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Logo of jperinatedOfficial Journal of Lamaze(R) InternationalEditorial BoardAdvertiseSubscribeAuthor InformationJournal of Perinatal Education Online
J Perinat Educ. 2005 Fall; 14(4): 24–35.
PMCID: PMC1595264

Development and Testing of a Prenatal Breastfeeding Education Intervention for Hispanic Women

Jane Schlickau, PhD, RN, ARNP, FACCE and Margaret Wilson, PhD, CPNP

Abstract

Many immigrant Hispanic women in the United States choose to bottle-feed rather than breastfeed. This article describes an intervention that was developed and tested in a two-step process. Two studies were undertaken. First, a qualitative inquiry explored the breastfeeding beliefs, attitudes, meanings, and practices of Hispanic women. Results informed the design of a culturally appropriate prenatal breastfeeding education intervention. Secondly, the researchers undertook a quantitative study of the intervention's success in increasing breastfeeding duration among Hispanic women. Methodology and findings of this study have implications for future interventions that promote breastfeeding.

Keywords: breastfeeding, Hispanic, education, self-efficacy

In 1996, 60.5% of Hispanic women in the United States initiated breastfeeding and 19.5% continued to breastfeed for 6 months (Ryan, Wenjun, & Acosta, 2002). In 2001, breastfeeding rates for Hispanic women in the United States increased when 73% initiated breastfeeding and 32.8% continued for 6 months (Ryan et al., 2002). Regional breastfeeding rates are not known. Even though breastfeeding rates are rising, they fall short of the Healthy People 2010 goals for 75% of women to initiate breastfeeding and 50% to continue breastfeeding for 6 months (Centers for Disease Control, 2004). The Hispanic population in the United States is projected to increase from 12.5% in 2000 to 17% in 2020 (U.S. Census Bureau, 1999). Additionally, persons of Hispanic origin experience an unequal share of poverty and poor health outcomes in the United States (Policy and Research, National Coalition of Hispanic Health and Human Services Organization, 1995). Therefore, breastfeeding for the growing population of Hispanic families in the United States is vital to promoting a healthy start to life.

Breastfeeding gives an infant a good nutritional beginning to life. Children who are breastfed acquire immunological protection against infections and iron deficiency (Giachello, 1994). Breastfeeding rarely causes allergic reactions; furthermore, it provides an uncontaminated source of nutrition in areas where economic conditions are poor (Hanson, Jahil, & Ashraf, 1991). Breastfed infants have fewer respiratory infections; therefore, mortality rates and childhood medical costs for breastfed infants are lower (Giachello, 1994).

Breastfeeding is recommended by the American Academy of Pediatrics Work Group on Breastfeeding (2005), which affirms exclusive breastfeeding provides ideal nutrition that is sufficient to support optimal growth and development for approximately the first 6 months of life. Benefits of breastfeeding for the mother include the following: increased levels of ocytocin, resulting in less postpartum bleeding and more rapid involution; earlier return to prepregnant weight; delayed resumption of ovulation resulting in increased child spacing; improved postpartum bone remineralization and reduced hip fractures in the postmenopausal period; and reduction in the risk of ovarian cancer and premenopausal breast cancer (American Academy of Pediatrics Work Group on Breastfeeding, 2005).

REVIEW OF LITERATURE

A comprehensive literature search using MEDLINE and CINAHL was performed. Articles published after 1990 and classic findings were reviewed for reference to breastfeeding and Hispanic or Latina women. Critical analysis of previous research on breastfeeding revealed several limitations. Most of the research focused on Caucasian, middle-class, well-educated American women. Research related to breastfeeding among Hispanic women did not acknowledge the country of origin or the ethnicity of the population and, thus, did not address the potential differences among Hispanic groups (Balcazar, Trier, & Cobas, 1995; Gorman, Byrd, & VanDerslice, 1995; Kiehl, Anderson, Wilson, & Fosson, 1996; Locklin & Naber, 1993; Obermeyer & Castle, 1997). Moreover, many researchers studied breastfeeding initiation and/or duration, but the length of follow-up efforts varied, ranging from 1 week to, seldom, 6 months (Boettcher, Chezem, Roepke, & Whitaker, 1999; Hill, 1991; Long, Funk-Arculeta, Geiger, Mozar, & Heins, 1995; Perez & Valdes, 1991; Perez-Escamilla, Segura-Milan, Pollitt, & Dewey, 1993; Pugin, Valdes, Labbok, Perez, & Aravena, 1996; Rassin et al., 1994; Spake & Harris, 1993). Furthermore, breastfeeding, in terms of exclusivity, was not clearly defined in most studies. Several researchers recommended further inquiry into the cultural influences associated with breastfeeding success (Boettcher et al., 1999; Dettwyler & Fishman, 1992; Heinig & Dewey, 1996; Kannan, Carruth, & Skinner, 1999; Obermeyer & Castle, 1997; Rassin et al., 1994).

Most studies on breastfeeding among Hispanic women were quantitative, focusing on barriers, positive influences, and social support. Acculturation was a barrier to breastfeeding for Hispanic women (Gorman et al., 1995; Perez-Escamilla et al., 1998; Rassin et al., 1994). Other barriers to successful breastfeeding were the Hispanic mother's perceptions of inadequate quality and quantity of milk (Gorman et al., 1995; Obermeyer & Castle, 1997; O'Campo, Faden, Gielen, & Wang, 1992) and social discomfort (Perez-Escamilla et al., 1998). The mother's perception of the father's positive attitude was a predictor of breastfeeding success (Gorman et al., 1995; Perez-Escamilla et al., 1998). Additional positive influences were social support from others (O'Campo et al., 1992) and advice to breastfeed during prenatal care (Balcazar et al., 1995; Perez-Escamilla et al., 1998).

Several researchers have proposed but not tested strategies or models for increasing breastfeeding initiation and duration among Hispanic women (Denman-Vitale & Murillo, 1999; Moreland, Lloyd, Braun, & Heins, 2000; Skeel & Good, 1988; Spake & Harris, 1993). The only published intervention studies that focused on breastfeeding among women of Hispanic heritage used social-support interventions with women living in Mexico (Langer, Campero, Garcia, & Reynoso, 1998), Chile (Pugin et al., 1996), Honduras (Cohen, Brown, Rivera, & Dewey, 1999), and Florida (a group of 26 low-income women, 5.6% of whom were Hispanic; Arlotti, Cottrell, Lee, & Curtin, 1998). The applicability of studies of Hispanic women living in other countries to immigrant women in the United States is limited.

While generally positive attitudes, the intention to breastfeed, and feelings of support for the decision to breastfeed were documented to promote breastfeeding among Hispanic women (Libbus, 2000), few qualitative studies have focused on the experience of breastfeeding for cross-cultural populations. Bottorff and Morse (1990) found that middle-class Canadian women were concerned about changes in the quality of their breast milk. Locklin and Naber (1993) examined the breastfeeding experience of African-American and Hispanic women and discovered that breastfeeding seemed to empower these women. Maclean (1998) found that breastfeeding was linked to the mother's sense of self, but was shrouded in silence among Canadian women. Barriers to breastfeeding for low-income, Mexican women included lack of support from caregivers and professionals, embarrassment, pain, and inconvenience (Gill, Reifsnider, Mann, Villarreal, & Tinkle, 2004).

Barriers to breastfeeding for low-income, Mexican women included lack of support from caregivers and professionals, embarrassment, pain, and inconvenience.

In summary, quantitative studies failed to provide a holistic understanding of the beliefs, attitudes, meanings, and practices that Hispanic women hold concerning breastfeeding. Barriers, benefits, social support, and commitment were identified as important breastfeeding concepts, but interventions to promote breastfeeding among Hispanic women have not been tested adequately. Although researchers identified cultural influences and acculturation as important variables in breastfeeding success, culturally appropriate interventions to support breastfeeding need more development and testing.

Although researchers identified cultural influences and acculturation as important variables in breastfeeding success, culturally appropriate interventions to support breastfeeding need more development and testing.

This article describes a two-part preliminary study undertaken as part of a program of research to develop a prenatal intervention to promote breastfeeding among Hispanic women in the United States. The first phase was a qualitative endeavor; the second phase tested a culturally appropriate intervention. Methods and findings from both studies informed the design of a prenatal breastfeeding intervention to increase breastfeeding self-efficacy, initiation, and duration for Hispanic women.

ETHNONURSING STUDY OF BREASTFEEDING AMONG HISPANIC WOMEN

Qualitative methods were employed to explore and describe the breastfeeding beliefs, attitudes, meanings, and practices of Hispanic women. The goal of this first step was to acquire the cultural understanding necessary to design a culturally appropriate intervention to promote breastfeeding. Findings and how they inform future studies are discussed.

Purpose

The purpose of this pilot work was to explore breastfeeding beliefs, attitudes, meanings, and practices among immigrant Hispanic women in a Midwestern city located in the United States.

Specific Aims/Questions

Four questions guided the research:

  • What beliefs, attitudes, meanings, and practices do Hispanic women hold concerning breastfeeding and its promotion of infant nutritional health?
  • In the acculturation process to the United States, what influences the Hispanic woman's infant-feeding decision?
  • What generic (folk or home-based) practices positively influence breastfeeding duration among Hispanic women?
  • What interventions or practices by health-care professionals positively influence breastfeeding duration among Hispanic women?

Sample and Setting

The researcher chose a mix of Hispanic participants from a convenience sample of women who participated in “Moms and Mentors,” a peer-modeling program in the Planeview community of Wichita, Kansas. The researcher chose to select a mix of Hispanic participants from the Planeview community because residents in the area have recently relocated to the area from Mexico, Puerto Rico, and Central and South America. Although focusing exclusively on women from a certain country would lend specificity to cultural information, it also would limit proposed interventions to certain groups. Because Hispanic is the term this group of Planeview residents use to refer to themselves and because women from several Latin American countries mix and socialize together, the selection of two key and six general informants was believed to be inclusive for this pilot work. Interviews took place at the Planeview community center and in the participants' homes.

One key informant (age 19 years, pregnant, and planning to breastfeed) was from Mexico, and the other (a 25-year-old breastfeeding mother of a 6-month-old infant) was from Guatemala. The two key informants had immigrated to the United States within the past year. Six general informants had been in the United States for 1–7 years and included mothers of young children and two grandmothers whose diverse experiences enhanced the richness of the information, particularly concerning breastfeeding barriers and positive influences. Four general informants from Mexico were from the same family (a grandmother, age 75 years, and her three daughters, ages 26 to 35 years, each with small children). One general informant (age 34 years, mother of small children) was from El Salvador and another (a 65-year-old grandmother) was from Peru. Of the eight informants, two were bilingual. None of the informants was born in the United States.

Method

Ethnonursing methods were derived from ethnographic research techniques developed by anthropologists to study other cultures. Leininger (1978) defines ethnonursing as “the study and analysis of the local or indigenous people's viewpoints, beliefs, and practices about nursing care phenomena and process of designated cultures” (p. 15). The ethnonursing research process is aimed at documenting, describing, and explaining nursing phenomena using both emic (insider's view) and etic (outsider's view) interpretations (Leininger, 1978).

Procedures

After institutional review board approval was received from the University of Nebraska Medical Center in Omaha and informed consent was given, the informants were interviewed with the assistance of a Spanish-language interpreter. Interviews consisted of broad, general questions and open-ended statements that allowed follow-up elaboration and contrast questions. Lead-in phrases included the following:

  • “Tell me about what it means to breastfeed your baby.”
  • “I would like to learn about the best way to feed a baby.”
  • “What do you believe about breastfeeding?”

Interviews were conducted in Spanish with the assistance of a Spanish interpreter. The audiotapes were transcribed verbatim from the portions of audiotaped interviews spoken in English only. Sandalowski (1994) acknowledges that transcripts are accurate only to the extent the researcher understands their created reality. The interpreter was key in assisting the researcher to understand informational contents during interview sessions with each informant. Sandalowski explains that gaps will occur between what is lived, what is narrated, and what is translated. To enhance the credibility of information, transcriptions were validated between the interpreter, the informant, and the researcher.

Data Analysis

“QSR NUD.IST” Software for Qualitative Data Analysis was used to index and organize categories within Leininger's (1991) Phases of Ethnonursing Analysis. The first phase of analysis consisted of studying the raw emic data by reading and rereading the descriptive observations. In the second phase, descriptors and components were identified, and similar or dissimilar statements were organized into categories. The third phase of analysis involved scrutinizing, identifying, and coding data to discover patterns of behavior while looking for evidence of saturation, consistencies, and credibility of data. The fourth phase entailed synthesis and abstraction of ideas from previous phases and discovering themes. Journal entries proved valuable for recording observations and reflecting upon perceptions.

Themes

Theme 1: Breastfeeding is a natural choice among Hispanic women.

This theme was derived from informants' responses to questions about when one decides to breastfeed. Verbatim descriptors of key informants' beliefs are representative of this theme:

  • “I never doubted”
  • “you just know you will breastfeed”
  • “it's the way it's supposed to be”
  • “it's a natural thing.”

No decision was made about feeding methods; each woman simply knew she would breastfeed. Although fathers were reported to be supportive of breastfeeding, they had no input into the feeding method. Breastfeeding was described as “easy, convenient, and makes sense.”

Theme 2: Hispanic women strive to be strong, self-sufficient, and self-assured.

Evidence of these attitudes was apparent in the following comments in answer to a follow-up question about support (“Who cheers you up when you are down?”):

  • “I never thought I needed cheering up. I just started crying but kept working.”
  • “I knew that I could do it [breastfeed] even with no one there to help me.”

Some statements about self-sufficiency related to families and the tradition of la cuarentena (the 40 days after birth in which the mother rests, avoids housework, and eats a special diet):

  • “My mom was not like that. I am not like that.”
  • “I had to take care of the children. I could not stay in bed.”
  • “I was on the farm with the cows and the kids and could not stay in bed for 40 days. Those are antiquated ideas that are still followed among the poor [in Mexico]. You have to take care of yourself, though, during that time.”
  • “My aunt and mother in Mexico were modern; they did not follow la cuarentena.”

Theme 3: Breastfeeding is a healthy state for Hispanic women who seek current breastfeeding information.

Remarks related to the practice of attending classes and seeking information were:

  • “They have pamphlets about breastfeeding that I got at the church.”
  • “When I have questions, I call the clinic.”
  • “I went to a mother's class that they presented to me about pumps and everything because I was working full-time.”
  • “There's La Leche League in California, so I made a couple of calls to them.”
  • “I am not a typical taboo lady, I like to be informed.”

Four women who previously lived in Mexico (all from the same family) spoke of government programs that require employers to give time off from work after birth. They reported that the government in Mexico also provides medical insurance and promotes breastfeeding by requiring that hospitals do not offer formula. While the Mexican government did not offer breastfeeding classes, the government's influence on breastfeeding was positive.

Each informant displayed knowledge of how to stay healthy during pregnancy and breastfeeding, as evidenced by these comments:

  • “You have to eat well because you are breastfeeding.”
  • “You just understand to eat good.”
  • “If you are healthy, the baby is healthy.”
  • “You have to be healthy to have milk for the baby.”

When asked about what one should eat while breastfeeding, everyone spoke about eating a lot of vegetables (fruit was not mentioned), chicken, and fish. One should not eat peppers or hot spices while breastfeeding because it will upset the baby's stomach. In addition, atole (rich oatmeal cooked with milk and sugar) was confirmed by six informants as important for making milk.

Theme 4: Hispanic women express with pride that they have healthy children.

This theme was derived from statements by mothers in answer to questions about how one can tell if her baby is healthy. Comments included:

  • “if they are never sick”
  • “heavy”
  • “if skinny, they are poor”
  • “weight”
  • “no sickness”
  • “no problems—I am proud of myself that I did that”
  • “a child that doesn't eat well can't stay well”
  • “we had a lot of children in our family, but they were all healthy—we had a good mother.”

One informant was not able to breastfeed her baby because “he would not take it,” and another bottle-fed two of her four children because she worked outside the home. However, both women stated they pumped their breasts to feed colostrum for about seven days because they knew it gave a lot of protection and they wanted their babies to be healthy.

Theme 5: Suffering is an expected part of pregnancy, childbirth, and motherhood.

Because the term suffering was frequently used by informants, it was coded as a recurrent pattern for reflection. Three of the eight informants used the term in response to questions about their husband's support of breastfeeding. Examples include the following:

  • “I was suffering with morning sickness, so I tell my husband he will help me with the baby. He bring him to me at night. I never have to get up.”
  • “I cried when I had girls because I knew they would suffer more than boys.”
  • “You suffer a lot for that period of time and [because] he was with me in labor and delivery…, he say women they suffer a lot and I need to do something.”

How Findings Informed the Design of the Intervention

The results of this qualitative pilot work concur with Pearce's (1998) findings that Hispanic women seek a healthy baby by caring for themselves, eating well, receiving support and advice, and accepting care from providers. The participants also expressed an understanding that breastfeeding is a natural and healthy way to feed their infants. In addition, they articulated their desire for healthy infants and openness to receiving breastfeeding information. These Hispanic women with varying acculturation levels (as assessed by language preference and length of time in the United States) intended to breastfeed their infants even when they had left supportive family members behind in their country of origin. Each participant expressed knowledge of customary ways to stay healthy while pregnant and breastfeeding; however, most rejected traditional postpartum restrictions and care for the mother, primarily due to lack of support to make those feasible.

Although the participants sought to be “modern” and not bound by cultural traditions, they recognized traditional ways of staying healthy. With these considerations in mind, and with a desire to develop an appropriate intervention for Hispanic women that extends beyond “standard of care” (handouts and information on maternal nutrition), an educational intervention that builds upon the strong, self-sufficient, self-assured attitude of Hispanic women was hypothesized to potentially be effective to promote breastfeeding initiation and duration.

A PRENATAL BREASTFEEDING EDUCATION INTERVENTION TO PROMOTE BREASTFEEDING DURATION AMONG HISPANIC WOMEN

A prenatal breastfeeding education (PBE) intervention was developed using information from the ethnonursing study reported above. It consisted of two levels. The first level was designed to enhance knowledge, increase perception of benefits, and decrease perception of barriers to breastfeeding. The second level consisted of a session involving the PBE intervention in which a selected group of participants formulated a specific plan for breastfeeding and committed to breastfeed for a certain length of time. Perceived barriers, benefits, and commitment are constructs that influence health behavior within the Health Promotion Model (Pender, Murdaugh, & Parsons, 2002). Thus, the Health Promotion Model was chosen to guide the development of the intervention.

Purpose

The primary purpose of the intervention phase of this research was to pilot test a two-level prenatal intervention to promote breastfeeding among Hispanic women. A second objective was to estimate statistical effect sizes and feasibility of conducting more definitive intervention research with this population. Content of the intervention focused on imparting breastfeeding benefits, promoting infant health, and encouraging commitment to breastfeed by proposing the use of a baby quarantine (la cuarentena del bebe), a culturally appropriate strategy that encourages exclusive breastfeeding (Moreland et al., 2000). Details of the program are outlined in the Table.

Table
Prenatal Breastfeeding Education Content Summary

Hypotheses

Two hypotheses were developed:

  1. Women who receive the PBE intervention have a longer duration of breastfeeding than those who do not receive the intervention.
  2. The women who receive PBE and, then, demonstrate a commitment to breastfeed by formulating a plan for breastfeeding have a longer duration of breastfeeding than those who do not receive any intervention.

Research Design

An experimental pilot was performed to explore changes in duration of breastfeeding. Participants were randomly assigned to one of three groups:

  1. Control (usual-care group);
  2. Level 1 (PBE-only group); and
  3. Level 2 (PBE-plus-commitment-to-breastfeed group).

Sample

The researchers enrolled 30 low-risk, primigravid Hispanic women in their third trimester who received care at the Sedgwick County Department of Health's Mother and Infant Clinic, which is located in Wichita, Kansas. Choosing low-risk clients controlled for maternal variables, which may have affected the childbirth outcome. Selecting primigravid clients controlled for previous breastfeeding experience. Each participant had a normal breast and nipple exam, as recorded on her prenatal assessment. Also, each participant came from a stable family and was not planning to work outside the home for 6 months. All participants were of Hispanic heritage and between the ages of 16 and 45 years, with a mean age of 22 years. Eighty-five percent (n = 25) of the participants had emigrated from Mexico within the last 7 years. All participants preferred to speak Spanish rather than English. Five of the participants (17%) could not be contacted at 6–7 weeks postpartum despite multiple attempts.

Procedures

Clients from the Sedgwick County Department of Health's Mother and Infant Clinic who met the inclusion criteria were identified and referred to the researcher by the clinic's staff. While each participant waited to see the physician, the researcher delivered the intervention in a small classroom with the assistance of a Spanish language interpreter. After providing informed consent, participants were randomly assigned to one of the three described treatment groups (Control, Level 1, or Level 2). Approximately 15 minutes were required for the Control group, and 1 hour was needed to administer each of Level 1 and Level 2 interventions.

Intervention

Level 1.

During a clinic visit and after informed consent and the random selection assignment, the researcher approached the expectant mother and began with the following question, “Have you thought about how to feed your baby?” All participants answered they were planning to breastfeed. Further content included confirmation of the benefits of breastfeeding, such as economic advantages, nutritional qualities, and convenience. Charts and pictures were used to present supply-and-demand concepts and prenatal breast preparation. Early and consistent breastfeeding practices were emphasized. A doll was used as a model for instruction about holding and positioning the baby and breastfeeding discreetly.

Level 2.

The second level of the intervention was administered to those who had completed the first level during a previous clinic visit and who had been randomized to the Level 2 group at the time of enrollment. Participants were introduced to the concept of “baby quarantine,” which is modeled after one aspect of the Hispanic tradition known as la cuarentena, where, among other customs, the mother introduces nothing into her vagina for 40 days after childbirth. During the baby quarantine, nothing enters the baby's mouth, except the mother's breast, for at least 40 days after birth. This concept was developed by Moreland and colleagues (2000) and was adopted here, related only to breastfeeding and not to maternity care. However, the analogy of 40 days has the potential to resonate with an Hispanic population. The benefits of avoiding bottles, pacifiers, and supplementation to promote establishment of milk for successful breastfeeding are reinforced (Hill, Humenick, Brennan, & Woolley, 1997), while cultural traditions are highlighted (Moreland et al., 2000). Breastfeeding commitment was encouraged through the use of a checklist that asks the prenatal participant to check off commitment strategies that include the following: specifying a length of time to breastfeed; breastfeeding within a set time after birth; offering no bottle, formula, or pacifier for a specified length of time; asking the postpartum nurse to assist with breastfeeding at least twice; and asking for lactation consultation while in the hospital.

Control group.

Participants in the control group received standard-of-care breastfeeding information at the research site. Standard-of-care includes offering advice to breastfeed and distributing handouts during the initial prenatal visit, but further skill building related to breastfeeding is not included.

Data Collection

Demographic data collected at the time of the intervention included place of birth, years in the United States, language preference, and marital status. At 6–7 weeks postpartum (approximately 45 days), each mother was telephoned and asked the status of infant feeding: breast only, partially breastfeeding, or bottle only. If the mother was not breastfeeding, she was asked the number of days she breastfed before weaning. Weaning was defined as not breastfeeding in the last 48 hours and not intending to breastfeed the child again (Cronenwett et al., 1992).

Results of Data Analysis

Hypotheses were tested using t-tests and one-way analysis of variance. By 45 days, 29% of the control group continued to breastfeed, 33% in the first-level intervention group continued to breastfeed, and 56% in the second-level intervention group continued to breastfeed. The seven participants in the control group (data missing for three) breastfed for an average duration of 16.9 days (SD = 18.24) out of a possible 45 days. Nine participants in the first-level PBE group (data missing for one) breastfed an average of 23.1 days (SD = 15.90) out of a possible 45 days. The nine participants who received the two-level intervention (data missing for one) breastfed an average of 31.1 days (SD = 16.22) out of a possible 45 days. The breastfeeding duration of those who received the first-level PBE intervention was 6.3 days and greater than the duration of those in the control group (t = −0.732; df = 14; p = 0.476). Participants who received the two-level intervention breastfed 14.3 days more than those in the control group (t = −1.652; df = 16; p = 0.121) and 8 days more than those in the first-level PBE intervention group (t = −1.057; df = 16; p = 0.306). A one-way analysis of variance comparison of the duration of breastfeeding between the control group, the first-level intervention group, and the second-level intervention subgroup who committed to breastfeed for a predetermined length of time was nonsignificant at p = 0.252. The effect size was .821 (Buchner, Franz, & Erdfelder, 2003), a figure used to calculate sample size for a future randomized clinical trial.

Discussion

The PBE intervention was pilot tested with a sample of immigrant Hispanic women who received prenatal care at a public health clinic. Of the 32 women who were approached as potential participants, 30 were recruited and randomly assigned to control or intervention groups. Only five participants were unavailable for follow-up data collection (a 17% attrition rate). Follow-up telephone calls required an average of 2.3 attempts per participant.

The t-tests of mean demographic differences between each of the three groups were nonsignificant. Mean duration of breastfeeding between the three groups compared by single-factor analysis of variance was also nonsignificant. However, the trend of the outcome was consistent with the hypothesized trend. If these trends held in a larger sample, it would be reasonable to anticipate that statistical significance would be reached. This pilot study was designed to determine feasibility and to estimate effect size of the intervention; therefore, the study was deliberately underpowered in terms of the number of subjects. The research objectives of developing an intervention, determining effect sizes, and examining the feasibility of conducting research with this population of Hispanic women were accomplished.

The mechanism by which the PBE intervention may achieve a positive breastfeeding outcome needs to be better understood. According to many researchers, breastfeeding self-efficacy and the related concepts of confidence and perception of success are correlated with breastfeeding initiation and duration (Blyth et al., 2002; Boettcher et al., 1999; Cleveland, 1999; Cohen et al., 1999; Coriel & Murphy, 1988; De Bocanegra, 1998; Dennis, 1999; Dennis & Faux, 1999; Gorman et al., 1995; Hill, 1991; Locklin & Naber, 1993; Obermeyer & Castle, 1997; Sheehan, 1999; Tarrka, Paunonen, & Laippala, 1999; Torres, M., Torres, R., Rodriguez, & Dennis, 2003; Wood, Sasonoff, & Beal, 1998). Thus, breastfeeding self-efficacy across cultures may be a mediator through which increased breastfeeding initiation and duration are achieved. This is important to investigate through intervention studies with Hispanic populations specifically and other populations in general.

Breastfeeding self-efficacy across cultures may be a mediator through which increased breastfeeding initiation and duration are achieved.

The unique mix of persons who make up the Hispanic population presents a challenge for health-care professionals. Schwarzer and Fuchs (1995) emphasize the social stressors that accompany immigrants as they acculturate to different ways of life and suggest that health-promoting interventions should target self-efficacy among these groups. A culturally appropriate intervention that combines the two-level PBE intervention with strategies designed to increase breastfeeding self-efficacy was developed. It is guided by the Health Promotion Model (Pender et al., 2002) and detailed in the Table.

IMPLICATIONS FOR PRACTICE

Prenatal education for breastfeeding has been shown by others to increase duration, and it can be supported with postpartum support for Hispanic women, especially those who have committed to breastfeed. It logically follows that in-hospital and postpartum support that respects cultural beliefs is also central to promoting breastfeeding and can complement prenatal education efforts. Self-efficacy as a health-promotion construct for breastfeeding can also be applied to childbirth efficacy and other healthy behaviors such as pregnancy self-care. Perinatal educators can use this article's Table depicted as a model for curriculum development.

Footnotes

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Ethnonursing differs from ethnography in that its focus is the discovery of new nursing knowledge as perceived or experienced by nurses and consumers of nursing and health services (Leininger, 1985).

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Effect size measures the magnitude of a treatment effect. Unlike tests of statistical significance, these indices are independent of sample size. However, they can be used to determine how large a sample size is needed for a similar future study to most likely reach statistical significance. For more information on effect size measures, log on to http://web.uccs.edu/lbecker/Psy590/es.htm

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Perceived self-efficacy is a core aspect of Albert Bandura's (1986) social cognitive theory. Self-efficacy expectancies refer to per-sonal action control and are regarded as a self-confident view of one's capability to deal with certain life stres-sors. For more information, log on to http://www.fu-berlin.de/gesund/gesu_engl/lingua5.htm

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