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.

Promoting equity in breastfeeding through peer counseling: the US Breastfeeding Heritage and Pride program.

BACKGROUND: In the United States, Black and Hispanic mothers have lower breastfeeding rates compared with White mothers. To address breastfeeding inequities, the Breastfeeding Heritage and Pride program (BHP) provides breastfeeding support for predominately low-income minority mothers in Connecticut and Massachusetts. We described the process of designing BHP, the program model, and its impact on breastfeeding outcomes. METHODS: This BHP case study is based on in-depth interviews with BHP designers and implementers, peer counselors, and clients; a literature review of BHP impact evaluation studies; and a review of BHP materials. To guide the analysis and organize results, we used the Community Energy Balance Framework, an equity-oriented, multi-level framework for fostering healthy lifestyles. RESULTS: The Hispanic Health Council designed BHP to address barriers to breastfeeding identified through formative qualitative research with the Latino community, namely lack of role models, limited social support, embarrassment when breastfeeding in public, lack of breastfeeding knowledge, and a norm of formula feeding. According to the BHP model, clients receive education and support through in-person home and hospital visits supplemented by phone calls, beginning prenatally and continuing through one year postpartum. Counseling is delivered by peer counselors, women who have successfully breastfed, have similar cultural roots and life experiences as the clients they serve, and have completed intensive training on lactation management and communication skills. International Board Certified Lactation Consultants provide clinical guidance and ongoing training to peer counselors, as well as direct support to clients, if more specialized knowledge and clinical expertise is needed. Clients facing housing and food insecurity or other socio-economic obstacles that may negatively influence breastfeeding and health and well-being more broadly are connected to other health and social services needed to address their social determinants of health needs, including health care access and food and rent assistance programs. To continuously improve service delivery, BHP has a robust monitoring and evaluation system. In two randomized-controlled trials, BHP was shown to improve breastfeeding initiation and duration of any and exclusive breastfeeding. CONCLUSIONS: BHP highlights the importance of community-engaged formative research for informing breastfeeding program design. It also provides an evidence-based example of a program model that offers a continuum of breastfeeding support, considers cultural-contextual influences on breastfeeding and social determinants of health, and incorporates continuous quality improvement.

Inflammation and Stress Biomarkers Mediate the Association between Household Food Insecurity and Insulin Resistance among Latinos with Type 2 Diabetes.

BACKGROUND: Household food insecurity (HFI) is a stressor that is associated with type 2 diabetes (T2D). However, little is known about HFI and the insulin resistance (IR) underlying T2D, and the mechanisms involved. OBJECTIVE: We examined the cross-sectional association between HFI and IR among low-income Latinos with T2D and tested whether inflammation and stress hormones mediated this association. METHODS: HFI was measured with the 6-item US Household Food Security Survey module. IR was calculated from fasting plasma blood glucose and serum insulin. Inflammation was indicated by high-sensitivity C-reactive protein (hsCRP), and stress hormones included urinary cortisol, metanephrine, and normetanephrine. To test for an indirect effect of HFI on homeostasis model assessment of IR, a parallel multiple mediation model was run with biological markers that significantly differed between food security status-entered as mediators in the model. We used 95% bias-corrected bootstrap CIs, with 10,000 bootstrap samples, to assess the significance of the indirect effects. RESULTS: The 121 participants with T2D were primarily Puerto Rican (85.8%), aged mean = 60.7 y, and 74% were female. Eighty-two (68%) were classified as food insecure. Compared with food-secure individuals, food-insecure individuals had a significantly higher IR [mean difference (Δ) = 7.21, P = 0.001], insulin (Δ = 9.7, P = 0.019), glucose (Δ = 41, P < 0.001), hsCRP (Δ = 0.8, P = 0.008), cortisol (Δ = 21, P = 0.045), and total cholesterol (Δ = 29, P = 0.004). Groups did not differ on other lipids, metanephrine, normetanephrine, or A1c. The mediation model showed a significant direct effect of HFI on hsCRP (P = 0.020) and on cortisol (P = 0.011). There was a direct effect of cortisol (P = 0.013), hsCRP (P = 0.044), and HFI on IR (P = 0.015). The total combined indirect effect of HFI through cortisol and hsCRP indicated partial mediation. CONCLUSIONS: Among Latinos with T2D, HFI is associated with IR partially through inflammation and stress hormones. Interventions to ameliorate HFI and mitigate its effects on inflammation, stress, and IR are warranted. This trial was registered at clinicaltrials.gov as NCT01578096.

Evaluation of a culturally appropriate peer coaching program for smoking cessation.

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of a peer coaching smoking cessation program in a high-risk Medicaid population. DESIGN AND SAMPLE: In this manuscript, we present an evaluation of a pilot program. Participants (N = 138) were recruited out of a larger smoking cessation program administered statewide and funded by the Center for Medicare and Medicaid Services. The participant sample was diverse, with 52% self-identifying as White, 39% as Black, and 56% Latino ethnicity (any race). METHODS: Motivational interviewing techniques were utilized by peer coaches in clinical and community settings to achieve smoking cessation using face-to-face, telephone, and text/email encounters over a period of 6 months. RESULTS: There was a statistically significant increase in the number of participants who had quit smoking from program enrollment to discharge (5.1%-18.5%, p = 0.02). Number of peer coaching encounters predicted quitting in program participants. CONCLUSIONS: This study adds to the literature that community-based smoking cessation services led by peer coaches can be effective in a diverse, high-risk population.

Nutrition Facts Panel use is associated with diet quality and dietary patterns among Latinos with type 2 diabetes.

OBJECTIVE: The study aims were to (i) identify determinants of Nutrition Facts Panel (NFP) use and (ii) describe the association between NFP use and dietary intake among Latinos with type 2 diabetes. DESIGN: Baseline cross-sectional data from a clinical trial were used to assess the association between NFP use and dietary intake. Diet was measured using two methods: (i) a diet quality score (the Healthy Eating Index-2010) derived from a single 24 h recall and (ii) dietary pattern (exploratory factor analyses) from an FFQ. Multivariable logistic and non-parametric quantile regressions were conducted, as appropriate. Settings Hartford County, Connecticut, USA. SUBJECTS: Latino adults (n 203), ≥21 years of age, with diagnosed type 2 diabetes, glycosylated Hb≥7 %, and without medical conditions limiting physical activity. RESULTS: Participants' education level, diabetes-related knowledge and English speaking were positively associated with NFP use. At the higher percentiles of diet quality score, NFP use was significantly associated with higher diet quality. Similarly, NFP users were more likely to consume a 'healthy' dietary pattern (P=0·003) and less likely to consume a 'fried snack' pattern (P=0·048) compared with NFP non-users. CONCLUSIONS: The association between reported NFP use and diet quality was positive and significantly stronger among participants who reported consuming a healthier diet. While NFP use was associated with a healthier dietary pattern, not using NFP was associated with a less-healthy, fried snack pattern. Longitudinal studies are needed to understand whether improving NFP use could be an effective intervention to improve diet quality among Latinos with type 2 diabetes.

Psychological Distress Mediates the Association between Food Insecurity and Suboptimal Sleep Quality in Latinos with Type 2 Diabetes Mellitus.

BACKGROUND: Evidence increasingly indicates that poor sleep quality is a major public health concern. Household food insecurity (HFI) disproportionately affects Latinos and is a novel risk factor for poor sleep quality. Psychological distress may be a potential mechanism through which HFI affects sleep quality. Sleep, food insecurity, and distress are linked to type 2 diabetes mellitus. OBJECTIVES: We examined the relations between HFI, psychological distress, and sleep quality and tested whether psychological distress mediates the relation between HFI and sleep in people with diabetes mellitus. METHODS: Latinos with type 2 diabetes mellitus (n = 121) who completed baseline assessments for the CALMS-D (Community Health Workers Assisting Latinos Manage Stress and Diabetes) stress management intervention trial completed the US Household Food Security Survey, and measures of depressive symptoms [Personal Health Questionnaire Depression Scale (PHQ-8)], anxiety symptoms [Patient-Reported Outcomes Measurement Information System (PROMIS)-short], diabetes distress [Problem Areas in Diabetes Questionnaire (PAID-5)], and sleep quality [Pittsburgh Sleep Quality Index (PSQI)]. Psychological distress was operationalized with the PHQ-8, PROMIS-short, and PAID-5 scales. We used unadjusted and adjusted indirect effect tests with bias-corrected bootstrapped 95% CIs on 10,000 samples to test both relations between variables and potential mediation. RESULTS: Mean age was 61 y, 74% were women, and 67% were food insecure. Experiencing HFI was associated with both greater psychological distress and worse sleep quality (P < 0.05). Depressive symptoms (adjusted R2: 2.22, 95% CI: 1.27, 3.42), anxiety symptoms (adjusted R2: 1.70, 95% CI: 0.87, 2.85), and diabetes mellitus distress (adjusted R2: 0.60, 95% CI: 0.11, 1.32) each mediated the relation between HFI and worse sleep quality with and without adjustment for age, education, income, marital status, and employment status. CONCLUSIONS: Household food insecurity is a common and potent household stressor that is associated with suboptimal sleep quality through psychological distress. Efforts to improve food security and decrease psychological distress may yield improved sleep in this high-risk population. The CALMS-D stress management trial was registered at clinicaltrials.gov as NCT01578096.

Applying the Program Impact Pathways (PIP) evaluation framework to school-based healthy lifestyles programs: Workshop Evaluation Manual.

BACKGROUND: The Mondelez International Foundation hosted a seven country Healthy Lifestyles Program Evaluation Workshop in Granada, Spain, 13-14 September 2013. OBJECTIVE: To present the Workshop Evaluation Manual developed to support the work of the participants before, during and after the workshop. METHODS: The manual presents a brief introduction to program evaluation, a section on the Program Impact Pathways (PIP) framework using a USA school-based healthy lifestyle education program as an example, and a section on how to select PIP-informed indicators of the programs' impact on healthy lifestyles. The manual was refined using feedback received from the users before, during, and after the workshop. RESULTS: As illustrated in additional articles in this Supplement chronicling the workshop, all seven countries benefited from and were successful at using the PIP manual presented here to develop their own PIP analyses and identify their suite of indicators of the programs' impact on healthy lifestyles to improve the evaluation of their programs. CONCLUSION: The PIP analyses were central for systematically identifying strengths and weaknesses of each country's program, as well as the key program activities, processes and impact indicators that need to be monitored to improve them.

Night Eating Among Latinos With Diabetes: Exploring Associations With Heart Rate Variability, Eating Patterns, and Sleep.

OBJECTIVES: We explored associations between night eating and health outcomes in Latinos with type 2 diabetes. METHODS: Participants (n = 85) completed surveys, were measured for anthropometrics, provided blood samples, and wore Holter monitors for 24 hours to assess heart rate variability. RESULTS: Participant mean age was 60.0 years, hemoglobin A1c was 8.7%, most preferred Spanish (92%), and had less than a high school education (76%). Compared with their counterparts who denied night eating, night eaters had lower heart rate variability in the low (Cohen's d = -0.55; P = 0.04) and very-low-frequency bands (d = -0.54, P = 0.05), and reported more emotional eating (d = 0.52, P = 0.04), and poorer sleep quality (Cohen's h = 0.64). They did not differ on beverage intake or depressive symptoms. In regression that included depressive symptoms, associations between night eating and outcomes became nonsignificant. CONCLUSIONS AND IMPLICATIONS: Night eaters demonstrated worse health outcomes. If results are replicated, nutrition education for this population might focus on night eating.

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.

Egg contribution towards the diet of pregnant Latinas.

Proper nutrition during gestation is important to prevent adverse pregnancy outcomes. Eggs contain many important nutrients necessary for fetal development and human survival. Three focus groups were conducted with Latina women living in Connecticut to identify cultural beliefs toward egg consumption during pregnancy, traditional egg dishes, and methods of preparation. A cross-sectional study was then carried out with a sample of predominately Puerto Rican pregnant Latinas (N = 241) to identify the frequency of consumption of eggs and egg-containing dishes as well as methods of preparation using a tailored food frequency questionnaire modified for this population. Paired sample t-tests were used to examine if there were differences in weekly mean egg intake patterns between the year prior to the pregnancy and during pregnancy based on a Food Frequency Questionnaire. Women were categorized into eggs consumers and non-consumers if they consumed or did not consume eggs during the previous day based on 24-hour recall data. Independent-sample t-test and chi-square cross-tabulation analyses were conducted to examine the association between egg consumption and nutrient intake categories. Results showed that eggs and egg-containing traditional dishes are consumed by Latinas before and during pregnancy. Egg consumers had higher intakes of protein, fat, vitamin K, vitamin E, selenium, beta carotene, lutein and zeaxanthin, cholesterol, total polyunsaturated fatty acids, and docosahexaenoic acid. Eggs contribute significantly to the diet of pregnant Latinas.