Community-Based Focus Group Development: Identifying Strategies to Address Critical Issues Underlying Racially Disparate Breastfeeding Outcomes

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Community-Based Focus Group Development: 
Identifying Strategies to Address Critical 
Issues Underlying Racially Disparate 
Breastfeeding Outcomes 
Contributors: Angela Johnson & Maria Muzik 
Pub. Date: 2017 
Product: SAGE Research Methods Cases in Health 
Methods: Focus groups, Community-based research 
Disciplines: Health 
Access Date: February 3, 2021 
Academic Level: Advanced Undergraduate 
Publishing Company: SAGE Publications Ltd 
City: London 
Online ISBN: 9781526413529 
DOI: https://dx.doi.org/10.4135/9781526413529 
© 2017 SAGE Publications Ltd All Rights Reserved. 
This PDF has been generated from SAGE Research Methods Cases. 

Abstract 
This case study details one aspect of a qualitative research program developed as part of a 2-year postdoctoral translational research program designed to inform readers of socially contextualized issues associated with disparate breastfeeding outcomes. The case sheds light on unique challenges in using focus group study design particularly in the context of a community environment and with a population whose unique socio-historical experiences oftentimes negatively affect the ability to engage them successfully in 
research protocols. The research goal was to identify potential strategies for an intervention that support breastfeeding behavior in African American women and infants. Focus groups are considered an effective approach to achieve these goals for its power to help design interventions that address social and health needs of African American women and children. African American women experience the lowest rates of breastfeeding compared with other groups and yet represent little of the current perspective or “voice” that espouses breastfeeding recommendations for engaging them. Earlier work applies a social ecological framework to characterize African American mothers’ breastfeeding challenges as a result of intersections between macro-level factors (media, public policy, and legislation) and micro-level factors (community, neighborhood, and workplace). This work often fails, however, to engage with African American women about their contextualized life challenges and to shed light on what these women think about designing culturally appropriate research and intervention programs that enhance breastfeeding among African American women. 

Learning Outcomes 
By the end of this case, students should be able to 
• Have a better understanding of potential methodological challenges of focus group study as a community-based participatory research approach 
• Assess the advantages and disadvantages of focus group study methods as a means for understanding the social experiences of socially disenfranchised community members 
• Understand the importance of research–community relationships in designing and developing a focus group study 
• Describe how a social ecological framework might help build culturally appropriate breastfeeding support interventions for African American women and their infants 

Project Overview and Context: Identifying Strategies That Support 
Breastfeeding Among African American Women 
This case study is focused on research that was developed as part of a translational research study designed to identify and understand strategies for addressing the social context of racial disparities in breastfeeding (BF) behaviors among African American women in Southeastern Michigan. 
It is well-documented that BF is a critical public health behavior with significant positive impacts on developmental, physiological, psychological, and other health outcomes for mothers and their babies.

Considerable national efforts have been made to enhance U.S. BF rates over the past 25 years. Despite the benefits of BF and the national initiatives to improve outcomes, BF in the United States is characterized by persistent racial differences in BF behavior. BF rates among African American mothers persistently lag behind, showing, by far, the lowest BF rates. Fewer than 60% of African American mothers initiate BF compared with 75% of all new mothers nationally. Lack of BF has implications for infant mortality and morbidity rates—both of which are significantly higher among African American women in Detroit, Michigan. 
African American mothers and their babies are, subsequently, at higher risk of poor post-natal outcomes. Much of the research on racial and ethnic disparities in BF foci is from the perspective of medical, academic, and other professionals and rarely reflects thoughts, attitudes, or ideas from African American women about what they feel might best support BF. Because African American women experience significant barriers to BF such as an unequal elevated burden of disease and illness (Mullings, 2006; Williams, 2000), occupational 
segregation with inflexible work environments (Smith-Gagen, Hollen, Walker, Cook, & Yang, 2014), shorter maternity leave (Spencer & Grassley, 2013), and less social support, our research practices were designed to highlight these unique challenges facing African American pregnant and postpartum women and to understand what psychosocial strategies and resources are needed to increase BF initiation and duration. 

We predicted that BF barriers would be reinforced as maternal physical and mental health issues, early maternity leave cessation, inflexible work environment, and lack of social support and that these would be more prevalent. Findings from previous research suggest that the context of disparate BF rates are manifestations of complex social and structural arrangements in society mediated by biological, cultural, and interpersonal factors (Johnson, 2010). Successful interventions will reflect comprehensive, multi-level system 
approaches which treat the complex, yet unique social circumstances that characterize BF practices among African American women. 

Research Practicalities and Design 
This postdoctoral research study was carried out between February and November of 2013. The work was supported by grant funding #2UL1TR000433 from the National Center for Advancing Translational Sciences and was based at the University of Michigan Health System (UMHS), Women and Infants Mental Health Program in the Department of Psychiatry and Depression Center. Staff support time was provided by the Program for Multicultural Health also at the UMHS. The study was approved by University of Michigan Institutional Review Board. 
Historically, qualitative studies like these which aim to collect data from minority and disenfranchised populations commonly experience multiple methodological challenges related to collecting and interpreting 
the data. First, research protocols have struggled to recruit and to engage adequate numbers of participants sometimes as a result of a historical lack of trust between participants and researchers based at least in part on participants’ perception that research is exploitative (Horowitz, Robinson, & Seifer, 2009). The well documented history of prior abuses of minority groups during the research process also could interfere with participation (Russell, Maraj, Wilson, Shedd-Steele, & Champion, 2008). Second, collected data are often criticized for failing to accurately represent the target community’s needs (Stewart & Nápoles-Springer, 2003). 
Third and final, community-based research has sometimes done little to build critical positive relationships between researchers and target population, and thus, studies often fall short of contributing to the development of successful interventions that address persistent health disparities (Horowitz et al., 2009). 

Recruiting Hard-to-Reach Participants: Community–Academic Relationships Are Vital 
Our study team considered the myriad of individual, social, and environmental issues embedded in BF barriers for African American women and, for these reasons, chose to loosely align our research practices with the community-based participatory research (CBPR) approach using focus group study design. CBPR is recognized as an effective process for helping to identify specific community-level problems as well as potential solutions by partnering with existing, respected community organizations who can help engage target community members (Kieffer, Salabarria-Pena, Willis, Palmisano, & Guzman, 2013).

Successful CBPR research hinges on mutual trust and perceived bi-directional support built from long-standing relationships between community and academic entities. Our initial recruitment plans were optimistic and included 
proactive outreach to general community locations, professional and personal networks, and a finite list of community organizations with known, trusted ties to target populations. However, additional work was needed to secure additional participants when initial efforts fell short of the goal of 48 total participants. 
Additional outreach was done to recruit participants by contacting organizational representatives and asking them to recommend other organizational contacts, community members, or other sources who might be 
willing to help recruit additional participants. Recruitment was also supported by the principal investigator’s (PI) part-time role in another unit at the UMHS, the Program for Multicultural Health (PMCH), Department of Community Programs and Services (CPS). The PMCH has more than two decades of developing initiatives that address health disparities, health education, training, health outreach, and health research and well established relationships with community partners. Using community connections established through work 
at the PMCH, the PI was able to access additional community organizations and members which in turn resulted in the recruitment of several participants.

Finally, the PI attended multiple events to meet and to greet prospective women and to promote the study through in-person rapport-building. In addition, interested prospective women were asked to refer fellow mothers, colleagues, and others who might qualify for the study to effectually contribute to snowball sampling methods. The snowball sampling method is considered an effective, culturally appropriate way to engage hard-to-reach segments of the population in qualitative research by igniting a “semi-directed, chain-referral recruitment process.” Study participants are proactively asked to serve as a “source” or “seed” for identifying and recruiting other potential participants through their 
own social networks and personal associations. Participants seek out others who have the same desired characteristics sharing relevant study information and endorsing the study simultaneously based on their own positive experience. One major advantage of the snowball method is the inherent trust it engenders among participants (Sadler, Lee, Lim, & Fullerton, 2010).

Respondents in turn recruit other participants, starting a process analogous to a snowball rolling down a hill (Wasserman, Pattison, & Steinley, 2005). 
Approximately 30%-40% of participants who successfully completed the study were recruited via snowball sampling methods. However, this success was not achieved without some challenges. At least two agencies we contacted declined to respond even after face-to-face introduction and dialogue. This was despite the fact that we were referred to one of the agencies by another more supportive one. We recognized that community trust is not transferable and must be built and maintained with each and every community partner, participant, and other functional entity in order for the CBPR intent to remain active. 
The most productive outcomes of our “snowball methods” came from our connections to a few non-profit organizations, two Women, Infant, and Children programs, and a well-established community-based BF coalition each of whom had concrete ties and history of positive work with African American mothers and children. A final count of 38 post-screening participants fell short of the 48-participant goal but achieved “topic saturation” based on salient themes and issues participants shared in group discussions. 

Ideally, CBPR-informed process should be in place long before the research project begins. However, we formed relationships with some of our most useful community organization partners only after the initial focus group members were recruited. In fact, partnerships were formed, in part, because we realized that we needed trusted support to make valuable inroads into community spaces and to gain the traction needed to carry out data collection. Indeed, a few of our community organizational partners who helped recruit and coordinate participants for focus groups expressed a strong interest in receiving support for their own organizations’ work to provide BF support. Not surprisingly, a number of our partner organizations expressed a desire to have this mutually beneficial relationship, characterized by a bi-directional exchange of information and support, perhaps as a way to offset or to balance power differentials that most research work threatens to impose on their community. 
Although we developed a clear written research plan outlining research justification, target population, data collections sites, appropriate timeline, consent process, and even participant protections as required by the Institutional Review Board, our plan reflected, in some ways, the same “helicopter” research practices which generations of “community” researchers have been accused of conducting, particularly targeting lowincome, minority, prison, or other disenfranchised populations.

The common practice in helicopter research projects is that community contribute their feedback, information, time, efforts, and other resources to research projects whose teams have landed to extract these vital elements; community members customarily receive little to no return for their investment before the research team packs up and flies away. Helicopter research practices, though commonplace, are considered exploitative and traumatic and may destroy chance for future positive community–academic relationships. Therefore, despite our best intentions as informed, seasoned, investigators trained in disciplines (sociology, psychology, social work, and psychiatry) that are designed to try to understand and address the human experience, we followed traditional, perhaps scientific research methods criticized for being somewhat less culturally appropriate and less sensitive to target community’s needs. Our quest to meet academic institutional expectations as well as the time constraints for research development perhaps overshadowed adequate sensitivity for the very group we sought to help. 

But we eventually incorporated community engagement and community approval as an additional and vital component for our research project’s survival. The consequences of our initial research design and development were that participants did not have the opportunity to help design the focus group guides which served as our data collection rubric and essentially helped define our pre-assumptions about how BF should be characterized as a research problem. 
Thus, community voice was missing from our initial list of BF barriers. To help redress this void, we as research team members worked tirelessly to follow a formative process of focus group development; to elicit participants’ insightful thoughts and ideas; to sort through, organize, and share aggregate data outcomes with all participants for review (“data analysis”); and to verify and approve that the feedback represented their community’s input to the best of our ability. As part of a critical plan to sustain community–academic relationships, we also provided professional capacity-building support to our partner community organizations (per their request) who were conducting ongoing work around building community interventions that enhance 
BF support among diverse group of customers. So, for example, we agreed to provide several educational trainings including a national webinar to lactation professionals on culturally appropriate ways to support BF in African American women. Our efforts to sustain ongoing relationship-building also included agreeing to serve on a non-profit board of directors to support fundraising, stewardship, and other capacity-building exercises that contribute to the organization’s ongoing BF promotion and support efforts. 

Qualitative research design and development provide powerfully rich in-depth information, but, if void of genuine CBPR approach as guiding principles, the process could have the same exploitative hierarchal power influence that perpetuates rather than helps to ameliorate health disparities. Outcomes learned in this research project indicate that a collaborative community–academic partnership with shared power represents vital components to building effective community-beneficial research and interventions. 

Method in Action 
Choosing Your Theoretical Perspective 
This study, guided by principles of grounded theory research design and adapted social ecological framework, helped the study team to analyze and to translate existing focus group data to highlight and propose strategies for supporting BF among African American women and their babies. As social scientists undertaking scientific research, we are challenged with designing translational research that addresses the complex and contextualized nature of social behavior around BF. We chose the social ecological perspective as a framework for analysis because it is considered an effective way to explore potential intervention strategies for enhancing BF by offering a multi-level, comprehensive redress that considers barriers at the individual, community, and macro-structural levels (Tiedje et al., 2002).

Contemporary philosophies offer multiple explanations for how racial disparities in BF persist. First, feminist perspective argues that the social ecological rubric is inadequate for addressing disparate BF because it does not specifically address the powerful manifestations of gender inequities such as those reflected in unequal pay, paid employment, and unequal distribution of domestic labor (Hausman, 2012). A second theoretical perspective is that lactation practice and research experts reinforce the social ecological perspective and argue that this second idea allows us a clear understanding steeped in BF realities; the social constraints embedded in common BF barriers are inarguably outputs of racism at multiple levels: institutional, personal, and internalized; and these are based on a multi-level systems influence similar to levels within the social ecological model (Dodgson, 2012). So, for example, the tendencies to hyper-sexualize African American’s women’s bodies and their roles as mothers (including the act of BF itself) represent gendered and racist notions that perpetuate the long history of sexual exploitation and devaluation of Black women and their children (Blum, 1999) As well, African American women’s self-perceptions and the perceptions imposed upon them by family are shaped by tendencies to sexualize bodies and behavior. Data analysis reflected that mothers shared personal accounts of being discouraged to publicly breastfeed as well as to breastfeed their baby around men and children or to adopt measures to modestly breastfeed their baby by covering their body during BF or by feeding the baby breastmilk pumped earlier. 

This study adds to the idea that culturally appropriate intervention models must also incorporate the social 
and historical context of African American women’s lives in ways that address the impactful legacy of slavery, 
racial discrimination, and other social alienation (Johnson, Kirk, Rosenblum, & Muzik, 2015). 

Avoiding Researcher Bias in Data Collection 
We interviewed pregnant African American, women who had given birth recently, and health professionals who served women in two Southeastern Michigan cities. Focus group participants represented mothers who breastfeed their babies (exclusive and non-exclusive), mothers who used formula to feed their babies, as well as an assortment of health professionals who served mothers during their pre- and post-natal experiences. Because we were interested in creating comfortable, convenient environments for participants, we knew it was imperative that we remove as many of the traditional barriers to successful research participation among African American women (transportation, child care, lack of trust, etc.) as possible by incorporating 
as many of recommended motivators (e.g., education) around BF as a benefit for African American women and babies, minority representation on the research team, compensation, and by using existing community networks to help reach qualified participants (Smith et al., 2007).

The rationale for this approach was to create a transparent, comfortable, and convenient social and physical environment that encouraged participation. The focus group discussions were divided and scheduled by participant type—professional versus non-professional— and then by the infant feeding method women used or pregnant women planned to use after their baby was born. Participants were divided into one of six focus groups. Each group ranged in size from five to 11 members and group discussions lasted 50 to 75 min. 

A focus group guide was used in each focus group to help guide discussion and to help maintain some consistency in focus across groups. Focus group guides were intended to create semi-structured, open discussions within groups that collected participants’ feedback on personal and professional experiences and 
interactions related to BF and were organized to encourage discussion to flow from the general to specific incorporating open-ended as well as specific questions. We developed focus group questionnaires that were semi-structured and a mixture of open-ended and specific as it was our intention to help “discover” what participants thought and felt about BF barriers and to hear ideas they may have for strategies to support BF in African American mothers. The purpose of the specific questions was to test study hypothesis related to 
the social ecological context of BF. 

We expected that the mixture of specific and open-ended questions would offer an opportunity to learn new ideas as well as to confirm or question presumptions about best practices for BF support. Interviewing is one of the major ways in which qualitative researchers collect and generate data for their studies; however, it may present potential problems. First, study output could be prone to researcher bias as the researcher who conducts the interviews becomes the “research instrument” and the key person for collecting data 
from respondents by facilitating communication, interactions, and in this way creating a context through which participants might share life experiences and perspective. Chenail (2011) cautions that researcher bias could occur if the researcher does not “remain humble and work within a team where triangulation and peer evaluation” of collected data take place (p. 256). This was especially important as discussions were rich and revealing and sometimes threatened to stray from topic as is often an issue in focus groups.

Our skills as trained focus group facilitators were tested as we posed questions, reflectively listened to answers, helped group members stay on task, and worked to manage dominant group participants. A second facilitator 
supplemented the audio-taping of group discussions by making detailed handwritten notes to capture group member perceptions and body language. We conducted a reflective, open discussion of session dialogues among our research team immediately following each focus group session to reinforce the rigor of the study instrumentation as well as to help guard against bias. 

African American mothers frequently revealed in focus group discussions that they believe that BF is a healthy option but felt competing life demands sabotaged BF intention or attempts. Stories shared from group participants were often poignant and painful accounts that highlighted impactful personal challenges and community social problems often detailed within the context of paid employment or other life demands (Johnson, Kirk, & Muzik, 2015) and interactions with health care (Johnson, Kirk, Rooks, & Muzik, 2016). Thus, 
it became imperative to remain as neutral, yet as sensitive and attentive, as possible during sessions without influencing feedback. Mothers who had given birth, especially, were excited to share their personal stories sometimes citing a range of positive and difficult personal experiences. Participants recounted efforts around BF that were intertwined with stories and laughter around triumph over difficult situations and the shedding of tears during recounts of insurmountable pain around overwhelming issues like stress and the unexpected death of a loved one. 

Results from the study highlight the unique socio-historical perspective sorely missing from the dialogue represented in the literature around BF and African American women and one that negatively affects their BF capacity. We found it interesting that mothers and professionals, alike, agreed that mothers too often do not get the critical social and other support to offset the negative impacts of personal, social, and environmental barriers despite clear understanding that this help is direly needed. 

Using the CBPR Approach in Focus Groups: Practical Lessons Learned 
This case study, thus far, has described some of the methodological challenges associated with using focus groups within the CBPR approach to discover social phenomena inherent in barriers that prevent successful BF among African American women as well as what is necessary to build ideas for interventions or strategies that support. The aforementioned issues are important for qualitative researchers new to community research to learn and for the seasoned investigator to practice consistently to improve critical interviewer skills (Chenail, 2011). There is abundant instructional information in the methodological literature on how to set up and follow focus group design, how to analyze the collected data, as well as how to apply the CBPR approach to this entire process. Understanding and practicing these skills are critical to achieve best results on building positive community–academic relationships, transforming these relationships into partnerships that support a culturally appropriate process for generating ideas and practices that address racial disparities in BF. However, it is not our intention to duplicate these methodological recommendations pertinent to this practice.

Alternatively, we offer additional practical tips that may not necessarily be found in research design texts: 
1. Learn from experienced CBPR participants before designing or starting a study using this design. Talk with other CBPR participants—both academic and community partners who’ve completed most or all process of at least one CBPR-shaped focus group study. We found few investigators who had followed this research trajectory and experienced challenges with accessing them. Published accounts of their work existed and provided some supportive guidance for our work. But we thought it might have been helpful to also have spoken to ask 
specific questions about information not available in their published work. 

2. Talk to as many community members about your intentions as possible before starting your research process. Kieffer et al. (2013) highlights that community partners who could offer the informed community perspective are often unable to remain active in CBPR research initiatives that may consist of time-intensive community-based steering committee and community research coordinator roles. CBPR relationships are meant to strengthen the chance to secure authentic and accurate insight but perhaps most importantly to create 
sustainable connections useful for future community engagement and effective social problem treatment. However, community members have personal life demands that could prevent them from participating. A possible alternative to this is to proactively seek out this expertise beforehand. 

3. Be prepared to reciprocate by supporting at least some of target community members’ needs. Only two of our community partner organizations openly requested and received support for their own work. We imagine that all community entities involved might have found some value in having similar support but just didn’t ask for it. Barring challenges (e.g., time constraints, 
skill deficits, logistical challenges, etc.) associated with delivering reciprocal help, supporting community organizations with related cause may help create the sustainable relationships helpful for supporting the CBPR process. 

4. Allow as much time as possible from start through entire research process. My 2-year research postdoctoral fellowship imposed natural time constraints and institutional demands that limited the direction and speed of process flow I could follow for this study. Ideally, one has some time, although it is hard to say how much is adequate, for establishing relationships—with community, academicians, and practitioners, to learn from those who’ve conducted work similar to what you aim to do under the CBPR model. 

Conclusion: Focus Group Study Guided by CBPR Approach 
The goal of this postdoctoral research project was to add to the current knowledge on ways to support BF practices from as close to a grass roots–level community perspective as possible. I struggled with adopting practices that would satisfy not only research principles but also practices that might allow me to put on my community thinking cap and welcome community collaborators so that we could explore potential strategies to a major public health problem. I found abundant amounts of information in the literature that detailed barriers African American women faced around BF but much less frequently suggested culturally appropriate viable solutions. Moreover, the community’s own perspective was often missing or clouded by the voice of the researcher whose own cultural bias and experience remained questionable. 

We navigated disappointing results from our initial recruitment attempts and novice knowledge about correct CBPR methods. But our perseverance paid off. Focus group conversations yielded some ideas and sparked the start of what we plan as authentic community relationships ripe for growth time if power dynamics are monitored and don’t interfere. Our case account describing our attempts to follow CBPR methods and to reach community allies so that we may better support African American women and children is a cautionary tale which we hope society may learn from. 

Exercises and Discussion Questions 
1. We discuss snowball sampling as part of qualitative data collection. Why is this especially important when working with disenfranchised communities? 

2. This case study touched briefly on the potential for researcher bias to occur in the qualitative research process. List the possible ways that researcher bias may occur from the various sociological perspectives, including a social class perspective, a racial perspective, and a gender perspective. 

3. What are the various ways in which breastfeeding behavior might be negatively affected by social, cultural, and historical contexts which are encountered by African American women? What are other challenges a researcher may encounter when attempting to design and complete focus groups using the CBPR approach? 

4. What other strategies can be adopted to ensure rigor when using focus groups guided by the 
CBPR approach? 

Further Reading 
Israel, B.A., Eng, E., Schulz, A. J., Parker, & Edith, E. A. (Eds.). (2013) Methods for community-based 
participatory research for health. San Francisco, CA: Jossey-Bass. 

References 
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