The study was approved by the IRB department of Howard University and conducted in three privately managed clinics catering to low-income residents of Washington, DC. The clinics were selected for two reasons: 1) they had a large roster of African-American clients, and 2) each had a site office for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), which made it easier for clients to get their healthcare and WIC vouchers at the same time. The ultimate goal in selecting these clinics was to promote retention and to reduce attrition.
Beginning in April 1999, recruitment of 105 postpartum women who met the study’s criteria was embarked upon. Each mother and infant dyad was followed up until the infant returned for the six-to-seven-month well-baby visit. After signing a consent form to participate, each mother completed several questionnaires with the assistance of the primary investigator. The first questionnaire completed was the Social Demographic Questionnaire, which contained variables, such as maternal age, parity, marital status, education, family income, number of household residents, and use of social services (such as WIC). At the first meeting, mothers were also asked to make verbal assessments of their perceptions of their infant’s body size at birth and visual assessments by using a body silhouette scale. The African-American Infant Body Habitus Scale (AAIBHS) was used for the visual assessment and was developed and validated by the primary investigator prior to the study. It was tested for face validity to make sure that the images outlined represented the age group on which questions were being asked. When administered, 74% of the pilot test group agreed that the image represented infants at six months of age, and the remainder thought the images were between five and seven months old. The AAIBHS was administered at the first and last well-baby visits and evaluated maternal perception of infant body size in four specific categories: typical infant size, healthy infant size, preferred infant size, and current infant size. The scale contained two sex-specific frames with five images ranging from #1—thin to #5—obese. It was administered by asking mothers the following four questions: 1) Which of these figures do you think represents a typical six-month-old African-American female/male in your neighborhood?, 2) Which of these figures represents a healthy body size for a six-month-old male/female infant in your neighborhood?, 3) Which of these figures would you prefer your baby to look like in six months?, and 4) Which of these figures represents the size of your baby at six months of age or currently? Whereas the first three questions were presented at the first meeting, the fourth question, which assessed mothers’ current perception of their infant’s body size, was asked at the infants’ last well-baby visit.
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Data on maternal attitudes and beliefs about infant feeding and infant fatness were gathered using the Maternal Infant Feeding Attitude Questionnaire (MIFAQ) and Maternal Infant Feeding Practice Questionnaires (MIFPQ)—both of which were developed from the broad infant literature specific to this population. Several of the questions were adapted from the study by Kramer, which is one of the only two studies that dealt with body image in infancy. In addition to these two questionnaires, a supplemental semistructured interview schedule was administered to substantiate the contents of the MIFPQ and the MIFAQ. Additionally, a food frequency questionnaire was administered at the first and subsequent meetings with mothers to capture the introduction of nonmilk foods into the infants.
Using the normative Body Parts Ranking Scale (BPRS), which consisted of six cards each labeled with the name of one of six body parts, mothers were asked to rank the cards according to their perceived importance in determining infant fatness. The six body parts individually listed were thighs, buttocks, arm, leg, face, and stomach. The rank order of the body parts was used to determine perceived importance in assessing infant fatness. Higher rank order meant greater importance in determining fatness.
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Figure 1. African-American Infant Body Habitus Scale
Using the values for the images in Figure 1 (AAIBHS), the mean of each body size category was calculated by summing up the given value of all the images selected by mothers in response to the question specific to that category. For example, the numerical value of all the images selected by mothers in response to the question of “Healthy Body Size” was summed up and divided by the total number of respondents to acquire the mean for that category. The same procedure was followed for the remaining three categories. A larger mean meant that the mothers generally selected a larger body size in response to the corresponding question, and a smaller mean meant that a smaller size was selected. To assess whether the mean for each category was significantly different in this group, paired t-tests analysis was conducted.
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Anthropometrical measures of the infant and mother were gathered at the first and subsequent clinic visits until the study was terminated. As the study progressed, infant feeding practices, specifically the introduction of solids and other nonmilk foods, were assessed monthly at each well-baby visit and periodically over the phone if mothers missed their well-baby visits.
Whenever a clinic visit was missed, mothers were called and their next clinic visits confirmed with both the mother and the pediatric nurse and the WIC dietitian, if applicable. All of this was to ensure that mothers were not lost to follow-up. In addition, mothers were also called on the telephone by the primary investigator, whenever possible, to remind them of their appointments and confirm changes in schedule if noted on the clinic appointment books. All participating mothers were compensated with token baby gifts for each clinic visit that they kept with the primary investigator in an effort to reduce loss to follow-up. It is important to note that all the clinics selected had a consistently high history of patients not showing up for their appointments, and this was being addressed at the time of the study by the managing entity selected by the District of Columbia.