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Candice Belanoff, MPH Department of Society, Human Development and Health

Population Disparities in Breastfeeding in the United States: Key theoretical and methodological issues for research. Candice Belanoff, MPH Department of Society, Human Development and Health Harvard School of Public Health

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Candice Belanoff, MPH Department of Society, Human Development and Health

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  1. Population Disparities in Breastfeeding in the United States:Key theoretical and methodological issues for research Candice Belanoff, MPH Department of Society, Human Development and Health Harvard School of Public Health Presentation to the 13th Annual Maternal and Child Health Epidemiology Conference, Atlanta, GA December 12, 2007

  2. Breastfeeding patterns in the U.S. • Patterns and disparities in breastfeeding are not uniform across states in the U.S. • Summary measures may not fully describe breastfeeding patterns and disparities. • Documenting patterns and disparities lays the ground work for studying/explaining them.

  3. Breastfeeding patterns in the U.S. We observe patterns.... • By region Breastfeeding initiation rates, 2004 Source: National Immunization Survey, 2004

  4. Breastfeeding patterns in the U.S. We observe.... • Variable disparities across states 4% 32% Breastfeeding initiation by income (in LA, OR) Breastfeeding initiation by race/ethnicity (in MA, TX) Source: NSCH, 2003 Data Resource Center for Child and Adolescent Health

  5. Breastfeeding patterns in the U.S. We observe.... • Variable rates over time Source: NIS, NSFG

  6. Breastfeeding and contexts • Limited body of research around contextual effects on breastfeeding: • Social policy (welfare-to-work; pro-breastfeeding legislation) • Community social status measures • Social policy which mitigates disparities • Research suggests potential of contextual analyses in explaining disparities....

  7. Multilevel modeling • Predictors measured at multiple levels • Estimation of effects at different levels • How does each level contribute to overall variance? DATA STRUCTURE 2 1 3 Level 2 – States- Level 1 - Individuals 1 2 3… 1 2 3… 1 2 3… Adapted from Subramanian and Jones, 2004

  8. What breastfeeding research questions can we address with this model? • “How do broader social contexts drive patterns of breastfeeding both across and within states in the U.S.?” • Across states: • “Are there differences in rates of breastfeeding across states, once you account for individual factors?” • “What state-level, contextual factors (e.g. policy, resources, social conditions) contribute to different rates of breastfeeding across states?” • Within states: • “Does the effect of being poor in Louisiana differ from the effect of being poor in Oregon?” • “What contextual factors account for this difference?” • “For whom is breastfeeding adversely affected by contextual factors?”

  9. Considerations in measuring health disparities (from Keppel, “Methodological Issues in Measuring Health Disparities” 2005) • The reference groups chosen for all analyses in this study will be the most socially advantaged • As recommended by Keppel, both absolute and relative measures of BF disparity will be reported in these analyses. • Disparities can also be expressed in terms of either adverse or positive events. The choice will influence the direction and magnitude of the relative disparity and thus should be made explicit. For ease of interpretation, I will use the positive event, the log odds of BF-I or BF-6, in all analyses. • For the socio-demographic domains for which there are categories, comparisons will be made in a “pair-wise” fashion; that is, comparing each group individually to the referent group. • In the case of an ordinal variable like “household % poverty,” the level of disparity will be summarized for the entire domain by examining the overall coefficient for that variable, (i.e. the slope for household poverty).

  10. Some proposed areas of inquiry for contextual effects.... • “Do variations in state-level social policy affecting the poor impact breastfeeding disparities by household income?” • “Is the social status of women linked to state breastfeeding rates?” • “Do disparities in the status of women by race/ethnicity explain breastfeeding disparities?” • More….

  11. Research gaps Analyses needed to: • Better understand contextual effects/mechanisms • Investigate contextual/individual interactions • Understand associations between social inequalities & breastfeeding • Understand how state-level policy & programs may be related to patterns of breastfeeding & how different populations may be differently affected

  12. Conclusions • Summary estimates of breastfeeding are inadequate to characterize social patterns of breastfeeding. • Analyses must consider social-contextual factors driving patterns of breastfeeding and BF disparities. • Future research should continue to pursue multiple levels of breastfeeding predictors.

  13. Thank You!!!! Special acknowledgement of my dissertation committee:Dr. Lisa Berkman Dr. Nancy Krieger Dr. Marie McCormick Dr. SV Subramanian And my colleagues at MDPH:Dr. Hafsatou Diop Dr. Susan Manning Emily Lu, MPH Diane Gradozzi

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