A community-centered intervention to improve infant feeding practices among Pakistani and Bangladeshi families living in the UK
Lead Research Organisation:
Coventry University
Department Name: Ctr for Intelligent Healthcare
Abstract
Breastfeeding is known to be the best way to feed an infant. Compared to bottle-fed babies, those who are breastfed for longer have a lower risk of serious infections, sudden infant death, and are less likely to become overweight as children. Breastfeeding longer also helps to reduce the risk of maternal cancers. The UK has one of the lowest rates of breastfeeding in the World, with less than 1% of mothers exclusively breastfeeding until 6 months as recommended by the World Health Organisation. Most programmes or extra support for breastfeeding are targeted at disadvantaged, white mothers, who are thought to be most in need of breastfeeding support, and much less attention has been paid to mothers from ethnic minorities who are thought to have relatively high rates of breastfeeding. Mothers of Indian, Pakistani and Bangladeshi origin are often grouped together as one 'South Asian' group when looking at breastfeeding rates (or other health behaviours), and when viewed this way it appears that their breastfeeding rates are relatively high. However, our recent research has separated these groups and has identified that infants from Pakistani and Bangladeshi communities are much less likely to be breastfed than infants from Indian communities. This means that families from the Pakistani and Bangladeshi communities have been left vulnerable to misinformation about breastfeeding and formula feeding and this could have significant consequences for the health of these communities. Research has shown that there are specific cultural beliefs and practices in these communities that may be harmful to successful initiation and maintenance of breastfeeding or might encourage early weaning. This means that a specific intervention is required which sensitively addresses the beliefs and practices unique to these communities. In order to successfully change practices that are considered social norms, an approach is required which engages the community and works with them to develop appropriate strategies. In this project we will employ a novel, community-based method to intervention development (the REPLACE approach) which has been developed to tackle female genital mutilation or other practices which are driven by social or cultural norms. We will host engagement events in the target communities and recruit six 'community research facilitators' who will help us to approach research participants and facilitate communication with them in a series of 13 workshops. Each workshop will address an area of interest to the research, discuss social norms and beliefs and discuss opportunities for behaviour change. We will present the outcomes of this research in three seminars for health and community practitioners and invite them to discuss their resource and training needs for working with the target communities. We will then develop a toolkit of resources (including key messages, images, infographics, and a user manual, available in several languages) that can be used by community and healthcare practitioners to enable them to offer culturally sensitive information and support.
Technical Summary
Low rates of UK breastfeeding mean that infants and mothers are at risk of serious morbidity and mortality. Resources are targeted at mothers from white, disadvantaged communities who are considered the least likely to breastfeed, whereas mothers from ethnic minorities are considered to have relatively high breastfeeding rates. However, re-analysis of national data showed high heterogeneity in breastfeeding rates amongst South Asian mothers; Pakistani and Bangladeshi mothers are less likely to breastfeed exclusively at 6-8 weeks (17.5% and 21% respectively) than Indian mothers (32%). Mothers from these communities are vulnerable to infant feeding misinformation, and may participate in cultural practices which could be harmful to breastfeeding and/or result in early weaning. A culturally specific, sensitive approach is needed to facilitate infant feeding behaviour change in these communities. To achieve this, we will employ a four stage community-focussed methodology that has previously been applied to tackling FGM: (1) Community engagement via celebration events; (2) Recruitment of individuals from target communities to facilitate participation; (3) workshops with community members will address the specific problem areas identified by research (e.g. prelacteal feeds, discarding colostrum, early weaning), identify readiness to change, discuss acceptable key messages likely to be effective in behaviour change and appropriate behaviour change techniques and modes of delivery; (4) seminars with community and healthcare practitioners to understand resource needs. This will inform the development of a toolkit of resources including guidance on assessing readiness for change within local communities, key messages and delivery materials, and guidance for their use. Future research will examine the feasibility of the intervention (acceptability, uptake, recruitment and retention) before a trial of the intervention for increasing breastfeeding and age-appropriate weaning.
Planned Impact
Long term impact of this project will occur once the intervention has been developed, tested for effectiveness and implemented into practice in public health and community services around the UK, and it is expected to have significant impact on short and long term health for mothers and infants, and for community cohesion. Immediate impacts as a result of this research include benefits for the target communities who are involved in the project who will have the opportunity to explore their beliefs around infant feeding, the researchers (academic and community based) who will benefit from the experiences offered in the project, and at a wider scientific and social level in deepening our understanding of ethnic diversity and how to reduce inequalities in health.
Who will benefit?
The primary beneficiaries of this research are the communities of Pakistani and Bangladeshi origin living in the UK; specifically, the communities involved in the research will benefit directly from this research project. Other beneficiaries include the NHS, national and local public health bodies who are responsible for providing infant feeding services in order to increase rates of breastfeeding at 6-8 weeks, and for ensuring services are accessible and appropriate to all groups including ethnic minorities. The community and charity sector is often commissioned by public health for this purpose and so they are also beneficiaries of the project. In addition there is significant academic benefit from this work which is described elsewhere.
How will they benefit?
Mothers and their infants will be direct beneficiaries because both the process of intervention development (in the short term) and the implementation of the developed intervention into practice (in the long term) will support increased breastfeeding initiation, exclusivity and duration and encourage age-appropriate weaning. This will result in improvements to infant and maternal health throughout their life-course. The communities involved in the research will benefit directly from this research project due to our strategy for engagement and opportunities to become involved in the research and participate in workshops intended to facilitate learning about infant feeding.
The NHS will benefit from reduced costs associated with fewer GP visits, hospital appointments and costs associated with chronic diseases which breastfeeding helps to prevent (e.g. ovarian and breast cancers). National and local public health bodies will see improvements in their ability to deliver effective and engaging infant feeding services in order to increase rates of breastfeeding at 6-8 weeks, with better accessibility and engagement for ethnic minorities. The community and charity sector will similarly benefit directly from the learning acquired during this research project to facilitate delivery of the services described above, and also from the intervention development and evaluation research from this and future research projects.
There is an important wider impact of the process of developing culturally specific interventions for academics as well as public policy bodies, health providers and professionals and the communities and families involved. All of these beneficiaries could benefit from the long term outcomes of refining best practice in the design and delivery of culturally sensitive interventions which could have major and long term impact on the reduction of health inequalities.
Who will benefit?
The primary beneficiaries of this research are the communities of Pakistani and Bangladeshi origin living in the UK; specifically, the communities involved in the research will benefit directly from this research project. Other beneficiaries include the NHS, national and local public health bodies who are responsible for providing infant feeding services in order to increase rates of breastfeeding at 6-8 weeks, and for ensuring services are accessible and appropriate to all groups including ethnic minorities. The community and charity sector is often commissioned by public health for this purpose and so they are also beneficiaries of the project. In addition there is significant academic benefit from this work which is described elsewhere.
How will they benefit?
Mothers and their infants will be direct beneficiaries because both the process of intervention development (in the short term) and the implementation of the developed intervention into practice (in the long term) will support increased breastfeeding initiation, exclusivity and duration and encourage age-appropriate weaning. This will result in improvements to infant and maternal health throughout their life-course. The communities involved in the research will benefit directly from this research project due to our strategy for engagement and opportunities to become involved in the research and participate in workshops intended to facilitate learning about infant feeding.
The NHS will benefit from reduced costs associated with fewer GP visits, hospital appointments and costs associated with chronic diseases which breastfeeding helps to prevent (e.g. ovarian and breast cancers). National and local public health bodies will see improvements in their ability to deliver effective and engaging infant feeding services in order to increase rates of breastfeeding at 6-8 weeks, with better accessibility and engagement for ethnic minorities. The community and charity sector will similarly benefit directly from the learning acquired during this research project to facilitate delivery of the services described above, and also from the intervention development and evaluation research from this and future research projects.
There is an important wider impact of the process of developing culturally specific interventions for academics as well as public policy bodies, health providers and professionals and the communities and families involved. All of these beneficiaries could benefit from the long term outcomes of refining best practice in the design and delivery of culturally sensitive interventions which could have major and long term impact on the reduction of health inequalities.
Title | Adapted REPLACE methodology using BCW and co-creation |
Description | To develop the LIFt intervention for optimising infant feeding we uniquely combined use of the Behaviour Change Wheel approach to intervention development along with co-creation by academics, practitioners and members of the target community. The community members were typically mothers and grandmothers of Bangladeshi or Pakistani origin, many of whom did not work, and did not have advanced formal education. The methods used had to translate the theoretical and systematic approaches from the researchers so that they could be understood and applied by a lay audience, without reducing the quality and theoretical content of the approach. |
Type Of Material | Model of mechanisms or symptoms - human |
Year Produced | 2018 |
Provided To Others? | No |
Impact | The participants enjoyed the workshops and found them a positive, educational experience. They reported feeling proud of what they were able to achieve. The work is currently being written up so that the approach can be shared with other researchers or community organisations. |
Description | FWT |
Organisation | Foleshill Womens Training |
Country | United Kingdom |
Sector | Charity/Non Profit |
PI Contribution | Intellectual expertise on research design and intervention development. We have provided training to staff on data protection and research principles. |
Collaborator Contribution | They are specialists in engaging and supporting women from BME communities and run a MAMTA programme which offers support around pregnancy and motherhood. FWT have helped organise and deliver the engagement events and workshops and invited key individuals from the target communities to attend. THey offer expertise on the traditions and customs around engaging with the target communities. |
Impact | Three engagement events and one introductory workshops attended by 100-200 people in total. |
Start Year | 2017 |
Description | Celebration event |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | Local |
Primary Audience | Study participants or study members |
Results and Impact | In June 2018 we held a celebration event with our previous workshop participants and their friends and families. We presented the findings from the workshops and had further discussions about how and where change in infant feeding could be made. The event included food, music, dancing and activities from the South Asian culture and provided cultural affirmation, as well as an opportunity to develop trust between the researchers, third sector organisations and the participants themselves. We presented all participants with a certificate of their contribution. At this event we invited 6 individuals to become part of a working group to develop the intervention materials. |
Year(s) Of Engagement Activity | 2018 |
Description | Family Fun Day |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | Local |
Primary Audience | Public/other audiences |
Results and Impact | Over 100 people attended a family fun day which was held to begin engagement with the Pakistani and Bangladeshi communities living in the city. We recorded interest in further engagement with the research. A local councillor was planning to attend (unfortunately could not attend on the day) but a report and photographs appeared in council magazine. |
Year(s) Of Engagement Activity | 2017 |
Description | Health Professional Seminars |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | Local |
Primary Audience | Professional Practitioners |
Results and Impact | We held a series of 3 seminars with health professionals (i. midwives, ii. health visitors, iii. infant feeding leads and management) to discuss the findings from the work informing this project, and explain the aims and methods of the LIFT project. Practitioners completed a short questionnaire before and after, which demonstrated that some were aware of cultural practices influencing infant feeding in this group but most thought they no longer happened in the UK. Practitioners also explained that they were unable to communicate about these issues with families for fear of causing offence and due to language barriers. Practitioners said their practice would change as a result of being more aware of the issues, but wanted support for how to communicate about sensitive issues. |
Year(s) Of Engagement Activity | 2018 |
Description | Inaugural Lecture |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | Regional |
Primary Audience | Public/other audiences |
Results and Impact | Approximately 150 people attending a public lecture at Aston University on 22/11/2018 delivered by Professor Jackie Blissett on the Psychology of Children's Eating Behaviour, in which the LIFT project was described. There was much discussion after the lecture from attendees, who included general public, health professionals as well as broad academic audience and students. Members of the public asked questions specific to their own circumstances. Undergraduate students have asked questions specifically about the project with some taking themes from the LIFT project to consider within their own work. Health professionals discussed how themes raised in the lecture could be incorporated into service provision, and contacts were made which may facilitate further work in this area. |
Year(s) Of Engagement Activity | 2018 |
URL | https://www.youtube.com/watch?v=l3WTRpnTVU4&feature=youtu.be |
Description | Intervention Development Group |
Form Of Engagement Activity | A formal working group, expert panel or dialogue |
Part Of Official Scheme? | No |
Geographic Reach | Local |
Primary Audience | Study participants or study members |
Results and Impact | In October 2018 to February 2019 an expert working group met monthly to plan the intervention development materials. This included giving short talks to thr groups about the science behind the benefits of breastfeeding, an understanding of why bottle feeding has become popular and a simple overview of behaviour change model (COM B). IN these workshops we identified the key target behaviours by rating them for need for change, likelihood of change, potential for causing offence (or other risk). We worked on the key messages needed to make change, and identified potential methods for delivery of key messages. |
Year(s) Of Engagement Activity | 2018,2019 |
Description | Introductory Workshop |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | Local |
Primary Audience | Public/other audiences |
Results and Impact | The first introductory workshop was held in February 2018. Local women were invited to attend a workshop where we discussed our own infant feeding journeys. THe aim was the highlight cultural similarities and differences and provide cultural affirmation. This informed plans for future workshop activity with this community to co-develop the intervention. |
Year(s) Of Engagement Activity | 2018 |
Description | Radio show discussion on the parenting hour (on Unity FM) |
Form Of Engagement Activity | A press release, press conference or response to a media enquiry/interview |
Part Of Official Scheme? | No |
Geographic Reach | Regional |
Primary Audience | Public/other audiences |
Results and Impact | Invited speaker on the parenting hour (on Unity FM, Birmingham) to discuss the social and cultural infant feeding barriers experienced by the South Asian community and how the LIFT project is supporting infant feeding within this community. This discussion sparked a debate and resonated with a lot of individuals in the audience. |
Year(s) Of Engagement Activity | 2018 |
Description | Study Website and blog |
Form Of Engagement Activity | Engagement focused website, blog or social media channel |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Public/other audiences |
Results and Impact | A study website was published in 2018 to allow us to share information with study members, general public, health professionals, other community organisations and stakeholders who will be interested in the work and in using the intervention developed a the end of the study. As well as information about the study we have published a monthly blog which is shared on social media |
Year(s) Of Engagement Activity | 2018 |
URL | http://liftproject.coventry.ac.uk/ |
Description | UKSBM Oral Presentation |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Other audiences |
Results and Impact | Oral presentation delivered to the UK Society for Behavioural Medicine Conference, December 2018. Learning about Infant Feeding Together (LIFT):Optimising infant feeding amongst UK families of Pakistani and Bangladeshi origin Since the conference I have received several requests for further information, with the potential for future research collaboration. |
Year(s) Of Engagement Activity | 2018 |
URL | https://www.kc-jones.co.uk/files/uploads/1544715922.pdf |
Description | UNICEF Annual Conference Poster Presentation |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Professional Practitioners |
Results and Impact | We presented a poster of the work at the UNICEF BabyFriendly Conference with the aim of promoting the research to health professionals and community organisations who may make use of the intervention when developed (i.e. to increase possibility of implementation and impact from final intervention). Had discussions with practitioners who viewed the poster who thought the project was relevant and asked for information when the intervention was available. |
Year(s) Of Engagement Activity | 2018 |
URL | https://www.unicef.org.uk/babyfriendly/wp-content/uploads/sites/2/2018/12/Posters-Unicef-UK-Baby-Fri... |
Description | Women's Lunches |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | Local |
Primary Audience | Public/other audiences |
Results and Impact | Two women-only lunches were held in the city to promote the research project and invite further participation. These resulted in discussions about infant feeding experiences and interest in further activity. |
Year(s) Of Engagement Activity | 2017 |
Description | Workshops |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | Local |
Primary Audience | Study participants or study members |
Results and Impact | We held a series of 3 workshops (each run twice with different participants) over March-May 2018. These were attended by between 5 and 15 mothers and grandmothers from the local Pakistani and Bangladeshi communities. We used the workshops to identify the key barriers and facilitators relating to infant feeding in these communities, how and why different feeding methods were valued, tensions between generations about infant feeding and identify readiness to change and potential mechanisms for change. |
Year(s) Of Engagement Activity | 2018 |