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Title:Development and evaluation of a breastfeeding intervention and the infant feeding subjective norm scale
Author(s):Kim, Julia Hai-Ji
Director of Research:Donovan, Sharon M.
Doctoral Committee Chair(s):Fiese, Barbara H.
Doctoral Committee Member(s):Nickols-Richardson, Sharon M.; Tabb Dina, Karen
Department / Program:Nutritional Sciences
Discipline:Nutritional Sciences
Degree Granting Institution:University of Illinois at Urbana-Champaign
Degree:Ph.D.
Genre:Dissertation
Subject(s):Breastfeeding intervention African American Process evaluation Impact evaluation Psychometric testing Theory of Planned Behavior
Abstract:Breastfeeding is the ideal source of nutrition for an infant’s health. However, breastfeeding rates among African American, adolescent mothers are much lower than same-aged mothers of different races. Therefore, the overall goal of my dissertation research was to further our understanding of the factors contributing to lower breastfeeding rates among African American, adolescent mothers and to develop and evaluate an intervention targeting this population. My research was guided by the Theory of Planned Behavior, which suggests that an individual’s attitude (someone’s evaluation of behavior outcomes), subjective norm (social acceptance and pressure to perform a behavior), and perceived behavioral control (amount of control overcoming obstacles while performing a behavior) influence one’s intention to perform a behavior. In addition, intention and perceived behavioral control directly influence whether someone will choose to breastfeed. The Breastfeeding Attrition Prediction Tool, a validated questionnaire that measures attitude, subjective norm, and perceived behavioral control, was used in this research. However, the lack of a validated questionnaire that measures only subjective norm regarding infant feeding practices represented a gap in the literature and was addressed in aim 3. Therefore, the overall goals were to influence African American mothers’ attitude, subjective norm, and perceived behavioral control that are favorable to breastfeeding and validate a questionnaire that measures subjective norm. Our central hypothesis was that a culturally tailored breastfeeding intervention will result in favorable changes in attitude, subjective norm, and perceived behavioral control in African American, adolescent mothers. To test this hypothesis, three aims were undertaken. The goal of aim 1 was to identify breastfeeding facilitators and barriers using a mixed-methods study design (n=15) among African American mothers. Breastfeeding facilitators were social support, and knowledge about health benefits of breastfeeding. However, mothers lived in a formula-feeding culture indicated by negative comments from family and friends. A novel finding was that mothers believed that they had to eat healthy to breastfeed, which may deter some mothers from breastfeeding. Participants suggested providing social support to mothers in high school through a local non-profit organization called the GOALS (Going On Against Life’s Struggles) project. In aim 2, a breastfeeding intervention was implemented and evaluated among African American, adolescent mothers (n=19) in the GOALS project. The HAPPY (Healthy and Proper Parenting for Youth) intervention was comprised of three workshops. Using a pretest, posttest study design, a significant change in breastfeeding knowledge was observed among participants who attended two or more workshops (n=12, +1.7 ± 1.6) compared to those who attended 1 or fewer workshops (n=7, -0.6 ± 1.8, p<0.05). Significant differences were not observed for positive breastfeeding attitude, negative breastfeeding attitude, subjective norm, and perceived behavioral control between participants who attended two or more workshops and those who did not (p>0.05). To address the lack of a validated questionnaire to measure subjective norm, the objectives of aim 3 were to develop and validate an instrument that can be used by the broader research community. The 8-item Infant Feeding Subjective Norm Scale was developed through a 7-step process to assess the content, construct, and concurrent validity and reliability (internal consistency and test-retest reliability). The instrument measured two constructs: motivation to comply (willingness to do what other people want you to do) and normative beliefs for extended breastfeeding (important people’s approval for breastfeeding longer than 12 months). Motivation to comply scores can range from 0 to 25, with higher scores indicating greater willingness to do what others think you should do. Normative beliefs for extended breastfeeding scores can range from 0 to 15, with higher scores indicating greater approval by others to breastfeed longer than 12 months. The instrument had adequate internal consistency of α=0.85 and α=0.86 for the motivation to comply and normative beliefs for extended breastfeeding subscales, respectively. It also had adequate content validity based on a content validity index of 0.89, and construct validity through exploratory factor analysis, confirmatory factor analysis and known group analyses. The confirmatory factor analysis of a two-factor solution with 8 items had good goodness-of-fit indices (GFI: 0.97, CFI: 0.99, SRMR: 0.028, RMSEA: 0.017). At two months postpartum, motivation to comply scores did not differ between breastfeeding mothers and mothers who were not breastfeeding. On the other hand, normative beliefs for extended breastfeeding were significantly higher for breastfeeding mothers (Median=13 IQR=5) compared to mothers who were no longer breastfeeding at 2 months postpartum (Median=9 IQR=7). We found that motivation to comply was significantly higher for mothers who were no longer breastfeeding at 13 months postpartum (M=14.8 SD=4.9) compared with mothers who were breastfeeding at 13 months (M=13.4 SD=5.2, p=0.0145). Additionally, normative beliefs for extended breastfeeding was significantly higher for mothers who were breastfeeding at 13 months postpartum (Median=14 IQR=4) compared with mothers who were weaned prior to 13 months (Median=12 IQR=6, p=0.0008). Motivation to comply (OR: 0.93, 95% CI: 0.87-0.99) and normative beliefs for extended breastfeeding (OR: 1.12, 95% CI: 1.01-1.24) predicted intention to definitely breastfeed at 14 months postpartum after adjusting for attitude, confidence, maternal age, race, parity, and education. This instrument had insufficient evidence for concurrent validity, using breastfeeding duration as the criterion. Additionally, the motivation to comply subscale did not distinguish between mothers who weaned prior to 12 months and mothers who were still breastfeeding until 12 months, suggesting that motivation to comply scores are a better indication of whether a mother will breastfeed longer than 12 months. Future directions for this study is to further validate this instrument for African American, Latino, Asian, and other mothers. Despite the breastfeeding disparity of African American, adolescent mothers, my dissertation research highlighted the successful strategies used by these mothers who were able to overcome barriers in a formula-dominant culture. This research has shown that a culturally tailored breastfeeding intervention had the potential to influence knowledge in this population, who may be skeptical of breastfeeding information. However, further improvement of the intervention may be needed to observe significant findings of other predictors of breastfeeding.
Issue Date:2018-07-06
Type:Text
URI:http://hdl.handle.net/2142/101672
Rights Information:2018 Julia Hai-Ji Kim
Date Available in IDEALS:2018-09-27
2020-09-28
Date Deposited:2018-08


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