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11-2019

Las Dos Cosas versus Exclusive Breastfeeding: A Culturally and versus Exclusive Breastfeeding: A Culturally and

Linguistically Exploratory Intervention Study in Hispanic Mothers Linguistically Exploratory Intervention Study in Hispanic Mothers

Living in Kentucky Living in Kentucky

Ana Maria Linares University of Kentucky, [email protected]

Diana Cartagena Old Dominion University

Mary Kay Rayens University of Kentucky, [email protected]

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Repository Citation Repository Citation Linares, Ana Maria; Cartagena, Diana; and Rayens, Mary Kay, "Las Dos Cosas versus Exclusive Breastfeeding: A Culturally and Linguistically Exploratory Intervention Study in Hispanic Mothers Living in Kentucky" (2019). Nursing Faculty Publications. 52. https://uknowledge.uky.edu/nursing_facpub/52

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Las Dos Cosas versus Exclusive Breastfeeding: A Culturally and Linguistically versus Exclusive Breastfeeding: A Culturally and Linguistically Exploratory Intervention Study in Hispanic Mothers Living in Kentucky Exploratory Intervention Study in Hispanic Mothers Living in Kentucky

Digital Object Identifier (DOI) https://doi.org/10.1016/j.pedhc.2019.07.009

Notes/Citation Information Notes/Citation Information Published in Journal of Pediatric Health Care, v. 33, issue 6.

© 2019 by the National Association of Pediatric Nurse Practitioners

© 2019. This manuscript version is made available under the CC-BY-NC-ND 4.0 license https://creativecommons.org/licenses/by-nc-nd/4.0/.

The document available for download is the authors' post-peer-review final draft of the article.

This article is available at UKnowledge: https://uknowledge.uky.edu/nursing_facpub/52

“Las dos cosas” versus exclusive breastfeeding: A culturally and linguistically exploratory intervention study in Hispanic mothers living in Kentucky

ANA MARIA LINARES, DNS, RN, IBCLC [Visiting Professor], College of Nursing, University of Kentucky, Lexington, KY.

Faculty of Health Science, Universidad de Tarapaca, Arica, Chile.

DIANA CARTAGENA, PHD, RN, CPNP, School of Nursing, Old Dominion University, Norfolk, VA50

MARY KAY RAYENS, PhD College of Nursing and College of Public Health, University of Kentucky, Lexington, KY.

Abstract

Introduction.—Supplementation with formula feeding among infants of immigrant Hispanics

that breastfeed is common. This phenomenon is known as las-dos-cosas. The purpose of this study

was to assess the feasibility/effectiveness/acceptability of a culturally/linguistically intervention to

promote exclusive breastfeeding (EBF) for the first six months.

Methods.—A sample of 39 Hispanic pregnant women were recruited and randomly assigned to

Intervention (n=20) and Control groups (n=19). The intervention incorporated a peer counselor/

professional support and mothers were followed from pregnancy to 6-months after birth.

Results.—After the intervention, the post-hoc comparison of the two treatment groups indicates

that compared with the Control group, those in the Intervention group were over three times more

likely to EBF their baby, when considering all four postpartum timepoints assessed (OR: 3.1;

95%CI: 1.1 to 8.7).

Corresponding author: Ana M. Linares, DNS, RN, IBCLC, 315 College of Nursing Building, University of Kentucky, Lexington, KY, 40536-0230, USA. Phone: 859-323-4626, Fax: 859-323-1057, [email protected]. Contributor Statement A.M.L. developed the framework, implemented the study, and supervised the findings of this study. M.K.R. run the statistical analysis than were verified by A.M.L. and D.C. All authors discussed the results and wrote the final manuscript. The final manuscript was approved by all authors.

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical Statement This study was approved by the Medical Institutional Review Board (IRB) of the University of Kentucky. Additionally, a Certificate of Confidentiality was obtained from the National Institutes of Child Health and Human Development to assure privacy and protect participants’ sensitive information on immigration status and/or mistrust in sharing their personal information.

HHS Public Access Author manuscript J Pediatr Health Care. Author manuscript; available in PMC 2020 November 01.

Published in final edited form as: J Pediatr Health Care. 2019 ; 33(6): e46–e56. doi:10.1016/j.pedhc.2019.07.009.

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Conclusion.—This culturally/linguistically intervention contributed to increasing EBF duration

in this sample of Hispanic mothers and significantly decreased formula supplementation at 6-

months post-birth.

Keywords

Exclusive Breastfeeding; Lactation Consultant; Peer Counselor; Breastfeeding intervention; Hispanics

Introduction

There are racial and ethnic disparities in breastfeeding (BF) duration and exclusivity

impacting maternal and child health outcomes and cost (Bartick et al., 2017; Jones, Power,

Queenan, & Schulkin, 2015). Compared with non-Hispanic white children, Hispanic

children have an increased risk of excess diseases attributable to suboptimal BF such as

acute otitis media, gastrointestinal infection, and child death (Bartick et al., 2017).

Hispanic women who immigrate to the U.S. bring with them cultural traditions and

healthcare practices from their native country that are protective behaviors, such as the

culture of exclusive breastfeeding (EBF). However, researchers have identified increased use

of formula feeding among low-income immigrant Hispanic women once in the US, referring

to this phenomenon as “las dos costs” (both things), denoting the use of formula and

breastmilk simultaneously (Bartick & Reyes, 2012; Hernandez, 2006; Hohl, Thompson,

Escareno, & Duggan, 2016; Linares, Rayens, Dozier, Wiggins, & Dignan, 2015; Nommsen-

Rivers, Chantry, Cohen, & Dewey, 2010). Factors impacting the use of formula among

Hispanic women include easy and affordable access to formula and misperceptions

regarding the nutritional and health benefits and parental responsibilities pertaining to

formula use (Bartick & Reyes, 2012; Flores, Anchondo, Huang, Villanos, & Finch, 2016;

Hernandez, 2006). Mixed feeding not only jeopardizes milk production but also produces

overfeeding that leads to childhood overweight and obesity, as well as increased risk of other

diseases (Bartick et al., 2017; Cartagena, McGrath, & Linares, 2018; Cartagena et al., 2014).

These risks may be preventable with longer duration of EBF.

Few investigators have described tailored interventions targeting exclusively immigrant or

first generation of Hispanic women. Most interventions targeting Hispanic mothers have

been effective in increasing the initiation of BF; behavior that is known as usual in Hispanic

women; but have had only modest impact on duration and exclusivity (Bunik et al., 2010;

Howell, Bodnar-Deren, Balbierz, Parides, & Bickell, 2014; Joshi, Amadi, Meza, Aguire, &

Wilhelm, 2016; Reeder, Joyce, Sibley, Arnold, & Altindag, 2014; Washio et al., 2017).

Lutenbacher et al. (2018) implemented a peer home visiting program and showed a

significant effect on EBF for at least six weeks compared with the attentional matched

control group. The strong belief among Hispanics that formula is a healthy choice and the

best solution to BF difficulties appear to be the factors in the lack of successful interventions

promoting duration of EBF (Bartick & Reyes, 2012; Bunik et al., 2010; Chapman, 2010). In

the absence of an effective early intervention to engage immigrant Hispanic mothers in

sustained EBF, disparities in health risk behavior and associated diseases among Hispanic

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children and families are destined to continue escalating over the next decade, further

exacerbating inequities in quality of life and health-care burden in this vulnerable

population.

The purpose of this exploratory randomized clinical trial (RCT) study was to assess the

feasibility, effectiveness, and acceptability of a culturally tailored intervention to promote

EBF for the first six months. In particular, the aims were to evaluate the group differences

trends in Intention to BF and BF knowledge during the prenatal period (2 assessments) and

EBF status starting with discharge from the hospital and continuing for six months (4

assessments), as well as summarize acceptability as rated by those randomized to the

intervention group.

Methods

This study used an exploratory longitudinal design, single site, RCT, and was approved by

the Medical Institutional Review Board (IRB). After IRB approval, a Certificate of

Confidentiality was obtained from the National Institutes of Child Health and Human

Development to assure privacy and protect participants’ sensitive information on

immigration status and/or mistrust in sharing their personal information. This study was

retrospectively registered in clinicaltrial.gov, number .

Sampling

A sample of 39 self-identified Hispanic pregnant women was recruited and randomly

assigned to Intervention (n=20) and Control (i.e., standard care) groups (n=19). To ensure a

relatively homogenous group, the inclusion criteria were: 1) self-identify as Immigrant

Hispanic women; 2) pregnant at or beyond 30 weeks of gestation; 3) intention to at least try

to breastfeed; 4) planning to deliver at a local birthing hospital; and 5) planning to remain in

the area for at least 6 months after the birth of their child. There were no age limits for

participation. To avoid potential complications with BF efforts, the exclusion criteria were:

1) prior or current participation in any study to enhance BF; 2) pregnant with twins; 3)

history of breast surgery; 4) contraindication to BF (e.g., HIV-positive status, chronic

therapy with medications incompatible with BF, alcohol dependence or other substance

abuse); and 5) presumed or known congenital fetus defects. The CONSORT flow diagram

for this study is presented in Figure 1 (Eldridge et al., 2016). Given the exploratory nature of

this study, a priori power analysis was not conducted.

Procedure

Participants were recruited from a local primary health care clinic that provides care to most

of the Hispanics in Central X. Women were approached in a waiting area reserved for

pregnant patients by bilingual and bicultural trained research personnel, who explained the

objectives of the study, checked for eligibility and invited them to participate in the study.

Women who agreed to participate were scheduled for an appointment at their home or clinic

to get the baseline information. Women participating signed a written informed consent and

HIPAA forms, and younger of 18 years old signed the assent form, except if they were

emancipated minors. Recruitment, informed consent documents, and interviews were

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administered in Spanish because all participants spoke Spanish as their primary language.

Participants received their group assignment after the baseline interview was completed.

Data collection was conducted by a trained research staff member who was blinded about

participant randomization; blinding was maintained to decrease the potential for any

discomfort the mother may have felt in responding to questions about infant feeding status if

she was not BF her infant. Data were collected twice during pregnancy (at or past 30 and 37

weeks), medical chart review after the birth of the infant, and at 1-, 3- and 6-months

following birth. Women participating in the study were compensated with a gift card for

their time in each visit.

Intervention

The Principal Investigator (PI), a bilingual and bicultural International Board Certified

Lactation Consultant (IBCLC), led the intervention. The Peer Counseling Training Platform

from United States Department of Agriculture was used to train the Peer Counselor (PC),

who was recruited from the local Hispanic community and who had two previous successful

experiences of EBF her infants for six months. The PC completed 20 hours of training.

Mothers randomly assigned to the Intervention group were contacted by the PI and the

trained bicultural PC to initiate the intervention. The content of the intervention was guided

by concepts of the Behavior-Specific Cognitions and Affect variables within the Health

Promotion Model (HPM) (Pender, Murdaugh, & Parsons, 2002). These variables constitute a

critical core for intervention and are considered to be of major motivational significance

because they are subject to modification. Five HPM concepts were included for the

development of the intervention: perceived benefits to action, perceived barriers to action,

perceived self-efficacy, interpersonal influence, and situational influence (Figure 2). Key

components of the intervention were: First, informational material was prepared with the

goals of 1) raising consciousness—through seeking and processing awareness of benefits of

adopting a healthy behavior (i.e., EBF for six months, delaying introduction of solid food) or

discontinuing a risky behavior (e.g., supplement with formula, infant solid food before six

months); 2) anticipating barriers to EBF—perceptions concerning the unavailability,

inconvenience, difficulty, or time-consuming nature of the action; and 3) promoting self-

efficacy. BF self-efficacy was acknowledged and referred to beliefs about being able to carry

out progressively more demanding levels of EBF, and to overcome barriers to engage in the

behavior (empower). Second, individual home-visit sessions were designed to increase trust

to enhance the benefits of change (e.g., reinforcing motivation, benefit and positive

outcomes derived from the behavior), and self-efficacy to control interpersonal and

situational influences. Third, a commitment to a plan of action was developed based on

adapting (including cultural and linguistic adaptation) My Action Plan for BF (MAP) from

the California Nutrition and Physical Activity Guidelines for Adolescents (California

Department of Public Health, 2015). The intensive peer counselor/professional support (1–2

prenatal visits, one in-hospital visit, two home postpartum visits, and pre/post-natal follow-

up phone calls as needed) was conducted individually with each mother until six months

after the birth of the infant (Table 1). In case of failure to meet an encounter either for the

data collection and/or intervention (e.g., preterm birth, lack of time, work, sickness, etc.),

participants were not excluded from the study. The IBCLC, PCs, and research staff remained

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flexible to the participants’ schedule in order to acquire complete data and arrange the

intervention sessions.

Women in the usual care group received the regular education on BF that was given to all

women during their prenatal care visit in the clinic. Additionally, women from both groups

gave birth in a “Baby Friendly Hospital” that allowed them to receive support from a clinical

IBCLC from the birthing hospital. Women in the control group did not have any contact

with the IBCLC/PC study team.

Measures

Demographic and Personal Characteristics.—Once participants were screened for

eligibility and enrolled in the study, demographic characteristics in the baseline survey

included age (in years) and a series of yes/no items, including whether they lived with their

partner or husband, were employed, had health insurance, and enrolled in the Women,

Infant, and Children Program (WIC). Mode of delivery was recorded from the medical

record following the birth.

Previous Experience with BF was measured with a single question that assessed if the

mother has ever had anyone close to her breastfeed (yes/no response option); for those who

answered ‘yes,’ there was a follow-up item asking who this person was.

Acculturation.—The 7-item short version of the Hispanic Acculturation Scale (Marin,

Sabogal, Marin, Otero-Sabogal, & Perez-Stable, 1987) assessed the likelihood of using

Spanish or English in different situations. Responses are rated in a five-point choice: only

Spanish; Spanish better than English; both equally; English better than Spanish; and only

English. The responses are summed, with the total score ranging from 5 to 35, with higher

scores indicating a greater degree of acculturation. Cronbach’s alpha was 0.91 for this

sample.

Infant Feeding Plan and Potential BF Goal were assessed at baseline and again before the

birth of the infant using the Infant Feeding Intentions Scale, Spanish version (IFI)

(Nommsen-Rivers, Cohen, Chantry, & Dewey, 2010). This scale has five items, with

response options ranging from 0 = ‘Very much disagree’ to 4 = ‘Very much agree.’ The total

score is obtained by averaging the first two items (which include planning about giving BF a

try and another item that is reverse-coded as it is an endorsement of planning to use formula)

and adding the remaining three items to this mean. The range of scores is from 0 to 16, with

higher scores indicating a stronger intention to EBF for six months. Cronbach’s alpha for

this sample was 0.87.

BF Knowledge was assessed at baseline and again before the birth of the infant using an

adapted Spanish version of the BF Knowledge Questionnaire (Wambach et al., 2011). The

questionnaire has 25 items, with response options 1= True, and 0 = False. The total score is

obtained by first reversing eight of the items by assigning a value of 1 for each correct

answer of ‘False’ and then adding all the items. The range of scores is from 0 to 25, with

higher scores indicating greater knowledge of BF. Kuder-Richardson 20 for this sample was

0.72.

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Infant Feeding Status was determined at discharge from the hospital immediately following

birth via medical chart review from reports in the infant’s chart, and compared for accuracy

with mother’s chart notes from the physician, lactation consultant, nurse or another clinician.

Follow-up infant feeding status at each encounter post-discharge (1, 3, and 6 months), was

assessed via the mother’s report; First the mother was asked to choose the practice that most

closely resembles how she was feeding her infant with possible options of EBF, predominant

breast milk; mixed feeding; predominant formula milk; and exclusive formula milk (Thulier,

2010; World Health Organization, 2017). Then, the mother was also asked, ‘Does your baby

receive water, juice, or any solids?’ If the mother agreed that the infant is receiving

additional food, mothers were asked when they introduced the food to their child. Only those

who replied that were only given breastmilk without any additional food were recorded as

EBF for feeding status.

Acceptability of the Intervention was assessed at the end of the study for the participants that

were assigned to the intervention group. Only participants who completed the study were

evaluated using this instrument. This scale has 5-items assessing the work of PC and

IBCLC, and a woman’s feeling of satisfaction with the intervention experience. Response

options ranging from 1= “very dissatisfied” to 5= “very satisfied.” The range of scores is

from 5 to 25, with higher scores indicating greater acceptability of the intervention.

Data Analysis

Study variables were summarized using means and standard deviations or frequency

distributions. Comparisons of the intervention and control groups, or between those who

completed the study and those who dropped out, were accomplished using two-sample t-

tests, chi-square tests of association, or Fisher’s exact tests as appropriate. The longitudinal

group comparisons of Intention to BF and BF Knowledge were done using mixed modeling

for repeated measures. The initial model contained the main effects of group (Intervention

vs. Control), time (2 timepoints during prenatal period), and their interaction.

Similarly, the group comparison of EBF status over the four timepoints (discharge and 1, 3,

and 6 months) was accomplished using generalized estimating equations (GEE) modeling

given the binary outcome. In this model, we included baseline Intention to BF as a covariate

because although the group difference in intention at baseline was not significant at the

specified alpha level, there was a difference in means between the groups at the 0.1 level,

with the Intervention group having higher average Intention to BF scores than Controls. In

addition to the covariate, the initial GEE model included the main effects of treatment

(Intervention vs. Control), time (4 timepoints) as well as their interaction. In all three final

longitudinal models (i.e., for Intention, Knowledge, and EBF status), the treatment by time

interaction was not included since this term was not significant in any of the models. Data

analysis was conducted using SAS, v 9.4; an alpha of 0.05 was used.

Results

The average age of the 39 participants was 25.4 years (SD = 5.9), with a range from 13 to

37. Most lived with their partner (71.8%), were not employed outside the home (71.8%), did

not have medical insurance (66.7%), and were registered (66.7%) in WIC. The mode of

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delivery was most often vaginal (76.9%), and the same percentage reported that someone

close to them had breastfed previously. Acculturation scores were typically relatively modest

compared with the maximum possible score of 35, with a mean of 11.7 (SD = 5.9) and

scores ranging from 7–24. In the full sample (comprising both Intervention and Control

participants), the Intention to BF score was relatively high at enrollment: the mean was 12.3

(SD = 3.6), with a range from 0–16. BF Knowledge scores were also relatively high, with an

average of 19.5 (SD = 3.6), and scores ranged from 10 to 25. As shown in Table 2, there

were no significant differences between the two treatment groups on any of these

demographic, clinical, or personal variables. Only baseline Intention to BF demonstrated a

marginal difference (p = .1), with a higher average score in the Intervention group relative to

Control.

The comparisons of those who completed the study (n=29) to those who dropped out by six

months (n=10) on these baseline characteristics suggested that completers and dropouts were

comparable as well. For each of the variables listed in Table 2, there was no difference

between these two subgroups (p > .2 for each comparison).

The repeated measures model for Intention to BF was significant overall (Likelihood ratio

χ2 = 29.0, p < .001). While the enrollment Intention to BF score did not differ significantly

between the two treatment groups (p = .10, see Table 2), the group main effect in the

repeated measures model was significant (F = 5.0, p = .031); the Intervention group had

higher average scores during the prenatal period than the Control group. Averaged over the

two prenatal assessments, the mean Intention to BF scores for the Intervention and Control

groups were 13.6 and 11.1, respectively. The main effect of Time was not significant in this

model (p = .68), suggesting the degree of change over time was not significant for the two

groups combined. The repeated measures model for the BF Knowledge was not significant

overall (Likelihood ratio χ2 = 2.7, p .10). Although the mean for the Intervention group

exceeded that of the Control, this observed difference was not great enough to lead to overall

model significance, so the group comparison is not warranted.

BF initiation at hospital stay was high in both groups, with 100% and 90% in the

Intervention vs. Control group respectively. However, for the more stringent standard of

EBF, 45% of mothers in the Intervention group and 21% of those in the Control group were

in the EBF group during hospitalization following the birth. More mothers in the Control

group initiated “las dos cosas” or BF and supplementing with formula (68%) compare with

the Intervention group (55%). Since the baseline mean for Intention to BF was somewhat

higher in the Intervention group relative to the Control, albeit not statistically significant,

this was used as control variable in the longitudinal analysis of EBF status. The final model

for the repeated measures assessment of group and time differences in EBF status,

controlling for baseline Intention to BF, indicated that the Group main effect was significant

(χ2 = 4.3, p = .038), and was the main effect of Time (χ2 = 10.6, p = .014). The post-hoc

comparison of the two treatment groups indicates that compared with the Control group,

those in the Intervention group were three times more likely to EBF their baby (odds ratio

[OR]: 3.1), when considering all four postpartum timepoints (95% confidence interval for

the OR: 1.1 to 8.7), and controlling for baseline Intention to BF. The significance of the

main effect of Time corresponds to the decrease in EBF prevalence over time, especially

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between three and six months. While the lack of a significant interaction between Group and

Time precludes the post-hoc comparison of EBF status at each timepoint; Figure 3 displays

the frequency of EBF mothers at each timepoint, with a clear pattern of greater percent of

EBF success in the Intervention group regardless of timepoint. In the Intervention group in

particular, the greater decline in EBF prevalence between 3 to 6 months was largely due to

the introduction of solid foods during months 4–5 at the advice of their care providers: while

half of Intervention group participants were still using breastmilk as the only liquid food

source at 6 months, 71% of these mothers had introduced solid food prior to this assessment

and so were not considered EBF at 6 months for this analysis.

Although the difference in retention was not significant between the groups, there was a

slightly higher retention rate at six months among those in the Control group relative to the

Intervention group (79% vs. 70%, respectively; Fisher’s exact p = .72). In light of this

difference, we also considered a sensitivity analysis of the GEE model, in which we

assumed that all missing EBF status observations were ‘no’ for this variable, for mothers in

both groups. This is a conservative analysis since it favors the null hypothesis of no group

difference in EBF status. The sensitivity model, also with Intention to BF included as a

covariate, was relatively consistent with the GEE model described above. In particular, the

main effect of Group was significant (χ2 = 4.2, p = .040), and the Time main effect was as

well (χ2 = 12.8, p = .0051). The post-hoc comparison of the Treatment main effect indicates

that compared with the Control group, those in the Intervention group were three times (OR

= 3.0) times more likely to EBF their baby, when considering all four post-birth timepoints

(95% confidence interval for the OR: 1.1 to 8.8). The consistency of findings from the

original model and sensitivity analysis underscores the stability of this evaluation, even with

26% of the participants not completing the study.

Intervention.

Seventy percent (n=14) of participants in the intervention group received two prenatal home

visits as was established by the intervention; while 30% (n=6) only got one home visit.

Similarly, the hospital visit was received by 70% of participants in the intervention group.

IBCLC visited 75% (n=15) of mothers at their house while PC was able to complete the

home visit to 45% (n=9) of mothers. Most of the mothers (60%) got at least two follow-up

calls before delivery, while the rest got one. During postpartum, most of the mothers (75%)

got two follow-up calls. No answer to the phone calls and unreachable were the causes why

some sessions were not completed. Attrition in the intervention group (30%) was mostly

during the six months follow up phone call (Figure 1).

The average score in Acceptability of the intervention among participants in the intervention

group and completed the study was 22.7 points (SD = 2.5), with a range from 17 to 25. Most

of the participants that completed the intervention (93%) were satisfied or very satisfied with

the intervention. All except four participants were very satisfied (71%) with the support

given by the PC, and also all except two participants were satisfied to very satisfied (86%)

with the intervention of the IBCLC.

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Discussion

In this RCT exploratory study, we aimed to assess the effectiveness of a culturally/

linguistically tailored intervention to promote EBF for the first six months in a sample of

Hispanics mothers living in X. Specifically, we aimed to evaluate the group differences

(Intervention vs. Control) in Intention to BF and BF Knowledge during the prenatal period

and EBF status starting with discharge from the hospital and continuing for six months. The

treatment groups (Intervention vs. Control) were comparable at baseline, and there was not a

difference in baseline characteristics between dropouts and completers.

Our findings indicate that most of the women in both groups reported a high intention to

initiate BF and were planning to EBF their infants. However, when both Intention to BF scores collected during pregnancy were included in a longitudinal model, the Intervention

group had an average score that was 2.5 points higher than the Control group across the two

timepoints, which occurred after at least one face to face intervention session was received

by the Intervention group, and this difference was significant. This suggests that prenatal

support by the bilingual/cultural trained PC and IBCLC had a positive effect. Intention to BF has been described as one of the modifiable behaviors to increase adherence to EBF

(Meedya, Fahy, & Kable, 2010). The prenatal portion of the intervention included phone

contact with the IBCLC and PC home visiting with discussions of BF educational modules,

anticipatory guidance on the management of barriers, solving problems, and enhancing self-

efficacy on BF. We believe the personalized education and home visiting is highly

recommended for this population that most of the time report lack of time or transportation

issues to visit the clinic or another place (Kaiser Family Foundation, 2018). Additionally,

building of trust between the IBCLC and PC with the participant was encouraged with the

individualized culturally/linguistically tailored support and home visiting (Park, Schwei,

Xiong, & Jacobs, 2018). The Department of Human and Health Services has reported the

effectivity of implementing home visiting in minority groups (Sama-Miller et al., 2017).

The group effect was significant for EBF status—combining across the four post-birth

assessments, and controlling for baseline Intention to BF, those in the Intervention group

were three times more likely to EBF, relative to Control participants. This group effect was

maintained even when missing EBF status observations were replaced with ‘no’ values. It

has been demonstrated that Hispanic mothers are typically willing to initiate BF (Hohl et al.,

2016; Linares et al., 2015) as was verified in our study with almost 95% of the mothers

participating in our study (including both Control and Intervention groups) initiating BF at

hospital stay. However, in the Control group, many mothers requested formula during the

hospitalization (las dos cosas). This phenomenon has been highly discussed from others

authors (Bartick & Reyes, 2012; Hohl et al., 2016; Nommsen-Rivers, Chantry, et al., 2010)

and seems to be the factor that jeopardizes the exclusivity of BF. Additionally, some

researchers in South America have warned about the declining of EBF in their countries

with a switch to “las dos cosas” (Boccolini, Boccolini, Monteiro, Venancio, & Giugliani,

2017; Gonzalez de Cosio, Escobar-Zaragoza, Gonzalez-Castell, & Rivera-Dommarco,

2013). It seems like Hispanic mothers want to breastfeed their infants but at the same time

supplement with formula, which increases the risk of overfeeding their infants (Cartagena et

al., 2014). There is evidence that EBF children that are introduced to solids right after six

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months and continued to receive breastmilk (≥12 months) are less likely to become

overweight/obese (Papoutsou et al., 2018). Hispanic infants are at high risk of childhood

obesity and this risk factor is presented at an early stage as was reported by the National

Health and Nutrition Examination Survey (2014), where the prevalence of high weight for

recumbent length (≥95th percentile) among infant and toddlers from birth to 2 years was

6.6% in Whites, 8.4% in Blacks, and 9.4% in Hispanics (Ogden, Carroll, Kit, & Flegal,

2014). Promotion of EBF for six months in Hispanic children potentially decreases the high

risk of childhood obesity. This intervention was able to provide mothers with the support

that was required to avoid supplementation with formula from the infant’s birth until at least

three months of age. However, many mothers in the Intervention group who had maintained

EBF until this point were advised by their health care provider to supplement with juice and

solid food at ages 4–5 months, thus ending EBF prior to 6 months. Consistent with this

phenomenon, the largest decline in EBF prevalence in the Intervention group was between

three and six months. The American Academy of Pediatrics (AAP) and World Health

Organization (WHO) recommend EBF for a minimum of six months followed by continued

BF for a minimum of one year as complementary foods are introduced (AAP, 2012; WHO,

2017); however, as was observed in our study many mothers were advised to initiate the

introduction of food before the recommended time.

Implication for Practices

A common infant feeding option for Hispanics is “las dos cosas.” Researchers have

observed that even this behavior is common in newly immigrant, low-income Hispanic

women once in the US. It is known that most of the immigrant Hispanic mothers are going

to initiate breastfeeding, however, they learn from their peers that formula is acceptable and

could be easily available from the Women, Infants, and Children (WIC) program, which

makes combination feeding, or even discontinuation of breastfeeding altogether, possible

(Hernandez, 2006). Our study showed that mothers that received the intense peer counselor/

professional lactation support were able to overcome the misconception that “las dos cosas” is a healthy choice, and they were more likely to keep their infant with EBF for a longer

time. An important implication for practice is that the cultural/linguistically appropriate

intervention, which included home visits by the PC and IBCLC to support the Hispanic

mothers were able to produce the behavioral change needed. It is evidence that when

mothers are from a cultural background different from the health provider, additional

challenges are described including language, different cultural beliefs, mistrust, and limited

illiteracy (Lutenbacher et al., 2018; Park et al., 2018; Sobel & Metzler Sawin, 2016).

Therefore, cultural sensitivity is encouraged in health providers to be responsive to the

health beliefs, practices, cultural and linguistic needs of diverse patients with the goal to help

bring positive health outcomes (Park et al., 2018).

Another important implication is that health providers need to evaluate the benefit of

maintaining a child with EBF and encourage mothers that are EBF to do so until six months.

Our study showed that many mothers that were EBF incorporated solid food or other foods

following the recommendation of their infant’s health providers. A Cochrane review showed

that for infants at four to six months, there was no evidence of benefit from additional foods

earlier than six months (Becker & Remmington, 2014; Smith & Becker, 2016). Further

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intervention with health providers to promote current evidence-based practices

recommendations on infant feeding is warranted.

Strengths and Limitations

The primary strength of this exploratory study was that the randomization yielded two

treatment groups that were statistically comparable in every demographic, clinical, and

personal characteristic included. Knowing the high probability that Hispanics have to leave

an area to move for better opportunities, a 74% retention at six months postpartum was

considered relatively high. Further, there were no demographic differences between those

who completed the study and those who dropped out. This latter observation helps bolster

the use of a repeated measures modeling strategy that allows for the inclusion of participants

in the analysis even if they have missing data, if it can be assumed that the data are missing

at random. An additional strength is the finding that the significant group difference for EBF

status in the postpartum period is maintained even if all missing values are replaced with

EBF status equal to ‘no.’ The main limitation to this exploratory study is the sample size, but

we were able to discern group differences in key outcomes, including Intention to BF and

BF Knowledge, both assessed during pregnancy, and EBF status in the postpartum period.

An additional limitation is that those randomized to the Intervention group had a slightly

higher Intention to BF at baseline (p = .10), but this concern is mitigated since the group

difference in EBF status during the postpartum 6-month period is maintained with Intention to BF included as a covariate. These findings underscore the impetus for a larger study to

further evaluate this culturally/linguistically tailored intervention for the promotion of EBF

in this population. Finally, not all variables that affect breastfeeding behavior in Hispanics

are included in this analysis. However, we prioritized the potentially modifiable factors that

have the potential to be affected by an innovative, culturally, and linguistically appropriate

intervention.

Conclusions

This novel, culturally/linguistically tailored intervention approach was highly acceptable to

participants, contributed to increasing EBF duration in this sample of Hispanic mothers, and

significantly decreased formula supplementation, something that has been rarely reported at

six months postpartum in previous studies. The potential of this intervention is important in

this at-risk population, particularly since government agencies have warned of the risk of

formula supplementation at early stage, which is a detriment to both mothers and infants,

compared with the health benefits of EBF. Future work will evaluate if any specific

component of the intervention was significantly associated with duration of EBF or if the

intervention as a whole help promotes extended EBF.

Funding

The project described was supported by the NIH National Center for Advancing Translational Sciences through grant number UL1TR000117 and UL1TR001998. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

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References

American Academy of Pediatrics. (2012). Breastfeeding and the use of human milk. Pediatrics, 129(3), e827–841. doi:10.1542/peds.2011-3552 [PubMed: 22371471]

Bartick MC, Jegier BJ, Green BD, Schwarz EB, Reinhold AG, & Stuebe AM (2017). Disparities in breastfeeding: Impact on maternal and child health outcomes and costs. Journal of Pediatrics, 181, 49–55.e46. doi:10.1016/j.jpeds.2016.10.028 [PubMed: 27837954]

Bartick M, & Reyes C (2012). Las dos cosas: an analysis of attitudes of Latina women on non- exclusive breastfeeding. Breastfeeding Medicine, 7(1), 19–24. doi:10.1089/bfm.2011.0039 [PubMed: 22007765]

Becker GE, & Remmington T (2014). Early additional food and fluids for healthy breastfed full-term infants. Cochrane Database Systematic Review (11), Cd006462. doi: 10.1002/14651858.CD006462.pub3

Boccolini CS, Boccolini PMM, Monteiro FR, Venancio SI, & Giugliani ERJ (2017). Breastfeeding indicators trends in Brazil for three decades. Revista de Saude Publica, 51, 108. doi:10.11606/ s1518-8787.2017051000029 [PubMed: 29166437]

Bunik M, Shobe P, O’Connor ME, Beaty B, Langendoerfer S, Crane L, & Kempe A (2010). Are 2 weeks of daily breastfeeding support insufficient to overcome the influences of formula? Academic Pediatrics, 10(1), 21–28. doi:10.1016/j.acap.2009.09.014 [PubMed: 20129478]

California Department of Public Health. (2015). California Nutrition and Physical Activity Guidelines for Adolescents. https://www.cdph.ca.gov/Programs/CFH/DMCAH/CDPH%20Document %20Library/NUPA/NUPA-Guidelines-Adolescents.pdf

Cartagena D, McGrath JM, & Linares AM (2018). Associations between introduction of age- inappropriate foods and early eating environments in low-socioeconomic Hispanic infants. Journal Pediatric Health Care, 32(2), e27–e36. doi:10.1016/j.pedhc.2017.09.005

Cartagena DC, Ameringer SW, McGrath J, Jallo N, Masho SW, & Myers BJ (2014). Factors contributing to infant overfeeding with Hispanic mothers. Journal Obstetrics Gynecology Neonatal Nurses, 43(2), 139–159. doi:10.1111/1552-6909.12279

Chapman DJ (2010). Exploring breastfeeding ambivalence among low-income, minority women. Journal of Human Lactation, 26(1), 82–83. doi:10.1177/0890334409355773 [PubMed: 20150336]

Eldridge SM, Chan CL, Campbell MJ, Bond CM, Hopewell S, Thabane L, & Lancaster GA (2016). CONSORT 2010 statement: extension to randomized pilot and feasibility trials. Pilot Feasibility Study, 2, 64. doi:10.1186/s40814-016-0105-8

Flores A, Anchondo I, Huang C, Villanos M, & Finch C (2016). “Las dos cosas,” or why Mexican American mothers breast-feed, but not for long. Southern Medical Journal, 109(1), 42–50. doi: 10.14423/smj.0000000000000400 [PubMed: 26741873]

Gonzalez de Cosio T, Escobar-Zaragoza L, Gonzalez-Castell LD, & Rivera-Dommarco JA (2013). Infant feeding practices and deterioration of breastfeeding in Mexico. Salud Publica Mexico, 55 Suppl 2, S170–179.

Hernandez IF (2006). Promoting exclusive breastfeeding for Hispanic women. MCN American Journal of Maternal Child Nursing, 31(5), 318–324. [PubMed: 17013073]

Hohl S, Thompson B, Escareno M, & Duggan C (2016). Cultural norms in conflict: Breastfeeding among Hispanic immigrants in rural Washington state. Maternal Child Health Journal, 20(7), 1549–1557. doi:10.1007/s10995-016-1954-8 [PubMed: 27021068]

Howell EA, Bodnar-Deren S, Balbierz A, Parides M, & Bickell N (2014). An intervention to extend breastfeeding among black and Latina mothers after delivery. American Journal Obstetrics Gynecology, 210(3), 239.e231–235. doi:10.1016/j.ajog.2013.11.028

Jones KM, Power ML, Queenan JT, & Schulkin J (2015). Racial and ethnic disparities in breastfeeding. Breastfeeding Medicine, 10(4), 186–196. doi:10.1089/bfm.2014.0152 [PubMed: 25831234]

Joshi A, Amadi C, Meza J, Aguire T, & Wilhelm S (2016). Evaluation of a computer-based bilingual breastfeeding educational program on breastfeeding knowledge, self-efficacy and intent to breastfeed among rural Hispanic women. International Journal Medical Informatics, 91, 10–19. doi:10.1016/j.ijmedinf.2016.04.001

LINARES et al. Page 12

J Pediatr Health Care. Author manuscript; available in PMC 2020 November 01.

A uthor M

anuscript A

uthor M anuscript

A uthor M

anuscript A

uthor M anuscript

Kaiser Family Foundation. (2018). Health and health care for Hispanics in the United States. KFF KFF Website. Retrieved from https://www.kff.org/infographic/health-and-health-care-for-hispanics-in- the-united-states/

Linares AM, Rayens MK, Dozier A, Wiggins A, & Dignan MB (2015). Factors influencing exclusive breastfeeding at 4 months postpartum in a sample of urban Hispanic mothers in Kentucky. Journal Human Lactation, 31(2), 307–314. doi:10.1177/0890334414565711

Lutenbacher M, Elkins T, Dietrich MS, & Riggs A (2018). The efficacy of using peer mentors to improve maternal and infant health outcomes in Hispanic families: Findings from a randomized clinical trial. Maternal & Child Health Journal, 22(Suppl 1), 92–104. doi:10.1007/ s10995-018-2532-z

Marin G, Sabogal F, Marin BV, Otero-Sabogal R, & Perez-Stable EJ (1987). Development of a short acculturation scale for Hispanics. Hispanic Journal of Behavioral Sciences, 9 (2), 183–205

Meedya S, Fahy K, & Kable A (2010). Factors that positively influence breastfeeding duration to 6 months: a literature review. Women and Birth, 23(4), 135–145. doi:10.1016/j.wombi.2010.02.002 [PubMed: 20299299]

Nommsen-Rivers LA, Chantry CJ, Cohen RJ, & Dewey KG (2010). Comfort with the idea of formula feeding helps explain ethnic disparity in breastfeeding intentions among expectant first-time mothers. Breastfeeding Medicine, 5(1), 25–33. doi:10.1089/bfm.2009.0052 [PubMed: 20043707]

Nommsen-Rivers LA, Cohen RJ, Chantry CJ, & Dewey KG (2010). The infant feeding intentions scale demonstrates construct validity and comparability in quantifying maternal breastfeeding intentions across multiple ethnic groups. Maternal Child Nutrition, 6(3), 220–227. doi:10.1111/j. 1740-8709.2009.00213.x [PubMed: 20929494]

Ogden CL, Carroll MD, Kit BK, & Flegal KM (2014). Prevalence of childhood and adult obesity in the united states, 2011–2012. JAMA, 311(8), 806–814. doi:10.1001/jama.2014.732 [PubMed: 24570244]

Papoutsou S, Savva SC, Hunsberger M, Jilani H, Michels N, Ahrens W, … Hadjigeorgiou C. (2018). Timing of solid food introduction and association with later childhood overweight and obesity: The IDEFICS study. Maternal Child Nutrition, 14(1). doi:10.1111/mcn.12471

Park L, Schwei RJ, Xiong P, & Jacobs EA (2018). Addressing cultural determinants of health for Latino and Hmong patients with limited English proficiency: Practical strategies to reduce health disparities. Journal of Racial Ethnic Health Disparities, 5(3), 536–544. doi:10.1007/ s40615-017-0396-3 [PubMed: 28791616]

Pender N, Murdaugh C, & Parsons M (2002). Health promotion in nursing practice: New Jersey, USA: Upper Saddle River

Reeder JA, Joyce T, Sibley K, Arnold D, & Altindag O (2014). Telephone peer counseling of breastfeeding among WIC participants: a randomized controlled trial. Pediatrics, 134(3), e700– 709. doi:10.1542/peds.2013-4146 [PubMed: 25092936]

Sama-Miller E, Akers L, Mraz-Esposito A, Zukiewicz M, Avellar S, Paulsell D, & Grosso PD (2017). Home visiting evidence of effectiveness review. Retrieved from Washington, DC: https:// homvee.acf.hhs.gov/homvee_executive_summary_august_2017_final_508_compliant.pdf Lactation, 25(4), 404–411. doi:10.1177/0890334409337308

Smith HA, & Becker GE (2016). Early additional food and fluids for healthy breastfed full-term infants. Cochrane Database Syst Rev(8), Cd006462. doi:10.1002/14651858.CD006462.pub4

Sobel LL, & Metzler Sawin E (2016). Guiding the process of culturally competent care with Hispanic patients: A grounded theory study. Journal of Transcultural Nursing, 27(3), 226–232. doi: 10.1177/1043659614558452 [PubMed: 25409673]

Thulier D (2010). A call for clarity in infant breast and bottle-feeding definitions for research. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 39(6), 627–634. doi:10.1111/j. 1552-6909.2010.01197.x

Wambach KA, Aaronson L, Breedlove G, Domian E, Rojjanasrirat W, & Yeh HW (2011). A randomized controlled trial of breastfeeding support and education for adolescent mothers. Western Journal Nursing Research, 33(4), 486–505. doi: 410.1177/0193945910380408. Epub 0193945910382010 Sep 0193945910380427.

LINARES et al. Page 13

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Washio Y, Humphreys M, Colchado E, Sierra-Ortiz M, Zhang Z, Collins BN, … Kirby KC (2017). Incentive-based intervention to maintain breastfeeding among low-income Puerto Rican mothers. Pediatrics, 139(3). doi:10.1542/peds.2016-3119

World Health Organization. (2017). Nutrition exclusive breastfeeding. Retrieved from http:// www.who.int/nutrition/topics/exclusive_breastfeeding/en/

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Figure 1. CONSOR flow diagram pilot study (Eldridge et al, 2016)

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Figure 2. Promotion of EBF in Hispanics Women in Kentucky. Adapted from the Health Promotion

Model (Pender et al., 2002).

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Figure 3. Frequency of EBF in each group over time (N=39)

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Table 1:

Description of Sessions for Intervention Participants

Session Activities*

2 Prenatal home visit sessions (30–40 minutes each) by PC

Participant was oriented to the purpose of the intervention; collaboration was established between peer counselor and participant. Discussion of participant’s past experiences with breastfeeding was initiated. Intervention was explained, including discussion of the benefits of adopting a healthy behavior (e.g., exclusive breastfeeding (EBF) for six months, delay introducing formula and/or solid until after six months old). Infant feeding and qualms about mixed feeding were described and discussed (las dos cosas), and barriers to EBF and self-efficacy were assessed. A general review of provided binder material: benefits of EBF, breastfeeding logistics, avoidance of pacifiers, feeding cues, breastfeeding video review. My Action Plan to Breastfeed was described, and participant settled her own goals.

Prenatal Follow-up phone calls (10–15 minutes each) by a PC

My Action Plan to Breastfeed was reviewed, and participant commitments to breastfeeding goals were reinforced.

Barriers to EBF were reviewed, including perceptions concerning the lack of availability, inconvenience, difficulty, or time-consuming nature of the future action; and promoting self- efficacy with problem-solving.

Participant was encouraged to study program materials and was asked about any concerns associated with breastfeeding goals. Strategies available to accomplish her breastfeeding goals were discussed. All questions were answered. Follow-up calls were done every week until the birth of the infant.

Hospital Visit (20–30 minutes) by PC. Assessment of infant feeding pattern. Observation of breastfeeding techniques with hands-on assistance when was needed. Discussion of techniques, feeding cues, demand feeding, and other support essential to maintain EBF, anticipate barriers, problem-solving, and self-efficacy. All questions were answered. Praised for her commitment to initiate breastfeeding was included.

1 Postpartum home-visit (40–60 minutes) at ± 2–3 days after discharge by an IBCLC

Assessment of infant feeding pattern. Observation of breastfeeding techniques with hands-on assistance if needed. Discuss techniques, feeding cues, demand feeding, and other issues needed to maintain the exclusivity of breastfeeding, anticipate barriers, share problem-solving strategies, and encourage self-efficacy. If needed, provide supplemental breastfeeding devices as needed (e.g., nipple shields, manual breast pump, nipple cream). Anticipatory guidance was given and all questions answered.

Lactation consultant followed-up with a phone call as needed. A second visit was scheduled when needed.

1 Postpartum home-visit (30–40 minutes) at 7–10 days after discharge by PC.

Home visit by PC to follow-up and encourage the mother in her commitment to EBF her infant. Guidance given on problems/concerns and questions were answered. Motivation and self-efficacy were promoted.

Praised the mother for her efforts in taking care of her infant. Anticipatory guidance based on the age of the infant was given. Mother was encouraged to call the IBCLC if any concerns arise.

Postpartum phone calls (10–20 minutes each) at least once a month for 6 months by PC.

We asked the mother to describe her experience with infant feeding.

We asked about problems/concerns and answered questions. Promoted motivation and self- efficacy.

Praised the mother for her effort in taking care of her infant. Anticipatory guidance based on the age of the infant. Encouraged the mother to call the peer counselor and/or lactation consultant if any concerns arise. Initial follow-up phone calls were no later than 2 weeks after the birth of the infant. Repeated phone calls at least once a month for 6 months. Refered to IBCLC when needed.

* For further information visit ClinicalTrial.gov

BF = breastfeed; EBF = Exclusive breastfeeding; PC = peer counselor; IBCLC = lactation consultant

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Table 2.

Group Comparisons of Demographic, Clinical and Personal Variables at Enrollment (N=39)

Variable Intervention group Mean (SD) or n (%) (n=20)

Control group Mean (SD) or n (%) (n=19)

p-value for group comparison

Mother’s age 24.3 (5.2) 26.6 (6.6) .24

a

Live with partner

Yes 15 (75.0) 13 (68.4) .65

b

No 5 (25.0) 6 (31.6)

Employed

Yes 5 (25.0) 6 (31.6) .65

b

No 15 (75.0) 13 (68.4)

Insurance

Yes 7 (35.0) 6 (31.6) .82

b

No 13 (65.0) 13 (68.4)

WIC

Yes 14 (70.0) 12 (63.2) .65

b

No 6 (30.0) 7 (36.8)

Mode of Delivery

Vaginal 16 (80.0) 14 (73.7) .72

c

C-section 4 (20.0) 5 (26.3)

Anyone close to you breastfeed?

Yes 16 (80.0) 14 (73.7) .72

c

No 4 (20.0) 5 (26.3)

Acculturation 13.0 (6.4) 10.3 (5.2) .16

a

Intention to breastfeed 13.3 (1.9) 11.3 (4.7) .10

a

Breastfeeding knowledge 20.1 (3.1) 18.8 (3.9) .25

a

a p-value for two-sample t-test

b p-value for chi-square test of association

c p-value for Fisher’s exact test

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