeeding and their opinions of

breastfeeding impact on the infants, mothers, family as a whole, society, and economy

1. Many managers agreed that breastfeeding would be cost-effective. When
compared breastfeeding to formula feeding, many managers agreed that
breastfeeding would be cheaper and healthier, but some did not see the difference

between the two feeding choices.

2. Many managers felt breastfeeding was viewed positively in society and they saw

more issues about breastfeeding in the public than in the workplace.

3. Some managers agreed that breastfeeding would be healthier for mothers and

infants, but some disagreed. Some only believed the benefits of breastfeeding if

they personally experienced those benefits.

4. Some managers felt that breastfeeding would be the best feeding choice if desired

by both mother and babies.

5. Some managers were not aware of the typical breastfeeding duration and how

often breast milk would need to be pumped.

76

6. Some managers viewed the decision to breastfeeding was dependent on mothers’
career, financial situation, health, willingness to sacrifice a social life, support

received at home and in the workplace.

7. Some managers indicated that nutritional status, smoking, alcohol intake, stress
level, and mental health of the mothers would influence the breastfeeding benefits

that mothers and infants received.

8. Few managers felt that infant formula would be a better feeding choice for infants
if mother might not be receiving proper nutrition, but others responded that it
would be more reasonable and economical for mothers to eat right and breastfeed

their infants than feeding them with infant formula.

9. In one of the focus groups, two managers were inaccurate about what they said
about breastfeeding. One indicated that breast milk stayed in the stomach longer
than formula and breast milk would inflate and blow up the stomach. Another

said lactose intolerance was the consequence of not breastfeeding.

77

Theme #2: Personal Experiences with Breastfeeding

Definition: Description and comments about experiences managers have or do not have

in breastfeeding with people outside workplace

1. Many managers or their partners had experience in breastfeeding their babies or

they had family members or friends breastfeeding their babies.

2. Many managers had positive personal experience with breastfeeding but some
viewed it as an unpleasant experience. In this context, breastfeeding created
tension, guilt, or stress to breastfeed in general or combine breastfeeding and

employment.

3. Many female managers felt that their partners were supportive of them

breastfeeding.

4. Many male managers were comfortable with breastfeeding and they would help

bring babies to work for their partners to breastfeed.

5. Some female managers or their partners chose not to continue breastfeeding when
returned to work after maternity leave, because of the following reasons:
0 They decided that it was time to be done with breastfeeding.

0 They did not want to deal with breastfeeding in the workplace.

78

0 They did not feel comfortable to breastfeed at work.

0 They did not have the knowledge about needs for breastfeeding at work.

0 For those who combined breastfeeding with work had a difficult time doing
it, because there was not a place to breastfeed or pump and they were afraid

of making others feel uncomfortable.

. Some female managers were able to pump milk at work or bring their babies to

work and breastfeed them in the workplace.

. Some managers indicated that their parents’ generation was not comfortable with

them breastfeeding.

. Few managers or their partners did not plan on breastfeeding their babies, but they

changed their minds because of the positive influence by doctors or nurses.

79

Theme #3: Workplace Experiences with Breastfeeding

Definition: Description and comments about experiences managers have or do not have

in breastfeeding with people in the workplace

1. Many managers have had experiences in breastfeeding with their employees or
others in the workplace and these managers all had positive experiences. Some of
these employees were able to pmnp breast milk at work or bring their babies to be

breastfed in the workplace.

2. Many managers said breastfeeding in the workplace did not come up often. Few

indicated that employees would let them know if they were planning on

breastfeeding in the workplace.

3. Few managers have had experience with customers who wanted to breastfeed or

pump breast milk in the workplace.

4. Few managers did not know how their employees took care of breastfeeding at

work or they did not notice any difference in their work routines.

5. Few managers have heard of other managers that had experiences with employees

who wanted to breastfeed at work.

80

Theme #4: Managerial Support for Breastfeeding in the Workplace

Definition: (1) Presence or absence of managerial support to help mothers combine

breastfeeding and employment; (2) Managers’ views between providing breastfeeding

support and other types of support to accommodate employees ’ personal needs

1.

4.

Physical ficommodations: some managers said they identified space and provided
supplies (refrigerator, sign, door with lock, sink) needed to make breastfeeding

comfortable for employees.

Time accommodations: many managers said they provided extra breaks or arranged
breaks by separating or moving lunch and breaks around but some managers were

not sure if women should be compensated for these breaks.

Emotional support: many managers encouraged breastfeeding due to positive
personal experience and knowledge of breastfeeding benefits. Also, many managers
would accommodate breastfeeding because they felt supporting breastfeeding was a
happy and good thing to do. Few managers indicated that they would accommodate
breastfeeding because they support employees to balance personal/family life and

work.

Autonomy: many managers allowed breastfeeding employees to make decisions

about what they needed to do in order for them to continue breastfeeding in the

81

workplace. Few managers indicated that their supervisors could also make

decisions to accommodate employees for breastfeeding without informing them.

. Communication: many managers were willing to discuss with employees about

needs to make breastfeeding at work as a positive experience.

Advocacy: few managers said they would advocate for additional space while doing

new development or reconstruction in the company.

. Resources: few managers said they would seek help from other employees if

needed.

Managers had mixed views about breastfeeding accommodations and other types of
accommodations:
a. Some felt they were the same because breastfeeding would just be another
accommodation important to employees and managers felt every reasonable

accommodation should be made.

b. Some felt they were different because breastfeeding required more

accommodations, but others felt breastfeeding was a positive thing compared

to other accommodations, e. g. smoking and divorce.

82

Theme #5: Company Support for Breastfeeding in the Workplace

Definition.“ Description of existing breastfeeding support at the company level to help

mothers combine breastfeeding and employment

1. Policy: managers had mixed views on company policy related to breastfeeding:

a. Many said there was no policy related to breastfeeding and few did not know

if there was a policy related to breastfeeding.

b. Some said that they never had employee asked if policy available.

c. Across all focus groups, there was a wide range of response regarding how

often policies/practices were used to accommodate breastfeeding.

d. Only one participant reported that her organization had a policy related to

supporting breastfeeding in the workplace.

2. Corpogite culture:

a. Some managers indicated their companies were family friendly to support

breastfeeding or their companies would support employees of different needs.

b. Few managers said flexibility was given by the company to allow them to

make breastfeeding accommodations.

83

3. Physical accommodation:

a. Many managers reported no designated place for breastfeeding in the

workplace.

b. Many managers said most space for accommodating breastfeeding would be

woman’s bathroom or closet space or storage room.

c. Few managers said that their companies had small offices, extra break rooms,

or other private space to accommodate breastfeeding.

d. Few managers expressed that workplace lacked facilities and privacy to

accommodate breastfeeding. '

e. Few managers saw the need to accommodate both employees and clients in

the workplace.

84

Theme #6: Positive Outcomes of Workplace Breastfeeding Accommodations

Definition: Advantages perceived or anticipated by managers from accommodating

breastfeeding in the workplace

1. Many managers felt they would be appreciated and breastfeeding employees

would be more willing to help in return.

2. Many managers saw that the workplace could become more enjoyable because it

would improve morale and create positive company image.

3. Many managers felt that co-workers would have positive reactions from

employees being accommodated for breastfeeding.

4. Many managers saw breastfeeding employees would be happier.

5. Many managers saw productivity increase as a result of workplace breastfeeding.

6. Some managers felt that women could return to work faster.

7. Some managers felt it would help reduce stress for breastfeeding employees.

8. Some managers felt it would enhance relationship with breastfeeding employees.

85

9. Some managers felt that breastfeeding accommodations would help retention and

recruitment of employees.

10. Few managers felt that they might not need to hire another employee temporarily

if women were allowed to breastfeed at work.

11. Few managers believed it would help reduce healthcare cost for the company.

86

Theme #6: Negative Outcomes of Workplace Breastfeeding Accommodations

Definition: Disadvantages perceived or anticipated by managers fiom accommodating

breastfeeding in the workplace

1.

Many managers felt breastfeeding accommodations would cause interruptions or

inefficiencies in the workplace.

Many managers said that there would be complaints by co-workers who were

negative or jealous of accommodations made to breastfeeding employees.

However, managers felt that some of these were disgruntled employees.

Some managers were not comfortable with employees breastfeeding at work or

other employees seeing that in the workplace.

Some managers felt breastfeeding accommodations might be perceived as

favoritism toward breastfeeding employees by co-workers.

Some managers reported perceived risk of reduced productivity from

breastfeeding employees.

Some managers indicated inequity issues might rise among other employees

seeking for other accommodations.

87

. Few managers perceived no disadvantages from accommodating breastfeeding but

anticipated problems if accommodations could not be made for breastfeeding.

. Few managers felt that breastfeeding employees might be perceived as taking

advantage of the system if breastfeeding went on for a while.

. Few managers expressed concern about liability to the company if babies were

present at work.

88

Theme #7: Organizational Feasibility in Workplace Breastfeeding

Accommodations

Definition: Issues at the organizational level that facilitates or poses a barrier for

employees to breastfeed in the workplace or managers to provide breastfeeding

accommodations

1.

Some managers felt there would be no need for policy due to infrequent request and
they felt that accommodations could be handled on a case by case basis and policy
would not allow much flexibility to work with. Some other managers felt that
policy could inform breastfeeding employees about would be acceptable in the
workplace and that would allow consistency in providing accommodations and

showed that employer valued employees.

Some managers felt that breastfeeding accommodations would be easier in a farnily-
oriented workplace or company with greater proportion of women or having the

culture in accommodating personal needs.

Some managers indicated that having corporate training or educational materials on

breastfeeding would be helpful because all employees would have equal access to

materials that could about breastfeeding that applies to the workplace.

89

. Some managers expressed that the extent of accommodations would vary across

departments because of availability of facilities.

. Few managers saw breastfeeding policy would need to be formulated based on

medical need of mother and child, as well as consideration of co-worker reactions.

. Few managers felt that they would be more comfortable to accommodate

breastfeeding if there was an existing policy.

. Few managers felt that more planning on the use of the office space and providing

supplies would be helpful in accommodating breastfeeding.

. Few managers said that it would be more difficult to accommodate breastfeeding in

a small business and union setting.

. Few managers viewed private or family businesses would be more inclined to have

a policy than public company due to their family-friendly image.

10. Few managers viewed hospital and school would be more supportive and more

accommodating to breastfeeding.

11. Few managers felt that company would have more concerns toward employees

bringing child to work to be breastfed instead of employees pumping milk at work.

90

Theme #9: Individual Feasibility in Workplace Breastfeeding Accommodations

Definition: Issues related to individual ’s characteristics or behavior within the
company that facilitates or poses a barrier for employees to breastfeed in the workplace

or managers to provide breastfeeding accommodations

1. Co-worker:
a. Many managers said there would be both positive and negative reactions
from co—workers due to their background, but these reactions would not

affect how they accommodated breastfeeding.

2. Breastfeeding employee:
a. Some managers felt that employees would find it difficult to speak to their
managers about breastfeeding due to self-discomfort with breastfeeding or

manager’s gender.

b. Some managers indicated that employee’s job nature could affect how they

would accommodate breastfeeding.

c. Few managers said employees would be more stressed if breastfeeding was

not accepted in the workplace.

91

Some managers viewed that the level of privacy needed for breastfeeding

varied among employees.

e. Some managers would be more inclined to accommodate high performers,
but some felt employees’ performance would have no influence.

f. Few managers said that providing accommodations would be difficult if
employees abused the situation, but managers felt these employees would
ofien be the same individuals who abused other accommodations.

g. Few managers indicated that having a time limit on how long employees
could breastfeed at work would help provide accommodations.

Manager:

a. Many managers said they would be comfortable with breastfeeding if
everyone in the workplace felt comfortable.

b. Many managers said their work or individual relationship with breastfeeding
employees would not influence how they accommodated breastfeeding.

c. Many managers felt that having experiences with and knowledge of

breastfeeding helped them become more accommodating to and have more

understanding of breastfeeding, which would help formulate policy related

92

to breastfeeding; whereas some managers felt that they would have less
understanding and be less accommodating to breastfeeding if lacking such

experiences and knowledge.

. Some managers felt that female managers who had children or had breastfed
before would be more supportive of and have more understanding about

breastfeeding.

Few managers said that male managers’ comfort with breastfeeding would
depend on their age and general comfortableness with human body. Some
felt that male managers with no children or never married would feel more
uncomfortable and they might be indifferent or ignorant toward

breastfeeding.

Few managers indicated they would be open to discussing needs for
breastfeeding accommodations. Some managers would be more comfortable
to discussing these issues if employees approached them first. Few
managers would want to have an open door policy or hold the discussion in a

group setting with other female employees present.

93

APPENDIX B

94

    
     
    
   
   
   
   
 
  

Concerns and Benefits

Experience with of Breastfeeding
Breastfeeding

Manager Attitudes
toward Workplace
Breastfeeding
Support

   

Company Support
for Breastfeeding

   

Individual Support
for Breastfeeding

 

Figure 1. Conceptual framework for measuring manager attitudes toward workplace
breastfeeding support

95

INITIAL INSTRUMENT

 

 

MANAGER SURVEY

 

 

The Breastfeeding and Employment Study:

Instructions:

1.

Please answer each statement in this questionnaire as they pertain to
full-time employees.

Please provide one response per statement unless otherwise specified.

. Please use a pen and check appropriate boxes to complete this

questionnaire.

Please use the last page to provide additional comments you may
have.

Terms:

1.

“Breastfeeding” refers to women directly nursing their infants or
young children from the breast.

“Pumping” refers to women pumping breast milk either by hand
expression, or by using a manual or electric pump, and storing it for
later use.

“Company” refers to any place of employment whether it be non-profit

or for-profit organizations, private or public sectors, educational or
government bodies.

96

 

 

Individual Support for Breastfeeding

 

 

This category includes two sections about breastfeeding support provided by
either managers or co-workers. It pertains to your current place of employment.

The following section asks about your support as a manager toward employees
who wish to combine breastfeeding with work. Please respond each statement
about employees who report to you on a regular basis. .

 

Strongly
agree

Strongly

Agree Disagree disagree

 

1. I would feel comfortable speaking
with an employee who wished to Cl D E] El
combine breastfeeding with work.

 

2. I would feel more comfortable
speaking with an employee about 1:] 1:] Cl Cl
breastfeeding or pumping if she
approached me first.

 

3. I would feel comfortable supporting
an employee who wished to Cl E] Cl C]
breastfeed or pump at work.

 

4. It would be easier for me to support
a breastfeeding employee if our Cl Cl D U
company had a written policy for
breastfeeding support.

 

5. I would be more likely to support a
breastfeeding employee if she was a Cl El Cl Cl
high performer.

 

6. I would be more likely to support a
breastfeeding employee if I knew it E] El Cl Cl
was for a limited period of time.

 

7. If an employee needed time to
breastfeed or pump, I would make Cl Cl C] C]
sure that her duties were covered.

 

8. I would help an employee balance
her job responsibilities so she could Cl Cl E] El
breastfeed or pump at work.

 

 

 

 

 

 

 

97

 

Strongly
agree

Agree

Disagree

Strongly
disagree

 

I would give an employee flexibility
to arrange her work schedule, so that
she could have sufficient time to
breastfeed or pump at work.

 

10.

If there were no designated space for
breastfeeding or pumping, I would
find a space for my employee.

 

11.

If there were no designated space for
breastfeeding or pumping, I would
advocate for designated space.

 

12.

As their manager, my employees
would consider it part of my job to
support an employee who combined
breastfeeding with work.

 

13.

Providing breastfeeding support to
an employee is the same to me as
supporting her for any other personal
needs.

 

14.

Providing breastfeeding support to
an employee requires more effort on
my part than supporting her for other
personal needs.

 

15.

I believe that providing
breastfeeding support to an
employee requires more company
resources than supporting her for
other personal needs.

 

16.

I believe that providing
breastfeeding support to an
employee is a reasonable
accommodation.

 

 

17.

I believe that providing
breastfeeding support to an
employee is fair.

 

 

 

 

 

98

 

 

Strongly
agree

Agree

Disagree

Strongly
disagree

 

18.

I believe that providing
breastfeeding support to an
employee is necessary.

1:]

El

 

19.

It is more satisfying to me to provide
breastfeeding support to an
employee than to provide some other
type of personal support.

 

20.

I would seek help from other people
in this company if I needed help
with supporting a breastfeeding
employee.

 

21.

As a manager, I should M. be
responsible for supporting an
employee who is breastfeeding or
pumping at work.

 

22.

As a manager, I would n_ot feel
limited by a written policy that
specifies how to support a
breastfeeding employee.

 

23.

It is part of my job as a manager to
help employees combine
breastfeeding or pumping with work.

 

24.

If one of my employees was
considering combining breastfeeding
or pumping with work, I would
know about it.

 

 

25.

If one of my employees was
breastfeeding or pumping at work, I
would know about it.

 

 

 

 

 

99

 

The following section asks about support provided by co-workers toward
employees who wish to combine breastfeeding with work. In each of the
statements, “employees” refers to all employees in this company.

 

Strongly
agree

Agree

Disagree

Strongly
disagree

 

26.

Employees would have positive
feelings if this company provided
breastfeeding accommodations.

D

D

 

27.

Employees would have positive
feelings if the manager at this
company provided support for
breastfeeding.

 

28.

Employees would support a co-
worker wishing to combine
breastfeeding with work.

 

29.

Co-workers would be willing to
change work schedules with an
employee if she needed to
breastfeed or pump.

 

30. Co-workers would be willing to

cover the duties of an employee if
she needed time to breastfeed or

pump.

 

31.

Employees would feel comfortable
speaking to their co-workers about
breastfeeding or pumping.

 

32.

Employees would feel comfortable
with the idea of a co-worker
breastfeeding (not pumping) at
work.

 

 

33.

Employees would feel comfortable
with the idea of a
co-worker pumping at work.

 

 

 

 

 

100

 

 

 

 

Strongly . Strongly
agree Agree Disagree disagree
34. I would po_t be concerned about
co-worker jealously if
breastfeeding support was D D D D
provided at work.
35. I would n_ot be concerned about
co—worker reactions if
breastfeeding support was D D D D
provided at work.

 

 

 

 

 

 

 

 

 

Company Siflrport for Breastfeeding

 

 

This category has two sections about support for breastfeeding at companies in
general and at your company specifically.

The following section pertains to support provided at companies in general to
help employees who wish to combine breastfeeding with work.

 

Strongly
agree

Agree

Disagree

Strongly
disagree

 

36. A written breastfeeding support
policy would ensure consistent
accommodations across the
company.

E]

El

 

37. Accommodations for a
breastfeeding employee can be
handled on an as-needed basis.

 

38. Accommodations for a
breastfeeding employee would be
the same across departments.

 

 

39. The company should provide a
private space for breastfeeding or
pumping so that an employee does
n_ot need to use a restroom for this

purpose-

 

 

 

 

 

101

 

 

Strongly
agree

Agree

Disagree

Strongly
disagree

 

40. The restroom is an acceptable

place for an employee to
breastfeed or pump.

Cl

C]

 

41

. The company should provide a

space for breastfeeding or
pumping that is close to
employees’ work areas.

 

42.

The company should supply the
equipment (e.g., breast pump) that
employees would need for
pumping.

 

43

. The company should provide

information about combining
breastfeeding with work to all of
its employees.

 

. The company should provide

information about combining
breastfeeding with work only to
female employees who become

pregnant.

 

 

45.

Providing breastfeeding support is
important even if it is only needed
at times by a small number of
employees.

 

 

 

 

 

102

 

The following section pertains to support provided at your company to help

employees who wish to combine breastfeeding with work.

 

Strongly
agree

Agree

Disagree

Strongly
disagree

 

46.

It is acceptable for employees to
request assistance for
breastfeeding support.

Cl

[3

 

47.

It is acceptable for employees to
bring their babies to work to
breastfeed.

 

48.

It is acceptable for employees to
pump at work.

 

49.

Employees would feel
comfortable asking for
breastfeeding support.

 

50.

Employees would feel
comfortable asking for assistance
to bring their babies to work to
breastfeed.

 

51.

Employees would feel
comfortable asking for
accommodations to pump at
work.

 

52.

There is little employee demand
for breastfeeding support.

 

 

53.

It is this company’s
responsibility to provide
breastfeeding support to its
employees.

 

 

 

 

 

103

 

 

 

Outcomes of Breastfeeding

 

 

This category includes three sections about workplace outcomes of breastfeeding
support at companies in general and at your company specifically, as well as
health and cost outcomes of breastfeeding.

The following section pertains to both positive and negative outcomes of

providing breastfeeding support at companies in general.

 

Strongly
agree

Agree

Disagree

Strongly
disagree

 

54.

The rules introduced by a labor
union would make it difficult to
support breastfeeding at work.

El

[3

 

55.

Having breastfeeding
accommodations would help
employee retention.

 

56.

Company’s healthcare costs could
be reduced by providing
breastfeeding accommodations.

 

57.

Having breastfeeding
accommodations would help
employee recruitment.

 

58.

It would contribute to a positive
public image if companies provided
breastfeeding accommodations.

 

59.

Companies would show that it
values its employees if they have a
written policy for breastfeeding

support.

 

60.

Employees would have improved
job satisfaction if companies
provided breastfeeding
accommodations.

 

 

61.

If an employee received
breastfeeding support, she could
return to work sooner after having a
baby.

 

 

 

 

 

104

 

 

Strongly
agree

Agree

Disagree

Strongly
disagree

 

62.

A breastfeeding employee would
take the same amount of time as her
co-workers to get her work done.

Cl

[I

[I

 

63.

A breastfeeding employee would be
as productive as her
co-workers.

 

. An employee who could continue

breastfeeding upon returning to
work would need to take fewer days
off.

 

65.

An employee who combined
breastfeeding with work would still
be able to focus on her
responsibilities.

 

66.

An employee’s morale would
increase if she received support in
combing breastfeeding with work.

 

67.

Employee’s loyalty would increase
if companies provided breastfeeding
accommodations.

 

 

68.

An employee would experience

reduced stress when returning to

work after having a baby if she
received support in combining
breastfeeding with work.

 

 

 

 

 

105

 

The following section pertains to both positive and negative outcomes of
providing breastfeeding support at your company specifically.

 

 

Strongly . Strongly
agree Agree Disagree disagree
69. It would M be a safety concern if
employees brought their babies to
work to be breastfed at this D D D D
company.

 

70. Allowing storage of pumped milk at
this company would pg present a Cl 1:] Cl El
safety concern.

 

71. I would have a better relationship
with an employee if I helped her E] Cl E] El
combine breastfeeding with work.

 

72. Co-workers would be pleased if I
helped an employee combine 1:] E] El 1:]
breastfeeding with work.

 

73. I would be appreciated by other
employees if I helped an employee 1:] E] Cl C]
combine breastfeeding with work.

 

74. If I did pp; provide accommodations
to a breastfeeding employee, I would Cl Cl [I] [3
receive complaints from other
employees.

 

 

 

 

 

 

 

The following section asks about health and cost outcomes of breastfeeding.

 

 

 

 

 

 

 

 

True False
75. Formula feeding costs more than breastfeeding. E] El
76. Breastfed infants have fewer health problems than formula-fed
. Cl Cl
infants.
77. Breastfeeding is better for mothers’ mental health than formula Cl Cl
feeding.
78. Breastfeeding is better for mothers’ physical health than
. Cl [:1
formula feeding.

 

 

106

 

 

Experience with Breastfeeding

 

This category includes two sections about your workplace and personal
experiences with breastfeeding. Please answer each statement either yes or
no. Then, if applicable, check the box that best describes your opinion.

The following section pertains to your past and current workplace experiences

with employees who combined breastfeeding with work.

79. I have supervised an employee who combined breastfeeding or pumping with work.

1:] No (IF NO, skip to Question #80)

 

 

Cl Yes
L'IF YES: I had a positive experience with this employee.
Strongly agree Agree Disagree Strongly disagree
E] E] E] El

 

 

 

 

 

80. I know of other employees, ppt under my supervision, who have combined

breastfeeding or pumping with work.
C] No (IF NO, skip to Question #81)

 

 

I] Yes
L’IF YES: It appeared to me that these emflryees had positive experiences.
Strongly agree Agree Disagree Strongly disagree
El El 1:] Cl

 

 

 

 

 

81. I know other managers who have supervised employees who combined

breastfeeding or pumping with work.
Cl No (IF NO, skip to Question #82)

 

 

1:] Yes
"' IF YES: It appeared to me that these managers had positive experiences with
their employees.
Strongly agree Agree Disagree Strongly disagree
El Cl C] El

 

 

 

 

 

82. I have helped find accommodations for breastfeeding or pumping at the workplace

for individuals other than employees (e.g., clients, customers).

Cl No (IF NO, skip to Question #83 on the next page)

 

 

Cl Yes
“P [F YES: My experience of making this accommodation was positive. _
Strongly agree Agree Disagree Strongly disagree
[I ' Cl [:1 Cl

 

 

 

 

 

107

 

 

 

 

 

The following section pertains to your past and current personal experiences
with breastfeeding.

If you are female, please answer questions 83 and 84.

If you are pile, please answer questions 85 and 86.

 

83. I have breastfed a baby and/or pumped milk.
[I No (IF NO, skip to Question #87 on the next page)

D Yes

" IF YES: My experience was positive.

 

Strongly agree Agree Disagree Strongly disagree

1:] E] El Cl

 

 

 

 

 

 

 

Females

84. I have tried to combine breastfeeding or pumping with work.
1:] No (IF NO, skip to Question #87 on the next page)
Cl Yes

I" IF YES: My experience was positive.

 

Strongly agree Agree Disagree Strongly disagree

Cl C] E] El

 

 

 

 

 

 

 

 

 

 

 

85. I have had a partner who breastfed and/or pumped.
El No (IF NO, skip to Question #87 on the next page)
[I Yes

L IF YES: Her experience was positive.

 

Strongly agree Agree Disagree Strongly disagree

 

Cl [:1 El El

 

 

 

 

 

 

86. My partner tried to combine breastfeeding or pumping with work.
1:] No (IF NO, skip to Question #87 on the next page)

T'Yes
IF YES: Her experience was positive.

 

Strongly agree Agree Disagree Strongly disagree

 

 

 

 

Cl C] [I] D

 

 

 

 

 

 

108

87. One or more of my family members or friends have had experience with

breastfeeding or pumping.
E] No (IF NO, skip to Question #88)

iYes

IF YES: I perceived her e§perience to be @sitive.

 

Strongly agree Agree

Disagree

Strongly disagree

 

 

 

 

E] E]

El

 

El

 

88. One or more of my family members or friends have had tried to combine

breastfeeding or pumping with work.
CI No (IF NO, skip to Question #89)
El Yes

IF YES: I perceived her experience to be positive.

 

Strongly agree Agree

Disagree

Strongly disagree

 

Cl El

 

 

 

El

 

Cl

 

 

 

Demographic Information

 

Reminder: Any information you provide in this survey will be kept confidential.

89. This company has a written policy for breastfeeding support.

El Yes
1:] No
El Do not know

90. This company has a designated space for breastfeeding or pumping.

Cl Yes
Cl No
El Do not know

91. How many companies have you worked at including your current job?

Companies

 

92. Including previous work experience, how many years have you been in a

management position?

Years

 

109

 

 

 

93.

94.

95.

96.

97.

98.

99.

How many years have you been in a management position at your current job?

Years

 

What is the approximate number of people you manage currently?

People

 

What is your job title?

 

 

What percentage of the employees you manage are women?

Cl 0-25%

C] 26-50%

C] 51-75%

Cl 76-100%

Are any of the women you manage within childbearing age?

Cl Yes

1:] No

El Do not know

How many employees are employed at this company?
At this worm: In the US: Globally:
Cl < 50 Cl < 50 Cl < 50
[350—99 [150—99 [350—99
[1100—499 [3100—499 [1100-499
El 500 - 999 El 500 — 999 El 500 — 999
CI 1,000 — 4,999 CI 1,000 — 4,999 CI 1,000 — 4,999
Cl 2 5,000 El 2 5,000 D _>. 5,000

Which of the following best describes your company’s primary industry? [Please
choose only one]

CI Communication

[J Finance

Cl Health Care

[:1 Insurance

Cl Administration

El Education

Cl Real Estate

El Utilities

Cl Other (Please specify):

 

110

100.

101.

102.

103.

104.

105.

What is your gender?
El Male
Cl Female

What is your age in years? Years

 

What is your marital status?
El Married

Cl Separated

Cl Divorced

Cl Widowed

El Never married

What race do you consider yourself to be? [Please choose all that apply]
CI White

El Black or Afi'ican American

El American Indian or Alaska Native

El Asian

1:] Native Hawaiian or Other Pacific Islander

Cl Other (Please specify):

 

Which of the following ethnicity do you consider yourself? [Please mark one]
[I Hispanic or Latino
Cl Non-Hispanic or Non-Latino

What is the highest level of education you have completed?
1:] Less than high school

Cl High school diploma or GED

Cl Some college

Cl 2-year college degree (Associates)

1:] 4-year college degree (BS, BA.)

[:1 Masters degree/MBA

El Doctoral degree

D Professional degree (M.D., J .D.)

Cl Other (Please specify):

 

111

106. Thank you for your time completing this survey. Please provide any other
comments you may have.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

112

EXPERT REVIEW FORM (1)

Expert Review Form
Breastfeeding and Employment Study:
Manager Survey

Instructions:

1.
2.
3.

Please read the definition (below) of experience with breastfeeding.
Then, read each of the following statements one at a time.
Rate each statement as Low, Moderate, or High depending on how well
you think each statement fits the definition of experience with
breastfeeding.

Experience with Breastfeeding - this category includes statements that
look at the manager’s personal or workplace experiences with

 

 

 

 

 

 

 

 

breastfeeding.
Goodness-of-Fit for
Experience with
Statement from the Manager’s Survey Breastfeeding
Low Moderate High
. I have supervised an employee who combined Cl Cl C]
breastfeeding or pumping with work.
2. I know of other employees, n_ot_ under my
supervision, who have combined breastfeeding or El 1:] E]
pumping with work.
3. I know other managers who have supervised
employees who combined breastfeeding or E] Cl C]
pumping with work.
4. I have helped find accommodations for
breastfeeding or pumping at the workplace for E] E] El
individuals other than employees (e. g., clients,
customers).
5. I have breastfed a baby and/or pumped milk. El 1:] Cl
6. I have tried to combine breastfeeding or pumping Cl C] E]
with work.

 

 

 

 

 

113

 

 

Good ness-of-F it for

 

 

 

 

 

 

 

 

 

Experience with
Statement from the Manager’s Survey Breastfeeding
Low Moderate High
7. I have had a partner who breastfed and/or El Cl C]
pumped.
8. My partner tried to combine breastfeeding or E] Cl C]
pumping with work.
9. One or more of my family members or friends
have had experience with breastfeeding or C] D E]
pumping.
10. One or more of my family members or friends
have tried to combine breastfeeding or pumping D 1:] [I
with work.

 

Please provide any comments you may have regarding this category:

 

 

 

 

 

 

 

 

 

 

 

 

114

 

Instructions:

1.

2.
3.

Please read the definition (below) of individual support for
breastfeeding.
Then, read each of the following statements one at a time.

Rate each statement as Low, Moderate, or High depending on how well
you think each statement fits the definition of individual support for
breastfeeding.

 

Individual Support for Breastfeeding - this category includes statements
that look at breastfeeding support provided by either managers or co-
workers to help employees who wish to combine breastfeeding with work.

 

 

 

 

 

 

 

 

 

 

 

Goodness-of-F it for
Individual Support for
Statement from the Manager's Survey Breastfeeding
Low Moderate High
. I would feel comfortable speaking with an

employee who wished to combine Cl [:1 Cl
breastfeeding with work.

2. I would feel more comfortable speaking with
an employee about breastfeeding or pumping Cl 1:] 1:!
if she approached me first.

3. I would feel comfortable supporting an
employee who wished to breastfeed or pump El El 1:]
at work.

4. It would be easier for me to support a
breastfeeding employee if our company had a El Cl 1:]
written policy for breastfeeding support.

5. I would be more likely to support a
breastfeeding employee if she was a high [:1 [:l E]
performer.

6. I would be more likely to support a
breastfeeding employee if I knew it was for a 1:] E] 1:]
limited period of time.

7. If an employee needed time to breastfeed or
pump, 1 would make sure that her duties were Cl Cl [I
covered.

 

 

 

115

 

 

Statement from the Manager’s Survey

Goodness-of-F it for
Individual Support for

Breastfeeding

 

Low

Moderate

High

 

I would help an employee balance her job
responsibilities so she could breastfeed or
pump at work.

El

El

Cl

 

I would give an employee flexibility to
arrange her work schedule, so that she could
have sufficient time to breastfeed or pump at
work.

 

10.

If there were no designated space for
breastfeeding or pumping, I would find a
space for my employee.

 

11.

If there were no designated space for
breastfeeding or pumping, I would advocate
for designated space.

 

12.

My employees would consider it part of my
job to support an employee who combined
breastfeeding with work.

 

13.

Providing breastfeeding support to an
employee is the same to me as supporting her
for any other personal needs.

 

14.

Providing breastfeeding support to an
employee requires more effort on my part than
supporting her for other personal needs.

 

15.

I believe that providing breastfeeding support
to an employee requires more company
resources than supporting her for other
personal needs.

 

16.

I believe that providing breastfeeding support
to an employee is a reasonable
accommodation.

 

17.

I believe that providing breastfeeding support
to an employee is fair.

 

 

18.

I believe that providing breastfeeding support
to an employee is necessary.

 

 

 

 

116

 

 

Statement from the Manager’s Survey

Goodness-of-Fit for
Individual Support for
Breastfeeding

 

Low Moderate High

 

19.

I believe that a restroom is an acceptable place
for an employee to breastfeed or pump.

El E] El

 

20.

It is more satisfying to me to provide
breastfeeding support to an employee than to
provide some other type of personal support.

 

21.

I would seek help from other people in this
company if I needed help with supporting a
breastfeeding employee.

 

22.

I consider combining breastfeeding or
pumping with work a personal choice, not
something that I should have to deal with.

 

23.

As a manager, I would po_t feel limited by a
written policy that specifies how to support a
breastfeeding employee.

 

24.

It is part of my job as a manager to help
employees combine breastfeeding or pumping
with work.

 

25.

If one of my employees was considering
combining breastfeeding or pumping with
work, I would know about it.

 

26.

If one of my employees was breastfeeding or
pumping at work, I would know about it.

 

27.

Employees would have positive feelings if this
company provided breastfeeding
accommodations.

 

28.

Employees would have positive feelings if the
manager at this company provided support for
breastfeeding.

 

 

29.

Employees would support a co-worker
wishing to combine breastfeeding with work.

 

 

 

 

117

 

 

Goodness-of-F it for

Individual Support for
Statement from the Manager's Survey Breastfeeding

 

Low Moderate High

 

30. Co-workers would be willing to change work
schedules with an employee if she needed to Cl Cl C]
breastfeed or pump.

 

31. Co-workers would be willing to cover the
duties of an employee if she needed time to El [:1 Cl
breastfeed or pump.

 

32. Employees would feel comfortable speaking
to their co-workers about breastfeeding or 1:1 1:1 1:1
pumping.

 

33. Employees would feel comfortable with the
idea of a co-worker breastfeeding (not C1 1:1 [I
pumping) at work.

 

34. Employees would feel comfortable with the C1 Cl [:1
idea of a co-worker pumping at work.

 

35. I would n_ot anticipate co-worker jealousy if 1:] 1:] El
breastfeeding support was provided at work.

 

36. I would n_ot anticipate negative co-worker
reactions if breastfeeding support was [:1 Cl 1:]
provided at work.

 

 

 

 

 

 

Please provide any comments you may have regarding this category:

 

 

 

 

 

 

 

118

Instructions:

1.
2.
3.

Please read the definition (below) of company support for breastfeeding.
Then, read each of the following statements one at a time.

Rate each statement as Low, Moderate, or High depending on how well
you think each statement fits the definition of compa_ny support for

breastfeeding.

Company Support for Breastfeeding - this category includes statements
that look at breastfeeding support at the company level that helps
employees combine breastfeeding with work.

 

Statement from the Manager’s Survey

Goodness-of-F it for
Company Support for
Breastfeeding

 

Low Moderate High

 

. A written breastfeeding support policy would

ensure consistent accommodations across the
company.

El Cl Cl

 

Accommodations for a breastfeeding employee
can be handled on an as-needed basis.

 

. Accommodations for a breastfeeding employee

would be the same across departments.

 

The company should provide a private space for
breastfeeding or pumping so that an employee
does n_ot need to use a restroom for this

purpose-

 

The company should provide a space for
breastfeeding or pumping that is close to
employees’ work areas.

 

The company should supply the equipment
(e.g., breast pump) that employees would need
for pumping.

 

The company should provide information about
combining breastfeeding with work to all of its
employees.

 

 

The company should provide information about
combining breastfeeding with work only to
female employees who become pregnant.

 

 

 

 

119

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Goodness-of-Fit for
Company Support for
Statement from the Manager’s Survey Breastfeeding
Low Moderate High
9. Providing breastfeeding support is important
even if it is only needed at times by a small [:1 E] El
number of employees.
10. It is acceptable for employees to request 1:] E] El
assistance for breastfeeding support.
11. It is acceptable for employees to pump at work. 1:] E] El
12. It is acceptable for employees to have their El 1:] 1:]
babies brought to work to breastfeed.
13. Employees would feel comfortable asking for
. El 1:] CI
breastfeeding support.
14. Employees would feel comfortable asking for
assistance to bring their babies to work to Cl E] El
breastfeed.
15. Employees would feel comfortable asking for El [:1 El
accommodations to pump at work.
16. There is little employee demand for 1] Cl C]
breastfeeding support.
17. It is this company’s responsibility to provide [:1 Cl 1:]
breastfeeding support to its employees.

 

 

 

 

Please provide any comments you may have regarding this category:

 

 

 

 

 

 

120

Instructions:

1. Please read the definition (below) of outcomes of breastfeedig.

2. Then, read each of the following statements one at a time.

3, Rate each statement as Low, Moderate, or High depending on how well
you think each statement fits the definition of outcomes of
breastfeeding.

 

 

Outcomes of Breastfeeding - this category includes statements that look at
health and cost outcomes of breastfeeding as well as positive and negative
workplace outcomes of breastfeeding support.

 

Goodness-of-Fit for
Statement from the Manager’s Survey Outcomes Of 3703339911109

 

Low Moderate High

 

1. The rules introduced by a labor union would

 

make it difficult to support breastfeeding at [1 Cl El
work.
2. Havrng breastfeeding accommodations would Cl [:1 1:]

help employee retention.

 

3. Company’s healthcare costs could be reduced
. . . . El 1:] Cl
by provrding breastfeeding accommodations.

 

4. Having breastfeeding accommodations would
. [:1 El E1
help employee recruitment.

 

5. It would contribute to a positive public image if
companies provided breastfeeding El 1:] El
accommodations.

 

6. Companies would show that it values its
employees if they have a written policy for [3 C] D
breastfeeding support.

 

7. Employees would have improved job
satisfaction if companies provided [:1 Cl C]
breastfeeding accommodations.

 

8. If an employee received breastfeeding support,

 

she could return to work sooner after having a Cl E] El
baby.
9. A breastfeeding employee would be as El [:1 D

productive as her co-workers.

 

 

 

 

 

 

121

 

Statement from the Manager’s Survey

Goodness-of-Fit for
Outcomes of Breastfeeding

 

Low

Moderate

High

 

10.

An employee who could continue breastfeeding
upon returning to work would need to take
fewer days off.

Cl

Cl

C]

 

11.

An employee who combined breastfeeding with
work would still be able to focus on her
responsibilities.

 

12.

An employee’s morale would increase if she
received support in combining breastfeeding
with work.

 

l3.

Employee’s loyalty would increase if
companies provided breastfeeding
accommodations.

 

14.

An employee would experience reduced stress
when returning to work after having a baby if
she received support in combining
breastfeeding with work.

 

15.

It would ppt be a safety concern if employees
had their babies brought to work to be breastfed
at this company.

 

l6.

Allowing storage of pumped milk at this
company would M present a safety concern.

 

17.

I would have a better relationship with an
employee if I helped her combine breastfeeding
with work.

 

18.

Co-workers would be pleased if I helped an
employee combine breastfeeding with work.

 

19.

I would be appreciated by other employees if I
helped an employee combine breastfeeding
with work.

 

20.

If I did pp! provide accommodations to a
breastfeeding employee, I would receive
complaints from other employees.

 

 

21.

Formula feeding costs more than breastfeeding.

 

 

 

 

122

 

 

Statement from the Manager’s Survey

Goodness-of-Fit for
Outcomes of Breastfeeding

 

 

 

 

health than formula feeding.

 

 

 

 

Low Moderate High
22. Breastfed infants have fewer health problems [:1 Cl C]
than formula-fed infants.
23. Breastfeeding is better for mothers’ mental E] El [:1
health than formula feeding.
24. Breastfeeding is better for mothers physrcal El [:1 Cl

 

Please provide any comments you may have regarding this category:

 

 

 

 

 

 

 

123

 

Thank you for your time reviewing this survey. Please take a few minutes to
answer additional questions concerning the survey.

1. Given with the existing four categories (i.e., individual support for breastfeeding,
company support for breastfeeding, outcomes of breastfeeding, and experience with
breastfeeding), are there any categories that need to be added, combined, or
eliminated?

 

 

 

2. Are there any statements not properly fitting the designated category?

 

 

 

3. What do you think of the phrase “combine breastfeeding with work”? Is it clear to
you?

 

 

 

4. What do you think of the term “breastfeeding support”? Is it clear to you?

 

 

 

124

5. In the Company Support for Breastfeeding category, there are questions about what
managers think of support for breastfeeding at companies in general M at their
company specifically. Do you think it is appropriate to have both types of
questions?

 

 

 

6. Do you have any other comments on statements content, clarity, appropriateness,
organization, or other suggestions?

 

 

 

 

 

 

 

 

 

--- Thank you for your time and help! ---

125

EXPERT REVIEW FORM (2)

Expert Review Form
Breastfeeding and Employment Study:
Manager Survey

Instructions:

1. Have a clear understanding of the four category definitions listed below;
you will be using them to evaluate the statements in the remaining

pages.

2. For each statement, select a category that best fits its definition.

 

 

 

Category Definition
Breastfeeding support provided by either
Individual Support for managers or co-workers toward employees
Breastfeeding who wish to combine breastfeeding with
work
Company Support for if??? ’éipffmfl’bi‘éfiiiééiif“
Breastfeeding p p y g

with work.

 

Health and cost outcomes of breastfeeding
Outcomes of Breastfeeding as well as positive and negative workplace
outcomes of breastfeeding support.

 

Experience with Manager’s personal or workplace
Breastfeeding experiences with breastfeeding.

 

 

 

 

126

 

Individual
support

Company
support

Outcomes

Expeflence

 

. A breastfeeding
employee would be as
productive as her co-
workers.

[:1

Cl

C]

 

. A written breastfeeding
support policy would
ensure consistent
accommodations across
the company.

 

. Accommodations for a

breastfeeding employee
can be handled on an as-
needed basis.

 

. Company’s healthcare
costs could be reduced
by providing
breastfeeding
accommodations.

 

. Allowing storage of
pumped milk at this
company would n_ot
present a safety concern.

 

. An employee who
combined breastfeeding
with work would still be
able to focus on her
responsibilities.

 

. I know other managers
who have supervised
employees who
combined breastfeeding
or pumping with work.

 

 

. An employee who could

continue breastfeeding
upon returning to work
would need to take
fewer days off.

 

 

 

 

 

127

 

 

Individual
support

Company
support

Outcomes

Expedence

 

Employees would feel
comfortable asking for
assistance to bring their
babies to work to
breastfeed.

 

10.

An employee’s morale
would increase if she
received support in
combining breastfeeding
with work.

 

11.

As a manager, I would
M feel limited by a
written policy that
specifies how to support
a breastfeeding
employee.

 

12.

Breastfed infants have
fewer health problems
than formula-fed infants.

 

13.

It is acceptable for
employees to request
assistance for
breastfeeding support.

 

14.

Companies would show
that it values its
employees if they have a
written policy for
breastfeeding support.

 

15.

I would feel more
comfortable speaking
with an employee about
breastfeeding or
pumping if she
approached me first.

 

 

16.

Co-workers would be
pleased if I helped an
employee combine
breastfeeding with work.

 

 

 

 

 

128

 

 

Individual
support

Company
support

Outcomes

Expeflence

 

17.

Having breastfeeding
accommodations would
help employee retention.

1:]

D

[:1

El

 

18.

I have had a partner who
breastfed and/or
pumped.

 

l9.

Co-workers would be
willing to cover the
duties of an employee if
she needed time to
breastfeed or pump.

 

20.

Employee’s loyalty
would increase if
companies provided
breastfeeding
accommodations.

 

21.

I would feel comfortable
supporting an employee
who wished to
breastfeed or pump at
work.

 

22.

It would pp! be a safety
concern if employees
had their babies brought
to work to be breastfed
at this company.

 

23.

Breastfeeding is better
for mothers’ mental

health than formula
feeding.

 

24.

Employees would feel
comfortable asking for
breastfeeding support.

 

 

25.

I would be more likely
to support a
breastfeeding employee
if she was a high
performer.

 

 

 

 

 

129

 

 

Individual
support

Company
support

Outcomes

Expefience

 

26.

The company should
provide information
about combining
breastfeeding with work
only to female
employees who become

pregnant.

 

27.

Employees would feel
comfortable with the
idea of a co-worker
breastfeeding (not
pumping) at work.

 

28.

I know of other
employees, m under
my supervision, who
have combined
breastfeeding or
pumping with work.

 

29.

Providing breastfeeding
support to an employee
requires more effort on
my part than supporting
her for other personal
needs.

 

30.

Employees would have
positive feelings if the
manager at this
company provided
support for
breastfeeding.

 

31.

If one of my employees
was breastfeeding or
pumping at work, I
would know about it.

 

32.

Employees would
support a co-worker
wishing to combine
breastfeeding with work.

 

 

33.

Formula feeding costs
more than breastfeeding.

 

 

 

 

 

130

 

 

Individual
support

Company
support

Outcomes

Expeflence

 

34. Having breastfeeding
accommodations would
help employee
recruitment.

El

 

35. If there were no
designated space for
breastfeeding or
pumping, I would
advocate for designated
space.

 

36. I believe that a restroom
is an acceptable place
for an employee to
breastfeed or pump.

 

37. I believe that providing
breastfeeding support to
an employee is a
reasonable
accommodation.

 

38. If an employee received
breastfeeding support,
she could return to work
sooner after having a
baby.

 

39. I would be appreciated
by other employees if I
helped an employee
combine breastfeeding
with work.

 

40. The company should
provide information
about combining
breastfeeding with work
to all of its employees.

 

 

41. I would p_o_t anticipate
negative co-worker
reactions if
breastfeeding support
was provided at work.

 

 

 

 

 

131

 

 

Individual
support

Company
support

Outcomes

Exponence

 

42.

I consider combining
breastfeeding or
pumping with work a
personal choice, not
something that I should
have to deal with.

 

43.

I have breastfed a baby
and/or pumped milk.

 

. I have helped find

accommodations for
breastfeeding or
pumping at the
workplace for
individuals other than
employees (e. g., clients,
customers).

 

45

. Breastfeeding is better

for mothers’ physical
health than formula
feeding.

 

46.

I have supervised an
employee who
combined breastfeeding
or pumping with work.

 

47.

Employees would feel
comfortable asking for
accommodations to
pump at work.

 

48.

Co-workers would be
willing to change work
schedules with an
employee if she needed
to breastfeed or pump.

 

 

49.

I would be more likely
to support a
breastfeeding employee
if I knew it was for a
limited period of time.

 

 

 

 

 

132

 

 

Individual
support

Company
support

Outcomes

Expeflence

 

50.

I would give an
employee flexibility to
arrange her work
schedule, so that she
could have sufficient
time to breastfeed or
pump at work.

 

51.

I would have a better
relationship with an
employee if I helped her
combine breastfeeding
with work.

 

52.

I would n_ot anticipate
co-worker jealousy if
breastfeeding support
was provided at work.

 

53.

I would seek help from
other people in this
company if I needed
help with supporting a
breastfeeding employee.

 

54.

If an employee needed
time to breastfeed or
pump, I would make
sure that her duties were
covered.

 

55.

If I did n_ot provide
accommodations to a
breastfeeding employee,
I would receive
complaints from other
employees.

 

 

56.

I believe that providing
breastfeeding support to
an employee is
necessary.

 

 

 

 

 

133

 

 

Individual
support

Company
support

Outcomes

Expefience

 

57.

Employees would have
positive feelings if this
company provided
breastfeeding
accommodations.

 

58.

If one of my employees
was considering
combining breastfeeding
or pumping with work, I
would know about it.

 

59.

It is more satisfying to
me to provide
breastfeeding support to
an employee than to
provide some other type
of personal support.

 

60.

Providing breastfeeding
support to an employee
is the same to me as
supporting her for any
other personal needs.

 

61.

I would feel comfortable
speaking with an
employee who wished to
combine breastfeeding
with work.

 

62.

If there were no
designated space for
breastfeeding or
pumping, I would find a
space for my employee.

 

 

63.

I would help an
employee balance her
job responsibilities so
she could breastfeed or
pump at work.

 

 

 

 

 

134

 

 

Individual
support

Company
support

Outcomes

Expedence

 

64.

It is acceptable for
employees to have their
babies brought to work
to breastfeed.

 

65.

An employee would
experience reduced
stress when returning to
work after having a
baby if she received
support in combining
breastfeeding with work.

 

66.

It is acceptable for
employees to pump at
work.

 

67.

Employees would have
improved job
satisfaction if companies
provided breastfeeding
accommodations.

 

68.

It is part ofmyjob as a
manager to help
employees combine
breastfeeding or
pumping with work.

 

69.

It is this company’s
responsibility to provide
breastfeeding support to
its employees.

 

 

70.

I believe that providing
breastfeeding support to
an employee requires
more company
resources than
supporting her for other
personal needs.

 

 

 

 

 

135

 

 

Individual
support

Company
support

Outcomes

Expefience

 

71.

It would be easier for
me to support a
breastfeeding employee
if our company had a
written policy for
breastfeeding support.

 

72.

It would contribute to a
positive public image if
companies provided
breastfeeding
accommodations.

 

73.

The company should
provide a space for
breastfeeding or
pumping that is close to
employees’ work areas.

 

74.

My employees would
consider it part of my
job to support an
employee who
combined breastfeeding
with work.

 

75.

My partner tried to
combine breastfeeding
or pumping with work.

 

76.

One or more of my
family members or
friends have had
experience with
breastfeeding or
pumping.

 

77.

Employees would feel
comfortable with the
idea of a co-worker
pumping at work.

 

 

78.

I have tried to combine
breastfeeding or
pumping with work.

 

 

 

 

 

136

 

 

Individual
support

Company
support

Outcomes

Expeflence

 

79.

One or more of my
family members or
friends have tried to
combine breastfeeding
or pumping with work.

[:1

 

80.

Providing breastfeeding
support is important
even if it is only needed
at times by a small
number of employees.

 

81.

The company should
provide a private space
for breastfeeding or
pumping so that an
employee does p_o_t need
to use a restroom for this

purpose.

 

82.

The company should
supply the equipment
(e.g., breast pump) that
employees would need
for pumping.

 

83.

Employees would feel
comfortable speaking to
their co-workers about
breastfeeding or

pumping.

 

84.

The rules introduced by
a labor union would
make it difficult to
support breastfeeding at
work.

 

8S.

Accommodations for a
breastfeeding employee
would be the same
across departments.

 

 

86.

I believe that providing
breastfeeding support to
an employee is fair.

 

 

 

 

 

137

 

 

 

breastfeeding support.

 

 

 

 

 

Individual Company .
support support Outcomes Experience
87. There is little employee
demand for 1:] El 1:] Cl

 

Thank you for your time reviewing this survey. Please take a few minutes to
answer additional questions concerning the survey.

7. Given with the existing four categories (i.e., individual support for breastfeeding,
company support for breastfeeding, outcomes of breastfeeding, and experience with
breastfeeding), are there any categories that need to be added, combined, or

eliminated?

 

 

 

 

8. Are there any statements not properly fitting the designated category?

 

 

 

 

9. What do you think of the phrase “combine breastfeeding with work”? Is it clear to

you?

 

 

 

 

138

 

10. What do you think of the term “breastfeeding support”? Is it clear to you?

 

 

 

 

11. Do you have any other comments on statements content, clarity, organization, or
other suggestions?

 

 

 

 

 

 

--- Thank you for your time and help! --—

139

EXPERT REVIEW FORM (3)

Expert Review Form
Breastfeeding and Employment Study:
Manager Survey

Instructions:

1. Read each statement on the questionnaire one at a time.

2. Comment on any statements you may have in the space below.
3. Answer the additional questions at the end.

 

Statement # Please provide comments you may have for any statements:

 

 

 

 

 

 

 

 

 

 

 

 

140

 

Statement it

Please provide comments you may have for any statements:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

141

 

Thank you for your time reviewing this survey. Please take a few minutes to
answer additional questions concerning the survey.

1. Given with the existing four categories (i.e., individual support for breastfeeding,
company support for breastfeeding, outcomes of breastfeeding, and experience with
breastfeeding), are there any categories that need to be added, combined, or
eliminated?

 

 

 

 

2. Are there any statements not properly fitting the designated category?

 

 

 

 

3. What do you think of the phrase “combine breastfeeding with work”? Is it clear to
you?

 

 

 

 

142

4. What do you think of the term “breastfeeding support”? Is it clear to you?

 

 

 

5. Do you have any other comments on statements content, clarity, organization, or
other suggestions?

 

 

 

 

 

 

--- Thank you for your time and help! --

143

APPENDIX C

144

EXPERT REVIEW RESULTS — ITEM’S FIT

Experience with Breastfeeding (Exp): manager’s personal or workplace

experiences with breastfeeding.

 

 

 

 

 

 

 

 

 

 

 

 

breastfeeding or pumping.

 

 

 

Statement erom the Manager’s 8:32:16; 00:13:;35' Category Fitting
“my Y N L M H Ind pr Out Exp
1. I have supervised an
employee who combined XX X XX xxxx
. . XX . X X
breastfeeding or pumping X (ind) X X x
with work.
2.1 know of other employees,
po_t under my supervision, XX X XX xxxx
who have combined xx . d x xx x
breastfeeding or pumping x (m ) x
with work.
3. I know other managers who
have supervised employees XX x x
who combined XX (ind) XX x X xx xxxx
breastfeeding or pumping X
with work.
4.1 have helped find
accommodations for
breastfeeding or pumping at XX X X XX X
the workplace for XX . d x x xx X
individuals other than x (m l ’0“
employees (e.g., clients,
customers).

5.1 have breastfed a baby 3:: X :X X x xxx
and/or pumped milk. x (ind) XX x
6.1 have tried to combine XX x XX xxxx

breastfeeding or pumping XX . X X

with work. x ("‘d) X x
7.1 have had a partner who XX: x X XX x xxxx

breastfed and/or pumped. x (ind) X X x
8. My partner tried to combine XX x xx xxxx

breastfeeding or pumping XX . x X

with work. X (1nd) X x
9. One or more of my family X X

members or friends have XX X XX x XX X xxxx

had experience with X (ind) x

 

145

 

 

 

 

 

 

 

 

Statement fi'oSm the Manager’s 83:23:: Gocpfdpietss- Category Fitting
“my Y N L M H Ind pr om Exp
10. One or more of my family
members or friends have XX X XX
tried to combine xx . d X xxxx
breastfeeding or pumping x (m )
with work.

 

Individual Support for Breastfeeding (Ind): breastfeeding support provided by
either managers or co-workers to help employees who wish to combine
breastfeeding with work.

 

 

 

 

 

 

 

 

 

 

 

Statement from the 8:553:12“ Goodpietss-of- Category Fitting
Manager 8 survey Y N L M H Ind cpy Out Exp
11. I would feel
comfortable speaking
. XX
With an employee who X XX xx
. . XX X X XX
Wished to combine XX (exp) XX XX
breastfeeding with
work.
12. I would feel more
comfortable speaking
with an employee about xx XX X xx XX xx x xx
breastfeeding or XX (exp) XX
pumping if she
approached me first.
13. I would feel
comfortable supporting XX XX XX XX
an employee who X (exp) XX XX
wished to breastfeed or X
pump at work.
14. It would be easier for
me to support a xxxx
breastfeeding employee (cpy) xx xx xxxx x x
if our company had a xx x
written policy for (exp)
breastfeeding support.
15. I would be more likely
to support a x (out)
breastfeeding employee x xx x x xx xxx
if she was a high xx (exp) x XX
performer.

 

146

 

 

 

Statement

Goodness-of-

 

 

 

 

 

 

 

 

 

itiagfiggisfisourpvteh; Sorting Fit Category Fitting
Y N L M H Ind pr Out Exp
16. I would be more likely
to support 3 xx xx xx
breastfeeding employee xx x (out) x x x x
if I knew it was for a x x xx
limited period of time.
17. If an employee needed x
time to breastfeed or xx (ex ) xx xx
pump, I would make p x xx
. xx x xx xx
sure that her duties
were covered. (CW)
18. I would help an
employee balance her xx
job responsibilities so xx xxx xx xx xx x
she could breastfeed or X (cp y) x x
pump at work.
19. I would give an
employee flexibility to
arrange her work x xx
schedule, so that she xx (CXP) xx xx xx
could have sufficient x xx x xx
time to breastfeed or (cp y)
piunp at work.
20. If there were no
designated space for x
breastfeeding or xx (exp) xx xx
pumping, I would find x xx x xx xx x x
a spelice for my (cpy)
emp oyee.
21. If there were no
designated space for
breastfeeding or xx x xx xx
. xx xx x x
pumping, I would (cpy) xx
advocate for designated x x
space.
22. My employees would
consider it part of my xx
job to support an xx (cpy) xx xx
employee who x x xx xx x x x
combined breastfeeding (exp) x

with work.

 

 

 

 

147

 

 

Statement

Goodness-of-

 

 

 

 

 

 

 

 

 

iiiagrearlngzisfisourpvtch; Sorting Fit Category Fitting
Y N L M H Ind pr Out Ex
23. I believe that providing
breastfeeding support x
to an employee is the xx (exp) xx xx xx x xx x
same to me as xx x x
supporting her for any (cpy)
other personal needs.
24. I believe that providing
breastfeeding support
to an employee requires xx x xx
more effort on my part xx (exp) x xx xx xx x x
than supporting her for X (out)
other personal needs.
25. I believe that providing
breastfeeding support x
to an employee requires (exp)
more company x xx x x xx xxxx x
resources than (out) X x
supporting her for other xx
personal needs. (CW)
26. I believe that providing xx
breastfeeding support (exp) xx
to an employee is a xx xx x xx xxx x
reasonable (cpy) xx
accommodation. x (out)
27. I believe that providing
breastfeeding support xx xx xx xx xx xx xx
to an employee is fair. xx (CW) x
28. I believe that restroom x
is an acceptable place (exp) xx xx
xx x (out) xx x xx
for an employee to x x x
breastfeed or pump. (cpy)
29. It is more satisfying to
me to provide
breastfeeding support xx
to an employee than to £68332) x xx x xx x xxx
provide some other x (ind)
type of personal
support.

 

 

 

 

148

 

 

 

 

 

 

 

 

 

 

 

Statement from the 8:32;!th Goodpietss-of- Category Fitting
Manager’s Survey g
Y N L M H Ind pr Out Exp
30. I would seek help from
other people in this xx
company if I needed xx £2523) x xx :3 x
help with supporting a xx
breastfeeding x x
employee. (exp)
31. I consider combining
breastfeeding or
pumping with work a xx xx xx xx
personal choice, not x (exp) xx x x x XXX
something that I should x (out)
have to deal with.
32. As a manager, I would
n_ot_ feel limited by a xx
written policy that xx (cpy) xx xx xx x xxx
specrfies how to xx x
support a breastfeeding (exp)
employee.
33. It is part ofmyjob as a
manager to help xx
employees combine xx (CW) x xx xx x x
breastfeeding or XX xx xx
pumping with work. (exp)
34. If one of my employees
was considering xxxx
combining (exp) xx
. x xx xx xx xx
breastfeeding or x x
pumping with work, I (cpy)
would know about it.
35. If one of my employees
was breastfeeding or xxxx xx xx
pumping at work, I xx (exp) x xx x xxx
would know about it.
36. Employees would have
positive feelings if this xx
company provided (out) x xx xxxx
breastfeeding xxxx xx xx
accommodations. (cp y)

 

 

 

 

149

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Statement Goodness-of- . .
flaggzisfisourpvtge Song Fit Category Fitting
Y N L M H Ind pr Out Exp
37. Employees would have
positive feelings if the xx
manager at this (cpy) xx xx
company provided xx x x xx x x xx
support for £252)
breastfeeding.
38. Employees would
support a co-worker xx xx xx
wishing to combine xx x (out) xx xx
breastfeeding with x x xx
work.
39. Co-workers would be
willing to change work xx xx xx
schedules with an xx x xx x
employee if she needed xx xx x
to breastfeed or pump.
40. Co-workers would be
willing to cover the xx x xx xx
duties of an employee xx (c ) xx xx
if she needed time to x py x xx
breastfeed or pump.
41. Employees would feel
comfortable speaking xx x xx xx
to their co-workers xx x x x
about breastfeeding or x (CW) xx xx
pumping.
42. Employees would feel
comfortable with the x xx
idea of a co-worker :: (cpy) x x xx x
breastfeeding (not x (out) xx
pumping) at work.
43. Employees would feel
comfortable with the xx xx xx
idea of a co-worker XX x (out) XX xx
pumping at work. x x
44. I would m1 anticipate
negative co-worker x (out) xx
reactions if xx x xx xx x xx x
breastfeeding support xx (exp) x
was provided at work.

 

150

 

Company Support for Breastfeeding (pr): breastfeeding support at the company
level that helps employees combine breastfeeding with work.

 

 

 

 

 

 

 

 

 

 

to all of its employees.

 

 

 

Statement from the Statement Goodness- Category Fitting
Manager’s Survey Sorting of-Fit
Y N L M H Ind ij Out Exp
45. A written breastfeeding
support policy would xx xx xxxx
ensure consistent xx x (out) xx x x
accommodations across x x
the company.
46. Accommodations for a
breastfeeding employee xx . x xx xx
can be handled on an as- xx x (1nd) x x x xx x
needed basis. x
47. Accommodations for a
breastfeeding employee xx xx xxxx
xx x x
would be the same across xx x
departments. xx
48. The company should
provide a private space
for breastfeeding or xx xx
pumping so that an xx xx xxxx x
employee does n_ot need xx x x
to use a restroom for this
purpose.
49. The company should
provide a space for xx xx
breastfeeding or pumping xx xx xx xx x x
that is close to xx x x
employees’ work areas.
50. The company should
supply the equipment xx xx
(e.g., breast pump) that xx xx xxxx x x
employees would need xx x
for pumping.
51. The company should
provide information xx xx
about combining xx xx xxxx x
breastfeeding with work xx x x

 

151

 

 

Statement

Goodness-

 

 

 

 

 

 

 

 

 

Statemeni from the Sorting o f-Fi t Category Fitting
Manager 3 Survey
Y N L M H Ind pr Out Exp
52. The company should
provide information
about combining xx xxxx
breastfeeding with work xx X (out) xx xx x x
only to female employees x
who become pregnant.
53. Providing breastfeeding
support is important even xx
if it is only needed at xx x x xx xx x x xx
times by a small number x (exp) xx x
of employees.
54. It is acceptable for
xx xx
employees to request x xx
assistance for xx (exp) xx x x xx
breastfeeding support. x x
55. It is acceptable for x (out) xx
employees to pump at xx xx xx xx x x
work. x (exp) x x
56. It is acceptable for
. . x (out) xx
employees to bring their xx
babies to work to x xx XX xx xx x x
breastfeed. (exp) X
57. There is little employee x (out)
. xxxx
demand for breastfeeding xx xx xx x x x
support. (exp)
58. It is this company’s
responsibility to provide xx xx
breastfeeding support to f): x: x xxxx x

its employees.

 

 

 

 

152

 

Outcomes of Breastfeeding (Out): health and cost outcomes of breastfeeding as
well as positive and negative workplace outcomes of breastfeeding support.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Statement from the Statement Goodness- Category Fitting
Manager’s Survey Sorting of Fit
Y N L M H Ind pr Out Exp
59. The rules introduced by
a labor union would xxx
make it difficult to xx (cpy) x x xx xxx x xx
support breastfeeding x (exp) x
at work.
60. Having breastfeeding
accommodations would xx xx
help employee :3 x xx x x xxxx
retention.
61. Company’s healthcare
costs could be reduced xx xx xxxx
by providing xx xx x
breastfeeding xx x x
accommodations.
62. Having breastfeeding
. xx xx
accommodations would
help employee :2: x: x xx xxx
recruitment.
63. It would contribute to a
positive public image if xx xx xxxx
companies provided xx x (cpy) x
breastfeeding x xx xx
accommodations.
64. Companies would
show that it values its
employees if they have x xxxx x x xx x xxx xx
a written policy for (CW) x
breastfeeding support.
65. Employees would have
improved job
satisfaction if XX xx xxxx
companies provided xx x (cp y) x xx x
breastfeeding x
accommodations.
66. If an employee
received breastfeeding xx xxxx
support, she could xx xx xx x
return to work sooner xx
after havinga baby.

 

153

 

 

Statement from the
Manager’s Survey

Statement
Sorting

Goodness-
ofFfi

Category Fitting

 

Y N

LMH

Ind pr Out Exp

 

67.

A breastfeeding
employee would be as
productive as her co-
workers.

xx xx (exp)
x x (ind)

XX
XX
X

 

68.

An employee who
could continue
breastfeeding upon
returning to work
would need to take
fewer days off.

xx
xx x (cpy)

XX
XX

XXXX

 

69.

An employee who
combined breastfeeding
with work would still
be able to focus on her
responsibilities.

x (cm)
x (cm)
x (ind)

XX

XX
XX

X XX XXX

 

70.

An employee’s morale
would increase if she
received support in
combing breastfeeding
with work.

XX
xx x (cm)

XX

 

71.

Employee’s loyalty
would increase if
companies provided
breastfeeding
accommodations.

3855?

XX
XX

X XXX XX

 

72.

An employee would
experience reduced
stress when returning to
work after having a
baby if she received
support in combining
breastfeeding with
work.

xx x (cpy)

XX
XX

XXXX

 

73.

It would M be a safety
concern if employees

brought their babies to
work to be breastfed at
this company.

XXXX

xx (pr)

XX
XX

 

 

74.

Allowing storage of
pumped milk at this
company would n_ot
present a safety
concern.

 

XXXXX
(pr)

 

 

X XXX XX

 

154

 

 

Statement Goodness-

Statement from the Sorting of-Fit

Category Fitting

 

Manager 3 Survey Y N L M H Ind pr Out Exp

 

75. I would have a better
relationship with an
employee if I helped xx (ind)
her combine x xxx x xx x x xxx x
breastfeeding with (exp)
work. (now placed
under Ind)

 

76. If I did n_o_t provide
accommodations to a
breastfeeding xxx
employee, I would xx (ind) x x xx xx x xx x
receive complaints x (exp)
from other employees.
(now placed under Ind)

 

77. Formula feeding costs
more than
breastfeeding.

XX X XXXX X

§§§

 

78. Breastfed infants have
fewer health problems
than formula-fed
infants.

XX X
XX

XX XXX X

55?:

 

79. Breastfeeding is better xx
for mothers’ mental xx x xx x xxx x
health than formula x x

feeding.

 

 

80. Breastfeeding is better

for mothers’ physical xx x xx x xxxx
health than formula xx x
feeding.

 

 

 

 

155

 

SUMMARY OF THE EXPERTS’ REVIEWS

Experts’ input (n=31) resulted in a number of improvements to the instrument.
Changes to the instrument were based on consensus between the primary investigator

and the co-investigator. Their comments are summarized into the following categories.

1. Minor grammatical issues were addressed to improve readability and clarity. Two
examples are provided below.
a. Origian item: I have supervised an employee who combined breastfeeding
or pumping with work.
Revised item: I have supervised an employee(s) who combined
breastfeeding or pumping with work.
b. Original item: Companies would show that it values its employees if they
have a written policy for breastfeeding support.
Revised item: Companies would show that they value their employees if

they have a written policy for breastfeeding support.

2. Some survey items were placed into a new designated category that better fit with
the definition of the category. Two examples are provided below.
a. If one of my employees was considering combining breastfeeding or
pumping with work, I would know about it.
This item was initially included in the Experience with Breastfeeding
category, but now it has been placed under Individual Support for

Breastfeeding category. The reason is that this item was intended to assess

156

manager’s awareness of whether his/her employee(s) was considering

breastfeeding or pumping with work.

b. If I did pp! provide accommodations to a breastfeeding employee, I would
receive complaints from other employees.

This item was initially included in the Concerns and Benefits of
Breastfeeding category, but now it has been placed under Individual Support
for Breastfeeding category. The reason is that this item was intended to
assess manager support for breastfeeding, whether he/she would receive
complaints from other employees if breastfeeding accommodations were not

provided.

3. Others comments:
a. Most experts indicated that the four categories: (i) Individual Support for
Breastfeeding, (ii) Company Support for Breastfeeding, (iii) Concerns and
Benefits of Breastfeeding, and (iv) Experience with Breastfeeding, were

sufficient and no categories needed to be combined or eliminated.

b. Most experts reported that in the Company Support for Breastfeeding
category, it was appropriate and important to have both types of questions
asking what managers think of support for breastfeeding at companies in

general and at their company specifically.

157

C.

One additional term was defined on the front page of the instrument. This
term was “breastfeeding support” and it was defined as, any formal and
informal forms of assistance and behaviors that help women to combine
breastfeeding and work. The reason is that some experts were not certain
about what breastfeeding support was included. The definition would
provide a consistent understanding of “breastfeeding support” for the

respondents.

Clarifications were made to survey items related to how managers perceive
workplace support for breastfeeding from their employees’ perspectives.
Those items were designed to capture managers’ impressions of their
employees’ perceptions. An example is provided below.

i. Original item: My employees would consider it part of my job to
support an employee who combined breastfeeding with work.
Revised item: I believe that my employees would consider it part of
my job to support an employee who combined breastfeeding with

work.

158

SUMMARY OF THE COGNITIVE INTERVIEWS

Eight cognitive interviews were conducted with managers who had experience
with managing female employees. Changes to the instrument were based on consensus
between the primary investigator and the co-investigator. Participants’ comments are

summarized into the categories below.

1. Most comments were related to rewording of the items to improve readability and
clarity. Two examples are provided below.

a. (i) It is acceptable for employees to bring their babies to work to be
breastfeed.
(ii) It is acceptable to have their babies brought in to work for

breastfeedings.

Item (i) was found unclear whether babies were at work with

employees during work hours or babies were only brought to the workplace
by employees’ family members or fi'iends to be breastfed. Therefore, item

(i) was reworded as shown in item (ii) for clarification.

b. (i) It is acceptable for employees to request assistance for breastfeeding
support.
(ii) It is acceptable for employees to request breastfeeding accommodations.
The word “assistance” in item (i) was found confusing. Interview

participants were not certain whether “assistance” was related to financial,

159

structural, or emotional assistance. Therefore, item (i) was reworded as
shown in item (ii) for clarification.
2. Two survey items were replaced to better address the intent of the items. Two
examples are provided below.
a. (i) It is this company’s responsibility to provide breastfeeding support to its

employees.
(ii) It is a right thing for this company to provide breastfeeding support to its
employees.

Item (i) was changed to item (ii), because interview participants
indicated that item (ii) would be more appropriate to assess the degree of
workplace breastfeeding support than item (i). In addition, the researchers

felt that item (ii) would be more relevant and important.

b. (i) The company should provide information about combining breastfeeding
with work to all of its employees.
(ii) The company should include information about breastfeeding
accommodations in the employee handbook.

Item (i) was replaced by item (ii), because interview participants felt
that item (i) was too general, which did not specify where the information
would be provided. They suggested that the employee handbook would be
an appropriate place to distribute the information to all of the employees in

the company.

160

3. The following item was eliminated, “I believe that providing breastfeeding support
to an employee is necessary”, because of its lack of relevance to the purpose of this
instrument. This item was found unclear in asking whether providing breastfeeding
support to an employee is necessary for what specific purpose such as medical or
other personal reasons. This instrument has two additional items, “I believe
providing breastfeeding support to an employee is a reasonable accommodation ”
and ” I believe providing breastfeeding support to an employee is fair ”, which the
researchers felt these two items would more accurately address the intent of the

items.

4. No additional subscales were reported to be necessary and no survey items were
frequently reported by the interview participants as needing an alternative option to
“neither agree nor disagree”. Therefore, this instrument will remain as four
subscales with a four-point Likert scale to maximize response rate for each survey

item.

161

 

FINAL INSTRUMENT

The Breastfeeding and Employment Study:

 

MANAGER STUDY

 

 

Instructions:

1. Please answer each statement in this questionnaire as it pertains to
full-time employees.

2. Please provide one response per statement unless otherwise specified.

3. Please use a pen and check appropriate boxes to complete this
questionnaire.

4. Please use the last page to provide additional comments you may
have.

Terms:

1. “Breastfeeding” refers to women directly nursing their infants or
young children from the breast.

2. “Pumping” refers to women pumping breast milk either by hand
expression, or by using a manual or electric pump, and storing it for
later use.

3. "Breastfeeding Support" refers to any formal and informal forms of
assistance and behaviors that help women to combine breastfeeding
with work.

4. “Company” refers to any place of employment whether it be non-

profit or for-profit organizations, private or public sectors, educational
or government bodies.

162

 

 

Individual Support for Breastfeeding

 

This category includes two sections about breastfeeding support provided by either

managers or co-workers. It pertains to your current place of employment.

The following section asks about your supportiveness, as a manager, of employees who
wish to combine breastfeeding with work. Please respond to each statement about

employees who report to you on a regular basis.

 

Strongly

agree Agree Disagree

Strongly
disagree

 

1. I would feel comfortable speaking
with an employee who wished to Cl Cl [I
combine breastfeeding with work.

Cl

 

2. I would feel more comfortable
speaking with an employee about I] E] El
breastfeeding or pumping if she
approached me first.

 

3. I would be more likely to support a
breastfeeding employee if she was Cl C] E]
a high performer.

 

4. I would be more likely to support a
breastfeeding employee if I knew D E] C]
it was for a limited period of time.

 

5. If an employee needed time to
breastfeed or pump, I would make Cl C] C]
sure that her duties were covered.

 

6. I would help an employee balance
her job responsibilities so she E] E] El
could breastfeed or pump at work.

 

7. I would give an employee
flexibility to arrange her work
schedule, so that she could have [:1 Cl C]
sufficient time to breastfeed or
pump at work.

 

8. If there were no designated space
for breastfeeding or pumping, I [:1 Cl C]
would find a space for my
employee.

 

9. If there were no designated space
for breastfeeding or pumping, I E] E] El
would advocate for designated
space.

 

 

 

 

 

 

163

 

 

 

Strongly
agree

Agree

Disagree

Strongly
disagree

 

10.

If one of my employees was
considering combining
breastfeeding or pumping with
work, I would know about it.

Cl

El

E1

 

11.

If one of my employees was
breastfeeding or pumping at work,
I would know about it.

 

12.

If I did git provide
accommodations to a
breastfeeding employee, I would
receive complaints from other
employees.

 

13.

It is part of my role as a manager
to help employees who wish to
combine breastfeeding or pumping
with work.

 

14.

I believe that my employees would
consider it part of my role to
provide breastfeeding support.

 

15.

I believe that my employees would
think I am a better manager if I
provided breastfeeding support.

 

16.

I would have a better relationship
with an employee if I helped her
combine breastfeeding with work.

 

17.

I believe that providing
breastfeeding support to an
employee is the same to me as
supporting her for any other
personal needs.

 

18.

I believe that providing
breastfeeding support to an
employee is a reasonable
accommodation.

 

19.

I believe that providing
breastfeeding support to an
employee is fair.

 

 

20.

I do n_ot believe that providing
breastfeeding support to an
employee requires more effort on
my part than supporting her for
other personal needs.

 

 

 

 

 

164

 

 

Strongly
agree

Agree

Disagree

Strongly
disagree

 

21.

I do 93! believe that providing
breastfeeding support to an
employee requires more company
resources than supporting her for
other personal needs.

Cl

C]

 

22.

I do n_ot believe that a restroom is
an acceptable place for an
employee to breastfeed or pump.

 

23.

It is more satisfying to me to
provide breastfeeding support to
an employee than to provide some
other type of personal support.

 

24.

It would be easier for me to
support a breastfeeding employee
if our company had a written
policy for breastfeeding
accommodations.

 

25.

I would seek help from other
people in this company if I needed
help supporting a breastfeeding
emplglee.

 

26.

I consider combining
breastfeeding with work an
employee’s personal choice, and

not something I should have to
deal with.

 

27.

I would at feel limited by a
written policy that specifies how to
support a breastfeeding employee.

 

 

28.

I would n_ot anticipate negative co-
worker reactions if breastfeeding
support was provided at work.

 

 

 

 

 

165

 

The following section asks about your general expectations of co-workers' support
toward employees who wish to combine breastfeeding with work. In each of the
following statements, "employees" refers to employees in general, but not limited to
your direct reports in this company.

 

Strongly
agree

Agree

Disagree

Strongly
disagree

 

29.

Employees would feel comfortable
speaking to their co-workers about
breastfeeding or pumping.

D

E]

 

30.

Employees would feel comfortable
with the idea of a

co-worker breastfeeding (not
pumping) at work.

 

31.

Employees would feel comfortable
with the idea of a
co-worker pumping at work.

 

32.

Employees would support a co-
worker wishing to combine
breastfeeding with work.

 

33.

Employees would have positive
feelings if this company provided
breastfeeding accommodations.

 

34.

Employees would have positive
feelings if the manager(s) at this
company provided support for
breastfeeding.

 

35.

Co-workers would be willing to
adjust work schedules with an
employee if she needed to
breastfeed or pump.

 

 

36.

Co-workers would be willing to
cover the duties of an employee if
she needed time to breastfeed or

pump.

 

 

 

 

 

166

 

 

 

Company Support for Breastfeeding

 

This category has two sections about support for breastfeeding at companies in general
and at your company specifically.

The following section pertains to support provided at companies in general to help
employees who wish to combine breastfeeding with work.

 

Strongly
agree

Agree

Disagree

Strongly
disagree

 

37.

A written breastfeeding support
policy would ensure consistent
accommodations across the
company.

[:1

E]

El

E1

 

38.

Accommodations for a
breastfeeding employee can be
handled on an as-needed basis.

 

39.

Accommodations for a
breastfeeding employee should be
the same across departments.

 

40.

A company should provide a
private space for breastfeeding or
pumping that is lg a restroom
stall.

 

41.

A company should provide a space
for breastfeeding or pumping that
is close to employees’ work areas.

 

42.

A company should supply the
equipment (e. g., breast pump) that
employees would need for
Running-

 

43.

A company should include
information about breastfeeding
accommodations in the employee
handbook.

 

44.

A company should provide
information about combining
breastfeeding with work only to
female employees who become

pregnant.

 

 

45.

A company should provide
breastfeeding support even if it is
only needed at times by a small
number of employees.

 

 

 

 

 

167

 

 

The following section pertains to support provided Qvou; company to help employees
who wish to combine breastfeeding with work.

 

 

 

 

 

 

 

accommodations to its
employees.

 

 

 

 

Strongly . Strongly
agree Agree Disagree disagree
46. It is acceptable for employees to
request breastfeeding C] [:1 Cl C]
accommodations at this company.
47. It is acceptable for employees to
have their babies brought to work
for breastfeedings at this D D D D
company.
48. It is acceptable for employees to E] E] Cl [:1
pump at work at this company.
49. There is little demand for
breastfeeding support by Cl Cl C] E]
employees at this company.
50. It is a right thing for this company
to provide breastfeeding E] El Cl C]

 

51.

52.

This company has a written policy for breastfeeding support.

Cl Yes
[I No
C] Do not know

This company has a designated space(s) for breastfeeding or pumping (other than

a restroom).

[:1 Yes

D No

C] Do not know

168

 

 

 

Concerns and Benefits of Breastfeeding

 

 

This category includes two sections about concerns and benefits of supporting

breastfeeding in the workplace as well as health and cost outcomes of breastfeeding.

Please respond to each of the following statements to your best ability.

 

Strongly

agree Agree Disagree

Strongly
disagree

 

53. The rules introduced by a labor
union would make it difficult to E] E] El
support breastfeeding at work.

Cl

 

54. Allowing storage of pumped milk at
this company would 991 present a [3 E] El
safety concern.

[:1

 

55. It would M be a safety concern at
this company if employees had their [:1
babies brought to work for
breastfeedings.

 

56. It would contribute to a positive
public image if companies provided [:1 Cl C]
breastfeeding accommodations.

 

57. Having breastfeeding
accommodations would help D Cl [:1
employee retention.

 

58. Having breastfeeding
accommodations would help E] El [:1
employee recruitment.

 

59. Companies’ healthcare costs would
be reduced by providing [:1 D C]
breastfeeding accommodations.

 

60. Companies show that they value
their employees if they have a Cl C]
written policy for breastfeeding
accommodations.

 

61. Employees would have improved
job satisfaction if companies [:1 Cl
provided breastfeeding
accommodations.

 

62. Employees’ loyalty would increase
if companies provided breastfeeding E] Cl C]
accommodations.

 

63. Employees would be pleased if a
manager helped an employee El D E]
wishing to combine breastfeeding
with work.

 

 

 

 

 

 

169

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Strongly . Strongly
agree Agree Disagree disagree
64. If an employee received
breastfeeding support, she would
return to work sooner after having a D D E] D
baby.
65. A breastfeeding employee would be
as productive as her E] Cl C] C]
co-workers.
66. An employee who could continue
breastfeeding upon returning to
work would need to take fewer days D D D D
off.
67. An employee’s morale would
increase if she received support in E] El [3 Cl
combining breastfeeding with work.
68. An employee would experience
reduced stress if breastfeeding E] Cl E! El
accommodations were provided.
The following section asks about health and cost outcomes of breastfeeding.
Agree Disagree
69. Formula feeding costs more than breastfeeding. El Cl
70. Breastfed infants have fewer health problems than
. E] El
formula-fed infants.
71. Compared to formula feeding, breastfeeding is better for E] El
mothers’ mental health.
72. Compared to formula feeding, breastfeeding is better for E] D

 

mothers’ physical health.

 

 

 

170

 

 

 

 

Experience with Breastfeeding

 

This category includes two sections about your workplace and personal experiences
with breastfeeding. Please answer each statement either yes or no. Then, if applicable,
check the box that best describes your opinion.

The following section pertains to your past and current workplace experiences with
employees who combined breastfeeding with work.

72. I have supervised an employee(s) who combined breastfeeding or pumping with

73.

74.

75.

 

 

work.
D No (IF NO, skip to Question #74)
E] Yes
IF YES: I had an overall positive experience with this employee(s).
Strongly agree Agree Disagree Strongly disagree
E] E] E] D

 

 

 

 

 

I know of other employees, go_t under my supervision, who have combined
breastfeeding or pumping with work.
Cl No (IF NO, skip to Question #75)

 

 

D Yes
L’ IF YES: It appeared to me that these em algees had positive experiences.
Strongly agree Agree Disagree Strongly disagree
El [3 Cl C]

 

 

 

 

 

I know other managers who have supervised employees who combined
breastfeeding or pumping with work.
[:1 No (IF NO, skip to Question #76)

Cl Yes

L"IF YES: It appeared to me that these managers had positive experiences with

their enmloyees.

 

Strongly agree

Agree

Disagree

Strongly disagree

 

 

D

 

Cl

 

El

 

Cl

 

I have helped find accommodations for breastfeeding or pumping at the workplace

for individuals other than employees (e. g., clients, customers).

C] No (IF NO, skip to Question #77 on the next page)

 

 

[:1 Yes
IF YES: My experience in making this accommodation was Dositive.
Strongly agree Agree Disagree Strongly disagree
1:] E] D D

 

 

 

 

 

171

 

 

 

 

 

The following section pertains to your past and current personal experiences with
breastfeeding.

If you are female, please answer questions 77 and 78.
If you are male, please answer questions 79 and 80.

 

Females

 

76. I have breastfed a baby and/or pumped milk.

C] No (IF NO, skip to Question #81 on the next page)

D Yes

I" IF YES: My experience was positive.

 

Strongly agree

Agree

Disagree

Strongly disagree

 

 

Cl

 

Cl

 

Cl

 

Cl

 

77. I have tried to combine breastfeeding or pumping with work.

C] No (IF NO, skip to Question #81 on the next page)

E] Yes

IF YES: My experience was positive.

 

 

 

 

 

 

 

 

 

 

Males

 

 

 

 

 

Strongly agree Agree Disagree Strongly disagree
[:1 E] El E1
78. I have had a partner who breastfed and/or pumped.
C] No (IF NO, skip to Question #81 on the next page)
E] Yes
IF YES: Her experience was positive.
Strongly agree Agree Disagree Strongly disagree
Cl Cl Cl C]

 

 

 

 

79. My partner tried to combine breastfeeding or pumping with work.

CI No (If NO, skip to Question #81 on the next page)

E] Yes

IF YES: Her experience was positive.

 

Strongly agree

Agree

Disagree

Strongly disagree

 

 

 

 

El

 

E]

 

D

 

El

 

 

 

 

 

80. One or more of my family members or friends (other than my partner) have had
experience with breastfeeding or pumping.
E] No (If NO, skip to Question #83)

 

 

Cl Yes
IF YES: I perceived their overall experience to be positive.
Strongly agree Agree Disagree Strongly disagree
[:1 C] [3 Cl

 

 

 

 

 

 

81. One or more of my family members or friends (other than my partner) have tried to
combine breastfeeding or pumping with work.
E] No (IF NO, skip to Question #83)

 

 

El Yes
IF YES: I perceived their overall experience to be positive.
Strongly agree Agree Disagree Strongly disagree
El [:1 Cl CI

 

 

 

 

 

 

 

 

Demographic Information

 

Reminder: Any information you provide in this survey will be kept confidential.

82. How many companies have you worked at including your current job?

Companies

 

83. How many years have you been in a management position at your current job?

Years

 

84. Including previous work experience, how many years have you been in a
management position?

Years

 

173

 

85

86.

87.

88

89.

90.

. What is the approximate number of people you currently manage directly?

People

 

What is your job title?

 

What percentage of the employees you manage are women?
[:1 O-25%

C] 26-50%

C] 51-75%

[:1 76-100%

. Are any of the women you manage within childbearing age?

Cl Yes
1:] No
C! Do not know

How many employees are employed at this company?

[:1 < 50

[:1 50 — 99

[J 100 - 499

El 500 — 999

[I] 1,000 — 4,999
E] _>_ 5,000

Which of the following best describes your company’s primary industry? [Please
choose only one]

[:1 Communication

[:1 Finance

[3 Health Care

C] Insurance

D Administration

El Education

Cl Real Estate

El Utilities

[:1 Other (Please specify):

 

174

91.

92.

93.

94.

95.

96.

What is your gender?

C] Male
[3 Female

What is your age? Years

 

What is your marital status?

Cl Married

(:1 Separated

El Divorced

El Widowed

[:1 Never married

CI Partner not married

Which of the following ethnicity do you consider yourself? [Please mark one]

C] Hispanic or Latino
Cl Non-Hispanic or Non-Latino

What race do you consider yourself to be? [Please choose all that apply]

C] White
Cl Black or African American

Cl American Indian or Alaska Native

D Asian

C] Native Hawaiian or Other Pacific Islander
Cl Other (Please specify):

 

What is the highest level of education you have completed?

E] Less than high school
C] High school diploma or GED

[:1 Some college

D 2-year college degree (Associates)
E] 4-year college degree (BS, BA.)
El Masters degree/MBA

El Doctoral degree

C] Professional degree (M.D., J.D.)
El Other (Please specify):

 

175

97. Thank you for your time completing this survey. Please provide any other
comments you may have.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

176

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