Developing a Culturally Grounded Breastfeeding Assessment for Low

Home , Breastfeeding in public

Developing a Culturally Grounded

Breastfeeding Assessment for Low-Income, African American Women

Dissertation

Presented in Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy

in the Graduate School of The Ohio State University

Rebecca Reno, M.S.W., M.A., B.A.

Graduate Program in Social Work

The Ohio State University

2016

Dissertation Committee:

Audrey Begun, Advisor

Dawn Anderson-Butcher

René Olate

Rebecca Marie Reno

2016

Abstract

The benefits of breastfeeding for mothers and infants have been well established

in the literature, as have pervasive racial disparities in breastfeeding initiation and duration (Centers for Disease Control and Prevention, 2013a). The American Academy of Pediatrics recommends exclusive breastfeeding to 6 months of age, and Healthy

People 2020 aims to have 60.6% of all infants exclusively breastfed to 6 months of age.

A review of existing literature revealed a dearth of research focused specifically on the breastfeeding beliefs or behaviors of low-income, African American women. Reported studies are either atheoretical or utilize health behavior theories focusing on individual- level factors. Little attention has been paid to the unique sociocultural context within which this population is situated. Further, many existing breastfeeding interventions were not specifically designed for low-income African American women, and therefore may overlook their unique barriers to breastfeeding. Taken together, critical feminist theory and a social cultural model could provide a more comprehensive, culturally grounded framework from which to understand breastfeeding disparities, and to begin working to address them.

Utilizing these two theories, a multi-phase, mixed methods research study was designed to identify breastfeeding barriers and supportive factors for low-income African

American women, and to help empower them to meet their breastfeeding goals through the design and testing of a breastfeeding assessment process. Phase 1 utilized a ii community-based participatory action research methodology called group model building

to answer the following research question: How do low-income, pregnant and postpartum

African American women describe breastfeeding within their socio-cultural context,

including factors that help or hinder breastfeeding? In Phase 2A, the set of statements that

emerged from Phase 1 activities were evaluated by breastfeeding scholars and

practitioners for inclusion in a set of Q-sort cards. These cards formed the foundation of a

Dynamic Breastfeeding Assessment Process (D-BAP). In Phase 2B, the D-BAP was

tested with a sample of lactation specialists and pregnant women to answer the research

question: What would an assessment process look like if it were informed by the

perspectives of the women as captured in the model building process? Finally, in Phase 3

the D-BAP underwent feasibility testing. Mixed methods were used to answer two

research questions: 3A. How do pregnant, low-income African American women

experience the culturally grounded Dynamic Breastfeeding Assessment Process? 3B.

When the Dynamic Breastfeeding Assessment Process is delivered, is there a measurable

difference in breastfeeding self-efficacy and intent among pregnant, low-income African

American women? Completion of the D-BAP was hypothesized to be associated with

increased breastfeeding intent and higher levels of breastfeeding self-efficacy. A pre-post,

paired-samples design was utilized in Phase 3.

The Phase 1 and 2 activities successfully resulted in a testable Dynamic

Breastfeeding Assessment Process. In Phase 3, women who participated in the D-BAP iii demonstrated a statistically significant increase in breastfeeding self-efficacy, but not in their breastfeeding intent. The qualitative and quantitative findings from this study can inform future research, particularly as it pertains to supporting low-income African

American women to meet their breastfeeding goals: a critically important public health and social work goal.

Acknowledgments

Much love, support, and encouragement goes into the making of a successful PhD

student; I will be forever indebted to those who have seen me through. I am compelled to

do my best to express my humble gratitude, though inevitably my words will be

inherently insufficient.

First, I am incredibly honored and deeply humbled by the generosity of all of the

women who lent their time, their experiences, and their voices to this project. Thanks also

to the indispensable Tanikka Price. Without her unparalleled facilitation skills and

ongoing support, this study simply would not have come to fruition.

To each of my committee members, I offer my deepest gratitude for the insights,

guidance, mentorship, and encouragement offered over the years. I am honored that

Professor Audrey Begun was willing to chair my committee. She has been incredibly supportive and unwaveringly confident in my ability to do things I was not sure I was capable of at the time. I would also like to offer my sincerest appreciation to Professor

Dawn Anderson-Butcher. It was her passion and scholarship that first attracted me to social work, and her encouragement and guidance that saw me through. A thank you is

owed to Professor René Olate as well, whose well-timed and insightful questions have

led me down many inspiring theoretical and methodological paths.

I am also deeply appreciative of the support and guidance I have received from

many faculty and staff at the College of Social Work at The Ohio State University, v especially Tamara Davis. Your mentorship and ongoing support has strengthened my research skills, developed my knowledge about community partnerships, and expanded my research horizons. Thank you also to Dr. Pat Gabbe and the entire Moms2B team.

Your tireless work in the community is an ongoing source of inspiration. Appreciation is due for the generous funding from the Department of Women's, Gender and Sexuality

Studies and the Coca-Cola Critical Difference for Women Grants for Research on

Women, Gender and Gender Equity. Support from the Merriss Cornell Research

Scholarship is also deeply appreciated.

I would be remiss if I did not acknowledge my proverbial village as well. There is simply no substitute for the love, laughter, and generosity of dear friends. For Marissa

Kaloga and Sheila Barnhart, I would not like to ponder, even for a moment, what it would have been like without you. We may have survived, but there would have been a lot less laughter. My gratitude goes to Kristin Coppock and Sarah Moreno as well, who have come early, stayed late, and many times over have loved my kids as though they were their own.

To my three boys—Wyatt, Silas, and Levi—if you remember nothing else of this time, I hope you have seen what it means to set your sights on a goal, and to work tirelessly to achieve it. I am enduringly grateful that my own mother gave me that gift through the playful recitation of all of the abbreviations following her name. Finally, for my husband, Clinton—never a word of doubt uttered, not a single discouragement, not vi even so much as a sigh. For every time that someone said to me, "I don't know how you do it,” the answer is "you." Always, you.

vii

Vita

2000…………………………………………B.A. Psychology, The Ohio State University

2003-2010…………………….…………….Senior Research Associate, The Kirwan

Institute

2007…………………………………………M.A. Education, The Ohio State University

2010-2011…………………….…………….Graduate Research Associate, College of

Social Work, The Ohio State University

2011-2013…………………….…………….Graduate Teaching Associate, College of

Social Work, The Ohio State University

2013…………………………………………M.S.W., The Ohio State University

2013-2016…………………….…………….Graduate Research Associate, College of

Social Work, The Ohio State University

Publications

Davis, T. S., Guada, J., Reno, R., Peck. A., Evans, S., Moskow Sigal, L., & Swenson, S.

(2015). Integrated and culturally relevant care: A field education model for social

work in primary care. Social Work in Health Care, 54(10), 909-938.

Iachini, A., Buettner, C., Anderson-Butcher, D., & Reno, R. (2013). Exploring students’

perceptions of academic disengagement and re-engagement in a dropout recovery

charter school setting. Children & Schools, 25(2), 113-120. viii

powell, j., & Reno, R. (2011). A democratic merit agenda: An alternative approach.

Readings on Equal Education, 25, 275-296.

Fields of Study

Major Field: Social Work

Table of Contents

Abstract ...... ii

Acknowledgments...... v

Vita ...... viii

List of Tables ...... xvi

List of Figures ...... xvii

Chapter 1: Introduction ...... 1

Background of the Study ...... 1

Statement of the Problem ...... 3

Significance of the Study ...... 4

Description of the Current Study ...... 5

Chapter 2: Literature Review ...... 6

Breastfeeding Literature...... 6

Benefits of breastfeeding...... 6

Risk factors for suboptimal breastfeeding practices...... 9

Factors promoting breastfeeding persistence...... 12

Existing breastfeeding interventions...... 18

Gaps in breastfeeding literature...... 21

Theoretical and Methodological Underpinnings ...... 27

Epistemological positioning...... 27

Mixed methods inquiry...... 30

Overarching theoretical frameworks...... 33

Theory-driven methodologies...... 39

Design of the Current Study ...... 51

Phase 1...... 51

Phase 2...... 52

Phase 3...... 52

Chapter 3: Phase 1 Methods, Results, and Implications ...... 55

Phase 1 Methods ...... 55

Sampling and participant characteristics...... 56

Data collection procedures...... 62

Data terminology...... 67

Data analysis procedures...... 68

Results ...... 72

Factors that make breastfeeding easier...... 73

Factors that make breastfeeding more challenging...... 77

Final model...... 82

Discussion ...... 85

Social ecological model...... 85

Cultural considerations...... 89

Theoretical implications...... 101

Conclusions and Recommendations ...... 103

Study limitations...... 105

Areas for further study...... 107

Chapter 4: Phases 2A and 2B Methods, Results, and Implications ...... 112

Phase 2A: Q-Sort Statement Selection ...... 112

Methods...... 112

Results...... 117

Discussion...... 159

Conclusions and recommendations...... 161

Phase 2B: Refining the Dynamic Breastfeeding Assessment Process...... 164

Methods...... 164

Results...... 179

Discussion...... 183

Conclusions and recommendations...... 184

Chapter 5: Phase 3 – Testing the Dynamic Breastfeeding Assessment Process...... 186

xii

Methods...... 188

Sampling and participant characteristics...... 188

Measures...... 191

Data collection procedures...... 193

Data analysis...... 194

Results ...... 195

Participants’ experiences of the D-BAP...... 195

Breastfeeding intent...... 200

Breastfeeding self-efficacy...... 202

Discussion ...... 203

Participants’ experiences of the D-BAP...... 203

Impact on breastfeeding intent and self-efficacy...... 204

Conclusions & Recommendations ...... 206

Chapter 6: Conclusions ...... 210

Mixed Methodologies ...... 210

Critical Feminist Theory and Social Ecological Framework ...... 211

Cultural contextualization of breastfeeding support...... 212

Moving from conceptualization to action...... 217

Community Based Participatory Action Research ...... 218

xiii

References ...... 224

Appendix A: IRB Approval Letter ...... 244

Appendix B: Email and/or Phone Script for WIC Peer Helpers ...... 245

Appendix C: Screening Script for WIC Peer Helpers ...... 246

Appendix D: Pregnant/Postpartum Recruitment Flyer ...... 247

Appendix E: Recruitment Script for Pregnant/Postpartum Participants ...... 248

Appendix F: Screening Script for Pregnant/Postpartum Participants ...... 249

Appendix G: Group Model Building Protocol...... 250

Appendix H: Consent ...... 253

Appendix I: Demographics for Peer Helpers ...... 257

Appendix J: Demographics for Pregnant/Postpartum Participants ...... 258

Appendix K: Phase 1 Rating of Factors that Facilitate Breastfeeding...... 261

Appendix L: Phase 1 Rating of Factors that Make Breastfeeding More Challenging .... 268

Appendix M: Phase 2B and 3 Semi-Structured Interview Protocol ...... 274

Appendix N: Session Evaluation Questionnaire ...... 275

Appendix O: Session Rating Scale ...... 276

xiv

Appendix P: Meeting My Breastfeeding Goals Handout ...... 277

Appendix Q: Breastfeeding Information and Myths Handouts ...... 278

Appendix R: D-BAP Administrator Sheet ...... 283

Appendix S: Infant Feeding Intentions Scale ...... 284

Appendix T: Breastfeeding Self-Efficacy Scale – Short Form ...... 285

Appendix U: Infant Feeding Intention Scale Results ...... 287

Appendix V: Breastfeeding Self-Effiacacy Scale - Short Form Results ...... 288

List of Tables

Table 1. Alignment between intervention research steps and current study design ...... 51

Table 2. Phase 1 pregnant and postpartum mothers’ demographics ...... 60

Table 3. Factors and themes that make breastfeeding easier ...... 74

Table 4. Factors and themes that make breastfeeding more challenging ...... 79

Table 5. Experts' rankings of themes and factors that facilitate breastfeeding (n=49) ... 119

Table 6. Experts' rankings of themes and factors that make breastfeeding more challenging (n=49) ...... 124

Table 7. Phase 2B and Phase 3 D-BAP protocol ...... 164

Table 8. Session Evaluation Questionnaire ...... 182

Table 9. Session Rating Scale ...... 183

Table 10. Phase 3 participant demographics ...... 190

Table 11. Session Evaluation Questionnaire results ...... 199

Table 12. Session Rating Scale item results ...... 200

Table 13. Session Rating Scale categorical results ...... 200

Table 14. Phase 1 rating of factors that facilitate breastfeeding ...... 261

Table 15. Phase 1 rating of factors that make breastfeeding more challenging ...... 268

Table 16. Infant feeding intention scale results ...... 287

Table 17. Breastfeeding Self-Efficacy Scale results ...... 288 xvi

List of Figures

Figure 1. Research design ...... 54

Figure 2. Final model of factors impacting breastfeeding ...... 83

Figure 3. Sources of support card ...... 134

Figure 4. Breastfeeding knowledge cards ...... 135

Figure 5. Supplies card ...... 136

Figure 6. Comfort breastfeeding card ...... 137

Figure 7. Bonding card ...... 138

Figure 8. Convenience card ...... 139

Figure 9. Resilience card...... 141

Figure 10. Pumping card ...... 142

Figure 11. Breastfeeding at work/school card ...... 143

Figure 12. Open-ended card ...... 144

Figure 13. Going back to work/school and pumping cards ...... 145

Figure 14. Time consuming card ...... 146

Figure 15. Low supply and painful cards...... 147

Figure 16. Don't know how to breastfeed card ...... 148

Figure 17. Lack of support card ...... 149

Figure 18. Role of medical provider card ...... 150 xvii

Figure 19. Others feeding card...... 151

Figure 20. Socializing card ...... 152

Figure 21. Sexual trauma card ...... 153

Figure 22. Sexualization of breasts card ...... 154

Figure 23. Uncomfortable about breastfeeding card ...... 155

Figure 24. Cultural beliefs card ...... 156

Figure 25. Formula card ...... 158

Figure 26. Open-ended barrier card ...... 159

xviii

Chapter 1: Introduction

Background of the Study

The importance of breastfeeding for infants, as well as their mothers, has been well established in the research literature; breastfeeding is associated with health, immunity, social, nutrition, psychological, and physiological benefits for infants (Purdy,

2010). Further, breastfeeding is associated with positive maternal mental and health outcomes (Asiodu & Flaskerud, 2011; Borra, Iacovou, & Sevilla, 2014; Ma, Brewer-

Asling, & Magnus, 2012; Mattox, 2012). Unfortunately, African American women have some of the lowest breastfeeding initiation and duration rates in the United States (Allen et al., 2013).

Given the aforementioned benefits, breastfeeding is a critical public and behavioral health issue. Breastfeeding decision-making and behavior have been studied extensively in research literature in fields such as nursing, medicine, and public health.

Unfortunately, the vast majority of studies fail to utilize a culturally grounded lens. In light of the racialized history of the United States, as well as the historical connection between breastfeeding and slavery, some have argued that race must be at the center of any contemporary research that aims to identify causes of low breastfeeding initiation and duration rates (Asiodu & Flaskerud, 2011; Cricco-Lizza, 2007; Lewallen & Street, 2010).

Most breastfeeding studies focus on middle-class, White women, and studies that do include a significant number of African American women often conflate race and class 1

by collapsing subcategories of women under a broader Women, Infants, and Children

(WIC) categorization (Tenfelde, Finnegan, Miller, & Hill, 2012).

To date, a number of individual and community interventions have been designed

and implemented to increase breastfeeding initiation rates and/or lengthen the duration of

breastfeeding. Critics have argued that many of them have been unsuccessful because

they fail to address the cultural-specific mechanisms that impact breastfeeding behavior

among African American women (Mattox, 2012; Purdy, 2010; Zamora, Lutter, & Peña-

Rosas, 2015). Among those interventions demonstrating success with low-income

African American women, many are time-intensive and cost-prohibitive, or are largely unstandardized (Spencer & Grassley, 2013; Chapman & Pérez-Escamilla, 2012). In order to address this critical public and behavioral health issue, effective, standardized, and culturally-responsive assessments and interventions are needed.

Additional research that identifies the breastfeeding beliefs, behaviors, and experiences of low-income African American women is necessary for developing these

responsive assessments and interventions. This study utilized a grounded research

process in order to identify the relevant factors and expand on existing research literature.

The findings were then used to develop and pilot test a Dynamic Breastfeeding

Assessment Process (D-BAP). The D-BAP was designed to provide lactation counselors

with a brief, easily accessible, semi-structured process for empowering low-income

African American women to meet their own breastfeeding goals.

Statement of the Problem

In 2008, 58.9% of African American mothers initiated breastfeeding as compared

to 75.2% of White mothers in the United States (Allen et al., 2013). This disparity is

particularly stark when factoring in socioeconomic status (SES). The breastfeeding

initiation rate among African American women with a poverty income ratio below 1.85

was only 37% (McDowell, Wang, & Kennedy-Stephenson, 2008). In the last fifteen

years, breastfeeding rates among African American women have improved; the percentage of African American women who breastfed increased between 1993 and

2008. For example, among non-Hispanic Black women, only 36% initiated breastfeeding in 1993-1994; by 2008, 58.9% initiated breastfeeding (Allen et al., 2013).

Despite this encouraging progress, a sizeable breastfeeding racial disparity gap still exists; by 6 months of age, only 30.1% of all African American infants were still breastfed compared to 46.6% of White infants (Allen et al., 2013). This 6-month attrition rate is critical as it represents an important breastfeeding benchmark; the American

Academy of Pediatrics not only emphasizes the importance of breastfeeding to 6 months, they recommend exclusive breastfeeding for that 6 month duration. Exclusive breastfeeding, defined by the World Health Organization, means the infant receives no other liquid or solids, with the exception of medicine, minerals, or vitamins. In 2012, only 16.4% of mothers of any racial or ethnic category were exclusively breastfeeding at

6 months (Centers for Disease Control and Prevention, 2013a). This falls significantly short of the ambitious goal set forth by Healthy People 2020 for 60.6% of all infants to be exclusively breastfed to 6 months of age.

Significance of the Study

In light of the importance of breastfeeding, the low breastfeeding rates among

African American women represent a critical public health and social justice issue.

Practitioners in a number of different fields have attempted to implement various

breastfeeding interventions, but have seen only modest success (Spencer & Grassley,

2013). Many interventions are time-intensive and cost prohibitive and nearly all lack a nuanced, race-based lens to understand and address low breastfeeding rates (Mattox,

2012; Renfrew et al., 2007). Lactation counselors need a culturally grounded, fast, effective tool through which to positively impact breastfeeding beliefs and behavior among low-income African American women. Social work is a discipline well poised to address this critical public health issue.

To date, breastfeeding has been a largely neglected topic within the field of social work; it resides primarily in the domain of nursing, public health, and medicine.

Although a substantial amount of research has demonstrated racial disparities in

breastfeeding rates, as well as the importance of this infant feeding practice on a wide variety of indicators, attention to this topic by social work scholars and researchers has been scarce. Breastfeeding research and interventions would benefit from social work’s

emphasis on the biopsychosocial approach, knowledge of systemic oppression and racial

disparities, and commitment to social justice and effecting positive social change.

Additionally, efforts to increase breastfeeding rates among low-income, African

American women can work towards health equity, which has been identified as a grand

4 challenge for the field of social work by the American Academy of Social Work & Social

Welfare (Walters et al., 2016).

In short, social work, in conjunction with other disciplines, has the potential to build a culturally responsive, grounded, and collaborative breastfeeding research and intervention agenda. This approach could recognize and account for the tremendous complexity of breastfeeding decision-making and behaviors, particularly among marginalized women (Van Esterik, 2012).

Description of the Current Study

Considering the relative absence of culturally relevant research and appropriate and effective breastfeeding assessments and interventions specific to low-income African

American women, additional work is needed in this area. A transformative, sequential study was designed utilizing mixed methods. This study sought to address the knowledge gap and to help low-income African American women meet their own breastfeeding goals through the grounded development and testing of a culturally responsive assessment process. This research project also sought to move the topic of breastfeeding more centrally into the purview of social work. The theories and methodologies utilized herein utilize principal components of social work values, and represent an attempt to apply a social work lens to a topic of which the field has been noticeably absent.

Chapter 2: Literature Review

Breastfeeding Literature

Benefits of breastfeeding. Breastfeeding has long been established as beneficial for infants and mothers alike.

Infant health. Through breastfeeding, an infant receives a complex combination of nutrients and antibodies that have long term impacts on a child’s neurological and immunological health (American Academy of Pediatrics, 2012). Among infants, breastfeeding is associated with decreased risk of developing diabetes, celiac disease, acute ear infections, upper and lower respiratory disease, childhood leukemia, asthma, and Type 1 and Type 2 diabetes (Asiodu & Flaskerud, 2011; Ma et al., 2012; Mattox,

2012; Stuebe, 2009). Additionally, breastfeeding is associated with a reduced risk of sudden infant death syndrome (SIDS) and decreased infant mortality rates, especially when breastfeeding is exclusive (Bartick & Reinhold, 2010; Hauck, Thompson, Tanabe,

Moon, & Vennemann, 2011; Sankar et al., 2015). This is in large part because of the decreased incidence rate of infections among breastfed babies; formula feeding is associated with increased rates of otitis media, gastroenteritis, and pneumonia (Stuebe,

2009).

Chen and Rogan (2004) found that breastfeeding is related to a 21% reduction in infant mortality in the first year of life, and those breastfed to at least 3 months of age had a 38% reduction in infant mortality. This is critical as African American infants are more 6

than twice as likely to die in infancy compared to White infants (Mathews &

MacDorman, 2013). Using survival tables and Cox regression techniques, Forste, Weiss, and Lippincott (2001) found that low birth weight and formula feeding account for comparable amounts of the racial disparity in infant mortality. This is an important finding as breastfeeding is a more easily modified factor than is birth weight.

The protective mechanisms that breastfeeding may provide are particularly important within low-income communities. Unfortunately, those living in conditions of concentrated poverty experience disproportionately high rates of the aforementioned illnesses, and are at greater risk of infant mortality (Centers for Disease Control and

Prevention, 2013b). Thus, increasing breastfeeding may protect at-risk infants against a wide range of physical ailments and their secondary developmental consequences; it may also be associated with reduced health disparity gaps between low-income African

American populations and their White counterparts (Chapman & Pérez-Escamilla, 2012;

Jones, Power, Queenan, & Schulkin, 2015).

Mothers’ health. Mothers who breastfeed may experience a number of long-term health benefits (Horta & Victoria, 2013). Breastfeeding is associated with a decreased maternal risk of breast, ovarian, cervical, and endometrial cancers (Ip et al., 2007; Stuebe,

2009). Additionally, women who breastfeed have a reduced risk of Type 2 diabetes, and decreased risk of coronary heart disease in the postmenopausal period (Schwarz et al.,

2009; Stuebe, Rich-Edwards, Willett, Manson, & Michels, 2005).

Maternal mental health and the mother-infant relationship. In addition to the physical protective factors, breastfeeding may also have a host of emotional benefits for

mothers and infants. Breastfeeding is associated with increased levels of maternal infant

bonding and decreased postpartum depression and anxiety, both of which are correlated

with higher levels of attachment between the mother and her child (Asiodu & Flaskerud,

2011; Condon & Corkindale, 1997; Ertel, Rich-Edwards, & Koenen, 2011). One cannot simply infer that breastfeeding results in better mental health, however as the existing research does not establish causality.

Conversely, failure to meet one’s breastfeeding goals is correlated with higher rates of postpartum depression (Borra et al., 2014). This is critical; although African

Americans are no more likely to experience maternal depression than their White counterparts, they are less likely to receive mental health services when they do experience maternal depression (Ertel et al., 2011).

Economics. Breastfeeding has been found to be cost effective for families, as well as for states and the nation. One cost/benefit analysis found that by improving breastfeeding rates so that 48% of infants are exclusively breastfeed for six months,

Louisiana could save $186,371,125 in health care costs annually, and could potentially prevent 16 infant deaths per year (Ma et al., 2012). On the national level, Bartik and

Reinhold (2010) estimated that if 80% of infants were breastfed for the first 6 months of life, the United States could save approximately $10.5 billion in health care costs annually, and 741 maternal and infant deaths could be prevented annually. If 90% of women met the 6 month recommendation, this could save $13 billion and 911 mother’s and children’s lives per year. These savings were calculated by examining the direct and indirect costs of treating children with diseases such as asthma, leukemia, and Type 2

8 diabetes. As mentioned, breastfeeding is associated with a reduction in the risk of those diseases in infants and children. Researchers then compared these projected reduced costs to the current costs of treatment (Bartik & Reinhold, 2010). It is important to note that this study did not take into account any economic losses experienced by formula companies as a result of decreased formula usage, thus this would offset overall economic gains.

Risk factors for suboptimal breastfeeding practices. Considering the aforementioned physical, emotional, and fiscal benefits of breastfeeding, it is critical that the gap between breastfeeding recommendations and rates among low-income African

American women be addressed. In order to design and implement effective interventions, it is important to first understand the specific individual and cultural factors that impact

African American women’s breastfeeding decision making during the prenatal period and breastfeeding behaviors in the postpartum period.

A number of factors are correlated with low breastfeeding intention and persistence rates. Perhaps the most notable, as mentioned, is race. African American women have the lowest breastfeeding rates among all racial groups measured in the

United States (Jones et al., 2015). Additional risk factors include lower socioeconomic status, lower education levels, being a young mother, and being a single mother

(Hundalani, Irigoyen, Braitman, Matam, & Mandakovic-Falconi, 2013; Lee et al., 2005).

Women are also less likely to breastfeed if their baby is born prematurely, or via a caesarean section (Callen, 2005; Cakmak & Kuguoglu, 2007). Women with low birth

weight infants also had lower rates of breastfeeding than women whose infants were not

low birth weight (Pineda, 2011; Sparks, 2011)

Physical and mental health. Infant physical health and mother’s physical and mental health have a direct impact on the duration of breastfeeding. Women who were overweight or obese had shorter duration breastfeeding than women who were not obese

(Dozier, Nelson, & Brownell, 2012; Tenfelde, Finnegan, & Hill, 2011). Women who

smoked, drank alcohol, had poor nutrition, or indicated they were sick or in poor health

also had lower intentions of breastfeeding and higher levels of breastfeeding ambivalence

than their counterparts who did not smoke or drink, consumed a healthy diet, or indicated

they were in good health (Chapman, 2010; Lee et al., 2005; Sparks, 2011). Finally, women experiencing depressive symptoms had shorter durations of breastfeeding than their counterparts (Karp, Lutenbacher, & Dietrich, 2010).

Ertel et al. (2011) further explored racialized components of maternal depression and found that African American women were more likely to experience adversity

(poverty, unemployment, financial difficulties, and unstable relationships) and had lower levels of overall daily functioning. Higher levels of stress, particularly financial and traumatic stress, are correlated with a lower overall duration of breastfeeding (Dozier et al., 2012). Finally, African American women are less likely than White women to receive supportive services related to maternal stress and depression (Ertel et al., 2011).

All these factors are critical in understanding the breastfeeding disparity gap

between African American women and women of other races because African American

women are at increased risk of experiencing these aforementioned factors due in large

part to structural racism, and residential segregation in communities of concentrated

poverty.

Situational and support factors. In addition to physical and mental health factors,

a number of situational variables influence breastfeeding initiation and duration. Women

with truncated or no maternity leave have lower levels of breastfeeding initiation and

breastfeed for shorter durations than women who delay their return to work for at least

six weeks (Ogbuanu, Glover, Probst, Liu, & Hussey, 2011). Additionally, women

working in settings that are not supportive of breastfeeding and who are not allowed time

or space to pump their breast milk are less likely to breastfeed (Godfrey & Lawrence,

2010; Sparks, 2011). Unfortunately, African American women are more likely to return

to work earlier than White women, and often work in settings that are not supportive of

breastfeeding (Johnson, Kirk, & Muzik, 2015; Mattox, 2012). These situational factors

can contribute to women experiencing high levels of stress, which in turn negatively

impacts their milk production (Dewey, 2001).

A lack of institutional support has been associated with low levels of

breastfeeding self-efficacy and self-confidence among low-income African American

women. Many women receive little encouragement and support from friends, family, and

medical personnel (Purdy, 2010; Tenfelde et al., 2011). Gee, Zerbib, and Luckett (2012)

found that African American mothers received less professional breastfeeding support

than White mothers during their postpartum hospital stay. Evans, Labbock, and

Abrahams (2011) also found reduced institutional breastfeeding support in African

American communities. Their research demonstrated that in one state, WIC offices that

11 served higher numbers of African American clients provided more limited and less intensive breastfeeding support services than WIC offices that served predominantly

White or Hispanic women.

Taken together, insufficient institutional support accumulates in what Chin and

Dozier (2012) describe as structural violence, defined as “indirect violence perpetuated on the poor through the higher order structures of the social ecology that leave the poor materially disadvantaged and at great risk for harm” (p. 65). This structural violence is disproportionately experienced by low-income African American women who receive an abundance of targeted pro-breastfeeding messages, yet have decreased access to institutional support for actualizing this health behavior. Perpetuating the pervasive public message that “breast is best” and emphasizing the importance of breastfeeding without providing the supports necessary to help women breastfeed, can further alienate and marginalize these women.

Factors promoting breastfeeding persistence. Despite numerous, socially entrenched barriers to breastfeeding among low-income African American women, researchers have identified factors that foster resilience in women who wish to breastfeed. Identifying these breastfeeding promoting factors is just as critical as identifying barriers. It provides information regarding where assessments and interventions can be targeted, in order to empower and equip women to meet their own breastfeeding goals.

Women who have knowledge from taking prenatal classes are more likely to breastfeed exclusively than women who do not take a class, as are women who receive

prenatal care in their first trimester compared to women who receive no prenatal care

(Tenfelde et al., 2011). A woman’s level of confidence is also a significant predictor of breastfeeding behavior (Blyth et al., 2002). Women who report higher levels of support from peer counselors and family members (particularly their mothers), are more likely to initiate breastfeeding and to breastfeed exclusively than women with lower levels of

support (Pugh et. al., 2010; Tenfelde et al., 2011). Finally, women who initiate

breastfeeding in the immediate postpartum period are able to breastfeed for longer

durations compared to women who introduce formula for the infant’s first feed

(Hundalani et al., 2013).

Prenatal breastfeeding intention. Many of the factors that have been found to

directly and indirectly influence a woman’s decision to breastfeed are in place long

before that woman becomes pregnant (Asiodu & Flaskerud, 2011). This includes her

exposure to other women who have breastfed, her attitudes and knowledge about infant

feeding practices, and her beliefs about the appropriateness of breastfeeding in social

situations (Asiodu & Flaskerud, 2011; Nommsen-Rivers, Chantry, Cohen, & Dewey,

2009; Stuebe & Bonuck, 2011; Tenfelde et al., 2011). Once a woman becomes pregnant,

her intention to breastfeed is a significant predictor of breastfeeding initiation and

persistence (Donath & Amir, 2007). Given this connection between intention and action, the prenatal period represents one critical point for intervention.

A number of micro and macro-level factors are correlated with a woman’s intention to breastfeed. For example, a woman’s friends and family, particularly the woman’s mother and the baby’s father, are influential in her breastfeeding intention level

(Bentley & Caulfield et al., 1999; Furman, Banks, & North, 2012; Furman & Dickinson,

2012). Additionally, a woman whose doctor expresses a preference for breastfeeding is

more likely to intend to breastfeed (Bentley & Caulfield et al., 1999). One retrospective, nationally representative survey found that African American women who received provider encouragement were five times more likely to initiate breastfeeding as those who reported no provider encouragement (Lu, Lange, Slusser, Hamilton, & Halfon,

2001). Unfortunately, African American women are less likely to receive information regarding breastfeeding from obstetrical care providers, WIC counselors, pediatricians, and hospital staff during the immediate postpartum period (Beal, Kuhlthau, & Perrin,

2003; Kaufman, Deenadayalan, & Karpati, 2010).

Nommsen-Rivers and Dewey (2009) found that women’s level of comfort with

breastfeeding and their breastfeeding self-efficacy, or the belief that they would be

successful at breastfeeding, were also significant in predicting breastfeeding intention.

The most significant factor in predicting women’s intention to breastfeed however, was their indicated comfort level with formula feeding; the more comfort women had with formula feeding, the less likely they were to express an intention to breastfeed. African

American women were more comfortable with formula feeding than women of any other race or ethnicity (Nommsen-Rivers et al., 2009). Comfort with formula feeding reflects the effects of women’s exposure to, and experiences with formula, which implicates cultural practices as well as broader societal influences. Women may be more comfortable with formula because they know more women who have chosen this method of infant feeding. Formula is also seen as a status symbol in some communities, and is

readily available through hospital gift packs and WIC (Chapman & Pérez-Escamilla,

2012; Stevens, Patrick, & Pickler, 2009).

Unfortunately, having an intent to breastfeed is necessary but not sufficient to ensure that a successful breastfeeding relationship is established. One study found that low-income African American women were more likely to intend to breastfeed than their non-Hispanic White counterparts, despite higher rates of breastfeeding initiation and duration among non-Hispanic Whites (Lee et al., 2005). Further, in recent years the gap between African American women and White women who initiate breastfeeding is steadily narrowing. Unfortunately, the disparity in breastfeeding duration rates remains firmly entrenched. This suggests the existence of barriers or impediments impacting low- income African American women’s breastfeeding intention, initiation, and persistence through the extended postpartum period. While researchers have illuminated multiple correlates of breastfeeding discontinuation and breastfeeding persistence, a significant gap exists in the literature to account for the trends in intention, initiation, and breastfeeding duration rates among women in this population.

Breastfeeding self-efficacy. Self-efficacy, a concept at the center of Bandura’s social efficacy theory, is related to an individual’s assessment of her ability to perform a particular action (Bandura, 1997). This theoretical foundation was used by Dennis (1999) to develop the breastfeeding self-efficacy theory, which focuses on a woman’s confidence in her own ability to breastfeed her newborn. In this theory, breastfeeding self-efficacy is a function of a woman’s performance accomplishments, her vicarious experiences, verbal persuasion and encouragement, and inferences she may make from

her own physiological and/or affective states. For example, a woman may mistakenly

assume that she cannot adequately feed her baby because she is small-breasted, or due to

the size or shape of her nipples. Her self-efficacy then shapes her individual response, which includes thought patterns, emotional reactions, and her persistence levels related to breastfeeding. This goes on to impact her actual breastfeeding behavior (Blyth et al.,

2002; Dennis, 1999).

Self-efficacy theory is supported by research that shows higher levels of self- efficacy are associated with positive health behaviors in a number of arenas, including breastfeeding (Ertem, Votto, & Leventhal, 2002; O'Campo, Faden, Gielen, & Wang,

1992; Robinson & VanderVusse, 2011). A positive relationship has been established between a woman’s self-efficacy and her breastfeeding intention, initiation, duration, and the degree to which she breastfeeds exclusively. Women who had higher levels of self- efficacy during the prenatal period were more likely to initiate breastfeeding, and were twice as likely to be still breastfeeding at 2 months (Ertem et al., 2002). A woman’s postpartum self-efficacy has been shown to be one of the strongest predictors of duration, as well. Self-efficacy scores, as measured with the Breastfeeding Self-Efficacy Scale,

were found to be most predictive of breastfeeding duration and exclusivity when

measured at one week postpartum (O'Campo et al., 1992; Robinson & VanderVusse,

2011). Women with a higher score at one week postpartum were more likely to be breastfeeding at 4 months, and to be breastfeeding exclusively (Blyth et al., 2002).

Breastfeeding self-efficacy can be undermined, however, if the woman

experiences breastfeeding difficulties, particularly among first-time mothers (Semenic,

Loiselle, & Gottlieb, 2008). If an infant’s latch is not correct, for example, women may

experience nipple damage, increased risk of infection, and pain at each feeding. This may

lead to a decrease in self-efficacy, and a lower level of breastfeeding persistence. The

connection between breastfeeding self-efficacy and breastfeeding behaviors has

important implications for targeting interventions to address breastfeeding difficulties and

to increase maternal self-efficacy during the immediate postpartum period.

Unfortunately, most of the studies focusing on the relationship between

breastfeeding self-efficacy and breastfeeding behavior have focused predominantly on

White women; there is a dearth of research exploring breastfeeding self-efficacy among

African American mothers (Robinson & VanderVusse, 2011). One study focusing on

low-income women, in which 44% of the sample was African American, demonstrated

that women who intend to breastfeed have higher rates of breastfeeding self-efficacy in

the prenatal period than women planning on formula feeding (Mitra, Khoury, Hinton, &

Carothers, 2004). The only published study focused exclusively on African American women found that breastfeeding self-efficacy measured at 1 week postpartum was a significant predictor of breastfeeding at 1 month and 6 months postpartum. Additionally, it was a predictor of breastfeeding exclusivity; women with higher levels of self-efficacy were more likely to be breastfeeding exclusively at 1 month postpartum (McCarter-

Spaulding & Gore, 2009). In light of the demonstrated importance between breastfeeding self-efficacy and breastfeeding duration and exclusivity, additional research is needed that focuses specifically on African American women.

To date, two randomized controlled trials have been published examining the

impact of interventions designed to increase maternal breastfeeding self-efficacy. Both studies were conducted in Canada, and both interventions had varied results. In the first study (N = 110), Noel-Weiss, Rupp, Cragg, Bassett and Woodend (2006) tested a breastfeeding intervention designed to increase women’s breastfeeding self-efficacy during the prenatal period. They found that the duration of breastfeeding was longer and

the rate of exclusive breastfeeding was higher for the intervention group, both at

statistically significant levels. The Noel et al. (2006) intervention involved a significant

time commitment for participants; the intervention lasted 2.5 hours and the study was not

specifically focused on low-income African American women.

In the other randomized controlled trial (N = 150), the women were randomly

assigned to the breastfeeding self-efficacy intervention group or the control group. The

intervention was provided to women in the early postpartum period, and was repeated 24

hours later. Researchers found that the intervention increased breastfeeding self-efficacy, duration, and exclusivity, although none at statistically significant levels (McQueen,

Dennis, Stremler, & Norman, 2011).

Existing breastfeeding interventions. In addition to the two aforementioned breastfeeding interventions aiming to increase breastfeeding self-efficacy, across multiple disciplines there has been no shortage of tested breastfeeding interventions aiming to increase breastfeeding intention, duration, or exclusivity. A number of randomized controlled trials have been designed to test the impact of different interventions including group breastfeeding classes, peer support programs, professional support (postpartum

nursing support both at the hospital and at home), and breastfeeding-specific clinic appointments (Chapman & Pérez-Escamilla, 2012). Although it is often not explicitly stated, typically these interventions apply a health beliefs model, aiming to address women’s attitudes, knowledge, or beliefs about breastfeeding, and omitting structural, cultural, or situational elements.

A number of breastfeeding interventions have demonstrated statistically significant impacts, yet more often than not they fail in replication studies taking them to scale across multiple locations. This may be due to the absence of information on the cost effectiveness of different interventions, or the cost prohibitive nature of many of the interventions (Renfrew et al., 2007). Many of the interventions are very time and resource intensive; they often consist of home visits and long-term professional support, or the intervention may require several hours to deliver (Pugh et al., 2010). Many of the published studies also lack important details, which reduces the validity of their findings.

Intervention studies to increase breastfeeding self-efficacy or breastfeeding intent which utilize a longitudinal design often fail to report on the characteristics of the women who discontinued participation in the study. Women who are retained for the full duration of the study may have had higher levels of breastfeeding self-efficacy at baseline, for example, and this may skew the results. Poor or unknown study retention represents a significant limitation in breastfeeding intervention studies; without this information, the findings must be interpreted with caution.

Another limitation of existing interventions is that most have focused primarily on increasing breastfeeding rates regardless of the women’s racial and socioeconomic

backgrounds. There is a dearth of research on the effectiveness of specific interventions

on low-income African American women specifically, although a few studies show some

promise. Pugh and colleagues (2010) conducted a randomized control trial with low-

income women, with 87% of the 328 participants being African American women. This

postnatal intervention was designed to increase breastfeeding rates through the provision

of breastfeeding support and knowledge for the first 6 months postpartum. A community

nurse and peer counselor worked collaboratively to provide daily hospital support,

postpartum home visits, and around the clock telephone support. For the women who

received the intervention, the odds of breastfeeding at 6 and 12 weeks postpartum were

greater than women in the control group, but the odds were not significantly greater at 24

weeks postpartum (Pugh et al., 2010).

Engaging peer counselors. Perhaps the most effective and widespread intervention that has focused specifically on increasing breastfeeding rates among low- income women and replicated with different populations in multiple countries is the peer counselor approach. Peer counselors are broadly defined as women who have experience breastfeeding an infant, who have received some training in breastfeeding promotion and support, and who reside in communities that are similar to the ones where their clients reside (Chapman, Morel, Anderson, Damio, & Pérez-Escamilla, 2010). The first formal peer counselor program for breastfeeding was implemented in Chicago in 1987. It was based in part on Paulo Freire’s work on training health care workers to utilize an approach to foster empowerment and self-esteem among patients (Kistin, Abramson, &

Dublin, 1994). Since 1987, peer counseling programs have been widely utilized and

studied extensively in order to determine their impact on breastfeeding behaviors.

Chapman and colleagues (2010) conducted a systematic review of 32 empirical research studies to determine the impact of peer counselor programs on breastfeeding initiation, duration, and exclusivity. The majority of these studies focused on low-income women.

The results were significantly positive; the authors found that “the overwhelming

majority of evidence from randomized controlled trials evaluating breastfeeding peer

counseling indicates that peer counselors effectively improve rates of breastfeeding

initiation, duration, and exclusivity” (Chapman et al., 2010, p. 325).

The peer counselor intervention has potential to be scaled up in a cost-effective

manner, however research has yet to determine the components of the peer counselor

intervention that are effective. The methods utilized by the peer counselors are not

standardized. A peer counselor’s role is broadly defined as providing breastfeeding

education and support, but the mechanisms through which the counselor provides this are

unclear. Some peer counselors provide one-on-one education while others work within

groups. Additionally, the means through which a peer counselor provides education and

support are broad. A session with a peer counselor may be held with a pregnant or

postpartum woman and may consist of any combination of office, home, or hospital

visits, or phone support (Caulfield et al., 1998; Chapman et al., 2010). Providing the peer

counselors with a tool or activity that is research-based and theory-driven may lead to a

more standardized, replicable, and effective breastfeeding intervention.

Gaps in breastfeeding literature. As mentioned, breastfeeding has been studied

extensively by multiple disciplines in order to determine the causes of suboptimal

breastfeeding practices, and to develop interventions that can address them. A significant

gap exists in the research literature, however, related to the theories being applied to this topic, and the absence of an applied, culturally grounded lens.

Absence of multi-level theories. The relative absence of research that recognizes low-income African American women’s unique position in racialized social structures and institutions of the United States is problematic. It is critical that research on increasing breastfeeding initiation and duration be theory driven, as theory “...does provide a conceptual framework for selecting key constructs hypothesized to influence health behavior and thus provides a foundation for empirical investigations, intervention development, implementation, monitoring, and evaluation” (Crosby, Kegler, &

DiClemente, 2002, p. 3). Without a theory delineating the complexity of breastfeeding beliefs and behavior, researchers may continue to study this public health issue one variable at a time, without capturing the dynamic nature of each variable within the larger systemic framework. Interventions that emerge from this research will likely fall short in increasing breastfeeding rates and closing the breastfeeding disparity gap (Godfrey &

Lawrence, 2010; Ma et al., 2012).

Unfortunately, the majority of breastfeeding research is focused on a single causal or correlational factor related to breastfeeding initiation, duration, or exclusivity. Those studies also tend to focus primarily on the individual sphere, examining the role of factors such as motivation, knowledge, and self-efficacy. When a theory is applied to

understanding this critical public health issue, it is most often one that favors individual- level determinants. Theories such as the interpersonal model of client health behavior and

the theory of planned behavior are often applied to breastfeeding, with little

acknowledgement of the complex and multiple external factors that impact infant feeding

decision making and behaviors (Bai, Wunderlich, & Fly, 2011; Tenfelde et al., 2011).

While undoubtedly individual-level factors are important, in and of themselves

they only provide a partial picture of the broader environment in which low-income,

African American women are nested. Some preliminary research has identified the importance of family and community level factors in breastfeeding beliefs and decision-

making among African American women, but these publications are most often

theoretical and descriptive, not experimental designs (Center for Social Inclusion, 2015).

When studies fail to account for this complexity, the research and the interventions that

emerge from them are incomplete, and thus may be less effective (Dodgson, 2012). In order to develop truly culturally responsive assessments and interventions, research needs to better delineate the complex interplay of factors across multiple levels, rather than rely on simplistic linear models that have dominated research on issues related to public health, including breastfeeding (Chin & Dozier, 2012).

A multidimensional framework such as a social ecological model has the potential

to incorporate factors that influence infant feeding choices at the individual,

interpersonal, community/environment, organizational, policy, and media levels (Sparks,

2011). Unfortunately, however, very few articles exist that apply the central tenants of

this framework to breastfeeding among African American women. Further, none of these

utilize experimental designs. One theoretical article demonstrated the applicability of a

social ecological model to breastfeeding among low-income African American women.

The authors provided examples of the type of factors identified under each influential sphere (Bentley, Dee, & Jensen, 2003). While these factors were not all unique to African

American women (e.g. breastfeeding legislation at the policy level), applying an

intersectionality framework in conjunction with the social ecological framework can

illuminate distinct ways in which African American women are differentially impacted

by them. Social work, with its person-in-environment emphasis, is well poised to explore

this theoretical gap, and to provide evidence of the interplay of the multiple factors on

numerous dimensions in order to develop more effective, culturally responsive

breastfeeding assessments and interventions.

Culturally grounded research. Prior to the development and testing of

breastfeeding assessments and interventions, the research literature needs to be more

culturally inclusive and grounded in the lived experiences of low-income African

American women. This includes an examination of the contexts shaping experiences for low-income African American women, and consideration of how this impacts breastfeeding beliefs and behaviors.

An extensive amount of research has been conducted documenting the ways that structures and institutions in American were designed to confer advantages to some on the basis of race and ethnicity, and to directly and indirectly disadvantage others, namely people of color. While the full scale of these inequities is outside the scope of this project, nonetheless this study was conducted in recognition of this racialized history, and the pervasive effects of the inscription of race into the fabric of American society. Taking but one example of how this history may impact breastfeeding, consider the built

environment that many low-income African Americans reside in, in large major

metropolitan areas. Racist housing policies and practices have created pockets of

disadvantage for low-income African Americans in every city in America. These include

the historic practices of redlining, the explicit and implicit mechanisms creating and

perpetuating geographic segregation, and chronic disinvestment of neighborhoods in

urban cores (Massey & Denton, 1993). Schools extend this disadvantage as they are

highly racially and economically segregated, under-funded, and are often staffed by

teachers with fewer years of experience and lower levels of teaching credentials (Orfield

& Frankenberg, 2014). As a result, low-income African Americans are invariably sorted

into these underperforming schools, which impacts their lifelong job opportunities

(Ladson-Billings & Tate, 1995). The lower-wage jobs in service and manufacturing

sectors that are most often available to them, typically do not afford a woman the security

and opportunity to take extended family leave postpartum, or even to have the time or

space to pump breast milk upon her return (Fass, 2009). Thus, this unique sociocultural

context that many low-income African American women reside in, may impact their

breastfeeding beliefs and behaviors.

Although for decades the gap in breastfeeding rates has been well documented,

research focused exclusively on breastfeeding among African American women is

relatively sparse. A 2012 integrated literature review sought articles with high

methodological rigor, written between 1994 and 2011, and with at least 25% African

American women comprising their sample. Utilizing these criteria, only 37 studies qualified (Spencer & Grassley, 2013). Among these, very few privileged the perspectives

of African American women, allowing them voice and agency to shape the research

agenda directly. Spencer and Grassley (2013) illuminated the pervasiveness of the

dominant top-down approach and argued that “the lived experiences of African American women represent valid knowledge that is shadowed by White privilege, power, and

normative assumptions” (p. 621). In short, the predominant practices of generating

research questions in absentia of the populations that are directly impacted is replicating patterns of the pervasive marginalization that permeates society.

This not only creates an incomplete picture of breastfeeding in the African

American community, it runs the risk of further oppressing low-income African

American women. Increasing the pressure on a woman to breastfeed, without comprehensively understanding the reasons behind why that may not be a viable option, is extremely problematic. The strategy of many breastfeeding advocates has been to emphasize the importance of breastfeeding through education campaigns rooted in the health beliefs model such as the “breast is best” messaging strategy (Glaser & Basch,

2013). Preliminary research demonstrates that low-income African American women have received this message; women have reported being well informed about the benefits of breastfeeding (Alexander, Dowling, & Furman, 2010). Encouraging women to breastfeed by emphasizing the benefits of breast milk and the inferiority of formula, without providing the skills and support to breastfeed, could contribute to further disempowerment, guilt, shame, and marginalization (Taylor, 2012; Van Esterik, 2012).

McCann, Baydar, and Williams (2013) found that among all racial and ethnic subgroups, African American women were the most likely to agree with statements

demonstrating barriers to breastfeeding. Researchers must be knowledgeable about those

barriers in order to equip African American women with the tools, skills, and resources they need to meet their breastfeeding goals. Integrating the perspectives of these women in the breastfeeding research and intervention agenda is not only a useful tool to create more valid research, it is a moral and ethical imperative. When African American women are invited into to collaboratively shape the research agenda, studies can be designed to recognize women’s “agency contingent on context” (Chin & Dozier, 2012, p. 68).

Culturally grounded research could produce assessments and interventions that are designed to harness individual and cultural strengths, and address barriers to breastfeeding, from the individual to the institutional level, for low-income African

American women.

Theoretical and Methodological Underpinnings

Epistemological positioning. This research study was borne out of my direct experiences working with low-income, pregnant and postpartum African American women, and receiving firsthand accounts of many women’s beliefs and experiences related to breastfeeding. As demonstrated, a literature review resulted in discovering a scant amount of articles focusing specifically on breastfeeding beliefs and behaviors among low-income, African American women. A more extensive exploration of breastfeeding literature inclusive of all populations revealed the utilization of some health theories such as the theory of planned behavior, and the health belief model. These theories focused predominantly on individual determinants; however, they did not encapsulate some cultural barriers I had encountered in the clinical setting. Given this

cultural and theoretical gap in the literature, I determined that a study that explored

breastfeeding beliefs and behaviors in the socio-cultural context within which low-

income African American women are situated was warranted.

Interpretivist research examines the social construction of reality and posits that

the context in which an individual is situated inherently impacts their worldview

(LeCompte & Schensul, 2010). There are distinct epistemological approaches within the interpretivist approach of research. These approaches vary regarding their beliefs on the nature of reality, the role of values in research, and the overarching purpose of research itself (Creswell & Plano Clark, 2011). Considering my own race and socioeconomic status, I selected a constructivist approach to theory building. This approach employed a participatory worldview, with an emphasis on participant empowerment. The participatory worldview prioritizes a collaborative approach to building a research agenda, and sees advocacy and change as a central goal of a research project. This epistemology reflects my own personal worldview, and my central purpose in conducting research. As a social work researcher, I place great value in creating a more just set of social arrangements. I am well versed in structural and institutional racism, and have a particular interest in understanding and addressing the ways our social constructions privilege some and marginalize others. I see low breastfeeding rates in African American communities as a convergence of these factors. Women who choose not to breastfeed may be asserting control over their bodies in one of the few ways available to them, and may be eschewing a practice that is often morally imposed by members of the dominant community, i.e. White, middle class health care practitioners and public health officials.

Without an understanding of the socio-cultural context of breastfeeding in the African

American community, the majority of current initiatives to increase breastfeeding rates may be disempowering and stigmatizing, ultimately contributing to further marginalization of these women.

Conversely, I felt that a culturally grounded approach to increase breastfeeding rates among low-income African American women could be a vehicle through which women can become empowered. Despite my passion for this topic, as a White, middle class woman, my perspective was inherently limited. I recognized that my identity shapes my worldview in a way that cannot be shed, thus I felt unable to examine this topic without bias. To compensate for this I felt that the best way to ethically and effectively study this topic was to do so in a participatory manner. Through a collaborative, mixed methods approach, I sought to elucidate the worldview of members of the African

American community, in order to create a tool that can be used to empower women to establish and meet their own breastfeeding goals. It is also for this reason that I focused predominantly on women who had an expressed goal of breastfeeding. I wished to honor the self-determination of women who have decided that breastfeeding is neither best for them nor their families, at this time.

Finally, the epistemology driving this study was nested within a larger goal of creating social change. I feel that a participatory research agenda has the potential to empower entire communities. A traditional research design often positions the researcher as expert and participants as passive subjects. Through group model building, and through the engagement of WIC peer helpers, I sought to create a more egalitarian,

29 collaborative research process that privileged the input of community members, and fostered dialogue. Although breastfeeding is inherently an individual act, individuals are nested within a set of social arrangements and social institutions that confer messages about the appropriateness and value of breastfeeding. Until that social context begins to shift, low-income African American women may continue to struggle to meet their breastfeeding goals in an environment where this method of infant feeding is seen as socially unacceptable. Although this study does not purport to shift this paradigm singlehandedly, it represents an attempt to take a first step towards systemic change around this issue.

Mixed methods inquiry. In light of these epistemological considerations, and absence of research describing the unique experiences of breastfeeding among African

American women, a mixed methods approach was indicated. A transformative, sequential design was determined to be the most effective for developing a culturally grounded assessment process that aimed to empower women to meet their breastfeeding goals.

Transformative research seeks to address social injustices through the utilization of mixed methods, and thus represents a paradigm appropriate for this research inquiry

(Mertens, 2007). A transformative approach also places the marginalized women at the center of the design, in an explicit attempt to both learn from and empower them.

A mixed methods research design benefits from the strengths of both qualitative and quantitative research, and can provide a means to answer complex research questions. The following represents a simplistic overgeneralization of the two epistemological traditions, but provides a foundation from which to build a common

30 understanding of a mixed methodological study. Qualitative methodologies, rooted in an inductive approach, seek to prioritize the worldviews of the participants and yield rich data grounded in the lived experiences of individuals (Bryman, 2008). This is particularly beneficial when there is an absence of substantive literature on a topic, as is the case with breastfeeding research specific to low-income African American women. Quantitative methodologies are associated with deductive reasoning, hypothesis testing, and determining the degree to which research findings are generalizable to the larger population. Quantitative research provides a means to quantify findings, and to test the impact of specific interventions and assessments, such as the D-BAP. A mixed methods study combines methodologies from both traditions, although the degree to which they are integrated varies widely (Bergman, 2008). Utilized together, qualitative and quantitative methods can provide the tools through which specific phenomenon can be studied in more comprehensive, and culturally appropriate ways (Bryman, 2008).

Mixed methods research comes with a unique set of challenges and limitations, however. Some scholars have identified the paradigmatic tensions between qualitative and quantitative research and have questioned whether these methods can effectively be utilized within a single study (Creswell, 2011; Howe, 2004). They argue that qualitative research inherently privileges a constructivist perspective, while quantitative research is fundamentally rooted in postpositivism. The assumptions at the center of each perspective are considered to be inherently at odds with one another, and thus the assertion is that research designs seeking to combine the two methodologies are fundamentally incompatible (Creswell & Plano Clark, 2011).

As a way to eschew these tensions, mixed methods research is sometimes

undertaken by utilizing an additive approach. A study may have one qualitative and one

quantitative component, with little blending between the two epistemological traditions.

An alternative to this is acknowledging mixed methods as a third paradigmatic

movement. The transformative-emancipatory approach falls within this purview which

asserts that mixed methods research employs a unique paradigm when it engages

marginalized populations and acknowledges power in the research process, in order to

address social injustices (Mertens, 2007). This type of interpretivist approach does not

prioritize one tradition over another, but rather calls for an inclusive research study

through the engagement of research participants in a meaningful and democratic dialogue

throughout the research process (Howe, 2004).

Even in employing this third paradigmatic approach, some tensions inevitably exist within a design that moves between qualitative and quantitative methodologies.

Culturally grounded knowledge is gained, but complexity may ultimately be lost.

Unfortunately this is a fundamental weakness inherent in mixed methods (Creswell,

2011). A mixed methods research design also faces a limitation regarding threats to

external validity. Yin (2014) argues, however, that while statistical generalization about

populations is not possible with qualitative designs, analytic generalizations can be

extrapolated. Analytic generalization aims to contribute to the development of theoretical

concepts and hypotheses by “reinterpreting the results of existing studies of other

concrete situations (that is, other cases or experiments) or to define new research focusing

on yet additional concrete situations” (Yin, 2014, p. 41).

A mixed methods research design has the flexibility to address complex research

questions, however a study blending these qualitative and quantitative traditions must be

deliberately constructed to ensure it can achieve the research aims. Central to this process

is the identification of applicable theories and the application of appropriate research

methods. The following discusses the theories guiding this study’s three-phase design,

and the methods utilized to achieve the research aims.

Overarching theoretical frameworks. In a mixed methods research study, it is

important not only to identify the paradigmatic worldview in which the study is

grounded, but also the theoretical lenses that are applied (Creswell & Plano Clark, 2011).

To address the need for research grounded in a more expansive theory, this research was

rooted in grounded theory. Critical feminist theory was also utilized, in conjunction with

the application of a social ecological framework.

Social ecological framework. As a core value, the social work profession is dedicated to understanding and remedying social injustices and inequities across multiple levels (Chu, Tsui, & Yan, 2009). Few frameworks, however, have the breadth necessary to guide social work research and interventions across this complex systemic perspective.

A social ecological framework recognizes the complexity of our nested environments.

Social ecological models have been widely applied to a number of public health issues

including understanding and remedying health disparities (Reifsnider, Gallagher, &

Forgione, 2005). The model was first introduced by Bronfenbrenner (1977) and was

comprised of nested spheres including the microsystem, mesosystem, exosystem, and

macrosystem. Bronfenbrenner proposed this model to address what he recognized as a

pressing issue – that contemporary research was caught between a “…rock and a soft

place. The rock is rigor, and the soft place is relevance” (Brofenbrenner, 1977, p. 513). In

short, he felt that quantitative methodological practices removed the individual from the

contexts by which they were inherently shaped and which they in turn helped to shape.

Bronfenbrenner also felt this compromised the utility and applicability of most research,

and that qualitative inquiries largely lacked scientific rigor. The social ecological model

was based on the idea that factors within each level are as important as the interactions

between them, as humans are a dynamic part of their own environment and adapt

continuously in response to it.

Social ecological models have been adapted and utilized by agencies such as the

Center for Disease Control and Prevention (CDC) and the World Health Organization

(WHO) to craft preventative approaches to public health issues, and to create effective

interventions for addressing them. This framework is functionally absent from most

literature on breastfeeding, however.

Utilizing a social ecological model in this research design served multiple

purposes. In the first phase, a social ecological framework was utilized during the model

building process to ensure factors were captured across multiple levels. In the spirit of

grounded theory, which will be discussed, this framework did not presuppose the final

categories and subcategories of data collected, however. For example, a social ecological

model suggests the existence of macro-level factors that impact breastfeeding, but the

researcher did not presume there would be a category or subcategory of factors within the

final model dedicated to this. Thus the application of this theory is compatible with the

use of grounded theory in this study. In the testing of the D-BAP (Phase 2B and Phase 3),

a woman was able to identify factors on any level to be a significant barrier or source of

support for her personally. In this manner, a social ecological framework was incorporated into all phases of this research project.

Critical feminist theory. Critical feminist theory is a broad and expansive theory that can act as a stand-alone theoretical approach, or be utilized in conjunction with other theories. Critical feminist theory emerged as scholars grappled with the shortcomings of both critical theory and feminist theory (Few, 2007; Wing, 2003). In essence, these scholars felt critical theory lacked a feminist lens, overlooked the pervasive effects of patriarchy, and was too male dominated. They also argued that feminist theories focused predominantly on White women, and did not go far enough in recognizing the range of experience women may have based on other characteristics such as their race or socioeconomic status. Others critiqued feminist theories for being disconnected from social change (Few, 2007).

Although there is no singular feminist theory, theories which fall under this overarching label have several shared components. Broadly speaking, feminist theory seeks to explore the ways our social and political experiences are gendered, and are situated within a broader set of arrangements that are patriarchal in nature. Within this set of arrangements, the experiences and perspectives of men are considered to be privileged and normalized. As a result, these become the metric against which women’s experiences and perspectives are evaluated, rather than being evaluated on their own merits. While many scholars utilizing a feminist theory lens call for action to remedy this situation,

social transformation itself is not a core component of the theory (Few, 2007; Wood,

2008).

Critical theory also encompasses an expansive range of theories lacking in

cohesion and unification (Gibson, 2007). It can be traced back to the Frankfurt School,

which was established in the early twentieth century. Early critical theorists challenged

the notion of positivism, and were originally rooted in Marxism, although that alignment

has since diverged among some branches of critical theory (Morrow & Brown, 1994).

Although it is difficult to summarize critical theory as though it was unified, it can be

broadly understood as a set of theories that largely rejects the positivist approach of

conceptualizing a singular, unified reality and instead identifies multiple realities which

are socially constructed. Critical theory is broadly summarized by Kincheloe & McLaren

(2002) as having the following components: “Critical social theory is concerned with

issues of power and justice and explores the construction of a social system through interactions between the economy, race, class, and gender, cultural ideologies and discourses, social institutions, and cultural dynamics” (Kincheloe & McLaren, 2002, p.

90).

Critical theory and feminist theory have evolved and branched out into many

different theories. Critical feminist theory stands at the convergence of these two

theoretical traditions, and is similarly broad; a number of theoretical subsets exist (Wing,

2003). An inclusive conceptualization of the critical feminist approach is provided by

Wood (2008) who defines it as a combination of theories that “identify, critique, and seek

36 to change inequities and discrimination, particularly those that are based on sex and gender” (p. 326).

Critical feminist theory seeks to understand the inequitable ways that power and opportunities are distributed in western patriarchal systems due to the historical legacy of institutional and interpersonal racism and the current perpetuation of disparities through seemingly race-neutral mechanisms (Alexander-Floyd, 2012). Critical feminist theory has been categorized as “feminist politics of resistance” (Dietz, 2003, p. 409) because the emphasis is placed not only on understanding the current set of social arrangements, but on rejecting them and collaboratively working towards a more inclusive social reconstruction.

Certainly gender stands at the center of its analysis, however; critical feminist theory broadly, and intersectionality more specifically, recognize that opportunities are inequitably distributed along multiple identity characteristics. Structures of domination can impact individuals by race, class, ethnicity, sexuality, and immigration status as well.

Intersectionality posits that oppression is not experienced along these identity characteristics in an additive fashion. For example, to understand breastfeeding behaviors among low-income African American women, we cannot look to the disempowerment they may feel as women, and add it to the oppression they may experience as African

Americans (Crenshaw, 2003). Instead, due to the complex, multiplicative effects of our current social arrangements, breastfeeding perceptions, knowledge, beliefs, and behaviors are unique, and situated in a complex matrix constituted by historical practices, cultural

norms, perceptions of race and gender oppression, and treatment by individuals and

institutions in positions of power (Dodgson, 2012; Mojab, 2015).

Critical feminist theory and intersectionality were included as critical components of this research as they call for putting African American women at the center of their own experiences, and for researchers and practitioners to decenter themselves. Further, it deeply contextualizes the social ecological model. In Bronfenbrenner’s social ecological model, the nested systems are functionally neutral; they are not inherently interlaced with an understanding of historical and present day contexts that give shape and meaning to factors within each system, or the operations between systems. Yet the vast amount of disparities across nearly every social institution in America implicates a deeply inequitable system with pervasive negative consequences for women and persons of color.

Breastfeeding is an example of a public health issue arising from a long history of structural arrangements that inequitably confer opportunities to those who are privileged, and conversely deny them to those who are marginalized (Center for Social Inclusion,

2015). This includes the history of African American women as wet nurses, the early

marketing strategies employed by formula companies, and the ongoing relationship

between WIC and formula companies. Initially, formula was marketed towards White, wealthy families, conferring a degree of status. Once this demographic was captured, their marketing strategies shifted during the 1950s to target low-income families, many of whom were quick to adopt formula feeding given the public perception that it was best for baby (Asiodu & Flaskerud, 2011). Further, the partnership between WIC and formula

38 companies is not without controversy. With rebates, WIC only pays approximately 15% of the wholesale cost of formula (Oliveira, 2011). These deep discounts have led some to criticize the partnership (Kent, 2006). Critics have point out that WIC enrollees have lower overall breastfeeding rates than the general population even when controlling for other demographic factors such as race and SES. In a retrospective study analyzing data from 1978 to 2003, Ryan and Zhou (2006) found that women enrolled in WIC were two times as likely to have discontinued breastfeeding by 6 months as those who were not enrolled. WIC administrators maintain that their central role is to support a woman’s preferred infant feeding method, however many argue that the provision of free formula unduly influences that choice (Kent, 2006).

These examples illustrate a few ways that seemingly neutral structural arrangements are functionally and theoretically biased. Approaches that fail to recognize the inequity interwoven into existing institutions and practices may at best omit some critical factors impacting infant feeding practices, and at worse further oppress and marginalize women of color. Thus, critical feminist theory is at the center of this research design and the methodology chosen, in order to ensure the findings are valid, the assessment is effective, and the study does not inadvertently further marginalize African

American women.

Theory-driven methodologies. Critical feminist theory and a social ecological framework necessitated the selection of appropriate research methods for each phase of this study. These methods, and their application in this study, are discussed below.

Grounded theory. Although called a theory, grounded theory can be more

accurately understood as a general research method that supports a constructivist

approach to theory building. Grounded theory was initially introduced by Glasser and

Straus in 1967 as a qualitative methodology, although its utility has since been extended

into the quantitative realm (Bryant & Charmaz, 2007a). Grounded theory provides a

flexible, yet systematic method of designing and conducting research studies. It is an

inductive, iterative approach to theory building that prioritizes direct engagement with members of the population of interest. Research utilizing a grounded theoretical approach can open conceptual space for the development of new theories, and can provide an

inductive means through which existing theories can be tested (Bryant & Charmaz,

2007a). In grounded theory, data collection and analysis occur concurrently, and theoretical sampling is used, whereby research participants are deliberately selected based upon the unique contributions they can make (Wuest, Merritt-Gray, Berman, &

Ford-Gilboe, 2002).

Grounded theory is rooted in a fundamental set of principles that align closely

with social justice, and with a degree of deliberateness, it can be used in conjunction with

other theories and frameworks, particularly if they are descriptive rather than prescriptive

(Seaman, 2008). Critical feminist theory and a social ecological model have the

conceptual flexibility to work with grounded theory. Neither presupposes analytic

categories, but rather each offers a framework to guide data collection methods, conduct

analyses, or generate solutions based on findings in a study utilizing grounded theory.

Critical feminist theory, for example, is sensitive to the risk of researchers objectifying

participants and/or inadvertently prioritizing their own worldviews over those of

participants (Gibson, 2007; Oleson, 2007). Critical feminist theory and a social ecological

model can help contextualize findings within a broader systemic framework, and can

extend the utility of grounded theoretical research by identifying leverage points for

change that can advance social justice (Charmaz, 2008).

It should be noted that there is not one universally accepted approach to grounded

theory, thus it is important to clarify the grounded approach applied herein. In the years

since the introduction of grounded theory by Glaser and Strauss, scholars have diverged

on their beliefs regarding its positivist or post-positivist assumptions, and the methods guiding grounded theory data collection and analysis (Walker & Myrick, 2006). One branch of contemporary theorists stresses that grounded theory was originally rooted in positivist assumptions, and that in order to use grounded theory to advance issues of social justice, researchers must be reflexive regarding their own role in co-constructing an interpretive reality, as opposed to identifying an objective one (Charmaz, 2008). This has implications for the degree to which the researcher should be embedded in the data collection and analytic processes, and the timing for consulting research literature

(McGhee, Marland, & Atkinson, 2007). Strauss and Corbin argue that the researcher plays a pivotal role in constructing complex themes, by defining the properties of a category ( i.e. dimensionalizing) and through active involvement in making connections between categories and subcategories (i.e. axial coding) (Strass & Corbin, 1990; Kendall,

1999). As part of this, they argued that a preliminary literature review was not only warranted, but that it strengthened the research process (McGhee, Marland, & Atkinson,

2007). Glaser (1992), in turn, argues that this strays too far from the participant-driven paradigm. Tasks such as axial coding are thought to inherently centralize the researcher as opposed to letting the participants guide the process. Further, Glaser asserted that an initial literature review inherently contaminated the very nature of grounded theory, as it may unduly influence the researchers’ perception of the topic under study.

This study seeks to elevate the voices of low-income African American women and provide them the means through which they can elaborate on their own cultural worldview, as it relates to breastfeeding. Thus, the methods and analyses were deliberately selected with this aim in mind. In group model building methodology, which was utilized in Phase 1 of this study, the data were generated directly by participants, however researchers’ insights and thematic connections served to create a more comprehensive and reliable model. This approach was closely aligned with the axial coding, as championed by Strauss and Corbin (Kendall, 1999). However, as discussed, axial coding is considered by some to be a positivist methodology for data analysis, producing a tension between this study’s aims and the methods which were selected to achieve them (Bryant & Charmaz, 2007a). Axial coding, however, aligned closely with the output generated from group model building, and represented the most appropriate method of data analysis. The danger of researchers superimposing their own worldview through coding was taken into consideration during the data analysis step in Phase 1, and a series of checks and balances were incorporated in order to address some of the criticisms of this approach (Walker & Myrick, 2006). Participants’ own language was

deliberately retained as much as possible, a conservative approach was taken in the

construction of themes, and all findings were validated with a subset of participants.

The use of research literature in this study design was closely aligned with the

approach championed by Strauss and Corbin. They advocate for a two stage process

regarding the consultation of literature. The first review is a cursory one, providing the

rationale for the use of grounded theory on a specific topic, and providing the researcher

with some context for the nature of the study. Once the research activities are underway,

the literature is consulted a second time. The purpose of this subsequent review is to link

the emerging theoretical components with prior findings; in essence building in a process

of data validation (McGhee, Marland, & Atkinson, 2007). This approach, aligned with

Strauss and Corbin, was utilized in this study. A preliminary literature review was

conducted prior to the design of this study. The research literature was again consulted

during the data analysis processes in Phase 1 and Phase 2A to contextualize the research

findings, and participants’ comments.

All three phases of this research study utilized a social ecological framework and

critical feminist theory. The identification of these theories prior to data collection might

seem antithetical to the grounded theory method as well, thus it is also important to clarify the ways these theories were used in this research process (Gibson, 2007; Seaman,

2008). Critical feminist theory provided a rationale for this study and suggested the need for the research design and associated methodologies selected. The central tenants of feminist theory are highly compatible with grounded theory and the two have frequently been linked, particularly in studies focused on women’s health issues (Kushner, 2003).

Grounded theory, when it is used as a means through which to achieve social justice, calls for an understanding of the interrelationships between individuals and the social structures in which they are nested (Charmaz, 2008). Thus, grounded theory is

highly congruent with a social ecological framework as well (Wuest et al., 2002).

Community based participatory action research. Community based participatory

research (CBPR) is an approach that emphasizes the development of a research agenda with the participation of individuals whose perspectives are integral to understanding the complexity of the topic being studied (Israel et al., 2003). In breastfeeding research, this consists of community stakeholders, academic partners, practitioners, and other individuals. CBPR differs from CBPAR in that CBPAR calls for an action component to the research. This places an emphasis on ensuring the research benefits the population and communities being engaged in practical, and applicable ways (Reason & Bradbury,

2008). CBPAR aims to bridge the gap between scholars and research participants in order to foster connections, set more effective research agendas, and develop more culturally responsive interventions (Wallerstein & Duran, 2010).

In many ways the utility of CBPAR extends far beyond the research itself; one of the primary benefits of CBPAR is that it results in a transfer of “information, decision making power, resources, and support among members of the partnership” (Israel,

Schulz, Parker, & Becker, 1998, p. 179). CBPAR has the potential to functionally transform the traditional research process so that individuals who are typically passive subjects of study become active members whose participation in the research process becomes a catalyst for individual and community level change. CBPAR has been utilized

in international pilot programs seeking to improve maternal and infant health along a

number of indicators, thus demonstrating that CBPAR approaches can lead to the development of grounded research and effective intervention tools (Rosato et al., 2008).

An approach emphasizing the action component of community based

participatory research was selected for this study in recognition of the troubled history of

health research on African Americans (Washington, 2006). Additionally, an attempt was

made to ensure the research was not perpetuating the practice of researchers parachuting

into communities, extracting information about the presence of inequities, then leaving

neighborhoods untouched and disparities unaddressed (Robinson & Trochim, 2007). In

the case of breastfeeding among low-income African American women, research utilizing a CBPAR approach has the opportunity to not only have an immediate impact on a woman’s decision to breastfeed, it may also have an impact that reverberates across time and space as community members’ increased breastfeeding practices and acceptance change social norms around infant feeding practices.

To achieve the aims of CBPAR, in Phase 1, Phase 2B, and Phase 3, pregnant women were engaged in this study and participated in activities designed to examine their assumptions, experiences, thoughts, and feelings around breastfeeding. They may have emerged more knowledgeable about the realities of breastfeeding, and thus may have been better equipped to meet their breastfeeding goals. Postpartum women who were engaged in Phase 1 of the research may have emerged with knowledge to support other women in their community in their decision to breastfeed. Purdy (2010) has found that

family and friends are typically the most utilized source of information for breastfeeding

women. This type of peer-to-peer support has been shown to have a positive impact on

exclusive breastfeeding, and on breastfeeding duration (Arlotti, 1998). The impact of increasing the number of women who are knowledgeable about, and supportive of breastfeeding in the African American community could reach far beyond those directly participating in the research process. Thus in selecting methodologies for this research study, an emphasis was placed on ensuring they were aligned with the principles of

CBPAR

Group model building. Group model building (GMB) was the methodology used in Phase 1. GMB is a type of problem structuring method, which provides a way to graphically represent a complex issue by capturing areas of shared understanding and illuminating conflicts of perspective (Renger, Kolfschoten, & Vreede, 2008). GMB emerged from systems dynamics and was first introduced by researchers at the University of Albany SUNY in the late 1970s. It has since been utilized with a diverse array of stakeholders to study a range of topics, predominantly in engineering and business. It is a methodology that is increasingly being applied to topics in the social sciences, although there is room for expansion in this arena (Vennix, 1999).

There are two distinct ways with GMB to utilize a model generated through the data collection processes. The first is to quantify the model through metrics, which transforms it from a conceptual representation of an issue to a simulation model. This approach renders it into what systems dynamicists consider a hard model (Vennix, 1999).

Validating a hard model requires an emphasis on syntactic quality, which examines the power of the model to quantitatively explain a phenomenon through metrics. The soft

model approach strives for achieving semantic quality, which is “the correctness of the

model in terms of content, and whether or not it represents the system it describes”

(Renger et al., 2008, p. 70).

Considering that the dynamic assessment process developed in this study is

dependent on the model as a theoretical foundation, the soft model approach was utilized,

with an explicit effort made towards achieving semantic quality. The group model

building process used in Phase 1 consisted of collaboratively building a model of

breastfeeding. Participants begin by sharing their individual perspectives, which were

then organized and grouped into broader themes. Those themes were then interconnected

through a collaborative and iterative process. This process resulted in a singular

descriptive model that captured the factors impacting African American women’s

breastfeeding behaviors (Hovmand, 2014).

The group model building process places participants as experts at the center of

their own experiences, thus it is closely aligned to the central principals of critical

feminist theory (BeLue, Carmack, Myers, Weinreb-Welch, & Lengerich, 2012). Group

model building also provides an effective means of applying a social ecological

framework to the topic of breastfeeding; the primary aim of GMB is to work with individuals within a system to identify factors relevant to a specific issue, and to define the interactions among those factors (Vennix, 1996).

Group model building methodology is also congruent with the goals of community based participatory action research. Rouwette (2012) has discussed the potential of model building to facilitate the co-production of knowledge and the

integration of local knowledge into scientific research. This demonstrates how closely

aligned GMB can be with the priorities of CBPAR, and why GMB presents a good

methodological fit for the aims of this study.

Most research studies utilizing GMB emphasize individuals’ participation in the process in order to elicit and clarify group member’s perspectives on an issue, and to create a common understanding of it. Research focused on participants’ experiences in a model building session has demonstrated the ability of this method to structure discussions about a particular issue, which may help individuals shift from a linear, problem-oriented framework to a more robust, systemic view. Additionally, through the collaborative process of building a conceptual representation of the issue, and generating insights relevant to the topic, individuals are more knowledgeable and thus empowered to create intraorganizational change (Rouwette, Korzilius, Vennix, & Jacobs, 2010; Vennix,

1999). Participants have reported that their involvement in group model building sessions

has helped them identify critical leverage points for intervention (Videira, Lopes,

Antunes, Santos, & Casanova, 2012). Thus, GMB is well positioned to contribute to the

“action” component of CBPAR. This study also used GMB as a method to work towards some level of reciprocity in the research process, which is prioritized in CBPAR.

As this study aimed to ensure that findings were grounded in the experiences of

low-income African American women, a process was needed that could generate specific

factors that could serve as a foundation for a culturally grounded breastfeeding

assessment process. GMB proved to be an indispensable tool to collaboratively generate

factors, connect them in a model, and provide a concrete representation of participants’

mental conceptualization of breastfeeding within their unique socio-cultural context.

Q-methodology. Q-sort cards were developed from the factors and themes

generated in Phase 1, and were validated with breastfeeding experts (scholars and

practitioners) in Phase 2A. They served as the foundation of the D-BAP. The Q-sort cards represent a technique rooted in Q-methodology. In Q-methodology, the emphasis is on capturing individual’s perspectives through the use of Q-sort cards. Its popularity has ebbed and flowed over the years, although proponents have long felt that the methodology is widely underutilized and underappreciated (Brown, 2006). Q- methodology can provide a structured and systematic, yet flexible way to understand a specific phenomenon (McKeown & Thomas, 2013). It is a true mixed methods approach in that Q-statements originate from qualitative research, yet the final output is often quantitative; thus it provides a way to measure individual’s subjective perspectives. The

Q-sort process can also be quite simple, making it appropriate for use with a range of participants from small children to older adults (Dziopa & Ahern, 2011). It has been lauded for its potential to place a marginalized individual at the center of her experiences, while simultaneously decentering the perspective of the researcher (Brown, 2005). This methodology is in close alignment with critical feminist theory and is another tool with which to conduct grounded research.

In the Q-methodology process, Q-sort cards are developed from concourses of communication, which are defined as subjective descriptions of a specific topic. They can be gathered from both direct and indirect sources including qualitative interviews and

49 focus groups. For the purposes of this study, the full concourse of communication was constituted of the dialogues held in the multiple group model building sessions as well as the factors generated therein. This is considered a naturalistic source of Q-statements, which is ideal as they originated directly from stakeholder’s engagement, and represent their direct perspectives (McKeown & Thomas, 2013). It is from this concourse of communication that the Q-statements were selected, then validated by experts in Phase

2A.

Motivational interviewing. The D-BAP approach in Phase 2B and Phase 3 was informed by motivational interviewing (MI) methods, which have been widely used to foster health behavior change (Rollnick, Miller, & Butler, 2007). MI is structured as a collaboration between practitioner and client, seeking to activate the motivation within clients, while honoring that individual’s autonomy. This is all done with a central goal of empowering the client to meet her own goals (Rollnick et al., 2007). To date, only two studies have been published that examined the effectiveness of motivational interviewing on breastfeeding. Both studies focused on postpartum, breastfeeding women. The first study found an increase in breastfeeding duration among the MI treatment group, although the increase was not statistically significant (Wilhelm, Stepans, Hertzog,

Rodehorst, & Gardner, 2006). The second study, a randomized controlled trial in

Australia, found an improvement in exclusive breastfeeding rates when a flowchart, designed in the spirit of motivational interviewing, was utilized with postpartum women

(Elliot-Rudder, Pilotto, McIntyre, & Ramanathan, 2014). Although motivational interviewing has not been utilized to increase breastfeeding initiation rates in the prenatal

50 period, given its connection to health behavior change more broadly, and the alignment of its central tenants with the goals of this study, it was used to inform the development of the D-BAP protocol.

Design of the Current Study

A three-phase research study was designed utilizing the aforementioned theories and methods. This study design was informed by the first three steps in intervention development, as suggested by Frasier, Richman, Galinsky, & Day (2009). See Table 1 for a table outlining the steps of intervention research, their alignment with the phases of the current study, and the chapter where the research is presented and discussed.

Steps in Intervention Research Design of the Current Study Associated Chapter

Step 1: Problem specification and Systematic literature on Chapter 2 program theory breastfeeding development

Step 2: Creation and revision of Phase 1 Chapter 3 intervention materials Phase 2A and 2B Chapter 4

Step 3: Refining and confirming Phase 3 Chapter 5 program components

Table 1. Alignment between intervention research steps and current study design

The following outlines the research questions and primary research activities for each phase; see Figure 1 for a graphic representation of the full research design.

Phase 1. Phase 1 was designed to answer the following research question: How do low-income, pregnant and postpartum African American women describe

breastfeeding within their socio-cultural context, including factors that help or hinder

breastfeeding? Groups of two to seven low-income African American women

participated in a total of five group model building sessions. The model building sessions were designed to collaboratively identify supports and barriers related to breastfeeding decision-making and behavior. The factors identified were categorized into overarching themes and the five individual models were consolidated into a single model by the research team. The factors and the final model were validated with the WIC peer helpers and a sub-group of participants.

Phase 2. The model generated in Phase 1 was used to develop and refine the

Dynamic Breastfeeding Assessment Process (D-BAP). Phase 2 sought to answer the

research question: What would an assessment process look like if it were informed by

the perspectives of the women as captured in the model building process? In Phase 2A,

statements generated from the model building sessions were adapted for Q-sort cards,

which form the foundation of the D-BAP. The factors and themes, which were

thematically grouped by the research team, were refined and finalized using the Delphi

method, with input from 49 breastfeeding scholars and practitioners. Phase 2B tested the

D-BAP, gathering input from three lactation specialists and two pregnant, low-income

African American women. Qualitative and quantitative feedback together were used to

refine the assessment process.

Phase 3. The research activities in Phase 3 were selected to answer the research question: What is the feasibility of a Dynamic Breastfeeding Assessment Process? The

Dynamic Breastfeeding Assessment Process (D-BAP) was pilot tested with a unique

group of 25 low-income, African American women. To determine the feasibility of the

D-BAP, two sub-questions were posed. The first was: How do pregnant, low-income,

African American women experience the culturally grounded Dynamic Breastfeeding

Assessment Process? Two standardized questionnaires and a semi-structured interview were administered and analyzed. The second sub-question was: When the Dynamic

Breastfeeding Assessment Process is delivered, is there a measurable difference in the

breastfeeding self-efficacy and intent among pregnant, low-income, African American

women? A pre-post, paired-samples design was utilized in order to determine the

relationship between completion of the D-BAP and women’s breastfeeding self-efficacy

and infant feeding intentions.

5 4

Figure 1. Research design

Chapter 3: Phase 1 Methods, Results, and Implications

In order to develop a culturally grounded breastfeeding assessment, more

information was needed on the specific barriers and facilitators of breastfeeding that low- income, African American women perceived and experienced. Phase 1 was designed to answer the first research question:

1) How do low-income, pregnant and postpartum African American women

describe breastfeeding within their socio-cultural context and the factors that

help or hinder breastfeeding?

This chapter describes the methods used to identify the socio-cultural context of breastfeeding as described by low-income, African American women, and the factors that help or hinder breastfeeding. The Phase 1 study participants, data collection procedures, and methods used for data analyses are described. Additionally, the results for Phase 1 are presented and discussed, including the factors impacting breastfeeding, the themes into which these factors were organized, and the model representing the interactions between them.

Phase 1 Methods

The Dynamic Breastfeeding Assessment Process is dependent on the validity of the initial barriers and supports identified in Phase 1, thus grounded theory was selected as the most appropriate theoretical approach. As discussed, grounded theory is an

inductive approach that allows for an ongoing, iterative approach to data collection,

analysis, and theory development. When used in conjunction with critical theory, it

acknowledges the power differential between researcher and subject, and seeks to “avoid

objectifying and misrepresenting research subjects” (Gibson, 2012, p. 450). There are

numerous qualitative methodologies aligned with grounded theory, each with their own

strengths and weaknesses. For the purpose of eliciting specific factors related not only to

the experience of breastfeeding, but also factors representing both barriers and supports,

group model building (GMB) was determined to be the best methodological fit. GMB is a

methodology well suited to “messy problems” such as breastfeeding (Vennix, 1999). One

strength of this methodological approach is that it not only can identify factors that

present as both supports for and barriers to breastfeeding, but it can also capture the

complex and dynamic nature of the socio-cultural context within which breastfeeding is

situated.

Sampling and participant characteristics. In order to achieve the credibility in

the final model, triangulation of sources was utilized; participation was sought from breastfeeding specialists, as well as pregnant and postpartum women.

Breastfeeding specialists. Before the model building sessions with low-income,

African American women, an initial model building session was conducted with Central

Ohio WIC peer helpers who had direct experience working with the study population and their breastfeeding needs. Requirements for employment as a WIC peer helper include having previous breastfeeding experience, being a former WIC recipient, and having received training through the Loving Support through Peer Counseling program (Collins,

Rappaport, & Burstein, 2010). Considering their direct contact with pregnant and

postpartum women related to breastfeeding, the Central Ohio WIC peer helpers have

extensive knowledge of breastfeeding beliefs and experiences among low-income,

African American women. Conducting the initial model building session with these

women not only strengthened the model, their knowledge and opinion of the group model

building process may also have been important and influential for the participation of community members (P. Hovmand, personal communication, March 18, 2014).

Nine peer helpers were employed at the Central Ohio WIC offices. All nine peer helpers were contacted with a study recruitment message (See Appendix B: Email and/or

Phone Script for WIC Peer Helpers) and those who indicated an interest were screened

(See Appendix C: Screening Script for WIC Peer Helpers). Following this recruitment and screening process, five peer helpers agreed to participate in the study. Of these five, three attended the model building session. The ages of the five WIC peer helper participants were 31-32 years old. Their length of employment with WIC ranged from 1-

2 years, with a mean of 1.8 years (SD = .58). When asked to estimate the percentage of

African American women they worked with, their responses ranged from 35%-80% with a mean of 55% (SD = 22.91).

Pregnant and postpartum mothers. Following the initial model building session with peer helpers, a total of 21 pregnant and postpartum women were engaged across four model-building groups; attendance at each group ranged from 2-8 participants.

Theoretical sampling strategies were utilized to recruit low-income, African American women. Flyers for the study were posted at sites serving this population: Central Ohio

WIC offices serving high proportions of African American women; Moms2B, a

community-based prenatal and parenting program; federally qualified health centers

located in predominantly African American communities; and two obstetric clinics

affiliated with The Ohio State University (see Appendix D: Pregnant/Postpartum

Recruitment Flyer). The researcher also attended Moms2B program sessions to introduce the study and recruit potential participants (see Appendix E: Recruitment Script for

Pregnant/Postpartum Participants).

Inclusion criteria consisted of women who identified as African American and were either 20 or more weeks pregnant, or up to 12 months postpartum. As a proxy for socioeconomic status, women who qualified for WIC were included. WIC eligibility is set at or below 185% of federal poverty guidelines; for example, a single woman with no children and an annual gross income at or below $21,257 could be eligible for the WIC program. Prior breastfeeding experience was not required for participation in the model building sessions.

Oversampling was used as some attrition was anticipated given the numerous barriers women face in attending a scheduled group such as a lack of transportation

and/or childcare. Women who indicated an interest in participating were screened for

eligibility (see Appendix F: Screening Script for Pregnant/Postpartum Participants).

Eligible women were asked to select a time and location for a group that was most

convenient to them. Participants received a follow-up phone call and/or email one to two

days before the scheduled session; in several instances the follow-up call was not

received due to the phone being disconnected and/or the participant being unavailable.

The actual attendance rate of women who had signed up for a session ranged from 28.6%

to 80.0%; across all sessions the average attendance rate was 61.8%.

For the full sample of pregnant and postpartum women (n = 21), participants ranged from age 15-39 and the mean age was 24.81 years (SD = 6.05). Eight of the participants (38.10%) were currently pregnant, with a mean of 28.75 weeks pregnant (SD

= 8.21). Regarding parturition, 19.0% were first time moms while 81.0% had one or more children. Among those multiparous moms, 82.35% indicated that they had previously breastfed; previous breastfeeding duration ranged from 4 days to 8 months. When asked to indicate their highest level of education completed, participants ranged from 8th grade to college graduate. Additional demographic information for pregnant and postpartum study participants is available in Table 2.

Participant Characteristics n % Participant age 15-17 1 4.8% 18-24 9 42.9% 25-29 6 28.6% 30-34 4 19.0% 35-39 1 4.8% Education 8 years grade school 2 9.5% 1-3 years high school 3 14.3% High school graduate 11 52.4% 1-3 years college 2 9.5% College graduate 3 14.3% Current relationship status with baby's father Married 0 - Romantically involved 8 38.1% Separated/Divorced 1 4.8% Just friends 4 19.0% Not in any kind of relationship 8 38.1% Race Black or African American 17 81.0% Multiple 2 9.5% Other 2 9.5% Ethnicity Hispanic or Latino 0 - Non-Hispanic or Non-Latino 21 100.0% Monthly household cash income <$800 13 61.9% $801-$1,100 4 19.0% $1,101-$1,400 1 4.8% $1,401-$2,000 1 4.8% $2,001-$2,500 1 4.8% $2,501-$3,000 1 4.8%

Table 2. Phase 1 pregnant and postpartum mothers’ demographics

The validation groups. Once all of the initial model building sessions were held, the investigators consolidated the factors and the model and presented this content back to some of the previous participants for validation. This is a critical component in the

model building process, and one that often goes overlooked or underreported. Involving

participants in the validation process lends to the credibility of the final model, increases

confidence among participants in the representativeness of the model, and can even generate new insights (Nistelrooij, Rouwette, Verstijnen, & Vennix, 2015).

These two validation groups were comprised of women who were engaged in a previous model building session and had expressed an interest in participating in this

review process. The first validation group included the WIC peer helpers; all three of the

original WIC peer helper participants were contacted and agreed to attend. The second

group included a subset of pregnant and postpartum women who had participated in an

earlier model building session.

For factor and model validation, a group size of five to eight women was sought.

Initially random sampling was used. Ten women were randomly selected, but of those

ten, only two were available to participate. Additional women were then contacted; the

order in which they were called was determined by a random number generator. The

majority of women had their phones disconnected, or did not answer or return the call.

For those who did respond, several had a scheduling conflict or did not have

transportation. Eventually attempts were made to reach all 21 prior participants; 4

committed to attending the follow-up session. During the scheduled time, however, no

one arrived. Finally, it was determined that a convenience sample would be most

61 effective in engaging the women. The validation session was then held prior to a

Moms2B program meeting. Three women, who represented two unique model building groups, participated in the final model validation session.

Data collection procedures.

Initial group model building procedures. Model building sessions were scheduled in two hour blocks at two different locations in the city; locations were selected with an emphasis on accessibility for the women. Participants were provided a

$20 gift card to a local grocery store, and food was provided during the model building sessions.

Each group model building session was co-facilitated by myself (a White woman) and an African American woman who was knowledgeable about and comfortable discussing breastfeeding. An African American facilitator was deliberately sought to encourage rapport building within the group. A strong rapport between research participants and study personnel not only increases the validity of the research, it has also been shown to strengthen recruitment efforts with low-income, racially diverse populations (Barnett, Aguilar, Brittner, & Bonuck, 2012; Padgett, 2008). Hiring an

African American co-facilitator was also an attempt to decenter myself as the “expert.”

As Manders and Galvani (2015) explain, “as with social work practice, researchers need to be aware of the power inherent within their role, along with the role of others” (p.

206). This is especially important when the researcher is a cultural outsider, and when participants may consider the topic to be sensitive or taboo (Padgett, 2008).

The principal role of the African American facilitator was to act as the guide for

the model building process, and her tasks included keeping participants on task and

eliciting input from all participants. I provided an introduction about the purpose of the

study, sought clarification when necessary, and translated group discussions into the

model. Each model building session was audio recorded and transcribed verbatim.

All model building sessions followed the group model building protocol (see

Appendix G: Group Model Building Protocol). Participants were briefed about the purpose of the research and given a consent form that outlined the risks and benefits of participation (see Appendix H: Consent). All procedures associated with Phase 1 were approved by The Ohio State University’s Institutional Review Board for the protection of human subjects (see Appendix A: IRB approval letter). Participants were informed that sessions were being audio recorded, and that they were allowed to discontinue participation in the research at any time. Individuals then completed a demographic form and were introduced to the facilitators and the format of the model building session (see

Appendix I: Demographics for WIC Peer Helpers and Appendix J: Demographics for

Pregnant/Postpartum Participants). A few ground rules were discussed, including the importance of respecting the confidentiality of others in the group. Conflicting perspectives were welcomed as part of the process, however the importance of respectful communication during the session was emphasized. Each participant then introduced herself in turn, and briefly discussed what breastfeeding means to her and within the context of her community.

Following this introduction, group model building scripts were utilized for the initial steps of the model building process. GMB scripts are a collection of evidence- informed instructions compiled by systems dynamicists which represent a “best” or

“promising” practice in community-based model building (Hovmand, Rouwette,

Andersen, Richardson, & Kraus, 2013). To begin the process, individuals made two lists.

The first list included factors that make it easier to breastfeed and the second list

consisted of factors that make it more challenging. In a round robin process, each

participant provided one response, captured on large wall-sized post-its, until all participants’ items were captured. This technique has been shown to increase divergent thinking, which is a critical component in building a comprehensive and inclusive model

(Andersen & Richardson, 1997).

The co-facilitators next asked participants if there were some individual factors that could be organized into overarching themes. For example, women generated a number of ways that breastfeeding benefitted the mother, including reducing her risk of cancer, contributing to rapid weight loss, and delaying menstruation. In this example, participants typically organized these types of factors into an overarching category

(hereafter called themes) such as Benefits for the Mother.

Once the factors had been captured and categorized, the co-facilitators explained that the next task was to connect these separate items in ways that created a visual representation of the relationships between them and to breastfeeding. The group was shown an example of a very simple model, and walked through the notations present in that model, namely the arrows to and from each factor, and the plus and minus signs

64 indicating the quality of the relationships between them. The plus sign indicated that the relationship had a positive polarity; as one factor went up (or down) the other did as well.

A negative sign indicated that the items moved in the opposite direction; as one factor went up, the other went down.

Participants were then guided through the model building process. At the center of the model was the item “breastfeeding” and one at a time, participants selected individual factors or themes and indicated the ways that they were connected to other factors or themes, and to breastfeeding. The co-facilitator drew those arrows, and captured the polarity, asking for clarification as necessary. If, during this process, a new factor was generated, a co-facilitator added that factor to a card and incorporated it into the model.

In instances where participants disagreed about the relationship between variables, the co-facilitators guided the discussion and sought the input of other group members in order to achieve resolution within the model. Most often, disagreement arose related to the polarity of a factor or theme. For example, some women thought that pumping decreased breastfeeding duration while others felt that it increased it. In instances such as this, group participants were asked to consider “more often than not” the direction of the relationship. This helped participants recognize that while their perception and/or experience was valid, it might not necessarily encapsulate the experiences of most women. Through this process, participants were able to reach consensus on the polarity of the interaction. Instances where individuals had differing insights about the polarity of the relationship are included in the discussion section.

This dynamic process of collaborative and iterative model building ultimately resulted in a visual representation of participants’ beliefs about the central concepts impacting breastfeeding, and the relationships between them. Once the model was finalized, participants reviewed the model and contributed any final input. The women were then handed three star stickers and asked to place them on factors or themes they felt were most influential in a woman’s decision to initiate or sustain breastfeeding. This process helped participants prioritize factors, and the insights generated were useful for

Phase 2. Facilitators then provided a brief summary of the findings, thanked participants, and asked them to provide their contact information if they were interested in attending the follow-up session to validate the factors and final model. After the WIC peer helper group and the four groups with pregnant and postpartum women, the co-facilitators concurred that conceptual saturation had been achieved.

Model validation procedures. In the model validation groups, participants were provided with one handout listing all the consolidated factors and themes, and another handout with the consolidated model; the construction of the consolidated model will be discussed below. The co-facilitators informed participants that all of the model building sessions had been completed. The women were provided a brief summary of how the factors were consolidated, the themes were constructed, and the individual models were incorporated into one cohesive model. The women were then asked to review the factors presented and to voice any questions or comments related to the factors themselves or their thematic organization. Next the model was presented, and the participants were reminded of the meaning of the models notations. Some relationships between factors

were highlighted to remind participants of the organizational structure of the model. The

women were again asked if clarification of the model was needed, or if they had any

suggested revisions. The model validation sessions lasted one hour; all participants were

reimbursed $10 for their participation in this final validation session.

Data terminology. Several terms are used in the following section related to data

coding which occurred during and after the group model building sessions. It is helpful to

first define the terminology used throughout to add transparency and clarity to the data

analysis processes.

The initial unit of data directly generated by the women in the model building

process is referred to as a factor. A factor is a word or phrase that was typically identified by participants during the factor identification activity, or on occasion, while the model was being constructed. (Note that the term “factors” has a meaning in model building unrelated to statistically analyzing the factor structure of survey data.) During the Phase 1 analytic process, these factors were labeled ‘codes.’ Codes represent a single data point, and in this study they are comprised of an explicit word or phrase that emerged directly

from the group model building participants. These codes were then used in the

construction of themes. Themes represent more complex, overarching, and occasionally

more subtle connections between codes. Themes sometimes emerged during a model

building session, such as the Benefits for the Mother example above, but they also arose

out of an iterative data collection and analysis process, as more group model building

sessions were conducted. Themes typically encapsulate several codes.

In this study, themes were labeled as either semantic or latent. With semantic

themes, participants explicitly named a category or grouped a set of items during the

model building process. Latent themes emerged from the researchers’ coding processes

and included groupings of items that were interrelated in ways that may not have been

directly identified by participants. Finally, the two overarching categories that

encapsulated all of the data were the categories: factors that make it harder to breastfeed,

and those that support breastfeeding.

Data analysis procedures. In GMB, data analysis can be conducted in two

cycles. The first occurs directly with the participants and concurrently during the individual group model building sessions. As each factor is named and each model constructed, group members are engaged in an ongoing stream of dialogue about the degree to which the factors and the model represent their own perspectives. Eventually the group reaches consensus on the factors included in the model and the relationships between them. This simultaneous model building and analytic process gets repeated by each group. In this study, this resulted in five models (one model per group). Although sessions had overlapping content, each session made unique contributions to the emerging factors and the model. This process of concurrent data generation and analysis

with participants built in a level of data validity, and helped ensure that findings were

representative of participants’ perspectives, which is a critical component of grounded

theory research (Bryant & Charmaz, 2007b).

The second cycle of data analysis is conducted by session facilitators, and occurs both during and after group model building sessions. During each breastfeeding session,

the co-facilitators captured theoretical memos, and afterwards reflective observations

were documented. This process is central in studies utilizing grounded theory

methodologies (Kendall, 1999), and is recommended by Bryant and Charmaz (2007b) as

a critical component of iterative data collection and analyses. These theoretical memos

were used as a means to capture and analyze data in addition to the factors identified and models generated in each group. The memos included meaningful connections between themes and congruent themes across model building sessions, and contained documentation of different group dynamics. As is common with coding utilizing grounded theory, the memos and connections therein became increasingly complex as the study progressed (Glaser & Strauss, 1967). These memos were utilized during the final coding process, as well as during the construction of the final group model.

Once all of the model building sessions were held, the data were analyzed by the co-facilitators, in order to identify a comprehensive set of factors and construct a consolidated model. This analysis was done collaboratively to reduce bias, to encourage

the incorporation of different perspectives and observations, and to lead to a more

trustworthy set of final items (Elo et al., 2014; Gibson, 2007). In light of the

constructivist nature of the data analysis process, I was mindful of a common critique of

feminist research rooted in postmodernism, which is the failure to “recognize the

embeddedness of the researcher and thus obscure the researcher’s considerable agency in

data construction and interpretation, as well as the framing of accounts” (Olesen, 2007, p.

422). If there was any disagreement regarding codes or language, I typically chose to

retain my co-facilitators codes or interpretation over my own.

As was indicated with the employment of grounded theory methodology, an

inductive approach was used to code the data, whereby themes were permitted to organically arise from codes, as opposed to retrofitting data to pre-identified themes. Two

cycles of coding were used to analyze the data. In the first cycle, in vivo coding was used

as it prioritized the participants’ own language. This is appropriate for a study utilizing

grounded theory as it preserves the linguistic and cultural integrity of the themes

(Saldaña, 2016). For this cycle, each factor identified during the group model building

session was transcribed onto a single notecard. Similar factors (e.g. breastfed baby is less

sick and breastfed baby is healthier) were combined into a single code. Co-facilitators

collaboratively named the code by selecting the most concise and descriptive term

provided by the group. Considering the structure of the group model building sessions

with participants directly providing the factors themselves, most of the codes initially

identified were factors taken verbatim from participants.

To transition between the first and second cycle of coding, a visual review of each

code and the connections between them is sometimes recommended (Saldaña, 2016). The

group model building methodology is particularly helpful in this regard as it provides a

direct operational model to work from. We had copies of all five models during the

second cycle of coding, and we referred to these frequently, as well as the typed

transcripts of the model building sessions. This helped us clarify the meaning of codes

when there was uncertainty or ambiguity, and to identify some of the overarching

connections between codes.

Following the identification of the in vivo codes (first cycle), and the review of model building documentation (coding transition), the co-facilitators moved into the second cycle of coding, which utilized axial coding. Axial coding involves identifying implicit and explicit connections between codes and acknowledging overarching thematic relationships. It is the culmination of the participants’ identification of factors, the first cycle of coding, input from analytic memos, and our own personal insights from group facilitation (Saldaña, 2016).

Once all of the codes were identified and organized into themes, the next step in the analysis process was to consolidate the five individual models into a unified, final model. We reviewed each theme and the codes encapsulated by them to identify the way that themes and/or codes had been represented in each individual model. This included an examination of the codes’ relationships to each other as well as their relationships to breastfeeding. We then began constructing a consolidated model.

In the individual model building sessions, some of the factors were grouped into themes by participants, while other individual factors were incorporated directly into the model. In order to construct a more parsimonious model in the model consolidation process, we focused predominantly on the overarching themes, as opposed to the individual factors. We began the consolidation process by selecting themes that were repeated across all of the individual models. We then examined the relationship between those themes and other themes or factors in each individual model, adding themes into the consolidated model as indicated. An emphasis was placed on retaining some component of the relationships originally documented in the individual models. In

71 addition to including components of the original models, we also included our insights as captured in the analytic memos, using this input for clarification or elaboration. This model elaboration conducted by facilitators outside of the group model building sessions is recommended, as interconnections and complex themes often arise from comparing multiple models (Luna-Reyes et al., 2006).

Once the themes were identified and the consolidated model was drafted, member-checking was utilized to ensure the factors were comprehensive and the categorization/consolidation of codes was valid. This final step of the process ensured that the sorted factors and final model resonated with the women whose perspectives it attempted to depict (Padgett, 2008). The categorization of factors and the consolidated model were presented to the original group of WIC peer helpers for their feedback. The model was then revised based on their input and presented to the subset of the low- income, African American participants for additional feedback and revisions. Participants confirmed that the final model represented a valid translation of the cumulative insights generated in their model building sessions. Although the validation sessions generated dialogue regarding the factors and the final model, participants had no additions or modifications to the factors, and suggested only one minor addition to the model.

Results

This section provides the results of the group model building process including the factors that make it easier to breastfeed and the themes they are organized into, the factors that make it more difficult to breastfeed and their thematic categorization, and the final model.

Factors that make breastfeeding easier. Participants across all groups were

easily able to name multiple factors that made breastfeeding easier. The number of

factors identified in each group related to supporting breastfeeding ranged from 21-28.

The mean number of factors across all groups was 24.80 (SD = 2.86). Perhaps not

surprising given their experiences and expertise, the WIC peer helper group identified the

highest number of factors at 28. The total number of factors that make breastfeeding

easier, once consolidated, numbered 82.

All of the identified factors that make breastfeeding easier were consolidated into

ten overarching themes. As mentioned, these themes were identified as either semantic or

latent. The semantic themes were named specifically by program participants during the model building process, and participants grouped a number of individual factors under

these terms. Eight of the ten themes were semantic. These included: Patience/Persistence;

Convenience; Pumping; Supplies/Tools; Support; Knowledge About How/Why to

Breastfeed- General; Knowledge about Why to Breastfeed- Benefits for Baby; and

Knowledge About Why to Breastfeed- Benefits for Mother. The latent themes were constructed by the co-facilitators after all of the individual model building sessions were held, and account for two of the themes which were Social Acceptance and Emotional

Benefits/Bonding. The three themes with the most factors included in them were:

Knowledge about Why to Breastfeed- Benefits for Baby (15), Knowledge about Why to

Breastfeed- Benefits for Mother (15), and Support (13). For a full list of themes and the factors identified under each see Table 3.

Factors and Themes Type of Theme Knowledge about Why to Breastfeed - Benefits for Baby Semantic Health Healthier baby Has all the vitamins Reduces chance of illness/builds immune system Can breastfeed closer to surgery time than bottle feed Reduces colic Reduces SIDS Reduces asthma Better bowel system Won’t throw up as much Protects baby as they grow Less time spent in NICU Emotional Baby happier/less crying Mom is a pacifier Baby has a better attitude Intelligence Baby is more accelerated/intelligent/higher IQ Knowledge about Why to Breastfeed - Benefits for Mother Semantic Most natural thing a mother can do Physical Health benefits that fit each family’s situation Moms’ health benefits Breasts stay firmer longer Weight loss Uterus shrinks quicker Baby goes back to sleep faster at night Reduces the risk of cancer in moms Increased libido Delays menstruation Continued

Table 3. Factors and themes that make breastfeeding easier

Table 3 continued

Factors and Themes Type of Theme Emotional Stress reliever Relaxing Less likely to have postpartum depression Material Cheaper Support Semantic Baby’s Father Physical support from baby’s father Emotional support from baby’s father Peer Peer support Support groups Woman’s mother/family Support/influence of woman’s mother Support from the family Runs in the family Agency/Programs WIC supports/expertise Hospital support Baby-friendly hospitals Support from community programs Social Acceptance Latent Social acceptance of breastfeeding Getting praise for breastfeeding Knowing where to breastfeed baby in public (nursing rooms) Having places to breastfeed or pump at work/school Comfortable in public Religion Breastfeeding as a trend Workplace acceptance Facebook/social media

Continued

Table 3 continued

Factors and Themes Type of Theme Convenience Semantic Convenience Food always with you/easy access Milk is at the proper temperature Baby sleeps longer Convenient at night No measuring Don’t have to make/wash bottles Light diaper bag Time management Patience/Persistence Semantic Determination to breastfeed

Patience

Self-esteem

Confidence

Perseverance

Positive attitude

Trying it out

Knowledge about How/Why to Breastfeed - General Semantic Awareness – word of mouth Knowledge/information about why to breastfeed WIC Breastfeeding education programs Knowing where to go to ask questions Knowing how to breastfeed Knowledge about breastfeeding benefits Supplies/Tools Semantic Having the right materials (nipple shields, breastfeeding covers, nursing bras, etc.) Having a pump Knowing how to hand express milk

Continued

Table 3 continued Factors and Themes Type of Theme Emotional Benefits/Bonding Latent Bonding with the baby Feeling needed/wanted/valuable Getting alone time with the baby Fun Empowering Skin to skin Pumping Semantic Pumping Pumping more socially acceptable

Participants were also asked to rank the top three factors that they felt were most important to a woman’s success in breastfeeding. The most important factor across all model building sessions was Bonding/Connecting with the Baby. Seventeen women assigned a star to this item, indicating it was among the top three factors they felt were most important. The Health Benefits for Baby (nine stars) and for Mom (six stars) were the second and third factors most frequently identified as important. Other commonly selected included Having the Right Materials (seven stars), Convenience (five stars), and the Cost Benefits of Breastfeeding (five stars). For the full list of items selected as participant’s top three factors see Appendix K: Phase 1 Rating of Factors that Facilitate

Breastfeeding.

Factors that make breastfeeding more challenging. On average, participants were able to identify more factors that made breastfeeding more challenging than those that made breastfeeding easier. The number of factors that participants identified for

77 making breastfeeding more difficult ranged from 18 to 39 with a mean of 26.40 (SD =

7.96). Again, WIC peer helpers were able to identify more factors than any other group; they identified 39 barriers, which was 11 more than the group with the second-highest number of factors (28).

Once the factors were consolidated and categorized, fourteen themes were identified; eight of these themes were semantic and six were latent. Semantic themes included: Lack of Support, Issues with Breastfeeding in Public/Around Others,

Sexualization of Breasts, Lack of Breastfeeding Knowledge, Pumping, Time Consuming,

Returning to Work or School, and Inconvenience. The latent themes were: Emotional

Barriers to Breastfeeding, Baby’s Dependence on Mom, Physical Barriers to

Breastfeeding, the Impact of Breastfeeding on Mom’s Lifestyle, Cultural Beliefs, and

Concerns about the Impact on the Mother’s Body. The themes with the highest number of factors included Lack of Support (16) which included both individual as well as institutional support, Emotional Barriers (9), Issues with Breastfeeding in Public/Around

Others (9), and Baby’s Dependence on Mom (8). For a full list of themes and the factors identified under each see Table 4.

Factors and Themes Type of Theme Lack of Support Semantic Religion/belief system Lack of peer support Society doesn’t accept Overall lack of support Lack of professional support Receiving different messages – doctor, family, lactation counselor Medical provider puts baby on formula (nurse/doctor) Doctors aren't educated about breastfeeding Lack of institutional support No postpartum hospital class for breastfeeding Lack of services for breastfeeding support Negative energy/negative people Baby's dad doesn't support Mother/Family/Tradition Mother didn’t breastfeed Not knowing how to talk to or educate family on breastfeeding Emotional Barriers Latent Stressful Lazy No patience Loss of interest Negative attitude Takes a lot of work Postpartum depression Feel weird/it’s nasty “These breasts are mine”

Continued

Table 4. Factors and themes that make breastfeeding more challenging

Table 4 continued Factors and Themes Type of Theme Discomfort Breastfeeding in Public/Around Others Semantic Fear of breastfeeding in public Fear of perverts staring at breasts Discomfort breastfeeding/pumping around others Don’t live alone/ live in a shelter Embarrassed Privacy is hard when baby is distracted Older baby Larger breasts Controversy about breastfeeding in public Baby's Dependence on Mom Latent Baby is attached at the hip Father wants to be involved with feeding/bonding Don’t want to spoil the baby Other people can’t feed Can’t leave the baby with others Mom is a pacifier Baby always wants your attention Baby doesn’t want to sleep away from you Physical Barriers to Breastfeeding Latent Pain (latch/engorgement)

Discomfort

Baby biting C-section recovery Low milk production Medically unable to breastfeed (breast cancer, implants, breast reduction, AIDS) Breast structure/size/shape Sexualization of Breasts Semantic Breasts are sexual “These breasts are my boyfriends”

Women were molested/sexual trauma

Feel like you’re sexually molesting your baby

Feel weird feeding male baby

Afraid the baby will turn gay

Continued

Table 4 continued Factors and Themes Type of Theme Impact of Breastfeeding on Mom's Lifestyle Latent Limits socializing Not able to party Can’t drink Can’t smoke Can’t do drugs Less sleep Lack of Breastfeeding Knowledge Semantic No early education about breastfeeding (e.g. child care classes) Don’t know how/lack of skill Not knowing all the benefits Pumping Semantic Pumping Thinking pumping is reflective of supply Pumping is time consuming Pump is hard to get Time Consuming Semantic Time consuming Busy schedule/life Lack of help with other kids No time with partner Exhausting Cultural Beliefs Latent Lack of cultural support “Black people don’t breastfeed” Lack of cultural knowledge “do Black people breastfeed? No expectation of breastfeeding History of breastfeeding during slavery Concerns about Impact on Mother's Body Latent Weight gain/hungry Breasts different/saggy Decreases libido Returning to Work or School Semantic Going back to work/school Daycare

Continued

Table 4 continued Factors and Themes Type of Theme Inconvenience Semantic Inconvenient Baby wakes more frequently WIC – receiving formula, esp. in the 1st month

When participants were asked to rank their top three factors, the item with the

highest number of stars was Pain Related to Latch/Engorgement, with 11 individuals

ranking this in their top three factors that influenced a woman’s willingness to

breastfeed. Several other factors that made breastfeeding more difficult received five

stars including: Stress, a Return to Work or School, and the Breastfed Baby’s

Attachment to “Mom’s Hip.” For the full list of items selected as participants’ top three

barriers see Appendix L: Phase 1 Rating of Factors that Make Breastfeeding More

Challenging.

Final model. The final model illustrated relationships between the sub-categories and their relationship to breastfeeding. See Figure 3 for a diagrammatic representation of the full model. As mentioned, this model was constructed by the co-facilitators in an iterative process to consolidate the individual models. An emphasis was placed on creating a parsimonious model without sacrificing the integrity of the relationships between the factors and overarching themes found in each individual model. This final model was validated with the peer helpers who participated in the original model building group, and the subset of pregnant and postpartum women.

Figure 2. Final model of factors impacting breastfeeding

The final model included all of the themes identified across the individual model- building groups, although for parsimony in the model some sub-categories were consolidated when the inverse was duplicative. For example, Convenience was a sub- category related to factors that make breastfeeding easier while Inconvenience was a sub-category identified that made breastfeeding more difficult. These were consolidated and labeled Convenience in the final model; relationships to this sub-category included those identified both as a facilitator (Convenience) and a barrier (Inconvenience).

The model-building process helped participants document their mental model, illustrating the non-linear relationships among the factors. The final model contained three primary domains with several feedback loops within them. Those domains were: 1.

Breastfeeding and Returning to Work or School, 2. Breastfeeding and Social

Acceptance, and 3. The Relationships between Knowledge, Support, and Persistence, as they relate to breastfeeding.

Some of these feedback loops represent reinforcing loops; a reinforcing loop is a cycle that continues without any external forces interrupting it (Lane, 2008). One example of this is the loop between knowledge about how to breastfeed leading to decreased physical barriers to breastfeeding, which leads to increased persistence, which leads to more breastfeeding.

The other kind of feedback loop is a balancing loop. Balancing loops are the relationships between factors that exert an overall negative force on the system (Lane,

2008). In this instance, a balancing loop represents a set of relationships that decrease breastfeeding. This can be seen in the relationships between themes related to a mother

returning to work or school. As she returns to work or school, she utilizes a breast pump

more, which often leads to a reduction in milk supply, which leads to decreased

breastfeeding. This decreased breastfeeding then means that baby is less dependent on

mom and other people can help take care of the baby, thus facilitating a woman’s return

to work. Through this feedback loop, the return to work can be understood as a

mechanism through which a woman’s breastfeeding relationship is impacted.

Discussion

Prior to the model building session, it was determined that the study would utilize

a social ecological framework and critical feminist to ensure that the factors identified

would be inclusive of levels ranging from the micro to the macro system, and that factors

related to the systematic subjugation of women of color would be identified. Although

the identification of a theory a priori to data collection might suggest a deductive analytic

approach, the purpose of the study was not theory testing, but rather ensuring the factors

were comprehensive, spanning multiple levels (if applicable), and unique to low-income,

African American mothers (Elo & Kyngas, 2008). Considering the findings in the context of a social ecological framework and critical feminist theory might also contribute to analytic generalizations about breastfeeding beliefs held by low-income African

American women (Yin, 2009).

Social ecological model. Without prompting, each group identified factors and themes spanning micro, meso, exo and macro levels. For example, on the micro level, women identified a number of individual-level traits that they felt helped breastfeeding initiation and duration including perseverance, self-confidence, and knowledge. They

85 also discussed the ways that emotions such as a lack of patience and overall negative attitude toward breastfeeding can serve as a barrier to breastfeeding. On the meso level, participants discussed the ways that support, or lack thereof, can influence a woman’s decision to breastfeed. This included both physical and emotional support from the baby’s father, and support from the woman’s mother, family members, or peers.

The exosystem was represented with factors related to the knowledge and support women received through programs such as WIC, and from health care professionals including doctors, nurses, and lactation counselors. One participant discussed the way the support of these professionals was directly connected to her patience and persistence:

…now it doesn’t hurt anymore when she drinks or latches or whatever, but I kept

calling [lactation consultant] like “Can you help me? I don’t understand it hurts so

bad.” and she just said “Keep trying and keep doing it, don’t stop” so I guess it

made me want to keep trying, I guess.

Two groups also discussed the early availability of formula through WIC and how it inadvertently discouraged breastfeeding. One participant shared her experience with this; she did not have her first postpartum appointment until a month after her child’s birth. She spoke about choosing to establish a breastfeeding relationship in that interim, rather than spending the money out of pocket on formula. This prompted discussion within the group about the ways to address the impact WIC may have in potentially undermining a mom’s willingness to initiate or continue breastfeeding. One woman explains:

I think WIC, what should they do, they should start their milk a month after you

have the baby. So you have to breastfeed, unless there is a medical necessity, and

that would promote it. And then so if you don’t want to breastfeed then you will

come out of pocket for, you know, what you want. So after that month if you had

no success then you can start, if you want, formula. I think that would promote it.

This discussion illuminates some of the ways that the women perceive the availability of formula through meso-level institutions such as WIC, and how this impacts breastfeeding initiation rates in their community.

Finally, women identified macro-level factors that were related both to Black culture and to broader American society. Participants discussed the relationship between the sexualization of breasts and breastfeeding, and the general lack of acceptance for breastfeeding both in African American culture and in American culture. Women talked at length about their comfort levels breastfeeding in public. They indicated an awareness of negative publicized incidents related to breastfeeding in public (e.g. at Target), and how that may impact a woman’s decision to breastfeed. During a discussion of one such incident, a participant shared a story she had heard about a woman in a restaurant being told she could not breastfeed her baby there. The participant went on to share her thoughts on how that might impact her personally:

I feel like if that happened to me and at first I was kind of leery about

breastfeeding then all the sudden I went somewhere and someone was like

"you shouldn't do that...you can't do that here" that would make me feel like "oh,

ok, maybe I shouldn’t."

Upon the identification of public breastfeeding as a barrier, women in several

groups suggested possible solutions. Participants in some groups talked about using a

breastfeeding cover while in public, while participants in another group introduced more meso-, exo-, and macro-level solutions. In one discussion of the need to feed baby while out and the public backlash that can potentially come from it, one participant suggested:

“They should start making places where you can go somewhere and do that if you are

(breastfeeding)... it don't got to be a big place.” Another participant chimed in: “They got

changing stations, why can't there be a breastfeeding station?”

Another macro-level factor identified as a barrier to breastfeeding was housing

insecurity. This, in conjunction with a woman’s discomfort breastfeeding or pumping in

front of others, led to the premature termination of one woman’s breastfeeding

relationship with her child. In discussing her own housing situation she stated:

If you don’t live in your own house and you have to breastfeed and there’s people

around…like pumping and living in a shelter, it makes it harder because if you

have a roommate. Have you ever tried to pump while holding a sheet over you,

trying to adjust your breasts?

As in the above example, several women recognized the intertwined nature of

these multi-level internal and external factors on their breastfeeding decision making

and behavior. One example that was frequently raised was a woman’s ability to continue

breastfeeding upon return to work or school. This involved factors on multiple levels

such as the age of the baby when she had to return to work (family leave laws and

policies), the willingness of the baby’s caregiver to provide the baby with breast milk in

88 the mother’s absence, the mother’s ability to secure a breast pump, and her consideration of whether her employer would honor her legal right to pump and provide her with the time and space to do so. Any one of these could negatively impact her milk supply and make it more challenging to breastfeed. One participant spoke of her experience:

You can’t feed while you’re while you’re going [to work]… I know that’s part of

my issue and why… I work third shift. So like, usually the time he would be

eating is when I get really full, and I’m like, “I can’t do anything right now.”

Then the milk goes down.

Some women did indicate that they felt a cultural shift was underway, with more celebrities breastfeeding and with more support groups online. They recognized some of the shifts they had seen in their own communities as well. One participant explained:

Because some people still look at you kind of weird when you do it but I guess –

like I don’t know- because me and my best friend were out and she breastfeeds,

and a lady was honking her horn, and was like, “Good job I breastfeed too!”.

Overall, however, the majority of women felt that many in their surrounding environments were not supportive of breastfeeding and they felt that acted as a barrier to breastfeeding for women in their community.

Cultural considerations. As discussed, this study design was based on critical feminist theory and examining the specific intersections of identity characteristics as they related to breastfeeding. Thus this study was predicated on the assumption that the barriers to breastfeeding within African American communities differed from those in dominant White culture. It is therefore important to discuss some of the findings that may

be unique to, or experienced more frequently by lower income women within African

American culture.

Breastfeeding knowledge, attitudes, and myths. Perhaps the most pervasive

narrative running through the African American community related to breastfeeding can

best be summed up by a simple summative statement made by one participant: “Black

women don’t breastfeed.” When asked to elaborate, women discussed an overall lack of

communal knowledge, a lack of support, and the pervasiveness of myths related to

breastfeeding. As one participant described:

People just hear different stuff about breastfeeding and they are going off of what

they hear, but if you really knew about breastfeeding like maybe you would

change your actions or …maybe you will want to breastfeed. Like you know what

I am saying, because like ‘oh we heard this and that,’ you know.

These myths may go back generations. One participant discussed a conversation she had with her own mother about breastfeeding, which highlights one of the more common misperceptions about a mother’s ability to produce enough milk. She stated: “My mom said she didn't breastfeed me and I asked her why, and she said because her grandma told her that her milk would dry up.”

Several groups reiterated the sentiment that women in their communities did not know a lot about breastfeeding, and how that negatively impacted support for breastfeeding. Many participants discussed how breastfeeding is not common, is typically not accepted by friends and family members, and is considered by many to be “nasty.”

One woman even expressed the idea that her infant found it nasty. In describing her son’s immediate reaction to breastfeeding she stated:

He didn’t like it, he don’t like to latch on, nothing. He didn’t like it. It was in his

mouth, and the breast milk… and he just thought it was nasty. He was making this

face like (showing disgust), in the hospital.

The use of the word nasty was of interest as another breastfeeding study conducted with

low-income women over fifteen years ago also found that women described

breastfeeding as nasty (Guttman & Zimmerman, 2000). This shows the persistence of

negative public opinions related to breastfeeding among low-income populations, and

the characterization of it as disgusting.

Participants in the current study also discussed how growing up in their

community, most women viewed formula feeding as standard, and breastfeeding as

deviant. This finding is supported by previous research that found a greater degree of

comfort with formula feeding among African American women as compared to women

of other races or ethnicities (Nommsen-Rivers et al., 2009).

Wet nurses during slavery. As an underlying cause of why many in the African

American community asserted that Black women do not breastfeed, in four of the five groups participants discussed the common historical practice of African American slaves serving as wet nurses for the slave masters’ children. Not every participant within these groups was aware of this history; once the topic was raised it often sparked an engaged conversation. One woman explained the practice to others in the group, stating:

Back in the day, when all the Black women were slaves, and like the masters?

They would impregnate their wives and they will also make sure that there was a

slave also pregnant too, so she could nurse their baby and her baby at the same

time. I said “wow.” So us Black women, we done came a long way.

Participants who were previously aware of this history discussed the impact it had on their decision to breastfeed, and those responses varied. Some felt that this history had negatively impacted them, and that they were not interested in replicating a practice that was a source of so much emotional pain and trauma. Others found empowerment through the history, seeking to reclaim the practice formerly used as a tool of oppression.

Sexualization of breasts. Beyond the historical legacy of slavery and wet nursing, women were asked to expand upon the reasons that breastfeeding was not as accepted in the Black community. In response to this, women in every group discussed the perception of breasts as being strictly sexual in nature. While the convergence between sexualization of the breasts and resistance to breastfeeding has been studied among low- income women, to date no article has explored this topic using an intersectional approach, focusing specifically on low-income African American women (Johnston-

Robledo & Fred, 2008). Scholars have examined the forces contributing to the hypersexualization of Black women (e.g. in the media and hip hop culture), yet this lens has scarcely been applied to breastfeeding (Hunter, 2011; Littlefield, 2008). This represents an arena where more targeted research is needed.

The tension between sexualization of the breasts and breastfeeding manifests as

barriers to breastfeeding in a multitude of ways. The items categorized by co-facilitators

under the latent sub-theme Sexualization of Breastfeeding highlight several of the ways

that beliefs regarding the sexualization of breasts and resistance to breastfeeding

converge. For example, several women discussed their concerns about breastfeeding in

public. Some felt comfortable feeding their baby as the need arose, however others

expressed concern that pubic nursing would draw the attention of “perverts.” This led

many women to make the decision to supplement with formula when they were with

baby outside of the home, which can lead to decreased milk supply, and over time an

irreversible disruption in breastfeeding.

Women also expressed concerns related to breastfeeding that had undercurrents of the sexualization of breasts. One participant lamented: “A lot of people who don't have

the knowledge just see breasts as a sexual thing.” Another participant responded “The

world make everything sexual now.” Participants in a separate group discussed the fear that breastfeeding a female infant could turn that child gay. Another group raised the issue perpetuated by some that breastfeeding an older baby (i.e. close to 1 year) could be considered by some to be a form of sexual molestation. One participant even speculated

“I wonder if someone could go to jail by somebody just taking it out of context...” While some women dismissed these as myths during the group, most women acknowledged having heard these ideas within their community.

In all groups, women discussed the impact of sexual trauma on a woman’s

willingness to breastfeed generally, or more specifically her willingness to breastfeed by

93 putting baby to breast. Some women opted to pump and feed their baby expressed breast milk through a bottle, as they felt they could still give baby the benefits of breast milk, while skirting their negative associations with direct physical contact with their breasts.

The relationship between sexual trauma and breastfeeding among low-income, African

American women warrants future research. While accurate incidence rates are difficult to ascertain, this group is believed to be at increased risk of sexual violence, and it is often underreported due to systemic and interpersonal cultural barriers (Tillman, Bryant-

Davis, Smith, & Marks, 2010; Wadsworth & Records, 2013). As a result, women often fail to receive physical or mental health services related to the trauma. This can impact breastfeeding in several ways. As mentioned, women may opt out of breastfeeding altogether. For those who do wish to provide their baby with breast milk, they may do so through expression, which requires access to a breast pump, a private location to pump, and possibly someone to care for her baby during that time. These barriers may contribute to the low breastfeeding continuation rate among women who exclusively express breast milk; only 1/3 of women who exclusively pump are still breastfeeding at one month postpartum (Shealy, Scanlon, Labiner-Wolfe, Fein, & Grummer-Strawn,

2008).

Support for breastfeeding. The perception of breastfeeding as sexual can also impact support, particularly from baby’s father, which one study has found to be the most influential person related to a woman’s breastfeeding decision-making and behaviors

(Bentley & Caulfield et al., 1999). Women who participated in the group model building sessions experienced differing degrees of support for breastfeeding from the baby’s

father. Some women discussed instances where the baby’s father supported breastfeeding

while others cited examples of a father’s explicit resistance.

Support from the father may depend on the degree to which he feels entitled to, or ownership over the woman’s body. One participant shared the experience of a close friend: “She letting her boyfriend make her decisions – he told her she couldn’t

breastfeed. I told her it's your body your decision, but (she) did not believe that.” When another woman raised the topic of breastfeeding with her partner, he responded to her by simply stating: “these breasts are mine.”

A father’s support may also hinge on his willingness to differentiate between

breasts as sexual, and breasts as a source of baby’s food. As one mom explained:

Being in a relationship like, it makes it harder to breastfeed, because men

sometimes don’t understand that, you know? And I don’t always talk to my

husband who I’m married to about breastfeeding. He’s like: “you shouldn’t do

that, like we do this with those.” Like, we don’t want to feed them to our baby.

Women also discussed the impact of breastfeeding on her libido, which may also impact

the father’s willingness to support breastfeeding over time. One woman stated:

Some moms have the opposite problem where they breastfeed they don’t have any

sex drive, because some people feel like all day somebody has been on me,

touching me. So when your partner or your husband…you’re like “get off me.”

You know what I mean? I don’t want nobody else touching me.

In discussing other reasons why the father may not encourage breastfeeding,

women talked about the father’s desire to be part of the infant feeding process,

95 especially because they felt like feeding the baby was an important way to bond. This finding is supported by previous research; low-income, African American women who participated in one study stated that they choose formula so that the baby’s father could be part of the infant feeding process (Fischer & Olson, 2014).

During the group model building sessions, some women reported that when they breastfed, the baby became more attached to them and the father felt left out. In one group, participants were discussing the connection between two factors- the strong bond with a breastfed baby and the support they received from the baby’s father. One woman felt there was the negative relationship between these, explaining: “well when the baby only wants mom, that’s a negative for the dad, because they may feel like they can’t take care of the kid, or there’s no…the kid doesn’t like him.”

Women also discussed the ways in which the baby’s father can support them in breastfeeding. One woman shared the ways that her partner helped her put baby to breast, and to keep her milk supply up through pumping:

My boyfriend, I thought I was going to feel awkward trying to breastfeed but he

was all into it. He be trying to hold my boob, he be like “you need a pillow?”

helping me like, readjust. (Laughs) I be like “you just hold her.” He was always

trying to help then when I was pumping he be like "you pump today?" He would

like call me on his breaks like "you need to pump a couple more times.” He's all

for it, and I don't even think his mom breastfed or anybody in his family but I

explained it to him and he was just all for it.

This support from baby’s father could be critical for helping women meet their breastfeeding goals, and represents a critical arena where more interventions can be developed. Increasing awareness of the benefits of breastfeeding among men and teaching them tangible ways they can help support the baby’s mother could have a positive impact on a woman’s breastfeeding decision making and duration.

In addition to the baby’s father, participants indicated that their own mother played a significant role in how she decided to feed her infant. This has also been supported in earlier research demonstrating the importance of the grandmother’s role in the mother’s infant feeding decision (Bentley & Caulfield et al., 1999; Grassley &

Eschiti, 2008). Grandmother’s influence can sometimes act as a barrier to breastfeeding.

Considering the scarcity of breastfeeding experience, especially among older generations, many participants in the model building sessions indicated that their own mothers expressed an explicit lack of support for breastfeeding. Other qualitative studies support these findings; when the grandmother is not comfortable handling breast milk, gives the baby formula without mom’s permission, or even encourages the baby’s mother to introduce formula and/or solid food, this may ultimately undermine the breastfeeding relationship (Bentley, Gavin, Black, & Teti, 1999; Bronner et al., 1999).

This has direct implications for breastfeeding interventions as it suggests that if the woman’s mother is not included in breastfeeding information and support efforts, the intervention may be ineffective.

On the other hand, some group model building participants indicated the critical ways that grandmothers can play a supportive role in regards to breastfeeding. Some

97 women discussed the important role her own mother or another mother-figure played in normalizing breastfeeding. One participant discussed how her step-mom modeled breastfeeding and the effect that had on her and her siblings:

I really think that a big part of breastfeeding has to do with the influence of if

your mom breastfed. My mom didn’t breastfeed so it’s like “eww” to her, but my

stepmom breastfed and due to us seeing her breastfeed, with our baby dolls we

tried to act like we was breastfeeding.”

Grassley and Eschiti (2008) also found that when a woman grew up seeing her own mother breastfeed, this set an early expectation that she too would choose to breastfeed her infant. Participants indicated that when the grandmother is supportive of breastfeeding, this also eliminates some of the other barriers women identified such as a fear of breastfeeding in front of others, knowing where she could go for questions or difficulties, and just generally feeling supported in her decision to breastfeed.

Breastfeeding and socializing. In every group, women discussed the demeanor of the breastfed baby, and ways that can negatively impact the mother. Breastfed babies were often described as spoiled, greedy, and connected to mom’s hip. This is often seen as negative because it limits the woman’s ability to be away from the baby and impacts her opportunities for socializing and peer interaction.

Breastfeeding can serve as a barrier to socializing in two primary ways. The first is related to a mom’s ability to leave her baby for long stretches of time while breastfeeding. Women discussed the need to pump if baby is exclusively breastfed, which requires equipment, storage, and a care provider willing to feed the baby

98 expressed breast milk. Participants also discussed a breastfed baby’s connection to mom.

While overwhelmingly participants identified the cultivation of a strong bond with baby as a benefit of breastfeeding, women also discussed the ways this relationship can constrain their social life. One of the participants explained:

Trying to leave her with somebody? Yeah that’s going to be a hassle. Why?

Because she’s so used to being under mommy, and mommy wanna go have some

fun but mommy can’t because got somebody calling like “she won’t stop crying, I

need you, I need you, can you please come get her?” Like I just got here and now

I gotta leave? Really?

These findings are supported by an earlier study with African American and

Latina teens; women in this study expressed concerns about their babies becoming overly attached to them, limiting their mobility (Hannon, Willis, Bishop-Townsend,

Martinez, & Scrimshaw, 2000). In the model building sessions, women discussed the challenges of leaving a breastfed baby with a caregiver, which for new moms, may result in fewer sources of social support. This limited access to social support may negatively impact her coping strategies, which many women have developed as a response to living in a high-crime, community of concentrated poverty (Budescu,

Taylor, & McGill, 2011).

Breastfeeding and substance use. Women’s social interactions and breastfeeding behaviors are also connected to their decisions around the use of tobacco, alcohol, and other drugs, particularly in a social context. Several participants classified this as some mothers wanting to “party” or prioritizing “an unhealthy way of life” over her baby.

Women in all groups of Phase 1 of this study raised this issue. As one participant explained: “Some people that’s what they live for, and they just be like ‘I can’t go without the drink’ so that may stop them from wanting to breastfeed.” Women expressed differing beliefs about the safety of breastfeeding and smoking, drinking, and using drugs, although most indicated that if a mother were to engage in any of these, she should completely opt out of breastfeeding. One participant explained these social norms through her friends’ response to her own breastfeeding and drinking: “I know when we go out everyone’s like, ‘No, you can’t drink, you’re feeding.’ I’m like ‘I wasn’t going to.’”

The understanding of alcohol consumption and breastfeeding as mutually exclusive may, in part, be related to public health messages that stress an abstinence- only approach. In some instances, with tobacco, alcohol, marijuana use, for example, a harm-reduction messaging strategy may be more appropriate (Friguls et al., 2010). A woman is still able to consume alcohol safely while breastfeeding, although it is important for her to know about the transmission of alcohol through breast milk, and how to restructure her infant feeding practices if she has been drinking. A woman who smokes is also able to breastfeed; research has found that even when a mother smokes, breastfeeding is still preferable to formula feeding, as it helps mitigate some of the negative effects of exposure to smoke (Dorea, 2007). A harm reduction strategy for smoking among breastfeeding women could focus on second and third hand smoke exposure, and practices to minimize her baby’s exposure to smoke and smoke residue.

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Certainly with this theme the assertion is not that substance use among mothers is unique to low-income, African American communities, however myths around the safety of substance use during pregnancy and breastfeeding (e.g. the use of marijuana to combat morning sickness) may differ (Savage, Anthony, Lee, Kappesser, & Rose,

2007). Additional research is needed to better understand myths and norms around substance use and breastfeeding that are prevalent among African American communities, and efforts should be made to craft and communicate culturally appropriate public health messages. The public health messages African Americans receive related to substance use and breastfeeding may be transmitted and/or understood differently, depending on the extent to which they trust healthcare providers and researchers, and the extent to which the messages are culturally tailored (Kreuter &

Haughton, 2006). Unquestionably, the best option is for a breastfeeding mother to opt out of smoking, drinking, or using drugs altogether, but for women who use one or more of these substances during the prenatal and postpartum period, more nuanced interventions must be developed. These interventions should offer a range of culturally responsive solutions, from risk reduction to cessation support.

Theoretical implications. This study was designed to apply critical feminist theory with special attention to intersectionality, and a social ecological model to the topic of breastfeeding. This phase of the research utilized a grounded theory approach, seeking to decenter the perspective of the researcher, and to prioritize the worldview of the women who are nested within their communities. According to the principles undergirding grounded theory it is antithetical for a study to verify any single theory; the

101 emphasis instead is placed on engaging in an ongoing, iterative process of theorization through the direct engagement with the population being studied (Bryant & Charmaz,

2007b). The findings from Phase 1 suggest that there are factors unique to low-income,

African American women related to breastfeeding initiation and continuation, thus the use of a grounded theoretical approach was justified.

Considering the group model building findings in the context of a social ecological model demonstrates that both barriers to and supports for breastfeeding, as experienced by low-income, African American women, are multi-level, ranging from the individual to the systemic. Adding an intersectional approach to this illuminates the way that low-income, African American women are situated within a unique socio-cultural context. Finally, incorporating critical feminist theory posits that the disparity in breastfeeding rates between low-income, African American women and women of other races and from more affluent socioeconomic backgrounds, is not accidental. Rather, it is the direct outgrowth of centuries of the systematic subjugation of the Black woman’s body.

The Phase 1 findings demonstrate that for some women, the origins of present day breastfeeding beliefs and behaviors can be traced back to slavery. The practice of slave masters’ utilization of wet nurses has left a legacy of pervasive breastfeeding myths and a general aversion to breastfeeding for many women. Present day dynamics, such as the hypersexualization of Black women, creates a further cultural disconnect and impacts women’s receptiveness to breastfeeding, support for breastfeeding, and comfort breastfeeding in front of others. This hypersexualization is perpetuated through media,

102 and is embodied by some African American men and women alike. Women who wish to breastfeed encounter resistance from the interpersonal level through the structural level where women cannot get the assistance they need, when they need it, from breastfeeding professionals.

While critical feminist theory and a social ecological model do not provide a straightforward or simple solution for addressing this public health issue, they nonetheless add a rich contextual understanding of the ways that pregnant and postpartum African American women experience breastfeeding within their socio- cultural context. This study identified individual-level barriers as well as facilitating factors, which will be utilized as a foundation for the Dynamic Breastfeeding

Assessment Process. As a result of the theoretical lenses employed, the findings also provided potential avenues for systemic change. While individual-level interventions are critical, the root causes of many of the barriers will not be addressed until breastfeeding disparities among this population is championed as a critical public health and social justice issue.

Conclusions and Recommendations

As previously mentioned, very few studies have focused on breastfeeding experiences among this specific population of low-income, African American mothers despite their depressed breastfeeding rates. Phase 1 of the research sought to identify the factors that help as well as hinder breastfeeding. Through five separate group model building sessions engaging 24 unique women, an extensive list of factors were identified.

The relationships between these factors were well articulated in the final model.

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Without prompting, specific to the identification of multi-level factors in a social

ecological model, the women were able to identify both supporting factors and those that

created resistance to breastfeeding that spanned multiple levels. Women acknowledged individual-level factors such as the ways that their own knowledge and determination impacted their success in breastfeeding. They discussed meso-level factors including the positive and negative impact of multiple health professionals, and pregnancy and postpartum service agencies on their own breastfeeding initiation and persistence. They also addressed macro-level factors such as the impact of returning to work or school on

milk supply and the continuation of breastfeeding. Women had varying degrees of

knowledge about laws designed to protect a woman’s right to the time and space to

express breast milk, but regardless many found it difficult if not impossible to incorporate pumping into their structured time away from baby.

This phase of the research uncovered a number of ways that low-income, African

American women are situated within a unique cultural milieu. Women acknowledged the importance of cultural beliefs about breastfeeding that are rooted in slavery practices, and manifest in the present day as intergenerational breastfeeding myths and attitudes.

Cultural norms also shape the beliefs of the individuals closest to mom (e.g. the baby’s father or maternal grandmother), to whom she may turn in her decision-making about infant feeding practices. This has implications for a woman’s knowledge about breastfeeding and the support she receives related to it. This also has important ramifications for the design of culturally-responsive interventions.

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Study limitations. Phase 1 of this project encountered some limitations, and there

are ways that this research can be built upon and expanded. Perhaps one of the most

significant limitations in this study is transferability (Padgett, 2008). This study utilized a theoretical sample of women from a mid-sized, Midwestern metropolitan region, thus it is geographically bound. It is feasible that low-income, African American women from other types of locales (i.e. rural areas), in other regions of the country, or future cohorts may experience a different set of barriers or facilitating factors. While qualitative studies, particularly those rooted in grounded theory, often are not immediately concerned with transferability, the mixed methods design of this study compels an acknowledgment of this limitation.

Additionally, sampling bias may inherently impact these findings. Despite a diligent effort to recruit women from the population in a variety of settings including health centers, WIC agencies, and obstetric offices, the majority of study participants were involved in a prenatal support program. Difficulty recruiting African American participants has been previously documented, particularly in studies focusing on medical and health issues (Shavers, Lynch, & Burmeister, 2002). In this study, participants who also attended the prenatal program may have increased knowledge about the benefits of breastfeeding and/or may feel more or differently supported in their decision to breastfeed than women in the general public. Through the design of this study, specifically Phase 2A, whereby national scholars and practitioners validated the items generated in Phase 1, efforts have been made to minimize both the transferability and sampling bias errors.

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Finally, it is important to acknowledge that women in this study were engaged for

a relatively brief period; group model building sessions sometimes occur in multiple

sessions across much longer stretches of time. In consideration of the difficulty engaging

this population, and challenges retaining them for a significant amount of time, it was

determined a priori that this longitudinal engagement period was not feasible. Although

it is always possible that new insights could have emerged if participants attended a more extended modeling session, participants in each group indicated that they felt both the factors and the model were exhaustive.

These limitations are not only limitations of this study, but represent a broader

source of tension between studies applying grounded theory methodologies and those

employing critical theory (Gibson, 2007). This study is predicated on the idea that women are the experts of their own lived experiences, and that their reflections on their culture serve as the true representation of that reality. In this regard, it runs the risk of applying a positivist stance. It is easy to concretize these findings as an objective representative of low-income, African American women’s reality, however that runs the risk of oversimplifying the experience of any individual woman nested in that community. In order to continue building on these findings, and in order to develop a more horizontally and vertically complex theory, additional grounded research is needed.

Future studies building off of these findings could further illuminate the breadth and

depth of low-income women’s breastfeeding beliefs and behaviors in African American

communities.

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Areas for further study. In light of the knowledge generated in Phase 1, the study made a substantial contribution to the research literature related to supportive factors and barriers to breastfeeding for low-income, African American women. In addition to these contributions, the study also generated ideas for several potential future research projects and interventions. Avenues for future research are discussed below, as

are some considerations for possible interventions.

Suggested interventions. One of the strengths of utilizing group model building

methodology is that it provides feedback regarding potential leverage points for change

(Meadows, 1997). The utilization of a social ecological framework to guide data

collection and interpret results provides some insight regarding how multi-level interventions could be targeted to impact a woman’s decision to breastfeed, and to help her be successful in doing so. This, in conjunction with the incorporation of an intersectional lens rooted in critical feminist theory, may result in the design of culturally responsive, and thus potentially more effective interventions.

One of the strengths of this study’s design is that it not only sought to identify barriers, but also factors that facilitate breastfeeding. Multi-level interventions must focus not only on removing barriers to breastfeeding, but also harnessing those supportive factors. Using the example of a woman who decides not to breastfeed because she is not comfortable breastfeeding in public, there are several possible interventions ranging from the individual to the macro level. On the individual level, lactation counselors could teach women techniques to breastfeed discretely, and they could empower them with knowledge about laws related to public breastfeeding, should they encounter public

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resistance. Breastfeeding women could also be equipped with messages to help them

articulate the importance of breastfeeding to others, in order to garner support for public

breastfeeding. This could be done in conjunction with a meso-level neighborhood intervention. Local businesses and community institutions (e.g. a library) could be provided with “breastfeeding friendly” signs to post in their windows, and employees could be educated about the importance of breastfeeding and a woman’s legal right to breastfeed. On the macro level, public health messages could be crafted to help normalize breastfeeding, and to work towards creating a more welcoming climate for breastfeeding.

Activists could advocate for policy change, in order to provide women with spaces to

breastfeed in public domains.

Phase 1 of this study generated a number of intervention suggestions. While some

of these interventions were introduced explicitly by the women themselves, others

emerged from the discussion of specific barriers or facilitating factors. This illuminates

the type of rich data that can emerge from studies employing participatory methods. The

women in this study demonstrated an individual and cultural self-awareness in

acknowledging the barriers and facilitating factors they face in breastfeeding. They also

revealed a degree of creativity in suggesting interventions as well as avenues for future

research.

Future research. As mentioned previously, in the move from qualitative data

collection to a quantitative assessment process, rich contextual data is often lost. The

design of this study was such that it generated a specific set of subcategories and factors,

for validation with breastfeeding scholars and practitioners. The model building process

108 was valuable as it contextualized the factors and themes, and provided a visual representation of the relationships among them. The model itself, however, was not being directly tested in this research study; this represents a significant arena for future research. The model building process employed herein aimed to document participants’ mental models of breastfeeding barriers and facilitating factors. Future research can focus on quantitatively testing this model and identifying critical leverage points for change, utilizing methods designed for simulation models.

This study also illuminated another arena where more research is needed; several groups identified a relationship between sexual abuse/trauma and willingness to breastfeed generally, and to put baby to breast more specifically. In consideration of the sensitive nature of this topic, a group setting is neither the most appropriate, nor the most effective environment for gathering data related to this connection. Additional research is needed on the prevalence of sexual abuse among this population, the most effective way to help a woman who have experienced sexual trauma cope, and ways to help support those women who wish to breastfeed.

In multiple instances participants offered up suggestions for breastfeeding interventions. These included developing educational programs tailored for individuals who support the mom (e.g. baby’s dad and maternal grandmother), creating programmatic efforts such as providing at-home breastfeeding support in the immediate postpartum period, and revisiting agency policies such as the provision of formula through WIC in the immediate postpartum period. Unprompted, women generated these solutions in response to some of the barriers that were identified. This illuminates an

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arena where future participatory action research could be conducted. More culturally

responsive interventions are needed in order to increase breastfeeding rates among this

population; a future study could focus on the direct engagement of women to design and

implement interventions dedicated to addressing breastfeeding barriers in their

communities.

Finally, this research process could benefit from geographic expansion and

additional theoretical sampling. Although there was variance in the women included in

this research, in order to truly build a more pluralistic foundation, additional research is

needed that focuses on specific subsets of low-income, African American women. An

African American woman who is low-income and working, for example, likely faces a different set of barriers than a woman who is low-income and not attending work or school. Similarly, a woman who is involved with the baby’s father may face different barriers than a single woman who is raising a baby without his support.

This particular phase of the overarching research project sought to identify specific barriers and facilitating factors related to breastfeeding among low-income,

African American women. After five group model building sessions, these factors emerged, as did the themes into which they were organized. This step was a critical component of developing the D-BAP, as its validity hinges upon the degree to which these factors represent the women’s lived experiences. Although future research can expand upon these, women in each model building session and in the final validation sessions felt the list was fully representative, and exhaustive. Thus these factors represent

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the items presented to experts in Phase 2A, for their input regarding the importance of each item for inclusion in the D-BAP.

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Chapter 4: Phases 2A and 2B Methods, Results, and Implications

The next step in the research process was to select a subset of the factors and

themes generated in Phase 1, for inclusion on the Q-sort cards. These cards then served as the foundation of the Dynamic Breastfeeding Assessment Process. In order to create these cards, experts first needed to evaluate these statements, which represents the primary research activity of Phase 2A. In Phase 2B, the assessment process was developed, administered and refined, for feasibility testing in Phase 3. Thus taken together, the activities in Phase 2 of this study were designed to answer the following research question:

What would an assessment process look like if it were informed by the

perspectives of the women as captured in the model building process?

This chapter will describe the methods used to develop and refine the D-BAP. This includes a description of the study participants, data collection procedures, and data analyses for both phases. The results and conclusions for Phase 2A and 2B will be discussed as well, to document the justification for decisions related to the development and testing of the D-BAP.

Phase 2A: Q-Sort Statement Selection

Methods. The Delphi method was used to assess experts’ opinions on the

statements that emerged from the final model generated in Phase 1. The Delphi method is

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a technique that elicits expert feedback by allowing each individual to weigh in on the

relative value of statements for inclusion in a survey or assessment (Landeta, 2006). Input

from the experts was used to determine the final selection of items for the Q-sort cards,

which constitutes the primary activity in the D-BAP.

Sampling and participant characteristics. In order to evaluate the drafted

statements, snowball sampling procedures were used to identify appropriate experts with

knowledge about, or experience working with low-income, African American women to address their breastfeeding goals (Worthington & Whittaker, 2006). Breastfeeding scholars and practitioners across the United States were directly contacted through an email recruitment message. Breastfeeding scholars were identified through manuscripts published in the last 10 years that focused specifically on breastfeeding beliefs and/or behaviors among low-income, African American women, or that assessed the effectiveness of breastfeeding interventions with this population. Breastfeeding practitioners were identified through online resources identifying WIC program directors, breastfeeding coordinators, and peer helpers. Other practitioners included in recruitment efforts were lactation counselors employed in hospitals located in urban, inner-city environments in Ohio, lactation counselors at children’s hospitals, and counselors who were members of the National Association of Professional and Peer Lactation Supporters of Color. Finally, individuals affiliated with organizations to increase breastfeeding among African American women were contacted, such as the Black Mothers

Breastfeeding Association (BMBFA) and Reaching our Sisters Everywhere (ROSE).

These scholars and practitioners were asked to identify others with expertise as well; five

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people provided additional names. A minimum of 25 respondents were initially sought,

as reliability has been established with this sample size (Akins, Tolson, & Cole, 2005).

The number of expert participants who responded to all items was 49 out of 165 contacted, which reflects an overall 29.69% response rate. Listwise data deletion was used for respondents who did not complete the rating. Among respondents, 22.45% self- identified as scholars (n = 11), 55.10% (n = 27) self-identified as practitioners, and

22.45% (n = 11) self-identified as both a scholar and a practitioner. Of the 165 people

originally contacted, five people declined to complete the survey citing reasons that

included time constraints, a lack of expertise related to the population, and preference for

working with researchers of color. All those who completed the process provided

consent, and were given the opportunity to enter into a drawing for a $25 Amazon gift

card, with 1 of every 4 respondents randomly selected to receive the incentive. Twenty

one women provided contact details for the raffle and five gift cards were distributed. All

procedures associated with Phase 2A were approved by The Ohio State University’s

Institutional Review Board for the protection of human subjects.

Respondents were asked to rank their level of expertise on a five point scale

ranging from no expertise to a high amount of expertise; overall, individuals indicated a

relatively high degree. Among the 49 scholars and practitioners, 4.08% (n = 2) indicated they had knowledge just below the average level, 26.53% (n = 13) felt they had an average amount of expertise, 44.90% (n = 22) indicated an above average level, and

24.49% (n = 12) stated they had a high amount of expertise. Individuals were also asked

about the length of time they had studied and/or worked with this population. The

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duration of respondents’ experience in working with African American mothers to

address breastfeeding needs ranged from 5 months to 40 years with a mean of 11.90 years

(SD = 9.31).

Data collection procedures. The factors and themes representing breastfeeding

barriers and supports generated during Phase 1 were compiled for expert evaluation. For

breastfeeding barriers, all factors identified by Phase 1 participants were included. For

factors that made breastfeeding easier all factors identified in Phase 1 also were included with the exception of items falling under two categories: Health Benefits for Baby and

Physical Benefits for Mom. Taking Health Benefits for Baby as an example, participants in several model building sessions listed a number of separate benefits for baby (e.g.

immunological benefits, reduced colic, etc.), however when they began constructing the

models, they always combined those benefits into an overarching theme titled something

along the lines of Health Benefits for Baby. Both co-facilitators felt that this semantic category represented a single theme as opposed to several individual factors. This was also true for Physical Benefits for Moms. Thus, in the final set of items evaluated by experts, the broader themes of Health Benefits for Baby and Physical Benefits for Mom were used instead of the individual factors appearing below them.

With all statements, the wording was modified as little as possible in order to keep the study grounded in the perspectives of the participants of Phase 1 (Saldaña,

2016). In some instances, however, supporting language was needed for elaboration or clarification. For example, one factor identified in Phase 1 by the women was “lazy”

(indicating that a mother may not choose to breastfeed because she was lazy). For the

115 experts’ feedback this item was reworded to state: “Breastfeeding takes a lot of work, I may feel lazy.” All statements were compiled into an item pool; breastfeeding support items presented to experts numbered 60, while 82 breastfeeding barrier items were identified.

The items were circulated to experts via Qualtrics, an internet-based survey program. Respondents were asked to rank the importance of each item for inclusion on a final set of cards numbering approximately 25, using a nine-point semantic differential scale ranging from least important to include to most important to include (DeVelis,

2011). Following each set of items (typically around 10 per page), the expert reviewers had an open text box in order to suggest any wording modifications. At the end of the complete set of barriers, and again following the complete set of facilitating factors, experts were asked to identify any items that were not included.

Data analysis. The mean scores for each factor and theme, transcripts from Phase

1, and relevant research literature constituted the sources of data that informed the selection of statements for the D-BAP cards. For the purposes of continuity and considering familiarity with the content, the co-facilitators from Phase 1, also referred to as the research team, made the final determination regarding content to include on the Q- sort cards.

Step one in this item-selection process involved calculating experts’ ratings of each factor and theme using mean scores. Once these means were documented, step two involved selecting a set of statements representing barriers to breastfeeding and a separate set of statements representing factors that made breastfeeding easier. The two co-

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facilitators worked independently on this first iteration of item selection, in order to

reduce bias and increase trustworthiness (Elo, Kaariainen, Kanste, Polkki, Utriainen, &

Kyngas, 2014; Gibson, 2007). In step three, following the independent item selection

process, we met to discuss our decisions, and collaboratively selected the final set of

statements to be included on cards for the D-BAP.

In the decision-making process regarding the final set of items, the mean score for

each item was reviewed with special attention to factors and themes with a rating above

the composite mean. Participants’ discussions during the group model building session

were also taken into consideration; model building transcripts were utilized for reference

when we had discordant recollections regarding the context or meaning of specific

statements. Finally, open-ended feedback from scholars and practitioners was reviewed;

consideration was given to comments and suggestions that substantively built upon

findings from the model building sessions or other published breastfeeding research.

During the item selection session, we decided that regardless of the mean score, at least one item per theme should be represented amongst the cards.

Results. Following the aforementioned steps, we were able to determine the ranking of each individual factor, as well as the computed mean of each theme. These data informed the statement selection process, and led to the development of a set of cards which represented factors that help facilitate breastfeeding and those that make breastfeeding more challenging.

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Item ranking. Statements were categorized by the theme they represent and a

mean score was calculated for each factor as well as for each theme. Rankings for each

theme as well as responses from open-ended questions are presented below.

Factors that make it easier to breastfeed. Regarding facilitators for breastfeeding, themes rated above the average item mean of 7.22 include Knowledge about How to

Breastfeed (M = 8.05), Support (M = 7.82), Patience/Persistence (M = 7.81), and

Knowledge about Why to Breastfeed including Benefits for Baby (M = 7.73) and

Benefits for Mother (M = 7.43). Under the Support theme, the ranking by support person

is as follows: Hospital Support, Baby’s Father, Woman’s Mother/Family, Peer, and

Agency/Programs. Table 5 provides the calculated means for all facilitating factors as

well as the organizational themes.

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Factor Themes and Factors M (SD) Knowledge about Why to Breastfeed - Benefits for Baby Knowing the health benefits of breastfeeding for baby 7.63 (1.60) Knowing the emotional benefits of breastfeeding for baby 7.71 (1.61) Knowing the mental benefits of breastfeeding for baby (intelligence, acceleration, etc.) 7.63 (1.58) Knowledge about Why to Breastfeed - Benefits for Mother Breastfeeding feels more natural 6.65 (2.08) Knowing the physical benefits of breastfeeding for me (weight loss, reduces cancer risk, etc.) 7.71 (1.56) Knowing the emotional benefits of breastfeeding for me (relaxing, stress relieving) 7.63 (1.51) Breastfeeding is cheaper 7.73 (1.50) Support 119 Baby’s Father

Getting physical support from my baby’s father (getting pillows, snacks, etc.) 7.76 (1.61) Getting emotional support from my baby’s father 8.08 (1.35) Peer Getting support from peers/friends 8.18 (1.11) Joining support groups 7.24 (1.61)

Continued

Table 5. Experts' rankings of themes and factors that facilitate breastfeeding (n=49)

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Table 5 continued

Factor Themes and Factors M (SD) Woman’s mother/family My mother's support 7.96 (1.21) My family's support 7.96 (1.35) Knowing breastfeeding is accepted and practiced in my family 7.43 (1.57) Agency/Programs Support from WIC 8.00 (1.34) Support from community programs 7.39 (1.51) Hospital support

120 Knowing the hospital supports breastfeeding 7.61 (1.67)

Support from the hospital when I give birth (from nurses, lactation counselors, etc.) 8.37 (1.09) Social Acceptance Social acceptance of breastfeeding 7.84 (1.65) Getting praise for breastfeeding 7.02 (1.94) Knowing where to breastfeed baby in public (nursing rooms) 7.00 (1.85) Having a place to breastfeed or pump at work/school 7.64 (1.70) Being comfortable breastfeeding in public 7.43 (1.75) Feeling that breastfeeding is accepted by my religion 6.02 (2.37) Breastfeeding is a trend and is now more accepted 6.39 (2.10) Feeling that breastfeeding is accepted at work/school 7.23 (1.66) Knowing other people/groups on Facebook/social media who are supportive of breastfeeding 7.37 (1.80)

Continued

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Table 5 continued

Factor Themes and Factors M (SD) Convenience Breastfeeding seems convenient 7.08 (1.61) Baby's food is always with me 6.90 (1.90) Milk is always at the proper temperature 6.69 (2.04) Baby may sleep longer 6.45 (2.42) Breastfeeding is more convenient at night 7.43 (1.76) Don't have to measure formula 5.82 (2.52) Don’t have to make/wash bottles 6.35 (2.15)

121 Diaper bag is lighter 5.18 (2.36) Breastfeeding can help me manage time better 6.12 (2.25) Patience/Persistence Determination to breastfeed 7.98 (1.52) Patience with breastfeeding 7.61 (1.89) Self-esteem in breastfeeding 7.86 (1.64) Confidence in breastfeeding 8.07 (1.41) Persistence in breastfeeding 7.70 (1.66) Having a positive attitude towards breastfeeding 7.73 (1.71) Openness to trying out breastfeeding 7.66 (1.77)

Continued

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Table 5 continued

Factor Themes and Factors M (SD) Knowledge about How to Breastfeed Having knowledge about why to breastfeed 8.02 (1.25) Getting breastfeeding information from WIC 7.86 (1.31) Getting breastfeeding information from community programs 7.61 (1.63) Knowing where to go for breastfeeding questions 8.45 (1.02) Having information about how to breastfeed (getting a good latch, troubleshooting, etc.) 8.49 (1.00) Having knowledge about breastfeeding benefits 7.86 (1.59) Supplies/Tools Having the right materials (nipple shields, breastfeeding covers, nursing bras, etc.) 4.96 (2.49) 122 Having a pump 5.63 (2.60) Knowing how to hand express milk 6.63 (2.33) Emotional Benefits/Bonding Bonding with my baby 7.96 (1.31) Feeling needed/wanted/valued 7.18 (1.91) Getting alone time with the baby 6.57 (2.07) Breastfeeding can be fun 6.00 (2.15) Breastfeeding can be empowering 7.53 (1.52) Being skin to skin with my baby 7.47 (1.77) Pumping Pumping makes breastfeeding easier 4.90 (2.44) Pumping is more socially acceptable than putting baby to breast 3.96 (2.29) Overall Mean 7.22 (0.91)

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Respondents provided some language modifications to the items, such as

amending Feeling Wanted/Needed to Feeling Wanted/Needed by Your Child. Research

participants in Phase 2A also provided some suggestions regarding factors that they felt

were omitted. These included a focus on mom’s overall mental health status, a general

sense of self-efficacy on the part of the mother (beyond breastfeeding self-efficacy), and access to hospital-grade breast pumps. One respondent also suggested that a women may be successful in meeting their breastfeeding goals because she “knows she has a voice in something she believes in; she has a platform to encourage other African American women.”

Factors that make breastfeeding more challenging. The overall item mean for breastfeeding barriers was 6.10. The themes that are rated higher than this measure of central tendency included: Returning to Work or School (M = 7.29); Physical Barriers to

Breastfeeding (M = 7.20); Lack of Support (M = 6.85); Lack of Breastfeeding Knowledge

(M = 6.81); Pumping (M = 6.73); Cultural Beliefs (M = 6.65); Discomfort Breastfeeding

in Public/Around Others (M = 6.45); Baby’s Dependence on Mom (M = 6.22); and

Inconvenience (M = 6.15). The theme Support also includes the following sources of

breastfeeding support, ranging from highest rated to lowest: Professional, Baby’s Father,

Peer/Friends, Institutional, and Mother/Family. Table 6 provides the calculated means for the factors and overarching themes representing barriers to breastfeeding.

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Factor Themes and Factors M (SD) Lack of Support Breastfeeding is not accepted by my religion 4.66 (2.90) Peers/friends don't support 7.07 (2.11) Society doesn't accept it 6.32 (2.24) Overall lack of support 7.84 (1.36) Lack of professional support Getting different messages from different medical providers 7.68 (1.58) Medical providers put baby on formula 8.11 (1.21) Doctors aren't educated about breastfeeding 7.16 (2.34) Lack of institutional support 124 No postpartum classes for breastfeeding 6.82 (2.31) Lack of services for breastfeeding support 7.16 (1.95) People are generally negative about breastfeeding 6.32 (2.49) My baby's dad doesn't support breastfeeding 7.55 (2.03) Mother/Family My mother didn’t breastfeed 7.09 (2.31) I don't know how to talk to friends/family about breastfeeding 6.36 (2.33)

Continued

Table 6. Experts' rankings of themes and factors that make breastfeeding more challenging (n=49)

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Table 6 continued

Factor Themes and Factors M (SD) Emotional Barriers Can be stressful 5.05 (2.56) Breastfeeding takes a lot of work, I may feel lazy 4.50 (2.67) Lack of patience to breastfeed 5.43 (2.81) Losing interest in breastfeeding 4.98 (2.72) Overall negative attitude towards breastfeeding 5.84 (2.82) Breastfeeding takes a lot of work 5.66 (2.95) Postpartum depression 6.55 (2.49) 125 133 126 It may feel weird or seem nasty 6.25 (2.47)

My breasts are mine (not baby's) 5.45 (2.66) Discomfort Breastfeeding in Public/Around Others Fear of breastfeeding in public 6.93 (1.88) Fear of perverts staring at my breasts if I'm breastfeeding in public 5.95 (2.44) Discomfort breastfeeding/pumping around others 6.50 (2.12) No privacy to breastfeed/pump if living with others or in a shelter 6.95 (2.20) Feel embarrassed about breastfeeding 7.25 (1.96) Privacy is hard when my baby is distracted 5.57 (2.63) Breastfeeding is less acceptable the older baby gets 6.45 (2.33) Larger breasts 5.66 (2.36) Controversy about breastfeeding in public 6.30 (2.12)

Continued

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Table 6 continued

Factor Themes and Factors M (SD) Baby's Dependence on Mom Breastfeeding makes baby too attached to me 6.07 (2.66) Father wants to be involved with feeding/bonding 6.86 (2.06) Breastfeeding spoils the baby 6.27 (2.59) Other people can't feed my baby 6.48 (2.45) Breastfeeding makes it hard to leave my baby with others 6.27 (2.64) Being a pacifier for baby 6.05 (2.42) Breastfeeding baby always wants my attention 5.91 (2.50) Breastfeeding baby doesn't want to sleep away from me 5.93 (2.51) Physical Barriers to Breastfeeding Breastfeeding is painful 7.59 (2.03) Breastfeeding is uncomfortable 7.25 (2.24) Baby may bite while breastfeeding 7.32 (1.67) Breastfeeding is harder with a c-section recovery 6.55 (2.17) Concern about low milk supply/production 7.98 (1.59) Unable to breastfeed for medical reasons (aids, breast cancer, breast reduction) 6.86 (2.33) Concerns about my breast structure, size, or shape 6.84 (2.12)

Continued

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Table 6 continued

Factor Themes and Factors M (SD) Sexualization of Breasts Breasts are sexual 6.16 (2.77) My breasts are my boyfriend's (not my baby's) 6.18 (2.83) My history of sexual trauma 7.09 (1.96) Feels like breastfeeding is sexually molesting my baby 5.23 (3.14) Feels weird breastfeeding a male baby 5.43 (3.08) Fear that breastfeeding will turn my baby gay 4.93 (3.20) Impact of Breastfeeding on Mom's Lifestyle

127 Breastfeeding limits socializing 4.32 (2.58)

Breastfeeding means I can't party 5.07 (2.78) Feel like I can't drink if I breastfeed 5.80 (2.79) Feel like I can't smoke if I breastfeed 5.57 (2.90) Feel like I can't do drugs if I breastfeed 5.16 (3.00) I may get less sleep if breastfeeding 6.00 (2.06) Lack of Breastfeeding Knowledge I didn't get education about breastfeeding earlier in life (e.g. high school child care classes) 5.93 (2.49) Don't know how to breastfeed (how to get a good latch, how many feedings a day, etc.) 7.82 (1.44) Don't know the benefits of breastfeeding (for me or my baby) 6.68 (2.35)

Continued

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Table 6 continued

Factor Themes and Factors M (SD) Pumping Having to pump 6.59 (2.23) Low supply when pumping 7.14 (1.79) Pumping is time consuming 6.98 (1.99) Pump is hard to get 6.11 (2.34) Time Consuming Breastfeeding is time consuming 5.50 (2.80) 128 Breastfeeding is difficult with a busy schedule/life 5.68 (2.75)

Breastfeeding is harder without help for my other kids 5.27 (2.72) Breastfeeding takes time away from my partner 4.89 (2.86) Breastfeeding is exhausting 4.93 (2.53) Cultural Beliefs Lack of cultural support 7.27 (2.04) Lack of cultural knowledge 7.34 (1.89) People in the Black community don't expect women to breastfeed 6.68 (2.16) The history of breastfeeding during slavery 5.36 (2.52) Concerns about Impact on Mother's Body Causes me to gain weight/be hungry 3.39 (2.30) Causes my breasts to look different/be saggy 4.20 (2.97) Decreases libido 3.57 (2.26)

Continued

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Table 6 continued

Factor Themes and Factors M (SD) Returning to Work or School Going back to work or school 8.00 (1.55) Putting my baby in daycare 6.55 (2.22) Inconvenience Breastfeeding is inconvenient 5.84 (2.77) Breastfed babies wake more frequently 6.23 (2.65) WIC giving out free formula makes it easier to just formula feed 6.25 (2.77)

129 Overall Mean 6.10 (1.37)

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Experts also provided minor modifications to the wording of a few of the

statements. For example, one revisions included changing the factor Breasts are Sexual to

read Breasts are for Sex. Additionally, a number of additions were proposed to the factors representing barriers to breastfeeding. These include: comfort and familiarity with formula, low overall self-efficacy, fear of doing something different, fear of not having

enough milk, baby has medical problems, no place to pump at work, and fear of violence.

Finally, one expert weighed in with a reaction to the barriers presented, and provided the

following response:

Most of these items are myths or misconceptions. Breastfeeding education of

mother, intimate partner and supporting family. Grandmothers especially need

education because HTR [Historical Trauma Response]. They are the matriarchs...

old wives tells and stories cause fear. Such as "doctors (ob/gyn) have always

experimented on Black people. Don't listen to what they tell you."

This open-ended input, as well as the quantitative data provided by scholars and

practitioners, was considered alongside the qualitative data gathered in Phase 1. The

research team then selected a series of factors and themes to be included on the Q-sort cards, which constitutes the primary activity in the D-BAP. This process is described

below.

Card selection. Although the final number of statements was not predetermined,

an effort was made to keep the number of cards to a manageable number for use in

practice (approximately 25), while still being as inclusive and comprehensive as possible.

Recommendations for the number of Q-sort cards typically range from 40-90, however

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researchers have demonstrated the effectiveness of using as few as 25 Q-sort cards (Watts

& Stenner, 2012). For the purposes of this study, a deliberate emphasis was placed on

parsimony due to the limited time a lactation counselor has to work with a woman, and to

leave more time for the interactive and personalized nature of the assessment process.

Q-sort cards were comprised of a statement paired with an image representing

each concept. An effort was made to select images that featured women and children of

color. The purpose of the card format was twofold; first, the cards may have been better

received by individuals who had different perceptual learning and information processing

styles when a pictorial representation was included (Dunn, Griggs, Olson, Beasley, &

Gorman, 1995). Additionally, including a visual marker may have helped individuals

with limited literacy skills (Houts, Doak, Doak, & Loscalzo, 2006). The final cards, each

measuring 4x7 inches, were printed on cardstock and laminated. A background color was

applied to the set of barriers (grey) and the facilitating factors (blue), to distinguish each set.

The first step in this process was to select the statements to appear on each card.

Through the aforementioned analysis process, the research team met to collaboratively achieve this. It was during this discussion that the treatment of two separate categories arose - Returning to Work or School, and Pumping. One team member suggested that items under these themes should be presented only if those cards were relevant to a woman, i.e. if she was planning on returning to work or school and/or planning to pump.

This option was problematic as a woman’s decision about either of these categories may influence or be influenced by her decision to breastfeed, warranting a discussion with a

131 lactation counselor. For example, a woman may indicate that she is not planning to return to work or school because she does not think it is compatible with breastfeeding. If she is presented with a card and this prompts discussion, however, the lactation counselor may help her explore ways it is feasible to continue breastfeeding upon returning to work or school. Conversely, if this set of cards is not available to her, the effectiveness of the D-

BAP may be limited.

The research team wrestled with different ways these two categories (Returning to

Work or School and Pumping) could be handled, including procedural processes during the assessment process or through card content. After in-depth discussion, an idea arose that multiple, related factors could be collapsed onto a single card, with the overarching theme serving as the unifying heading. A check box was presented next to each factor, so that a woman could select one or more of the factors if the overarching theme pertained to her. This addressed the tension of ensuring the factors on the cards were as comprehensive as possible, while simultaneously being conservative with the number of individual cards a woman had to sort. Once this revised format was agreed upon, additional themes and factors were revisited to determine how this structure could be applied to maximize choices for the participant while minimizing time spent reviewing and sorting cards. On several barrier and facilitator cards, this format was applied. The final statement selection, with the aforementioned formatting schema applied, resulted in eleven facilitating factor cards and fifteen barrier cards.

In consideration of the utilization of grounded theory, and the challenges associated with moving a study from the qualitative realm to the quantitative, every effort

132

was made to be transparent about how the cards were chosen. The following section

discusses that selection process in detail, including how qualitative input from Phase 1

and the quantitative input from Phase 2A was weighed in the case of each of cards. For

ease of reference, each card is presented in the text following the discussion of how it

was selected.

Factors that make it easier to breastfeed. Beginning with the Support theme, all

of the themes listed under the overarching factor were reviewed. Among those, a

distinction was made between two types of support. The first was support from hospital

staff, and the second was support from a range of sources including individuals and

community agencies. We determined that support from hospital staff is conceptually

distinct from other sources of support. Hospital support is offered in a time-restricted environment, and in light of the importance of early breastfeeding initiation, a woman’s entire breastfeeding relationship can hinge on the availability and quality of lactation

support in the hospital. In Phase 1, participants spoke at length about their hospital

experiences with nurses and lactation counselors, and the critical role they played in

establishing breastfeeding. Hospital support was also ranked relatively highly by experts.

Compared to support from hospital staff, support from the other sources represents

ongoing sources of support. This may include individuals, such as the baby’s father, or

community agencies and organizations. This general support card was selected for the

multi-choice design, offering a woman the option to indicate the sources of support that

are specific to her and her situation.

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Figure 3. Sources of support card

Several cards presented factors related to breastfeeding knowledge including

Knowing Where to Go for Breastfeeding Questions, Having Information about How to

Breastfeed, and Knowing the Benefits of Breastfeeding for Baby and Me. These statements were included on cards as they were ranked above the mean and were representative of overarching themes.

134

Figure 4. Breastfeeding knowledge cards 135

Although Having Supplies/Materials Needed to Breastfeed was rated relatively

low by experts, it was included as it was a theme frequently mentioned by the participants

in Phase 1, and the content was not included on any other card.

Figure 5. Supplies card

Under the theme Social Acceptance, two of the highest rated factors were Being

Comfortable Breastfeeding around Others and Social Acceptance of Breastfeeding. Of these two, the research team felt that Being Comfortable Breastfeeding around Others encapsulated both and was worded in a way that a woman may find more relevant and 136 applicable. Of the two, Being Comfortable Breastfeeding around Others asks the woman to consider her own internal comfort level as opposed to providing an external evaluation of the broader social climate related to breastfeeding.

Figure 6. Comfort breastfeeding card

Bonding with My Baby was the only factor under Emotional Benefits/Bonding that was above the item mean. Bonding was also consistently emphasized in women’s narratives related to the benefits of breastfeeding, and it was the factor most frequently selected by the Phase 1 participants as being among the top 3 in the stars activity. Thus one card was selected to represent Bonding. 137

Figure 7. Bonding card

Although several factors were listed under the theme Convenience, only

Convenient at Night was rated above the item mean. Nevertheless there was a concern that limiting the card to overnight convenience was too narrow. Thus the language was revised to Breastfeeding Seems More Convenient, Especially at Night to be inclusive of overall convenience, while still acknowledging the convenience of breastfeeding at night.

138

Figure 8. Convenience card

The My Resilience card underwent the most dramatic changes from the original factorial and thematic organization emerging from the group model building sessions and the experts’ rankings. This revision was justified by the use of the constant comparative

method employed by grounded theory; as new information is received, the data may be

recoded to accommodate it, as necessary (Charmaz, 2014). In Phase 2A, one expert

provided feedback about a woman’s choice to breastfeed, and how that might be driven

by a desire to empower other African American women. This prompted an in-depth

exploration to determine how this concept could be incorporated. The focus group

transcripts and the variables and themes were revisited and the research team determined 139

that a theme encapsulating a woman’s intrinsic motivation to breastfeed could be better constructed. The factors categorized under Patience/Persistence seemed closely aligned with this theme. Those included: Confidence, Determination, Self-Esteem, Persistence,

Positive Attitude, and Openness to Trying out Breastfeeding. Of these, Determination and

Confidence were the highest ranked factors, thus they were selected for inclusion on a card. In addition, Mom’s Empowerment to Breastfeed seemed applicable. This variable was originally categorized under Emotional Benefits/Bonding. These factors were added to the My Resilience card, in addition to a new factor suggested by one of the experts which was worded My Breastfeeding Encourages Other African American Women to

Breastfeed.

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Figure 9. Resilience card

In both the model building and model validation sessions in Phase 1, Returning to

Work or School and Pumping were two topics that generated the most discussion. Using pumping as an example, some felt that pumping allowed more women to breastfeed as it provided a means through which a mother could provide her baby breast milk, without having to put baby to breast. It also allows other people to help feed the baby, thereby potentially increasing support. Others argued that pumping inherently had an overall negative impact on breastfeeding as most women who express breast milk experience decreased milk supply. The discussion concerning pumping inevitably steered the conversation towards workplace accommodations for pumping, and the impact that had on breastfeeding. Thus the two cards capturing work related issues and pumping required much in-depth discussion to finalize.

The theme Pumping had a very low expert rating (M = 4.36), as did the two factors below it (Pumping makes Breastfeeding Easier, and Pumping is more Socially

Acceptable than Putting Baby to Breast). Upon review of this theme, the research team agreed that it was incomplete. The research team revisited the transcripts and realized the utility of pumping so that the woman to return to work or school while still breastfeeding was not captured, nor was the benefit of pumping so that other people could feed the baby. Thus these two factors were included as checkboxes on the card, as was the original factor, Pumping Makes Breastfeeding Easier. An open-ended checkbox labeled

Other was included so that participants could write in any other factor related to pumping. This was included due to the conceptual complexity of the theme.

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Figure 10. Pumping card

This review of the theme Pumping led the research team to revisit statements related to a woman’s return to work or school as well. Two items previously sorted under

Convenience were applicable to this theme, and both were rated above the overall factor mean. These included Having a Place to Breastfeed or Pump at Work/School and Feeling that Breastfeeding is Accepted at Work/School. The wording of these two statements was abbreviated and pulled out for inclusion on to their own card titled

Breastfeeding/Pumping at Work or School. 142

Figure 11. Breastfeeding at work/school card

In the final set of Q-sort cards, a blank card was created, allowing each woman to

write in specific factors that may not have been included. Although every effort was

made to ensure this was a grounded research study, inevitably some common factors may

have been overlooked, or alternatively, individuals may have factors that are unique to

them. This card provided women with the flexibility of ensuring their own individual factors were captured and they were incorporated in the individually-tailored D-BAP.

143

Figure 12. Open-ended card

Factors that make it breastfeeding more challenging. Once all of the facilitating factor cards were selected, the research team used the same process to select statements for the barrier cards. The following represents the processes of selecting the fifteen barrier cards. Again, every effort was made to stay true to the wording of the original factors and themes, while also incorporating the expertise of Phase 2A participants, and new insights generated from the research process.

Going Back to Work or School was the highest rated factor that experts asserted made breastfeeding more challenging, thus this constituted one card. This is inherently tied to pumping, although pumping remains a separate theme and therefore a separate 144

card. On the Pumping card, separate factors with checkboxes include Where to Pump at

Work/School, Milk Supply, and Getting a Pump.

Figure 13. Going back to work/school and pumping cards

All of the items under the theme Breastfeeding Is Time Consuming were ranked relatively low, however for the purposes of having thematic representation, they were included on a card.

145

Figure 14. Time consuming card

Under the theme Physical Barriers to Breastfeeding, mean scores demonstrated scholars’ and practitioners’ relatively high valuation of Concern about Low Supply and

Milk Production; therefore this statement was selected for inclusion on a card. Under this same theme two separate factors - Breastfeeding is Painful and Breastfeeding is

Uncomfortable were also highly rated. These were determined to be constitutionally similar, thus they were combined onto one card titled Breastfeeding is Painful or

Uncomfortable.

146

Figure 15. Low supply and painful cards

Under the theme Lack of Breastfeeding Knowledge, the highest ranked factor was

I Don’t Know How to Breastfeed, and we felt this was representative of the overarching

theme, thus it was selected to appear on a card.

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Figure 16. Don't know how to breastfeed card

Similar to the Support card in facilitating factors, the Lack of Support card also was organized with specific check-boxes including Baby’s Dad, my Mom/Other Family,

Friends, and Medical Providers/Hospital Personnel.

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Figure 17. Lack of support card

Related to medical providers, two of the highest ranked factors in the support

theme were related to specific actions and interactions between the breastfeeding woman

and the medical provider. These were Medical Providers Putting Baby on Formula and

Getting Different Messages from Different Medical Providers. Given the specificity of

these it was determined that the nuance would be lost under the general banner of

Support, thus a new theme emerged and the card was titled The Role of the Medical

Provider, with the two aforementioned factors listed with checkboxes.

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Figure 18. Role of medical provider card

One of the reasons that participants discussed a lack of support was due to other people’s perceptions that they could not participate in the feeding of, or bonding with baby. This was the highest ranked factor under the theme Baby’s Dependence on Mom, thus it was selected as an individual card.

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Figure 19. Others feeding card

As mentioned, breastfeeding also limits a woman’s opportunities for socializing including both spending time with friends away from baby, and using tobacco, alcohol, or other drugs. The research team discussed at length, how this theme should be translated on to the cards. While theoretically it seemed that each factor could stand on its own, in

practice there was concern that women would not select a card disclosing their use of drugs or alcohol. Mothers would likely be hesitant to disclose this type of information as

it can have implications for the involvement of children’s services. The African

American co-facilitator suggested the consolidation of these factors onto one card so that

clinically, it opens space for a conversation. If the woman leads with a discussion of the 151

impact of breastfeeding on her social life, the facilitator can use this as a leverage point to

explore what the individual means by socializing, and the implications this may have on

breastfeeding. Certainly arguments can be made that theoretically these factors should be

presented on separate cards, however for the purpose of the initial testing of the D-BAP,

the assessment process would be administered by an individual the woman was not

familiar with. Thus all factors were placed on one card titled Breastfeeding Means I Can’t

Go Out, and in parenthesis the modifiers included: meet up with friends, smoke, drink, or do drugs.

Figure 20. Socializing card

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Another factor which represents a sensitive topic is a woman’s experience of

physical or sexual trauma. This was the highest ranked factor under Sexualization of

Breasts and it has important implications for a woman’s breastfeeding behavior, thus it

constituted one card titled My History of Sexual Trauma.

Figure 21. Sexual trauma card

Considering the specificity of this theme, it was determined that an overarching factor related to the sexualization of breasts should be available on a card as well. In the open text field on the experts’ ranking, one respondent commented that Breasts Are for

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Sex was more concise than the Sexualization of Breasts. Upon review we concurred, and this language was utilized.

Figure 22. Sexualization of breasts card

The theme Discomfort Breastfeeding in Public/Around Others was reviewed and the two highest ranked factors under this theme included Fear of Breastfeeding in Public and Feel Embarrassed about Breastfeeding. We explored the overarching wording of this theme, and felt that it could be more inclusive to incorporate a woman’s overall emotional discomfort with breastfeeding. As other factors were reviewed, a factor previously sorted under Emotional Barriers was revisited. This was the statement It May 154

Feel Weird or Seem Nasty. We determined that this was also related to a woman’s

discomfort with breastfeeding. Thus this statement was incorporated onto this card

through the checkbox format, with an overarching title Feeling Uncomfortable about

Breastfeeding.

Figure 23. Uncomfortable about breastfeeding card

The Cultural Beliefs theme underwent in-depth examination as the research team

acknowledged that this was one of the most complex themes and necessitated careful

consideration. Under this theme, Lack of Cultural Support and Lack of Cultural

Knowledge were the two highest rated factors. Although The History of Breastfeeding 155

During Slavery was rated the lowest among the factors in this theme, in light of the depth to which group participants felt affected by this, we felt that it was important to include.

In addition to these items, which were extracted directly from the group model building sessions, we discussed at length, the open-ended comment related to the pervasiveness of breastfeeding myths and misconceptions in the Black community. We recognized the ways that these old wives tales were intertwined throughout the group model building sessions, without being explicitly named. Thus, again utilizing the constant comparison method of grounded theory, we chose to include this as a checkbox item on the Cultural

Beliefs card.

Figure 24 . Cultural beliefs card

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The final barrier card which also emerged as a part of the constant comparison

method was a card titled Formula. One expert in Phase 2A suggested the addition of

Comfort and Familiarity with Formula. This is supported by research demonstrating a woman’s comfort with formula as the factor most closely associated with her intent to breastfeed (Nommsen-Rivers et al., 2009). Thus considering this open-ended input and corroboration from the research literature, it was determined that it should be included on a card. Upon review, it was determined that another factor was related to this; the factor sorted under Inconvenience originally called WIC Giving Out Free Formula Makes It

Easier to Just Formula Feed also referenced the role of formula in a woman’s breastfeeding success. This wording was unnecessarily complex, however, as indicated

by input from several experts. One respondent suggested “Formula is easy to get through

WIC,” and that language was adopted. These two items were included with checkboxes

on the card titled Formula.

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Figure 25. Formula card

Finally, as was the case with the facilitating factor cards, a blank card was included in the set of barriers so that participants could write in a barrier that was unique

to them, and specific to their own set of circumstances.

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Figure 26. Open-ended barrier card

Discussion. Phase 2A represented the nexus at which the findings from the qualitative research were translated into statements quantitatively evaluated by experts. It is through this process of condensing the full set of factors and making modifications to the wording, that the grounded nature of the research had the potential to be compromised. Nuances of the qualitative data are inherently lost in distilling over 10 hours of focus groups into a set of 26 statements. Nevertheless this process was necessary in order to identify a concise set of statements most applicable to low-income, African

American women, as it relates to their barriers and facilitating factors related to breastfeeding. 159

The purpose of having experts rank each statement was to identify those factors

and themes most relevant to the broadest audience, however the rankings themselves

illuminated interesting trends. In review of the factors and themes as rated by

breastfeeding scholars and practitioners, for example, it is interesting to note that overall, the mean of facilitating factors and themes were higher than barriers. The experts engaged in this study recognized the importance of these supportive features, yet

frequently breastfeeding interventions are focused on providing education and support, with the implicit assumption that these represent deficits in the women’s lives.

Interventions typically do not contain a component recognizing existing sources of strength among the women (Chapman & Pérez-Escamilla, 2012). This represents a compelling finding where more attention in intervention development is needed.

It is also worth noting that the barriers with the highest thematic mean were those representing macro and meso-level factors (e.g. Lack of Professional Support and

Returning to Work or School). Experts who participated in this study may have been acutely aware of some of the intractable, institutional, and policy-level forces that interfere with breastfeeding. One example is the fewer maternity care practices that support breastfeeding in hospitals located in neighborhoods with a higher percentage of

African Americans, as compared to hospitals in predominantly White neighborhoods

(Lind, Perrine, Li, Scanlon, & Grummer-Strawn, 2014). Abysmal maternity leave laws and policies that disproportionately disadvantage low-wage workers provides another example (Fass, 2009). These findings, especially in light of similar findings from Phase

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1, suggest a need for increased understanding of the macro and meso-level forces which contribute to breastfeeding disparities.

Overall, participants in Phase 2A were able to provide substantive feedback on the importance of various facilitators and barriers to breastfeeding. The contributions they made, not only by rating each item but also through substantive open-ended input, were critical in moving this study from the qualitative realm to the quantitative. The insights they shared, particularly around breastfeeding as an act of empowerment and the pervasive role of breastfeeding myths and old wives’ tales, suggest a need for more in- depth engagement of lactation specialists. Certainly the women themselves are the best experts in their own lived breastfeeding experiences, however the practitioners that work with these women around breastfeeding become story keepers, with cumulative, collective knowledge. Breastfeeding scholars can lend their own expertise to this arena as well; some may have a comprehensive grasp on what has been published regarding this population as well as any theoretical or methodological gaps. Based upon a review of the literature, both breastfeeding scholars and lactation specialists are a largely untapped resource of knowledge and expertise.

Conclusions and recommendations. An inherent tension is present in any grounded study, and any research utilizing this theory must be prepared to answer “in whose worldview is this study grounded?” The approach to grounded theory utilized in this study asserts that it is impossible to design and conduct a research study entirely outside of the worldview of the researcher. Nevertheless, decentering myself in the research process, to the extent possible, remains a paramount priority.

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The incorporation of scholars’ expertise as well as the selection of final

statements by the co-facilitators could be perceived by some as inherently undermining

the grounded foundation of the study that was established in Phase 1. Nevertheless it was

determined a priori that scholars and practitioners could make a substantive contribution to that data generated by pregnant and postpartum women, thus the challenge was to

design a way for that contribution to be incorporated, while still prioritizing the perspectives of the women. One of the limitations of this expert validation, however, was that the race of the respondent was not collected. Considering the relatively small number of peer helpers and scholars working with, or conducting research focused on breastfeeding among African American women, there was a concern that respondents may not answer honestly if they felt they could be identified. The respondent’s race may be relevant, and their perspectives may be shaped by their own racialized worldview, however, which may have impacted their responses.

Another limitation of Phase 2A is the loss of complexity of the rich data collected in Phase 1. Following Phase 1, 10 themes emerged as facilitators to breastfeeding and 14 themes were identified as barriers to breastfeeding; organized under these, over 160 individual factors were collected. For the purposes of the Dynamic Breastfeeding

Assessment Process, these were distilled into 26 statements. In this transmission, much of the complexity of the data is collapsed, and nuances are inevitably lost. Part of the richness of the data generated in Phase 1 comes from the grounding of each individual factor in personal stories and experiences. Certainly the theme Pumping can never encapsulate the embarrassment one woman felt when trying to pump breast milk while

162 living in a homeless shelter, or another woman’s experience as a server, crouching on the bathroom floor hurriedly trying to manually express breast milk between waiting tables.

The purpose of this process, however, was to move from the theoretical to the applied with the development of a breastfeeding assessment activity. In an attempt to account for the loss of complexity, the D-BAP was designed with an aim of flexibility, in order to be responsive to a woman’s lived experiences.

As this study moves from these complex, intensely personal stories into an assessment process with only 26 statements, a rich trove of data remains that can further inform future breastfeeding research as well as the actions of practitioners. Phase 1 generated lists of these complex forces on breastfeeding decision-making and behavior and the connections between them; Phase 2A has produced a quantitative measure of those factors, as they are understood by breastfeeding scholars and lactation specialists.

Phase 2A has also demonstrated the collective wisdom of these experts. The input provided through the open-ended text fields demonstrated participants’ familiarity with some of the overarching forces impacting breastfeeding beliefs and behavior among low- income, African American women. Future research can build upon these findings, and scholars and practitioners can be more extensively engaged. Thus through this research, and the studies that can build off of this knowledge, a more comprehensive understanding of the causes and consequences of low breastfeeding rates among African American can be developed.

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Phase 2B: Refining the Dynamic Breastfeeding Assessment Process

Methods. Once the final set of cards was selected, the next step was to refine the

Dynamic Breastfeeding Assessment Process. The D-BAP represented the convergence of

the culturally grounded data from Phase 1, and the expert validation and statement

selection from Phase 2A, into a prenatal breastfeeding activity for low-income, African

American women. The D-BAP was designed to help a woman identify her own unique

barriers and supportive factors for breastfeeding through a sort and rank activity, and a

processing component that draws upon motivational interviewing techniques. The D-

BAP, which was designed for administration by a lactation specialist (peer helper,

lactation counselor, or lactation consultant), seeks to empower a woman to meet her own

breastfeeding goals. For the full D-BAP protocol, see Table 7.

D-BAP Administration Step Instructions 1. Introduction Welcome the woman and introduce yourself.

2. Consent the participant Administer the research consent, highlight the risks and benefits of participation.

3. Describe the purpose of the study Explain that the purpose today is to conduct an activity that is designed to help

women identify barriers to and supports for breastfeeding. We want to learn more about how women experience this activity so that we can improve it. In order to do this we need open and honest feedback about what the experience was like. Outline the activities the participant is expected to complete. Continued

Table 7. Phase 2B and Phase 3 D-BAP protocol

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Table 7 continued

D-BAP Administration Step Instructions Demographics Form 4. Administer form(s) Infant Feeding Intentions Scale pre-test (Phase 3 only) Breastfeeding Self-Efficacy Scale Short Form pre-test (Phase 3 only)

5. Conduct D-BAP

A. Introduction Welcome the woman and introduce yourself. Engage in informal small talk,

e.g. When are you due? Do you know if you’re having a boy or a girl? How has your pregnancy been? Do you have any other children or is this your first?

B. Describe the purpose of the D- Confirm that the woman is planning on BAP breastfeeding. Express support for her decision and affirm her commitment to

breastfeeding by being there with you today. Acknowledge that some women face barriers in breastfeeding, and the purpose of the time today is to make sure the woman feels equipped to address those barriers so that she may meet her breastfeeding goals.

Continued

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Table 7 continued

D-BAP Administration Step Instructions

C. Outline your role and the woman’s Express support for the woman, but role acknowledge that much of what happens with breastfeeding is when the woman is

not with the lactation counselor. Thus, it is important that the woman has a plan for addressing some barriers that may arise, and knows what she can draw on for support if she needs it. Explain that your role is to help her think through some of those things so that she can make a plan to meet her breastfeeding goals.

D. Introduce the D-BAP Give a brief overview of the D-BAP process. Give the participant her handout and encourage her to complete it during your time together and take it home with her.

E. Provide Q-sort instructions Introduce her to the Q-sort cards and give a brief explanation of how the cards represent factors that may be barriers or supports for her in meeting her breastfeeding goals. Inform her that she will sort and rank them, and together you will use this information to help her form a breastfeeding plan.

F. Gather preliminary information Ask her how long she plans on breastfeeding, and ask her to identify her

primary reason for breastfeeding. Encourage her to write this information on her participant handout.

Continued

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Table 7 continued

D-BAP Administration Step Instructions

G. Q-Sort and ranking Explain that the cards will be sorted to look at some of the things that will make it easier for the woman to meet her breastfeeding goals, and some of the things that could make it more challenging. Ask if the woman has any questions before she begins.

Starting with the barriers pile, ask the woman to rank her top 3 cards of factors that make breastfeeding more challenging. Then ask her to rank her top 3 cards representing factors that make breastfeeding easier. Explain that some of the cards may have checkboxes, and if one of those cards is among her top 3, she may choose to select one or more things that are relevant to her. Then show her the blank cards at the bottom of each stack, and explain that these are for any barriers or supports that may not be represented in the cards.

Clarify your role; you are there to help her if she gets stuck or if it would be helpful to talk through some of the cards. She can also ask questions at any time. Ask the woman if she has any questions before she begins, and once she indicates she is ready, have her sort the cards.

Continued

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Table 7 continued

D-BAP Administration Step Instructions

H. Develop a breastfeeding plan Ask the woman about each barrier, e.g. tell me about this barrier. What makes

this barrier so challenging? If she indicates this barrier is the result of previous experience ask her to elaborate on that.

Allow the client to generate her own solutions to each barrier. Ask some probing questions such as: What might your breastfeeding relationship look like without this barrier? What happens if you don’t address this barrier? What would you have to do to address this barrier? If she indicates this was a barrier in the past, ask her to identify some of the ways she overcame that barrier.

Ask the woman to tell you about each strength she selected. Ask probing questions such as: Why was this card chosen? How does you feel this factor will help you meet your breastfeeding goals?

Allow the participant to generate her own ways to harness those strengths. Ask probing questions such as: Is there anything you can do now, while you are pregnant, to make sure those strengths are available to you once your baby is here?

Continued

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Table 7 continued

D-BAP Administration Step Instructions

Encourage the woman to write the ideas generated down under “Breastfeeding Plan” on her handout. Provide the woman with any applicable resources or referrals.

6. Wrap up

Ask participant the questions from the A. Conduct semi-structured interview semi-structured interview schedule.

B. Administer surveys Session Evaluation Questionnaire Session Response Scale Infant Feeding Intentions Scale post-test (Phase 3 only) Breastfeeding Self-Efficacy Scale Short Form post-test

C. D-BAP conclusion Thank the participant, provide the two handouts related to breastfeeding, give participant the gift card, and encourage her to follow-up should she have any questions.

Continued

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Table 7 continued

D-BAP Administration Step Instructions

7. Document the D-BAP session After the client has left, complete the “Administrator Sheet.” First, capture the

ranking of the top three barriers, and the remaining barriers cards. Next, write the ranking of the top three supports cards and the remaining supports cards. Finally, document which cards the women identified as not applicable. Place an asterisk next to any card the client wrote in.

Write down the strategies for each barrier and the strategies for each support. Include any additional pertinent information in the last section.

The purpose of Phase 2B was to test the D-BAP with a small sample of lactation counselors who had experience working with low-income, African American women, and a small sample of pregnant women for whom the assessment process was designed.

Triangulation of sources was used in this phase as it was hypothesized that it would lead to more robust feedback. The data obtained in Phase 2B was necessary to ensure that the

D-BAP administration protocol was clearly articulated, and that the cards contained statements that were representative of individual barriers and facilitators for breastfeeding. In Phase 2B and Phase 3, as a trained lactation counselor, I served as the

D-BAP administrator.

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Sampling and participant characteristics. The content and process of the D-BAP

were evaluated by lactation specialists and pregnant, low-income, African American

women. Theoretical sampling was used to identify lactation specialists. A mix of

individuals with different levels of training and applied experience in different practice settings, was sought. Practitioner participants included a WIC peer helper (one who was not a Phase 1 participant), a hospital lactation consultant, and a lactation counselor working at a community program serving the target population. The number of years of experience each lactation specialist had ranged from 2 to 10 years (M = 5.33, SD = 4.16) and the proportion of the women they served who were African American ranged from

55.0% to 90.0%.

Convenience sampling was used to identify two African American women who were pregnant, over 18 years of age, 20 or more weeks pregnant, recipients of WIC, and planning on breastfeeding. Both participants were recruited from a community-based parenting program. Both women were in their third trimester of pregnancy, and had previous breastfeeding experience.

All Phase 2B participants consented to participate in the research, and each received a $10 gift card to a local grocery store for their time. All procedures associated with Phase 2B were approved by The Ohio State University’s Institutional Review Board for the protection of human subjects.

Measures. To evaluate the D-BAP, participants were asked to provide feedback on both the content of the Q-sort cards and the assessment process. Based on

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recommendations from intervention research, a mixed methods approach was utilized to

gather input on the assessment protocol (Frasier et al., 2009).

Qualitative measure. A semi-structured interview was used to gather qualitative data from participants (see Appendix M: Phase 2B and 3 Semi-Structured Interview

Protocol). This interview schedule included nine questions related to components of the

D-BAP including the clarity of the instructions, the content of the cards, and the overall utility of the activity.

Quantitative measures. To determine how participants experienced the D-BAP, quantitative assessments were sought. Although a survey designed specifically to evaluate an intervention would have been preferable, a literature review and consultation with two scholars revealed an absence of applicable instrumentation (S. McMurtry, personal communication, November 19, 2014; B. Melnyk, personal communication,

March 5, 2015). Session evaluation tools, often used to measure the impact of counseling sessions, were recommended as a potential source for applicable tools. A search yielded two instruments that contained items adaptable for the D-BAP. This included the Session

Rating Scale (SRS) and the Session Evaluation Questionnaire (SEQ) (Duncan et al.,

2002; Stiles, Gordon, & Lani, 2002).

Although it was not originally designed for the evaluation of assessments or interventions, authors of the SEQ have stated that “the SEQ’s content and format make it appropriate for assessing anything that could be called a session” (Stiles et al., 2002, p.

328) (see Appendix N: Session Evaluation Questionnaire). The original Session

Evaluation Questionnaire included two sets of items; the first focused on the evaluation

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of the session while the second included items related to an individual’s mood following

the session. For the purposes of this study, only items measuring the evaluation of the session were included. Measures of mood were excluded in the interest of participants’ time, and because feedback related to an individual’s mood was considered less relevant than assessment-specific feedback. The session evaluation domain on the SEQ consists of

eleven sets of bipolar adjectives, with a seven-point scale between them (e.g. valuable- worthless, weak-powerful). Respondents were asked to select the circle closest to the

adjective that most accurately represents their experience of the session.

Confirmatory factor analyses have identified two dimensions of the SEQ - depth and smoothness (Stiles, 1980; Stiles, Shapiro, & Firth-Cozens, 1988). Depth included five adjective pairs such as powerful-weak and valuable-worthless, and measured the degree to which the session delved into meaningful topics (Stiles, Reynolds, Hardy, Rees,

Barkham, & Shapiro, 1994). Smoothness included five pairs and referred to the degree to which an individual felt that the session was relaxed and comfortable. Smoothness was operationalized through items such as easy-difficult, and pleasant-unpleasant. The mean was calculated for each item as well as for each dimension. The scale also has one global evaluation item measured with the good-bad adjective pair. The domains measured by the

SEQ have been found to be reliable with alpha coefficient of .90 for depth and .92 for smoothness (Styles et al., 1994).

The Session Rating Scale (SRS) is a brief, four-item instrument originally designed to measure alliance between a therapist and client (See Appendix O: Session

Rating Scale). Although therapeutic alliance has largely been limited to the domain of

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psychotherapy, some studies have found a positive relationship between therapeutic

alliance and health behavior change, and this represents an area of emergent inquiry

(Arnow, & Steidtmann, 2014; Bennett, Fuertes, Keitel, Phillips, 2011).

In the SRS, each item on the instrument represents a different dimension:

relationship, goals and topics, approach or method, and overall evaluation. This

instrument consists of a visual analog scale, with opposing statements separated by a

horizontal line. Individuals are asked to place a vertical mark on the line that best

represents their experience. To score these items, the location of the mark is measured in

centimeters from the left, and assigned the corresponding value.

This instrument has demonstrated reasonable concurrent validity; an examination of the correlation between the SEQ and the Helping Alliance Questionnaire-II revealed a correlation of .48 (p < .01) (Duncan et al., 2002). In regards to reliability, this instrument has demonstrated strong internal consistency, with a Chronbach’s alpha coefficient of

.88. This suggests the four items provide a global evaluation of a working alliance during the session, as opposed to measures of individual dimensions. An overall score is obtained by summing the scores for the four items, and can range from 0-40. Poor alliance is defined as a score ranging from 0-34, with scores in the range of 35-38 reflecting a fair alliance, and 39-40 indicating a strong alliance (Miller & Duncan, 2008).

Although these guidelines are helpful, this tool was originally developed and tested for use in a therapeutic setting. An evaluation of the working alliance between a research participant and the administrator of a brief, semi-structured assessment process differs qualitatively from an evaluation of an individual and clinician engaged in an

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ongoing therapeutic relationship. Regardless, the concept of alliance can provide a

meaningful quantification of an individual’s experience of the D-BAP. Additionally, although the scale summary score is presented, attention was also directed to the

individual items, as they also provided insight into the specific components of participants’ experiences of the D-BAP.

Data collection procedures. A protocol was developed to guide the facilitator through the activities of the D-BAP. At the start of each D-BAP session, each participant was asked to consent to participate in the research. Next, the participant completed a demographics form. As the activities in the protocol presume that the participant is planning on breastfeeding, lactation specialists were asked to role play during the assessment process and to evaluate the activity through their clients’ eyes. Additionally, they were also asked to consider the utility of the D-BAP in their own practices.

All participants were asked to state their intended breastfeeding duration, and to identify their primary motivation for breastfeeding their child. Participants were asked to identify their motivation for breastfeeding as it is represents one of the guiding principles for MI; eliciting a client’s motivation may be an impetus for an individual to achieve change (Rollnick et al., 2007). This information was collected on a sheet that was given to the participant following the D-BAP (See Appendix P: Meeting My Breastfeeding

Goals Handout).

The D-BAP administrator then led the woman through a set of instructions tailored for the Q-sort and rank process. Participants were informed that this activity was designed to help them identify their top three barriers to breastfeeding as well as the top

175 three factors that would make it easier for them to breastfeed. Prior to handing the woman the first set of cards containing factors that made breastfeeding easier, participants were shown a few sample cards. Attention was directed specifically to the few cards with multiple check boxes, and participants were told that if one of those cards was selected as among their top three, and if one or more of the sub-categories on the card applied to them, they could select those statements that were applicable. Women were also shown the blank card at the back of each set. The administrator informed the woman that if there was a specific barrier or facilitating factor that was relevant to her personally, and that was not located in the set, she could write it in on one of those cards. Following these instructions, women were provided with the set of supporting factor cards and a dry erase marker. This sorting and ranking process was then repeated with the cards containing factors that made breastfeeding more challenging.

This sorting strategy was designed based on research literature that suggested barriers to breastfeeding may be more salient for African American women than for women of other racial and ethnic groups (McCann et al., 2007). It was hypothesized that through the identification of breastfeeding barriers in the prenatal period, women may be able take the steps necessary to address those while she is still pregnant. The supportive factors are meant to empower the woman and increase her breastfeeding self-efficacy.

Through the identification of those strengths-based factors, it was hypothesized that women may feel equipped to meet their breastfeeding goals, and to overcome any breastfeeding challenges that may arise (Alexander et al., 2010).

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Following the card sorting and ranking process, the facilitator then engaged the

woman in a discussion about the cards she selected, and discussed strategies for

overcoming her barriers and harnessing her supports. This portion of the D-BAP draws

on motivational interviewing. In MI, three communication skills are utilized: following, directing, and guiding (Rollnick et al., 2007). Following involves listening as the client leads the conversation, directing occurs when the clinician takes the lead in providing information and making recommendations, and guiding occurs when a balance is struck between the two, recognizing client autonomy in order to empower her to achieve her health behavior goals. These communication skills are applicable to the D-BAP. Active listening was used to determine what the woman needed to meet her breastfeeding goals.

Directing was often necessary when the woman sought specific information or referrals related to breastfeeding. Finally, guiding was critical as client empowerment is the ultimate goal of the D-BAP. Woman were provided with breastfeeding information during the D-BAP, however in order for this assessment process to impact breastfeeding behavior, the onus fell on the woman to utilize the information acquired upon leaving the session. To facilitate this, there was space on the Meeting My Breastfeeding Goals handout where the woman could take notes, if she chose.

Following the processing component, the participant was then provided with two handouts related to breastfeeding; one provided information about breastfeeding, and the other addressed breastfeeding myths (see Appendix Q: Breastfeeding Information and

Myths Handouts). These handouts contained information from the Office on Women’s

Health, at the U.S. Department of Health and Human Services as part of the It’s Only

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Natural campaign. This campaign developed targeted messages to educate African

American women about the benefits of breastfeeding (U.S. Department of Health and

Human Services’ Office on Women’s Health, 2013). Upon review, this information was deemed appropriate for the population engaged in this study, thus the handouts were crafted from their website content.

The administrator then thanked the participant, provided her with the gift card, and asked if she had any additional questions. After the participant left, the administrator captured information in the D-BAP administrator sheet (see Appendix R: Phase 2B & 3:

D-BAP Administrator Sheet). This contained information about the cards that the participant selected, as well as the solutions that were discussed related to addressing barriers to breastfeeding and utilizing existing supports.

Data analysis.

Qualitative analysis. Thematic analysis was used to sort any comments made during the assessment process, as well as statements gathered through the semi-structured interview. These were coded using a template approach with structural coding. This method of coding is appropriate for a semi-structured interview protocol, particularly when the desired output is to categorically organize the responses into a set of foundational themes (Saldaña, 2016). A preliminary typology of themes was established including: problematic wording on a card, difficulty distinguishing between two cards, confusion regarding the instructions given, and uncertainty about the sorting process.

Other themes were added as categories arose including one containing suggestions for

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long-term modifications to the D-BAP, and another focused on confusion regarding the study instruments.

Quantitative analysis. Descriptive statistics are used to report the findings from both the Session Rating Scale and the Session Evaluation Questionnaire. For the SRS, the mean, standard deviation, and range of each item were calculated as was the mean, standard deviation, and range for both dimensions of the scale (smoothness and depth).

For the SEQ, the overall mean, standard deviation, and range for the instrument were calculated to determine overall working alliance. The mean score, standard deviation, and range were also computed for each item on the SEQ. Data analysis was performed with version 9.0 of SPSS for Windows.

Results. The following includes results generated from testing the D-BAP content and protocol with three lactation specialists and two pregnant women. Findings are presented according to the methodology used to gather data. Information from the semi- structured interviews is presented first, followed by the quantitative findings from the

SRS and the SEQ.

Qualitative results. Although Phase 2B only included five participants, the data generated from the semi-structured interview yielded rich data from which to improve the

D-BAP. Some feedback focused on immediate, minor changes, while other comments focused more on the long-term expansion of the D-BAP.

Overall, the reactions from both lactation specialists as well as the pregnant participants were positive. All participants felt that the activity was helpful, with one pregnant woman lamenting that she wished she had the opportunity to engage in a similar

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conversation with her first pregnancy. She felt that with exposure to some of the ideas

introduced in the D-BAP she might have identified and addressed potential barriers

before they disrupted her breastfeeding relationship with her child.

Regarding specific components of the D-BAP, participants indicated that the sorting process was straightforward and the wording on the cards was clear. Two participations specifically expressed appreciation for the write-in cards. One woman valued the structured nature of the activity, feeling that it may encourage a woman to open up. Regarding the length of the activity, four felt that it was an appropriate amount of time while one felt that it could have been longer. Those who were satisfied with the duration of the activity described it as “quick-moving,” “interactive,” and “just enough

time.” One piece of feedback from the semi-structured interview that did not fit into the structured domains was a focus on the overall tone of the D-BAP. One woman described it as an easy conversation, and felt that the facilitator was “relatable.”

One data analysis category which was not identified a priori but rather emerged from participants’ comments while completing the activity was related to the completion of the survey instruments. On both of the posttest measures, individuals expressed some confusion regarding the content and formatting. With the SRS, the antonym pairs are occasionally reverse coded; positive items appear on both the left and the right sides of the continuum. Two participant asked for clarification while completing this survey.

After the instructions were reiterated, one individual still expressed significant confusion.

This indicated a need in Phase 3 to ensure that the scale was adequately explained to

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participants upon administration. Instructions for the SEQ were more straightforward,

however two of the participants asked for clarification prior to marking their response.

Participants also provided constructive feedback and innovative ideas regarding

how to strengthen and improve the D-BAP. One woman felt that the instructions given upfront could be more detailed, to ensure the participant knew exactly what the primary purpose of the assessment process was, and what participation entailed. One lactation specialist suggested reversing the order of the card sort. She felt that by providing barriers first, and then introducing positive factors, this would help the woman generate her own strengths, and it may empower her to realize that she has supports she can harness in order address many of her own barriers to breastfeeding. Referencing some of the more sensitive cards (i.e. sexual trauma), one woman felt that the intervention might

be received differently by an African American woman if the facilitator was also African

American.

Finally, two participants (lactation specialists) raised the issue about how a

woman could be supported following the D-BAP process. One individual suggested

putting a list of possible solutions to address some of the barriers on the back of the cards,

or providing a handout containing information specific to each barrier. For example, if a

woman indicated having a lack of knowledge about breastfeeding, it may be helpful to

have a handout listing breastfeeding courses in the area. One lactation specialist felt that

this would help standardize the use of the cards, and would help newer lactation

specialists to be prepared to provide resources or referrals, as appropriate. The other

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lactation specialists suggested using the tool in a follow-up session postpartum, in order to address any unexpected breastfeeding barriers that the woman may have encountered.

Quantitative results. The Session Evaluation Questionnaire and the Session

Rating Scale provided valuable information about the participants’ experiences of the D-

BAP. On the global evaluation item of the SEQ (bad-good), all five participants gave it the highest rating, which was 7 on the scale of 1-7. The mean scores for both Depth and

Smoothness were also high. Among the items constituting the Depth dimension, respondents felt that in particular it was both valuable and powerful. The highest ranked items for Smoothness were Relaxed and Pleasant. See Table 8 for the results for all survey items.

Item M (SD) Range Depth 6.76 (.33) 6.4-7.0 Worthless-Valuable 7.00 (.00) 7.0 Shallow-Deep 6.60 (.55) 6.0-7.0 Ordinary-Special 6.60 (.55) 6.0-7.0 Empty-Full 6.60 (.55) 6.0-7.0 Weak-Powerful 7.00 (.00) 7.0 Smoothness 6.96 (.09) 6.8-7.0 Easy- Difficult 6.80 (.45) 6.0-7.0 Tense-Relaxed 7.00 (.00) 7.0 Unpleasant-Pleasant 7.00 (.00) 7.0 Rough-Smooth 6.60 (.89) 5.0-7.0 Comfortable-Uncomfortable 7.00 (.00) 7.0 Global Evaluation (Bad-Good) 7.00 (.00) 7.0

Table 8. Session Evaluation Questionnaire

Note. Scale range from 1-7.

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The Session Rating Scale, measuring the alliance between the D-BAP administrator and the participant, had a mean score of 38.0 (SD = 2.19). This falls within the upper end of the range of scores constituting a “Fair Alliance,” although as mentioned, this designation should be interpreted with caution. The respondents’ marks on this instrument can range from 0-10 centimeters, and in its utilization in Phase 2B, all four survey items had a mean over 9.0. This indicates a high degree of feeling heard, understood and respected (relationship), working on/talk about what the participant wanted to work on/talk about (goals and topics), feeling the approach is a good fit

(approach or method) and indicating that the activity was right for the woman (overall).

Thus although the composite score demonstrates a fair, and not a strong alliance, responses on the individual items indicate a strong positive rating. See Table 9 for the findings from the SRS.

Item M (SD) Range Relationship 9.22 (0.93) 7.9-10.0 Goals and Topics 9.52 (0.69) 8.5-10.0 Approach or Method 9.66 (0.48) 9.0-10.0 Overall 9.62 (0.50) 8.9-10.0 Total Score 38.02 (2.19) 35.4-40.0

Table 9. Session Rating Scale

Note. Scale range from 1-10.

Discussion. Phase 2B sought to test elements of the D-BAP including the content and the process of the activity. Through the engagement of lactation specialists and

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pregnant women in the inaugural administrations of the D-BAP, feedback was received

from both the intended recipients and the eventual administrators of this assessment

process. The feedback shared through the semi-structured interviews led to several improvements in Phase 3. These included the introduction of breastfeeding barriers prior

to facilitating factors, the provision of a more explicit description of the purpose and

procedures involved in the D-BAP, and clarification of the instructions for the two

session evaluation instruments. The semi-structured interview also generated ideas for

possible long-term expansion of the D-BAP including a follow-up component and the development of handouts containing resources for specific barriers.

The data generated through the SEQ and the SRS were also useful in that they

provided a measurable summary of participants’ experiences. For the purpose of Phase

2B, however, their primary utility came in helping explicate some of the challenges that

participants may experience in Phase 3 with the structure and content of the instruments.

With the feedback received from the five participants in Phase 2B, the D-BAP was

refined in preparation for administration to Phase 3 participants.

Conclusions and recommendations. Although Phase 2B was undertaken with a relatively small sample size, this initial administration of the D-BAP helped illuminate some of the ways the process could be improved upon, prior to undergoing feasibility testing in Phase 3. Through the engagement of lactation specialists, input was sought from women who could give feedback on the degree to which this activity might be helpful in their own practice settings. The feedback received from pregnant women provided more applied feedback. They were able to speak specifically to the degree to

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which this activity was helpful for them personally, as they prepared to breastfeed their infant.

One of the limitations of this phase concerned the applicability of the standardized

research instruments. As mentioned, an instrument designed specifically for the

measurement of assessment processes or interventions would likely result in more valid

representation of participants’ experiences. Additionally, instruments normed on diverse populations are needed. The degree of confusion regarding the SEQ and the SRS indicated that the instruments may not be well suited for the population engaged in this study. Equipped with an awareness of the struggles some individuals had with these instruments, as well as with the input of participants regarding the immediate ways the D-

BAP can be improved, minor modification were made to the protocol and instructions in

preparation for the feasibility study in Phase 3.

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Chapter 5: Phase 3 – Testing the Dynamic Breastfeeding Assessment Process

Completion of Phase 1 and Phase 2A resulted in a dynamic breastfeeding

assessment that is based on qualitative input, research literature, and expert opinion.

Modifications were made to the D-BAP protocol based on input from participants and lactation specialists in 2B. This chapter describes Phase 3, the culminating activity in this

research study. In Phase 3, the D-BAP underwent feasibility testing with a group of 25 pregnant, low-income, African American women. This phase was designed to answer the research question: 3. What is the feasibility of a Dynamic Breastfeeding Assessment

Process? To determine this, two supporting research questions were posed:

3A. How do pregnant, low-income, African American women experience the

culturally grounded Dynamic Breastfeeding Assessment Process?

3B. When the Dynamic Breastfeeding Assessment Process is delivered, is

there a measurable difference in the breastfeeding self–efficacy and intent

among pregnant, low-income, African American women?

Breastfeeding self-efficacy and breastfeeding intent in the prenatal period are two variables that have demonstrated a positive impact on breastfeeding initiation and duration (Donath & Amir, 2007; Ertem et al., 2002). Considering the importance of these, and the identified need for a quick, customizable, and culturally responsive breastfeeding activity, the D-BAP was designed with a deliberate effort made to try to increase breastfeeding intention and self-efficacy. 186

In one study of African American WIC recipients, a strong predictor of a

woman’s intent to breastfeed was her perception of her physician’s endorsement of

breastfeeding (Bentley & Caulfield et al., 1999). Although the D-BAP is not designed for

administration by a physician, it is hypothesized that the information provided by a

lactation counselor may have a positive influence on the woman’s breastfeeding intention

in the prenatal period. This is supported by Humphreys, Thompson, and Minor (1998)

who, in a study focused on low-income women, found a positive correlation between

information provided by lactation counselors about the importance of breastfeeding, and

a woman’s intent to breastfeed.

Factors that have shown an influence on an individual’s level of self-efficacy

related to a particular behavior are psychological and affective states, behavioral mastery,

vicarious experience, and verbal persuasion (Bandura, 1997; Dennis, 1999). It was

hypothesized that participation in the assessment process will positively impact a

woman’s psychological state by decreasing anxiety and stress about breastfeeding, and

thus increase her level of self-efficacy. The purpose of the D-BAP was to equip a woman with knowledge of her unique barriers and strengths, and to develop a personalized plan around how to move forward to meet her breastfeeding goals. Participation in the assessment process was also hypothesized to impact a woman’s self-efficacy through verbal support; the expressed endorsement of breastfeeding and support provided by a lactation counselor is thought to boost a woman’s beliefs about her ability to breastfeed her child (Dennis, 1999).

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Methods

Although there exists some disagreement among scholars regarding what constitutes a feasibility versus a pilot test, general consensus is that one or both of these

are necessary first steps in preparing for a more extensive evaluation of a research

activity or intervention (Arain, Campbell, Cooper, & Lancaster, 2010; Whitehead, Sully,

& Campbell, 2015). The purpose of a feasibility or pilot test is twofold. The first is to

better understand challenges that the researcher may encounter in executing the research.

This includes difficulty recruiting study participants, identifying limitations related to

study instruments, and uncovering hiccups in the intervention delivery. The second

identified goal, most often associated with a pilot test, is to conduct some preliminary

hypothesis testing. This is often used to identify an effect size, so that a subsequent study

could be adequately powered (Melnyk & Morrison-Beedy, 2012).

The research activities in Phase 3 were designed to accomplish both of these

goals. Input was sought regarding participants’ perceptions and experiences of the assessment process. In addition to the input gathered from Phase 2B, this may lead to protocol or content modifications prior to conducting a larger scale study to evaluate the effectiveness of the D-BAP. Additionally, some hypothesis testing is being conducted to determine whether participation in the D-BAP is associated with an increase in breastfeeding self-efficacy or intent. To answer this research question an A-B-A research design was utilized.

Sampling and participant characteristics. For the quasi-experimental design employed in Phase 3, theoretical sampling strategies were used to identify 25 women

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who were African American, WIC recipients, 20 or more weeks pregnant, over 18 years of age, and planning on breastfeeding. To recruit this population, flyers were posted in

Ohio State University’s prenatal clinic, in WIC clinics and federally qualified health centers located in predominantly African American neighborhoods, and at Moms2B, a community-based program designed to address the social determinants of health and reduce infant mortality. Additionally, the study was posted on ResearchMatch, a web- based recruitment tool that connects researchers with potential research participants. The

pretests, Q-sort process, and posttests lasted approximately 30-45 minutes; all

participants were reimbursed with a $15 gift card to a grocery store for their time.

Participants ranged from age 18-43 years (M = 27.64, SD = 6.30). They were

between 22-38 weeks pregnant (M = 30.44, SD = 4.87). Regarding paturation, 6 women were first time mothers, while the remaining 19 had one or more children. Of those 19 women, 13 (68.4%) had some previous breastfeeding experience ranging from 2 weeks to

13 months (M = 24.77 weeks, SD = 19.52). The majority of the sample had an education

level of high school graduate or above (72%) and 48% of the women subsisted on a

household income less than $800 a month. See Table 10 for the demographics of all

Phase 3 participants.

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Participant Characteristics n % Participant age 18-24 9 36.0% 25-29 7 28.0% 30-34 6 24.0% 35-39 3 12.0% Number of weeks pregnant 20-24 3 12.0% 25-29 9 36.0% 30-34 5 20.0% 35-40 8 32.0% Parity Primiparous 19 76.0% Multiparous 6 24.0% Breastfeeding Experience (among multiparous women) Experience 13 65.0% No Experience 7 35.0% Education 1-7 years grade school 1 4.0% 8 years grade school 2 8.0% 1-3 years high school 4 16.0% High school graduate 14 56.0% 1-3 years college 3 12.0% College graduate 0 0.0% Post graduate 1 4.0% Current relationship status with baby's father Married 5 20.0% Romantically involved 9 36.0% Separated/Divorced 1 4.0% Just friends 3 12.0% Not in any kind of relationship 7 28.0% Race Black or African American 23 92.0% Multiple Races 2 8.0%

Continued

Table 10. Phase 3 participant demographics

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Table 10 continued

Participant Characteristics n % Ethnicity Hispanic or Latino 1 4.0% Non-Hispanic or Non-Latino 24 96.0% Monthly household cash income <$800 12 48.0% $801-$1,100 6 24.0% $1,101-$1,400 2 8.0% $1,401-$2,000 3 12.0% $2,001-$2,500 1 4.0% $2,501-$3,000 1 4.0%

Measures. The research questions in Phase 3 called for a mixed methods

approach. In intervention research, mixed methods evaluation is recommended as

qualitative data can significantly enhance quantitative findings (Creswell, Shope, Plano

Clark, & Green, 2006). In order to address the first question related to women’s experiences of the D-BAP, the same semi-structured interview and standardized instruments from Phase 2B were employed. The information that emerged from the semi- structured interview and from the SRS and SEQ were used to describe how women experience the D-BAP, and to contextualize any findings related to the impact of the D-

BAP.

In order to answer the second research question related to the impact of the D-

BAP on breastfeeding self-efficacy and breastfeeding intent, standardized instruments were identified that have undergone psychometric testing with samples similar to the present study. The Infant Feeding Intentions Scale (IFIS) and the Breastfeeding Self-

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Efficacy Scale – Short Form (BSES-SF) were selected. Psychometric properties of these two instruments are below.

The Infant Feeding Intentions Scale. This instrument consists of five items, which assess a woman’s intended infant feeding method, her willingness to try breastfeeding, and the duration and degree of exclusivity a woman intends to breastfeed

(see Appendix S: Infant Feeding Intentions Scale). The instrument has been validated with low-income populations and women of multi-ethnic backgrounds (Nommsen-

Rivers, Cohen, Chantry, & Dewey, 2010). Regarding internal consistency, Chronbach’s alpha coefficient was .90. The IFIS also demonstrated predictive validity, with a woman’s responses in the prenatal period showing a strong association with her infant feeding behavior in the postpartum period (Nommsen-Rivers & Dewey, 2009).

Responses range from 0 (not at all confident) to 5 (very confident). The score on the IFIS is calculated by averaging the score of the first two items, then adding this score to the sum of items 3-5 which measure the duration a woman intends to breastfeed (1, 3 and 6 months, respectively).The score of this scale can range from 0-15, with a high score indicating a strong intention to breastfeed (Nommsen-Rivers & Dewey, 2009).

The Breastfeeding Self-Efficacy Scale. The Breastfeeding Self-Efficacy Scale –

Short Form has fourteen questions, and has undergone psychometric testing with a range of populations (See Appendix T: Breastfeeding Self-Efficacy Scale – Short Form).

Regarding reliability, among African American women, the Chronbach’s alpha coefficient was .94. Factor analysis found that the factor loadings for each item were greater than .32, suggesting all items should be retained. Finally, predictive validity was

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established as self-efficacy was found to be a significant predictor of breastfeeding initiation and discontinuation at four weeks postpartum (McCarter-Spaulding & Dennis,

2010). Responses range from 1 (not at all confident) to 5 (very confident).

Data collection procedures. For purposes of continuity with Phase 2B, the principal investigator administered the D-BAP during Phase 3. All of the data collection procedures mirrored those in Phase 2B with the exception of administration of the infant feeding intention and breastfeeding self-efficacy pre- and posttests. (See Data Collection

Procedures in Chapter 4). In Phase 3, women who expressed an interest in the research and who met all of the study criteria were consented for participation in the study. All procedures associated with Phase 3 were approved by The Ohio State University’s

Institutional Review Board for the protection of human subjects.

After providing consent, participants completed the demographics worksheet and two pretests: the Infant Feeding Intentions Scale (IFIS) and the Breastfeeding Self-

Efficacy Scale-Short Form (BSES-SF). The administrator then provided instructions and administered the Q-sort cards as described in the D-BAP protocol (Chapter 4). Each women identified her top three barriers to breastfeeding and her top three facilitating factors. Using techniques rooted in the spirit of motivational interviewing, the participant worked in conjunction with the administrator to brainstorm possible solutions to her barriers and to conceptualize ways to harness her supports.

As in Phase 2B, women had the opportunity to capture these barriers and supports and potential next steps in a worksheet that she could take home. Following the assessment process, women again completed the Breastfeeding Self-Efficacy Scale –

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Short Form and the Infant Feeding Intentions Scale to determine the impact, if any, of participating in this Q-sort assessment process on these two measures. In addition, each woman was engaged in a semi-structured interview, and completed the Session Rating

Scale and the Session Evaluation Questionnaire. Women were then thanked for their participation in the study and provided with the two breastfeeding handouts described in

Phase 2B: breastfeeding information and cultural-specific breastfeeding myths.

Data analysis.

Experiences with the D-BAP. Structural coding was again used to sort the feedback collected through semi-structured interviews with participants. Statements were coded using a template approach with the following domains: problematic wording on a card, difficulty distinguishing between two cards, confusion regarding the instructions given, uncertainty about the sorting process, and challenges with data collection instruments. Although these were once again identified a priori, the coding process left room for flexibility if the need for other themes arose.

For the SRS and the SEQ, descriptive statistics were used to summarize the data.

For both scales all individual item means, standard deviations, and ranges were calculated. Although both scales have either a composite score (SEQ) or contain specific dimensions (SRS), the content of each item provides unique insight. For example, the

Session Evaluation Questionnaire results in an overall score that measures the working alliance between the D-BAP administrator and the woman engaged in the assessment process. The individual items also have utility, however, as they provide additional insight into the degree to which the activity addressed their specific goals, and whether

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they considered the approach to be a good fit. The Session Rating Scale has two

dimensions: depth and smoothness. While these provide some insight into women’s

opinions, individual items provide a more nuanced understanding of how women

characterized the D-BAP.

Breastfeeding Self-Efficacy and Intent. In order to determine whether

completion of the D-BAP impacted a woman’s intent to breastfeed or her self-efficacy in

meeting her own breastfeeding goals, a Wilcoxon Signed Ranks test was used. This repeated measures test is appropriate for nonparametric data to explore whether there is a difference in women’s breastfeeding self-efficacy and/or infant feeding intention before and after completing the dynamic assessment. The Wilcoxon Signed Rank test was selected after a review of the histogram and a Shapiro-Wilk test indicated that pre- and posttest data from the BSES-SF and the IFIS were not normally distributed; in all

instances, the scores were negatively skewed. Given the structure of the research study,

the D-BAP administrator was able to check for missing data prior to the conclusion of the

assessment process, thus missing data was addressed immediately with the participant.

Chronbach’s alpha was used to measure the internal consistency of each scale. Data

analysis was performed with version 9.0 of SPSS for Windows.

Results

Participants’ experiences of the D-BAP.

Semi-structured interview. The insight gathered through the semi-structured interview provided an important context for understanding how women experienced the

D-BAP. It also helped inform the interpretation of the results related to both

195 breastfeeding self-efficacy and intent. Overall, women reported that the activity was helpful for meeting their breastfeeding goals. When asked for specificity regarding which parts of the process were helpful, participants most frequently cited the card sort, which they felt gave them the opportunity to identify both the challenges to breastfeeding, as well as some of the reasons why they were choosing to breastfeed (e.g. bonding with baby and providing baby with a range of health benefits). None of the participants reported any difficulty with cards. All women reported that the wording on the cards were clear, distinct, and that they captured the issues that were important. One woman expressed an appreciation for the list of barriers so that she did not have to try to generate those on her own. Women also felt that the pictures were helpful, not only for providing examples of the statements, but also because it just made it “more fun.”

Another respondent felt that the cards not only captured the factors most relevant to her, but she felt that as a whole, they represented a wide range of issues that are important for any woman planning on breastfeeding.

Several women expressed an appreciation that the information was tailored to them. They felt that having the opportunity to talk through the issues that were raised on the cards helped the activity feel more personalized. Women also felt that it was helpful to have time at the end to ask questions about what was discussed, as well as any questions or concerns they had related to breastfeeding that were not covered.

Women with breastfeeding experience as well as those without reported that participation in the D-BAP made them more aware of factors that could act as barriers to breastfeeding. For some this seemed to be empowering; one woman reported that the act

196 of identifying barriers was useful for her because then she felt equipped to “attack those before baby came.” For other women, however, this introduction to potential barriers to breastfeeding may have been overwhelming. One first time mother stated that before she completed this activity she thought “I’m just gonna do it [breastfeeding],” but as she was approaching the end of her pregnancy and becoming more aware of some of the potential barriers, she stated that she was “starting to think about everything I don’t know.”

Another respondent echoed this sentiment, stating that this activity “made [her] realize how much planning needs to go into breastfeeding.”

Several women reported gaining knowledge as a result of participating in the D-

BAP. When asked to elaborate on what knowledge was most useful they mentioned the importance of reaching out to a lactation counselor in the hospital, knowing more about breastfeeding resources such as the ability to weigh baby at WIC to ensure they were producing an adequate amount of breast milk, and the awareness they gained of helpful practices to increase milk supply, such as putting baby skin to skin in the immediate postpartum period.

As was the case in 2B, women suggested a couple of ways that the activity could be improved. One woman with previous breastfeeding experiences felt that this activity should be repeated in the immediate postpartum period, and again a couple of months after baby is born. She felt that her own barriers shifted during her previous breastfeeding tenure, and for many women “what’s your top three now might not be your top three later.”

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The final suggestions for improving the D-BAP were related to the study

instruments and evaluation protocol. One participant suggested that the two evaluation

measures (SEQ and SRS) should be mailed to participants so that they could respond

outside the presence of the administrator. She reported that a participant could potentially

feel pressured to provide a positive evaluation so as not to offend the D-BAP administrator.

Given the feedback from Phase 2B related to the SEQ and the SRS, the administrator attempted to give very explicit instructions, directing the participants’ attention to each instrument, and elaborating on the instructions for each. Even after these

more directive instructions were given, several women in the sample still expressed

confusion and frustration about how they should be completed. Women also included

other barriers external to the D-BAP protocol in their evaluation. One woman, for

example, completed the form correctly, but as she was leaving she stated “I ranked this as

‘tense and rough,’ but only because I had my kids with me. The activity was great

though!”

Standardized measures of the D-BAP. The SEQ and the SRS provided a

standardized tool with which to measure participants’ experiences of the D-BAP. As

mentioned, however, in light of the difficulty women had in understanding the

instructions, these measures should be interpreted with caution. On the global evaluation

(Bad-Good), the respondents rated the D-BAP positively (M = 6.64, SD = 1.22). The

Smoothness dimension was rated slightly higher (M = 6.20, SD = 1.39) than the Depth dimension (M = 5.58, SD = 1.22). See Table 11 for the full results of the SEQ.

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Item M(SD) Range Depth 5.58 (1.22) 2.4-7.0 Worthless- Valuable 5.92 (1.89) 1-7 Shallow-Deep 5.28 (1.57) 1-7 Ordinary-Special 5.08 (2.12) 1-7 Empty-Full 5.64 (1.96) 1-7 Weak-Powerful 6.00 (1.44) 1-7 Smoothness 6.20 (1.39) 2.4-7.0 Difficult-Easy 6.52 (1.26) 1-7 Tense-Relaxed 6.04 (1.84) 2-7 Unpleasant-Pleasant 6.40 (1.68) 1-7 Rough-Smooth 6.16 (1.43) 1-7 Uncomfortable-Comfortable 5.88 (2.13) 1-7 Global Evaluation (Bad-Good) 6.64 (1.22) 1-7

Table 11. Session Evaluation Questionnaire results

Note. Scale range from 1-7.

Although in previous studies Smoothness and Depth, as measured by the SEQ, were typically uncorrelated, because this instrument was utilized in a non-clinical setting, a Spearman’s rank-order correlation was computed to determine the relationship between the two scale dimensions (Stiles et al., 2002). Through a visual assessment of a scatterplot, the relationship was monotonic. This test showed a strong positive correlation between Depth and Smoothness (rs(23) = .79, p < .001). Chronbach’s alpha was calculated for each dimension; both demonstrated a high level of internal consistency (.82 for Smoothness, .88 for Depth).

A review of the Session Rating Scale demonstrated that overall the mean for the four items was high. Participants felt that the approach was helpful, the goals and topics were applicable to them, and that they felt heard, understood, and respected. This scale 199

had a moderate level of internal consistency, as determined by Chronbach’s alpha of .79.

See Table 12 for the results of the SRS.

Item M (SD) Range Relationship 9.10 (1.32) 4.7-10.0 Goals and Topics 9.17 (1.23) 4.5-10.0 Approach or Method 9.20 (1.20) 4.8-10.0 Overall 9.07 (1.34) 5.4-10.0 Total Score 36.6 (3.99) 24.9-40.0

Table 12. Session Rating Scale item results

Note. Scale range from 1-10.

The predetermined scoring categories showed that the scores for eight of the participants reflected a poor alliance, eight reported a fair alliance, and nine met the criteria for a strong alliance. Although caution must be used in the interpretation of these scores, they provide a useful metric through which participants’ experiences can be understood. Table 13 displays the categorical results of the SRS.

Scoring category n percent Poor alliance (0-34) 8 32.0% Fair alliance (35-38) 8 32.0% Strong alliance (39-40) 9 36.0%

Table 13. Session Rating Scale categorical results

Breastfeeding intent. The Wilcoxon Signed Rank Test indicated that the

difference between the breastfeeding intent scores from the pretest to the posttest measure 200

was not statistically significant (z = -.71, p = .48). The pretest was non-normally

distributed with skewness of -1.45 and kurtosis of 3.02. The posttest also was non-

normally distributed, with a skewness of -0.57 and kurtosis of -1.49. The effect size was small (r = .14) according to the Cohen’s calculation, which is recommended for use with the Wilcoxon Signed Rank Test (Pallant, 2013).

The data indicated that overall participation in the D-BAP did not increase women’s intent to breastfeed at a statistically significant level. Of the 25 women who

participated in Phase 3, six showed an increase in their breastfeeding intent, while the

remainder either had lower levels of intent (n = 6) or their intent remained the same (n =

13). The scale, at both the pretest and posttest administration, had a high level of internal

consistency, as demonstrated by Chronbach’s alpha of .91, and .82 respectively. For the

reported median and means on all scale items see Appendix U: Infant Feeding Intention

Scale Results.

After an examination of the demographic data, it was discovered that for those participants who had previous breastfeeding experience, their mean duration of previous breastfeeding experience was high (M = 24.77 weeks). Thus a separate analysis was conducted with a subsample of the women, limited to those who had no breastfeeding experience (n = 12) in order to determine whether their receipt of the D-BAP had a differential impact on their breastfeeding intent. This subsample also violated assumptions of normality so the Wilcoxon Signed Rank Test was used. Within this subsample, again there was no statistically significant increase in the participants’ intent to breastfeed (z = -1.58, p = .12). In this instance, however, the effect size was medium (r

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= .46). Four of the women with no previous breastfeeding experience demonstrated an

increase in their breastfeeding intent, six experienced no change, and two experienced reported lower levels of intent to breastfeed.

Breastfeeding self-efficacy. The nonparametric Wilcoxon Signed Rank Test used to analyze the pre- and posttest data from the BSES-SF indicated that participants

experienced a statistically significant increase in their self-efficacy after completing the

D-BAP (z = -2.01, p = .04). The effect size for self-efficacy is considered medium using

Cohen’s calculation for effect size (r = .40). Of the 25 women who completed the D-

BAP, 18 of them demonstrated an increase in their self-efficacy, however five had lower

levels of self-efficacy and two had no change. The BSES-SF scale, at both the pretest and

posttest administration, had a high level of internal consistency, as demonstrated by

Chronbach’s alpha of .92, and .96 respectively. For the reported median and means on all

scale items see Appendix V: Breastfeeding Self-Efficacy Scale- Short Form Results.

As was the case with breastfeeding intent, a sub-sample of women with no

breastfeeding experience (n = 12) was analyzed to determine whether the D-BAP had a

differential impact on their breastfeeding self-efficacy. Again the data violated

assumptions of normality so the Wilcoxon Signed Rank Test was used. This subsample

also demonstrated a statistically significant increase in their breastfeeding self-efficacy (z

= -2.36, p = .02). This effect size for this sub-sample was large (r = .68). Among this group of women, 10 experienced an increase in their breastfeeding self-efficacy score, while 2 women reported lower levels of self-efficacy.

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Discussion

Participants’ experiences of the D-BAP. The semi-structured interview and the two assessments (SEQ and SRS) reflect an overall positive experience for women who were engaged in Phase 3, although this conclusion should be interpreted with caution. It is important to note that participant responses may have been positively skewed as the semi-structured interview was conducted by the D-BAP administrator, and the SEQ and

SRS were returned to the administrator following their completion; thus, a lack of anonymity may have influenced participants’ evaluation. Further, the racial mismatch between participants and the D-BAP administrator may have affected participants’ responses, particularly in regards to the working alliance. Participants may have felt uncomfortable working with someone who was White, particularly on a topic as sensitive and personal as breastfeeding.

In the semi-structured interview, respondents reported feeling that the statements on the cards were applicable to them and the structure of the assessment process was helpful in helping them consider their own unique barriers and facilitating factors. In addition, participants reported feeling heard and respected in the process. The SEQ and

SRS demonstrated that participants’ experiences with the D-BAP were positive overall, indicating it was both smooth, and deep. Additionally, most women reported having established a moderate to high working alliance with the D-BAP administrator.

During a question regarding the utility of the D-BAP, several women asserted that it was helpful, particularly as it increased their awareness regarding specific barriers to breastfeeding. For those who had breastfed before it reminded them of some of the

203 challenges they faced, while those with no breastfeeding experience may have been introduced to a number of breastfeeding barriers that they had not previously considered.

This is important to take into consideration, particularly in light of the findings related to breastfeeding intent and self-efficacy.

Impact on breastfeeding intent and self-efficacy. This study hypothesized that the completion of the D-BAP would be associated with a statistically significant increase in a woman’s breastfeeding intent and self-efficacy. In the case of breastfeeding intent, this hypothesis was not supported. This finding may indicate that the D-BAP is not effective in significantly increasing participants’ intent to breastfeed. Alternatively, this could be an indication of a biased sample. Considering the recruitment process retrospectively reveals one mechanism through which this sample may have inadvertently been skewed. All of the study recruitment and screening materials informed women that they were only eligible to participate if they were planning on breastfeeding. A woman might have only expressed interest in such a study if she already had a high level of intent to breastfeed. If she was undecided or ambivalent about breastfeeding, she may have self- selected out of the study. Thus the sample may have inherently been biased in that it might have only been comprised of women with a relatively high intent to breastfeed at baseline. An examination of the IFIS pretest supports this; 64% of the sample at the pretest stated they either somewhat or very much agreed that they would be breastfeeding at 3 months postpartum. Further, 88% reported that they somewhat or very much agreed that they were planning to exclusively breastfeed. In order to get a better understanding of whether there is a relationship between completion of the D-BAP and a woman’s

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intent to breastfeed, more women would need to be enrolled, with a greater variance

regarding level of intent to breastfeed.

In the case of self-efficacy, the hypothesis that participation in the D-BAP would

be associated with an increased level, as measured by the BSES-SF, was supported.

Overall, participants demonstrated a statically significant increase in self-efficacy, with a

medium effect size among those with breastfeeding experience, and a strong effect size

among women with no previous experience. This is important as a woman’s breastfeeding self-efficacy in the prenatal period is positively associated with an

increased rate of breastfeeding initiation and continuation (McCarter-Spaulding &

Dennis, 2010).

Although the data indicated a statistically significant increase in breastfeeding self-efficacy, it is still interesting to consider the five women for whom the D-BAP was associated with a decrease in breastfeeding self-efficacy. Although it is possible that the identification of breastfeeding barriers might lead some women to feel less confident in their ability to breastfeed, these findings may instead indicate a response-shift bias. A response shift may occur when an instrument is not simply measuring an individual’s change on a given dimensions, in this case self-efficacy, but when it is also capturing a change in the subject’s comprehensive of an issue (Howard, 1980). The decrease in breastfeeding self-efficacy for these five women may indicate that their initial response on the BSES-SF may not have been rooted in a comprehensive understanding or consideration of all of the barriers to breastfeeding. If this is the case, this raises a question about the appropriateness of a pre-post measure; the use of a retrospective

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pretest may be more valid (Hill & Betz, 2005). Prior to the design and implementation of

a full-scale study, a retrospective pre-post design should be considered to determine

whether it would be a more valid representation of the impact of completing the D-BAP

on a woman’s breastfeeding self-efficacy.

Future studies could also benefit from assessing self-efficacy longitudinally for women who participated in the assessment process. For some, after participating in the

D-BAP, their feedback indicated an increased awareness of the barriers to breastfeeding.

The identification of barriers may have a differential impact on women, depending on whether the introduction of challenges motivates them, or if they respond by feeling overwhelmed by them. If a woman was planning on breastfeeding, and expected the process to be easy and natural, introducing her to some of the ways it may be difficult could be disempowering in the short-term, but useful in the long run. Thus additional research is needed to explore the differential impact of the assessment.

Conclusions & Recommendations

The purpose of a feasibility study can be summarized as an exercise designed to provide insight that can be utilized in the design of a full study (Melnyk & Morrison-

Beedy, 2012). The data collected in Phase 3 documents the women’s experiences of the

D-BAP and demonstrates the relationship between completion of the D-BAP on women’s breastfeeding self-efficacy and intent. It not only provided preliminary insight into ways the assessment process may be useful, it also suggested a number of modifications which can inform a full study. With the D-BAP, the administration to 25 women provided the researcher with an in-depth understanding of some of the challenges of this research

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design, as well as some improvements to the D-BAP content and process that could be

made.

Regarding recruitment, engaging low-income, pregnant African American women, especially those who were planning on breastfeeding, again proved very difficult. Women faced many of the same limitations to participation in Phase 3 as they did in Phase 1, including a lack of transportation and childcare. For a full study, recruitment strategies should include an effort to be embedded in a health care center. A woman attends multiple appointments with an obstetrician during the prenatal period, and may be more amenable to participating in a study if it does not require additional time or effort.

As one participant suggested in Phase 2B, after administering the D-BAP to 25 women it became apparent that having a menu of standardized resources may be beneficial. Although in some instances women generated creative ideas to address their own barriers, by and large the solutions women proposed remained consistent. For example, women who asserted that they had no knowledge regarding how to breastfeed were asked to generate some ideas regarding how they could get this information. In response, most stated that they could take a breastfeeding class. When pressed, however, many women were unsure about where and when classes were offered. Having a pre- established list of classes in the community, tailored to the neighborhood in which the woman resided, may increase the woman’s follow-through in getting connected to community resources.

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In regards to the implementation of the current study, another limitation is that

women may have been unwilling to discuss breastfeeding with someone unfamiliar to

them, especially a cultural outsider. In order to better understand the effectiveness of the

D-BAP, a full research study should include the training of WIC peer helpers to administer the assessment process. Research demonstrates the effectiveness of the peer helper in increasing breastfeeding duration and exclusivity, especially for women with low breastfeeding self-efficacy (Srinivas, Benson, Worley, & Schulte, 2015). Although this introduces a new set of challenges such as implementation fidelity, it would provide insight into how the D-BAP can feasibly be used in a practice setting. Additionally, if this assessment is used in a clinic setting, it would be possible to randomize the treatment, which would strengthen the internal validity of the study. It would also serve to foster a relationship between the peer helper and the pregnant woman, which can extend into the postpartum period. This provides a venue for longitudinal data collection, which is critical in order to determine whether the D-BAP impacts self-efficacy and intent, as well as breastfeeding behavior including initiation, duration, and exclusivity.

Study limitations. This feasibility study faced limitations, particularly related to data collection. As discussed, women experienced difficulty with the data collection instruments, and this feedback was provided directly to the administrator, thus the data likely reflect some response bias. Additionally, given the difficulties with the SEQ and the SRS, these results should be interpreted with caution. If women’s experiences of the

D-BAP are to be measured in future studies, the development of an instrument specific to this use, should be considered.

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The generalizability of the study is also limited; because individuals were able to

self-select into the study, sampling bias has occurred. This is apparent in the non-

normality of the initial breastfeeding self-efficacy and intent data. In both instances, the distribution of the data was negatively skewed, indicating that individuals who agreed to participate in the study had a stronger intent to breastfeed and higher self-efficacy levels than the general population.

The validity of the pre-post design, particularly related to self-efficacy, may also

be a limitation of this study. Some of the women may have had an inflated sense of self-

efficacy prior to completing the D-BAP. After completing the card sort and breastfeeding planning process women may have been apprised of the potential barriers to breastfeeding, and may have emerged with a more comprehensive understanding of the work of breastfeeding. This might impact women’s conceptualization of their confidence

to meet their breastfeeding goals, and thus would impact the validity of the BSES-SF.

Another limitation of this study is that it is temporally constrained; the evidence generated does not connect to a woman’s actual breastfeeding behavior, only her intentions and self-efficacy. Future research on the utility of the D-BAP must employ a longitudinal design. This will not only contribute to the literature on the connections between breastfeeding intent, self-efficacy, and behavior, it will also demonstrate what impact, if any, the D-BAP has on breastfeeding initiation and persistence.

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Chapter 6: Conclusions

Conclusions specific to each phase of the study were presented at the culmination

of each research chapter; this concluding chapter provides reflections related to the

overarching framework and methodologies employed in this study. This chapter also

examines the extent to which the aims of CBPAR research have been met.

Mixed Methodologies

This study drew upon the foundations and theoretical assumptions of both qualitative and quantitative research methodologies. Qualitative research was utilized to gather insights and input from pregnant and postpartum women related to their perceptions of breastfeeding in Phase 1, and their experiences of the D-BAP in Phase 2B and Phase 3. Lactation specialists were engaged through qualitative methodologies in

Phase 1, and both scholars and practitioners provided open-ended input in Phase 2A, and

Phase 2B. Quantitative methodologies were utilized to calculate respondents’ rating of statements in Phase 2A, and to evaluate the impact of the D-BAP in Phases 2B and 3.

As noted previously, however, this amalgamation of qualitative and quantitative

research methodologies is not without tension. Invariably in mixed methods research,

components of a study do not always fit together neatly and the challenges of tying

together two different epistemological traditions must be acknowledged. These tensions

exist both as a result of the research methodologies employed (i.e. group model building

and Q-methodology), as well as the positivist or post-positivist assumptions each one 210

embodies. This tension is a conceptual one, which cannot be fully resolved here, but

rather represents an ongoing theoretical debate in social science research. This study was

posited on the assumption that both qualitative and quantitative methodologies can be

utilized in conjunction to produce quantitative research findings that are rooted in the

lived experiences of low-income African American women. Furthermore, this research

was designed with the underlying expectation that the application of critical feminist

theory and a social ecological framework could be utilized to contextualize findings.

Critical Feminist Theory and Social Ecological Framework

Critical feminist theory and social ecological framework comprised the overarching theoretical lens that informed both the design and the analysis of the study.

These theories provided a lens through which the study could explore the degree to which low-income, African American women experienced breastfeeding barriers and supports at multiple systemic levels. Barriers were explored as the result of unfortunate, but often not unintended structural arrangements that effectively work to oppress and marginalize women of color. Supports were explored as sources of resiliency and to identify the strengths-based resources low-income, African American women can harness to meet

their breastfeeding goals.

The findings discussed throughout this study, particularly those that emerged from the group model building sessions, support the applicability of these two frameworks to the issue of breastfeeding among low-income, African American women.

Many of the factors women identified as barriers to breastfeeding, from the interpersonal to the macro level, provided evidence that the structures and institutions within which

211 these women were situated, work to undermine their ability to breastfeed. This has the unfortunate consequence of further marginalizing them by undermining their self- efficacy, and contributing to the entrenchment of poor health outcomes for themselves and their children. In an attempt to demonstrate this, Support, as one of the most frequently-cited contributors to positive breastfeeding outcomes, is deconstructed utilizing critical feminist theory and a social ecological framework, in the following paragraphs.

Cultural contextualization of breastfeeding support. Support for breastfeeding was one of the themes that frequently arose throughout this research process, and support has long been understood as a mechanism through which a woman can meet her breastfeeding goals. This study, and other studies have shown that support from the baby’s father, the woman’s mother, and from her peers, is associated with an increased likelihood of a woman’s achievement of her breastfeeding goals. The danger of universally applying this term however, is that it may obscure some of the qualitatively different ways that support is experienced based on a woman’s socio-cultural context.

Support in a low-income urban African American community may be conceptually different than it is in a White, middle-class, suburban community. Support should not be understood simply as the degree to which others agree with a mother’s choice to breastfeed, or the level at which an individual provides assistance to a woman breastfeeding. Support, rather, is functionally nested within social, structural, and institutional arrangements.

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Support for low-income African American women is directly and indirectly moderated by structural factors. Taking the women who were engage in Phase 1 of this research, for example, 38% of the women were not romantically involved with their child's father; in Phase 2, 28% of the fathers were not involved. Evaluating this through a functionalist lens might lead to the conclusion that this is evidence of a moral decline and/or poor choices on the part of the individuals involved. Examining this through a critical lens, however, illuminates the devastating impacts our policies and institutions have on high poverty, African American communities.

Michelle Alexander (2010) has written extensively about the ever-increasing criminalization of African American males due to “tough on crime” laws, and disproportionate sentencing related to drug offenses. In low-income, African American communities the criminal justice system operates as a new Jim Crowe, relegating African

American males to the margins of society. Goffman picks up that work, describing the destructive impact this has had on African American communities (2014). In short it has resulted in the destabilization of support networks, leaving African American women responsible for cohesion and caregiving in their communities. This identity of the “strong

Black woman” has positive associations, such as increased self-efficacy, but it also has direct, negative implications for the women’s health, including breastfeeding (Watson &

Hunter, 2015). A woman who chooses to breastfeed needs increased physical and emotional support. Despite the pervasive message that breastfeeding comes naturally and should not be painful, the experiences of many women contradict this. In addition to being physically and emotionally difficult for many women, particularly in the early days

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and weeks, breastfeeding can also be time consuming. For women with multiple children,

taking the time to feed baby in a relaxed, seated position, may be an impossibility without

the father’s or another partner’s help in caring for other children. In these high poverty,

African American neighborhoods, time is a luxury many women are not afforded.

Another issue related to the criminalization of males is the impact it has on

putting women at risk of sexual and physical trauma. In many communities women are hesitant to report instances of sexual or physical trauma to the police, for fear of backlash from extended family, or in an attempt to protect them from the criminal justice system

(Nash, 2005). Several women during the study discussed the relationship between sexual trauma and breastfeeding. In Phase 1 the WIC peer helpers discussed their extensive experience working with women who have been victims of sexual trauma, and how this often results in the woman’s unwillingness to put baby to breast. Those who overcome these negative associations and still wish to provide their infant with breast milk will often choose to exclusively pump. As demonstrated, this often leads to supplementation with formula and has a negative impact on the duration of breastfeeding.

Another way that support may be fundamentally distinct for low-income, African

American women is the relationship between support and others’ influence on infant feeding decisions. It is common in many low-income, African American communities for support networks to be informally constructed of immediate and extended family members and friends; this can serves as a protective and buffering mechanism through which some of the stressors associated with racial marginalization are mediated

(Mendenhall, Bowman, & Zhang, 2013). While this can provide a source of emotional

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support and stability for single mothers, they may also be more vulnerable to others’ opinions regarding infant feeding practices.

The absence of the baby’s father among many low-income, African American

women may shift the woman’s primary source of support to her own mother, or another

member of her kin network. These individuals may have little experience with

breastfeeding, and may be generally unsupportive of it (Grassley & Eschiti, 2008). This is

especially important if the maternal grandmother is involved with infant caregiving.

Depending on the grandmother’s comfort handling breast milk and overall support of

breastfeeding, they may intentionally or unintentionally undermine that breastfeeding relationship by supplementing with formula while the mother is away.

During this research study several women shared stores of their mothers giving

bottles to their baby without their consent. In some instances this was due to an

unwillingness to handle breast milk, and in others it was related to the cultural myth that women do not make enough milk and that the baby is constantly hungry. This, in conjunction with other macro-level forces such as family leave laws and policies, and the challenges women face in pumping breast milk in lower-wage jobs, ultimately decreases the woman’s milk supply. Again this leads to the vicious cycle of supplementing and low milk production, which eventually leads the premature cessation of breastfeeding.

A critical theoretical lens can also uncover the support a woman receives for breastfeeding from national and state level policies. Every group model building session included a discussion about returning to work or school and how that undermined a woman’s ability to meet her own breastfeeding goals. This finding is supported through

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other studies (Fischer & Olson, 2014). Low-income women who do return to work often have to do so before her milk supply is adequately established, due to abysmal family leave policies. More likely than not, considering the inequitable system of education in

America, her only feasible work option might be in a low-wage job in sectors such as fast food or retail, or in factories. These workplaces are typically not associated with being supportive of breastfeeding; even though a woman’s right to pump during work is protected by federal law, this is not always honored. In Phase 3, several women mentioned that they were afraid to ask for the time and space to pump for fear that they would lose their job. Thus low-income a woman who must return to work shortly after delivering her baby has her support critically undermined through a complex interplay of structures and institutions.

An examination of some of the demographic characteristics of the sample engaged in this study demonstrates the vulnerable position these women occupy. In Phase

1, nearly 80% of the women lived on a monthly household income that was less than

$1,100 and 76% of the women had a high school diploma or less. In Phase 3, these percentages were 72% and 84%, respectively. For women who are currently pregnant, who have no substantive paid leave laws and no financial safety net, retaining their employment is likely their first priority. If breastfeeding is seen as a threat to that, it reasonable to expect that it would be discontinued.

Breastfeeding support, or lack thereof, is also the direct result of institutional policies and practices related to health professionals as well. Not only did women report getting conflicting messages from different health providers, those who did have

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breastfeeding experience often reported that they did not receive lactation support in the

hospital. This anecdotal evidence supports research demonstrating decreased

breastfeeding support in hospitals and communities serving low-income women of color

(Gee et al., 2012).

At the risk of over-extending this example, this nuanced look at support was

meant to demonstrate that this singular concept is rooted in a set of structural and cultural

arrangements that are often not well understood. Support is often applied as a universal

concept in breastfeeding research studies with little recognition of the many ways that

support is experienced in fundamentally different ways by low-income, African

American women. This deconstruction and recontextualizing of support as a function of

structural and institutional oppression can be replicated with each one of the factors identified in Phase 1.

Moving from conceptualization to action. Until the nuances of these

mechanisms that serve as barriers to breastfeeding are better understood, any intervention

to address them may be ineffective or may possibly even further marginalize women.

This is problematic as breastfeeding, as mentioned, has been associated with a wide-

range of health benefits for both mother and child (Victoria et al., 2016). Breastfeeding is

a mechanism which could possibly serve to improve the health of low-income African

Americans in both the short and long-term. Thus this represents a critical social justice issue given the pervasive and entrenched health disparities for this population (Centers for Disease Control and Prevention, 2013b). Nonetheless it remains a health behavior that

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is often overlooked or ignored in targeted efforts to improve the health of people of color

(U.S. Department of Health and Human Services’ Office of Minority Health, 2011).

This demonstrates a need for a culturally grounded understanding of the problem,

as well as for culturally responsive, flexible interventions. This research represents one effort to work towards that achievement. Unequivocally, this study is not meant to be interpreted as a terminal study through which breastfeeding behaviors in low-income,

African American communities have been definitively identified, nor conclusively addressed. Rather this represents an attempt to work incrementally toward that goal. This purpose, as well as the recognition of the need for a study design that honored the knowledge of community members, and methodologies that worked to achieve a more equitable exchange of information, is what led to the selection of CBPAR as a research methodology. The following section discusses to what extent the aims of CBPAR were achieved.

Community Based Participatory Action Research

The questions, inevitably, that any CBPAR design must answer, is what constitutes the A (action) in CBPAR, and how is that action measured in order to ensure the research is not reproducing patterns of inequity? This section will explore that question in the context of this research, and will identify the efforts to achieve reciprocity

between the researcher and research participants.

This study represents an effort to understand and address breastfeeding disparities

among low-income, African American women as a public health concern and as a social justice, health gap imperative. Some could argue that the extensive steps involved with

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group model building in Phase 1 were unnecessary, and that the information could have

been extracted from existing literature. As a cultural outsider who values a constructivist

approach to research, I felt that only ethical way to conduct this research was to work

directly with the women, and, to the extent possible, ensure the research activities were

mutually beneficial.

There is a long history, particularly in communities where institutions of higher

education are nested, of researchers parachuting into communities, extracting information, and leaving those neighborhoods as they were. This compounds the mistrust many African Americans have regarding research participation, particularly in medical and health research, and in studies led by White researchers (Freimuth et al., 2001). This study recognizes that cultural mistrust, and represents an attempt to move beyond the researcher-as-parasite paradigm.

The concept of reciprocity was proposed as an alternate lens through which researchers can evaluate the extent to which they are meeting the ethical obligations of

CBPAR (Maiter, Simich, Jacobson, & Wise, 2008). At the center of this is the recognition of privilege and power in research relationships. This includes attention directed towards whose knowledge is considered authentic, and the degree to which community members are engaged in research practices (Janes, 2015). This represented one of the unresolved, central challenges of this study. Grounded theory was used in order to privilege the perspectives of the women, particularly in the problem- identification process (Phase 1). The experience and insight from practitioners as well as scholars was sought in Phase 2A. This was done as an effort to honor the multiple

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sources of knowledge on the topic of breastfeeding, and to cull the wisdom that has been

collected through years of experience either through research or direct work with low-

income, African American women. This inherently results in the tension “in whose

perspective is this work grounded?” The hope is that it is grounded in enough individual

perspectives to provide insight into the collective experiences related to breastfeeding

among low-income, African American women, yet not being so prescriptive that it

presumes to represent any single individual’s experience.

The methods used throughout were selected in an attempt to achieve a balance of

reciprocity. Relationships were established with WIC and with a university obstetric

clinic, and existing relationships were extended with a community prenatal program and

a federally qualified health center. In some instances, such as with WIC, prior to the design of this research study a question was posed to individuals within the organization:

“What research questions do you have related to breastfeeding and African American women?” After the study was underway, I frequently asked community partners “What could I offer that could be of help either during or after the research study?”

To date, the findings have been presented to a team of nurses working in an obstetric clinic serving a large proportion of low-income, African American women, a group of social worker trainees working in an integrated health care setting, and employees of a community program that serves a high proportion of pregnant, low- income, African American women. Plans are underway to discuss the findings with

Franklin County peer helpers, and medical personnel at a family medicine practice.

Findings also will be disseminated to the lactation experts who participated in phase 2A.

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During this phase of the research several participants reached out to express their

appreciation for the study, and requested that the findings be shared upon completion of

the project. In addition, two manuscripts will be drafted from this study, in an attempt to contribute to the knowledge base related to the source of breastfeeding disparities, to move breastfeeding into the purview of social work, and to provide insight regarding how to better support low-income, African American women who choose to breastfeed.

Certainly all of this is important, and represents a first step in fulfilling the

“action” obligation. Unfortunately, however, it does not result in an immediate change for the women who participated in this research project, or for the innumerable women residing in similar communities, facing their own barriers to breastfeeding.

Empowerment is an oft-touted goal of CBPAR; it has been used quite liberally yet it

often fails to be adequately operationalized (Perkins & Zimmerman, 1995). Despite this

ambiguity, it can provide a jumping off point from which to begin working towards

reciprocity. Empowerment in the context of this study was actualized through the

recognition and honoring of the many ways that low-income, African American women

have harnessed strengths in order to work towards achieving their breastfeeding goals.

All of the research activities sought to empower the participants by prioritizing their lived

experiences, and by ensuring their insights were adequately translated through member

checking processes. The purpose of Phase 1 and Phase 3, which together engaged 42 low-

income, African American women, was to not only learn from them, but also to imbue

them with a sense of collective efficacy. Through this they may have been equipped to

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meet their own breastfeeding goals, and to also serve as a source of knowledge and

support for other breastfeeding women in their community.

A concluding analysis warranted in a study utilizing CBPAR is the identification

of what has changed as a result of the study. I would be remiss in not acknowledging the

direct impact this study has had on me. As a researcher, I gained a more inclusive

perspective of the lived experiences of low-income African American women as they relate to breastfeeding. I have a more expansive perspective of the cultural and structural context within which these women reside, and my understanding is more nuanced regarding the factors that shape their decision-making around breastfeeding. Overall, this research has provided me with a culturally-grounded foundation from which I can design and conduct culturally-responsive research. In addition, this study may further contribute to the fulfillment of “action” through the education and experience that the co-facilitator received as a result of her participation in this study. She remains directly engaged with this population around a wide range of issues related to maternal and child health. She felt that she has learned a great deal about breastfeeding and how to better engage women in discussion of this topic. Thus through the co-facilitator’s participation, the impact of this study may ripple out into the community.

The final question then is, “is it enough?” The answer, unequivocally must be

“no.” The achievement of full reciprocity within a CBPAR research study represents a lofty goal, yet one worth striving for. The efforts to fulfill the ethical obligation of

“action” in CBPAR are inherently insufficient, no matter how well-intentioned. The

“action” must ultimately be comprised of individual action, but also collective action on

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all levels; it represents a marathon, not a sprint. The barriers to breastfeeding can only be

addressed through ongoing commitment, advocacy, and empowerment. Disparities in breastfeeding rates are a direct manifestation of an inequitable society comprised of structures, institutions, policies, and practices with racial inequity deeply embedded in them. By empowering individual low-income, African American women in their efforts

to breastfeed their infants, and by working simultaneously to remove their barriers to

success on the meso and macro levels, only then will this critical public health and social

justice issue be addressed.

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Appendix A: IRB Approval Letter

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Appendix B: Email and/or Phone Script for WIC Peer Helpers

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Appendix C: Screening Script for WIC Peer Helpers

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Appendix D: Pregnant/Postpartum Recruitment Flyer

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Appendix E: Recruitment Script for Pregnant/Postpartum Participants

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Appendix F: Screening Script for Pregnant/Postpartum Participants

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Appendix G: Group Model Building Protocol

Consent will be obtained just prior to the GMB session & women will complete a demographics sheet. 1. Introduction: Welcome the woman and introduce group facilitators. 2. Describe the initial purpose: Explain to the women that our interest is in finding out their perceptions and experiences of breastfeeding, including barriers and some factors that make it easier. Emphasize that the group is not just for women who breastfed, and the purpose is not to try to convince women to breastfeed. Rather, we’re just interested in better understanding breastfeeding from their perspective. Describe the overarching process –approximately four model building sessions will be held with women, and one will be held with WIC peer counselors. The model will then be consolidated and reviewed by WIC peer helpers and a subset of women who participated in the original model building sessions. 3. Outline your role and the woman’s role. Clarify that in this process the participants are the experts. Our job as facilitators is to help guide that conversation, but ultimately we are there to learn from the women. 4. Generate ground rules: Discuss how it is natural that conflict will come up in a group conversation such as this. Everyone is approaching topic with their own perspectives and experiences, which is great, but we want to be sure that we are respectful of other’s opinions. Ask the group to generate some ground rules for our time together. Example question: What are some of the ways we can make sure everyone feels comfortable and safe in sharing their opinion? Provide a few examples if necessary, e.g. don’t interrupt, speak from your own experience, challenge ideas, not people, etc.

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5. Introduce group model building basics: Lead a conversation with participants to define the group model building process. Give a simple example so they can see how we will look for connections between variables, and feedback loops. Explain that from this conversation we are going to be building a model or a map of factors that impact breastfeeding and how they are related. 6. Generate variables: Begin by asking participants to reflect on a few questions. What does breastfeeding mean to you? How is breastfeeding perceived in your community? Ask women to join in groups of two or three to discuss these questions for 2-3 minutes, then ask them to share with the larger group. Summarize some of the main points raised. Next, ask participants to first make a list of things that make it easier to breastfeed. Encourage them to brainstorm and list everything they can think of, even if they think it is not important. Then, ask them to make a list of things that make it hard to breastfeed. Starting with factors that make breastfeeding easier, go around the room and ask women to share one factor. Write each response down on a separate sticky sheet. Go around the room until all responses are captured. Group together and reword, if necessary, any factors that seem similar. With each step of the process, check in with the group to get their feedback before making any changes. Repeat this process with the breastfeeding barriers. 7. Initiate and elaborate a casual loop diagram: Write breastfeeding in the center of a large sheet of paper. Ask participants which variable they would like to start with, to describe how it affects breastfeeding. Ask for clarification on the relationship between that variable and breastfeeding. Ask probing questions about other variables that might interact with that one to elicit causal loops. The co-facilitator should be making these changes to the model directly to represent the conversation. Check in with the group on an ongoing basis to see if all agree to changes or if there are other perspectives. Continue this process with the variables captured. If a factor or relationship between factors is unresolved, “park” that factor and move on to another. Revisit that factor towards the end of the model building session. 8. Model review: Once the group seems to be approaching a final model, lead the group through a model review. Ask the women to take a look at the model, and to raise any residual concerns or make any last minute amendments.

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9. Dots- Select critical factors: Once the women feel comfortable with the model that has been constructed, emphasize that there are a lot of variables, and we would like to get a sense of which are the most important to breastfeeding. Provide each woman with three red dots. Ask her to stick a dot on the three factors that she feels are most important, or that have the biggest impact on breastfeeding decision making and/or behavior.

10. Reflector Feedback: The facilitators should then summarize the model and provide feedback. Thank the participants for their time and emphasize what an important contribution they have made. Let the women know that if they have any questions, or would like to further discuss anything with either of the facilitators that they will be available immediately after the model building session or by email or phone. 11. Capture the Model: Facilitators should take photos of the model to ensure data is not lost in transferring the paper. Then collect materials for later electronic transcription of the model.

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Appendix H: Consent

The Ohio State University Consent to Participate in Research

Developing a Culturally Grounded Breastfeeding Study Title: Assessment for Low-Income African American Women: Phase 1 Researcher: Dr. Audrey Begun, PhD & Rebecca Reno, MSW

Sponsor: OSU College of Social Work

This is a consent form for research participation. It contains important information about this study and what to expect if you decide to participate. Your participation is voluntary. Please consider the information carefully. Feel free to ask questions before making your decision whether or not to participate. If you decide to participate, you will be asked to sign this form and will receive a copy of the form.

Purpose: You are being asked to participate in this research study to help researchers understand some of the factors that influence infant feeding decisions. Researchers are especially interested in identifying some of the barriers to breastfeeding, and some of the factors that help make breastfeeding easier.

Procedures/Tasks: You are being asked to voluntarily participate in a focus group. A facilitator will ask you a series of predetermined questions related to your perception of breastfeeding, and your experience with different infant feeding practices. You do not have to have experience breastfeeding to participate in this research.

Duration: Two hours You may leave the study at any time. If you decide to stop participating in the study, there will be no penalty to you, and you will not lose any benefits to which you are otherwise entitled. Your decision will not affect your future relationship with The Ohio State University, with WIC, or with your healthcare provider.

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Risks and Benefits: Because this research is taking place in a group setting, there is the possibility other participants could share your responses outside of the group. We will make every effort to minimize this risk by establishing group norms of respect and confidentiality. You may benefit from this research through the opportunity to better understand factors that shape infant feeding decisions, solidify your perspective and experience, and hear the perspective and experiences of others. Further, you may find it rewarding to participate in a research project that will help women in situations similar to yourself.

Confidentiality: This group session will be digitally recorded and transcribed for data analysis. The recording will be stored in a locked file cabinet in the College of Social Work for safety. The transcript will be stored on a secure, password- protected computer Only the principle investigators will have access to the recording and transcript. The recording will be erased once it is transcribed. Also, because this research is taking place in a group setting, other participants will hear your responses, and there is the possibility they could share information outside of the group. Therefore, confidentiality cannot be guaranteed, but we will make every effort to instill group norms of respect and confidentiality to prevent breaches of confidentiality by group members.

Agencies (WIC, health care providers, etc.) will not have access to any lists of participants. They will not be aware of who chose to participate in the research and who did not, and they will not see any identifiable study data.

Efforts will be made to keep your study-related information confidential. However, there may be circumstances where this information must be released. For example, personal information regarding your participation in this study may be disclosed if required by state law. Personnel in this study are mandated reporters and must disclose evidence of child abuse, threats of violence to self or others, and reasonable knowledge that a felony has been (or is being) committed.

Also, your records may be reviewed by the following groups (as applicable to the research):

• Office for Human Research Protections or other federal, state, or international regulatory agencies; • The Ohio State University Institutional Review Board or Office of Responsible Research Practices; • The sponsor, if any, or agency (including the Food and Drug Administration for FDA-regulated research) supporting the study.

Incentives: Each individuals will be given a $20 Kroger gift card.

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Participant Rights: The group model building session involves research, and your participation is voluntary. You may withdraw at any time without penalty.

You may refuse to participate in this study without penalty or loss of benefits to which you are otherwise entitled. If you are a student or employee at Ohio State, your decision will not affect your grades or employment status.

If you choose to participate in the study, you may discontinue participation at any time without penalty or loss of benefits. By signing this form, you do not give up any personal legal rights you may have as a participant in this study.

An Institutional Review Board responsible for human subjects research at The Ohio State University reviewed this research project and found it to be acceptable, according to applicable state and federal regulations and University policies designed to protect the rights and welfare of participants in research.

Contacts and Questions: For questions, concerns, or complaints about the study, or if you feel you have been harmed as a result of study participation you may contact Becky Reno, 614-354-5201 or Audrey Begun, PhD 614-292-1064.

For questions about your rights as a participant in this study or to discuss other study- related concerns or complaints with someone who is not part of the research team, you may contact Ms. Sandra Meadows in the Office of Responsible Research Practices at 1- 800-678-6251.

If you are injured as a result of participating in this study or for questions about a study- related injury, you may contact Becky Reno, 614-354-5201 or Audrey Begun 614-292- 1064.

Signing the consent form I have read (or someone has read to me) this form and I am aware that I am being asked to participate in a research study. I have had the opportunity to ask questions and have had them answered to my satisfaction. I voluntarily agree to participate in this study.

I am not giving up any legal rights by signing this form. I will be given a copy of this form.

Printed name of subject Signature of subject

AM/PM Date and time

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Printed name of person authorized to consent for subject Signature of person authorized to consent for subject (when applicable) (when applicable)

AM/PM Relationship to the subject Date and time

Investigator/Research Staff I have explained the research to the participant or his/her representative before requesting the signature(s) above. There are no blanks in this document. A copy of this form has been given to the participant or his/her representative.

Rebecca Reno Printed name of person obtaining consent Signature of person obtaining consent

AM/PM Date and time

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Appendix I: Demographics for Peer Helpers

Age (at last birthday):

How long have you been a WIC peer helper?

What is your estimated percentage of WIC recipients you work with who are African American? %

Check the ethnicity you identify with:

O Hispanic or Latino O Non-Hispanic or non-Latino

Check the race category that you identify with (you may check more than one):

O American Indian or Alaskan Native O Asian O Black or African American O Native Hawaiian or other Pacific Islander O White O Other

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Appendix J: Demographics for Pregnant/Postpartum Participants

Age (at last birthday):

Pregnant?

O Yes O No

If yes, how many weeks pregnant?

Have you given birth to any other children?

O Yes O No

If yes, did you breastfeed any of them?

O Yes O No

If yes, what is the longest length of time you breastfeed?

What is the highest grade in school (including GED) that you completed? O 1-7 years grade school O 8 years grade school O 1-3 years high school O High school graduate O 1-3 years college O College graduate O Post graduate

Average monthly household cash income (do not include food stamps):

O Less than $800 O $801 – $1,100 O $1,101 – $1,400 O $1,401 - $2,000 O $2,001 - $2,500 O $2,501 - $3,000 258

Check the ethnicity you identify with:

O Hispanic or Latino O Non-Hispanic or non-Latino

Check the race category that you identify with (you may check more than one):

O American Indian or Alaskan Native O Asian O Black or African American O Native Hawaiian or other Pacific Islander O White O Other

Note: The following questions ask you about your relationship with your baby’s father. If you are in a relationship with someone other than the baby’s father who will fill that role, please answer the questions below about that person.

What is your current relationship with the baby’s father? (please choose one)

O Married O Romantically involved O Separated/Divorced O Just friends O Not in any kind of relationship

Do you live together?

O Yes O No

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Mark the degree to which the father of your baby supports breastfeeding or check unsure.

O Unsure

Not at all Very Supportive Neutral Supportive

Mark the degree to which your mother supports breastfeeding or check unsure.

O Unsure

Not at all Very Supportive Neutral Supportive

Mark the degree to which your closest friend supports breastfeeding or check unsure.

O Unsure

Not at all Very Supportive Neutral Supportive

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Appendix K: Phase 1 Rating of Factors that Facilitate Breastfeeding

Number of Groups Identifying Stars Themes and Factors Each Factor Received Knowledge about Why to Breastfeed - Benefits for Baby Health Healthier baby 4 9 Has all the vitamins 1 0

261 Reduces chance of illness/builds immune system 3 0 Can breastfeed closer to surgery time than bottle feed

1 0 Reduces colic 1 0 Reduces SIDS 3 0 Reduces asthma 1 0 Better bowel system 1 0 Won’t throw up as much 1 0 Protects baby as they grow 1 0 Less time spent in NICU 1 0

Continued Table 14. Phase 1 rating of factors that facilitate breastfeeding

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Table 14 continued

Number of Groups Identifying Stars Themes and Factors Each Factor Received Emotional Baby happier/less crying 2 0 Mom is a pacifier 1 0 Baby has a better attitude 1 0 Intelligence Baby is more accelerated/intelligent/higher IQ 4 2

262 Knowledge about why to Breastfeed - Benefits for Mother

Most natural thing a mother can do 1 0 Physical Health benefits that fit each family’s situation 2 1 Moms’ health benefits 3 6 Breasts stay firmer longer 1 0 Weight loss 2 0 Uterus shrinks quicker 2 0 Baby goes back to sleep faster at night 2 0 Reduces the risk of cancer in moms 1 0 Increased libido 1 0 Delays menstruation 1 0

Continued 262

Table 14 continued

Number of Groups Identifying Stars Themes and Factors Each Factor Received Emotional Stress reliever 1 0 Relaxing 1 0 Less likely to have postpartum depression 1 0 Material Cheaper 4 5

263 Support

Baby’s Father Physical support from baby’s father 1 0 Emotional support from baby’s father 4 0 Peer 0 Peer support 7 0 Support groups 1 0 Woman’s mother/family Support/influence of woman’s mother 5 2 Support from the family 1 0 Runs in the family 1 2

Continued

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Table 14 continued

Number of Groups Identifying Stars Themes and Factors Each Factor Received Agency/Programs WIC supports/expertise 2 0 Hospital support 1 0 Baby-friendly hospitals 1 0 Support from community programs 3 0 Social Acceptance

264 Social acceptance of breastfeeding 1 0

Getting praise for breastfeeding 1 0 Knowing where to breastfeed baby in public (nursing rooms) 2 0 Having places to breastfeed or pump at work/school 2 0 Comfortable in public 1 0 Religion 1 0 Breastfeeding as a trend 1 0 Workplace acceptance 1 0 Facebook/social media 1 0

Continued

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Table 14 continued Number of Groups Identifying Stars Themes and Factors Each Factor Received Convenience Convenience 1 5 Food always with you/easy access 2 3 Milk is at the proper temperature 2 Baby sleeps longer 1 1 Convenient at night 1 0 No measuring 1 0 265 Don’t have to make/wash bottles 1 0

Light diaper bag 1 0 Time management 1 0 Patience/Persistence Determination to breastfeed 1 0 Patience 2 0 Self-esteem 1 1 Confidence 2 0 Perseverance 1 0 Positive attitude 1 3 Trying it out 1 0

Continued

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Table 14 continued Number of Groups Identifying Stars Themes and Factors Each Factor Received Knowledge about How/Why to Breastfeed - General Awareness – word of mouth 1 0 Knowledge/information about why to breastfeed 3 0 WIC 1 0 Breastfeeding education programs 2 2 Knowing where to go to ask questions 1 0 Knowing how to breastfeed 2 2

266 Knowledge about breastfeeding benefits 1 1

Supplies/Tools Having the right materials (nipple shields, breastfeeding covers, nursing bras, etc.) 4 7 Having a pump 2 0 Knowing how to hand express milk 2 0 Emotional Benefits/Bonding Bonding with the baby 7 17 Feeling needed/wanted/valuable 2 0 Getting alone time with the baby 2 0

Fun 1 0 Empowering 1 0 Skin to skin 1 3

Continued

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Table 14 continued

Number of Groups Identifying Stars Themes and Factors Each Factor Received Pumping Pumping 3 0 Pumping more socially acceptable 1 0 267

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Appendix L: Phase 1 Rating of Factors that Make Breastfeeding More Challenging

Number of Groups Identifying Stars Themes and Factors Each Factor Received Lack of Support Religion/belief system 2 0 Lack of peer support 1 0 Society doesn’t accept 1 0 268 Overall lack of support 6 3 Lack of professional support Receiving different messages – doctor, family, lactation counselor 2 1 Medical provider puts baby on formula (nurse/doctor) 1 0 Doctors aren't educated about breastfeeding 2 0 Lack of institutional support No postpartum hospital class for breastfeeding 1 0 Lack of services for breastfeeding support 2 0 Negative energy/negative people 3 0 Baby's dad doesn't support 2 0

Continued

Table 15. Phase 1 rating of factors that make breastfeeding more challenging 268

Table 15 continued

Number of Groups Identifying Stars Themes and Factors Each Factor Received Mother/Family/Tradition 4 0 Mother didn’t breastfeed 1 0 Not knowing how to talk to or educate family on breastfeeding 1 0 Emotional Barriers Stressful 1 5 Lazy 1 1 No patience 1 1 269 Loss of interest 1 0

Negative attitude 1 0 Takes a lot of work 1 2 Postpartum depression 1 0 Feel weird/it’s nasty 3 2 “These breasts are mine” 1 0 Discomfort Breastfeeding in Public/Around Others Fear of breastfeeding in public 3 0 Fear of perverts staring at breasts 1 0 Discomfort breastfeeding/pumping around others 1 0 Don’t live alone/ live in a shelter 1 0 Embarrassed 1 4 Privacy is hard when baby is distracted 1 0 Continued 269

Table 15 continued

Number of Groups Identifying Stars Themes and Factors Each Factor Received Older baby 1 0 Larger breasts 1 0 Controversy about breastfeeding in public 1 0 Baby's Dependence on Mom Baby is attached at the hip 2 5 Father wants to be involved with feeding/bonding 1 3 Don’t want to spoil the baby 2 0 270 Other people can’t feed 1 0

Can’t leave the baby with others 1 0 Mom is a pacifier 1 2 Baby always wants your attention 1 0 Baby doesn’t want to sleep away from you 1 0 Physical Barriers to Breastfeeding Pain (latch/engorgement) 6 11 Discomfort 1 0 Baby biting 1 0 C-section recovery 1 1 Low milk production 2 2 Medically unable to breastfeed (breast cancer, implants, breast reduction, AIDS) 2 2 Breast structure/size/shape 3 2 Continued 270

Table 15 continued

Number of Groups Identifying Stars Themes and Factors Each Factor Received Sexualization of Breasts Breasts are sexual 2 2 “These breasts are my boyfriends” 2 0 Women were molested/sexual trauma 1 0 Feel like you’re sexually molesting your baby 1 0 Feel weird feeding male baby 1 0 Afraid the baby will turn gay 271 1 0 Impact of Breastfeeding on Mom's Lifestyle

Limits socializing 2 0 Not able to party 2 2 Can’t drink 5 1 Can’t smoke 3 2 Can’t do drugs 1 0 Less sleep 1 0 Lack of Breastfeeding Knowledge No early education about breastfeeding (e.g. child care classes) 1 0 Don’t know how/lack of skill 3 2 Not knowing all the benefits 1 0

Continued

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Table 15 continued

Number of Groups Identifying Stars Themes and Factors Each Factor Received Pumping Pumping 3 0 Thinking pumping is reflective of supply 1 0 Pumping is time consuming 1 1 Pump is hard to get 1 0 Time Consuming Time consuming 4 2

272 Busy schedule/life 2 1

Lack of help with other kids 2 0 No time with partner 1 0 Exhausting 1 4 Cultural Beliefs Lack of cultural support “Black people don’t breastfeed” 1 0 Lack of cultural knowledge “do Black people breastfeed? 1 0 No expectation of breastfeeding 1 0 History of breastfeeding during slavery 2 0 Concerns about Impact on Mother's Body Weight gain/hungry 2 1 Breasts different/saggy 2 1 Decreases libido 2 0 Continued

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Table 15 Continued

Number of Groups Identifying Stars Themes and Factors Each Factor Received Returning to Work or School Going back to work/school 5 5 Daycare 1 0 Inconvenience Inconvenient 1 0 Baby wakes more frequently 2 1 WIC – receiving formula, especially in the 1st month 1 0 273

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Appendix M: Phase 2B and 3 Semi-Structured Interview Protocol

1. Do you feel like this activity was helpful to you for meeting your breastfeeding goals?

a. If yes, what parts of the process were helpful?

2. In what ways do you feel like this process could be improved?

3. Wording on the card: Do you feel like the cards captured the issues that are the most important to you?

4. Instructions:

a. How clear was the initial card sorting process? (putting cards into three stacks).

b. How clear was the ranking process (top 3 barriers, top 3 supports)?

5. Was the length of the activity appropriate?

6. Any other comments?

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Appendix N: Session Evaluation Questionnaire

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Appendix O: Session Rating Scale

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Appendix P: Meeting My Breastfeeding Goals Handout

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Appendix Q: Breastfeeding Information and Myths Handouts

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Adapted From Office on Women’s Health U.S. Department of Health and Human Services http://www.womenshealth.gov/itsonlynatural/

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Myth: If your breasts are too small, you can’t breastfeed. Size and shape of breasts do not affect ability to breastfeed and have nothing to do with how much milk a woman actually produces. This includes women with large areolas (the area around the nipple), flat nipples, and even women who’ve had breast surgery.

Myth: If your breasts are too large or you’re plus size, you can’t breastfeed. Women of all sizes can successfully breastfeed. So if you’re a larger mom-to-be, you should not let the size of your breasts automatically rule it out. If you’re big breasted, it may take some extra patience or some assistance from a lactation consultant. But with the right help and support, you can do it.

Myth: You won’t be able to make enough milk. Moms almost always make enough milk to feed their babies. Your baby is likely getting more than you think at each feeding. A newborn's stomach is only the size of an almond. If you have any concerns about your milk supply or your child's weight, check in with your baby's doctor or nurse.

Myth: Your milk will turn sour or dry up. A woman’s body can do many amazing things, but curdling milk inside your breasts isn’t one of them. And don’t worry about your milk drying up; breastfeeding is a simple case of supply and demand. As long as you’re breastfeeding (or pumping) regularly, your body will make more milk. Only if you stop breastfeeding, skip feedings, or start supplementing with formula will your milk production go down.

Myth: You need to supplement, because your baby seems hungry or is crying all the time. When you breastfeed on demand, your baby stays satisfied. Remember, newborn tummies are tiny, so they fill up fast, empty, and then need to be filled up again. Also realize a baby cries for reasons other than hunger — sleepiness, feeling gassy or sick, having a dirty diaper, or just needing to be held.

Myth: Bigger babies are healthier babies. The idea that big, chubby babies are healthier babies is not necessarily true. Every baby grows at his or her own pace, which is monitored at every well-baby visit by a doctor or nurse. Breastfed babies know how to self-regulate, which means they stop eating when their tummy is full, not when the bottle is empty.

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Myth: Breastfeeding spoils a child. After spending nine months growing inside you, it’s completely natural for a baby to be attached to his or her mother and vice versa. Despite what you’ve heard, newborns don’t need to learn to fend for themselves at such a young age. In reality, breastfeeding provides a unique bond with your child that can last a lifetime.

Myth: Breastfeeding hurts. The truth is that breastfeeding is not supposed to be a painful experience. In fact, pain is usually a red flag that something is wrong. While a baby’s latch can be strong, it’s not actually biting, not even when the baby is cutting teeth. As with any new skill, there is an adjustment period.

Myth: You can’t breastfeed in public. In Ohio, the law allows you to nurse wherever you and your baby have a legal right to be. The law does not say you have to be covered up, but if it makes you more comfortable there are ways to discretely cover up.

Adapted from the Department of Health and Human Services: It’s Only Natural Additional information can be found at: http://www.womenshealth.gov/itsonlynatural/

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Appendix R: D-BAP Administrator Sheet

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Appendix S: Infant Feeding Intentions Scale

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Appendix T: Breastfeeding Self-Efficacy Scale – Short Form

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Appendix U: Infant Feeding Intention Scale Results

Pre-test Post-test

Item Median M (SD) Range Median M (SD) Range I am planning to only formula feed my baby (I will not breastfeed at all) 4.00 3.44 (1.04) 0-4 4.00 3.48 (1.05) 0-4

I am planning to at least give breastfeeding a try 4.00 3.88 (0.60) 1-4 4.00 4.00 (0.00) 4 When my baby is 1 month old I will be breastfeeding

291 without using any formula or other milk 4.00 3.16 (1.14) 0-4 4.00 3.36 (0.91) 2-4

When my baby is 3 months old I will be breastfeeding without using any formula or other milk 4.00 3.12 (1.13) 0-4 4.00 3.28 (0.98) 1-4

When my baby is 6 months old I will be breastfeeding without using any formula or other milk 2.00 2.72 (1.10) 0-4 3.00 2.96 (1.06) 1-4

Total Score 14.00 12.66 (3.752) 15 13.34 (3.051)

Table 16. Infant feeding intention scale results

Note. Scale range from 0-4.

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Appendix V: Breastfeeding Self-Effiacacy Scale - Short Form Results

Pre-test Post-test

Item Median M (SD) Range Median M (SD) Range I will always be able to determine that my baby is getting enough milk 4.00 3.92 (1.04) 2-5 4.00 4.04 (0.89) 2-5

I will always be able to successfully cope with breastfeeding like I have with other challenging tasks 5.00 4.36 (0.81) 2-5 5.00 4.48 (0.77) 3-5

292 I will always be able to breastfeed my baby without 4.00 3.68 (1.07) 2-5 4.00 3.92 (1.04) 2-5 using formula as a supplement

I will always be able to ensure that my baby is properly latched on for the whole feeding 4.00 4.04 (1.10) 2-5 4.00 4.12 (0.97) 2-5

I will always be able to manage the breastfeeding situation to my satisfaction 4.00 3.96 (1.02) 2-5 4.00 4.24 (0.66) 3-5

I will always be able to manage to breastfeed even if my baby is crying 4.00 3.96 (0.98) 2-5 4.00 4.16 (0.80) 2-5

Continued

Table 17. Breastfeeding Self-Efficacy Scale results

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Table 17 continued

Pre-test Post-test

Item Median M (SD) Range Median M (SD) Range I will always be able to keep wanting to breastfeed 4.00 3.72 (1.10) 1-5 5.00 4.28 (0.98) 2-5

I will always be able to comfortably breastfeed with my family members present 5.00 4.40 (1.16) 1-5 5.00 4.32 (1.11) 1-5

I will always be able to be satisfied with my breastfeeding experience 4.00 3.92 (0.95) 2-5 4.00 4.08 (0.86) 2-5

I will always be able to deal with the fact that

293 breastfeeding can be time consuming 4.00 4.36 (0.70) 3-5 4.00 4.36 (0.70) 3-5

I will always be able to finish feeding my baby on one breast before switching to the other breast 4.00 3.84 (1.03) 2-5 4.00 3.72 (0.94) 2-5

I will always be able to continue to breastfeed my baby for every feeding 4.00 4.12 (1.01) 2-5 4.00 4.20 (0.96) 2-5

I will always be able to keep up with my baby's breastfeeding demands 4.00 4.00 (0.91) 2-5 4.00 4.24 (0.78) 3-5

I will always be able to tell when my baby is 4.00 3.92 (0.86) 2-5 4.00 4.08 (0.91) 2-5 finished breastfeeding Total 58.00 56.20 (9.605) 59.00 58.24 (9.955)

Note. Scale range from 1-5.

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