Detección de deficiencias

There were two changes from the original study proposal in terms of study sampling. First, a decision was made to not utilize the Western Pennsylvania Hospital as a data collection site.

(Magee Womens Hospital of UPMC), it became unnecessary to include a secondary site. The other change involved the ethnic background of those enrolled. While initial plans included enrollment of at least one mother-infant dyad of Asian descent, the available study pool at times of recruitment did not permit this. Enrollment of male and female infants, as well as Black participants, was closely aligned with initial projections, however.

Table 4. Actual study enrollment

ETHNIC CATEGORY FEMALES MALES TOTAL

Hispanic or Latino 0 0 0

Not Hispanic or Latino 14 8 22

Ethnic Category: Total of All

Subjects 14 8 22

RACIAL CATEGORY

American Indian/Alaskan Native 0 0 0

Asian 0 0 0

Native Hawaiian or other Pacific

Islander 0 0 0

Black or African American 3 1 4

White 11 7 18

Racial Categories: Total of All

Subjects 14 8 22

The additional data collection methods instituted in an attempt to achieve methodological triangulation had mixed success. While no participants attempted audio diaries, five completed one or more email diary “entries” and two took part in the video-recorded breastfeeding and stimulated recall interviews. Reasons for non-participation in video data collection included lack of preparatory grooming, breastfeeding sessions not coinciding with scheduled interviews, and privacy concerns. Reasons for non-participation in email or audio diaries included a lack of time, unfamiliarity and complexity associated with the audio-recording device, and no computer

access. The limited uptake of these exploratory data collection methods indicates that future implementation may require more explicit participant direction (e.g., setting expectations for frequency and content of diaries, demonstrating operation of audio-recorder), pilot-testing, improved coordination of timing of data collection, integration of more user-friendly audio recording devices, and added incentives for participation. Despite these issues, the email and video review data contributed to more focused interviews, clarification of participant statements, and confirmation of emergent themes. Because the email diaries were participant-driven, they also permitted insight into thoughts and events as they occurred and reduced the possibility of investigator bias.

Additional implementation issues involved the impact of volume during video reviews on transcription accuracy and the difficulty in managing the video-recorder while interviewing and taking fieldnotes simultaneously. The latter issue underscores the value of a second data collector to operate devices or take field notes. The volume problem was resolved by muting sound during the video reviews, thereby placing emphasis on participants’ responses to what was happening in the videos, rather than what was being said. Occasionally, this (and email diaries) led to discrepancies between maternal memory and real-time interview data. Though a natural reflection of how information is processed over time and represented to others (Sandelowski, 1993), the inconsistencies required some form of action or resolution. When they occurred, clarification was sought, which sometimes led to even deeper reflection and understanding.

When the discrepancy persisted, real time event data was considered “correct.”

The interview schedule instituted (1-2 days, 1 week, 2 weeks, and 6-8 weeks postpartum) seemed to adequately capture early breastfeeding establishment among late preterm dyads and did not appear overly burdensome. Indeed, with few exceptions related to participant time

conflicts, this schedule was adhered to. However, at the final interview at 6-8 weeks postpartum, several participants anticipated modifying breastfeeding based on return to work, family issues, or new information received from healthcare providers. For this reason, around the time that the sixth participant was being interviewed, the decision was made (after IRB approval, see Appendix F) to re-contact all participants at 4-6 months postpartum to ascertain breastfeeding outcome. At the time of this writing, eight of ten mothers have been re-contacted via mail, and five have sent back written responses. As suspected, the two mothers who were considering breastfeeding cessation at the time of the last interview did stop at around 2.5 months. Two other mothers, both successful in establishing at-breast feeds and a milk supply during the early postpartum period, continued to breastfeed exclusively to 3 and 6 months, respectively. The former participant introduced formula at 3 months and ceased breastfeeding altogether at 5 months, because “bottles and formula were easier [at that point], since she [was] in daycare.” A fifth participant, who had early difficulty with at-breast feeds but diligently worked to maintain milk supply, was still breastfeeding at the time of re-contact (approximately 6 months postpartum) and had continued at-breast feeds exclusively until 4 months, at which time other foods had been introduced.

The length and nature of in-home interviews were well received by participants, as indicated by their positive verbal feedback and 100% participant retention rate. Although mothers had the option of interviewing elsewhere (e.g., coffee shop), they felt that their homes were most convenient and comfortable. The fact that they did not have to prepare their infants to leave the house or find a babysitter for other children was perceived as advantageous. For the most part, the home environment also provided privacy, perhaps allowing participants to share more and breastfeed more openly than they may have in a public setting or unfamiliar location.

For some participants, however, the home interview setting may not have been ideal, as they split their attention in caring for other children during the interview. Some mothers also had limited space and privacy from other family members during home interviews, leading to palpable discomfort at times. For one participant, a 21 year-old, there was a distinct change in her demeanor from the first two hospital interviews (without family present) to the last two home interviews, in which close quarters did not afford any privacy. For these latter interviews, the participant became more defensive and defiant as family members offered their opinions during the interview process. Another participant confided in the last interview that her spouse had actually been unsupportive in her breastfeeding efforts. It was noted that this was the only interview in which her spouse had not been present. These experiences highlight the need to discuss the dynamics of the home setting prior to scheduling in-home interviews if possible.

When appropriate, alternate settings, still convenient for the participant, should be suggested.