Improving maternal and infant nutrition: a framework for action

Chapter 5: Process for Development of the Framework

Formation of Strategy Group

5.1 Representatives from key organisations with an interest in maternal and infant nutrition research, policy and practice were invited to become members of the Maternal and Infant Nutrition Strategy group. Membership of the Strategy group is listed in Appendix 1. The overall aim of the group was to work with the Infant Nutrition Co-ordinator to develop a Maternal and Infant Nutrition Framework and Action Plan for Scotland. The objectives of the group were to:

• Identify and share current activity in progress across Scotland to improve maternal and infant nutrition;
• Review the evidence base on maternal and infant nutrition and identify gaps in research and propose future research to inform policy;
• Recommend specific actions that will contribute to improving maternal and infant nutrition;
• Facilitate and ensure communication between the Scottish Government, NHS Boards, local authorities, voluntary sector and other relevant stakeholders concerned with maternal and infant nutrition.

5.2 At the first meeting of the group, terms of reference, the scope and key themes of the Framework were agreed. Key themes were based on those identified in the EU Blueprint ³³ and these became the focus for three sub-groups. Although the EU Blueprint focused solely on breastfeeding, the group reached consensus that these themes; Education, Training and Practice Development, Communication and Engagement for Behaviour Change, and Research, Monitoring and Evaluation, were equally relevant to the broader issues of maternal nutrition, complementary feeding and nutrition for young children.

Formation of Sub-Groups

5.3 Members of the Maternal and Infant Nutrition Strategy group were invited to join one of the three sub-groups. Additional invitations were extended to a range of voluntary organisations and practitioner networks to enable greater inclusion and participation. The Infant Nutrition Co-ordinator attended each sub-group meeting to ensure continuity and avoid duplication. Membership of each sub-group is listed in Appendix 2.

Education, Training and Practice Development sub-group - Terms of Reference:

• Identify the target workforce;
• Scope whether maternal and infant nutrition is included in preparation programmes, ^{( 6 )} post graduate programmes or CPD programmes currently available;
• Identify gaps in training provision and make appropriate recommendations to address these

5.4 The sub-group identified key groups of staff as follows, although the list is illustrative not exhaustive:

• NHS: midwifery teams, public health nursing teams including nursery nurses, GPs and practice staff, paediatricians, obstetricians, dietitians, nutritionists, oral health staff including dentists, oral health educators, dental hygienists, dental nurses, dental health support workers, health promotion staff, pharmacists, learning disability teams, mental health teams, addiction services teams, sexual health staff.
• Local authority: social services staff, social care staff, early years workers, teachers, family support workers, community learning & development teams.
• Community and voluntary sector staff: community food initiative workers and volunteers, healthy living centre staff, charity/voluntary organisation staff and volunteers e.g. National Childbirth Trust, Breastfeeding Network, La Leche League.
• Others: Childminders, private and partnership nursery staff, prison staff , foster carers

5.5 There are groups of staff whose role requires in-depth knowledge of, and expertise in, maternal and infant nutrition such as midwives, public health nurses and GPs. Other staff, however, such as early years staff and family support workers are expected to have a basic awareness and understanding of the importance of maternal and infant nutrition, and be able to signpost parents and carers to appropriate sources of support. It is important that all staff and volunteers, across all organisations, have the appropriate level of education and training required for their scope of practice.

Communication and Engagement for Behaviour Change sub-group - Terms of Reference:

• Identify the key target audiences that need to be reached through the Framework;
• Identify current communications activity in progress across Scotland to improve maternal and infant nutrition;
• Recommend specific actions for delivering and supporting the uptake of key messages that will contribute to achieving the communications outcomes of the Framework.

5.6 Enabling and supporting parents, particularly mothers, to change their behaviour through improving their knowledge, motivation and skills, is a key aim of this Framework. The diagram overleaf highlights the complexity of supporting behaviour change due to the various factors, people and organisations that influence women prior to conception, during pregnancy and in the earliest years of their child's life. One of our biggest challenges is reaching those who may not normally access services and they are likely to be those that will benefit most from additional support. Building supportive relationships and tailoring services to meet the needs of those in our target audiences is central to how we communicate engage with women and their families.

Research, Monitoring and Evaluation sub-group - Terms of Reference

• Identify current sources of information to assess and monitor maternal and infant nutrition in Scotland;
• Identify potential indicators to assess the outcomes of the Maternal and Infant Nutrition Framework;
• Recommend future research required to improve our understanding of maternal and infant nutrition in Scotland.

Development of the Maternal and Infant Nutrition Logic Model

5.7 The Strategy group agreed that development of a logic model would provide a useful tool to identify key outcomes for improving maternal and infant nutrition and specify the activities that should be undertaken to achieve them. The aim of developing the Framework in this way was to make it more systematic, explicit and targeted. Outcomes frameworks are currently being created for other Scottish Government priority areas including alcohol, physical activity, tobacco, food and healthy weight and mental health. The approach used to describe the development of the maternal and infant nutrition logic model is based on that used in the 'Outcomes framework for Scotland's mental health improvement strategy' (2010). ⁷³

What is a Logic Model?

5.8 A logic model is a visual and systematic way of presenting how it is believed a programme will work and describes the sequence of activities thought to bring about change and how these activities are linked to the results the programme is expected to achieve. Logic models also map out the time sequence in which the outcomes need to be achieved. Most of the value in a logic model is in the process of creating, validating and modifying the model. The Kellogg Foundation states " The clarity of thinking that occurs from building the model is critical to the overall success of the programme." ⁷⁴

Evidence Underpinning the Activities

5.9 The logic models help us to understand two broad questions. The first can be loosely categorised as the "whats" and incorporate issues such as the identification of the determinants of maternal and infant nutrition. Evidence of association and causation are normally the key evidence types here. The second set of questions can be loosely categorised as the "hows" and help us to identify areas for effective intervention or action.

5.10 Evidence from NICE Public Health Guidance 11 'Improving the nutrition of pregnant and breastfeeding mothers in children in low-income households' (2008) ⁷⁵ and the Scottish Perspective on NICE Public Health Guidance 11 (2009) ⁷⁶ has been used to inform the development of the Framework's activities. Full details about this process is presented in the supplementary document 'Rationale supporting the Maternal and Infant Nutrition Action Plan' accompanying this Framework.

5.11 The information drawn on can be described as highly-processed evidence. Additional sources of evidence and theory have been drawn from relevant Scottish Government and WHO publications. It should be noted that NICE have formalised, robust and centrally quality-assured processes for the conduct of systematic reviews and generation of evidence-informed recommendations; however, as NICE guidance has no formal status in Scotland Scottish Perspectives are produced as appropriate.

Plausible Theory

5.12 Evidence of effectiveness underpins the maternal and infant nutrition logic model where it is available but it is not a limiting factor. However, the lack of evidence of effectiveness does not necessarily mean ineffectiveness, it may " be due to inadequate or inappropriate evaluation, failure of implementation, or simply lack of evaluation." ⁷⁷ Despite the lack of evidence in some areas, a pragmatic approach using practitioner opinion and experience was adopted, therefore, some activities are evidence-informed rather than evidence-based and took account of the ten ethical principles for health promotion, public health and health improvement proposed by Tannahill (2008) ⁷⁷ : do good, do not harm, equity, respect, empowerment, sustainability, social responsibility, participation, openness and accountability. Where gaps in the evidence were identified these were included in the recommendations for future research.

Scope and Limitations of the Logic Model

5.13 The purpose of the logic model is to identify key outcomes for improving maternal and infant nutrition and outline which activities should be carried out to achieve them based on evidence or plausible theory. The logic model is not a causal pathway for improving maternal and infant nutrition and does not try to explain all of the interactions between activities and outcomes. The logic model does not depict the true complexity of improving maternal and infant nutrition; it only attempts to clarify some of the key paths to achieving the outcomes.

5.14 The logic model presents a snapshot of what is currently known and represents our best collective understanding of how to improve maternal and infant nutrition at this point in time. It will need to be regularly reviewed and refined to reflect changes in understanding of maternal and infant nutrition over time.

Generation of Short, Medium and Long Term Outcomes

5.15 Over the course of two facilitated meetings, the group reached consensus on the short, medium and long term outcomes for improving maternal and infant nutrition. All of these contribute to the achievement of two national outcomes:

• Our children have the best start in life and are ready to succeed ;
• We live longer, healthier lives.

5.16 Following these consensus meetings, the sub-groups worked independently to further develop and refine the outcomes. Any suggested amendments to the wording of the outcomes proposed by a sub-group were agreed by the other sub-groups and approved by the Strategy group. This continuous refinement process took place over a period of 12-18 months. During this process various drafts of the outcomes framework were shared and discussed widely with key stakeholder groups. By being explicit about the developmental process and the assumptions which have been made, it has led to the outcomes framework being more amenable to rational examination and, therefore, in the long term more robust.

5.17 All of the outcomes are presented overleaf. Several of the short term outcomes refer to "all those working with", it is recognised that there is a range of staff and organisations who have a role in improving maternal and infant nutrition. Whilst the NHS plays a key role, local authorities, the community and voluntary sector are also crucial. Short term outcome (1) refers to "optimal nutrition" which in this context means the healthy eating advice for women prior to conception, during pregnancy and following birth, as detailed in Appendix 3.

5.18 The outcomes identified in the logic model need to be considered alongside those in The Early Years National Logic Model and the 4 Equally Well Logic Models, along with the Health Promoting Health Service "Every Healthcare contact is a Health Improvement Opportunity" ⁷⁸

5.19 Addressing inequality is a key aim of Scottish Government policy. It is proposed that there are three ways of tackling health inequalities. ⁷⁹

1. Improving the health of the poor

2. Narrowing health gaps

3. Reducing health gradients

5.20 The logic model attempts to target the most disadvantaged by being specific about the population group whom activities are intended to reach, for example specific groups of women who are at risk of poor nutrition during pregnancy and those least likely to breastfeed. As far as possible the outcomes in the logic model are inequalities sensitive to attempt to reduce the gaps between groups. For example, if an outcome is to improve breastfeeding rates, it is focused on improving breastfeeding rates in all population groups. However if at the same time as improving rates overall, the gap in breastfeeding rates between groups is to be reduced, then as well as rates in the whole population improving, they need to improve faster in deprived communities. Since breastfeeding rates tend to be lower in deprived communities, investment will need to be heavily weighted towards interventions here.

5.21 Clearly, the achievement of the long term outcomes is dependent on other work and will not be achieved solely by the delivery of the Framework to improve maternal and infant nutrition, for example work underway to tackle overweight and obesity and work to improve the availability and affordability of healthy food and drink will have a significant impact on these outcomes.

Mapping of Evidence to the Identified Outcomes

5.22 While the refinement of the outcomes took place over several monthly meetings, a small group comprising each sub-group Chair, the Infant Nutrition Co-ordinator, plus others, considered the implications of NICE Public Health Guidance 11 ⁷⁵ for the Framework. This small group mapped the recommendations from NICE Guidance/Scottish Perspective to the short, medium and long term outcomes. The rationale for this process was that each recommendation made by NICE was underpinned by a robust and acceptable evidence base. Therefore, it was concluded, if the recommendations from NICE Guidance/Scottish Perspective were implemented in Scotland, progress towards the outcomes identified in the logic model could be achieved.

Generation of Activities to Achieve Outcomes

5.23 The Education, Training and Practice Development sub-group and the Communication and Engagement sub-group were asked to identify what activities would be required to achieve the short and medium term outcomes relevant to their sub-group theme.

5.24 The activities were compared to the NICE Guidance/Scottish Perspective recommendations to establish where there was concordance and where the suggested activities were at odds with these.

5.25 Three situations arose:

1. Consensus was reached between practitioner opinion and NICE/Scottish Perspective recommendations.

2. Practitioner opinion on a particular action or intervention was identified which was not included in the NICE Guidance/Scottish Perspective recommendations. In this case it was agreed that further searching of the evidence base could be done and/or evaluation of current practice or piloting of a particular activity which would contribute to gathering an evidence base.

3. If an activity/intervention recommended by NICE Guidance/Scottish Perspective was not identified by practitioners, they were asked to consider whether the activity should be included because it was plausible, practical or achievable.

5.26 The activities and the rationale underpinning each are presented in the supporting document to the Framework 'Rationale supporting the Maternal and Infant Nutrition Action Plan activities'. In addition, the activities are contained in the Action Plan on page 66.