Who knows what: An exploration of the infant feeding message environment and intracultural differences in Port-au-Prince, Haiti

Storytelling for persuasion: Insights from community health workers on how they engage family members to improve adoption of recommended maternal nutrition and breastfeeding behaviours in rural Bangladesh

Community health workers (CHWs) increasingly provide interpersonal counselling to childbearing women and their families to improve adoption of recommended maternal and child nutrition behaviours. Little is known about CHWs' first‐hand experiences garnering family support for improving maternal nutrition and breastfeeding practices in low‐resource settings. Using focused ethnography, we drew insights from the strategies that CHWs used to persuade influential family members to support recommendations on maternal diet, rest and breastfeeding in a behaviour change communication trial in rural Bangladesh. We interviewed 35 CHWs providing at‐home interpersonal counselling to pregnant women and their families in seven ‘Alive & Thrive’ intervention sites. In‐depth probing focused on how CHWs addressed lack of family support. Thematic coding based on Fisher's narrative paradigm revealed strategic use of three rhetorical principles by CHWs: ethos (credibility), pathos (emotion) and logos (logic). CHWs reported selectively targeting pregnant women, husbands and mothers‐in‐law based on their influence on behavioural adoption. Key motivators to support recommended behaviours were improved foetal growth and child intelligence. Improved maternal health was the least motivating outcome, even among mothers. Logically coherent messaging resonated well with husbands, while empathetic counselling was additionally required for mothers. Mothers‐in‐law were most intransigent, but were persuaded via emotional appeals. Persuasion on maternal rest was most effort‐intensive, resulting in contextually appealing but scientifically inaccurate messaging. Our study demonstrates that CHWs can offer important insights on context‐relevant, feasible strategies to improve family support and uptake of nutrition recommendations. It also identifies the need for focused CHW training and monitoring to address scientifically flawed counselling narratives.

Analysis of narratives of nutrition‐promoting, rural Bangladeshi community health workers (CHWs) suggest that behavior change communication (BCC) strategies to persuade husbands require logical and credible information (logos and ethos) to establish their support, while childbearing women may additionally require emotional appeals (pathos) to adopt promoted behaviors. Mothers‐in‐law, who traditionally influence multiple nutrition behaviors, can be persuaded via strategic use of ethos and pathos.

CHW communication strategies are useful in developing persuasive narratives that capture influential family members’ value beliefs and outcome expectancies and promote behavior change. However, additional programmatic efforts are needed to discourage use of unscientific narratives by CHWs.

A focused ethnographic study on the role of health and sustainability in food choice decisions

In the United States, typical dietary patterns are not necessarily healthy and sustainable. In order to shift diets, we need to provide support to individuals in a way that reflects what matters most to them. In this study, we aimed to identify the considerations that are most important to individuals regarding food-related decisions, and to determine how those considerations relate to specific foods, with a focus on health and environmental sustainability. In a sequential mixed-methods design, we first conducted 27 semi-structured interviews with participants in California and Nebraska. These interviews included a free-listing activity, where we used a technical construct of salience, Smith's S Index, to identify the considerations that were most important to our participants. We followed up with 20 of those participants to complete a pile-sorting survey, where participants sorted and rated 42 food items for price, taste, health, convenience, familiarity, and environmental impact. Our findings showed that the most salient considerations cited by our participants were price, health, taste, and time. There was consensus for how participants rated the foods for price, taste, convenience, and familiarity. However, there was only weak consensus for how participants rated the foods for health impact, and no consensus for how participants rated the foods for environmental impact. There was also disagreement on how to sort new plant-based products intended to replace or substitute meat and other animal-based foods. These findings have implications for how to communicate about healthy and sustainable diets. They highlight conflicting considerations, disagreement in classification of new products, and limited consensus for perceived health and environmental impact of foods, which present challenges to the achievement of diets that are healthy and environmentally sustainable in the United States.

Realities and challenges of breastfeeding policy in the context of HIV: a qualitative study on community perspectives on facilitators and barriers related to breastfeeding among HIV positive mothers in Baringo County, Kenya

Background

Although recent policies have sought to increase the rates of exclusive breastfeeding (EBF) and continued breastfeeding for HIV exposed infants, few programs have considered the multiple social and cultural barriers to the practice. Therefore, to generate evidence for exclusive and continued breastfeeding policies in Kenya, we examined community perspectives on the facilitators and barriers in adherence to EBF for the HIV positive mothers.

Methods

Qualitative research was conducted in Koibatek, a sub-County in Baringo County Kenya, in August 2014 among 205 respondents. A total of 14 focus group discussions (n = 177), 14 In-depth Interviews and 16 key informant interviews were conducted. Transcribed data was analyzed thematically. NVivo version 10.0 computer qualitative software program was used to manage and facilitate the analysis.

Results

Facilitators to exclusive breastfeeding were perceived to include counselling at the health facility, desire to have a healthy baby, use of antiretroviral drugs and health benefits associated with breastmilk. Barriers to EBF included poor dissemination of policies, knowledge gap, misinterpretation of EBF, inadequate counselling, attitude of mother and health workers due to fear of vertical HIV transmission, stigma related to misconception and misinformation that EBF is only compulsory for HIV positive mothers, stigma related to HIV and disclosure, social pressure, lack of male involvement, cultural practices and traditions, employment, food insecurity.

Conclusions

There are multiple facilitators and barriers of optimal breastfeeding that needs a holistic approach to interventions aimed at achieving elimination of mother to child transmission. Extension of infant feeding support in the context of HIV to the community while building on existing interventions such as the Baby Friendly Community Initiative is key to providing confidential support services for the additional needs faced by HIV positive mothers.

#EveryGenerationMatters: Intergenerational Perceptions of Infant Feeding Information and Communication Among African American Women

Objective: African American (AA) women look to their mother and maternal grandmother for parenting information and support; this intergenerational communication may reinforce or hinder breastfeeding practices. Rooted in Black Feminist Thought, this study's objective was to use an asset-based approach to explore infant feeding information shared across at least two generations of AA female family members. Materials and Methods: Fifteen family triads/dyads (N = 35 women), residing in Southeastern United States, participated in semistructured interviews in 2019. Qualitative data were analyzed using thematic analysis. Results: Infant feeding information shared across generations was characterized into six themes: Guidance, Practical assistance, Reservations, Affirmations, Observational learning, and Perceived undermining. Typically, conversations occurred in one of four reproductive life stages (preconception, prenatal, birth, and post-birth) of the youngest adult generation and may have been influenced by each family's feeding history ("One generation breastfed," "Two generations breastfed," and "Three generations breastfed"). Notably, with each additional generation of breastfeeding experience, perceived undermining and reservation reporting decreased. In addition, families reclaimed and reconnected with ancestral breastfeeding practices. Conclusions: Findings suggest that every generation matters to breastfeeding behaviors in AA families. Therefore, nuanced, family-centered approaches should build on assets within AA families to support them in meeting their feeding goals. Practitioners should recognize the importance of oral tradition as a mode of transmitting infant feeding information among AAs and understand the influence of family feeding history in intergenerational infant feeding communication. When working with AAs, practitioners must be flexible, respectful, supportive, and actively learning about an individual's beliefs and culture, creating space to reframe, without judgment or paternalism.

Capturing Changes in HIV-Infected Breastfeeding Mothers' Cognitive Processes from Before Delivery to 5 Months Postpartum: An Application of the Pile-Sorting Technique in Haiti

BACKGROUND

The cognitive processes involved in individuals' perceptions and prioritization of information, and how these change with experience or exposure to interventions, are rarely examined in the evaluation of nutrition interventions. Exclusive breastfeeding counseling is a common infant and young-child feeding intervention and is used to promote HIV-free survival in the prevention of mother-to-child transmission programs. However, it is often designed without adequate attention to the changes in mothers' perceptions over the course of their early breastfeeding experiences.

OBJECTIVE

The aim of this study was to identify HIV-infected breastfeeding mothers' cognitive structure (their organization of messages and ideas) of infant feeding messages and to characterize whether their cognitive organization of infant feeding messages changed from pregnancy through the first 5 mo postpartum.

METHODS

With the use of semistructured interviews and the cognitive mapping technique of pile sorting, we interviewed 30 HIV-infected breastfeeding mothers in Port-au-Prince, Haiti. We asked them to sort and rate 18 infant feeding messages 3 times (during pregnancy, 0- to 1-mo postpartum, and 3- to 5-mo postpartum). We analyzed their responses by using multidimensional scaling, property fitting, and partition analyses.

RESULTS

At all 3 visits, we found consistency in women's cognitive mapping of messages. For example, mothers consistently differentiated messages pertinent for exclusive breastfeeding compared with those that pertained to other practices. However, subtle variations in mothers' cognition over time were also evident, particularly at 0- to 1-mo postpartum, when message proximity was tightly clustered compared with the earlier and later periods.

CONCLUSIONS

We conclude that mothers share a common cognitive organization of infant feeding messages and that this organization changes over time. Attention to variations in cognition can support context-sensitive, patient-centered counseling by practitioners and improve the effectiveness of nutrition interventions. Pile sorting is an efficient, systematic technique to examine cognitive processes related to health and nutrition.

Who knows what: An exploration of the infant feeding message environment and intracultural differences in Port-au-Prince, Haiti

Worldwide, mothers with young children receive many messages about infant feeding. Some messages are generated by health providers and others by the households, communities, and social contexts in which women live. We aimed to determine the scope of infant feeding messages in urban Haiti and to examine intracultural differences in salience of these messages and their alignment with international guidelines. We applied the method of free listing with 13 health workers and 15 human immunodeficiency virus (HIV)-infected and 15 HIV-uninfected mothers with infants 0-6 months old at Groupe Haïtien d'Etude du Sarcome de Kaposi et des Infections Opportunistes in Port-au-Prince, Haiti. Participants listed all messages women receive about infant feeding and specifically about HIV and infant feeding. Message salience was determined by frequency of mention and recall order; messages were coded for key themes. For all groups, the World Health Organization infant feeding recommendations were salient, especially those related to exclusive breastfeeding. Messages across all groups focused on infant health outcomes, with less emphasis on maternal outcomes. Cultural beliefs were also elicited and showed higher salience for mothers than health workers, particularly for consequences of poor maternal nutrition. Health workers' free lists were poorly correlated to those of mothers, whereas those of mothers were highly correlated, regardless of HIV status. Inasmuch as many salient messages were culturally generated, and differences existed between mothers and health workers, we conclude that it is important for health workers to acknowledge the broader infant feeding message environment, and discrepancies within that environment, to address successes and failures in the messages reaching mothers, given potential consequences for mothers' breastfeeding behaviours.