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

End-user understanding of qualitative comparative analysis used within evidence synthesis: A mixed-methods study

BACKGROUND

Enhanced uptake of systematic reviews that use qualitative comparative analyses (QCA) requires knowing how end-users interpret such findings. The study purpose was to identify effective approaches to communicating results from a QCA within a systematic review.

METHODS

Sequential exploratory mixed methods design; thematic analysis of interviews with 11 end-users followed by a randomized experiment with 254 participants that provided QCA results for a hypothetical review presented through three formats (text, table, and figure). A survey administered after the experiment assessed subjective and objective comprehension of QCA results.

RESULTS

Interview themes included use of jargon; appropriate use of appendices, tables, figures; and integration of QCA results within the systematic review. In the experiment, we observed a significant difference (p = 0.035) in subjective comprehension across the three presentation formats. Participants randomized to the figure and text formats scored higher compared to the table. No significant differences were observed for objective comprehension overall (p = 0.11). However, for parameter interpretation (a unique component of QCA results), scores among participants that received the figure format were significantly higher than scores for participants who received the text (p = 0.001) or table (p = 0.004). No significant differences (p = 0.09) were observed in objective comprehension for configuration interpretation.

CONCLUSIONS

End-users of systematic reviews saw value in the use of QCA, but unfamiliar methods and terminology were barriers to full understanding of the findings. When presenting results, a figure format appears to be superior to text or table formats based on measures of subjective comprehension and some measures of objective comprehension.

Evaluating the implementation of Cradle to Kinder: An intensive home-visitation support program for families experiencing disadvantage

BACKGROUND

The Australian evidence supporting the effectiveness of home visitation programs for families experiencing disdavantage is mixed. These inconsistent findings could be attributed to the varied ways in which home visitation programs are implemented, and a lack of evaluation.

OBJECTIVE

This qualitative paper explores the barriers and facilitators to the implementation of Cradle to Kinder - a long-term, intensive, home visitation family support program for vulnerable young caregivers at risk of child removal across Victoria, Australia.

METHOD

Semi-structured interviews and focus groups were conducted with 37 stakeholders from all levels of intervention delivery (i.e., clients, internal staff, external stakeholders). Data collection and thematic analysis were informed by the Consolidated Framework for Implementation Research (CFIR).

RESULTS

According to stakeholders, four key CFIR constructs facilitated the implementation of Cradle to Kinder: Effective Engagement, Relative Advantage, Organisational Culture, and Learning Climate. Implementation was challenged by factors within the Peer Pressure construct, which involved managing expectations and push-back from external organisations and services.

CONCLUSION

The current findings highlight the importance of organisational commitment to successful implementation. The next phase of this research is to establish the effectiveness of Cradle to Kinder. Indeed, greater implementation-effectiveness evaluations of family support programs are required to ensure that such programs effectively meet the needs of families and improve their outcomes.

Exploring theoretical mechanisms of community-engaged research: a multilevel cross-sectional national study of structural and relational practices in community-academic partnerships

Background

Community-Based Participatory Research (CBPR) is often used to address health inequities due to structural racism. However, much of the existing literature emphasizes relationships and synergy rather than structural components of CBPR. This study introduces and tests new theoretical mechanisms of the CBPR Conceptual Model to address this limitation.

Methods

Three-stage online cross-sectional survey administered from 2016 to 2018 with 165 community-engaged research projects identified through federal databases or training grants. Participants (N = 453) were principal investigators and project team members (both academic and community partners) who provided project-level details and perceived contexts, processes, and outcomes. Data were analyzed through structural equation modeling and fuzzy-set qualitative comparison analysis.

Results

Commitment to Collective Empowerment was a key mediating variable between context and intervention activities. Synergy and Community Engagement in Research Actions were mediating variables between context/partnership process and outcomes. Collective Empowerment was most strongly aligned with Synergy, while higher levels of Structural Governance and lower levels of Relationships were most consistent with higher Community Engagement in Research Actions.

Conclusions

The CBPR Conceptual Model identifies key theoretical mechanisms for explaining health equity and health outcomes in community-academic partnerships. The scholarly literature’s preoccupation with synergy and relationships overlooks two promising practices—Structural Governance and Collective Empowerment—that interact from contexts through mechanisms to influence outcomes. These results also expand expectations beyond a “one size fits all” for reliably producing positive outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01663-y.

The use of Qualitative Comparative Analysis (QCA) to address causality in complex systems: a systematic review of research on public health interventions

Background

Qualitative Comparative Analysis (QCA) is a method for identifying the configurations of conditions that lead to specific outcomes. Given its potential for providing evidence of causality in complex systems, QCA is increasingly used in evaluative research to examine the uptake or impacts of public health interventions. We map this emerging field, assessing the strengths and weaknesses of QCA approaches identified in published studies, and identify implications for future research and reporting.

Methods

PubMed, Scopus and Web of Science were systematically searched for peer-reviewed studies published in English up to December 2019 that had used QCA methods to identify the conditions associated with the uptake and/or effectiveness of interventions for public health. Data relating to the interventions studied (settings/level of intervention/populations), methods (type of QCA, case level, source of data, other methods used) and reported strengths and weaknesses of QCA were extracted and synthesised narratively.

Results

The search identified 1384 papers, of which 27 (describing 26 studies) met the inclusion criteria. Interventions evaluated ranged across: nutrition/obesity (n = 8); physical activity (n = 4); health inequalities (n = 3); mental health (n = 2); community engagement (n = 3); chronic condition management (n = 3); vaccine adoption or implementation (n = 2); programme implementation (n = 3); breastfeeding (n = 2), and general population health (n = 1). The majority of studies (n = 24) were of interventions solely or predominantly in high income countries. Key strengths reported were that QCA provides a method for addressing causal complexity; and that it provides a systematic approach for understanding the mechanisms at work in implementation across contexts. Weaknesses reported related to data availability limitations, especially on ineffective interventions. The majority of papers demonstrated good knowledge of cases, and justification of case selection, but other criteria of methodological quality were less comprehensively met.

Conclusion

QCA is a promising approach for addressing the role of context in complex interventions, and for identifying causal configurations of conditions that predict implementation and/or outcomes when there is sufficiently detailed understanding of a series of comparable cases. As the use of QCA in evaluative health research increases, there may be a need to develop advice for public health researchers and journals on minimum criteria for quality and reporting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10926-2.

Addressing embodied inequities in health: how do we enable improvement in women's diet in pregnancy?

OBJECTIVE

To disrupt cycles of health inequity, traceable to dietary inequities in the earliest stages of life, public health interventions should target improving nutritional wellbeing in preconception/pregnancy environments. This requires a deep engagement with pregnant/postpartum people (PPP) and their communities (including their health and social care providers, HSCP). We sought to understand the factors that influence diet during pregnancy from the perspectives of PPP and HSCP, and to outline intervention priorities.

DESIGN

We carried out thematic network analyses of transcripts from ten focus group discussions (FGD) and one stakeholder engagement meeting with PPP and HSCP in a Canadian city. Identified themes were developed into conceptual maps, highlighting local priorities for pregnancy nutrition and intervention development.

SETTING

FGD and the stakeholder meeting were run in predominantly lower socioeconomic position (SEP) neighbourhoods in the sociodemographically diverse city of Hamilton, Canada.

PARTICIPANTS

All local, comprising twenty-two lower SEP PPP and forty-three HSCP.

RESULTS

Salient themes were resilience, resources, relationships and the embodied experience of pregnancy. Both PPP and HSCP underscored that socioeconomic-political forces operating at multiple levels largely determined the availability of individual and relational resources constraining diet during pregnancy. Intervention proposals focused on cultivating individual and community resilience to improve early-life nutritional environments. Participants called for better-integrated services, greater income supports and strengthened support programmes.

CONCLUSIONS

Hamilton stakeholders foregrounded social determinants of inequity as main factors influencing pregnancy diet. They further indicated a need to develop interventions that build resilience and redistribute resources at multiple levels, from the household to the state.

Models and frameworks that enable nurses to develop their public health practice-A scoping study

AIMS AND OBJECTIVES

This scoping review commissioned by the Public Health England, WHO collaborating Centre, aimed to explore the models and frameworks which enable nurses to develop their public health practice and deliver public health interventions to individuals, families and communities.

BACKGROUND

There is a plethora of literature regarding the role, activities and scope of practice undertaken by public health nurses across the world. However, only two reviews have explored the models and frameworks used for public health nursing practice.

DESIGN

The study drew upon an established framework with a narrative review drawing upon five methodological steps.

METHODS

A search of databases, Medline, PsycINFO, Embase, CINHAL and British Nursing Index, was undertaken. The search took place between April 2018 and June 2018 retrieving 9,513 peer-reviewed articles published from 2008.

RESULTS

Ninety-five studies were retrieved and analysed thematically. From an initial review of literature, two themes were identified: public health models used in practice and models used in public health education. Within the first theme, three subthemes were emerged: Characteristics of the interventions; Characteristics of the public health nurse; and Lack of measurable health benefits. Within the second theme, three subthemes were identified: Faculty and Students Working Together; The Experiential Academic Approach, and What works in Educating Nurses for Public Health.

CONCLUSION

The review identified that many models and frameworks are used in practice. However, within public health practice there is a limited evidence base and it fails to demonstrate that the frameworks and models developed for practice result in measurable health benefits on an individual or population level. However, within education innovative models were apparent with collaborative partnerships enabling preregistration nursing students to develop public health nursing competencies.

RELEVANCE TO CLINICAL PRACTICE

Innovative approaches to education of preregistration nursing students could point the way forward for the delivery of public health nursing practice.

Partnerships, Processes, and Outcomes: A Health Equity-Focused Scoping Meta-Review of Community-Engaged Scholarship

In recent decades, there has been remarkable growth in scholarship examining the usefulness of community-engaged research (CEnR) and community-based participatory research (CBPR) for eliminating health inequities.This article seeks to synthesize the extant literature of systematic reviews, scoping reviews, and other related reviews regarding the context, processes, and research designs and interventions underlying CEnR that optimize its effectiveness. Through a scoping review, we have utilized an empirically derived framework of CBPR to map this literature and identify key findings and priorities for future research. Our study found 100 reviews of CEnR that largely support the CBPR conceptual framework.

Developing and testing intervention theory by incorporating a views synthesis into a qualitative comparative analysis of intervention effectiveness

Qualitative comparative analysis (QCA) was originally developed as a tool for cross-national comparisons in macrosociology, but its use in evaluation and evidence synthesis of complex interventions is rapidly developing. QCA is theory-driven and relies on Boolean logic to identify pathways to an outcome (eg, is the intervention effective or not?). We use the example of two linked systematic reviews on weight management programs (WMPs) for adults-one focusing on user views (a "views synthesis") and one focusing on the effectiveness of WMPs incorporating dietary and physical activity-to demonstrate how a synthesis of user views can supply a working theory to structure a QCA. We discuss how a views synthesis is especially apt to supply this working theory because user views can (a) represent a "middle-range theory" of the intervention; (b) bring a participatory, democratic perspective; and (c) provide an idiographic understanding of how the intervention works that external taxonomies may not be able to furnish. We then discuss the practical role that the views synthesis played in our QCA examining pathways to effectiveness: (a) by suggesting specific intervention features and sharpening the focus on the most salient features to be examined, (b) by supporting interpretation of findings, and (c) by bounding data analysis to prevent data dredging.

School-based self-management interventions for asthma in children and adolescents: a mixed methods systematic review

BACKGROUND

Asthma is a common respiratory condition in children that is characterised by symptoms including wheeze, shortness of breath, chest tightness, and cough. Children with asthma may be able to manage their condition more effectively by improving inhaler technique, and by recognising and responding to symptoms. Schools offer a potentially supportive environment for delivering interventions aimed at improving self-management skills among children. The educational ethos aligns with skill and knowledge acquisition and makes it easier to reach children with asthma who do not regularly engage with primary care. Given the multi-faceted nature of self-management interventions, there is a need to understand the combination of intervention features that are associated with successful delivery of asthma self-management programmes.

OBJECTIVES

This review has two primary objectives.• To identify the intervention features that are aligned with successful intervention implementation.• To assess effectiveness of school-based interventions provided to improve asthma self-management among children.We addressed the first objective by performing qualitative comparative analysis (QCA), a synthesis method described in depth later, of process evaluation studies to identify the combination of intervention components and processes that are aligned with successful intervention implementation.We pursued the second objective by undertaking meta-analyses of outcomes reported by outcome evaluation studies. We explored the link between how well an intervention is implemented and its effectiveness by using separate models, as well as by undertaking additional subgroup analyses.

SEARCH METHODS

We searched the Cochrane Airways Trials Register for randomised studies. To identify eligible process evaluation studies, we searched MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, the Cochrane Database of Systematic Reviews (CDSR), Web of Knowledge, the Database of Promoting Health Effectiveness Reviews (DoPHER), the Database of Abstracts of Reviews of Effects (DARE), the International Biography of Social Science (IBSS), Bibliomap, Health Technology Assessment (HTA), Applied Social Sciences Index and Abstracts (ASSIA), and Sociological Abstracts (SocAbs). We conducted the latest search on 28 August 2017.

SELECTION CRITERIA

Participants were school-aged children with asthma who received the intervention in school. Interventions were eligible if their purpose was to help children improve management of their asthma by increasing knowledge, enhancing skills, or changing behaviour. Studies relevant to our first objective could be based on an experimental or quasi-experimental design and could use qualitative or quantitative methods of data collection. For the second objective we included randomised controlled trials (RCTs) where children were allocated individually or in clusters (e.g. classrooms or schools) to self-management interventions or no intervention control.

DATA COLLECTION AND ANALYSIS

We used qualitative comparative analysis (QCA) to identify intervention features that lead to successful implementation of asthma self-management interventions. We measured implementation success by reviewing reports of attrition, intervention dosage, and treatment adherence, irrespective of effects of the interventions.To measure the effects of interventions, we combined data from eligible studies for our primary outcomes: admission to hospital, emergency department (ED) visits, absence from school, and days of restricted activity due to asthma symptoms. Secondary outcomes included unplanned visits to healthcare providers, daytime and night-time symptoms, use of reliever therapies, and health-related quality of life as measured by the Asthma Quality of Life Questionnaire (AQLQ).

MAIN RESULTS

We included 55 studies in the review. Thirty-three studies in 14,174 children provided information for the QCA, and 33 RCTs in 12,623 children measured the effects of interventions. Eleven studies contributed to both the QCA and the analysis of effectiveness. Most studies were conducted in North America in socially disadvantaged populations. High school students were better represented among studies contributing to the QCA than in studies contributing to effectiveness evaluations, which more commonly included younger elementary and junior high school students. The interventions all attempted to improve knowledge of asthma, its triggers, and stressed the importance of regular practitioner review, although there was variation in how they were delivered.QCA results highlighted the importance of an intervention being theory driven, along with the importance of factors such as parent involvement, child satisfaction, and running the intervention outside the child's own time as drivers of successful implementation.Compared with no intervention, school-based self-management interventions probably reduce mean hospitalisations by an average of about 0.16 admissions per child over 12 months (SMD -0.19, 95% CI -0.35 to -0.04; 1873 participants; 6 studies, moderate certainty evidence). They may reduce the number of children who visit EDs from 7.5% to 5.4% over 12 months (OR 0.70, 95% CI 0.53 to 0.92; 3883 participants; 13 studies, low certainty evidence), and probably reduce unplanned visits to hospitals or primary care from 26% to 21% at 6 to 9 months (OR 0.74, 95% CI 0.60 to 0.90; 3490 participants; 5 studies, moderate certainty evidence). Self-management interventions probably reduce the number of days of restricted activity by just under half a day over a two-week period (MD 0.38 days 95% CI -0.41 to -0.18; 1852 participants; 3 studies, moderate certainty evidence). Effects of interventions on school absence are uncertain due to the variation between the results of the studies (MD 0.4 fewer school days missed per year with self-management (-1.25 to 0.45; 4609 participants; 10 studies, low certainty evidence). Evidence is insufficient to show whether the requirement for reliever medications is affected by these interventions (OR 0.52, 95% CI 0.15 to 1.81; 437 participants; 2 studies; very low-certainty evidence). Self-management interventions probably improve children's asthma-related quality of life by a small amount (MD 0.36 units higher on the Paediatric AQLQ(95% CI 0.06 to 0.64; 2587 participants; 7 studies, moderate certainty evidence).

AUTHORS' CONCLUSIONS

School-based asthma self-management interventions probably reduce hospital admission and may slightly reduce ED attendance, although their impact on school attendance could not be measured reliably. They may also reduce the number of days where children experience asthma symptoms, and probably lead to small improvements in asthma-related quality of life. Many of the studies tested the intervention in younger children from socially disadvantaged populations. Interventions that had a theoretical framework, engaged parents and were run outside of children's free time were associated with successful implementation.

Evaluation of community-level interventions to increase early initiation of antenatal care in pregnancy: protocol for the Community REACH study, a cluster randomised controlled trial with integrated process and economic evaluations

Background

The provision of high-quality maternity services is a priority for reducing inequalities in health outcomes for mothers and infants. Best practice includes women having their initial antenatal appointment within the first trimester of pregnancy in order to provide screening and support for healthy lifestyles, well-being and self-care in pregnancy. Previous research has identified inequalities in access to antenatal care, yet there is little evidence on interventions to improve early initiation of antenatal care. The Community REACH trial will assess the effectiveness and cost-effectiveness of engaging communities in the co-production and delivery of an intervention that addresses this issue.

Methods/design

The study design is a matched cluster randomised controlled trial with integrated process and economic evaluations. The unit of randomisation is electoral ward. The intervention will be delivered in 10 wards; 10 comparator wards will have normal practice. The primary outcome is the proportion of pregnant women attending their antenatal booking appointment by the 12th completed week of pregnancy. This and a number of secondary outcomes will be assessed for cohorts of women (n = approximately 1450 per arm) who give birth 2–7 and 8–13 months after intervention delivery completion in the included wards, using routinely collected maternity data. Eight hospitals commissioned to provide maternity services in six NHS trusts in north and east London and Essex have been recruited to the study. These trusts will provide anonymised routine data for randomisation and outcomes analysis. The process evaluation will examine intervention implementation, acceptability, reach and possible causal pathways. The economic evaluation will use a cost-consequences analysis and decision model to evaluate the intervention. Targeted community engagement in the research process was a priority.

Discussion

Community REACH aims to increase early initiation of antenatal care using an intervention that is co-produced and delivered by local communities. This pragmatic cluster randomised controlled trial, with integrated process and economic evaluation, aims to rigorously assess the effectiveness of this public health intervention, which is particularly complex due to the required combination of standardisation with local flexibility. It will also answer questions about scalability and generalisability.

Trial registration

ISRCTN registry: registration number 63066975. Registered on 18 August 2015.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2526-6) contains supplementary material, which is available to authorized users.

'They aren't really black fellas but they are easy to talk to': Factors which influence Australian Aboriginal women's decision to disclose intimate partner violence during pregnancy

OBJECTIVES

intimate partner violence is a significant global health problem but remains largely hidden. Understanding decisions about whether or not to disclose violence in response to routine enquiry in health settings can inform safe and responsive systems. Elevated rates of violence and systematic disadvantage found among Indigenous women globally, can impact on their decisions to disclose violence. This study aimed to test, among Indigenous women, a model for decisions on whether to disclose intimate partner violence in the context of antenatal routine screening.

DESIGN

we employed Qualitative Configurative Analysis, a method developed for the social sciences to study complex phenomena with intermediate sample sizes. Data were drawn from single semi- structured interviews with Indigenous women 28+ weeks pregnant attending antenatal care. Interviews addressed decisions to disclose recent intimate partner violence in the context of routine enquiry during the antenatal care. Interview transcripts were binary coded for conditions identified a priori from the model being tested and also from themes identified within the current study and analysed using Qualitative Configurative Analysis to determine causal conditions for the outcome of disclosure or non-disclosure of violence experienced.

SETTINGS

five Aboriginal and Maternal Infant Health Services (two urban and three regional), and one mainstream hospital, in New South Wales, Australia.

PARTICIPANTS

indigenous women who had experienced partner violence in the previous year and who had been asked about this as part of an antenatal booking-in visit. Of the 12 participants six had elected to disclose their experience of violence to the midwife, and six had chosen not to do so.

FINDINGS

pathways to disclosure and non-disclosure were mapped using Qualitative Configurative Analysis. Conditions relevant to decisions to disclose were similar to the conditions for non-Aboriginal women found in our earlier study. Unique to Aboriginal women's decisions to disclose abuse was cultural safety. Cultural safety included elements we titled: Borrowed trust, Build the relationship first, Come at it slowly and People like me are here. The absence of cultural safety Its absence was also a factor in decisions not to disclose experiences of violence by this group of women.

KEY CONCLUSIONS

cultural safety was central to Indigenous women's decision to disclose violence and processes for creating safety are identified. Other forms of safety which influenced disclosure included: safety from detection by the abuser; safety from shame; and safety from institutional control. Disclosure was promoted by direct asking by the midwife and a perception of care. Non-disclosure was associated with a lack of care and a lack of all four types of safety. Experiences of institutional racism were associated with Indigenous women's perceived risk of control by others, particularly child protection services.

IMPLICATIONS FOR PRACTICE

policies to ask abuse questions at first visits and models where continuity of care is not maintained, are problematic for Aboriginal women, among whom relationship building is important as is ample warning about questions to be asked. Strategies are needed to build cultural safety to counter widespread racism and promote safe opportunities for Indigenous women to disclose intimate partner violence and receive support. Elements of cultural safety are necessary for vulnerable or marginalised populations to fully utilise available health services.

Using qualitative comparative analysis in a systematic review of a complex intervention

BACKGROUND

Systematic reviews evaluating complex interventions often encounter substantial clinical heterogeneity in intervention components and implementation features making synthesis challenging. Qualitative comparative analysis (QCA) is a non-probabilistic method that uses mathematical set theory to study complex phenomena; it has been proposed as a potential method to complement traditional evidence synthesis in reviews of complex interventions to identify key intervention components or implementation features that might explain effectiveness or ineffectiveness. The objective of this study was to describe our approach in detail and examine the suitability of using QCA within the context of a systematic review.

METHODS

We used data from a completed systematic review of behavioral interventions to improve medication adherence to conduct two substantive analyses using QCA. The first analysis sought to identify combinations of nine behavior change techniques/components (BCTs) found among effective interventions, and the second analysis sought to identify combinations of five implementation features (e.g., agent, target, mode, time span, exposure) found among effective interventions. For each substantive analysis, we reframed the review's research questions to be designed for use with QCA, calibrated sets (i.e., transformed raw data into data used in analysis), and identified the necessary and/or sufficient combinations of BCTs and implementation features found in effective interventions.

RESULTS

Our application of QCA for each substantive analysis is described in detail. We extended the original review findings by identifying seven combinations of BCTs and four combinations of implementation features that were sufficient for improving adherence. We found reasonable alignment between several systematic review steps and processes used in QCA except that typical approaches to study abstraction for some intervention components and features did not support a robust calibration for QCA.

CONCLUSIONS

QCA was suitable for use within a systematic review of medication adherence interventions and offered insights beyond the single dimension stratifications used in the original completed review. Future prospective use of QCA during a review is needed to determine the optimal way to efficiently integrate QCA into existing approaches to evidence synthesis of complex interventions.

Deciding to tell: Qualitative configurational analysis of decisions to disclose experience of intimate partner violence in antenatal care

RATIONALE

Intimate partner violence (IPV) is a significant global public health risk causing premature death and morbidity that largely remains hidden. Understanding decisions about whether or not to disclose abuse when asked about it in health settings is important to ensuring that those experiencing violence are provided with access to services to support their safety and wellbeing.

OBJECTIVE

This study tested a model for women's decisions to disclose IPV in response to routine inquiry as part of antenatal assessment.

METHODS

Qualitative configurational analysis, suited to the study of causal pathways in complex social phenomena, was used to analyse interviews with 32 women who had experienced IPV in the past 12 months and who elected, when asked, to either disclose this to the midwife (n = 24) or not to do so (n = 8).

FINDINGS

Multiple pathways to disclosure were identified. While no single factor was necessary or sufficient for a decision to disclose, direct asking and care, defined as showing interest and a non-judgemental attitude, were found to be key conditions. The absence of care was also central to decisions not to disclose, as were perceptions of relevance of the abuse at the time of assessment.

CONCLUSION

Confirming key elements of the original model, these findings highlight the importance of being asked about abuse in women's decisions to disclose, as well as the relational nature of this process. Trauma-informed practices for identifying and responding to intimate partner violence are needed.

ABM Clinical Protocol #19: Breastfeeding Promotion in the Prenatal Setting, Revision 2015

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.