Mental Health and Feeding Styles in Parents of Formula-Fed Infants

Abstract

Background:

Nonresponsive feeding styles can contribute to rapid weight gain in infancy and subsequent obesity in childhood. There is a need to investigate factors such as parental mental health symptoms (stress, depression, and anxiety) that may contribute to nonresponsive feeding styles. The purpose of this study was to investigate the relationship between parental mental health symptoms and feeding styles in parents of healthy, term formula-fed infants during the first year of life.

Methods:

A cross-sectional, descriptive correlational design was employed using online surveys. We recruited participants through Facebook groups and pediatricians' offices. Instruments included a demographic questionnaire, the Perceived Stress Scale-10, Patient Health Questionnaire–Depression Module-9, 7-item Generalized Anxiety Disorder Assessment, and Infant Feeding Style Questionnaire.

Results:

Participants were 306 parents of formula-fed infants. Greater depressive symptoms was the strongest predictor of the pressuring style (β = 0.54), while greater symptoms of stress (β = −0.13) and anxiety (β = −0.28) were associated with lower pressuring scores. Greater depressive symptoms was the strongest predictor of the laissez-faire style (β = 0.48), while greater symptoms of stress (β = −0.17) and anxiety (β = −0.23) were associated with lower laissez-faire scores. Engaging in ≤50% of the infant's feeds was the strongest control variable predictor for the pressuring and laissez-faire styles. None of the mental health variables were significantly related to the restrictive style.

Conclusions:

We recommend increased screening for depressive symptoms in parents of infants and responsive feeding support, especially for those experiencing depressive symptoms.

Introduction

While there are joys of having an infant, stressors are also introduced, including juggling new responsibilities, pressure to breastfeed, and changing family dynamics.¹ Mental health challenges may impact caregivers' abilities to appropriately engage during infant feeding sessions,² and symptoms of anxiety and depression among parents have been positively correlated with obesity in children from birth through adolescence.³ Infants depend on their caregivers for adequate nutrition,⁴ and the ways caregivers engage with their infants during feeding sessions can have long-term implications on health outcomes, including obesity.⁵

Childhood obesity has been linked to feeding styles.^6,7 Feeding styles emerged out of the concept of parenting styles, which is the general emotional climate that parents create in relationships with their children.^8,9 Similarly, feeding styles broadly describe how parents engage with their children during mealtimes, including parents' approaches to changing or maintaining children's eating behaviors¹⁰ and the emotional climate that exists within parent–child dyads during feeding sessions.⁹

Feeding styles can be categorized as responsive or nonresponsive (Table 1). The responsive feeding style refers to caregivers providing a pleasant feeding environment and being attuned and attentive to infant hunger and satiety cues.^9,10 Responsive feeding may facilitate infant appetite self-regulation and subsequent healthy weight trajectories,⁵ thus it is recommended by advisory agencies such as the American Academy of Pediatrics¹¹ and World Health Organization.¹²

Table 1.

Feeding Styles in Infancy Applicable to Bottle-Feeding ²

Responsive	Nonresponsive
	Pressuring
Definition: “The parent is attentive to child hunger and satiety cues.”10, p.211 Associated practices: • No distraction during feeds • Attentive to hunger and satiety cues • Feeding “on demand”	Definition: “The parent is concerned with increasing the amount of food the infant consumes and uses food to soothe the infant.”10, p.211 Associated practices: • Adding cereal to the bottle • Feeding the infant to make them stop crying • Feeding the infant in the absence of hunger cues/feeding on a strict schedule • Continuing to feed when satiety cues are exhibited by the infant
	Restrictive
	Definition: “The parent limits the infant to healthful foods and limits the quantity of food consumed.”10, p.211 Associated practices: • Limiting the amount of intake • Not feeding the infant when hunger cues are exhibited/feeding on a strict schedule
	Laissez-faire
	Definition: “The parent does not limit infant diet quality or quantity and shows little interaction with the infant during feeding.”10, p.211 Associated practices: • Distractions (i.e., watching television while feeding the infant) • Propping the bottle

Nonresponsive feeding styles (laissez-faire, pressuring, and restrictive) are characterized by caregivers not being attuned and attentive to infant hunger and satiety cues.^10,13 Parental mental health symptoms have been linked to insecure parent–infant bonding and attachment,^14–16 which may influence parents' sensitivity to their infant's cues.¹⁷

Thus, it is conceivable that mental health symptoms may influence parents' abilities to engage in responsive feeding. A chronic mismatch of infant feeding cues and parents' behavior during feeding sessions may lead to impaired appetite self-regulation among infants and subsequent obesity.¹⁸

What and how infants are fed can impact their weight trajectories. Rapid weight gain (RWG) in infancy has been linked to obesity later in life^19–21 and predisposes individuals to health consequences such as type 2 diabetes, cardiovascular disease, and psychological issues.²² Bottle-feeding may allow parents to have more control and rely on external cues (e.g., amount of milk in the bottle) compared with feeding directly from the breast, which tends to naturally be more infant led.²³

Additionally, formula feeding in infancy has been associated with increased risk for RWG²⁴ and higher BMI in childhood.²⁵ Thus, we have focused our study on parents who bottle-feed with formula. Because parental feeding styles have been associated with infant weight²⁶ and formula-fed infants are at greater risk for RWG,²⁴ it is crucial to understand factors such as mental health symptoms that may contribute to nonresponsive feeding styles in parents of formula-fed infants.

Conceptual Model

Our study was guided by the El-Behadli et al. extended care model,⁹ which uses a systems approach to highlight that the emotional climate of the parent–child relationship, including parental stress and depression, may impact feeding interactions. While anxiety is not included in this model, it was explored in our study because anxiety commonly co-occurs with depression^27–29 and it has been linked to nonresponsive feeding styles in infancy.³⁰

Purpose

The purpose of this study was to investigate the relationship between parental mental health symptoms and feeding styles in parents of healthy, term formula-fed infants.

Methods

Using a cross-sectional, descriptive correlational design, we examined relationships between mental health symptoms and feeding styles through an online survey in parents of formula-fed infants residing in the United States. We collected data using REDCap^®, a secure web-based data management program.³¹ We obtained ethical approval for this study from the University and Medical Center Institutional Review Board at East Carolina University.

Participants

Inclusion criteria were parents of healthy, term formula-fed infants <1 year of age, who understood English, were living in the United States, and were exclusively formula feeding at the time of the survey. We recruited participants through Facebook groups given the potential to yield a diverse sample.³² Seventy percent of adults aged 18 to 49 years use Facebook,³² including those of childbearing age, consistent with our target population. We pursued Facebook groups specifically related to fathers of infants in addition to general parent groups because father-focused advertisements are more successful at recruiting fathers than gender-neutral parent advertisements.³³

We also recruited parents through local pediatricians' offices in Pitt County, North Carolina, by placing flyers in the offices after receiving permission as it is recommended to use a mixed recruitment approach, including online and traditional methods.³⁴ We offered participants to enter a drawing for 1 of 20 $50 Walmart e-gift cards as an incentive to participate.

Instruments

Feeding styles

The Infant Feeding Style Questionnaire (IFSQ) measures parents' beliefs about early child feeding and behaviors exhibited when feeding their infants.¹⁰ Feeding styles are separated into five constructs: laissez-faire, pressuring, restrictive, responsive, and indulgent (Table 1). The indulgent construct was not measured in this study as it is more applicable to feeding solid foods.

The full scale has demonstrated good internal reliability (α = 0.75–0.95).^10,35 It was originally validated in a sample of African American mothers in North Carolina¹⁰ and has since been validated in diverse perinatal samples.^36–38 Items are coded on a five-point scale (never, seldom, half of the time, most of the time, or always). The number of items and a sample of a behavior and belief item for each of the feeding style constructs are presented in Table 2.

Table 2.

Infant Feeding Style Questionnaire Constructs and Sample Questions

Feeding style construct	Number of items	Sample items, (1) behavior and (2) belief
Pressuring	15	(1) I try to get my infant to finish his/her formula (2) Putting cereal in the bottle is good because it helps an infant feel full
Restrictive	9	(1) I am very careful not to feed my infant too much (2) A toddler should never eat sugary food such as cookies
Laissez-faire	9	(1) I watch TV while feeding my infant (2) I think it is okay to prop an infant's bottle
Responsive	10	(1) I let my infant decide how much to eat (2) I talk to my infant to encourage him/her to drink his/her formula

Stress

The 10-item Perceived Stress Scale (PSS-10) was used to measure symptoms of stress. It is designed to measure self-perception of how stressful one's life has been over the past month. Each item is scored from 0 to 4, with total scores ranging from 0 to 40, with higher sums of scores indicating greater perceived stress.³⁹ We used a cutoff score of ≥14 to detect moderate to high perceived stress, as suggested by other researchers studying the perinatal population.^40,41

The PSS-10 has been used to measure stress in the postpartum period among mothers and fathers, with Cronbach's alpha ranging from 0.75 to 0.89.^40,42,43

Depression

The 9-item Patient Health Questionnaire–Depression Module (PHQ-9) is a 4-point Likert-type scale that assesses the frequency of experiences with depressed mood and lack of pleasure in the past 2 weeks.⁴⁴ We used a ≥10 cutoff to detect moderate depression severity.^44,45 Survey instructions stated that if participants indicated they had thoughts of harming themselves, they should immediately call the provided National Suicide Prevention Lifeline.

In a meta-analysis on the use of the PHQ-9 in the perinatal population, Wang et al.⁴⁶ detected a pool sensitivity of 0.84 and specificity of 0.81. While the PHQ-9 has not been specifically validated in the paternal population, it has been validated in primary care populations, including men of varying ages.^47,48

Anxiety

The 7-item Generalized Anxiety Disorder Assessment (GAD-7) is a 4-point Likert-type scale that assesses the frequency of experiences with worrying, nervousness, or anxiousness in the past 2 weeks.⁴⁹ We used a cutoff score of ≥13, which has been established for detecting moderate to severe anxiety in the perinatal population with a sensitivity of 61.3% and specificity of 72.7%.⁵⁰

GAD-7 differentiates the comorbid anxiety and depressive symptoms as separate manifestations⁵¹ and has displayed greater accuracy in detecting generalized anxiety in perinatal women with comorbid depression compared with the Edinburgh Postnatal Depression Scale (EPDS) and EPDS Anxiety Subscale.⁵⁰ GAD-7 has demonstrated acceptable reliabilities for measuring anxiety in maternal (α = 0.86)⁵¹ and paternal (α = 0.85)⁵² populations during the perinatal period.

Results

Sample

Administrators of 44 Facebook groups related to infant feeding or fathering were contacted between November 2021 and January 2022. Six groups shared the Facebook study page or survey link with their members. After recruiting through Facebook and local pediatricians' offices, 573 people opened the survey, and 306 respondents met eligibility criteria and participated in the survey.

Demographic Characteristics

Demographic data are presented in Table 3. Participants were from 39 states, with most being from California (n = 54), North Carolina (n = 37), and Texas (n = 28). The mean age of participants was 29.3 (standard deviation = 4.88) years. Most participants were White (81.7%), female (86.3%), married or in a partnership (93.8%), and educated with some college or higher (89.1%).

Table 3.

Sample Characteristics

Characteristic	Total	%
Sex of caregiver
Male	34	11.1
Female	264	86.3
Nonbinary	8	2.6
Race/ethnicity
White	250	81.7
Hispanic/Latino	22	7.2
Black	19	6.2
Native American	20	6.5
Asian	2	0.7
Multiracial	3	1
Education
High school or less	33	10.8
Some college or degree obtained	234	76.4
Graduate degree	29	12.7
Marital status
Single/never married	11	3.6
Married/partnered	287	93.8
Divorced/separated	8	2.6
Household annual income (US dollars)
<50,000	99	32.4
50,000–99,999	128	41.9
100,000–149,999	49	16
150,000+	30	9.8
Infant sex
Male	162	52.9
Female	144	47.1
Infant age
<6 Months	74	24.2
6 Months to <12 months	232	75.9
Number of children in the home besides the infant
0	201	65.7
1	76	24.8
2–5	29	9.4
PHQ-9 score: depression
<10	151	49.3
≥10	155	50.7
GAD-7 score: anxiety
<13	275	89.9
≥13	31	10.1
PSS-10 score: stress
<14	40	13.1
≥14	266	86.9
Age, years, M and SD	29.3	4.88

GAD-7, 7-item Generalized Anxiety Disorder Assessment; PHQ-9, 9-item Patient Health Questionnaire–Depression Module; PSS, Perceived Stress Scale-10; SD, standard deviation.

Regarding mental health, 10.1% of participants reported experiencing moderate to severe anxiety symptoms. Over half (50.7%) reported experiencing moderate to severe depressive symptoms. Most (86.9%) reported experiencing moderate to high stress symptoms.

Characteristics Related to Infant Feeding

While all respondents were exclusively formula feeding at survey completion, 65.7% initially breastfed their infant. Approximately 46% of participants reported being shamed for their choice to formula feed; sources of shame included the internet and social media (29.4%), friends (28.4%), family (27.5%), health care professionals (HCPs; 23.2%), and other sources (3.9%).

Participants reported receiving infant feeding information from HCPs (56.5%), the internet (15.7%), family (14.7%), friends (11.8%), and other sources (1.3%) and most (58.8%) reported personally feeding their infant for ≤50% of the infant's feeds.

Parental Mental Health and Feeding Styles

Our hypotheses were that higher symptoms of stress, depression, and anxiety would be associated with nonresponsive feeding styles and lower symptoms of stress, depression, and anxiety would be associated with the responsive feeding style. The psychometric properties for the IFSQ and mental health scales in our sample are presented in Table 4.

Table 4.

Psychometric Properties for Infant Feeding Style Questionnaire and Mental Health Scales

Scale	M	SD	Range		Cronbach's α
			Min	Max
IFSQ
Laissez-faire	2.63	0.60	1	3.67	0.69
Pressuring	2.64	0.73	1	4.53	0.90
Restrictive	3.02	0.73	1	4.78	0.79
Responsive	3.38	0.79	1.40	5.0	0.88
Mental health
PSS-10	18.78	4.66	1	32	0.77
GAD-7	7.73	4.28	0	21	0.84
PHQ-9	9.11	5.02	0	23	0.83

N = 306.

IFSQ, infant feeding style questionnaire.

We used hierarchical multiple regression to examine how well mental health variables (symptoms of stress, depression, and anxiety) predicted feeding style constructs when controlling for other variables (i.e., shame, education, children in the home, percentage of feeds in which the respondent feeds the infant, age, and income). The control variables related to infant feeding styles were coded into a binary score (1,0) where items coded as 1 are the predictor variables (Table 5), and infant feeding styles are the outcome variables (Table 6).

Table 5.

Control Variables Related to Infant Feeding Styles

Variable	n	%
Shame
0 = No	164	53.6
1 = Yes	142	46.4
Education
0 = <Bachelor's degree	195	63.7
1 = ≥Bachelor's degree	111	36.3
Children
0 = Infant only	201	65.7
1 = Infant+other children	105	34.3
Feed percent
0 = ≤50%	180	58.8
1 = >50%	126	41.2
Age
0 = <30	167	54.6
1 = 30+	139	45.4
Income
0 = <75k	172	56.2
1 = 75k+	134	43.8

N = 306. Feed percent = percentage of the infant's feeds the respondent reported engaging in.

Table 6.

Hierarchical Regression for Feeding Style Constructs

Step and predictor variable	Pressuring, β	Restrictive, β	Laissez-faire, β	Responsive, β
Step 1
Shame	−0.20***	−0.07	−0.10	0.11*
Education	−0.17**	−0.08	−0.17**	0.14*
Children	−0.16**	−0.14*	−0.11	0.06
Feed percent	−0.29***	−0.09	−0.21***	0.27***
Age	−0.02	0.02	−0.06	0.12*
Income	−0.16**	−0.09	−0.11	0.05
	R2 = 0.26***	R2 = 0.06**	R2 = 0.15***	R2 = 0.16***
	ΔR2 = 0.26***	ΔR2 = 0.06**	ΔR2 = 0.15***	ΔR2 = 0.16***
Step 2
Shame	−0.18***	−0.08	−0.09	0.04
Education	−0.05	−0.08	−0.05	−0.02
Children	−0.16**	−0.14*	−0.11*	0.07
Feed percent	−0.17***	−0.09	−0.09	0.13*
Age	0.02	0.02	−0.03	0.05
Income	−0.14**	−0.09	−0.10	0.06
Stress	−0.13**	0.01	−0.17**	0.32***
Anxiety	−0.28***	0.03	−0.23**	0.40***
Depression	0.54***	0.02	0.48***	−0.57***
	R2 = 0.39***	R2 = 0.06	R2 = 0.27***	R2 = 0.36***
	ΔR2 = 0.13***	ΔR2 = 0.00	ΔR2 = 0.12***	ΔR2 = 0.20***

^* p < 0.05; ^**p < 0.01; and ^***p < 0.001.

Pressuring

At step 1, 25.9% of the variance in pressuring feeding style scores was explained by six control variables. Feeding percent was the strongest predictor of the pressuring feeding style (β = −0.29); engaging in ≤50% of the infant's feeds was related to increased pressuring style scores. At step 2, symptoms of stress, depression, and anxiety accounted for an additional 12.8% of the variance. All three mental health variables were significant.

Greater depressive symptoms was the strongest predictor of the pressuring feeding style (β = 0.54), while greater symptoms of stress (β = −0.13) and anxiety (β = −0.28) were associated with lower pressuring scores.

Restrictive

At step 1, 5.7% of the variance in restrictive feeding style scores was explained by the six control variables. The only control variable that was significantly related to the restrictive feeding style construct was having additional children in the home (β = −0.14). At step 2, symptoms of stress, depression, and anxiety only accounted for an additional 0.2% of the variance in the restrictive style scores. None of the three mental health variables were significantly related to the restrictive feeding style.

Laissez-faire

At step 1, 15% of the variance in laissez-faire feeding style scores was explained by the six control variables. The beta weights for education (β = −0.17) and feeding percent (β = −0.21) were statistically significant, with feeding percent being the strongest predictor. Having less than a bachelor's degree and engaging in ≤50% of the infant's feeds were significantly related to increased laissez-faire feeding style scores.

At step 2, symptoms of stress, depression, and anxiety accounted for an additional 11.5% of the variance. All three mental health variables were significant. Greater depressive symptoms was the strongest predictor of the laissez-faire feeding style (β = 0.48), while increased symptoms of stress (β = −0.17) and anxiety (β = −0.23) were associated with lower laissez-faire scores.

Responsive

At step 1, 16.1% of the variance in responsive feeding style scores was explained by the six control variables. The beta weights for shame (β = 0.11), education (β = 0.14), age (β = 0.12), and feeding percent (β = 0.27) were statistically significant, with feeding percent being the strongest predictor. Experiencing shame for choosing to formula-feed, having higher than a bachelor's degree, and engaging in >50% of the infant's feeds were significantly related to increased responsive feeding style scores.

At step 2, symptoms of stress, depression, and anxiety accounted for an additional 19.6% of the variance. All three mental health variables were significant. Lower depressive symptoms were the strongest predictor of the responsive feeding style (β = −0.57), while increased symptoms of stress (β = 0.32) and anxiety (β = 0.40) were associated with higher responsive scores.

Discussion

The purpose of this study was to investigate the relationship between parental mental health symptoms and feeding styles in parents of healthy, term formula-fed infants. Greater depressive symptoms were the strongest predictor of pressuring and laissez-faire feeding styles in our sample. This finding is consistent with other studies that found mothers with depressive symptoms exhibited less responsiveness during infant feeding compared with mothers without depressive symptoms,^53–56 and this growing body of evidence has significant implications. There is a need to develop responsive feeding interventions tailored to parents experiencing depressive symptoms to improve parental mental health and, subsequently, infant growth trajectories.

In our sample, lower symptoms of stress and anxiety were associated with the pressuring and laissez-faire feeding styles, while higher symptoms of stress and anxiety were associated with the responsive feeding style. These findings are different from a previous study, which found that maternal stress and anxiety symptoms were positively associated with nonresponsive feeding styles in a sample of WIC-enrolled Maryland residents.³⁰ The reasons for our findings are not known, and fewer studies have examined parental stress and anxiety symptoms related to infant feeding styles, compared with depressive symptoms. Thus, further research is needed to explore these relationships.

Engaging in ≤50% of the infant's feeds was the strongest control variable predictor for the pressuring and laissez-faire feeding styles. Infants exhibit various feeding cues,⁵⁷ and our findings suggest the less time the parent spends feeding the infant, the less they will understand the infant's cues and be responsive to them. Of note, 58.9% of our sample reported feeding their infant for less than half of the infant's feeds. This means that the infants of the parents in our sample are fed by another caregiver most of the time, including the other parent (49.3%), family members (56.5%), and daycare workers (19.3%).

Thus, there are important practice and policy implications to consider. First, we recommend responsive feeding education by HCPs for both parents, family members, and daycare workers. Second, state guidelines related to infant feeding policies in childcare facilities should align with standards published by the National Resource Center for Health and Safety in Child Care and Early Education,⁵⁸ which recommend responsive feeding, including feeding one infant at a time, holding the infant and engaging with the infant through eye contact and vocalizations, and initiating and ending feeds based on the infant's hunger and satiety cues. However, we recognize the systemic barriers related to these recommendations, such as limited resources in childcare settings.

Because fathers are significantly underrepresented in infant feeding and obesity prevention research,^59–61 we attempted to recruit them through father-focused Facebook groups. This recruitment strategy has shown success in recruiting fathers of young children compared with strategies such as in-person, direct mailing, and other websites.⁶² About 11% of participants in our study identified as male. Comparatively, in another study where parents of healthy bottle-fed infants were primarily recruited through e-mail listservs or pediatric clinics, fathers only represented 5% of the sample.⁶³

While we were able to recruit more fathers in our study, they remain underrepresented compared with mothers. The few researchers who have examined paternal feeding styles in infancy and toddlerhood have found that fathers exhibit more nonresponsive feeding styles compared with mothers.^64,65 The amount of time fathers report caring for their children has nearly tripled over the last half-century,⁶⁶ and many families choose to formula-feed so that a nonmaternal caregiver can help with infant feeds,^67–69 yet father–infant feeding interactions are much less studied. We recommend employing qualitative methods to understand fathers' unique needs related to infant feeding as a first step for future research.

When examining parental mental health symptoms, the effect of the COVID-19 pandemic must be considered. In a recent systematic review and meta-analysis examining the mental health status of postpartum mothers during the COVID-19 pandemic, Gao et al. found that rates of mental health symptoms were more prevalent compared with prepandemic rates and mothers who formula fed their infants had an increased risk of experiencing postpartum mental health symptoms compared with parents who breastfed.⁷⁰

These findings are relevant because our survey was conducted during the pandemic and included parents of formula-fed infants. Since we detected a strong association between parental depressive symptoms and two nonresponsive feeding styles, we recommend increased postpartum depression screening and responsive feeding support for all postpartum mothers and fathers regardless of the infant feeding method during and beyond the pandemic.

Limitations

Despite our attempts to recruit a diverse sample, our sample was 81.7% White and 86.3% female, limiting the generalizability of our findings. While social media recruitment can introduce sampling bias, it has been shown to be an effective method in mental health research.⁷¹ Due to the large difference in group size, we were not able to assess differences in feeding styles and mental health symptoms between mothers and fathers.

Depressive and stress symptoms were more prevalent in our sample, 50.7% and 86.9%, respectively, compared with those estimated in a meta-analysis of studies examining the prevalence of depressive (26.7%) and stress (55%) symptoms among postpartum women during the COVID-19 pandemic.⁷⁰ Data were obtained through parental self-report, and participants were asked to answer ∼100 survey items.

In an attempt to offset the potential burden of the lengthy questionnaire, participants could enter a lottery incentive drawing as a token of appreciation for their time and efforts.

Conclusions

Our primary findings were that high levels of depressive symptoms, low levels of anxiety and stress symptoms, and engaging in fewer feeding interactions were the strongest predictors of pressuring and laissez-faire feeding styles. We recommend increased screening for depressive symptoms in parents of infants and responsive feeding support for all families regardless of the infant feeding method and especially for those experiencing depressive symptoms.

Impact Statement

Our primary findings were that high levels of depressive symptoms, low levels of anxiety and stress symptoms, and engaging in fewer feeding interactions were linked to nonresponsive feeding styles. We need to support the mental health of all parents of infants and encourage responsive feeding to mitigate childhood obesity.

Disclaimer

The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Authors' Contributions

T.N.R. was involved in conceptualization, methodology, formal analysis, investigation, writing—original draft, visualization, project administration, and funding acquisition. P.R. was involved in conceptualization, methodology, writing—review and editing, and supervision. M.S. was involved in formal analysis, data curation, writing—review and editing, and visualization.

Funding Information

This research was supported by internal grant funding from the East Carolina University College of Nursing Doctoral Research Grant Program, totaling $1,000 for participant incentives. Additionally, Dr. Taylor N. Richardson's work is supported by the National Institutes of Health (NIH) National Institute of Nursing Research (NINR) under award number T32NR007091.

Author Disclosure Statement

No competing financial interests exist.