Experiences of breastfeeding peer counseling among women with low incomes in the US: a qualitative evaluation.

BACKGROUND: Person-centered breastfeeding counseling is a key but often overlooked aspect of high-quality services. We explored women's experiences of the Breastfeeding Heritage and Pride™ program, an evidence-based breastfeeding peer counseling program serving women with low incomes in the United States. METHODS: This study was conducted through an equitable community-clinical-academic partnership and guided by the World Health Organization (WHO) quality of care framework for maternal and newborn health, which highlights three domains of positive experiences of care: effective communication; respect and dignity; and emotional support. In-depth interviews were conducted with a purposive sample of women participating in the Breastfeeding Heritage and Pride™ program. Women were asked to describe their experiences with the program including examples of when good quality counseling was or was not provided. Each interview was conducted in English or Spanish, audio-recorded, and transcribed verbatim. Data were analyzed using reflexive thematic analysis. Once themes were generated, they were organized according to the three care experience domains in the WHO quality of care framework. RESULTS: Twenty-eight in-depth interviews were conducted with a racially/ethnically and socio-economically diverse sample of women. Three themes described effective communication practices of peer counselors: tailoring communication to meet women's individual needs; offering comprehensive and honest information about infant feeding; and being timely, proactive, and responsive in all communications across the maternity care continuum. Two themes captured why women felt respected. First, peer counselors were respectful in their interactions with women; they were courteous, patient, and non-judgmental and respected women's infant feeding decisions. Second, peer counselors showed genuine interest in the well-being of women and their families, beyond breastfeeding. The key theme related to emotional support explored ways in which peer counselors offered encouragement to women, namely by affirming women's efforts to breastfeed and by providing reassurance that alleviated their worries about breastfeeding. These positive experiences of counseling were appreciated by women. CONCLUSIONS: Women described having and valuing positive experiences in their interactions with peer counselors. Efforts to expand access to high-quality, person-centered breastfeeding counseling should, as part of quality assurance, include women's feedback on their experiences of these services.

Navigating and manipulating childbirth services in Afar, Ethiopia: A qualitative study of cultural safety in the birthing room.

Access to maternal health services has increased in Ethiopia during the past decades. However, increasing the demand for government birthing facility use remains challenging. In Ethiopia's Afar Region, these challenges are amplified given the poorly developed infrastructure, pastoral nature of communities, distinct cultural traditions, and the more nascent health system. This paper features semi-structured interviews with 22 women who were purposively sampled to explore their experiences giving birth in government health facilities in Afar. We used thematic analysis informed by a cultural safety framework to interpret findings. Our findings highlight how women understand, wield, and relinquish power and agency in the delivery room in government health facilities in Afar, Ethiopia. We found that Afari women are treated as 'others', that they manipulate their care as they negotiate 'cultural safety' in the health system, and that they use trust as a pathway towards more cultural safety. As the cultural safety framework calls for recognizing and navigating the diverse and fluid power dynamics of healthcare settings, the onus of negotiating power dynamics cannot be placed on Afari women, who are already multiply marginalized due to their ethnicity and gender. Health systems must adopt cultural safety in order to ensure health quality. Providers, particularly in regions with rich cultural diversity, must be trained in the cultural safety framework in order to be aware of and challenge the multidimensional power dynamics present in health encounters.

A qualitative study of smokers' assessments of four smoking cessation interventions delivered in a hospital emergency department.

BACKGROUND: A recent clinical trial of 1056 adults who smoke tested the efficacy of four components of a treatment intervention initiated in a hospital emergency department (ED) and found two of them to be clinically effective. This paper explores study participants' attitudes towards the four components, whether they identified important interactions, and suggestions for further tailoring. METHODS: Telephone interviews were conducted with participants at the end of the three-month study period. Each participant had received at least one intervention component: nicotine replacement therapy, referral to a smokers' telephone quitline, a brief negotiation interview, or the smartphone-enabled SmokefreeTXT program. Interviews were audio-recorded, transcribed, and analyzed using an iterative approach, grounded in the data, using thematic analysis. RESULTS: Between March 2017 and September 2018, 63 interviews were conducted with participants who received at least one intervention component. The sample was diverse with respect to race, ethnicity, gender, and sociodemographic status. Intervention components were generally well-received by participants. Four themes were identified: Intervention Context, Intervention Content, Communications, and Recommendations. Provision of smoking cessation interventions to ED patients led to reduced self-reported smoking for most. Nicotine replacement therapy diminished cravings, while behavioral interventions provided social support that helped motivate and sustain behavior change. CONCLUSIONS: Intervention components were feasible and acceptable. The data suggest that pharmacological and behavioral interventions be offered simultaneously, that communication skills training be provided to those who deliver the interventions, and that interventions should respect participants' autonomy and preferences concerning intervention timing, frequency, and termination.

Shifting to virtual breastfeeding counseling for low-income women in the US during COVID-19: A partner-engaged multimethod evaluation of program adaptations.

Background: The Breastfeeding Heritage and Pride program (BHP) provides evidence-based breastfeeding peer counseling to low-income women. Due to the COVID-19 pandemic, BHP shifted from delivering in-person and virtual services to providing only virtual services. Program adaptations can impact implementation success, which could influence program effectiveness. We documented program adaptations and explored their impacts on implementation outcomes, guided by the Model for Adaptation Design and Impact. Methods: Through a community-clinical-academic partnership, we conducted in-depth interviews with 12 program implementers and peer counselors and conducted a rapid qualitative analysis. To efficiently capture information on adaptations over time, we collected and analyzed information from program meetings and extracted data from a program report. We then triangulated data from these multiple sources. Results: Peer counselors received training on virtual service delivery and increased supportive supervision. They recruited women via phone instead of in hospitals, which was viewed as feasible. In-person counseling visits at hospitals and clients' homes were replaced with phone and video calls. Examples of changes to the content delivered included breastfeeding education in the context of the pandemic such as the latest COVID-related infant feeding guidance, provision of face masks, and more assistance with social and economic challenges. Although peer counselors increasingly adopted video calls as a substitute for in-person visits, they emphasized that in-person visits were better for relationship building, helping with breastfeeding problems like latching, and identifying barriers to breastfeeding in the home environment like limited familial support. While adaptations were reactive in that they were made in response to the unanticipated COVID-19 pandemic, most were made with clear goals and reasons such as to ensure the safety of peer counselors and clients while maintaining service delivery. Most adaptations were made through a systematic process based on program implementers' expertise and best practices for peer counseling and were largely but not fully consistent with BHP's core functions. Discussion: BHP was able to shift to virtual service delivery for continued provision of breastfeeding counseling during the pandemic. Overall, virtual services worked well but were less optimal for several aspects of counseling. Evaluations of program effectiveness of virtual services are still needed.

Challenges in the sociocultural milieu of South Asia: a systematic review of community health workers.

INTRODUCTION: Community health workers (CHWs) connect patients in rural and remote communities to health service organizations. This diverse group of healthcare workers has helped improve healthcare access and outcomes and enhance the quality of life for people in hard-to-reach communities. However, CHWs face numerous challenges rooted in the sociocultural milieu of the region and country in which they reside. METHODS: This systematic review and qualitative meta-synthesis of 38 studies examines the sociocultural challenges that CHWs experience; it focuses on the unique history, geography, and sociocultural milieu of South Asia. RESULTS: This study found the following challenges that CHWs regularly face when working in communities: religious and cultural norms and practices, gender and biological sex, caste, and generation. All challenges in some way relate to one another and stem from the unique sociocultural milieu of South Asia, and the various subcultures that exist in this diverse region. CONCLUSION: This article presents important guidance for program planning and CHW deployment that reflects the sociocultural realities of practice. The findings of this investigation may serve as an essential resource for program planners and decision-makers in improving the effectiveness and reach of CHW programs.

The design and delivery of maternal health interventions in Pakistan: a scoping review.

Hundreds of women die daily due to preventable causes related to pregnancy and childbirth. Multiple programs have been developed to support efforts to reduce maternal mortality. However, no synthesis has been conducted to date that reviews the design, delivery, and impact of these initiatives in Pakistan. After conducting a systematic literature search, we found 23 articles describing interventions. We analyzed these articles for intervention characteristics. In this scoping review the authors identify the characteristics of interventions to improve maternal health services in Pakistan and priorities for future programs and research. Recommendations include multi-level interventions, stakeholder engagement, and rigorous evaluations of existing interventions.