*2.2. Survey Development*

As a first step towards designing this survey, a state-wide collaboration of multiple NH agencies, local coalitions, programs, and universities partnered to inform a questionnaire of breastfeeding in the workplace among NH WIC program participants. The team consisted of faculty and staff from the Institute on Disability, New Hampshire Occupational Health Surveillance Program in the University of New Hampshire's College of Health and Human Services, Keene State College Department of Public Health and Department of Health Science, New Hampshire Department of Health and Human Services' Division of Public Health Services, the Director of the New Hampshire WIC Nutrition Program, and a subcommittee of the New Hampshire Breastfeeding Taskforce. Based on a literature review of breastfeeding in the workplace and using focus groups, online feedback, and expert commentaries and reviews, a nine-page survey was iteratively developed to identify and measure person- and environment-level barriers and supports to breastfeeding initiation and continuation in the workplace.

Informed by prior breastfeeding studies of women using NH WIC services, survey questions were categorized into worker well-being domains operationalized by the NIOSH TWH Program [29]. The domains included in this study were (1) workplace physical environment and safety climate, (2) workplace policies and culture, (3) health status, and (4) work evaluation and experience [30]. The survey items used in this study identified concepts in the workplace related to the supports, knowledge/training, policies, physical space, and culture that encourage or discourage breastfeeding after returning to work.

Question content (i.e., concepts, topics, and phrasing) was based broadly on the existing literature and the state-wide partnership formed for this study. Survey questions were also included from (1) the Monadnock Region's Community Coalition for the Promotion of Breastfeeding Survey implemented in the Keene and Manchester NH WIC Programs, and (2) lactation support questions from the Centers for Disease Control and Prevention's Worksite Health ScoreCard [21,35]. Where possible, questions offered multiple choice responses similar to the'Monadnock Region's Promotion of

Breastfeeding Survey, where the respondent could check more than one response [21]. This research, combined with the NH Breastfeeding Taskforce's experience and feedback, found breastfeeding to be a sensitive topic and recommended an anonymous survey with multiple choice responses to allow mothers to answer more honestly and in a fast, efficient manner.

When answering work questions, survey participants were instructed to reply for their current job, and if they were currently on maternity leave or recently left their job, they were asked to respond for their most recent job. Further, some survey items also included a step-wise, conditional design where participants were only asked to answer some secondary questions that were dependent on responses to the previous question in the survey. Topics with conditional questions included maternity leave, breastfeeding policies, break times for pumping at work, reactions to breastfeeding at work, and supports for breastfeeding longer at work.

The paper survey was pilot-tested for feasibility in the spring of 2016 using a random 1% of each the four local WIC agencies caseload. The results of the pilot informed the survey design and ensured the viability of a multi-agency study design. Once the survey was finalized, the University of New Hampshire Institutional Review Board granted approval for data collection. The study was conducted in accordance with the Declaration of Helsinki and the protocol was approved by the University of New Hampshire Research Integrity Services Institutional Review Board as IRB#6491.
