ADAPT: Breastfeeding clinical adaptation

We’re working with 11 FNP sites from around the country and Dartington Social Research Unit to co-design a number of adaptations to the FNP programme which we will put through rapid-cycle testing over the next year. The ADAPT project (Accelerated Design and Rapid Programme Testing), is part of the wider FNP Next Steps programme.

ADAPT sites have developed clinical innovations to test in their area and are finalising their plans for implementation. We expect to start the roll-out of clinical adaptations in sites from later on in 2016.

In the second of our blog series about the ADAPT clinical adaptations, Blackpool FNP supervisor Lynne MacKinnon talks about the breastfeeding intervention developed by her team, clients and local stakeholders.

In Blackpool our breastfeeding initiation is good, with 64.5% of young mums initiating after their babies are born. This figure is higher than the average FNP rate across England of 57.4% and slightly higher than the total Blackpool population initiation rate of 61.6% (Blackpool Child Health profile, 2016). However, our breastfeeding continuation rates fall sharply soon after delivery to just 10.9% at six weeks. That’s why we’ve chosen to focus on breastfeeding for ADAPT.[1]

We know in Blackpool the embedded cultural norm is to formula feed babies; it is viewed by families as the best choice. By including wider family members, in particular grandmothers, in the work we do, we hope to influence mothers, albeit in a ‘drip-drip’ approach which is similar to much of the ‘change’ work we do within FNP. Our aim is to change the cultural norm in Blackpool over the long-term, so that both FNP clients and the wider population view breastfeeding as a natural choice.

What does the clinical adaptation look like?

Through our clinical intervention, we plan to increase the number of opportunities family nurses have to support clients not only to consider initiating breastfeeding, but then continuing to breastfeed for longer. We identified that families and partners have a huge influence on young mum’s choices about feeding their baby so we want to build our engagement with them in a more in-depth manner.

To achieve these outcomes, we will introduce new facilitators[2] in pregnancy to help clients think more about their choices, and give them the skills to have challenging conversations with others about their choices.

We plan to design new facilitators targeted directly at families and partners to help them to understand why breastfeeding is a good choice and how important they are in supporting mothers with breastfeeding. We want to ensure that clients, partners and family members are well prepared in pregnancy to manage breastfeeding from birth, with the ability to manage any problems from day one. Family nurses will receive further training which builds on their advanced communication skills to support the complex process of behaviour change.

In line with research evidence and feedback from local FNP clients, building a peer support network of breastfeeding clients has been identified as an important part of the adaption. Although this may be challenging, we hope to train a number past FNP clients to become breastfeeding peer supporters to offer some unique support for any clients who may want it.

How were clients involved in development work?

During the process of developing our adaptation, initial client consultation was completed using a questionnaire to elicit early views on what FNP clients felt would have helped them. It was great to see these results mirrored the evidence that was shared by the FNP National Unit and Dartington Social Research Unit in terms of what works to support breastfeeding and what the barriers are[3] [4]. In particular, peer support was identified by 90% of the young mums we consulted with as being a real positive.

In another parallel with the evidence, we found there was a feeling that being told “breast is best” is unhelpful. Clients said it made them feel as though they were not doing the best they could if they choose to bottle feed or if they were unable to breastfeed. There was also the feeling that breastfeeding can be seen as perfection and therefore unattainable[5].

We held a group session with FNP mums who were brilliant in their enthusiasm and willingness to complete another questionnaire, this time about the development of a peer support group. We asked what they would want a group to look like, including whether they felt peer supporters should have breastfed themselves.

We recently invited a young mum who came to our group session to an FNP Advisory Board meeting, to help share feedback about how it has felt to be involved in the project and to talk about what young FNP mums feel they have got from it.

Before any new facilitators or materials are introduced via our intervention, we also hope to ask clients, partners and family members for their thoughts so they have an input into the design.

What does success look like?

Through our clinical adaptation, we hope to see an improvement in our longer term breastfeeding rates in FNP clients and we aim to positively shift and shape some of the cultural norms surrounding breastfeeding in Blackpool. We know that breastfeeding can improve health outcomes for mother and baby so having a knock-on impact on longer term health outcomes is also an aspiration.

Collecting data, as we do for breastfeeding initiation and continuation with FNP clients, means that there are already mechanisms in place for collecting the numbers. In addition to this, there will also be an opportunity to learn from clients themselves about the influences that helped them choose their feeding method and we hope to collect some qualitative data from clients, partners and family to enhance the richness of what we collect. The exciting thing about this whole process is that we may have some influence on the wider Blackpool population and will hopefully be able to share our learning, not only with local health colleagues, but on a national scale too.

The ADAPT journey

Choosing our area of focus was extremely easy! Even from our initial calls and contact with the ADAPT team, we thought the project sounded really exciting. To be at the forefront of an innovation of this scale and have the opportunity to work with experts in rapid-cycle design and testing was inspiring.

We began by designing a logic model and dark logic model for our desired adaptation outcomes. To start this process, I contacted colleagues locally who had a wealth of expertise and knowledge around breastfeeding to ask if they would be part of our Co-Production Team[6] to help with the process.

The hardest part was the designing of the logic model. We went through several iterations before it was deemed good-to-go. Meeting others supervisors from other sites has been really helpful in understanding this is all part of the process and it wasn’t just that the Blackpool model that was pulled apart and put back together several

[1] These figures were obtained from the FNP Information System as of 30 September 2016.

[2] Facilitators are FNP specific materials and activities that family nurses use during their visits with clients and families. Facilitators are designed to generate a conversation about a topic, such as smoking, breastfeeding, domestic violence etc., to support behaviour change. They are also used for issues such as returning to work/education and can help the family consider their options and plans.

[3] Sipsma, H. L., Magriples, U., Disney, A., Gordon, D., Gabzydl, E. & Kershaw, T. (2013). Breastfeeding behavior among adolescents: initiation, duration, and exclusivity. Journal of Adolescent Health, 53(3), 394-400.

[4] Sipsma, H. L., Jones, K. L. & Cole-Lewis, H. (2015) Breastfeeding among adolescent mothers: a systematic review of interventions from high-income countries. Journal of Human Lactation, 31(2), 221-229.

[5] Smith et al. (2012). Early breastfeeding experiences of adolescent mothers: a qualitative prospective study. International Breastfeeding Journal, 7(13), 1-14.

[6] Each ADAPT site identified a Co-Production Team to help them identify and develop their clinical adaptation. This team was often made up of local experts in the area of focus, commissioners of FNP and provider leads. For sites who are part of the ‘A Better Start’ (ABS) initiative from The Big Lottery, teams often featured one or more ABS representatives.