Evaluating the real-world implementation of the Family Nurse Partnership in England: a data linkage study.

Background/objectives: The Family Nurse Partnership is an intensive home visiting programme for adolescent mothers. We aimed to evaluate the effectiveness of the Family Nurse Partnership on outcomes up to age 7 using national administrative data. Design: We created a linked cohort of all mothers aged 13-19 using data from health, educational and children's social care and defined mothers enrolled in the Family Nurse Partnership or not using Family Nurse Partnership system data. Propensity scores were used to create matched groups for analysis. Setting: One hundred and thirty-six local authorities in England with active Family Nurse Partnership sites between 2010 and 2017. Participants: Mothers aged 13-19 at last menstrual period with live births between April 2010 and March 2019, living in a Family Nurse Partnership catchment area and their firstborn child(ren). Interventions: The Family Nurse Partnership includes up to 64 home visits by a family nurse from early pregnancy until the child's second birthday and is combined with usual health and social care. Controls received usual health and social care. Main outcome measures: Indicators of child maltreatment (hospital admissions for injury/maltreatment, referral to social care services); child health and development (hospital utilisation and education) outcomes and maternal hospital utilisation and educational outcomes up to 7 years following birth. Data sources: Family Nurse Partnership Information System, Hospital Episode Statistics, National Pupil Database. Results: Of 110,520 eligible mothers, 25,680 (23.2%) were enrolled in the Family Nurse Partnership. Enrolment rates varied across 122 sites (range: 11-68%). Areas with more eligible mothers had lower enrolment rates. Enrolment was higher among mothers aged 13-15 (52%), than 18-19 year-olds (21%). Indicators of child maltreatment: we found no evidence of an association between the Family Nurse Partnership and indicators of child maltreatment, except for an increased rate of unplanned admissions for maltreatment/injury-related diagnoses up to age 2 for children born to Family Nurse Partnership mothers (6.6% vs. 5.7%, relative risk 1.15; 95% confidence interval 1.07 to 1.24). Child health and developmental outcomes: there was weak evidence that children born to Family Nurse Partnership mothers were more likely to achieve a Good Level of Development at age 5 (57.5% vs. 55.4%, relative risk 1.05; 95% confidence interval 1.00 to 1.09). Maternal outcomes: There was some evidence that Family Nurse Partnership mothers were less likely to have a subsequent delivery within 18 months of the index birth (8.4% vs. 9.3%, relative risk 0.92; 95% confidence interval 0.88 to 0.97). Younger and more vulnerable mothers received higher numbers of visits and were more likely to achieve fidelity targets. Meeting the fidelity targets was associated with some outcomes. Limitations: Bias by indication and variation in the intervention and usual care over time and between areas may have limited our ability to detect effects. Multiple testing may have led to spurious, significant results. Conclusions: This study supports findings from evaluations of the Family Nurse Partnership showing no evidence of benefit for maltreatment outcomes measured in administrative data. Amongst all the outcomes measured, we found weak evidence that the Family Nurse Partnership was associated with improvements in child development at school entry, a reduction in rapid repeat pregnancies and evidence of increased healthcare-seeking in the mother and child. Future work: Future evaluations should capture better measures of Family Nurse Partnership interventions and usual care, more information on maternal risk factors and additional outcomes relating to maternal well-being. Study registration: The study is registered as NIHR CRN Portfolio (42900). Funding: This award was funded by the National Institute of Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/99/19) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 11. See the NIHR Funding and Awards website for further award information.

The Family Nurse Partnership is an intensive home visiting service that offers first-time young mothers up to 64 visits with a family nurse from pregnancy to their child's second birthday. The Family Nurse Partnership aims to improve birth outcomes, child health and development and promote economic self-sufficiency among young mothers. Previous research in England found no differences in birthweight, maternal smoking, repeat pregnancies or accident and emergency attendances between mothers who did or did not take part in the Family Nurse Partnership. However, children in the Family Nurse Partnership group had better measures of development at school age. We aimed to add to the evidence from earlier studies, by using electronic records that are routinely collected as part of health, education and social care services, to compare outcomes for around 26,000 mothers enrolled in the Family Nurse Partnership between 2010 and 2019 with similar mothers who were not enrolled. This study showed that around one in four mothers who were eligible for the programme were enrolled in the Family Nurse Partnership, and family nurses gave priority to mothers who were younger, more deprived or who had other markers of vulnerability (e.g. a history of substance misuse violence, self-harm or mental health conditions). We found no evidence of a difference in indicators of child maltreatment between mothers who were enrolled in the Family Nurse Partnership and those who were not enrolled, but we found weak evidence to suggest that children born to mothers enrolled in the Family Nurse Partnership were more likely to achieve a Good Level of Development at school entry (age 5). We also saw that mothers enrolled in the Family Nurse Partnership were less likely than those who were not enrolled to have their next child within 18 months of their first child. More research is needed to understand which elements of intensive home visiting services work best, for whom and when. This will help inform decisions about whether it is better to offer highly intensive services for a small portion of the target population or to extend and enhance existing universal health visiting services to better support all adolescent mothers.

Examining the quality of care across the continuum of maternal care (antenatal, perinatal and postnatal care) under the expanded free maternity policy (Linda Mama Policy) in Kenya: a mixed-methods study.

BACKGROUND: Kenya still faces the challenge of mothers and neonates dying from preventable pregnancy-related complications. The free maternity policy (FMP), implemented in 2013 and expanded in 2017 (Linda Mama Policy (LMP)), sought to address this challenge. This study examines the quality of care (QoC) across the continuum of maternal care under the LMP in Kenya. METHODS: We conducted a convergent parallel mixed-methods study across multiple levels of the Kenyan health system, involving key informant interviews with national stakeholders (n=15), in-depth interviews with county officials and healthcare workers (HCWs) (n=21), exit interview survey with mothers (n=553) who utilised the LMP delivery services, and focus group discussions (n=9) with mothers who returned for postnatal visits (at 6, 10 and 14 weeks). Quantitative data were analysed descriptively, while qualitative data were analysed thematically. All the data were triangulated at the analysis and discussion stage using a framework approach guided by the QoC for maternal and newborns. RESULTS: The results showed that the expanded FMP enhanced maternal care access: geographical, financial and service utilisation. However, the facilities and HCWs bore the brunt of the increased workload and burnout. There was a longer waiting time for the initial visit by the pregnant women because of the enhanced antenatal care package of the LMP. The availability and standards of equipment, supplies and infrastructure still posed challenges. Nurses were multitasking and motivated despite the human resources challenge. Mothers were happy to have received care information; however, there were challenges regarding respect and dignity they received (inadequate food, over-crowding, bed-sharing and lack of privacy), and they experienced physical, verbal and emotional abuse and a lack of attention/care. CONCLUSIONS: Addressing the negative aspects of QoC while strengthening the positives is necessary to achieve the Universal Health Coverage goals through better quality service for every woman.

Does a free maternity policy in Kenya work? Impact and cost-benefit consideration based on demographic health survey data.

This paper evaluates the overall effect of the Kenyan free maternity policy (FMP) on the main outcomes (early neonatal and neonatal deaths) and intermediate outcomes (delivery through Caesarean Section (CS), skilled birth attendance (SBA), birth in a public hospital and low birth weight (LBW)) using the 2014 Demographic Health Survey. We applied the difference-in-difference (DID) approach to compare births (to the same mothers) happening before and after the start of the policy (June 2013) and a limited cost-benefit analysis (CBA) to assess the net social benefit of the FMP. The probabilities of birth resulting in early neonatal and neonatal mortality are significantly reduced by 17-21% and 19-20%, respectively, after the FMP introduction. The probability of birth happening through CS reduced by 1.7% after implementing the FMP, while that of LBW birth is increased by 3.7% though not statistically significant. SBA and birth in a public facility did not moderate the policy's effects on early neonatal mortality, neonatal mortality, and delivery through CS. They were not significant determinants of the policy effects on the outcomes. There is a significant causal impact of the FMP in reducing the probability of early neonatal and neonatal mortality, but not the delivery through CS. The FMP cost-to-benefit ratio was 21.22, and there were on average 4015 fewer neonatal deaths in 2013/2014 due to the FMP. The net benefits are higher than the costs; thus, there is a need to expand and sustainably fund the FMP to avert more neonatal deaths potentially.

Effects of Telephone Consultation on Safety, Service Use, Patient Satisfaction, and Workload: Systematic Review and Meta-Analysis of Randomized Trials.

Objective: Telephone consultation (TC) is widely used for its easy access and convenience. This review aimed to assess the effects of TC including triage on safety, service use, patient satisfaction, and health professionals' workload to inform directions for future health service practice. Methods: CENTRAL, MEDLINE, Embase, CINAHL, ProQuest Dissertation & Theses (Health & Medicine), ClinincalTrials.gov, and International Clinical Trial Registry Platform were searched on April 7, 2022. The included were randomized controlled trials that compared TC with standard (face-to-face [F2F]) management or that by another group of call advisers. Cochrane methods were used to select eligible studies, assess the risk of bias, estimate summary effect measure, and grade evidence certainty. Meta-analysis was performed on important outcomes with moderate- or high-quality evidence. Results: Eight studies were included involving 40,002 participants. TC could increase call resolution-proportion of callers' concerns being addressed by telephone advice alone (two studies; high certainty) and reduce F2F contacts with doctors for the first consultation (two studies, moderate certainty) compared with standard management or TC by doctors. None of included studies reported increases in adverse events, including all-cause mortality, acute and emergency department visit, and hospitalization. There was inadequate evidence regarding the effects of TC on patient satisfaction and length of consultation. Conclusion: The findings support the benefits of TC on improving call resolution and reducing F2F contacts with doctors on the day of first management for regular day service; and TC by nurses can provide better effects than that by doctors for out-of-hours service.

A global approach to promoting research and evidence-based practice for community nurses.

Community health nurses world-wide provide health promotion and preventative care, support and guidance as well as clinical care for people with long-term conditions or needing acute care at home and end-of-life care, across all age groups. The importance of health care in the community has been growing globally as health systems recognise both the economic and human need for people to remain in their communities rather than in hospital. Research in community nursing provides evidence to support policy, practice and education. This article describes the global contribution that the International Collaboration for Community Health Nursing makes towards disseminating evidence that could improve the lives and health of communities.

Exploring the Adaptations of the Free Maternity Policy Implementation by Health Workers and County Officials in Kenya.

BACKGROUND: In 2017, Kenya launched the free maternity policy (FMP) that aimed to provide all pregnant women access to maternal services in private, faith-based, and levels 3-6 public institutions. We explored the adaptive strategies health care workers (HCWs) and county officials used to bridge the implementation challenges and achieve the FMP objectives. METHODS: We conducted an exploratory qualitative study using Lipsky's theoretical framework in 3 facilities (levels 3, 4, and 5) in Kiambu County, Kenya. The study involved in-depth interviews (n=21) with county officials, facility in-charges and HCWs, and key informants from national and development partner agencies. Data were audio-recorded, transcribed, and analyzed using a framework thematic approach. RESULTS: The results show that HCWs and county officials applied several strategies that were critical in shaping the policymaking, working practice, and professionalism and ethical aspects of the FMP. Strategies of policymaking: hospitals employed additional staff, and the county developed bylaws to strengthen the flow of funds. Strategies of working practice: hospitals and HCWs enhanced patient referrals, and facilities enhanced communication. Strategies of professionalism and ethics: nurses registered and provided service to mothers, and facilities included employees in planning and budgeting. Maladaptations included facilities having leeway to provide FMP services to populations who were excluded from the policy but had to bear the costs. Some discharged mothers immediately after birth, even before offering the fully costed policy benefits, to avoid incurring additional costs. CONCLUSIONS: The role of policy implementers and the built-in flexibility and agility in implementing the FMP could enhance service delivery, manage the administrative pressures of implementation, and provide mothers with personalized, responsive service. However, despite their benefits, some resulting unintended consequences may need interventions.

Lessons learned from using linked administrative data to evaluate the Family Nurse Partnership in England and Scotland.

Introduction: "Big data" - including linked administrative data - can be exploited to evaluate interventions for maternal and child health, providing time- and cost-effective alternatives to randomised controlled trials. However, using these data to evaluate population-level interventions can be challenging. Objectives: We aimed to inform future evaluations of complex interventions by describing sources of bias, lessons learned, and suggestions for improvements, based on two observational studies using linked administrative data from health, education and social care sectors to evaluate the Family Nurse Partnership (FNP) in England and Scotland. Methods: We first considered how different sources of potential bias within the administrative data could affect results of the evaluations. We explored how each study design addressed these sources of bias using maternal confounders captured in the data. We then determined what additional information could be captured at each step of the complex intervention to enable analysts to minimise bias and maximise comparability between intervention and usual care groups, so that any observed differences can be attributed to the intervention. Results: Lessons learned include the need for i) detailed data on intervention activity (dates/geography) and usual care; ii) improved information on data linkage quality to accurately characterise control groups; iii) more efficient provision of linked data to ensure timeliness of results; iv) better measurement of confounding characteristics affecting who is eligible, approached and enrolled. Conclusions: Linked administrative data are a valuable resource for evaluations of the FNP national programme and other complex population-level interventions. However, information on local programme delivery and usual care are required to account for biases that characterise those who receive the intervention, and to inform understanding of mechanisms of effect. National, ongoing, robust evaluations of complex public health evaluations would be more achievable if programme implementation was integrated with improved national and local data collection, and robust quasi-experimental designs.

Study protocol: evaluation of the 0-5 public health investment in England - a mixed-methods study integrating analyses of national linked administrative data with in-depth case studies.

INTRODUCTION: Health visiting is a long-established, nationally implemented programme that works with other services at a local level to improve the health and well-being of children and families. To maximise the impact and efficiency of the health visiting programme, policy-makers and commissioners need robust evidence on the costs and benefits of different levels and types of health visiting, for different families, in different local contexts. METHODS AND ANALYSIS: This mixed-methods study will analyse individual-level health visiting data for 2018/2019 and 2019/2020 linked with longitudinal data from children's social care, hospitals and schools to estimate the association of number and type of health visiting contacts with a range of children and maternal outcomes. We will also use aggregate local authority data to estimate the association between local models of health visiting and area-level outcomes. Outcomes will include hospitalisations, breast feeding, vaccination, childhood obesity and maternal mental health. Where possible, outcomes will be valued in monetary terms, and we will compare total costs to total benefits of different health visiting service delivery models. Qualitative case studies and extensive stakeholder input will help explain the quantitative analyses and interpret the results in the context of local policy, practice and circumstance. ETHICS AND DISSEMINATION: The University College London Research Ethics Committee approved this study (ref 20561/002). Results will be submitted for publication in a peer-reviewed journal and findings will be shared and debated with national policy-makers, commissioners and managers of health visiting services, health visitors and parents.

Health visiting in the UK in light of the COVID-19 pandemic experience (RReHOPE): a realist review protocol.

INTRODUCTION: Health visiting services, providing support to under 5s and their families, are organised and delivered in very different ways in different parts of the UK. While there has been attention to the key components of health visiting practice and what works well and how, there is little research on how health visiting services are organised and delivered and how that affects their ability to meet their objectives. The COVID-19 pandemic rapidly disrupted service delivery from March 2020. This realist review aims to synthesise the evidence on changes during the pandemic to identify the potential for improving health visiting services and their delivery. METHODS AND ANALYSIS: This review will follow the RAMESES (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) quality standards and Pawson's five iterative stages to locate existing theories, search for evidence, select literature, extract data, synthesise evidence and draw conclusions. It will be guided by stakeholder engagement with practitioners, commissioners, policymakers, policy advocates and people with lived experience. This approach will consider the emerging strategies and evolving contexts in which the services are delivered, and the varied outcomes for different groups. A realist logic of analysis will be used to make sense of what was happening to health visiting services during and following the pandemic response through the identification and testing of programme theories. Our refined programme theory will then be used to develop recommendations for improving the organisation, delivery and ongoing postpandemic recovery of health visiting services. ETHICS AND DISSEMINATION: General University Ethics Panel approval has been obtained from University of Stirling (reference 7662). Dissemination will build on links to policymakers, commissioners, providers, policy advocates and the public. A range of audiences will be targeted using outputs tailored to each. A final stakeholder event focused on knowledge mobilisation will aid development of recommendations. PROSPERO REGISTRATION NUMBER: CRD42022343117.

Research engagement and research capacity building: a priority for healthcare organisations in the UK.

PURPOSE: To research involvement of healthcare staff in the UK and identify practical organisational and policy solutions to improve and boost capacity of the existing workforce to conduct research. DESIGN/METHODOLOGY/APPROACH: A mixed-method study presenting three work packages here: secondary analysis of levels of staff research activity, funding, academic outputs and workforce among healthcare organisations in the United Kingdom; 39 Research and Development lead and funder interviews; an online survey of 11 healthcare organisations across the UK, with 1,016 responses from healthcare staff included for analysis; and 51 interviews of healthcare staff in different roles from six UK healthcare organisations. FINDINGS: Interest in research involvement is strong and widespread but hampered by a lack of systematic organisational support despite national policies and strategies to increase staff engagement in research. While useful, these external strategies have limited universal success due to lack of organisational support. Healthcare organisations should embed research within organisational and human resources policies and increase the visibility of research through strategic organisational goals and governance processes. A systems-based approach is needed. RESEARCH LIMITATIONS/IMPLICATIONS: The research gathered data from a limited number of NHS trusts but these were purposively sampled to provide a range of different acute/community health service organisations in different areas. But data was therefore more detailed and nuanced due to a more in-depth approach. PRACTICAL IMPLICATIONS: The findings are relevant for developing policies and practice within healthcare organisations to support research engagement. The findings also set out key policy and strategic recommendations that will support greater research engagement. SOCIAL IMPLICATIONS: Increased research activity and engagement in healthcare providers improves healthcare outcomes for patients. ORIGINALITY/VALUE: This is a large scale (UK-wide) study involving a broad range of healthcare staff, with good engagement of nurses, midwives and Allied Healthcare Professionals who have not been previously achieved. This allowed valuable analysis of under-researched groups and comparisons by professional groups. The findings highlight the need for tailored action to embed research reporting, skills, professional development and infrastructure into organisational policies, strategies and systems, along with broader system-wide development.

Scaling up breastfeeding in England through the Becoming Breastfeeding Friendly initiative (BBF).

Breastfeeding is the most accessible and cost-effective activity available to public health and has been shown to be one of the most effective preventive measures mothers can take to protect their children's health. Despite the well-documented benefits, the UK has one of the lowest breastfeeding rates in the world. The Becoming Breastfeeding Friendly (BBF) toolkit was developed through highly structured technical and academic collaboration, led by Yale University. It provides an evidence-based process to help countries assess their breastfeeding status and readiness to scale up, and identifies concrete measures countries can take to sustainably increase breastfeeding rates, based on data-driven recommendations. BBF is grounded in the Breastfeeding Gear Model complex adaptive systems framework which is made up of eight simultaneous conditions that sustain breastfeeding. In 2018, a committee of multi-agency stakeholders implemented the BBF process in England, collecting evidence to score the 'gear' components of England's breastfeeding environment against 54 benchmarks. The Training and Programme Delivery gear received the highest score, attributable to existing learning outcomes for health professionals and practitioners, peer supporters and specialist services, although there is a need for greater coordination and integration. The lowest scores were given for Promotion and Coordination, Goals and Monitoring due to the lack of a dedicated national strategy for breastfeeding and poor sharing of localised strategies and programmes. The process generated clear recommendations highlighting the need for more robust routine infant feeding data collection and reporting, and the necessity for strengthening leadership, monitoring and oversight to scale up and sustain breastfeeding.

Becoming breastfeeding friendly in Great Britain-Does implementation science work?

The Becoming Breastfeeding Friendly (BBF) in Great Britain study was conducted during 2017-2019 comprising three country studies: BBF England, Wales and Scotland. It was part of an international project being coordinated during the same period by the Yale School of Public Health across five world regions to inform countries and guide policies to improve the environment for the promotion, protection and support of breastfeeding. This paper reports on the application of the BBF process that is based on an implementation science approach, across the countries that constitute Great Britain (England, Wales and Scotland). The process involves assessing 54 benchmarks across eight interlocking gears that drive a country's 'engine' towards a sustainable policy approach to supporting, promoting and protecting breastfeeding. It takes a consensus-oriented approach to the evaluation of benchmarks and the development of recommendations. This paper provides a critical overview of how the process was conducted, the findings and recommendations that emerged and how these were managed. We draw on critical theory as a theoretical framework for explaining the different outcomes for each country and some considerations for future action.

Validation of the Italian version of the Tool to Measure Parenting Self-Efficacy questionnaire using data from an intervention study.

BACKGROUND: Parent self-efficacy (PSE), parents' confidence in their ability to successfully raise their children, has proved to be a powerful direct predictor of specific positive parenting practices. The aim of this study was to validate the Italian version of the Tool to Measure Parenting Self-Efficacy (TOPSE) using data from the questionnaires previously completed in a controlled before-after study conducted in 2015 to evaluate a newsletter programme to help improve parenting. Mothers and fathers of newborns were asked to complete the TOPSE at the child's birth (t0), at 6 months (t1) and at 12 months (t2): 265 TOPSE questionnaires were collected at t0 (43%), 158 at t1 (26%) and 188 at t2 (31%). METHODS: We measured internal reliability using Cronbach's alpha for each of the eight domains of the TOPSE. The intracluster correlation coefficient (ICC) was used to evaluate the external reliability only for parents with more than one child. Responsiveness was measured by testing the ability of the questionnaire to detect differences between groups and times that we expected to be measurable, based on consolidated findings in the literature. Mean scores of PSE improved from t0 to t2 (Hypothesis 1), PSE was lower at baseline for first-time parents than for those with multiple children (Hypothesis 2) and the improvement from t0 to t2 was stronger for first-time parents than for parents with multiple children (Hypothesis 3). RESULTS AND CONCLUSION: Based on our sample of questionnaires, the Italian version of the TOPSE was reliable for almost all of the domains except for Emotion, Self-acceptance and Learning, which could be refined by re-framing or dropping one item. External reliability was moderate, bearing in mind that the questionnaire was repeated at different times over 12 months, during which parents normally change. Responsiveness was good, especially for the Emotion and Empathy domains.

Print media coverage of breastfeeding in Great Britain: Positive or negative?

Media can be a powerful communication tool to promote breastfeeding, influence mothers' breastfeeding behaviour, create positive social norms and generate support among stakeholders and policymakers for breastfeeding. However, negative stories could deter women from starting or continuing to breastfeed. This study aimed to describe the breadth and focus of the media coverage of breastfeeding and the message frames that are found in three of the most widely read national newspapers and three popular women's magazines in Great Britain over a 12-month period, as part of the Becoming Breastfeeding Friendly in Great Britain (BBF-GB) study. For this retrospective media analysis, 77 articles were identified and 42 were included in the study for coding and analysis. We conducted two content analyses to examine the articles' (1) message framing and (2) alignment with the eight components of an 'enabling breastfeeding environment' using the BBF Gear framework. Articles featuring breastfeeding appear in British newspapers and women's magazines all year round. Twenty-four per cent had a neutral tone, while 59% predominantly focused on the positive aspects or positive social support for breastfeeding, and 17% were predominantly focused on the negative aspects or negative social attitudes towards breastfeeding. The articles mainly focused on personal stories reflecting societal barriers and positive shifts (68%), with 12% presenting an analysis of breastfeeding evidence or barriers. There were fewer references to the legislation (5%) and availability of funding (2%) and support (9%). There was no coverage of national coordination and strategy, evaluation systems, or the political will to raise breastfeeding rates.

Implementing the Becoming Breastfeeding Friendly initiative in Scotland.

Despite strong policy support in Scotland, United Kingdom, key challenges to scaling up promotion, protection and support for breastfeeding remain. These include low breastfeeding rates and socioeconomic and regional inequalities. The Becoming Breastfeeding-Friendly (BBF) process was implemented to highlight actions that could address these challenges. The Scottish BBF committee employed an iterative process of documentary analysis and evidence reviews supplemented by 18 interviews with key informants. The data were mapped to BBF benchmarks and each gear was scored accordingly. Nineteen draft recommendations addressing policy and practice gaps were prioritised. Ten recommendations were grouped into eight themes, which cross-cut the BBF gears. The process took place from May 2018 to May 2019. The overall BBF Index score for Scotland was 2.4 indicating a strong scaling-up environment for breastfeeding. Five gears were assessed as strong gear strength, and the remaining three were judged as moderate gear strength. Three recommendation themes illuminate strengths and areas for development. The theme 'reinforcing political will' showed effective leadership, strong policies and significant investment in supporting breastfeeding and highlights actions to sustain this. The theme 'strengthening and coordinating breastfeeding messages' revealed a need for coordination between government, health services and the third sector. The theme 'promoting a supportive return to work environment' highlighted that, while employment legislation is not devolved to the Scottish government, action could be taken by employers to optimise an enabling environment for breastfeeding. The BBF process identified strengths and triggered actions to enhance breastfeeding promotion, protection and support in Scotland.

Gearing to success with national breastfeeding programmes: The Becoming Breastfeeding Friendly (BBF) initiative experience.

Evidence-based policy toolboxes are essential for decision makers to effectively invest in and scale up maternal-child health and nutrition programs, and breastfeeding is no exception. This special issue focuses on the experiences implementing the Becoming Breastfeeding Friendly (BBF) toolbox in England, Scotland, and Wales. BBF is an initiative that includes a toolbox for decision making based on the Complex Adaptive System-based Breastfeeding Gear Model. The BBF initiative experience in Great Britain presented in this special issue illustrates how versatile BBF is as it can be readily adapted to the specific application context. In this instance one country, England was trained by the Yale School of Public Health team that developed BBF. England, in turn, trained and assisted Scotland and Wales with the implementation and oversight of BBF in those countries. The positive experience implementing BBF in Great Britain is fully consistent with findings related to this initiative in other countries with contrasting economic, social, political and health care systems; including Germany, Ghana, Mexico, Myanmar, and Samoa. In all instances BBF has led to breastfeeding policy improvements with strong implications for enabling breastfeeding environments including maternity benefits, workforce development, the Baby Friendly Hospital Initiative and behavior change communication campaigns. In conclusion, BBF is a powerful tool to help guide the effective scaling up of evidence-based programmes to advance breastfeeding protection, promotion and support globally.

First-time Mothers' Understanding and Use of a Pregnancy and Parenting Mobile App (The Baby Buddy App): Qualitative Study Using Appreciative Inquiry.

BACKGROUND: Internationally, there is increasing emphasis on early support for pregnant women to optimize the health and development of mothers and newborns. To increase intervention reach, digital and app-based interventions have been advocated. There are growing numbers of pregnancy health care apps with great variation in style, function, and objectives, but evidence about impact on pregnancy well-being and behavior change following app interaction is lacking. This paper reports on the qualitative arm of the independent multicomponent study exploring the use and outcomes of first-time mothers using the Baby Buddy app, a pregnancy and parenting support app, available in the National Health Service App Library and developed by a UK child health and well-being charity, Best Beginnings. OBJECTIVE: This study aims to understand when, why, and how first-time mothers use the Baby Buddy app and the perceived benefits and challenges. METHODS: This paper reports on the qualitative arm of an independent, longitudinal, mixed methods study. An Appreciative Inquiry qualitative approach was used with semistructured interviews (17/60, 28%) conducted with new mothers, either by telephone or in a focus group setting. First-time mothers were recruited from 3 study sites from across the United Kingdom. Consistent with the Appreciative Inquiry approach, mothers were prompted to discuss what worked well and what could have been better regarding their interactions with the app during pregnancy. Thematic analysis was used, and findings are presented as themes with perceived benefits and challenges. RESULTS: The main benefit, or what worked well, for first-time mothers when using the app was being able to access new information, which they felt was reliable and easy to find. This led to a feeling of increased confidence in the information they accessed, thus supporting family and professional communication. The main challenge was the preference for face-to-face information with a health care professional, particularly around specific issues that they wished to discuss in depth. What could have been improved included that there were some topics that some mothers would have preferred in more detail, but in other areas, they felt well-informed and thus did not feel a need to seek additional information via an app. CONCLUSIONS: Although this study included a small sample, it elicited rich data and insights into first-time mothers' app interactions. The findings suggest that easily accessible pregnancy information, which is perceived as reliable, can support first-time mothers in communicating with health care professionals. Face-to-face contact with professionals was preferred, particularly to discuss specific and personalized needs. Further studies on maternal and professional digital support preferences after the COVID-19 global pandemic and how they facilitate antenatal education and informed decision-making are recommended, particularly because digital solutions remain as a key element in pregnancy and early parenting care. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1017/S1463423618000294.

Characteristics of enrolment in an intensive home-visiting programme among eligible first-time adolescent mothers in England: a linked administrative data cohort study.

BACKGROUND: Intensive home visiting for adolescent mothers may help reduce health disparities. Given limited resources, such interventions need to be effectively targeted. We evaluated which mothers were enrolled in the Family Nurse Partnership (FNP), an intensive home-visiting service for first-time young mothers commissioned in >130 local authorities in England since 2007. METHODS: We created a population-based cohort of first-time mothers aged 13-19 years giving birth in English National Health Service hospitals between 1 April 2010 and 31 March 2017, using administrative hospital data linked with FNP programme, educational and social care data. Mothers living in a local authority with an active FNP site were eligible. We described variation in enrolment rates across sites, and identified maternal and FNP site characteristics associated with enrolment. RESULTS: Of 110 520 eligible mothers, 25 680 (23.2% (95% CI: 23.0% to 23.5%)) were enrolled. Enrolment rates varied substantially across 122 sites (range: 11%-68%), and areas with greater numbers of first-time adolescent mothers achieved lower enrolment rates. Mothers aged 13-15 years were most likely to be enrolled (52%). However, only 26% of adolescent mothers with markers of vulnerability (including living in the most deprived areas and ever having been looked after as a child) were enrolled. CONCLUSION: A substantial proportion of first-time adolescent mothers with vulnerability markers were not enrolled in FNP. Variation in enrolment across sites indicates insufficient commissioning of places that is not proportional to level of need, with mothers in areas with large numbers of other adolescent mothers least likely to receive support.

Study protocol: a mixed-methods study to evaluate which health visiting models in England are most promising for mitigating the harms of adverse childhood experiences.

INTRODUCTION: Exposure to adverse childhood experiences (ACEs) is associated with poorer health outcomes throughout life. In England, health visiting is a long-standing, nationally implemented service that aims to prevent and mitigate the impact of adversity in early childhood, including for children exposed to ACEs. A range of health visiting service delivery practices exist across England (from the minimum five recommended contacts to tailored intensive interventions), but there is a lack of evidence on who receives what services, how this varies across local authorities (LAs) and the associated outcomes. METHODS AND ANALYSIS: This study will integrate findings from analysis of individual-level, deidentified administrative data related to hospital admissions (Hospital Episode Statistics (HES)) and health visiting contacts (Community Services Data Set (CSDS)), aggregate LA-level data, in-depth case studies in up to six LAs (including interviews with mothers), a national survey of health visiting services, and workshops with stakeholders and experts by experience. We will use an empirical-to-conceptual approach to develop a typology of health visiting service delivery in England, starting with a data-driven classification generated from latent class analysis of CSDS-HES data, which will be refined based on all other available qualitative and quantitative data. We will then evaluate which models of health visiting are most promising for mitigating the impact of ACEs on child and maternal outcomes using CSDS-HES data for a cohort of children born on 1 April 2015 to 31 March 2019. ETHICS AND DISSEMINATION: The University College London Institute of Education Research Ethics Committee approved this study. Results will be submitted for publication in a peer-reviewed journal and summaries will be provided to key stakeholders including the funders, policy-makers, local commissioners and families.