Seeing other women breastfeed: how vicarious experience relates to breastfeeding intention and behaviour

Vicarious experience gained through seeing women breastfeed may influence infant feeding decisions and self-efficacy. Our aim was to measure the attributes of seeing breastfeeding and to investigate how these relate to feeding intention (primary outcome) and behaviour (secondary outcome). First, we developed a Seeing Breastfeeding Scale (SBS), which consisted of five attitudes (Cronbach's alpha of 0.86) to most recently observed breastfeeding: 'I felt embarrassed'; 'I felt uncomfortable'; 'I did not know where to look'; and 'It was lovely' and 'It didn't bother me'. Test-retest reliability showed agreement (with one exception, kappas ranged from 0.36 to 0.71). Second, we conducted a longitudinal survey of 418 consecutive pregnant women in rural Scotland. We selected the 259 women who had never breastfed before for further analysis. Following multiple adjustments, women who agreed that 'It was lovely to see her breastfeed' were more than six times more likely to intend to breastfeed compared with women who disagreed with the statement [odds ratio (OR) 6.72, 95% confidence interval (CI) 2.85-15.82]. Women who completed their full-time education aged 17 (OR 3.09, 95% CI 1.41-6.77) or aged 19 (OR 7.41 95% CI 2.51-21.94) were more likely to initiate breastfeeding. Women who reported seeing breastfeeding within the preceding 12 months were significantly more likely to agree with the statement 'It was lovely to see her breastfeed' (P = 0.02). Positive attitudes to recently seen breastfeeding are more important determinants of feeding intention than age of first seeing breastfeeding, the relationship to the person seen and seeing breastfeeding in the media.

Why do interventions work in some places and not others: a breastfeeding support group trial

In a cluster randomised controlled trial of a policy to provide community breastfeeding support groups in Scotland, breastfeeding rates declined in 3 of 7 intervention localities. From a preliminary study, we expected breastfeeding outcomes to vary and we prospectively used qualitative and quantitative methods to ask why. Ethnographic in-depth interviews, focus groups, observations and survey data were analysed to build seven embedded case studies. A pyramidal model of how primary health service organisations implemented the policy was constructed prior to knowing trial outcomes to minimise bias. Informed by a realist approach, the model explained variation in (a) policy implementation (b) the breastfeeding outcomes, whereas the quantity of intervention delivered did not. In the three localities where breastfeeding rates declined, negative aspects of place including deprivation, unsuitable premises and geographical barriers to inter-professional communication; personnel resources including staff shortages, high workload and low morale; and organisational change predominated (the base model tiers). Managers focused on solving these problems rather than delivering the policy and evidence of progress to the higher model tiers was weak. In contrast, where breastfeeding rates increased the base tiers of the model were less problematic, there was more evidence of leadership, focus on the policy, multi-disciplinary partnership working and reflective action cycles (the higher model tiers). We advocate an ethnographic approach to the design and evaluation of complex intervention trials and illustrate how this can assist in developing an explanatory model. More attention should be given to the complex systems within which policies and interventions occur, to identify and understand the favourable conditions necessary for a successful intervention.

Effectiveness of policy to provide breastfeeding groups (BIG) for pregnant and breastfeeding mothers in primary care: cluster randomised controlled trial

OBJECTIVE

To assess the clinical effectiveness and cost effectiveness of a policy to provide breastfeeding groups for pregnant and breastfeeding women.

DESIGN

Cluster randomised controlled trial with prospective mixed method embedded case studies to evaluate implementation processes.

SETTING

Primary care in Scotland.

PARTICIPANTS

Pregnant women, breastfeeding mothers, and babies registered with 14 of 66 eligible clusters of general practices (localities) in Scotland that routinely collect breastfeeding outcome data.

INTERVENTION

Localities set up new breastfeeding groups to provide population coverage; control localities did not change group activity.

MAIN OUTCOME MEASURES

PRIMARY OUTCOME

any breast feeding at 6-8 weeks from routinely collected data for two pre-trial years and two trial years.

SECONDARY OUTCOMES

any breast feeding at birth, 5-7 days, and 8-9 months; maternal satisfaction.

RESULTS

Between 1 February 2005 and 31 January 2007, 9747 birth records existed for intervention localities and 9111 for control localities. The number of breastfeeding groups increased from 10 to 27 in intervention localities, where 1310 women attended, and remained at 10 groups in control localities. No significant differences in breastfeeding outcomes were found. Any breast feeding at 6-8 weeks declined from 27% to 26% in intervention localities and increased from 29% to 30% in control localities (P=0.08, adjusted for pre-trial rate). Any breast feeding at 6-8 weeks increased from 38% to 39% in localities not participating in the trial. Women who attended breastfeeding groups were older (P<0.001) than women initiating breast feeding who did not attend and had higher income (P=0.02) than women in the control localities who attended postnatal groups. The locality cost was pound13 400 (euro14 410; $20 144) a year.

CONCLUSION

A policy for providing breastfeeding groups in relatively deprived areas of Scotland did not improve breastfeeding rates at 6-8 weeks. The costs of running groups would be similar to the costs of visiting women at home.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN44857041.

A systematic review of measures assessing mothers' knowledge, attitudes, confidence and satisfaction towards breastfeeding

In order to support breastfeeding interventions, there is a need for objective, reliable, valid and sensitive measures of factors related to breastfeeding. Publications on the development and testing of tools measuring mothers' knowledge, attitudes, confidence or self-efficiency and/or satisfaction towards breastfeeding were systematically reviewed. Twenty-two papers evaluating 13 self-report measures matched our selection criteria, and were critically appraised by two independent reviewers. All scales were tested with pregnant women or breastfeeding mothers. The 13 measures varied markedly in ease of completion and cultural appropriateness and none reached our highest level of evidence grading. Four of the measures had sufficient evidence to support their use, including the Breastfeeding Attrition Prediction Tool, the Modified Breastfeeding Evaluation Scale, the Breastfeeding Self-Efficiency Scale and the Iowa Infant Feeding Attitude Scale. There has been a tendency to develop new measures rather than evaluate the strengths and weaknesses of existing measures, particularly in different populations.

Recruitment issues when primary care population clusters are used in randomised controlled clinical trials: Climbing mountains or pushing boulders uphill?

Cluster randomised controlled trials for health promotion, education, public health or organisational change interventions are becoming increasingly common to inform evidence-based policy. However, there is little published methodological evidence on recruitment strategies for primary care population clusters. In this paper, we discuss how choosing which population cluster to randomise can impact on the practicalities of recruitment in primary care. We describe strategies developed through our experiences of recruiting primary care organisations to participate in a national randomised controlled trial of a policy to provide community breastfeeding groups for pregnant and breastfeeding mothers, the BIG (Breastfeeding in Groups) trial. We propose an iterative qualitative approach to recruitment; collecting data generated through the recruitment process, identifying themes and using the constant comparative method of analysis. This can assist in developing successful recruitment strategies and contrasts with the standardised approach commonly used when recruiting individuals to participate in randomised controlled trials. Recruiting primary care population clusters to participate in trials is currently an uphill battle in Britain. It is a complex process, which can benefit from applying qualitative methods to inform trial design and recruitment strategy. Recruitment could be facilitated if health service managers were committed to supporting peer reviewed, funded and ethics committee approved research at national level.

Health professionals, implementation and outcomes: reflections on a complex intervention to improve breastfeeding rates in primary care

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.

One-to-one or group-based peer support for breastfeeding? Women's perceptions of a breastfeeding peer coaching intervention

BACKGROUND

Studies reporting one-to-one peer support interventions have been successful in some countries with high breastfeeding initiation rates, but less so in Great Britain, where low uptake of peer support has occurred. We conducted a peer coaching intervention study in rural Scotland that improved breastfeeding initiation and duration. This study reports qualitative data about participants' perceptions of the coaching intervention. The aim was to investigate why group-based peer support was more popular than one-to-one peer support.

METHODS

Qualitative data were collected and analyzed from an initial focus group; 21 semi-structured interviews; and 31 coaching group observations and respondents (n = 105/192) in response to an open question about reasons for not choosing a personal coach in a survey of breastfeeding experiences. We developed a coding frame, identified themes, and constructed charts for analysis and interpretation of data.

RESULTS

Analysis revealed that groups were more popular because they normalized breastfeeding in a social environment with refreshments, which improved participants' sense of well-being. Groups provided flexibility, a sense of control, and a diversity of visual images and experiences, which assisted women to make feeding-related decisions for themselves, and they offered a safe place to rehearse and perform breastfeeding in front of others, in a culture where breastfeeding is seldom seen in public. Women often felt initial anxiety when attending a group for the first time, and they expressed doubt that one set of "breastfeeding rules" would suit everyone.

CONCLUSIONS

Pregnant women and breastfeeding mothers will voluntarily engage in an activity to support breastfeeding if there is a net interactional (verbal, visual, emotional and gustatory) gain and a minimum risk of a negative experience. One-to-one peer coaching was perceived as a greater risk to confidence and empowerment than group- based peer coaching.

Effectiveness of a breastfeeding peer coaching intervention in rural Scotland

BACKGROUND

Breastfeeding initiation in Scotland in 2000 was 63 percent, compared with over 90 percent in Norway and Sweden. Although peer support is effective in improving exclusivity of breastfeeding in countries where over 80 percent of women initiate breastfeeding, the evidence for effectiveness in countries with lower initiation is uncertain. Our primary aim was to assess whether group-based and one-to-one peer breastfeeding coaching improves breastfeeding initiation and duration.

METHODS

Action research methodology was used to conduct an intervention study in 4 geographical postcode areas in rural northeast Scotland. Infant feeding outcomes at birth and hospital discharge; at 1, 2, and 6 weeks; and at 4 and 8 months were collected for 598 of 626 women with live births during a 9-month baseline period and for 557 of 592 women with live births during a 9-month intervention period. Groups met in 5 locations, with 266 groups meeting in the period when intervention women were eligible to attend. Data on place of birth and length of postnatal hospital stay were also collected. Control data from 10 other Health Board areas in Scotland were compared. An intention-to participate survey about coaching participation was completed by 206 of 345 women initiating breastfeeding. Group attendance data were collected by means of 266 group diaries.

RESULTS

There was a significant increase in any breastfeeding of 6.8 percent from 34.3 to 41.1 percent (95% CI 1.2, 12.4) in the study population at 2 weeks after birth compared with a decline in any breastfeeding in the rest of Scotland of 0.4 percent from 44 to 43.6 percent (95% CI -1.2, 0.4). Breastfeeding rates increased compared with baseline rates at all time points until 8 months. However, the effect was not uniform across the 4 postcode areas and was not related to level of deprivation. Little difference was seen in receipt of information and knowledge about the availability of coaching among areas. All breastfeeding groups were well attended, popular, and considered helpful by participants. A minority of women (n = 14/206) participated in formal one-to-one coaching. Women who received antenatal, birth, and postnatal care from community midwife-led units were more likely to be breastfeeding at 2 weeks (p = 0.007) than women who received some or all care in district maternity units.

CONCLUSIONS

Group-based and one-to-one peer coaching for pregnant women and breastfeeding mothers increased breastfeeding initiation and duration in an area with below average breastfeeding rates.

Sickness certification system in the United Kingdom: qualitative study of views of general practitioners in Scotland

OBJECTIVES

To explore how general practitioners operate the sickness certification system, their views on the system, and suggestions for change.

DESIGN

Qualitative focus group study consisting of 11 focus groups with 67 participants.

SETTING

General practitioners in practices in Glasgow, Tayside, and Highland regions, Scotland.

SAMPLE

Purposive sample of general practitioners, with further theoretical sampling of key informant general practitioners to examine emerging themes.

RESULTS

General practitioners believed that the sickness certification system failed to address complex, chronic, or doubtful cases. They seemed to develop various operational strategies for its implementation. There appeared to be important deliberate misuse of the system by general practitioners, possibly related to conflicts about roles and incongruities in the system. The doctor-patient relationship was perceived to conflict with the current role of general practitioners in sickness certification. When making decisions about certification, the general practitioners considered a wide variety of factors. They experienced contradictory demands from other system stakeholders and felt blamed for failing to make impossible reconciliations. They clearly identified the difficulties of operating the system when there was no continuity of patient care. Many wished either to relinquish their gatekeeper role or to continue only with major changes.

CONCLUSIONS

Policy makers need to recognise and accommodate the range and complexity of factors that influence the behaviour of general practitioners operating as gatekeepers to the sickness certification system, before making changes. Such changes are otherwise unlikely to result in improvement. Models other than the primary care gatekeeper model should be considered.

A qualitative study of women's views about how health professionals communicate about infant feeding

OBJECTIVE: To look at how communication by health professionals about infant feeding is perceived by first time mothers. DESIGN: Qualitative semi-structured interviews early in pregnancy and 6-10 weeks after birth. SUBJECTS AND SETTING: Twenty-one white, low income women expecting their first baby were interviewed mostly at home, often with their partner or a relative. RESULTS: The personal and practical aspects of infant feeding which were important to women were seldom discussed in detail in ante-natal interviews. In post-natal interviews women described how words alone encouraging them to breastfeed were insufficient. Apprenticeship style learning of practical skills was valued, particularly time patiently spent watching them feed their baby. Women preferred to be shown skills rather than be told how to do them. Some felt pressure to breastfeed and bottle feeding mothers on post-natal wards felt neglected in comparison. Women preferred their own decision-making to be facilitated rather than being advised what to do. Some women experienced distress exposing their breasts and being touched by health professionals. Continuity of care and forming a personal relationship with a health professional who could reassure them were key factors associated with satisfaction with infant feeding communication. CONCLUSIONS: The infant feeding goal for many women is a contented, thriving baby. In contrast, women perceive that the goal for health professionals is the continuation of breastfeeding. These differing goals can give rise to dissatisfaction with communication which is often seen as 'breastfeeding centred' rather than 'woman centred.' Words alone offering support for breastfeeding were often inadequate and women valued practical demonstrations and being shown how to feed their baby. Spending time with a caring midwife with whom the woman had developed a personal, continuing relationship was highly valued. Women were keen to maintain ownership, control and responsibility for their own decision-making about infant feeding.

Identifying which women will stop breast feeding before three months in primary care: a pragmatic study

BACKGROUND

In Britain only 42% of women who initiate breast feeding are still breast feeding at four months, despite well documented health benefits.

AIM

To explore whether sociodemographic and social support information collected routinely by health visitors at the new birth assessment can help predict which women will give up breast feeding before three months.

METHOD

A survey of 279 consecutive births in three general practices in an inner-London borough. Health visitors collected sociodemographic, infant feeding, and social support data at the new birth assessment 10 to 14 days after birth and at an immunisation visit at three to four months after birth. A data collection form was piloted and used by health visitors as part of their routine clinical care. Stepwise logistic regression was performed on 160 women who initiated breast feeding to identify predictors for those who would still be breast feeding at three months.

RESULTS

Three variables were found to be significantly associated with breast feeding at three months. Younger women and women with moderate to poor emotional support as assessed by their health visitor were less likely to still be breast feeding at three months. White women who left full-time education at age 16 years or below are least likely to be breast feeding at three months but educational level is not a significant predictor for women from other ethnic backgrounds.

CONCLUSION

This pragmatic study illustrates how information collected during routine clinical care by health visitors can help predict which women will give up breast feeding before three months. This could be useful to identify women whose social support needs are not being met and who may benefit from local initiatives. Infant feeding researchers should consider the influence of ethnicity and levels of social support on breast feeding outcomes.

Qualitative study of decisions about infant feeding among women in east end of London

OBJECTIVE

To improve understanding of how first time mothers who belong to a socioeconomic group with particularly low rates of breast feeding decide whether or not to initiate breast feeding.

DESIGN

Qualitative semistructured interviews early in pregnancy and 6-10 weeks after birth.

SETTING

Women's homes in east end of London.

SUBJECTS

21 white, low income women expecting their first baby were interviewed mostly at home, often with their partner or a relative. Two focus groups were conducted.

RESULTS

Women who had regularly seen a relative or friend successfully breast feed and described this experience positively were more confident about and committed to breast feeding. They were also more likely to succeed. Exposure to breast feeding, however, could be either a positive or a negative influence on the decision to breast feed, depending on the context. Women who had seen breast feeding only by a stranger often described this as a negative influence, particularly if other people were present. All women knew that breast feeding has health benefits. Ownership of this knowledge, however, varied according to the woman's experience of seeing breast feeding.

CONCLUSIONS

The decision to initiate breast feeding is influenced more by embodied knowledge gained from seeing breast feeding than by theoretical knowledge about its benefits. Breast feeding involves performing a practical skill, often with others present. The knowledge, confidence, and commitment necessary to breast feed may be more effectively gained through antenatal apprenticeship to a breastfeeding mother than from advice given in consultations or from books.

Qualitative research interviewing by general practitioners. A personal view of the opportunities and pitfalls

OBJECTIVE

This study looked look at the role of the GP as a qualitative research interviewer and aimed to illustrate areas of methodological difficulty using personal observations made during a qualitative study in general practice.

METHODS AND RESULTS

The recently published literature on qualitative research in general practice was reviewed by the author to inform her own qualitative study looking at how women decide how to feed their babies. Some women in the study were patients of the author; some knew that she is a GP but were registered at another practice and some did not know that she is a doctor. In-depth and semi-structured interviews were tape recorded and transcribed. Observations about combining general practice and qualitative research were recorded by the author in a research diary.

CONCLUSION

Qualitative research is being advocated as a methodology appropriate for general practice, yet there are many unanswered questions about methodological detail. There are no guidelines to help GPs to decide whether it is appropriate for them to do the interviewing, the practicalities of doing it, and whether they should use their own patients. There is clearly a need for more methodological research to look at how these decisions influence the data and to inform GPs who are considering a qualitative study.

A review of recently published qualitative research in general practice. More methodological questions than answers?

OBJECTIVE

This study aimed to review published papers which use qualitative interviewing in general practice as their methodology. To look specifically at the detail of how the methodology is presented to the reader, with particular emphasis on the clarity of detail about recruitment, the relationship of the interviewer to the respondents, the setting and how the research was presented to the respondents.

METHODS AND RESULTS

A systematic search using Medline and hand searching the British Journal of General Practice, Family Practice and Social Science and Medicine identified 29 recent papers using qualitative interviewing techniques in general practice. The papers were analysed for eight methodological criteria by the author. A second analysis, blind to the results of the first analysis was performed by the author 6 weeks later. An independent assessor analysed 12 randomly selected papers. There was 98.3% intra-assessor agreement and 89.6% inter-assessor agreement about whether the eight criteria were met. Overall 140 of a possible 232 criteria were met (60.3%).

CONCLUSION

Published papers using qualitative interviewing in general practice often lack explicit methodological detail about the relationship between the interviewer and the respondents, the setting, who did the recruiting and how the research was explained to the respondents. This methodological detail is important for the critical appraisal of qualitative research, where the context of the research can influence the data.