Full text




Sree Sathya Deepthi Dintyala

A paper presented to the faculty of The University of North Carolina at Chapel Hill in partial fulfillment of the requirements for the

degree of Master of Public Health in the Department of Maternal and Child Health.

Chapel Hill, N.C.

30th April 2020

Approved by:

(Dr. Kavita Singh Ongechi)

(Dr. Aunchalee Palmquist)


MPH core competencies

1. Analyze quantitative and qualitative data using biostatistics, informatics, computer-based programming and software, as appropriate.

2. Interpret results of data analysis for public health research, policy or practice. MCH foundational competencies



Objective: To examine the association between antenatal visitation and adherence to

exclusive breastfeeding at 6 months in Bangladesh.

Methods: This study included 1,958 mother-infant dyads from Bangladesh

Demographic Health survey (BDHS), 2014. Two-model logistic regression was used for

the analysis of the association.

Results: 451/1958 (23%) children were EBF at 6th month. Women with secondary

education had 1.84 times the odds to EBF at 6th month as those with higher education

(p-value<0.05). Antenatal care (ANC) from medically trained providers (MTP) had 4.77

times the odds of EBF adherence as receiving ANC from NON-MTP (p-value<0.01). On

adjusting for covariates, 4+ ANVs had 2.8 times the odds of EBF adherence at 6

months as no ANVs (p-value<0.01) establishing a mediating effect of place of delivery


Conclusion: This study substantiates the significant role played by ANV, maternal

education, maternal age, ANC provider on EBF at 6 months. The analysis found a

positive association between ANV and EBF at 6th month. The findings point to

developing initiatives to strengthen quality of ANC, perinatal counseling and support for


Table of Contents

1. Introduction... 4

2. Methods... 6

3. Variables... 6

3.1. Dependent variable... 6

3.2. Independent variable... 7

3.3. Covariates... 7

4. Analysis... 8

5. Ethics Review... 8

6. Results... 9

6.1. Descriptive analysis... 9

6.2. Perinatal characteristics... 10

6.3. Logistic regression analysis... 11

7. Discussion... 12

8. Conclusion and Recommendations... 15

Acknowledgments... 16


1. Introduction

Human milk is the best source of nourishment for an infant because it is natural and the

safest food they can be given. Human milk contains all of the essential nutrients for a

newborn until they attain 6 months of age to thrive and grow adequately. Besides the

nutrients, human milk also contains maternal antibodies that cast a significant level of

immunity against gastrointestinal and frequent upper respiratory tract infections for the

infant, besides aiding optimal weight gain and mental development. Human milk has

also shown several benefits on the long-term health outcomes of the child in terms of

warding off obesity, diabetes, and other chronic conditions while showing potential

protection against dental malocclusions.1 BF also confers several maternal benefits

such as improved mental health, the more rapid loss of pregnancy-related maternal

weight, lactational amenorrhea which also has a contraceptive benefit, long-term

protection against breast cancer, and most importantly aids mother-infant dyad


To elicit the significant impact of EBF, a systematic review indicated that

provided evidence that the mortality rate was significantly higher in infants under 5

months who were predominantly (RR 1.5), partially (RR 4.8) and not breastfed (RR

14.4) when compared to those who were exclusively breastfed, with consistent trends

for infection-related mortalities.4 Considering the plethora of benefits for both mothers

and children, WHO recommends EBF for the first 6 months of the baby, followed by

systematic weaning with nutritious complementary foods subsequently, with continues

breastfeeding until the age of 2 years.2

Low- and middle-income countries (LMIC), especially in South Asia and Africa,

have a high rate of BF intention and initiation, owing to the strong socio-cultural

practices which bolster breastfeeding. However, most of the countries face difficulties in

establishing economic, health, and other social support systems to facilitate a mother’s

ability to breastfeed as recommended.5,6 In LMICs, it is estimated that about 63% of

children under the age of 6 months are not exclusively breastfed, also influenced by

cultural pre-lacteal feeding7. Although the rates of EBF show an upward trend over the


universal BF practices, we can reduce 823,000 preventable child deaths and 20,000

breast cancer deaths at a global level, annually.1

Understanding the determinants of poor adherence to EBF can be elusive by

global trends due to the evident differences in the cultural, and social-ecological factors

underlying BF practices. Bangladesh has almost universal BF (96%), yet the rate of

EBF for 6 months is as low as 55%. Although Bangladesh is at par with the WHO

proposed national rates for EBF, due to pertinent high infant mortality rate, it may be

advisable to have an increased emphasis on EBF for 6 months.8

Several previous studies have established the role played by antenatal education

and support in early initiation of BF and the continuation of EBF over varying time

frames. One prospective cohort study conducted in rural Bangladesh showed positive

association (OR 1.48; 95% CI 1.14,1.91) between counseling during the antenatal

period and increased EBF intention leading to adherence.9 Despite the low rates of BF

in Ethiopia, a systematic review conducted showed evidence that women who had

ANVs were two times (OR 2.1; 95% CI 1.5, 2.8) more likely to EBF their children when

compared to their counterparts, indicating that ANVs have a positive impact on

adherence to EBF.10

Several studies have also established the positive association of ANV and early

BF initiation, besides several other factors. One randomized controlled trial in Canada

was successful in establishing the positive effects on EBF adherence at 4 months (OR

2.84; 95% 1.76–4.60) owing to individualized antenatal counseling and postnatal

support.11 Likewise, an interventional study conducted in India, which provided

one-on-one perinatal education to mothers, showed about 7.4 times the odds of sustained EBF

at 6 months as opposed to the standard care group as control (95% CI 3.98-13.92).12

Considering the significance of adherence to EBF and the potential benefits of

ANVs, it is imperative to study the association between the two entities. Moreover, the

WHO/UNICEF baby-friendly hospital initiative includes antenatal BF promotion as step

3 of the ten steps for successful BF initiative. The ten steps also include training of

health personnel, early initiative, postnatal counseling, and community-based support


association between the quality of ANC and EBF, was to also understand the role of

other maternal and perinatal characteristics on this association.

2. Methods

This project was a secondary data analysis of the 2014 Demographic health survey

data conducted in Bangladesh. The method of data collection was in person conducted

by trained interviewers who visited selected households over a four to six-month period.

The survey used a 2-stage sampling methodology, which was first stratified into rural

and urban areas and further divided into clustered samples by utilizing probability


For the analysis, the dataset used was the Children Recode (KR) subset of the

BDHS 2014 data set. It is a complete birth history of each child born to the interviewees,

including but not limited to, demographic characteristics of the interviewee, perinatal

characteristics, feeding practices, and nutritional, and health status. The unit of analysis

(case) in this file is the child ever born of eligible women in the past two years. The

women’s response rate was 98% in both urban and rural areas in Bangladesh. 8

Finally, to focus on the latest live birth, each child born within 2 years prior to the

date of the interview, living with the mother of age 15-49 years were considered and all

of the entries with children younger than 6 months and older than 24 months were

dropped. Since the unit was measured from the child records, multiple pregnancies

yielded the corresponding number of dyads. Further, to ensure complete real values for

the regression analysis, all of the entries which had any missing data were dropped. As

a result, the final working sample consisted of a total of 1,958 mother-infant dyads,

wherein the mothers were of ages 15-49 with a live birth in the last two years, and had

the child over 6 months living with them.

3. Variables


Dependent variable

The outcome variable for this study is a dichotomous variable created from the DHS


giving the child water, country-specific liquids, tinned milk, formula, fresh animal milk,

solid food. For this study, ‘exclusive breastfeeding’ comprised of only breastfed category

and ‘not-exclusively breastfeeding’ included feeding any other food, including water and

formula.14 Children were categorized by age and divided into categories ‘under 6

months’ and ‘6 months and above’. By utilizing these two base variables, the outcome

variable was generated to be ‘Exclusively breastfed at 6th month and above’, thus

eliminating the children under the age of 6 months. A result of “Yes” indicated that the

child was EBF at 6th month, and “No” indicated that the child consumed other food at

6th month and was not adherent to EBF.


Independent variable

The primary independent variable for the study is ANV. This data was collected during

the survey by recording the number of ANV during the given pregnancy. For this study,

the variable was recoded to have three categories, ‘No antenatal visits’, ‘Less than 4

antenatal visits’, and ‘4 or more antenatal visits. The rationale behind the recoding was

to comply with the WHO guidelines for quality ANC, recommending that each pregnant

woman had at least 4 antenatal visits for positive perinatal outcomes. Although the

recommendations now require at least 8 visits, the data available is for 4 visits.15



Several covariates were checked for potential confounding and mediating effects on the

association between the primary independent and dependent variables.

Maternal age – The original variable for maternal age in DHS data was recoded into five

categories’ 15-19’, ‘20-24’, 25-29’, ‘30-34’, and ‘35-49’.

Maternal Education - DHS datasets standardized categorized the highest level of

maternal education attained into four ordinal groups, namely, ‘No education’, ‘Primary

education’, ‘Secondary education’, and ‘Higher than secondary’.

Relative wealth - Wealth index in the DHS surveys is a composite measure of a

household’s cumulative living standard. By utilizing a statistical procedure known as

principal components analysis, DHS categorizes households into five wealth quintiles,


Assistance by MTP – A dichotomous variable was created based on questions asked in

the questionnaire regarding the provider who provided ANC. For dichotomization,

medically trained doctors, nurses, and community health officers/nurse were

categorized as “MTPs” and the traditional birth attendants, village health volunteers, and

others categorized as “Non-MTPs”.

POD - According to the standardized DHS coding, the POD is categorized into

“attendant’s home” and several healthcare facilities, including but not limited to public

and private hospitals, clinics, and government health complexes. To focus broadly on

the care they receive at delivery, POD was dichotomized into categories’ Institutional’

and ‘Non-institutional’.

Postnatal counseling on BF – The standardized DHS dichotomous variable on whether

counseling on BF was received within two days after delivery.14



The statistical analysis was conducted on STATA version SE-16.0. Descriptive analysis

was performed by bivariate analysis using chi-square independent test to understand

the demographic and characteristics of the study population. For the multivariate

analysis, modeling was adopted for conducting a logistic regression analysis. Firstly, a

logistic regression was performed for each of the independent variables with the

dependent variable to examine the bivariate relationship, and the crude odds ratios

(ORs) and 95% confidence intervals (CIs). Further, the potential confounders were

adjusted for in the first model, and potential mediators were included in the second

model to yield the adjusted ORs and 95% CIs. P-values <0.05 were taken to depict the

statistical significance of the findings.

Regression equation:

Y = α + β1j (ANCVISITS)+ β2, j (MAGE)+ β3, j (MEDU) + β4, j (WEALTHQUINTILE) +

β5, j (ANCMTP) + β6, j (PLACEDEL) + ϵ … (1)


The University of North Carolina Institutional Review Board determined that this project

was exempt from ethical review as it entails secondary data analysis of publicly


6. Results


Descriptive analysis

By applying the inclusion criteria and eliminating the mothers and children who fell in the

exclusion window, the total number of mother-child dyads that could be included in the

final analysis was 1,958. Within the sample, 451(23%) children were exclusively

breastfed at 6th month, while 1,507(77%) were not exclusively breastfed. As seen in

Table 1, there is a significant difference between the percentage of mothers in the ages

15-19 years between the two groups, with a relatively higher percentage of women who

exclusively breastfed in the ages 15-19, while the lesser relative percentage of women

in the 20-24 years when compared to those who did not EBF (p-value = 0.02). As it

pertains to education, there was a significantly higher percentage (52.3%) of women

who were educated up to secondary education who did not EBF as opposed to those

who exclusively breastfed (42.1%) (p-value<0.01). These findings were flipped in the

category who attained higher education. Approximately comparable distribution was

found among the various wealth quintiles.

Table 1 : Bangladesh – Sociodemographic characteristics of mothers of children under the age of 2 years during the period 2012-2014, BDHS 2014


Socio – demographic Characteristics

Exclusive BF at 6m Status EBF


Not EBF (n=1,507)

Total (n=1,958)

Number (%) Number (%) Number (%) p-value

Mother’s age

15-19 134(29.7%) 333 (22.1%) 467 (23.9%) 0.02*

20-24 142 (31.5%) 547 (36.3%) 689 (35.2%) 24-29 106(23.5%) 370 (24.5%) 476 (24.3%) 30-34 49 (10.9%) 190 (12.6%) 239 (12.2%)

35-49 20 (4.4%) 67 (4.5%) 87 (4.4%)

Mother’s Education

No education 56 (12.4%) 145 (9.6%) 201 (10.3%) 0.00* Primary 113 (25.0%) 367 (24.4%) 480 (24.5%)

Secondary 190 (42.1%) 788 (52.3%) 978 (50.0%) Higher 92 (20.4%) 207 (13.7%) 299 (15.3%) Wealth quintile

Poorest 65 (14.4%) 251 (16.7%) 316 (16.14%) 0.21 Poorer 85 (18.9%) 228 (15.1%) 313 (16.0%)


Richer 97 (21.5%) 351 (23.3%) 448 (22.9%) Richest 120 (26.6%) 368 (24.4%) 488 (24.9%)

Total 451(100%) 1,507(100%) 1,958(100%)



Perinatal characteristics

Table 2 shows the analysis of the frequency of the adherence to EBF at 6months by

stratifying each of the antenatal characteristics. There was no significant difference in adherence by ANV or whether they received counseling on BF within the first two days of delivery. The analysis shows evidence that a larger percent (76.5%) of mothers among the exclusively breastfed category received their ANC by a MTP as opposed to a larger percent (59.5%) of women who did not exclusively breastfeed received their care from a non-MTP (p-value<0.01). Similarly, among the women who adhered to EBF, a significantly larger percent (57.2%) delivered institutionally (p-value= 0.01).

Table 2: Bangladesh – Perinatal characteristics of mothers of children under the age of 2 years during 2012-2014, BDHS 2014


Perinatal characteristics

Exclusive BF at 6m Status EBF


Not EBF (n=1,507)

Total (n=1,958)

Number (%) Number (%) Number (%) P-Value

Number of ANC Visits

No ANC 51 (11.3%) 194 (12.9%) 245 (12.5%) 0.67 Less than 4 ANC 221 (49.0%) 721 (47.8%) 942 (48.1%)

4 or more ANC 179 (39.7%) 592 (39.3%) 771 (39.4%)


ANC by Non-MTP 106 (23.5%) 896 (59.5%) 1,002(52.2%) 0.00* ANC by MTP 345 (76.5%) 611 (40.5% 956 (48.8%)


Non-institutional 193 (42.8%) 744 (49.4%) 937 (49.4%) 0.01* Institutional 258 (57.2%) 763 (50.6%) 1,021(50.6%)

Post-natal BF counselling

Did not receive counselling 118 (26.2%) 406 (26.9%) 524 (26.8%) 0.74 Received counselling 333(73.8%) 1,101 (73.1%) 1,434(73.2%)

Total 451 (100%) 1,507(100%) 1,958(100%)



Logistic regression analysis

Table 3 is the multivariate regression analysis of the association between ANV and

adherence to EBF at 6 months. Firstly, a logistic regression analysis was performed for each of the independent variables with the dependent variable EBF at 6 months, and the crude ORs were noted. ANV, wealth quintile, and postnatal counseling had no significant effect on the odds of adherence to EBF at 6th month. However, older women of ages 20-24, 25-30, and 31-34 were 1.55, 1.4 and 1.56 times more likely, respectively, to adhere to EBF at 6months when compared with those in the ages 15-19(p-value<0.05). As it pertains to education, women who had completed primary and secondary education had 1.44 and 1.84 times the odds of EBF at 6th month when compared to women with higher than educational attainment(p-value<0.05). The analysis also found evidence that a woman who received her ANC from a non-MTP was 4.77 times as likely to EBF as a woman who received ANC from a MTP (p-value<0.01). Likewise, women who delivered at a medical institution were 1.3 times as likely to EBF as women who delivered in domestic conditions (p-value<0.05).


Table 3: Bangladesh - Logistic regression analysis for EBF at 6 months adjusted for covariates

Logistic Regressio n Analysis

Crude Model (n = 1,958)

Adjusted Model 1 (n = 1,958)

Adjusted Model 2 (n = 1,958)

OR 95% CI

p-value Adj OR 95%CI p-value Adj OR 95%CI p-value Number of ANC visits

No ANC Ref - - -

-4 or less 0.86 0.61-1.21 0.38 0.82 0.57-1.17 0.28 2.96 1.91- 4.59 0.00*

4+ ANC 0.87 0.61-1.23 0.43 0.85 0.58-1.25 0.42 2.80 1.77-4.43 0.00* Mother’s age (years)

15-19 Ref - - -

-20-24 1.55 1.18-2.04 0.00* 1.68 1.27-2.22 0.00* 1.45 1.08-1.94 0.01*

25-29 1.40 1.05-1.89 0.02* 1.57 1.57-2.13 0.00* 1.32 0.96-1.82 0.09 30-34 1.56 1.07-2.26 0.02* 1.87 1.27-2.75 0.00* 1.50 1.00-2.26 0.05 35-49 1.35 0.79-2.31 0.28 1.74 1.00-3.04 0.05* 1.58 0.88-2.85 0.12

Mother’s Education


education 1.15 0.78-1.71 0.49 1.00 0.65-1.59 0.95 0.77 0.47-1.24 0.28 Primary 1.44 1.04-2.00 0.03* 1.47 1.02-2.12 0.04* 1.16 0.78-1.71 0.47 Secondary 1.84 1.38-2.47 0.00* 1.98 1.45-2.71 0.00* 1.71 1.22-2.38 0.00*

Higher Ref - - -

-Wealth Quintile

Poorest 1.26 0.89-1.77 0.19 1.28 0.86-1.89 0.22 1.05 0.69-1.60 0.82 Poorer 0.87 0.63-1.21 0.42 0.84 0.58-1.20 0.34 0.69 0.47-1.02 0.07 Middle 1.20 0.87-1.65 0.26 1.15 0.82-1.63 0.41 1.03 0.72-1.49 0.86 Richer 1.18 0.87-1.60 0.29 1.15 0.84-1.59 0.38 0.97 0.69-1.36 0.86

Richest Ref - - -

-ANC by MTPs (MTP)

Non-MTP 4.77 3.75-6.07 0.00* - - - 6.93 5.11-9.42 0.00*

ANC- MTP Ref - - -


Non-institution 1.30 1.05-1.61 0.01* - - - 1.19 0.92-1.54 0.19

Institution Ref - - -

-Received Counselling

No 1.04 0.82 -1.32 0.74 - - - 0.93 0.72-1.20 0.58

Yes Ref - - -


7. Discussion

Breastfeeding confers immense benefits for the child-mother dyad that are both

short-and long-term. Owing to these benefits, the WHO recommends EBF for 6 months

followed by systematic weaning with nutritional supplementation.2 Southeast Asian

countries have high adherence to BF due to deep-rooted cultural values and practices

that encourage BF.1,16 Bangladesh has almost universal BF with up to 96% of women


percentage is not reflective of adherence to EBF.8 For this analysis, EBF was

considered when the infant was fed nothing but human milk, also excluding water. The

rationale behind this is the evident differences between the positive health outcomes of

adhering to EBF as opposed to giving other food. For years, one of the major barriers

was the increased marketing of formula milk and supplemental feeding of infants.

However, Bangladesh was one of the first countries in Southeast Asia to adopt strict

policies against formula feeding and already has several initiatives to promote BF at the

government level. Despite all of the efforts, Bangladesh continues to have low

adherence to EBF as per WHO recommendations.17

The analysis found that women of ages 20 and above had a significantly higher

odds of adherence to EBF when compared to teenage mothers. As also, there were

higher odds of adherence among women who were less educated when compared to

women who had attained higher levels of education. As per DHS data, a higher level of

education comprises of diplomas, bachelorette degrees, and professional degrees,

which qualify the women to employment. Existing literature shows evidence of negative

outcomes of a mother’s work status on EBF owing to barriers due to a lack of policies

supporting BF at the workplace. Initiatives such as UNICEF’s Alive and Thrive initiative,

maternity leave for 6 months, paid breaks for BF, which have proven immensely

beneficial in Bangladesh. It is worthwhile to note that non-adherence to EBF and using

breastmilk substitutes are more common among women who remain at work and at

school, contrary to the literature that cites BF as a reason to stop women from

working.6,18Hence, subsequent surveys with a specific focus on the barriers for BF could

yield a better understanding of the association and may be able to provide greater

insights to policymakers as they develop further initiatives to supporting educated and

working mothers.

Existing studies show evidence that quality ANC which included imparting

counseling on BF, had a positive impact on early initiation of BF and the intention to

breastfeed. Although several other factors are responsible for adherence to the

recommendations, it can be said that with greater intention, there could be a possible

improvement in the adherence to EBF.9–11There is a possible inadequate education as it


adequate education during pregnancy when the women tend to be most receptive to

such education.

Existing literature also shows evidence that antenatal counseling and education

have a positive effect on early initiation of BF and adherence to EBF for up to 4

months.11 The analysis asserts the positive association between ANV and adherence to

EBF at 6 months on adjusting for the covariates. However, the analysis does not

provide a comprehensive picture of the quality of ANC received by the mothers during

the ANV especially on antenatal BF education/counseling and their effect on adherence

to EBF, as the questionnaire does not attempt to assess the nature of BF counseling in

the antenatal period.8 Considering the cited beneficial effect of antenatal BF education

on self-efficacy, intention, and early initiation, further studies which try to assess the

association between quality of ANV taking into account all of the components of the

ANC may provide greater insight into the importance of ANC period for adherence to


The study also found that women who received their ANC from non-MTP such as

TBAs and VHWs, as opposed to MTPs, had higher adherence to EBF at 6 months. As

per existing evidence, the presence of TBA at delivery has 6 times the positive effect on

the continuation of EBF at 6 months when compared to being delivered by a MTP.19,20

Additionally, peer counselors have also found to have a positive impact on adherence to

EBF at 5 months when compared to a control group (RD=64%, p-value<0.001).21 TBAs

are valued community members who play an important role as they provide mothers

with services not restricted to delivery services, but also in extending emotional support

and practical guidance during pregnancy and after birth. As they are respected

individuals in the community, they tend to have a more profound influence on the

practices of mothers when compared to external medical providers.22 Thus, training the

TBAs and integrating them in the healthcare system could have immense positive BF

outcomes besides other maternal and child health outcomes.

The analysis found that in Bangladesh, having an institutional delivery had a

significant association with adherence to EBF for 6 months. Having a high-risk

pregnancy may be a potential confounder to this association, which would also affect


pregnancies mandate greater ANC. Additionally, having a high-risk pregnancy, assisted

delivery, and other high-risk factors could lead to separation which encourages

pre-lacteal supplementation, and breastmilk substitutes, which create additional challenges

in adherence to EBF.6 Although DHS data did not include questions on the topic, further

research on the influence of high-risk factors on BF practices by asking questions on

pregnancy related complications may be helpful to understand the nature of the

association fully.

There are several limitations to this study, as evident from the discussion above.

Although the study considered several covariates, the survey may be lacking data

regarding certain important and potentially informative determinants. One other

important limitation is the missing data from one or more of the variables, which

required us to drop about 1009 respondents. Also, there could be other limitations in

terms of the recall by the mothers, and also a possibility of non-differential

misclassification as the understanding of EBF is unclear and could lead to ambiguity.

8. Conclusion and Recommendations

Despite the limitations, this study substantiates the significant role played by ANV,

maternal education, maternal age, ANC provider on adherence to EBF for 6 months.

The study illustrates the positive association of ANV with EBF adherence after

eliminating the possible effect of other factors considered. The study established a

potential mediating effect of the POD on this association. Additionally, higher adherence

to EBF at 6 months was found among mothers of ages 20-30 years when compared

with teenage mothers, mothers receiving ANC from a non-MTP, and women who

received secondary education when compared with women who received higher than

secondary education.

On close examination of the existing literature with conjuncture with the study

findings, it may be recommended that the country establish more robust initiatives that

provide support and opportunities which encourage BF practices among all women with

special provisions for women pursuing higher education and careers. Secondly,

considering the substantial numbers and influence of traditional birth attendants in the


outcomes for the country. Further, it may be important to conduct studies that would

help gain deeper insights into the quality of ANC in association with EBF, type of

education, and the associated employment, high-risk nature of pregnancy to gain a

complete picture of the barriers for adherence to EBF. It is worthwhile to reiterate the

importance of quality of antenatal care and antenatal attendance in yielding desirable

pregnancy-, breastfeeding-, and health outcomes for both mothers and infants.


I would like to express my deepest gratitude to my academic advisor Dr. Kavita Singh

Ongechi, Associate Professor at the University of North Carolina – Chapel Hill for her

guidance and detailed review in the process of developing this document versions. Dr.

Singh has always been unconditionally supportive of my academic and career pursuits

at UNC and beyond. I very much appreciate her mentorship. I would also like to

acknowledge and thank Dr. Aunchalee Palmquist, Assistant Professor at UNC-Chapel

Hill for her knowledgeable, insightful, and thoughtful commentary throughout the writing

process. I would like to acknowledge the valuable guidance provided by Cathy Zimmer,

Odum Institute, UNC, and Karar Zunaid Ahsan for their valuable guidance in conducting

the data analysis. Finally, I would like to acknowledge my family, friends, and

colleagues who have offered immense support thought the process of writing this paper,



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