Peer support for breastfeeding mothers is defined by The National Institute for Health and Care Excellence (NICE) as:
‘Support offered by women who have themselves breastfed, are usually from similar socioeconomic backgrounds and locality to the women they are supporting, and who have received minimal training to support breastfeeding women.’
There are numerous factors that contribute to the initial motivation amongst volunteers (Clary et al, 1998). For some people, volunteering may meet a psychological need: volunteers may feel driven by their own personal values, such as altruism and humanitarianism. For others, motivation may come from a desire to build social relationships, to learn, to grow and develop psychologically, or to gain career-related experience (Clary et al, 1998). Further research conducted into the motivational factors of breastfeeding peer supporters found that personal values and a desire to build social relationships were the two key reasons for volunteering (Curtis et al, 2007; Aiken and Thomson, 2013).
Previous studies have also identified that there are benefits for peer supporters themselves. Working as a peer supporter has been shown to increase the individual's sense of wellbeing and social connectedness (Vecina and Fernando, 2013) and this has also been demonstrated to be the case for breastfeeding peer supporters (Dennis 2002; Curtis et al, 2007).
These findings (Clary et al, 1998; Vecina and Fernando, 2013) were used to develop Hopper and Skirton's (2016) framework for breastfeeding support (Figure 1). Hopper and Skirton (2016) investigated factors influencing the sustainability of volunteer peer support for breastfeeding mothers within a hospital environment. The framework followed a three step structure: expectations (what the peer predicts to gain), experience (what is needed to be in place to sustain voluntary activity), and outcomes (the benefits from volunteering). Nevertheless, the training that the peer supporters in the study received did not appear to be underpinned by any model of support, despite studies showing that having a shared framework has been shown to be beneficial to teamwork (Ottman, Unpublished; Moore et al, 2013).
The Solihull Approach
The Solihull Approach is one such model; an integrated psychodynamic and behavioural approach to support professionals to think about their work with children and families and understand children's emotional development. It is also accompanied by a useful resource pack for practitioners (Solihull NHS Care Trust and Birmingham City University, 2006). The Solihull Approach was initially developed to help health visitors manage pre-school children's sleeping, feeding, toileting and behavioural difficulties, but has since been cascaded to many different professions, such as nursery nurses, child and adolescent mental health services, social workers, and breastfeeding peer supporters (Solihull NHS Primary Care Trust, 2006). The breastfeeding peer support training is fully compliant with UNICEF UK's Baby Friendly Initiative and aims to give a ‘way of thinking’ based on the Solihull Approach model (Solihull NHS Care Trust and Birmingham City University, 2006).
The Solihull Approach's theoretical model integrates concepts of containment, reciprocity and behaviour management. Supporters use containment to help a mother process intense emotions and anxiety by understanding their feelings without being overwhelmed by them, and communicating this understanding back to the mother (Bion, 1959; Currie, 2015). Reciprocity is defined as a supporter becoming attuned with the mother's emotions and supporting mothers to grow healthy interactions with their babies (Brazleton et al, 1974; Currie, 2015). Supporters also use theories of behaviour management (Pavlov, 1927; Skinner, 1938) to help parents set boundaries for behaviour (Currie, 2015). Both containment and reciprocity would facilitate sensitive and effective behaviour change, setting boundaries that are appropriate to the mother, her situation and informing appropriate advice.
Whitehead and Douglas (2005) explored health visitors' experiences of implementing the Solihull Approach. Their findings indicated that the Solihull Approach training increased reflective practice, produced more holistic assessments, increased job satisfaction and improved teamwork. Ottmann (unpublished) also examined the Solihull Approach's impact on professionals within a multidisciplinary team. Participants reported increased confidence, a better understanding of parent-child relationships and enhanced team closeness. Moore et al (2013) designed a questionnaire based on these findings to address the impact of the Solihull Approach on the practice of different professionals. Their findings showed that training on the Solihull Approach improved teamwork by providing a shared framework of support, made up on containment, reciprocity and behaviour, and by encouraging attention to professional relationships within peer groups.
This article focuses on the Solihull Approach and its impact on breastfeeding peer supporters. However, there are other organisations and approaches that have similar aims of providing training and encouraging breastfeeding mothers. Although this paper does not assess these other organisations' approaches, it is important to acknowledge their existence and the benefits they offer in helping to broaden the knowledge and support aimed at achieving a shared objective. Other organisations that train breastfeeding peer support workers include the National Childbirth Trust (NCT), the Association of Breastfeeding Mothers and La Leche League. All these organisations have a network of local peer supporters available to offer support and advice.
Similarities can be drawn between the Solihull Approach and NCT training, which are underpinned by a series of shared aims, including valuing the experiences of individuals, being mother-centred and applying good listening practices. The NCT training has been previously evaluated elsewhere (Muller et al, 2009). Where the models differ, however, is that the Solihull Approach is based on a strong theoretical base of the relationships between human beings, including between the peer supporter and the mother, and between the mother and her baby.
It is important to evaluate the impact of the Solihull Approach on different professionals' practices as they are introduced to the model. This will be especially useful as there are a limited number of studies which have done so (Moore et al, 2013), with none looking specifically at the impact on breastfeeding peer supporters.
This study
As such, this study has adopted a qualitative methodology of semi-structured interviews to explore peer supporters' personal decisions to volunteer, their experiences of the Solihull Approach peer supporter breastfeeding training, and their experiences of putting the approach into practice. Furthermore, this study hopes to use the findings to add to existing literature and advise future interventions for how to support breastfeeding mothers, given that an understanding of such factors can significantly help in improving health outcomes.
Objectives
The main objectives of this study were to explore breastfeeding peer supporters' motivations to volunteer, their experiences of the Solihull Approach peer supporter breastfeeding training, and their experiences of putting the training into practice. It also sought to identify factors that could contribute to improving the service.
Design
As part of a descriptive qualitative study, peer supporters were interviewed using a semi-structured schedule. Data were analysed using thematic analysis coupled with an inductive approach.
Setting and participants
The participants in this study were peer support volunteers who worked predominantly within breastfeeding cafés. Recruitment took place between November 2016 and December 2016. There were two settings in this study; both were breastfeeding cafés (one in North and one in South Solihull). The breastfeeding cafés were identified through the Heart of England NHS maternity website. The maternity department gave permission to recruit participants before the study and assisted in setting up the interviews. Seven semi-structured interviews were conducted by the principle researcher during November 2016. The peer supporters interviewed were a mix of paid peer supporters (n=4) and voluntary supporters (n=3). All participants gave informed consent; including permission to digitally record each interview so that transcripts could be made.
Data collection
Semi-structured interviews were conducted in a separate quiet room at the breastfeeding café venues on an individual basis. Each interview lasted between 30-40 minutes, and was audio-recorded and transcribed verbatim. Before the interview, the two sites had been visited by the main investigator to assess where would be best to interview participants. Observational data, including the number of women attending the sessions, the number of peer supporters available at the sessions, the peer supporters' behaviour and the parents' behaviour towards the peer supporters, were also gathered before the interview. This information assisted the formation of interview questions.
Data analysis
Thematic analysis (Braun and Clarke, 2006) was conducted using an inductive approach. Each transcript was checked against the audio recording to ensure they were accurate and complete. The transcripts were then read and re-read, with the researcher marking sections of the transcript that related to emerging themes. These were refined and dominant themes identified.
Findings
The findings are presented under the themes that emerged from the analysis.
Theme 1: motivation for volunteering
Peer supporters' motivations to volunteer mirrored those in the existing literature with regards to a altruistic desire to provide support. Their motivation was fuelled either by a desire to help others gain the same enjoyment they experienced, or a desire to repay the services that had supported them. The peer supporters explained that they volunteered:
‘To help other mums in the same way that breastfeeding cafés and peer supporters supported me.’
‘Because I realised what a journey breast feeding was, I didn't breastfeed at first, and that was literally down to the support that I didn't get the last time, but did get this time, and I thought how I need to pay that back.’
‘I just wanted to help other people enjoy it as much as I did and I guess I'm a bit of a “do-gooder” and wanna help.’
Being able to grow psychologically by working as a peer supporter was seen to be another strong motivational factor. Participants expressed how working as a peer supporter gave them a purpose and made them feel useful at a time when they perhaps otherwise would not have, saying:
‘As nice as volunteering is for other people, it kind of gives you a purpose sometimes, it gives you confidence and it makes you feel good at some things that you wouldn't necessarily have been good at, useful and all those things that you sometimes don't feel when you're on maternity leave.’
Interest in the Solihull Approach model was also seen as a motivational factor, and attending the training was a way to understand and learn more about the approach. As one peer supporter said,
‘I learned about the approach during the training and thought this is interesting, so that's why I trained really.’
Theme 2: experiences of being a peer supporter
Experiences of being a peer supporter were brought up by the participants in three ways: satisfaction with the Solihull Approach training, supervision and support, and positive experience of providing peer support.
Satisfaction with the Solihull Approach training
It was evident from their tone of voice and language that peer supporters were passionate about the Solihull Approach breastfeeding training and were keen to promote its usefulness. Peer supporters discussed how the training taught how to communicate properly with parents and provided them with sufficient information, saying that they learned:
‘How to talk […] and how to listen. ‘Cause it's not that easy to have that conversation and you think you're having a decent conversation but you're not, because you're interrupting, so it teaches you the basics of actually communicating with a mum.’
Peer supporters were also positive about the amount of information that the training provided, saying that,
‘It gives them knowledge and information, but appropriate knowledge and information. Some courses you go on, they are so widespread that actually you will use some of it, but not necessarily all of it, but then it's holding everything in your head. Whereas I think the Solihull Approach, what they do here is cover what we really need to know. The fact that we've got our folders, the fact that we're working through, we've got that to always go back to, but it's relevant information given in a timely fashion that we can actually almost go straight out and use—which is perfect.’
Peer supporters also emphasised how the course gave them confidence to support mothers, or otherwise gave them the foundations for confidence, which was then built up once the peer supporters had applied the training in practice.
‘I feel like you really have to get into it to understand it more, sometimes. So you understand it and the theory's there in your head, but it's like with anything I think, until you apply it … I felt like I could go in and talk to someone, but until you employ it in practice, you kind of don't know how it works. And I think your confidence only increases once you do it, once you've been with the women and you know that it works and you've seen it in practice working. And then it makes you feel like, “Actually, all this stuff I've learned does really work, because I've actually seen it work!”’
Supervision and support
The supervision and support that the peer supporters received was seen as very positive. Ongoing support was available from their managers in the form of regular one-to-one meetings and peer supporters indicated that they could contact management whenever they felt necessary. As one peer supporter explained,
‘We regularly have one-to-one's monthly, so gives us a chance to talk. Also contact them at any stage if there's something particularly worrying, but yeah, just that meeting gives you a chance to sit down and talk about any issues that are concerning you and [the manager] emails us constantly.’
All of the peer supporters talked enthusiastically about their team, using words such as ‘fantastic’. Furthermore, when describing the team, peer supporters would express that they valued each other's opinion, communicated among themselves and enjoyed working together, saying:
‘I just think it's a fantastic team. They all really like each other, they all really get on, they all communicate with each other and they all appreciate each other's opinions, which sometimes you don't get in a team.’
Positive experience of providing peer support
It was evident that the peer supporters were passionate about breastfeeding and enjoyed working as peer supporters. They reported that the mothers they supported felt cared for by the peer supporters, regardless of feeding choice. Peer supporters also commented on receiving extremely positive feedback from mothers both on antenatal visits and from audits. As one peer supporter commented during interview:
‘They feel like actually that we really do care, that's the thing, isn't it, they really do feel cared about and that we're not just a number, or they're not just a number or a name, or whatever, that we do care. Even when they're not breastfeeding, you know, we've had really nice feedback from mums that we've seen antenatally, that have not intended to breastfeed.’
Theme 3: Practical and personal applications of the Solihull Approach
All the peer supporters had similar experiences of using the Solihull Approach within their work with mothers, but had differing stories of using the Approach in their personal lives. However, all the peer supporters found the Solihull Approach training and work as a peer supporter had enriched and improved their personal life.
Impact on practice
Peer supporters could easily identify times they used containment when working with mothers since having attended the Solihull Approach breastfeeding peer support training, with many of them reporting using it on a daily basis, saying that it was used,
‘All the time. Like, every day. Women can be very tearful and overwhelmed. It's overwhelming just having a baby generally, let alone the tiredness and the pain, everyone in your ear telling you different things. So yeah, regularly someone cries so I just kind of give them a moment, ask them if they want a drink or a hug and just say to them, “It's ok not to be ok.” It is overwhelming, and just saying that I do understand how they feel, it is ok to feel like this and hopefully try and make them feel a little bit better and kind of unpick what it is that's upsetting them. But sometimes when you have just had a baby, even if someone just gives you tea in the wrong mug, you're like, “I didn't want this mug!” So just kind of working out what are worries and real issues and letting them know that there are solutions to make it better.’
Peer supporters also described witnessing reciprocity in action, another component of the Solihull Approach model, to be a positive emotional experience since developing an understanding of this component.
‘Obviously with feeding. Looking out for feeding cues and babies trying to get Mum's attention, when Mum [responds] and they've got all that eye contact going on, then baby sort of doesn't have that eye contact any more. Then Mum focuses on getting baby latched on because obviously baby has decided to break that eye contact because then the next focus is food! So yeah that's … and then obviously they come back to each other afterwards. It's really nice and magical to watch someone else go through it.’
Improved professional relationships
It was clear that the Solihull Approach also had an impact on how peer supporters interacted as a team. Peer supporters enthusiastically reported using containment within the team, as well as being able to depend on their managers should they need containment themselves.
‘If there's something in terms of containment for ourselves we can talk to our manager but we can talk to each other, we haven't really got to talk to our manager, we can contain each other [laughs].’
‘We have regular sort of one-to-ones and meetings and we do a lot of containment in the office ourselves with us girls! We'll all come in like, “Oh what's happened today?” [laughs] We get it all off our chest. We do a lot of that.’
Personal applications
Peer supporters understood the importance of their own self-containment, and found the training to help them recognise when they need containing. As one peer supporter reported,
‘Obviously the whole containment thing, I think you realise that if you feel like you're sort of being weighed down and you can't concentrate on anything else then you do need to talk to someone; you can't just keep it bottled up and expect to be able to continue, because you can't listen or help your own children if you can't help yourself. So you need to learn to help yourself and I think me being quite independent and OCD [obsessive compulsive disorder] and headstrong—to put it politely rather than ‘stubborn’—erm, I think it's made me realise that actually I do need sometimes to talk to my partner about stuff, even if it is just a mini little rant and then that's it done, over, and he listens (or pretends to listen) [laughs] and that makes me feel just a little bit better.’
‘I think I'm quite aware of when my head's too full. I think it's made me very aware of when I need containment.’
Further personal benefits from attending the training and working as a peer were identified by many of the participants, who found that it gave them purpose. Peer supporters also indicated that the Solihull Approach training could provide employability skills as they felt the training could be applied to other situations.
Peer supporters described being able to use the skills learned from the Solihull Approach training among their social circles, as well as within their family and working lives. The peer supporters were aware of the multiple uses of the training and found that they adopted it into other conversations, even those outside the workplace, saying:
‘If I look at myself in conversations with friends and family now; often I do that naturally now. I don't bumble in and just go off and talk about myself; I'll say “How are you?” and, y'know, listen [and] contribute when I'm ready and established where they are. I think it's something you take into your own art of conversation as well and how you communicate.’
Theoretical framework
The findings from this study were used to develop a conceptual framework of the Solihull Approach breastfeeding peer support. Similarly to the findings of Hopper and Skirton's framework of breastfeeding support (2016), and using the stages which were originally identified from work by Clary et al (1998) and Vecina and Fernando (2013), this conceptual framework was further developed using the themes which emerged from the data generated in this study.
This conceptual framework (Figure 2) comprises three stages in the volunteer process and contributes to our understanding of the relationship between the Solihull Approach model and its applications. The first component, motivation, refers to individual's reasons to volunteer as a Solihull Approach peer supporter; the second, experience, identifies what is needed to sustain peer activity; and the third, outcomes, highlights the benefits of the Solihull Approach model to an individual, both in their working and personal lives.
Discussion
This study is the first to explore how breastfeeding peer supporters view the impact of the Solihull Approach model. The overall aim was to explore breastfeeding peer supporters' motivation to volunteer, and to gather their experiences of the Solihull Approach breastfeeding peer supporter training, as well as their experiences of putting the training into practice. The study also sought to identify factors which could contribute to improving the service.
Peer supporters in this study frequently cited a desire to help other mothers as a strong motivating factor for volunteering. Previous research in volunteering has also identified this motivation to express altruistic values (Clary et al, 1998). Additional motivating factors mentioned by peer supporters were their desire to increase their understanding of the Solihull Approach, and enhancement-based factors, whereby the peer supporters wanted to develop psychologically and feel ‘a sense of purpose’. This sense of self-worth and feeling of purpose was further strengthened when peer supporters received positive feedback from mothers who had accessed the service. It has previously been documented that volunteering can improve an individual's sense of well-being (Dennis 2002; Vecina and Fernando, 2013); therefore this was included in the conceptual framework as an ‘experience’.
Peer supporters in this study were incredibly passionate about their roles, eager to discuss their positive experiences of volunteering as well as the clear benefits to organisational communication that the Solihull Approach allowed. Peer supporters talked about their team with enthusiasm, reporting that they supported each other, communicated regularly and valued one another's opinions. Furthermore, they had adopted aspects of the Solihull Approach into the work environment by using containment when talking with their colleagues. This feedback is consistent with previous work in this area (Whitehead and Douglas, 2005). Dwiggins-Beeler et al (2011) noted that good organisational communication was positively associated with overall job satisfaction and consequently sustaining volunteer participation. Therefore, positive leadership was also included in the second part of the conceptual framework as it was felt to be a key factor contributing to the sustainability of the service.
The benefits of attending the Solihull Approach peer support training were identified for the peer support workers themselves. They found that the training increased their confidence and self-esteem, as well as creating positive feelings that they were doing something good for others. Peer supporters were also clearly able to detect when their own daily stressors were getting too much, and were willing to request help through containment from the appropriate people. Similar positive effects on confidence levels and enhanced team closeness were reported in a study by Ottmann (unpublished) when examining the Solihull Approach in a multidisciplinary team.
While the main impact of the Solihull Approach peer support training was targeted at helping the service users, it is interesting to consider the wider effect that attending this peer support training has on the individual peer supporters, their families, social groups and the peer support team as a whole.
Strengths and limitations
A strength of this study was that the researchers were not previously known to the peer supporters, and the researchers had no expectancy regarding the results. There are numerous limitations that need to be considered regarding the results of this study. As the study has a small sample size, it became difficult to generalise the findings being similarly applied to other settings, and as the data was obtained from just one hospital Trust, findings may not automatically be transferrable to other institutions. Nonetheless, results from the study can offer some preliminary evidence on the impact of the Solihull Approach on breastfeeding peer support workers and can help improve future training and post-training support.
Conclusions
Breastfeeding peer supporters frequently cited their altruistic values as their main motivation to volunteer, indicating it held the most importance. Their experience of the peer supporter breastfeeding training was positive, and they felt it gave them the confidence to then put the training into practice. Peer supporters in this study experienced several benefits when incorporating the Solihull Approach into practice, including improved team communication and positive outcomes in their personal lives. While there were no recommended improvements to the service, highlighting these benefits to potential volunteers could increase voluntary activity. Further research could also be carried out on a larger scale to compare between peer supporters who have not yet received training in the Solihull Approach.