Capturing Changes in HIV-Infected Breastfeeding Mothers' Cognitive Processes from Before Delivery to 5 Months Postpartum: An Application of the Pile-Sorting Technique in Haiti

Abstract

Background: The cognitive processes involved in individuals' perceptions and prioritization of information, and how these change with experience or exposure to interventions, are rarely examined in the evaluation of nutrition interventions. Exclusive breastfeeding counseling is a common infant and young-child feeding intervention and is used to promote HIV-free survival in the prevention of mother-to-child transmission programs. However, it is often designed without adequate attention to the changes in mothers' perceptions over the course of their early breastfeeding experiences.

Objective: The aim of this study was to identify HIV-infected breastfeeding mothers' cognitive structure (their organization of messages and ideas) of infant feeding messages and to characterize whether their cognitive organization of infant feeding messages changed from pregnancy through the first 5 mo postpartum.

Methods: With the use of semistructured interviews and the cognitive mapping technique of pile sorting, we interviewed 30 HIV-infected breastfeeding mothers in Port-au-Prince, Haiti. We asked them to sort and rate 18 infant feeding messages 3 times (during pregnancy, 0- to 1-mo postpartum, and 3- to 5-mo postpartum). We analyzed their responses by using multidimensional scaling, property fitting, and partition analyses.

Results: At all 3 visits, we found consistency in women's cognitive mapping of messages. For example, mothers consistently differentiated messages pertinent for exclusive breastfeeding compared with those that pertained to other practices. However, subtle variations in mothers' cognition over time were also evident, particularly at 0- to 1-mo postpartum, when message proximity was tightly clustered compared with the earlier and later periods.

Conclusions: We conclude that mothers share a common cognitive organization of infant feeding messages and that this organization changes over time. Attention to variations in cognition can support context-sensitive, patient-centered counseling by practitioners and improve the effectiveness of nutrition interventions. Pile sorting is an efficient, systematic technique to examine cognitive processes related to health and nutrition.

Keywords: HIV; Haiti; breastfeeding; cognitive mapping; infant and young child feeding; maternal perceptions; pile sorting; pregnant and lactating women.

FIGURE 1

HIV-infected mothers’ cognitive structures about infant feeding messages at pregnancy (as mapped by using MDS, hierarchical cluster, and PROFIT analyses). This figure represents the MDS plot of 27 HIV-infected mothers. The Kruskal stress test indicated a good fit, less than the cutoff of 0.273. Numbers represent individual messages (as described in Table 2) and the circles around the numbers indicate clusters based on hierarchical cluster analysis. From this figure, we can discern that mothers’ perceptions are patterned into 3 main clusters. The distance between numbers (i.e., messages) indicates how closely related they are to one another—the greater the distance, the less similar the message pair, and the smaller the distance, the more similar the message pair. For example, messages 1 and 12 were grouped close together and are more similar to one another than, for example, messages 5 and 15, which are much further apart. The lines in the figure represent the dimensions of the MDS plots based on the PROFIT analysis. The direction of the arrows indicates the increasing value of the dimension. MDS, multidimensional scaling; PROFIT, property fitting.

FIGURE 2

HIV-infected mothers’ cognitive structures about infant feeding messages over time (as mapped by using MDS, hierarchical cluster, and PROFIT analyses). This figure represents the MDS plot of 27 HIV-infected breastfeeding mothers at pregnancy, 22 HIV-infected breastfeeding mothers at 0- to 1-mo postpartum, and 19 HIV-infected breastfeeding mothers at 3- to 5-mo postpartum. The Kruskal stress indicated a good fit, at <0.273. Numbers represent individual messages (as described in Table 2) and the circles around the numbers indicate clusters based on hierarchical cluster analysis. The lines in the figure represent the dimensions of the MDS plots based on the PROFIT analysis. The direction of the arrows indicates the increasing value of the dimension. The 3 main clusters of messages were maintained over time. The shading in the figure depicts how the proximity or similarity between messages changed over time (i.e., the spread of the clusters). MDS, multidimensional scaling; PROFIT, property fitting.