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Getting to Know Your Baby: Development of a 6-week Countdown Calendar for Participants in WIC Program

      Introduction

      Focus groups consisting of participants in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) reported that infant crying and waking were major reasons for early breastfeeding cessation.
      • Heinig M.J.
      • Follett J.R.
      • Ishii K.D.
      • Kavanagh-Prochaska K.
      • Cohen R.
      • Panchula J.
      Barriers to compliance with infant feeding recommendations among low-income women.
      Mothers who breastfeed may interpret infant crying and waking as indicators of hunger and introduce formula or solid food to calm their infants and increase sleep duration.
      • Heinig M.J.
      • Follett J.R.
      • Ishii K.D.
      • Kavanagh-Prochaska K.
      • Cohen R.
      • Panchula J.
      Barriers to compliance with infant feeding recommendations among low-income women.
      • Anderson A.S.
      • Guthrie C.A.
      • Alder E.M.
      • Forsyth S.
      • Howie P.W.
      • Williams F.L.R.
      Rattling the plate—reasons and rationales for early weaning.
      • Bentley M.
      • Gavin L.
      • Black M.M.
      • Teti L.
      Infant feeding practices of low-income, African-American, adolescent mothers: an ecological, multigenerational perspective.
      • Bunik M.
      • Clark L.
      • Zimmer L.M.
      • et al.
      Early infant feeding decisions in low-income Latinas.
      • Savage S.A.
      • Reilly J.J.
      • Edwards C.A.
      • Durnin J.V.
      Weaning practices in the Glasgow Longitudinal Infant Growth Study.
      • Scott J.A.
      • Binns C.W.
      • Graham K.I.
      • Oddy W.H.
      Predictors of the early introduction of solid foods in infants: results of a cohort study.
      The practice of feeding to modify behavior often extends beyond breastfeeding cessation, resulting in overfeeding of infant formula and inappropriate introduction of solid food (ie, cereal in a bottle).
      The Fit WIC Baby Behavior Study was an educational intervention aimed at improving mother-baby interactions, increasing breastfeeding exclusivity and duration, and reducing overfeeding and inappropriate feeding practices among participants in the WIC program. This multicenter intervention consisted of staff training sessions covering infant cues and sleep cycles, educational materials, and participant classes, all designed to transform WIC clinics into valuable resources for mothers with questions about baby behavior. Detailed information about the intervention design and results will be published elsewhere.
      One element of the Fit WIC Baby Behavior Study was the “Getting to Know Your Baby” calendar. The first 6 weeks can be the most challenging time for new parents, because infants feed and wake up quite frequently, and parents must adjust to meeting the needs of their new infant. This 6-week, countdown-style calendar was created to address the concerns of new parents by incorporating tips and facts about newborn infants, motivational messages, and breastfeeding support information. The calendar was distributed to pregnant women participating in the WIC program at the intervention clinics. This paper will describe the development and preliminary testing of the calendar.

      Calendar Content

      Before designing the calendar, focus groups were conducted among participants in the WIC program to identify the common problems encountered by new mothers and specific information that would be of most use during the first 6 weeks postpartum. The focus group script was developed and reviewed by the research team. Once completed, the script was translated into Spanish and then back-translated to ensure that it was consistent with the English version.
      Two members of the research team attended each focus group, 1 to facilitate the discussion and 1 to take notes. Only parents who had infants 3 months of age or younger, who were enrolled in the WIC program, and who spoke either English or Spanish were eligible to participate. Four focus groups were conducted, 2 in English and 2 in Spanish. A total of 24 participants attended the groups, 12 in each language group. This study was approved by the Institutional Review Board of the University of California–Davis.
      Transcripts of the focus groups were reviewed independently by each member of the research team, and themes were categorized into key topics to be discussed in the calendar. The key topics were organized within the calendar based on chronological need for the information. For example, the need to explain the onset of lactation was addressed by including a simplified description on a page reflecting the first few days postpartum.
      The focus group participants confirmed that the first 6 weeks are the most difficult and that lack of sleep and infant crying were the major problems new parents encounter. In addition, the importance of getting help from others, maternal healing, dealing with visitors and other responsibilities, and infant feeding were identified as important topics to include in educational materials for new parents.

      Calendar Design

      The calendar was designed by the first author. The goal was to maximize the information that could be included while minimizing the amount of text and ensuring readability. Each day was labeled with the age of the baby (eg, Day 1, Day 2) and the number of days remaining until the baby turned 6 weeks old. Relevant tips, advice, and facts about babies were included on each day, and quotes from mothers and pictures of babies were placed at the top of each page (Figure 1). The text was written at or below a sixth-grade level to ensure that it would appeal to participants with a broad range of education levels. A brief introduction and description of how to use the calendar was included on the inside cover, and the last 2 pages included a list of resources. The original design included extra space for mothers to record information about their babies, but because of funding limitations, the calendar size was reduced and the blank space was eliminated. The calendar measured 7 in. × 7 in. The cover was printed on heavy paper and saddle-stapled (Figure 2).
      Figure thumbnail gr1
      Figure 1Example of 1 page in the “Getting to Know Your Baby” calendar.
      Figure thumbnail gr2
      Figure 2The cover of the “Getting to Know Your Baby” calendar.

      Cognitive Testing

      A draft version of the calendar was tested at a local WIC clinic. Mothers were interviewed to ensure that the calendar was accepted, understood, and useful to new mothers. Pregnant women and mothers of children 2 years old and younger were asked to review the calendar while waiting for their appointments. A member of the research team interviewed the mothers and asked their opinions about the design and usefulness, and asked them to provide suggestions for improvements. Comprehension of the calendar's messages was tested by asking participants to look at a specific day and explain, in their own words, how they would use the information provided. The research team discussed the results and revised the calendar accordingly.
      Thirteen mothers agreed to participate in this preliminary testing and indicated that the calendar was considered attractive. Eleven mothers (85%) reported that they liked the cover; 2 mothers (15%) suggested the cover should include photos of infants rather than cartoon animals. All of the mothers considered the layout easy to follow and the font easy to read. All of the mothers correctly identified the purpose of the calendar. Eleven (85%) stated that the calendar would be very useful; the remaining mothers reported that they had obtained similar information from other materials (books, pamphlets, etc.). Full testing of the efficacy of the calendar will be performed at the end of the Fit WIC Baby Behavior study.

      Calendar Use in the Baby Behavior Study

      Six thousand copies of the calendar in each language (English and Spanish) were ordered for the Fit WIC Baby Behavior Study at $.75 per copy. The cost of printing is dependent on a number of factors, including the quantity. For example, upon completion of the study, the estimated cost of printing 168,000 copies of each language was $.46 per copy.
      The final version of the calendar was just 1 element of the Fit WIC Baby Behavior Study and was not designed to be used independently. Detailed data regarding the calendar's influence on the study outcomes were not collected, however, 88% of WIC staff reported that the study handouts were useful for delivering the Baby Behavior messages, and both staff and participants were impressed by the quality of the calendar. One staff member explained that “the calendar is like a gift for moms!” The results of the Fit WIC Baby Behavior study will be published elsewhere.

      Summary

      High-quality, participant-focused educational materials may be used to deliver messages to participants in public health programs such as the WIC program. The “Getting to Know Your Baby” calendar was designed with information collected directly from the target population and aims to clarify expectations of what it is like to bring home a new baby and provide guidance through the first 6 weeks of the baby's life. It was well received by both staff and participants in the WIC program, and it continues to be used by clinics now that the intervention is complete. In addition, other public health professionals have expressed interest in obtaining the calendar for their programs.

      Notes

      The calendar, along with all of the other Fit WIC Baby Behavior intervention materials, will be available to be downloaded from the WICWorks Web site upon approval by United States Department of Agriculture (USDA), Food and Nutrition Service (FNS). The contents of the publication described do not necessarily reflect the view or policies of the USDA, nor does the mention of trade names, commercial products, or organizations imply endorsement by the US government.

      Acknowledgments

      The authors would like to thank the Community Resource Project WIC in Sacramento California for allowing the authors to conduct the focus groups and testing at their clinic. The authors would also like to acknowledge the mothers who spent time discussing their experiences with them. This project was funded at least in part with Federal funds from the USDA FNS.

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