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Guilt, Research on Populations, and Cultural Competence

by Cynthia Good Mojab, MS, IBCLC, RLC

Popular culture in the media age is grounded in the values of and driven by the goals of the media. In the US - and in many other countries - the mass media is created by powerful industries that strive to profit via every aspect of their marketing strategies. One of those powerful industries is the infant formula industry. When risk-based language is used to describe health outcomes of formula-feeding, a common response from the formula industry (and the mass media and popular culture it helps create) is that such wordings are "negative" and will only serve to induce "guilt" in women who choose to formula feed. However, the goal of this response is necessarily the protection of profit, not the protection of women. Health care professionals who have been immersed in the popular culture and/or who work with institutions, colleagues and families who have been immersed in the popular culture may also ponder this declared "negativity" and ascribed "guilt". I have listened to many discussions about guilt and infant feeding rhetoric (i.e., risk-based versus benefit-based language). Here are a few of my thoughts on the matter.

1. A propensity to feel guilt is not inherent in all cultural heritages. It requires belief in a certain type of cause and effect; the power, right, and/or responsibility of an individual to enact change (in his or her own life and/or in the lives of others); a focus on the future; etc. Not all cultures tend to emphasize such beliefs.

2. The goal of multi-focus group research (such as that done as part of the development of the US National Breastfeeding Awareness Campaign) is to uncover trends at the population level so that the intervention most likely to enact the most change can be developed.

3. Among other things, the development of cultural competence is a life-long process whereby people can learn the information and skills, develop the attitudes and beliefs, and create/modify the structure and processes of institutions so that the culturally based needs of diverse groups of people can be met effectively and equitably. This process includes developing an understanding of the high applicability of research on a population to the population studied and the potentially more limited applicability of research on a population to a subpopulation, an individual within that population, a completely different population, etc. It includes developing an understanding of how culturally based beliefs may influence both a mother's evaluation of information (e.g., the particular rhetoric of a particular public health message) and her emotional responses to that evaluation.

4. The code of ethics of IBCLCs requires guarding against cultural bias. Measuring health outcomes against the cultural norm of formula feeding (using benefit-based language) rather than the biological norm of breastfeeding (using risk-based language) is a widespread example of cultural bias in research reports. It is an example of cultural bias because if we consider which came first in history, breastfeeding or artificial substitutes for breastfeeding, we can see that the manipulation in the experimental design is actually the use of formula, not the use of breastfeeding. It is poor science to report outcomes measured against the results of the actual manipulation.

5. Part of clinical competence is counseling competence. When we are ethically obligated to share information that may be difficult for a mother (or colleague or administrator or ...) to hear (for any reason), it behooves us to assess and attend to her (or his) evaluation of the information, and to her (or his) emotional reaction to that evaluation. It behooves us to establish whatever rapport is needed with the mother (or colleague or administrator or ...) before sharing that information so that she (or he) has some supportive emotional context in which to place that difficult information and our intent in sharing it. It behooves us to work to change our institutions' structures and processes if those structures and processes prevent us from having enough time to engage in effective counseling (and other interpersonal interactions).

I think that the heatedness of discussions about guilt among healthcare professionals and breastfeeding advocates is due, in part, to the challenge of addressing all of these issues in one intervention. Yet that is not what we are actually trying to do. We are trying to develop multiple interventions for diverse circumstances. We need interventions at the population level (hence the many focus groups of the US National Breastfeeding Awareness Campaign). We need multiple interventions for subpopulations (hence, the work of local coalitions, organizations, and agencies in their own communities). We need multiple interventions for individuals (hence, the work of individual IBCLCs, other health care providers, and peer counselors with individual breastfeeding mothers). What is effective at one level in one location at one point in history may be ineffective at another.

I think the heatedness of discussions about guilt and language is also due to people's deep concern about the mortality and morbidity associated with insufficient breastfeeding, their anger and frustration with the continued and widespread unethical marketing of artificial substitutes for breastfeeding, and their recognition of the importance and challenge of developing and applying cultural and counseling competence. The seemingly contradictory comments that I have heard from many caring professionals often are actually not contradictory: they address different pieces of this big picture. Each perspective expressed is important and illustrative. And, each of us can play an important part in creating and implementing one or more of these multiple interventions, regardless of whether it is at the level of a population, a subpopulation or an individual.

© Cynthia Good Mojab, 2004. All rights reserved. 

This essay is adapted from text first posted on May 21, 2004 to LACTNET, a netlist for professionals working in the field of breastfeeding and human lactation, in response to multiple posts from colleagues regarding guilt and risk-based language.

Cynthia Good Mojab, MS clinical psychology, IBCLC, RLC is a private researcher, author, and educator focusing on issues related to culture, psychology and the family particularly the area of breastfeeding. She also works as Research Associate in La Leche League International's Publications Department, was a member of the LLLI Editorial Review Team for THE BREASTFEEDING ANSWER BOOK (3rd ed.), and serves on Mothering magazine's Ask the Experts panel, answering questions about breastfeeding. She has experience providing both psychological and breastfeeding counseling. Ms. Good Mojab has taught and guest lectured for undergraduate psychology and statistics courses, and has spoken about breastfeeding, parenting, culture and psychology to groups, organizations, and the media. She is an award-winning researcher whose work was recognized in 1995 by the American Psychological Foundation. Her website, Ammawell (, offers breastfeeding and parenting information and support. 

Cynthia Good Mojab, PO Box 5803, Aloha, OR 97006 USA; (website) 

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