Low-income African American Women Research Articles

A Pilot Study of a Culturally Grounded Breastfeeding Intervention for Pregnant, Low-Income African American Women.

Increasing breastfeeding rates among low-income African American women may work toward the achievement of health equity. The dynamic breastfeeding assessment process (D-BAP) is a community-grounded, equity-focused intervention designed to increase prenatal breastfeeding self-efficacy. Research aim: The aims of the pilot study were (a) to determine the effect of the D-BAP on breastfeeding self-efficacy among pregnant, low-income African American women, (b) to examine the findings among women with no previous breastfeeding experience, and (c) to compare the findings between women with prior breastfeeding experience and those without it. A pre/post, paired-samples design was utilized. Convenience sampling was used to recruit pregnant, low-income African American women ( N = 25). Participants completed the Breastfeeding Self-Efficacy Scale-Short Form prior to and following the D-BAP. The Wilcoxon signed rank test indicated that participation in the D-BAP had a statistically significant influence on breastfeeding self-efficacy ( z = -2.01, p = .04). Among a subsample of participants with no previous breastfeeding experience ( n = 12), completion of the D-BAP resulted in a statistically significant increase in breastfeeding self-efficacy ( z = -2.36, p = .02). There was no statistically significant difference between those with prior breastfeeding experience and those without it. Breastfeeding among low-income African American women is a health equity issue for which culturally responsive, effective breastfeeding interventions are needed. This research demonstrates an association between completion of the D-BAP and an increase in prenatal breastfeeding self-efficacy.

Abstract P317: An Activity Space Approach to Assessing the Food Environments of Food Secure and Insecure Women

Introduction: Community food environments (FE) are an important correlate of diet- and weight-related CV health. Conventional approaches to measuring the FE focus on residential neighborhoods, and do not assess the full extent of food sources regularly encountered and used. Further, little attention has been given to how individual diet-related experiences, like food insecurity, may interact with features of the FE to affect health. To address these limitations, we use an activity space approach, defined by the locations women routinely visit, to measure FE exposure and use, and assess differences by food security status. Hypothesis: Food-related spatial behavior and features of the FE differ between a) conventional and activity space definitions, and b) food secure and insecure women. Methods: We present initial results (n=51) from an ongoing clinic-based study of low-income African American women in Atlanta, GA. Data are collected in-person using a Google Map-powered activity space questionnaire. USDA’s 10-item adult scale is used to measure food insecurity. Retail FE data are from Dun & Bradstreet. ArcGIS 10.5 was used to define three environments: residential census tract (CT), and convex hull polygons of overall and food-specific activity spaces. We tested differences, by food security status, in mean behaviors and FE features with one-way ANOVAs. Results: Eighty-eight percent of women were food insecure. Food insecure women were lower income, less often employed, and less often had access to a car. CTs contained fewer supermarkets (μ=1.2 SD =1.4) and fast food restaurants (μ=3.9 SD =3.2) than activity spaces (μ=7.9 SD =7.0; μ=55.5 SD =44.1, respectively). On average, 6.7% ( SD =13.5) of utilized food sources fell within CT bounds, while 53.4% ( SD =35.5) fell within activity spaces. Compared to food secure women, food insecure women had smaller overall (μ=329.8km 2 SD =340.4 vs. μ=548.3km 2 SD =422.4; p =0.16) and food-specific (μ=48.1km 2 SD =74.3 vs. μ=85.6km 2 SD =106.4; p =0.28) activity spaces, and a smaller proportion of their utilized supermarkets fell within their activity spaces (μ=60.9% SD =42.4 vs. μ=81.9% SD =21.4; p =0.24). FE features did not differ by food security status. Conclusions: Conventional FE definitions likely underestimate the number of food sources women encounter, and do not capture the majority of sources used. Smaller activity spaces among food insecure women suggest that routine spatial mobility may be constrained by factors like transportation access. Still, food insecure women more often traveled outside of their activity spaces to utilize supermarkets, suggesting a dual burden of constrained spatial mobility and access. Interestingly, FE features did not differ by food security status. In planned future analyses, any observed differences in diet and weight may indicate variation in how women interact with the FE, rather than differences in exposure.

Determinants of Successful Weight Loss in Low-Income African American Women: A Positive Deviance Analysis.

Objective: We set out to investigate the behaviors of low-income African American women who successfully lost weight. Methods: From an urban, academic, family medicine practice, we used a mixed methods positive deviance approach to evaluate 35 low-income African American women who were obese and lost at least 10% of their maximum weight, and maintained this loss for 6 months, comparing them with 36 demographically similar control participants who had not lost weight. Survey outcomes included demographics and behaviors that were hypothesized to be related to successful weight loss. Interviews focused on motivations, barriers, and what made weight loss successful. Survey data were analyzed using t tests and linear regression for continuous outcomes and chi-square tests and logistic regression for categorical outcomes. Interviews were analyzed using a modified approach to grounded theory. Results: In adjusted analyses, women in the positive deviant group were more likely to be making diet changes compared with those women who did not lose at least 10% of their initial body weight. Major themes from qualitative analyses included (a) motivations (of health, appearance, quality of life, family, and epiphanies), (b) opportunity (including time and support), (c) adaptability. Conclusions: The findings of this study may be useful in developing motivational interviewing strategies for primary care providers working with similar high-risk populations.

Evaluation of a Palpable Breast Mass in a Young Female: Implications when Working with Underserved Populations

We report the case of a 37 year-old uninsured African American female who came to the office complaining of a breast mass for about a month. The patient was examined during the initial office visit and proper imaging was ordered based on current guidelines for this type of complaint. Literature shows that female patients who present to primary care providers with breast symptoms, approximately 42 percent of them report a breast mass. Even though most masses are benign, they are the most common presenting symptom in patients diagnosed with breast cancer. A palpable mass in a woman’s breast requires a prompt evaluation. Correct diagnosis of a breast mass is essential for optimal treatment planning, with the primary aim being to confirm or exclude cancer. Breast cancer is the most common cancer among women of all races, and it is the leading cause of cancer death among Hispanic women and second among white, black, Asian/Pacific Islander, and American Indian/Alaska Native women. The triple test (TT) advices the evaluation of palpable breast masses by physical examination, mammography, and fine-needle aspiration (FNAC), and it has proven to be a reliable and accurate tool due to its technical simplicity and reduced expense and morbidity compared with open surgical biopsy. Low-income African-American women often report lower receipt of medical risk information, and due to lack of insurance they do not have a regular source of care, which in turn leads to decreased utilization of medical health services. This case highlights the importance of the utilization of the triple test when evaluating young females complaining of breast masses, but it also emphasizes the important role that providers play when working with underserved populations.

Views of Low-Income Women of Color at Increased Risk for Breast Cancer

Individual risk assessment (IRA) for breast cancer may increase adherence to risk-appropriate screening and prevention measures. However, knowledge gaps exist regarding how best to communicate IRA results and support women at increased risk in future health care decisions, in part because patients conceptualize and make meaning of risk differently from the medical community. Better understanding the views of low-income women of color identified as being at increased risk for breast cancer can inform efforts to conduct IRA in an ethical and respectful manner. We conducted in-depth interviews with 13 low-income African American and Latina women who receive care at a federally qualified health center (FQHC) and had recently learned of their increased risk for breast cancer. These interviews explored their experience of the IRA process, their interpretation of what being at increased risk means, and their reactions to provider recommendations. Eight key themes were identified. We conclude with recommendations for the implementation of IRA for breast cancer in underserved primary care settings.

Developing a Mass Media Campaign to Promote Mammography Awareness in African American Women in the Nation's Capital.

This study developed and examined the reach and impact of a culturally appropriate mass media campaign pilot, designed to increase awareness about the importance of mammography screening and the available community mammography services for low-income African American women ages 40 and above. We conducted formative research using focus groups to inform campaign development, resulting in five emergent themes-good breast health, holistic views of healthiness, cancer fatalism, fear of mammogram machines, and mammogram affordability. The campaign targeted specific low-income African American communities in the District of Columbia via print ads in Metro stations and on buses, print ads in the Washington Informer, and online ads on a local TV network website. Data were collected before, during, and after campaign implementation to assess reach and impact. Reach was measured by number of impressions (number of people exposed to the campaign), while impact was assessed via online ad click-through rates, website use and referrals, and mammography center calls. The campaign was successful in reaching the target audience, with a total combined reach from all media of 9,479,386 impressions. In addition, the mammography center received significant increases in new website visitors (1482 during the campaign, compared to 24 during the preceding period) as well as 97 calls to the dedicated phone line. Further research involving a more long-term investment in terms of funding and campaign run time, coupled with a more robust evaluation, is needed to assess if culturally appropriate mass media campaigns can generate increased mammography screening rates and decrease breast-cancer-related mortality.

“Maybe black girls do yoga”: A focus group study with predominantly low-income African-American women

ObjectiveTo explore African American (AA) women’s use of mind-body therapies, such as yoga and mindfulness, and factors that impact their experiences, observations and opinions. DesignFocus groups were conducted to better understand how AA women perceive mind-body therapies and how to best bring these interventions into their community. Interviews were audiotaped and transcribed. SettingThe urban Midwest. Outcome measuresIn addition to qualitative outcomes, descriptive measures included the Perceived Stressor Scale, Beliefs About Yoga Scale, and Determinants of Meditation Practice Inventory (DOMPI). ResultsTwenty-two, predominantly low-income (75% reported income <$50,000) and single (82%) women participated in three age stratified focus groups (18–34 years, 35–65 years, 66 years and older). Participants acknowledged life stress and shared common coping mechanisms. They recognized that yoga and mindfulness could be beneficial and discussed barriers to practice (including personal and structural). Younger women reported more time constraints as barriers, middle aged women had more experience with yoga, and older women identified the spiritual component to yoga/mindfulness as potentially conflicting with current coping strategies. Participants suggested ways to share mind-body therapies within the AA community along with solutions for engagement. ConclusionsAA women acknowledged stress in their lives and recognized the need for additional coping measures. Although women reported interest in yoga/mindfulness they identified barriers, including limited access to convenient classes, and offered suggestions for bringing yoga and mindfulness to their communities.

Childhood Abuse, Intrapersonal Strength, and Suicide Resilience in African American Females who Attempted Suicide

There is a significant association between childhood abuse and suicidal behavior in low-income African American women with a recent suicide attempt. Increasingly, empirical focus is shifting toward including suicide resilience, which mitigates against suicidal behavior. This cross-sectional study examines childhood abuse, intrapersonal strengths, and suicide resilience in 121 African American women, average age of 36.07 years (SD = 11.03) with recent exposure to intimate partner violence and a suicide attempt. To address the hypothesis that childhood abuse will be negatively related to suicide resilience and that this effect will be mediated by intrapersonal strengths that serve as protective factors, structural equation modeling examined the relations among three latent variables: childhood abuse (measured via physical, sexual, and emotional abuse), intrapersonal strengths (assessed by self-efficacy and spiritual well-being), and suicide resilience (operationalized via the three components of suicide resilience—internal protective, external protective, and emotional stability). The initial measurement model and the structural model both indicated excellent fit. Results indicated that childhood abuse was negatively associated with intrapersonal strengths and suicide resilience, intrapersonal strengths were positively associated with suicide resilience, and intrapersonal strengths fully mediated the association between childhood abuse and suicide resilience. Thus, the results suggest a positive and protective influence of intrapersonal strengths on suicide resilience in the face of childhood abuse in suicidal African American women. The clinical implications and directions for future research that emerge from these findings are discussed.

Disadvantaged Status and Health Matters Networks among Low-Income African American Women.

A significant gap in current network research relates to understanding the factors that shape the health matters (HM) networks of marginalized, socially disadvantaged populations. This is noteworthy, given that these networks represent a critical resource for mitigating the adverse health effects of both acute and chronic strains associated with marginalized status. Further, research has suggested that the networks of such populations—especially low-income African American women—are unique, and may operate in substantively different ways than those of other groups. Using two waves of data from a sample of low-income African American women, this research identifies the demographic, health status, and health behavior measures at time one that correspond to HM network characteristics at time two, six months later. This study offers preliminary insights on the relationship between key sociodemographic and health status characteristics of low-income African American women and their HM networks, including criminal justice involvement. Findings reveal that though poorer health status and criminal justice involvement correspond to smaller health matters networks, they also correspond to more active and supportive networks.

Lessons Learned Recruiting Minority Participants for Research in Urban Community Health Centers

To help understand and mitigate health disparities, it is important to conduct research with underserved and underrepresented minority populations under real world settings. There is a gap in the literature detailing real-time research staff experience, particularly in their own words, while conducting in-person patient recruitment in urban community health centers. This paper describes challenges faced at the clinic, staff, and patient levels, our lessons learned, and strategies implemented by research staff while recruiting predominantly low-income African-American women for an interviewer-administered survey study in four urban Federally Qualified Health Centers in New Jersey. Using a series of immersion-crystallization cycles, fieldnotes and research reflections written by recruiters, along with notes from team meetings during the study, were qualitatively analyzed. Clinic level barriers included: physical layout of clinic, very low or high patient census, limited private space, and long wait times for patients. Staff level barriers included: unengaged staff, overburdened staff, and provider and staff turnover. Patient level barriers included: disinterested patients, patient mistrust and concerns over confidentiality, no-shows or lack of patient time, and language barrier. We describe strategies used to overcome these barriers and provide recommendations for in-person recruitment of underserved populations into research studies. To help mitigate health disparities, disseminating recruiters' experiences, challenges, and effective strategies used will allow other researchers to build upon these experience in order to increase recruitment success of underserved and underrepresented minority populations into research studies.

Body Image Models among Low-income African American Mothers and Daughters in the Southeast United States.

Obesity among low-income African American women has been studied using the concepts of both satisfaction and acceptance. The satisfaction frame suggests greater satisfaction with their bodies than their white counterparts, irrespective of size. The acceptance frame suggests that alternative aesthetics serve as resistance against intersectional marginalization. Yet, while these women accept their body size in defiance of thinness ideals, they may not be satisfied. We describe cultural models of body image among mothers and daughters in Alabama. We found that respectability, material consumption, and parental support were important factors determining positive body image, exceeding descriptions of physical features. We further found that those expressing greater body dissatisfaction emphasized respectability, whereas those with less dissatisfaction assigned importance to consumerism and physical form. These findings suggest divergences between biomedical messaging and lived experience. They also challenge uncritical or universalist applications of these frames when interpreting African American women's perceptions of their own bodies.

Using group model building to develop a culturally grounded model of breastfeeding for low-income African American women in the USA.

To identify barriers and supporting factors for breastfeeding, and the dynamic interactions between them, as identified by low-income African American women and lactation peer helpers. Stark breastfeeding disparities exist between African American mothers and their White counterparts in the USA. This pattern is often replicated across the globe, with marginalised populations demonstrating decreased breastfeeding rates. While breastfeeding research focused on sociocultural factors for different populations has been conducted, a more dynamic model of the factors impacting breastfeeding may help identify effective leverage points for change. Group model building was used as a grounded theoretical approach, to build and validate a model representing factors impacting breastfeeding and the relationships between them. Low-income African American women (n=21) and lactation peer helpers (n=3) were engaged in model building sessions to identify factors impacting breastfeeding. A two-cycle process was used for analysis, invivo and axial coding. The final factors and model were validated with a subgroup of participants. The participants generated 82 factors that make breastfeeding easier, and 86 factors that make breastfeeding more challenging. These were grouped into 10 and 14 themes, respectively. A final model was constructed identifying three domains impacting breastfeeding: a mother's return to work or school, her knowledge, support and persistence, and the social acceptance of breastfeeding. This study documented the sociocultural context within which low-income African American women are situated by identifying factors impacting breastfeeding, and the dynamic interactions between them. The model also provided various leverage points from which breastfeeding women can be supported. Postpartum nurses are critical in supporting breastfeeding practices. To be most effective, they must be aware of the factors impacting breastfeeding, some of which may be unique to women based on their culture.

Compassion-Based Meditation in African Americans: Self-Criticism Mediates Changes in Depression.

This study examines self-criticism as a mechanism through which compassion meditation reduces depressive symptoms in low-income African American men and women (N=59) who had recently attempted suicide. After completing several measures, including the Levels of Self-Criticism Scale and Beck Depression Inventory-II, participants were randomly assigned to receive either a six-session compassion meditation (CM) group (Grady Compassion and Meditation Program) or a six-session support group. As predicted, path analysis results showed that treatment condition led to changes in self-criticism from pre- to posttreatment, with those receiving CM showing greater reductions in levels of self-criticism than those randomized to the support group. Path analyses also revealed that changes in self-criticism fully mediated the link between condition and changes in depressive symptoms. These findings highlight the importance and value of targeting levels of self-criticism in compassion-based interventions to reduce the depressive symptoms of suicidal African Americans.

Overcoming Obesity: A Mixed Methods Study of the Impact of Primary Care Physician Counseling on Low-Income African American Women Who Successfully Lost Weight.

Low-income, African American women are disproportionately impacted by obesity. Little is known about the interactions between low-income, African American women who successfully lost weight and their primary care physicians (PCPs). Mixed methods, positive deviance study. Urban university-based family medicine practice. The positive deviance group comprised low-income, African American women who were obese, lost 10% body weight, and maintained this loss for 6 months. The PCP- and patient-reported weight-related variables collected through the electronic medical record (EMR), surveys, and interviews. Logistic regression of quantitative variables. Qualitative analysis using modified grounded theory. The EMR documentation by PCPs of dietary counseling and a weight-related medical problem were significant predictors of positive deviant group membership. Qualitative analyses of interviews revealed 5 major themes: framing obesity in the context of other health problems provided motivation; having a full discussion around weight management was important; an ongoing relationship with the physician was valuable; celebrating small successes was beneficial; and advice was helpful but self-motivation was necessary. The PCP counseling may be an important factor in promoting weight loss in low-income, African American women. Patients may benefit from their PCPs drawing connections between obesity and weight-related medical conditions and enhancing intrinsic motivation for weight loss.

Depression and Intimate Partner Violence Among African American Women Living in Impoverished Inner-City Neighborhoods.

Mental health correlates of intimate partner violence (IPV) victimization including negative physical and mental health outcomes are well documented. However, certain subgroups of African American women, such as those living in impoverished, urban communities, are underrepresented in most studies and may experience IPV at higher rates. Furthermore, the circumstances of this women including poverty makes them at risk to IPV and its consequences. The present study estimated the prevalence of IPV victimization and its association with depression in a sample of low-income African American women participating in the Mobile Youth and Poverty Study. Participants in this study were caregivers of adolescents living in extremely impoverished conditions and were part of the Mobile Youth Survey, a community-based, longitudinal, multiple cohort survey conducted between the years 1998 and 2011. Data for the current study were collected between the years 2001 and 2010. The dependent variable was depressive symptoms as measured by the Center for Epidemiological Studies-Depression Scale (CES-D). The independent variable was IPV measured using a subsample of items from the Conflict Tactics Scale. Nearly three quarters (73.6%, n = 489) of the sample experienced some form of IPV and 49.1% (n = 326) had a CES-D depression score of 16 or greater indicating mild to severe depression symptoms. The highest proportion of women who met the CES-D criteria for depression were those experiencing the most severe IPV irrespective of category (i.e., physical, psychological, or combined). Logistic regression analyses showed that women reporting the most severe abuse, irrespective of category, were significantly more likely to meet the CES-D criteria for depression. In addition, low education and receipt of economic assistance were significantly associated with depressive symptoms. The combination of poor economic conditions and IPV may predispose African American women living in impoverished, urban communities to mental health outcomes such as depression.

Abstract C86: Distance to free and low cost screening centers and cervical cancer screening behaviors of low income women in New Jersey

Abstract Racial/ethnic disparities in cancer outcomes have been well documented. Access to Pap testing may account for some of the variation in the racial and socioeconomic differences in cervical cancer outcomes. The rate of Pap testing within the past three years has been shown to vary by both race/ethnicity and by access to medical care. Given this, there has been an increase in the use of GIS to explore and understand cancer screening behaviors. The goal of this analysis was to evaluate and characterize the relationship between geographic proximity to free or low-cost cancer screening facilities and screening behaviors among low-income women in New Jersey using data collected from a cross-sectional survey (N= 459). Address data from 376 participants were geocoded using an ArcGIS address locator, using TIGER road map data as the source, to conduct a distance analysis between participant location and New Jersey Cancer Education &amp; Early Detection (NJCEED) locations, which offer free and low cost screenings based on income. A majority of participants (60.6%) lived less than five miles from the nearest NJCEED location. There was no statistically significant difference in being screened between living &amp;lt;2 miles versus &amp;gt; 8 miles from a NJCEED location (OR = 1.40, 95%CI = 0.60 - 3.26) after adjusting for age, race, transportation, BMI, insurance, and perceived risk. However, when stratified by race, African American women who lived within 2 miles of a screening location were 5.59 times more likely to report being screened compared to women living more than 8 miles away (95% CI = 1.08 - 28.90), although this trend was not statistically significant (p=.06). Distance to free and low cost screening centers were associated with screening behaviors among low income African American women in NJ, but not low income white and Hispanic women, indicating a need for tailored interventions to reach this at risk population. Citation Format: Michelle L. Gardner, Elisa V. Bandera, Beth A. Jones, Kitaw Demisse, Stephanie AN Silvera. Distance to free and low cost screening centers and cervical cancer screening behaviors of low income women in New Jersey. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr C86.

Long-Term Breastfeeding in African American Mothers.

According to the Centers for Disease Control and Prevention, 39.1% of African American infants are breastfed at 6 months. However, few studies have explored the breastfeeding experiences of African American women who successfully breastfeed to 6 months or longer durations. Research aim: The goal of this qualitative study was to explore the long-term breastfeeding experiences of low-income African American women using the positive deviance approach. African American women with breastfeeding experience were recruited through Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) breastfeeding peer counselors. Eligibility criteria included being age 18 or older, currently participating in WIC, and having breastfed one child for at least 6 months in the past 2 years. Semistructured, in-depth interviews were conducted with 11 participants. Interviews were audio-recorded and professionally transcribed. Transcripts were then analyzed for emerging themes using thematic analysis in NVivo software. Participants had on average three children each, with an average length of breastfeeding of 10.5 months per child. Four main themes developed: (a) deciding to breastfeed, (b) initiating breastfeeding, (c) breastfeeding long-term, and (d) expanding breastfeeding support. Participants offered culturally tailored suggestions to improve breastfeeding support for other African American women: prenatal discussions of breastfeeding with health care providers, African American lactation support personnel and breastfeeding support groups, and African American breastfeeding promotion in print and digital media. Women who participated in this study breastfed for longer durations than the national average for African Americans. Findings can inform practice and research efforts to improve breastfeeding rates in this population using lessons learned from successful women.

Resilience in low-income African American women living and aging with HIV

ABSTRACTWomen are living with HIV into middle and older age and are likely to face multiple comorbidities and stressors as they age. This study focused on understanding how women who experience multiple forms of oppression and ongoing adversity are still able to adapt and stand strong. Using a theoretical framework of resilience and a feminist research ideology, interviews of eight middle-aged and older African American women living with HIV were analyzed. Despite experiences of HIV-related discrimination, trauma, and violence, these women demonstrated a remarkable ability to adapt and maintain support. Implications for research and practice are discussed.

Patient Experiences with Pregnancy Planning and Perspectives on Reproductive Care in Community Health Centers: A Qualitative Study of African American Women in Chicago

IntroductionGiven the potential benefits of preventive reproductive health care for both women and children, it is important that clinicians routinely offer preconception and contraceptive counseling in ways that are responsive to patients’ wishes. The goal of this study is to gain knowledge about the components of preventive reproductive health care that patients at Federally Qualified Health Centers value, and to elicit patient perspectives on how best to deliver this care. MethodsWe conducted three focus groups with African American women (n = 21) at two Federally Qualified Health Centers in Chicago. The groups were facilitated using an open-ended, semistructured interview guide. We asked women to reflect on past experiences, advice they would give their teenage daughters, and how to design an ideal clinic. All groups were recorded and transcribed verbatim. Transcripts were coded and analyzed using an inductive approach with ATLAS.ti software. ResultsAlthough participants wanted comprehensive information about sex and pregnancy, they reported receiving no information at all, or many negative messages. The idea of timing and spacing pregnancies was generally embraced by participants. They described an ideal clinic as having a patient population diverse in income, trusting relationships with providers, comprehensive services, and educational opportunities. ConclusionsThe women in our study expressed a desire for more information and comprehensive care in the setting of an equitable clinic where they feel respected as individuals. Our findings support the idea behind the patient-centered medical home and challenge prior literature, which suggests the concept of pregnancy planning does not resonate with low-income African American women.

Factors Distinguishing Positive Deviance Among Low-Income African American Women: A Qualitative Study on Infant Feeding.

Positive deviant individuals practice beneficial behaviors in spite of having qualities characterizing them as high risk for unhealthy behaviors. This study aimed to identify and understand factors distinguishing low-income African American women who breastfeed the longest (positive deviants) from those who breastfeed for a shorter duration or do not breastfeed. Seven mini-focus groups on infant-feeding attitudes and experiences were conducted with 25 low-income African American women, grouped by infant-feeding practice. Positive deviants, who had breastfed for 4 months or more, were compared with formula-feeding participants who had only formula fed their babies and short-term breastfeeding participants who had breastfed for 3 months or less. Positive deviant women had more schooling, higher income, breastfeeding intention, positive breastfeeding and unfavorable formula-feeding attitudes, higher self-efficacy, positive hospital and Special Supplemental Nutrition Program for Women, Infants, and Children experiences, more exclusive breastfeeding, and greater comfort breastfeeding in public. Short-term breastfeeding women varied in breastfeeding intention and self-efficacy, seemed to receive insufficient professional breastfeeding support, and supplemented breastfeeding with formula. Some showed ambivalence, concern with unhealthy behaviors, and discomfort with breastfeeding in public. Formula-feeding women intended to formula feed, feared breastfeeding, thought their behaviors were incompatible with breastfeeding, were comfortable with and found formula convenient, and received strong support to formula feed. Tapping into the strengths of positive deviants; tailoring interventions to levels of general and breastfeeding self-efficacy; increasing social, institutional, and community supports; and removing inappropriate formula promotion may offer promising strategies to increase breastfeeding among low-income African American women.