Date of Award

January 2021

Document Type


Degree Name

Medical Doctor (MD)



First Advisor

Rafael Pérez-Escamilla


The objective of this study was to determine the social and cultural factors that influence the use of formula in two rural and indigenous communities in Central Mexico. We used a qualitative methodology based on the socioecological framework and integrative model of behavior. Interviews and focus groups were carried out with mothers, fathers, and grandparents of children two years of age or younger and healthcare providers attending to mothers and infants. We found that breastfeeding was still favored in both communities, however, many mothers viewed formula as a complement for breastfeeding. Young and first-time mothers were more likely to prefer formula for the convenience and as a solution for breast pain, insufficient milk, and body image. Healthcare providers promoted the use of formula through their own beliefs, information, communication, and conflicts of interest with formula industry representatives. The recent social and economic changes in these communities combined with the increased advertising and availability of breast milk substitutes, have facilitated the preference for formula. Women in rural, indigenous communities in Central Mexico are increasingly using formula. Efforts at the policy and institutional levels are needed to protect mothers and their children from the detrimental consequences of unregulated formula promotion and the formula culture that it brings with it.


This thesis is restricted to Yale network users only. It will be made publicly available on 10/12/2023