Complex posttraumatic stress disorder is described as a chronic condition with several severe and concurrent symptoms. Symptoms influence and impair not only the affected individuals but also their social surroundings and their relatives. The literature describes relatives as a key factor in managing symptoms, both as a barrier and a facilitator.This research aimed to explore and to reconstruct the views, perceptions, experiences, facilitations and barriers of relatives who support the symptom management of persons with CPTSD in everyday life.A theoretical sampling was used to recruit for an interview 18- to 65-year-old relatives of patients with diagnosed CPTSD. The 17 semi-structured interviews were audio-recorded and transcribed verbatim. The transcriptions were uploaded into MAXQDA, and a Grounded Theory method based on that of Corbin and Strauss was used to analyse the data.We provide a process model with 5 interacting phases: the initial situation, state of permanence, being an anchor, recognizing limits, and potential outcomes. Each phase is further divided into subcategories.Participants experienced their condition as unpredictable. Although they mastered different strategies through own exploration and in cooperation, there is a clear need for more education, advice and support for relatives caring for those affected by CPTSD. Health care services should consider providing family support, educational services and increase the involvement of relatives in treatment. Over all, well-supported relatives can play a facilitative, key role in improving symptom management.DRKS00012268.Ethical approval was obtained from the Swiss Cantonal Ethic Commission . This research was also registered at the World Health Organization Clinical Trials Search Portal through the German Clinical Trial Register, Trial  The World Health Organization’s (WHO) 11th version of the International Classification of Disease (ICD-11) will supposedly be introduced in 2018 . In lineRecent literature provides first results concerning adverse factors of patients with CPSTD, such as poorer functioning , 16, uneAccording to the literature, there are different forms of social support –26, for In general, as informal social support, patients’ relatives play a significant and vital role in research on symptom management –33. RelaAgain, there is a growing body of literature on caregiver burden and several studies highlight the difficulties and specific needs of relatives providing care and support for those affected by chronic mental illness –43. For The literature for PTSD patients and their relatives shows similar findings. Moreover, patients with PTSD would like their relatives to be more involved in their mental health care –48. SociOverall, research on relatives’ support and symptom management is still developing –62. HoweThe goal of this study was to explore and reconstruct the everyday life views, perceptions, experiences, facilitations and barriers of relatives during the symptom management of those with CPTSD.In line with the explorative nature of our research aim, we chose a qualitative study design and used Grounded Theory. Grounded Theory is described as a suitable research method for investigating phenomena of social processes and for developing a theoretical framework , 66. TheThe study is based on a systemic approach. This approach considers interaction among humans as an object of psychological analysis and is therefore essentially focused on interpersonal systems . This syAs part of a larger research project , this stOver a ten-month period, CPTSD patients from a previous qualitative study  were chosen from a larger sample of another prior quantitative study . For each participant with CPTSD diagnosed according to the ICD-11 proposal, one relative was recruited. These relatives comprised the sample for this study. The Zurcher cantonal ethics review board approved the study. The current investigation comprised participants collected through theoretical sampling. Participants were required to meet the following criteria for inclusion: The patient has been diagnosed with CPTSD. The participants had to be adults, 18 years or older and with a good knowledge of German. Relatives were defined as persons who are self-defined relatives, who may or may not be bound by blood, law, friendship and who had declared commitment, shared deep personal connections with the participant and provided various forms of support in times of need , 78. ExcThe first author, experienced in the treatment of and caring for patients with PTSD, was responsible for the qualitative data collection with semi-structured interviews. The first questions were developed based on the results of the prior qualitative study exploring the experience of persons affected by CPTSD relating to their symptom management . Similarly the domains of the symptom management model  were useTo create the largest possible contrasts between the interview partners, the participants were chosen using purposive sampling. The first three participants were identified based on the level of symptom burden of the patients . Theoretical sampling was used as the study progressed and concepts emerged from the data. Thus, further participants were identified and chosen during the analyses, based on the questions arising during the process. For instance, relationships in which a single relative and the patient made up the unit were included in the study in contrast to cases with 3 or more relatives. Furthermore, we included blood and non-blood relatives as a contrast.The interviews took place after the inpatient treatment of the person affected. The data collection took place between 1st March 2017 and 31st December 2017 at the psychiatric institution ipw in Winterthur, Switzerland. The semi-structured interviews lasted between 50 and 95 min; an additional 30 min after the interviews were available for questions and explanations. If any psychological crises had arisen due to the interviews, these could have been dealt with by a mental health nurse on the ward. The nursing team guarantees the shift organization on the ward 24 h a day.The interviews were audio-recorded and subsequently transcribed verbatim. To comply with data protection, all names were anonymized. The semi-structured interviews were analysed based on the Grounded Theory proposed by Corbin and Strauss . After uThe data analysis resulted in a process with five categories or themes which we sorted into an explanatory framework that sequences the progression as well as the interactions and experiences of the relatives through their life whilst supporting a patient with symptoms of CPTSD. This framework Fig.  is separCausal Condition. Being “supporting and caring for a relative with CPTSD” is given by the nature of the research aim. Most, but not all, relatives knew, even though not in detail, about the traumatic experiences of the affected persons. With time, they felt and thought something stressful had happened in their relative’s past, causing reactions they did not understand, for instance sudden shaking, sudden crying or having difficulties relaxing. If they did not know about the traumatic experience, they often tried to elaborate and make it a subject of discussion, while affected persons avoided the topic.This phase describes the “I know she has experienced many bad things. What exactly, I do not know, but I know she still suffers.” Jan, 53“Yes, I know her diagnosis, I informed myself, so I could support her as good as I can. After all we are siblings.” Ami, 32In the literature, permanence is described as a state of lasting or remaining unchanged . This ph“And then she gets up and down. It’s like she is going high, high, high and she loses it and starts breathing. And she then like goes away. After half an hour she comes down. Sometimes it takes two or three hours.” Marc, 45.“I was always aware, that was normal for me. I had to take care for my mum” Luna, 28Context identifies factors such as “social situation”, “frequency of symptoms” and “intensity of symptoms”. Relating to the social financial situation, participants with a secure income described less ambiguity and stress regarding their future. Contrastingly, participants with neither secure income nor financial support experienced psychological distress. Thus, having financial issues was described as a major barrier. This situation was described as a context factor that made it difficult for relatives to cope with their daily life, to manage bills and to manage their administrative tasks.Relatives living together with a sufferer of CPTSD more often had to handle demanding situations and reported experiencing a high frequency of symptoms, for instance, with sleep disturbances, outbursts of anger, inability to show affection, and a lack of energy to handle the household. Those symptoms had a high impact on the organization of daily routine. Individuals reported experiencing the need to manage symptoms nearly every day. While the frequency was high, the intensity varied. Most intense were visible symptoms, such as dissociation and self-injuries. These experiences were basically related to being present during the everyday life of those affected by CPTSD.Contrastingly, relatives not living with the person with CPTSD reported having physical distance and living in another place as helpful in handling intense situations and symptoms. The context factor of living apart and distance had an influenced their perceived experience. However, those relatives also experienced the frequency and intensity as challenging and present when they spent time with their relative.“The worst is when I see new wounds. How can she… Even after years, I’m not sure how to react. Even though I should get used to it.” Adriana, 35“Well it is not easy, she…, can’t work any longer. She can’t even do household chores. So, I have to take care financially that’s not easy.” Sasuke, 62The intervening conditions comprise perceived facilitators and barriers for symptom management in everyday life. The subcategory “relatives’ dynamics” comprised interactions between participants and the person with CPTSD. This subcategory can function as a facilitator as well as a barrier. The ability to learn to talk openly and respectfully with each other proved highly important. Those affected by CPTSD who shared some of their traumatic experience with their relatives helped the relatives to understand the cause of their condition and to better classify reactions. While in a first step relatives felt deeply shocked and unsure how to react, the information later provided orientation. Contrastingly, participants with no information about the disorder or the cause of the condition experienced disorientation and a lack of comprehension towards the person affected.“But, well, I feel I don’t understand him. He sometimes acts weird and aggressive and I feel it’s my fault, although I know it’s not. There must be something else.” Rei, 53Another subcategory was “social support”. Social support was described as formal social support. Here again, it was perceived as a facilitator as well as a barrier. If there were health care professionals or social workers involved, this was helpful and a major facilitator. While this support was described as a facilitator, relatives complained about the lack of involvement and information provided to them. When this involvement or information was absent, participants wished for formal social support not only for their affected relatives but also for themselves. This wish was most commonly based on lack of knowledge concerning the condition of their relatives, as described in “psycho-education”.Major barriers were lack of information of the trajectory of the illness, what should be focused on, how to react best and the inability to make associations between the condition and some reactions. Another barrier was “perceived suffering”. Perception of visible suffering was a factor rendering it difficult to provide support for symptom management. Seeing a relative suffering inhibited possible support. This barrier was based on feelings of compassion, helplessness, sadness, lack of understanding and coping strategies. In general, relatives suspected persons with CPTSD of having more symptoms than they perceived or knew. If the relative’s “own health status” was impaired, for instance due to physical or mental illness, support for the relatives was also limited. Results reported in “duration of the support” were inconsistent. While some relatives experienced difficulties providing support at the beginning of the relationship but improved and became experienced with time, others reported feeling exhausted and burdened after years or decades of providing support.“She is like… a fairy. Not always comprehensible. She never was. But somehow we managed to master our life together.” Sasuke, 62Being an anchor defines many different strategies for supporting the persons affected. The subcategory “instrumental support” describes how relatives took over tasks that had been neglected due to the illness trajectory. Duties included making dinner, doing the dishes, laundry, providing possibilities to rest, helping to structure the day and being a contact person for issues concerning children. Further tasks were taking care of financial issues, providing transportation, accompanying to doctors’ appointments and taking over administrative tasks, for instance with public authorities. Structures and predictable schedules helped to generate a sense of stability and security. Another subcategory described as “emotional support” refers to strategies such as minimizing stress at home or during daily routine, accepting the conditions patiently, not complaining at incomprehensible reactions, not pressurizing the affected person to explain every reaction, being there if that person wants to talk, and being a good listener. Further strategies were providing a feeling of being reliable and being a part of the affected person’s life. These strategies further imply expressing commitment to the relationship.“For me she is number one, and my friends are number 10. It is like it is.” Ami, 32“He can relax at home, I mostly take care, so he can calm down.” Amalia, 32If the sufferer had knowledge of specific skills, they sometimes asked their relatives for assistance as described in the subcategory “support with skills”. Skills used were diverse. Some sufferers instructed their relatives to place a cold pack on their neck if they were dissociating, while others helped them to inhale an aroma therapy mixture. Often porcupine balls were used to deal with stressful situations. Prior to the assistance, relatives were informed where to find specific items, for example the cold pack, aroma therapy mixture, or massage tools, such as porcupine ball. Moreover, sometimes relatives also helped with taking medication, such as reminding the sufferer to take it or giving emergency medication during stressful situations. Relatives were required as an anchor to reality, for instance helping the sufferer to focus on their environment and to describe what they perceive around them. Likewise, relatives helped during a crisis to escort them out through a crowd.“I use ice. That’s something I grabbed hold of somewhere. We always have some ice in our freezer and I know when she is fading again I must use it. Not sure how. But it works.” Mikel, 45“Well I have her medications and when she is fading away, I have to give her a pill, so she can come down.” Mikel, 45The subcategory “making distraction possible” was described as vital for relatives as well as for the people affected. The possibility of experiencing activities and situations not related to the condition strengthens personal ties and helps to ameliorate the sufferer’s symptoms. Another subcategory described as “motivation and empowerment” refers to efforts and attempts to keep the affected person encouraged and forward-looking. Described strategies were, for instance, motivating to go out for a short walk, going out for dinner despite feeling unwell, accompanying during shopping, or spending time with other friends. Furthermore, providing calming conversation during a crisis, pointing out strengths and resources and reminding of goals were described as motivational interventions.“I think it is important to be there. No one can be alone. Everyone needs someone right?” Nicole, 24.“Sometimes it doesn’t need a lot. Just telling him he is doing great can help” Ava, 40During the process of support, relatives experienced a phase of possible consequences. The subcategory “setting boundaries” implies reactions such as learning to say no if they feel uncomfortable with a request, being able to speak with the affected person about their own needs and worries, redefining the time and resources spent with the sufferer and thus having more time for themselves. These strategies imply deciding the extent of support that can be provided. This support is, for example, redefining how much help is needed with a daily routine, for instance with cooking or washing the dishes.“Well I know she is not well, but I also have to take care of myself and the children you know. So, I tell her sometimes I can’t, even though I might feel guilty afterwards” Marc, 45Relatives realizing that they could not take on all burdens and recognizing that the person affected is also responsible for him- or herself is described in “acceptance”. This subcategory includes not only acceptance of the condition but also acceptance of one’s own limits and sometimes having mixed or negative feelings toward the sufferer. In this phase, participants described realizing the burden of caregiving and supporting.This burden may lead to strategies in “search of balance”. This subcategory implies relatives’ strategies such as sharing responsibility and tasks with other relatives, for instance, with siblings or other friends and taking care of themselves with a support system (e.g. friends or people who share their hobbies), where the relatives could speak about their feelings and worries.“I love her, I really do. But I also love myself and I sometimes need distance between us” Serenity, 49.For some relatives setting boundaries was difficult, which led to a condition described as the evolvement of a “symbiotic connection”. The relationship was described as very close and intimate. Relatives felt they had to take responsibility for every aspect related to the well-being and the security of the person affected. Questions arose about whether the sufferer was sometimes in a bad condition because the relative had failed to support them adequately. If the relative failed to provide the desired support, feelings of guilt, shame, helplessness and emptiness arose for letting the sufferer down. The relative’s own needs, feelings, and necessities were in background. On the positive side, through providing support, feelings of satisfaction, a sense of value but also feelings of dependence were described.“She had no one else. I was there for my mum, always… and often I had to listen to stuff I didn’t really wanted to.” Therese, 23meaningful work, the desire to prevent negative effects for the person and feelings of being able to ameliorate symptoms were described as important for the relatives. Moreover, a sense of purpose includes meaningfulness in being there for a person in need, duty and obligation towards the sufferer and sometimes pride in being able to help and master various demanding situations together. The subcategory “own maturation” describes personal fulfilment, growth, and the mastery of new skills through the support, for instance, being able to handle a household, cooking, buying groceries and being a conversational partner for a person with CPTSD at an early age.Potential results whilst caring and providing support for a person with CPTSD are described as follows: being capable of mastering difficult experiences together as well as experiencing situations unrelated to the condition improved the quality of the relationship. Furthermore, sharing memories and experiencing mutual trust helped to nurture the relationship as described in the subcategory “strengthening the relationship”. Positive results arose not only for the relationship but also for individuals providing support. Helping a suffering relative also generated a “sense of purpose”. Thus, seeing the support as “Well I guess I can’t compare our relationship with others. It is strong and trustful, after all we went through a lot of struggles.” Mia, 23On the other hand, negative results were also reported, for instance, “social isolation”. In this subcategory relatives felt secluded from their friends and social life. Supporting the person in need claimed not only a huge amount of time but also energy and personal resources. Difficulties in sharing experiences of tough situations when supporting a person with CPTSD were affected by either negative stereotypes, fear of negative stereotypes or by stigma towards those with a mental health condition. These feelings lead to the situation of having to deal, mostly alone, with rising emotions and distress.“It takes time being there, so I have less time for my other friends. I feel somehow alone.” Kei, 23Prolonged support with a lack of coping strategies, difficulties in balancing one’s own needs with the need to support and in pacing oneself led to a state described in “chronic burden”. Hereby relatives described the resulting condition as feeling exhausted, frustrated, sometimes angry with the sufferer, struggling with a bad mood as well as feeling emotionally empty and alone with the situation.“I really feel alone. But what should I do? I can’t leave him and at the same time it makes me really furious.” Rei, 53Emerging evidence suggest CPTSD to be a chronic condition in mental health setting , 83, 84.In our study, one difficulty is described as the main phenomenon of being under the constant state of living with the unpredictable condition. This result adds new findings specific to the context of CPTSD. The participants in this research criticized the lack of information, lack of involvement in therapeutic processes and the lack of formal social support. Hence, providing more professional medical knowledge and psycho-educational interventions might lead to clarification and an improved understanding of the condition.The inability to understand the condition of the person affected is in line with several proposals to develop specialized family support and educational services , 95–98 tWhereas our sample reflects heterogenic relationships providing a broad spectrum of experiences, views and strategies supporting affected persons, it raises the question of whether different social relationships experience different views, needs and strategies. For instance, are children of a parent with CPTSD in need of the same support and guidance as the spouse of a sufferer. Evidence from Mital and colleagues suggests there might be differences . They stWhile previous research has examined the relationship between PTSD symptom severity and caregiver burden, this is the first study to gain insight into the social process of relatives providing support in symptom management for sufferers of CPTSD. It aimed to understand their views, needs and experiences and possibly to build up a basis for family-oriented support. Not all the described influencing factors can be changed or controlled. For instance, no supportive intervention for the relatives can influence the severity of the illness. However, how those affected handle their symptoms greatly influence their relative’s experience. Our results suggest that being able to reduce self-injuries or a better management of dissociative symptoms may reduce perceived symptom intensity and hence distress in relatives. The literature supports the assumption that the severity of the symptoms has a great influence on the relative’s experience in providing support, perceived burden, and the perceived severity of an illness , 91. It This study focused on the unique views and experiences of relatives providing support for symptom management in CPTSD. Participants experienced the condition as unpredictable. Although they mastered different strategies through own exploration and in cooperation, there is a clear need for more education, advice and support for relatives helping sufferers of CPTSD. Over all, well-supported relatives can play a facilitative and key role in improving symptom management.Not every relative was automatically burdened or overwhelmed by providing support. For those who were, community health services should consider providing family support and educational services, thus leading to more involvement of relatives in treatment. Moreover, the unpaid informal support provided by relatives makes a major contribution to the health and social service system, which would be very costly to replace with paid formal support.This research also has some limitations that should be considered in evaluating the results. Questions were designed by the first author; it can be assumed he is not value-free and that he inadvertently influenced the results due to his own professional and personal beliefs. Moreover, these values may influence how the researchers conducted and reported their research. Different findings might have been generated elsewhere by different researchers.Based on our qualitative study design, our sampling was selective and purposive; it focused on participants with different kinds of relationships and socio-demographic factors identified during the ongoing analyses. Further contextual influences were not considered. Hence, the results cannot be generalized. Further, we do not know whether our results apply to other cultures, other countries or other settings in the Swiss health care system. We recognize that the conceptual model presented does not represent the unique symptom experiences of relatives providing support for those with CPTSD. In addition, the design of our study project might have a great impact on the results. The sample in this study was recruited on quantitative results of a first study and in dependence of CPTSD affected inpatients investigated in a second study. This structed not only could have provide holistic and supplementary results but could have created hidden bias.We do not claim causal inferences based on our data and framework. As previously stated, further quantitative research testing our results is needed to determine possible cause and effects or correlations. Research is also needed to expand the conceptual model and to discover attributes specific to each phase. Despite these limitations, our study contributes primary results regarding the views and life experiences of relatives supporting the symptom management of persons affected and contributes to the expanding literature related to CPTSD.


Worldwide, there are between 50–67 million migrant domestic workers, the majority of whom are women. In many countries, provisions are not in place to protect female migrant domestic workers. These women may be at risk of occupational and social stressors, including exploitation and abuse, which may negatively impact on their quality of life, including psychological health. Research examining the occupational, social, and psychological needs of FMDWs from a public health perspective is critical to guide the development of policies which ensure wellbeing, prevent abuse, and align with international priorities to improve population health. Though there have been a number of high-profile incidents of exploitation and abuse, there has been limited research on the stressors experienced by these communities, their perceived impact, or coping mechanisms.Thematic analysis was used to analyse qualitative free-text written responses collected as part of a cross-sectional survey on the relationship between social and occupational stressors and the health and quality of life of FMDWs in Singapore. Responses correspond to open-ended questions in the qualitative component of the survey examining three domains: causes of stress, coping strategies, and what people can do to help with stress.Responses from 182 FMDWs were analysed. Key themes were identified around causes of stress , coping strategies, and social support. Each theme describes key factors which contribute to the occupational and social stressors experienced and reported by FMDWs.This research highlights the stressors FMDWs in Singapore experience, as well as key coping mechanisms. There is a clear need for policies which facilitate FMDWs’ ability to utilise these coping resources, and which protect against coercive or exploitative employment conditions. Strategies are also needed to monitor and evaluate policies intended to protect FMDWs, and to strengthen the implementation of global frameworks targeted at improving workplace conditions and workers’ rights. There are between 50–67 million migrant domestic workers (MDWs) worldwide –5, the m24% of female migrant domestic workers (FMDWs) are in South-Eastern Asia and the Pacific  and a ‘gIn many countries, provisions are not in place to protect the health or safety of FMDWs, leaving them vulnerable to abuse and exploitation . AccordiSuch work environments may increase the risk of exposure to psychosocial hazards including occupational stressors that have been shown to impact on mental and physical health , 13–20. Previous research has also pointed to the multidimensional stressors that migrant domestic workers, and women in particular, may experience in both the countries in which they are working, and their countries of origin ,18. ThisDespite many resources developed by WHO around health workplaces , the impSingapore has a large population of MDWs, with over 230,000 registered work permits . Recent Research examining the occupational, social, and psychological needs of FMDWs from a public health perspective is critical to guide the development of policies which ensure wellbeing, prevent abuse, and align with international priorities to improve population health. However, there is insufficient research exploring the needs of FMDWs, their psychological health or access to coping resources , 20. To This study uses qualitative data from a cross-sectional survey on stressors, social connectivity, coping mechanisms, and QoL among FMDWs in Singapore . The surPrior to data collection, the researcher (SGA) engaged with Transient Workers Count Too (TWC2), a civil society organisation working with female migrant domestic workers in Singapore, as well as St. Andrews Cathedral in Singapore, which played a gatekeeping role, facilitating her engagement with migrant domestic workers.Data were collected by SGA, a female researcher from Indonesia and Singapore, through a written English language survey. The purpose and aims of the study, as well as what it involves, were explained by the researcher. Paper copies of the survey were distributed to women in public places of gathering. Participants were approached in person by the researcher, and identified through convenience and snowball sampling. If women elected to participate, they were able to fill out the paper survey in their own time on their own, and return it to the researcher or gatekeeping organisations.The survey included an open-ended free-text response section asking women to qualitatively describe: 1) causes of stress, 2) coping strategies, 3) social support, and 4) whether coping strategies and social support helped them to feel less stressed. The selection of these prompts and their use as a framework for the analysis was guided by the evidence-base around the salience of these factors for migrant domestic workers, a related survey being carried out with this community examining these areas , and theEnglish language proficiency is a requirement for a work permit in Singapore, and all participants thus had proficiency in English to complete the questionnaire and provide fully informed consent. However, translation resources were also available through the multilingual field researcher and gatekeeping organisations. Additional methodological data on the cross-sectional survey can be found elsewhere .Descriptive analyses for the quantitative data from the surveys were carried out using Stata/SE 15.1. Qualitative data from the free-text responses were imported into Excel and Nvivo for data management and analysis, and differences in the socio-demographic characteristics of respondents and non-respondents to the free-text questions analysed in Stata. Qualitative data were analysed using thematic analysis, in line with Braun and Clarke’s (2006) guidelines. Content analysis was also used to quantify the occurrence of key themes identified through the qualitative analysis. The analysis was guided by the framework of the survey, in which participants were asked about causes of stress, coping strategies and social support. Codes and themes within each of these components of the framework were derived from the data and developed through an iterative process by two researchers (LBN and TVB). During this process, saturation was achieved. Researchers developed the coding framework and themes through a collaborative and iterative process. This discursive co-production approach supported the quality and rigour of the analysis and trustworthiness of the results by comparing codes and themes, and reaching a consensus on the results of the analysis. All authors were immersed in the data and involved in the analysis throughout the project to increase rigour. Throughout the research, a process of active reflexivity  was undertaken in an effort to examine the authors’ roles and influence on the interpretative process, which is recognised as a key part of improving the quality and rigour of qualitative research. The importance of this process of active reflexivity throughout the analysis is situated within a constructivist philosophy underpinning the research, whereby the knowledge or ‘findings’ identified through the data collection and analysis are informed by the active involvement of not only the participant, but also the researcher in generating data, which is informed by the lived experience of both.The codes and themes identified from the data were examined across participant demographics, however all themes were found to be described across all groups in relation to country of origin, religion, age, and work experience. Themes within each of the core areas  are presented in italics. Sub-themes are presented with single quotation marks, and participant quotes are indicated using double quotes.Data collected in this study can be obtained by contacting the authors, and is also presented in Full ethical approval was granted by the King’s College London Psychiatry, Nursing and Midwifery Research Ethics Committee on 3 April 2012 PNM/11/12-77. Written informed consent was obtained from all participants, and confirmed through submission of the written survey. As this was a community-based study and not a health services study, ethical approval was not needed from medical or health bodies in Singapore; no patients or health services were involved and the study only engaged community members.In total, 220 surveys were distributed, and 182 women elected to participate (82.7% response rate). Of these, 100 women responded to the free-text questions, and were included in the qualitative analysis.The mean age of participants was 35.1 years . The mean number of months of work experience was 89.9 . Participants were from the Philippines (n = 104), Indonesia (n = 68), Myanmar (n = 9), and Sri Lanka (n = 1), and identified as Christian (n = 117), Muslim (n = 56), Buddhist (n = 6), Sikh (n = 1), or as ‘freethinkers’ (n = 2) . There wwork and agency; the pervasiveness of financial need; and family and obligation .Three interrelated and hierarchical themes were identified describing the overarching causes of stress women experienced: ligation . Work anpervasiveness of financial need and family and obligation). This theme included the sub-themes: ‘power inequalities in relation to their superiors’; ‘being subject to their employment contract and the demands of the job’; and ‘insecurity in relation to their employment’.Participants consistently reported work was a primary source of stress, and the limited agency they felt they often had in their workplaces, exacerbating the stresses associated with work, and contributing to the other stressors .” In particular, they reported the stresses they experienced because employers were “in a bad mood (participant 115)”, which included “job pressure and unreasonable decision, expectation of high standard (participant 109)”.Respondents also described the stresses associated with ‘being subject to their employment contract and the demands of the job’, which encompassed the restrictions associated with their work visas as migrant domestic workers, and the corresponding requirements of their employment contract to which their visa was tied, which also prevented them from leaving a specific employment contract as they could thus lose their visa. 38 of the participants (20.8%) reported how stressful their work was, and in particular, that they had too much work, and it consequently impacted on their mental health and well-being. Participants felt “overworked ”, “stress about the work and how to manage to do all duties (participant 10)”, and reported not getting enough rest, sleep, time to eat, or flexibility to maintain their physical or mental health.Participants’ feelings of ‘insecurity in relation to their employment’ related to the uncertainty surrounding either finding work or retaining work: “[What is stressful is] my situation today, losing my job and looking for another employer (participant 132).” One participant explained feeling “[stressed] about the future—it’s not clear where I would be in the future (participant 86).”Overall, within this theme the narratives of respondents highlighted the precariousness of their situations both in relation to their legal status as migrants and their employment, capturing the stresses that resulted from that.Financial needs exacerbate the stresses associated with employment insecurity, and resulted in exploitative situations because of the necessity of prioritising employment. 16 (87.9%) of women described that financial concerns were making them feel stressed, in many cases illustrating that even when women were working long hours and being paid, their wages were not sufficient to sustain them or their families. Women explained, “[My] salary not enough to cover up my and my children’s need (participant 7)” and “I can’t give the amount of money my family needs (participant 63),” a sentiment which was echoed in the responses of many others. Women’s inability to support their families with the salaries they received highlights the interrelationship between this theme and ‘family and obligation’.The stressors associated with families’ needs may represent a gendered experience, whereby these women experienced obligations both as the carer and breadwinner: “[I feel stressed] when I can’t reach someone at home and I can’t call…When loved ones demand time that I could not give due to working (participant 120).” Women reported stress emanating from worrying about loved ones and being far from family: “When people or my close friends tell how their life or their problem…that makes me feel stressed because I feel that I absorbed their problem (participant 141).” This was evident in other women’s words: “miss my family ”; “broken family (participant 37)”; “my children way back home (participant 4).” This theme was very prevalent among the women, with 31 (17.0%) reporting family related stressors.time for self; managing their thoughts; and religion ”; “I feel ok again to have strength (participant 148)”; “my thoughts can be comforted or kept busy by my activities outside (participant 56).” However, participants reported they were often unable to take time for themselves.Given the demands of their work life, participants consistently reported a need for managing their thoughts, a second theme, included positivity, focusing on the present, and avoiding thinking too much. One participant described she would “keep myself busy and avoid too much thinking (participant 3).” Other participants described they liked to “think of something funny (participant 103),” or “have positive feelings (participant 73).” As one participant explained, “Thinking positively gives me good result (participant 61).” Participants also described how focusing on the present and making the best of things helped them to manage their stress: “As a domestic worker, what to do is to enjoy your housework most of the time…because once in a while, I forget all the things happened around us (participant 72).” Another participant explained, “I just relax and never think so much. I just concentrate on my work (participant 71).”Participants’ efforts to cope by Religion, the third theme, was reported to be an important coping resource. Participants spoke about how singing, prayer, church attendance, and reading religious texts helped them to cope. Across all religions, women described the importance of their faith in addressing stress: “Just pray in a temple (participant 15)”; “Pray and speak to the God where I am believe. To give thanks and to ask for help (participant 34).” When asked if these things helped them to cope, participants’ replies included: “Casting all my anxieties and cares to God help me relax (participant 100)”; “Yes. Because I feel the comfort of God (participant 14)”; “Praying clear my mind and refresh my inner thoughts (participant 165).”the comfort of company, and having someone to talk to.Social support was described as a salient coping resource, and two themes were identified: the comfort of company was beneficial because others gave their understanding, acceptance, comfort, encouragement, love, and physical presence, and that it was helpful for someone to “just be around (participant 96).” Participants spoke about the importance of having someone to talk to: “We share each other’s’ concerns. Fellowship (participant 100)”; “By sharing to my friends, give me advice…how to handle such a problem, talking to others is really great (participant 3).” This also included having someone to “listen”, “give advice”, and “make me happy.”Participants described that Participants reported the benefits of having someone who would smile or make them smile, tell jokes or a funny story and “make me laugh (participant 98).” The benefits of such social support were obvious in participants’ responses: “Making jokes and fun with me so I can feel less stressed cos I can forget about the problems (participant 52).” Women also described that having someone to encourage their “positive thinking” or provide a positive outlook was helpful. One participant described she liked to “interact with some positive conversation to release any negative thought that weaken the immune system, and to avoid mental disorder (participant 109).”Eight participants however indicated social support was not helpful: “Just leave me alone and don’t ask what happened. Cos asking why seems rather making me feeling worse and better yet don’t ask what happened with the eyes if it’s obviously sore from crying (participant 120).” Another participant stated, “I don’t need people when I’m stressed (participant 182).”Psychosocial risks in the workplace are deeply connected with the experience of work-related stress, and have been acknowledged as major public health concerns –20. ThisThree hierarchical interrelated themes were identified as causes of stress, including ‘work and agency’, ‘the pervasiveness of financial need’, and ‘family and obligation’. The analysis highlighted how participants’ agency in their workplace is interrelated with ‘the pervasiveness of financial need’. The need for employment to support both themselves and their families contributes to participants’ limited agency, puts them at risk of exploitation, and ultimately presents barriers to being able to take advantage of an entitlement to a rest day . These ffamily and obligation with the other themes also echoes previous research highlighting the politics of reproductive labour. Specifically, it describes the experience among female foreign domestic workers of being caught in the middle of the division of labour between work and home life, and the role that globalisation and the gendered division of labour play in driving these women’s migration [The participants also described how stressors experienced by their loved ones abroad consequently affected them, a finding that is consistent with previous research on foreign domestic workers and the emotional impact of ‘mothering from a distance’  or labouigration , and theigration , 36. Theigration ,3.Coping mechanisms were identified in the research highlighting the need for space and time to cope with stressors, reasonable work hours and pay, and entitlement to a day off. Religion was an important coping resource in the analysis, consistent with a significant body of research on the value and benefit of religion as a way of maintaining a feeling of connectedness to one’s culture –39.The significance of coping mechanisms and women’s resilience has often been overlooked in research on FMDWs due to a focus on their vulnerability. There is limited literature examining the ways in which women, and their strategies to achieve ‘mobility’ or agency, are disempowered in these contexts . Future Throughout the women’s responses, the social support women described related to forms of ‘emotional support’, for example the role someone played as a confidant or source of advice, rather than ‘instrumental support’, through a physical or tangible source of help or assistance . Social support was predominantly perceived to be a beneficial resource, consistent with previous research –44. HoweProblematically, the prevention and management of psychosocial risks has not been high on the policy making agenda. While international agencies have helped draw global attention to domestic workers, and resolutions to improve employment conditions for domestic workers worldwide have been adopted , and the ILO strategy for action (2011–15)), further efforts are needed to raise awareness of all stakeholders to improve working conditions and employee wellbeing. More progress is needed on integrating healthy workplaces initiatives into policy and practice, devising plans to implement and evaluate the global plan of action on workers’ health, and developing evidence-based policies.This study addresses an important gap in research on FMDWs in Singapore, and represents the first empirical data collected on these issues with a large respondent base. Whilst previous studies have often focused on the ‘vulnerability’ of FMDWs based on their increased risk of poor mental health outcomes, our study highlights the coping mechanisms utilised by this population. This is key to developing successful and sustainable initiatives to foster healthy workplaces  and to sWhile all participants were proficient in English and did not require the translation resources that were available, we acknowledge that language barriers may still have impacted on their interpretations of the questions and their responses, and consequently the data generated. Further research is needed with populations who experience more significant language barriers, who may be more vulnerable to marginalisation or exploitation due to their literacy and associated factors.Whilst the study design allowed us to collect free-text qualitative data on the experiences of a large number of women, there is also a need to generate more data for these groups using other qualitative approaches (e.g. in-depth interviews or focus groups) to further deepen understandings of the lived experiences of these groups. Though the responses participants elected to provide were brief, the structure of the free-text questions in the survey allowed us to examine similarities and differences in women’s experiences around the core themes within the framework in our analysis of the qualitative data. However, further in-depth research should also be carried out in this area using other qualitative methods to generate additional data, explore this data using diverse epistemological approaches, and contextualise our findings. The data for the analysis were also limited, as only 100 of the 182 respondents provided free-text data. Whilst there may be differences in experience among those for whom we do not have data, these women had similar socio-demographic backgrounds to those who did provide data, suggesting the data are likely to be representative.Finally, the results may not be generalisable to FMDWs who did not have access to or were not able to take advantage of rest days. At the time of the research, a similar survey with this group found that 54% of migrant domestic workers reported a weekly day off, however 40% of respondents reported that they had a rest day less than once a week . This poIt is also important to acknowledge the influence of the researchers on the findings. The researchers have personal experience of migration, and we recognise that our own experiences of relocating to new countries, leaving behind family members or other loved ones, and learning how to access or develop our own coping mechanisms in relation to stressors may have contributed to our interpretation of the experiences of the immigrant women in the study, and that our experiences are likely to be vastly different. In the analysis, a process of active reflexivity (assessing and documenting the researchers’ perspectives in the research) was undertaken. It is important to recognise that the process of qualitative analysis is interpretative, and requires the researchers’ active and subjective involvement in the production of data. The process of active reflexivity increases the rigour of the research, not by removing the researcher’s influence on the findings or isolate bias (as suggested by a positivist approach assuming a single ‘truth’ exists), but rather to acknowledge multiple realities: the data are grounded in an individual’s experience and informed by the greater context within which they live and the research is conducted.This study highlights the stressors FMDWs in Singapore experience, and the coping mechanisms utilised to help address these stressors.It is important to recognise that this population requires protection in policy not only from deliberate exploitation, but also employment that may be potentially coercive or exploitative due to the socio-economic pressures many FMDWs face and the limited agency that may result from this. Such circumstances could be alleviated by strengthening and expanding the implementation of global frameworks targeted at improving workplace conditions and workers’ rights.Evaluation and monitoring strategies are also needed to ensure the protection of this population. Such recommendations are in line with key global priorities, for example the Sustainable Development Goals 3, 5, and 8, which emphasise the need to promote wellbeing, gender empowerment, productive employment and decent work.In relation to the stresses women experience, there is a need to better understand and seek to improve stressors stemming from ‘work and agency’, ‘the pervasiveness of financial need’, and ‘family and obligation’ among FMDWs. The importance of action plans like the WHO ‘Healthy Workplaces’ global model , which pS1 TableThis is the relevant qualitative dataset supporting the findings presented in this manuscript.(XLSX)Click here for additional data file.S2 TableThis is the completed COREQ Checklist.(PDF)Click here for additional data file.


We found workplace policy factors supporting breastfeeding  varied by industry. Women in specific service-oriented industries  reported the lowest rates of breastfeeding initiation and workplace supports for breastfeeding and pumping. Further, how a woman hoped to feed and having a private pumping space at work were significantly associated with industry, breastfeeding initiation, and breastfeeding duration. A substantial portion of women reported being not sure about their workplace environment, policies, and culture related to breastfeeding. Additional studies with larger sample sizes of women participating in WIC are needed to further characterize the barriers to breastfeeding associated with specific industries.Variations in the barriers and contributors to breastfeeding across industries have not been well characterized for vulnerable populations such as mothers participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Our study used the Total Worker Health Framework to characterize workplace factors acting as barriers and/or contributors to breastfeeding among women participating in the New Hampshire WIC. Surveys were collected from WIC mothers ( Over the last two decades, the global public health community established that working outside the home was negatively associated with breastfeeding ,2,3,4. TMoreover, women planning to work full-time postpartum were less likely to initiate breastfeeding than women who planned to work part-time and women were more likely to cease breastfeeding the first month prior or subsequent to returning to work ,4. EmploHaving identified this disparity, recent research has recognized the need to explore factors that influence breastfeeding cessation when returning to work . MothersBreastfeeding disparities experienced by low-income women due to individual, social, and environmental barriers are well documented ,16. BreaThe type of employment generally obtained by WIC eligible mothers further contributes to the disparities found in the U.S. WIC eligible mothers are more likely to have low-income jobs in childcare, home healthcare, or in one of the service industries . These jThe studies among WIC mothers identify a vulnerable population at risk of experiencing disparities in breastfeeding, which vary by employment type. However, employment supports and policies for breastfeeding are geographically and industry-dependent. For example, in New Hampshire (NH), according to the 2016 NH WIC Pediatric Nutrition Surveillance data, 76.8% of WIC mothers initiate breastfeeding after delivery, compared to 87.4% of all mothers in New Hampshire ,27. FurtThe Total Worker Health (TWH) Program, created by the National Institute for Occupational Safety and Health (NIOSH) in 2012, supports protective and preventive efforts to improve the health and well-being of workers . The TWHBreastfeeding-friendly worksites have been associated with benefits for both mothers and employers that include reduced employee absenteeism, increased employee retention, increased employee morale and loyalty, healthcare cost savings, and positive public relations and company image ,32. AlthTo the best of our knowledge there have been no studies exploring breastfeeding behavior across industries among WIC mothers. Using the TWH framework to characterize workplace factors for breastfeeding, this study examined the barriers and contributors to breastfeeding experienced by mothers in the NH WIC Program and focused on identifying workplace polices, supports, and practices that encourage or discourage breastfeeding after returning to work.This study used a cross-sectional design to survey women utilizing the WIC services in NH. In order to represent the entire state, all four local agencies providing WIC services in NH with catchment areas covering all ten counties in the state were utilized in the study.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 . The domQuestion content  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 ,35. WherWhen 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.Study eligibility criteria required women be enrolled in the WIC program and the birth mother of their child or that their child was enrolled in the WIC Program. Each local WIC office’s breastfeeding coordinator directed survey implementation at their respective agency. WIC participants were recruited by referrals from WIC staff, and flyers in the WIC offices. Surveys were offered to all women participating in the NH WIC program that visited local agency offices during August, September, and October of 2016. Surveys were administered in English and staff were available for respondent questions while completing the survey. Immediately prior to administration, respondents received instructions as to the purpose, audience, risks, benefits, and completion of the survey. Surveys were completed immediately onsite and took approximately 15 minutes to finish.A total of 682 mothers responded to the survey. This degree of survey participation represents approximately 5.0% of the total WIC caseload in NH at the time of the study.Paper surveys were completed during an office visit to WIC agencies while participants were at a WIC appointment receiving benefits or waiting to be called for their appointment. As the study proceeded, agency staff collected and periodically sent surveys to the research team. A student entered each respondent’s data into an online version of the survey designed in Qualtrics Software to create an excel data file.Age was coded as 15 to 17, 18 to 34, and 35 and over. Race/ethnicity was coded as non-Hispanic White, and Other.“Breastfeeding initiation” was based on three questions including: (1) declared breastfeeding status ; (2) “One week after you gave birth, how were you feeding your baby?”, with responses of breast milk only, formula only, both breast milk and formula; and (3) “How old was your baby when you stopped breastfeeding completely?”, with responses of one through thirteen months or baby has not stopped breastfeeding. Ever having breastfed was defined as reporting currently breastfed, previously breastfed, feeding breast milk one week after birth (only or in combination with formula), having stopped breastfeeding, or having a baby that has not stopped breastfeeding. Never having breastfed was defined as reporting planning to breastfeed, never having breastfed, not feeding with breast milk the first week after birth, not having stopped breastfeeding, and not having a baby that continues to breastfeed. “Duration of breastfeeding” was based on the declared breastfeeding status and the question: “How old was your baby when you stopped breastfeeding completely?” . Breastfeeding for less than 4 months was defined conditionally on having reported previously breastfeeding and having stopped breastfeeding after one, two, or three months. Breastfeeding for greater than or equal to 4 months was defined conditionally on having reported previously breastfeeding and having stopped breastfeeding after four or months. “Reason for stopping breastfeeding” was based on the question: “What were your reasons for stopping breastfeeding?” Responses were categorized as physiological , other commitments , and met goal . More than one reason could be reported.“Employment status” was based on the question: “What is your employment status?” Responses were categorized as full-time, part-time, and other. Other included individuals not in the labor force, unemployed, in school, disabled, seasonal workers, and/or stay at home mothers. “Industry” was coded according to 2012 Census Industry Classification Codes. Industry responses were combined into broader categories to increase the number of responses in those categories for analysis purposes. “Accommodation, food, and hospitality” included responses from women working in restaurant, travel and hotel jobs. “Healthcare” included women working in healthcare or in a hospital setting as well as working in home healthcare, as a licensed nursing assistant, or in an assisted living or nursing home environment. “Retail” included women working in grocery, clothing, convenience, and department stores. “Other” included all other industries with sample sizes too small to consider separately. This included but was not limited to education, social assistance services, manufacturing, and other services. Study participants were asked to respond to the industry question only if they were currently employed or planning to return to work.“Hoping to feed” was based on the question: “While you were pregnant, how had you hoped to feed your baby?”, with responses of breastfeeding only, formula only, or a combination of breastfeeding and formula. “Received information” was based on the question: “Did you receive information about breastfeeding during pregnancy?”, with responses of yes or no.“Paid maternity leave” was based on the question: “Does your workplace offer paid maternity leave and is it separate from any other leave such as sick and or vacation leave?”, with responses of yes, no, and “not sure.” Conditional on having reported no to having paid maternity leave, “other maternity leave” was based on the question: “can employees take paid maternity leave using other leave such as sick time or vacation time?”, with responses of yes, no, and ”not sure.” “Breastfeeding policy” was based on the question: “Does your workplace have a written policy on breastfeeding or pumping?”, with responses of yes, no, and ”not sure.” “Seen policy” was conditional on having reported yes to having a breastfeeding policy at work and based on the question: “Have you seen or do you have a copy of the written policy on breastfeeding at your workplace?”, with responses of yes, no, and ”not sure.” “Pumping break times” was based on the question: “Does your workplace provide break times to allow mothers to pump breastmilk?”, with responses of yes, no, and ”not sure.” Conditional on having reported yes to having break times for pumping, “flexible breaks” was based on the question: “Is the break time flexible ?”, with responses of yes, no, and ”not sure.”“Private pumping space” was based on the question: “Does your workplace have a private space  for you to use a breast pump?”, with responses of yes, no, and ”not sure.” “Onsite items” was based on the question: “Does your workplace offer the following items on-site for employees to use when expressing breastmilk?”, with responses categorized as utilities  and physical (chair and/or space with locked door). More than one item could be reported. “Supportive coworkers” was based on the question: “Are your co-workers supportive of mothers who need to use a breast pump during work?”, with responses of yes, no, and ”not sure.” “Supportive supervisor” was based on the question: “Is your supervisor supportive of mothers who need to use a breast pump during work?”, with responses of yes, no, and ”not sure.”“Pumped at work” was based on the question: “Have you had to use a breast pump at work?”, with responses of yes, no, and “not sure.”“Reaction to pumping” was conditional on having reported yes to having pumped at work and based on the question: “What type of reaction, if any, have you received from those you work with?”, with responses categorized as negative (negative reactions only or some positive and some negative reactions) and positive (no reactions given or positive reactions only). “Pumped longer if easier” was based on the question: “Would you have continued breastfeeding longer if it was easier to pump at work?”, with responses of yes, no, and ”not sure.” Conditional on having reported yes to breastfeeding longer if it was easier at work, “factors” asked people to report what factors would have made it easier, with responses categorized as policy , and environment (a place to store breastmilk or a private space for pumping). More than one factor could be reported.All analyses were conducted using SAS Version 9.4 . Univariate and bivariate methods were used to estimate counts and percentages. Bivariate associations in contingency tables were tested either using Fisher’s exact tests or Fisher’s exact tests with Freeman and Halton’s adaptations for non-standard RowxColumn tables . Monte Cp = 0.025). There were no differences in race/ethnicity or employment status by breastfeeding initiation . By industry, a greater percentage of women who had ever breastfed worked in healthcare (26.3% vs. 20.0%) and a smaller percentage worked in accommodation and retail (20.4% vs. 33.8% and 16.1% vs. 24.6%) than women who had never breastfed (p = 0.011). Among women who had breastfed, 64.2% had hoped to exclusively breastfeed during pregnancy, compared to 12.6% of women who had never breastfed (p = 0.000). Among women who had never breastfed, approximately 40.3% had hoped to breastfeed during pregnancy. There was no difference in the percentage of women who had received information about breastfeeding during pregnancy by breastfeeding initiation status (p = 0.224).p = 0.000), compared to women who had never breastfed. There was no difference in having paid maternity leave, other maternity leave, a breastfeeding policy, having seen the workplace breastfeeding policy, or having flexible break times for pumping by breastfeeding initiation status . Within the physical environment and safety climate domain, by breastfeeding initiation status (ever vs. never), there were significant differences in having private spaces for pumping , supportive coworkers , and supportive supervisors .In addition, in p > 0.099). During pregnancy, 73.8% of women who breastfed for 4 months or longer hoped to only breastfeed, compared to 50.4% of women who breastfed less than 4 months (p = 0.000), and there was no difference in the percentage of women who receive information about breastfeeding during pregnancy by duration of breastfeeding (p = 0.736). Across reasons for stopping breastfeeding, compared to women who breastfed 4 months or longer, a greater percentage of women who breastfed for less than 4 months stopped breastfeeding for physiological reasons , a smaller percentage stopped breastfeeding when they met their breastfeeding goal , and there was no difference in the percentage of women who stopped breastfeeding due to other commitments (p = 0.888).p = 0.032, not significant after Bonferroni correction). Within the physical environment and safety climate domain, there were two marginally significant differences by duration of breastfeeding. Compared to women who breastfed less than 4 months, a greater percentage of women who breastfed 4 months or longer had private pumping spaces  and utilities that supported breastfeeding . Among women who breastfed 4 months or longer, 56.3% pumped at work, compared to 13.6% of women who breastfed less than 4 months (p = 0.000). Within the work evaluation and experience domain, there were no significant differences by duration of breastfeeding .Similar to p = 0.023). There was no association between industry and race/ethnicity (p = 0.191). Employment status varied significantly by industry with the largest and smallest percent of full-time workers in accommodation and retail , and the largest and smallest percent of part-time workers in retail and healthcare .p = 0.029, not significant after Bonferroni correction). The greatest and smallest percentage of women who received information about breastfeeding were in healthcare and accommodation . Reasons for stopping breastfeeding did not vary significantly by industry (p = 0.256).Across industries, there were marginally significant differences in how women hoped to feed or if they received information about breastfeeding during pregnancy. The greatest and smallest percentage of women who hoped to only breastfeed were in other industries and accommodation , and the greatest and smallest percentage of women who hoped to only feed with formula were in accommodation and other industries . Further, women working in healthcare and accommodation had the greatest and smallest percentages of other forms of maternity leave . In addition, there were marginally significant differences in paid maternity leave by industry. The greatest percentages of paid maternity were found among women working in healthcare and other industries and the smallest percentages were found among women working in accommodation and retail .p = 0.000). Further, women in healthcare and “other” industries had the greatest percentages of supportive coworkers in the workplace, compared to accommodation and retail , and women in healthcare and “other” industries had the greatest percentages of supportive supervisors in the workplace, compared to accommodation and retail . Within the health behavior domain, greater percentages of women in healthcare and other industries pumped at work, compared to women in accommodation and retail . There were no significant differences within the work evaluation and experience domain factors by industry Within the physical environment and safety climate domain, there were significant and marginally significant differences by industry. Women in healthcare and other industries had the greatest percentages of private pumping spaces in the workplace, compared to accommodation and retail  reported the lowest rates of breastfeeding initiation and workplace supports for breastfeeding and pumping . CompareNotably, workplace policy factors supporting breastfeeding  varied by industry but were not associated with breastfeeding initiation or duration. Further, how a woman hoped to feed and having a private pumping space at work were significantly associated with industry, breastfeeding initiation, and breastfeeding duration. Our study confirms previous findings by Snyder et al. (2018) that having a breastfeeding policy, a space to pump, and coworker and supervisor support towards pumping at work vary by industry with the highest rates found among women in a professional industry  . FurtherThis study was cross-sectional and we were unable to assess the temporality of associations such as having received information on breastfeeding, how a woman hoped to feed her child, and subsequent breastfeeding behavior. We were also unable to assess supervisor or coworker support of pumping in the workplace pre-partum and its impact on pumping behavior. Survey responses were based on self-report and subject to several biases including but not limited to response bias, nonresponse bias, recall bias, and observation bias. Women who were employed, initiated breastfeeding, or had difficulty breastfeeding may have been more likely to take the survey, respond to all survey questions, and more accurately remember their breastfeeding experiences.The survey also directed women who were currently on maternity leave or who had recently left their job to also respond to workplace questions. This may have resulted in increased rates of employment, having breastfed, and difficulties breastfeeding than in the entire WIC population. Due to this design effect, we were also unable to reliably identify and analyze the rates of women who were pregnant or gave birth and decided to no longer work (and their workplace environment).Income, a key factor in the initiation and duration of breastfeeding, was not collected in this study. However, we assumed study participants were of a similar, lower socioeconomic status given they had qualified for the WIC program. All WIC families are at or below 185% of the family poverty level unless they adjunctively qualified through participation in the Supplemental Nutrition Assistance Program, Temporary Assistance for Needy Families Program, and/or Medicaid. The types of jobs and industries reported in our study reflect the low to moderate income of WIC participants. Our study also did not collect the age of the child and we were unable to determine who was still on paid maternity leave at the time of survey administration. Categories for industry were especially broad due to small sample sizes and we were not able to calculate numerous factors related to industry and occupation, employment, and the workplace including occupation alone, additional industries, size of the workplace (greater than or less than 50 people), and exempt versus non-exempt jobs.Many breastfeeding studies focusing on workplace support by employment type are limited to their sample population ,21. ThisOur study illustrates how breastfeeding worksite supports are critical to TWH and well-being and suggests that women with a supportive environment are more likely to initiate breastfeeding and breastfeed longer compared to those without a supportive environment. When women begin the WIC program, they are often overwhelmed with the demands of working and caring for their family on a limited income. Although women are encouraged to explore their specific workplace policies and environment during breastfeeding education sessions and counseling appointments, these factors may contribute to the high rates of “not sure” reported in this study. Recently, there has been increased attention to breastfeeding support within the workplace to ensure compliance with the Patient Protection and Affordable Care Act (2010), which amended Section 7 of the Fair Labor Standards Act to require employers to provide: (1) “reasonable break time for an employee to express breast milk for her nursing child for 1 year after the child’s birth each time such employee has need to express the milk,” and (2) “a place, other than a bathroom, that is shielded from view and free from intrusion from coworkers and the public, which may be used by an employee to express breast milk.” ,38. ThisCurrently, there are numerous ambiguities across breastfeeding research, policies, and practice at the state and federal level. There is a need to make clear connections between federal statutes, public health research, official company-specific policies, and actual practices in the workplace, especially the transparent designation of a workplace contact for breastfeeding policies and practice. Human resource or occupational health personnel in the workforce who write policies or design lactation space should be educated on core components that make up comprehensive lactation programs. Managers and supervisors need to be aware of the unique, acute, and transient needs of breastfeeding mothers returning to work specific to their job class, duties, schedules, and locations. Providing education and training directed toward leadership, supervisors, and human resource personnel regarding the benefits of breastfeeding for both employees and employers and the supports needed when returning to work should be included in any TWH framework. In addition, our study found that many women were unaware of their employer’s benefits for lactation support after returning to work, demonstrating the need for improved communication and awareness about the benefits of health-related employer policies in the context of the TWH framework.Additional studies with larger sample sizes of women participating in WIC, characterizing the barriers to breastfeeding associated with specific industries and subpopulations, would inform future interventions, policy development, and education for employers of this population. Currently, lack of support for breastfeeding across industries is only discussed anecdotally, especially within the WIC program. Given our sample population, we suggest that an equality lens be considered in providing and communicating lactation support; studies should examine whether or not women are afraid to ask about the breastfeeding policies in their workplace, how employers disseminate health benefit information, and the availability and visibility of spaces for breastfeeding in the workplace. More broadly, learning about workplace policies and attitudes towards breastfeeding often involves speaking with coworkers and supervisors suggesting worksite power imbalances between employee and employer be examined. Future studies should also consider the high rates of “not sure” reported in this study in response to questions about workplace support and policies for breastfeeding. In order to better educate WIC participants, methods to improve the provision or dissemination of informational materials should be explored.In breastfeeding research, policy, and practice a variety of social justices are being addressed by agencies, leaders, and grass roots groups that believe breastfeeding is a human right that should not be denied or sacrificed when returning to work after having a baby. The priorities for these organizations include equal access to prenatal and postpartum lactation care and support, as well as targeted, evidence-based approaches to address the large disparities in workplace accommodations found in this study.


Dear editorvulnerabilis, or from the Greek vulnus, and means “to hurt”.The word “vulnerability” derives from the Latin term Since then, the term “vulnerable” has been used in caring ethics, and can be attributed to individuals, patients, family members, caregivers, health professionals or populations that are incapable of consent and/or reduced autonomy.The vulnerability among chronic renal patients is multifactorial and multi-faceted, as these patients are deprived of their autonomy, requiring the availability, access and adherence to various forms of renal replacement therapy (RRT) for the maintenance of one’s life.et al.’sIn this context, Obregón A recent paper produced by our group sought to expand the view on vulnerability in the developing countries that make up the BRICS .Regarding renal transplantation, there were permissive legislation on organ tourism (South Africa), the occurrence of renal transplants with deceased donors without prior consent (China), a high number of kidney transplants involved with evidence of commercialization of organs (India), difficulty concerning extra-official data in the international literature (Russia) and regional disparities in access to renal transplantation .While equity is a bioethical concept distinct from vulnerability, based on the Aristotelian premise that “unequal must be treated unequally,” promoting a fair provision of RRT to the most vulnerable countries, especially developing countries, would bring an improvement to the individuals’ vulnerabilities, as a bioethical reference, both for patients (due to better accessibility to treatment) and for nephrologists themselves . The “Kidney Health for All” theme for the celebrations for the 2019’s World Kidney Day is an invitation to such a reflection. In fact, issues related to inequality in access to renal health are increasingly common in the world literature.