Predictors of breast-feeding duration among WIC and non-WIC mothers

Why WIC Women Stop Breastfeeding?

Women who receive benefits from Women, Infants, and Children (WIC) are not meeting the recommendations for breastfeeding duration. The purpose of this descriptive correlational study was to examine maternal sociodemographic and time factors related to the reason for discontinuing breastfeeding for 238 WIC participants who initiated breastfeeding. This study is a secondary data analysis of existing longitudinal survey and administrative data from a Chicago-area community health center and WIC clinic. The average length of breastfeeding within this sample was 16 weeks. Women in this sample reported a perception of insufficient milk (PIM; 46%), returning to work/school (13%), and other maternal problems (13%) as the main reasons for discontinuing breastfeeding. Within the first 16 weeks, 65% of the women who discontinued breastfeeding cited PIM as the main reason, with 2 distinct time points at 5 weeks and 13 weeks. Women of Hispanic descent were more likely than non-Hispanic women to report this perception (odds ratio 2.66, P = .01, 95% confidence interval = 1.21-5.83). Although these women initiated breastfeeding, the national recommendation for breastfeeding duration was not met in this population. Additionally, many women stopped breastfeeding early due to PIM. There are distinct time points where culturally tailored interventions may be most effective.

The relationship between breastfeeding test weights and postpartum breastfeeding rates

This secondary analysis was conducted to determine the relationship between test weights and days of breastfeeding. Test weights were performed with a scale (accurate to 2 grams) before and after feeding. Days of breastfeeding was measured by self-reporting. All test weights were interrelated and were associated with higher days of breastfeeding. Test weights at day 2 to 4 and at 2 weeks were not correlated significantly with either intention or self-efficacy at any time. However, 6-week test weights were correlated with intention at all 3 times, and self-efficacy at 6 weeks. Women with higher breastfeeding self-efficacy scores tended to report higher intention to breastfeed for 6 months.

A barrier to exclusive breastfeeding for WIC enrollees: limited use of exclusive breastfeeding food package for mothers

BACKGROUND

In the first 2 weeks of life, most breastfeeding mother-infant dyads in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) receive infant formula from WIC, instead of a larger food package designed for exclusively breastfeeding mothers. This study was designed to explore reasons for high rates of formula supplementation of breastfeeding newborns enrolled in WIC and the limited use of the WIC expanded food package.

METHODS

We conducted in-depth interviews with 29 mothers who either partially or exclusively breastfed for at least 2 months. Interviews were transcribed verbatim, analyzed, coded, and organized into 10 themes.

RESULTS

Participants view the WIC program in a contradictory manner. They see it as highly supportive of breastfeeding, but also as a promoter of infant formula. The expanded food package for mothers is not valued, but free supplemental formula is highly valued. Misinformation about breastfeeding pervades the healthcare system, and exclusive breastfeeding is not promoted as an important health goal. Lack of access to breast pumps, the unacceptability of pumping in the workplace, and difficulties with nursing in public all contribute to formula supplementation.

CONCLUSIONS

The healthcare system, the WIC program, and demands of daily life all contribute to low rates of exclusive breastfeeding in the WIC program. The available expanded food package for mothers who are exclusively breastfeeding is both disliked and underutilized, while free supplemental formula is rarely discouraged.

Links between maternal breast-feeding duration and Québec infants' health: a population-based study. Are the effects different for poor children?

OBJECTIVES

To determine whether the relationship between breastfeeding duration and the health status of 5-month-old Quebec infants differs by poverty status.

METHODS

Cross-sectional study of Quebec Longitudinal Study of Child Development data of a sample of 2223 infants who were 5 months old. Two infant health indicators were considered: presence of chronic diseases and hospitalization for at least one night since birth. Differences in the associations between infant health and breastfeeding duration according to poverty status were explored using a logistic regression model and controlling for children's and mothers' characteristics.

RESULTS

Infants of low-income mothers were breastfed less often and for shorter periods of time. At five months, they had poorer health compared with children from families with adequate income. However, a positive association between breastfeeding duration and these health indicators was observed and was independent of poverty level. There was no interaction between poverty level and breastfeeding duration for the two health indicators studied.

CONCLUSIONS

The associations between maternal breastfeeding for 4 months or more and both hospitalizations before 5 months of age and chronic diseases are independent of family income level. However, low-income mothers breastfeed less often and for shorter periods of time. Interventions intended to promote and support breastfeeding should especially target mothers living in poverty conditions.

Breastfeeding as health-promoting behaviour for Hispanic women: literature review

AIM

This paper reports a literature review to synthesize the evidence that breastfeeding is a health-promoting behaviour for Hispanic women and to demonstrate the usefulness of the Health Promotion Model in understanding and increasing breastfeeding behaviours in Hispanic women.

BACKGROUND

While breastfeeding has been shown to promote the health of both mother and infant, it has not been widely viewed from the perspective of the Health Promotion Model.

METHODS

The CINAHL and MEDLINE databases were searched using the terms 'Hispanic' or 'Latina', 'breastfeeding' and concepts specific to the Health Promotion Model (interpersonal relationships, social support, acculturation, self-efficacy, barriers, benefits, and commitment). Only papers in the English language from 1990 to 2003 (except for classic papers) that used research techniques were reviewed. Only those addressing breastfeeding intention, initiation or duration were included. The reference lists of each paper were examined for additional empirical papers that linked any of the determinants of the Health Promotion Model to breastfeeding among Hispanic women. Papers were organized using the ten determinants as headings: prior related behaviour, personal factors, perceived benefits, perceived barriers, perceived self-efficacy, activity-related affect, interpersonal influences, situational influences, immediate competing demands, and commitment to a plan of action. The review was conducted in 2003.

FINDINGS

The literature verifies that each of the 10 determinants of health-promoting behaviour also promotes breastfeeding for Hispanic women, particularly through the constructs of acculturation, interpersonal support, self-efficacy and immediate competing demands. Breastfeeding is not consistently defined in all studies, nor are Hispanic population groups uniformly classified according to country of origin. Specific interventions to promote breastfeeding have been implemented for women of Latin American origin, but randomized designs to measure outcomes have not been consistently employed with Hispanic women in the United States of America. Further intervention research is needed to confirm breastfeeding as a health-promoting behaviour and to inform breastfeeding education for this group.

Primary and secondary mediators' influence on milk output in lactating mothers of preterm and term infants

This study examined potential primary mediators, such as intended length to breastfeed, maternal education, income, and infant gestation, and secondary mediators, such as early frequency of breast stimulation, early milk output, and supplementation with artificial milks that may influence milk output in mothers of preterm and term infants the first 6 weeks postpartum. Analysis suggested that for mothers of a preterm infant (n = 95), the primary mediators, income and infant gestation, and the secondary mediators, early milk output/d and early frequency/d, accounted for 53.5% of the variance in milk output/d at week 6. For mothers of a term infant (n = 98), the primary mediator, income, and secondary mediators, early milk output/d and supplementation, accounted for 48.4% of the variance in milk output/d at week 6. Further research is needed to determine what early interventions may improve milk output in mothers at risk for lactation failure.

Development and testing of a prenatal breastfeeding education intervention for Hispanic women

Many immigrant Hispanic women in the United States choose to bottle-feed rather than breastfeed. This article describes an intervention that was developed and tested in a two-step process. Two studies were undertaken. First, a qualitative inquiry explored the breastfeeding beliefs, attitudes, meanings, and practices of Hispanic women. Results informed the design of a culturally appropriate prenatal breastfeeding education intervention. Secondly, the researchers undertook a quantitative study of the intervention's success in increasing breastfeeding duration among Hispanic women. Methodology and findings of this study have implications for future interventions that promote breastfeeding.

Hormonal correlates for the initiation of breast-feeding in Bangladeshi women

Hormonal changes that occur before or during parturition are known to trigger early postpartum maternal behaviors in many mammals. In humans, little evidence has been found for hormonal mediation of early postpartum maternal behavior. In this paper, we investigate associations between fetoplacental hormone concentrations in late pregnancy on the time from parturition to initiation of breast-feeding. A sample of 91 pregnant rural Bangladeshi women, enrolled in a 9-month prospective study, provided twice-weekly urine specimens and structured interviews. The subjects provided self-reports of time from parturition to initiation of breast-feeding. Specimens were assayed for urinary concentrations of human chorionic gonadotropin (hCG), pregnanediol-3alpha-glucuronide (PdG, a metabolite of progesterone), and urinary estrone conjugates (E1C). Parametric hazards analysis was used to investigate the effects of hCG, PdG, and E1C concentrations and other covariates (mother's age, parity, and child's sex) on the duration from parturition to breast-feeding. Mother's age, parity, the child's sex, hCG, and PdG showed no association with the onset of breast-feeding. Urinary E1C was significantly associated with time to initiation of breast-feeding, explaining about 4% of the variation in the behavior. The relationship was positive so that higher prepartum concentrations of EIC were associated with later times to initiation of breast-feeding. The direction of this relationship is opposite that found for many other species of mammals but is consistent with some recent findings in primates.

Patterns for the initiation of breastfeeding in humans

Establishment of lactation has important biological and emotional health consequences for the newborn. Even so, substantial variation within a culture and among different cultures is seen in the onset of breastfeeding. Parametric mixture models are used to explore this variation and to uncover general human patterns for the initiation of breastfeeding. The model components reflect two hypothesized patterns of behavior. The first component is a "natural" pattern of breastfeeding that reflects, to some extent, a general mammalian behavior. The second component arises through culturally mediated behaviors that affect the initiation of breastfeeding. The model was fit by maximum likelihood to interval- and right-censored observations on 26220 mother-infant pairs collected from 25 previously published studies of breastfeeding behavior. Both model components were clearly statistically identified. Effects of cultural and geographic covariates were found to have significant effects on all components of the model. Although there is clear evidence for two distinct patterns of behavior in the initiation of breastfeeding, the results suggest that learned behaviors play an important role in mediating even "natural" breastfeeding behavior.

An ecological approach to breastfeeding

PURPOSE

Current numbers of breast-feeding mothers are well below Healthy People 2010 goals of 75% in the early postpartum period, 50% at 6 months, and 25% at 1 year. A promising line of research is the use of an ecological model for breastfeeding that includes factors traditionally examined in breastfeeding (mother/infant and family) as well as mesosystem and exosystem sources of influence on families (healthcare delivery system, community, and societal/cultural).

STUDY DESIGN AND METHODS

A telephone survey was conducted with 95 primiparous, postpartum women using closed and open-ended items. Content analysis was used with the transcribed comments from these telephone interviews, to test the fit of a preexisting ecological model for breastfeeding.

RESULTS

The comments of postpartum women provided a rich source of information about the many mother-infant, family, healthcare delivery system, community, and societal/cultural factors that influence breastfeeding. These all fit the ecological breast-feeding model proposed.

CLINICAL IMPLICATIONS

Efforts to improve rates of breastfeeding in this country to meet year 2010 goals must consider the many contextual factors that influence feeding. Interventions to promote breastfeeding should exceed the individual level, and occur at many layers simultaneously. The ecological model provides direction for the multiple interventions needed to increase rates and duration of breastfeeding.

Update on breastfeeding: healthy people 2010 objectives

Increasing the rates of both initiation of breastfeeding and duration of breastfeeding are national health objectives. In the United States, the actual in-hospital breastfeeding initiation rate is 64%, and duration rate (at 6 months postpartum) is 29%. These percentages fall short of the Healthy People 2010 goal for breastfeeding, which states that we should increase the proportion of mothers who initiate breastfeeding to at least 75%, and increase the proportion of mothers who continue to breastfeed until their infant is 6 months old to at least 50%. Factors influencing breastfeeding such as sociodemographics, maternal attitudes toward breastfeeding, influence of significant others, and the workplace environment are examined. Approaches to increasing the initiation and prolonging the duration of breastfeeding are discussed.

Breastfeeding duration in a multiethnic population in Hawaii

BACKGROUND

The increasing ethnic diversity in the United States necessitates a study of variations in infant feeding patterns among ethnic groups. This study was conducted as part of Hawaii's surveillance system to identify infant feeding patterns in Hawaii; specifically, to identify factors influencing duration of breastfeeding among ethnically diverse mothers.

METHODS

All women who delivered an infant in Hawaii between January 1 and March 31, 1989, were mailed surveys 14 to 19 months after delivery. Fifty-one percent (n = 2011) of women responded, of whom 1574 (78%) did some breastfeeding and are included in the analysis of prediction of weaning (cessation of breastfeeding). Cox regression (survival) analysis was used to predict weaning.

RESULTS

The median duration of breastfeeding was 150 days; 45 percent of infants were still breastfeeding at age 6 months and 16 percent at age 1 year. Factors associated with early weaning were Japanese ethnicity; mother born in a country other than the United States, Japan, or the Philippines; first language other than English, or two languages at home; employed full-time outside the home; introduced formula or fruit before age 6 months; received formula from the WIC program; and stopped breastfeeding for convenience, breast problems, problems getting breastfeeding started, insufficient milk, baby refusing the breast, and a sick baby. Factors associated with late weaning were older maternal age; college education; living on a rural island; previous breastfeeding experience; helpful breastfeeding advice from family or friends; receiving WIC for breastfeeding mothers; introducing the cup before age 6 months; and not giving fruit to the baby.

CONCLUSION

In Hawaii, programs that address how and when to introduce foods, use of formula, and management of outside employment and breastfeeding should be made available to those groups of women at risk for early weaning to lengthen their duration of breastfeeding.

Connection and pleasure, disruption and distress: women's experience of breastfeeding

Interview data collected in a recent study of first time motherhood were used to explore the experience of breastfeeding. Twenty-five Australian women participated in a series of semistructured interviews begun during late pregnancy and continuing until 6 months postpartum. Discourse analysis was used to examine the transcribed data. The analysis revealed that breastfeeding was central to these women's experience of motherhood. The majority of women were strongly committed to breastfeeding. Their decision to breastfeed was influenced by a range of public and professional discourses. Breastfeeding was also an embodied experience that was difficult to articulate. For some, this embodied experience was connected, harmonious and pleasurable and for others, disruptive, unpleasant, and violent. This paper describes the embodied experience of breastfeeding and highlights the complexity of the relationship between embodied experience and contemporary meanings and context of breastfeeding.

Effect of labor analgesia on breastfeeding success

BACKGROUND

The effect of labor analgesia on breastfeeding success is not well defined. Some authors have hypothesized that labor analgesia may affect lactation success. The purpose of this observational study was to determine if intrapartum analgesia influenced breastfeeding success at 6 weeks postpartum in a setting that strongly supported breastfeeding.

METHODS

Healthy women with uncomplicated term pregnancies who planned to breastfeed consented to a telephone interview. We recorded demographic data, labor induction status, delivery mode, and analgesic medications. At between 6 and 8 weeks postpartum, patients were asked to describe breastfeeding use, problems encountered, solutions derived, sources of support and information, and satisfaction. We created a logistic regression model using intrapartum analgesia information and controlling for demographic factors previously correlated with lactation success.

RESULTS

We enrolled 189 women, contacted 177 women postpartum, and obtained complete data on 171 women. Of these, 59 percent received epidural analgesia, 72 percent breastfed fully, and 20 percent breastfed partially (> 50% of infant nutrition) at 6 weeks postpartum. After controlling for demographics and labor outcome, we could not demonstrate a correlation between breastfeeding success at 6 to 8 weeks and labor analgesia.

CONCLUSIONS

In a hospital that strongly promotes breastfeeding, epidural labor analgesia with local anesthetics and opioids does not impede breastfeeding success. We recommend that hospitals that find decreased lactation success in parturients receiving epidural analgesia reexamine their postdelivery care policies.

Factors associated with very early weaning among primiparas intending to breastfeed

OBJECTIVES

The major objective of this study was to identify predictor variables that accurately differentiated breastfeeding women who weaned during the first 4 weeks, those who weaned between 5 and 26 weeks, and those who weaned after 26 weeks. Predictors were demographic variables, Theory of Planned Behavior (TPB) variables, breastfeeding knowledge, and difficulties experienced during the first month.

METHODS

Primiparas who delivered healthy infants in an urban midwestern hospital provided initial data prior to discharge. Follow-up occurred at 1, 3, 6, 9, and 12 months. Following appropriate bivariate analyses, polychotomous logistic regression was used to determine predictors of weaning group. Linear multiple regression was used to predict intended duration.

RESULTS

Most of the 84 women who weaned very early had intended to breastfeed considerably longer. According to the multivariate analysis, women who weaned earlier were younger, had completed fewer years of education, had a more positive bottle-feeding attitude and a less positive breastfeeding attitude, intended to breastfeed less time, had lower knowledge scores, had higher perceived insufficient milk scores, and planned to work outside the home. Variables postulated by the TPB to be direct predictors of intention explained 36% of the variance in intended duration.

CONCLUSIONS

Women at risk for early weaning can be identified with reasonable accuracy using a TPB-based conceptual framework expanded to include breastfeeding specific variables. Casefinding using empirically derived screening methods and careful postpartum follow-up, along with professional intervention, should be used to avert unintended early weaning.

Using a breastfeeding prevalence survey to identify a population for targeted programs

Often, efforts to improve overall population health require identifying and targeting programs to specific high-risk populations. Breastfeeding is an example. In order to determine initiation and duration rates among various groups in the City of Toronto, a random sample of 434 mothers with infants at four months of age was surveyed to determine the prevalence of breastfeeding and major impacts on its duration. The study found that, overall, 83% of mothers initiated breastfeeding at birth. The greatest rate of decline occurred during the first month. At four months postpartum, 57% of mothers continued to breastfeed, including 35% who were exclusively breastfeeding and 22% who were supplementing breast milk with formula. Breastfeeding duration was related to a number of factors, including information and support, parity, education, use of formula supplements and country of birth. Specific groups are identified for targeted programs, and a number of strategies are proposed.

Effects of parity and weaning practices on breastfeeding duration

The purpose of this project was to examine (a) patterns of breastfeeding and (b) duration with parity and breastfeeding experience, and (c) mothers' reasons for termination of breastfeeding. A convenience sample of 120 breastfeeding mothers was followed by home visits and telephone for 20 weeks after delivery. The sample consisted of 69 primiparas, 40 multiparas with previous breastfeeding experience, and 11 multiparas with no prior breastfeeding experience. Parity was not significantly associated with the continuation of breastfeeding but there was a trend toward a difference made by breastfeeding experience. Inadequate milk supply and employment were the two most common reasons reported for weaning. Implications for support in the workplace and for first-time breastfeeding mothers are discussed.

Does early supplementation affect long-term breastfeeding?

The purpose of this secondary data analysis from two different samples was to examine the effect of early supplementation with manufactured milks on breastfeeding status at 20 weeks postpartum in mothers of healthy term infants. In two convenience samples of 120 and 223, respectively, breastfeeding mothers were followed up for 20 weeks postpartum or until weaning occurred. The breastfeeding rate at 20 weeks postpartum was significantly greater for mothers who reported feeding exclusively mother's milk the second week after delivery compared with mothers who breastfed and simultaneously supplemented with manufactured infant milks. Of the mothers in samples one and two who exclusively fed human milk during week 2 postpartum, 63.0% and 59.7%, respectively, were still breastfeeding at week 20, compared with 28.1% and 24.2%, respectively, who supplemented with artificial milks. There was no significant difference between these two groups of mothers and their intended duration of breastfeeding. Early introduction of supplemental bottles of artificial milks is associated with a decrease in the amount of human milk the infant receives as well as with early weaning.

Social status, mother-infant time together, and breastfeeding duration

Chart review and direct observation were used to study the relationship between social status, mother-infant time together, and breastfeeding duration among 138 mothers who were breastfeeding at hospital discharge. Overall breastfeeding rate was 73 percent for patients with private insurance and 37 percent for patients without private insurance. Breastfeeding duration to six months was not related to social status. Mother-infant time together from birth through 48 hours was 3 hours greater for private insurance mothers. These three hours, which were statistically significantly different, did not correlate with breastfeeding duration in any way. Ancillary findings were that married mothers were more likely that unmarried mothers to be breastfeeding at six months, and that mothers who received epidurals were less likely to be breastfeeding at six months than mothers who did not receive epidurals.

Impact of attitudes on maternal decisions regarding infant feeding

It is essential that physicians and other health care professionals seeking to increase the rate of initiation and duration of breast-feeding build on the body of information concerning factors that influence a woman's attitudes about breast-feeding. The relation between positive attitudes concerning breast-feeding and its initiation is important to the development of programs targeting women before they become pregnant, and to the provision of active support for breast-feeding throughout the pregnancy, perinatal, and postnatal period. However, it is not sufficient for these programs to target only the mother or potential mother; members of a woman's social network must be considered as information targets. Educational programs must also be directed to the appropriate racial or ethnic group to develop programs that reach the individuals (father, female relative, or friend) most likely to influence the mother's breast-feeding decision. Physicians may be very knowledgeable about the nutritional and immune properties of human milk and yet not be supportive of the act of breast-feeding. This lack of support may be manifested by the lack of verbal support for women who intend to or are in the process of breast-feeding, the provision of infant formula before or at the time of birth of the baby, or encouragement to terminate breast-feeding should the mother encounter any difficulties with lactation. To increase physician awareness of the process of breast-feeding and the properties of human milk, information about the benefits should be integrated in both the basic science and the clinical curricula of medical schools. Primary care training programs, including obstetrics, should actively involve trainees in the management of breast-feeding women so that trainees become aware of the spectrum of circumstances that confront women seeking to establish and maintain successful breast-feeding. This type of involvement would provide a contextual base for physicians' understanding the attitudes and behaviors supportive of breast-feeding. Attitudes and behavior of women, although more complex then demographic factors, provide a powerful tool for meeting the Healthy People 2000 goals for the initiation and duration of breast-feeding. It is important to build on the base of research reviewed here to develop new and and more powerful interventions. Thus the emphasis on the known health advantages of human milk or the discovery of additional health benefits of breast-feeding should continue to be discussed because they may tip the balance in favor of breast-feeding for some women. Nevertheless, it may ultimately be more important to increase the amount of information provided to women (and girls and boys) about the practical aspects of the breast feeding process (e.g., ease of night feeding, fathers ability to feed mother's milk by bottle, lower cost, strategies to control leaking) then to rely solely on the positive health outcomes related to breast-feeding.

Infant feeding decisions in the Missouri WIC Program

A breastfeeding questionnaire was developed to help determine how we could better support our WIC mothers' efforts to breastfeed. The questionnaire was pilot tested in 12 local WIC agencies, wherein 878 participants returned the instrument for tabulation. Forty-six percent of the women who returned questionnaires initiated breastfeeding. The main support for women choosing to breastfeed came from their husbands. Women choosing not to breastfeed identified "self" as the person who most discouraged them from breastfeeding. Using this tool has helped to highlight the breastfeeding needs of our participants.

Mothers of low birthweight infants: breastfeeding patterns and problems

The feeding behavior and problems of mothers of low birthweight (LBW) infants following hospital discharge have not been well documented. The purpose of this paper is to report the feeding patterns of LBW infants and their mothers' reasons for a decline in breastfeeding. A convenience sample of 110 mothers and infants from eight midwestern hospitals was surveyed. Eight weeks after delivery, 28 percent of the mothers were providing mother's milk exclusively, 29 percent were providing a combination of mother's milk and artificial milk, and 43 percent had weaned their infants. An inductive analysis of the reasons for a decline in breastfeeding given by the mothers yielded two primary maternal concerns: milk production and transfer of milk to the infant. Lactation management strategies that meet the special needs of these mothers and infants should be taught during hospitalization and after hospital discharge.

Insufficient milk supply among black and white breast-feeding mothers

The purpose of this study was to investigate whether ethnicity is associated with insufficient milk supply (IMS) among breast-feeding mothers. A major reason reported by mothers for early termination or introduction of formula and/or solids is insufficient milk. A retrospective survey was conducted among 42 black and 148 white breast-feeding mothers participating in the WIC program in a midwestern state. The results suggested that: (1) the incidence of IMS was similar for black and white mothers; (2) controlling for education, black mothers initiated breast-feeding later and stopped sooner; IMS mothers fed less frequently and for shorter periods; and (3) controlling for education, there were no ethnic differences in the determinants or indicators of IMS.

Perspectives of common breastfeeding situations: a known group comparison

Infant feeding choice is influenced by social and cultural factors, as reflected in sociodemographic correlates of breastfeeding, which show consistently low breastfeeding rates among women from low-income populations. This study examines attitudes and beliefs that are thought to affect feeding choice and breastfeeding behavior among diverse social and cultural groups. A breastfeeding behavior questionnaire asking women to respond to a variety of breastfeeding situations presented as narratives was administered to members of a La Leche League group and to a group of WIC participants. Results support the idea that different social groups of women display divergent attitudes toward and perceptions of breastfeeding. Although small sample size prohibits generalization of results, the findings reinforce the necessity of designing breastfeeding education programs within specific cultural contexts.