Family Practice Advance Access originally published online on December 7, 2006
Family Practice 2007 24(1):84-91; doi:10.1093/fampra/cml061
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Health professionals, implementation and outcomes: reflections on a complex intervention to improve breastfeeding rates in primary care
a Centre For Rural Health, Aberdeen University, The Greenhouse, Beechwood Business Park North, Inverness, Scotland
b Department of General Practice, School of Medicine, Centre for Health Sciences Research, Cardiff University, 3rd Floor, Neuadd Meirionnydd, Heath Park, Cardiff, Wales
c Fraserburgh Hospital, Fraserburgh, UK
Correspondence to: Pat Hoddinott; Email: p.hoddinott{at}abdn.ac.uk
Received 17 March 2006; Revised 30 June 2006; Accepted 25 October 2006.
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Abstract |
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 Top Abstract IntroductionMethodsResultsDiscussionDeclarationAppendix: Interview QuestionsReferences |
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Objectives. To understand why a complex breastfeeding coaching intervention, which offered health professional-facilitated breastfeeding groups for pregnant and breastfeeding mothers and personal peer coaches, was more effective at improving breastfeeding rates in some areas than others.
Methods. This controlled intervention study was designed, implemented and evaluated using principles from action research methodology. We theoretically sampled 14 health professionals with varying levels of involvement and 12 consented to be interviewed. We analysed data from 266 group diaries kept by health professionals, 31 group observations, 10 audio-recorded steering group meetings and field notes. Women's perspectives were obtained by analysing qualitative data from one focus group, 21 semi-structured qualitative interviews and responses to open-survey questions.
Results. The intervention was more effective at improving breastfeeding rates in areas where health visitors and midwives were committed to working together to implement the intervention, where health professionals shared group facilitation and where inter- and intra-professional relationships were strong. The area where the intervention was ineffective had continuity of a single group facilitator with breastfeeding expertise and problematic relationships within and between midwife and health visitor teams. No one style of group suited all women. Some preferred hearing different views, others valued continuity of help from a facilitator with breastfeeding expertise.
Conclusions. We hypothesise that involving several local health professionals in implementing an intervention may be more effective than a breastfeeding expert approach. Inter- and intra-health professional relationships may be an important determinant of outcome in interventions that aim to influence population behaviours like breastfeeding.
Keywords. Action research, breastfeeding, complex intervention, groups, implementation research.
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Introduction |
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TopAbstractIntroductionMethodsResultsDiscussionDeclarationAppendix: Interview QuestionsReferences |
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Effective breastfeeding intervention studies often provide little information about the process of implementation, organisational structures and cultural contexts.1–5 It is therefore difficult to know why some interventions fail where others succeed. This article sets out some reflections on the role of health professionals in planned interventions, drawing on evidence collected as part of a larger breastfeeding coaching intervention which successfully increased breastfeeding rates in a rural area of Scotland.6
Unlike much previous work that sought to control the type of professional intervention in order to measure its success, in this project some components of the intervention were fixed and some flexibility in implementation was both expected and encouraged.6 Our intervention was complex and existing evidence guiding the design was uncertain.
From the outset, it was hypothesised that allowing professionals to adapt and modify their approach to suit their local circumstances would improve breastfeeding outcomes. Therefore, in addition to measuring outcomes, action research methods7 were chosen to study the implementation process in four geographical areas. These were deliberately selected for their variation in population levels of deprivation and in the organisation of maternity services.
The main study involved a non-randomised controlled breastfeeding coaching intervention in rural North East Scotland. The National Child Health Surveillance Programme breastfeeding data for 10 Scottish Health Boards (excluding the study Health Board) were used as a control. The intervention offered health professional-facilitated breastfeeding groups to pregnant and breastfeeding mothers and/or a group lay member as a one-to-one coach. Four breastfeeding groups in small towns corresponded closely to four postcode areas enclosed within the study area boundaries. A rural group overlapped three of these postcode areas (Fig. 1). The groups were more popular than one-to-one peer coaching and the reasons for this are reported separately.8 The intervention increased any breastfeeding overall by 6.8% from 34.3% to 41.1% [95% confidence interval (CI) 1.2, 12.4] at 2 weeks compared to a decline in any breastfeeding in the rest of Scotland of 0.4% from 44% to 43.6% (95% CI –1.2, 0.4). However, the effect was not uniform across the four areas and further analysis showed that breastfeeding outcomes were not related to the following: level of deprivation measured by the Scottish index of multiple deprivation scores9; group attendance rates; the mothers' knowledge about the project; receipt of information pack and their reports about the helpfulness of the groups.6 In one geographical area, breastfeeding rates had a non-significant decline.
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Given these findings, we explored the qualitative data on process and attitudes provided by health professionals implementing the intervention and supported by data from women receiving the intervention. We put forward emergent hypotheses which illustrate how variations in implementation relate to breastfeeding outcomes and provide insights into aspects of the intervention that may have contributed to effectiveness.
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Methods |
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TopAbstractIntroductionMethodsResultsDiscussionDeclarationAppendix: Interview QuestionsReferences |
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Several sources of qualitative data (qualitative interviews with professionals and women, open-survey questions, group observations, tape recordings and minutes of steering group meetings and field notes) were collected to triangulate and strengthen rigour (Fig. 1). Data were collected and analysed concurrently, to inform subsequent data collection and analysis.
Interviews with health professionals
During the intervention, it became apparent from steering group meetings that relations between and attitudes of health professionals might be crucial to understanding variations in intervention implementation and breastfeeding outcome. To investigate this emerging theory, we used theoretical sampling.10 The lead nurse (Liz Taylor), a health promotion specialist (Mary Bellizzi), and PH identified 14 midwives and health visitors (group facilitators and non-facilitators) from the four geographical areas. Twelve consented to be interviewed by an outside independent consultant (Thelma Harvey), who was employed by the Scottish Executive to investigate health professional skills necessary to implement the coaching project to inform the production of the National Occupational Standards for the practice of public health.11 PH and Thelma Harvey developed an interview guide through meetings and correspondence, which met the data collection requirements of both projects (Appendix). There were several shared themes including collaborative working, knowledge and skills and communication and organisational aspects of the project. Audio-recorded interviews that took place in a health service interview room were independently anonymised by Thelma Harvey and transcribed outside the study area.
Coaching group and steering group observations
PH observed eight groups and MC co-facilitated 23 area 2 groups. Group observation data were recorded in field notes and provided information about health professional facilitation styles, structure and content of groups. A project steering group of health visitor and midwife group facilitators, their nurse manager, a health promotion specialist, two women representatives and a GP (PH) met every 6–8 weeks. Meetings were audio-recorded, minuted and PH made field notes. The principles of reflective practice were used.12 Members discussed aspects that were going well and less well, and changes were implemented and proposed. Observational data informed subsequent qualitative interview data collection and analysis in an iterative manner. This served to triangulate data collected from interviews and to search for disconfirming data.
Group attendance registers and diaries
Group facilitators kept registers and diaries for 266 groups (mean attendance n = 9) in the intervention period and reported free text observations and feedback. We were able to calculate the number of groups taking place in each area, the number of women attending and the median number of attendances per woman when pregnant and when breastfeeding.6 The diaries provided data on structure and content to triangulate with other data sources.
Coaching participant interviews and survey data
The sampling, recruitment and data collection of qualitative interview and survey data provided by women participating in breastfeeding coaching are described in detail elsewhere.8
Qualitative data analysis
All health professional and participant interview and survey data were entered into Atlas ti software. PH and Thelma Harvey independently listened to, summarised and coded health professional interviews. Coding was discussed and modified as data collection and analysis progressed. We created Atlas ‘families’ of data by breastfeeding group and by geographical area, allowing us to compare between families and between participant and professional data from all sources. Summaries of themes emerging from the data were cut and pasted from Atlas into Microsoft Word XP charts, allowing patterns and interpretation to take place as described in the Framework method of analysis.13 Themes were discussed at steering groups and this informed subsequent coaching implementation and data collection in an iterative manner. There was no interim analysis of breastfeeding outcome or survey data. We compared our final breastfeeding outcome data by group and geographical area with qualitative data and group attendance survey data6 with the aim of understanding and explaining variations in breastfeeding outcome.
Validation
Two independent researchers were involved; Thelma Harvey conducted all interviews with health professionals, independently analysed the data and agreed the findings. RP oversaw the study design; chose five interview transcripts at random and reviewed the coding frame, themes, analysis charts and interpretation. The findings were discussed with the steering group, who commented on their accuracy.
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Results |
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TopAbstractIntroductionMethodsResultsDiscussionDeclarationAppendix: Interview QuestionsReferences |
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The pre- and post-intervention audit data on breastfeeding for the total number of eligible women in the four areas where the intervention took place are shown in Table 1. The characteristics of the interview participants and attendance at steering group meetings are shown in Table 2. Quotations are from interview data unless otherwise stated.
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Variations in group characteristics between areas
All groups had a social and informal component, with light refreshments provided, and were popular with the women attending. There were variations in group structure, facilitation, style and dynamics between and within areas throughout the 21-month data collection period (Table 3). All groups were new at the start of the intervention, apart from group 1, which already had a fortnightly breastfeeding mothers support group. This group adopted the intervention protocol, invited pregnant women and increased group frequency to weekly.
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Groups in areas 2 and 3 were the most effective in improving breastfeeding rates. Group 2, alternate group 3 meetings and the rural group had an informal single group discussion, with one-to-one networking occurring over refreshments. Women often initiated and maintained the discussion:
Well you just usually chat about your experiences, ask people if they have had any problems and see if we can help them. (Participant aged 23, area 2)
Group 1 served the largest population and had the highest median attendance rates.6 It was the most informal group, running as a weekly drop-in, which women valued: "nobody will tut or look at the clock when you come in." Multiple conversations occurred simultaneously and facilitators moved around the room. It suited many, but one first-time mother felt that more information from the facilitator might improve her confidence:
She (the facilitator) won't actually sit down and speak to you about information. We have got to speak amongst ourselves. Is this right or is this right? So she's not really telling us what's right and what's wrong. I find it would be better if she had done something like that because I mean we are all new mums. (Participant aged 25, area 1)
Group 4 was in the area where breastfeeding rates did not improve. One facilitator facilitated group 4 and alternate groups in area 3. She led an interactive structured teaching session for the first half-hour with an emphasis on correct positioning and attachment, followed by more informal discussion, similar to other areas.
We went through the procedure of how you would sit with the baby and how the baby would latch on. There was like different steps .... So there was mothers telling their stories and then there was us that was in and we got to practice with our cushions and our dolls or whatever. Very informative, very, very good. (Participant aged 31, area 4)
Variations in professional commitment, involvement and relationships between areas
We analysed data describing professional relationships within disciplines (health visitor and midwife) and between disciplines. In particular, we examined reports of discontent between health professional group facilitators and non-facilitators.
In areas 2 and 3, which achieved the greatest increase in breastfeeding rates, health professional commitment was strong, with widespread support and ownership of the project and no reported discontent. Several health visitors were keen to facilitate groups and attend steering groups. In area 2, three monthly rotation of health visitor facilitator was considered optimum for providing continuity and maximising commitment.
Everybody had asked to go on the rota, so they are keen. (Health visitor, area 2)You've got to rotate it. You know for holidays, some people work part-time, but if you're rotating these things and you are all singing from the same hymnbook then the same message will be getting out. (Health visitor, area 3)
In area 1, there were one or two dissenting voices among the health professional team.
I've managed to convince all the midwives except one and unfortunately she works full time. She is so anti-breastfeeding she is going to be a real problem. (Midwife, area 1; steering group)
Women sometimes detected professional disharmony and found this unhelpful, as described by this woman with difficulties getting her baby to latch on to her breast:
The health visitor side from (area 1) were very much: "well it is the midwives who should have sorted this out before you came over to us". That's no use to me. (Participant aged 33, area 1)
Some health professionals felt the coaching project had strengthened midwife and health visitor relationships:
We now have a daily meeting which may only take 5 minutes depending on the patients but when we are handing over to the health visitors at day 10 or day 15 or whatever then we meet every day. It's good. What a difference it has made to relationships. (Midwife, area 1)
In area 4, the area where breastfeeding rates did not improve, health professional support for the project was weaker and relationships between midwives and health visitors were problematic. Health visitor representation at steering groups was lower (Table 2). The intervention protocol asked all midwives to recruit women antenatally and all health visitors to recruit post-natally; however, some health visitors did not feel recruitment was their role:
Midwives invite the mothers to the groups not the health visitors. (Health visitor, area 4)
In area 4, one midwife facilitated the group throughout, with only occasional health visitor attendance. She was widely considered by health professionals and women to have breastfeeding expertise and ran a 2-hour breastfeeding training session for all health visitors and midwives in the intervention area:
Through the grapevine I heard that not everybody took it on board or some people actually were quite negative about it. But I think for a lot of people it was very helpful and constructive. (Health visitor, area 2)
She also co-facilitated in rotation with health visitors in area 3, where teamwork was strong. Some midwives covering areas 3 and 4 felt their relationships with clients were being undermined. They described the facilitator contradicting or ‘taking over’ breastfeeding care for an individual without negotiation with the client's named midwife or health visitor.
They wanted this particular midwife to come and aid them with their breastfeeding and (pause) she wasn't always there to do it. She could have been off sick or having a day off, but also it made the rest of us, who did have an interest in breastfeeding feel that we were becoming second class citizens. (Midwife, area 4)
During the intervention, working patterns of midwives changed in areas 3 and 4. Single-duty midwives, based in the midwife-led maternity unit located in area 4, replaced the community-based, dual-role district nurse and midwife in area 3. This was unpopular with some staff and women. It may have weakened health professional involvement with the study in these areas.
Women's perspectives on continuity or rotation of group facilitator and facilitator style
In areas 2 and 3, some women acknowledged the benefit of having several facilitators, with differing styles and suggestions:
They sort of took time about ... so it could be 3–4 weeks before you saw ... It was alright—so it was just nice to hear everybody's different viewpoint. It just felt, to begin with, like you weren't sort of building up rapport with the same person, it was different people. (Participant aged 23, area 2)
In particular, women valued group facilitators who responded flexibly to their feedback, allowing groups to vary over time, reflecting the differing needs of women attending.
Some of the girls were saying, yeah, we would like them structured, some of them were saying, maybe not so much this week, might just speak about maybe one thing in particular. (Participant aged 24, area 2)
This woman describes two different group 3 facilitators:
I liked Q's approach anyway. She makes suggestions rather than saying you must. (Participant aged 27, area 3, about facilitator Y)It was kind of like stage managed almost. It was like the person in charge was I'll say what I have to say and then I will ask certain people about their experiences and that'll be it basically. There won't be has anyone got any questions or to open a conversation. It was the aggressive attitude towards it. Pro breastfeeding but there wasn't any of the subtlety. (Participant aged 27, area 3, about facilitator X)
Facilitator X was the sole facilitator for group 4 and facilitated alternate weeks in group 3. Many appreciated her breastfeeding expertise and more didactic teaching style:
It was really good to get the solid information and advice from X and it was all kind of backed up by all the information and experiences that other mums had had. (Participant aged 33, area 4)Conflicting advice until I met (Facilitator X). Brilliant. She made me feel confident in what I was doing—I wasn't doing anything wrong. (Survey respondent, area 3)
In areas 1 and 4, some women reported benefits of continuity of facilitator, who ‘knew’ group attenders and could introduce women with similar experiences.
I think because Z (group facilitator) is aware of everybody's problems as such or who's had the problems, she just sort of utilises what they know to help you as well as the recommendations or like medical ways to fix it. (Participant aged 27, area 1)
Women recipients of our breastfeeding intervention had differing expectations and needs, which varied over time. No overriding group style and structure suited all. A combination of informal peer networking, facilitated group discussion and an educational component seemed to meet the needs of most.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionDeclarationAppendix: Interview QuestionsReferences |
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We have described how a group-based peer coaching intervention varied in implementation processes and breastfeeding outcomes in different geographical areas. Multi-method action research, where some aspects of the intervention remained fixed throughout and some aspects of implementation were open to participant feedback and experiment, have enabled us to generate new hypotheses, which would not have arisen if our intervention had been rigidly defined at the onset. For example, rotation or sharing of facilitation by midwives and health visitors may be more effective at improving breastfeeding rates than continuity of a single ‘breastfeeding expert’ group facilitator. This was unexpected. We might have chosen a continuity of breastfeeding expert model of facilitation as a fixed part of the intervention, which may have resulted in different outcomes. We suggest that action research can be a useful additional stage in the development of a complex intervention.14
Our finding that strong inter- and intra-professional relationships and commitment appeared to relate to improved breastfeeding outcomes has several possible theoretical explanations: recruitment to and promotion of groups may be improved; health professionals may feel more empowered if expertise and experience is shared within and between teams and strong personality and style effects on outcome will be diluted. It is also possible that differences in breastfeeding outcomes occurred due to changes in professional orientation towards breastfeeding or other unidentified confounders.
It is clear that one style of group or group facilitation does not suit all. Needs differ at different stages of a woman's breastfeeding journey and between women. With more professionals involved in implementing the intervention, wider range of styles are offered and this is more likely to meet the needs of many. With continuity of one group facilitator, there is a higher risk of the intervention appealing to a smaller number of women and professionals, and of alienating some. The lack of significant change in breastfeeding rates in area 4 is unlikely to be purely a facilitator style or personality effect. The same facilitator co-facilitated in rotation in area 3 where breastfeeding rates increased, group attendance rates differed little between areas and many valued her.
Interviewing health professionals about professional relationships can be a sensitive area. The close professional involvement of the researchers may be considered either as a strength in view of reflective practice, transparency and level of trust achieved or as a weakness and inherent source of bias. To address the latter point, we used external consultants and steering group members to validate our findings.
The complexity of defining teams in primary care has been discussed by others15 and our study highlights the importance of inter- and intra-professional relationships in health visiting and midwifery to achieve set aims and objectives. This warrants further consideration by policymakers and providers who are trying to increase breastfeeding rates to reach government targets.16,17 It is likely to have wider importance in the design and evaluation of other complex interventions where the outcome of interest is a population-based behavioural change. It also highlights the need for further research into the role of experts in promoting and sustaining healthy behaviours, their relationship to other health professionals, their impact on teamwork and consequent intended and unintended outcomes.
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Declaration |
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TopAbstractIntroductionMethodsResultsDiscussionDeclarationAppendix: Interview QuestionsReferences |
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Funding: Grampian Primary Care NHS Trust, Scotland and The Chief Scientist Office, Scottish Executive Research Practice Scheme, Scotland. PH has a Chief Scientist Office, Scottish Executive Primary Care Research Career Scientist Award.
Ethical approval: Grampian Ethics Committee, Scotland, UK.
Conflicts of interest: None.
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Appendix: Interview Questions |
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TopAbstractIntroductionMethodsResultsDiscussionDeclarationAppendix: Interview QuestionsReferences |
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- 1. How did you become involved in the project?
- • At what stage or when did you get involved in project
- 2. Thinking back to when you started to be involved in the project, what do you feel that you contributed?
- 3. How enthusiastic were other colleagues from your area about the project?
- • Which other healthcare professionals were involved in the project?
- • What was it like working together as a team?
- 4. How confident did you feel when working with the mothers in groups?
- • Probe here for any training needs
- 5. What has been the most positive aspect of the project for you and your practice?
- • Communication with mothers on the benefits of breastfeeding
- • Group work
- • Other opportunities
- 6. What have been the most negative aspects about the project?
- 7. If you could choose, what changes would you make to improve the running of the project?
- If these do not come up in discussion ... .
- 8. In your team, do you feel there is a place for one person having breastfeeding expertise or should all members have equal knowledge and skills?
- 9. Did you receive adequate information and feedback about the project?
- 10. Do you have any suggestions about the project?
- 11. What are your views about professional facilitation of groups—1 person with continuity vs rota?
- 12. Ideal characteristics of facilitators?
- • At what stage or when did you get involved in project
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Acknowledgments |
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The authors thank the steering group members and all midwives, health visitors and women participants. Amanda J. Lee, Department of General Practice and Primary Care, University of Aberdeen, provided statistical support; Mary Bellizzi, Health Promotions, National Health Service Grampian, contributed to the study design and Liz Taylor assisted with sampling health professionals. PH, MC, Mary Bellizzi and Liz Taylor were members of the project steering group. Thelma Harvey interviewed health professionals and is one of the team of independent consultants who worked on the production of the National Occupational Standards (NOS) for the practice of public health. The NOS development was led by Skills for Health the Sector Skills Council for Health, Bristol, UK. Interventions made by the research team and in particular the health care professionals involved in the study were used as part of the consultation phase in the production of the NOS. Gillian Gauld, Linda Stephen and Netta Clark transcribed audio-recorded interviews.
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Notes |
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Hoddinott P, Pill R, and Chalmers M. Health professionals, implementation and outcomes: reflections on a complex intervention to improve breastfeeding rates in primary care. Family Practice 2007; 24: 84–91.
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References |
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TopAbstractIntroductionMethodsResultsDiscussionDeclarationAppendix: Interview QuestionsReferences |
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