INFANT FEEDING KNOWLEDGE, ATTITUDES, EXPOSURE, AND INTENTIONS
AMONG NON-PREGNANT ADOLESCENTS
A Research Grant Proposal
Presented to the faculty of the School of Nursing
California State University, San Marcos
Submitted in partial satisfaction of the requirements for the degree of
MASTER OF SCIENCE
in
Nursing
(Family Nurse Practitioner)
by
Natalie Alonzo
SPRING 2016
© 2016 Natalie Alonzo
ALL RIGHTS RESERVED
ii
ACKNOWLEDGEMENTS
I would like to take the opportunity to acknowledge the network of faculty, family, and mentors that provided support and guidance through the progression of this grant proposal. Dr. Denise Boren, Dr. JoAnn Daugherty, Dr. Linea Axman, and Dr. Amy Carney guided the early development of this proposal and introduced a true appreciation for research and statistics. My committee chair Dr. Patricia Hinchberger and committee member Dr. Deborah Bennett have nurtured my proposal step-by-step through this process with their patience and passion for education. My family and mentors supported me through the necessary sacrifices to make this proposal successful. Life, health, and distance may have complicated this process from time to time, but my family and friends are truly what kept me going. They have taught me the importance of achieving my goals, never giving up, prayer is powerful, and following my heart. I am blessed to have had this opportunity to grow and develop a new appreciation for those currently in my life and those whom this journey has brought into my life. My sincere gratitude extends to all who have made this possible.
vi
PREFACE
Specific Aim
The purpose of this study is to assess the benefits of a school-based infant feeding education session in order to determine perceived breastfeeding knowledge, attitudes, exposure, and intentions among non-pregnant 10th, 11th, and 12th grade students, ages 15 to 19. Four measurement tools will be used to compare pre-test and post-test results with the use of a control group to enrich the quality of this study, and they include: Infant Feeding Knowledge Test Form-
A (knowledge), Iowa Infant Feeding Attitude Scale (Attitudes), Breastfeeding Exposure
Questions (Exposure), Breastfeeding Behavior Questionnaire (intention), and demographic information.
Research confirms school-based health education curriculum often lacks content that educates adolescents on infant feeding options and the health benefits of breastfeeding.
Considering the reality of pregnancy in adolescents and the lack of breastfeeding curriculum in schools it is necessary to equip adolescents with the knowledge, positive attitudes, and exposure in order to create a breastfeeding culture. It is important to introduce adolescents to these concepts with the intent to promote future breastfeeding practice. Learning the basic physiology of breastfeeding, hazards of formula feeding, family and community support, and establishing breastfeeding role models through media will initiate a socio-cultural shift. If these changes are addressed, breastfeeding initiation and retention statistics should reflect an increase overall with a decrease in health-related conditions that result from not breastfeeding.
vii
Specific Objective
To test the given hypothesis that “ Participation in a school-based infant feeding education session will deduce perceived knowledge, attitudes, exposure, and intention in 10th ,
11th, and 12th grade students, age 15-19 year-olds.
viii
Table of Contents ACKNOWLEDGEMENTS ...... vi PREFACE ...... vii Specific Aim ...... vii Specific Objective ...... viii INTRODUCTION ...... 1 Significance ...... 1 The Problem ...... 2 Nursing Implications ...... 2 Innovation: Research Hypothesis & Variables ...... 3 REVIEW OF LITERATURE ...... 5 Introduction ...... 5 Gaps ...... 17 Adolescent Psychosocial and Cognitive Development ...... 17 Applying a Theory ...... 19 Summary ...... 20 METHODOLOGY ...... 21 Introduction ...... 21 Hypothesis ...... 21 Research Variables ...... 21 Design ...... 21 Intervention ...... 22 Sample & Sampling ...... 23 Inclusion/Exclusion Criteria ...... 23 Data Collection ...... 23 Measurement Tools ...... 24 Data Management ...... 25 Data Coding ...... 25 Data Analysis ...... 26 Research Bias ...... 26 Protection of Human Subjects/Ethical considerations ...... 27 Summary ...... 27 GRANT ELEMENTS ...... 32 Potential Grants & Feasibility ...... 32 Budget ...... 33 Timeline ...... 35 REFERENCES ...... 36 Appendix A: Instruments ...... 36 Appendix B: Demographic Survey Form ...... 40 Appendix C: Informed Consent ...... 42 Appendix D: IRB Application ...... 45
ix 1
INTRODUCTION
Significance
In the world of maternal-child health there has been an ongoing socio-cultural shift that began in 1991 as a result of the United Nations International Children's Emergency Fund
(UNICEF) and World Health Organization (WHO) Baby Friendly Hospital-Initiative based on the “10-steps to Successful Breastfeeding” (UNICEF, 1991). The primary shift resulted from research that identified health benefits to both mother and baby with a direct correlation to breast milk and breastfeeding. It was determined that properties contained in breast milk decreased the risk of chronic diseases like asthma, atopic dermatitis, Sudden Infant Death Syndrome (SIDS),
Type 1 Diabetes, obesity, and leukemia in newborns (NAPNAP, 2011). The act of breastfeeding was found to decrease risk for postpartum hemorrhage, metabolic disease, cardiovascular disease, and the incidence of ovarian and breast cancer (NAPNAP, 2011; Brodribb, 2012).
Based on these findings the United States (US) has identified breastfeeding as a Healthy
People 2010-2020 goal embedded within the Maternal, Infant, and Child Health objectives.
California has made efforts to meet these objectives through the sponsorship of the California
WIC Association to improve breastfeeding rates by supporting the development of the California
Breastfeeding Coalition (CBC) (CBC, 2014). The CBC has been working tirelessly over the past
12 years to promote standards set by the National Association of Pediatric Nurse Practitioners
(2011) and American College of Obstetricians and Gynecologists (2009) to support optimal nutrition in the newborn and infant for the first 6 months of life, then at 6 months in combination with appropriate solid foods to be continued for 12 months or more. Despite these efforts, there is an on-going struggle to improve breastfeeding initiation and retention rates.
1 2
The Problem
In order to improve breastfeeding rates overall, research has identified adolescents as an ideal, developmentally appropriate segment of the population to introduce concepts of infant feeding with the goal of promoting a socio-cultural shift that establishes a breastfeeding culture
(Allen, 2008; Leffler, 2000; Spears, 2007). The California School Health Centers Association
(CSHCA) has had guidelines and a definition of sexual health education; however, it does not directly address breastfeeding and/or infant feeding education as a health promoting behavior in their curriculum (CSHCA, 2010). Based on the 1999-2006 National Center for Health Statistics
(NCHS) data brief, the survey identified adolescents as a vulnerable population with low incidence of postnatal breastfeeding (McDowell, Wang, & Kennedy-Stephen, 2008). Currently, there is little to no school-based education related to breastfeeding and/or infant feeding in school curriculum which is contributing to the low breastfeeding retention rates in California
(Allen, 2008; Marrone, Vogeltanz-Holm, & Holm, 2008; Leffler, 2000). Considering the reality of pregnancy in adolescents and the lack of breastfeeding curriculum in schools it is necessary to equip adolescents with the knowledge, positive attitudes, and exposure in order to create a breastfeeding culture. Therefore, prior to the stressors of pregnancy methods of providing education to non-pregnant adolescents to promote knowledge, positive attitudes, exposure, and intentions towards future breastfeeding practices need to be identified.
Nursing Implications
As introduced above, the low breastfeeding retention rates in California, and the low initiation and retention rates globally reflect a need to educate about infant feeding (Walsh et al.,
2008). Therefore, this proposal will focus on exposing non-pregnant adolescents, both male and female, to infant feeding with the hope of positively influencing future decisions to breastfeed.
2 3
By presenting infant feeding education in a school-based education setting, it allows for students to reinforce existing knowledge, introduce new concepts, clarify misconceptions, encourage reflection and dialogue, and foster healthy lifestyle choices (Walsh et al., 2008). There are many avenues to creatively present such content in school curriculum such as family studies, social studies, business, marketing, science, biology, health nutrition, history, and ecology (Hamade et al., 2014; Walsh et al., 2008). School Nurses, Public Health Nurse, and Advance Practice Nurses in the community are in a unique position to gather support and work in collaboration with teachers, school boards, parents, school groups, community groups, and public health authorities to help establish infant feeding curriculum and methods to encourage breastfeeding as a socio- cultural norm (Hamade et al., 2014; Walsh et al., 2008). This research is intended to generate data that will transition current infant feeding practice in the USA by targeting the adolescent population during a critical window when they are developing personal values and behaviors that they will take with them into adulthood.
Innovation: Research Hypothesis & Variables
The following research proposal is intended to determine the effect of an infant feeding education session on the non-pregnant adolescents’ knowledge, attitudes, exposure, and intentions. Several San Diego County high schools will be identified as an optimal learning environment that best represents the population in the greater San Diego area. The research hypothesis is: Infant feeding knowledge, attitudes, exposure, and intention for high school students who received an education session will be significantly different from the high school students who did not receive an educational session on infant feeding. There is a need to increase breastfeeding numbers in order to prevent the incidence of chronic health conditions in both mothers and infants, as well as promote a socio-cultural shift in the norms related to
3 4
American infant feeding practices. An education intervention in the non-pregnant adolescent population prior to encountering pregnancy has potential for sustained future breastfeeding practice.
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REVIEW OF LITERATURE
Introduction
The literature search was conducted using CINAHL with full-text and Google Scholar via
California State University San Marcos on-line Library. Initial search phrases included: adolescent breastfeeding health promotion, and adolescent breastfeeding education. The literature search was limited to peer-reviewed academic journal articles published after 2000.
The articles were also limited to English translation from the United States, Canada, Australia,
Ireland, Middle East, and the United Kingdom. The final literature search terms included: breastfeeding, knowledge, promotion, adolescent, teenager, and health education. There were 16 articles reviewed for inclusion and 9 articles were selected for this review. In this review the level of evidence included self-administered surveys, a qualitative study, a randomized controlled trial, a quasi-experimental control with pre-test and post-test design, and cross- sectional studies with one applying a theoretical framework. Those studies whose participants were younger than age 11 years and older than 31 were excluded. Only the studies that were conducted in a school environment with student participants were used.
In 2000, Leffler conducted a study using 100 female participants evenly distributed from grades 9 through 12 at two suburban high schools in Massachusetts, US. A self-administered survey tool made up of 18- questions was developed and used to assess “demographics, the participant’s intent to have children, her choice of infant feeding, and her knowledge of the breastfeeding benefits ”(p. 37). Majority of participants identified themselves as Caucasian, but
African American, Hispanics, Chinese, Indian, and Pakistani ethnic groups were represented as well. Data was analyzed as a whole, plus grouped according to grade; in addition, it was
“examined by exposure to breastfeeding and by infant feeding decisions” (p. 37). Differences in
5 6
“response rates by grade, breastfeeding exposure, and infant feeding decision” were analyzed using a standard chi-square calculation with the level of α of 0.05. In this group of participants it was found 79% intend to have children, 52% plan to breastfeed, and 60% reported they were breastfed. Overall data identified significance (P < 0.01) in those who were breastfed as infants and exposed to breastfeeding planned to breastfeed, saw the positive benefits for mother and infants, and found breastfeeding in public acceptable. Conversely, the girls that were least likely to choose to breastfeed had not been breastfed, or exposed to breastfeeding. Only 33% of the participants felt breastfeeding had benefits to the mother. Regarding the type of feeding and advised breastfeeding duration resulted in a wide distribution of responses. Only 34% felt it possible for working mothers to breastfeed, and out of that percent 68% planned to breastfeed
(χ2 = 13.09, P < 0.001). Both “greater awareness of breastfeeding” and “lower rates of negative perception about breastfeeding” were correlated with those who planned to breastfeed. Over all this study identified teenagers as “an important target group for breastfeeding promotion”, and consider the choice of infant feeding with the potential to choose breastfeeding.
Martens (2001) conducted a study using a randomized pre-test/post-test control group design to evaluate a breastfeeding education session. The Sagkeeng First Nation 7th and 8th grade female and male students of Canada were used. The control group received the education session following the post-test, and the intervention group received the session before. All students received a retention test 10 days later. The 50-minutes education session addressed the
“benefits of breastfeeding to mother and baby, overcoming cultural barriers to breastfeeding, and the importance of peer support by males and females for the breastfeeding women” (p.
246). Students watched a 10-minute video that included interviews with Sagkeeng women and men, and while women were breastfeeding. Survey tools examined breastfeeding belief, bottle-
6 7 feeding belief, and breastfeeding attitude. Statistical analysis was conducted using “repeated measure (split unit) analysis of variance (ANOVA) incorporated the explanatory variables of group (intervention and control), time (pretest, posttest, or retention test), and gender and interaction of group by time, gender by time, and group by gender by time. A P value was set for 0.05 or less to qualify as significant. For single item post hoc analysis a Bonferroni correction factor with a critical P value of 0.05 and divided by the number of comparisons to ensure a Type I error of 0.05. True treatment effects (TTE) measured in standard deviation units
(SDU) and crude differences were used to compare magnitude of differences across the three survey tools. The results revealed breastfeeding beliefs in the intervention group increased (x ±
SD = 41.9 to 47.00, P =0.0047) pre-test to post-test with no changes in bottle-feeding beliefs or breastfeeding attitudes. In all students, breast-feeding beliefs increased from the pre-test to retention test (true treatment effect [TTE] = 0.85 standard deviation units [SDU], P = 0.004). In female participants learning was gender specific, they experienced an increase in breastfeeding beliefs (TTE =1,12 SDU, P = 0.004), decrease in bottle-feeding beliefs (TTE = -0.77 SDU, P=
0.04), and a tendency to increased breastfeeding attitudes (TTE = 0.41 SDU, NS). Small (TTE =
0.25 SDU) inconsistent learning effects occurred among male participants. Overall students learned concepts related “health, convenience, cost, and decreased embarrassment” (p. 245).
Spear (2007) surveyed 515 college students, ages 18 to 31 years, with the intent to
“examine the attitudes and experiences of male and female college students relative to breastfeeding education within middle and high school programs of study” (p. 276). The student participants attended a private coeducational university in the southeastern region of the US.
The survey tool was composed of “four close-ended questions related to middle and high school education about breastfeeding, six items about breastfeeding attitudes, nine demographics items
7 8 and one open-ended question regarding the participants’ attitudes and experiences related to breastfeeding”(p. 277). Out of the female participants (n=335) and male participants (n=180), less than half of the participants (n=189, 36.7%) reported they received breastfeeding education in high school. A small percentage of participants (n=58, 11.3%) confirmed they received breastfeeding in middle school. For those participants who did receive breastfeeding education in high school, the majority (n=313, 60.8%) received the content in health and family courses.
Participants’ breastfeeding attitudes reflected a majority (n=449, 87.2%) when asked if the benefits of breastfeeding should be incorporated in high school curriculum; however, only 34.9%
(n=189) believed it was appropriate in middle school level curriculum. Participants (n=349,
67.8%) believed public breastfeeding was not acceptable, and 77.7% (n=400) reported breastfeeding was an intimate act that should be done in a private place. Overall most participants (n=512, 99.4%) acknowledged health care providers should inform mothers about breastfeeding, and agreed with the importance of the US promoting a breastfeeding culture. A single open-ended question generated several themes including “breastfeeding education, public breastfeeding, and attitudes and knowledge about breastfeeding”(p. 279). Based on a Spearman rho correlation, the belief in a breastfeeding culture was correlated with those who received education in high school and middle school (p <0.01); approved of breastfeeding in public (p
<0.01); acknowledged benefits of breastfeeding (p <0.01); with those women planning to breastfeed (p <0.001); with men planning to encourage breastfeeding with their partner (p
<0.01); and age (p <0.05). Lastly, Spear (2007) proposed that school nurses were the perfect vehicles to promote an intervention of this nature for the purpose of creating a breastfeeding culture.
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Walsh, Mosley, and Jackson (2008) conducted a study that proposed “health education intervention designed to promote positive attitudes toward breastfeeding may influence adolescents’ choices or intentions to breast-feed future children” (p. 165). This study utilized a quasi-experimental design to recruit a convenience sample (n=121) to establish a control and intervention group from two urban high schools in Nova Scotia, Canada. The study participants were ages 15 to 19 years, and were both male and female. Both groups received questionnaires composed of 18 true/false questions to establish baseline breastfeeding knowledge, five questions evaluating previous exposure to breastfeeding, and one question addressing intent to breastfeeding future children. Questionnaires were completed three times: pre and post same day, and 10 weeks later. Control group received questionnaires only, and intervention group received a “60-minute classroom activity on infant feeding facilitated by a nurse educator who was certified as a lactation consultant” (Walsh et al., 2008, p. 166). Classroom activity provided information and facilitated discussion “relating to bottle-feeding culture that exists today, the loss of a breast-feeding culture and knowledge, the marketing of infant formula, and the profits made by formula companies” (Walsh et al., 2008, p. 166). Both groups had similar knowledge of breastfeeding, but the intervention group had a significant (P <0.001) increase in knowledge and knowledge over time. The intention to choose to breastfeed was similar in both groups.
However, following the classroom activity the percentage of students in the intervention was significant (P <0.05) for those “who intended to choose or who would prefer breastfeeding for their future children” at post-intervention and a 10–week follow-up (Walsh et al., 2008, p.167).
Study findings suggested, “adolescents’ knowledge of and intentions toward breastfeeding may be positively influenced in their teen years”(p.164). Lastly, the implication for school nurses
9 10 was discussed and the unique position of influence they have to promote breastfeeding education among adolescents in schools.
A qualitative study conducted by Allen (2008) presented a 2-hour health promoting breastfeeding sessions. Following the session, a student volunteer focus group made up of those favored breastfeeding over formula as a part of the Personal, Social, and Health Education
(PSHE) program were interviewed. Secondary school students, ages 15 to 16 years, attending
Lawnswood School in Leeds, United Kingdom were deemed by teachers to be most suitable participants for this session. The curriculum developed addressed “physiology of breastfeeding and the health outcomes, as well as the benefits and risk associated with different infant feeding methods”(Allen, 2008). The focus group following the session generated data that strengthened the research by capturing a “broad range of opinions represented in the small sample” (p. 333).
Key points were taken away from the focus group that covered conflicting societal norms, breastfeeding mothers experience, lack of positive exposure to breastfeeding, the need to change cultural norms to make breastfeeding less taboo, sending the message formula feeding is hazardous, and acknowledging breastfeeding education is worthwhile to school-age students.
Lastly, based on the results of this study it was determined a multi-faceted approach to effect the normalization of breastfeeding should address education and exposure in both school and home, positive depiction of breastfeeding in the media, breastfeeding role models, and legal protection of breastfeeding mothers in public and the workplace.
Marrone and colleagues (2008) questioned 161 undergraduate psychology students (111 women and 50 men) at the University of North Dakota. The purpose of the study was to “gather information about knowledge, thoughts, and opinions of infant feeding methods”(p. 187). Upon consent each student was asked to complete the Infant Feeding Knowledge Test Form-A (score
10 11 ranges 0-20, the higher the score the greater breastfeeding knowledge), the Iowa Infant Feeding
Attitude Scale (score ranges 17-85, the higher the score the more positive attitudes toward breastfeeding), the Breastfeeding Behavior Questionnaire (score ranges 12-72, a lower score reflects more positive attitudes and accurate knowledge regarding breastfeeding), and a socio- demographic questionnaire. Those students who participated received extra course credit as an incentive. The collected data was analyzed using a factorial ANOVA (to test gender and age differences on the breastfeeding measures), a Pearson bivariate correlation (to test relationships between measurement and demographic tools for the overall sample and gender subsample), and an exploratory regression (to predict breastfeeding). The Infant Feeding Knowledge Test Form-
A scores revealed female participants were more knowledgeable (13.83 ± 2.65) than male participants (12.48 ± 3.38). There was a Cronbach's α reliability estimate of 0.54 for this tool.
The Infant Feeding Attitudes Scale scores averaged 55.72 ± 4.05 for women, and 56.00 ± 2.97 for men; however, based on the Cronbach's α reliability estimate of 0.14 no further analyses were done. The Breast Behavior Questionnaire scores averaged 39.58 ± 6.16 for women, and 37.48 ±
6.30 for men. The Cronbach's α reliability was estimated at 0.72, so further analyses were conducted. This data revealed a main effect for age of participants. Those age 20 years and older reported more exposure to breastfeeding in public compared to those age 20 year and younger, F(1, 157) = 7.59, P=0.001. A significant main effect resulted in those participants age
20 years and older showing more positive attitudes toward breastfeeding in public compared to those age 20 year and younger, F(1, 157) = 8.74, P=0.001. In addition, there was a significant interaction between age and gender related to exposure to breastfeeding in public F(1, 157) =
8.40, P=0.001. A bivariate correlation of the overall sample revealed few significant relationships among “men and women on the 3 dependent measures (Infant Feeding Knowledge
11 12 test and Breastfeeding Behavior Questionnaire), and the intention to breastfeed, exposure to breastfeeding, and socio-demographic variables”(p. 190). Several correlations resulted between breastfeeding knowledge and being breastfed as a child (P ≤ 0.01), age and duration of breastfeeding (P ≤ 0.05), and family exposure and breastfed as a child (P ≤ 0.01). Based on a regression analysis of five variables it was determined that the Breastfeeding Behavior
Questionnaire reflecting attitude was the most significant predictor of intention to breastfeed an infant, with the Infant Feeding Test Form A reflecting knowledge as second. In conclusion, this research identified the need to develop more effective measurement tools for young adults, as well as an intervention targeting young men that have not yet had children in order to expand their understanding and promote positive attitudes towards breastfeeding (Marrone et al., 2008).
Fujimori and colleagues (2008) conducted a cross-sectional study of 503 male and female students in the urban area of Barra do Garças (MT), Brazil grades 4 through 8 with a mean age of
11. 7 years. The objective was to assess breastfeeding attitudes and evaluate the influence of an educational lecture on knowledge. A questionnaire was developed and used to evaluate demographic information; previous experiences; the students’ knowledge, behavior, and attitudes; and interest in the subject. The composed of 25 multiple-choice questions, and 5 open- ended questions was administered to both control and intervention groups. Those students in the intervention group received a 30-minute lecture and slide projector presentation that included an
“explanation about the practicality and reduced cost of breastfeeding when compared with artificial methods; the start and duration of exclusive complemented breastfeeding and their significance to infant nutrition”(p. 225). Data was analyzed using Maental-Haenszel chi-square test and Student’s t-test with level of significance equaling p < 0.05. It was discovered that there was a relationship between students who were breastfed as babies and those intending to
12 13 breastfeed as mothers (p < 0.05). Out of the 79.7% of students who showed an interest in being future parents, 96% intended to breastfeed them. It was seen that 98.3% of the boys expressed a willingness to support breastfeeding with their future wives; however, 37.5% agreed they would be uncomfortable with their wives breastfeeding in public. Based on the analysis of student’s knowledge, attitudes and behaviors with relationship to breastfeeding plus the effect of intervention several differences were noted. The control groups had a significant (p < 0.05) number of students who selected powdered milk was most beneficial to baby, powdered milk is the most practical way to feed a baby, approval of feeding anything other than mother’s milk to baby, breastfeeding a baby for up to one month, and giving a pacifier. In terms of interest in breastfeeding, students reported most information was received through media 39.3% (172). A total of 39.6 % (199) believed teachers should promote breastfeeding, and 61% (307) believed it should be included in school curriculum. Overall, 86.3 % of students expressed a desire to learn more about breastfeeding as a subject. In conclusion, it was indicated that promoting positive beliefs about breastfeeding to young people through education and media is an important step towards increasing breastfeeding in the future (Fujimori et al., 2008).
Giles and colleagues (2010) conducted a cross-sectional survey of 2012 senior school students, ages 13 to14 years, in Northern Ireland. Students were sorted by key stratification variables, and then randomly sampled. This study applied the Theory of Planned Behavior
(TPB) to design an intervention to positively promote breastfeeding among adolescents, by influencing three main categories of beliefs to predict both intention and behavior. The three categories of beliefs included, “beliefs about the outcomes of a particular behavior; beliefs about the expectations of others and; beliefs about the presence of factors that might encourage or prevent a particular behavior”(p. 286). The TPB is composed of five constructs intention,
13 14 attitude, subjective norm (SN), perceived control (PC), and self-efficacy (SE). Survey tools were developed based on the TPB constructs. A 4-section questionnaire was developed to gather demographic information, assess previous exposure to breastfeeding, assess acceptance of breastfeeding, and incorporate all TPB constructs using both direct and belief based measures.
Two versions of the form were used. A version for females asked to consider the possibility if they had a baby in the future, and indicate the extent in which they would likely breastfeed that baby. A version for males asked to indicate the extent they would encourage their partner to breastfeed. Three questions (yes/no) were used to assess experience of/exposure to breastfeeding. The 5-items measured on a 4-point scale (strongly agree to strongly disagree) were used to assess acceptance of breastfeeding. Three items were used to measure the extent to intend/encourage a partner to breastfeed. Five questions were used for direct measure of attitudes, and 12-outcome evaluation and corresponding behavioral beliefs were employed for indirect measure of attitude. The 14-statements were developed to assess knowledge of infant feeding (score 0-14, maximum score of 14). Data was analyzed using ANOVA, correlation, and hierarchical multiple regression. Results revealed a significant (P < 0.001) correlation in intention to breastfeed in both male and females who were breastfed and who saw a mother breastfeed. Breastfeeding intentions among males and females were significantly (P < 0.001) correlated with the direct constructs of the TPB in the following descending order attitude, SN,
SE, and PC. A hierarchical multiple regression using intention to breastfeed/encourage partner to breastfeed as the dependent variable, and the TBP “successfully predicted intention among males and females”(Giles et al., 2010, p. 285). The significance of exposure and role models were discussed in terms of how they increased positive breastfeeding attitudes so that a culture where breastfeeding is accepted would foster positive attitudes and increase breastfeeding
14 15 initiation. Ultimately, it was determined based on the study findings that TPB can be used to design an intervention to promote attitude change, and emphasize the key the constructs of the theory in predicting intentions to breastfeed.
Hamade and colleagues (2014) directed a cross-sectional study in the Middle East to examine breastfeeding knowledge, attitude, exposure, and perceived behavior among female undergraduates students. A total of eight universities in Beirut and Damascus were selected based on socioeconomic diversity. A convenience sample approach resulted in 306 female student participants ranging from ages 18-25 years. Students were consented to complete a questionnaire composed of five-subsections addressing breastfeeding exposure, knowledge
(Infant Feeding Test Form A), attitude (Iowa Infant Feeding Attitude Scale), perceived behavior
(Breastfeeding Behavior Questionnaire), and intentions (Infant Feeding Intention Scale). Three of the tools applied to this study have been previously described above. However, the Infant
Feeding Intention Scale which is a made-up 5 infant feeding statements graded on a five-point
Likert scale is unique to this study, and has a Cronbach’s α = 0.9. The Infant Feeding Intention
Scale scores range from 0 to 16, with the higher scores representing a stronger intention to initiate and sustain exclusive breastfeeding. Data was analyzed to evaluate the association of intention with breastfeeding knowledge, exposure, perceived behavior, and attitude with a power of 80% with an α level of 0.05. In order to estimate correlation, a Pearson correlation coefficient of 0.2 was used. Results revealed knowledge mean score (10.39 ± 2.09), and 49.4% of all participants scored over the midpoint (scores range 0 to 20). Several low scoring items recorded included “maternal breastfeeding benefits, adequacy of milk supply, maternal restrictions or contraindications to breastfeeding, and the suitability of breastfeeding for working mother” (p.
183). Data showed attitude mean scores (58.12 ± 6.49), and 85.5% of participants scored above
15 16 the midpoint (scores range 17 to 85). Participant’s shared attitudes towards breastfeeding as a bonding experience for mother and baby, health benefits of breast milk with the belief benefits last only as long as the baby is breastfed, formula is a better choice for working mothers, and feel breastfeeding can leave the father out. Analysis of perceived behavior reflected mean scores
(22.00 ± 3.68), and 17% of participants scored above the midpoint (scores range 12 to 36).
Negative behavioral perceptions were identified related to breastfeeding in public places
(restaurants and places of worship), and in front of male or female friends. Results revealed breastfeeding intention mean score (11.11 ± 3.38), and 81.4% scored above the midpoint (scores range 0 to 16). The majority of participants planned to breastfeed (Syrian 76.4% and Lebanese
88.7%), but up to 10% of both groups disagreed with continuing exclusive breastfeeding at 6 months. As for breastfeeding exposure mean scores, they were (2.67 ± 0.59) and 72.5% of participants scored above the midpoint (0 to3). Lastly, correlation analysis revealed knowledge, attitude, and perceived behavior scores were associated with the intention to breastfeed.
Based on the literature review exposure to breastfeeding and history of being breastfed as an infant significantly impacted the participant’s intention to breastfeed future children.
Intention to breastfeed as seen in several cross-sectional studies was significantly correlated with knowledge, attitudes, perceived behavior, perceived control, and self-efficacy. However, they varied from to study to study in order of significance. Exposure over time in the form of knowledge, personal encounters, and media was correlated with future intent to breastfeed as well. Attitudes towards breastfeeding at times were more significantly correlated with future intent to breastfeed than knowledge alone.
Several survey based studies conducted among college students identified that very few high schools are incorporating infant feeding education in school curriculum, participants
16 17 believed in the benefits of the content, and reported high school adolescents were an optimal age group to receive content. However, social and cultural norms significantly are negatively influencing beliefs and attitudes related to public breastfeeding, barriers to breastfeeding as a working mother, physical changes in appearance of breasts, and lack of male support for breastfeeding partner. With this in mind there is a need to incorporate infant feeding education that establishes knowledge, attitudes, perceived behavior, and intentions in school education curriculum.
Gaps
Over the past 25 years the efforts of UNICEF to guide a cultural shift and promote breastfeeding in-hospital in order to transition to in-home practice out in the community has been evident. Despite on going efforts to improve initiation and retention rates as previously mentioned other avenues must be explored. The need to promote a breastfeeding intervention prior to the stress of pregnancy, and at an appropriate maturational age is evident based on research. Several gaps in the literature clearly identify specific considerations. First, the lack of infant feeding curriculum educating both in male and females was made apparent. Second, adolescents were recognized as an ideal population for delivery of this topic. Lastly, there was limited research that applied theoretical framework, but clearly drew relationships between future breastfeeding practices related to knowledge, attitudes, exposure, and intentions.
Adolescent Psychosocial and Cognitive Development
Adolescents are in a unique place of psychosocial and cognitive development. By understanding this developmental process, specific learning needs can be identified to create an effective breastfeeding health promotion with a problem-focused intervention. Adolescence development encompasses psychosocial and cognitive transition from childhood to adulthood,
17 18 and theories have been developed to understand this complex transition. Erik Erikson’s Theory of Psychosocial Development has identified eight periods of human life (Ball, Bindler, &
Cowen, 2014). Each stage of Erikson’s theory is based on crisis, or challenges that exist in order for healthy personality development to occur (Ball et al., 2014). A crisis can result in two possible outcomes for an individual. If an individual’s needs are met, the result is a strong and healthy developmental transition into the next stage. If an individual’s needs are not met, the result is an unhealthy outcome that influences social relationships. In adolescence, the thought process becomes more complex and the body matures resulting in a new sense of identity.
Erikson refers to this stage as identity versus role confusion, which occurs during age 12 to 18 years and requires a redefining of identity in terms of family, peers, and community; however, if this redefinition does not occur in adolescence role confusion develops with lifelong implications
(Ball et al., 2014).
Cognitive development as theorized by Jean Piaget explores how a child views the world, which he theorizes is influenced largely by age and maturational ability (Ball et al., 2014).
Piaget identifies this natural maturational process by way of assimilation (incorporation of new experiences) and accommodation (changes to deal with new experiences). An adolescent’s thinking is abstract in regards to objects or concepts, and has the ability to consider different alternatives with variations in outcomes (Ball et al., 2014). In adolescence is when Piaget believes an individual learns how to conceptualize about past and future events, as well as relate actions to consequences (Burns, Dunn, Brady, Starr, Blosser, & Garzon, 2016). An under- standing of human nature (good versus evil), the ability to identify contradictions, and under- standing the significance of one’s place within the construct of time (past, present, and future) these are values that are being developed in the adolescent stage. These developmental theories
18 19 support infant feeding as a health promotion for adolescence, which can be presented in an abstract way resulting in future breastfeeding behaviors, values, and promote concepts of role development in terms of self-identity (Burns et al., 2016).
Applying a Theory
As identified above adolescents are undergoing a unique developmental process, with this in mind the development of an infant feeding education intervention guided by the Social
Learning Theory (SLT) is germane. Psychologist Albert Bandura first introduced the SLT in
1977, which conceptualized the relationship between the environment, cognitive factors, and behavior (Peterson & Bredow, 2016). Since the birth of this theory, nursing has identified numerous applications related to health promotion behaviors and chronic disease management in a learning and middle range theory capacity (Peterson & Bredow, 2016). The constructs of SLT speak to the natural process occurring in adolescent development, which in turn can guide an education intervention related to infant feeding in this population. Based on SLT core concepts like reciprocal determinism (person-behavior-environment interaction) and social influences that affect learning, adolescents can be educated on infant feeding through (observation and listening to peers and role models) vicarious learning (McEwen & Willis, 2014). It is through vicarious learning adolescents are developing self-efficacy, or gaining awareness and becoming confident in a challenging behavior in which they have valued outcomes (McEwen & Willis, 2014). An infant feeding education session can fosters active selection and involvement with the environment through personal selection of role models, intentionality, and self-regulation of personal attitudes.
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Summary
Adolescents developmentally are in a maturational appropriate place, both psychosocially and cognitively, to benefit from infant feeding education as identified above. Based on this knowledge, the constructs of the SLT contain what the literature has clearly found to be the factors impacting future infant feeding practices of adolescents. By conducting an infant feeding education session modeled after Bandura’s SLT, it lends itself to a conceptual framework and therefore draws a relationship between environment (exposure), cognitive factors (knowledge, attitudes), and behavior (intention) concepts previously identified in the literature as factors influencing infant feeding practices. In combination, developmental age and Bandura’s SLT will be proved an appropriate population and foundation for this research.
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METHODOLOGY
Introduction
The following will explain the methodology behind this research proposal, including how the data will be generated and analyzed based on the hypothesis.
Hypothesis
The infant feeding knowledge, attitudes, exposure, and intention for high school students who received an education session will be significantly different from the high school students who did not receive an educational session on infant feeding.
Research Variables
The dependent variables in this study are the students’ knowledge, attitudes, exposure, and intentions as measured by Infant Feeding Knowledge Test Form-A (FORMA), Iowa Infant
Feeding Attitude Scale (IIFAS), Breastfeeding Behavior Questionnaire (BBQ), and Breast- feeding Exposure Questions (BEQ). The independent variable is an infant feeding education session. Demographic variables will be used for sampling purposes only.
Design
Based on the nature of the SLT framework and literature review a quasi-experimental design was selected. Due to the challenges related to randomization as revealed in the literature a nonrandomized convenience sample method was selected (Allen 2008). The intervention group will receive a baseline infant feeding education session lasting 90-minutes with pre-test and post- test evaluation, and the control group will receive a pre-test and post-test evaluation only. The data will be collected over a 2-day period.
In this design threats to internal validity include temporal ambiguity, historical events prior to education infant feeding session, between group differences related to class environment and
21 22 systematic difference in respondents, repeated test occurrence from pre-test to post-test exposure, and attrition related to sick or absent students.
Intervention
The intervention is aimed at promoting breastfeeding knowledge, attitudes, exposure, and future intent by conducting an infant feeding education session for non-pregnant male and female adolescents. The intervention will take place over a 2-day period. Considering time as a limitation pre-test surveys will be collected on day 1 and may benefit this study by increasing variability in groups. On day 2 the intervention group will receive a 90-minute infant feeding education session: (a) an infant feeding video (Breastfeeding advantages, How–to Support
Breastfeeding Families, and How-to Build Breastfeeding Friendly Community); (b) health care provider led discussion (Basic Physiology of Breastfeeding, Infant feeding methods, and Risk versus Benefits of human milk compared to artificial); (c) breastfeeding poster activity
(Identifying positive images, role models, and medium to dispel breastfeeding myths)(Allen,
2008; Giles et al., 2010; Hamade et al., 2014; Marrone et al., 2008; Martens, 2001; Spears, 2007;
Walsh et al., 2008). On day 2 after the intervention group receives the infant feeding education session they will complete the post-test survey. The control group on day 2 will complete the post-test survey. Intervention and testing will be held at the end of the school day to prevent minimal disruption in students’ class schedule.
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Sample & Sampling
The sample of non-pregnant high school students will be selected from San Diego
County high schools offering the CalSAFE program, and closely represents the diverse population throughout San Diego County. This non-randomized convenience sample will be composed of both male and female non-pregnant high school students between the ages of 15-19 years old. The target sample of the N=90 participants was determined by an α level of 0.05 and a power of 0.80, plus 20% rate of attrition which resulted in a total of N=108 participants.
The method of obtaining the non-random convenience sample of participants will require a request for the researcher to present the research design to school board members during an official meeting to gain approval and cooperation from school and parents. The CalSAFE program school should adequately represent a generalizable portion of the population in San
Diego County. For those high schools that agree to student participation, students who meet criteria must complete both a parental consent and student assent to participate.
Inclusion/Exclusion Criteria
For the purpose of this research, the sample inclusion criterion are as follows participants must 15-19 year of age, male or female, attending a CalSAFE program high school, and currently not pregnant, breastfeeding, or parenting. Exclusion criterion will include all previously mentioned inclusion criterion, and those students who are unable to complete intervention as a result of emotional distress provoked by infant feeding session content.
Data Collection
Prior to the collection of research data the researchers will attain study protocol approval from California State University San Marcos Institutional Review Board, and the approval from the selected North San Diego County School District. In general, adolescents are considered a
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vulnerable segment of the population so safeguards will be exercised in the data collection
process. The data will be collected after parental/guardian consent and student assent are
attained. For those participants who are between 18 and 19 years old, an informed consent tool
will be developed if recommended by the Institutional Review Board at California State
University San Marcos. All demographic surveys and questionnaire to responses will remain
confidential. The data will be collected at two points in time (pre-test and post-test). Time
limitations require the first set of surveys be collected the day prior to education session.
However, the goal is for all the survey data to be collected over a 2-day period with the control
and intervention group scheduled to receive the education session during the last period of the
day to minimize loss of scheduled class time.
Measurement Tools
A total of four surveys will be used to evaluate the infant feeding education for both the control and intervention groups. These four self-report instruments tools include:
FORMA/knowledge, IIFAS/attitudes, BBQ/perceived behavior, BEQ/exposure, and demographic information. The FORMA has an internal consistency reliability measured by Cronbach’s α coefficient of 0.64 (Hamade et al., 2014; Marrone et al., 2008). The FORMA contains 10- multiple choice and 10-True/False questions, and score ranges from 0 to 20 with a higher score indicating a greater knowledge of breastfeeding (Marrone et al., 2008, p. 187). The IIFAS has an internal consistency reliability measured by Cronbach’s α coefficient of 0.86 (Hamade et al.,
2014). IIFAS is based on a five-point Likert scale that ranges from 1 (strongly disagree) to 5
(strongly agree), and the scores range from 17 to 85 (Marrone et al., 2008). The IIFAS is composed of 17-statements that measure attitudes toward infant feeding with respect to cost, nutrition, convenience, sexuality, and infant bonding, and a more positive attitude toward
24 25 breastfeeding is reflected in a higher score (Marrone et al., 2008). The BBQ has a high “test- retest reliability”, and a “correlation coefficient 0.88” (Marrone et al., 2008, p. 187). This BBQ is based on a six-point Likert scale, scores range from 12 to 72 with positive behaviors towards breastfeeding reflected in a lower overall score (Hamade et al, 2014; Marrone et al., 2008). This
BBQ questionnaire is composed 12-scenarios “that a mother might encounter if she was breastfeeding” (Marrone et al., 2008, p. 187). There will be five questions to evaluate BEQs, and they will be presented in a yes/no format with a 0 to 5 point scale. These questions are based on the literature and include: (a) Were you breastfed as an infant, (b) Do you plan to breastfeed or encourage partner to breastfeed, (c) Have you received education on breastfeeding in school, (d)
Have you seen movies on breastfeeding in school, and (e) Have you seen anyone breastfeed
(Allen, 2008; Giles et al., 2010; Marrone et al., 2008; Martens, 2001; Walsh et al., 2008). A pilot test will be required after measurement tools are evaluated for content validity for use in ages 15 to 19 years, as well as to ensure internal validity reliability. Lastly, demographics (age, gender, ethnicity, pregnant vs. non-pregnant, and grade) will be collected for the purpose of exclusion.
Data Management
All surveys will be collected and stored for security on the California State University
San Marcos campus in a locked cabinet. All surveys will remain confidential. Analysis of data
will be completed using IBM Statistical Package for Social Science Software (SPSS) Statistics
version 2015 on a secured network.
Data Coding
A demographic data form will be collected from each participant. Participants’ will
complete the demographic data form utilizing the following numeric codes: Age (15=1, 16=2,
17=3, 18=4, 19=5); Gender (Female=1, Male=2, Transgender=3); Culture/Ethnicity (Non-
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Hispanic white=1, African American=2, Hispanic American=3, Asian American=4, Native
American Indian=4, Other=5); Pregnancy status (Pregnant=1, Non-pregnant=2); and Grade
(Sophomore/10th =1, Junior/11th =2, Senior/12th =3).
Data Analysis
The data analysis will determine the effects of an infant feeding health promotion education session on the non-pregnant adolescents’ knowledge, attitudes, exposure, and intentions toward infant feeding. Based on the hypothesis, research design, and level of data, a two-tailed, paired t-test will be conducted. Two-tailed refers the non-directional nature of the hypothesis, and the expectation that the scores will be found on the extreme ends of the distribution. According to Plichta and Kelvin (2013), this research design has met the following assumptions for a paired t-test:
• “Two paired measures pre-test and post-test scores of control vs. intervention group”
• “Two measures compared are normally distributed, and are at least 30 pairs and the
distribution is not badly skewed”
• “The measurement scales are interval and sometimes ordinal”(p. 30)
For the two-tailed, paired t-test there will be an α level of 0.05, a power of 0.80, and an effect size 0.30.
Research Bias
Based on the research design several sources of potential bias may have been introduced.
The nonrandomized sample population could affect the outcome of the study, and create bias within the research design. The investigator’s may show personal bias related to knowledge and personal attitudes regarding breastfeeding in the evaluation of research data. The California
School Age Family Education (CalSAFE) program environment may create bias among
26 27 participants, because they may be more open and aware to the importance of promoting a breastfeeding culture. The adolescent student populations may be more prone to social desirability response bias when completing self-reported surveys, as well as the halo effect and error of leniency when completing rate based survey tools (Polit & Beck, 2012).
Protection of Human Subjects/Ethical considerations
Adolescents are a high-risk population, so special attention was paid to safeguard each participant. Proper consent from parent/guardian and student assent will be required and collected prior to participation. Information will be provided to students and parents in the form of a letter that will be sent home with students explaining details of the study, and the opportunity to submit question or concerns to the researcher. It will be made clear that limited class time will be used to complete this study, participants will be free to withdraw at anytime, and if the session provokes any emotional response the student will be excused from the study without penalty to seek support from a school counselor.
Summary
The methodology as described above is intended to generate research data, and through this analysis, it will reveal the effects of an infant feeding education session on adolescents’ knowledge, positive attitudes, exposure, and intentions towards future breastfeeding practices.
This research will add to the body of knowledge and help to validate the implementation of infant feeding in high school curriculum.
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Ball, J., Bindler, R., & Cowen, K. (2014). Principles of Pediatrics Nursing Caring for Children
(4th ed.). New Jersey: Pearson.
Burns C.E., Dunn A.M., Brady M.A., Starr N.B., Blosser, C.G. (2016). Pediatric primary care
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California Breastfeeding Coalition. (2014). Our Work: About Us. Retrieved from
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California Department of Public Health (2014). In-hospital Breastfeeding Initiation Data:
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feeding attitude scale: Analysis of reliability and validity. Journal of Applied Social
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Giles, M., Connor, S., McClenahan, C., & Mallet, J. (2010). Attitudes to breast-feeding among
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10.1111/j.1365-277X.2010.01048.x
Harris, A.D, McGregor, J.C., Perencevich, E.N., Furuno, J.P., Zhu, J., Peterson, D.E., &
Finkelstein, L. (2006). The use and interpretation of quasi-experimental studies in
medical informatics, Journal of The American Medical Informatics Association, 13(1),
16-32. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1380192/.
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Leffler, D. (2000). U.S. high school age girls may be receptive to breastfeeding promotion.
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Libbus, M.K. (1992). Perspectives of common breastfeeding situations: a known group
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Marrone, S., Vogeltanz-Holm, N., & Holm, J. (2008). Attitudes, knowledge, and intentions
related to breastfeeding among university undergraduate women and men. Journal of
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Martens, P. (2001). The effects of breastfeeding education on adolescent beliefs and attitudes: a
randomized school intervention in the Canadian Ojibwa Community of Sagkeeng.
Journal of Human Lactation, 17(3), 245-255. Retrieved from
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States: Findings from the National Health and Nutrition Examination Surveys 1999-
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p://www.unicef.org/nutrition/index_24806.html
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GRANT ELEMENTS
Potential Grants & Feasibility
Three grants were considered for primary funding of this research study from the
National Institute of Health. Two of the selected grants are Research Project Grants (R01). The
R01 grant’s primary objective is to support the research of the Principal Investigator based on his or her interests and competencies. A Small Grant Program (R03) was considered as well. The
R03 grant’s primary objective is to provide funding to “pilot, feasibility, and methodology development studies” (p. 705). All three grants are feasible and will be reviewed below.
Based on a feasibility assessment time, cooperation of school board, availability of participants, and facility and equipment suggests this proposed research study could be carried out. All three grants will have to be completed to meet the Cycle I schedule. The scientific review of this research proposal will be in June to July. The earliest start date to begin research would be in December. This schedule allows for the desired seven-month timeline starting in
December and ending in May. This will be conducive to the dissemination by June. School board approval from CalSAFE high schools will ensure the sample size needed. Cal SAFE high school campuses logistically are suitable for this infant feeding intervention, and equipment needed is accessible to participants and research team.
The R01 grant opportunity titled Behavioral and Social Science Research on
Understanding and Reducing Health Disparities with number PA-13-292 was selected. There is no ceiling on this grant allowing for flexibility in funding with justified budget. The description of this R01 purpose supports health care, public policy and disease and disability prevention.
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Budget
The research budget consists of primary investigator, assistant researcher, lactation consultants, research consultants, necessary equipment, and supplies necessary to conduct and disseminate this research investigation.
Personnel Costs: Primary Investigator. The primary investigator, Natalie Alonzo, will be compensated at the rate of $ 50 per hour for 80 hours per month over six month period for total of $ 24,000.00 Assistant Researcher. The assistant researcher, Thoa Nguyen, will be compensated at the rate of $ 50 per hour for 40 hours per month over nine month period for a total of $ 12,000.00. Certified Lactation Consultants. The lactation consultants, Allison Mondragon and Cindi Corta, will be trained to provide pre/post test questionnaires and to present infant feeding education session. They will be paid $ 50 per hour for 80 hours to include training to prepare for infant feeding education session, day of presentation, and travel for a total of $ 4,000.00 per consultant. Faculty Research Consultants. Faculty research consultants, Dr. Patricia Hinchberger (Research Chair) and Dr. Deborah Bennett (Research Committee Member), are necessary for this investigation, statistical data analysis, and mentoring for safe implementation of proposed research. They will provide 40 hours of consultation each month over six-month research period at the rate of $ 60.00 per hour for a total of $ 14,400.00 per consultant. Spanish translation services. $ 20.00/page. Consent and Assent translation in Spanish by Mario Martinez for a total of $ 40.00.
Estimated total: $ 72,840.00
Equipment: IBM SPSS 21.0. Statistics graduate pack with a 2-year license for Windows or Mac for an estimated cost of $ 1,800.00. Laptop computer and Designated printer. Laptop computer and dedicated printer are necessary for data input and analysis, reports and preparing necessary documents. Computer and printer costs are $ 2000. Ameda On-line Videos: Free of Cost
Estimated total: $ 3,800.00
Office Supplies: Flash Drive. Flashdrive 8GB for an estimated cost of $ 8.99. Poster boards. White premium poster boards 22 x 28 inches pack of 5 a total of 21 for an estimated cost of $ 146.79. Glue Sticks. Washable clear glue sticks 18 pack a total of for an estimated cost of $ 60.99. Scissors. All-purpose value scissors 8 inches pack of 21 a total of 5 packs for an estimated cost of $ 196.45. Printer Paper. Office paper standard letter size one case 5000 sheets for an estimated cost of $ 60.00.
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Printer Ink. Cannon 5320 printer ink 4-color pack a total of 4 packs for an estimated cost of $ 83.96. Manila Envelopes. Brown Kraft-clasp envelope 9 x12 inches 12-pack for an estimated cost of $3.00. Parenting Magazines and donated breastfeeding informational pamphlets. Media for poster project donate at no cost by supporters of this research.
Estimated total: $ 552.18
Other Expenses: Dissemination of Research. Research disseminated at National Association of School Nurses (NASN) 2017 Conference via booth presentation. Corner booth cost 8 x 10 feet for an estimated $ 2000.00. Conference program advertising ¼ of a page estimated cost $ 1000.00. Exhibitor passport-Booth driver where attendees visit your booth to be entered into the NASN Passport prize drawing at an estimated cost of $ 500.00.
Postage. Submission of reports, correspondence with the primary investigative committee members, and communications with NASN conference supervisory committee for a cost of $ 125.00.
Graphic Media Services. Conference approved regulation poster 36 x 48 inches for an estimated cost of $ 45.00, and informational pamphlets handouts (count 500) $ 89.57.
Conference Transportation and Hotel Cost. Airline flight arranged via American Airlines total of 2 round trip tickets to Indianapolis, Indiana at an estimated cost for $ 1558. Vehicle rental reserved through Hertz for a total of 5 days at an estimated cost of $ 288.63. One queen room reserved at host hotel JW Marriot, Indiana for a total of 4 nights at an estimated cost of $ 780.00.
Estimated total: $ 6, 386.20
Total Estimated Budget: $ 83, 578.38
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Timeline
This research study will follow a six month timeline with goal of having results ready for dissemination at the National Association of School Nurses (NASN) 2017. The NASN
Conference will be schedule for Summer 2017. The start of this research study will begin in
December 2016-May 2017. The primary investigator will begin contacting CalSAFE high schools in san Diego County for the opportunities to present research design to school board to gain approval. During this time, assistant researcher and lactation consultants will receive training in preparation for research and infant feeding session. Faculty consultants and investigators will meet monthly to discuss progress. The education session will be held between months five and six to allow time to collect for analysis. The education session will be 90 minutes. The research study will be conducted over two days. On day one pre-test surveys will be collected from both control and intervention groups. Participants will be given 30 minutes to complete the surveys. On day two the intervention group will receive the infant feeding education session with post-test surveys, and the control groups will receive post-test surveys only. The infant feeding education session will include, three videos lasting 15 minute, a lactation consultant led discussion lasting 15 minutes, poster activity lasting 30 minutes, and post-test surveys lasting 30 minutes. On day two the control group will receive 30 minutes to complete post-test surveys. The data analysis and final results will be completed and ready for presentation and dissemination by June 2017.
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REFERENCES
Appendix A: Instruments
Infant Feeding Test Form-A (FORMA):
Questions Yes No 1-Breastfeeding cuts down on the mother's bleeding after delivery. 2-Breast milk makes up a complete diet for baby. No extras (foods, vitamins etc.) are needed until the baby is close to one year of age. 3-If your breasts are small, you might not have enough milk to feed the baby. 4-When a mother is sick with the flu or a bad cold, she can usually continue to breastfeed her baby. 5-Babies who are breastfed tend to get fewer allergies than babies who get formula. 6-The pill is the best way to keep from getting pregnant while you are breastfeeding. 7-You shouldn't try to breastfeed if you are planning to go back to work or school since you won't be able to be with your baby for feedings. 8-The more often you breastfeed, the more milk you will have for your baby. 9-Babies who are breastfed tend to get fewer infections than babies who get formula. 10-Many women are not able to make enough milk to feed their baby.
11- The best food for a newborn is: a.______breast milk. b.______formula. c.______breast milk and water.
12-Because babies may get a bad reaction to certain foods, breastfeeding mothers should never eat: a.______pizza or other spicy foods. b.______coffee or tea or other drinks with caffeine. c.______all of the above. d.______none of these are correct. 13-After the baby loses weight following birth, he will probably gain it back faster if: a.______he is breastfed. b.______he is bottlefed. c.______neither is correct.
14-You shouldn't try to breastfeed if you: a.______have twins. b.______have a c-section. c.______drink a lot of alcoholic beverages.
15-Breastfeeding mothers' nipples get sore if: a.______the baby's feeding position is not right. b.______the mother has light colored skin. c.______this is the first baby she has breastfed.
16-When you breastfeed the best way to tell if the baby is getting enough milk is that: a.______he does not suck on his fist after he is done nursing. b.______he does not cry. c.______he has 6 or more wet diapers in 24 hours.
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17-When you breastfeed: a.______you may get your figure back easier. b.______you nearly always gain weight. c.______you may feel weak when you feed your baby. 18-If you breastfeed: a.______no one else can help you with the baby since you have to feed her. b.______more of your time will be taken up by the baby than if you bottlefeed. c.______it will be very difficult to feed the baby in public places. d.______none of the above are correct.
19-Breastfeeding will probably make: a.______your breasts sag. b.______your breasts larger after you stop breastfeeding your baby. c.______no difference in the size or shape of your breasts.
20-Breastfed babies need: a.______only breast milk for the first 4 to 6 months. b.______a bottle of formula every day or so. c.______extra water daily.
Grossman L, Harter C, Hasbrouck MA. Testing mothers' knowledge of breastfeeding: instrument development and implementation and correlation with infant feeding decision. J Pediatr Perinat Nutr. 1990;2:43-63.
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Breastfeeding Behavior Questionnaire (BBQ):
A= Agree D= Disagree
Situation A D
1. Jane Johnson, a new mother, is breastfeeding her baby in the living room. Her girlfriend from next door comes to see the new baby. Jane covers her breast and the baby's head with a receiving blanket and the baby continues to nurse while the two women talk. Do you agree that it was all right for Jane to continue breastfeeding? 2. Estelle Green is breastfeeding her baby in the living room. The man and woman from next door come to see the new baby. Estelle covers her breast and the baby's head with a receiving blanket and the baby continues to breastfeed while the neighbors talk. Do you think Estelle should have stopped breastfeeding? 3. Martha Smith is at McDonald's eating lunch with her girlfriends. When her baby wakes up and seems hungry, she decides to breastfeed him under her blouse. Do you think Martha should have taken the baby out of the public place to breastfeed? 4. Kathy Brown is eating lunch at Dairy Queen with her girlfriends. When her baby wakes up and seems hungry, she decides to breastfeed him under her blouse. Her friends are embarrassed by this, so she takes him out to the car to breastfeed him instead. Do you agree with Kathy’s decision to take her baby out to the car to breastfeed him? 5. Anne Evans and her husband take their baby to church. When it is time for the baby to breastfeed, Ann takes her into the ladies' bathroom. Do you think it was necessary for Ann to take the baby out of church breastfeed? 6. Marie Schultz and her husband take their baby to church. When it is time for the baby to eat, Marie breastfeeds the baby under her blouse. She also covers the baby's head with a receiving blanket in case the blouse slips. Do you think Marie should have taken the baby out of church to breastfeed? 7. June Moon is expecting her first baby and wants to breastfeed. June's mother tells her that no one in their family has been able to successfully breastfeed since all the women have small breasts and can't make enough milk. June decides to breastfeed anyway. Do you agree with June’s decision? 8. Laura Baxter is expecting her first baby and wants to breastfeed. Laura’s husband wants her to bottle- feed the baby because he says that breastfeeding is "embarrassing". Laura decides to bottle-feed instead of breastfeeding. Do you agree with Laura’s choice to not breastfeed because of her husband's opinion? 9. Linda Martin is pregnant and her doctor tells her that she should plan to breastfeed her new baby. Linda had planned to bottle-feed but changes her mind. Do you agree with Linda’s decision to follow her doctor's advice? 10. Jane Blaine, who is expecting her first baby, was advised to breastfeed her new baby because "human milk is better for human babies". Jane decides to bottle-feed instead because she has heard that formula is every bit as good as breastmilk. Do you agree with Jane's decision to not breastfeed her baby? 11. Peggy Kelley is expecting her first baby very soon. She was advised to breastfeed but decides to bottle-feed instead because she wants to go back to work when the baby is 3 months old and has heard that a breastfed baby won't take a bottle. Do you agree with Peggy's decision not to breastfeed her baby? 12. Jeanette James is expecting her second baby. Even though she has been told that breastfeeding is better for babies, she decides to bottle-feed. She tried to breastfeed her first baby and had to stop because the baby lost weight during the first week. Do you agree with her decision to not breastfeed this baby?
Libbus MK. Perspectives of common breastfeeding situations: a known group comparison. J Hum Lactr. 1992;8:199-203.
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The Iowa Infant Feeding Attitude Scale
For each of the following statements, please indicate how much you agree or disagree by circling the number that most closely corresponds to your opinion. The number “1” indicates strong disagreement, whereas “5” indicates strong agreement. You may choose any number from 1 to 5. *Permission has been granted by the author use this tool on the basis this tool not be included in this grant proposal in its’ entirety. 1 2 3 4 5 Strongly Disagree Neutral Agree Strongly Disagree Agree
1. The nutritional benefits of breast milk last only until the baby is weaned from breast milk.
2. Formula feeding is more convenient than breast-feeding.
3. Breast-feeding increases mother-infant bonding.
4. Breast milk is lacking in iron.
5. Formula fed babies are more likely to be overfed than breast-fed babies.
6. Formula feeding is the better choice if a mother plans to work outside the home.
7. Mothers who formula feed miss one of the great joys of motherhood.
8. Women should not breast-feed in public places such as restaurants.
9. Babies fed breast milk are healthier than babies who are fed formula.
10. Breast-fed babies are more likely to be overfed than formula fed babies.
11. Fathers feel left out if a mother breast-feeds.
Scoring: Items that are asterisked should be reversed (i.e., 1=5, 2=4, 4=2, 5=1), and the scores for each item then summed together. The following is a guide for interpreting scores, higher scores indicate more positive attitudes toward breastfeeding, however, it is only a guide as the scores can fluctuate somewhat between participants. 81-85 Very Positive toward breast-feeding 70-80 Positive toward breast-feeding 49-69 Neutral 38-48 Positive toward formula-feeding 17-37 Very Positive toward formula-feeding
Copyright © 1997 de la Mora, A., Russell, D.W., Dungy, C.I., Losch, M., & Dusdieker, L. (1999). The Iowa infant feeding attitude scale: Analysis of reliability and validity. Journal of Applied Social Psychology, 29 (11) 2362- 2380.
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Appendix B: Demographic Survey Form
Demographic Survey
Age: ☐ 15 ☐ 16 ☐ 17 ☐ 18 ☐ 19
Gender: ☐ Female ☐ Male ☐ Transgender
Culture/Ethnicity: ☐ Non-Hispanic ☐ African American
☐ Hispanic American ☐ Asian American ☐ Native American ☐ Other
Pregnancy status: ☐ Pregnant ☐ Non-pregnant
Grade: ☐ Sophomore/10th ☐ Junior/11th ☐ Senior/12th
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Breastfeeding Exposure Questionnaire
1. Were you breastfed as an infant?
☐ yes ☐ no
2. Do you plan to breastfeed or encourage partner to breastfeed?
☐ yes ☐ no
3. Have you received education on breastfeeding in school?
☐ yes ☐ no
4. Have you seen movies on breastfeeding in school?
☐ yes ☐ no
5. Have you seen anyone breastfeed?
☐ yes ☐ no
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Appendix C: Informed Consent
Consent to Participate in Research
Invitation to Participate My name is Natalie Alonzo. I am a student at California State University San Marcos and Registered Nurse at Tri-City Medical Center in the Neonatal Intensive Care Unit. I plan to gain knowledge of student perceptions (knowledge, attitudes, exposure, and intentions) towards future infant feeding. This information will be used to help guide and promote future infant feeding education curriculum. The criteria, to be a student in this group, are based on being a male or female student between the age of 15-19 years-old, and who is neither pregnant or currently has a child.
Requirements of Participation (What you will be asked to do) Your son or daughter will have the opportunity to receive a 90-minute breastfeeding education session to include pre and post questionnaires. The education session and questionnaires will be voluntary and students will not be forced to participate. Students will be asked to keep the conversation and information shared in the education session confidential.
Risks are minimal in this study but include: 1. Participants will loose some class time during the education session. 2. Other participants in the education session may compromise confidentiality. The questionnaires may be seen by other than the researcher. 3. Discussion related to infant feeding education may cause emotional discomfort/distress.
Safeguards to minimize risk include: 1. Research will be conducted at the end of the day to account for extra time needed to complete all surveys with minimal loss of class time. 2. All participants will be reminded to maintain confidentiality and not share responses. The questionnaires will be kept in a secure location accessible only to the researchers. 3. Participants will be informed if at anytime the content is uncomfortable he/she may be excused to speak with a school counselor without penalty.
Benefits The research involved with this study will benefit health education as a whole. Teachers, leaders of education, school nurses, public health associations, and community based health organizations may find the information valuable to ensure future breastfeeding practice plus increase retention rates in California.
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Voluntary Participation and Consent Information Your participation is entirely voluntary, and may be withdrawn at any time. There are no consequences if you decide not participate.
This study has been approved by the California State University San Marcos Institutional Review Board (IRB). All questions or concerns may be directed to the researcher, Natalie Alonzo, alonz006 @cougars.csusm.edu, (760) 691-9031, or the researchers advisor/professor Dr. Patricia Hinchberger, [email protected], (760) 750-7557. Questions about your rights as a research participant should be directed to the IRB at (760) 750-4029. You will be given a copy of this form to keep for your records.
____I agree for my child to participate in this research study.
Students Name______
Parent Name______Parent Signature ______Date______
Researcher’s Signature ______
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Assent to Participate in Research
Dear Student,
My name is Natalie Alonzo; I am a student at California State University San Marcos and Registered Nurse at Tri-City Medical Center in the Neonatal Intensive Care Unit. I am conducting a research study with the goal of learning more about your awareness of infant feeding and what you think about it overall.
In order to help me learn about what you think, you will be asked to participate by answering questions, watching infant feeding videos, and talking about your experiences. Questions will be answered in the form of surveys and in-class discussion. All responses written and spoken are voluntary, will remain confidential, and have no influence over your class grade. If at anytime the content is uncomfortable you may be excused to speak with a school counselor.
This study has been approved by the California State University San Marcos Institutional Review Board (IRB). All questions or concerns may be directed to the researcher, Natalie Alonzo, alonz006 @cougars.csusm.edu, (760) 691-9031, or the researchers advisor/professor Dr. Patricia Hinchberger, [email protected], (760) 750-7557. Questions about your rights as a research participant should be directed to the IRB at (760) 750-4029. You will be given a copy of this form to keep for your records.
____I agree for my child to participate in this research study.
Participant’s Name______
Participant’s Signature______Date______
Researcher’s Signature ______
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Appendix D: IRB Application
California State University
San Marcos Full Expedited Review
Project Title: Breastfeeding Knowledge, Attitudes, Exposure, and Intentions Among Non-pregnant Adolescents Project Start Date: March 2016 Student Investigator: Natalie Alonzo Name Department/College: CSUSM/ School of Nursing (SON) Phone number E-mail: 760-213-8510/[email protected] Date Training Completed: Faculty Advisor: Dr. Patricia Hinchberger Department/College: CSUSM/School of Nursing (SON) Date CITI Completed:
1. Purpose of Project and Project Background. In the world of maternal-child health there has been an ongoing sociocultural shift that began in 1991 as a result of the United Nations International Children's Emergency Fund (UNICEF) and World Health Organization (WHO) Baby Friendly Hospital-Initiative based on the “10-steps to Successful Breastfeeding” (UNICEF, 2005). The shift resulted from research that identified breast milk and breastfeeding as having health benefits to both infants and mothers. Infants who receive breast milk have a decreased risk of chronic diseases like asthma, atopic dermatitis, Sudden Infant Death Syndrome (SIDS), Type 1 Diabetes, obesity, and leukemia in newborns (NAPNAP, 2011). Mothers who breastfeed have a decreased risk of postpartum hemorrhage, metabolic disease, cardiovascular disease, and the incidence of ovarian and breast cancer (NAPNAP, 2011; Brodribb, 2012).
In 2011 the Surgeon General’s Call to Action to Support Breastfeeding acknowledged all health professionals who provide care to women and children need breastfeeding education as well as the need to support “breastfeeding as a standard of care for midwives, obstetricians, family physicians, nurse practitioners, and pediatricians”(U.S Department of Health & Human Services [DHHS], 2011, p. 47; Spatz & Byod, 2013, p. 83). In the state of California efforts have been made through the sponsorship of the California WIC Association to improve breastfeeding rates and the number of International Board Certified Lactation Consultants (IBCLCs) and Certified Lactation Counselors (CLCs) by supporting the development of the California Breastfeeding Coalition (CBC) (CBC, 2014). The CBC has been working tirelessly over the past 11 years to meet the Healthy People 2010-2020 breastfeeding goals for optimal nutrition in the newborn and infant for the first 6 months of life, at 6 months in combination with appropriate solid foods, and continued for 12 months or more (National Association of Pediatric Nurse Practitioners [NAPNAP], 2011; American College of Obstetricians and Gynecologists [ACOG], 2009).
Recent studies support adolescents as an ideal developmentally appropriate segment of the population to introduce concepts of infant feeding education as a health promoting behavior within a school environment as a component of health, science, and family life curriculum
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(Allen, 2008; Leffler, 2000; Spears, 2007). The minimal focus on education related to breastfeeding and infant feeding options in the non-pregnant teen population are contributing to the low breastfeeding rates in California (Allen, 2008; Marrone, Vogeltanz-Holm, & Holm, 2008; Leffler, 2000). Methods of providing education to non-pregnant adolescents to promote knowledge, positive attitudes, exposure, and sustained intentions towards future breastfeeding practices need to be identified.
The following research proposal is intended to determine the non-pregnant Adolescents’ knowledge, attitudes, exposure, and intentions toward infant feeding by examining the effects of an infant feeding health promotion education session.
2. Recruitment Procedures & Participants A) List the expected number of participants for each population group included in the study: 108 study participants.
B) Describe all characteristics relevant to being selection of participants. (e.g., demographics, ethnicity, vulnerabilities, etc.) Explain why you are targeting this specific population. The target population will be non-pregnant high school students selected from San Diego County high schools that currently offers the California School Age Family Education program (CalSAFE), and closely represents the diverse population throughout San Diego County. The California Department of Education (2014) described the CalSAFE program as providing a continued learning environment for pregnant teens and teen parents including childcare and developmental services. The non-probability convenience sample will be composed of both male and female non-pregnant high school students between the ages of 15-19 years old. A demographic data form will be collected from each participant. Participants’ will complete the demographic data form utilizing the following numeric codes: Age (15=1, 16=2, 17=3, 18=4, 19=5); Gender (Female=1, Male=2, Transgender=3); Culture/Ethnicity (Non- Hispanic white=1, African American=2, Hispanic American=3, Asian American=4, Native American Indian=4, Other=5); Pregnancy status (Pregnant=1, Non-pregnant=2); and Grade (Sophomore/10th =1, Junior/11th =2, Senior/12th =3). See Demographic Data form (Appendix).
C) Indicate whether anyone might be excluded from participating and explain why. Exclusion criteria for this study included: age (no participants will be less than 15 years-old or greater than 19 years-old), students not attending a CalSAFE program high school, non-English speakers, and those students who are currently breastfeeding, pregnant, or parenting. The literature has identified 15-19 years olds as optimal for research of this nature, and age may contribute to parental approval. By utilizing CalSAFE program high schools for this research the hope is to more easily identify host schools to conduct this research. Education material will be presented in English; so all participants must be fluent in English. Currently breastfeeding, pregnant, or parenting are impacted by their present state and are beyond the initial exposure to infant feeding for establishing future breastfeeding practices.
D) How will you find, recruit, or identify potential subjects? How will you select from volunteers, the final group of participants? Submit flyers, posters, or other oral or written invitations used to recruit potential participants? A request for IRB approval will be completed on a southern California university campus prior to conducting research, and after
46 47 approval is obtained letters to school boards of CalSAFE campuses will be mailed. Once permission is granted by school board for researcher to present infant feeding health promotion education plan including Informed Consents and Assents, then the school board will need to approve or disapprove plan. If approved parental Informed Consents, student Informed Consents, and student Assents will be collected. Two weeks prior to the education session parents will receive Informed Consent via mail with the request to return within seven days to researcher. Students who are recognized as adults will receive Informed Consent at the same time all other participants receive Assent forms on the day of education session. A thorough explanation of forms will be provided, and participants will be instructed to return consents/assents prior to the start of the education session. Based on the San Diego County Area consents/assents will be available in English and Spanish.
E) Will you be offering an incentive? No. If yes, please explain procedure for any incentives that will be offered. Include how much participants must do to be eligible.
3. Informed Consent Process. A) How and when will you explain the study and the required elements of informed consent? Will you be doing this or be handled by a research assistant? Details of Informed Consent will first be presented at a school board presentation to all attendees by researcher. Research assistants will log and record parental Informed Consents, student Informed Consents, and student Assents. Two weeks prior to the education session parents will complete Informed Consent in an arranged parent meeting. A class role sheet will be developed based on returned consents and confirmed by school generated class roster. Primary investigator’s contact information will be provided on consent if parents need further clarification. Students who are recognized as adults will receive Informed Consent at the same time all other participants receive Assent forms on the day of education session. A through explanation of forms will be provided, and participants will be instructed to return consents/assents prior to the start of the education session. Based on the San Diego County Area consents/assents will be available in English and Spanish.
B) How much times will participants have to consider participating between the explanation described above, the receipt of consent document, and the beginning of the study? Parental Informed Consent will be completed and collected two weeks prior to research study with an opportunity for review and questions in an arranged parent meeting. Students will be given time on the day of prior to the start research to read form and ask questions.
C) If there are subjects under the age of 18, how will the study be explained to them? How will parental consent and child assent be handled? Parental Informed Consent will be completed and collected two weeks prior to research study at that time parents will be made aware all students will sign Assents and those students over the age of 18 will complete an Informed Consents on the day of research. Students will be given time on the day of prior to the start research to read Assent and Informed Consent forms and ask questions.
D) If you are requesting a Waiver of Consent or a Waiver of Documentation of Consent, explain why this is needed. Outline alternative procedures for obtaining consent or
47 48 providing study information (e.g. information sheet, introduction screen for web survey, etc.). I am not requesting a Waiver of Consent or a Waiver of Documentation of Consent.
E) Indicate the primary language(s) of your participants. If any participants are not fluent and comfortable with English, explain how you will ensure that participants’ understand the activity of which they are giving consent. The two primary languages reflective of San Diego County are English and Spanish. All parental Informed Consent forms will be made available in English and Spanish, and contained in the parental consent will be acknowledgment of child’s fluency in the English language. Informed Consents for those students over the age of 18 and Assents will contain acknowledgement of English language fluency.
4. Procedures and Methodology: Provide descriptions of each distinct procedure and each population group.
A) Provide a step-by-step explanation of your research activities and methodologies that involve human subjects. Be thorough. This research is quasi-experimental in design. The principle researcher, associate researcher will present and collect data on day of research. Research assistants will collect data forms and assist with maintain fluidity to the education session presentation. There will be a control group and an intervention group. The control group will receive a baseline infant feeding education session and intervention group will receive a baseline education session plus intervention. A pre-test and post-test education session evaluations will be conducted. The same-day education session is aimed at establishing breastfeeding knowledge, attitudes, exposure, and intentionality by conducting a baseline evaluation for non-pregnant male and female adolescents. The following will be included in the intervention groups’ infant feeding education session: (a) an infant feeding video (Breastfeeding advantages, How–to Support Breastfeeding Families, and How-to Build Breastfeeding Friendly Community); (b) healthcare provider led discussion (Basic Physiology of Breastfeeding, Infant feeding methods, and Risk versus Benefits of human milk compared to artificial); (c) breastfeeding poster activity (Identifying positive images, role models, and medium to dispel breastfeeding myths)(Allen, 2008; Giles et al., 2010; Hamade et al., 2014; Marrone et al., 2008; Martens, 2001; Spears, 2007; Walsh et al., 2008). Both the control and intervention groups will be scheduled for the infant feeding education session at the same time of the day for a 90-minute class period. The control group will view the video only, and then continue with the regular scheduled lesson. The principle researcher will conduct
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B) Where will the research be conducted? Describe any risks or confidentiality issues related to using this location. Research will be conducted on the participating San Diego CalSAFE High School campus in a classroom location to be determined by Principal Administrator, and class time will be conducted at the last period of the day at a regularly scheduled class session to decrease the risk of confidentiality concerns of consented/assented participants.
C) State the specific dates/timeframe in which you plan to conduct your research. December 2015- May 2016.
5. Participants Debriefing or Feedback. If deception is involved in your research, participants should be debriefed about the nature of the study as soon as possible. Participants should be given the opportunity to request a copy of the results of the study/ your final report. No deception will be involved in this research study.
A) Describe any feedback or information you will offer participants. Parents and students will be provided results, and the opportunity for feedback at a follow-up school board meeting, and a follow-up letter will be mailed to parents after school board meeting with highlights and request for additional feedback from both parents and students. The intent of this research study is to promote breastfeeding education for both female and male students as standard content in high school curriculum.
6. Risks: List Risks for each population participating in the research and for each methodology. Please be sure the risk listed here match the risks mentioned in consent letter or information sheets. Consider all risks very carefully. For more information on risks, see Example of Risks.
A) Explain potential risks to your participants. Risks may be physical, psychological (e.g. strong emotional reactions to research questions), or inconveniences (e.g., time required). 1. Participants will loose some class time during the education session. 2. Providing information related to infant feeding may provoke emotional discomfort/distress.
B) Vulnerable Subjects: Select which, if any, of the following vulnerable subjects will be involved in your research. Adolescents.
C) Describe any special risks to vulnerable populations or your population profile 3. Adolescents will require parental consent and assent forms for participation. D) List risks related to confidentially of data. What could happen if an unauthorized person accessed the data? For instance, others could know participant identity or personal information. 4. Other participants in the education session may compromise participant confidentiality. The questionnaires may be seen by other than the researcher. E) Will any personal identifying data be recorded? If so, what information will be recorded? (e.g. Social security number, driver’s license number, student id, address, phone number, birth date, and personal email address). Minimal demographic information (gender,
49 50 age, ethnicity, pregnant vs. non-pregnant, and grade) will be collected with limited identifying information.
7. Safeguard Procedures to Minimize Risks.
A) Please respond to each risk that you listed in #6 above. State how will you minimize each risk and protect confidentiality. 1. Research will be conducted at the end of the day to account for extra time needed to complete all surveys with minimal loss of class time. 2. All participants will be reminded to maintain confidentiality and not share responses. The questionnaires will be kept in a secure location accessible only to the researchers. 3. Participants will be informed if at anytime the content becomes uncomfortable he/she may be excused to speak with a school counselor without penalty. 4. Participating students will need a parental consent, and complete an assent prior to the start of research with opportunity to ask questions.
B) How will safeguard data? Where/how data will be stored? Who will have access to the data? How will access be limited? All data will be stored in a locked file in the California State University San Marcos, School of Nursing. Both principal investigator and associate researcher will log and analyze data collected. Lactation consultants/assistants will distribute and collected forms, and assist with fluidity of education session on day of research.
C) If using student or research assistants, how you will ensure that these assistants are trained and qualified to assist. All assistants should complete the CITI training on the protection of human participants in research. Data will be review using associate researcher. The principle researcher will confirm that the associate researcher has completed the IRB training prior to conducting any work on the study. The associate research received her Family Nurse Practitioner (FNP) degree at California State University, and has successfully completed a research methods course. The course content must have included lessons on ethics in research.
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8. Study Benefits
A) Discuss any potential individual or societal benefits. Note, often there is no direct benefit fort he participants. However, the study may contribute to the literature and/ or future research. This format will help to foster a breastfeeding culture, by recognizing community support and laws, establishing health benefits, introduction breast anatomy, and dispel breastfeeding myths and promote positive role models. By incorporating infant feeding into standard high school curriculum breastfeeding retention rates will increase over time, and the 2- year breastfeeding goal advised by the American Academy of Pediatrics could be reached.
B) Do the benefits of the study exceed the risks to participants? Explain why. Participants’ risk is minimal, and the potential for societal benefits exceed the minimal risk. Participants will benefit by receiving an intervention that might not otherwise be available to them, and directly influence their health and the health of their future children
9) Researcher(s) qualifications and experience A) Briefly outline the primary researcher(s)’s qualification and experience relative to the subject oft his research. Principal researcher is a Family Nurse Practice (FNP), Masters of Science student attending California State University San Marcos, School of Nursing (SON). This researcher has worked a total of 9 years as a licensed RN, and for the past 2.9 years in the Neonatal Intensive Care Unit (NICU) at Tri City Medical Center in Oceanside, Ca. She has received training in-hospital by lactation and staff to assist breastfeeding mothers while their neonates are being cared for in the NICU. She has been working towards helping her floor reach Baby Friendly Hospital Initiative goals. She has taught as a Pediatric Clinical Instructor and participated in Congestive Heart Failure research in association with California State University San Marcos, SON, under the principal investigator and the current Director of the SON, Dr. Denise Boren.
B) If this is a student project, include faculty sponsor’s qualifications. The primary faculty research chairperson is Dr. Patricia A. Hinchberger. She is the Associate Director for California State University San Marcos, School of Nursing (SON) graduate studies. Her focus is education, as a clinical nurse specialist and doctoral prepared nurse educator she is guiding this research. Dr. Deborah Bennett is serving as faculty committee member and doctoral prepared in nursing. She coordinates Simulation/Skills/Lab Director/Pediatrics Faculty at California State University San Marcos, School of Nursing (SON) for 10.2 years, and is providing consultation in the research process.
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