HD: Effectiveness of Nutrition Intervention Methods (2010)
- To determine whether the Mississippi peer counseling program has effectively increased the incident of breastfeeding
- To indentify staff or program characteristics that are associated with higher success rates.
- Infants enrolled in WIC clinics in Mississippi
- Had a first clinic visit between 1989 and 1993
- Clinic must have had a peer counseling program as of January 1, 1993 for inclusion in secondary research question.
None listed.
Recruitment
All children enrolled in WIC programs in Mississippi from 1989 to 1993.
Design
- Before-after study
- Pediatric Nutrition Surveillance System (PedNSS) used for data from 1989 to 1993:
- Continuous statewide surveillance system
- Data collected each time a child visits a WIC clinic
- Only data for 'infant's first visit' used in analysis
- Change in proportion of infants 'ever breast-fed' from 1989 to 1993 compared in clinics with and without peer counseling program
- Peer counseling program questionnaire mailed in 1994 to all clinics with programs at that time
- Change in proportion of infants 'ever breast-fed' from 1989 to 1993 in clinics with peer counseling programs with and without specific staff and program characteristics.
Intervention
- Peer counseling program implemented in WIC clinics in the state of Mississippi
- Established in October 1990 and programs were added in counties over time
- A peer counselor is assigned a WIC client and makes contact immediately after enrollment and must continue contacts at least once a month throughout pregnancy and after baby is born:
- Peer counselor may be a lactation consultant, lactation specialist or a peer counselor
- Contacts may be via telephone, mailings or prenatal classes
- Discussion includes breastfeeding advantages and how to start as well as post-partum issues.
Statistical Analysis
- Baseline proportion of 'ever breastfed' determined in 1989
- 1993 used as comparative year after programs in WIC clinics were begun
- Absolute differences in proportion of infants 'ever breast-fed' in clinics from 1989 to 1993 with and without peer counseling programs were measured and a T-test was used for level of significance:
- E= (Pa,1993- Pa,1989) - (Pb,1993- Pb,1989)
- Pa = Clinics with peer counseling
- Pb= Clinics without peer counseling
- Logistic regression used to test significance of the ratio of the odds ratios for trend:
- R = ORa/ORb
- ORa = Odds ratio of ever breastfeeding in 1993 vs. 1989 in clinics with peer counseling
- ORb = Odds ratio of ever breastfeeding in 1993 vs. 1989 in clinics without peer counseling
- Analogous statistics used for the program and staff characteristics comparing clinics with peer counseling programs with and without certain characteristics:
- E= (Pa,1993- Pa,1989) - (Pb,1993- Pb,1989)
- Pa = Clinics with characteristic
- Pb = Clinics without characteristic
- R = ORa/ORb
- ORa = Odds ratio of ever breastfeeding in 1993 vs. 1989 in clinics with characteristic
- ORb = Odds ratio of ever breastfeeding in 1993 vs. 1989 in clinics without characteristic.
Timing of Measurements
- Data extracted from PedNSS:
- 1989 and 1993
- Infants first visit used
- Questionnaire mailed in 1994 to all WIC clinics with a peer counseling program as of January 1, 1993.
Dependent Variables
Incidence of breastfeeding was calculated as proportion of infants ever breastfed at a first visit to a WIC clinic in 1989 and 1993.
Independent Variables
- Presence of a peer counseling program at WIC clinic
- Staff characteristics:
- Job title
- WIC experience
- Race
- Age
- Professional experience
- Breastfeeding history
- Program characteristics
- Length of time program in place
- Average monthly caseload
- Frequency of contact during pregnancy
- Amount of time peer counselors spent each month with client
- Amount of time lactation specialists and consultants spent with each client
- Total hours worked divided by the number of woment enrolled
- Lifestyle discussion.
Control Variables
Race.
Initial N
- 30,000 children per year included in data set
- 140 WIC clinics had peer counseling programs in their county as of January 1, 1993
- 97 staff members from 51 clinics were mailed questionnaires.
Attrition (Final N)
- 18,889 infants in 1989 (63%)
- 17,216 infants in 1993 (57%)
- 36% (51 of 140) WIC clinics had peer counseling programs by January 1, 1993
- 94% (91/97) of staff members returned questionnaires.
Age
- Infant, first visit to WIC clinic
- Exact age not given.
Ethnicity and Demographics
- WIC enrollees from 1989 to 1993:
- Median age of mothers enrolled in WIC was 23 years
- 38% infants classified as white non-Hispanic
- 61% infants classified as black
- Staff and program characteristics
- Approximately half of staff classified as peer counselors
- Approximately half of staff had previously been WIC participants
- Median age of staff was 32 years
- 86% of staff were white non-Hispanic
- All staff members had children and had breastfed their last child
- Median duration of breastfeeding among staff was 18 months
- Staff worked 10 hours per week and contacted 40 to 49 WIC participants each month
- Median of seven contacts during pregnancy for peer counselors
- Median of three contacts for lactation specialists and consultants.
Anthropometrics
Baseline incidence of breastfeeding was higher in counties that implemented peer counseling program than those who did not (9.2% vs. 12.3%).
Location
WIC clinics in Mississippi.
Program Effectiveness
Overall Percentage of WIC Infants in Mississippi Who Were Ever Breastfed Rose from 10.9% in 1989 to 15.8% in 1993
|
Without Program |
With Program |
Difference (E) |
Ratio of Odds ratio for trends (R) |
All WIC enrollees |
|
|
||
1989 |
9.2 |
12.3 |
||
1993 |
10.7 | 19.9 | 6.1* | 1.48* |
White |
|
|
|
|
1989 |
19.6 | 20.9 | ||
1993 |
22.0 | 30.8 | 7.5* | 1.46 |
Black |
|
|
|
|
1989 |
3.7 | 6.3 | ||
1993 |
5.1 | 12.1 | 4.4* | 1.47 |
Adjusted for all other characteristics and race | ||||
One or more specialist or consultant in clinic | 4.4* | 1.47* | ||
One or more peer counselor in clinic | -2.6 | 0.72* | ||
50% or more of staff was in WIC | 0.5 | 1.26* | ||
Mean age of staff more than 35 years | 3.2* | 1.29* | ||
Program started before July 1991 | 2.1* | 1.25* | ||
PCs spent more than 45 minutes per participant | 2.9* | 1.50* |
* Significant at the 5% level.
- The incidence of breastfeeding rose more significantly in clinics with peer counseling programs than in those without programs
- Demonstrates ability of program to affect overall incidence of breastfeeding on a population basis, especially in low-income populations
- Certain program and staff characteristics can be attributed to the success of the peer counseling program by affecting breastfeeding rates.
Government: | Centers for Disease Control, Mississippi WIC program |
- Authors use proportion of infants ever breastfed as a surrogate for incidence rates of breastfeeding in this population
- Unclear as to actual effect on incidence state-wide, may be only applicable to a small sample of low-income infants in Mississippi enrolled in WIC
- Small sample size of clinics in state, only 51 studied
- Large amount of missing data, up to 40% in 1993, may affect validity of results.
Quality Criteria Checklist: Primary Research
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Relevance Questions | |||
1. | Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) | Yes | |
1. | Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) | Yes | |
2. | Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? | Yes | |
2. | Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? | Yes | |
3. | Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? | Yes | |
3. | Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? | Yes | |
4. | Is the intervention or procedure feasible? (NA for some epidemiological studies) | Yes | |
4. | Is the intervention or procedure feasible? (NA for some epidemiological studies) | Yes | |
Validity Questions | |||
1. | Was the research question clearly stated? | Yes | |
1. | Was the research question clearly stated? | Yes | |
1.1. | Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? | Yes | |
1.1. | Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? | Yes | |
1.2. | Was (were) the outcome(s) [dependent variable(s)] clearly indicated? | Yes | |
1.2. | Was (were) the outcome(s) [dependent variable(s)] clearly indicated? | Yes | |
1.3. | Were the target population and setting specified? | Yes | |
1.3. | Were the target population and setting specified? | Yes | |
2. | Was the selection of study subjects/patients free from bias? | No | |
2. | Was the selection of study subjects/patients free from bias? | No | |
2.1. | Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? | No | |
2.1. | Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? | No | |
2.2. | Were criteria applied equally to all study groups? | ??? | |
2.2. | Were criteria applied equally to all study groups? | ??? | |
2.3. | Were health, demographics, and other characteristics of subjects described? | No | |
2.3. | Were health, demographics, and other characteristics of subjects described? | No | |
2.4. | Were the subjects/patients a representative sample of the relevant population? | ??? | |
2.4. | Were the subjects/patients a representative sample of the relevant population? | ??? | |
3. | Were study groups comparable? | No | |
3. | Were study groups comparable? | No | |
3.1. | Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) | No | |
3.1. | Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) | No | |
3.2. | Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? | No | |
3.2. | Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? | No | |
3.3. | Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) | N/A | |
3.3. | Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) | N/A | |
3.4. | If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? | Yes | |
3.4. | If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? | Yes | |
3.5. | If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) | No | |
3.5. | If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) | No | |
3.6. | If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? | N/A | |
3.6. | If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? | N/A | |
4. | Was method of handling withdrawals described? | Yes | |
4. | Was method of handling withdrawals described? | Yes | |
4.1. | Were follow-up methods described and the same for all groups? | No | |
4.1. | Were follow-up methods described and the same for all groups? | No | |
4.2. | Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) | Yes | |
4.2. | Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) | Yes | |
4.3. | Were all enrolled subjects/patients (in the original sample) accounted for? | Yes | |
4.3. | Were all enrolled subjects/patients (in the original sample) accounted for? | Yes | |
4.4. | Were reasons for withdrawals similar across groups? | Yes | |
4.4. | Were reasons for withdrawals similar across groups? | Yes | |
4.5. | If diagnostic test, was decision to perform reference test not dependent on results of test under study? | N/A | |
4.5. | If diagnostic test, was decision to perform reference test not dependent on results of test under study? | N/A | |
5. | Was blinding used to prevent introduction of bias? | No | |
5. | Was blinding used to prevent introduction of bias? | No | |
5.1. | In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? | N/A | |
5.1. | In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? | N/A | |
5.2. | Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) | No | |
5.2. | Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) | No | |
5.3. | In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? | No | |
5.3. | In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? | No | |
5.4. | In case control study, was case definition explicit and case ascertainment not influenced by exposure status? | N/A | |
5.4. | In case control study, was case definition explicit and case ascertainment not influenced by exposure status? | N/A | |
5.5. | In diagnostic study, were test results blinded to patient history and other test results? | N/A | |
5.5. | In diagnostic study, were test results blinded to patient history and other test results? | N/A | |
6. | Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? | Yes | |
6. | Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? | Yes | |
6.1. | In RCT or other intervention trial, were protocols described for all regimens studied? | N/A | |
6.1. | In RCT or other intervention trial, were protocols described for all regimens studied? | N/A | |
6.2. | In observational study, were interventions, study settings, and clinicians/provider described? | Yes | |
6.2. | In observational study, were interventions, study settings, and clinicians/provider described? | Yes | |
6.3. | Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? | Yes | |
6.3. | Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? | Yes | |
6.4. | Was the amount of exposure and, if relevant, subject/patient compliance measured? | Yes | |
6.4. | Was the amount of exposure and, if relevant, subject/patient compliance measured? | Yes | |
6.5. | Were co-interventions (e.g., ancillary treatments, other therapies) described? | Yes | |
6.5. | Were co-interventions (e.g., ancillary treatments, other therapies) described? | Yes | |
6.6. | Were extra or unplanned treatments described? | Yes | |
6.6. | Were extra or unplanned treatments described? | Yes | |
6.7. | Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? | Yes | |
6.7. | Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? | Yes | |
6.8. | In diagnostic study, were details of test administration and replication sufficient? | N/A | |
6.8. | In diagnostic study, were details of test administration and replication sufficient? | N/A | |
7. | Were outcomes clearly defined and the measurements valid and reliable? | Yes | |
7. | Were outcomes clearly defined and the measurements valid and reliable? | Yes | |
7.1. | Were primary and secondary endpoints described and relevant to the question? | Yes | |
7.1. | Were primary and secondary endpoints described and relevant to the question? | Yes | |
7.2. | Were nutrition measures appropriate to question and outcomes of concern? | Yes | |
7.2. | Were nutrition measures appropriate to question and outcomes of concern? | Yes | |
7.3. | Was the period of follow-up long enough for important outcome(s) to occur? | Yes | |
7.3. | Was the period of follow-up long enough for important outcome(s) to occur? | Yes | |
7.4. | Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? | No | |
7.4. | Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? | No | |
7.5. | Was the measurement of effect at an appropriate level of precision? | Yes | |
7.5. | Was the measurement of effect at an appropriate level of precision? | Yes | |
7.6. | Were other factors accounted for (measured) that could affect outcomes? | No | |
7.6. | Were other factors accounted for (measured) that could affect outcomes? | No | |
7.7. | Were the measurements conducted consistently across groups? | Yes | |
7.7. | Were the measurements conducted consistently across groups? | Yes | |
8. | Was the statistical analysis appropriate for the study design and type of outcome indicators? | Yes | |
8. | Was the statistical analysis appropriate for the study design and type of outcome indicators? | Yes | |
8.1. | Were statistical analyses adequately described and the results reported appropriately? | Yes | |
8.1. | Were statistical analyses adequately described and the results reported appropriately? | Yes | |
8.2. | Were correct statistical tests used and assumptions of test not violated? | Yes | |
8.2. | Were correct statistical tests used and assumptions of test not violated? | Yes | |
8.3. | Were statistics reported with levels of significance and/or confidence intervals? | Yes | |
8.3. | Were statistics reported with levels of significance and/or confidence intervals? | Yes | |
8.4. | Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? | No | |
8.4. | Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? | No | |
8.5. | Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? | No | |
8.5. | Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? | No | |
8.6. | Was clinical significance as well as statistical significance reported? | Yes | |
8.6. | Was clinical significance as well as statistical significance reported? | Yes | |
8.7. | If negative findings, was a power calculation reported to address type 2 error? | No | |
8.7. | If negative findings, was a power calculation reported to address type 2 error? | No | |
9. | Are conclusions supported by results with biases and limitations taken into consideration? | Yes | |
9. | Are conclusions supported by results with biases and limitations taken into consideration? | Yes | |
9.1. | Is there a discussion of findings? | Yes | |
9.1. | Is there a discussion of findings? | Yes | |
9.2. | Are biases and study limitations identified and discussed? | Yes | |
9.2. | Are biases and study limitations identified and discussed? | Yes | |
10. | Is bias due to study's funding or sponsorship unlikely? | Yes | |
10. | Is bias due to study's funding or sponsorship unlikely? | Yes | |
10.1. | Were sources of funding and investigators' affiliations described? | No | |
10.1. | Were sources of funding and investigators' affiliations described? | No | |
10.2. | Was the study free from apparent conflict of interest? | Yes | |
10.2. | Was the study free from apparent conflict of interest? | Yes | |