The breastfeeding support team for low-income, predominantly-minority women: a pilot intervention study

Using qualitative comparative analysis (QCA) in systematic reviews of complex interventions: a worked example

BACKGROUND

Systematic reviews that address policy and practice questions in relation to complex interventions frequently need not only to assess the efficacy of a given intervention but to identify which intervention - and which intervention components - might be most effective in particular situations. Here, intervention replication is rare, and commonly used synthesis methods are less useful when the focus of analysis is the identification of those components of an intervention that are critical to its success.

METHODS

Having identified initial theories of change in a previous analysis, we explore the potential of qualitative comparative analysis (QCA) to assist with complex syntheses through a worked example. Developed originally in the area of political science and historical sociology, a QCA aims to identify those configurations of participant, intervention and contextual characteristics that may be associated with a given outcome. Analysing studies in these terms facilitates the identification of necessary and sufficient conditions for the outcome to be obtained. Since QCA is predicated on the assumption that multiple pathways might lead to the same outcome and does not assume a linear additive model in terms of changes to a particular condition (that is, it can cope with 'tipping points' in complex interventions), it appears not to suffer from some of the limitations of the statistical methods often used in meta-analysis.

RESULTS

The worked example shows how the QCA reveals that our initial theories of change were unable to distinguish between 'effective' and 'highly effective' interventions. Through the iterative QCA process, other intervention characteristics are identified that better explain the observed results.

CONCLUSIONS

QCA is a promising alternative (or adjunct), particularly to the standard fall-back of a 'narrative synthesis' when a quantitative synthesis is impossible, and should be considered when reviews are broad and heterogeneity is significant. There are very few examples of its use with systematic review data at present, and further methodological work is needed to establish optimal conditions for its use and to document process, practice, and reporting standards.

The 'active ingredients' for successful community engagement with disadvantaged expectant and new mothers: a qualitative comparative analysis

AIMS

To explore which conditions of community engagement are implicated in effective interventions targeting disadvantaged pregnant women and new mothers.

BACKGROUND

Adaptive experiences during pregnancy and the early years are key to reducing health inequalities in women and children worldwide. Public health nurses, health visitors and community midwives are well placed to address such disadvantage, often using community engagement strategies. Such interventions are complex; however, and we need to better understand which aspects of community engagement are aligned with effectiveness.

DESIGN

Qualitative comparative analysis conducted in 2013, of trials data included in a recently published systematic review.

METHODS

Two reviewers agreed on relevant conditions from 24 maternity or early years intervention studies examining four models of community engagement. Effect size estimates were converted into 'fuzzy' effectiveness categories and truth tables were constructed. Using fsQCA software, Boolean minimization identified solution sets. Random effects multiple regression and fsQCA were conducted to rule out risk of methodological bias.

RESULTS/FINDINGS

Studies focused on antenatal, immunization, breastfeeding and early professional intervention outcomes. Peer delivery (consistency 0·83; unique coverage 0·63); and mother-professional collaboration (consistency 0·833; unique coverage 0·21) were moderately aligned with effective interventions. Community-identified health need plus consultation/collaboration in intervention design and leading on delivery were weakly aligned with 'not effective' interventions (consistency 0·78; unique coverage 0·29).

CONCLUSIONS

For disadvantaged new and expectant mothers, peer or collaborative delivery models could be used in interventions. A need exists to design and test community engagement interventions in other areas of maternity and early years care and to further evaluate models of empowerment.

Community engagement to reduce inequalities in health: a systematic review, meta-analysis and economic analysis

Background

Community engagement has been advanced as a promising way of improving health and reducing health inequalities; however, the approach is not yet supported by a strong evidence base.

Objectives

To undertake a multimethod systematic review which builds on the evidence that underpins the current UK guidance on community engagement; to identify theoretical models underpinning community engagement; to explore mechanisms and contexts through which communities are engaged; to identify community engagement approaches that are effective in reducing health inequalities, under what circumstances and for whom; and to determine the processes and costs associated with their implementation.

Data sources

Databases including the Cochrane Database of Systematic Reviews (CDSR), The Campbell Library, the Database of Abstracts of Reviews of Effects (DARE), the Health Technology Assessment (HTA) database, the NHS Economic Evaluation Database (NHS EED) and EPPI-Centre’s Trials Register of Promoting Health Interventions (TRoPHI) and Database of Promoting Health Effectiveness Reviews (DoPHER) were searched from 1990 to August 2011 for systematic reviews and primary studies. Trials evaluating community engagement interventions reporting health outcomes were included.

Review methods

Study eligibility criteria: published after 1990; outcome, economic, or process evaluation; intervention relevant to community engagement; written in English; measured and reported health or community outcomes, or presents cost, resource, or implementation data characterises study populations or reports differential impacts in terms of social determinants of health; conducted in an Organisation for Economic Co-operation and Development (OECD) country. Study appraisal: risk of bias for outcome evaluations; assessment of validity and relevance for process evaluations; comparison against an economic evaluation checklist for economic evaluations. Synthesis methods: four synthesis approaches were adopted for the different evidence types: theoretical, quantitative, process, and economic evidence.

Results

The theoretical synthesis identified key models of community engagement that are underpinned by different theories of changes. Results from 131 studies included in a meta-analysis indicate that there is solid evidence that community engagement interventions have a positive impact on health behaviours, health consequences, self-efficacy and perceived social support outcomes, across various conditions. There is insufficient evidence – particularly for long-term outcomes and indirect beneficiaries – to determine whether one particular model of community engagement is likely to be more effective than any other. There are also insufficient data to test the effects on health inequalities, although there is some evidence to suggest that interventions that improve social inequalities (as measured by social support) also improve health behaviours. There is weak evidence from the effectiveness and process evaluations that certain implementation factors may affect intervention success. From the economic analysis, there is weak but inconsistent evidence that community engagement interventions are cost-effective. By combining findings across the syntheses, we produced a new conceptual framework.

Limitations

Differences in the populations, intervention approaches and health outcomes made it difficult to pinpoint specific strategies for intervention effectiveness. The syntheses of process and economic evidence were limited by the small (generally not rigorous) evidence base.

Conclusions

Community engagement interventions are effective across a wide range of contexts and using a variety of mechanisms. Public health initiatives should incorporate community engagement into intervention design. Evaluations should place greater emphasis on long-term outcomes, outcomes for indirect beneficiaries, process evaluation, and reporting costs and resources data. The theories of change identified and the newly developed conceptual framework are useful tools for researchers and practitioners. We identified trends in the evidence that could provide useful directions for future intervention design and evaluation.

Funding

The National Institute for Health Research Public Health Research programme.

Costs related to promoting breastfeeding among urban low-income women

OBJECTIVE

To describe the costs of providing support to breastfeeding low-income women and compares costs to cost offsets of the intervention.

DESIGN

Secondary analysis of data from a randomized controlled trial of an intervention to promote breastfeeding among low-income women with full-term infants.

SETTING

A university hospital and a community hospital in Baltimore, Maryland.

PARTICIPANTS

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) eligible breastfeeding women (N = 328) were randomized to usual care or the community health nurse/peer counselor intervention.

METHODS

The researchers collected and described personnel and mileage costs over the entire duration of the intervention (24 weeks). Researchers also compared (using t tests) change in resources associated with breastfeeding including the number of clinic visits, hospital nights, emergency room visits, prescriptions, and formula feedings per day up to 12 weeks.

RESULTS

The cost of the personnel and travel required for the intervention was $296 per woman. The use of medical care and number of formula feedings per day were similar for the intervention and usual care groups. When differences in use of medical care and formula feeding were statistically significant, the intervention group used fewer resources.

CONCLUSION

Support for breastfeeding by community health nurses and peer counselors is partially offset by reducing medical care utilization and formula feeding costs.

A randomized controlled community-based trial to improve breastfeeding rates among urban low-income mothers

OBJECTIVE

The purpose of this study was to assess whether providing a breastfeeding support team results in higher breastfeeding rates at 6, 12, and 24 weeks postpartum among urban low-income mothers.

DESIGN

A randomized controlled trial with mother-infant dyads recruited from 2 urban hospitals.

PARTICIPANTS

Breastfeeding mothers of full-term infants who were eligible for Special Supplemental Nutrition Program for Women, Infants, and Children (n=328) were randomized to intervention (n=168) or usual-care group (n=160).

INTERVENTION

The 24-week intervention included hospital visits by a breastfeeding support team, home visits, telephone support, and 24-hour pager access. The usual-care group received standard care.

OUTCOME MEASURE

Breastfeeding status was assessed by self-report at 6, 12, and 24 weeks postpartum.

RESULTS

There were no differences in the sociodemographic characteristics between the groups: 87% were African American, 80% single, and 51% primiparous. Compared with the usual-care group, more women reported breastfeeding in the intervention at 6 weeks postpartum, 66.7% vs 56.9% (odds ratio, 1.71; 95% confidence interval, 1.07-2.76). The difference in rates at 12 weeks postpartum, 49.4% vs 40.6%, and 24 weeks postpartum, 29.2% vs 28.1%, were not statistically significant.

CONCLUSIONS

The intervention group was more likely to be breastfeeding at 6 weeks postpartum compared with the usual-care group, a time that coincided with the most intensive part of the intervention.

Evaluating effects of a prenatal breastfeeding education programme on women with caesarean delivery in Taiwan

AIMS

The aims of this study were: (1) to evaluate the effectiveness of a prenatal breastfeeding education programme for primigravida women who have elected caesarean section as a model of delivery and (2) to evaluate its effectiveness for encouraging a positive attitude to breastfeeding and rooming-in and to increase exclusive breastfeeding rates within hospital and at one month postpartum.

BACKGROUND

Prenatal preparation for pregnant women about breastfeeding enhances their practical knowledge and skills about breastfeeding techniques, which prepares them when encountering possible difficulties.

DESIGN

A quasi-experimental design was used.

METHODS

The targeted population was primigravidas at 36-39 weeks and who had chosen to deliver by caesarean section. The study consisted of approximately 100 individuals; the control group consisted of 46 subjects and the following 54 made up the experimental group. The study was conducted at a hospital in Taiwan.

RESULTS

The results of the study show that the subjects of the experimental group exhibited a more positive breastfeeding attitude (88.9 vs. 79.8, t = 7.40, p < 0.001), a higher 24 hours rooming-in rate (87% vs. 63%, chi(2) = 16.06, p < 0.001) and a higher exclusive breastfeeding rate (79.6% vs. 52.2%, chi(2) = 8.38, p = 0.004) during hospital stays and a higher exclusive breastfeeding rate (75.9% vs. 34.7%, chi(2) = 16.98, p < 0.001) for the one month postpartum period.

CONCLUSION

Results suggest that providing education booklets, videos and telephone interview on breastfeeding prior to a caesarean delivery may contribute to breastfeeding attitude and improved rooming-in and exclusive breastfeeding rates.

RELEVANCE TO CLINICAL PRACTICE

This breastfeeding education programme has proven to be successful in aiding women breastfeeding after a caesarean delivery and provides health care professionals with an evidence-based intervention.

Impact of peer nutrition education on dietary behaviors and health outcomes among Latinos: a systematic literature review

OBJECTIVE

This systematic review assesses the impact of peer education/counseling on nutrition and health outcomes among Latinos and identifies future research needs.

DESIGN

A systematic literature search was conducted by: (1) searching Internet databases; (2) conducting backward searches from reference lists of articles of interest; (3) manually reviewing the archives of the Center for Eliminating Health Disparities among Latinos; (4) searching the Journal of Nutrition Education and Behavior; and (5) directly contacting researchers in the field. The authors reviewed 22 articles derived from experimental or quasi-experimental studies.

OUTCOME MEASURES

Type 2 diabetes behavioral and metabolic outcomes, breastfeeding, nutrition knowledge, attitudes and behaviors.

RESULTS

Peer nutrition education has a positive influence on diabetes self-management and breastfeeding outcomes, as well as on general nutrition knowledge and dietary intake behaviors among Latinos.

CONCLUSIONS AND IMPLICATIONS

There is a need for longitudinal randomized trials testing the impact of peer nutrition education interventions grounded on goal setting and culturally appropriate behavioral change theories. Inclusion of reliable scales and the construct of acculturation are needed to further advance knowledge in this promising field. Operational research is also needed to identify the optimal peer educator characteristics, the type of training that they should receive, the client loads and dosage (ie, frequency and amount of contact needed between peer educator and client), and the best educational approaches and delivery settings.

Barriers to breastfeeding in a Vietnamese community: a qualitative exploration

PURPOSE

Vietnamese women's breastfeeding experience and challenges were explored, as were their families' needs for prenatal and postpartum health professional programs and services.

METHODS

A qualitative study was conducted in Middlesex-London, Ontario, using in-depth, semi-structured interviews in a heterogeneous sample of 11 Vietnamese mothers of children younger than two years. Diverse subject characteristics were sought in terms of parity, maternal age, infant age, marital status, education, employment, and breastfeeding initiation and duration. The 45- to 60-minute interviews were audiotaped and transcribed verbatim. Research team members independently reviewed interview transcripts at several stages during data collection. Qualitative analysis was sequential, and involved a combination of editing and template organizing styles.

RESULTS

Lack of knowledge and misinformation were major barriers to breastfeeding. Inability to communicate in English and a lack of effective transportation were key obstacles to the women's ability to access mainstream prenatal and postpartum health programs and services. Standard nursing prenatal and postpartum services appear not to have reached this group of mothers effectively.

CONCLUSIONS

Culturally and linguistically sensitive breastfeeding promotion and postpartum support services are needed for this Vietnamese community.

WITHDRAWN: Home-based support for disadvantaged adult mothers

BACKGROUND

Babies born to socio-economically disadvantaged mothers are at higher risk of a range of problems in infancy. Home visiting programs are thought to improve outcomes, both for mothers and children, largely through advice and support.

OBJECTIVES

To assess the effectiveness of home visiting programmes for women who have recently given birth and who are socially or economically disadvantaged.

SEARCH STRATEGY

We searched the following electronic databases: The Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 3, 2006); MEDLINE (1966 to March 2006); EMBASE (1980 to 2006 week 12); CINAHL (1982 to March week 4 2006); PsycINFO (1872 to March week 4 2006); ASSIA (1987 to March 2006); LILACS (1982 to March 2006); and Sociological Abstracts(1963 to March 2006). We searched grey literature using ZETOC (1993 to March 2006); Dissertation Abstracts International (late 1960s to 2006); and SIGLE (1980 to March 2006). We also undertook communication with published authors about ongoing or unpublished research.

SELECTION CRITERIA

Included studies were randomised controlled trials investigating the efficacy of home visiting directed at disadvantaged adult mothers.

DATA COLLECTION AND ANALYSIS

Two reviewers (EC and JP or CB) independently assessed titles and abstracts identified in the search for eligibility. Data were extracted and entered into RevMan (EC, JP and CB), synthesised and presented in both written and graphical form (forest plots). Outcomes included in this review were established at the protocol stage by an international steering group. The review does not report on all outcomes reported in included studies.

MAIN RESULTS

We included 11 studies with 4751 participants in this review. Data show no statistically significant differences for those receiving home visiting, either for maternal outcomes (maternal depression, anxiety, the stress associated with parenting, parenting skills, child abuse risk or potential or breastfeeding) or child outcomes (preventive health care visits, psychosocial health, language development, behaviour problems or accidental injuries. Evidence about uptake of immunisations is mixed, and the data on child maltreatment difficult to interpret.

AUTHORS' CONCLUSIONS

This review suggests that for disadvantaged adult women and their children, there is currently no evidence to support the adoption of home visiting as a means of improving maternal psychosocial health, parenting or outcomes for children. For reasons discussed in the review, this does not amount to a conclusion that home visiting programmes are ineffective, but indicates a need to think carefully about the problems that home visiting might influence, and improvements in the conduct of outcome studies in this area.

WITHDRAWN: Home-based support for disadvantaged teenage mothers

BACKGROUND

Babies born to socio-economically disadvantaged mothers are at higher risk of injury, abuse or neglect and health problems than babies born to more affluent mothers; disadvantaged teenage mothers are at particular risk of adverse outcomes. Home-visiting programs are thought to improve outcomes for both mothers and children, largely through advice and support.

OBJECTIVES

To assess the effectiveness of home-visiting programmes for women who have recently given birth and who are socially or economically disadvantaged.

SEARCH STRATEGY

The following electronic databases were searched: CENTRAL (2006, Issue 3); MEDLINE (1966 to March 2006); EMBASE (1980 to week 12 2006); CINAHL (1982 to March week 4 2006); PsycINFO (1872 to March week 4 2006); ASSIA (1987 to March 2006); LILACS (1982 to March 2006); and Sociological Abstracts (1963 to March 2006). Grey literature was also be searched using ZETOC (1993 to March 2006); Dissertation Abstracts International (late 1960s to 2006); and SIGLE (1980 to March 2006). Communication with published authors about ongoing or unpublished research was also undertaken.

SELECTION CRITERIA

Included studies were randomised controlled trials investigating the efficacy of home visiting directed at teenage mothers.

DATA COLLECTION AND ANALYSIS

Titles and abstracts identified in the search were independently assessed for eligibility by two review authors (EC and JP or CB). Data were extracted and entered into RevMan (EC, JP and CB), synthesised and presented in both written and graphical form (forest plots). Outcomes included in this review were established at the protocol stage by an international steering group. The review did not report on all outcomes reported in included studies.

MAIN RESULTS

Five studies with 1838 participants were included in this review. Data from single studies provided support for the effectiveness of home visiting on some outcomes, but the evidence overall provided only limited support for the effectiveness of home visiting as a means of improving the range of maternal and child outcomes considered in this review.

AUTHORS' CONCLUSIONS

This review suggests there is only limited evidence that home-visiting programmes of the kind described in this review can impact positively on the quality of parenting of teenage mothers or on child development outcomes for their offspring. For reasons discussed in the review, this does not amount to a conclusion that home-visiting programmes are ineffective but indicates a need to think carefully about the problems that home visiting might influence and about improvements in the conduct and reporting of outcome studies in this area.

Home-based support for disadvantaged adult mothers

BACKGROUND

Babies born to socio-economically disadvantaged mothers are at higher risk of a range of problems in infancy. Home visiting programs are thought to improve outcomes, both for mothers and children, largely through advice and support.

OBJECTIVES

To assess the effectiveness of home visiting programmes for women who have recently given birth and who are socially or economically disadvantaged.

SEARCH STRATEGY

We searched the following electronic databases: The Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 3, 2006); MEDLINE (1966 to March 2006); EMBASE (1980 to 2006 week 12); CINAHL (1982 to March week 4 2006); PsycINFO (1872 to March week 4 2006); ASSIA (1987 to March 2006); LILACS (1982 to March 2006); and Sociological Abstracts(1963 to March 2006). We searched grey literature using ZETOC (1993 to March 2006); Dissertation Abstracts International (late 1960s to 2006); and SIGLE (1980 to March 2006). We also undertook communication with published authors about ongoing or unpublished research.

SELECTION CRITERIA

Included studies were randomised controlled trials investigating the efficacy of home visiting directed at disadvantaged adult mothers.

DATA COLLECTION AND ANALYSIS

Two reviewers (EC and JP or CB) independently assessed titles and abstracts identified in the search for eligibility. Data were extracted and entered into RevMan (EC, JP and CB), synthesised and presented in both written and graphical form (forest plots). Outcomes included in this review were established at the protocol stage by an international steering group. The review does not report on all outcomes reported in included studies.

MAIN RESULTS

We included 11 studies with 4751 participants in this review. Data show no statistically significant differences for those receiving home visiting, either for maternal outcomes (maternal depression, anxiety, the stress associated with parenting, parenting skills, child abuse risk or potential or breastfeeding) or child outcomes (preventive health care visits, psychosocial health, language development, behaviour problems or accidental injuries. Evidence about uptake of immunisations is mixed, and the data on child maltreatment difficult to interpret.

AUTHORS' CONCLUSIONS

This review suggests that for disadvantaged adult women and their children, there is currently no evidence to support the adoption of home visiting as a means of improving maternal psychosocial health, parenting or outcomes for children. For reasons discussed in the review, this does not amount to a conclusion that home visiting programmes are ineffective, but indicates a need to think carefully about the problems that home visiting might influence, and improvements in the conduct of outcome studies in this area.

Home-based support for disadvantaged teenage mothers

BACKGROUND

Babies born to socio-economically disadvantaged mothers are at higher risk of injury, abuse or neglect and health problems than babies born to more affluent mothers; disadvantaged teenage mothers are at particular risk of adverse outcomes. Home-visiting programs are thought to improve outcomes for both mothers and children, largely through advice and support.

OBJECTIVES

To assess the effectiveness of home-visiting programmes for women who have recently given birth and who are socially or economically disadvantaged.

SEARCH STRATEGY

The following electronic databases were searched: CENTRAL (2006, Issue 3); MEDLINE (1966 to March 2006); EMBASE (1980 to week 12 2006); CINAHL (1982 to March week 4 2006); PsycINFO (1872 to March week 4 2006); ASSIA (1987 to March 2006); LILACS (1982 to March 2006); and Sociological Abstracts (1963 to March 2006). Grey literature was also be searched using ZETOC (1993 to March 2006); Dissertation Abstracts International (late 1960s to 2006); and SIGLE (1980 to March 2006). Communication with published authors about ongoing or unpublished research was also undertaken.

SELECTION CRITERIA

Included studies were randomised controlled trials investigating the efficacy of home visiting directed at teenage mothers.

DATA COLLECTION AND ANALYSIS

Titles and abstracts identified in the search were independently assessed for eligibility by two review authors (EC and JP or CB). Data were extracted and entered into RevMan (EC, JP and CB), synthesised and presented in both written and graphical form (forest plots). Outcomes included in this review were established at the protocol stage by an international steering group. The review did not report on all outcomes reported in included studies.

MAIN RESULTS

Five studies with 1838 participants were included in this review. Data from single studies provided support for the effectiveness of home visiting on some outcomes, but the evidence overall provided only limited support for the effectiveness of home visiting as a means of improving the range of maternal and child outcomes considered in this review.

AUTHORS' CONCLUSIONS

This review suggests there is only limited evidence that home-visiting programmes of the kind described in this review can impact positively on the quality of parenting of teenage mothers or on child development outcomes for their offspring. For reasons discussed in the review, this does not amount to a conclusion that home-visiting programmes are ineffective but indicates a need to think carefully about the problems that home visiting might influence and about improvements in the conduct and reporting of outcome studies in this area.