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Michigan State
Unlversity

 

 

 

 

 

 

 

 

This is to certify that the

thesis entitled

THE RELATIONSHIP OF INTERACTION BETWEEN PEER COUNSELORS AND
LOW-INCOME WOMEN AND DURATION OF BREASTFEEDING

presented by

Cynthia Jane Church

has been accepted towards fulfillment
of the requirements for

MASTER OF SCIENCE degreein NURSING

 

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Major professor

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MICHIGAN STATE UBRAR ES

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THE RELATIONSHIP OF INTERACTION BETWEEN PEER COUNSELORS AND
LOW-INCOME WOMEN AND DURATION OF BREASTFEEDING

BY

Cynthia Jane Church

A THESIS
Submitted to
Michigan State University
in partial fulfillment of the requirements for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

1997

ABSTRACT

THE RELATIONSHIP OF INTERACTION BETWEEN PEER COUNSELORS AND
LOW-INCOME WOMEN AND DURATION OF BREASTFEEDING

BY

Cynthia Jane Church

Breastfeeding is recommended for six to twelve months, a
goal that is far from being met all women. Multiple regression
was performed on selected data from a sample of 250 low-income
women to examine the relationship of early postpartum
interaction between first time breastfeeding women and peer
counselors and duration of breastfeeding. King's model of
interaction within the theory of goal attainment was used as the
conceptual framework. The variables, timing of the first contact
and number of contacts in the first two weeks, after controlling
for prenatal contacts, did not predict or explain duration of
breastfeeding. An implication for the.Advanced Practice Nurse
(APN) is that a woman's decision to breastfeed is complex as is
breastfeeding peer counseling. The findings of this study
suggest that the APN needs to intervene with the breastfeeding
woman at 2-3 weeks postpartum and again near 3 months, to

evaluate, support and promote longer breastfeeding.

To all breastfeeding women and infants

and those who faithfully support them.

iii

ACKNOWLEDGMENTS

Special thanks are due Millie Omar for her many hours of
reading of drafts and for her endurance, guidance, and belief in
my research. Char McKay was most helpful in allowing the use of
the data of the Breastfeeding Initiative (BFI) and I appreciated
her enthusiasm for my work.

I also wish to thank the other committee members, Jenny
Bond and Rachel Schiffman, for their valuable input, time and
support. Randy Fotiu saved the day when the SPSS instructions
failed to help. Thanks to George Allen for wisdom imparted
during Nursing 509 that was invaluable during my data analysis.

My friends provided optimistic encouragement when I most
needed it. My daughters, Lori and Teresa, hung in there when I
was unable to be with them. Most importantly, I wish to
acknowledge my husband, Ed, for his time spent proof-reading
drafts, computer assistance, and love and patience with me

during the process of the thesis.

iv

TABLE OF CONTENTS

LIST OF TABLES ............................................. vii
LIST OF FIGURES ........................................... viii
Introduction ................................................. 1
Background of the Problem ............................... 1
Purpose of the Study .................................... 3
Statement of the Problem ..................................... 4
Research Question ....................................... 4
Conceptual Framework ......................................... 5
Conceptual Discussion of Peer Counseling ................ 5
Conceptual Definitions of the Study Variables ........... 7
Conceptual Model ........................................ 9
Review of Literature ........................................ 12
Methods ..................................................... 16
Research Design ................................. . ....... 16
Sample ................................................. 16
Operational Definitions of the Variables ............... 17
Procedures ............................................. l8
Instrumentation ........................................ 18
Reliability and Validity ............................... 19
Protection of Human Subjects ........................... 20
Data Analysis .......................................... 20
Assumptions ............................................ 22
Limitations ........................................... 22

Results ..................................................... 23

Demographic Characteristics ............................ 23
Description of the Research Variables .................. 24
Analysis of the Research Question ...................... 26
Additional Analyses .................................... 27
Discussion .................................................. 27
Demographic Characteristics ............................ 27
Research Question ...................................... 28
Implications for Advanced Practice Nurses ................... 32
Recommendations for Future Research ......................... 34
Conclusion .................................................. 36
APPENDIX A; Breastfeeding Peer Counselor Initiative ......... 38

.APPENDIX B: Special Supplemental Nutrition Program for

Women, Infants, and Children (WIC) .............. 41
APPENDIX C: Data Collection Procedures ...................... 42
APPENDIX D: Individual WIC Nutrition Education Log .......... 43
.APPENDIX E: Letter From.MSUE ................................ 44
LIST OF REFERENCES .......................................... 45

Vi

LIST OF TABLES

Table 1: Summary of Hierarchical Stepwise Multiple Regression
Analysis for Timing and Number of Postpartum Contacts
as Predictor Variables of Duration of Breastfeeding,
Controlling for Number of Prenatal Contacts
(N = 184). .......................................... 26

vii

LIST OF FIGURES

Figure 1: Diagram of King’s Theory of Goal Attainment (1981,
p. 157) ........................................... 10

Figure 2: An Adaptation of King's (1981) Theory
of Goal.Attainment ................................ 11

Figure 3: Bar Graph Reflecting Duration of Breastfeeding
Among Women in the Sample ......................... 25

viii

Introduction

Background of the Problem

 

Breastfeeding is recognized as optimal nourishment for
infants, providing antimicrobial, anti—inflammatory, and
immunologic factors to the infant and additional benefits to the
lactating mother. Major authorities on maternal and child health
strongly advocate breastfeeding for most infants (American
Academy of Pediatrics [AAP], 1982; American Dietetic Association
[ADA], 1997; American Medical Association [AMA], 1979; Spitzer,
1984; United States Public Health Service [USPHS], 1994; World
Health Organization [WHO], 1989). Recognition by health
authorities of breastfeeding as a means of preventive care and
health promotion is reflected by efforts to promote longer
duration of breastfeeding (USPHS, 1994). The ADA in the revised
breastfeeding position statement, advocates breastfeeding,
ideally for 12 months, because of "the indisputable nutritional,
immunological, psychological, and economic benefits" (p. 662).

Healthy People 2000 (United States Department of Health and

 

Human Services [USDHHS], 1991) has a breastfeeding objective
which is: To increase to at least 75% the proportion of women
who breastfeed their babies upon hospital discharge and to at
least 50%, the proportion of women who continue breastfeeding
until their babies are 5—6 months old (p. 123, 379). Identifying
factors which promote the duration of breastfeeding, especially

for low—income women, could favorably impact the current

2
proportion of women who continue to breastfeed and thus move the

nation closer to the breastfeeding objective of Healthy People

 

2000.

 

A problem is that many women who initiate breastfeeding do
not continue to breastfeed as long as recommended (Ryan, 1997;
USDHHS, 1991). Nationally, the percentage of women continuing
to breastfeed at 5-6 months postpartum peaked in 1984 at 27.5%
(Martinez & Krieger, 1985). In 1995, the percentage of all women
breastfeeding at 5—6 months had fallen to 20.6% (Ryan, 1997). In
1987, the percentage of low-income women breastfeeding their
babies at 5-6 months of age was 7% (Ross Pediatrics, 1996) and
had increased to 12.8% by 1995 (Ryan, 1997), a percentage,
however, which remains well below the objective of Healthy

PeOple 2000.

 

Breastfeeding beyond early infancy, i.e., one month of
age, and in some studies, beyond 3, 4, 6 or 8 months has been
related to reduced morbidity in infants and children, e.g., less
incidence of lower respiratory tract infections,
gastroenteritis, skin disorders, acute and recurrent otitis
media, water intoxication, atopic disease, childhood cancer, and
Hodgkin's disease (Davis, Savitz, & Graubard, 1988; Duncan et
al., 1993; Keating, Schears, & Dodge, 1991; Saarinen &
Kajosaari, 1995; Schwartzbaum, George, Pratt, & Davis, 1991; van
den Bogaard, van den Hoogen, Huygen, & van Weel, 1991; Wright et

al., 1989). Montgomery and Splett (1997) have demonstrated that

3
economic benefits, e.g., a mean reduction of $478 in WIC costs
and Medicaid expenditures per infant, resulted from
breastfeeding infants compared to formula feeding infants among
those enrolled in the Special Supplemental Nutrition Program for
Women, Infants, and Children (WIC), a program for low—income
women.

A reason suggested for fewer women breastfeeding by
anthropologist, Dettwyler (1995), is a lack of socio-cultural
support for breastfeeding. One of the more recent forms of
support for low—income women is that of structured
breastfeeding peer counselor programs (Kistin, Abramson, &
Dublin, 1994; Long, Funk-Archuleta, Geiger, Mozar, & Heins,
1995).

Purpose of the Study

 

The purpose of this descriptive study was to examine the
relationship of interaction between peer counselors and low-
income, first time breastfeeding women and their duration of
breastfeeding. Secondary data collected by peer counselors from
January, 1994 to May, 1996 were used. Because of the definitive
benefits of breastfeeding to the infant and the number of women
who are not breastfeeding their infants or, if breastfeeding,
not continuing to breastfeed of longer duration, breastfeeding
education, promotion, and support becomes an essential concern
of the Advanced Practice Nurse (APN). Interaction with a peer

counselor might be an important source of support for low-income

4
breastfeeding women and an important community resource and
referral source for APNs providing care to childbearing and
childrearing women.
Statement of the Problem
Since breastfeeding is associated with many positive
benefits, identifying factors that promote breastfeeding

duration is an important component in meeting the Healthy People

 

2000 breastfeeding objective. Interaction with a breastfeeding
peer counselor may be one factor enhancing breastfeeding
duration among women of low-income. However, limited research
exists regarding the relationship of interaction between peer
counselors and first time breastfeeding women and duration of
breastfeeding. If early interaction with a peer counselor and a
concentration of visits in the first two weeks were shown to be
effective in increasing the duration of breastfeeding, programs
with early interaction and peer counselors need to be considered
as a form of support. As a result, the advantages of
breastfeeding longer in duration can reach more low-income
mothers and infants.

Research Question

 

The research question was: What is the relationship of
interaction between peer counselors and first time breastfeeding
women within the first two weeks of the infant's birth and the
duration of breastfeeding after controlling for prenatal

interactions? The hypothesis was that an early postpartum

5
interaction with a peer counselor and an increased number of
interactions with a peer counselor in the first two weeks
postpartum is related to longer duration of breastfeeding in
this population of first time breastfeeding mothers than among
women who had an interaction with a peer counselor which began
later postpartally with fewer number of contacts in the first
two weeks.
Conceptual Framework

This section includes the conceptual discussion of peer
counseling in general and breastfeeding peer counseling in
particular, followed by the conceptual definitions of the study
variables of interaction with a peer counselor and duration of
breastfeeding. The conceptual framework of King's (1981) theory
of goal attainment is then discussed and linked to the
conceptual definitions.

Conceptual Discussion of Peer Counseling

 

Peer Counseling in General. Peer counseling or peer

 

educators have been used regularly in other health, educational,
and social programs since the mid—1960's when the federal
government sponsored training programs to develop
paraprofessional or "new career" opportunities in the various
human services fields (Cohen, 1976). The role of the peer
counselor or paraprofessional was to help bridge the gap between
consumers and human service agency personnel by a sharing of

values, attitudes, and experiences because of their peer status

6
and, often, the same socio-economic status (Cohen, 1976; Giblin,
1989). Peer counselors also assume some of the routine duties of
professionals (Cohen), such as, education, referral to other
sources, problem-solving, listening and provision of support.
Marin and colleagues (1995) discuss the needs of people of major
ethnic groups, low-income populations, women, and the elderly
who are often underserved. People of these populations have
needs which may not be recognized or understood by health
professionals who are often not of similar backgrounds. People
of these groups, because of socio-demographic factors and
sharing of background characteristics, might be predisposed to
perform damaging health behaviors or avoid health promotion
measures (Marin et al.). One strategy for meeting the needs of
the underserved and for promotion of health and disease
prevention is the use of peer counselors (Marin et al.).

Breastfeeding Peer Counselor. The peer counselor of a

 

breastfeeding peer counseling program is a non-professional, or
paraprofessional, who provides low-income women with support,
teaching, and counseling during the prenatal and postpartum
period to help them with breastfeeding (Long et al., 1995). The
peer counselor program examined in this study was the
Breastfeeding Peer Counselor Initiative (BFI) in Michigan (see
Appendix A). The peer counselor in BFI was someone who had
breastfed a baby herself and who perceived her breastfeeding

experience as successful. A peer counselor often has had the

7
experience of living in poverty or might be of low income
(Kistin et al., 1994), giving her a bond with the low-income
woman. This commonality represents a sharing of attitudes,
values, and behaviors between peer counselor and the woman
(Giblin, 1989). Interaction between the peer counselor and the
woman might be facilitated by the nature of the relationship
with a person like herself, often because of a mutual trust and
caring (Giblin).

Conceptual Definitions of the Study Variables

 

Interaction with a Peer Counselor. In this study,

 

interaction with a peer counselor included two components,
timing of the first contact after the birth of the infant and
the number of contacts in the first two weeks postpartum.
Conceptually, interaction between a peer counselor and a first
time breastfeeding woman was defined as adequacy of support by a
peer counselor. Timing and number was a measure of the
quantitative component of adequacy of support, an indirect
measure.

The first of the two aspects of interaction was timing of
the first interaction by a peer counselor. In BFI, either the
mother or peer counselor initiated contacts. Timing of the first
interaction postpartum varied depending on whether or not the
peer counselor routinely visited or made telephone calls to the
woman in the hospital, or waited until after discharge to

interact with the mother and infant. Timing also depended on

8
when the peer counselor was notified that a woman had delivered
her baby or was requested to visit. Timing of the first
interaction with a peer counselor was assumed to be important
because in the early days of breastfeeding, a woman who has
never breastfed lacks experience, perhaps confidence, might be
exhausted, and is more likely to become discouraged or might
wean without someone who knows how to help her (Barron, Lane,
Hannah, Struempler, & Williams, 1988). A health care
professional might not have the training, the time, or the
rapport with the woman, to help a woman through these problems
at the time the mother needs the help. Early first contact by
the peer counselor with the breastfeeding woman might be crucial
for the woman in overcoming technical breastfeeding difficulties
and for gaining confidence that she can breastfeed.

The second aspect of the concept of interaction with the
peer counselor was the number of contacts by a breastfeeding
peer counselor with the woman in the first two weeks postpartum,
another component of adequacy of support. In BFI, an emphasis
was on increased contacts during the first two weeks postpartum
to assist in overcoming early obstacles in the learning process.
An assumption was that the woman felt comfortable initiating
interaction with the peer counselor. One aspect of the
relationship of the peer counselor with the woman was of
increased accessibility through a pager, 24 hours a day, so that

the woman could request help when she needed it, which

9
facilitated the scheduling of an interaction. The peer counselor
and mother cooperatively scheduled follow-up visits.

Duration of Breastfeeding. Duration of breastfeeding was

 

conceptually defined as the length of time that the infant
receives any human milk along with nutritional, anti-infective,
immunologic, social, emotional, economic and hygienic benefits
of breastfeeding (ADA, 1997), which are present during the
breastfeeding period and beyond, for the mother and infant.
Increased duration of breastfeeding extends the benefits of
human milk and the breastfeeding process to the infant and
mother(Cunningham, Jelliffe, & Jelliffe, 1991; Goldman, 1993;
Lawrence, 1994; Minchin, 1987; Walker, 1993). The length of
time of the benefits is immeasurable and not limited to the
actual duration of breastfeeding.

Conceptual Model

 

The conceptual framework used to describe the
relationship between the study variables was that of interaction
within King's (1981) nursing theory of goal attainment (see
Figure 1). The primary focus of the theory is that of the human
being's interactions with another human being in a specific
situation in mutual presence (King). King describes interaction
as "a sequence of verbal and non-verbal behaviors that are goal
directed between two or more individuals" (p. 60), a reciprocal
ongoing process of reaction and action, based on each person's

perceptions. Within these interactions information is gathered

10

........
........ -- ---....-. -.--- .-o s...._._--
-.o .............
............
u --
'-

. Perceptions‘\! Transactions \
, "a Perception
JSE H}; .Agree to .Action "..4—-""’”.
NU Means i CLI
Reaction E
Explore f
Communication means Disturbance/
I \t. K‘ Communi cation

Mutual goal
~-H._setting

.0
,0
a a
""""
0‘ ‘n
......
........
‘O- -0. 'n- .......
...........................
"" —--oo..--o0‘

Figure 1. Diagram of King’s Theory of Goal Attainment

 

(1981, p. 157) .

11

and appropriate information is given to agree on means to help
reach the desired goal. In Figure 1 interaction occurs in the
center where nurse and client meet with their individual
perceptions after ongoing communication. The interaction leads
to a transaction of goal attainment. The outcome or goal for
nursing in King's theory is "helping individuals maintain a
state of health" (1989, p. 155).

In this study interaction between a peer counselor and a
breastfeeding woman included the components of timing of
interactions postpartum and number of interactions in the first

two weeks (see Figure 2). The peer counselor communicates

- ........................
.a -.
_-_------ ................
- ........
.......
.-' 4“.
n

"' Interaction with ..
.x , Peer counselor ~K‘ Peer counselor
;"Breastfeeding .5 Postpartum (PP) *
’ woman '
Timing of contact PP

 

Number of contacts PP

 

c“
l .-
I— _.
........
. . - -
.......................
.........
..............

Figure 2. An Adaptation of King's (1981) Theory of Goal
Attainment.

 

12
with the breastfeeding women either in a face-to-face meeting or
through telephone contact. During communication the information
component of the theory of goal attainment takes place as well
as problem solving of the needs of the woman, i.e.,
breastfeeding concerns or other stresses in her life. t is the
reciprocal interactive process of communication which assists
the woman and peer counselor in the decision-making that leads
to the transactions of goal attainment, breastfeeding duration.
The common goal of the woman and counselor during the first two
weeks is to help the woman learn to breastfeed whereby she
continues to breastfeed to whatever duration she desires. In
Figure 2, the center where the circles of peer counselor and
breastfeeding woman meet, depicts open and constant interaction
between a peer counselor and breastfeeding woman, which
facilitate decision-making regarding the goal, i.e.,
breastfeeding duration.
Review of Literature

This section reviews the available research on
breastfeeding peer counselor programs and duration of
breastfeeding and on the timing of the first postpartum contact
and number of contacts and the duration of breastfeeding. Two
studies exist on the former, none on the timing of the first
postpartum contact and one on a study involving 1-3 postpartum
contacts. This is followed by a critique of the literature and

how this study fills the gaps in the literature.

13

Recent research has demonstrated that duration of
breastfeeding among low-income populations can be prolonged by a
woman's interaction with a breastfeeding peer counselor. A study
by Kistin and colleagues (1994) of low—income women in Chicago
showed that women who interacted with trained peer counselors by
telephone (2 = 59), had a statistically significant greater
duration of breastfeeding (15 weeks) than the women with no
interactions with a peer counselor (n = 43), who breastfed for 8
weeks, p < .05. It was not reported how many contacts were made
with the subjects or when the interactions occurred. The sample
consisted primarily of.African-American women (68%) with no
significant difference in demographics between the control and
experimental groups. The control group consisted of women who
requested counselors but due to inadequate numbers of
counselors, did not have a counselor.

Long et al.(1995) studied a peer counseling breastfeeding
program with WIC clients who received peer counseling visits
following the infants' births. The women (n = 63) were primarily
Native American (95%) and lived in a rural area. The control
group (n = 78) consisted of women who were enrolled in WIC one
year prior to the peer counselor program. No significant
differences in demographics were found between the control and
experimental group. This study found that at 3 months

postpartum, 49% of women in the experimental group were

14
breastfeeding compared to 36% in the control group, p = .08. The
type, timing, and number of interactions were not reported.

In summary, similarities were noted between the two
studies of Kisten et al. (1994) and Long et al. (1995). All
women participating in a breastfeeding counseling program
postpartum were WIC participants and, therefore considered low-
income. Although a convenience sample of women was used in each
study, ethnicity and geographic area of residence differed. The
duration of breastfeeding for the experimental groups in both
studies was similar, with at least 64% of the women still
breastfeeding at 4 weeks and at least 44% of the women
breastfeeding at 12 weeks.

The third study (Saunders & Carroll, 1988) was a quasi—
experimental, prospective study without random assignment. The
sample (n = 80) was a group of low-income WIC women who
delivered at a rural hospital and initiated breastfeeding during
a 16—month period. While the experimental group of women
received three interactions within a two week period by someone
under the direction of the WIC nutritionist, it was not known if
this person was a peer counselor. The researchers noted that
while the experimental group reported 80% of the women
breastfeeding at 4 weeks and 50% at 16 weeks, the control group
(n = 75) reported 71% of the women breastfeeding at 4 weeks and
47% at 16 weeks; the difference between the two, however, was

not statistically different. Of women in the experimental group

15
who received all three interactions (n = 36), however, 95% were
breastfeeding at 4 weeks and 67% at 16 weeks which was
significantly longer than the control group, p = .001 at 4 weeks
and p = .03 at 16 weeks (Saunders & Carroll). The experimental
group was also found to be significantly poorer than the control
group (p < .05). Other demographics of age and ethnicity were
not significantly different.

In all studies breastfeeding was defined in a similar
manner, i.e., breastfeeding one or more times a day. Limitations
of the studies were the small sample size, lack of knowledge of
how many were lost to follow up, and lack of control for the
variable of previous breastfeeding experience. Saunders and
Carroll's (1988) research and Long and colleagues'(1995) did not
address previous breastfeeding experience of the study
participants. None of the studies had random assignment and two
used historical controls. Other limitations of the study by
Saunders and Carroll were self-report of the women for the
duration variable, and not knowing whether the person or persons
involved in the interactions was a professional or a peer
counselor.

Gaps to be filled by the current study while not
prospective, include a larger sample size, knowledge about the
peer counselor, examination of the interventions of timing of
the first contact postpartum and of the number of contacts in

the first two weeks, control for the number of prenatal

16
contacts, and control for the variable of previous breastfeeding
experience by limiting the sample to women who had no previous
breastfeeding experience.
Methods

The methods utilized in this study are presented in this
section and include: the research design, sampling procedures,
the operational definitions of the study variables,
instrumentation, reliability and validity, protection of human
subjects, data analysis, and limitations of the study.

Research Design

 

This descriptive study was a retrospective study using a
non-experimental, cross-sectional approach. This study was part
of a larger study and a secondary analysis of data of the
Breastfeeding Peer Counselor Initiative (BFI). The purpose of
the original study was to evaluate BFI in relation to the
program objectives, one of which was to increase initiation and
duration of breastfeeding among women of low-income.

Sample

The sample was selected from the original sample of 1531
low-income women enrolled in WIC who had entered and completed
Breastfeeding Initiative (BFI) in Michigan from January, 1994 to
May, 1996. "Completed BFI" meant women had participated in BFI,
were no longer breastfeeding and were no longer receiving
contacts from the peer counselor. Inclusion criteria for this

study were as follows:

l7

0 Women who entered the program during the prenatal period and

had at least one interaction prenatally and postpartally,
0 women who had no previous breastfeeding experience,
0 women who had delivered and had initiated breastfeeding, and

0 women who continued to breastfeed for at least two weeks
postpartum.

After applying the inclusion criteria, the initial sample
consisted of 264 women. Missing forms on 12 cases and two
missing values for number of prenatal contacts required
exclusion of those 14 cases with a final sample size of 250
women.

Operational Definitions of the Variables

 

Interaction with a peer counselor. Interaction with a peer

 

counselor was operationally defined as the timing of initial
postpartum contact of the peer counselor with the woman and
total number of contacts between the peer counselor and woman in
the first two weeks after delivery. Timing of initial contact
was the number of days postpartum when the contact was made,
within the first two weeks, calculated from the date of birth to
the date of the first contact, and was recorded on the Nutrition
Education Log.

Number of contacts was the total number of contacts
between a peer counselor and a woman in the first two weeks
following the birth of the baby. This number was calculated by

counting the number of contacts since the date of birth,

18
recorded on the Nutrition Education Log. In addition, the number
of prenatal interactions with each woman was recorded on the
Nutrition Education Log.

Duration of breastfeeding. Duration of breastfeeding was

 

the number of weeks the woman breastfed or fed her infant
expressed breast milk at least one time per day. This data was
collected during the original study by the peer counselor when
the woman self-reported that she had weaned. The data was then
entered onto the peer counselor records.

Procedures

 

See Appendix C for data collection procedures of the
original study. The variables, number of prenatal contacts,
duration of breastfeeding, timing of the first contact and
number of postpartum contacts, were recorded on the Nutrition
Education Log (see Appendix D) and gathered by an employee of
MSUE who transferred the numbers to computer disk. Subjects were
identified by a number only on disk. These data were retrieved
from the computer disk for analysis by the researcher.

Instrumentation

 

The form from which data was collected for this study and
from which it was transferred to computer disk for the
researcher was the Individual WIC Nutrition Education Form. On
this form was recorded the date of birth and date and type of

each contact with the woman who is identified by a number.

19
Duration of breastfeeding was on computer disk from the previous
study.

Reliability and Validity

 

Reliability was not established for the instruments for
the original study. Measures were taken to minimize the threats
to reliability. These measures were ongoing inservices by the
administrator and statistician of BFI for the peer counselors on
use of the instrument. Consistency of collection of data among
the peer counselors and consistency within the individual peer
counselor across their clients was encouraged.

Content validity was not established in the original
study. A measure taken to lessen the threat to validity was that
of face validity by having approval of the registered dietitians
and lactation consultant in the BFI program that "the instrument
looks as though it is measuring the appropriate construct"
(Polit & Hungler, 1995, p. 354).

A recheck of 21 subjects' data by an employee other than
the original employee who entered data on the computer disk,
showed a lack of consistency in 17% of the variables, timing of
the first contact, number of contacts, and prenatal contacts.
The variables of age, race, and duration of breastfeeding showed
100% consistency. A.major limitation was lack of access by the
researcher to the records in order to establish reliability on

all of the data used in this study.

20
In this study the researcher checked reliability of the
variable duration by a cross check of other data on the computer
disk which indicated the duration of breastfeeding. The data was
consistent on all cases checked.

Protection of Human Subjects

 

The original data collection had approval from the
University Committee on Research Involving Human Subjects
(UCRIHS). This researcher ensured the confidentiality of
subjects by not having access to any forms with identifying
information and did not trace the coded identifying numbers to
the original participants. The data for this study are
maintained on a computer disk on which subjects were entered by
an ID number only with no identifying information. No
potentially dangerous or adverse effects to women or infant
participants are known or have been identified. The present
study obtained approval from UCRIHS (See Appendix F).

Data Analysis

 

Data analysis was performed by the investigator using the
computer program, SPSS 7.0 for Windows. Descriptive statistics
of frequencies, percentages, and measures of central tendency,
were utilized to analyze the demographic characteristics of the
sample.

The only demographic data available were age and race. In
addition to the descriptive statistical analysis, chi square

analysis was performed on the demographic variables of age and

21
race and the dependent variable, duration, to ascertain any
systematic differences between the three groups of women and how
long they breastfed. A significance level of p = < .05 was used
in all analyses.

To answer the research question, what is the relationship
of the interaction between peer counselors and first time
breastfeeding women of low-income within the first two weeks of
the infants' birth and the duration of breastfeeding after
controlling for prenatal contacts, hierarchical stepwise
regression was performed. The extraneous variable of number of
prenatal contacts was entered first to control for any effect
prenatal contact might have on duration of breastfeeding. The
next variable entered was timing of the first contact followed
by the number of contacts. The regression procedure was
performed to show which variable or combination of variables
accounted for the most variance in the duration of breastfeeding
once the variance from prenatal contacts was removed.

Timing was entered into the hierarchical regression before
number of contacts based on the following reasons: (a) The

correlation matrix validated that the earlier the contact, the

greater the number of contacts (5 .466, p = .01); (b) early
contact makes possible an increase number of contacts, so it
must come first. An initial contact that is not early might

preclude an increased number of contacts in the first two weeks.

The study of Saunders and Carroll (1988) suggested this because

22
of those women who had 3 contacts, a postpartum contact within
1-3 days of the infant's birth occurred; and (c) deductively, it
can be concluded that without early establishment of
breastfeeding it is not possible to breastfeed to 6 months and
for some women, an early contact insures that she will continue
to breastfeed past difficulties.

Assumptions

 

The assumptions were that the data on breastfeeding
duration was accurate. Another assumption was that the mothers
accurately reported cessation of breastfeeding to the peer
counselor.

Limitations

 

The design of secondary analysis inherently has some
limitations due to previously designed forms with predetermined
data. This limits the availability of other data, such as more
information on demographics, in particular, level of education,
marital status, and income. Lack of established reliability and
validity of the instruments was a limitation. Inaccuracies in
the data entry likely occurred and because of limited access
there was no way for the researcher to verify and correct the
errors. Access to the original forms was restricted to employees
of MSUE by the consent originally signed by the women.

A convenience sample was used in which only women who
voluntarily agreed to participate were included. With this type

of non-probability sampling, there is no way to determine if

23
there were any systematic differences between women who agreed
to participate in the peer counselor program.and those who did
not. In addition the inclusion criteria for this sample created
a limitation in the study by not allowing the researcher to
include those who weaned before two weeks.

Further limitations of the study were the selection of
only two aspects of the peer counselor program, that of the
quantitative components of the timing of the first contact and
number of contacts in the first two weeks. These components did
not measure qualitative aspects of the peer counselors'
interactions or of the program and thereby created a significant
limitation in evaluation of the program.

Results

This section includes the description of the sample and
study variables, the analysis of the research question, and
additional analyses.

Demographic Characteristics

 

The ages of the women ranged from 14 to 35 years with a
mean age of 21.58 years (SD = 4.02). Sixty-four percent of the
women were white (n = 160), 26% were Black (2 = 65), % were
Hispanic (n = 12), % were Asian or Pacific Islander (n = 3), 1%

represented themselves as biracial (n = 2), and only one was

American Indian or Alaskan Native.

24

Description of the Research Variables

 

The research variables were timing of the first postpartum
contact in the first two weeks, number of postpartum contacts in
the first two weeks, and duration of breastfeeding. Sample size
for the frequency analyses was 250, with the exception of timing
of the first contact. The mean timing of the first contact

(n = 184) was 3.59 days ( D = 3.39), and the mode was on the day

O
H)

birth. An unexpected finding was that 66 women had no contact
in the first two weeks, which became a missing value for timing
of the first contact. This decreased the sample size for the
regression to 184 women, as well as affected the mean number of
contacts in the first two weeks. The number of postpartum
contacts (n = 250) ranged from 0 to 10 contacts with a mean of
1.85 contacts (_D = 1.80). The number of prenatal contacts (2 =
250), the extraneous variable, ranged from one contact to 19
contacts with the mean number of 2.13 contacts (SD = 1.91).

The range of duration of breastfeeding (n = 250) was 2 to

76 weeks with mean of 14.58 weeks (SD = 13.07). However, it is
important to note that the median, 10.50 weeks, and the mode, 3
weeks, created a different picture of the distribution which
was, in fact, positively skewed (see Figure 3). In this study,
74% of the women were breastfeeding at 4 weeks, 69% at 6 weeks,
43% at 12 weeks, 30% at 16 weeks, and 16% at 26 weeks. The graph

shows a pattern of decline of breastfeeding after a peak of

those who breastfed 3 weeks and again at 13 weeks.

Number of women

 

 

 

 

15

I.
. I III II II I I I I

2468101 21416182022242628303335384145525871

 

 

 

 

 

 

NUmber of weeks of breastfeeding

Figure 3. Bar Graph Reflecting Duration of Breastfeeding

 

.Among Women in the Sample (N'= 250).

26

Analysis of the Research Question

 

The research question asked: What is the relationship of
interaction between peer counselors and first time breastfeeding
women within the first two weeks of the infant's birth and the
duration of breastfeeding after controlling for prenatal
interactions? Analysis of the data failed to demonstrate a
relationship between these variables (see Table 1). Therefore,
neither timing of the first postpartum contact nor the number of
postpartum contacts within the first two weeks were found to be
significant predictors of breastfeeding duration. The p-value
for the significance test (t) failed to reach significance for
either variable. The hypothesis that earlier postpartum

interactions of first time breastfeeding women with a peer

Table 1

Summarygof Hierarchical Stepwise Multiple Regression Analysis for Timing and

 

Number of Prenatal and Postpartum Contacts as Predictor variables of Duration

 

of Breastfeeding, Controlling for Number of Prenatal Contacts (N = 184).

 

 

 

Variable 5f B B p-value of t
Number of prenatal contacts .01 .68 .11 .16
Timing of the first contact postpartun1 .02 .47 .12 .14

Number of contacts in the first two weeks .03 .70 .09 .29

 

27
counselor and increased number of interactions with a peer
counselor in the first two weeks postpartum was related to
longer duration of breastfeeding was not supported.

Additional Analyses

 

Other factors were explored to provide further insight
into the association between the demographic characteristics,
age and race, and duration of breastfeeding. Chi square analyses
were performed. Analyses of the data failed to demonstrate a

significant relationship between the variables, age and race,
15(4, n = 243) = 6.271, E = .180 and X; (4, n = 243) = 1.171,
p = .883, respectively, with duration of breastfeeding.

A.t-test was performed to ascertain if there was a
significant difference of duration of breastfeeding between the
group of women who had contact by a peer counselor within the
first two weeks postpartum (g = 184) and those who had no
contact in the first two weeks (n = 66). No significant
difference was found (9 = 0.414).

Discussion

In this section the results of the analysis are discussed

in relation to the review of literature and the conceptual

framework.

Demographic Characteristics

 

The mean age, 21.58 years, of the women in this study was
similar to that of two studies reviewed in the literature,

(Kisten et al., 1994; Saunders & Carroll, 1988). Race of the

28
women of the current study and studies in the review of
literature varied greatly primarily due to the geographic areas
within which the women lived. In the current study, the majority
of the women were white as compared to other studies on
breastfeeding duration where the women sampled were African-
American (Kisten et al.), Native American (Long et al., 1995) or
Hispanic (Saunders & Carroll).

Researchgguestion

 

The research question asked if there was a relationship of
interaction between peer counselors and first time breastfeeding
women in the first two weeks postpartum and duration of
breastfeeding after controlling for prenatal contacts. This
study’s findings did not support that timing of the first
contact and number of contacts in the first two weeks was
significantly related to breastfeeding duration.

The conceptual model demonstrated that the
breastfeeding woman is part of an open interaction system.
The variables chosen to conceptually define interaction in
this study were two aspects of interaction meant to
represent adequacy of support. Timing of the first contact
and number of contacts looked at quantitative aspects of
adequacy of support and not the qualitative component of
content of the interactions such as: (a) ability of the peer
counselor to interact, (b) her approach, (c) teaching

techniques, e.g., use of hands-on teaching of actual

29
techniques, or verbal explanation, and (d) receptiveness of
the mother. Not studied was the type of interaction: (a) a
face-to-face interaction in the hospital, at home, or in the
clinic, or (b) telephone interaction. Qualitative components
of prenatal contact were not considered and might also
account for the lack of significant results.

Other possible explanations for the lack of
significance might be that perceptions in the interactions
of the peer counselor and breastfeeding woman were not
accurate. Poor perception of the verbal and non-verbal
behavior can result in less than accurate communication or
understanding of what was to be communicated (King, 1981).
Possibly an increase in stress in the woman's environment
narrowed her perceptual field, thus reducing her ability to
communicate with the peer counselor, and ability for both to
understand the other and to make decisions. These stresses
might be the need to return to work, lack of social support,
a move of residence, or financial concerns.

Other factors to consider in the open interaction
system of King (1981) are the women's interactions with
family members, significant other, and other members of the
health care system regarding breastfeeding matters, whether
positive or negative. This, too, could result in inaccurate
perceptions and interfere with the woman's decision-making

process or her ability to accurately perceive the peer

30
counselor's communications.

Most of the above reflects external factors. Also to be
considered are internal factors within the woman, such as
what is motivating her to breastfeed, ability to persist
through difficulties, self-esteem level, prenatal intent of
length of time of breastfeeding, and her perception of
support. King’s model helps to explain the complexity of the
issue surrounding a choice to continue to breastfeed. While
the findings did not support the relationship within King’s
model (1981), the model is still appropriate if other
aspects of interaction are found to be important and are
added to the model.

In comparing the results to the breastfeeding peer
counseling literature, inconsistencies exist where some
authors failed to report the timing of the first contact or
the number of contacts in the first two weeks; only one
study by Saunders and Carroll (1988) reported the number of
postpartum contacts. Saunders and Carroll's findings did
reveal a significant longer duration of breastfeeding in the
group (n = 36) who received all three contacts in the first
two weeks as compared to the women who did not receive the
full number of contacts postpartum.

Statistically, the homogeneity of the sample of this
study might have been a factor. Inclusion of the women who

had weaned within the first two weeks might have helped show

31
significance. Also, removal of outliers in the variable,
duration of breastfeeding, was attempted without a
significant change in the regression results.

Women did continue to breastfeed in this study for a
mean duration of 14.58 weeks. This finding is similar
compared to Kistin et al.'s (1994) results which reported a
mean duration for breastfeeding being 15 weeks. Duration of
breastfeeding in this study with 78% breastfeeding at 4
weeks was slightly longer than Long et al.’s study (1995) of
71% breastfeeding at 4 weeks. The percent of women (69%)
breastfeeding at 6 weeks was slightly higher in this study
as compared to the percent of women (64%) breastfeeding at 6
weeks in Kistin et al's study. The percent of women
breastfeeding at 12 weeks was similar in all three studies,
with 43% in this study, 44% in Kisten et al.’s study, and
49% in Long et al.'s study. In this study 16% were
breastfeeding at 6 months; however, no data was available
from the other peer counseling studies for breastfeeding at
6 months.

In the current study women were excluded from the
analysis if they had had any previous breastfeeding
experience. One study (Saunders & Carroll, 1988) while
reporting a significantly longer duration of breastfeeding
for women with more frequent contacts postpartum, did not

report previous breastfeeding experience of the women which

32
might have impacted the duration of breastfeeding. The other
studies (Kisten et al., 1994; Long et al., 1995) did not
exclude women who had previous breastfeeding experience.
Previous breastfeeding experience has been shown to be
significantly related to longer duration (Grossman,
Fitzsimmon, Larsen-Alexander, Sachs, & Harter, 1990) and
might increase the mean of duration of breastfeeding in a
sample. This must be considered when comparing the results
of this study with the aforementioned studies and it sheds
positive light on the mean duration of breastfeeding for

this study.

Implications for Advanced Practice Nurses (APNs)

Advanced practice nurses who provide care to pregnant
and postpartum women and their infants have an important
opportunity to interact with women regarding breastfeeding
and how long they might choose to breastfeed. This study
demonstrated the complexity of the individual woman's
decision—making or goal setting in relation to duration of
breastfeeding and the complexity of the relationship of
interaction between the peer counselor and women. Reducing
interaction to two factors explaining quantitative aspects
of adequacy of support was not explanatory of how long a
woman breastfed.

In examining the graph for duration of breastfeeding it

was striking that after 3 weeks postpartum a drop in

33
duration of breastfeeding occurred and gradually continued,
with another noticeable decline at 14 weeks. For the APN to
provide adequate support to breastfeeding women, this
finding indicates a need for intervention prior to the
critical times of 3 weeks and 14 weeks postpartum. The
intervention might be a telephone call or face-to-face
contact, to evaluate how the breastfeeding is progressing
and to determine whether or not the woman is meeting her own
goal for duration of breastfeeding.

From this study we learned that a critical time for
ending breastfeeding occurred 3-4 weeks after the birth.
According to the current medical protocol, women are seen at
6 weeks postpartum for a medical evaluation. There is a need
then for a shift in thinking and change in protocol
regarding timing of the postpartum follow-up for
breastfeeding women. In addition coordination of services by
the peer counselor, Maternal and Infant Support Service
staff, community health nurse, WIC personnel and lactation
consultant may be indicated. Based on the findings from this
study on breastfeeding duration, collaboration of all
involved services and continuity of care might assist each
woman to meet her goal of breastfeeding duration. APNs are
in a position to serve as change agents and advocates for
breastfeeding women in order to modify the traditional 6

week postpartum visit practice protocol and to coordinate

34
services to improve adequacy of support.

In order to reach the Healthy People 2000 breastfeeding

 

objective, the standards of care for follow—up of
breastfeeding women postpartum need to be re-evaluated in
all health care practices and systems. Based on this study's
findings, peer counseling programs need to continue visits
beyond the early days targeting the critical times of
weaning at 3 weeks and 3 months.
Recommendations for Future Research
The APN can advance knowledge of breastfeeding

support through research and dissemination of findings.
While the study failed to demonstrate a relationship between
the timing of the first postpartum contact and number of
contacts in the first two weeks and duration of
breastfeeding, it did reveal that the women of this study
were breastfeeding beyond the early days. Further research
might include other variables, such as type of contact,
content of teaching, content of prenatal contacts, social
support of the woman, and style of the peer counselor, in
relation to duration of breastfeeding in peer counseling
programs.

This study examined the interaction between the peer
counselor and the woman. Other family members who may have
had an influence on the mother's decision-making regarding

breastfeeding duration might have been present during the

35
interaction with the peer counselor; therefore inclusion or
exclusion of the other family members in the interaction
with the peer counselor could be studied.

A qualitative approach might suggest aspects of a peer
counseling program which are important to the women and
address other issues, such as self-esteem of women, and
style of peer counselors. A combination of quantitative and
qualitative methods might provide new knowledge regarding
transactions whereby women breastfeed for longer duration.

A different analysis might have been done to determine
reasons for the skewness of the variable of duration of
breastfeeding. An ANOVA could have been performed to examine
duration using a categorical level of measurement, e.g.,
with timing of contacts and numbers of contacts, to look at
differences in these aspects of interaction compared to
duration, rather than examining duration as a continuous
variable.

One thing that could have been done differently was to
include the women who had weaned in the first two weeks.
Also, having a control group of women from WIC in the same
communities, who wanted to breastfeed but did not have the
opportunity to have a peer counselor, would have provided
the study with additional data regarding the outcome of this
particular peer counselor program and breastfeeding

duration.

36
Conclusion

Evidence exits in the literature that participation in
breastfeeding peer counseling programs has been related to
significantly longer duration of breastfeeding among low-income
women. An attempt in this study to examine two variables, timing
and number of contacts in the first two weeks postpartum as
related to duration, failed to show significance.

However, it was found that women in this study were
breastfeeding beyond the early days. Information gleaned from
patterns of weaning dictate that protocols for postpartum
follow-up of breastfeeding women and their infants be re-
evaluated to address the critical weaning times which occurred
at 3 weeks and 3 months, to provide interventions that might
support longer duration of breastfeeding.

Clearly more research is needed as peer counseling and the
decision to continue to breastfeed is a complex issue.
Breastfeeding has been established in the literature as the
optimal form of nourishment for infants as well as an important
source of components that promote the health of the infant and
prevent disease. In the words of the American Dietetic
Association (1997), ". . . broadly based additional efforts are
clearly needed to increase duration rates of breastfeeding. The
establishment of breastfeeding for at least 6 months, but
optimally for at least one year, as a cultural norm supported by

medical, social and economic practices, is a fundamental

37
cornerstone of true promotion of wellness" (p. 665). As APNs it
is our privilege to foster the promotion of wellness among the
mothers and babies in our communities and within our health care

system by the promotion and support of breastfeeding.

APPEND I CE 8

Appendix.A

Breastfeeding Peer Counselor Initiative

The Breastfeeding PeerCounselor Initiative (BFI), begun
in June, 1993, is managed cooperatively by Michigan State
University Extension (MSUE) and the Special Supplemental Food
program for Women, Infants, and Children (WIC) (see Appendix B).

In Michigan, Extension programs are financed by federal,
state, and county funds. The BFI and a nutrition education
program, Expanded Food and Nutrition Education Program (EFNEP),
are both managed under the Children, Youth, and Family (CYF)
division of MSUE.

The purpose of the BFI program is to increase the rate of
initiation and duration of breastfeeding among low income women
in 13 counties in Michigan with very low breastfeeding rates
(MSUE, 1996). BFI models its home visit component after that of
EFNEP. A.select number of EFNEP paraprofessionals are trained to
be breastfeeding peer counselors with BFI. These breastfeeding
peer counselors might have visited the woman who enters BFI
prenatally more than once in order to teach the basic nutrition
class offered by EFNEP. A criterion for the breastfeeding
counselors is that they have had a positive breastfeeding
experience themselves breastfeeding their infant. Most of the
peer counselors are from the same socioeconomic group as WIC

clientele (MSUE, 1996).

38

39

Within each county, an Extension Home Economist
supervises the peer counselor with guidance from the BFI program
manager in coordination with the local WIC agency staff.
Supervising professionals in WIC and MSUE receive identical
training to the newly hired breastfeeding counselor.

The two— or three-day training by the state WIC lactation
consultant is followed by a six month probationary period for
each peer counselor. Topics covered in training are: Cultural
considerations and.myths surrounding breastfeeding, identifying
and addressing the barriers to breastfeeding with mothers or
pregnant women, benefits of breastfeeding, breastmilk
properties, anatomy of the breast and physiology of milk
production and of milk ejection, breast care, prenatal
assessment of nipples, infant feeding cues and behavior, adding
solids, and weaning. Also taught are specific techniques of
effective breastfeeding including latch on and positioning,
signs of milk transfer, assessment of adequate intake in the
baby, counseling techniques, problem-solving, and when and where
to refer for additional help.

The local WIC staff identify women as potential BFI
clients at time of enrollment into the WIC program which
commonly occurs during pregnancy or following delivery. The
women referred are those who are considering breastfeeding and
express an interest in receiving support, or are otherwise

identified as needing encouragement and support to breastfeed.

40

Peer counselors contact clients through a home visit, telephone
calls, hospital visits and clinic visits.

Once a referral is received, the breastfeeding counselor
makes a telephone call or home visit to enroll the women in BFI
and this occurs either prenatally or postpartally. Sometimes a
woman is referred prenatally and does not wish to enter the
program. After the birth of her child, however, she may
reconsider or encounter problems and initiate contact with the
breastfeeding counselor.

Either the peer counselor or the mother can initiate the
contacts. The breastfeeding counselor is available 24 hours a
day to the mother by pager in order to facilitate accessibility
to clients. All women receive at least one home visit. The
frequency and number of subsequent visits varies, depending on
the need of the mother. The plan is that a woman receives
several visits or phone calls during the first two weeks after
the baby’s birth. After the baby is three months of age the peer
counselor contacts the women by telephone or face-to-face at
least once a month while she continues to breastfeed. In the
model used from 1994-1996, breastfeeding women remained in the
program until the mother weaned the baby. After 1996, women exit
the program.when they wean or when their breastfeeding infant
reaches 6 months of age (C. McKay, personal communication, March

12, 1997).

APPENDIX B

SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS,
AND CHILDREN (WIC)

WIC is a food and nutrition program funded by the U. S.
Department of Agriculture through the Michigan Department of
Community Health (MDCH), formerly the Michigan Department of
Public Health (MDPH). WIC is mandated to provide breastfeeding
promotion services to WIC participants. Participants must be at
185% of poverty or below and meet the nutritional or risk factor
criteria of the programw WIC is governed under the regulations
in the Child Nutrition Act of 1966 (Code of Federal Regulations
[CFR], 1997, p. 266). Local health departments in Michigan
deliver the WIC services to the eligible public. WIC's purpose
is to correct and prevent malnutrition in low—income pregnant
and breastfeeding women, women who are postpartum, and infants
and children up to 5 years old who are at health risk due to

inadequate nutrition (CFR).

41

APPENDIX C

Data Collection Procedures

The peer counselors were trained upon commencement of
employment on use of standardized forms on which to record
information on each of their clients. These sheets were
submitted to the administrative office of MSUE upon a woman's
exit from the program. The forms were developed in a coordinated
effort with other state extension programs who also had peer
counseling programs. The data the program was interested in
analyzing was collected from the forms completed by the peer
counselors and entered into a computer using the statistical
program, Stat View. Early 1997 the data was transferred to IBM
SPSS. The forms are kept in a locked file in the MSUE office and

will be discarded after seven years.

42

APPENDIX D

MMn Number Marmot! Eduction 1
m

 

43

 

CHILDREN. YOUTH
AND FAMILY
PROGRAMS

202mm
must-cw
trauma

517-3341”
FAX 517-33“

”mama-w
mus-use“!
sac-surmount.
“an. a an .

ups-mus
mama-r
“m
We.“

Appendix E

Letter from.MSUE

MIG-IICANSIATE
UNIVERSITY

EXTENSION

May 7. 1996
TO: Cindy Church .
. c" b
mom: Barb Mutch U“ 5
Coordinating Program Leader
RE: Secondary Analysis of BFI Date

Thisisinresponsetoyourrequesttousedatacollectedthrough the
Breastfeeding Peer Counselor Initiative (BFI) for secondary analysis for a
masters thesis through the College of Nursing.

ImderstanddiatChuMcKay.BFIngramMmacer.hasdiscussedwithyou
confidentiality issues and her. as well as Anne Murphy's. time limitations. We
do request shared authorship of any journal publications that may result from this
work. '

I am pleased MSU Extension will have this opportunity to work in collaboration
with the college. Char feels your analysis will be of benefit to the project Best
vn'shes with the project.

c. Char McKay. Peg McConnell, Anne Murphy

“My.

44

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