Introduction
The 2005 Infant Feeding Survey (Boiling et al, 2007) showed that nationally 78% of babies were breastfed at birth. In Sefton, a borough of Merseyside, breastfeeding initiation in 2008 to 2009 was 55%. Only three of the 22 wards in the borough achieved a figure near to the national average. In wards with high deprivation indicators, initiation was as low as 31%. Sefton is one of the five metropolitan boroughs of Merseyside and covers an area larger than Liverpool or Manchester. In the south of the borough, people experience above average mortality from a variety of preventable causes (Sefton Community Voluntary Services, accessed 2010).
The Healthcare Commission (2007) identified breastfeeding initiation as a good proxy indicator for infant health, because infants who are not breastfed are five times more likely to be admitted to hospital with infections during the first year of their life. Increasing breastfeeding rates is one of eight areas selected by Sefton Primary Care Trust's operational plan (2008) to stem and reverse the increasing levels of obesity.
UNICEF's Baby Friendly Initiative (BFI) states: 'Inform all pregnant women about the benefits and management of breastfeeding' (BFI, accessed 2010). Promotion of positive discussion about breastfeeding for those families and even practitioners where bottle-feeding is deeply embedded is challenging.
The Infant Feeding Survey (Bolling et al, 2007) found that mothers who said they intended to breastfeed were more likely to be aware of the health benefits. This suggests that raising awareness of the health benefits may be a motivating factor for the population of Sefton to support breastfeeding.
Social marketing data collected on behalf of three primary care trusts in North West England (Sefton, Liverpool and Knowsley) indicated that even those who felt 'breast was best' were easily swayed and believed bottle-feeding was almost as good, lacking knowledge of the actual health benefits (Alchemy Research Associates, 2008).
Sefton's joint strategic needs assessment points to the need for a shift in culture where breastfeeding is seen as the first choice in infant feeding (Wilson, 2008). It identifies the need for better education for the whole family and across the age ranges.
Breastfeeding Treasure Box
In Sefton, breastfeeding was discussed during parentcraft sessions but no specific format was used. A staff change in 2008 provided an opportunity to develop a new approach. A search for resources found that tools enabling the development of discussion in small groups were limited.
A lesson plan for a 'Breastfeeding Treasure Box' was found on the internet, designed for use within a socially deprived community in Arkansas as part of a series of workshops for a Special Supplemental Nutrition Program for Women, Infants and Children (Arkansas Department of Health, accessed 2010). The project ran from 2002 to 2004, but it was never evaluated.
The lesson plan contained a list of 14 items that were selected to indicate a benefit of breastfeeding, along with instructions on how the session should be run. This was accepted as detailed enough to enable delivery without any specific training.
One session in which participants take an object from the box and put forward a possible benefit of breastfeeding is intended to encourage discussion, increase knowledge and stimulate participants' interest to find out more. The interactive nature of the session allows members of the group and the group leader the opportunity to build upon experience and knowledge to help begin debriefing any preconceived notions or prejudices that individuals may have, helping people in the process of making an informed choice. Initial trial use of the tool proved successful with the group leader and the participants, so it was shared with the breastfeeding group to increase its use.
This paper describes a local evaluation of the use of this resource.
Box 1. Staff questionnaire* Why did you choose to use this tool?* Did you enjoy running this session? (yes/no)* Which groups have you delivered this session to? eg parentcraft* How many times have you delivered this session?* Approximately how big were the groups?* Do you think this tool can be delivered by staff with differentskills? (yes/no: nursery nurses, family health nurses, healthvisitors, midwives, peer support workers, health trainers,children's centre workers, teachers, others)* What training or preparation do you think is needed to run thissession?* Are there other groups you think would benefit from this session?If so please state which?* Are you aware of any similar tools to deliver education on thebenefits of breastfeeding? (yes/no) If so which do you prefer andwhy?* What are the disadvantages of this tool?* Are there further resources that would help you deliver thissession more effectively?* Any other comments?
Aim and objectives
The aim of the evaluation was to examine the acceptability of the Breastfeeding Treasure Box in parentcraft sessions and consider its potential for other settings. The objectives were to assess:
* Opinions of staff regarding their experience of delivering this session
* Opinions of staff regarding the effectiveness of the session in different settings
* Opinions of participants regarding their experience of this session
* Whether participants' experiences have resulted in learning
* Whether session participation resulted in any changes in personal belief or thinking.
Methods
Two questionnaires were designed, one for staff who delivered the sessions and one for clients who attended them. The validity of the client questionnaire was tested with staff who had experience of delivering the session and altered accordingly.
Staff questionnaires
Questionnaires were sent to staff electronically and collected by hand or email during May 2009. The small number of staff involved allowed the use of open questions (see Box 1). This enabled the collection of more in-depth answers and identification of common themes.
Client questionnaires
The client questionnaire used a five-point Likert scale and included two open questions. The scale was simple to construct, administer and score. It also gave the freedom for clients to have neutral views (Huxham, 2005).
Client questionnaires were completed following parentcraft sessions in children's centres that were located in deprived wards within Sefton. They were distributed to participants and collected by the leaders during sessions that took place from May to July 2009, placed in a sealed envelope and returned to the researchers.
In line with recognised best practice (BFI, accessed 2010) participants were not asked if they were more likely to breastfeed as a direct result of this session. Instead they were allowed the opportunity to continue considering available information so they could make an informed choice when their child was born.
Research governance
Ethical approval was not required because this was deemed to be a service evaluation. The evaluation proposal and questionnaires were scrutinised by the local research governance and public and patient involvement committees. Amendments were made accordingly. Participants were given a letter informing them of the evaluation and asking for their participation.
Data analysis
The staff questionnaire was analysed to look for common themes using content analysis.
The participant questionnaire was analysed using simple frequencies and qualitative data was analysed thematically.
Findings
Staff questionnaires
Six members of staff were surveyed, but one person did not return their questionnaire. The staff who responded included two midwives, a health visitor, a public health nurse and an infant feeding support worker.
The infant feeding support worker was also a La Leche League peer counsellor.
Four of the members of staff enjoyed delivering the session, and none were aware of any similar tools. One was unhappy at having to deliver sessions, but positive about the Breastfeeding Treasure Box itself.
In addition to parentcraft sessions, the staff had experience of delivering the session during or with:
* Antenatal clinics
* Children's centre staff
* National Breastfeeding Awareness Week
* Teenage parents
* Reception staff.
In total, the session had been delivered 24 times. One member of staff had delivered it at 12 parentcraft sessions, one had delivered it eight times in four different settings, one at three parentcraft sessions, and one had only used it once. The size of the groups varied from two to 30 participants.
When members of staff were asked about training and preparation, no special training was identified by them as being necessary to run the session. Familiarity with the lesson plan and the items in the Breastfeeding Treasure Box along with observation of a session were identified as helpful. It was agreed that the more background knowledge a session leader had, the better their ability to deal with myths, answer questions and reinforce positive messages. In addition, it was identified that facilitators with less breastfeeding knowledge may need an additional source of support for further information.
All of the staff surveyed agreed that health visitors, midwives and peer support workers trained in breastfeeding could deliver the session. Opinion was mixed regarding the ability of nursery nurses, staff nurses, health trainers, children's centre workers and teachers to deliver the session effectively. Knowledge, experience and enthusiasm were all identified as equally important to deliver an effective session:
'Could be delivered by anyone who has background knowledge and is enthusiastic. I think better session delivered by someone experienced in breastfeeding as can give antenatal experience.'
Other appropriate groups identified included antenatal groups, postnatal groups, play groups, reception staff, child minders, child care students, school children, teenagers and groups for older people.
Specific advantages were reported:
'Interactive.'
'A great way to get breastfeeding across in a group session.'
'Enjoyable and easy to deliver'
The staff member who had only delivered the session once commented:
'It was my first time using this tool and my first parentcraft session and it went really well'.
Three disadvantages were identified:
'People may only remember minor benefits'.
'It is not sufficient as a stand alone tool in the antenatal period'.
'Not everyone likes joining in.
Client questionnaires
In total, 48 questionnaires were collected (see Tables 1 and 2). Of the respondents, 16 (33%) reported no family history of breastfeeding, 16 (33%) reported not knowing much about breastfeeding prior to the session and two (4%) reported significant knowledge. This suggested that the majority of participants recognised they could learn more.
* 47 (98%) stated that they would recommend the Breastfeeding Treasure Box session to others
* 44 (92%) thought the session was fun, and the objects in the box helped them to learn or remember a benefit of breastfeeding
* 42 (88%) reported that taking an object from the box helped them to join in the session.
The Breastfeeding Treasure Box appeared to be able to influence the way people think about breastfeeding--26 (55%) reported a change in thinking and 29 (60%) wanted to learn more. In addition, 30 (63%) participants gave specific examples of their learning, which included 16 specific health benefits for the baby, six for the mother, five social benefits and 10 general benefits.
Health benefits for the baby included reducing the risk of diabetes, improving the immune response, the effect on a baby's vision, the effect of jaw action on reducing ear infections, and reducing the risk of overfilling the baby's small stomach.
Health benefits identified for mothers included reduction of breast cancer, weight loss and impact of breastfeeding on the menstrual cycle.
Social benefits included the potential for saving money, babies recognise mothers smell and 'sweeter smelling poo'.
Eight participants stated that they learned many benefits including benefits for mother as well as the baby, long-term benefits and nutritional benefits.
One participant commented:
'I didn't realise there were so many benefits to mum and baby.'
Further information was requested on the social implications of breastfeeding and details about the composition of breastmilk, and two people requested information on the benefits of bottle-feeding.
Five people commented that:
'It was a very good session.'
One person commented:
'It is a very interactive session, much better than leader led sessions.'
Limitations
The evaluation design allowed for distribution of the questionnaire to participants at five sessions, but at one session insufficient time was allocated and no questionnaires were distributed. The option to return questionnaires by post was not given, but could be considered for future evaluations.
The staff reported that everybody attending the sessions completed questionnaires though the question on gender became invalid as some couples chose to complete one form between them.
Although the participants' responses to questions were anonymous, staff could have introduced an element of bias because they had an opportunity to see the responses before returning them to the researchers.
The short time frame of the study meant that the total number of questionnaires was small. The evaluation did not extend to determining actual behaviours adopted or retention of information after the session.
Discussion
Overall, the Breastfeeding Treasure Box was viewed by staff and participants as an enjoyable and acceptable way to discuss the health benefits of breastfeeding. It encouraged participation, provided visual reinforcement and was preferred to either a leaflet or a DVD.
The package came with adequate resources, was easy to use and no specific training needs were identified. Staff saw potential for the tool to be used in a range of other settings. The best sessions were delivered by those with the most knowledge, experience and enthusiasm. It is interesting that enthusiasm was seen as important. This suggests that enthusiastic members of the community could be supported to gain the knowledge and skills to deliver the session to a wide variety of groups.
Background knowledge was important to enable the group leader to answer questions effectively, tackle myths and reinforce positive messages. The most highly trained staff should therefore deliver sessions to those who are in the process of making a choice about infant feeding.
Increased knowledge of the health benefits increases likelihood of people choosing to breastfeed (Bolling et al, 2007). It is therefore an important benefit of the session that knowledge is increased. The present lesson plan and contents of the box could be further improved to ensure that the group leader has an opportunity to cover health benefits that are supported by the most reliable evidence (BFI, 2008).
The objects in the box helped people to participate and were a significant aid to learning. This supports research that shows adult learners like to share their knowledge and contribute to the learning experience (Knowles et al, 1998). Regardless of any previous knowledge, the majority of the group learned something they did not expect to, showing that the tool reinforces existing knowledge and builds new knowledge.
Although some participants were able to quote benefits of breastfeeding at the end of the session, it was not always clear if they had understood the whole message. This shows the need to reinforce benefits regularly throughout the antenatal period. The findings reflect that learning does not always result in an instant change in thinking (Kolb et al, 1974).
The National Institute for Health and Clinical Excellence (2008) recommends the adoption of a multifaceted approach across different settings to increase breastfeeding rates. The Breastfeeding Treasure Box is a suitable tool to help people through the changes in attitude necessary to achieve this.
Two suggestions were made about how to improve the session:
* Information about practical aspects of breastfeeding, which is now provided in a breastfeeding workshop
* Two people asked for information about bottle-feeding.
This reflects the findings of local social marketing research asking for a comparison of bottle versus breast, and has been provided by the development of a local leaflet and website (Alchemy Research Associates, 2008).
Recommendations for practice
* The most highly trained staff should continue to deliver sessions to those who are in the process of making an informed choice about breastfeeding, in order to ensure that questions are dealt with effectively
* The lesson plan and the box of objects need to be adapted to reflect more specific health benefits of breastfeeding as identified by the BFI
* This tool should be used not only in the antenatal or children's settings but to educate those who may influence potential mothers, such as fathers, grandparents, childminders and teenagers
* Willing volunteers and workers from settings such as children's centres should be trained to deliver this session so that a wider variety of people are reached.
Declared potential competing interests: The authors both work for the organisation providing the service that was evaluated.
KEY POINTS
* Breastfeeding Treasure Box sessions were enjoyed by both staff and participants
* Participants reported learning and changes in the way they thought about breastfeeding
* The Breastfeeding Treasure Box lesson plan and contents could be developed to include more research based health benefits of breastfeeding
* The Breastfeeding Treasure Box has potential for use in a wide range of settings
* The tool is suitable to be used as part of a variety of approaches and in a variety of settings to increase knowledge and contribute to change in attitudes to breastfeeding
References
Alchemy Research Associates. (2008) Increasing breastfeeding rates across North Mersey: public health consultation. Sefton: NHS Sefton, NHS Liverpool and NHS Knowsley.
Arkansas Department of Health. (undated) Arkansas WIC program. See: www.healthy.arkansas.gov/ programsServices/WIC (accessed 14 Dec 2010).
Baby Friendly Initiative/BFI. (undated) Point 3 Inform all pregnant women about the benefits and management of breastfeeding. See: www.babyfriendly.org.uk/page.asp?page=74 (accessed 14 Dec 2010).
BFI. (undated) Health benefits of breastfeeding. See: www.babyfriendly.org.uk/page.asp?page=20 (accessed 14 Dec 2010).
BFI. (2005) Inform all pregnant women of the benefits and management of breastfeeding. See: www.babyfriendly.org.uk/items/item_detail.asp? item=42 (accessed 14 Dec 2010).
BFI. (2008) Three day course in breastfeeding management: participant's handbook. London: BFI.
BFI. (2009) Train the trainer course handbook. London: BFI.
Bolling K, Grant C, Hamlyn B, Thornton A. (2007) Infant Feeding Survey 2005. London: Office for National Statistics.
Department of Health. (2004) CAMHS Standard, National Service Framework for children, young people and maternity services. London: Department of Health.
Dykes F. (2006) Breastfeeding in hospital: midwives, mothers and the production line. London: Routledge
Healthcare Commission. (2007) Infant health and inequalities: breastfeeding initiation rates. London: Healthcare Commission.
Huxham M. (2005) Scientific methods: introduction to questionnaires. See: www.lifesciences.napier.ac.uk/ teaching/SM/Quest.htm (accessed 14 Dec 2010).
Knowles MS, Hoton EF, Swanson RA. (1998) The adult learner (fifth edition). Oxford: Butterworth Heinman.
Kolb DA, Rubin IM, McIntyre JM. (1974) Organizational psychology: a book of readings (second edition). Englewood Cliffs, New Jersey: Prentice-Hall.
National Institute for Health and Clinical Excellence/NICE. (2008) Maternal and child nutrition. London: NICE.
Scientific Advisory Committee on Nutrition. (2008) Infant Feeding Survey 2005: a commentary On Infant practices in the UK. London: Stationery Office.
Sefton Community Voluntary Services. (undated) Sefton profile. See: www.seftoncvs.co.uk/index.php? option=com_content&task=view&id=24 (accessed 14 Dec 2010).
Sefton Primary Care Trust. (2008) Sefton PCT operational plan 2008-2009. Sefton: Sefton Primary Care Trust.
Wilson A. (2008) Better life better health: Seftons joint strategic needs assessment. Waterloo: Sefton Community Voluntary Services.
Monica K Clarkson PGDip, BSc, Dip, RHV, RGN
Infant feeding coordinator, NHS Sefton
Ruth A du Plessis MSc, BN, DipHAT, RHV, RN
Public health development manager, NHS Sefton
Correspondence: monica.clarkson@sefton.nhs.uk
Table 1. Client questionnaires: questions 1 to 8StronglyStatement agree Agree NeitherParticipating in the session 34% (n=16) 58% (n=28) 4% (n=2)was funThe object I took from the 38% (n=18) 50% (n=24) 6% (n=3)box helped me join inEach object helped me learn 46% (n=22) 46% (n=22) 8% (n=4)or remember a benefit ofbreastfeedingAttending the session has 15% (n=7) 40% (n=19) 35% (n=17)changed the way I think aboutbreastfeedingI could have learned as much 2% (n=1) 2% (n=1) 40% (n=19)as I did today by watching aDVDI could have learned as much 0 4% (n=2) 14% (n=7)today by reading a leafletI already knew lots about 4% (n=2) 34% (n=16) 29% (n=14)breastfeeding prior to thissessionPeople in my family have 13% (n=6) 33% (n=16) 21% (n=10)mostly breastfedStronglyStatement Disagree disagreeParticipating in the session 4% (n=2) 0was funThe object I took from the 6% (n=3) 0box helped me join inEach object helped me learn 0 0or remember a benefit ofbreastfeedingAttending the session has 10% (n=5) 0changed the way I think aboutbreastfeedingI could have learned as much 50% (n=24) 6% (n=3)as I did today by watching aDVDI could have learned as much 67% (n=32) 15% (n=7)today by reading a leafletI already knew lots about 29% (n=14) 4% (n=2)breastfeeding prior to thissessionPeople in my family have 23% (n=11) 10% (n=5)mostly breastfedTable 2. Client questionnaires: questions 9 to 11Statement/question Yes No No responseI want to find out more about 60% (n=29) 38% (n=18) 2% (n=1)breastfeeding as a result oftoday's sessionI would recommend this 98% (n=47) 2% (n=1) 0session to othersWas there something you 71% (n=34) 25% (n=12) 4% (n=2)learned that you did notexpect to?
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