Developing a Culturally Grounded Breastfeeding Assessment for Low-Income, African American Women Dissertation Presented in Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy in the Graduate School of The Ohio State University By Rebecca Reno, M.S.W., M.A., B.A. Graduate Program in Social Work The Ohio State University 2016 Dissertation Committee: Audrey Begun, Advisor Dawn Anderson-Butcher René Olate Copyright by Rebecca Marie Reno 2016 Abstract The benefits of breastfeeding for mothers and infants have been well established in the literature, as have pervasive racial disparities in breastfeeding initiation and duration (Centers for Disease Control and Prevention, 2013a). The American Academy of Pediatrics recommends exclusive breastfeeding to 6 months of age, and Healthy People 2020 aims to have 60.6% of all infants exclusively breastfed to 6 months of age. A review of existing literature revealed a dearth of research focused specifically on the breastfeeding beliefs or behaviors of low-income, African American women. Reported studies are either atheoretical or utilize health behavior theories focusing on individual- level factors. Little attention has been paid to the unique sociocultural context within which this population is situated. Further, many existing breastfeeding interventions were not specifically designed for low-income African American women, and therefore may overlook their unique barriers to breastfeeding. Taken together, critical feminist theory and a social cultural model could provide a more comprehensive, culturally grounded framework from which to understand breastfeeding disparities, and to begin working to address them. Utilizing these two theories, a multi-phase, mixed methods research study was designed to identify breastfeeding barriers and supportive factors for low-income African American women, and to help empower them to meet their breastfeeding goals through the design and testing of a breastfeeding assessment process. Phase 1 utilized a ii community-based participatory action research methodology called group model building to answer the following research question: How do low-income, pregnant and postpartum African American women describe breastfeeding within their socio-cultural context, including factors that help or hinder breastfeeding? In Phase 2A, the set of statements that emerged from Phase 1 activities were evaluated by breastfeeding scholars and practitioners for inclusion in a set of Q-sort cards. These cards formed the foundation of a Dynamic Breastfeeding Assessment Process (D-BAP). In Phase 2B, the D-BAP was tested with a sample of lactation specialists and pregnant women to answer the research question: What would an assessment process look like if it were informed by the perspectives of the women as captured in the model building process? Finally, in Phase 3 the D-BAP underwent feasibility testing. Mixed methods were used to answer two research questions: 3A. How do pregnant, low-income African American women experience the culturally grounded Dynamic Breastfeeding Assessment Process? 3B. When the Dynamic Breastfeeding Assessment Process is delivered, is there a measurable difference in breastfeeding self-efficacy and intent among pregnant, low-income African American women? Completion of the D-BAP was hypothesized to be associated with increased breastfeeding intent and higher levels of breastfeeding self-efficacy. A pre-post, paired-samples design was utilized in Phase 3. The Phase 1 and 2 activities successfully resulted in a testable Dynamic Breastfeeding Assessment Process. In Phase 3, women who participated in the D-BAP iii demonstrated a statistically significant increase in breastfeeding self-efficacy, but not in their breastfeeding intent. The qualitative and quantitative findings from this study can inform future research, particularly as it pertains to supporting low-income African American women to meet their breastfeeding goals: a critically important public health and social work goal. iv Acknowledgments Much love, support, and encouragement goes into the making of a successful PhD student; I will be forever indebted to those who have seen me through. I am compelled to do my best to express my humble gratitude, though inevitably my words will be inherently insufficient. First, I am incredibly honored and deeply humbled by the generosity of all of the women who lent their time, their experiences, and their voices to this project. Thanks also to the indispensable Tanikka Price. Without her unparalleled facilitation skills and ongoing support, this study simply would not have come to fruition. To each of my committee members, I offer my deepest gratitude for the insights, guidance, mentorship, and encouragement offered over the years. I am honored that Professor Audrey Begun was willing to chair my committee. She has been incredibly supportive and unwaveringly confident in my ability to do things I was not sure I was capable of at the time. I would also like to offer my sincerest appreciation to Professor Dawn Anderson-Butcher. It was her passion and scholarship that first attracted me to social work, and her encouragement and guidance that saw me through. A thank you is owed to Professor René Olate as well, whose well-timed and insightful questions have led me down many inspiring theoretical and methodological paths. I am also deeply appreciative of the support and guidance I have received from many faculty and staff at the College of Social Work at The Ohio State University, v especially Tamara Davis. Your mentorship and ongoing support has strengthened my research skills, developed my knowledge about community partnerships, and expanded my research horizons. Thank you also to Dr. Pat Gabbe and the entire Moms2B team. Your tireless work in the community is an ongoing source of inspiration. Appreciation is due for the generous funding from the Department of Women's, Gender and Sexuality Studies and the Coca-Cola Critical Difference for Women Grants for Research on Women, Gender and Gender Equity. Support from the Merriss Cornell Research Scholarship is also deeply appreciated. I would be remiss if I did not acknowledge my proverbial village as well. There is simply no substitute for the love, laughter, and generosity of dear friends. For Marissa Kaloga and Sheila Barnhart, I would not like to ponder, even for a moment, what it would have been like without you. We may have survived, but there would have been a lot less laughter. My gratitude goes to Kristin Coppock and Sarah Moreno as well, who have come early, stayed late, and many times over have loved my kids as though they were their own. To my three boys—Wyatt, Silas, and Levi—if you remember nothing else of this time, I hope you have seen what it means to set your sights on a goal, and to work tirelessly to achieve it. I am enduringly grateful that my own mother gave me that gift through the playful recitation of all of the abbreviations following her name. Finally, for my husband, Clinton—never a word of doubt uttered, not a single discouragement, not vi even so much as a sigh. For every time that someone said to me, "I don't know how you do it,” the answer is "you." Always, you. vii Vita 2000…………………………………………B.A. Psychology, The Ohio State University 2003-2010…………………….…………….Senior Research Associate, The Kirwan Institute 2007…………………………………………M.A. Education, The Ohio State University 2010-2011…………………….…………….Graduate Research Associate, College of Social Work, The Ohio State University 2011-2013…………………….…………….Graduate Teaching Associate, College of Social Work, The Ohio State University 2013…………………………………………M.S.W., The Ohio State University 2013-2016…………………….…………….Graduate Research Associate, College of Social Work, The Ohio State University Publications Davis, T. S., Guada, J., Reno, R., Peck. A., Evans, S., Moskow Sigal, L., & Swenson, S. (2015). Integrated and culturally relevant care: A field education model for social work in primary care. Social Work in Health Care, 54(10), 909-938. Iachini, A., Buettner, C., Anderson-Butcher, D., & Reno, R. (2013). Exploring students’ perceptions of academic disengagement and re-engagement in a dropout recovery charter school setting. Children & Schools, 25(2), 113-120. viii powell, j., & Reno, R. (2011). A democratic merit agenda: An alternative approach. Readings on Equal Education, 25, 275-296. Fields of Study Major Field: Social Work ix Table of Contents Abstract ............................................................................................................................... ii Acknowledgments............................................................................................................... v Vita ................................................................................................................................... viii List of Tables ................................................................................................................... xvi List of Figures ................................................................................................................. xvii Chapter 1: Introduction ....................................................................................................... 1 Background of the Study ................................................................................................ 1 Statement of the Problem ................................................................................................ 3 Significance of the Study ...............................................................................................