A community-centered intervention to improve infant feeding practices among Pakistani and Bangladeshi families living in the UK

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.

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.

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.