Abstract of thesis entitled

“The Effectiveness of Postnatal Telephone Support

Intervention in Prolonging the Duration of Breastfeeding

after Hospital Discharge”

Submitted by

Chu Pui Kei Peggy

for the degree of Master of Nursing

at The University of Hong Kong

in August 2014

Breastfeeding promotion programs have successfully increased the

breastfeeding initiation rate and breastfeeding duration in Hong Kong over the

past ten years. The breastfeeding rate on discharge from hospitals has increased

from 56.8% in 2001 to 85.8% in 2012 and the exclusive breastfeeding rate for

infants 4 to 6 months old has increased from 6% in 1997 to 14% in 2010.

However, the duration of breastfeeding in Hong Kong is still far below World

Health Organization (WHO) recommendations.

Insufficient breastfeeding support for mothers after hospital discharge

could be a reason accounting for the short breastfeeding duration in Hong Kong. A

postnatal telephone support intervention is therefore proposed to prolong the

duration of breastfeeding by providing continuous support for mothers even when

they are home. Nowadays, the telephone is considered an easily accessible,

convenient and economical medium of communication. It is hoped that by

adopting the intervention, those mothers who are usually ‘home bound’ in the

early postpartum period can be better served and supported in the establishment

and continuation of breastfeeding.

Evidence-based practice guidelines which consist of a list of

recommendations have been developed from five recent studies. The five studies

provided strong evidence that telephone support is effective in prolonging the

duration of breastfeeding. The implementation potential, the implementation plan

and evaluation plan of this innovation will be developed and discussed in this

project.

The Effectiveness of

Postnatal Telephone Support Intervention in Prolonging

the Duration of Breastfeeding

after Hospital Discharge

by

CHU PUI KEI PEGGY

School of Nursing

The University of Hong Kong

A thesis submitted in partial fulfillment of the requirements for

the Degree of Master of Nursing

at The University of Hong Kong.

August 2014

i

Declaration

I declare that this dissertation represents my own work, except where due

acknowledgment is made. It has not been previously included in a thesis,

dissertation, or report submitted to this university or to any other institution for a

degree, diploma, or other qualifications.

Signed……………………………………………………………………

CHU PUI KEI PEGGY

ii

Acknowledgements

I would like to express my sincere gratitude to my supervisor, Dr. Marie

Tarrant, who provided expert advice, valuable opinions, guidance and support for

my dissertation. She gave me lots of suggestions and relevant information on

subjects ranging from deciding the topic of my dissertation to finalizing my

dissertation work. Her attitude, professionalism and enthusiasm for breastfeeding

enlightened me and influenced me in pursuing issues related to breastfeeding.

Also, I would like to offer my special thanks to my classmates. They were

generous, cheerful and supportive. I had a great time studying with them.

Lastly, I would like to thank my beloved family members. Their love and

care were so important to me in getting through my demanding master study. I

would also like to thank my fiancé for being so supportive and patient and giving

me lots of encouragement throughout these two years.

iii

Table of Contents

Declaration..…………………….…………………………………………………………..i

Acknowledgements………………………………………………………..……………....ii

Table of contents……………………………………………..………………………..….iii

Chapter 1 - Statement of the Problem……………………………………….. 1

Background…………………………………………………………….………….1

Affirming the need……………………………………….………………………..3

Objective and Research Question……………………..……………….….………7

Significance of problem…………………………………………………….……..7

Chapter 2 - Review of Evidence………………………………………………..10

Study selection criteria…………………………………………………………...10

Search strategy……………………………………………………………….…..10

Table of evidence…………………………………………...……………………12

Quality assessment…………………………………………………………….…17

Summary and Synthesis………………………………………………………….21

Chapter 3 - Implementation Potential…………………………………………28

Target setting and audience.………………………………….…...……………...28

Transferability of findings…………………..……………………………………28

Feasibility of the innovation………….………………………..………………...30

Cost-Benefit ratio of the innovation…………………….…………………….….34

Chapter 4 - Evidence-Based Practice Guidelines…..…………….…………..38

Title of the guidelines...….…...…………..…………….....………………..……38

Objective of the guidelines……………………………………………………....38

Purpose of the guidelines………………………………………………………...38

Target group of the guidelines……………………………………...…………….38

Recommendations…………………………………………………………….….39

Chapter 5 - Implementation Plan…………………………………………..….43

Communication plan with potential users………………………………………..43

Pilot testing………………………………………………………..…………......46

Chapter 6 - Evaluation Plan…………………………………………………....49

Intervention outcomes……………………………………………………………49

Nature and Number of clients………...………………………………………….49

Outcome measurements………………………………………………………….51

Data analysis……………………………………………………………………..51

Criteria for effectiveness…………………………………………………………52

Conclusion…………………………………………………………………….....53

References……………………………………………………………………….55

Appendices………………………………………………………………………65

1

Chapter 1 - Statement of the Problem

Background

The benefits of breastfeeding for infants and mothers have been widely

recognized by the public. Breastfeeding provides the most natural and nutritious

food source for the health, growth and development of infants (World Health

Organization [WHO], 2003). It also reduces the incidence of infant and maternal

pathologies (James & Lessen, 2009). A history of breastfeeding is associated with

a reduced risk of various infant illnesses such as severe lower respiratory tract

infection, gastroenteritis, otitis media and sudden infant death syndrome

(American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome,

2005; Bachrach, Schwarz & Bachrach, 2003; Chien & Howie, 2001; Ip et al.,

2007; Kramer et al., 2001). Mothers who have breastfed have a lower incidence of

type 2 diabetes, breast and ovarian cancers (Danforth et al., 2007; Ip et al., 2007;

Stuebe, Rich- Edwards, Willett, Manson & Michels, 2005; Stuebe, Willet, Xue &

Michels, 2009b). Multiple studies have shown a dose-dependent effect of

breastfeeding. Infants enjoy better health outcomes the longer they are breastfed

(Bachrach et al., 2003; Kramer et al., 2001). Moreover, prolonged and exclusive

breastfeeding has been shown to improve cognitive and motor development in

children (Dewey, Cohen, Brown & Rivera, 2001; Kramer et al., 2008).

2

According to the recommendations of the World Health Organization

(WHO), exclusive breastfeeding for the first six months of life is optimum to feed

infants. Thereafter, breastfeeding can be continued up to two years of age or

beyond, along with the introduction of complementary foods (WHO, 2003).

Exclusive breastfeeding means infants receive only breast milk, without any

additional food, drink or water (WHO, 2001).

In Hong Kong, decades of breastfeeding promotion programs implemented

by governmental and nongovernmental organizations (NGOs) have greatly

improved the breastfeeding initiation rate and duration. The breastfeeding rate on

discharge from hospitals has increased from 56.8% in 2001 to 85.8% in 2012

(BFHIHKA, 2013a; CHP, 2014) and the exclusive breastfeeding rate for infants 4

to 6 months old has increased from 6% in 1997 to 14% in 2010 (DH, 2011).

Despite the substantial increase in the breastfeeding rate over the past ten years,

the duration of breastfeeding in Hong Kong remains far below WHO

recommendations (WHO, 2003). Indeed, most mothers stop breastfeeding within

the first few months after delivery (Dodgson, Tarrant, Fong, Peng & Hui, 2003). A

survey conducted in 2013 revealed that although 82.9% of mothers breastfed their

infants at 1 month or less, only 32.7% of mother breastfed until 6 months (CHP,

2014).

The high breastfeeding initiation rate and the remarkable decline in the

3

breastfeeding rate at a few months postpartum may indicate that mothers are

aware of the benefits of breastfeeding and they intend to breastfeed after delivery.

Nevertheless, they may encounter breastfeeding difficulties soon after discharge

from hospitals. Unlike other developed countries, there is a lack of active

postpartum breastfeeding support such as home visits for new mothers in Hong

Kong. As a result, many mothers stop breastfeeding before they receive any help

during the early postpartum period (Tarrant, Dodgson & Wu, 2014).

Breastfeeding support for mothers should not terminate after hospital

discharge (Tahir & Al-Sadat, 2012). The immediate post-discharge period is a

very delicate psychological moment of adaptation. It is defined as a ‘phase of

calibration’ in which mothers are overwhelmed by various problems in assessing

infants’ needs and maintaining milk supply. Hence, breastfeeding promotion

should start during pregnancy and continue in hospitals and at home after

discharge (Semenic, Loiselle, & Gottlieb, 2008).

The availability and accessibility of an effective evidence-based

breastfeeding support intervention during the postnatal period is therefore crucial

to provide continuous breastfeeding support for mothers to avoid early

discontinuation of breastfeeding after hospital discharge.

Affirming the need

In Hong Kong, the Department of Health (DH) and Hospital Authority,

4

together with some NGOs such as the Baby Friendly Hospital Initiative Hong

Kong Association (BFHIHKA) and the La Leche League Hong Kong promote

breastfeeding through hotline services, support groups and breastfeeding

education workshops to support breastfeeding mothers in the postpartum period

(BFHI HKA, 2013). Despite the availability of these resources, the duration of

breastfeeding in Hong Kong remains short. This shows there is room for

improvement in current postnatal breastfeeding support interventions in

addressing mothers’ needs and concerns.

The DH has been actively involved in breastfeeding promotion in Hong

Kong. From the year 2000, a breastfeeding policy incorporating the 'Ten Steps to

Successful Breastfeeding' and the ‘International Code of Marketing of Breastmilk

Substitutes’, has been implemented in all Maternal and Child Health Centers

(MCHCs) to advocate breastfeeding (Leung, 2009). Nurses in the MCHCs have

received professional breastfeeding training and are competent in providing

postnatal breastfeeding support to mothers through breastfeeding coaching,

hands-on guidance and some individual and telephone counseling services (Lam,

2005).

Currently, the breastfeeding coaching service provided by MCHCs is

considered an effective postnatal breastfeeding support intervention. It is a direct

coaching service offered to mothers who accompany their babies to the MCHCs.

5

The breastfeeding coaching is comprehensive. Apart from giving breastfeeding

instruction and support to mothers, demonstrations and return demonstrations of

breastfeeding techniques, for example, attachment and positioning, are done and

assessed by nurses. By assessing and correcting the breastfeeding skills of

mothers, the risk of breastfeeding complications due to poor attachment or

positioning can be reduced.

Despite the effectiveness of the breastfeeding coaching service, there are

some limitations in its coverage. Because it is conducted face-to-face, the service

can only be offered to mothers who take the initiative to seek help (Tarrant, Kwok,

Lam, Leung & Schooling, 2010). According to Chinese cultural beliefs, mothers

should stay at home for the first month postpartum. This is a major barrier for

mothers to access the coaching service. Nevertheless, the first month is a critical

time for the continuation of breastfeeding, especially the immediate

post-discharge period. Problems related to milk production become more

prominent as the milk supply is established during that period. If these problems

cannot be well-addressed, mothers may decide to discontinue breastfeeding earlier

(Gerd Bergman, Dahlgren, Roswall & Alm, 2012).

In view of the inadequacy and limitations of current postnatal breastfeeding

support resources in Hong Kong, more effort should be placed on providing

mothers with more accessible breastfeeding support during the immediate

6

post-discharge period, especially the first month, to improve breastfeeding

performance and duration.

A telephone breastfeeding support intervention could be considered another

method of providing continuous breastfeeding support to mothers after hospital

discharge. Unlike the breastfeeding hotline services provided by the DH for

decades that reactive calls are made by mothers, this telephone support

intervention is proactive. Nurses take the initiative in making regular phone calls

to offer breastfeeding education and support to mothers. The telephone is the

chosen medium for communication as it is easily accessible, convenient and

economical compared with other kinds of supportive services such as home visits

(Bunik et al., 2010; Tahir & Al- Sadat, 2012). As it is not limited to geographical

and physical barriers, mothers who are usually ‘house-bound’ in the early

postpartum period, especially Chinese mothers, can be served by a telephone

support intervention (Tahir & Al- Sadat, 2012). It is hoped that by adopting the

innovation, mothers can continue receiving breastfeeding instruction and support

even if they are at home.

In Hong Kong, more than 90% of infants go to MCHCs soon after

discharge from hospitals. As they are publicly funded, MCHCs provide free and

convenient service, which ensures a high utilization rate for primary health care

services compared with that in other countries (Lam, 2005). Furthermore, Lee,

7

Lui, Chan, Wong and Lau (2006) found that, when mothers encountered problems

during breastfeeding, 77% of them considered the medical and nursing staff at

MCHCs their prime source of assistance. Therefore, the MCHC is an ideal place

for implementation of the proposed innovation.

Objective and Research Question

The objective of the dissertation is to prolong the duration of breastfeeding

through a telephone breastfeeding support intervention provided by nurses.

The research question is “What is the effectiveness of a postnatal telephone

support intervention in prolonging the duration of breastfeeding after hospital

discharge?”

Significance of problem

Improving the breastfeeding duration is not only beneficial to the health of

infants and mothers, it also has positive impacts on the health care industry, the

economy and the environment.

Infant and maternal health benefits

Innate immune factors in breast milk protect infants from infectious

morbidity in the first year of life (Hamosh, 2001). Infants who are breastfed have

a lower incidence of various infectious diseases, such as lower respiratory tract

infection, gastrointestinal infection and otitis media. They also have a lower

incidence of non-communicable diseases such as obesity and type 2 diabetes

8

compared with infants who are formula-fed (Bachrach et al., 2003; Harder,

Bergmann, Kallischnigg & Plagemann, 2005; Horta, Bahl, Martines & Victora,

2007; Ip et al., 2007; Kramer et al., 2001). Evidence shows that children have

earlier motor development, better performance on intellectual tests, and higher

academic ratings when they are breastfed longer (Dewey et al., 2001; Kramer et

al., 2008).

Breastfeeding increases the oxytocin level in mothers, which induces

more rapid uterine contractions to reduce postpartum hemorrhage (Leung et al.,

2006). Multiple data suggest that women who do not breastfeed face higher risks

of breast and ovarian cancers, obesity, type 2 diabetes, metabolic syndrome and

cardiovascular diseases (Danforth et al., 2007; Ip et al., 2007; Stuebe et al., 2005;

Stuebe et al., 2009a).

Health care benefits

Breastfeeding provides substantial protection from hospitalization due to

infectious diseases for infants. In the short term, it reduces doctor visits, hospital

admissions and hospital stays during the first 6 months of life (Leung, Lam, Ho &

Lau, 2005; Tarrant et al., 2010). In the long term, breastfeeding can save costs

from health care utilization and lower the workload and stress of health care

professionals.

9

Economic benefits

Breastfeeding is good for the economy of our community. It reduces costs

from pediatric health care services, premature death from infant illnesses and

infant formula purchases. It was estimated that if 90% of mothers in the United

States could comply with medical recommendations on breastfeeding, the country

could save US$ 3.7 billion in direct and indirect health costs, US$ 10.1 billion

from prevention of premature death from pediatric illnesses and US$ 3.9 billion in

infant formula costs (Bartick, 2011).

Environmental benefits

While everyone recognizes the importance of environmental conservation,

breastfeeding can contribute a lot to saving the environment. It provides the most

environmentally-friendly way to feed infants by decreasing the environmental

burden from disposal of artificial formula cans and bottles. It also reduces the

energy demands of formula milk production and transportation (Cohen, Mrtek &

Mrtek, 1995; Jarosz, 1993; Levine, Huffman & Center to Prevent Childhood

Malnutrition, 1990).

10

Chapter 2 - Review of Evidence

Study selection criteria

To be eligible for the review, the studies had to meet the following criteria.

Participant characteristics

Mothers who delivered healthy full term babies.

Type of intervention

Studies which compared postnatal telephone breastfeeding support

intervention delivered by nurses to standard care or other kinds of supportive

interventions.

Outcome measures

The duration of any or exclusive breastfeeding.

Exclusion criteria

Studies with a combination of postnatal breastfeeding support interventions

were excluded as the single effect of a postnatal telephone support intervention

was investigated.

Search strategy

The study search was conducted on 13 June 2013. Two electronic databases,

CINAHL plus and PubMed were selected for the study search. Keywords that

were used in the search were ‘breastfeed’, “breastfeeding”, “breastfeeding

duration”, “breastfeeding rate”, ”duration of breastfeeding”, “rate of

11

breastfeeding”, “telephone intervention’, “telephone counseling”, “telephone

support” ,“ professional support”, “midwife”, “midwives”, ”nurse”, “lactation

counselor” , “lactation consultant” and “ health care professional”. There was no

limitation set on the year of journal publication. Randomized controlled trial

studies and studies which were published in English were included.

A summary of the search strategy is presented in the Table of the Search

Strategy (Appendix A) and illustrated by a flow diagram (see Figure 1). Eight

articles were obtained from CINAHL plus and 297 articles from PubMed. After

screening the titles and abstracts of the articles, one study was available in

CINAHL plus and four studies were available in PubMed. After removing

duplicated articles, one study from CINAHL plus and three studies from PubMed

were considered eligible for the review. In addition, one more eligible study was

obtained from a manual search. The reference lists of all retrieved studies were

then screened and finally five eligible, relevant studies were included for the study

review.

12

Figure 1. Flow diagram of the search strategy

Table of evidence

A summary of the extracted data of each of the five selected studies is

presented in the Table of Evidence (see Table 1). The authors, type of study and

evidence level of each study are shown. The table consists of a brief description of

the number and characteristics of the study participants, details of the

interventions and control treatments, length of follow up, outcome measures and

effect sizes of the study results.

305 relevant articles identified through

CINAHL plus - 8

PubMed - 297

7 articles

298 articles excluded by

title and abstract

Search by keywords

Database selection

CINAHL plus & PubMed

5 articles included in the review

2 articles excluded by full text

5 articles 1 article

obtained

by manual

search 1 article excluded by duplication

13

Sample size

The five selected studies were all randomized controlled trials (RCT), one

of which was a cluster RCT (Fu et al., 2014). The sample size of four studies

varied from 69 to 357. The cluster RCT had a larger sample size of 722.

Characteristics of study participants

Healthy mothers were recruited from Hong Kong, Italy, and Malaysia in

three studies (Fu et al., 2014; Simonetti, Palma, Giglio, Mohn & Cicolini, 2012;

Tahir & Al-Sadat, 2012). One study targeted low-income Latina mothers (Bunik et

al., 2010), and another study targeted mothers who were living in a disadvantaged

area as study participants (Hoddinott, Craig, Maclennan, Boyers & Vale, 2012). In

four studies, mothers who intended to breastfeed or considered breastfeeding were

included (Bunik et al., 2010; Fu et al., 2014; Simonetti et al., 2012; Tahir &

Al-Sadat, 2012).

Intervention groups

Four studies had postnatal telephone support as their single intervention.

One study consisted of two intervention groups, a telephone support group and an

in-hospital support group (Fu et al., 2014). The telephone support interventions

were carried out by nurses in all the studies. The qualifications of the nurses were

mentioned in four studies, and included licensed midwives (Fu, et al., 2014;

Simonetti, et al., 2012), lactation consultants (Fu, et al., 2014), lactation

14

counselors (Tahir & Al- Sadat, 2012) and nurses who had completed a 2-day

United Nations Children’s Fund (UNICEF)-accredited training program

(Hoddinott et al., 2012).

Comparison groups

Four studies compared telephone support interventions with standard

counseling or usual care (Bunik et al., 2010; Fu et al., 2014; Simonetti et al., 2012;

Tahir & Al-Sadat, 2012). The remaining study allowed mothers to make reactive

telephone calls in the comparison group (Hoddinott et al., 2012).

Outcome measures

The outcome measures in the five studies were the duration of any or

exclusive breastfeeding.

Effect sizes

The effect sizes of the reviewed studies were presented as relative risk (RR)

or odds ratios (OR).

15

Table 1. Table of Evidence (1)

Biblio- graphic citation

Study type

Evi level

No. of Participant

s

Participant characteristics

Intervention Comparison Length of follow up

Outcome measures Effect size

* : p<0.05 ; ** : p=0.01

Bunik et al., 2010

RCT 1+ 335

1. Latina primiparous mothers

2. Low- income 3. Delivered healthy

term babies 4. Considered BF

1. 2-week intervention by nurses 2. First call on the day of hospital discharge 3. Daily calls

Remarks: Training/ qualification of nurses not mentioned n=155

Standard care n=178

24 weeks Rate of any BF & PBF

6

at 4th

12th

24th

week

Any BF 4

th wk: RR =1.00

12th

wk : RR = 0.91 24

th wk : RR = 0.76

PBF 4

th wk : RR =1.00

12th

wk : RR = 0.77

24th

wk : RR = 0.68

Fu et al., 2014

Cluster RCT

1++ 722 1. Hong Kong Chinese primiparous mothers

2. Intended to BF

Telephone support 1. 4-week intervention

by midwives/ lactation consultant

2. First call within 72hr of hospital discharge

3. Weekly calls n= 268

In- hospital support 1. 3-sessions 2. First 48 hr

intervention by midwives/ lactation consultant

3. 30 min hands-on professional BF support

n=191

Standard care n=263

24 weeks Rate of any BF & EBF

5

at 4th

8th

12th

week

Telephone vs Standard care Any BF 4

th wk : OR = 1.63**

8th wk : OR = 1.48*

12th wk : OR = 1.37

EBF 4

th wk : OR = 1.90**

8th wk : OR = 1.44

12th wk : OR = 1.20

16

Table 1. Table of Evidence (2)

1 FEST: Feeding Support Team (Nurses had breastfeeding induction and completed a 2-day UNICEF accredited training program)

2 LM : Licensed midwives

3 STC: Structured telephone counseling

4 LC: Lactation counselors (RNs who had post-basic training in midwifery)

5 EBF: Exclusive breastfeeding

6 PBF: Predominant breastfeeding

Biblio- graphic citation

Study type

Evi level

No. of Participants

Participant characteristics

Intervention Comparison Length of follow up

Outcome measures Effect size

* : p<0.05 ; ** : p=0.01

Hoddinott et al., 2012

RCT (pilot)

1+ 69

1. Mothers living in disadvantaged areas in Scotland

2. BF at the time of hospital discharge

Proactive + Reactive telephone calls

1. 2-week intervention by FEST1

2. First call within 24 hr of hospital discharge

3. 1st week: Daily calls

2nd

week: Decided by mothers 4. Reactive calls by mothers at any

point over the 2 weeks n=35

Reactive-only telephone calls

Reactive calls at any point over the 2 weeks n=34

8 weeks Rate of any BF & EBF at 6

th -8

th week

Any BF: RR = 1.5 EBF : RR = 1.7

Simonetti et al., 2012

RCT (pilot)

1- 114

1. Italian healthy primiparous mothers

2. Delivered healthy term babies

3. Intended to BF 4. Telephone access

1. 6-week STC3

by WHO-UNICEF LM2

2. Weekly calls (or more frequent) 3. Phone call timing planned by mothers

and LM n=55

Standard counseling program n= 59

20 weeks Rate of EBF at 4

th 12

th 20

th week

EBF 4

th wk :RR = 1.8 **

12th wk :RR = 1.9 **

20th wk : RR = 2.1**

Tahir & Al-Sadat, 2012

RCT 1++ 357

1. Malaysian mothers 2. Delivered normal

babies 3. Intended to BF 4. Telephone access

1. 24-week intervention by LC4

2. Biweekly calls n=179

Standard care n=178

24 weeks Rate of EBF at 4

th 16

th 24

th week

EBF 4

th wk : RR = 1.1*

16th wk : RR = 1.1

24th wk : RR = 1.0

17

Quality assessment

The Scottish Intercollegiate Guidelines Network (SIGN) methodology

checklist for controlled trials was chosen to rate the evidence level for the five

reviewed studies (SIGN, 2004). It is an appraisal tool which is divided into two

parts. The first part consists of 10 items which assess the internal validity of

studies and the second part consists of 4 items which provide an overall

assessment of the level of the methodological quality of studies.

The ratings of the quality of the five studies are presented in the Table of

Quality Assessment (see Table 2).

Appropriate and clearly focused questions

All reviewed studies addressed appropriate and clearly focused questions

which examined the effectiveness of postnatal telephone support interventions on

the duration of any or exclusive breastfeeding.

Randomization

In four studies, either a computer software program or on-line

randomization sequence service program was used to generate the allocation

sequence for subject allocation (Bunik et al., 2010; Fu et al., 2014; Hoddinott et

al., 2012; Simonetti et al., 2012).

Concealment

Only one study reported using opaque sealed envelopes as the concealment

method (Bunik et al., 2010). In the cluster RCT, the concealment was achieved by

18

informing the research nurses and study sites of the weekly treatment allocation

48 hours before subject recruitment that week (Fu et al., 2014).

Blinding

As the intervention was delivered via telephone, it was difficult to blind the

intervention providers or the receivers. However, it was feasible to blind the

researchers who collected the outcome data in the studies, and three studies did

this (Fu et al., 2014; Hoddinott et al., 2012; Tahir & Al-Sadat, 2012).

Treatment and control groups were similar at the start of the trial

There was no significant difference in the participant characteristics in the

treatment and control groups before implementation of the interventions.

Difference between groups is the treatment under investigation

From the five studies, each group was treated equally and the only

difference between the intervention and control groups was the presence of the

treatment.

Outcomes measured in a standard, valid and reliable way

Three studies collected the outcome data by conducting telephone

interviews. Two studies used a combination of telephone interviews and

self-administered questionnaires (Simonetti et al., 2012; Tahir & Al-Sadat, 2012).

Percentage of dropouts

Two studies had dropout rates higher than 20% in either arm of the study,

with rates of 26.6% and 23.5% (Bunik et al., 2010; Hoddinott et al., 2012).

19

Intention–to-treat analysis

In data analysis, four studies reported using intention-to-treat analysis

(Bunik et al., 2010; Fu et al., 2014; Hoddinott et al., 2012; Tahir & Al-Sadat,

2012). This was not mentioned in the remaining study. However, the four subjects

who were excluded from that study after treatment allocation were not analyzed

(Simonetti et al., 2012).

Results are comparable for all sites

Only one study implemented the interventions at three different hospitals

and the results were comparable for all sites (Fu et al., 2014).

Statistical power of the study

The calculated sample sizes in both study arms were adequately met in

three studies (Bunik et al., 2010; Fu et al., 2014; Tahir & Al-Sadat, 2012).

However, there was no sample size calculation done in the two pilot studies

(Hoddinott et al., 2012; Simonetti et al., 2012).

Ratings of the studies

After assessing the overall risk of bias and the internal validity of the

reviewed studies, the level of evidence of the five studies was rated according to

the criteria in Appendix B. Two studies were rated 1++ (Fu et al., 2014; Tahir &

Al-Sadat, 2012), two were rated 1+ (Bunik et al., 2010; Hoddinott et al., 2012),

and one was rated 1- (Simonetti et al., 2012).

20

Table 2. Table of Quality Assessment (SIGN, 2004)

Bibliographic Citation 1.Bunik et al., 2010 2.Fu et al., 2014

3.Hoddinott et al.,

2012

(pilot)

4.Simonetti et al.,

2012

(pilot)

5.Tahir &

Al-Sadat, 2012

Appropriate and clearly focused question

Randomization X

Concealment X X X

Blinding X X

Treatment and control groups are similar at the start of the trial

The only difference between groups is the treatment under

investigation

The outcomes are measured in a standard, valid and reliable way

Percentage of dropouts I:23.2%

C:26.6%

Telephone group: 2.97%

In-hospital group: 0.52% Control group: 1.52%

I:8.6%

C:23.5% 0 I:10.6%

C:11.2%

Intention to treat analysis X

Are the results comparable for all sites Does not apply Does not apply Does not apply Does not apply

Remarks No sample size

calculation was done

No sample size

calculation was done

Level of evidence 1+ 1++ 1+ 1- 1++

21

Summary and Synthesis

Summary

The five reviewed studies investigated the effect of a postnatal telephone support

intervention on the duration of any or exclusive breastfeeding.

Diversity of outcomes

Three studies proved that a postnatal telephone support intervention

significantly increased the duration of any or exclusive breastfeeding, up to 4, 8

and 20 weeks postpartum (Tahir & Al-Sadat, 2012; Fu et al., 2014; Simonetti et al.,

2012). One of the other two studies shown a positive effect of telephone support

on the duration of any and exclusive breastfeeding but the result was not

statistically significant (Hoddinott et al., 2012). The other study found no

significant effect of a telephone support intervention on the duration of any or

predominant breastfeeding (Bunik et al., 2010).

Characteristics of participants

Mothers’ preferences for breastfeeding were assessed in four studies and

only mothers who wished to breastfeed or considered breastfeeding were eligible

for recruitment (Bunik et al., 2010; Fu et al., 2014; Simonetti et al., 2012; Tahir &

Al-Sadat, 2012). Two studies reported that the telephone accessibility of mothers

was assessed before subject recruitment (Simonetti et al., 2012; Tahir & Al-Sadat,

2012).

22

Qualifications of nurses

Breastfeeding-related qualifications acquired by nurses were reported by

four studies. These nurses were licensed midwives, lactation counselors, lactation

consultants or nurses who had completed a 2-day UNICEF accredited training

program (Fu et al., 2014; Hoddinott et al., 2012; Simonetti et al., 2012; Tahir &

Al-Sadat, 2012).

Refresher course

To maintain uniformity and consistency in the breastfeeding information

provided to mothers, a refresher course for nurses was organized prior to the

implementation of two studies (Fu et al., 2014; Tahir & Al-Sadat, 2012).

Duration of intervention

The intervention durations in the five studies varied from 2 to 24 weeks

postpartum. Two studies with insignificant outcomes on breastfeeding duration

had short intervention durations of less than 4 weeks (Bunik et al., 2010;

Hoddinott et al., 2012). The three studies with longer intervention durations from

4 to 24 weeks were shown to have significant positive outcomes on the

breastfeeding duration (Fu et al., 2014; Simonetti et al., 2012; Tahir & Al-Sadat,

2012).

Time of first call

The time of the first telephone call was reported in three studies (Bunik et

al., 2010; Fu et al., 2014; Hoddinott et al., 2012). In the Bunik et al. (2010) study,

23

the first call was done on the day of hospital discharge, in the Hoddinott et al.

(2012) study within 24 hours of discharge and in the Fu et al. (2014) study within

72 hours of discharge.

Frequency of calls

In one of the two studies with short intervention durations, daily calls were

done throughout the intervention period (Bunik et al., 2010). In the other study,

daily calls were made for the first week and the mothers decided on the frequency

of calls for the following week (Hoddinott et al., 2012). Weekly or biweekly

telephone calls were done in the remaining three studies.

Content of telephone support intervention

Four studies described the content of the support (Bunik et al., 2010; Fu et

al., 2014; Simonetti et al., 2012; Tahir & Al-Sadat, 2012). The nurses provided

breastfeeding information and instruction (Bunik et al., 2010; Fu et al., 2014;

Simonetti et al., 2012), assessed the emotional health of the mothers and feeding

patterns of the infants (Bunik et al., 2010; Fu et al., 2014), offered breastfeeding

support and counseling (Bunik et al., 2010; Fu et al., 2014; Simonetti et al., 2012;

Tahir & Al-Sadat, 2012), gave professional advice when mothers encountered

breastfeeding problems at home (Bunik et al., 2010; Fu et al., 2014), provided

information on breastfeeding in public places and expression and storage of breast

milk for mothers who returned to work (Bunik et al., 2010; Fu et al., 2014) and

addressed cultural issues (Bunik et al., 2010; Fu et al., 2014).

24

Synthesis

In view of the diversity of outcomes in the five reviewed studies, the

similarities and differences of the five studies were reviewed and synthesized.

Qualifications of nurses

Breastfeeding-related qualifications were necessary to ensure nurses were

capable of providing professional advice to assist mothers in establishing and

continuing breastfeeding (Fu et al., 2014; Simonetti et al., 2012; Tahir & Al-Sadat,

2012).

Intention to breastfeed

An intention to breastfeed could be associated with a better outcome in the

duration of breastfeeding. Among the three studies which shown significant

positive outcomes on duration of breastfeeding, mothers’ preferences for

breastfeeding were assessed and only those who expressed a wish and willingness

to breastfeed were recruited into the study.

Telephone accessibility

Two studies reported that the telephone accessibility of mothers was

assessed (Simonetti et al., 2012; Tahir & Al-Sadat, 2012). This is an important

point to note as the telephone was the only communication medium in the

intervention.

Refresher course

A refresher course prior to implementation of the telephone support

25

intervention ensured consistency and uniformity of the content of breastfeeding

support delivered to mothers (Fu et al., 2014; Tahir & Al-Sadat, 2012).

Intervention duration

Telephone support intervention for 4 weeks or more was associated with an

improvement in the breastfeeding duration (Fu et al., 2014; Simonetti et al., 2012;

Tahir & Al-Sadat, 2012). A 2-week intervention might be too short and therefore

inadequate to address breastfeeding problems which arise in the first month

postpartum (Bunik et al., 2010).

Time of first call

The first telephone call was made within 72 hours after hospital discharge

in order to provide continuous breastfeeding support to mothers at home (Bunik et

al., 2010; Fu et al., 2014; Hoddinott et al., 2012).

Frequency of calls

Weekly or biweekly telephone calls shown promising outcomes on the

duration of breastfeeding as breastfeeding problems or difficulties could be

regularly addressed by nurses in a timely manner (Fu et al., 2014; Simonetti et al.,

2012; Tahir & Al-Sadat, 2012).

Content of telephone support intervention

During the early stage of the telephone support intervention, apart from

providing breastfeeding knowledge to mothers (Bunik et al., 2010; Fu et al., 2014;

Simonetti et al., 2012), nurses assessed the emotional health of mothers and the

26

feeding patterns of infants (Bunik et al., 2010; Fu et al., 2014) and they advised

mothers to cope with breastfeeding problems encountered at home (Bunik et al.,

2010; Fu et al., 2014).

In the late stage, advice on breastfeeding in public places, and information

on breast milk expression and storage were important to help mothers prepare for

work (Bunik et al., 2010; Fu et al., 2014). Throughout the intervention, cultural

issues which might discourage mothers from continuing breastfeeding were

addressed by nurses (Bunik et al., 2010; Fu et al., 2014). Breastfeeding counseling

was also offered whenever needed (Bunik et al., 2010; Fu et al., 2014; Simonetti

et al., 2012; Tahir & Al-Sadat, 2012).

Implications for practice

To summarize, the findings of the five studies can be generalized to the

health care setting in Hong Kong. In order to provide an effective telephone

support intervention, nurses should acquire breastfeeding-related qualifications.

The target group of mothers for the innovation should be those who intend to

breastfeed and have telephone access. Refresher courses for nurses should be

arranged prior to the innovation. The innovation duration should be 4 weeks or

longer and the first call should be made within 72 hours after hospital discharge.

After that, weekly or biweekly telephone calls should be made.

To better address mothers’ concerns about breastfeeding, the content of the

telephone support should be divided into early and late phases. Breastfeeding

27

education and support is crucial in establishing breastfeeding in the early phase.

Apart from providing general and basic breastfeeding knowledge, the emotional

health of mothers and the feeding patterns of infants should be assessed by nurses.

Advice and assistance should be offered to mothers who have difficulties

establishing breastfeeding at home. In the late phase, focus should be put on

breastfeeding continuation after resumption of work or study. Information and

advice should be provided on breastfeeding in public places and breast milk

expression and storage in order to prolong breastfeeding.

In order to foster mothers’ confidence and commitment to continue

breastfeeding, cultural issues which could lead to early cessation of breastfeeding

should be frequently assessed and addressed. In addition, breastfeeding

counseling and support should be offered throughout the 4 week telephone

support intervention whenever it is needed.

28

Chapter 3 - Implementation Potential

Target setting and audience

The proposed setting of the innovation is a MCHC of the DH. The target

audience is mothers who deliver healthy full term babies, intend to breastfeed, go

to the designated MCHC with their babies within 72 hours after hospital discharge

and provide one contact number on first registration.

Transferability of findings

Similarity of the target setting and audience

The settings of the five reviewed studies were maternity wards, postnatal

wards and mother-baby units of community health centers where a sufficiently

large number of mother-infant pairs were available. Similarly, as it is the public

health service provider in Hong Kong, the MCHC ensures a potentially large

number of mother-infant pairs for recruitment for this innovation.

The target audiences of the reviewed studies were mothers who had just

given birth to healthy full-term babies, intended to breastfeed and had telephone

access, similar to the inclusion criteria of the target audience in our innovation.

Philosophy of Care of DH

The MCHC is under the Family Health Service (FHS) of the DH. The

vision of the FHS is to lead the community in promoting the health and well-being

of children, women and families in Hong Kong (DH, 2006). To achieve this, a

policy was established in 2000 to advocate breastfeeding in Hong Kong. The

29

policy stated that creation of a positive environment to support breastfeeding

clients and employees should be highly encouraged in all service settings (DH,

2013).

Philosophy of care underlying the innovation

Our innovation is to prolong the duration of breastfeeding by providing

telephone support to mothers after hospital discharge. Since prolonging the

breastfeeding duration can improve the health outcome of infants (Bachrach et al.,

2003), the philosophy of care underlying this innovation parallels that advocated

by the DH, which is to support and encourage mothers in breastfeeding in order to

promote the health and well-being of the mothers and infants in the community.

Number of clients benefitting from the innovation

Each month, around 90-110 mother-infant pairs seek care at the designated

MCHC within 72 hours after hospital discharge. Approximately, 90% of those

babies are still breastfeeding. After calculation, it was estimated that about 80-100

mother-infant pairs will meet the inclusion criteria and can benefit from the

innovation each month.

Time frame for innovation implementation

It will take 18 months to implement the innovation. The first 5 months will

be used to establish a communication team, gain the approval of the

administrators of the DH and FHS, communicate with the stakeholders at the

management level of the designated MCHC, organize orientation programs and

30

refresher programs for all frontline nurses and prepare materials for the innovation.

The pilot study will last for 3 months and will include subject recruitment, pilot

test implementation and evaluation. Lastly, the actual innovation will be

conducted over a course of 6 months and will include subject recruitment,

innovation implementation and data collection. The following 4 months will be

spent on data analysis, data evaluation and overall evaluation of the innovation.

The timeline of the innovation implementation is shown in Appendix C.

Feasibility of the innovation

Administrative support

Administrative support from the DH and FHS is likely as this innovation

shares their philosophy of care, which is, to advocate breastfeeding and to

promote the health and well-being of children, women and families in Hong

Kong.

The innovation consists of evidence-based guidelines with a list of

recommendations which have been developed from the best evidence of the five

studies and have been shown to be effective in prolonging the breastfeeding

duration. In view of the potential benefits of prolonging the breastfeeding duration,

implementation of this innovation should be highly appreciated by the

administrators of the DH and FHS.

Consensus among stakeholders in MCHC

The FHS has been advocating breastfeeding promotion and education for

31

years. Therefore, the benefits and importance of prolonging the breastfeeding

duration are well-known by all staff in MCHCs and they have a good

understanding of and positive attitudes towards breastfeeding.

Telephone support intervention workload

Thirteen frontline nurses work at the designated MCHC to deliver

maternal and child health services to the public. One registered nurse will be

designated for the telephone support intervention each week. In order to ensure

the current service can be maintained with minimal disturbance, approval for an

extra registered nurse will be requested. Since this is a 4-week telephone support

innovation, the number of weekly cases should be calculated by adding the

number of cases from the previous 3 weeks to the number of the newly recruited

cases in the current week. Approximately, 20-25 new cases will be eligible for the

innovation in one week. About 60-75 cases will be carried over from the previous

3 weeks (i.e. 20-25 cases per week x 3 weeks) if there are no dropouts. Therefore,

a total number of 80-100 cases will be handled by the designated nurse each week,

that is, 16-20 cases per day (i.e. 80-100 cases / 5 days). A maximum of 20 minutes

can be allocated to each case.

Staff training and equipment needed

All MCHC nurses have completed the breastfeeding training workshop

organized by the FHS and they are qualified to provide breastfeeding guidance

and coaching for mothers. No extra equipment or materials will be required for

32

the innovation. Telephones have already been installed in each room of the clinic.

Electronic devices such as computers, printers, audiovisual devices and printed

breastfeeding materials are all already available at the designated MCHC.

Availability of the evaluation tool

The breastfeeding rates at 1 and 2 months and the level of satisfaction of

the frontline nurses will be the two identified outcomes of the innovation. A

breastfeeding data collection form has been designed to collect the breastfeeding

data that is reported by mothers through face to face interviews or by telephone at

the infant age of 1 and 2 months. A self-report questionnaire has been designed to

access the satisfaction level of the innovation by the frontline nurses.

Nurse-related barriers & strategies

People are always the most critical resources, supporters, barriers, and

risks in a change process (Victorian Quality Council, [VQC], 2006), so

understanding and addressing their concerns is very important. Potential barriers

which may discourage frontline nurses from engaging in the innovation

implementation have been identified and some strategies have been suggested

accordingly.

Different problems in implementing a change in a practice can arise

depending on the phase of the change process (Grol, 1997). During the innovation

dissemination phase, nurses may not be willing to engage in the process as they

may not be aware of or understand why a change is necessary (National Health

33

Service Modernisation Agency, 2005). Lack of support and resources during the

implementation phase may discourage nurses from continuing to perform the

innovation (Grol, 1997). These obstacles are the risks that could lead the nurses to

return to old practices.

Orientation program

Early communication and consultation is crucial in gaining commitment,

and getting people interested and prepared to participate in a change process

(VQC, 2006). An orientation program will be held soon after gaining approval

from the administrators. The details and potential benefits of the innovation

should be clearly addressed for the nurses. If they are familiar with the innovation,

a sense of ownership can be built among the nurses and it will become easier to

gain their support and cooperation in performing the innovation.

Continuous evaluation

To sustain the change process, continuous evaluation of the innovation

should take place. The outcomes of the change will be used to determine whether

the plan of the innovation should be modified (Grol, 1997). In addition, sharing

the outcomes of the evaluation with the nurses is important as people will be more

committed to the change if they can see that it does improve things (VQC, 2006).

Regular meetings should be held to encourage the nurses to voice their concerns

about continuing the innovation. Moreover, it is important to emphasize that the

change is an ongoing process, and their efforts in implementing the innovation are

34

highly valued by the MCHC and the public.

Innovation Evaluation

The effectiveness of the innovation and the willingness of the staff to

continue the innovation can be assessed by evaluating breastfeeding outcomes and

the level of satisfaction of frontline nurses during the innovation evaluation

process.

Cost-Benefit ratio of the innovation

Potential risks to clients

The success of the telephone support intervention relies on effective

communication between nurses and mothers. In this innovation, poor

breastfeeding instructions could impose a risk of breastfeeding-related

complications for mothers, such as sore nipple and mastitis, which could lead to

early discontinuation of breastfeeding.

Potential benefits from the innovation

Prolonging the breastfeeding duration reduces illness-related doctor visits

by infants (Leung et al., 2005), saves medical costs in the community (Batrick &

Reinhold, 2010), and conserves the environment (Cohen et al., 1995; Jarosz, 1993;

Levine et al., 1990). Apart from being the healthiest and safest kind of feeding

method, breastfeeding is also the least expensive method of feeding compared

with breast-milk substitutes or artificial formula (Leon-Cava, Lutter, Ross, &

Martin, 2002). A study found that families could save money by practicing

35

breastfeeding as the cost of formula milk is about twice that of extra food needed

by a lactating mother (Jarosz, 1993).

Material costs of implementing the innovation

These include hiring an extra registered nurse, installing telephones and

preparing printed materials for orientation and refresher programs. The material

costs of implementing the innovation are illustrated in Table 3 in Appendix D.

Material costs of not implementing the innovation

Early cessation of breastfeeding could occur if the innovation is not

implemented. The incidence of infant medical illnesses and related medical

expenditures will increase. Studies focusing on the economic benefits of

breastfeeding in Hong Kong are limited. The United States annual national health

care costs incurred for treatment of four medical conditions, diarrheal disease,

respiratory syncytial virus, insulin-dependent diabetes mellitus, and otitis media,

in infants who were not breastfed in 1997 (Riordan, 1997) will be used as a

reference in estimating additional medical expenditures due to not implementing

the innovation in Hong Kong.

Additional costs are incurred for purchase of formula milk for infants who

are not breastfed. In the United States, it was calculated that an additional US$

2,665,715 in federal funds is needed each year in the Women, Infants and Children

(WIC) program to provide formula to mothers who are not breastfeeding (Riordan,

36

1997). Details of the material costs of not implementing the innovation are shown

in Table 4 of Appendix E.

Potential non-material costs of implementing the innovation

Spending time attending orientation and refresher programs, increasing

workloads and stress are potential non-material costs. These could lower the

morale of nurses and decrease their willingness to implement the innovation if

those problems are not handled appropriately.

Potential non-material benefits of implementing the innovation

Apart from optimizing the health outcomes of mothers and infants, this

innovation offers a valuable opportunity to enrich the breastfeeding knowledge of

nurses and enhance their competency in supporting mothers who are breastfeeding.

Nurses can enjoy a great sense of satisfaction by delivering effective breastfeeding

support to mothers. The morale of the nurses is expected to improve with time as

they become more familiar with the innovation and can do the work more

efficiently, thereby fostering their confidence and increasing their willingness to

continue the innovation.

In summary, it will cost HK $34,036.4 to initiate the innovation. After that,

HK$ 31,200 is needed to pay the salary of an extra nurse to maintain the

innovation each month. On the other hand, the additional costs of not

implementing the innovation due to expenses for extra health care and infant

37

formula range from HK$ 9,270,812,577 to HK$ 10,169,372,577 per month.

To conclude, this innovation is highly transferrable and is considered

feasible for implementation. The potential benefits of implementing the

innovation are enormous. Apart from improving the health outcomes of the

mother-infant pairs, it can help save household expenditures and greatly reduce

health care expenses in Hong Kong in the long run. There are few potential risks

and costs and these could be fully outweighed by the benefits. Therefore, it is

worthwhile to implement this innovation in the proposed setting.

38

Chapter 4 - Evidence-Based Practice Guidelines

Title of the guidelines

Postnatal telephone support intervention for breastfeeding mothers after hospital

discharge.

Objective of the guidelines

a) To summarize the evidence of the reviewed studies for implementation of the

postnatal telephone support intervention.

b) To formulate clinical practice instructions for implementation of the postnatal

telephone support intervention based on the best evidence available.

c) To structure and standardize instructions for nurses to implement the

postnatal telephone support intervention more effectively.

Purpose of the guidelines

These guidelines are intended to provide a list of structured clinical

practice instructions for the MCHC nurses to facilitate delivery of a postnatal

telephone support intervention to breastfeeding mothers after hospital discharge.

Target group of the guidelines

The target population is mothers who deliver healthy full term babies,

intend to breastfeed, go to MCHC with their babies within 72 hours after hospital

discharge, and provide at least one contact number on registration.

39

Recommendations

Altogether, a total of 8 recommendations have been developed from the

five identified studies. The grading of the recommendations has been rated

according to the SIGN guidelines in Appendix B. Evidence that supports the

recommendations has been stated with the level of evidence provided. The

workflow of the innovation is shown in Appendix F.

1. Nurses are required to complete breastfeeding-related training or obtain

qualifications before delivering the postnatal telephone support intervention.

[Grade A]

a) Breastfeeding support and education offered by knowledgeable health care

professionals could help mothers and their families overcome obstacles in

breastfeeding (1++ Tahir & Al- Sadat, 2012).

b) Mothers felt that they could express their breastfeeding difficulties to a

competent midwife who was able to give them all the breastfeeding

information and support they need (1-Simonetti, 2012).

2. The breastfeeding intention of mothers is assessed and only mothers who

declare their intention to breastfeed are eligible for the innovation. [Grade

A]

a) The intention to breastfeed was assessed and mothers who planned to

breastfeed were recruited into the studies (1- Bunik et al., 2010; 1++ Fu et al.,

40

2014; 1- Simonetti et al., 2012; 1++ Tahir & Al-Sadat, 2012). This can ensure

that mothers who receive the intervention are willing to breastfeed.

3. The first telephone call should be made within 72 hours after mothers are

discharged from hospital. [Grade B] For mothers who go to MCHC at 72

hours after hospital discharge, the first call will be made on the same day.

a) The immediate postpartum period was the most relevant time to make

telephone calls. Having the infants present and struggling with the reality of

breastfeeding made this a powerful time for the telephone support

intervention (1- Bunik et al., 2010).

b) The immediate post-discharge period was a very delicate moment for

psychological adaptation. Breastfeeding promotion should start during

pregnancy and continue in the hospital and at home after hospital discharge

(1- Simonetti et al., 2012).

c) Problems related to milk production, for example, breast engorgement and

perceived insufficient milk supply, were commonly experienced by mothers

soon after hospital discharge. Mothers might decide to discontinue

breastfeeding if these problems were not well-addressed (Gerd et al., 2012;

Hegney, Fallon, & O’Brien, 2008).

4. A refresher program for nurses should be provided before the postnatal

telephone support intervention. [Grade A]

41

a) A refresher course on breastfeeding management and counseling should be

given to nurses to maintain uniformity and control the quality of the

breastfeeding counseling practices (1++ Tahir & Al- Sadat, 2012).

b) A training period of 8 hours was provided to ensure that breastfeeding

support practices were evidence-based and consistent (1++ Fu et al., 2014).

5. The duration of the postnatal telephone support should be 4 weeks or more.

[Grade A]

a) A 2-week telephone support intervention might be inadequate to overcome

some deeply entrenched issues (1- Bunik et al., 2010).

6. The time of subsequent calls should be decided by mothers and nurses.

[Grade A]

a) Timing of telephone support could be planned by mothers and midwives/

nurses (1++ Fu et al., 2014; 1- Simonetti, 2012) so that mothers could

negotiate times that best fit their family routines (1++ Fu et al., 2014).

7. Telephone support should be done at least weekly. [Grade A]

a) Regular telephone contact was especially helpful to mothers at a time when

they were less likely to receive any other kind of breastfeeding support (1++

Fu et al., 2014).

8. The content of the support should be structured in two stages. The early

stage should focus on providing general breastfeeding knowledge, assessing

infant feeding and stooling patterns, assessing maternal emotional and

42

physical health, and assisting mothers in managing breastfeeding problems

or complications. The late stage should mainly focus on breastfeeding in

public places, expression and storage of breast milk, and preparation for

returning to school or work. Cultural issues should be covered and addressed,

and breastfeeding counseling should be offered throughout the telephone

support intervention.[Grade A]

a) The content of support suggested by two studies (1- Bunik et al., 2010; 1++

Fu et al., 2014) was quite similar. Well-structured telephone support should

be able to meet the needs of mothers and help them resolve breastfeeding

problems they encounter at different stages during the postnatal period to

avoid premature discontinuation of breastfeeding.

b) In Chinese culture, mothers might have to deal with family or sociocultural

pressure to stop breastfeeding after hospital discharge (1++ Fu et al., 2014).

43

Chapter 5 - Implementation Plan

The implementation plan includes a communication plan with the

stakeholders, and a plan for pilot testing, followed by an evaluation of the overall

effectiveness of the evidence-based guidelines in the proposed clinical setting.

Communication plan with potential users

The purpose of a communication plan is to communicate with all the

stakeholders in the proposed innovation. A comprehensive communication plan

helps the stakeholders understand the innovation well and, more importantly, gain

their approval and support for the innovation implementation.

Identifying the stakeholders

Stakeholders are those people who will be influenced either directly or

indirectly by the implementation of the innovation (Melnyk & Fineout-Overholt,

2005). In this innovation, the identified stakeholders will be the administrators of

the DH and FHS, Medical Officers (MOs), Nursing Officers (NOs), Lactation

Consultants (LCs), and the frontline nurses of the designated MCHC.

Forming a communication team

After identifying the stakeholders, a communication team will be

established. The function of the communication team is to work out the

communication plans with different stakeholders. It is responsible for

coordinating MOs, NOs and frontline nurses during the innovation

implementation and evaluation process.

44

The team will consist of six team members including the innovation author,

one MO, one NO, one LC and two frontline nurses at the designated MCHC.

Having team members from different disciplines can enhance the

representativeness of the team and ensure that various expert opinions and

feedback can be collected to work out a comprehensive communication plan.

Communication plan with the administrators of the DH and FHS

The Deputy Director of Health of the DH and the chairperson of the FHS

are responsible for the decision making processes for administrative and executive

affairs of the public health services in Hong Kong. Therefore, their support and

approval are necessary for the implementation of the proposed innovation.

Two weeks before the formal meeting with the administrators of the DH

and FHS, details of the proposed innovation will be presented in a proposal and

sent to them via email. Details include the objectives of the innovation, the

program logistics, feasibility and transferability, potential risks and benefits, and

the proposed budget. Requisition of extra manpower for the innovation will be

mentioned in the proposal. The five reviewed studies which provide evidence

supporting the development of the evidence-based guidelines will be attached for

their reference.

Those administrators are encouraged and welcome to raise questions and

concerns about the innovation and these will be clarified, explained and answered

by the communication team during the formal meeting. Feedback from the

45

administrators will be collected and modification of the innovation will be made

accordingly.

Communication with the MO In-charge (MO IC) and NO In-charge (NO IC)

After gaining the approval of the administrators of the DH and FHS, a

meeting will be arranged with the MO IC and NO IC of the designated MCHC to

obtain their support in facilitating and offering help in the innovation

implementation process.

The timeline and logistics of the innovation, target number of participants,

manpower allocation and any breastfeeding materials required for the innovation

will be discussed in the meeting. Comments and feedback from the MO IC and

NO IC will be considered in order to implement the innovation smoothly without

disrupting the current service provided by the MCHC.

Communication plan with frontline nurses

A good consensus with the 13 frontline nurses will make it easier to gain

their cooperation to carry out the innovation more effectively. Two identical

orientation sessions will be held in the designated clinic in two different weeks to

ensure each of the frontline nurses can attend. The lactation consultant of the

communication team will be responsible for the orientation program. Apart from

introducing the innovation, the objectives and logistics of the innovation,

allocation of manpower and role of the frontline nurses in delivering the

intervention will be well covered in the orientation program. Lastly, it is important

46

to reassure frontline nurses that requisition of extra manpower has already been

approved by the FHS and therefore the extra workload due to the innovation

should be limited.

Pilot Testing

A pilot study is also known as a feasibility study. It is a small scale version

or a trial run carried out to prepare for the actual major study (van Teijlingen &

Hundley, 2002; Thabane et al., 2010). A pilot study is conducted to provide

opportunities to assess the feasibility of the actual innovation, identify logistical

problems which might occur during the implementation process and determine the

adequacy of resources (for example, staff and time) (van Teijlingen & Hundley,

2002). It can also be a pre-testing of a research instrument (Baker, 1994).

Therefore likelihood of the success of the actual study is increased. It is beneficial

to conduct a pilot study with a small number of subjects before an actual

innovation implementation (Melnyk & Fineout-Overholt, 2005).

Timeline of the pilot test

The pilot study will last for 3 months. Implementation of the pilot test will

take 2 months and another month will be spent on evaluation. The first month will

be the subject recruitment period and the pilot test will begin after the first subject

is recruited.

Number of subjects required

The target number of subjects required for the pilot test is 30. This ensures

47

each of the 13 frontline nurses will have adequate cases for practice before the

actual innovation implementation. Verbal consent will be obtained from mothers

who are eligible to the innovation.

Pilot test implementation

Frontline nurses are strongly advised to perform the pilot study according

to the evidence-based guidelines. The content of the telephone support checklist is

designed for nurses to document the content of the support they have delivered

each time and this will be kept in the child health record (Appendix G). By

referring to the checklist, nurses can review the type of breastfeeding information

and advice that were delivered in the previous telephone call to decide what kind

of breastfeeding information should be given the next time.

Throughout the 3-month pilot study, the communication team will assess

the feasibility of the whole implementation process. This will include the

sequence and logistical flow of the pilot study, sufficiency of time allocated to

each case, and adequacy of the content of the telephone support checklist. The

team will also assess the compliance of the nurses in using the evidence-based

guidelines and their competency in delivering the innovation.

Pilot test evaluation

Evaluation of the pilot test will be done by the communication team.

Evaluation will focus on the feasibility of the implementation process. Issues that

may affect the logistical flow of the pilot study should be identified and resolved

48

to ensure the implementation process is smooth and not time-consuming. The

average duration of the telephone support should be evaluated to assess the

capability of the innovation, the workload of the nurses and the adequacy of

manpower to deliver the innovation. Group meetings will be arranged with

frontline nurses to collect their feedback on the pilot study, for example, their

competency in providing the innovation, any problems they encounter in

performing the evidence-based guidelines and any difficulties in using the

telephone support checklist will be assessed. The identified problems will be

reviewed by the communication team, and possible solutions and

recommendations will be considered to refine the innovation and the guidelines

accordingly.

The results of the pilot test evaluation and any modifications of the

innovation will be reported to the administrators of the DH and FHS via email,

and directly reported to the MO IC and NO IC of the designated MCHC.

49

Chapter 6 - Evaluation Plan

The purpose of an evaluation plan is to assess the effectiveness of a

proposed innovation in terms of the identified outcomes. In this innovation, the

two identified outcomes are patient and health care professional outcomes.

Details of the evaluation plan will be illustrated in this section.

Intervention outcomes

Client outcome

The rates of any breastfeeding up to 2 months after delivery will be the

client outcome as well as the primary outcome of the innovation. Breastfeeding

data will be collected through verbal report by the mothers. The effectiveness of

the innovation will be evaluated by comparing the breastfeeding outcome of this

innovation with breastfeeding data from 2013 which were revealed in a recent

survey done by the FHS (CHP, 2014).

Health care professional outcome

The level of satisfaction perceived by the frontline nurses will be the

health care professional outcome in the innovation. This will be assessed by a

self-report questionnaire.

Nature and Number of clients

Participant Eligibility

Mothers who wish to breastfeed, go to the designated MCHC with their

healthy full term babies within 72 hours after hospital discharge and provide at

50

least one contact telephone number on first registration are eligible to the

innovation. Nurses will assess the eligibility of mothers and obtain their verbal

consent during the first registration interview for the innovation.

Sample size considerations

The sample size of the innovation has been calculated by the Piface

Application selector version 1.76 (Lenth, 2011). Previous studies of similar

postnatal telephone support interventions shown differences of 17- 85% in the

breastfeeding rates between the intervention and control groups (Albernaz

Victoria, Haisma, Wright, & Coward, 2003; Bonuck, Trombly, Freeman, &

McKee, 2005; Porteous, Kaufman, & Rush, 2000 & Su et al, 2007.). Therefore, to

compare a single proportion to a known proportion based on 80% power to detect

a 15% difference in the rates of any breastfeeding up to 2 months, with the level

of significance at 5%, the calculated sample size is 277. With consideration of a

5% of dropout rate according to a similar study conducted in Hong Kong (Fu et al.,

2014), a sample size of 290 is required.

It is predicted that 80-100 potential mother-infant pairs will be able to

meet the inclusion criteria of the innovation and be recruited in one month.

Therefore, the recruitment period should last for 3 months in order to achieve the

desired sample size.

51

Outcome measurements

Rate of any breastfeeding

A breastfeeding data collection form (Appendix H) has been designed for

nurses to collect breastfeeding data during the 1 and 2 month child health

follow-up visits, or by telephone follow-up if the mother-infant pair default a

follow-up visit or the mother did not accompany the baby at the last follow-up

visit. The age of the infant and type of feeding will be documented on the form.

For mothers who report using artificial formula milk, the time when she stopped

breastfeeding will be recorded.

Satisfaction level of health care professionals

The level of satisfaction of the frontline nurses will be measured by a

self-report questionnaire (Appendix I) which will be distributed to every frontline

nurse at the end of the innovation implementation. It is composed of 8 statements

describing the perceptions of nurses about the innovation preparation and

implementation process, the competency of nurses in providing the telephone

support intervention and the overall satisfaction of nurses with the program. A

5-point Likert scale with ‘strongly agree’, ‘agree’, ‘neutral’, ‘disagree’ and

‘strongly disagree’ will be used for rating each statement.

Data analysis

The evaluation objective is to determine if the rates of any breastfeeding at

1 and 2 months increase after the innovation compared with the existing rate of

52

breastfeeding. The statistical analysis will be conducted with the use of the SPSS

Statistics for Windows version 22. The outcome data collected at the end of the

innovation will be entered into the SPSS database. A two-tailed z-test for testing

one proportion will be performed as the outcome of a single group’s proportion is

going to compare with that of a large population (Campbell & Machin, 1999). For

the level of satisfaction of the health care professionals, the means of descriptive

statistics will be used to describe the outcome data from the self- report

questionnaire (Mann, 2006).

Criteria for effectiveness

To consider a proposed innovation effective, some criteria must be met by

the identified outcomes.

Client outcomes

According to the breastfeeding survey done by the FHS in 2013 (CHP,

2014), the rates of any breastfeeding at 1 and 2 months in 2012 were 68.6% and

55.5% respectively. The innovation will be considered effective if the rates of any

breastfeeding at 1 and 2 months after the innovation are higher than 68.6% and

55.5%.

Health care professional outcome

Another criterion deciding the effectiveness of the innovation is the health

care professional outcome. It is expected that 75% of the frontline nurses will rate

‘strongly agree’ or ‘agree’ for more than 5 statements in the self-report satisfaction

53

questionnaire.

Conclusion

Years of breastfeeding promotion programs in Hong Kong have

successfully increased public awareness of the benefits and importance of

breastfeeding. Despite the significant improvement in the breastfeeding initiation

rate and breastfeeding rate on discharge, the duration of breastfeeding in Hong

Kong is still far below WHO recommendations. This suggests that insufficient

breastfeeding support for mothers after hospital discharge accounts for the short

duration of breastfeeding.

Cell phones have become very common. They are easily accessible and

not limited by geographical barriers. A telephone support intervention could be a

way to help sustain the duration of breastfeeding by providing continuous

breastfeeding support for mothers after hospital discharge and overcoming some

cultural and traditional issues in Chinese society which discourage mothers from

leaving the home to seek breastfeeding support in the early postpartum period.

Although studies investigating the effect of a telephone support

intervention are limited, most have shown positive outcomes on breastfeeding.

The five reviewed studies selected provided strong evidence that implementation

of a telephone support innovation was effective in improving the breastfeeding

rate and duration. After assessing the implementation potential, risks and benefits,

cost effectiveness of the innovation, communication with the stakeholders, and

54

implementation of the pilot study and the actual innovation followed by a

comprehensive evaluation plan, it is recommended that the proposed innovation

and the evidence-based guidelines should be adopted in Hong Kong to prolong the

duration of breastfeeding. More research could be done in this area as improving

the breastfeeding outcome is not only good for mothers and babies, but it is also

highly beneficial for the health of the public, the economy and the environment as

a whole.

55

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Appendix A – Table of Search Strategy

Electronic Database CINAHL

plus PubMed

Manual

Search

Date of search 13 June 2013 13 June

2013 30 Aug 2013

Search by keywords 1. breastfeeding OR breastfeeding

duration OR breastfeeding rate OR duration of breastfeeding OR rate of breastfeeding

2. telephone intervention Or telephone counseling OR telephone support OR professional support

3. midwife OR midwives OR nurse OR lactation consultant OR lactation counselor OR health care professional

8 297 N/A

Screening by title and abstract 1 6 N/A

Reviewed by full text 1 4 N/A

Elimination of duplication 1 3 N/A

Screening of reference list 1 3 1

Total number of eligible studies 5

66

Appendix B - Level of Evidence by Scottish Intercollegiate Guidelines Network (SIGN, 2004)

Grades of Recommendations by Scottish Intercollegiate Guidelines Network (SIGN, 2004)

Grade Statement

At least one meta-analysis, systematic review, or RCT rated as 1++, and directly applicable to the target population; or

A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall

consistency of results

A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results;

or

Extrapolated evidence from studies rated as 1++ or 1+

A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results;

or

Extrapolated evidence from studies rated as 2++

Evidence level 3 or 4; or

Extrapolated evidence from studies rated as 2+

Good practice points

Recommended best practice based on the clinical experience of the guideline development group

Level of Evidence Statement

1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias

1+ Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias

1- Meta-analyses, systematic reviews, or RCTs with a high risk of bias

2++ High quality systematic reviews of case control or cohort or studies High quality case control or cohort studies with a very low risk of confounding or bias and

a high probability that the relationship is causal

2+ Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal

2- Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal

3 Non-analytic studies, e.g. case reports, case series

4 Expert opinion

67

Appendix C -Timeline of the innovation implementation

Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Establishment of communication team Application for approval from FHS & DH

Communication with in-charge of clinic

Arrangement of orientation program

Preparation of materials

Arrangement of refresher program

Subject recruitment for pilot test

Pilot test implementation

Pilot test evaluation

Subject recruitment for innovation

Innovation implementation

Data collection

Data analysis and data evaluation

Innovation evaluation

68

Appendix D - Material costs of implementing the innovation (Table 3)

Monthly salary: The mean point of monthly salary of registered nurse at point 20 in the Master Pay Scale w.e.f. 1.4. 2013: $ 31200 (Civil Service

Bureau, 2014)

Half day salary: $31200/ (44 hour per week x 4 weeks) x 4 hours (half day) = $ 709.1

The total material costs of implementing the innovation is HK$ 34,036.4.

Item Personnel / Materials Costs (HK dollars)

Refresher program (Half day)

2 identical sessions

Registered nurse of the communication team x1 Half day salary $709.1 x 2 sessions =$1,418.2

Printed materials, a room with visual and audio devices Nil (Available in MCHC)

Orientation program (Half day)

2 identical sessions

Registered nurse of the communication team x1 Half day salary $709.1 x 2 sessions =$1,418.2

Printed materials, a room with visual and audio devices Nil (Available in MCHC)

Innovation implementation

Registered nurse x1 Monthly salary $31,200

Telephone Nil (Available in MCHC)

Evaluation tool Printed questionnaires (printer, A4 papers) Nil (Available in MCHC)

Total $ 34,036.4

69

Appendix E - Material costs of not implementing the innovation (Table 4)

The total material costs of not implementing the innovation are ranged from $ 9,270,812,577 to $ 10,169,372,577.

*The author projected the amount of IDDM in the US population attributable to not breastfeeding ranging from 2% to 26% varying according to the

breastfeeding prevalence reported in other studies.

Item Estimated costs (US dollars)

Total estimated costs (US dollars)

Total estimated costs (HK dollars) [HK$7.8 = US$1 ]

Medical health care

Diarrheal disease $291,300,000

Low estimation: $1,185,900,000 High estimation: $1,301,100,000

Low estimation: $9,250,020,000 High estimation: $10,148,580,000

RSV $225,000,000

IDDM*

2%: $9,600,000 (low estimation)

26%: $124,800,000 (high estimation)

Otitis media $660,000,000

Purchasing infant formula $ 2,665,715 $ 20,792,577

Total Low estimation :$ 9,270,812,577 High estimation :$ 10,169,372,577

70

Appendix F – Workflow of the telephone support innovation

Is mother eligible to the innovation? (1) go to MCHC within 72 hours after hospital discharge [A] (2) intend to breastfeed [A] (3) has telephone access

All nurses acquired breastfeeding qualification or breastfeeding training [A] Refresher program before the innovation [A]

First call should be made within 72 hours after hospital discharge [B]

YES

Excluded from the innovation

YES

Time of next call is decided by mother and nurse [A]

Content of support Early stage: first week

1. provide general breastfeeding knowledge [A] 2. asses infant feeding and stooling patterns [A] 3. assess the emotional and physical health of

mothers [A] 4. assist mothers in managing their breastfeeding

problems [A] 5. address cultural issues [A] 6. provide breastfeeding counseling [A]

Content of support Late stage: second week onwards

1. advise on breastfeeding in public places [A] 2. advise on breast milk expression and

storage [A] 3. advise preparation for returning to school /

work [A] 4. address cultural issues [A] 5. provide breastfeeding counseling [A]

Assess whether mother is still breastfeeding the babies

Yes: Telephone support continues No: Telephone support ends

Late stage: second week onwards

Early stage: first week

71

Appendix G - Content of telephone support checklist

Content of telephone support checklist

Client Label

Content of support 1st week

2nd week

3rd week

4th week

Early stage ( first week)

1. Provide general breastfeeding knowledge (e.g. physiology of milk production, feeding frequency )

2. Assess infant feeding and stooling pattern

3. Assess mother emotional health and physical health

4. Assist mothers in managing breastfeeding related problems (e.g. sore nipples, thrush)

5. Address cultural issues on breastfeeding

Latter stage (second week onwards)

6. Advise breastfeeding in public places

7. Advise on breast milk expression and storage

8. Advise preparation for returning school/ work

9. Address cultural issues on breastfeeding

Remarks:

Week of support

Date of support Type of BF Done by

( Signature of nurse) Date of next

follow up

1st EBF / Predominant BF/

Partial BF /AF

2nd EBF / Predominant BF/

Partial BF /AF

3rd EBF / Predominant BF/

Partial BF /AF

4th EBF / Predominant BF/

Partial BF /AF

Please complete the checklist by the corresponding box(es) in which the content of support is provided.

72

Appendix H- Breastfeeding form for data collection

[At first registration] (less than 72 hours of life) Date:

Age:

Feeding type: Exclusive BF / Predominant BF/ Partial BF / Artificial formula

Signature of nurse:

[Follow- up visit] Date:

Method of data collection: Face- to face/ Telephone

Age: 1 month / 2 months / Others: months

Feeding type: Exclusive BF / Predominant BF/ Partial BF / Artificial formula

Time when stopped BF: At month(s)

Signature of nurse:

Signature of the nurse:

Breastfeeding form for telephone support intervention

Client Label

[Follow- up visit] Date:

Method of data collection: Face- to face/ Telephone

Age: 1 month / 2 months / Others: months

Feeding type: Exclusive BF / Predominant BF/ Partial BF / Artificial formula

Time when stopped BF: At month(s)

Signature of nurse:

73

Appendix I- Questionnaire of the satisfaction level of health care professionals

Please circle the most appropriate number of each statement which closely represents your feeling about the telephone support innovation

Strongly Disagree

Disagree Neutral Agree Strongly

Agree

Prior innovation implementation

1. The orientation program helps me understand the objectives and logistic of the innovation

1 2 3 4 5

2. The refresher program strengthens my BF knowledge

1 2 3 4 5

During innovation implementation

3. The workload of the innovation is acceptable 1 2 3 4 5

4. The content of telephone support checklist is easy to use

1 2 3 4 5

5. The time duration for each case is sufficient 1 2 3 4 5

6. The communication team is helpful and supportive 1 2 3 4 5

Competency & satisfaction of health care professionals

7. I am competent in providing telephone support to the mothers

1 2 3 4 5

8. I am satisfied with the innovation 1 2 3 4 5

9. The strength of this telephone support innovation: 10. The weakness of this telephone support innovation: 11. Any suggestions: