Experiences of breastfeeding peer counseling among women with low incomes in the US: a qualitative evaluation.

BACKGROUND: Person-centered breastfeeding counseling is a key but often overlooked aspect of high-quality services. We explored women's experiences of the Breastfeeding Heritage and Pride™ program, an evidence-based breastfeeding peer counseling program serving women with low incomes in the United States. METHODS: This study was conducted through an equitable community-clinical-academic partnership and guided by the World Health Organization (WHO) quality of care framework for maternal and newborn health, which highlights three domains of positive experiences of care: effective communication; respect and dignity; and emotional support. In-depth interviews were conducted with a purposive sample of women participating in the Breastfeeding Heritage and Pride™ program. Women were asked to describe their experiences with the program including examples of when good quality counseling was or was not provided. Each interview was conducted in English or Spanish, audio-recorded, and transcribed verbatim. Data were analyzed using reflexive thematic analysis. Once themes were generated, they were organized according to the three care experience domains in the WHO quality of care framework. RESULTS: Twenty-eight in-depth interviews were conducted with a racially/ethnically and socio-economically diverse sample of women. Three themes described effective communication practices of peer counselors: tailoring communication to meet women's individual needs; offering comprehensive and honest information about infant feeding; and being timely, proactive, and responsive in all communications across the maternity care continuum. Two themes captured why women felt respected. First, peer counselors were respectful in their interactions with women; they were courteous, patient, and non-judgmental and respected women's infant feeding decisions. Second, peer counselors showed genuine interest in the well-being of women and their families, beyond breastfeeding. The key theme related to emotional support explored ways in which peer counselors offered encouragement to women, namely by affirming women's efforts to breastfeed and by providing reassurance that alleviated their worries about breastfeeding. These positive experiences of counseling were appreciated by women. CONCLUSIONS: Women described having and valuing positive experiences in their interactions with peer counselors. Efforts to expand access to high-quality, person-centered breastfeeding counseling should, as part of quality assurance, include women's feedback on their experiences of these services.

Shifting to virtual breastfeeding counseling for low-income women in the US during COVID-19: A partner-engaged multimethod evaluation of program adaptations.

Background: The Breastfeeding Heritage and Pride program (BHP) provides evidence-based breastfeeding peer counseling to low-income women. Due to the COVID-19 pandemic, BHP shifted from delivering in-person and virtual services to providing only virtual services. Program adaptations can impact implementation success, which could influence program effectiveness. We documented program adaptations and explored their impacts on implementation outcomes, guided by the Model for Adaptation Design and Impact. Methods: Through a community-clinical-academic partnership, we conducted in-depth interviews with 12 program implementers and peer counselors and conducted a rapid qualitative analysis. To efficiently capture information on adaptations over time, we collected and analyzed information from program meetings and extracted data from a program report. We then triangulated data from these multiple sources. Results: Peer counselors received training on virtual service delivery and increased supportive supervision. They recruited women via phone instead of in hospitals, which was viewed as feasible. In-person counseling visits at hospitals and clients' homes were replaced with phone and video calls. Examples of changes to the content delivered included breastfeeding education in the context of the pandemic such as the latest COVID-related infant feeding guidance, provision of face masks, and more assistance with social and economic challenges. Although peer counselors increasingly adopted video calls as a substitute for in-person visits, they emphasized that in-person visits were better for relationship building, helping with breastfeeding problems like latching, and identifying barriers to breastfeeding in the home environment like limited familial support. While adaptations were reactive in that they were made in response to the unanticipated COVID-19 pandemic, most were made with clear goals and reasons such as to ensure the safety of peer counselors and clients while maintaining service delivery. Most adaptations were made through a systematic process based on program implementers' expertise and best practices for peer counseling and were largely but not fully consistent with BHP's core functions. Discussion: BHP was able to shift to virtual service delivery for continued provision of breastfeeding counseling during the pandemic. Overall, virtual services worked well but were less optimal for several aspects of counseling. Evaluations of program effectiveness of virtual services are still needed.

A randomized, controlled trial of a stress management intervention for Latinos with type 2 diabetes delivered by community health workers: Outcomes for psychological wellbeing, glycemic control, and cortisol.

AIMS: To test the efficacy of a community health worker (CHW) delivered stress management (SM) intervention on psychosocial, glycemic, and cortisol outcomes among U.S. Latinos with type 2 diabetes. METHODS: A randomized, controlled trial compared CHW-delivered diabetes education (DE; one group session) to DE plus CHW-delivered SM (DE+SM; 8 group sessions). Psychosocial variables and urinary cortisol were measured at baseline and posttreatment. HbA1c was measured at baseline, posttreatment, and 3-month follow-up. RESULTS: In intent to treat analysis, compared to DE (n=46), DE+SM (n=61) showed significantly improved symptoms of depression, anxiety, and self-reported health status. There were no significant group effects for HbA1c, diabetes distress, or urinary cortisol. However, there was a dose response effect for HbA1c and diabetes distress; increasing attendance at SM sessions was associated with greater improvements in HbA1c and diabetes distress. CONCLUSIONS: This is the first randomized, controlled trial demonstrating that CHWs can improve psychological symptoms and self-reported health among Latinos with type 2 diabetes. Efforts to increase intervention attendance may improve HbA1c and diabetes distress.

A randomized trial assessing the efficacy of peer counseling on exclusive breastfeeding in a predominantly Latina low-income community.

OBJECTIVE: To assess the efficacy of peer counseling to promote exclusive breastfeeding (EBF) among low-income inner-city women in Hartford, Conn. DESIGN: Participants recruited prenatally were randomly assigned to either receive support for EBF from a peer counselor plus conventional breastfeeding support (peer counseling group [PC]) or only conventional breastfeeding support (control group [CG]) and followed through 3 months post partum. SETTING: Low-income predominantly Latina community. PARTICIPANTS: Expectant mothers, less than 32 weeks gestation and considering breastfeeding (N = 162). Intervention Exclusive breastfeeding peer counseling support offering 3 prenatal home visits, daily perinatal visits, 9 postpartum home visits, and telephone counseling as needed. MAIN OUTCOME MEASURES: Exclusive breastfeeding rates at hospital discharge, 1, 2, and 3 months post partum (n = 135). RESULTS: At hospital discharge, 24% in the CG compared with 9% in the PC had not initiated breastfeeding, with 56% and 41%, respectively, nonexclusively breastfeeding. At 3 months, 97% in the CG and 73% in the PC had not exclusively breastfed (relative risk [RR] = 1.33; 95% CI, 1.14-1.56) during the previous 24 hours. The likelihood of nonexclusive breastfeeding throughout the first 3 months was significantly higher for the CG than the PC (99% vs 79%; RR = 1.24; 95% CI, 1.09-1.41). Mothers in the CG were less likely than their PC counterparts to remain amenorrheic at 3 months (33% vs 52%; RR = 0.64; 95% CI, 0.43-0.95). The likelihood of having 1 or more diarrheal episode in infants was cut in half in the PC (18% vs 38%; RR = 2.15; 95% CI, 1.16-3.97). CONCLUSION: Well-structured, intensive breastfeeding support provided by hospital and community-based peer counselors is effective in improving exclusive breastfeeding rates among low-income, inner-city women in the United States.

Community health workers assisting Latinos manage stress and diabetes (CALMS-D): rationale, intervention design, implementation, and process outcomes.

Latinos have high rates of diabetes and mental distress, but lack appropriate services. A study was designed to compare enhanced standard diabetes care with enhanced standard care plus community health worker (CHW) delivered stress management for Latinos with type 2 diabetes. This paper reports intervention design and process outcomes. A formative process was used to develop and implement an eight-session, group stress management intervention. One hundred twenty-one participants completed baseline assessments; n = 107 attended diabetes education and were then randomized. Recruits reported high credibility and treatment expectancies. Treatment fidelity was high. Participants reported high treatment satisfaction and therapeutic alliance and their diabetes knowledge and affect improved over the short term. Retention and attendance at group sessions was challenging but successful relative to similar trials. This comprehensive and culturally sensitive stress management intervention, delivered by a well-trained CHW, was successfully implemented.

The Connecticut Center of Excellence for Eliminating Health Disparities among Latinos (CEHDL).

CEHDL's mission is to contribute to the elimination of health disparities among Latino(a)s through the formation of human resources, community-based research, and culturally appropriate outreach/extension. CEHDL is structured as a consortium led by the University of Connecticut (UConn) in close partnership with the Hispanic Health Council (HHC), a community health agency located in inner-city Hartford, and Hartford Hospital (HH). Demonstrating best practice and culturally skilled, evidence-based outreach, and bringing the best of academic, community, and health institutions to socioeconomically disadvantaged communities, CEHDL fosters scientific-community interactions and supports training of undergraduate, graduate, and medical students. Building capacity in other agencies is one method through which CEDHDL seeks to accomplish its goals. Thus far, CEHDL has made substantial progress demonstrating that interdisciplinary community-academic-hospital partnerships are essential for addressing health inequities in our country.