Implementation of a community-based breastfeeding support intervention to prolong duration of and reduce social inequality in exclusive breastfeeding: a mixed-methods systematic process evaluation in a cluster-randomised trial

Abstract

Background Breastfeeding is a powerful public health intervention that produce long-term health benefits. Still, in high-income countries such as Denmark, breastfeeding rates are suboptimal and distributed unequally across socio-economic positions. The ‘Breastfeeding – a good start together’ intervention to promote longer duration of and reduce social inequality in exclusive breastfeeding, was rolled out in a cluster-randomised trial during 2022–2023 in a sample of 21 municipalities in two Danish regions. A process evaluation was conducted to assess the fidelity and quality of the implementation and identify possible contextual factors that might have impacted the proposed mechanisms of change. Methods The Medical Research Counsel framework for conducting process evaluations guided the study, which was conducted using mixed-methods in a convergence design. Quantitative data: contextual mapping survey (n = 20), health visitor survey (n = 284), health visitor records from 20 clusters and intervention website statistics. Qualitative data: dialogue meetings (n = 7), focus groups (n = 3) and interviews (n = 8). Results Overall, the intervention was delivered as planned to intended recipients, with few exceptions. Health visitors reacted positively to the intervention, which they expressed fitted well within their usual practice and which they believed to enhance families’ chances for breastfeeding. Mothers expressed having received the intervention, with few exceptions, and reacted positively to the intervention. Health visitors worried about stigmatisation of the mothers receiving the intensified intervention, however none of the interviewed mothers had felt stigmatised. Contextual factors impacting the intervention implementation and mechanisms were staff- and management turnover, project infrastructure and mothers’ context, including resources, social network and previous experiences. Conclusions The overall fidelity of the intervention delivery was high. Health visitors and families responded well to the intervention. Interventions aimed at enabling health care providers to deliver simplified and structured breastfeeding support, in accordance with the support in other sectors of the health care system, may be a means to increase breastfeeding rates and reduce social inequality in breastfeeding, also in international contexts. Trial registration Clinical Trials: NCT05311631. First posted April 5, 2022.