Process evaluation of The Breastfeeding Trial. What factors impact the intervention delivery?

BACKGROUND: Breastmilk is the ideal nutrition for infants, and breastfeeding is an important health promoting behaviour. In Denmark, most mothers initiate breastfeeding but many cease within the first months resulting in just 14% reaching the World Health Organization recommendation of six months exclusive breastfeeding. A large-scaled, cluster-randomized intervention study implemented in the Danish health visiting programme aimed to extent the duration of breastfeeding and reduce social inequality. To elucidate how the intervention was implemented, a process evaluation of the intervention was conducted. METHODS: Following the MRC guidelines for process evaluation, we used a mixed methods approach to assess the delivery of the intervention, and facilitators and barriers in the context that affected the implementation. Data from questionnaires distributed to the health visiting managers of 21 Danish municipalities and 242 health visitors employed there, and data from three focus groups with health visitors and eight individual interviews with mothers in the intervention informed the process evaluation. RESULTS: Preliminary findings from questionnaires imply that the training program slightly enhanced health visitors’ breastfeeding support competencies. However, health visitors explained in the focus groups that they provided support as usual. A contextual factor hindering the implementation was change of personnel. Having had favourable experiences with the intervention acted as facilitator. Findings from interviews with mothers indicated a high fidelity in the distribution of intervention materials and partner involvement. CONCLUSIONS: Preliminary findings of this study show variability in how the intervention was implemented throughout the intervention sites. This evaluation will assist in the interpretation of the results of the effectiveness study and inform policy makers about if and how this intervention could be scaled up. KEY MESSAGES: • Health visitors in intervention clusters seemed to have gained competencies in breastfeeding support; however, expressed that they provided support ‘as usual’. • Change of personnel acted as a barrier, while having had positive experiences with the intervention acted as a facilitator.