Pragmatic Trial to Evaluate the Effect of a Promotora Telephone Intervention on the Duration of Breastfeeding

The impact of continuous and intermittent supportive counseling on self-efficacy and continuation of breastfeeding in lactating women affected by COVID-19: a quasi-experimental trial

BACKGROUND

Promoting exclusive breastfeeding can have a great effect in reducing the complications and mortality rate of mother and child.

OBJECTIVE

The study aimed to compare the effects of continuous and intermittent supportive counselling on the self-efficacy and continuity of breastfeeding among Lactating mothers with COVID-19.

METHODS

The study was a semi-experimental research method and was conducted on 73 mothers with COVID-19 who were hospitalized in Ayatollah Mousavi Hospital in Zanjan, Iran from May 2021 to April 2022. In the continuous counselling group, counselling was provided daily for 14 days, while in the intermittent counselling group, counselling was provided once a week for four weeks. Breastfeeding continuity was assessed based on the World Health Organization's classification, and breastfeeding self-efficacy was measured using Dennis' standard breastfeeding self-efficacy questionnaire (BSE) up to four months after delivery. The data were analyzed using chi-square tests, independent t-tests, paired t-tests, analysis of variance with repeated measures, and survival analysis (Kaplan-Meier) with a 95% confidence level.

RESULTS

The survival analysis revealed that the cessation of exclusive breastfeeding occurred in 17 cases within the continuous counselling group and in 22 cases within the intermittent counselling group. The rates of continuation for exclusive breastfeeding were 52.8% and 40.5% in the continuous and intermittent counselling group respectively. However, no statistically significant differences were observed in the continuation of breastfeeding and the trend of changes in the mean scores of breastfeeding self-efficacies between the continuous and intermittent counselling groups. Furthermore, comparing the change in breastfeeding self-efficacy scores between the one-month and four-month follow-ups within the continuous counselling group, a statistically significant increase was observed.

CONCLUSION

The results indicated no difference in the effectiveness of continuous and intermittent counseling methods in improving breastfeeding continuity in women with COVID-19. Further research is needed to explore the long-term effects of different counseling approaches on breastfeeding outcomes during crises.

TRIAL REGISTRATION

The study was registered on the Iranian Registry of Clinical Trials website on 29/06/2021 with the registration code IRCT20150731023423N19. It can be accessed via this link: https://irct.behdasht.gov.ir/user/trial/55391/view .

Efficacy of a Gender-Relevant Smoking Cessation Intervention Among Women in Brazil: Findings from a Group Randomized Controlled Trial

Background: There is scarcity of smoking cessation programs that take gender into account during its development, implementation, and evaluation. We evaluated the efficacy of a theory-based, culturally, and gender-relevant smoking cessation intervention delivered by Community Health Workers (CHWs) among Brazilian women that augments the smoking cessation program offered through the public health system (PHS). Materials and Methods: A total of 328 women current smokers (100% cigarette smokers) were recruited across 8 towns in a tobacco producing state in Brazil between 2014 and 2017. Four towns were randomly assigned to the intervention (12 home visits by a CHW and a scheduled appointment to attend the smoking cessation program at the PHS) and four towns to the control condition (scheduled appointment to attend the cessation program at the PHS). The primary outcome was self-reported 7-day smoked tobacco abstinence at 7-month follow-up with biochemical verification. Results: Retention at 7-month follow-up was 80.7% (intervention) and 85.1% (control). Using intention-to-treat analysis, abstinence at 7-month-follow-up was 20% in the intervention arm versus 11% in the control arm. Multivariable modeling showed that participants in the intervention arm had 1.88 times the odds of self-reported smoking cessation than control participants after adjustment for depressive symptomatology, self-efficacy, and having someone in the house who smokes. Besides the intervention, only self-efficacy remained significant in the full model as a predictor of cessation. Replication of these analyses using the objective measure of carbon monoxide at a cutoff score of 8 ppm yielded similar results. Conclusions: A theory-based, culturally, and gender-relevant intervention, delivered by CHWs, can successfully promote smoking cessation among women. Clinical Trial Registration No. NCT03845413.

Support for healthy breastfeeding mothers with healthy term babies

BACKGROUND

There is extensive evidence of important health risks for infants and mothers related to not breastfeeding. In 2003, the World Health Organization recommended that infants be breastfed exclusively until six months of age, with breastfeeding continuing as an important part of the infant's diet until at least two years of age. However, current breastfeeding rates in many countries do not reflect this recommendation.

OBJECTIVES

1. To describe types of breastfeeding support for healthy breastfeeding mothers with healthy term babies. 2. To examine the effectiveness of different types of breastfeeding support interventions in terms of whether they offered only breastfeeding support or breastfeeding support in combination with a wider maternal and child health intervention ('breastfeeding plus' support).  3. To examine the effectiveness of the following intervention characteristics on breastfeeding support:      a. type of support (e.g. face-to-face, telephone, digital technologies, group or individual support, proactive or reactive);      b. intensity of support (i.e. number of postnatal contacts);      c. person delivering the intervention (e.g. healthcare professional, lay person);     d. to examine whether the impact of support varied between high- and low-and middle-income countries.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (which includes results of searches of CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP)) (11 May 2021) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing extra support for healthy breastfeeding mothers of healthy term babies with usual maternity care. Support could be provided face-to-face, over the phone or via digital technologies. All studies had to meet the trustworthiness criteria.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane Pregnancy and Childbirth methods. Two review authors independently selected trials, extracted data, and assessed risk of bias and study trustworthiness.  The certainty of the evidence was assessed using the GRADE approach.

MAIN RESULTS

This updated review includes 116 trials of which 103 contribute data to the analyses. In total more than 98,816 mother-infant pairs were included.  Moderate-certainty evidence indicated that 'breastfeeding only' support probably reduced the number of women stopping breastfeeding for all primary outcomes: stopping any breastfeeding at six months (Risk Ratio (RR) 0.93, 95% Confidence Interval (CI) 0.89 to 0.97); stopping exclusive breastfeeding at six months (RR 0.90, 95% CI 0.88 to 0.93); stopping any breastfeeding at 4-6 weeks (RR 0.88, 95% CI 0.79 to 0.97); and stopping exclusive breastfeeding at 4-6 (RR 0.83 95% CI 0.76 to 0.90). Similar findings were reported for the secondary breastfeeding outcomes except for any breastfeeding at two months and 12 months when the evidence was uncertain if 'breastfeeding only' support helped reduce the number of women stopping breastfeeding.  The evidence for 'breastfeeding plus' was less consistent. For primary outcomes there was some evidence that 'breastfeeding plus' support probably reduced the number of women stopping any breastfeeding (RR 0.94, 95% CI 0.91 to 0.97, moderate-certainty evidence) or exclusive breastfeeding at six months (RR 0.79, 95% CI 0.70 to 0.90).  'Breastfeeding plus' interventions may have a beneficial effect on reducing the number of women stopping exclusive breastfeeding at 4-6 weeks, but the evidence is very uncertain (RR 0.73, 95% CI 0.57 to 0.95). The evidence suggests that 'breastfeeding plus' support probably results in little to no difference in the number of women stopping any breastfeeding at 4-6 weeks (RR 0.94, 95% CI 0.82 to 1.08, moderate-certainty evidence). For the secondary outcomes, it was uncertain if 'breastfeeding plus' support helped reduce the number of women stopping any or exclusive breastfeeding at any time points.  There were no consistent findings emerging from the narrative synthesis of the non-breastfeeding outcomes (maternal satisfaction with care, maternal satisfaction with feeding method, infant morbidity, and maternal mental health), except for a possible reduction of diarrhoea in intervention infants.  We considered the overall risk of bias of trials included in the review was mixed. Blinding of participants and personnel is not feasible in such interventions and as studies utilised self-report breastfeeding data, there is also a risk of bias in outcome assessment.   We conducted meta-regression to explore substantial heterogeneity for the primary outcomes using the following categories: person providing care; mode of delivery; intensity of support; and income status of country.  It is possible that moderate levels (defined as 4-8 visits) of 'breastfeeding only' support may be associated with a more beneficial effect on exclusive breastfeeding at 4-6 weeks and six months. 'Breastfeeding only' support may also be more effective in reducing women in low- and middle-income countries (LMICs) stopping exclusive breastfeeding at six months compared to women in high-income countries (HICs). However, no other differential effects were found and thus heterogeneity remains largely unexplained. The meta-regression suggested that there were no differential effects regarding person providing support or mode of delivery, however, power was limited.  AUTHORS' CONCLUSIONS: When 'breastfeeding only' support is offered to women, the duration and in particular, the exclusivity of breastfeeding is likely to be increased. Support may also be more effective in reducing the number of women stopping breastfeeding at three to four months compared to later time points.  For 'breastfeeding plus' interventions the evidence is less certain. Support may be offered either by professional or lay/peer supporters, or a combination of both. Support can also be offered face-to-face, via telephone or digital technologies, or a combination and may be more effective when delivered on a schedule of four to eight visits. Further work is needed to identify components of the effective interventions and to deliver interventions on a larger scale.

Effect of Face-to-Face and WhatsApp Communication of a Theory-Based Health Education Intervention on Breastfeeding Self-Efficacy (SeBF Intervention): Cluster Randomized Controlled Field Trial

Background

The exclusive breastfeeding rate in Malaysia is still not satisfactory. Previous studies have shown that breastfeeding self-efficacy is one of the determinants of exclusive breastfeeding, and it can be improved using social cognitive theory. WhatsApp, which is widely used among Malaysians, could be leveraged as a platform to deliver health education interventions.

Objective

This study aimed to develop, implement, and evaluate the effect of using a face-to-face and WhatsApp-based health education intervention based on social cognitive theory, namely the Self-Efficacy in Breastfeeding (SeBF) module, on mothers' self-efficacy, knowledge, and attitudes in a district in Selangor state.

Methods

This study was a 2-arm, parallel, single-blind, cluster randomized controlled field trial with an intervention and a control group involving primigravida or multigravida mothers who reside in a district in Selangor state and did not exclusively breastfeed during their previous pregnancy. All 12 maternity and pediatric clinics in this district were randomly divided into 6 intervention and 6 control groups. A total of 172 pregnant mothers were randomly assigned to the intervention group (n=86) or the control group (n=86). The control group received usual routine care. The primary outcome was breastfeeding self-efficacy, while secondary outcomes were knowledge and attitude toward breastfeeding. Each subject was assessed at 4 time points: at baseline, immediately after the intervention, 4 weeks post partum, and 8 weeks post partum. Generalized mixed model analysis was applied to measure the effect of health education on breastfeeding self-efficacy, knowledge, and attitude after the intervention.

Results

The response rate was 81% (139/172), with the dropout rate being 7% (6/86) in the intervention group and 31% (27/86) in the control group. In the intent-to-treat analysis, the intervention group showed a significant increase in the mean total breastfeeding self-efficacy score 8 weeks after delivery compared with the control group (F_21,601=111.73, P<.001). In addition, the mean total score for breastfeeding knowledge increased significantly in the intervention group after the intervention compared to the control group (F_21,601=8.33, P<.001). However, no significant difference was found in the mean total score for breastfeeding attitude after the intervention (F_21,602=5.50, P=.47).

Conclusions

Face-to-face and WhatsApp-based participation in the SeBF program, designed on the basis of social cognitive theory, contributed to improved self-efficacy and knowledge about breastfeeding. Further studies need to be conducted with a longer duration (until 6 months post partum) to evaluate its effectiveness in increasing exclusive breastfeeding. Furthermore, new strategies in health education need to be developed to improve breastfeeding attitudes.

Trial Registration

Thaiclinicaltrials.org TCTR20200213004; https://www.thaiclinicaltrials.org/show/TCTR20200213004

Using Community Health Workers to Improve Health Outcomes in a Sample of Hispanic Women and Their Infants: Findings from a Randomized Controlled Trial

Introduction: The Maternal Infant Health Outreach Worker (MIHOW) program, an early childhood home visiting program, uses community health workers (CHWs) to improve health outcomes in underserved communities. Methods: This randomized clinical trial evaluated the impact of MIHOW's use of CHWs on selected maternal/infant outcomes up to 15 months postpartum. We hypothesized outcomes would be better among Hispanic women receiving MIHOW compared to a similar group of women eligible for MIHOW who received only a minimal education intervention (MEI). The study also expanded earlier research testing MIHOW's efficacy among Hispanic families using criteria set forth by federal guidelines. Women living in middle Tennessee enrolled during pregnancy (≤26 weeks gestation) and continued through 15 months postpartum. Results: Enrolled women (N = 132) were randomly assigned, with 110 women completing the study (MEI = 53; MIHOW = 57). Positive and statistically significant (p < .01) effects of MIHOW were observed on breastfeeding duration, safe sleep practices, stress levels, depressive symptoms, emotional support, referral follow through, parental confidence, and infant stimulation in the home. Conclusions: Findings provided strong evidence of the effectiveness of MIHOW for improving health outcomes in this sample. Using trained CHWs makes programs such as MIHOW a viable option for providing services to immigrant and underserved families.

The Effect of Educational Intervention on Improvement of Breastfeeding Self-Efficacy: A Systematic Review and Meta-Analysis

Background

Self-efficacy is an important psychological and motivational factor in breastfeeding, and it is a valuable framework that predicts breastfeeding outcomes and demonstrates maternal confidence in breastfeeding. The meta-analysis evaluated the effectiveness of educational interventions on improving breastfeeding self-efficacy (BSE).

Methods

The English and Persian databases including Medline, Embase, Cochrane Database of Systematic Reviews (CDSR), PubMed, Web of Science, Scopus, CINAHL, Sid, IRANDOC, and Marg-Iran were systematically searched for studies published from January 2005 to December 2020. The quality of studies was evaluated using the Cochrane risk of bias tool and the heterogeneity by I ² statistic. The extracted data were analyzed using RevMan 5 statistical software and presented using random effects standardized mean difference (SMD). The funnel plot was used for evaluating publication bias.

Results

Results from 40 RCTs showed that educational intervention had a positive effect on the BSE compared with the usual/standard care (pooled SMD = 1.20; 95% CI = 0.75-1.64, p value <0.001). The subgroup analysis indicated that the educational intervention was based on theory, group class format, direct method education, during the first week of postpartum, doing during pregnancy, on primiparous women, and health center setting, and the Asian region has a more effect on BSE than the others.

Conclusion

Breastfeeding education is considered an influential factor in the improvement of BSE. It is recommended that breastfeeding education should be continued for several weeks after childbirth for gaining its benefit. The Asian region has a more effect on BSE than the others. Therefore, it is important to add the values in content of education in each country.

Impact of breastfeeding interventions among United States minority women on breastfeeding outcomes: a systematic review

BACKGROUND

In the U.S., strong ethnic/racial, socioeconomic, demographic, and geographic breastfeeding (BF) inequities persist, and African American and Hispanic women are less likely to meet their breastfeeding goals compared to White women. This systematic review (SR) was designed to answer the question: What is the impact of breastfeeding interventions targeting ethnic/racial minority women in the U.S. on improving BF initiation, duration and exclusivity rates?

METHODS

The SR was conducted following the Institute of Medicine Guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. The study protocol was developed and registered a priori in PROSPERO (ID#CRD42020177764). The electronical databases searched was MEDLINE All (Ovid). Search strategies were led by the team's expert public health librarian using both controlled vocabulary and free text queries and were tested against a validated set of relevant papers included in existing reviews. The GRADE methodology was used to assess the quality of the studies.

RESULTS

We included 60 studies that had randomized (n = 25), observational (n = 24), quasi-experimental (n = 9), or cross-sectional (n = 2) designs. The studies focused on populations that were multi-ethnic/racial (n = 22), only Hispanic (n = 24), only Black (n = 13), and only American Indian (n = 1). The study interventions were classified following the socioecological model: macrosystem/policy level (n = 6); community level (n=51), which included healthcare organizations (n = 34), The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (n = 9), and community organizations/public health institutions (n = 8); and  interpersonal level (n = 3).

CONCLUSIONS

Policy and community level interventions delivered through WIC, healthcare facilities, and community agencies) are likely to improve BF outcomes among women of color. The combination of interventions at different levels of the socioecological model has not been studied among minority women in the U.S. Implementation science research is needed to learn how best to scale up and sustain effective BF interventions, taking into account the needs and wants of minority women. Thus, it is strongly recommended  to conduct large scale implementation research studies addressesing how to strengthen the different health and social environments surrounding women of color in the U.S. to improving their BF outcomes.

Process evaluations of early childhood obesity prevention interventions delivered via telephone or text messages: a systematic review

BACKGROUND

Increasingly, public health interventions are delivered via telephone and/or text messages. Recent systematic reviews of early childhood obesity prevention interventions have not adequately reported on the way interventions are delivered and the experiences/perceptions of stakeholders. We aimed to summarise the literature in early childhood obesity prevention interventions delivered via telephone or text messages for evidence of application of process evaluation primarily to evaluate stakeholders' acceptability of interventions.

METHODS

A systematic search of major electronic databases was carried out using the Population, Intervention, Comparison, Outcomes framework. Studies were included if interventions were delivered via telephone/text messages; aimed at changing caregivers' behaviours to prevent early childhood obesity; with one or more outcomes related to early obesity risk factors such as breastfeeding, solid feeding, tummy time, sleep and settling, physical activity and screen time; published from inception to May 2020. All eligible studies were independently assessed by two reviewers using the Cochrane Collaboration tool for assessing risk of bias. Qualitative studies were assessed using the Consolidated Criteria for Reporting Qualitative Research and Standards for Reporting Qualitative Research tools.

RESULTS

Twenty-four studies were eligible, and the overall risk of bias was low. Eight studies (33%) had evidence of process evaluation that examined participants' perceptions of interventions. Participants appreciated the convenience of receiving interventions via telephone or text messages. 63% of all studies in this review showed improvement in one or more behaviours related to childhood obesity prevention. Participants were likely to modify behaviours if they received information from a credible source such as from health professionals.

CONCLUSION

There is limited reporting of stakeholders' experiences in early obesity prevention studies delivered by telephone or text messages. Only one-third of studies examined participants' acceptability and the potential for delivery of childhood obesity prevention interventions conveniently using this mode of delivery. Interventions delivered remotely via telephone or text messages have the potential to reach equal or a greater number of participants than those delivered via face-to-face methods. Future research should build in process evaluation alongside effectiveness measurements to provide important insight into intervention reach, acceptability and to inform scale up.

TRIAL REGISTRATION

PROSPERO registration: CRD42019108658.

A multistakeholder evaluation of Lazos Hispanos: An application of a community-based participatory research conceptual model

The goal of Lazos Hispanos is to enhance the health and well-being of the Latinx community through promotoras, who connect community members with service providers for multiple health and social needs. A community-based participatory research conceptual model framed the multimethod evaluation of promotoras, service providers, and community participants at baseline and at the 1-year follow up. The promotoras increased their self-efficacy and knowledge, felt a strong sense of commitment to the community, viewed themselves as a bridge between participants and providers, and felt empowered by their new role. Service providers valued the promotoras as their ambassadors in the community and Lazos Hispanos as central to connecting service providers, promotoras, and community members; they noted that this collaboration increased their accountability with the Latinx community. This multistakeholder evaluation highlights the depth of positive changes achieved during the first year and the challenges of a community-embedded project and the benefits and possibilities of calling upon theoretically informed evaluation models.