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Abstract of thesis entitled
“The Effectiveness of Postnatal Telephone Support
Intervention in Prolonging the Duration of Breastfeeding
after Hospital Discharge”
Submitted by
Chu Pui Kei Peggy
for the degree of Master of Nursing
at The University of Hong Kong
in August 2014
Breastfeeding promotion programs have successfully increased the
breastfeeding initiation rate and breastfeeding duration in Hong Kong over the
past ten years. The breastfeeding rate on discharge from hospitals has increased
from 56.8% in 2001 to 85.8% in 2012 and the exclusive breastfeeding rate for
infants 4 to 6 months old has increased from 6% in 1997 to 14% in 2010.
However, the duration of breastfeeding in Hong Kong is still far below World
Health Organization (WHO) recommendations.
Insufficient breastfeeding support for mothers after hospital discharge
could be a reason accounting for the short breastfeeding duration in Hong Kong. A
postnatal telephone support intervention is therefore proposed to prolong the
duration of breastfeeding by providing continuous support for mothers even when
they are home. Nowadays, the telephone is considered an easily accessible,
convenient and economical medium of communication. It is hoped that by
adopting the intervention, those mothers who are usually ‘home bound’ in the
early postpartum period can be better served and supported in the establishment
and continuation of breastfeeding.
Evidence-based practice guidelines which consist of a list of
recommendations have been developed from five recent studies. The five studies
provided strong evidence that telephone support is effective in prolonging the
duration of breastfeeding. The implementation potential, the implementation plan
and evaluation plan of this innovation will be developed and discussed in this
project.
The Effectiveness of
Postnatal Telephone Support Intervention in Prolonging
the Duration of Breastfeeding
after Hospital Discharge
by
CHU PUI KEI PEGGY
School of Nursing
The University of Hong Kong
A thesis submitted in partial fulfillment of the requirements for
the Degree of Master of Nursing
at The University of Hong Kong.
August 2014
i
Declaration
I declare that this dissertation represents my own work, except where due
acknowledgment is made. It has not been previously included in a thesis,
dissertation, or report submitted to this university or to any other institution for a
degree, diploma, or other qualifications.
Signed……………………………………………………………………
CHU PUI KEI PEGGY
ii
Acknowledgements
I would like to express my sincere gratitude to my supervisor, Dr. Marie
Tarrant, who provided expert advice, valuable opinions, guidance and support for
my dissertation. She gave me lots of suggestions and relevant information on
subjects ranging from deciding the topic of my dissertation to finalizing my
dissertation work. Her attitude, professionalism and enthusiasm for breastfeeding
enlightened me and influenced me in pursuing issues related to breastfeeding.
Also, I would like to offer my special thanks to my classmates. They were
generous, cheerful and supportive. I had a great time studying with them.
Lastly, I would like to thank my beloved family members. Their love and
care were so important to me in getting through my demanding master study. I
would also like to thank my fiancé for being so supportive and patient and giving
me lots of encouragement throughout these two years.
iii
Table of Contents
Declaration..…………………….…………………………………………………………..i
Acknowledgements………………………………………………………..……………....ii
Table of contents……………………………………………..………………………..….iii
Chapter 1 - Statement of the Problem……………………………………….. 1
Background…………………………………………………………….………….1
Affirming the need……………………………………….………………………..3
Objective and Research Question……………………..……………….….………7
Significance of problem…………………………………………………….……..7
Chapter 2 - Review of Evidence………………………………………………..10
Study selection criteria…………………………………………………………...10
Search strategy……………………………………………………………….…..10
Table of evidence…………………………………………...……………………12
Quality assessment…………………………………………………………….…17
Summary and Synthesis………………………………………………………….21
Chapter 3 - Implementation Potential…………………………………………28
Target setting and audience.………………………………….…...……………...28
Transferability of findings…………………..……………………………………28
Feasibility of the innovation………….………………………..………………...30
Cost-Benefit ratio of the innovation…………………….…………………….….34
Chapter 4 - Evidence-Based Practice Guidelines…..…………….…………..38
Title of the guidelines...….…...…………..…………….....………………..……38
Objective of the guidelines……………………………………………………....38
Purpose of the guidelines………………………………………………………...38
Target group of the guidelines……………………………………...…………….38
Recommendations…………………………………………………………….….39
Chapter 5 - Implementation Plan…………………………………………..….43
Communication plan with potential users………………………………………..43
Pilot testing………………………………………………………..…………......46
Chapter 6 - Evaluation Plan…………………………………………………....49
Intervention outcomes……………………………………………………………49
Nature and Number of clients………...………………………………………….49
Outcome measurements………………………………………………………….51
Data analysis……………………………………………………………………..51
Criteria for effectiveness…………………………………………………………52
Conclusion…………………………………………………………………….....53
References……………………………………………………………………….55
Appendices………………………………………………………………………65
1
Chapter 1 - Statement of the Problem
Background
The benefits of breastfeeding for infants and mothers have been widely
recognized by the public. Breastfeeding provides the most natural and nutritious
food source for the health, growth and development of infants (World Health
Organization [WHO], 2003). It also reduces the incidence of infant and maternal
pathologies (James & Lessen, 2009). A history of breastfeeding is associated with
a reduced risk of various infant illnesses such as severe lower respiratory tract
infection, gastroenteritis, otitis media and sudden infant death syndrome
(American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome,
2005; Bachrach, Schwarz & Bachrach, 2003; Chien & Howie, 2001; Ip et al.,
2007; Kramer et al., 2001). Mothers who have breastfed have a lower incidence of
type 2 diabetes, breast and ovarian cancers (Danforth et al., 2007; Ip et al., 2007;
Stuebe, Rich- Edwards, Willett, Manson & Michels, 2005; Stuebe, Willet, Xue &
Michels, 2009b). Multiple studies have shown a dose-dependent effect of
breastfeeding. Infants enjoy better health outcomes the longer they are breastfed
(Bachrach et al., 2003; Kramer et al., 2001). Moreover, prolonged and exclusive
breastfeeding has been shown to improve cognitive and motor development in
children (Dewey, Cohen, Brown & Rivera, 2001; Kramer et al., 2008).
2
According to the recommendations of the World Health Organization
(WHO), exclusive breastfeeding for the first six months of life is optimum to feed
infants. Thereafter, breastfeeding can be continued up to two years of age or
beyond, along with the introduction of complementary foods (WHO, 2003).
Exclusive breastfeeding means infants receive only breast milk, without any
additional food, drink or water (WHO, 2001).
In Hong Kong, decades of breastfeeding promotion programs implemented
by governmental and nongovernmental organizations (NGOs) have greatly
improved the breastfeeding initiation rate and duration. The breastfeeding rate on
discharge from hospitals has increased from 56.8% in 2001 to 85.8% in 2012
(BFHIHKA, 2013a; CHP, 2014) and the exclusive breastfeeding rate for infants 4
to 6 months old has increased from 6% in 1997 to 14% in 2010 (DH, 2011).
Despite the substantial increase in the breastfeeding rate over the past ten years,
the duration of breastfeeding in Hong Kong remains far below WHO
recommendations (WHO, 2003). Indeed, most mothers stop breastfeeding within
the first few months after delivery (Dodgson, Tarrant, Fong, Peng & Hui, 2003). A
survey conducted in 2013 revealed that although 82.9% of mothers breastfed their
infants at 1 month or less, only 32.7% of mother breastfed until 6 months (CHP,
2014).
The high breastfeeding initiation rate and the remarkable decline in the
3
breastfeeding rate at a few months postpartum may indicate that mothers are
aware of the benefits of breastfeeding and they intend to breastfeed after delivery.
Nevertheless, they may encounter breastfeeding difficulties soon after discharge
from hospitals. Unlike other developed countries, there is a lack of active
postpartum breastfeeding support such as home visits for new mothers in Hong
Kong. As a result, many mothers stop breastfeeding before they receive any help
during the early postpartum period (Tarrant, Dodgson & Wu, 2014).
Breastfeeding support for mothers should not terminate after hospital
discharge (Tahir & Al-Sadat, 2012). The immediate post-discharge period is a
very delicate psychological moment of adaptation. It is defined as a ‘phase of
calibration’ in which mothers are overwhelmed by various problems in assessing
infants’ needs and maintaining milk supply. Hence, breastfeeding promotion
should start during pregnancy and continue in hospitals and at home after
discharge (Semenic, Loiselle, & Gottlieb, 2008).
The availability and accessibility of an effective evidence-based
breastfeeding support intervention during the postnatal period is therefore crucial
to provide continuous breastfeeding support for mothers to avoid early
discontinuation of breastfeeding after hospital discharge.
Affirming the need
In Hong Kong, the Department of Health (DH) and Hospital Authority,
4
together with some NGOs such as the Baby Friendly Hospital Initiative Hong
Kong Association (BFHIHKA) and the La Leche League Hong Kong promote
breastfeeding through hotline services, support groups and breastfeeding
education workshops to support breastfeeding mothers in the postpartum period
(BFHI HKA, 2013). Despite the availability of these resources, the duration of
breastfeeding in Hong Kong remains short. This shows there is room for
improvement in current postnatal breastfeeding support interventions in
addressing mothers’ needs and concerns.
The DH has been actively involved in breastfeeding promotion in Hong
Kong. From the year 2000, a breastfeeding policy incorporating the 'Ten Steps to
Successful Breastfeeding' and the ‘International Code of Marketing of Breastmilk
Substitutes’, has been implemented in all Maternal and Child Health Centers
(MCHCs) to advocate breastfeeding (Leung, 2009). Nurses in the MCHCs have
received professional breastfeeding training and are competent in providing
postnatal breastfeeding support to mothers through breastfeeding coaching,
hands-on guidance and some individual and telephone counseling services (Lam,
2005).
Currently, the breastfeeding coaching service provided by MCHCs is
considered an effective postnatal breastfeeding support intervention. It is a direct
coaching service offered to mothers who accompany their babies to the MCHCs.
5
The breastfeeding coaching is comprehensive. Apart from giving breastfeeding
instruction and support to mothers, demonstrations and return demonstrations of
breastfeeding techniques, for example, attachment and positioning, are done and
assessed by nurses. By assessing and correcting the breastfeeding skills of
mothers, the risk of breastfeeding complications due to poor attachment or
positioning can be reduced.
Despite the effectiveness of the breastfeeding coaching service, there are
some limitations in its coverage. Because it is conducted face-to-face, the service
can only be offered to mothers who take the initiative to seek help (Tarrant, Kwok,
Lam, Leung & Schooling, 2010). According to Chinese cultural beliefs, mothers
should stay at home for the first month postpartum. This is a major barrier for
mothers to access the coaching service. Nevertheless, the first month is a critical
time for the continuation of breastfeeding, especially the immediate
post-discharge period. Problems related to milk production become more
prominent as the milk supply is established during that period. If these problems
cannot be well-addressed, mothers may decide to discontinue breastfeeding earlier
(Gerd Bergman, Dahlgren, Roswall & Alm, 2012).
In view of the inadequacy and limitations of current postnatal breastfeeding
support resources in Hong Kong, more effort should be placed on providing
mothers with more accessible breastfeeding support during the immediate
6
post-discharge period, especially the first month, to improve breastfeeding
performance and duration.
A telephone breastfeeding support intervention could be considered another
method of providing continuous breastfeeding support to mothers after hospital
discharge. Unlike the breastfeeding hotline services provided by the DH for
decades that reactive calls are made by mothers, this telephone support
intervention is proactive. Nurses take the initiative in making regular phone calls
to offer breastfeeding education and support to mothers. The telephone is the
chosen medium for communication as it is easily accessible, convenient and
economical compared with other kinds of supportive services such as home visits
(Bunik et al., 2010; Tahir & Al- Sadat, 2012). As it is not limited to geographical
and physical barriers, mothers who are usually ‘house-bound’ in the early
postpartum period, especially Chinese mothers, can be served by a telephone
support intervention (Tahir & Al- Sadat, 2012). It is hoped that by adopting the
innovation, mothers can continue receiving breastfeeding instruction and support
even if they are at home.
In Hong Kong, more than 90% of infants go to MCHCs soon after
discharge from hospitals. As they are publicly funded, MCHCs provide free and
convenient service, which ensures a high utilization rate for primary health care
services compared with that in other countries (Lam, 2005). Furthermore, Lee,
7
Lui, Chan, Wong and Lau (2006) found that, when mothers encountered problems
during breastfeeding, 77% of them considered the medical and nursing staff at
MCHCs their prime source of assistance. Therefore, the MCHC is an ideal place
for implementation of the proposed innovation.
Objective and Research Question
The objective of the dissertation is to prolong the duration of breastfeeding
through a telephone breastfeeding support intervention provided by nurses.
The research question is “What is the effectiveness of a postnatal telephone
support intervention in prolonging the duration of breastfeeding after hospital
discharge?”
Significance of problem
Improving the breastfeeding duration is not only beneficial to the health of
infants and mothers, it also has positive impacts on the health care industry, the
economy and the environment.
Infant and maternal health benefits
Innate immune factors in breast milk protect infants from infectious
morbidity in the first year of life (Hamosh, 2001). Infants who are breastfed have
a lower incidence of various infectious diseases, such as lower respiratory tract
infection, gastrointestinal infection and otitis media. They also have a lower
incidence of non-communicable diseases such as obesity and type 2 diabetes
8
compared with infants who are formula-fed (Bachrach et al., 2003; Harder,
Bergmann, Kallischnigg & Plagemann, 2005; Horta, Bahl, Martines & Victora,
2007; Ip et al., 2007; Kramer et al., 2001). Evidence shows that children have
earlier motor development, better performance on intellectual tests, and higher
academic ratings when they are breastfed longer (Dewey et al., 2001; Kramer et
al., 2008).
Breastfeeding increases the oxytocin level in mothers, which induces
more rapid uterine contractions to reduce postpartum hemorrhage (Leung et al.,
2006). Multiple data suggest that women who do not breastfeed face higher risks
of breast and ovarian cancers, obesity, type 2 diabetes, metabolic syndrome and
cardiovascular diseases (Danforth et al., 2007; Ip et al., 2007; Stuebe et al., 2005;
Stuebe et al., 2009a).
Health care benefits
Breastfeeding provides substantial protection from hospitalization due to
infectious diseases for infants. In the short term, it reduces doctor visits, hospital
admissions and hospital stays during the first 6 months of life (Leung, Lam, Ho &
Lau, 2005; Tarrant et al., 2010). In the long term, breastfeeding can save costs
from health care utilization and lower the workload and stress of health care
professionals.
9
Economic benefits
Breastfeeding is good for the economy of our community. It reduces costs
from pediatric health care services, premature death from infant illnesses and
infant formula purchases. It was estimated that if 90% of mothers in the United
States could comply with medical recommendations on breastfeeding, the country
could save US$ 3.7 billion in direct and indirect health costs, US$ 10.1 billion
from prevention of premature death from pediatric illnesses and US$ 3.9 billion in
infant formula costs (Bartick, 2011).
Environmental benefits
While everyone recognizes the importance of environmental conservation,
breastfeeding can contribute a lot to saving the environment. It provides the most
environmentally-friendly way to feed infants by decreasing the environmental
burden from disposal of artificial formula cans and bottles. It also reduces the
energy demands of formula milk production and transportation (Cohen, Mrtek &
Mrtek, 1995; Jarosz, 1993; Levine, Huffman & Center to Prevent Childhood
Malnutrition, 1990).
10
Chapter 2 - Review of Evidence
Study selection criteria
To be eligible for the review, the studies had to meet the following criteria.
Participant characteristics
Mothers who delivered healthy full term babies.
Type of intervention
Studies which compared postnatal telephone breastfeeding support
intervention delivered by nurses to standard care or other kinds of supportive
interventions.
Outcome measures
The duration of any or exclusive breastfeeding.
Exclusion criteria
Studies with a combination of postnatal breastfeeding support interventions
were excluded as the single effect of a postnatal telephone support intervention
was investigated.
Search strategy
The study search was conducted on 13 June 2013. Two electronic databases,
CINAHL plus and PubMed were selected for the study search. Keywords that
were used in the search were ‘breastfeed’, “breastfeeding”, “breastfeeding
duration”, “breastfeeding rate”, ”duration of breastfeeding”, “rate of
11
breastfeeding”, “telephone intervention’, “telephone counseling”, “telephone
support” ,“ professional support”, “midwife”, “midwives”, ”nurse”, “lactation
counselor” , “lactation consultant” and “ health care professional”. There was no
limitation set on the year of journal publication. Randomized controlled trial
studies and studies which were published in English were included.
A summary of the search strategy is presented in the Table of the Search
Strategy (Appendix A) and illustrated by a flow diagram (see Figure 1). Eight
articles were obtained from CINAHL plus and 297 articles from PubMed. After
screening the titles and abstracts of the articles, one study was available in
CINAHL plus and four studies were available in PubMed. After removing
duplicated articles, one study from CINAHL plus and three studies from PubMed
were considered eligible for the review. In addition, one more eligible study was
obtained from a manual search. The reference lists of all retrieved studies were
then screened and finally five eligible, relevant studies were included for the study
review.
12
Figure 1. Flow diagram of the search strategy
Table of evidence
A summary of the extracted data of each of the five selected studies is
presented in the Table of Evidence (see Table 1). The authors, type of study and
evidence level of each study are shown. The table consists of a brief description of
the number and characteristics of the study participants, details of the
interventions and control treatments, length of follow up, outcome measures and
effect sizes of the study results.
305 relevant articles identified through
CINAHL plus - 8
PubMed - 297
7 articles
298 articles excluded by
title and abstract
Search by keywords
Database selection
CINAHL plus & PubMed
5 articles included in the review
2 articles excluded by full text
5 articles 1 article
obtained
by manual
search 1 article excluded by duplication
13
Sample size
The five selected studies were all randomized controlled trials (RCT), one
of which was a cluster RCT (Fu et al., 2014). The sample size of four studies
varied from 69 to 357. The cluster RCT had a larger sample size of 722.
Characteristics of study participants
Healthy mothers were recruited from Hong Kong, Italy, and Malaysia in
three studies (Fu et al., 2014; Simonetti, Palma, Giglio, Mohn & Cicolini, 2012;
Tahir & Al-Sadat, 2012). One study targeted low-income Latina mothers (Bunik et
al., 2010), and another study targeted mothers who were living in a disadvantaged
area as study participants (Hoddinott, Craig, Maclennan, Boyers & Vale, 2012). In
four studies, mothers who intended to breastfeed or considered breastfeeding were
included (Bunik et al., 2010; Fu et al., 2014; Simonetti et al., 2012; Tahir &
Al-Sadat, 2012).
Intervention groups
Four studies had postnatal telephone support as their single intervention.
One study consisted of two intervention groups, a telephone support group and an
in-hospital support group (Fu et al., 2014). The telephone support interventions
were carried out by nurses in all the studies. The qualifications of the nurses were
mentioned in four studies, and included licensed midwives (Fu, et al., 2014;
Simonetti, et al., 2012), lactation consultants (Fu, et al., 2014), lactation
14
counselors (Tahir & Al- Sadat, 2012) and nurses who had completed a 2-day
United Nations Children’s Fund (UNICEF)-accredited training program
(Hoddinott et al., 2012).
Comparison groups
Four studies compared telephone support interventions with standard
counseling or usual care (Bunik et al., 2010; Fu et al., 2014; Simonetti et al., 2012;
Tahir & Al-Sadat, 2012). The remaining study allowed mothers to make reactive
telephone calls in the comparison group (Hoddinott et al., 2012).
Outcome measures
The outcome measures in the five studies were the duration of any or
exclusive breastfeeding.
Effect sizes
The effect sizes of the reviewed studies were presented as relative risk (RR)
or odds ratios (OR).
15
Table 1. Table of Evidence (1)
Biblio- graphic citation
Study type
Evi level
No. of Participant
s
Participant characteristics
Intervention Comparison Length of follow up
Outcome measures Effect size
* : p<0.05 ; ** : p=0.01
Bunik et al., 2010
RCT 1+ 335
1. Latina primiparous mothers
2. Low- income 3. Delivered healthy
term babies 4. Considered BF
1. 2-week intervention by nurses 2. First call on the day of hospital discharge 3. Daily calls
Remarks: Training/ qualification of nurses not mentioned n=155
Standard care n=178
24 weeks Rate of any BF & PBF
6
at 4th
12th
24th
week
Any BF 4
th wk: RR =1.00
12th
wk : RR = 0.91 24
th wk : RR = 0.76
PBF 4
th wk : RR =1.00
12th
wk : RR = 0.77
24th
wk : RR = 0.68
Fu et al., 2014
Cluster RCT
1++ 722 1. Hong Kong Chinese primiparous mothers
2. Intended to BF
Telephone support 1. 4-week intervention
by midwives/ lactation consultant
2. First call within 72hr of hospital discharge
3. Weekly calls n= 268
In- hospital support 1. 3-sessions 2. First 48 hr
intervention by midwives/ lactation consultant
3. 30 min hands-on professional BF support
n=191
Standard care n=263
24 weeks Rate of any BF & EBF
5
at 4th
8th
12th
week
Telephone vs Standard care Any BF 4
th wk : OR = 1.63**
8th wk : OR = 1.48*
12th wk : OR = 1.37
EBF 4
th wk : OR = 1.90**
8th wk : OR = 1.44
12th wk : OR = 1.20
16
Table 1. Table of Evidence (2)
1 FEST: Feeding Support Team (Nurses had breastfeeding induction and completed a 2-day UNICEF accredited training program)
2 LM : Licensed midwives
3 STC: Structured telephone counseling
4 LC: Lactation counselors (RNs who had post-basic training in midwifery)
5 EBF: Exclusive breastfeeding
6 PBF: Predominant breastfeeding
Biblio- graphic citation
Study type
Evi level
No. of Participants
Participant characteristics
Intervention Comparison Length of follow up
Outcome measures Effect size
* : p<0.05 ; ** : p=0.01
Hoddinott et al., 2012
RCT (pilot)
1+ 69
1. Mothers living in disadvantaged areas in Scotland
2. BF at the time of hospital discharge
Proactive + Reactive telephone calls
1. 2-week intervention by FEST1
2. First call within 24 hr of hospital discharge
3. 1st week: Daily calls
2nd
week: Decided by mothers 4. Reactive calls by mothers at any
point over the 2 weeks n=35
Reactive-only telephone calls
Reactive calls at any point over the 2 weeks n=34
8 weeks Rate of any BF & EBF at 6
th -8
th week
Any BF: RR = 1.5 EBF : RR = 1.7
Simonetti et al., 2012
RCT (pilot)
1- 114
1. Italian healthy primiparous mothers
2. Delivered healthy term babies
3. Intended to BF 4. Telephone access
1. 6-week STC3
by WHO-UNICEF LM2
2. Weekly calls (or more frequent) 3. Phone call timing planned by mothers
and LM n=55
Standard counseling program n= 59
20 weeks Rate of EBF at 4
th 12
th 20
th week
EBF 4
th wk :RR = 1.8 **
12th wk :RR = 1.9 **
20th wk : RR = 2.1**
Tahir & Al-Sadat, 2012
RCT 1++ 357
1. Malaysian mothers 2. Delivered normal
babies 3. Intended to BF 4. Telephone access
1. 24-week intervention by LC4
2. Biweekly calls n=179
Standard care n=178
24 weeks Rate of EBF at 4
th 16
th 24
th week
EBF 4
th wk : RR = 1.1*
16th wk : RR = 1.1
24th wk : RR = 1.0
17
Quality assessment
The Scottish Intercollegiate Guidelines Network (SIGN) methodology
checklist for controlled trials was chosen to rate the evidence level for the five
reviewed studies (SIGN, 2004). It is an appraisal tool which is divided into two
parts. The first part consists of 10 items which assess the internal validity of
studies and the second part consists of 4 items which provide an overall
assessment of the level of the methodological quality of studies.
The ratings of the quality of the five studies are presented in the Table of
Quality Assessment (see Table 2).
Appropriate and clearly focused questions
All reviewed studies addressed appropriate and clearly focused questions
which examined the effectiveness of postnatal telephone support interventions on
the duration of any or exclusive breastfeeding.
Randomization
In four studies, either a computer software program or on-line
randomization sequence service program was used to generate the allocation
sequence for subject allocation (Bunik et al., 2010; Fu et al., 2014; Hoddinott et
al., 2012; Simonetti et al., 2012).
Concealment
Only one study reported using opaque sealed envelopes as the concealment
method (Bunik et al., 2010). In the cluster RCT, the concealment was achieved by
18
informing the research nurses and study sites of the weekly treatment allocation
48 hours before subject recruitment that week (Fu et al., 2014).
Blinding
As the intervention was delivered via telephone, it was difficult to blind the
intervention providers or the receivers. However, it was feasible to blind the
researchers who collected the outcome data in the studies, and three studies did
this (Fu et al., 2014; Hoddinott et al., 2012; Tahir & Al-Sadat, 2012).
Treatment and control groups were similar at the start of the trial
There was no significant difference in the participant characteristics in the
treatment and control groups before implementation of the interventions.
Difference between groups is the treatment under investigation
From the five studies, each group was treated equally and the only
difference between the intervention and control groups was the presence of the
treatment.
Outcomes measured in a standard, valid and reliable way
Three studies collected the outcome data by conducting telephone
interviews. Two studies used a combination of telephone interviews and
self-administered questionnaires (Simonetti et al., 2012; Tahir & Al-Sadat, 2012).
Percentage of dropouts
Two studies had dropout rates higher than 20% in either arm of the study,
with rates of 26.6% and 23.5% (Bunik et al., 2010; Hoddinott et al., 2012).
19
Intention–to-treat analysis
In data analysis, four studies reported using intention-to-treat analysis
(Bunik et al., 2010; Fu et al., 2014; Hoddinott et al., 2012; Tahir & Al-Sadat,
2012). This was not mentioned in the remaining study. However, the four subjects
who were excluded from that study after treatment allocation were not analyzed
(Simonetti et al., 2012).
Results are comparable for all sites
Only one study implemented the interventions at three different hospitals
and the results were comparable for all sites (Fu et al., 2014).
Statistical power of the study
The calculated sample sizes in both study arms were adequately met in
three studies (Bunik et al., 2010; Fu et al., 2014; Tahir & Al-Sadat, 2012).
However, there was no sample size calculation done in the two pilot studies
(Hoddinott et al., 2012; Simonetti et al., 2012).
Ratings of the studies
After assessing the overall risk of bias and the internal validity of the
reviewed studies, the level of evidence of the five studies was rated according to
the criteria in Appendix B. Two studies were rated 1++ (Fu et al., 2014; Tahir &
Al-Sadat, 2012), two were rated 1+ (Bunik et al., 2010; Hoddinott et al., 2012),
and one was rated 1- (Simonetti et al., 2012).
20
Table 2. Table of Quality Assessment (SIGN, 2004)
Bibliographic Citation 1.Bunik et al., 2010 2.Fu et al., 2014
3.Hoddinott et al.,
2012
(pilot)
4.Simonetti et al.,
2012
(pilot)
5.Tahir &
Al-Sadat, 2012
Appropriate and clearly focused question
Randomization X
Concealment X X X
Blinding X X
Treatment and control groups are similar at the start of the trial
The only difference between groups is the treatment under
investigation
The outcomes are measured in a standard, valid and reliable way
Percentage of dropouts I:23.2%
C:26.6%
Telephone group: 2.97%
In-hospital group: 0.52% Control group: 1.52%
I:8.6%
C:23.5% 0 I:10.6%
C:11.2%
Intention to treat analysis X
Are the results comparable for all sites Does not apply Does not apply Does not apply Does not apply
Remarks No sample size
calculation was done
No sample size
calculation was done
Level of evidence 1+ 1++ 1+ 1- 1++
21
Summary and Synthesis
Summary
The five reviewed studies investigated the effect of a postnatal telephone support
intervention on the duration of any or exclusive breastfeeding.
Diversity of outcomes
Three studies proved that a postnatal telephone support intervention
significantly increased the duration of any or exclusive breastfeeding, up to 4, 8
and 20 weeks postpartum (Tahir & Al-Sadat, 2012; Fu et al., 2014; Simonetti et al.,
2012). One of the other two studies shown a positive effect of telephone support
on the duration of any and exclusive breastfeeding but the result was not
statistically significant (Hoddinott et al., 2012). The other study found no
significant effect of a telephone support intervention on the duration of any or
predominant breastfeeding (Bunik et al., 2010).
Characteristics of participants
Mothers’ preferences for breastfeeding were assessed in four studies and
only mothers who wished to breastfeed or considered breastfeeding were eligible
for recruitment (Bunik et al., 2010; Fu et al., 2014; Simonetti et al., 2012; Tahir &
Al-Sadat, 2012). Two studies reported that the telephone accessibility of mothers
was assessed before subject recruitment (Simonetti et al., 2012; Tahir & Al-Sadat,
2012).
22
Qualifications of nurses
Breastfeeding-related qualifications acquired by nurses were reported by
four studies. These nurses were licensed midwives, lactation counselors, lactation
consultants or nurses who had completed a 2-day UNICEF accredited training
program (Fu et al., 2014; Hoddinott et al., 2012; Simonetti et al., 2012; Tahir &
Al-Sadat, 2012).
Refresher course
To maintain uniformity and consistency in the breastfeeding information
provided to mothers, a refresher course for nurses was organized prior to the
implementation of two studies (Fu et al., 2014; Tahir & Al-Sadat, 2012).
Duration of intervention
The intervention durations in the five studies varied from 2 to 24 weeks
postpartum. Two studies with insignificant outcomes on breastfeeding duration
had short intervention durations of less than 4 weeks (Bunik et al., 2010;
Hoddinott et al., 2012). The three studies with longer intervention durations from
4 to 24 weeks were shown to have significant positive outcomes on the
breastfeeding duration (Fu et al., 2014; Simonetti et al., 2012; Tahir & Al-Sadat,
2012).
Time of first call
The time of the first telephone call was reported in three studies (Bunik et
al., 2010; Fu et al., 2014; Hoddinott et al., 2012). In the Bunik et al. (2010) study,
23
the first call was done on the day of hospital discharge, in the Hoddinott et al.
(2012) study within 24 hours of discharge and in the Fu et al. (2014) study within
72 hours of discharge.
Frequency of calls
In one of the two studies with short intervention durations, daily calls were
done throughout the intervention period (Bunik et al., 2010). In the other study,
daily calls were made for the first week and the mothers decided on the frequency
of calls for the following week (Hoddinott et al., 2012). Weekly or biweekly
telephone calls were done in the remaining three studies.
Content of telephone support intervention
Four studies described the content of the support (Bunik et al., 2010; Fu et
al., 2014; Simonetti et al., 2012; Tahir & Al-Sadat, 2012). The nurses provided
breastfeeding information and instruction (Bunik et al., 2010; Fu et al., 2014;
Simonetti et al., 2012), assessed the emotional health of the mothers and feeding
patterns of the infants (Bunik et al., 2010; Fu et al., 2014), offered breastfeeding
support and counseling (Bunik et al., 2010; Fu et al., 2014; Simonetti et al., 2012;
Tahir & Al-Sadat, 2012), gave professional advice when mothers encountered
breastfeeding problems at home (Bunik et al., 2010; Fu et al., 2014), provided
information on breastfeeding in public places and expression and storage of breast
milk for mothers who returned to work (Bunik et al., 2010; Fu et al., 2014) and
addressed cultural issues (Bunik et al., 2010; Fu et al., 2014).
24
Synthesis
In view of the diversity of outcomes in the five reviewed studies, the
similarities and differences of the five studies were reviewed and synthesized.
Qualifications of nurses
Breastfeeding-related qualifications were necessary to ensure nurses were
capable of providing professional advice to assist mothers in establishing and
continuing breastfeeding (Fu et al., 2014; Simonetti et al., 2012; Tahir & Al-Sadat,
2012).
Intention to breastfeed
An intention to breastfeed could be associated with a better outcome in the
duration of breastfeeding. Among the three studies which shown significant
positive outcomes on duration of breastfeeding, mothers’ preferences for
breastfeeding were assessed and only those who expressed a wish and willingness
to breastfeed were recruited into the study.
Telephone accessibility
Two studies reported that the telephone accessibility of mothers was
assessed (Simonetti et al., 2012; Tahir & Al-Sadat, 2012). This is an important
point to note as the telephone was the only communication medium in the
intervention.
Refresher course
A refresher course prior to implementation of the telephone support
25
intervention ensured consistency and uniformity of the content of breastfeeding
support delivered to mothers (Fu et al., 2014; Tahir & Al-Sadat, 2012).
Intervention duration
Telephone support intervention for 4 weeks or more was associated with an
improvement in the breastfeeding duration (Fu et al., 2014; Simonetti et al., 2012;
Tahir & Al-Sadat, 2012). A 2-week intervention might be too short and therefore
inadequate to address breastfeeding problems which arise in the first month
postpartum (Bunik et al., 2010).
Time of first call
The first telephone call was made within 72 hours after hospital discharge
in order to provide continuous breastfeeding support to mothers at home (Bunik et
al., 2010; Fu et al., 2014; Hoddinott et al., 2012).
Frequency of calls
Weekly or biweekly telephone calls shown promising outcomes on the
duration of breastfeeding as breastfeeding problems or difficulties could be
regularly addressed by nurses in a timely manner (Fu et al., 2014; Simonetti et al.,
2012; Tahir & Al-Sadat, 2012).
Content of telephone support intervention
During the early stage of the telephone support intervention, apart from
providing breastfeeding knowledge to mothers (Bunik et al., 2010; Fu et al., 2014;
Simonetti et al., 2012), nurses assessed the emotional health of mothers and the
26
feeding patterns of infants (Bunik et al., 2010; Fu et al., 2014) and they advised
mothers to cope with breastfeeding problems encountered at home (Bunik et al.,
2010; Fu et al., 2014).
In the late stage, advice on breastfeeding in public places, and information
on breast milk expression and storage were important to help mothers prepare for
work (Bunik et al., 2010; Fu et al., 2014). Throughout the intervention, cultural
issues which might discourage mothers from continuing breastfeeding were
addressed by nurses (Bunik et al., 2010; Fu et al., 2014). Breastfeeding counseling
was also offered whenever needed (Bunik et al., 2010; Fu et al., 2014; Simonetti
et al., 2012; Tahir & Al-Sadat, 2012).
Implications for practice
To summarize, the findings of the five studies can be generalized to the
health care setting in Hong Kong. In order to provide an effective telephone
support intervention, nurses should acquire breastfeeding-related qualifications.
The target group of mothers for the innovation should be those who intend to
breastfeed and have telephone access. Refresher courses for nurses should be
arranged prior to the innovation. The innovation duration should be 4 weeks or
longer and the first call should be made within 72 hours after hospital discharge.
After that, weekly or biweekly telephone calls should be made.
To better address mothers’ concerns about breastfeeding, the content of the
telephone support should be divided into early and late phases. Breastfeeding
27
education and support is crucial in establishing breastfeeding in the early phase.
Apart from providing general and basic breastfeeding knowledge, the emotional
health of mothers and the feeding patterns of infants should be assessed by nurses.
Advice and assistance should be offered to mothers who have difficulties
establishing breastfeeding at home. In the late phase, focus should be put on
breastfeeding continuation after resumption of work or study. Information and
advice should be provided on breastfeeding in public places and breast milk
expression and storage in order to prolong breastfeeding.
In order to foster mothers’ confidence and commitment to continue
breastfeeding, cultural issues which could lead to early cessation of breastfeeding
should be frequently assessed and addressed. In addition, breastfeeding
counseling and support should be offered throughout the 4 week telephone
support intervention whenever it is needed.
28
Chapter 3 - Implementation Potential
Target setting and audience
The proposed setting of the innovation is a MCHC of the DH. The target
audience is mothers who deliver healthy full term babies, intend to breastfeed, go
to the designated MCHC with their babies within 72 hours after hospital discharge
and provide one contact number on first registration.
Transferability of findings
Similarity of the target setting and audience
The settings of the five reviewed studies were maternity wards, postnatal
wards and mother-baby units of community health centers where a sufficiently
large number of mother-infant pairs were available. Similarly, as it is the public
health service provider in Hong Kong, the MCHC ensures a potentially large
number of mother-infant pairs for recruitment for this innovation.
The target audiences of the reviewed studies were mothers who had just
given birth to healthy full-term babies, intended to breastfeed and had telephone
access, similar to the inclusion criteria of the target audience in our innovation.
Philosophy of Care of DH
The MCHC is under the Family Health Service (FHS) of the DH. The
vision of the FHS is to lead the community in promoting the health and well-being
of children, women and families in Hong Kong (DH, 2006). To achieve this, a
policy was established in 2000 to advocate breastfeeding in Hong Kong. The
29
policy stated that creation of a positive environment to support breastfeeding
clients and employees should be highly encouraged in all service settings (DH,
2013).
Philosophy of care underlying the innovation
Our innovation is to prolong the duration of breastfeeding by providing
telephone support to mothers after hospital discharge. Since prolonging the
breastfeeding duration can improve the health outcome of infants (Bachrach et al.,
2003), the philosophy of care underlying this innovation parallels that advocated
by the DH, which is to support and encourage mothers in breastfeeding in order to
promote the health and well-being of the mothers and infants in the community.
Number of clients benefitting from the innovation
Each month, around 90-110 mother-infant pairs seek care at the designated
MCHC within 72 hours after hospital discharge. Approximately, 90% of those
babies are still breastfeeding. After calculation, it was estimated that about 80-100
mother-infant pairs will meet the inclusion criteria and can benefit from the
innovation each month.
Time frame for innovation implementation
It will take 18 months to implement the innovation. The first 5 months will
be used to establish a communication team, gain the approval of the
administrators of the DH and FHS, communicate with the stakeholders at the
management level of the designated MCHC, organize orientation programs and
30
refresher programs for all frontline nurses and prepare materials for the innovation.
The pilot study will last for 3 months and will include subject recruitment, pilot
test implementation and evaluation. Lastly, the actual innovation will be
conducted over a course of 6 months and will include subject recruitment,
innovation implementation and data collection. The following 4 months will be
spent on data analysis, data evaluation and overall evaluation of the innovation.
The timeline of the innovation implementation is shown in Appendix C.
Feasibility of the innovation
Administrative support
Administrative support from the DH and FHS is likely as this innovation
shares their philosophy of care, which is, to advocate breastfeeding and to
promote the health and well-being of children, women and families in Hong
Kong.
The innovation consists of evidence-based guidelines with a list of
recommendations which have been developed from the best evidence of the five
studies and have been shown to be effective in prolonging the breastfeeding
duration. In view of the potential benefits of prolonging the breastfeeding duration,
implementation of this innovation should be highly appreciated by the
administrators of the DH and FHS.
Consensus among stakeholders in MCHC
The FHS has been advocating breastfeeding promotion and education for
31
years. Therefore, the benefits and importance of prolonging the breastfeeding
duration are well-known by all staff in MCHCs and they have a good
understanding of and positive attitudes towards breastfeeding.
Telephone support intervention workload
Thirteen frontline nurses work at the designated MCHC to deliver
maternal and child health services to the public. One registered nurse will be
designated for the telephone support intervention each week. In order to ensure
the current service can be maintained with minimal disturbance, approval for an
extra registered nurse will be requested. Since this is a 4-week telephone support
innovation, the number of weekly cases should be calculated by adding the
number of cases from the previous 3 weeks to the number of the newly recruited
cases in the current week. Approximately, 20-25 new cases will be eligible for the
innovation in one week. About 60-75 cases will be carried over from the previous
3 weeks (i.e. 20-25 cases per week x 3 weeks) if there are no dropouts. Therefore,
a total number of 80-100 cases will be handled by the designated nurse each week,
that is, 16-20 cases per day (i.e. 80-100 cases / 5 days). A maximum of 20 minutes
can be allocated to each case.
Staff training and equipment needed
All MCHC nurses have completed the breastfeeding training workshop
organized by the FHS and they are qualified to provide breastfeeding guidance
and coaching for mothers. No extra equipment or materials will be required for
32
the innovation. Telephones have already been installed in each room of the clinic.
Electronic devices such as computers, printers, audiovisual devices and printed
breastfeeding materials are all already available at the designated MCHC.
Availability of the evaluation tool
The breastfeeding rates at 1 and 2 months and the level of satisfaction of
the frontline nurses will be the two identified outcomes of the innovation. A
breastfeeding data collection form has been designed to collect the breastfeeding
data that is reported by mothers through face to face interviews or by telephone at
the infant age of 1 and 2 months. A self-report questionnaire has been designed to
access the satisfaction level of the innovation by the frontline nurses.
Nurse-related barriers & strategies
People are always the most critical resources, supporters, barriers, and
risks in a change process (Victorian Quality Council, [VQC], 2006), so
understanding and addressing their concerns is very important. Potential barriers
which may discourage frontline nurses from engaging in the innovation
implementation have been identified and some strategies have been suggested
accordingly.
Different problems in implementing a change in a practice can arise
depending on the phase of the change process (Grol, 1997). During the innovation
dissemination phase, nurses may not be willing to engage in the process as they
may not be aware of or understand why a change is necessary (National Health
33
Service Modernisation Agency, 2005). Lack of support and resources during the
implementation phase may discourage nurses from continuing to perform the
innovation (Grol, 1997). These obstacles are the risks that could lead the nurses to
return to old practices.
Orientation program
Early communication and consultation is crucial in gaining commitment,
and getting people interested and prepared to participate in a change process
(VQC, 2006). An orientation program will be held soon after gaining approval
from the administrators. The details and potential benefits of the innovation
should be clearly addressed for the nurses. If they are familiar with the innovation,
a sense of ownership can be built among the nurses and it will become easier to
gain their support and cooperation in performing the innovation.
Continuous evaluation
To sustain the change process, continuous evaluation of the innovation
should take place. The outcomes of the change will be used to determine whether
the plan of the innovation should be modified (Grol, 1997). In addition, sharing
the outcomes of the evaluation with the nurses is important as people will be more
committed to the change if they can see that it does improve things (VQC, 2006).
Regular meetings should be held to encourage the nurses to voice their concerns
about continuing the innovation. Moreover, it is important to emphasize that the
change is an ongoing process, and their efforts in implementing the innovation are
34
highly valued by the MCHC and the public.
Innovation Evaluation
The effectiveness of the innovation and the willingness of the staff to
continue the innovation can be assessed by evaluating breastfeeding outcomes and
the level of satisfaction of frontline nurses during the innovation evaluation
process.
Cost-Benefit ratio of the innovation
Potential risks to clients
The success of the telephone support intervention relies on effective
communication between nurses and mothers. In this innovation, poor
breastfeeding instructions could impose a risk of breastfeeding-related
complications for mothers, such as sore nipple and mastitis, which could lead to
early discontinuation of breastfeeding.
Potential benefits from the innovation
Prolonging the breastfeeding duration reduces illness-related doctor visits
by infants (Leung et al., 2005), saves medical costs in the community (Batrick &
Reinhold, 2010), and conserves the environment (Cohen et al., 1995; Jarosz, 1993;
Levine et al., 1990). Apart from being the healthiest and safest kind of feeding
method, breastfeeding is also the least expensive method of feeding compared
with breast-milk substitutes or artificial formula (Leon-Cava, Lutter, Ross, &
Martin, 2002). A study found that families could save money by practicing
35
breastfeeding as the cost of formula milk is about twice that of extra food needed
by a lactating mother (Jarosz, 1993).
Material costs of implementing the innovation
These include hiring an extra registered nurse, installing telephones and
preparing printed materials for orientation and refresher programs. The material
costs of implementing the innovation are illustrated in Table 3 in Appendix D.
Material costs of not implementing the innovation
Early cessation of breastfeeding could occur if the innovation is not
implemented. The incidence of infant medical illnesses and related medical
expenditures will increase. Studies focusing on the economic benefits of
breastfeeding in Hong Kong are limited. The United States annual national health
care costs incurred for treatment of four medical conditions, diarrheal disease,
respiratory syncytial virus, insulin-dependent diabetes mellitus, and otitis media,
in infants who were not breastfed in 1997 (Riordan, 1997) will be used as a
reference in estimating additional medical expenditures due to not implementing
the innovation in Hong Kong.
Additional costs are incurred for purchase of formula milk for infants who
are not breastfed. In the United States, it was calculated that an additional US$
2,665,715 in federal funds is needed each year in the Women, Infants and Children
(WIC) program to provide formula to mothers who are not breastfeeding (Riordan,
36
1997). Details of the material costs of not implementing the innovation are shown
in Table 4 of Appendix E.
Potential non-material costs of implementing the innovation
Spending time attending orientation and refresher programs, increasing
workloads and stress are potential non-material costs. These could lower the
morale of nurses and decrease their willingness to implement the innovation if
those problems are not handled appropriately.
Potential non-material benefits of implementing the innovation
Apart from optimizing the health outcomes of mothers and infants, this
innovation offers a valuable opportunity to enrich the breastfeeding knowledge of
nurses and enhance their competency in supporting mothers who are breastfeeding.
Nurses can enjoy a great sense of satisfaction by delivering effective breastfeeding
support to mothers. The morale of the nurses is expected to improve with time as
they become more familiar with the innovation and can do the work more
efficiently, thereby fostering their confidence and increasing their willingness to
continue the innovation.
In summary, it will cost HK $34,036.4 to initiate the innovation. After that,
HK$ 31,200 is needed to pay the salary of an extra nurse to maintain the
innovation each month. On the other hand, the additional costs of not
implementing the innovation due to expenses for extra health care and infant
37
formula range from HK$ 9,270,812,577 to HK$ 10,169,372,577 per month.
To conclude, this innovation is highly transferrable and is considered
feasible for implementation. The potential benefits of implementing the
innovation are enormous. Apart from improving the health outcomes of the
mother-infant pairs, it can help save household expenditures and greatly reduce
health care expenses in Hong Kong in the long run. There are few potential risks
and costs and these could be fully outweighed by the benefits. Therefore, it is
worthwhile to implement this innovation in the proposed setting.
38
Chapter 4 - Evidence-Based Practice Guidelines
Title of the guidelines
Postnatal telephone support intervention for breastfeeding mothers after hospital
discharge.
Objective of the guidelines
a) To summarize the evidence of the reviewed studies for implementation of the
postnatal telephone support intervention.
b) To formulate clinical practice instructions for implementation of the postnatal
telephone support intervention based on the best evidence available.
c) To structure and standardize instructions for nurses to implement the
postnatal telephone support intervention more effectively.
Purpose of the guidelines
These guidelines are intended to provide a list of structured clinical
practice instructions for the MCHC nurses to facilitate delivery of a postnatal
telephone support intervention to breastfeeding mothers after hospital discharge.
Target group of the guidelines
The target population is mothers who deliver healthy full term babies,
intend to breastfeed, go to MCHC with their babies within 72 hours after hospital
discharge, and provide at least one contact number on registration.
39
Recommendations
Altogether, a total of 8 recommendations have been developed from the
five identified studies. The grading of the recommendations has been rated
according to the SIGN guidelines in Appendix B. Evidence that supports the
recommendations has been stated with the level of evidence provided. The
workflow of the innovation is shown in Appendix F.
1. Nurses are required to complete breastfeeding-related training or obtain
qualifications before delivering the postnatal telephone support intervention.
[Grade A]
a) Breastfeeding support and education offered by knowledgeable health care
professionals could help mothers and their families overcome obstacles in
breastfeeding (1++ Tahir & Al- Sadat, 2012).
b) Mothers felt that they could express their breastfeeding difficulties to a
competent midwife who was able to give them all the breastfeeding
information and support they need (1-Simonetti, 2012).
2. The breastfeeding intention of mothers is assessed and only mothers who
declare their intention to breastfeed are eligible for the innovation. [Grade
A]
a) The intention to breastfeed was assessed and mothers who planned to
breastfeed were recruited into the studies (1- Bunik et al., 2010; 1++ Fu et al.,
40
2014; 1- Simonetti et al., 2012; 1++ Tahir & Al-Sadat, 2012). This can ensure
that mothers who receive the intervention are willing to breastfeed.
3. The first telephone call should be made within 72 hours after mothers are
discharged from hospital. [Grade B] For mothers who go to MCHC at 72
hours after hospital discharge, the first call will be made on the same day.
a) The immediate postpartum period was the most relevant time to make
telephone calls. Having the infants present and struggling with the reality of
breastfeeding made this a powerful time for the telephone support
intervention (1- Bunik et al., 2010).
b) The immediate post-discharge period was a very delicate moment for
psychological adaptation. Breastfeeding promotion should start during
pregnancy and continue in the hospital and at home after hospital discharge
(1- Simonetti et al., 2012).
c) Problems related to milk production, for example, breast engorgement and
perceived insufficient milk supply, were commonly experienced by mothers
soon after hospital discharge. Mothers might decide to discontinue
breastfeeding if these problems were not well-addressed (Gerd et al., 2012;
Hegney, Fallon, & O’Brien, 2008).
4. A refresher program for nurses should be provided before the postnatal
telephone support intervention. [Grade A]
41
a) A refresher course on breastfeeding management and counseling should be
given to nurses to maintain uniformity and control the quality of the
breastfeeding counseling practices (1++ Tahir & Al- Sadat, 2012).
b) A training period of 8 hours was provided to ensure that breastfeeding
support practices were evidence-based and consistent (1++ Fu et al., 2014).
5. The duration of the postnatal telephone support should be 4 weeks or more.
[Grade A]
a) A 2-week telephone support intervention might be inadequate to overcome
some deeply entrenched issues (1- Bunik et al., 2010).
6. The time of subsequent calls should be decided by mothers and nurses.
[Grade A]
a) Timing of telephone support could be planned by mothers and midwives/
nurses (1++ Fu et al., 2014; 1- Simonetti, 2012) so that mothers could
negotiate times that best fit their family routines (1++ Fu et al., 2014).
7. Telephone support should be done at least weekly. [Grade A]
a) Regular telephone contact was especially helpful to mothers at a time when
they were less likely to receive any other kind of breastfeeding support (1++
Fu et al., 2014).
8. The content of the support should be structured in two stages. The early
stage should focus on providing general breastfeeding knowledge, assessing
infant feeding and stooling patterns, assessing maternal emotional and
42
physical health, and assisting mothers in managing breastfeeding problems
or complications. The late stage should mainly focus on breastfeeding in
public places, expression and storage of breast milk, and preparation for
returning to school or work. Cultural issues should be covered and addressed,
and breastfeeding counseling should be offered throughout the telephone
support intervention.[Grade A]
a) The content of support suggested by two studies (1- Bunik et al., 2010; 1++
Fu et al., 2014) was quite similar. Well-structured telephone support should
be able to meet the needs of mothers and help them resolve breastfeeding
problems they encounter at different stages during the postnatal period to
avoid premature discontinuation of breastfeeding.
b) In Chinese culture, mothers might have to deal with family or sociocultural
pressure to stop breastfeeding after hospital discharge (1++ Fu et al., 2014).
43
Chapter 5 - Implementation Plan
The implementation plan includes a communication plan with the
stakeholders, and a plan for pilot testing, followed by an evaluation of the overall
effectiveness of the evidence-based guidelines in the proposed clinical setting.
Communication plan with potential users
The purpose of a communication plan is to communicate with all the
stakeholders in the proposed innovation. A comprehensive communication plan
helps the stakeholders understand the innovation well and, more importantly, gain
their approval and support for the innovation implementation.
Identifying the stakeholders
Stakeholders are those people who will be influenced either directly or
indirectly by the implementation of the innovation (Melnyk & Fineout-Overholt,
2005). In this innovation, the identified stakeholders will be the administrators of
the DH and FHS, Medical Officers (MOs), Nursing Officers (NOs), Lactation
Consultants (LCs), and the frontline nurses of the designated MCHC.
Forming a communication team
After identifying the stakeholders, a communication team will be
established. The function of the communication team is to work out the
communication plans with different stakeholders. It is responsible for
coordinating MOs, NOs and frontline nurses during the innovation
implementation and evaluation process.
44
The team will consist of six team members including the innovation author,
one MO, one NO, one LC and two frontline nurses at the designated MCHC.
Having team members from different disciplines can enhance the
representativeness of the team and ensure that various expert opinions and
feedback can be collected to work out a comprehensive communication plan.
Communication plan with the administrators of the DH and FHS
The Deputy Director of Health of the DH and the chairperson of the FHS
are responsible for the decision making processes for administrative and executive
affairs of the public health services in Hong Kong. Therefore, their support and
approval are necessary for the implementation of the proposed innovation.
Two weeks before the formal meeting with the administrators of the DH
and FHS, details of the proposed innovation will be presented in a proposal and
sent to them via email. Details include the objectives of the innovation, the
program logistics, feasibility and transferability, potential risks and benefits, and
the proposed budget. Requisition of extra manpower for the innovation will be
mentioned in the proposal. The five reviewed studies which provide evidence
supporting the development of the evidence-based guidelines will be attached for
their reference.
Those administrators are encouraged and welcome to raise questions and
concerns about the innovation and these will be clarified, explained and answered
by the communication team during the formal meeting. Feedback from the
45
administrators will be collected and modification of the innovation will be made
accordingly.
Communication with the MO In-charge (MO IC) and NO In-charge (NO IC)
After gaining the approval of the administrators of the DH and FHS, a
meeting will be arranged with the MO IC and NO IC of the designated MCHC to
obtain their support in facilitating and offering help in the innovation
implementation process.
The timeline and logistics of the innovation, target number of participants,
manpower allocation and any breastfeeding materials required for the innovation
will be discussed in the meeting. Comments and feedback from the MO IC and
NO IC will be considered in order to implement the innovation smoothly without
disrupting the current service provided by the MCHC.
Communication plan with frontline nurses
A good consensus with the 13 frontline nurses will make it easier to gain
their cooperation to carry out the innovation more effectively. Two identical
orientation sessions will be held in the designated clinic in two different weeks to
ensure each of the frontline nurses can attend. The lactation consultant of the
communication team will be responsible for the orientation program. Apart from
introducing the innovation, the objectives and logistics of the innovation,
allocation of manpower and role of the frontline nurses in delivering the
intervention will be well covered in the orientation program. Lastly, it is important
46
to reassure frontline nurses that requisition of extra manpower has already been
approved by the FHS and therefore the extra workload due to the innovation
should be limited.
Pilot Testing
A pilot study is also known as a feasibility study. It is a small scale version
or a trial run carried out to prepare for the actual major study (van Teijlingen &
Hundley, 2002; Thabane et al., 2010). A pilot study is conducted to provide
opportunities to assess the feasibility of the actual innovation, identify logistical
problems which might occur during the implementation process and determine the
adequacy of resources (for example, staff and time) (van Teijlingen & Hundley,
2002). It can also be a pre-testing of a research instrument (Baker, 1994).
Therefore likelihood of the success of the actual study is increased. It is beneficial
to conduct a pilot study with a small number of subjects before an actual
innovation implementation (Melnyk & Fineout-Overholt, 2005).
Timeline of the pilot test
The pilot study will last for 3 months. Implementation of the pilot test will
take 2 months and another month will be spent on evaluation. The first month will
be the subject recruitment period and the pilot test will begin after the first subject
is recruited.
Number of subjects required
The target number of subjects required for the pilot test is 30. This ensures
47
each of the 13 frontline nurses will have adequate cases for practice before the
actual innovation implementation. Verbal consent will be obtained from mothers
who are eligible to the innovation.
Pilot test implementation
Frontline nurses are strongly advised to perform the pilot study according
to the evidence-based guidelines. The content of the telephone support checklist is
designed for nurses to document the content of the support they have delivered
each time and this will be kept in the child health record (Appendix G). By
referring to the checklist, nurses can review the type of breastfeeding information
and advice that were delivered in the previous telephone call to decide what kind
of breastfeeding information should be given the next time.
Throughout the 3-month pilot study, the communication team will assess
the feasibility of the whole implementation process. This will include the
sequence and logistical flow of the pilot study, sufficiency of time allocated to
each case, and adequacy of the content of the telephone support checklist. The
team will also assess the compliance of the nurses in using the evidence-based
guidelines and their competency in delivering the innovation.
Pilot test evaluation
Evaluation of the pilot test will be done by the communication team.
Evaluation will focus on the feasibility of the implementation process. Issues that
may affect the logistical flow of the pilot study should be identified and resolved
48
to ensure the implementation process is smooth and not time-consuming. The
average duration of the telephone support should be evaluated to assess the
capability of the innovation, the workload of the nurses and the adequacy of
manpower to deliver the innovation. Group meetings will be arranged with
frontline nurses to collect their feedback on the pilot study, for example, their
competency in providing the innovation, any problems they encounter in
performing the evidence-based guidelines and any difficulties in using the
telephone support checklist will be assessed. The identified problems will be
reviewed by the communication team, and possible solutions and
recommendations will be considered to refine the innovation and the guidelines
accordingly.
The results of the pilot test evaluation and any modifications of the
innovation will be reported to the administrators of the DH and FHS via email,
and directly reported to the MO IC and NO IC of the designated MCHC.
49
Chapter 6 - Evaluation Plan
The purpose of an evaluation plan is to assess the effectiveness of a
proposed innovation in terms of the identified outcomes. In this innovation, the
two identified outcomes are patient and health care professional outcomes.
Details of the evaluation plan will be illustrated in this section.
Intervention outcomes
Client outcome
The rates of any breastfeeding up to 2 months after delivery will be the
client outcome as well as the primary outcome of the innovation. Breastfeeding
data will be collected through verbal report by the mothers. The effectiveness of
the innovation will be evaluated by comparing the breastfeeding outcome of this
innovation with breastfeeding data from 2013 which were revealed in a recent
survey done by the FHS (CHP, 2014).
Health care professional outcome
The level of satisfaction perceived by the frontline nurses will be the
health care professional outcome in the innovation. This will be assessed by a
self-report questionnaire.
Nature and Number of clients
Participant Eligibility
Mothers who wish to breastfeed, go to the designated MCHC with their
healthy full term babies within 72 hours after hospital discharge and provide at
50
least one contact telephone number on first registration are eligible to the
innovation. Nurses will assess the eligibility of mothers and obtain their verbal
consent during the first registration interview for the innovation.
Sample size considerations
The sample size of the innovation has been calculated by the Piface
Application selector version 1.76 (Lenth, 2011). Previous studies of similar
postnatal telephone support interventions shown differences of 17- 85% in the
breastfeeding rates between the intervention and control groups (Albernaz
Victoria, Haisma, Wright, & Coward, 2003; Bonuck, Trombly, Freeman, &
McKee, 2005; Porteous, Kaufman, & Rush, 2000 & Su et al, 2007.). Therefore, to
compare a single proportion to a known proportion based on 80% power to detect
a 15% difference in the rates of any breastfeeding up to 2 months, with the level
of significance at 5%, the calculated sample size is 277. With consideration of a
5% of dropout rate according to a similar study conducted in Hong Kong (Fu et al.,
2014), a sample size of 290 is required.
It is predicted that 80-100 potential mother-infant pairs will be able to
meet the inclusion criteria of the innovation and be recruited in one month.
Therefore, the recruitment period should last for 3 months in order to achieve the
desired sample size.
51
Outcome measurements
Rate of any breastfeeding
A breastfeeding data collection form (Appendix H) has been designed for
nurses to collect breastfeeding data during the 1 and 2 month child health
follow-up visits, or by telephone follow-up if the mother-infant pair default a
follow-up visit or the mother did not accompany the baby at the last follow-up
visit. The age of the infant and type of feeding will be documented on the form.
For mothers who report using artificial formula milk, the time when she stopped
breastfeeding will be recorded.
Satisfaction level of health care professionals
The level of satisfaction of the frontline nurses will be measured by a
self-report questionnaire (Appendix I) which will be distributed to every frontline
nurse at the end of the innovation implementation. It is composed of 8 statements
describing the perceptions of nurses about the innovation preparation and
implementation process, the competency of nurses in providing the telephone
support intervention and the overall satisfaction of nurses with the program. A
5-point Likert scale with ‘strongly agree’, ‘agree’, ‘neutral’, ‘disagree’ and
‘strongly disagree’ will be used for rating each statement.
Data analysis
The evaluation objective is to determine if the rates of any breastfeeding at
1 and 2 months increase after the innovation compared with the existing rate of
52
breastfeeding. The statistical analysis will be conducted with the use of the SPSS
Statistics for Windows version 22. The outcome data collected at the end of the
innovation will be entered into the SPSS database. A two-tailed z-test for testing
one proportion will be performed as the outcome of a single group’s proportion is
going to compare with that of a large population (Campbell & Machin, 1999). For
the level of satisfaction of the health care professionals, the means of descriptive
statistics will be used to describe the outcome data from the self- report
questionnaire (Mann, 2006).
Criteria for effectiveness
To consider a proposed innovation effective, some criteria must be met by
the identified outcomes.
Client outcomes
According to the breastfeeding survey done by the FHS in 2013 (CHP,
2014), the rates of any breastfeeding at 1 and 2 months in 2012 were 68.6% and
55.5% respectively. The innovation will be considered effective if the rates of any
breastfeeding at 1 and 2 months after the innovation are higher than 68.6% and
55.5%.
Health care professional outcome
Another criterion deciding the effectiveness of the innovation is the health
care professional outcome. It is expected that 75% of the frontline nurses will rate
‘strongly agree’ or ‘agree’ for more than 5 statements in the self-report satisfaction
53
questionnaire.
Conclusion
Years of breastfeeding promotion programs in Hong Kong have
successfully increased public awareness of the benefits and importance of
breastfeeding. Despite the significant improvement in the breastfeeding initiation
rate and breastfeeding rate on discharge, the duration of breastfeeding in Hong
Kong is still far below WHO recommendations. This suggests that insufficient
breastfeeding support for mothers after hospital discharge accounts for the short
duration of breastfeeding.
Cell phones have become very common. They are easily accessible and
not limited by geographical barriers. A telephone support intervention could be a
way to help sustain the duration of breastfeeding by providing continuous
breastfeeding support for mothers after hospital discharge and overcoming some
cultural and traditional issues in Chinese society which discourage mothers from
leaving the home to seek breastfeeding support in the early postpartum period.
Although studies investigating the effect of a telephone support
intervention are limited, most have shown positive outcomes on breastfeeding.
The five reviewed studies selected provided strong evidence that implementation
of a telephone support innovation was effective in improving the breastfeeding
rate and duration. After assessing the implementation potential, risks and benefits,
cost effectiveness of the innovation, communication with the stakeholders, and
54
implementation of the pilot study and the actual innovation followed by a
comprehensive evaluation plan, it is recommended that the proposed innovation
and the evidence-based guidelines should be adopted in Hong Kong to prolong the
duration of breastfeeding. More research could be done in this area as improving
the breastfeeding outcome is not only good for mothers and babies, but it is also
highly beneficial for the health of the public, the economy and the environment as
a whole.
55
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Appendix A – Table of Search Strategy
Electronic Database CINAHL
plus PubMed
Manual
Search
Date of search 13 June 2013 13 June
2013 30 Aug 2013
Search by keywords 1. breastfeeding OR breastfeeding
duration OR breastfeeding rate OR duration of breastfeeding OR rate of breastfeeding
2. telephone intervention Or telephone counseling OR telephone support OR professional support
3. midwife OR midwives OR nurse OR lactation consultant OR lactation counselor OR health care professional
8 297 N/A
Screening by title and abstract 1 6 N/A
Reviewed by full text 1 4 N/A
Elimination of duplication 1 3 N/A
Screening of reference list 1 3 1
Total number of eligible studies 5
66
Appendix B - Level of Evidence by Scottish Intercollegiate Guidelines Network (SIGN, 2004)
Grades of Recommendations by Scottish Intercollegiate Guidelines Network (SIGN, 2004)
Grade Statement
At least one meta-analysis, systematic review, or RCT rated as 1++, and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall
consistency of results
A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results;
or
Extrapolated evidence from studies rated as 1++ or 1+
A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results;
or
Extrapolated evidence from studies rated as 2++
Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good practice points
Recommended best practice based on the clinical experience of the guideline development group
Level of Evidence Statement
1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias
1+ Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias
1- Meta-analyses, systematic reviews, or RCTs with a high risk of bias
2++ High quality systematic reviews of case control or cohort or studies High quality case control or cohort studies with a very low risk of confounding or bias and
a high probability that the relationship is causal
2+ Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2- Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3 Non-analytic studies, e.g. case reports, case series
4 Expert opinion
67
Appendix C -Timeline of the innovation implementation
Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Establishment of communication team Application for approval from FHS & DH
Communication with in-charge of clinic
Arrangement of orientation program
Preparation of materials
Arrangement of refresher program
Subject recruitment for pilot test
Pilot test implementation
Pilot test evaluation
Subject recruitment for innovation
Innovation implementation
Data collection
Data analysis and data evaluation
Innovation evaluation
68
Appendix D - Material costs of implementing the innovation (Table 3)
Monthly salary: The mean point of monthly salary of registered nurse at point 20 in the Master Pay Scale w.e.f. 1.4. 2013: $ 31200 (Civil Service
Bureau, 2014)
Half day salary: $31200/ (44 hour per week x 4 weeks) x 4 hours (half day) = $ 709.1
The total material costs of implementing the innovation is HK$ 34,036.4.
Item Personnel / Materials Costs (HK dollars)
Refresher program (Half day)
2 identical sessions
Registered nurse of the communication team x1 Half day salary $709.1 x 2 sessions =$1,418.2
Printed materials, a room with visual and audio devices Nil (Available in MCHC)
Orientation program (Half day)
2 identical sessions
Registered nurse of the communication team x1 Half day salary $709.1 x 2 sessions =$1,418.2
Printed materials, a room with visual and audio devices Nil (Available in MCHC)
Innovation implementation
Registered nurse x1 Monthly salary $31,200
Telephone Nil (Available in MCHC)
Evaluation tool Printed questionnaires (printer, A4 papers) Nil (Available in MCHC)
Total $ 34,036.4
69
Appendix E - Material costs of not implementing the innovation (Table 4)
The total material costs of not implementing the innovation are ranged from $ 9,270,812,577 to $ 10,169,372,577.
*The author projected the amount of IDDM in the US population attributable to not breastfeeding ranging from 2% to 26% varying according to the
breastfeeding prevalence reported in other studies.
Item Estimated costs (US dollars)
Total estimated costs (US dollars)
Total estimated costs (HK dollars) [HK$7.8 = US$1 ]
Medical health care
Diarrheal disease $291,300,000
Low estimation: $1,185,900,000 High estimation: $1,301,100,000
Low estimation: $9,250,020,000 High estimation: $10,148,580,000
RSV $225,000,000
IDDM*
2%: $9,600,000 (low estimation)
26%: $124,800,000 (high estimation)
Otitis media $660,000,000
Purchasing infant formula $ 2,665,715 $ 20,792,577
Total Low estimation :$ 9,270,812,577 High estimation :$ 10,169,372,577
70
Appendix F – Workflow of the telephone support innovation
Is mother eligible to the innovation? (1) go to MCHC within 72 hours after hospital discharge [A] (2) intend to breastfeed [A] (3) has telephone access
All nurses acquired breastfeeding qualification or breastfeeding training [A] Refresher program before the innovation [A]
First call should be made within 72 hours after hospital discharge [B]
YES
Excluded from the innovation
YES
Time of next call is decided by mother and nurse [A]
Content of support Early stage: first week
1. provide general breastfeeding knowledge [A] 2. asses infant feeding and stooling patterns [A] 3. assess the emotional and physical health of
mothers [A] 4. assist mothers in managing their breastfeeding
problems [A] 5. address cultural issues [A] 6. provide breastfeeding counseling [A]
Content of support Late stage: second week onwards
1. advise on breastfeeding in public places [A] 2. advise on breast milk expression and
storage [A] 3. advise preparation for returning to school /
work [A] 4. address cultural issues [A] 5. provide breastfeeding counseling [A]
Assess whether mother is still breastfeeding the babies
Yes: Telephone support continues No: Telephone support ends
Late stage: second week onwards
Early stage: first week
71
Appendix G - Content of telephone support checklist
Content of telephone support checklist
Client Label
Content of support 1st week
2nd week
3rd week
4th week
Early stage ( first week)
1. Provide general breastfeeding knowledge (e.g. physiology of milk production, feeding frequency )
2. Assess infant feeding and stooling pattern
3. Assess mother emotional health and physical health
4. Assist mothers in managing breastfeeding related problems (e.g. sore nipples, thrush)
5. Address cultural issues on breastfeeding
Latter stage (second week onwards)
6. Advise breastfeeding in public places
7. Advise on breast milk expression and storage
8. Advise preparation for returning school/ work
9. Address cultural issues on breastfeeding
Remarks:
Week of support
Date of support Type of BF Done by
( Signature of nurse) Date of next
follow up
1st EBF / Predominant BF/
Partial BF /AF
2nd EBF / Predominant BF/
Partial BF /AF
3rd EBF / Predominant BF/
Partial BF /AF
4th EBF / Predominant BF/
Partial BF /AF
Please complete the checklist by the corresponding box(es) in which the content of support is provided.
72
Appendix H- Breastfeeding form for data collection
[At first registration] (less than 72 hours of life) Date:
Age:
Feeding type: Exclusive BF / Predominant BF/ Partial BF / Artificial formula
Signature of nurse:
[Follow- up visit] Date:
Method of data collection: Face- to face/ Telephone
Age: 1 month / 2 months / Others: months
Feeding type: Exclusive BF / Predominant BF/ Partial BF / Artificial formula
Time when stopped BF: At month(s)
Signature of nurse:
Signature of the nurse:
Breastfeeding form for telephone support intervention
Client Label
[Follow- up visit] Date:
Method of data collection: Face- to face/ Telephone
Age: 1 month / 2 months / Others: months
Feeding type: Exclusive BF / Predominant BF/ Partial BF / Artificial formula
Time when stopped BF: At month(s)
Signature of nurse:
73
Appendix I- Questionnaire of the satisfaction level of health care professionals
Please circle the most appropriate number of each statement which closely represents your feeling about the telephone support innovation
Strongly Disagree
Disagree Neutral Agree Strongly
Agree
Prior innovation implementation
1. The orientation program helps me understand the objectives and logistic of the innovation
1 2 3 4 5
2. The refresher program strengthens my BF knowledge
1 2 3 4 5
During innovation implementation
3. The workload of the innovation is acceptable 1 2 3 4 5
4. The content of telephone support checklist is easy to use
1 2 3 4 5
5. The time duration for each case is sufficient 1 2 3 4 5
6. The communication team is helpful and supportive 1 2 3 4 5
Competency & satisfaction of health care professionals
7. I am competent in providing telephone support to the mothers
1 2 3 4 5
8. I am satisfied with the innovation 1 2 3 4 5
9. The strength of this telephone support innovation: 10. The weakness of this telephone support innovation: 11. Any suggestions: