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Theorising breastfeeding peer support as intervention in a complex ecological system: lessons for implementation and evaluation in a Welsh context Heather Trickey This thesis is submitted in fulfilment of the degree of Doctor of Philosophy. School of Social Sciences Cardiff University 2018 Intentionally blank DECLARATION This work has not been submitted in substance for any other degree or award at this or any other university or place of learning, nor is being submitted concurrently in candidature for any degree or other award. Signed (candidate) Date: 22 August 2018 STATEMENT 1 This thesis is being submitted in partial fulfillment of the requirements for the degree of PhD Signed (candidate) Date: 22 August 2018 STATEMENT 2 This thesis is the result of my own independent work/investigation, except where otherwise stated. Other sources are acknowledged by explicit references. The views expressed are my own. Signed (candidate) Date: 22 August 2018 STATEMENT 3 I hereby give consent for my thesis, if accepted, to be available for photocopying and for inter- library loan, and for the title and summary to be made available to outside organisations. Signed (candidate) Date: 22 August 2018 Intentionally blank Acknowledgements To borrow terminology from intervention theory, this thesis exists because I have had access to an abundance of informational, instrumental, emotional and appraisal support. First, my thanks and appreciation to the parents, peer supporters, health professionals, policy makers and academic researchers – more than a hundred of them who contributed directly to this study – through interviews, research engagement days, focus groups and through one-to-one conversations about their own research findings. I am grateful for the funding that allowed me to undertake this study. Professor Mary Newburn (formerly at NCT charity) and Professor Laurence Moore (formerly at DECIPHer Cardiff University) enabled me to turn an area of interest, arising from work on infant feeding policy for NCT, into a funded research proposal. The Medical Research Council (MRC) and NCT charity joint-funded my PhD studentship. The thesis has been (ahem) quite some time in gestation and I have had the benefit of advice from four excellent supervisors. I am especially grateful for the steady approach to supervision that Professor Julia Sanders has provided from beginning to end, accommodating the reality that a PhD was only ever going to be one of many things I was trying to do at once – however unwise she correctly considered that approach to be. I am also grateful to Professor Simon Murphy, Director of DECIPHer. Simon picked up responsibility for supervision of this PhD in the last two years and has supported me in balancing my employed DECIPHer research role with my PhD study, helping me to draw the threads of my thesis together – a task that often felt like wrestling a bowl of spaghetti. Professor Laurence Moore and Professor Sally Holland have also supervised my work for short periods – both have since left Cardiff University – I consider it a privilege to have been able to discuss my early ideas with two such insightful, experienced and knowledgeable social science researchers. A period of serious illness interrupted my PhD studies. There were many times when I thought I would not finish. If you have ever gone through anything similar, you may know that picking yourself up and returning to work can be daunting … and embarrassing. Peer support is everything – it really matters who you work with. I have been so very lucky in my colleagues, particularly in sharing an office, some fun public health projects and the best conversations with Dr Rachel Brown. Also, for the support of Dr Rhiannon Evans, Dr GJ Melendez-Torres, Dr Jeremy Segrott, Dr Hannah Littlecott, Dr Sarah McDonald, Dr Ruth Turley, Mrs Kim Sheppard, Dr Sara Jones, Mr Luke Midgley and other friends in DECIPHer. One of the things that has kept me going is that the research has never felt too far from the real world of infant feeding policy and infant feeding support. Along the way, I have had opportunities to share my emerging findings in presentations, meetings and conversations with colleagues at Public Health Wales, Welsh Government, NCT Charity, The Association of Breastfeeding Mothers, the Breastfeeding Network and Unicef Baby Friendly UK – receiving feedback and stimulus to dig deeper. I am particularly grateful to Dr Sarah McMullen, Head of Knowledge at NCT, who has helped me integrate this work with a part- time role as a Senior Researcher for the charity and to Dr Karen Thompson, Consultant in Public Health at Public Health Wales, who has facilitated my taking forward research that builds on this this work. I’ve also had the benefit of opportunities to share ideas with academic colleagues beyond DECIPHer. The focus of the thesis on breastfeeding peer support arose from conversations with my friend Dr Gill Thomson (UCLAN), which became a paper on the experimental evidence that we wrote together in 2013. The realist review, reported in Chapter 8 of this thesis, became a paper written together with Gill, Julia and Simon and Dr Aimee Grant, Dr Mala Mann and Professor Shantini Paranjothy at Cardiff Medical School. I also benefited from a series of discussions about Welsh infant feeding policy with Professor Amy Brown (Swansea University) and from participating in related research led by Professor Kate Jolly (Birmingham). Ms Helen Oldridge provided me with practical help in manging my audio-files. I am grateful to family and many loving friends – Kate (thank you for proof reading!), Helen, Judith, Siân – and most of all to my generous husband Simon Brindle. So looking forward to having more guilt-free time to enjoy with our fabulous four – Silva, James, Arthur and Nancy … Hey, look! It’s nearly done! Heather Trickey August 2018 Publications arising from this research Trickey, H., 2013. Peer support for breastfeeding continuation: an overview of research. Perspective, (21), pp.15-20. Trickey, H., 2013. Could complex adaptive systems thinking reach the parts infant feeding policy is not reaching? Applying key concepts to policy making in Wales, [Conference Abstract]. Maternal and Child Nutrition 9 (Sup. 3) pp. 29-30. Thomson, G. and Trickey, H., 2013. What works for breastfeeding peer support? Time to get real. European Medical Journal: Gynaecology and Obstetrics, 2013(1), pp.15-22. Trickey, H., 2016. Peer support: how do we know what works? Perspective, 31, pp.44- 49. Trickey, H., 2016. Infant feeding: Changing the conversation: ecological thinking. Perspective, 133 Trickey, H., Thomson, G., Grant, A., Sanders, J., Mann, M., Murphy, S. and Paranjothy, S., 2018. A realist review of one‐to‐one breastfeeding peer support experiments conducted in developed country settings. Maternal & child nutrition, 14(1), p.e12559. Summary Background and Aim: By international standards, breastfeeding rates in the UK are low, with social and geographical polarisation in feeding decisions. The evidence for breastfeeding peer support intervention is mixed. As an intervention, peer support is heterogeneously described and poorly theorised. Through this thesis, I explore and articulate theories of breastfeeding peer support and consider their potential to inform intervention design. Methods: I use realist methods and an emergent fit approach to explore understandings about how peer supporters help mothers to breastfeed and what prevents them from doing so. The empirical research proceeds through three phases. I iterate between findings from Phase 1 (face-to-face interviews with 15 policy leads and infant feeding leads), from Phase 2 (realist review of 15 breastfeeding peer support intervention case study experiments), and Phase 3 (focus groups with parents, peer supporters and health professionals) to develop my conclusions. Findings: Stakeholder experiences are consistent with an understanding that ‘low breastfeeding rates’ are a ‘wicked problem’ in a complex system of influences. The implementation landscape is contested and policy rationales shift. Personal feeding journeys have powerful feedback effects. There is partial dissonance between breastfeeding advocates’ own motivation to improve women’s experiences and formal policy goals to increase breastfeeding rates as a mechanism to improve health outcomes. I identified three registers for understanding how breastfeeding peer support works: these were, (i) improving the health care pathway, (ii) creating a sub-community of mothers and sisters, and (iii) diffusing the practice of breastfeeding like ripples in the pond. The realist review showed that the experimental evidence is heterogeneous but almost exclusively relates to interventions that seek to improve the care pathway. From the review, I developed 20 statements and a staged thinking tool to inform future intervention design, highlighting the need to consider a sequence of interactions beginning with interaction with existing social norms and with the existing health care pathway. These statements were extended and nuanced on the basis of discussion with parents, peer supporters and health professionals, resulting in a total of 39 statements to support future intervention design. Conclusions: Theoretical approaches that rely on triggering mechanisms at the interpersonal level are likely helpful as part of intervention theory, but are insufficient, as they tend to be decontextualised. There is a need to explore new ‘registers’ for intervention development and evaluation that consider

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