Abstract of dissertation entitled

“Evidence-based Guideline for Peer Support Service

to Increases Breastfeeding Outcomes”

Submitted by

Yu Wai Ying Oma

For the degree of Master of Nursing

at The University of Hong Kong

in August 2016

Exclusive breastfeeding (EBF) is highly recommended by healthcare professionals

worldwide for babies below six months old. In Hong Kong, despite the high initiation rate of

breastfeeding at hospitals, the EBF rate drops significantly when measured in community and so

as the breastfeeding (BF) rate. Supportive measures for breastfeeding are present in community

for long time. These include breastfeeding workshops for pregnant women at antenatal period

and breastfeeding support groups for breastfeeding mothers at postnatal period. Both of these

interventions are nurse-led. However, new evidences suggested that peer-led breastfeeding

intervention is more effective in raising EBF and BF rate. This innovation is called peer support

service. It is a provision of breastfeeding support by peers who have similar backgrounds or

experiences to the pregnant women from antenatal to postnatal period. The support can be in

forms of information, knowledge, skills, encouragement, etc.

The aim of this paper is to explore the evidences of peer support service to increase

breastfeeding outcomes, analyze its implementation potential to apply in Hong Kong setting and

develop an evidence-based guideline for application. Finally, recommendations on its

implementation and evaluation are stated at the end.

Eight randomize-controlled studies of peer support service were identified after conduction

of a systematic literature review. Critical appraisal was done and the level of evidence was

graded according to the Scottish Intercollegiate Guidelines Network (SIGN) for each of the

studies. Then the implementation potential of the peer support service was assessed based on its

transferability, feasibility and cost-benefit ratio. Evidence-based practice guideline was

developed based on the level of evidence with grades of recommendation stated. Communication

plan and pilot study plan were suggested under the implementation plan. Finally evaluation plan

was discuss to evaluate the effectiveness of the innovation. With the implementation of this peer

support service in the community, breastfeeding mothers will be better supported and thus the

EBF and BF rate should be extended.

Evidence-based Guideline for Peer Support Service to Increase Breastfeeding

Outcomes

by

Yu Wai Ying Oma

BSc. (Hons) Nursing HKPU

A thesis submitted in partial fulfilment of the requirements for

the Degree of Master of Nursing

at The University of Hong Kong.

August 2016

i

Declaration

I declare that this thesis represents my own work, except where due acknowledgement is

made, and that 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………………………………………………………………………………

Yu Wai Ying Oma

ii

Acknowledgements

I would like to convey my deepest gratitude to my supervisor, Dr. Elizabeth Hui, for her

guidance, patience and expert advice in the process of writing this dissertation.

I would also like to thank the Department of Health for providing the sponsorship for me to

complete this Master of Nursing program. Special thanks must be said to the nursing officers in

my center and all of my colleagues. Without your support and help, I could not be released for all

the lectures on time and attend those urgent date-changed lectures.

Finally, I would like to thank my groupmates and peers who studied the same track with me

in these two years. My study would not be that smooth and happy without you.

iii

Contents

Declaration ....................................................................................................................................... i

Acknowledgements ......................................................................................................................... ii

Table of Contents ........................................................................................................................... iii

Chapter 1: Introduction ................................................................................................................... 1

1.1 Background ....................................................................................................................... 1

1.2 Affirming the Need ........................................................................................................... 2

Current breastfeeding rate ............................................................................................... 2

Current strategies ............................................................................................................ 3

Innovation ....................................................................................................................... 4

1.3 Objectives and Significance .............................................................................................. 5

Objectives ....................................................................................................................... 5

Significance..................................................................................................................... 6

Chapter 2: Critical Appraisal .......................................................................................................... 7

2.1 Search and Appraisal Strategies ........................................................................................ 7

Search strategies.............................................................................................................. 7

Inclusion criteria ............................................................................................................. 7

Exclusion criteria ............................................................................................................ 8

2.2 Results ............................................................................................................................... 8

Quality assessment ........................................................................................................ 10

2.3 Summary and Synthesis .................................................................................................. 12

Subject characteristics ................................................................................................... 13

Intervention ................................................................................................................... 13

Control .......................................................................................................................... 14

Peer supporters .............................................................................................................. 15

Methodological quality ................................................................................................. 16

Chapter 3: Implementation Potential and Clinical Guideline ....................................................... 18

3.1 Transferability of the Findings ........................................................................................ 18

Target setting ................................................................................................................. 18

Target population .......................................................................................................... 18

Philosophy of care......................................................................................................... 19

Number of beneficial clients ......................................................................................... 19

Time frame .................................................................................................................... 20

3.2 Feasibility ........................................................................................................................ 20

Nursing autonomy and current staff function ............................................................... 20

Administrative and organizational support ................................................................... 21

Risk of friction .............................................................................................................. 21

Resources and equipment ............................................................................................. 22

Evaluation ..................................................................................................................... 22

3.3 Cost-benefit Ratio ........................................................................................................... 23

Potential risks ................................................................................................................ 23

Potential benefits ........................................................................................................... 23

iv

Cost of implementation ................................................................................................. 24

Evidence-based practice guideline ................................................................................ 25

Chapter 4: Implementation Plan ................................................................................................... 26

4.1 Communication Plan ....................................................................................................... 26

Stakeholders .................................................................................................................. 26

Communication team .................................................................................................... 27

Communication with administrators ............................................................................. 27

Communication with frontline staffs and peer supporters ............................................ 27

4.2 Pilot Study Plan............................................................................................................... 28

Time frame of pilot study .............................................................................................. 28

Evaluation of pilot study ............................................................................................... 29

4.3 Evaluation Plan ............................................................................................................... 29

Intervention outcomes and measurement ...................................................................... 29

Nature of clients ............................................................................................................ 31

Sample size ................................................................................................................... 31

Data analysis ................................................................................................................. 32

4.4 Basis for Implementation ................................................................................................ 32

4.5 Conclusion ...................................................................................................................... 32

References: .................................................................................................................................... 34

Appendix I: Methodology Checklist for Randomized Controlled Trial ....................................... 40

Methodology Checklist 2: Controlled Trials ................................................................................ 40

Appendix II: Modified PRISMA 2009 Flow Diagram ................................................................. 42

Appendix III: Table of Evidence ................................................................................................... 43

Appendix IV: Quality Assessment Using SIGN Methodology Checklist for Controlled Trials ... 47

Appendix V: Budget Plan ............................................................................................................. 49

Appendix VI: Grade of Recommendations ................................................................................... 51

Appendix VII: Practicing Guideline ............................................................................................. 52

Appendix VIII: Evaluation Form for Peer Supporter ................................................................... 57

Appendix IV: Evaluation Form for Service Recipient .................................................................. 58

1

Chapter 1: Introduction

Breastfeeding has countless benefits to babies, mothers and the societies. Despite of these

benefits, the exclusive breastfeeding rate in Hong Kong is low and the duration is short.

Although the government has implemented the breastfeeding policy in public hospitals, after the

newborns were discharged to homes, breastfeeding could not be maintained. Intervention focus

on community setting like peer support service may be a possible solution for this problem. In

this chapter, the current breastfeeding practices, the needs and significant of change in current

interventions will be discussed and peer support service will be introduced.

1.1 Background

Exclusive breastfeeding for 6 months is the optimal way of feeding babies. About 800 000

children lives would be saved every year if they were fed in this optimal way (Black et al., 2013).

Even in developed countries where artificial feeding is affordable, clean water is available and

good hygienic conditions for preparing and feeding infant formula exist, all mothers should be

encouraged to breastfeed their babies. World Health Organization (WHO) recognized

breastfeeding as an economical, safe and effective strategy to solve undernutrition problem in

infancy. It recommended early initiation of breastfeeding within 1 hour of birth, exclusive

breastfeeding for the first 6 months of life and continuation of breastfeeding up to 2 years or

beyond together with complementary foods start at 6 months. Exclusive breastfeeding (EBF)

means that a baby only receives breast milk without any additional food or drink, not even water

(WHO et al., 2008). It should be fed on baby’s demand, as often as the baby wants in day and

night.

In 1989, WHO together with United Nations Children’s Fund (UNICEF) issued a joint

2

statement of “ten steps to successful breastfeeding” (WHO & UNICEF, 1989) as a guideline for

facilities which provide maternity or infant care service to implement practices that protect,

promote and support breastfeeding. It stated in step 10 that the facility should foster the

establishment of breastfeeding support groups and refer mothers to them on discharge from the

hospital or clinic. Peer support is one of the examples of breastfeeding support that can be

provided to breastfeeding mothers in public healthcare setting. In general, peer is defined as

people other than parents, siblings or relatives who have the same or similar experience as the

target people. In this paper, peer is a lay woman who has breastfeeding experience or living in

the same neighborhood as the clients with proper training of breastfeeding knowledge and skills.

Peer support service in this paper refers to the service provided by the peer to mothers with the

aim to motivate their determinacies of breastfeeding, solve their breastfeeding problems and

prolong their breastfeeding duration. This includes breastfeeding information provision,

demonstration and return demonstration of breastfeeding positioning, giving practical advice or

suggestion, emotional validation, counselling, sharing of breastfeeding experience, etc.

1.2 Affirming the Need

Current breastfeeding rate

Despite of numerous benefits of breastfeeding over formula milk feeding, exclusive

breastfeeding has not been practiced by the majority of public. When asked of future feeding

method, most pregnant women in Hong Kong planned of breastfeeding during antenatal period.

But when asked again after delivery for some days, most of them said they had ever tried

breastfeeding but only some of them continued breastfeeding. If asked in details, the number of

mothers who exclusively breastfed their babies was scanty and the breastfeeding duration was

short, especially those who planned to resume to work after maternal leave. According to a

3

survey done by UNICEF Baby Friendly Hospital Initiatives Hong Kong Association in 2015, the

breastfeeding rate on discharge was 86.3% while the EBF rate was 27.4%. At 6 month, the

breastfeeding rate was lowered by half to 41% while the EBF rate dropped to 1.2% (Department

of Health, 2015). The findings reflected that majority of Hong Kong mothers initiated

breastfeeding in hospitals but gradually changed to formula milk in 6 month time. The EBF rate

is low with partial BF is the main form of breastfeeding.

Current strategies

To promote breastfeeding, multiple strategies have been used and cooperation between

different organizations was required in order to facilitate and support breastfeeding mothers and

babies. In 1994, the Baby Friendly Hospital Initiative Hong Kong Association (BFHIHKA) was

registered with the aim of supporting mothers to breastfeeding. Activities such as the world

breastfeeding week in Hong Kong are held every year to raise public awareness of breastfeeding.

It also encourages all hospitals with maternity units to become “baby friendly”. Currently four

public hospitals namely Queen Elizabeth Hospital, Queen Mary Hospital, Kwong Wah Hospital

and Prince of Wales Hospital had started their Baby Friendly Hospital accreditation process.

Practices of “Ten steps to successful breastfeeding” and “International code of marketing of

breastmilk substitutes” were implemented in these hospitals as well as in some other hospitals.

Now over 90% of hospitals in Hong Kong including private hospitals have a written

breastfeeding policy to all health care staff and training of staff in skills necessary to implement

this policy.

Another public healthcare service provider which fully supports breastfeeding is maternal

and child health centers (MCHCs) under Department of Health (DH). There are 32 MCHCs all

over Hong Kong to provide maternal health service to pregnant and postnatal women and child

4

health service to children from newborn to age of 6. Breastfeeding promotion starts as early as

initial antenatal service by delivery of breastfeeding booklets and breastfeeding hotline. At third

trimester, pregnant women can join breastfeeding workshops to know more about benefits of

breastfeeding and learn different breastfeeding positions. When they come with their babies for

child health service, breastfeeding coaching can be provided to improve their breastfeeding skills

and solve their breastfeeding problems. A nurse-led breastfeeding support group is held monthly

in each MCHC with aims to share of breastfeeding experiences and prolong breastfeeding

duration. However, the attendance rates of this support group are low and thus the support to

breastfeeding mothers maybe insufficient.

Innovation

Although breastfeeding is a choice made by mothers, many factors can affect how they

make this choice. For example, their knowledge about breastfeeding, misconceptions of

breastfeeding, previous breastfeeding experiences and support from husbands, families and

friends. Peer support service can be a means to deliver the knowledge, correct the

misconceptions and share of breastfeeding experience while providing support to the mothers. A

recent study focused on factors contributing in early breastfeeding cessation in Chinese women

also suggested that greater postnatal breastfeeding support after mothers returned home would

increase their confidence in breastfeeding (Tarrant, Dodgson & Wu, 2014). Peer support service

has already shown positive effective especially in empowerment in mental illness patients, breast

cancer patients and parents of disabled children (Castelein, Bruggeman, Davidson & Gaag, 2015;

Mollica et al., 2014; Shilling, Bailey, Logan & Morris, 2015). Besides, evidence was found that

the provision of breastfeeding support, no matter from healthcare professionals or non-healthcare

professionals, might increase the number of women to continue breastfeeding (Oakley,

5

Henderson, Redshaw & Quigley, 2014; Tarrant et al., 2010). Peer support as an intervention to

raise EBF and BF rate was demonstrated by a numbers of studies (Chapman, Damio, Young &

Pérez-Escamilla, 2004; Kushwaha et al., 2014; Morrow et al., 1999; Tylleskär et al., 2011).

Evaluation of a peer support intervention showed a positive feedback from mothers, peer

supporters and also from the health care professionals (Ingram, 2013). Participated mothers

reported of an increase in confidence to breastfeed and thought it should be available to all

women. WHO also recognized breastfeeding support as one of the key element in successful

breastfeeding that need to be promoted. It seems that peer support service has the potential to

replace current breastfeeding support group and improve the low EBF rate and short duration in

current practice. The latest systematic review of the effectiveness of peer support in

breastfeeding was done in 2012 by Kaunonen and his colleagues. Their definition of peer

supporter was anyone who supported breastfeeding exclude healthcare professionals. This

included clients’ partners, grandmothers, relatives and friends and was different by definition

from the peer supporter mentioned in this paper. Also the reviewed studies were published

between 2000 and 2008. There is a need for an updated systematic view to include new

evidences from studies so as to explore the efficacy of this innovation in community level rather

than family level.

1.3 Objectives and Significance

Objectives

This paper is writing to answer a searchable clinical question “Can peer support

intervention increase breastfeeding outcomes in Hong Kong?” The target population is pregnant

women in Hong Kong. The intervention is the breastfeeding peer support service with

comparison to no peer support or standard care in current practice. The primary outcome was the

6

exclusive breastfeeding rate and secondary outcome was the duration breastfeeding. The

objectives of this paper are to (1) review published evidences of peer support to increase EBF

and BF rates, (2) critically appraise these evidences, (3) assess the feasibility of setting up peer

support service in Hong Kong, (4) develop of evidence-based practice guidelines of peer support

service, (5) recommend an implementation plan and (6) propose of an evaluation plan.

Significance

The phenomenon of high breastfeeding initiation rate but low exclusive breastfeeding rate

and short overall breastfeeding duration indicated that breastfeeding mothers were under support.

Local studies explored factors contributing to early breastfeeding cessation among Hong Kong

Chinese mothers revealed that unnatural expectation, uncertainty, insufficient breastmilk and left

to figure it out were the main reasons for weaning of breastfeeding (Tarrant, Dodgson & Wu,

2014; Wang, Lau, Chow & Chan, 2014). Since breastfeeding is “natural”, some mothers

expected it would come naturally and easily. But in reality, especially at the first few days after

delivery, they experienced insufficient breastmilk and uncertain whether babies were fed enough.

They would be prone to discontinue breastfeeding if left alone. Peer support service can help

mothers at this critical period. By sharing the experience from peer supporters, mothers would

have a more realistic expectation of breastfeeding and learn ways to increase breastmilk

production and breastfeeding skills. When they have uncertainties about breastfeeding, they

could contact peer supporters. Thus peer support service is a tailor-made breastfeeding service to

increase mothers’ confidence in breastfeeding and prolong breastfeeding duration and

exclusivity.

7

Chapter 2: Critical Appraisal

After affirming the needs and significance of using peer support service as an intervention

to boost the EBF and BF rate in Hong Kong, this chapter will review and assess the evidences of

its effectiveness.

2.1 Search and Appraisal Strategies

Search strategies

Three databases were searched for identifying literatures, namely PubMed, CINAHL

Plus(EBSCOhost) and OVIDSP Databases. Two sets of keywords were used when searching.

The first set was “peer” or “peer support” or “peer counsel”. The second set was “exclusive

breastfeed” or “exclusive breastfeeding” or “exclusively breastfeed”. Two trials of search were

done with each trial only used one set of keywords. After that in the third trial, the search was

done by combining all the results of the two trials together. The year of publication was set to

between 2000 and 2015. Manual search was done by reading the reference lists of literatures

related to peer support in breastfeeding. After screening and selection of studies, the resulted

studies were appraised by using the checklist for randomized controlled trail according to the

Scottish Intercollegiate Guidelines Network (SIGN) 2014 (Appendix I) to assess their quality

and level of evidence. Literatures were identified according to the following criteria.

Inclusion criteria

Studies using peer support as an intervention were included. The support could be started in

antenatal or postnatal period without time restriction. There was no restriction on the delivery

ways of support. It could be done by hospital visiting, home visiting or telephone interview. But

the peer must not be family members or relatives of participants and must share some similarities

with participants such as having breastfeeding experience or living in the same neighborhood as

8

the participants. The content of peer support must be limited to breastfeeding. This includes

promoting the benefits of breastfeeding, solving breastfeeding difficulties faced by participants,

helping participants to psychologically prepare and continue for breastfeeding, etc. Both paid and

voluntary peers were included. To increase the recognition level of evidences which later be

extracted to develop guideline for practice, only randomized controlled trial studies were

included.

Exclusion criteria

Mothers or pregnant women who had mental illness or other medical conditions that

affected breastfeeding were excluded. There was no restriction on the age of participants as long

as they were fit for breastfeeding. However, in known case of HIV in Hong Kong, mothers are

advised to feed formula milk instead of breastfeed due to the chance of HIV transmission to

babies. So known HIV positive women were excluded but screening of HIV status was not

compulsory for participants. Those mothers of babies with congenital abnormality, significant

illness and needed to stay in intensive care unit or special care unit were excluded. The gestation

of pregnancy was not limited as long as the babies born were healthy and abled to be breastfed

but twins or multiple births were excluded.

The primary outcome of current innovation is the prevalence of exclusive breastfeeding

while the secondary outcome is the prevalence of breastfeeding. Studies which did not measure

the prevalence of exclusive breastfeeding was excluded. Measurement of secondary outcome

was optional.

2.2 Results

The searching was done on 1st October 2015. Among a total of 124 studies, 76 studies were

found by PubMed, 9 studies were found by CINAHL Plus (EBSCOhost) and 39 studies were

9

found by OVIDSP Databases. Three studies were identified by manual search from reference

lists. After removal of duplicated studies, 81 studies were left for further filtering according to

the inclusion and exclusion criteria as stated before. At this stage, 63 studies were screened out,

and among the remaining 18 studies, only 12 of them were full-text articles in English and able

to be assessed. Four studies were screened out as they were either currently on-going controlled

trial without result released or unmatched study groups. Finally, 8 studies met all the criteria for

critical appraisal. The flow of selection can be referred to appendix II.

Eight studies were identified after searching and filtering. Two studies took place in Asia, 2

in Africa, 1 in South America and 3 in North America. The sample size in the studies was

ranging from 103 to 2,579. The publication year of the studies was between 2000 and 2015. All

were written in English. Five studies compared mothers with peer support service to those

without such service/standard care. Four of them found raised EBF rate (Dennis, Hodnett, Gallop

& Chalmers, 2002; Haider, Ashworth, Kabir & Huttly, 2000; Leite, Puccini, Atalah, Da Cunha &

Machado, 2005; Tylleskär et al., 2011) while 1 found raised BF rate as well (Dennis et al., 2002)

but 1 found no such effect on neither EBF nor BF rate (Srinivas, Benson, Worley & Schulte,

2015). Other 3 studies had 2 intervention arms. Mothers with breastfeeding peer support were

compared to mothers with childcare peer support and those without any peer support service. The

result was that breastfeeding peer support service raised both EBF and BF rate (Agrasada,

Gustafsson, Kylberg & Ewald, 2005). Two studies tried high and low frequency of peer support

service compare to standard care. One found no difference in breastfeeding outcomes between

high and low frequency but BF rate was raised (Reeder, Joyce, Sibley, Arnold & Altindag, 2014).

Another study found peer support raised both EBF and BF rate, especially the high frequency

service (Ochola, Labadarios & Nduati, 2013). The effect size of all the eight studies varied from

10

-2% to 64%. Four studies (Agrasada et al., 2005; Haider et al., 2000; Leite et al., 2005; Tylleskär

et al., 2011) delivered support by home visit while two studies delivered by telephone (Dennis et

al, 2002; Reeder et al., 2014). Other two studies used mix approach of home visit and

center-based (Ochola et al., 2013) or telephone and center-based (Srinivas et al., 2015). The

subject characteristic varied in different studies. Some with majority of uniparous, educated

women but others were multiparous, low education level women. The findings in each study

were summarized into table of evidences which can be referred to appendix III.

Quality assessment

All the 8 studies were assessed according to the SIGN 2014 (Appendix I) with methodology

checklist of randomized controlled trials. It included 10 aspects to assess whether a randomized

controlled trial is well conducted or not. All of the 8 studies addressed and focused clearly on the

effectiveness of peer support intervention in exclusive breastfeeding prevalence plus or minus

breastfeeding prevalence. Randomization method was mentioned in all the 8 studies. Three

studies (Ochola et al., 2013; Reeder et al., 2014; Tylleskär et al., 2011) used the computer

generated random numbers while another 3 studies (Agrasada et al., 2005; Haider et al., 2000;

Leite et al., 2005) used random number table. Srinivas and her colleagues (2015) used strata in

blocks of 4 method while Dennis and her colleagues (2002) invited a biostatistician who was not

involved in the recruitment process to construct the random numbers. Randomization was done

to the zones, villages or clusters rather than the women or mother-baby pairs in 3 studies (Haider

et al., 2000; Ochola et al., 2013; Tylleskär et al., 2011). Only three studies described concealment

method such as using sealed envelopes and coding (Agrasada et al.,2005; Dennis et al, 2002;

Leite et al., 2005). Other studies did not mention about it. Due to the nature of current

intervention, it was impossible to blind the subjects about the intervention or the peers who

11

provided support. But 3 of the studies had 2 intervention arms (differencing in frequency of peer

support or content of peer support), and the subjects were not informed of other intervention

arms (Agrasada et al., 2005; Ochola et al., 2013; Reeder et al., 2014). To minimized the bias,

blinding to data collectors was achieved in 7 studies (Agrasada et al., 2005; Dennis et al., 2002;

Haider et al., 2000; Leite et al., 2005; Ochola et al., 2013; Reeder et al., 2014; Tylleskär et al.,

2011).

Six studies reported no significant difference between intervention and control groups for

baseline characteristics (Agrasada et al.,2005; Haider et al., 2000; Leite et al., 2005; Reeder et al.,

2014; Srinivas et al., 2015; Tylleskär et al., 2011). One study (Dennis et al, 2002) reported higher

percentage of subjects in peer support group decided to breastfeed before pregnancy while

another study (Ochola et al., 2013) reported higher percentage of subjects in peer support group

knew that breastfeeding should be started within 1 hour after delivery. The only difference

between intervention and control groups was the presence of peer support service in all the 8

studies. But as mentioned before, 3 studies had 2 intervention arms, so the frequency of peer

support service was different between the two intervention arms. In Agrasada study, 1

intervention group was breastfeeding peer support while another intervention group was

childcare peer support. The difference between intervention and control groups was only the

presence of peer support but with different content. All the primary outcome of 8 studies was

measured in form of prevalence of EBF at particular time interval. Some studies also measured

breastfeeding or non-exclusive breastfeeding prevalence as secondary outcomes. Two studies

were analysis in intention to treat approach (Agrasada et al.,2005; Tylleskär et al., 2011). The

dropout rate of 8 studies ranged from 0% to 27.5% in time of 1 month to 6 months. Two studies

had a dropout rate more than 20% (Haider et al., 2000; Ochola et al., 2013). Three studies were

12

carried out at more than one site. But only 1 study (Tylleskär et al., 2011) listed the result of

intervention and control group with corresponding districts and the results were comparable for

all sites. The results in the other 2 studies of different villages or zones were merged together

with significant findings (Haider et al., 2000; Ochola et al., 2013). After reviewing the quality of

the 8 studies, 1 study was rated as 1++ as majority of criteria met with little risk of bias

(Agrasada et al., 2005). 2 studies were rated as 1+, indicating most criteria met with associated

risk of bias (Dennis et al, 2002; Leite et al., 2005). The rest of the studies were rated as 1-, as

allocation concealment were not mentioned and so with some risk of bias (Haider et al., 2000;

Ochola et al., 2013; Reeder et al., 2014; Srinivas et al., 2015; Tylleskär et al., 2011). The

summary of the quality assessment can be referred to appendix IV

2.3 Summary and Synthesis

The primary outcome of all the 8 studies was prevalence of EBF and some with secondary

outcome as breastfeeding prevalence. The quality of all the 8 studies was graded from 1- to 1++.

The measurement of the studies started as early as discharge and up to 24 weeks. Only one study

with quality of 1- found no positive effect of peer support on EBF rate or BF duration (Srinivas

et al., 2015). One 1++ study, two 1+ studies and four 1- studies demonstrated peer support can

increase the EBF rate (Agrasada et al.,2005; Dennis et al, 2002; Haider et al., 2000; Leite et al.,

2005; Ochola et al., 2013; Tylleskär et al., 2011). In addition, 3 of them also demonstrated

prolong BF duration in peer support groups (Agrasada et al.,2005; Dennis et al, 2002; Reeder et

al., 2014). One study showed the positive effect was partial. Peer support could increase the BF

rate but not the EBF rate (Reeder et al., 2014). The diversity of findings may be the results of the

following factors.

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Subject characteristics

Previous study suggested that giving birth at older age, having higher years of education,

living with a partner, having had previous pregnancies, were associated with increased likelihood

of 6-month exclusive breastfeeding (Al-sahab, Lanes, Feldman & Tamim, 2010). In the 7

identified studies, majority subjects were aged around 24 - 34. However, one study did not report

the age of subjects and only this study found no positive effect on breastfeeding outcomes

(Srinivas et al., 2015). The education level of the subjects varied in different studies, from mean

of 4.2 year to undergraduate university level. Majority of the subjects were married except those

in South Africa. Subjects in 3 studies were mainly uniparous (Agrasada et al.,2005; Dennis et al,

2002; Leite et al., 2005) while they were mainly multiparous in another 3 studies (Haider et al.,

2000; Srinivas et al., 2015; Tylleskär et al., 2011). It seems that education level, marital status

and frequency of pregnancy are not linked with breastfeeding likelihood in the 8 studies while

age of mother may be a factor.

Intervention

There were 3 modes of delivery of peer support in the 8 studies. The first one was by

telephone counseling (Dennis et al, 2002; Reeder et al., 2014). Participants in intervention group

received peer service by telephone in addition to standard care.

It is a convenient method to reach the clients as nowadays nearly everyone has a smart phone. In

addition to instant direct phone conversation, photos, videos, texts, emoji or voice messages

could be sent and read whenever peer supporters or mothers were free to do so. Timing is no

longer a problem in this type of peer support service. The second type was home visiting

(Agrasada et al.,2005; Haider et al., 2000; Leite et al., 2005; Tylleskär et al., 2011). Peer

supporters delivered support by visiting the homes of intervention clients. The number of visit

14

varied from 5-15 times in the studies. This allowed face-to-face interactions between peers and

mothers. Observation and modification of BF technique was possible in this type of support. The

last one was clinic-based meeting. Due to the personal safety of peer supporters, peer service

took place in clinic rather than client’s home in Srinivas (2015) study. Clinic-based peer service

also adopted in Ochola (2013) study where one of the intervention groups was clinic-based

meeting while another one was home visiting. In that study, both of the intervention groups had

positive results in prevalence of EBF. So all the three modes of support delivery seemed work in

peer support service and the support was on individual basis in all the 8 studies.

The peer support service commenced at 2 main different periods. Five studies initiated at

antenatal period (Haider et al., 2000; Ochola et al., 2013; Reeder et al., 2014; Srinivas et al.,

2015; Tylleskär et al., 2011). They began at third trimester or first week after enrollment. Other 3

studies initiated at postnatal period (Agrasada et al.,2005; Dennis et al, 2002; Leite et al., 2005).

The first service was provided within 2 days to 5 days after baby born or discharged. The

postnatal period was the most critical period as all the studies had peer service during the first

week of baby born. The frequency would be less intense as babies grew. Finally all the peer

services in the 8 studies ended between 10 weeks and 5.5 months after baby born.

Control

The control groups in 7 studies were without provision of peer support service (Agrasada

et al.,2005; Dennis et al, 2002; Haider et al., 2000; Leite et al., 2005; Ochola et al., 2013; Reeder

et al., 2014; Srinivas et al., 2015). They could still enjoy standard usual care from hospitals or

child health service for breastfeeding advice and support. In the study done by Tylleskär and her

colleagues (2011), control group mothers from South Africa had a peer supporter like those in

intervention group. But the supporters only helped in obtaining birth certificates and social

15

welfare grants without promotion of breastfeeding. So the control groups in all the 8 studies did

not receive any breastfeeding advice or breastfeeding support from the peer supporters.

Peer supporters

The peer supporters were paid in 4 studies (Haider et al., 2000; Leite et al., 2005; Reeder et

al., 2014; Srinivas et al., 2015). They were hired as part-time or paid equivalent of the local

minimum wage. 2 studies (Agrasada et al.,2005; Dennis et al, 2002) recruited volunteers as peer

supporters while another 2 studies (Ochola et al., 2013; Tylleskär et al., 2011) did not mention it.

All the peer supporters were female. Most of them had breastfeeding experiences and some even

had EBF for 6 months or breastfeeding for at least 1 year. They lived in the same area as the

subject samples or had been the clients of the same intervention centers within 5 years. Those

supporters in Burkina Faso had the lowest education level as none of them had more than 2-6

years schooling (Ochola, Labadarios & Nduati, 2013). In contrast, majority of the supporters in

Toronto had postsecondary education (Dennis et al, 2002).

Training was provided to peer supporters before they delivered support to mothers in all the

8 studies. The content of training was similar, mainly focused on breastfeeding and counselling

skills. The benefits of breastfeeding, position and attachment, milk transfer as well as

breastfeeding myths and communication skills were usually addressed. 3 studies reported the

course content was modified from the WHO/UNICEF breastfeeding counselling course (Haider

et al., 2000; Ochola et al., 2013; Tylleskär et al., 2011). Although peer supporters were taught to

assist mothers to solve breastfeeding problems, they could refer clients for professional help in

case of difficulties. Also, supervisors were presented in 2 studies to monitor and facilitate the

peer supporters (Haider et al., 2000; Tylleskär et al., 2011). In Dennis (2002) study, activity logs

written by peer supporters were reviewed to monitor compliance.

16

Methodological quality

The sample size in the 8 studies varied from 103 to 2,579. Three studies were large scale with

over 1,000 subjects (Leite et al., 2005; Reeder et al., 2014; Tylleskär et al., 2011). 4 studies were

in medium scale with 200 – 800 subjects (Agrasada et al.,2005; Dennis et al, 2002; Haider et al.,

2000; Ochola et al., 2013). However, 1 study was relatively small scale with 120 subjects

enrolled and 103 were included in the analysis since they had follow-up to at least 1 month

(Srinivas et al., 2015). At the end of this study, less than 90 of them could actually be contacted

and this 25% of loss contact subjects may be the cause of negative result to peer support service.

Although the drop-out rate of 2 studies was higher than 20%, their sample sizes were much

bigger and thus the effect of peer support service could still be measured (Haider et al., 2000;

Ochola et al., 2013).

Overall, peer support is an effective intervention to promote EBF rate and breastfeeding

duration. Only 1 study with small sample size and high percentage of loss contact subjects did

not find such effect. The support could be delivered in various forms, such as face-to-face

interview, telephone or home visit. The selection and training of peer supporters is crucial. Peer

supporters should be friendly and enthusiastic to encourage target mothers to breastfeeding and

help them to solve breastfeeding problems no matter they are paid or not. They should share

same characteristics to their target clients like having breastfeeding experiences, living in the

same neighborhood so that they can build the rapport with their targets more easily and exchange

their experiences. They should be properly trained with guidance or supervision to ensure their

breastfeeding knowledge or skills passing to the clients are correct. The contact may start during

pregnancy or at postnatal period. The contact would be most frequent right after delivery to

provide support on breastfeeding position, baby attachment and breastfeeding problems faced by

17

the mothers. The number of contact would be reduced as the clients gained confidence in

breastfeeding. This intervention was applicable to mothers of both uniparous and multiparous at

child-bearing age with any education level.

In conclusion, six randomized control trial studies with quality from 1- to 1++ using peer

support as intervention were identified to have positive effect on breastfeeding outcomes. One

study with quality 1- only found partial positive effect while another one study with quality 1-

found no such effect. Overall, the peer support service is considered to be effective in raising

EBF rate and prolong BF duration.

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Chapter 3: Implementation Potential and Clinical Guideline

After critical appraisal of the 8 studies, peer support service was found to be effective to

increase EBF rate and breastfeeding duration. However, none of these studies was carried out in

Hong Kong setting. This chapter explores the potential of applying this innovation in Hong Kong

in terms of transferability, feasibility and cost-benefit ratio. Finally evidence-based guidelines of

the peer support service will be developed based on these studies.

3.1 Transferability of the Findings

Target setting

The breastfeeding peer support service is proposed to be implemented in Maternal and

Child Health Centers (MCHCs). There are totally 31 MCHCs located in different districts in

Hong Kong. The two main service populations of MCHC are children from birth to age of 5 and

women under age of 65. In child service, growth and nutrition monitoring, breastfeeding

coaching, developmental surveillance, immunization and parenting are included. In women

service, antenatal and postnatal checkup, family planning and cervical smearing screening are

provided (Family Health Service, 2016). MCHC is a public setting for providing health service

for both children and women. In previous studies, breastfeeding peer support service also

delivered in public health setting such as hospitals and women, infants and children (WIC)

clinics.

Target population

The target population of this innovation is pregnant women who wish to breastfeeding. In

the selected studies, participants were mainly between twenty and thirty of age, with education

level from low to high and included both uniparous and multiparous mothers (Agrasada et

al.,2005; Dennis et al., 2002; Haider et al., 2000; Leite et al., 2005; Ochola et al., 2013; Reeder et

19

al., 2014; Srinivas et al., 2015; Tylleskär et al., 2011). Clients attended for maternal service in

MCHCs also share these characteristics. Since it is a public service for all entitled citizens,

women of any education qualifications are welcome. There is no restriction of their gravidities,

parities or their ages. But usually fertile females are aged between twenty and forty.

Philosophy of care

MCHC is under of the Family Health Service (FHS) in Department of Health. FHS was set

up with the aim to lead the community in promoting the health and well-being of children,

women and families in Hong Kong by developing evidence-based programs to meet the

changing needs of the community and empowering individuals, families and communities to

improve their health (Family Health Service, 2016). The breastfeeding peer support service is an

evidence-based intervention to promote the health of both infants and mothers as reflected by

various randomize controlled trial studies (Agrasada et al.,2005; Dennis et al, 2002; Haider et al.,

2000; Leite et al., 2005; Ochola et al., 2013; Reeder et al., 2014; Tylleskär et al., 2011). It is

consistent with the core value of FHS.

Number of beneficial clients

The number of clients benefited from peer support service is optimistic especially if it runs

in long term. In 2010, the overall attendance rate for maternal service was 152 000 in MCHCs

(Cheung, 2011). The child service in MCHC is also well supported by parents. Although private

clinics or hospitals also provide vaccinations to children by charge, majority parents bring their

newborns to MCHCs. In 2012, about 78% of all local newborns received services in MCHCs

(Department of Health, 2013). The good quality of service of MCHCs also attracts parents from

mainland China, especially to the MCHC where locates near to Lo Wu entry port. There were

about 4000 new cases for child service registered in that MCHC last year. Due to the “two-child

20

policy” of China, the number of new cases is believed to rise. There will be sufficiently large

number of babies and mothers benefited from this innovation.

Time frame

The peer support service can be launched within short time once the approval is obtained.

The first step is to recruit voluntary peer supporters. In general, 15 peer supporters can be

recruited in 2 months. After recruitment, training will be provided to equip the supporters with

breastfeeding knowledge which will take another month. At the same time, target population can

start enrolling during antenatal revisit sessions. Due to the high breastfeeding intention rate in

Hong Kong, targets meeting inclusion criteria of peer support service can be recruited within 1

month (Wang et al., 2014). Once the training is finished, peer support service can be started. The

evaluation of the peer support service can be done when participated mothers bring babies back

to MCHCs for child service. Usually they will come according to vaccination schedule at one,

two, four, six, twelve and eighteen months. Therefore, the time from implementation to

evaluation is seven to eight months.

3.2 Feasibility

Nursing autonomy and current staff function

Currently the breastfeeding peer support service in MCHCs is led by a nurse with

participated mothers actively shared their experiences during the group meeting. One nurse is

assigned to hold this breastfeeding support group every month. In the new service, a nurse will

train peer supporters and let these supporters to provide support to the participated mothers. The

format of peer support service is changed but it is still the nurses duties to run the peer support

service. Nurses do not have the autonomy to reject her assigned duties. In case they found

difficulties when carrying out their duties, they can seek help from and report to nursing officers.

21

Also, once the new service starts, the old peer support service stops. So it will not interfere

inordinately with current staff functions.

Administrative and organizational support

According to the breastfeeding policy of the Department of Health, it is committed to create

a positive environment to support breastfeeding clients and implement “Ten steps to successful

breastfeeding”. So if evidences revealed that the innovation is more effective than current service

to promote and support breastfeeding, the administration would be supportive to the innovation.

In fact, many of the MCHCs staffs have personal breastfeeding experiences. It is not limited to

nursing staffs, doctors and clerks also continued breastfeeding when they resumed to work after

maternity leaves. The whole organization climate welcomes breastfeeding.

Risk of friction

Increased workload may be a reason that frontline staffs resist to this innovation. Before

initiation of this innovation, some preparation works are needed. For example, decoration of

notice board to introduce the new service, designing leaflets for promotion of the service, editing

notes for training of peer supporters, etc. But all these materials and products made can be used

in subsequent peer support service. Also the workload will resume to current practice as the

existing peer support service stops if the new service starts. Another possible friction to the

innovation is the fear of change by some staffs. Basically, all RNs in MCHCs have been trained

for breastfeeding skills. No additional training of staff is need before implementation of the

innovation. But the format of peer support service is new to the staffs. They may have worries on

the flow of the service, the content of training, etc. Therefore, there is a need to develop clinical

guidelines for staffs to reference to.

22

Resources and equipment

The most demanding resource in the peer support service is the time for training peer

supporters. From previous studies, peer supporters were trained from 2.5 hours to 40 hours on

breastfeeding knowledge and counselling skills (Agrasada et al.,2005; Dennis et al, 2002; Haider

et al., 2000; Leite et al., 2005; Ochola et al., 2013; Srinivas et al., 2015; Tylleskär et al., 2011).

Since the peer supporters in this innovation are supposed to provide supplementary help to

mothers rather than replacing the duties of breastfeeding coaching nurses in MCHCs, 20 hours is

enough to cover necessary breastfeeding knowledge during the training. The venue of training

and meeting between peer supporters and breastfeeding mothers can be set in education room of

MCHCs where routine health talks or workshops take place. Equipment such as tables, chairs,

computer, projector and breastfeeding models are present in that room. Besides, printers, color

papers, photocopy machines and binding machines are already available in MCHCs for editing

the notes for peer supporters. References such as breastfeeding pamphlets and breastfeeding

coaching guidebooks are also available in the library of MCHCs.

Evaluation

The feeding practices of babies are routinely asked during interview in child service when

they come back for vaccination at 1, 2, 4, 6, 12 and 18 months. So the exclusivity and duration of

breastfeeding of the participated mothers-babies pairs can be traced with their case numbers.

Four months after starting each round of the peer support service, a reunion session will be held

in MCHC for peer supporters. A certificate of appreciation and incentives will be given to the

peer supporters who completed the service and evaluation can be done at that time.

23

3.3 Cost-benefit Ratio

Potential risks

Peer support service is an additional support offered to encourage mothers for breastfeeding.

For those who do not join the service, they can still enjoy existing breastfeeding service provided

in MCHCs. There is no potential risk of not trying this innovation. In previous studies, home

visit was provided by the peer supporters. However, with regard to the personal safety of both

the peer supporters and participated mothers, peer support service in this innovation does not

include home visit. Instead, they are advised to contact by phone or meet up at public places such

as hospitals or MCHCs when providing the service.

Potential benefits

The potential benefits of peer support service are numerous. In addition to the benefits to

babies and mothers which have already been discussed in previous section, the community and

society can also be benefited from it. The bonding within the community will be strengthened. In

peer support service, MCHC acts as a bridge to connect peer supporters and mothers within the

neighborhood. On one hand, peer supporters earn satisfaction and respect by providing voluntary

service. On the other hand participated mothers gain support and confidence in breastfeeding.

This win-win service will bring harmony to the community. The economic burden of the society

will also be lowered if this service can be implemented. Strong evidences have been shown that

breastfeeding protected babies from gastrointestinal (GI) illness, lower respiratory tract infection

(LRTI) and acute otitis media (AOM). It was estimated that if 21 % of British mothers

exclusively breastfeed their babies for 4 months, 1.2 million pounds per year could be saved due

to reduction of hospital cost associated with GI and 2 million pounds per year could be saved in

LRTI hospitalization costs. The potential cost saving from avoiding the need to treat AOM in

24

primary care was 0.28 million pounds per year. (Pokhrel et al., 2015; Renfrew et al., 2012) The

actual money saved by increasing breastfeeding rate and duration would be much more as

breastfeeding protect babies and mothers from more than the above listed diseases.

Cost of implementation

The cost of this innovation is mainly spent on materials for clients and as salary of staff.

Since printers and color papers are available in the MCHC, printing is free but decoration of

notice board may need money. Notes which include summary of the training content will be

prepared for every peer supporters. Although the service is in voluntary basis, certificate of

appreciation and incentives will be given to peer supporters who completed the service. As initial

start of the service, one nurse is given for 2 sessions (8 hours) to prepare the notes and content of

the training workshop. There will be 3 rounds of peer support service in a year. For every round

of the service, it will take 20 hours to train the peer supporters. At the end of each round of the

service, a half session (2 hours) will be needed to gather all the peer supporters together for

evaluation of the service and awarding certificates and incentives. Another half session (2 hours)

will be needed to trace the breastfeeding outcomes of the participated mothers-babies pairs and

do the statistical report. So to run the service, 24 hours is needed for 1 round of the service and

thus 72 hours in a year. However, once the proposed innovation started, the existing peer support

service will be cut, freeing 1 session (4 hours) monthly. As a result, extra 24 hours per year

needed to implement this innovation. Assuming the breastfeeding subject nurse reached the

maximum salary point, her hourly salary is $250 ($ 43105 4 weeks 44 hours/week) (Civil

Service Bureau, 2016). The estimated cost of implementing this innovation for a year is $ 12,600.

It was estimated that if exclusive breastfeeding rate increased to 45%, £2.49 and £ 9.44 per infant

could be saved due to treating GI and respiratory tract infection respectively (Pokhrel et al.,

25

2015). There were 62,305 babies born in Hong Kong in 2014 (Census and Statistic Department,

2015). Assume the admission rates of these diseases are same as a local cohort study findings,

$239,323 can be saved in a year which is more than to cover the cost of the innovation (Tarrant

et al., 2010). The cost-benefit ratio is calculated by dividing the cost ($12,600) by benefit

($239,323) and the ratio is 1:0.05 Details of the calculations refer to Appendix V.

Evidence-based practice guideline

A set of practice guidelines is developed to provide recommendations based on the latest

evidence for the best practice of the peer support service. It is applicable in MCHC setting and

should be followed by all MCHC staffs. The levels of evidence and grades of recommendations

are graded according to the rating scheme for the strength of the evidence of Scottish

Intercollegiate Guidelines Network based on previous appraised RCT studies. Details of the

guideline can be referred to appendix VI and VII.

26

Chapter 4: Implementation Plan

In previous chapter, breastfeeding peer support service is concluded to be transferable,

feasible and cost-beneficial to apply in Hong Kong MCHC setting. Before putting it into service,

detail planning of whole progress is needed to ensure smooth and well function of the service.

This chapter deliberates communication plan, pilot study plan, evaluation plan and basis for

implementation when running the peer support service.

4.1 Communication Plan

Stakeholders

Stakeholders are the people who have influences in or are affected by the proposed

innovation. Their attitudes, responses and commitments to the innovation will directly affect the

success of it. The stakeholders in this innovation are mainly divided into 3 groups. The first

group is the administrative group. It includes Nursing Officers (NO) in MCHCs, Senior Nursing

Officers, Cluster Nursing Officers and Principal Nursing Officer. Medical staffs are also involved

in daily function of MCHCs, especially in setting protocols and guidelines. So Medical Officers

in-charge, Senior Medical Officers, Principal Medical Officer as well as the Director of Health

are also belongs to this group. Any changes about service provision in MCHCs must be informed

and permitted by them. In addition, they are in charge of resources and manpower allocation.

Funding for operation of the innovation must be granted before it starts and responsible staff for

training peer supporters must be set ahead. The second group is the frontline staffs who carry out

the innovation and directly face the clients. Examples in this group are Registered Nurses (RN),

Enrolled Nurses (EN) and Medical Officers (MO). The frontline staffs are expected to recruit

peer supporters and potential breastfeeding mothers, train the peer supporters, pair up the peer

supporters and participated mothers, monitor the progress of peer supporters, interview and

27

report the feeding outcomes of babies of the participated mothers and help to solve breastfeeding

problems faced by participated mothers. The last group is the peer supporters. They are

volunteers recruited for providing breastfeeding support to participated mothers. On one hand,

they are recipients of breastfeeding knowledge and skill taught by nurses. On the other hand,

they are service provider who directly face and contact participated mothers. All these three

groups of people are essential to the innovation.

Communication team

In order to put the innovation into practice and connect all the 3 groups of stakeholders

together, there is a need to build a communication team. The communication team consists of 1

MO, 1 NO and 4 RNs. The innovation proposer (a RN) is definitely in the team as she is the one

who suggested the idea and presented it to the MOs and NOs in the MCHC. One of the MOs and

NOs are engaged in the team because they have windows to reach the administrative

stakeholders. The RNs in the team mainly deal with frontline staffs and peer supporters.

Communication with administrators

The MO and NO in the communication team can bring the innovation up to the

administrative group by emails or through regular meetings with them. They have to present the

needs of changing current peer support service, the benefits of it, the budget plan and workflow

of implement by PowerPoint slides or in form of proposal. After the innovation starts, they also

have to report the progress and outcomes to them.

Communication with frontline staffs and peer supporters

As discussed before, some staffs may concern of increase workload and have fear to change.

To gain their co-operation, the benefits and workflow of the innovation will be introduced to

them prior to implementation at clinic weekly meeting by PowerPoint slides. The evidence-based

28

guidelines of the new peer support service will be prepared before the start of the service. The

progress of peer supporters will be monitored by the nurses who hold the peer support service at

that round. Two nurses will hold one round of peer support service together so that they can

share the duties and ensure the training of peer supporters will not be affected due to sick leave

of the trainer. Phone follow-up allows peer supporters report any difficulties they faced during

the service. In general it can be finished within 5 minutes and the nurses can make use of the

time after daily interviews to do it without needing extra session. Two of the RNs in the

communication team will hold the first round of peer support service, allowing more time for the

rest of the frontline staffs to observe and adapt. Also staffs are welcomed to give feedback at any

time and guidelines may be reviewed if necessary based on the outcomes and evidences.

4.2 Pilot Study Plan

In order to detect any unforeseeable limitations and difficulties which may be faced in

actual implementation, a pilot study is essential for a trial run of the proposed innovation. The

number of clients involved in the pilot study will be fewer and the time frame of the study will

be shorter than proposed in the innovation since the aim of the pilot study is to test the feasibility

of the peer support service rather than to increase breastfeeding exclusivity and duration. Based

on the results of the pilot study, refinements and modifications can be made to ensure the success

of the innovation.

Time frame of pilot study

A pilot study will start as soon as the approval of the innovation granted from the

administrators. Members in communication team will start preparing the content and materials

needed in training peer supporters and introducing the peer support service to the frontline staffs.

The rest of the staffs will help in recruiting peer supporters and potential breastfeeding mothers

29

during interviews in child sessions and antenatal sessions respectively. The recruitment criteria of

both peer supporters and service recipients are same as the innovation. In a month time, 2

volunteer supporters will be recruited for training of the peer support service. The 20-hour

training will be provided in 5 consecutive mornings from nine am to one pm and 2 RNs will take

turns to hold the training sessions. At the end of the training, one 37-week pregnant woman will

be paired up with a peer supporter and the peer support service will start. After 2 weeks, a nurse

will contact the peer supporters for their progresses.

Evaluation of pilot study

Evaluation for peer supporters will be done when they came back for certificates of

appreciation and incentives at 2 months after the service started. Evaluation for participated

mothers will be done when they bring back their babies for vaccination at 1 month old. The

evaluation forms for both peer supporters and participated mothers can be referred to appendix

VII and VIII respectively. After collection of the feedbacks from both peer supporters and

participated mothers, communication team members will report the results of the pilot study

during clinic weekly meeting. All staffs can reflect their opinions about the pilot study during the

meeting and the guidelines may be refined according to the result of the evaluation.

4.3 Evaluation Plan

The purpose of the evaluation plan is to assess the effectiveness of the peer support service.

Intervention outcomes and measurement, nature and number of clients involved, data analysis

will be taken into account in the evaluation.

Intervention outcomes and measurement

Participated mothers and babies outcomes

The primary outcome of the peer support service is the exclusive breastfeeding rate at 4

30

month. It can be measured when participated mothers bring their babies back to MCHC for

vaccination at 4 months. Routine nurse interview will be conducted which includes asking for

feeding pattern of babies. In addition, evaluations form (Appendix IV) will be given to the

mothers to fill in so as to assess their satisfactory levels. The secondary outcome of the service is

breastfeeding rate (non-exclusive) at 6 months. Since solid food should be introduced at 6

months, it is common for babies to have both solid food and breastfeeding at this age. By

definition, it is not exclusive breastfeeding and so breastfeeding rate instead of exclusive

breastfeeding rate is measured at 6 months. Again, this outcome can be measured when mothers

bring their babies back to MCHC at 6 months vaccination schedule during routine nurse

interview.

Peer supporters outcome

The participation of peer supporters is crucial in this innovation because they are the ones

who provide support directly to the mothers. So their application of knowledge and skills to

mothers is another key outcome. An evaluation form (Appendix VIII) will be given to them to

fill in when they come back for reunion session 4 months after the start of the service. Also, they

are encouraged to give verbal feedback to the nurses at the end of each training sessions.

Healthcare professional outcome

One of the duties of staffs in DH is to promote breastfeeding. So the problem faced when

carrying out the innovation rather than their satisfaction to the innovation is the intervention

outcome for frontline staffs. From time to time, all staffs should report to their NOs or MOs

when they have problems in carrying out their duties. Also, the communication team members

may randomly approach frontline staffs and ask for their opinions for running the peer support

service. If no problems are reported, this outcome is achieved.

31

System outcomes

The system outcome can be reflected by the length of recruitment period. Since the quota of

clients for each round of service is set, the shorter the recruitment period indicates the higher

popularity of service. The quota of clients may be adjusted in the future depending on the

popularity of the service. The actual cost of launching the innovation is another system outcome.

It should be compared with the budget plan to ensure if it is cost effective.

Nature of clients

The clients in this innovation are Chinese pregnant women at 36 week or above who wish to

breastfeed their single born babies. They and their babies should be physically fit with no

congenital abnormality or condition that affects breastfeeding. They should attend the same

MCH for both maternal and child service and come back for service according to routine

schedule. For peer supporters, they should have breastfeeding experience of at least 6 months

and able to read and speak Chinese. All the clients, peer supporters should live in the same

district as the MCH located.

Sample size

Two-tailed z test for testing one proportion was used to calculate the sample size. The level

of significance was set to 5% with power of 80%. According to a local breastfeeding survey, the

current exclusive breastfeeding rate at 4 month is 27% (Department of Health, 2015). From

previous studies, the effect size of the intervention on exclusive breastfeeding ranged from -2%

to 64% in 12 to 24 weeks. Assuming the effect size is 20% when implement in Hong Kong

setting, the number of sample needed is 42. From previous studies, the drop-out rate of the

innovation is about 10%, thus 45 clients are needed. The number of peer supporters recruited in

each round was 15, so 1 peer supporter will be paired with 3 clients.

32

Data analysis

The collected data will be analyzed by a computerized Statistical Package for Social

Science (SPSS) software. Both the primary outcome of EBF rate at 4 month and secondary

outcome of BF rate at 6 month will be compared to current EBF and BF rate of MCHC

respectively by using one sample t-test to determine any difference after the implementation of

peer support service. Chi-square test will be used to determine whether clients and peer

supporters satisfied with the service.

4.4 Basis for Implementation

The ultimate goal of the peer support service is to increase EBF rate and prolong BF

duration so as to promote the health of babies, mothers as well as the families as a whole. The

effectiveness of the service is based on whether the primary outcome can be achieved. In

previous studies, the effect size of the service varied from -2% to 64% which is quite a large

variation. But focusing on the studies using telephone or clinic based peer support service, the

effect size contracted to between 1% and 23.9%. Since the peer support service in Hong Kong

will mainly be delivered by clinic based and telephone contact, the service will be regarded as

effective if the increased EBF rate is around 20%. The satisfaction levels of mothers towards the

service also play an important part in the innovation. The innovation will be fully implemented if

at least 60% of them showed “strongly agree” or “agree” in the service satisfaction in the

evaluation form.

4.5 Conclusion

Exclusive breastfeeding is the best way of feeding for babies under 6 months old. Babies,

mothers as well as the society can all be benefited from breastfeeding. However, local exclusive

breastfeeding rate and breastfeeding duration is below standard. More efforts should be put in

33

promoting breastfeeding in public health setting. Peer support service may be a solution to this

problem. Randomized controlled studies with low to high qualities showed that peer support

service is effective in boosting the exclusive breastfeeding rate and breastfeeding rate in foreign

countries. With regard to the transferability, feasibility and cost-benefit ratio, the peer support

service can be translated into Hong Kong setting. An evidence-based clinical guideline is also

developed to provide guidance for frontline staff when carrying out the peer support service.

After the pilot testing, it is believed that potential difficulties and problems will be identified and

tackled before the implementation of the service. Evaluations will be done to determine the

effectiveness of this local peer support service.

34

References:

Al-sahab, B., Lanes, A., Feldman, M. & Tamim, H. (2010). Prevalence and

predictors of 6-month exclusive breastfeeding among Canadian women: A national survey.

BMC Pediatrics. 10(20):1–9. doi: 10.1186/1471-2431-10-20.

Agrasada, G. V., Gustafsson, J., Kylberg, E. & Ewald, U. (2005). Postnatal peer counselling on

exclusive breastfeeding of low-birthweight infants: a randomized, controlled trial. Acta

Paediatr. 94(8):1109-15.

Black, R. E., Victora, C. G., Walker, S. P., Bhutta, Z. A., Christian, P., De Onis, M., Ezzati, M.,

Grantham-McGregor, S., Katz, J., Martorell, R. & Uauy, R. (2013). Maternal and child

undernutrition and overweight in low-income and middle-income countries. The Lancet,

382(9890), 427-451. doi: 10.1016/S0140-6736(13)60937-X

Castelein, S., Bruggeman, R., Davidson, L. & Gaag, Mv. (2015). Creating a Supportive

Environment: Peer Support Groups for Psychotic Disorders. Schizophr Bull, 41(6):1211-3.

doi: 10.1093/schbul/sbv113

Chapman, D. J., Damio, G., Young, S. & Pérez-Escamilla, R. (2004). Effectiveness of

breastfeeding peer counseling in a low-income, predominantly Latina population: A

randomized, controlled trial. Arch Pediatr Adolesc Med. 158:897–902.

Census and Statistic Department. (2015). Hong Kong Monthly Digest of Statistics: The

fertility trend in Hong Kong, 1981-2014. Retrieved from

http://www.censtatd.gov.hk/hkstat/sub/sp160.jsp?productCode=FA100090

Cheung, K. C. M. (2011, April 6). Written reply of Legislative Council questions. Retrieved from

http://www.lwb.gov.hk/eng/legco/06042011_1.htm

35

Chung, S. H., Kim, H. R., Choi, Y. S., & Bae, C. W. (2013). Trends of

Breastfeeding Rate in Korea (1994-2012): Comparison with OECD and

Other Countries. Journal of Korean medical science, 28(11), 1573-1580. doi:

10.3346/jkms.2013.28.11.1573

Civil Service Bureau. (2016, February 9). Master pay scale. Retrieved from

http://www.csb.gov.hk/english/admin/pay/42.html

Dennis, C-L., Hodnett, E., Gallop, R. & Chalmers, B. (2002). The effect of peer support on

breast-feeding duration among primiparous women: a randomized controlled trial. CMAJ.

66:21–28.

Department of Health. (2015). Breastfeeding survey 2015. Hong Kong : Hong Kong

Government.

Department of Health. (2013). Department of Health Annual Report 2012/2013. Hong Kong :

Hong Kong Government. Family Health Service. (2016, January 29). Home. Retrieved

from http://www.fhs.gov.hk/english/

Furuta, M., Sandall, J., Cooper, D. & Bick, D. (2015). Severe maternal morbidity and

breastfeeding outcomes in the early post-natal period: a prospective cohort study from one

English maternity unit. Matern Child Nutr. Retrieve September 20, 2015,

http://onlinelibrary.wiley.com.eproxy2.lib.hku.hk/doi/10.1111/mcn.12176/epdf. doi:

10.1111/mcn.12176

Häggkvist, A. P., Brantsæ ter, A. L., Grjibovski, A. M., Helsing, E., Meltzer, H. M., Haugen, M.

(2010). Prevalence of breast-feeding in the Norwegian Mother and Child Cohort Study and

health service-related correlates of cessation of full breast-feeding. Public Health

Nutr.13(12):2076-86.

36

Haider, R., Ashworth, A., Kabir, I. & Huttly, S. R. (2000). Effect of community-based peer

counsellors on exclusive breastfeeding practices in Dhaka, Bangladesh: a randomised

controlled trial. Lancet. 56(9242):1643-7.

Ingram, J. (2013). A mixed methods evaluation of peer support in Bristol, UK: mothers',

midwives' and peer supporters' views and the effects on breastfeeding. BMC Pregnancy

Childbirth. 13:192. doi: 10.1186/1471-2393-13-192.

Kaunonen, M., Hannula, L. & Tarkka, M. T. (2012). A systematic review of peer support

interventions for breastfeeding. J Clin Nurs. 21(13-14):1943-54. doi:

10.1111/j.1365-2702.2012.04071.x

Kushwaha, K. P., Sankar, J., Sankar, M. J., Gupta, A., Dadhich, J. P., Gupta, Y. P., Bhatt, G. C.,

Ansari, D. A. & Sharma, B. (2014). Effect of peer counselling by mother support groups

on infant and young child feeding practices: the Lalitpur experience. PLoS One. 9(11):

e109181. doi: 10.1371/journal.pone.0109181

Leite, A., Puccini, R., Atalah, A., Da Cunha, A. & Machado, M. (2005). Effectiveness of

home-based peer counselling to promote breastfeeding in the northeast of Brazil: A

randomized clinical trial. Acta Paediatrica. 94:741–746.

Liu, P., Qiao, L., Xu, F., Zhang, M., Wang, Y. & Binns, C. W. (2013). Factors associated with

breastfeeding duration: a 30-month cohort study in northwest China. J Hum Lact.

29(2):253-9. doi: 10.1177/0890334413477240

37

Mollica, M. A., Nemeth, L. S., Newman, S. D., Mueller, M. & Sterba, K. (2014). Peer navigation

in African American breast cancer survivors. Patient Relat Outcome Meas, 7(5):131-44.

doi: 10.2147/PROM.S69744

Morrow, A. L., Guerrero, M. L., Shults, J., Calva, J. J., Lutter, C., Bravo, J., Ruiz-Palacios, G.,

Morrow, R. C. & Butterfoss, F. D. (1999). Efficacy of home-based peer counselling to

promote exclusive breastfeeding: a randomised controlled trial. Lancet.

353(9160):1226-31.

Oakley, L. L., Henderson, J., Redshaw, M. & Quigley, M. A. (2014). The role of support and

other factors in early breastfeeding cessation: an analysis of data from a maternity survey

in England. BMC Pregnancy Childbirth. 26;14:88. doi: 10.1186/1471-2393-14-88

Ochola, S. A., Labadarios, D. & Nduati, R. W. (2013). Impact of counselling on exclusive

breast-feeding practices in a poor urban setting in Kenya: a randomized controlled trial.

Public Health Nutr. 16(10):1732-40. doi: 10.1017/S1368980012004405

Pokhrel, S., Quigley, M. A., Fox-Rushby, J., McCormick, F., Williams, A., Trueman, P., Dodds,

R. & Renfrew, M. J. (2015). Potential economic impacts from improving breastfeeding

rates in the UK. Arch Dis Child. 100(4):334-40. doi: 10.1136/archdischild-2014-306701

Reeder, J. A., Joyce, T., Sibley, K., Arnold, D. & Altindag, O. (2014). Telephone peer counseling

of breastfeeding among WIC participants: a randomized controlled trial. Pediatrics.

134(3):e700-9. doi: 10.1542/peds.2013-4146

Renfrew, M. J., Pokhrel, S., Quigley, M., McCormick, F., Fox-Rushby, J., Dodds, R., Duffy, S.,

Trueman, P. & Williams, A. (2012). Preventing disease and saving resources: the potential

contribution of increasing breastfeeding rates in the UK. UNICEF.

38

Santos, F. S., Santos, F. C., Santos, L. H., Leite, A. M. & Mello, D. F. (2015). Breastfeeding and

protection against diarrhea: an integrative review of literature. Einstein (Sao

Paulo).13(3):435-40. doi: 10.1590/S1679-45082015RW3107

Shilling, V., Bailey, S., Logan, S. & Morris, C. (2015). Peer support for parents of disabled

children part 1: perceived outcomes of a one-to-one service, a qualitative study. Child Care

Health Dev, 41(4):524-36. doi: 10.1111/cch.12223

Srinivas, G. L., Benson, M., Worley, S. & Schulte, E. (2015). A clinic-based breastfeeding peer

counselor intervention in an urban, low-income population: interaction with breastfeeding

attitude. J Hum Lact. 31(1):120-8. doi: 10.1177/0890334414548860

Tarrant, M., Dodgson, J. E. & Wu, K. M. (2014). Factors contributing to early breast-feeding

cessation among Chinese mothers: an exploratory study. Midwifery. 30(10):1088-95. doi:

10.1016/j.midw.2014.03.002

Tarrant, M., Fong, D. Y., Wu, K. M., Lee, I. L., Wong, E. M., Sham, A., Lam, C. & Dodgson, J. E.

(2010). Breastfeeding and weaning practices among Hong Kong mothers: a prospective

study. BMC Pregnancy Childbirth. 29;10:27. doi: 10.1186/1471-2393-10-27

Tarrant, M., Kwok, M. K., Lam, T. H., Leung, G. M. & Schooling, C. M. (2010). Breast-feeding

and childhood hospitalizations for infections. Epidemiology. 21(6):847-54. doi:

10.1097/EDE.0b013e3181f55803

Tylleskär, T., Jackson, D., Meda, N., Engebretsen, I. M., Chopra, M., Diallo, A. H., Doherty, T.,

Ekström, E. C., Fadnes, L. T., Goga, A., Kankasa, C., Klungsøyr, J. I., Lombard, C.,

Nankabirwa, V., Nankunda, J. K., Van de Perre, P., Sanders, D., Shanmugam, R.,

39

Sommerfelt, H., Wamani, H., Tumwine, J. K. & PROMISE-EBF Study Group. (2011).

Exclusive breastfeeding promotion by peer counsellors in sub-Saharan Africa

(PROMISE-EBF): a cluster-randomised trial. Lancet. 378(9789):420-7. doi:

10.1016/S0140-6736(11)60738-1

UNICEF Baby Friendly Hospital Initiatives Hong Kong Association. (2015). World

Breastfeeding Week Annual Survey 2015. Retrieved September 20, 2015,

http://unicef.org.hk:8080/download/WBWReport2015_E.pdf

Wang, W., Lau, Y., Chow, A. & Chan, K. S. (2014). Breast-feeding intention, initiation and

duration among Hong Kong Chinese women: a prospective longitudinal study. Midwifery.

30(6):678-87. doi: 10.1016/j.midw.2013.07.015

World Health Organization. (2015). Infant and young child feeding. Retrieved September 20,

2015, http://www.who.int/mediacentre/factsheets/fs342/en/

World Health Organization & UNICEF. (2003). Global strategy for infant and young child

feeding. World Health Organization. Geneva, Switzerland: World Health Organization and

UNICEF.

WHO & UNICEF. (1989). Joint statement on protecting, promoting and supporting

breast-feeding: The special role of maternity services. Geneva: World Health Organization

World Health Organization, UNICEF, the United States Agency for International Development,

the Food and Nutrition Technical Assistance project, the University of California at Davis

& International Food Policy Research Institute. (2008). Indicators for assessing infant and

young child feeding practices, Part I: Definitions. Geneva: World Health Organization

40

Appendix I: Methodology Checklist for Randomized Controlled Trial

S I G N

Methodology Checklist 2: Controlled Trials

Study identification (Include author, title, year of publication, journal title, pages)

Guideline topic: Key Question No: Reviewer:

Before completing this checklist, consider:

1. Is the paper a randomised controlled trial or a controlled clinical trial? If in doubt, check the study design

algorithm available from SIGN and make sure you have the correct checklist. If it is a controlled clinical trial

questions 1.2, 1.3, and 1.4 are not relevant, and the study cannot be rated higher than 1+

2. Is the paper relevant to key question? Analyse using PICO (Patient or Population Intervention Comparison

Outcome). IF NO REJECT (give reason below). IF YES complete the checklist.

Reason for rejection: 1. Paper not relevant to key question 2. Other reason (please specify):

Section 1: Internal validity

In a well conducted RCT study… Does this study do it?

1.1 The study addresses an appropriate and clearly focused question.

Yes

Can’t say

No

1.2 The assignment of subjects to treatment groups is randomised. Yes

Can’t say

No

1.3 An adequate concealment method is used.

Yes

Can’t say

No

1.4 The design keeps subjects and investigators ‘blind’ about treatment

allocation.

Yes

Can’t say

No

1.5 The treatment and control groups are similar at the start of the trial. Yes

Can’t say □

No

1.6 The only difference between groups is the treatment under investigation. Yes

Can’t say

No

1.7 All relevant outcomes are measured in a standard, valid and reliable way. Yes

Can’t say

No

1.8 What percentage of the individuals or clusters recruited into each

41

treatment arm of the study dropped out before the study was completed?

1.9 All the subjects are analysed in the groups to which they were randomly

allocated (often referred to as intention to treat analysis).

Yes

Can’t say

No

Does not apply

1.10 Where the study is carried out at more than one site, results are

comparable for all sites.

Yes

Can’t say

No

Does not apply

SECTION 2: OVERALL ASSESSMENT OF THE STUDY

2.1 How well was the study done to minimise

bias?

Code as follows:

High quality (++)

Acceptable (+)

Low quality (-)

Unacceptable – reject 0

2.2 Taking into account clinical considerations, your

evaluation of the methodology used, and the

statistical power of the study, are you certain that the

overall effect is due to the study intervention?

2.3 Are the results of this study directly applicable to the

patient group targeted by this guideline?

2.4 Notes. Summarise the authors’ conclusions. Add any comments on your own assessment of the study, and the

extent to which it answers your question and mention any areas of uncertainty raised above.

42

Appendix II: Modified PRISMA 2009 Flow Diagram

Records identified through database searching

(n = 124 )

Scre

enin

g El

igib

ility

Id

enti

fica

tio

n Additional records identified

through other sources (n = 3 )

Records after duplicates removed (n = 81 )

Records screened (n = 18 )

Records excluded (n = 63 )

Full-text articles assessed for eligibility

(n = 12 )

Full-text articles excluded, due to on-going studies

without results, unmatched study group

(n = 4 )

Studies included in qualitative synthesis

(n = 8 )

Incl

ud

ed

43

Appendix III: Table of Evidence

Citation/Design

(study quality)

Subject Characteristics Intervention Control Outcome Measure Effect Size

Agrasada et al.

(2005) /

RCT (++)

Mean age 22.7 (SD

4.5)

Uniparous

Majority had at least

secondary education

BP: breastfeeding

peer support by 8

home visits

(n = 68)

CP: childcare peer

support by 8 home

visits

(n =67 )

Conventional

in-hospital and

community postnatal

support service

(n = 69)

Prevalence of EBF at

24 week (%)

Prevalence of BF at

24 week (%)

BP: 32% (p < 0.001)

CP: 3% (p < 0.001)

BP: 34.2% (p < 0.001)

CP: 2.3% (p < 0.001)

Dennis et al.

(2002) /

RCT (+)

Majority were aged

25-34

Uniparous

Majority were at

least had college or

undergraduate

university education

Majority were

married

Peer support by

telephone as

frequent as mothers

deemed

(n = 132)

Conventional

in-hospital and

community postnatal

support service

(n = 124)

Prevalence of EBF at

4, 8 and 12 week (%)

Prevalence of BF at 4,

8 and 12 week (%)

At 4 week: 11.3% (p = 0.03)

At 8 week: 8.1% (p = 0.08)

At 12 week: 16.5% (p = 0.01)

At 4 week: 8.5% (p = 0.03)

(RR = 1.10; 95% CI 1.01-2.72)

At 8 week: 9.8% (p = 0.05)

(RR = 1.13; 95% CI 1.00-1.28)

At 12 week: 4.2% (p = 0.01)

(RR = 1.21; 95% CI 1.04-1.41)

Haider et al.

(2000) /

RCT (-)

Mean age 22.9 (SD

4.1)

Mean education

year 4.2 (SD 4.2)

Peer support by 15

home visits

(n = 363)

Conventional

in-hospital and

community postnatal

support service

(n = 363)

Prevalence of EBF at

day 4 and 20th week

(%)

At day 4: 54% (p < 0.0001)

At 20 week: 64% (p <

0.0001)

(95% CI: 57%-71%)

Footnote: SD = standard deviation, EBF = exclusive breastfeeding, BF = breastfeeding, CI = confidence interval, RR = relative risk,

44

Citation/Design

(study quality)

Subject Characteristics Intervention Control Outcome Measure Effect Size

Leite et al.

(2005) /

RCT (+)

Average age 23.6

Majority were

married

Majority were

uniparous

Average education

year ranged 6.2

Peer support by 6

home visits

(n = 503)

Conventional

in-hospital and

community postnatal

support service

(n = 500)

Prevalence of EBF

at 16 week (%)

At 16 week: 5.3%

(p = 0.044)

Ochola,

Labadarios &

Nduati. (2013) /

RCT (-)

Mean age ranged

24.5-24.8 (SD 5.4)

Majority were

married

All had at least

primary education

HP: Peer support by

7 sessions in health

center/home visit

(n = 120)

FP: Peer support by

1 sessions in health

center

(n = 120)

Conventional

in-hospital and

community postnatal

support service

(n = 120)

Prevalence of EBF

at 4 and 24 week

(%)

At 4 week:

HP: 87%

RR = 1.21; 95% CI 1.04,

1.39 (p = 0.011)

FP: 84.3%

RR = 1.17; 95% CI 1.00,

1.36 (p = 0.041)

At 24 week,

HP: 23.9%

RR = 4.20; 95% CI 1.66,

10.64 (p = 0.002)

FP: 9.2%, RR = 1.64;

95% CI 0.56, 4.81 (p =

0.371)

Footnote: SD = standard deviation, EBF = exclusive breastfeeding, BF = breastfeeding, CI = confidence interval, RR = relative risk,

45

Citation/Design

(study quality)

Subject Characteristics Intervention Control Outcome Measure Effect Size

Reeder et al.

(2014) /

RCT (-)

Mean age ranged

26.9 -27.3

More than half

were married

More than half had

high school

diploma

*Low frequency peer

support by 4 telephone

contacts

(n = 646)

*High frequency peer

support service by 8

telephone contacts

(n = 645)

Conventional

in-hospital and

community postnatal

support service

(n = 657)

Prevalence of EBF

at 4, 12, 24 week

(%)

Prevalence of BF at

4, 12, 24 week (%)

At 4 week: 7% (p > 0.1)

At 12 week: 10% (p >

0.1)

At 24 week: 1% (p > 0.1)

At 4 week: 16% (p <0.01)

At 12 week: 19% (p

<0.01)

At 24 week: 18% (p

<0.01)

Srinivas et al.

(2015) /

RCT (-)

Majority did not

complete high

school

Majority were

multiparous

Majority had no

prior breastfeeding

experience

Peer support by 12

clinic / hospital visit ±

telephone contacts

(n = 50)

Conventional

in-hospital and

community postnatal

support service

(n = 53)

Prevalence of EBF

at 4 and 24 week

(%)

Prevalence of BF at

4 and 24 week (%)

At 4 week: -5%

(p = 0.51, RR = 0.75;

95% CI 0.33-1.72)

At 24 week: -2%

(p = 0.51, RR = 0.47;

95% CI 0.05-4.89)

At 4 week: 15%

(p = 0.14, RR = 1.22;

95% CI 0.93-1.60)

At 24 week,

0% (p = 0.96, RR = 0.97;

95% CI 0.26-3.56)

*Remarks: Authors did not find any difference in breastfeeding outcomes between high and low frequency treatment groups, so the 2 treatment arms

were combined into a single category.

Footnote: EBF = exclusive breastfeeding, RR = relative risk, CI = confidence interval

46

Citation/Design

(study quality)

Subject Characteristics Intervention Control Outcome Measure Effect Size

Tylleskär et al.

(2011) /RCT (-)

Majority were

married in Burkina

Faso and Uganda

but opposite in

South Africa

Majority were

multipara in

Burkina Faso and

Uganda, around

half were

multipara in South

Africa

Year of education

ranged 0-12

Peer support by at

least 5 home visits

In Burkina Faso

(n = 392)

In Uganda

(n = 396)

In South Africa

(n = 535)

Conventional

in-hospital and

community postnatal

support service

In Burkina Faso

(n = 402)

In Uganda

(n = 369)

In South Africa

(n = 485)

Prevalence of EBF

at 12, 24 week (%)

At 12 weeks

Burkina Faso : 45%

(Prevalence ratio 2.29,

95% CI: 1.33-3.92)

Uganda: 38%

(Prevalence ratio 1.89,

95% CI: 1.70-2.11)

South Africa: 4%

(Prevalence ratio 1.72,

95% CI: 1.12-2.63)

At 24 weeks

Burkina Faso : 51%

(Prevalence ratio 3.33,

95% CI: 1.74-6.38)

Uganda: 44%

(Prevalence ratio 3.83,

95% CI: 2.97-4.95)

South Africa: 1%

(Prevalence ratio 5.70,

95% CI: 1.33-24.26)

Footnote: EBF = exclusive breastfeeding, CI = confidence interval

47

Appendix IV: Quality Assessment Using SIGN Methodology Checklist for Controlled Trials

Section 1: Internal Validity

Agrasada et

al. (2005)

Dennis et al.

(2002)

Haider et al.

(2000)

Leite et al.

(2005)

Ochola et al.

(2013)

Reeder et al.

(2014)

Srinivas et al.

(2015)

Tylleskär et al.

(2011)

Clearly Focused

Question

Yes Yes Yes Yes Yes Yes Yes Yes

Randomization Yes Yes Yes Yes Yes Yes Yes Yes

Allocation

Concealment

Yes Yes No Yes No No No No

Blinding No No No No No No No No

Comparable Groups Yes No Yes Yes No Yes Yes Yes

Treatment is the Only

Difference

Yes Yes Yes Yes Yes Yes Yes Yes

Valid and Reliable

Outcome Measures

Yes Yes Yes Yes Yes Yes Yes Yes

Drop-out Rate BP: 13.3%

CP: 10.4%

C: 14.5%

I: 0%

C: 1.6%

I: 20.7%

C: 21.5%

I: 15.1%

C: 13.6%

FP: 27.5%

HP: 25.8%

C: 25.8%

LP: 3.3%

TP: 3.1%

C: 3.3%

I: 18%

C: 13.2%

I: 10.2%

C: 11.5%

Intention to Treat

Analysis

Yes No No No No No No Yes

Comparable Results

from All Site

Not

applicable

Not

applicable

Can’t say Not

applicable

Can’t say Not

applicable

Not

applicable

Yes

Footnote: BP = breastfeeding peer support, CP = childcare peer support, C = control, I = intervention, FP = facility-based peer support, HP = home-based peer

support, LP = low frequency of peer support, TP = high frequency peer support,

48

Quality Assessment Using SIGN Methodology Checklist for Controlled Trials

Section 2: Overall Assessment

Agrasada et

al. (2005)

Dennis et al.

(2002)

Haider et al.

(2000)

Leite et al.

(2005)

Ochola,

Labadarios &

Nduati. (2013)

Reeder et

al. (2014)

Srinivas et

al. (2015)

Tylleskär et

al. (2011)

Risk of Bias

Minimized

++ + - + - - - -

Overall Effect

due to

Intervention

Alone

Yes Yes Yes Yes Yes Yes Yes Yes

Result

Applicable to

Target Group

Yes Yes Yes Yes Yes Yes Yes Yes

Notes Raise

exclusive

breastfeeding

rate

Extend

breastfeeding

duration

Raise

exclusive

breastfeeding

rate

Extend

breastfeeding

duration

Raise

exclusive

breastfeeding

rate

Raise

exclusive

breastfeeding

rate

Raise

exclusive

breastfeeding

rate

Raise

exclusive

breastfeedin

g rate

Extend

breastfeedin

g duration

Raise

exclusive

breastfeeding

rate

Extend

breastfeeding

duration

Raise

exclusive

breastfeeding

rate

Level of

Evidence

1++ 1+ 1- 1+ 1- 1- 1- 1-

49

Appendix V: Budget Plan

Item Estimated cost (HKD $) per year Subtotal (HKD $)

Decoration of notice board

(promotion of innovation)

100 100

Leaflets (promotion of

innovation)

0 (Free printing in MCHC) 0

Notes 0 (Free printing in MCHC) 0

Certificate of appreciation 0 (Free printing in MCHC) 0

Incentives $100 x 15 peer supporters x 3 rounds) 4,500

One-off preparation time for

training workshop

8 hours x 250 2,000

Extra time needed of running

3 rounds of service in a year

24 hours x 250 6,000

Total 12,600

Potential cost saving per infant

Percentage of exclusive

breastfeeding for 4 months

Disease needing

treatment

Potential cost saving

per infant (£)

Potential cost saving per

infant (HKD $) (correct to

the nearest dollar)

21%

GI

0.92 11

LRTI + AOM

3.47 42

45%

GI

2.49 30

LRTI + AOM

9.44 113

65%

GI

3.81 46

LRTI + AOM

14.41 173

Remarks:

GI = gastrointestinal illness; LRTI = lower respiratory tract infection; AOM = acute otitis media

1£ ⋍ HKD$ 12

50

Number of babies born in 2014 = 62,305

Admission rate of GI in first 3 months = 1.13%

Admission rate of LRTI + AOM in first 3 months = 3.1%

Number of admission due to GI = 62305 x 1.13% = 704 (correct to the nearest people)

Number of admission due to LRTI + AOM = 62305 x 1.13% = 1931 (correct to the nearest people)

Estimated cost saving

Percentage of

exclusive

breastfeeding

for 4 months

Disease Number of

admission

(correct to

the nearest

people)

Potential cost

saving per infant

(HKD$) (correct to

the nearest dollar)

Potential cost

saving

(HKD$)

Total Potential

cost saving

(HKD$)

21%

GI 704 11 7744 88,846

LRTI +

AOM

1931 42 81102

45%

GI 704 30 21120 239,323

LRTI +

AOM

1931 113 218203

65%

GI 704 46 32384 366,447

LRTI +

AOM

1931 173 334063

Remarks:

GI = gastrointestinal illness; LRTI = lower respiratory tract infection; AOM = acute otitis media

Cost-benefit ratio = $12,600 : $239,323

Cost-benefit ratio = 1: 0.05 (Correct to 2 decimal places)

51

Appendix VI: Grade of Recommendations

(Scottish Intercollegiate Guidelines Network, 2011)

Grade A 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

Grade B 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+

Grade C 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++

Grade D Evidence level 3 or 4; or

Extrapolated evidence from studies rated as 2+

Grade E Recommended best practice based on the clinical experience

of the guideline development group

52

Appendix VII: Practicing Guideline

Guidelines for breastfeeding peer support service

Aim: To provide guidance to staff when deliver of peer support

service

Objectives: To build a breastfeeding friendly environment in the

community

To promote breastfeeding and prolong breastfeeding

duration of pregnant women

To support breastfeeding mothers in community

Setting: MCHC

Target users: MCHC staffs

Recommendation

1. Target mothers should not include those with history of

mental illness

(Grade A)

Available evidence:

Mothers taking medications that may compromise

breastfeeding were excluded. (Agrasada et al., 2005; Haider

et al., 2000)(1++)

Mothers were excluded if they had a factor that could

significantly interfere with breastfeeding. (Dennis et al.,

2002 (1+) ; Ochola, Labadarios & Nduati, 2013 (1-) ;

Tylleskär et al., 2011 (1-) )

Discussion:

Breastfeeding is a stressful event for mothers especially at the

first few days before “milk come in”. Together with hormonal

changes after delivery, their mood may fluctuate a lot.

Professional support rather than peer support is more suitable for

these clients.

53

Recommendation

2. Target mothers should deliver of a singleton baby

(Grade A)

Available evidence:

Mothers were eligible if they had delivered a singleton.

(Agrasada et al., 2005 (1++) ; Dennis et al., 2002 (1+) ;

Tylleskär et al., 2011 (1-) )

Mothers were excluded in cases of multiple births. (Haider

et al., 2000 (1-) ; Leite et al., 2005 (1+) )

Discussion:

Mothers of twins or multiple births usually already have more

support than those who deliver a singleton. Also peer supporters

may not have experience in breastfeeding of twins or multiple

babies.

Recommendation

3. Peer supporters should have breastfeeding experience

(Grade A)

Available evidence:

Selected breastfeeding peer supporter had previous positive

personal breastfeeding experience. (Agrasada et al.,

2005(1++) ; Haider et al., 2000 (1-) ; Leite et al., 2005

(1+) )

Selection criteria of peer supporters: previous breastfeeding

experience of at least 6 months’ duration. (Dennis et al.,

2002 (1+) ; Reeder et al., 2014 (1-) )

Discussion:

With personal breastfeeding experience, peer supporters would

be easier to understand the feeling of breastfeeding mothers and

the difficulties they encounter. Thus peer supporters can act as

role model of successful breastfeeding.

54

Recommendation

4. Peer supporters should be trained before providing the

service

(Grade A)

Available evidence:

40 hours of training was provided for training of peer

supporters. (Agrasada et al., 2005 (1++) ; Haider et al.,

2000 (1+) ; Ochola, Labadarios & Nduati., 2013 (1-) ).

Selection criteria of peer supporters: completion of a 2.5

hours orientation session. (Dennis et al., 2002) (1+)

Peer supporters participated in a 20 hours breastfeeding

training course. (Leite et al., 2005) (1+)

Training was provided to peer supporters. (Reeder et al.,

2014) (1-)

Peer supporters were trained for 1 week by the national

research teams. (Tylleskär et al., 2011) (1-)

Discussion:

Training prior to service boosts peer supporters confidence in

providing the service. Also, it unifies how the supporters to

provide the support.

Recommendation

5. Content of the training should include breastfeeding

benefits, breastfeeding positioning and attachment,

identification of feeding cues, effective suckling and social

skills

(Grade A)

Available evidence:

The orientation session included telephone support and

referral skills while the handbook incorporated various

topics such as breastfeeding benefits, general breastfeeding

information and principles and breastfeeding myths.

(Dennis et al., 2002) (1+)

Parts of the WHO/UNICEF breastfeeding counselling

course were used as guides. (Haider et al., 2000 (1-) ;

Ochola, Labadarios & Nduati, 2013 (1-) ; Tylleskär et al.,

2011 (1-) )

Training course adapted from “Breastfeeding counselling: a

55

training course” (Leite et al., 2005) (1+)

The training covered technical breastfeeding topics,

methods of providing peer support, scope of practice and

the benefits of breastfeeding. (Reeder et al., 2014) (1-)

Discussion:

Content of the training should be practical and applicable to real

life situations that facilitate peer supporters to provide the

service.

Recommendation

6. Peer support service should be started at third trimester

of pregnancy

(Grade C)

Available evidence:

First visit started in the third trimester of pregnancy.

(Haider et al., 2000 (1-) ; Ochola, Labadarios & Nduati,

2013 (1-) ; Tylleskär et al., 2011 (1-) )

Discussion:

Time is needed for peer supporters and target mothers to build

up rapport. Also, maternal leave usually starts at third trimester

so that target mothers have time to meet up with their peer

supporters.

Recommendation

7. Peer support service should be provided within 1 week

after delivery

(Grade A)

Available evidence:

The first home visit started at infant age day 3-5. (Agrasada

et al., 2005) (1++)

Peer supporters were asked to contact the new mother

within 48 hours after hospital discharge. (Dennis et al.,

2002) (1+)

One visit provided within 48 hours of delivery. (Haider et

al., 2000) (1-)

56

First home visit was on the 5th

day from birth. (Leite et al.,

2005) (1+)

One visit or call was during the first week after delivery.

(Ochola, Labadarios & Nduati, 2013 (1-) ; Reeder et al.,

2014 (1-) ; Tylleskär et al., 2011 (1-) )

Discussion:

Breastfeeding problems may arise as soon as baby starts feeding.

So target mothers, especially those without breastfeeding

experience before, need support as soon as they deliver

Recommendation

8. Contact frequency should be intense when baby first

born and sparse as time passed by

(Grade A)

Available evidence:

Eight home visits were scheduled at infant age days 3-5, 7-10,

21 and at 1.5 month and then monthly up to 5.5 month.

(Agrasada et al., 2005) (1++)

Four visits were in the first month of delivery, then monthly

between months 2 and 5. (Haider et al., 2000) (1-)

Six home visit were on 5th

day from birth, 15th

, 30th

, 60th

, 90th

and 120th

. (Leite et al., 2005) (1+)

First visit was in third trimester, then first week after delivery

and then monthly up to 5 months. (Ochola, Labadarios &

Nduati, 2013) (1-)

2 calls were at antenatal, then at 1st and 2

nd week of postpartum

and then monthly up to 4 months. (Reeder et al., 2014) (1-)

Discussion:

As time pass by, mothers learn the feeding habit of their babies

and are more skillful in breastfeeding than before. So the contact

frequency can be decreased.

57

Appendix VIII: Evaluation Form for Peer Supporter

Evaluation Form for Peer Support Service

(For service provider)

1. Date of providing first service: __________________________________

2. Date of providing last service: ___________________________________

Please “” the boxes below:

Strongly

agree

Agree Neutral Disagree Strongly

disagree

3. The training is practical in

providing peer support

service

4. The notes are useful in

providing peer support

service

5. The length of the training

course is appropriate

6. I have enough knowledge

and skills on breastfeeding

after training

7. I applied what I have

learned to my client

8. I want to be a peer supporter

again

Comments

9. Difficulties found when providing service:

10. Other comments:

58

Appendix IV: Evaluation Form for Service Recipient

Evaluation Form for Peer Support Service

(For service recipient)

1. Date of receiving first service: __________________________________

2. Date of receiving last service: ___________________________________

Please “” the boxes below:

Strongly

agree

Agree Neutral Disagree Strongly

disagree

3. My peer supporter is nice

and friendly

4. My peer supporter is helpful

5.

6. The frequency of contact is

appropriate

7. I learned knowledge and

skills on breastfeeding from

my peer supporter

8. I am satisfied with the peer

support service

9. I will recommend this

service to my friends

Comments:

10. Difficulties found when providing service:

11. Other comments: