Health Care for Women International, 36:711–729, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0739-9332 print / 1096-4665 online DOI: 10.1080/07399332.2014.900060

Engaging Community With Promotores de Salud to Support Infant Nutrition and Breastfeeding Among Latinas Residing in Los Angeles County: Salud con Hyland’s BRITT RIOS-ELLIS Long Beach Center for Latino Community Health, Evaluation and Leadership Training, National Council of La Raza; and Department of Health Science, California State University Long Beach, Long Beach, California, USA

SELENA T. NGUYEN-RODRIGUEZ Department of Health Science, California State University Long Beach, Long Beach, California, USA

LILIA ESPINOZA Department of Health Science, California State University Fullerton, Fullerton, California, USA

GINO GALVEZ and MELAWHY GARCIA-VEGA Long Beach Center for Latino Community Health, Evaluation and Leadership Training, National Council of La Raza, California State University Long Beach, Long Beach, California, USA

The Salud con Hyland’s Project: Comienzo Saludable, Familia Sana [Health With Hyland’s Project: Healthy Start, Healthy Family],was developed to provide education and support to Latina mothers regarding healthy infant feeding practices and maternal health. The promotora-delivered intervention was comprised of two charlas (educational sessions) and a supplemental, culturally and linguistically relevant infant feeding and care rolling calendar. Results indicate that the intervention increased intention to breastfeed exclusively, as well as to delay infant initiation of solids by 5 to 6 months. Qualitative feedback identified barriers to maternal and

Received 15 October 2012; accepted 27 February 2014. Address correspondence to Gino Galvez, Long Beach Center for Latino Community Health, Evaluation, and Leadership Training, National Council of La Raza, California State University Long Beach, 6300 State University Drive, Suite 125, Long Beach, CA 90815, USA. E-mail: [email protected] 711

712

B. Rios-Ellis et al.

child health education as well as highlighted several benefits of the intervention. For women throughout the world, infant feeding education provides invaluable information to expecting mothers during prenatal care. Although this information is usually integrated into the prenatal care experience in many 1 countries, Hispanic women in the United States initiate prenatal care at a lower rate than non-Hispanic Whites, possibly due to limited access to health care as well as Spanish-speaking providers (Bromley, Nunes, & Phipps, 2012; Johnson-Kozlow, 2010; Yoon, Grumbach, & Bindman, 2004). To address this issue, the authors conducted a study of a promotores de salud (community health worker)-led health education program supplemented by a calendar with maternal and infant health information. We focused our research on Los Angeles, California, where a high proportion of Latinas with limited access to health care and resources reside. We found positive outcomes associated with participation in the program and high use and satisfaction with the calendar. Utilizing promotores de salud and calendars may be an effective approach to provide culturally relevant information to increase positive maternal and infant health outcomes for groups with limited access to health care services, information, and resources. Researchers have shown that Latinas engage in preventive health measures when communication between patient and physician is enhanced through the use of culturally and linguistically competent professional interpreters (Karliner, Jacobs, Chen, & Mutha, 2007; Shaffer, 2002). Cultural values, such as familismo (e.g., importance of family), have been shown by researchers to positively mediate health outcomes, participation in health services, and treatment adherence, highlighting the importance of cultural, not just linguistic, competence in health care delivery (Austin, Smith, Gianini, & Campos-Melady, 2013; Chong, 2002). Breast milk is a sufficient source of nutrients for infant development and should be the only nutrient source until a minimum age of 6 months (Eidelman et al., 2012; U.S. Department of Health and Human Services, 2011). Less acculturated Latinas are more likely to report higher prevalence rates of breastfeeding initiation, duration, and exclusive breastfeeding than highly acculturated Latinas (Ahluwalia, D’Angelo, Morrow, & McDonald, 2012; Gibson-Davis & Brooks-Gunn, 2006). Furthermore, low-income Latina mothers are likely to initiate combination feeding (both breast milk and formula) early in the infant’s life due to the conflicting messages that they receive from various sources, inconsistent knowledge and attitudes of physicians, and influence of media/marketing that often includes formula 1

The terms “Hispanic” and “Latino” are used interchangeably in this article. These terms broadly refer to persons of Mexican, Puerto Rican, Cuban, Central and South American, Dominican, Spanish, and other Hispanic descent; they may be of any race.

Engaging With Promotores de Salud

713

samples distributed by health professionals in hospital/clinic settings (Brown & Peuchaud, 2008; Bunik et al., 2006; Freed, Clark, Cefalo, & Sorenson, 1995; Holmes, Auinger, & Howard, 2011; Howard, Howard, & Weitzman, 1994; Williams & Hammer, 1995). Among Latinas, there are other factors that play a role in breastfeeding practices. For example, some researchers have found that relatives encourage mothers to use supplements for babies who cry excessively or who are not chubby (Bunik et al., 2006; Rios-Ellis, Enguidanos, Espinoza-Ferrell, & Sanchez, 2000). Additionally, researchers suggest that there are beliefs that a mother’s negative feelings are detrimental to breast milk as exemplified by Latina mothers’ perceptions that sadness and anger can spoil breast milk and lead to infant illness. Furthermore, pain or embarrassment associated with breastfeeding, strong beliefs of modesty, changes in the breasts, and dietary restrictions were all shown to be common barriers to breastfeeding among Latinas (Bunik et al., 2006). These findings support the need for education and encouragement of proper nutrition and breastfeeding practices among Latino parents during the pre- and post-natal periods. Importantly, the key message for parents is to teach them when to introduce certain foods to infants’ diets, with particular care taken during the first year to avoid potential harmful reactions including food allergies (Eidelman et al., 2012; Greer, Sicherer, & Burks, 2008; Tarini, Carroll, Sox, & Christakis, 2006).

Culturally Competent Strategies to Promote Breastfeeding and Child Nutrition For interventions to be effective, they must transcend language, and address specific cultural issues that may impede access and adherence to recommendations. A feasible method to provide nutritional information and proper introduction of liquids and solid foods in a culturally and linguistically relevant way is through health education materials targeting Latinas, such as calendars (Alcalay, Ghee, & Scrimshaw, 1993). A calendar approach has been shown to be a useful tool for knowledge acquisition, behavioral reinforcement, and to track infant development among Latinos. Calendars can be developed to incorporate combined methods through pictures and information as well as facilitate an active participant role by using stickers to track key maternal behaviors, such as breastfeeding initiation and duration, and infant developmental milestones, such as smiling and rolling over (de Nuncio et al., 2003). Calendars may be particularly useful among Latinos with lower literacy levels. Faruque and colleagues found that using a calendar approach helped illiterate mothers to become more aware of health conditions and motivated them to comply with positive health practices (Faruque, Hamadani,

714

B. Rios-Ellis et al.

Hoque, & Mahalanabis, 1998). To date, one study has incorporated a calendar approach in the form of a one-page handout to educate Latinas on breastfeeding guidelines (Rodriguez, Beverly, Correa-Matos, & Santibanez, 2008). The authors of the present study build upon prior research and evaluate a community-based, promotores-led health education program supplemented by a 13-month rolling date, Spanish-language calendar for maternal and infant health promotion among Latinas with limited access to health care services and information. Widely used throughout the world, the promotores (community health workers) model is an effective strategy in increasing access to care among underserved populations (Swider, 2002) and has been associated with increases in health-related knowledge and behavior change among ethnic minority women (Andrews, Felton, Wewers, & Heath, 2004; Balcazar et al., 2011). Promotores are community health advisors or peer educators hired from their respective communities who help advocate for and educate community members (Rosenthal et al., 2010; WestRasmus, Pineda-Reyes, Tamez, & Westfall, 2012). Promotores can “transcend cultural barriers” (pp. 55–56) thereby making it possible to buttress culturally specific health reinforcing beliefs and behaviors as well as to facilitate resolution of myths and misunderstandings to increase knowledge within their respective communities (McCloskey, 2009). Promotores-based interventions have been well established in the literature as a tool to increase healthy behaviors while facilitating empowerment within underserved populations to prevent adverse health outcomes (Anders, Balcazar, & Paez, 2006; Balcazar et al., 2011; Rosenthal et al., 2010; Swider, 2002; WestRasmus et al., 2012). In a predominantly Latina population, peer counselors were able to promote improvements in exclusive breastfeeding rates as well as decrease rates of breastfeeding cessation within 1–3 months (Anderson, Damio, Young, Chapman, & Perez-Escamilla, 2005; Chapman, Damio, Young, & PerezEscamilla, 2004). Promotoras have also been shown to improve healthseeking behaviors and infant feeding practices (P´erez-Escamilla, Hromi´ Fiedler, Vega-Lopez, Berm´udez-Mill´an, & Segura-P´erez, 2008). Further, a promotora-based outreach and education program with low-income pregnant Latina women found positive outcomes such as linking women to perinatal health care, decreasing barriers to prenatal care, and achieving higher birth weights and lower preterm birth rates compared with rates of Latinas that did not participate in the program (Bill, Hock-Long, Mesure, Bryer, & Zambrano, 2009). Using peer educators, a researcher found that mothers who were randomly assigned to an intervention group were more confident about following health professionals’ recommendations for infant feeding at 18 months when compared with controls (Gibson, 2007). These mothers also actively discouraged bottle feeding to the extent that it might jeopardize healthy feeding practices (Gibson, 2007).

Engaging With Promotores de Salud

715

Purpose Few have investigated whether interventions using both promotores and other educational tools (e.g., calendar and accompanying stickers to track development and positive behaviors) can reinforce healthy behaviors and increase infant nutrition knowledge and self-health advocacy among Latina mothers. The Salud con Hyland’s Project: Comienzo Saludable, Familia Sana [Health With Hyland’s Project: Healthy Start, Healthy Family] was designed to provide prenatal and postnatal Los Angeles County Latina residents access to culturally and linguistically relevant maternal–infant health education and improve health advocacy during provider encounters. A secondary purpose of the project was to describe the influence of promotoras-based education with this population of underserved Latinas. Our aim in this article is to describe a shorter community-based version of a previous experimentally designed intervention to determine whether this modified version would generalize to this particular population, as intense, longer-duration programs are typically not convenient and are often inaccessible to Spanish-speaking Latinas in the United States.

METHODS Recruitment Inclusion criteria for participation follow: (a) Spanish language-dominant Latina women; (b) minimum 18 years of age; and (c) no less than 9 weeks pregnant; thus, at follow-up, women may have given birth, but could have still been in their final 2 months of pregnancy. Participants were recruited from a health clinic in East Los Angeles and two health clinics in Long Beach, CA. Flyers were disseminated and placed in the clinics. A team of four promotoras approached women who met the eligibility requirements at different strategic periods such as during clinic baby showers, prenatal classes, and on days in which the obstetrician, nurse practitioner, or midwife was scheduled to see patients. For women who met the inclusion criteria, a brief description of the study was read to each potential participant by the promotora, and interested women provided verbal consent. Recruitment and data collection methods were approved by the Institutional Review Board at California State University Long Beach.

Intervention Procedures. Participants received two promotora-delivered charlas (educational sessions), conducted 2 months apart during either a clinic or in-home visit. Location of the visit (clinic or in-home) was based upon participant preference/request. Thus, participants may have had both visits at home (i.e., home), both visits at the clinic (i.e., clinic) or a mixture of clinic

716

B. Rios-Ellis et al.

and home-based visits (i.e., mixed). Clinic visits were abbreviated sessions (approximately 15–30 minutes), whereas in-home visits entailed longer sessions (approximately 60 minutes). Participants also received a supplemental Spanish-language rolling infant–maternal care calendar designed to accomplish the following: (a) provide culturally and linguistically relevant and literacy level specific maternal health and infant development information to monolingual Spanish-speaking women; and (b) reinforce positive health behaviors, facilitate tracking of key infant developmental milestones, and reinforce positive Latino cultural assets such as familismo through positive images, health education information, and culturally relevant messaging. Instructions regarding use of the calendar (e.g., starting the calendar at birth to signify infant’s first month, using stickers to track significant milestones) were provided upon distribution. Infant-related incentives, such as diaper bags, were provided to all participants. Promotora involvement and training. The promotoras were trained extensively regarding project procedures and maternal–child health educational content. Promotoras assisted in the development of outreach materials and instrumentation and, prior to initiating recruitment and intervention delivery, were tested on their knowledge of the intervention content and rehearsed message delivery to ensure they were properly and thoroughly prepared as health educators. Content. Infant development, the importance of breastfeeding exclusivity, including rationale and breastfeeding techniques to support continued breastfeeding, age-appropriate introduction of liquids and solids, maternal health and need for emotional and social support, the importance of vaccination and adherence to scheduled pediatric visits, and the birthing process were topics covered in the first charla. The second charla included education and reinforcement of healthy and recommended age-appropriate infant feeding (e.g., breastfeeding techniques, exclusivity and timing of introduction to solids) and care, infant development, issues with childproofing and safety, maternal health issues including mental health status, and recognition and response to basic infant health issues and illnesses such as fever and diaper rash. Specific focus was placed on the importance of maternal selfcare, while emphasizing healthy infant feeding (particularly breastfeeding exclusivity and duration) and care during a physically challenging period. The rolling calendar was designed to reinforce healthy behavior through inclusion of pertinent information regarding infant development and major milestones; methods to track infant’s progress; what to expect at well baby visits; vaccination schedule; and extensive explanation regarding infant feeding and maternal–infant care. Furthermore, the calendar included a set of stickers to mark key developmental milestones in infancy and to reinforce positive feeding behaviors (e.g., first smile, rolling over, time breastfeeding) to accommodate and encourage Latina mothers with lower literacy levels in tracking infant development. The artwork depicted Latino cultural traditions

Engaging With Promotores de Salud

717

and family involvement to reflect familismo and encourage family members’ involvement in infant feeding and care. All questionnaires, informed consent forms, curricula, and other documents used with the participants were developed in Spanish by a bilingual/bicultural team that included the promotoras. A baseline survey was administered on the day of, and prior to, the first charla, and post-charla surveys were administered immediately following both charlas. Baseline and post-charla surveys were either self- or verbally administered by the promotoras, depending on participant preference. A follow-up telephone or in-home survey was conducted by the promotoras approximately 2 months after completion of the second charla.

Measures Demographic characteristics and prenatal care use were assessed at baseline. Single items with ordinal response options were used to assess the following: anticipated feeding method; breastfeeding initiation, exclusivity, and duration; and planned age to introduce various solid foods common in the Latino infant’s diet. A sum score was calculated to measure knowledge of foods to avoid introducing in infant’s first year, using a check-all-that-apply response format; this included seven items such as shellfish, cow’s milk, and citrus fruits. Participants were also asked whether they intended to or had prepared a list of questions for their physicians prior to their doctor visits. Outcome variables were measured at baseline, post-charlas, and follow-up. Calendar use and utility were assessed at follow-up; both were measured by a single item. All measures were developed specifically for evaluation of this project with feedback and participation from the promotoras.

Postintervention Qualitative Evaluation Two group interviews were conducted by trained bilingual/bicultural staff with the participants to garner participant reactions to the intervention; these sessions occurred within 60 days after completing the follow-up survey. Those who had completed all program components were recruited by the promotoras and invited to participate in one of two group interviews held at a promotora’s home due to proximity with participants’ residences. Confidentiality was ensured by using aliases during the interviews and the nontranscription of personal identifying information. The aim of the group interviews was to garner additional contextual information relevant to the participants’ lives, as well as to gather data regarding their perspectives of the intervention. To supplement the quantitative findings, the interview guide was designed to elicit discussion on various topics that included barriers to maternal–child health education, program and educational materials’ impact

718

B. Rios-Ellis et al.

and efficacy, project logistics, and future directions. Additional questions were asked as the conversation warranted subsequent lines of inquiry (Patton, 2001). Discussions were tape-recorded and notes were taken by project staff, and recordings were transcribed verbatim and reviewed by additional staff for accuracy. Any disagreements in the transcriptions were discussed and resolved by the project staff.

Statistical Analyses Descriptive analyses were conducted to summarize sample characteristics. The outcomes of interest were anticipated feeding method (nominal); anticipated length of breastfeeding time (ordinal); planned age for introduction of solid foods into an infant’s diet (ordinal); foods to avoid feeding an infant during the first year (continuous); whether or not a participant prepares a list of questions to ask her doctor (dichotomous); and calendar use and evaluation. Participants with missing information on these items were excluded from the relevant analyses. To assess baseline to post-charla and follow-up changes, the Wilcoxon signed rank test was used for ordinal variables, a one-way ANOVA was used for continuous variables, and the paired-samples McNemar’s chi-square test was used for dichotomous data and to evaluate differential attrition among groups. Supplemental exploratory analyses were conducted to examine if changes were influenced by the location of the charlas (i.e., home, clinic, mixed). Transcripts of the group interviews were read and coded for themes and categories using basic content analysis techniques.

RESULTS Baseline Sample Characteristics and Attrition Demographic characteristics of the 243 participants are found in Table 1. Of the 243 participants, 171 women participated in the second charla (70.4%), and 140 participated in the follow-up survey (57.6%). Table 2 shows frequencies and percentages for anticipated feeding method, breastfeeding duration, and planned age of introduction to solids. Furthermore, as an indication of patient advocacy skills participants were queried regarding their intent to prepare, and actual development of, a list to facilitate physician response to questions and concerns across time points.

Quantitative Findings At baseline, combination feeding (i.e., breastfeeding and formula use) was the reported primary current or anticipated feeding method. There was a significant change in anticipated feeding method after the first charla (z = –5.91,

Engaging With Promotores de Salud

719

TABLE 1 Baseline Demographics, N = 243 Item Age (years) Foreign-born Years in U.S. (if > 1 year)a In the U.S. < 1 year Preferred language Spanish English Both Married / living with partner Number of children Number of weeks pregnant Receiving prenatal care Education No formal schooling Elementary to some high school High school graduate / GED Some college to graduate work

n

%

215

88.5

16

7.7

198 6 38 188

81.8 2.5 15.7 77.4

224

98.7

1 82 89 67

0.4 34.3 37.2 28.0

Mean

SD

Range

27.80

6.04

18–44

8.91

5.84

1.39 27.42

1.41 8.15

0–8 9–39

p < .001), wherein greater proportions of women intended to breastfeed exclusively. Supplemental analyses indicated that this change was significant only for the home (z = –4.45, p < .001) and mixed (z = –2.67, p = .008) charla location groups. The majority of participants planned to breastfeed TABLE 2 Frequencies and Percentages for Anticipated Feeding Method, Breastfeeding Duration, Age of Introduction to Solids, and Preparation of List for Doctor Visits Across Data Collection Time Points

Item

Baseline n = 243 n (%)

Anticipated feeding method Only breastfeed 79 (35.7) Only formula 5 (2.3) Both 137 (62.0) Planned breastfeeding duration∗ 1–3 months 14 (7.3) 4–5 months 16 (8.4) 6–9 months 48 (25.1) 10–12 months 14 (7.3) 1 year 68 (35.6) 1+ year 31 (16.2) Planned age of introduction to solids∗ 2–4 months 19 (10.4) 5–6 months 129 (70.5) 7–12 months 29 (15.8) After 1 year 6 (3.3) Prepare list for doctor visits Prepared list 88 (45.4) Intention to prepare list –

Post-charla 1 Post-charla 2 Follow-up n = 243 n = 171 n = 140 n (%) n (%) n (%) 119 (59.2) 1 (0.5) 81 (40.3)

– – – (1.3) (2.0) (19.5) (15.4) (49.0) (12.8)

– – –

5 (2.6) 17 (8.9) 37 (19.4) 21 (11.0) 79 (41.4) 32 (16.8)

2 3 29 23 73 19

4 2 23 1 75 12

(3.4) (1.7) (19.7) (0.9) (64.1) (10.3)

4 (2.0) 177 (86.3) 13 (6.3) 11 (5.4)

4 (2.4) 120 (72.3) 39 (23.5) 3 (1.8)

13 (9.6) 107 (78.7) 13 (9.6) 3 (2.2)

– 146 (95.4)

132 (79.0) –

84 (60.9) 71 (91.0)

720

B. Rios-Ellis et al.

for 1 year at baseline. Results indicate a statistically significant change across all time points, wherein greater proportions of women reported planning to breastfeed for longer durations. Supplemental analyses specifically indicated that for the group that received both charlas at home there was a significant change post-charla 2 (z = –2.71, p = .007), showing a shift toward more women intending to breastfeed for longer durations. These significant shifts toward anticipation of longer breastfeeding duration were also found for this group post-charla 2 (z = –2.61, p = .009) and at follow-up (z = –2.42, p = .016). At the initial assessment, the age at which most participants indicated that they would introduce foods other than breast milk or formula was 5 to 6 months. Overall, there was a significant change in planned age to introduce solids post-charla 2 (z = –2.08, p = .037), indicating planned introduction at later ages. Mean baseline score for foods to avoid during infant’s first year was 3.39 (SD = 1.88, with a possible range from 0 to 7). Analyses indicate an increase in knowledge regarding foods not to introduce in the infant’s first year (F 3,714 = 124.20, p < .001). Supplemental analyses indicate that the pattern held for all groups (p < .001), regardless of charla location. Regarding intentions to prepare a list for doctor visits, there were no significant changes across time points. Prior to the intervention, 45.4% of the entire sample reported making a list of questions for the doctor. After the second charla and at follow-up, there were significant increases in the proportion of participants indicating they had prepared a list for their doctors compared with baseline (70.9%, p < .001 and 60.9%, p = .01, respectively). Supplemental analyses revealed that the change from baseline to post-charla 2 was significant for all three groups (p < .001); however, between baseline and follow-up, this change was significant only for the home group (p < .001). At follow-up, 62.3% of women reported using the calendar, with 4.3% reporting the calendar was somewhat useful and 93.5% reporting that it was very useful. Supplemental analyses indicated no significant differences in usefulness of the calendar by charla location. At follow-up, a total of 140 women reported their pregnancy status. The majority of women, 68.6% (n = 96) reported having given birth at that point. Of those who had given birth, 94 responded to a question that asked whether they were currently breastfeeding. Nearly three-quarters of new mothers (74.5%; n = 70) reported that they were currently breastfeeding. Of the 31.4% (n = 44) who had not yet given birth at follow-up, 100% reported planning to breastfeed. Last, the effect of the intervention may have been attenuated by time at follow-up given that the frequency of “2–4 months planned age of introduction of solids” responses dropped during the intervention (2%–2.4%) compared with baseline (10.4%) but increased at follow-up (9.6%). This may have been a result of the smaller sample size at follow-up (compared with baseline) and the lack of booster sessions.

Engaging With Promotores de Salud

721

Qualitative Findings Two group interviews were attended by a total of nine mothers. Six attended the first group interview and three attended the second, two of whom were accompanied by their male partners. Among these participants, the average age was 27.7 (SD = 4.9). Participants were of Mexican origin, with most reporting being born in Mexico and two reporting being born in the United States. Five participants had given birth and four were still pregnant at the time of the group interviews. Participants had primarily received the charlas in the home (55.6%), followed by the mixed (clinic and home) visits (22.2%) and clinic only visits (22.2%). Two different sets of promotoras attended and hosted each group interview. Most of the dialogue occurred in Spanish. Participants reported various barriers (i.e., institutional, personal, structural) to receiving maternal and child health education. The major barriers included immigration, fear of reprisal for receiving subsidized services, or deportation. These barriers combined with lack of understanding of the health care system, little experience engaging in regular preventive visits in their home countries, embarrassment, lack of trust in authority figures, and language, represented a formidable combination of obstacles to acquiring health information and services. For example, one participant said, “Language [is a barrier], sometimes medical terms, I know a little bit of English, but when it’s medical terms, I don’t know how to explain myself with doctors.” Participants reported positive gains as a result of participating in the program. They reported a greater comprehension of the importance of breastfeeding and adherence to age-appropriate infant feeding guidelines, and they actively shared the information gained in their respective environments. They also stated that they were more confident, regularly made lists of questions to ask their doctors, had a greater understanding of their rights as patients, and were willing to change physicians when their needs were not met, as one participant said: It really motivated me right from the beginning to ask questions. In the beginning I had a doctor who would get upset with me when I would ask questions. So I made the decision to change doctors and my new doctor always answers my questions and gives me information even before I ask for it.

The participants found several facets of the program to be particularly useful, including the curriculum, the calendar, the stickers, and the promotoras themselves. Additionally, some participants reported an increase in the understanding of post-partum depression and where to go to get help. For example, one participant said, “She [promotora] helped us and told us where we could go for services. She told us to make sure that we asked any questions we had before or after pregnancy.”

722

B. Rios-Ellis et al.

Participants stated that the information in the calendar and the charla had helped them communicate more effectively with their physicians regarding the importance of feeding choices and developmental milestones. When queried as to calendar placement in the home, the women reported that the most frequent location was over the basinet, crib, or changing table, or on the refrigerator, thus indicating a place of relevance in the home that facilitated frequent visual contact. When asked about their preference of charla setting, the participants overwhelmingly chose the home setting as being the ideal location. Participants who had received the charla in the clinic setting said that there were too many distractions and the space was too small and noisy. Additionally, they reported feeling rushed, being interrupted when called in to see the doctor, and having to divide their attention between tending to their children and the charla. Reactions to the content of the charla were positive. Several participants recommended an increase in the numbers and frequency of the charlas and discussed the positive differences the promotoras themselves had made in their pregnancies and postpartum experiences, and held their respective promotora in high esteem. Both participants and promotoras reported that the promotora was actually serving in a type of madrina (godmother) role in the lives of the infants born during the project. Several of the promotoras reported visiting the new mothers at the hospital and at home, even when project visits or charlas were not scheduled. One participant said, “You can really tell that they want to help people. The promotoras aren’t just doing their jobs. It’s the way they want to help the community. You can see the passion that they have for what they are doing.” The involvement of male partners in the charla as well as the group interviews supported male involvement in female-centered interventions. While it was not an explicit aim to involve male partners in the group interviews, the two males reported having a better understanding of the perinatal process, comprehension and compassion regarding the physiological changes their female partners had been undergoing, and an increased willingness to talk about the pregnancy and their future offspring, as well as attend charlas and doctor visits. Additionally, both males reported that the charlas had improved their relationships with their partners and opened the doors for additional communication.

DISCUSSION Prior to the first charla, both breastfeeding and formula use was the primary anticipated feeding method. Post charla, however, exclusive breastfeeding was the primary intended method reported. Regardless of data collection time point, participants stated that they would breastfeed for 1

Engaging With Promotores de Salud

723

year. Since information on feeding method was only collected at baseline and post first charla, it is unknown if intentions to supplement or actual formula supplementation occurred over time. There was also a statistically significant change in anticipated breastfeeding duration across all time points, indicating a significant shift toward intention to breastfeed for longer durations. Regardless of the data collection point, 5 to 6 months was the preferred age of food introduction to an infant’s diet. In addition, there was a significant shift toward older ages such as 5 to 6 months and 7 to 12 months as the appropriate time for introduction of solids, which was in contrast with the charla content (i.e., 2009 American Academy of Pediatrics recommendation of introduction of solid foods between the ages of 4 and 6 months). Prior to the first charla, participants appeared to be familiar with avoiding some foods (e.g., fish/shellfish) during their infant’s first year. After the first charla, the number of food items to avoid during their infant’s first year increased significantly and retention of knowledge was demonstrated by most participants. The staging of food introduction and the avoidance of key foods known to cause allergic reactions has been documented in the literature (Eidelman et al., 2012; Noimark & Cox, 2008). Findings indicate that the intention to breastfeed for at least 1 year, as well as knowledge gained regarding age-appropriate introduction of highly allergenic foods, may have a potentially positive impact on infant health and decreased health care costs due to allergic reactions and asthma (Xu, Dailey, Freeman, Curbow, & Talbott, 2009). It should be noted, however, that there is controversy as to whether or not breastfeeding and later introduction of solids is protective against allergies (Friedman & Zeiger, 2005; Mihrshahi et al., 2007). Other noteworthy quantitative findings suggest that participants perceived the home setting as the best place for the educational sessions. Supplemental analyses exploring outcomes by place of the education sessions (at home vs. in the clinic) revealed that changes in anticipated breastfeeding method and duration, as well as using the calendar, seemed to be more consistent for those participants who received the charlas at home. It is possible that this difference is due to the fact that breastfeeding may be perceived as an intimate topic, which may have resonated better with participants in the comfort of their own homes. Additionally, noise, interruptions, and competing attention demands of the clinic setting may render it a suboptimal learning environment for charla delivery. Findings support the use of home-based community programs to increase breastfeeding duration among Latinas (Morrow et al., 1999). At pre-charla, the majority did not report preparing a list of questions to ask their doctors. At follow-up, the majority of participants intended to make, and reported having made, lists of questions and concerns to facilitate physician response and patient–physician communication. Multiple rationales support the preparation of a list of questions prior to doctors’ visits.

724

B. Rios-Ellis et al.

First, participants reported being intimidated by their physicians and often becoming nervous before or during their doctors’ visits, which often resulted in forgetfulness regarding their concerns or questions. Furthermore, participants’ physicians are often monolingual English speakers, and participants perceived them as rushed with little time to address patient needs. Participants also refrained from asking questions because physicians are perceived as authority figures who should be respected and not queried, regardless of whether or not the patient understood medical directions. By advising women to develop a list of questions and concerns, participants became better health advocates for themselves and their infants. Teaching patients to engage their health care providers in active dialogue regarding their concerns will do a great deal to overcome the language and cultural barriers experienced by many immigrant patients. Key steps to health advocacy for Latinas are integral to our nation’s health, particularly as the role of women and mothers as family health decisionmakers is highly evident within Hispanic cultures. The significant use of the calendar and the positive perception of its utility lend support to the notion that calendars may be a culturally acceptable strategy for knowledge acquisition and behavioral reinforcement in Latino populations. Although expectant mothers are frequently given journals to record their reactions to birth and infant development, they often go unused due to literacy level and writing skills needed, as well as required completion time (Rodriguez et al., 2008). The development of a calendar with simple illustrations and short explanations regarding healthy behaviors and infant development supplemented by stickers depicting an infant smiling or clapping for the first time, may facilitate maternal monitoring of infant growth and development (Alcalay et al., 1993; Faruque et al., 1998). This monitoring is not only useful for a mother’s record keeping, but also it can help facilitate early detection and intervention with infant development issues when needed.

Limitations, Future Recommendations, and Implications There are several limitations to consider. Of the 243 first charla attendees, only 140 participants continued at follow-up, which may have impacted project findings. Results may be biased if those who did not continue were less likely to engage in breastfeeding exclusivity, to breastfeed for at least a year, delay introduction of solids, or prepare lists to take with them to doctor visits. Furthermore, those mothers who were more secure in their environments may have been the ones who completed the intervention. Unfortunately, attrition of immigrants in research settings, particularly in states along the U.S.–Mexican border is becoming a current trend. Ainsworth reported over 50% attrition in intervention-related research with

Engaging With Promotores de Salud

725

underserved Latino populations in the identical timeframe of this intervention (Ainsworth, 2012). In our study, the economic recession, in combination with the passage of several anti-immigrant initiatives and overall anti-immigrant sentiment, contributed significantly to our ability to engage participants in the second charla and conduct the follow-up survey. Several telephones had been disconnected and the promotoras were told that many of the participants had returned to Mexico or moved out of state. It should be noted that some surveys were completed verbally, perhaps influencing participant responses, and thus potential social desirability bias cannot be eliminated. The population consisted of a convenience sample of Latinas in Los Angeles County and therefore findings cannot be extrapolated to Latinas in other geographic regions as they may be dissimilar to the largely Mexican origin population found in Southern California. Furthermore, the charlas were designed to educate and reinforce maternal–child health practices among pregnant Latinas and those who had delivered an infant within 2 months prior to follow-up, which limited our ability to clearly measure the effects of the intervention on the actual behaviors of breastfeeding initiation and exclusivity and duration of breastfeeding. Although we obtained at follow-up breastfeeding rates and duration among participants who had given birth, another limitation of this study was that we did not collect data on breastfeeding exclusivity. In some cases, variations were observed for participants who had received the charla in the home versus other locations. These differences, however, may be a result of self-selection bias and not the location per se because other factors that were not measured could have accounted for those dissimilarities. Although participants reported that they would recommend the program to others in their communities, the small number of participants in the group interviews may have biased the results and included only those most enthusiastic. Additionally, the presence of promotoras at each group interview may have influenced participant responses (i.e., social desirability bias) because they had likely established rapport with the promotoras throughout the study period. Similarly, the comments made by the two male partners who participated in one of the group interviews could have influenced that particular discussion. Furthermore, separate gender-specific groups may have garnered more extensive qualitative information that could be integral to developing culturally and linguistically relevant maternal–child health materials and interventions. Thus, the qualitative findings here are by no means intended to be representative of the sample or target population, but only provide further details and context regarding the quantitative findings and programmatic issues. Future studies with additional resources that allow for random sampling and produce minimal attrition over time are warranted.

726

B. Rios-Ellis et al.

Despite these limitations, the findings highlight the importance and effectiveness of promotora-delivered interventions for Latinas of childbearing age and the usefulness of a Spanish-language, culturally relevant calendar to supplement and reinforce positive behaviors. These community-based health service options are fundamental for accessing underserved and linguistically isolated Latinas and help to bridge the health disparity gap that currently exists, as they present brief, low-cost, non-resource-intensive modalities for health education. As future research is combined with existing studies on the effects of peer education on breastfeeding initiation, exclusivity, and duration among Latinas, findings support that widespread and long-ranging benefits might include decreased health care costs due to reduced illnesses, obesity, and other problems that have shown preventive potential (Anderson et al., 2005; Chapman et al., 2004; Gill, Reifsnider, & Lucke, 2007; P´erez-Escamilla et al., 2008). Furthermore, the rates of women who reported having talked with friends or family about what they had learned in the program were exceptionally high (99.5%), as were the number of people who said they would recommend the program to other Latinas. Promotores-based work within Latino communities on breastfeeding, infant feeding and care, and maternal–child health may potentially facilitate health advocacy and knowledge acquisition that remains within underserved communities, thus facilitating transfer of information to promote overall long-term community health.

ACKNOWLEDGMENTS Our sincere appreciation to Hyland’s CEO John P. (Jay) Borneman for his support and vision regarding this project. It is rare that community-based participatory researchers have the opportunity to work directly with corporate funders who are both giving of their resources because it is the “right thing to do” and who are completely willing to entrust the work to those to whom it was charged. Additional accolades go to Mary Borneman for acquiring incentives and providing other support needed for project implementation. We also thank Rachel Linares for her work in the development of the calendar. We also express our sincere gratitude to Thomas Siegmeth and Catherine Choi at AltaMed and Eleanor Cochran at St. Mary’s Medical Center for their willingness to support and engage in this project at their facilities. Thank you to Silvia Rodriguez, our program coordinator, for her hard work on this project. Finally, our deepest admiration to our promotores team: Concepcion Garcia, Pilar Hernandez, Maricela Parga, Luz Parra, and Patricia Nu˜nez for their heartfelt commitment, skill, and dedication; without their ability to engage community trust and participation, this project would not have been possible.

FUNDING Hyland’s Incorporated funded this work.

Engaging With Promotores de Salud

727

REFERENCES Ahluwalia, I. B., D’Angelo, D., Morrow, B., & McDonald, J. A. (2012). Association between acculturation and breastfeeding among Hispanic women: Data from the pregnancy risk assessment and monitoring system. Journal of Human Lactation, 28, 167–173. Ainsworth, B. (2012, April). Unveiling the myth of Latino inactivity: Measurement matters! Paper presented at the Strengthening Health Sciences with Culture/Fortaleciendo las Ciencias de la Salud con Cultura Conference, Long Beach, CA. Alcalay, R., Ghee, A., & Scrimshaw, S. (1993). Designing prenatal care messages for low- income Mexican women. Public Health Reports, 108, 354–362. Anders, R. L., Balcazar, H., & Paez, L. (2006). Hispanic community-based participatory research using a promotores de salud model. Hispanic Health Care International, 4, 71–78. Anderson, A. K., Damio, G., Young, S., Chapman, D. J., & Perez-Escamilla, R. (2005). A randomized trial assessing the efficacy of peer counseling on exclusive breastfeeding in a predominantly Latina low-income community. Archives of Pediatrics and Adolescent Medicine, 159, 836–841. Andrews, J. O., Felton, G., Wewers, M. E., & Heath, J. (2004). The use of community health workers in research with ethnic minority women. Journal of Nursing Scholarship, 36, 358–365. Austin, J. L., Smith, J. E., Gianini, L., & Campos-Melady, M. (2013). Attitudinal familism predicts weight management adherence in Mexican–American women. Journal of Behavioral Medicine, 36, 259–269. Balcazar, H., Rosenthal, E. L., Brownstein, J. N., Rush, C. H., Matos, S., & Hernandez, L. (2011). Community health workers can be a public health force for change in the United States: Three actions for a new paradigm. American Journal of Public Health, 101, 2199–2203. Bill, D., Hock-Long, L., Mesure, M., Bryer, P., & Zambrano, N. (2009). Healthy start programa madrina: A promotora home visiting outreach and education program to improve perinatal health among Latina pregnant women. Health Education, 41, 68–76. Bromley, E., Nunes, A., & Phipps, M. G. (2012). Disparities in pregnancy healthcare utilization between Hispanic and Non-Hispanic White win Rhode Island. Maternal and Child Health Journal, 16, 1576–1582. Brown, J. D., & Peuchaud, S. R. (2008). Media and breastfeeding: Friend or foe. International Breastfeeding Journal, 3, 15–17. Bunik, M., Clark, L., Zimmer, L. M., Jimenez, L. M., O’Connor, M. E., Crane, L. A., & Kempe, A. (2006). Early infant feeding decisions in low-income Latinas. Breastfeeding Medicine, 1, 225–235. Chapman, D. J., Damio, G., Young, S., & Perez-Escamilla, R. (2004). Effectiveness of breastfeeding peer counseling in a low-income, predominantly Latina population: A randomized controlled trial. Archives of Pediatrics and Adolescent Medicine. 158, 897–902. Chong, N. (2002). The Latino patient: A cultural guide for health care providers. Yarmouth, ME: Intercultural Press.

728

B. Rios-Ellis et al.

de Nuncio, M.L.Z., Nader, P. R., Sawyer, M. H., De Guire, M., Prislin, R., & Elder, J. P. (2003). A prenatal intervention study to improve timeliness of immunization initiation in Latino infants. Journal of Community Health, 28, 151–165. Eidelman, A. I., Schanler, R. J., Johnston, M., Landers, S., Noble, L., Szucs, K., & Viehmann, L. (2012). Breastfeeding and the use of human milk. Pediatrics, 129, e827–e841. Faruque, A., Hamadani, J., Hoque, S., & Mahalanabis, D. (1998). A picture calendar to promote oral rehydration therapy at home for illiterate mothers: A motivational tool. Journal of Tropical Pediatrics, 44, 182–183. Freed, G. L., Clark, S. J., Cefalo, R. C., & Sorenson, J. R. (1995). Breast-feeding education of obstetrics-gynecology residents and practitioners. American Journal of Obstetrics and Gynecology, 173, 1607–1613. Friedman, N. J., & Zeiger, R. S. (2005). The role of breast-feeding in the development of allergies and asthma. Journal of Allergy and Clinical Immunology, 115, 1238–1248. Gibson, S. (2007). Peer-led approaches to dietary change: Report of the food standards agency seminar held on 19 July 2006. Public Health Nutrition, 10, 980–988. Gibson-Davis, C. M., & Brooks-Gunn, J. (2006). Couples’ immigration status and ethnicity as determinants of breastfeeding. American Journal of Public Health, 96, 641–646. Gill, S. L., Reifsnider, E., & Lucke, J. F. (2007). Effects of support on the initiation and duration of breastfeeding. Western Journal of Nursing Research, 29, 708–723. Greer, F. R., Sicherer, S. H., & Burks, A. (2008). Effects of early nutritional interventions on the development of atopic disease in infants and children: The role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics, 121, 183– 191. Holmes, A. V., Auinger, P., & Howard, C. R. (2011). Combination feeding of breast milk and formula: Evidence for shorter breast-feeding duration from the national health and nutrition examination survey. Journal of Pediatrics, 159, 186–191. Howard, C. R., Howard, F. M., & Weitzman, M. L. (1994). Infant formula distribution and advertising in pregnancy: A hospital survey. Birth, 21, 14–19. Johnson-Kozlow, M. (2010). Colorectal cancer screening of Californian adults of Mexican origin as a function of acculturation. Journal of Immigrant and Minority Health, 12, 454–461. Karliner, L. S., Jacobs, E. A., Chen, A. H., & Mutha, S. (2007). Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Services Research, 42, 727– 754. McCloskey, J. (2009). Promotores as partners in a community-based diabetes intervention program targeting Hispanics. Family & Community Health, 32, 48–57. Mihrshahi, S., Ampon, R., Webb, K., Almqvist, C., Kemp, A. S., Hector, D., Marks, G. B., & for the CAPS Team. (2007). The association between infant feeding practices and subsequent atopy among children with a family history of asthma. Clinical & Experimental Allergy, 37, 671–679.

Engaging With Promotores de Salud

729

Morrow, A. L., Guerrero, M. L., Shults, J., Calva, J. J., Lutter, C., Bravo, J., ... Butterfoss, F. D. (1999). Efficacy of home-based peer counselling to promote exclusive breastfeeding: A randomised controlled trial. Lancet, 353, 1226–1231. Noimark, L., & Cox, H. E. (2008). Nutritional problems related to food allergy in childhood. Pediatric Allergy and Immunology, 19, 188–195. Patton, M. Q. (2001). Qualitative research & evaluation methods (3rd ed.). Thousand Oaks, CA: Sage. ´ P´erez-Escamilla, R., Hromi-Fiedler, A., Vega-Lopez, S., Berm´udez-Mill´an, A., & Segura-P´erez, S. (2008). Impact of peer nutrition education on dietary behaviors and health outcomes among Latinos: A systematic literature review. Journal of Nutrition Education and Behavior, 40, 208–225. Rios-Ellis, B., Enguidanos, S., Espinoza-Ferrell, T., & Sanchez, M. (2000, November). Early infant feeding practices of Latina immigrant mothers. Poster presented at the 128th Annual Meeting of the American Public Health Association, Boston, MA. Rodriguez, J. C., Beverly, R.L., Correa-Matos, N., & Santibanez, D. (2008). Development and pilot testing of a low literacy handout for Hispanic/Latino caregivers to promote breastfeeding and introduce age appropriate foods for infants. Florida Public Health Review, 5, 93–95. Rosenthal, E. L., Brownstein, J. N., Rush, C. H., Hirsch, G. R., Willaert, A. M., Scott, J. R., . . . & Fox, D. J. (2010). Community health workers: Part of the solution. Health Affairs, 29, 1338–1342. Shaffer, C. F. (2002). Factors influencing the access to prenatal care by Hispanic pregnant women. Journal of the American Academy of Nurse Practitioners, 14, 93–96. Swider, S. M. (2002). Outcome effectiveness of community health workers: An integrative literature review. Public Health Nursing, 19, 11–20. Tarini, B. A., Carroll, A. E., Sox, C. M., & Christakis, D. A. (2006). Systematic review of the relationship between early introduction of solid foods to infants and the development of allergic disease. Archives of Pediatrics and Adolescent Medicine, 160, 502–507. U.S. Department of Health and Human Services. (2011). The Surgeon General’s call to action and support breastfeeding. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General. WestRasmus, E. K., Pineda-Reyes, F., Tamez, M., & Westfall, J. M. (2012). Promotores de salud and community health workers: An annotated bibliography. Family & Community Health, 35, 172–182. Williams, E. L., & Hammer, L. D. (1995). Breastfeeding attitudes and knowledge of pediatricians-in-training. American Journal of Preventive Medicine, 11, 26–33. Xu, X., Dailey, A. B., Freeman, N. C., Curbow, B. A., & Talbott, E. O. (2009). The effects of birthweight and breastfeeding on asthma among children aged 1–5 years. Journal of Paediatrics and Child Health, 45, 646–651. Yoon, J., Grumbach, K., & Bindman, A. B. (2004). Access to Spanish-speaking physicians in California: Supply, insurance, or both. Journal of the American Board of Family Practice, 17, 165–172.

Copyright of Health Care for Women International is the property of Routledge and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.