Abstract
Perceived insufficient milk (PIM) is the primary reason for breastfeeding discontinuation globally. This study evaluated the short-term impact of mother–infant interactions through home interventions designed to overcome PIM as a result of the infant’s behavior, delivered to 14 dyads of breastfeeding mothers and their full-term singleton infants. A single group, three-occasion prepost design was used. Mother–infant interactions were measured by the Nursing Child Assessment Feeding Scale (NCAFS) at 6, 13, and 27 days postpartum. There were significantly increased mother–infant interactions during intervention. Specifically, significant growth over the intervention occurred for mother’s sensitivity to cues, cognitive growth fostering, infant’s clarity of cues, and responsiveness to caregiver. The NCAFS total score was also significantly improved. Although modifications are required, the three home intervention sessions showed promise in improving mother–infant interactions during breastfeeding. Further investigation using a randomized experimental design is warranted.
Keywords
Extensive evidence on the science of breastfeeding has demonstrated the long-lasting health benefits to both mothers and infants. Evidence also points to early initiation, longer duration, and exclusivity of breastfeeding as key to realizing health benefits and protective effects (Heinig, 2001; Ip, Chung, Raman, Trikalinos, & Lau, 2009; Kramer & Kakuma, 2004). The protective effects of breastfeeding occur as a result of dose-response; therefore, minimal breastfeeding may not be protective (Raisler, Alexander, & O’Campo, 1999). Despite the fact that the first 6 months of exclusive breastfeeding, either direct breastfeeding or through expressed milk, is recommended by World Health Organization (WHO)/UNICEF and the American Academy of Pediatrics (AAP; Section on Breastfeeding, 2012; WHO, 1991), only 16% of mothers in the United States do so (Centers for Disease Control and Prevention, 2014). Perceived insufficient milk (PIM), typically initiated in the first 1 to 2 weeks postpartum, accounts for the highest drop off rate of exclusive breastfeeding globally (Brown, Dodds, Legge, Bryanton, & Semenic, 2014; Camurdan et al., 2008; Hauck, Fenwick, Dhaliwal, & Butt, 2011). Infant crying and fussiness are the most common symptoms of PIM (Huang, Lee, Huang, & Gau, 2009; Sacco, Caulfield, Gittelsohn, & Martinez, 2006; Segura-Millán, Dewey, & Perez-Escamilla, 1994); the other leading symptoms involve perceptions of infants’ poor weight gain (Gerd, Bergman, Dahlgren, Roswall, & Alm, 2012; Odom, Li, Scanlon, Perrine, & Grummer-Strawn, 2013) and frequent feedings (Wagner, Chanty, Dewey, & Nommsen-Rivers, 2013; Wright, Parkinson, & Scott, 2006). These symptom clusters appear to make mothers uncertain about whether they have adequate milk supply to breastfeed their infants, and subsequently, they tend to supplement with formula to compensate for PIM (Chantry, Dewey, Peerson, Wagner, & Nommsen-Rivers, 2014; Flaherman, Hicks, Cabana, & Lee, 2012; Tang, Binns, & Lee, 2015). Formula supplements, however, interfere with maternal breast milk supply because it decreases the opportunities for infant suckling on the breast and decreased breast milk removal, which is a prerequisite for lactogenesis stages II to occur (Scott, Binns, & Oddy, 2007). Hence, it appears that many mothers may not realize that breastfeeding is a supply and demand relationship: When infant suckling decreases, breast milk supply will not increase, resulting in the inability to establishing exclusive breastfeeding directly on the breast (EBFOB). Research has also revealed that PIM is associated with maternal lack of confidence in her ability to breastfeed (Hill & Aldag, 1991; Otsuka, Dennis, Tatsuoka, & Jimba, 2008). Indeed, a breastfeeding self-efficacy intervention in the postpartum period promoted breastfeeding exclusivity and duration (Kronborg, Vaeth, Olsen, Iversen, & Harder, 2007). However, maternal perception of infant behavior remains unanswered (Wood, Woods, Blackburn, & Sanders, 2016) as crying is the main attribution mothers use to measure milk supply (Dykes & Williams, 1999). Previous studies suggest that mother–infant interactions of breastfeeding mothers are higher than those with other feeding types and methods (Bigelow, Power, Gillis, Maclellan-Peters, & Alex, 2014; Brandt, Andrews, & Kvale, 1998; Lavelli & Poli, 1998).
Purpose
The purpose of the present study was to evaluate the short-term effects of a home-based mother–infant breastfeeding education program designed to overcome PIM on growth in mother–infant interactions during first month postpartum.
Method
Design and Sample
A single group three-occasion pretest–posttest design was used. After being approved by the university review board, onsite recruitment at a Pediatric Care Center in the U.S. Pacific Northwest region serving a diverse urban community began with the clinic’s receptionist handing out a brochure to each mother who arrived, informing mothers of a new breastfeeding study when asked by the principal investigator (PI), who is also the first author. Then, the PI went to the mother either in the waiting room or the nursing room and introduced the study. Interested mothers received further explanation about the study and were asked questions for eligibility screening. As a primary health care intervention, the program was designed for all primiparous and multiparous mothers who were concerned about breastfeeding their infants. Inclusion criteria included all the following: (a) breastfeeding mothers whose goals were EBFOB; (b) mother’s ability to speak, write, and read English; (c) ability to attend three intervention sessions within 1 month postpartum; and (d) having recently given birth to a full-term, singleton infant with no congenital abnormalities. Exclusion criteria included mothers with medical contraindications, breast reduction, or breast cancer.
After recruitment, a sample of 15 mother and infant dyads with infants less than 7 days old were initially entered into the study during the first well-child visit or a follow-up visit to the pediatric care center. We had specifically targeted this sample size for this study as a sample size of 15 dyads and three measurement occasions would yield power exceeding 80% to detect effects of time on outcomes (assuming a one-way repeated measures ANOVA, a moderate to large effect size level of .30, approximately correlations of .20 among measurement occasions, and an alpha level of .05).
Ultimately, only 14 dyads completed the study sessions as one mother left her home country in 2 weeks postpartum (this mother reported being Arabic in ethnicity and had a normal vaginal delivery). For the 14 mother–infant dyads who completed the study, mothers’ age averaged M = 33.93 years (SD = 3.93), and infant gestational age averaged M = 39.69 weeks (SD = 1.43). Average infant birth weight was M = 3,447.29 grams (SD = 511.45). Additional demographic characteristics are provided in Table 1. Although not shown on Table 1, at the entry into study, six mothers (43%) were concerned about breast milk supply, five (36%) were either unable or had poor latch, one (7%) had a history of inverted nipples, and four (29%) had nipple pain. Three mothers (21%) were concerned about frequent feedings and two mothers (14%) about the infant not sleeping at night.
Sample Demographic Characteristics.
Note. N = 14 mothers, self-report information. None were smokers, and during pregnancy, all had planned to breastfeed their babies. Nine reported having had alcohol prior to pregnancy (but none during pregnancy), and all but one was primiparous during the study.
Protocol
Intervention
The program (titled “Protecting Your Ability to Breastfeed Your Baby: A Pilot Feasibility Study of an Educational Program for Breastfeeding Mothers and Babies”; Wood, 2015) targeted PIM as a conduit to addressing mutable causes of the problem, in particular, maternal perception of infant behavior and maternal confidence in her ability to breastfeed her infant (Wood et al., 2016). The intervention was designed to bolster mothers’ breastfeeding knowledge and skills, breastfeeding self-efficacy, and perceived milk supply to establish and sustain EBFOB in the first month postpartum. The intervention was guided and designed using three theoretical frameworks: Bandura’s (1986, 1997, 2001) social cognitive theory for building mothers’ breastfeeding skills; Mercer’s (2004) theory of becoming a mother to reflect mother’s readiness to learn, concomitantly occurring Lactogenesis II; and Barnard’s (1976) model of early mother and infant interaction, which guides ways to interpret infant behavior and respond through breastfeeding on the breast (BFOB).
Three home-based intervention sessions were delivered on the day immediately following the recruitment, 2 weeks postpartum, and 4 weeks postpartum (specifically, sixth, 13th, and 27th day of life). There were approximately 1-week intervals between Sessions 1 and 2, and a 2-week interval between Sessions 2 and 3. Each intervention session was delivered face-to-face, 60 to 90 min in length by the PI who is also an registered nurse (RN) in the United States, a registered Japanese midwife with extensive maternal infant nursing background, and a certified trainer on the Nursing Child Assessment Feeding Scale (NCAFS; Barnard, 1976). The uniqueness of the intervention was that it engaged mothers in specially designed breastfeeding behavior, BFOB in response to infant’s behavior, considering the fact that PIM is the main reason for early breastfeeding discontinuation, coupled with infant physiological weight loss in which mothers wonder whether they are producing enough milk for their infant. In other words, the intervention encouraged mothers to persevere with BFOB even while supplementing with formula which is often necessary during initial infant weight loss. The sequence of the process, BFOB in response to infant behavior, ensured the desired outcomes contributing to PIM. As a result, mothers would establish and sustain EBFOB. As such, the educational program may also be defined in part as nurse-guided breastfeeding practice. Internal cues were adapted after discussing the most common concerns mothers might have had about their infant’s behavior. Allowing the discussion to be didactic as well as interactive, it was hypothesized that increased mother–infant interactions would occur. Intervention fidelity and dosage were monitored and protected through the review of audio recording of each session, assessment by the performance checklists against the fully scripted educator manual, and discussion of completed as well as ongoing sessions with the committee chair.
The sessions included the following topics: reinforcing benefits of breastfeeding, enhancing the interpretation of infant behavior about breastfeeding, BFOB in response to infant behavior, assessing breast milk supply contingent to infant behavior, promoting self-care, and, last, anchoring breastfeeding behavior. Although varying in content, there were four core components to the intervention: (a) interactive didactic teaching delivered by the PI; (b) breastfeeding observations and feedback; (c) feeding logs that included the type, methods, and frequencies of feeding, infant crying, sleep–awake cycles, and excretions for 3 weeks; and (d) access to the PI by phone as needed between the home intervention sessions. Table 2 provides a brief description of each of the three intervention sessions.
Description of the Intervention Sessions.
Note. BFOB = breastfeeding on the breast.
Demographic questionnaire.
Modified Breastfeeding Self-Efficacy Scale–Short Form, modified from Dennis (2003).
Perceived adequate milk supply questionnaire.
NCAFS = Nursing Child Assessment Feeding Scale.
Measures
Demographic data, including pregnancy, labor, and delivery, were collected in Session 1. Mother–infant interactions were measured by NCAFS (Barnard, 1976). On this scale, there are 76 binary items with six subscales and a total score. Subscales include four mother and two infant categories, with caregiver scales involving Sensitivity to Cues (16 items), Response to Child’s Distress (11 items), Social–Emotional Growth Fostering (14 items), and Cognitive Growth Fostering (nine items). Infant scales include Clarity of Cues (15 items) and Responsiveness to Caregiver (11 items). Within the six subscales, there are contingency items for both mothers (15 items) and infants (three items). Contingency is a two-way communication between mother and infant, a behavior that brings a consequence. For example, if a mother interprets her infant is hungry, she breastfeeds her infant and then the infant responds through suckling. According to the test manual, reliabilities using Cronbach’s alpha have shown that the total NCAFS scale is .88, and caregiver subscales range from .60 to .88 (with caregiver total score internal consistency of .85). The two infant scales have reliabilities of .76 each (Oxford & Findlay, 2015). NCAFS is typically used for infants from birth to 1 year, cutoff points are not given with higher scores indicating more desirable mother–infant interactions. The PI, who was trained to administer the NCAFS, obtained a reliability certificate for more than 90% interrater reliability.
Data Collection and Analysis
All data collection and signed informed consent began after approval by the university human subjects committee. Mothers who were eligible to participate in the study had their charts reviewed for pregnancy and delivery records. When mothers and their infants met eligibility criteria, the PI obtained signed informed consent, scheduled appointments for home intervention sessions, and delivered interventions at home at 6, 13, and 27 days postpartum on average. All subsequent analyses included only the 14 mothers who completed all the sessions. Each mother was observed feeding her infant in her home at various times of the day from 9:30 to 14:30 over three sessions. It usually took place at the beginning of a session but when the infant was not ready to nurse, the education portion of the session was given followed by breastfeeding observations. When breastfeeding occurred more than once during a session, the PI scored the first practice before feedback was given. The subsequent observations were recorded in the clinical notes. As a check to make sure that there were no significant differences between teaching time frames (i.e., mothers who received teaching before vs. after breastfeeding), a series of two-group t tests were conducted at each time point. No significant differences were found (p > .05).
One-way within-subjects ANOVAs were used to analyze data. Time was treated as the within-subjects, fixed factor (three measurement occasions: pretest [6 days], midtest [13 days], and posttest [27 days]). For all ANOVAs, Mauchly’s test was used to determine whether sphericity was a tenable assumption; in cases where sphericity was violated, adjusted F tests were used (Greenhouse–Geisser df) to control the Type I error rate to .05. For each analysis, post hoc pairwise t tests (with alpha level adjusted for multiple comparisons using the Dunn–Sidak procedure) were used to determine the location of mean differences between time points. Finally, trend analyses were also conducted to determine whether change over time was constant (linear), and/or whether deceleration or acceleration in change over time had occurred (quadratic, for example, plateau effects).
Results
The “Results” section contains the quantitative analysis followed by qualitative analysis.
Quantitative Analysis
For each measurement occasion (pre, mid, and posttest), descriptive statistics are shown in Table 3, and correlations for scales in Table 4. Recall that each of the N = 14 participating mother–infant dyads were observed feeding their infants in their homes at three time points, including pretest (Time 1 with an average home intervention session on Day 6), midtest (Time 2 with an average home intervention session on Day 13), and posttest (Time 3 with an average home intervention session on Day 27). The results of the one-way, within-subjects ANOVAs to test mean differences across time are reported in Table 5. These results showed that there were a significant main effect of time on two of the four NCAFS mother subscales, including Mother’s Sensitivity to Cues and Cognitive Growth Fostering. There was also significant growth detected on both of the infant NCAFS subscales (Clarity of Cues and Responsiveness to Caregiver Over Time). Not surprisingly, significant growth was also detected for combined NCAFS total scores.
Descriptive Statistics for NCAFS Subscales and Total Score.
Note. N = 14 mother–infant dyads. NCAFS = The Nursing Child Assessment Feeding Scale.
Correlations Among Scales by Measurement Occasion.
Note. N = 14 mother–infant dyads. Pearson’s r shown. NCAFS Tot = Nursing Child Assessment Feeding Scale Total Score; SensCues = Mother’s Sensitivity to Cues; RespDistrss = Mother’s Response to Child’s Distress; EmoGrow = Mother’s Social–Emotional Growth Fostering; CogGrow = Mother’s Cognitive Growth Fostering; CueClear = Infant’s Clarity of Cues; RespCrgiv = Infant’s Responsiveness to Caregiver. 1 = Time 1 pretest (6 days); 2 = Time 2 midtest (13 days); 3 = Time 3 posttest (27 days). RespDistrss 3 had no variance (all mothers scored at the ceiling), and, therefore, no correlations could be computed for this measure at posttest.
p < .05. **p < .01.
Repeated Measures ANOVA Results Testing Effect of Time on Outcomes.
Note. N = 14 mother–infant dyads. F test df = 2, 26 to test effect of Time for all scales except for mother’s Sensitivity to Cues and infant’s Response to Distress due to sphericity violation (for these, Greenhouse–Geisser F test corrected df used). Effect size is partial eta-squared (
Follow-up analyses to main effects showed that most of the differences occurred between Time 1 (pretest; 1 week or 6 days) and Time 3 (posttest; 4 weeks or 27 days), and all the trends were linear rather than quadratic (i.e., no evidence for plateauing). One exception to this included mother’s sensitivity to cues, for which there were significant differences between Time 2 and Time 3 in addition to differences between Time 1 and Time 3 (Dunn–Sidak adjusted t test p < .05). In addition, there was a similar trend for infant’s responsiveness to mother to grow between Time 1 and 2 (adjusted p = .09) in addition to significant growth between Time 1 and 3 (adjusted p < .05). In other words, the pattern of findings was remarkably consistent: both mothers and infants grew on most of the NCAFS scales during the overall (Times 1 to 3) intervention period. Figure 1 shows a plot of means over time for each of the subscales for which there was significant growth over time.
Means for subscales exhibiting significant change over time.
Qualitative Analysis
Mother’s qualitative analysis
There were three patterns of change over time on sensitivity to infant behavioral cues, including overall improvement and maintenance, but also some backsliding. Ten mothers (71%) improved and maintained their sensitivity. For example, ID 4, who had a history of inverted nipples and early introduction of bottles and pacifier use during the infant’s hospitalization with meconium aspiration, could not sustain her breastfeeding practice. Although, she consistently improved her sensitivity to the infant’s satiation cues, this ultimately resulted in an appropriate termination of the bottle feeding. Two mothers (14%) lowered their sensitivity in Session 2 but improved in Session 3. For example, ID 1 joined the study with a full score for sensitivity. However, in Session 2, when her breast milk production increased, the mother was concerned about the infant choking with too much milk coming out at once, so the infant was not allowed to latch on to the areola deep enough or allowed to suckle without interruption. In Session 3, she regained her sensitivity to the infant’s behavioral cues again. ID 7 was still confused about satiation cues and nonnutritive sucking present before terminating breastfeeding in Session 2. However, she was able to obtain those skills by the end of Session 3. There were two mothers (14%) whose scores had 1-point reduction during the last two sessions. For example, the infant’s positioning of ID 11 who was using nipple shield was almost flat because she placed the infant on the nursing cushion in Session 3, causing nipple pain.
Response to child’s distress appeared that all the mothers were responsive to infant distress either through BFOB or supplementing with formula in a bottle. Item 22, caregiver diverts child’s attention by playing games, introducing toy, or making faces were not age appropriate.
The patterns for social–emotional growth fostering varied that nine mothers improved (64%), one mother maintained, one mother lowered in Session 2 but regained in Session 3, and three mothers (21%) lowered their scores. For example, ID 15, whose mother used a nipple shield during hospitalization and also introduced a pacifier at home, resulted in nipple confusion and being away from the breast for 24 hr on Day 5. However, she had a strong desire for EBFOB. During feedings, the mother engaged with enthusiastic mood, providing eye contact, social initiative, and affective reinforcement for her infant’s behavior. ID 14, who had been using a nipple shield since hospitalization, could not sustain her BFOB without the nipple shield even though the infant was able to latch on correctly without it in Session 2. She reduced her scores because she was distracted by the computer during feedings. Overall, mothers’ gazing, smiling, touching, and making positive statement were present in the early onset (n = 5, 36%), but praising her infant during feeding usually came in late at Session 3 (n = 7, 50%). Maternal response to infant’s smiling or vocalizing at caregiver started appearing at Session 3.
Finally, for cognitive growth fostering, 10 mothers (71%) increased their scores as evidenced by verbally stimulating their infants during feedings as they grew older. One mother maintained her score, and three (21%) lowered their scores. With that, ID 1 had her infant wear gloves and did not give a chance to explore the breast during feedings.
Infant’s qualitative analysis
Qualitative inspection of each infant’s trajectory of clarity of cues showed that eight infants (57%) improved their scores, one maintained, three (21%) lowered in Session 2 but improved in Session 3, one lowered in Session 2 and maintained in Session 3, and one lowered in Session 3. Cues, including hunger, satiation, engagement, and disengagement, were sent more clearly at Session 3 for those infants who improved their scores. Items of infant positive affect and social initiatives such as looking at mother, vocalizing, and smiling initiated by infant appeared to happen at Session 3. In the responsiveness to caregiver, the infants became more responsive to mother’s feeding attempts and mother’s consolable/soothing behaviors as they grew older. Items of infant’s vocalization and smiling were not fully developed yet in the first month of life.
Discussion
This is the first intervention focusing on PIM that assessed mother–infant interactions in the first month postpartum. Findings from this pilot study suggest that a structured, skill-building, efficacy-focused intervention has the potential to positively affect mother–infant interactions around BFOB. There are three plausible reasons why this intervention had impact. First, the intervention’s effects appear to be linked with the program’s ability to give structure to the mother’s way of interpreting infant behavior and responding through BFOB. Instead of assuming that mothers have a complete understanding of infant behavior, the program assessed maternal perception of infant behavior through breastfeeding observations and gave mothers concrete ways of interpreting infant behavior and how to respond to this behavior through BFOB. As a result, the program prevented erroneous attribution of infant behavior to PIM. In the process, mothers reported they became more aware of infant behavior, responsiveness cues, and the pattern of breastfeeding in response to infant behavior. The majority of mothers started BFOB when infants cried and were uncertain about when to switch to the other breast and when to finish breastfeeding at the entry into study. Concomitantly, almost all the mothers spent their time on gazing, smiling, and touching in Session 1 (Bigelow et al., 2014; Lavelli & Poli, 1998). The mothers then added skills enhancing their sensitivity and responsiveness to infant behavior through BFOB and assessing breast milk supply contingent on infant behavior. As a result, relatively little crying was reported, and mothers became more naturally verbally interactive with their infants in Sessions 2 and 3 (Bigelow et al., 2014; Lavelli & Poli, 1998). In response, the infants sent more clear cues and were more responsive to their mothers evidenced by the improved scores on the NCAFS infant behavior subscales.
Second, this program engaged mothers to BFOB in response to infant behavior. Behaviorally, BFOB involves a reciprocal interaction between mother and infant. Breastfeeding begins when mother senses infant’s hunger cues, draws the infant to her breast, and nurses. In return, the infant responds through suckling with self-regulated intake. Breastfeeding is embedded with skin-to-skin contact, eye-to-eye contact, facial and vocal expression, hearing, smiling, touching, odor, and heat transfer between mother and infant (Klaus & Kennell, 1976). Breastfeeding ends when the mother responds to infant’s satiation. Mother’s initiation for BFOB contributes to the infant responsiveness. Breastfeeding behavior is then shaped by responding to each other, modifying and adapting to each other’s behavior, that is, contingency. When contingency responses are positive, it gives the infant a sense of security that later allows him or her to feel safe, ready to explore his surroundings (Barnard, 1976). Biologically, breastfeeding stimulates oxytocin release, causing milk let down. Prolactin produces breast milk whose levels are higher at night due to the circadian rhythm. Oxytocin is important for maternal positive mood states. Prolactin reduces stress and pain reduction. These are likely the consequence of increased activity of brain systems with inhibitory effects in the hypothalamic-pituitary-adrenocortical axis (HPA axis) and/or a reduced activity of excitatory pathways such as norepinephrine, corticotropin-releasing hormone (CRH), and opioids (Kendall-Tackett, 2007). Suckling is suggested to have an inhibitory effect on the HPA axis (Heinriches et al., 2001).
Third, home intervention sessions were preferred by the participating mothers who stated that it is an arduous task to go to outside appointments when they are not physically recovered yet, and they are just assimilating their infant into the household. Having an objective, educated professional observe breastfeeding in the mother’s own environment facilitates individualized feedback, reinforcing breastfeeding practice in response to their infant behavior, and ensuring mothers can build skills as well as confidence in breastfeeding.
The findings from this study must be viewed with caution due to the single group with the convenience sample of educated mothers, scored by the PI, the same person as the interventionist. Some of the mothers, especially those who had difficulty with breastfeeding, sought help from the lactation consultant before or after enrollment into this study. Compared with the average scores of the mothers whose education is 13 years or above and whose infants aged from 0 to 5 months old (Oxford & Findlay, 2015), the NCAFS total score is lower for this study. This is due to some of items being not age appropriate as this study was measured strictly for infants within their first month. Nonetheless, the pattern of mother–infant interactions within the first month was notable. The findings suggest that it is reasonable to follow mothers during the early critical weeks at home. Future studies should include how mother–infant interactions affect breastfeeding outcomes (Brandt et al., 1998) in the long term or vice versa. The intervention developed for this current study might prove a good fit for further improving health disparities pertaining to breastfeeding. Further studies with more rigorous research design are warranted.
The content of the intervention can be taught by nurses, including public health nurses or nurses in well-child clinics who have been trained in breastfeeding in the context of maternity nursing. Nurses doing this intervention will need to be educated concerning infant behaviors. Nurses should also consider providing more opportunities for mothers to practice BFOB. Helping mothers to keep their infants close to them all the time, especially at night, will facilitate breastfeeding on demand (McKenna & McDade, 2005). Infant-led breastfeeding during skin-to-skin contact will naturally increase breast milk supply (Moore, Anderson, Bergman, & Dowswell, 2012).
Breastfeeding not only contains health benefits and protective effects for both mother and infant but also facilitates the relationship between mother and infant as shown in the current study. Breastfeeding is a natural process designed not for survival but for a thriving mother–child relationship. Breastfeeding builds human attachment, the uttermost love in which humans need to thrive.
Footnotes
Acknowledgements
The first author would like to thank Dr. Frances M. Lewis for mentoring clinical trials. The authors express appreciation for Dr. Kathleen R. Helfrich-Miller for the assistance of article preparation.
Authors’ Note
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Health.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number TL1TR00422, and the Hester McLaws National Scholarship as well as the Sigma Theta Tau International Psi-at-Large Chapter from the University of Washington School of Nursing.