Factors Associated with Exclusive Breastfeeding Practice by Mothers who Work as Health Workers

Introduction: Health workers play a notable role as "the significant others" in increasing maternal awareness and participation in fulfilling exclusive breastfeeding practices. In this case, female health workers tend to be the role models for other mothers in the community, including their child-feeding behavior. Based on the existing knowledge and work experience, female health workers should be able to breastfeed their babies exclusively. Yet several previous studies have shown the opposite result. This study aimed to analyze the factors associated with exclusive breastfeeding practice by mothers who work as health workers in Tulungagung Regency Public Health Centers. Methods: This study used a cross-sectional method. The sample in this study was 56 breastfeeding mothers who work as health workers in Tulungagung Regency Public Health Centers, selected by purposive sampling technique. Data were collected using a questionnaire and analyzed using the Chi-Square correlation test with a confidence limit of α=0.05. Results: Knowledge (p=0.091), attitude


INTRODUCTION
Exclusive breastfeeding is a fundamental right that is inherent in every baby born (Pemerintah Republik Indonesia, 2012). The impact of not exclusively breastfeeding includes: long-term cognitive loss, increased susceptibility to disease in mothers and children, and increased family spending on medication and purchasing formula milk (Fadhila and Ninditya, 2016).
Based on the data of Tulungagung Regency Public Health Office, the percentage of exclusive breastfeeding in Tulungagung Regency in 2019 is 68%, still far below the percentage of East Java Province exclusive breastfeeding coverage, which reached 78,3% (Dinas Kesehatan Provinsi Jawa Timur, 2020). Those data showed that there are still many people who don't know the importance of exclusive breastfeeding. They feed their babies with formula or a combination of formula and breast milk.
The breastfeeding mothers who go back to work have a greater chance of not giving exclusive breastfeeding than those who do not (Sari, 2016;Bahriyah, Jaelani and Putri, 2017;Khaliq et al., 2017). Based on several previous studies, working mothers tend not to give exclusive breastfeeding to their babies due to various factors, including poor knowledge and negative attitude towards exclusive breastfeeding, duration of working hours, duration of maternity leave, shyness of breastfeeding or pumping in the workplace, the lack of support for breastfeeding facilities in the workplace, lack of support from superiors, family, husband, coworkers, and health workers (Al-Darweesh et al., 2016;Soomro et al., 2016;Altamimi et al., 2017;Chhetri, Rao and Guddattu, 2018;Osibogun, Olufunlayo and Oyibo, 2018;Kim, Shin and Donovan, 2019;Gebrekidan et al., 2020).
One of the sectors most occupied by women is working as health workers. Based on the World Health Organization data in 2019, the involvement of women in the health and social sectors is increasing from year to year, and the numbers reached 70% in 104 countries studied (Boniol et al., 2019). In Indonesia, 1,326,227 women work in the health and social sectors. The percentage is 2.52%, three times more than men in the same sector (BPS, 2019). Based on Profil Kesehatan Jawa Timur 2019, the amount of health workers in all of the Tulungagung Regency Public Health Centers is 1004 people, with a percentage of female health workers at 83.57% and male health workers at 16.43% (Dinas Kesehatan Provinsi Jawa Timur, 2020).
The involvement of women in the health and social sectors that is increasing from year to year are expected to improve the health status of the community through women's empowerment programs, including empowering women to breastfeed their babies exclusively. Based on the existing knowledge and experience, female health workers who are still actively working should be able to breastfeed their babies exclusively.
Female health workers' experience breastfeeding their babies is expected to help them confidently and effectively educate other breastfeeding women in the community (Sadoh, Sadoh and Oniyelu, 2011).
Some researchers (Budiyanto, Asti and Yuwono, 2015;Damayanti, 2015;Septiani, Budi and Karbito, 2017;Ambarwati and Mutias, 2020;Putu et al., 2020;Widayati, Sulistianingsih and Saputri, 2020) have conducted studies related to exclusive breastfeeding by health workers previously. Those studies indicate a low percentage of exclusive breastfeeding given by breastfeeding mothers who work as health workers. In a row, the percentage of exclusive breastfeeding by mothers who work as health workers in those studies was 3,1%; 49,2%; 57,4%; 38,7%; 61,9.%; 43%. A study conducted on 32 breastfeeding mothers who work in the WHO office has shown the same result. There is 56% of respondents said that they gave formula milk to their babies. Back to work and not having enough breast milk were the most common factors that caused them to stop breastfeeding their babies (Iellamo, Sobel and Engelhardt, 2015).
A study conducted by Wibowo in 2016 stated that emotional attachment from significant others such as mother, mother-inlaw, husband, health cadres, neighbor, and other experienced people have an essential role in providing informational support regarding the importance of exclusive breastfeeding. Building a positive and supportive environment among breastfeeding mothers is an important thing done by significant others to encourage the realization of exclusive breastfeeding practice after the breastfeeding mothers have received informational support previously (Wibowo, 2016). In this case, female health workers tend to be the role models for other mothers in the community, including their child-feeding behavior. The decision made by female health workers to exclusively breastfeed or not exclusively breastfeed their babies is likely to be followed by other community members (Sadoh, Sadoh and Oniyelu, 2011). Thus the low percentage of exclusive breastfeeding practice by mothers who work as health workers in previous studies is a severe problem for the exclusive breastfeeding campaign in the community. This study aimed to analyze the factors associated with exclusive breastfeeding practice by mothers who work as health workers in Tulungagung Regency Public Health Center.

Design
This study was a quantitative study using a cross-sectional approach.

Population, Samples, and Sampling
The population of this study was all mothers who worked as health workers in Tulungagung Regency Public Health Centers and had babies aged 6-24 months by July 2021. The population in this study was 85 breastfeeding mothers.
The sample in this study was 56 breastfeeding mothers who work as health workers in Tulungagung Regency Public Health Centers, selected by purposive sampling based on the inclusive and exclusion criteria set before.
The inclusive criteria of this study include: 1) the mother is a health worker who works in Tulungagung Regency Public Health Centers, 2) the mother had breastfed, and when the study was conducted the baby was 6-24 months old, 3) the mother had returned to work when the baby was 0-6 months old, 4) the mother was willing to be a respondent in this study.
The exclusion criteria of this study include: 1) the baby has galactosemia, maple syrup urine disease, or phenylketonuria which is a contraindication to breastfeeding, 2) the baby was born prematurely at less than 32 weeks of gestation or a birth weight fewer than 1500 grams, 3) the mother had breast surgery which caused the breast milk glands not to function properly, 4) the mother suffers from severe illness such as psychosis, sepsis, or eclampsia so that it was challenging to give breast milk to the baby (Ikatan Dokter Anak Indonesia, 2013), 5) the mother refused or withdrawn its availability in being a respondent in this study.

Variables
The dependent variable in this study was exclusive breastfeeding practice by mothers who work as health workers. The independent variables of this study were knowledge and attitude related to exclusive breastfeeding and lactation management, working shifts, availability of breastfeeding facilities in the workplace, husband's support, and family support.

Instruments
Data in this study were collected using a questionnaire. The respondent's demographic characteristics consist of 6 questions and the specific variables data comprised 27 questions.
The questionnaire about knowledge related to lactation management and exclusive breastfeeding consists of six multiple-choice questions developed by the researchers based on the theory from Midwives and Lecturers of Midwifery Indonesia (Bidan dan Dosen Kebidanan Indonesia, 2017). The validity test results on this questionnaire were 0.647 (the highest value) and 0.442 (the lowest value). The result of the reliability test was 0.486.
The questionnaire about attitudes related to lactation management and exclusive breastfeeding was measured using a Likert scale with five statements. This questionnaire was a modification of the questionnaire in Dewi's study (Dewi, 2011). The validity test results on this questionnaire were 0.805 (the highest value) and 0.483 (the lowest value). The result of the reliability test was 0.530.
The questionnaire about working shifts consisted of one question with two answer: yes and no. This variable has two categories: 1) there were working shifts, 2) there were no working shifts.
The questionnaire about the husband's support was measured using a Likert scale with eight statements. This questionnaire was a modification of the questionnaire in Hargi, Hani, and Vera's study ((Hargi, 2013;Hani, 2014;Vera, 2017). The validity test results on this questionnaire were 0.867 (the highest value) and 0.573 (the lowest value). The result of the reliability test was 0.825.
The questionnaire about family support was measured using a Likert scale with five statements. This questionnaire was a modification of the questionnaire in Kinasih's study (Kinasih, 2017). The validity test results on this questionnaire were 0.800 (the highest value) and 0.593 (the lowest value). The result of the reliability test was 0.757.
The questionnaire about exclusive breastfeeding practice consisted of 2 questions. This variable has two categories: 1) exclusive breastfeeding if the baby is only given breast milk, vitamins, minerals, syrups, and or oral rehydration solutions for the first six months of life and gets food or drinks other than those mentioned above at the age of >6 months, 2) not exclusive breastfeeding if the baby is not only given breast milk, vitamins, minerals, syrups, and or oral rehydration solutions for the first six months of life and gets food or drinks other than those mentioned above at the age of <6 months.
The researchers conducted a validity and reliability test on 37 breastfeeding mothers in Tulungagung Regency for the knowledge variable. The researchers also conducted a validity and reliability test on 25 breastfeeding mothers who work as health workers in 15 public health centers throughout Kediri Regency for variables: attitude, working shifts, husband's support, and family support. All variables were declared valid and reliable because they have an r-count higher than the r-table and an r-value of Cronbach's Alpha higher than the r-table.

Procedure
The researchers applied for study permits from related parties and ethical feasibility permits from the Health Research Ethics Committee, Faculty of Medicine, Universitas Airlangga. The researchers collected data about the mother's name, baby's age, and mother's WhatsApp number when submitting a research permit to the head of administration or the director of the public health center. After the researchers received the ethical eligibility letter, the researcher tested the validity and reliability of the study questionnaire. When all variables were declared valid and reliable, the researchers selected population members to be used as samples according to the inclusion and exclusion criteria by contacting all population members personally via WhatsApp. After the researchers explained the research objectives, mothers who had understood the research objectives and were willing to become respondents were directed to fill out a consent form. Respondents answered all the questions through the Google form provided by the researchers.

Analysis
The researchers analyzed data using the Chi-Square correlation test with a confidence limit of α=0.05. If the p-value <0.05, there was a significant correlation between the two variables. If the p-value > 0.05, there was no significant correlation between the two variables. The researchers conducted data analysis using IBM SPSS Statistic 25 for Microsoft Windows.

Ethical Clearance
This study received the ethical eligibility letter from the Health Research Ethics Committee, Faculty of Medicine, Universitas Airlangga, number 106/EC/KEPK/FKUA/2021.

RESULT
ge. Table 1 shows that the sample consists of 7 types of professions in the health sector. The three professional groups that participated the most in this study were midwives, nurses, and nutritionists. The average sample covered a distance of 13 km to get to the workplace. In this study, 69.6% of the sample stated that they still live with their parents and or in-laws. The majority of the babies were cared for by the sample's parents and siblings when they went to work. Most of the sample (67.9%) received three months of maternity leave. The average age of babies when their mothers return to work is two months, with the youngest being 36 days. Table 2 shows that most respondents (75%) in this study had successfully provided exclusive breastfeeding. They have good knowledge (76.8%) and attitudes (69.6%) toward lactation management and exclusive breastfeeding. They were working without shifts (67.9%), had a husband (53.6%) and a family (64.3%) who supported exclusive breastfeeding practice. Table 3 shows that out of 9 respondents with good enough knowledge, 5 (55.6%) did not give exclusive breastfeeding to their babies. The Chi-Square test results showed that the p-value of these two variables was 0.091. Based on the attitude variable, from 17 respondents with a negative attitude, ten people (58.8%) still gave exclusive breastfeeding to their babies. The Chi-Square test results showed that the p-value of these two variables was 0.094. Of the 18 respondents who work in shifts, 16 of them (88.9%) gave exclusive breastfeeding to their babies. The Chi-Square test results showed that the pvalue of these two variables was 0.185. There was no significant correlation between knowledge, attitudes, and working shifts with exclusive breastfeeding practice.
Of the 30 respondents who received support from their husbands to continue breastfeeding, 29 respondents (96.7%) managed to breastfeed their babies exclusively. The Chi-Square test results showed that the p-value of these two variables was 0.000. Based on the family support variable, of 36 respondents who received support from their families to continue breastfeeding, 31 (86.1%) succeeded in providing exclusive breastfeeding to their babies. The Chi-Square test results showed that the p-value of these two variables was 0.024. A significant correlation exists between husband and family support with exclusive breastfeeding practice.

The Correlation between Knowledge Related to Lactation Management and Exclusive Breastfeeding with Exclusive
Breastfeeding Practice Based on the study's results described previously, there was no significant correlation between knowledge related to lactation management and exclusive breastfeeding with exclusive breastfeeding practice. Eberechukwu and Ada (2018) stated that certain conditions in the mother's workplace or social barriers might be crucial in exclusive breastfeeding practice. On the contrary, the level of mother education and knowledge related to exclusive breastfeeding does not affect their decision in exclusive breastfeeding practice. Several studies showed the same results; there was no significant relationship between the level of knowledge and exclusive breastfeeding practice (Imani, 2018; Pitaloka, Abrory and Pramita, 2018; Caitom, Rumayar and Tucunan, 2019). This study was not in line with (Zhang et al., 2018), which stated that knowledge about breastfeeding practice is the most critical factor contributing to exclusive breastfeeding behavior. Zhang explained that good knowledge regarding the benefits and importance of breastfeeding allows mothers to overcome obstacles during breastfeeding.
Most respondents (76.8%) in this study had good knowledge of lactation management and exclusive breastfeeding, yet some failed to give their babies exclusive breastfeeding. They had experienced a long learning process related to this topic in their previous educational institutions before finally working as health workers in their current workplace. Working in health centers can also increase their knowledge regarding these topics due to the high frequency of information and exchange of experiences between colleagues and fellow health workers. However, if not accompanied by other factors, a good level of knowledge alone was also not significant in changing one's health behavior, especially if that knowledge was a basic knowledge of their daily work.

The Correlation between Attitude Related to Lactation Management and Exclusive Breastfeeding with Exclusive Breastfeeding Practice
Based on the study's results described previously, there was no significant correlation between attitudes related to lactation management and exclusive breastfeeding with exclusive breastfeeding practice. Chatman et al (Pitikultang et al., 2017) stated that there was no significant difference between attitudes related to breastfeeding among mothers who exclusively breastfeed and mothers who did not exclusively breastfeed. Without support from family members and health workers, positive attitudes alone did not ensure the success of exclusive breastfeeding practice (Chatman et al., 2004). Several studies showed the same results; there was no significant relationship between attitudes and exclusive breastfeeding practice (Al-Darweesh et al., 2016;Alimuddin, Kapantow and Kawengian, 2017;Assriyah et al., 2020).
Respondents' positive or negative attitudes regarding exclusive breastfeeding and lactation management are not always related to exclusive breastfeeding behavior. The propensity to act could be manifested in a genuine act if there were other supporting factors: level of education, religious influence, sources of information, personal experience, significant other's support, social impact, culture, health status, and one's psychological readiness in an act (Prasetio, Permana and Sutisna, 2020).
Notoatmodjo divided attitudes into three components: cognitive, affective, and conative. The cognitive component came from the knowledge stimulus that would form certain beliefs about the attitudes object. The affective component was closely related to the emotional side of humans. The knowledge obtained previously will be processed involving the emotions possessed so that positive and negative attitudes or likes and dislikes are formed towards something. This component was evaluative and closely related to the values held by a person. The conative component was a person's inclination and readiness to take actions related to the attitude object ( (Secord and Backman, 1964) in (Apsari, 2009); (Notoatmodjo, 2010)).
Based on the analysis from the researchers, respondents in this study who had negative attitudes regarding exclusive breastfeeding and lactation management but still managed to give exclusive breastfeeding to their babies had a vital conative component in them. Thus, the initial tendencies formed in the cognitive and affective components can be transformed into tangible actions following what they want. The conative side became stronger because all respondents work as health workers in health centers. Other factors such as health education background and employment status may play a role in encouraging the conative component to influence respondents' actions in providing exclusive breastfeeding to their babies. Mothers were encouraged to continue breastfeeding their babies because they believed breast milk was the best food for their babies despite their negative attitude toward exclusive breastfeeding. As a health workers, they carried out their role as an educator in health promotion related to exclusive breastfeeding to the community.

The Correlation between Working Shifts with Exclusive Breastfeeding Practice
The majority of respondents (64.3%) in this study traveled a distance of 01-10 km to get to the public health center where they work. Thus, although 32.1% of respondents have to work in shifts, they can still go home to breastfeed their babies according to the baby's feeding schedule and then return to the public health center where they work.
This study is not in line with previous research conducted by (Rosyadi, 2016). Rosyadi noted that mothers who work in shifts would more easily experience fatigue due to the high workload at work. When she got home, it turned out that her baby was waiting to be breastfed. Working in a shift can affect the mother's physical and psychological condition. Excessive stress conditions can inhibit milk production (Dahro, 2012) in (Sari, Salimo and Budihastuti, 2017).
Respondents in this study were still able to provide exclusive breastfeeding to their babies even though they had to work in shifts because most respondents had good knowledge and attitudes about exclusive breastfeeding and lactation management. This statement is in accordance with the research conducted by (Sari and Adawiyah, 2021). Sari and Adawiyah stated that mothers who work in shifts can still provide exclusive breastfeeding to their babies due to the high motivation to continue breastfeeding their babies, such as: meet the nutritional needs of the babies, improve the baby's immune system, reduce the family's economic burden, provide comfort for the mother, as well as following in the footsteps of others who have succeeded in exclusive breastfeeding. Good knowledge and positive attitudes about exclusive breastfeeding and lactation management can assist respondents in overcoming obstacles that occur during expressing breast milk and breastfeeding babies while working in shifts.

The Correlation between Husband's Support with Exclusive Breastfeeding Practice
The result of this study is in accordance with research conducted by (Ayalew, 2020). Ayalew stated that mothers who received support from their husbands to continue breastfeeding were four times more likely to exclusively breastfeed their babies than mothers who did not receive support from their husbands to continue breastfeeding. She concluded that husbands play an essential role in being the decision-maker in the family, including in the practice of feeding babies.
Husband can support breastfeeding mothers to provide exclusive breastfeeding to their babies successfully in various ways. In this study, most respondents revealed that their husbands are willing to help mothers with household chores and wake up at night when mothers breastfeed their babies. Husbands also strengthen the psychological side of the mother to continue breastfeeding by giving encouragement and praise every time the mother breastfeeds the baby. The husband believes that his wife can still exclusively breastfeed their baby even though the wife has returned to work. When the milk that comes out is not smooth or only comes out a little, the husband does not immediately tell the mother to give formula milk to their baby. The husband also fulfills the additional nutritional needs of the mother during breastfeeding and buys equipment to express breast milk happily.
In this study, most respondents (69.6%) still live with their parents and or in-laws. When the mother returns to work, 30.4% of babies were taken care of by the mother's parents, 12.5% by the mother's siblings, and 3.6% by the mother-in-law. Husbands who fully support the mother's decision to breastfeed their baby exclusively can help the mother negotiate this matters with the extended family. Thus, a family who lives in the same house as the mother and helps take care of the baby when the mother goes to work will have the same perception regarding the importance of exclusive breastfeeding. This situation can increase the mother's self-confidence and make it easier for the mother to realize her desire to give exclusive breastfeeding to the baby. (Srisopa and Lucas, 2021), in their research, revealed that the husband's support is very vital for breastfeeding mothers to make decisions about breastfeeding their babies. When a breastfeeding mother and her husband have the same views regarding the purpose of breastfeeding, the husband tends to provide physical and psychological support to his wife regarding providing nutrition for their child. They also stated that breastfeeding is a learning process that must be jointly mastered by breastfeeding mothers and their husbands like a team. (Lok, Bai and Tarrant, 2017) also found that the husband is the most influential person in determining the mother's intention to continue breastfeeding her baby. Thus, since the antenatal care period, the husband should be involved in counseling related to the benefits of exclusive breastfeeding and how to support his wife to continue giving exclusive breastfeeding. In a qualitative study conducted by (Valizadeh et al., 2018), respondents revealed that emotional support from their husbands is the key to reducing the stress when they have to balance their responsibilities at work and their need to breastfeed their babies.

The Correlation between Family Support with Exclusive Breastfeeding Practice
The results of this study are in accordance with research conducted by (Ekawati, Salimo and Murti, 2017); (Septiani, Budi and Karbito, 2017); (Lindawati, 2019). Based on (Septiani, Budi and Karbito, 2017) research on 113 breastfeeding mothers who work as health workers in seven public health centers in Bandar Lampung City, there is a significant relationship between family support and exclusive breastfeeding. Breastfeeding mothers who get support from their families are 7.6 times more likely to give their babies exclusive breastfeeding than breastfeeding mothers who do not get support from their families. (Gebrekidan et al., 2021) revealed that support from husband and extended family provides opportunities for mothers to continue breastfeeding. This case can happen because the social interaction in the extended family is very close, so the support provided inside will be significant for breastfeeding mothers who have returned to work.
In this study, most respondents revealed that their families were willing to help mothers with household chores while mothers were breastfeeding their babies. Family members also strengthen the psychological side of the mother to continue breastfeeding by giving encouragement and praise every time the mother breastfeeds the baby. The family believes that the mother can still exclusively breastfeed their baby even though the mother has returned to work. When the milk that comes out is not smooth or only comes out a little, the family does not immediately tell the mother to give their babies water, bananas, porridge, or formula milk. Family members who had previous breastfeeding experiences also give some advice to the mothers on how to express breast milk and breastfeed their babies happily.
A nursing mother who returns to work can reduce the stress due to a high workload by seeking help from others. The mother feels that it is impossible to balance housework and responsibilities at work without adequate support. The division of household chores is one thing that can reduce the workload and stress felt by mothers (Valizadeh et al., 2018). One obstacle affecting the mother's belief to give exclusive breastfeeding is the influence of a close family. (Agustina, Prabandari and Sudargo, 2020) in their research, shows that working mothers tend to ask their parents for help to take care of their babies when they return to work. However, these parents have different perceptions regarding exclusive breastfeeding. An example is when a baby cries a lot, parents assume that it means the mother's milk is not enough to meet the baby's nutritional needs. This difference in perception causes working mothers to feel insecure regarding the practice of exclusive breastfeeding.
The majority of respondents (69.9%) in this study stated that they still live with their parents and or in-laws. Most respondents indicated that their babies were cared for when they returned to work by their parents (30.4%) and their siblings (12.5%). Those data prove that when mothers return to work, the babies spend more time with their grandmothers, grandfathers, aunts, and or uncles than their parents. A breastfeeding mother and her husband must also convey the exclusive breastfeeding planning and share the same perceptions about the importance of exclusive breastfeeding for all family members who will take care of the baby from a few weeks before the mother returns to work. Mothers can educate the family members about the baby's breastfeeding hours, signs when the baby is getting enough breast milk, and how to store and give expressed breast milk to the baby. Mothers and their families can also divide tasks regarding who will go to the public health center to collect the expressed breast milk. When all the parties involved in the baby care process have agreed and have the same perception regarding exclusive breastfeeding, the mother will feel more confident in realizing her desire to give exclusive breastfeeding to the baby even though she has returned to work.
Based on qualitative research conducted by (Omer-Salim et al., 2015) in India, mother-in-law's influence is an essential factor in family decision-making. Thus, their support is critical in the continuity of breastfeeding for working mothers. Sister-inlaw and biological father-in-law and father-inlaw have minor roles that are also important in supporting mothers to continue breastfeeding, such as: helping with baby care, doing household chores, providing psychological support, sharing experiences related to breastfeeding, and delivering babies to and from the workplace. The birth mother can also be reassuring, primarily if the mother-in-law does not support the plan to breastfeed the baby exclusively.

CONCLUSION
Good knowledge and positive attitudes regarding exclusive breastfeeding and lactation management alone are not strong enough to influence working mothers in providing exclusive breastfeeding to their babies. The presence or absence of work shifts also does not affect the mother's decision to breastfeed her baby. Meanwhile, breastfeeding mothers who get a lot of support from their husbands and families tend to be confident to continue to exclusively breastfeed their babies, even when faced with a heavy workload.
The health office should maximize the ongoing exclusive breastfeeding counseling program and create a new program that involves husbands and their families to participate in the planning and implementation of exclusive breastfeeding practice. Future researchers are expected to conduct similar research on a larger population and a more diverse health institution. In addition, the following researchers are expected to research other factors not examined in this study to find out how influential those factors are toward the breastfeeding practice.

ACKNOWLEDGEMENT
We sincerely express our deepest gratitude to all the heads of public health centers in Tulungagung and Kediri Regency who have allowed this study in their working area. We would also like to thank all the respondents who participated in this study.