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University of Kentucky University of Kentucky

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Nursing Faculty Publications College of Nursing

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

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