Why do interventions work in some places and not others: a breastfeeding support group trial.

In a cluster randomised controlled trial of a policy to provide community breastfeeding support groups in Scotland, breastfeeding rates declined in 3 of 7 intervention localities. From a preliminary study, we expected breastfeeding outcomes to vary and we prospectively used qualitative and quantitative methods to ask why. Ethnographic in-depth interviews, focus groups, observations and survey data were analysed to build seven embedded case studies. A pyramidal model of how primary health service organisations implemented the policy was constructed prior to knowing trial outcomes to minimise bias. Informed by a realist approach, the model explained variation in (a) policy implementation (b) the breastfeeding outcomes, whereas the quantity of intervention delivered did not. In the three localities where breastfeeding rates declined, negative aspects of place including deprivation, unsuitable premises and geographical barriers to inter-professional communication; personnel resources including staff shortages, high workload and low morale; and organisational change predominated (the base model tiers). Managers focused on solving these problems rather than delivering the policy and evidence of progress to the higher model tiers was weak. In contrast, where breastfeeding rates increased the base tiers of the model were less problematic, there was more evidence of leadership, focus on the policy, multi-disciplinary partnership working and reflective action cycles (the higher model tiers). We advocate an ethnographic approach to the design and evaluation of complex intervention trials and illustrate how this can assist in developing an explanatory model. More attention should be given to the complex systems within which policies and interventions occur, to identify and understand the favourable conditions necessary for a successful intervention.

Health professionals, implementation and outcomes: reflections on a complex intervention to improve breastfeeding rates in primary care.

OBJECTIVES: To understand why a complex breastfeeding coaching intervention, which offered health professional-facilitated breastfeeding groups for pregnant and breastfeeding mothers and personal peer coaches, was more effective at improving breastfeeding rates in some areas than others. METHODS: This controlled intervention study was designed, implemented and evaluated using principles from action research methodology. We theoretically sampled 14 health professionals with varying levels of involvement and 12 consented to be interviewed. We analysed data from 266 group diaries kept by health professionals, 31 group observations, 10 audio-recorded steering group meetings and field notes. Women's perspectives were obtained by analysing qualitative data from one focus group, 21 semi-structured qualitative interviews and responses to open-survey questions. RESULTS: The intervention was more effective at improving breastfeeding rates in areas where health visitors and midwives were committed to working together to implement the intervention, where health professionals shared group facilitation and where inter- and intra-professional relationships were strong. The area where the intervention was ineffective had continuity of a single group facilitator with breastfeeding expertise and problematic relationships within and between midwife and health visitor teams. No one style of group suited all women. Some preferred hearing different views, others valued continuity of help from a facilitator with breastfeeding expertise. CONCLUSIONS: We hypothesise that involving several local health professionals in implementing an intervention may be more effective than a breastfeeding expert approach. Inter- and intra-health professional relationships may be an important determinant of outcome in interventions that aim to influence population behaviours like breastfeeding.

One-to-one or group-based peer support for breastfeeding? Women's perceptions of a breastfeeding peer coaching intervention.

BACKGROUND: Studies reporting one-to-one peer support interventions have been successful in some countries with high breastfeeding initiation rates, but less so in Great Britain, where low uptake of peer support has occurred. We conducted a peer coaching intervention study in rural Scotland that improved breastfeeding initiation and duration. This study reports qualitative data about participants' perceptions of the coaching intervention. The aim was to investigate why group-based peer support was more popular than one-to-one peer support. METHODS: Qualitative data were collected and analyzed from an initial focus group; 21 semi-structured interviews; and 31 coaching group observations and respondents (n = 105/192) in response to an open question about reasons for not choosing a personal coach in a survey of breastfeeding experiences. We developed a coding frame, identified themes, and constructed charts for analysis and interpretation of data. RESULTS: Analysis revealed that groups were more popular because they normalized breastfeeding in a social environment with refreshments, which improved participants' sense of well-being. Groups provided flexibility, a sense of control, and a diversity of visual images and experiences, which assisted women to make feeding-related decisions for themselves, and they offered a safe place to rehearse and perform breastfeeding in front of others, in a culture where breastfeeding is seldom seen in public. Women often felt initial anxiety when attending a group for the first time, and they expressed doubt that one set of "breastfeeding rules" would suit everyone. CONCLUSIONS: Pregnant women and breastfeeding mothers will voluntarily engage in an activity to support breastfeeding if there is a net interactional (verbal, visual, emotional and gustatory) gain and a minimum risk of a negative experience. One-to-one peer coaching was perceived as a greater risk to confidence and empowerment than group- based peer coaching.

Students' views of reflective learning techniques: an efficacy study at a UK medical school.

OBJECTIVE: To describe the effects of a voluntary intervention using reflective learning techniques on students' learning. DESIGN: An interventional study with reflective learning techniques offered to medical students. SETTING: Year 3 of undergraduate medicine at Cardiff University where the curriculum is integrated with early clinical contact. PARTICIPANTS: All 232 Year 3 students were invited to participate. A total of 65 attended an introductory lecture. After the lecture 35 students agreed to take part; 15 of these subsequently dropped out (some before attending tutorial groups, others after taking part for some weeks). INTERVENTIONS: Participants kept learning journals for 2 terms and attended fortnightly, facilitated tutorial groups where they discussed their reflective journal entries. Main outcome measures were qualitative interviews and examination results. RESULTS: Interviews were carried out with 19 full participants, 4 initial participants and 7 non-participants. Participants perceived that they gained a greater ability to identify learning objectives and to integrate learning. The tutorial groups encouraged students to compare progress with their peers. Some students did not take part because they thought that the large factual content of the curriculum would make reflective learning less useful. There were no differences between the groups in examination results. CONCLUSIONS: Students among the small, self-selected group of participants were better able to identify what they needed to learn although there was no improvement in examination results. Students appear unlikely to take up voluntary reflective learning if they do not think it relates to the curriculum and assessments. Student culture exerts a potent effect on willingness to attend extra tutorial groups.

Effectiveness of a breastfeeding peer coaching intervention in rural Scotland.

BACKGROUND: Breastfeeding initiation in Scotland in 2000 was 63 percent, compared with over 90 percent in Norway and Sweden. Although peer support is effective in improving exclusivity of breastfeeding in countries where over 80 percent of women initiate breastfeeding, the evidence for effectiveness in countries with lower initiation is uncertain. Our primary aim was to assess whether group-based and one-to-one peer breastfeeding coaching improves breastfeeding initiation and duration. METHODS: Action research methodology was used to conduct an intervention study in 4 geographical postcode areas in rural northeast Scotland. Infant feeding outcomes at birth and hospital discharge; at 1, 2, and 6 weeks; and at 4 and 8 months were collected for 598 of 626 women with live births during a 9-month baseline period and for 557 of 592 women with live births during a 9-month intervention period. Groups met in 5 locations, with 266 groups meeting in the period when intervention women were eligible to attend. Data on place of birth and length of postnatal hospital stay were also collected. Control data from 10 other Health Board areas in Scotland were compared. An intention-to participate survey about coaching participation was completed by 206 of 345 women initiating breastfeeding. Group attendance data were collected by means of 266 group diaries. RESULTS: There was a significant increase in any breastfeeding of 6.8 percent from 34.3 to 41.1 percent (95% CI 1.2, 12.4) in the study population at 2 weeks after birth compared with a decline in any breastfeeding in the rest of Scotland of 0.4 percent from 44 to 43.6 percent (95% CI -1.2, 0.4). Breastfeeding rates increased compared with baseline rates at all time points until 8 months. However, the effect was not uniform across the 4 postcode areas and was not related to level of deprivation. Little difference was seen in receipt of information and knowledge about the availability of coaching among areas. All breastfeeding groups were well attended, popular, and considered helpful by participants. A minority of women (n = 14/206) participated in formal one-to-one coaching. Women who received antenatal, birth, and postnatal care from community midwife-led units were more likely to be breastfeeding at 2 weeks (p = 0.007) than women who received some or all care in district maternity units. CONCLUSIONS: Group-based and one-to-one peer coaching for pregnant women and breastfeeding mothers increased breastfeeding initiation and duration in an area with below average breastfeeding rates.

Stigma revisited, disclosure of emotional problems in primary care consultations in Wales.

The nature and effects of stigma have been widely discussed in the context of mental illness, and references to stigma are commonly used to explain a wide array of social processes. For example, it is often claimed that stigmatisation affects aspects of personal identity, that it underpins unjust and discriminatory behaviour, and that it is responsible for a reluctance among members of the lay public to disclose the presence of treatable psychiatric symptoms and problems to health professionals. A widespread reluctance to disclose symptoms of 'emotional problems' to health professionals is in fact well documented. Yet the reasons for such patterns of behaviour are far from clear. However, in this paper, on the basis of qualitative data collected from primary care attendees in Wales (N=127), the authors suggest that appeals to stigma are inadequate to explain the phenomenon. More likely, it seems, is that members of the lay public have markedly different images from health professionals of what constitutes a mild to moderate psychiatric problem. Consequently, it is argued that the phenomenon of non-disclosure could be viewed more accurately as a problem of alternative taxonomic systems than of fear of stigma. The implications of the argument for health practice and theory are outlined.

Working with Bangladeshi patients in Britain: perspectives from Primary Health Care.

BACKGROUND: The difficulties of ethnic minority communities in accessing appropriate primary care are well documented, but little is known about the experiences of Primary Health Care Teams (PHCTs) serving these communities, or their strategies to help patients overcome these difficulties. OBJECTIVE: The purpose of the study was to explore the PHCT perspective of working with Bangladeshi patients. METHODS: Qualitative group discussions with PHCTs were set up by four health centres in the Grangetown area of Cardiff, where a large proportion of the Bangladeshi community lives. Experiences of and attitudes to working with Bangladeshi patients were explored. Discussions were taped and transcribed for independent analysis by two researchers. Comparisons within and between PHCTs were made. RESULTS: PHCTs largely entered into full and frank discussions. Health visitors had made significantly more effort than others to get to know their Bangladeshi patients. This had costs in terms of time and effort, with no reduction in caseload. Cutting across this difference were common themes such as communication and cultural differences, and patients' difficulties in using NHS services appropriately, which caused disruption and frustration. While there was an awareness of the reasons for these difficulties, PHCTs generally were not able to allow for them because of the inflexibility of their workload and systems of working. CONCLUSIONS: Group discussions are a useful way to encourage PHCTs to reflect on their practice and share experiences. PHCTs are aware of their patients' needs and keen to explore racial awareness training and new ways of looking at how they work. However, the grind of heavy workloads makes this process unlikely without outside facilitation.

Evaluating meta-ethnography: a synthesis of qualitative research on lay experiences of diabetes and diabetes care.

Interest in how qualitative health research might be used more widely to inform health policy and medical practice is growing. Synthesising findings from individual qualitative studies may be one method but application of conventional systematic review methodology to qualitative research presents significant philosophical and practical challenges. The aim here was to examine the feasibility of synthesising qualitative research using qualitative methodology including a formative evaluation of criteria for assessing the research to be synthesised. Ten qualitative studies of adult patients' perspectives of diabetes were purposefully selected and questions proposed by the critical appraisal skills programme (CASP) adapted and used to assess papers prior to synthesis. Each study was reviewed independently by two experienced social scientists. The level of agreement between reviewers was determined. Three papers were excluded: one because it turned out not to be qualitative research, one because the quality of the empirical work was poor and one because the qualitative findings reported were also recorded in another paper already included. The synthesis, which had two distinct elements, was conducted using the meta-ethnographic method. Firstly, four papers containing typologies of patient responses to diabetes were synthesised. Secondly, six key concepts were identified from all seven papers as being important in enabling a person with diabetes to achieve a balance in their lives and to attain a sense of well-being and control. These included: time and experience, trust in self, a less subservient approach to care providers, strategic non-compliance with medication, effective support from care providers and an acknowledgement that diabetes is serious. None of the studies included in the synthesis referenced any of the early papers nor did they appear to have taken account of or built upon previous findings. This evaluation confirmed that meta-ethnography can lead to a synthesis and extension of qualitative research in a defined field of study. In addition, from it a practical method of qualitative research assessment evolved. This process is promising but requires further testing and evaluation before it could be recommended for more widespread adoption.

Patients' opinions of the use of psychiatric case-finding questionnaires in general practice.

BACKGROUND: The common mental disorders of depression and anxiety often remain undetected in general practice. Psychiatric screening instruments have been recommended to assist detection. AIM: To assess patients' attitudes towards the use of psychiatric screening questionnaires for common mental disorders within general practice. DESIGN: Twenty focus groups comprising 127 patients were conducted in Wales, UK. The groups were distinguished by age, sex and locality. RESULTS: The majority of respondents felt that the use of a screening questionnaire was acceptable and would be willing to complete one within a general practice setting. However, a number of individuals expressed concern about the validity of the kinds of questions asked and the usefulness of the instrument in practice. Respondents also discussed their concerns relating to issues of confidentiality and the doctor's response to the assessment. CONCLUSION: The study indicates that lay beliefs towards mental illness, particularly relating to perceived stigma, will continue to pose problems for the routine use of psychiatric case-finding questionnaires within general practice.

Using meta ethnography to synthesise qualitative research: a worked example.

OBJECTIVES: To demonstrate the benefits of applying meta ethnography to the synthesis of qualitative research, by means of a worked example. METHODS: Four papers about lay meanings of medicines were arbitrarily chosen. Noblit and Hare's seven-step process for conducting a meta ethnography was employed: getting started; deciding what is relevant to the initial interest; reading the studies; determining how the studies are related; translating the studies into one another; synthesising translations; and expressing the synthesis. RESULTS: Six key concepts were identified: adherence/compliance; self-regulation; aversion; alternative coping strategies; sanctions; and selective disclosure. Four second-order interpretations (derived from the chosen papers) were identified, on the basis of which four third-order interpretations (based on the key concepts and second-order interpretations) were constructed. These were all linked together in a line of argument that accounts for patients' medicine-taking behaviour and communication with health professionals in different settings. Third-order interpretations were developed which were not only consistent with the original results but also extended beyond them. CONCLUSIONS: It is possible to use meta ethnography to synthesise the results of qualitative research. The worked example has produced middle-range theories in the form of hypotheses that could be tested by other researchers.

A qualitative study of women's views about how health professionals communicate about infant feeding.

OBJECTIVE: To look at how communication by health professionals about infant feeding is perceived by first time mothers. DESIGN: Qualitative semi-structured interviews early in pregnancy and 6-10 weeks after birth. SUBJECTS AND SETTING: Twenty-one white, low income women expecting their first baby were interviewed mostly at home, often with their partner or a relative. RESULTS: The personal and practical aspects of infant feeding which were important to women were seldom discussed in detail in ante-natal interviews. In post-natal interviews women described how words alone encouraging them to breastfeed were insufficient. Apprenticeship style learning of practical skills was valued, particularly time patiently spent watching them feed their baby. Women preferred to be shown skills rather than be told how to do them. Some felt pressure to breastfeed and bottle feeding mothers on post-natal wards felt neglected in comparison. Women preferred their own decision-making to be facilitated rather than being advised what to do. Some women experienced distress exposing their breasts and being touched by health professionals. Continuity of care and forming a personal relationship with a health professional who could reassure them were key factors associated with satisfaction with infant feeding communication. CONCLUSIONS: The infant feeding goal for many women is a contented, thriving baby. In contrast, women perceive that the goal for health professionals is the continuation of breastfeeding. These differing goals can give rise to dissatisfaction with communication which is often seen as 'breastfeeding centred' rather than 'woman centred.' Words alone offering support for breastfeeding were often inadequate and women valued practical demonstrations and being shown how to feed their baby. Spending time with a caring midwife with whom the woman had developed a personal, continuing relationship was highly valued. Women were keen to maintain ownership, control and responsibility for their own decision-making about infant feeding.