Through these analyses, the size, composition, and network of the national breastfeeding stakeholder landscape was identified across links of command, dissemination, funding, technical assistance, and advocacy. The density of the networks ranged from 0.09 (technical assistance) to 0.20 (command), indicating that only as much as 20% of possible links in these networks exist. Furthermore, in the networks for command and funding, there were two-actors isolated from the larger network of actor within these two areas. While it would be inefficient to have a network density of 1.00 as certainly every actor need not to be connected to every other actor, a lower network density can place greater importance on actors who can connect other pairs of actors (i.e. actors with high betweenness centrality). Thus, strategically generating new and meaningful links between actors can help strengthen the breastfeeding environment by increasing the efficient flow of information and resources across relevant actors.
Unlike the landscape observed in India, where substantial proportion of actors had high relative influence , few actors in the current analysis were identified through the network and power mapping as influential actors. Two government partners, GHS and MOH, had the highest RI-W. These two actors were central in all of the networks analysed, as both a source and target for command as well as a target for funding and technical assistance with regards to breastfeeding. Furthermore, these actors were identified as important gatekeepers, or connectors, in many of the networks including command, funding and technical assistance (i.e. higher betweenness centrality). UNICEF and WHO, two UN agency actors, also received high RI-W across interviews and were present in all the networks mapped, with the exception that UNICEF was not cited in the command network. However, these actors were not as central as GHS and MOH in the social network analysis. The media ranked within the top 15% of RI-W (7th out of 49) and was an important connector in the dissemination as well as advocacy networks. Interestingly, development partners (represented as a singular actor) were not identified as being influential, yet they provided funding for breastfeeding to the largest number of actors. These results suggest that there are various actors that are important within different networks, but that GHS and MOH are the two critical institutions that are involved in the full landscape of breastfeeding programs and policy in Ghana.
While there were some similarities in the central actors across networks (i.e. GHS and MOH), as indicated above, most of the networks included a diverse spread of actor groups. This diversity of actors has been previously demonstrated by social network mapping of actors working in infant and young child feeding elsewhere [16, 22, 23]. In India, network analysis at both national and subnational levels reported diverse actors across both government and non-government agencies, and also spanned multiple sectors including, social protection, health and nutrition, research, health, planning, population sciences, media and trade unions . Similar findings were observed in Sri Lanka . This diversity can be valuable in the implementation of breastfeeding policies and programs because it allows for a multidisciplinary approach that relies on diverse partners and approaches.
Findings from the BBF toolbox previously identified suboptimal coordination of stakeholders working in the breastfeeding landscape in Ghana at the national level . While this is not the first time that a focus on stakeholders has been identified as an important component of breastfeeding policy and programming in Ghana , the current study is the first to systematically assess how stakeholders interact with and influence each other within Ghana’s breastfeeding friendly environment. The Linkages Project implemented between 1997 and 2004 in Northern Ghana identified and built capacity of multiple actors, resulting in improved breastfeeding outcomes . However, an assessment of barriers that limit adequate participation of actors is warranted as a next step to ensure that all relevant actors are sufficiently engaged with and influencing breastfeeding policy and programming in Ghana. The result of such an assessment can inform how actions are coordinated across all partners in order to optimize benefits from most actors involved in breastfeeding policy and programming.
Findings indicated that GHS is one of the most important actors in the breastfeeding landscape with respect to receiving technical assistance, command, and funding in Ghana, as indicated by high in-degree centrality and holding the highest relative influence among actors. MOH held the second highest relative influence among actors and was similarly central in specific networks including being a popular target of breastfeeding advocacy, and the greatest source of commend to other actors. Furthermore, both GHS and MOH served as connectors in networks, bridging links across various actors in the networks. This is consistent with the role that leading government health agencies are expected to play . In the current landscape, a well-functioning GHS and MOH is critical for optimal breastfeeding promotion, protection and support in Ghana. It is also apparent that GHS, in particular, is dependent on other agencies for funding, direction (i.e. commands), and technical assistance, which is “forwarded” (i.e. provided) to other institutions and organisations, as demonstrated by its high in-degree and betweenness centrality of GHS. Thus, any situation that threatens access to these supporting resources to GHS may adversely affect breastfeeding program implementation at the national and subnational levels. Policies and strategies that strengthen the capacity of GHS are thus warranted.
Study findings provide empirical evidence of how stakeholders are currently connected with each other with regards to breastfeeding policy and programming in Ghana. The clarity of relationships provided by this study can also inform future research, particularly, regarding barriers of stakeholder engagement. The findings also complement those of from the BBF committee, which together provide evidence to inform breastfeeding decision-making in Ghana . Decision-makers in Ghana can use the findings to determine which actors are better positioned to address policy recommendations identified in the BBF report, as well as identify areas within these networks that could be further developed to strengthen the breastfeeding friendly enabling environment.
This study had a few limitations. The current study mapped individual experiences of actor involvement in breastfeeding in Ghana. Although Net-Map interviews of individuals have been previously reported  and are considered valid , unlike a group Net-Map approach [16, 23], it may limit the precision and validity of recall of the role of actors by the respondents. In group Net-Map exercises, participants have an opportunity to calibrate their opinions and experiences with each other and to arrive at consensus on actor roles, linkages, and influence. Yet, this can mean that some voices are not heard as strongly as others. Alternatively, individual Net-Map exercises require the analyst to calculate agreement, such as the RI-W. However, each individual is allowed an equal voice. Therefore, pros and cons of groups vs. individual Net-Map experiences should be weighed to determine the best option within each study.
Within this study, the number of respondents was smaller (n = 10) than the previous smallest reported Net-Map interviewee size from previous studies (n = 17). The systematic selection of participants to include diverse, nationally representative individuals within the breastfeeding environment in Ghana supports the strength of this data. Additionally, findings are consistent with qualitative data showing the central role UN agencies and GHS have on strengthening the breastfeeding environment in Ghana . Finally, the study was limited to the national level and thus could not be applied for decision-making at sub-national levels, which will require interviews at that level.
These limitations suggest that further research is needed in this area. Future studies evaluating differences between group and individual Net-Map results have the potential for understanding the contextual pros and cons of each method. Additionally, replicating our findings using a larger sample size of interviewees, especially across various levels of political administration, can strengthen and extend this study’s methodology, results, and recommendations to sub-national and local levels.