The peer-professional interface in a community-based, breast feeding peer-support project

Use of volunteers in early years interventions for parents: A scoping review of roles and the extent of evaluation research in this area

Early years interventions, particularly those supporting parents in the first 1001 days of their infants life, support healthy development of infants and prevent adverse experiences that can have long term negative impacts. Volunteers are often used to deliver such interventions. This scoping review aimed to explore the roles and characteristics of volunteers across early years interventions and map the evaluation in this field to identify gaps in the literature. A scoping review was conducted according to the Arksey and O'Malley Framework. Academic databases and grey literature sources were searched to identify literature evaluating volunteer-based interventions for parents in the first 1001 days of their infant's life (conception to aged two). Research conducted in the UK or comparable high-income countries since the year 2000 were identified and data relating to the volunteer role, intervention design and evaluation methods were mapped. Sixty-six articles were eligible for inclusion in the review. Volunteers were commonly involved in interventions to provide peer support for a range of parenting related matters, support breastfeeding and the mental and emotional wellbeing of parents. Volunteer roles were categorised based on their background (peers or non-peer volunteers), their responsibilities (provider of peer support, educator or providers of practical support) and the delivery style of their role (in person one to one support, group leader or remote support). Research most often involved exploring the experiences of those involved in receiving or delivering the interventions and measuring outcomes in relation to breastfeeding and parent mental wellbeing. Volunteers play a large role in the provision of early years interventions. Their varied contribution is presented through a typology that will allow comparisons of roles in future research. Further research exploring the impact on the volunteers and the organisation will support decision making around choosing a volunteer led model within early years services.

Non-profit breastfeeding organisations' peer support provision in areas of socio-economic deprivation in the UK: A meta-ethnography

In many high-income countries such as the United Kingdom, inequalities in breastfeeding initiation and continuation rates exist, whereby socio-economically advantaged mothers are most likely to breastfeed. Breastfeeding peer support interventions are recommended to address this inequality, with non-profit breastfeeding organisations providing such support in areas of deprivation. As these organisations' roots and membership are often formed of relatively highly resourced women who have different backgrounds and experiences to those living in areas of deprivation, it is important to understand their practices in this context. In order to explore how UK non-profit organisations practice breastfeeding peer support in areas of socio-economic deprivation, a systematic review and meta-ethnography of published and grey literature was undertaken. Sixteen texts were included, and three core themes constructed: (1) 'changing communities' reveals practices designed to generate community level change, and (2) 'enabling one to one support', explains how proactive working practices enabled individual mothers' access to supportive environments. (3) 'forging partnerships with health professionals', describes how embedding peer support within local health services facilitated peer supporters' access to mothers. While few breastfeeding peer support practices were directly linked to the context of socio-economic deprivation, those described sought to influence community and individual level change. They illuminate the importance of interprofessional working. Further work to consolidate the peer-professional interface to ensure needs-led care is required.

Factors influencing the performance of community health volunteers working within urban informal settlements in low- and middle-income countries: a qualitative meta-synthesis review

BACKGROUND

There is limited information on community health volunteer (CHV) programmes in urban informal settlements in low- and middle-income countries (LMICs). This is despite such settings accounting for a high burden of disease. Many factors intersect to influence the performance of CHVs working in urban informal settlements in LMICs. This review was conducted to identify both the programme level and contextual factors influencing performance of CHVs working in urban informal settlements in LMICs.

METHODS

Four databases were searched for qualitative and mixed method studies focusing on CHVs working in urban and peri-urban informal settlements in LMICs. We focused on CHV programme outcome measures at CHV individual level. A total of 13 studies met the inclusion criteria and were double read to extract relevant data. Thematic coding was conducted, and data synthesized across ten categories of both programme and contextual factors influencing CHV performance. Quality was assessed using both the Critical Appraisal Skills Programme (CASP) and the Mixed Methods Assessment Tool (MMAST); and certainty of evidence evaluated using the Confidence in the Evidence from Reviews of Qualitative research (CERQual) approach.

RESULTS

Key programme-level factors reported to enhance CHV performance in urban informal settlements in LMICs included both financial and non-financial incentives, training, the availability of supplies and resources, health system linkage, family support, and supportive supervision. At the broad contextual level, factors found to negatively influence the performance of CHVs included insecurity in terms of personal safety and the demand for financial and material support by households within the community. These factors interacted to shape CHV performance and impacted on implementation of CHV programmes in urban informal settlements.

CONCLUSION

This review identified the influence of both programme-level and contextual factors on CHVs working in both urban and peri-urban informal settlements in LMICs. The findings suggest that programmes working in such settings should consider adequate remuneration for CHVs, integrated and holistic training, adequate supplies and resources, adequate health system linkages, family support and supportive supervision. In addition, programmes should also consider CHV personal safety issues and the community expectations.

Breastfeeding peer support by telephone in the RUBY randomised controlled trial: A qualitative exploration of volunteers' experiences

BACKGROUND

There is growing evidence that peer support programs may be effective in supporting breastfeeding mothers. A randomised controlled trial (RCT) (the RUBY study) that tested peer support in the Australian context found that infants of first-time mothers who received proactive telephone peer support were more likely to be receiving breastmilk at six months of age.

METHODS

This qualitative sub-study of the RUBY RCT explores the experiences and views of peer volunteers who delivered the intervention. Focus groups were conducted with 17 peers from the RUBY RCT between November 2015 and March 2016. All had provided peer support to at least one mother.

RESULTS

We found that volunteers identified strongly with the mothers' need for support when establishing breastfeeding. Key components of the support were strengthening the mothers' self-belief through affirmation and sharing experiential knowledge. Volunteers found the role rewarding and personally therapeutic although some women reported challenges initiating and maintaining contact with some mothers. Data were analysed using a hybrid approach to thematic analysis combining inductive and deductive techniques.

CONCLUSIONS

Breastfeeding peer support programs are reliant on recruitment of motivated volunteers who can provide empathetic mother-to-mother support. This study provides important information regarding volunteers' experiences that may support the upscaling of breastfeeding peer support for new mothers.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN 12612001024831.

Volunteers' experiences of providing telephone-based breast-feeding peer support in the RUBY randomised controlled trial

OBJECTIVE

The Ringing Up About Breastfeeding earlY (RUBY) randomised controlled trial (RCT) found that a telephone-based peer volunteer support intervention increased breast-feeding duration in a setting with high breast-feeding initiation. This sub-study of the RUBY RCT describes the motivation, preparation and experiences of volunteers who provided the peer support intervention.

DESIGN

An online survey was completed by 154 (67 %) volunteers after ceasing volunteering.

SETTING

Volunteers provided peer support to primiparous women (n 574) who birthed at one of three public hospitals in Melbourne, Australia, between February 2013 and December 2015.

PARTICIPANTS

Volunteers (n 230) had themselves breastfed for at least 6 months and received 4 h of training for the role.

RESULTS

The median number of mothers supported was two (range 1-11), and two-thirds of respondents supported at least one mother for 6 months. Volunteers were motivated by a strong desire to support new mothers to establish and continue breast-feeding. Most (93 %) considered the training session adequate. The majority (60 %) reported following the call schedule 'most of the time', but many commented that 'it depends on the mother'. Overall, 84 % of volunteers were satisfied with the role and reported that the experience was enjoyable (85 %) and worthwhile (90 %). Volunteers agreed that telephone support for breast-feeding was valued by women (88 %) and that the programme would be effective in helping women to breastfeed (93 %).

CONCLUSIONS

These findings are important for those developing similar peer support programmes in which recruiting volunteers and developing training requirements are an integral and recurrent part of volunteer management.

Exploring the space for task shifting to support nursing on neonatal wards in Kenyan public hospitals

BACKGROUND

Nursing practice is a key driver of quality care and can influence newborn health outcomes where nurses are the primary care givers to this highly dependent group. However, in sub-Saharan Africa, nursing work environments are characterized by heavy workloads, insufficient staffing and regular medical emergencies, which compromise the ability of nurses to provide quality care. Task shifting has been promoted as one strategy for making efficient use of human resources and addressing these issues.

AIMS AND OBJECTIVES

We aimed to understand the nature and practice of neonatal nursing in public hospitals in Nairobi so as to determine what prospect there might be for relieving pressure by shifting nurses' work to others.

METHODS

This paper is based on an 18-month qualitative study of three newborn units of three public hospitals-all located in Nairobi county-using an ethnographic approach. We draw upon a mix of 32 interviews, over 250 h' observations, field notes and informal conversations. Data were collected from senior nursing experts in newborn nursing, neonatal nurse in-charges, neonatal nurses, nursing students and support staff.

RESULTS

To cope with difficult work conditions characterized by resource challenges and competing priorities, nurses have developed a ritualized schedule and a form of 'subconscious triage'. Informal, organic task shifting was already taking place whereby particular nursing tasks were delegated to students, mothers and support staff, often without any structured supervision. Despite this practice, nurses were agnostic about formal institutionalization of task shifting due to concerns around professional boundaries and the practicality of integrating a new cadre into an already stressed health system.

CONCLUSION

Our findings revealed a routine template of neonatal nursing work which nurses used to control unpredictability. We found that this model of nursing encouraged delegation of less technical tasks to subordinates, parents and other staff through the process of 'subconscious triage'. The rich insights we gained from this organic form of task shifting can inform more formal task-shifting projects as they seek to identify tasks most easily delegated, and how best to support and work with busy nurses.

Using peer advocates to improve access to services among hard-to-reach populations with hepatitis C: a qualitative study of client and provider relationships

Background

Peer support programmes use individuals with specific experiences to improve engagement and outcomes among new clients. However, the skills and techniques used to achieve this engagement have not been mapped. This potentially restricts the development and replication of successful peer advocate models of care. This study explored how a group of peer advocates with experience of homelessness, alcohol and drug misuse made and sustained relationships with their client group. For the purposes of this project, the client group were located among a hepatitis C-positive cohort of people who have a history of injecting drug use and homelessness.

Methods

Five self-selecting advocates gave a narrative interview lasting 40–90 min. These interviews were double transcribed using both thematic analysis and narrative analysis in order to triangulate the data and provide a robust set of findings about the unique skills of peer advocates in creating and sustaining relationships with clients from hard-to-reach populations.

Results

Peer advocates build rapport with clients through disclosing personal details about their lives. While this runs counter to assumptions about the need to maintain distance in client-patient relationships, the therapeutic benefits appear to outweigh the potential costs of this engagement.

Conclusion

We conclude the therapeutic benefits of self-disclosure between peer advocates and their clients offer a moral grounding for self-disclosure as a means of building relationships with key hard-to-reach populations.

How female community health workers navigate work challenges and why there are still gaps in their performance: a look at female community health workers in maternal and child health in two Indian districts through a reciprocal determinism framework

BACKGROUND

Accredited Social Health Activists (ASHAs) are community health workers tasked to deliver health prevention in communities and link them with the health care sector. This paper examines the social, cultural, and institutional influences that either facilitate or impede ASHAs' abilities to deliver services effectively through the lens of the reciprocal determinism framework of social cognitive theory.

METHODS

We conducted 98 semi-structured, in-depth interviews with ASHAs (n = 49) and their family members (n = 49) in Gurdaspur and Mewat districts. Data were analyzed by comparing and contrasting codes leading to the identification of patterns which were explained with the help of a theoretical framework.

RESULTS

We found that while the work of ASHAs led to some positive health changes in the community, thus providing them with a sense of self-worth and motivation, community norms and beliefs as well as health system attitudes and practices limited their capacity as community health workers.

CONCLUSION

We outline potential mechanisms for improving ASHA capacity such as improved sensitization about religious, cultural, and gender norms; enhanced communication skills; and sensitization and advocating their work with health and state officials.

Expanding the meaning of 'being a peer leader': qualitative findings from a Canadian community-based cervical and breast cancer screening programme

Engagement of community members to act as peer workers is a key feature of many community-centred health promotion programmes. However, little is known about their experiences beyond the commonly reported themes of fulfilment through helping people in need and improvement of personal confidence, self-esteem and self-care. This gap in the literature is of particular interest given increasing involvement of peer workers in community-centred programmes addressing health disparities, such as uptake of cancer screening. This paper aims to explore experiences of the peer leaders who worked for the Cancer Awareness: Ready for Education and Screening (CARES) project to promote awareness, knowledge, and uptake of breast and cervical cancer screening among under-/never-screened women who belonged to ethnic minority, recent immigrant and low-income communities in Toronto, Canada. In 2013, three focus groups were conducted with 14 peer leaders to explore their experiences. All were immigrant women between 30 and 50 years of age. All discussions were audio recorded and transcribed verbatim. We used situational maps and analysis to create a visual representation of the data, and to investigate peer leaders experiences. Situational analysis was chosen to bring to light dominant and also silent underlying aspects which define the meaning of being a peer leader. The first level of analysis identified main themes that characterised peer leaders' experience: (i) Helping others (women, friends and family) and themselves by improved self-confidence, self-awareness and self-care and (ii) Redefining professional and social positions through their project activities leading to professional development and networking. The second level of analysis explored the redefining process and identified some peer leaders' negotiations in relation to knowledge (science vs. myth), beliefs (fear vs. assurance) and boundaries (private vs. work). Adding to the literature on the peer workers' experience, the findings are discussed in relation to empowerment of peer workers, training implications and theoretical contributions.

Peer Support Workers in Health: A Qualitative Metasynthesis of Their Experiences

OBJECTIVE

Peer support models, where an individual has a specific illness or lifestyle experience and supports others experiencing similar challenges, have frequently been used in different fields of healthcare to successfully engage hard-to-reach groups. Despite recognition of their value, the impact of these roles on the peer has not been systematically assessed. By synthesising the qualitative literature we sought to review such an impact, providing a foundation for designing future clinical peer models.

METHODS

Systematic review and qualitative metasynthesis of studies found in Medline, CINAHL or Scopus documenting peer worker experiences.

RESULTS

1,528 papers were found, with 34 meeting the criteria of this study. Findings were synthesised to reveal core constructs of reframing identity through reciprocal relations and the therapeutic use of self, enhancing responsibility.

CONCLUSIONS

The ability of the Peer Support Worker to actively engage with other marginalised or excluded individuals based on their unique insight into their own experience supports a therapeutic model of care based on appropriately sharing their story. Our findings have key implications for maximising the effectiveness of Peer Support Workers and in contributing their perspective to the development of a therapeutic model of care.

How stakeholder participation can contribute to systematic reviews of complex interventions

Although patient and public involvement in research is a requirement for research funding in many countries, the knowledge base for how to effectively involve people—and evidence of the effectiveness of involvement—is weak. This article describes how methods used in participatory health research were used to involve patients, clients, providers and community health workers across all stages of a realist review. Sustained involvement enabled better identification of the components of the complex intervention of community-based peer support. It also challenged assumptions of how peer support is constructed, leading the review team to question whether the process of designing and implementing interventions has more influence on effectiveness than previously recognised in empirical studies. We conclude with a discussion on when sustained involvement should be used, and the challenges of incorporating it into the traditional researcher-led approach to systematic reviews.

Factors influencing the sustainability of volunteer peer support for breast-feeding mothers within a hospital environment: An exploratory qualitative study

OBJECTIVES

the objectives of this study were to explore breast feeding peer supporters' motivation to volunteer within a hospital environment, to describe their experiences of volunteering within a hospital environment, to examine the relationships between peer supporters and ward staff, and to identify factors contributing to the future sustainability of the service.

DESIGN

a qualitative study; peer supporters and clinical ward staff were interviewed using a semi-structured schedule and data were analysed using Thematic Analysis with an inductive approach.

SETTING AND PARTICIPANTS

six peer supporters and ten ward staff, whose role included giving breast feeding support, working on a maternity ward in one consultant-led unit in England that had been hosting breast feeding peer support volunteers for the previous three years.

FINDINGS

three main themes were identified: 1. What peer supporters brought to the maternity ward; this included providing breast-feeding mothers with confidence, reassurance and empowerment, and spending 'unhurried time' with mothers; 2. What motivated the peer supporters; this included an interest in midwifery as a future career and a desire to help people; 3. Factors contributing to the sustainability of the service; these included an existing rolling training programme, however recruitment processes were causing long delays and some aspects of operational management needed improvement.

KEY CONCLUSIONS

individuals with a passion for breast feeding were willing to volunteer as peer supporters and their experience of the activity was positive. Organisational processes did not always provide peer supporters with a positive experience of the organisation and these needed to be improved as they contributed to the future sustainability of the service.

IMPLICATIONS FOR PRACTICE

the study indicates that a sustainable hospital-based volunteer service for breast feeding peer support requires a rolling training programme for peer supporters, efficient recruitment processes and effective operational management.

Peers experience of delivering a problem-solving programme to enhance antipsychotic medication adherence for individuals with schizophrenia

ACCESSIBLE SUMMARY

No research has been conducted into the experience of peer support in improving adherence with oral antipsychotic medication for consumers with schizophrenia. Altruism influences peers to participate in peer support. Engagement in peer support can be challenging and rewarding for peers, and helps improve their own confidence and well-being.

ABSTRACT

Many consumers with schizophrenia are reluctant to take their prescribed antipsychotic medications; however, non-adherence can lead to relapse. The aim of this study was to evaluate peers' perspectives of their participation in a problem-solving peer support programme to enhance adherence in consumers who are reluctant to take antipsychotic medication. Peers contacted consumers by a weekly telephone call for 8 weeks, and used a problem-solving approach to inform their discussion about medication adherence. Semi-structured qualitative interviews were used to evaluate peers' perspectives of their involvement in the programme. Three main themes were abstracted from the data: motivation to participate in the study, experience of peer support programme, and rewards and challenges of the peer experience. Helping others was an important motivator for peers in agreeing to participate in the study. Telephone delivery was a convenient way to deliver the peer support programme. However, at times, it was difficult to contact consumers by telephone and this caused some frustration. Despite these difficulties, peers recognized that being involved in the programme increased their confidence and made them feel worthwhile. The findings have implications for the use of peer support as an adjunct intervention to promote medication adherence in consumers with schizophrenia.

Building social capital through breastfeeding peer support: insights from an evaluation of a voluntary breastfeeding peer support service in North-West England

Background

Peer support is reported to be a key method to help build social capital in communities. To date there are no studies that describe how this can be achieved through a breastfeeding peer support service. In this paper we present findings from an evaluation of a voluntary model of breastfeeding peer support in North-West England to describe how the service was operationalized and embedded into the community. This study was undertaken from May, 2012 to May, 2013.

Methods

Interviews (group or individual) were held with 87 participants: 24 breastfeeding women, 13 peer supporters and 50 health and community professionals. The data contained within 23 monthly monitoring reports (January, 2011 to February 2013) compiled by the voluntary peer support service were also extracted and analysed.

Results

Thematic analysis was undertaken using social capital concepts as a theoretical lens. Key findings were identified to resonate with’bonding’, ‘bridging’ and ‘linking’ forms of social capital. These insights illuminate how the peer support service facilitates ‘bonds’ with its members, and within and between women who access the service; how the service ‘bridges’ with individuals from different interests and backgrounds, and how ‘links’ were forged with those in authority to gain access and reach to women and to promote a breastfeeding culture. Some of the tensions highlighted within the social capital literature were also identified.

Conclusions

Horizontal and vertical relationships forged between the peer support service and community members enabled peer support to be embedded into care pathways, helped to promote positive attitudes to breastfeeding and to disseminate knowledge and maximise reach for breastfeeding support across the community. Further effort to engage with those of different ethnic backgrounds and to resolve tensions between peer supporters and health professionals is warranted.

Can community-based peer support promote health literacy and reduce inequalities? A realist review

Background

Community-based peer support (CBPS) has been proposed as a potentially promising approach to improve health literacy (HL) and reduce health inequalities. Peer support, however, is described as a public health intervention in search of a theory, and as yet there are no systematic reviews exploring why or how peer support works to improve HL.

Objective

To undertake a participatory realist synthesis to develop a better understanding of the potential for CBPS to promote better HL and reduce health inequalities.

Data sources

Qualitative evidence syntheses, conceptual reviews and primary studies evaluating peer-support programmes; related studies that informed theoretical or contextual elements of the studies of interest were included. We conducted searches covering 1975 to October 2011 across Scopus, Global Health (including MEDLINE), ProQuest Dissertations & Theses database (PQDT) [including the Education Resources Information Center (ERIC) and Social Work Abstracts], The King’s Fund Database and Web of Knowledge, and the Institute of Development Studies supplementary strategies were used for the identification of grey literature. We developed a new approach to searching called ‘cluster searching’, which uses a variety of search techniques to identify papers or other research outputs that relate to a single study.

Study eligibility criteria

Studies written in English describing CBPS research/evaluation, and related papers describing theory, were included.

Study appraisal and synthesis methods

Studies were selected on the basis of relevance in the first instance. We first analysed within-programme articulation of theory and appraised for coherence. Cross-programme analysis was used to configure relationships among context, mechanisms and outcomes. Patterns were then identified and compared with theories relevant to HL and health inequalities to produce a middle-range theory.

Results

The synthesis indicated that organisations, researchers and health professionals that adopt an authoritarian design for peer-support programmes risk limiting the ability of peer supporters (PSs) to exercise autonomy and use their experiential knowledge to deliver culturally tailored support. Conversely, when organisations take a negotiated approach to codesigning programmes, PSs are enabled to establish meaningful relationships with people in socially vulnerable groups. CBPS is facilitated when organisations prioritise the importance of assessing community needs; investigate root causes of poor health and well-being; allow adequate time for development of relationships and connections; value experiential cultural knowledge; and share power and control during all stages of design and implementation. The theory now needs to be empirically tested via further primary research.

Limitations

Analysis and synthesis were challenged by a lack of explicit links between peer support for marginalised groups and health inequalities; explicitly stated programme theory; inconsistent reporting of context and mechanism; poor reporting of intermediate process outcomes; and the use of theories aimed at individual-level behaviour change for community-based interventions.

Conclusions

Peer-support programmes have the potential to improve HL and reduce health inequalities but potential is dependent upon the surrounding equity context. More explicit empirical research is needed, which establishes clearer links between peer-supported HL and health inequalities.

Study registration

This study is registered as PROSPERO CRD42012002297.

Funding

The National Institute for Health Research Public Health Research programme.

Interventions in exclusive breastfeeding: a systematic review

Now recognised as a worldwide public health issue, the significance of promoting and encouraging exclusive breastfeeding (EBF) has been acknowledged by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF). Documented policies about the importance of facilitating the support of breastfeeding women is currently receiving worldwide recognition (WHO, 2011; WHO and UNICEF, 2003). This literature review will examine provision of support mechanisms for breastfeeding mothers, focusing on peer support in encouraging the starting and maintaining of EBF. Consideration will also be given to any barriers that may prevent higher success rates, as cultural and educational factors may have a significant impact on the starting and maintaining of EBF. These factors must be considered when starting support groups, networks or activities that aim to address this significant public health issue.

Barriers and facilitators to the implementation of lay health worker programmes to improve access to maternal and child health: qualitative evidence synthesis

BACKGROUND

Lay health workers (LHWs) perform functions related to healthcare delivery, receive some level of training, but have no formal professional or paraprofessional certificate or tertiary education degree. They provide care for a range of issues, including maternal and child health. For LHW programmes to be effective, we need a better understanding of the factors that influence their success and sustainability. This review addresses these issues through a synthesis of qualitative evidence and was carried out alongside the Cochrane review of the effectiveness of LHWs for maternal and child health.

OBJECTIVES

The overall aim of the review is to explore factors affecting the implementation of LHW programmes for maternal and child health.

SEARCH METHODS

We searched MEDLINE, OvidSP (searched 21 December 2011); MEDLINE Ovid In-Process & Other Non-Indexed Citations, OvidSP (searched 21 December 2011); CINAHL, EBSCO (searched 21 December 2011); British Nursing Index and Archive, OvidSP (searched 13 May 2011). We searched reference lists of included studies, contacted experts in the field, and included studies that were carried out alongside the trials from the LHW effectiveness review.

SELECTION CRITERIA

Studies that used qualitative methods for data collection and analysis and that focused on the experiences and attitudes of stakeholders regarding LHW programmes for maternal or child health in a primary or community healthcare setting.

DATA COLLECTION AND ANALYSIS

We identified barriers and facilitators to LHW programme implementation using the framework thematic synthesis approach. Two review authors independently assessed study quality using a standard tool. We assessed the certainty of the review findings using the CerQual approach, an approach that we developed alongside this and related qualitative syntheses. We integrated our findings with the outcome measures included in the review of LHW programme effectiveness in a logic model. Finally, we identified hypotheses for subgroup analyses in future updates of the review of effectiveness.

MAIN RESULTS

We included 53 studies primarily describing the experiences of LHWs, programme recipients, and other health workers. LHWs in high income countries mainly offered promotion, counselling and support. In low and middle income countries, LHWs offered similar services but sometimes also distributed supplements, contraceptives and other products, and diagnosed and treated children with common childhood diseases. Some LHWs were trained to manage uncomplicated labour and to refer women with pregnancy or labour complications.Many of the findings were based on studies from multiple settings, but with some methodological limitations. These findings were assessed as being of moderate certainty. Some findings were based on one or two studies and had some methodological limitations. These were assessed have low certainty.Barriers and facilitators were mainly tied to programme acceptability, appropriateness and credibility; and health system constraints. Programme recipients were generally positive to the programmes, appreciating the LHWs' skills and the similarities they saw between themselves and the LHWs. However, some recipients were concerned about confidentiality when receiving home visits. Others saw LHW services as not relevant or not sufficient, particularly when LHWs only offered promotional services. LHWs and recipients emphasised the importance of trust, respect, kindness and empathy. However, LHWs sometimes found it difficult to manage emotional relationships and boundaries with recipients. Some LHWs feared blame if care was not successful. Others felt demotivated when their services were not appreciated. Support from health systems and community leaders could give LHWs credibility, at least if the health systems and community leaders had authority and respect. Active support from family members was also important.Health professionals often appreciated the LHWs' contributions in reducing their workload and for their communication skills and commitment. However, some health professionals thought that LHWs added to their workload and feared a loss of authority.LHWs were motivated by factors including altruism, social recognition, knowledge gain and career development. Some unsalaried LHWs wanted regular payment, while others were concerned that payment might threaten their social status or lead recipients to question their motives. Some salaried LHWs were dissatisfied with their pay levels. Others were frustrated when payment differed across regions or institutions. Some LHWs stated that they had few opportunities to voice complaints. LHWs described insufficient, poor quality, irrelevant and inflexible training programmes, calling for more training in counselling and communication and in topics outside their current role, including common health problems and domestic problems. LHWs and supervisors complained about supervisors' lack of skills, time and transportation. Some LHWs appreciated the opportunity to share experiences with fellow LHWs.In some studies, LHWs were traditional birth attendants who had received additional training. Some health professionals were concerned that these LHWs were over-confident about their ability to manage danger signs. LHWs and recipients pointed to other problems, including women's reluctance to be referred after bad experiences with health professionals, fear of caesarean sections, lack of transport, and cost. Some LHWs were reluctant to refer women on because of poor co-operation with health professionals.We organised these findings and the outcome measures included in the review of LHW programme effectiveness in a logic model. Here we proposed six chains of events where specific programme components lead to specific intermediate or long-term outcomes, and where specific moderators positively or negatively affect this process. We suggest how future updates of the LHW effectiveness review could explore whether the presence of these components influences programme success.

AUTHORS' CONCLUSIONS

Rather than being seen as a lesser trained health worker, LHWs may represent a different and sometimes preferred type of health worker. The close relationship between LHWs and recipients is a programme strength. However, programme planners must consider how to achieve the benefits of closeness while minimizing the potential drawbacks. Other important facilitators may include the development of services that recipients perceive as relevant; regular and visible support from the health system and the community; and appropriate training, supervision and incentives.

Professionalisation of a breast-feeding peer support service: issues and experiences of peer supporters

OBJECTIVES

to describe the issues faced by breast-feeding peer supporters as their roles altered from a voluntary to a professionalised role with targets, accountability and more formalised interface with health professionals.

DESIGN

a descriptive qualitative study utilising group and individual semi-structured interviews, with thematic network analysis.

SETTING

19 breast-feeding peer supporters were consulted from one peer support service located in the UK.

FINDINGS

thematic network analysis of the peer supporter data generated a global theme of 'Professionalising Breast-feeding Peer Support'. The three underpinning organising themes (and their associated basic themes): 'visibility and communication', 'guardianship of knowledge' and 'roles and boundaries' revealed the early and transitional tensions and anxieties that peer supporters faced when their role altered from a voluntary position to a formal model of service delivery, particularly within the clinical environment.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

professionalisation of peer support can lead to benefits in terms of providing a standardised and comprehensive service with increased capacity for service provision. However, the transitional difficulties faced by the peer supporters as they moved from a voluntary into a professionalised role included a lack of identity; restricted time to care for new mothers; pressures and anxieties of meeting targets and accountability of case recording and the hostility and gatekeeping practices experienced amongst some of the health professionals. Flexible systems incorporating service-user involvement and needs-led strategies may help to overcome these issues.

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.