Health Disparities

HD: Effectiveness of Nutrition Intervention Methods (2010)


Ryser FG. Breastfeeding attitudes, intention, and initiation in low-income women: The effect of the Best Start program. J Hum Lact. 2004 Aug; 20(3): 300-305. PMID: 15296584 

PubMed ID: 15296584
Study Design:
Randomized control trial.
A - Click here for explanation of classification scheme.
Quality Rating:
Positive POSITIVE: See Quality Criteria Checklist below.
Research Purpose:

To determine the effect of the Best Start breastfeeding educational program on breastfeeding attitudes, intention and initiation in a sample of urban women of lower socioeconomic status who were given the opportunity to make an informed decision about breastfeeding their infants.

Inclusion Criteria:
  • At least 18 years of age
  • English speaking
  • Able to read and write
  • Pregnant with subject's gestation sufficient to allow for four points of contact
  • Receiving prenatal care
  • Low income (eligible for Medicaid)
  • Having access to telephone
  • Stating the intention to "bottle-feed" or undecided about feeding method during initial contact with the researcher.
Exclusion Criteria:

If the subject stated that they intended to breastfeed during the initial contact with the researcher, they were excluded from the study.


Description of Study Protocol:


The setting for the study was a private, urban physician's office. The physician was an OB-GYN physician caring for a large number of low-income pregnant women in the practice. 90% of the patients were eligible for Medicaid benefits.


Every pregnant woman using the physician's office during the course of this research investigation was approached by the researcher to assess whether she met the inclusion criteria for participating in the study.  


Randomization was accomplished by having the subjects select a sealed envelope to determine their assignment to either the experimental group or the control group.    

Blinding Used

No blinding was used.  Per the article, it seems that the researcher conducted all of the intervention and all of the data collection.


The intervention was exposure to the Best Start program. Subjects were randomly assigned to either the experimental group (exposure to Best Start) or the control group (no exposure to Best Start). The intervention to which the experimental group was exposed consisted of very specific educational interventions designed to elicit and acknowledge the client's feelings and concerns and then to educate her about the benefits of breastfeeding. The intervention that was used from the Best Start program consisted of three steps. 

  • Step 1: Asking open-ended questions to elicit the client's perceptions of breastfeeding
  • Step 2: Carefully targeted messages that addressed the specific concerns of the particular client
  • Step 3: Carefully targeted messages that addressed the specific negative attitudes and social norms that may have been passed down by a close relative or friend. 

These messages were delivered through various means and included going to counseling, viewing videotapes, and reading written material that was specifically designed to address the common breastfeeding (BF) barriers perceived by low-income women. 

Measurement Tools

The effect of participating was measured by the Breastfeeding Attrition Prediction Tool (BAPT),  the Prenatal Infant Feeding Demographic Questionnaire, and the Post-partum Infant Feeding Telephone Survey. 

Statistical Analysis  

  • Measures included between (experimental vs. control) and within-factor (pre-test vs. post-test) repeated measures design
  • Data were coded and analyzed using the Statistical Package for the Social Sciences. Descriptive statistics were reported for all study variables. Data analyses consisted of descriptive and inferential techniques. Group (experimental and control) by time (pre-test vs. post-test) repeated measures analysis of variance (RM ANOVA) was performed to examine:
    • Group and intervention main effect 
    • Time of main effect
    • Group and intervention by time interaction effect on each of the outcome measures. 
  • A 2 x 2 Χ2 test of independence, corrected for continuity, was used to test any differences in intention and initiation of breastfeeding between the two groups.



Data Collection Summary:

Timing of Measurements 

  • The BAPT was administered by the researcher to all subjects during the initial contact and again during the last month of gestation
  • Within one week of delivery, each subject was telephoned and asked three pertinent questions: "How are you feeding your baby?", "How did you feed your infant in the hospital?" and "If you were breastfeeding in the hospital and stopped, what was the reason?"

Dependent Variables

  • Positive attitudes toward breastfeeding
  • Negative attitudes toward breastfeeding
  • Social and professional support
  • Breastfeeding control
  • Intention to breastfeed
  • Initiation of breastfeeding.

Independent Variables

Exposure to the Best Start program.

 Control Variables

No exposure to the Best Start program.


Description of Actual Data Sample:
  • Initial N: 26 experimental; 28 control
  • Attrition (final N): All 54 subjects completed the study
  • Age:
    • Experimental: 18 to 40 years (25.3±0.6 years)
    • Control: 18 to 36 years (22.6±4.6)
  • Parity:
    • Experimental: Zero to three  (1.4±1.1)
    • Control: Zero to five (1.0±1.2)
    • Age and parity for the two groups were not statistically significant
  • Ethnicity: Ethnicity was not described.
Summary of Results:


Key Results

BAPT Construct Experimental Group (N=26) Control Group (N=28)
  Pre-test Post-test Pre-test Post-test
Positive attitudes toward breastfeeding 338.9±89.2 393.3±66.7 323.7±76.9 335.1±72.3
Negative attitudes toward breastfeeding 213.4±68.6 179.0±75.7 254.2±101.3 275.6±102.6
Social and professional support 168.4±81.6 168.0±82.0 147.0±102.2 149.3±96.0
Breastfeeding control 40.9±13.7 46.3±10.5 38.9±11.7 36.1±12.4


Other Findings

The breakdown of these results into further analysis, looking at pre-test and post-test changes (within group), as well as intervention vs. control  is provided, mostly using RM ANOVA. Some significant results are as follows:

  • For the group receiving the intervention:  
    • Positive breastfeeding sentiment changed over time: F(1,52) = 6.82, P<0 .05
    • Negative breastfeeding sentiment changed overtime (decreased): F(1,52) = 11.94, P<0.01
    • The support scores remained the same both pre-test and post-test 
    • Breastfeeding control (the control a woman senses that she has over her ability to breastfeed) increased over time F (1, 52) = 11.11 P<0.01
  • For the control group, there were no changes except that negative breastfeeding sentiment increased over time t(25)= 2.75, P<0.01.

At the post-test administration of the BAPT, using a Χ2 test of independence, corrected for continuity, it was seen that the association between those who had received Best Start and those who indicated an intention to solely breastfeed was statistically significant Χ2 = 11.1, P<0.01.


Author Conclusion:
  • The present study supported previous findings that as negative attitudes decrease and positive attitudes increase, breastfeeding rates improve. The Best Start program developed by Bryant addresses the negative attitudes and barriers that deter women from breastfeeding. In addition, the program appears to be an effective method to increase the feelings a woman has regarding her ability to breastfeed.
  • During the sessions, several subjects asked about the safety of using marijuana or cocaine and its effect on the infant. Additional breastfeeding research that addresses a possible link between substance abuse and low breastfeeding rates in high-risk populations needs to be conducted. 
Funding Source:
Reviewer Comments:

This study contributes a valuable piece of information to the literature regarding prenatal attitudes toward breastfeeding and efforts to impact breastfeeding initiation upon birth.

Limitations of the study included the low sample size (54 subjects) and unbalanced groups with regard to feeding intentions. These differences may have contributed to the differences found in  post-test. Although the differences in BAPT scores between groups were not statistically significant at pre-test, they may have been clinically significant because more women in the experimental group had previous breastfeeding experience and more were undecided about feeding decisions. More subjects in the control group planned to formula feed. These differences were not controlled for during data analysis and may explain the higher initiation rates in the experimental group at post-test.

Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) Yes
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) Yes
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? Yes
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? Yes
  2.2. Were criteria applied equally to all study groups? Yes
  2.3. Were health, demographics, and other characteristics of subjects described? Yes
  2.4. Were the subjects/patients a representative sample of the relevant population? Yes
3. Were study groups comparable? Yes
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) Yes
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? Yes
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) Yes
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? N/A
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? N/A
  4.1. Were follow-up methods described and the same for all groups? Yes
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) N/A
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? Yes
  4.4. Were reasons for withdrawals similar across groups? N/A
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? No
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? No
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) No
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? Yes
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? Yes
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? N/A
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? Yes
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? Yes
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? N/A
  6.6. Were extra or unplanned treatments described? ???
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? N/A
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? N/A
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? Yes
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? Yes
  7.6. Were other factors accounted for (measured) that could affect outcomes? Yes
  7.7. Were the measurements conducted consistently across groups? Yes
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? Yes
  8.1. Were statistical analyses adequately described and the results reported appropriately? Yes
  8.2. Were correct statistical tests used and assumptions of test not violated? Yes
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? Yes
  8.6. Was clinical significance as well as statistical significance reported? N/A
  8.7. If negative findings, was a power calculation reported to address type 2 error? N/A
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? No
  10.2. Was the study free from apparent conflict of interest? ???