Determinants and strategies influencing implementation of a clinically integrated breastfeeding peer counseling program: an application of the Implementation Research Logic Model

Breastmilk feeding improves long term health outcomes, but few mother-infant dyads in the US meet recommendations, and breastfeeding duration is lowest for racially minoritized populations. Clinically integrated Breastfeeding Peer Counseling (ci-BPC) is an evidence-based practice that has been associated with improved breastfeeding outcomes for minoritized populations, but implementation evidence is limited. Our objective was to systematically evaluate how and why a ci-BPC program worked by identifying how implementation strategies addressed barriers and leveraged facilitators in the implementation setting, and explaining results using Implementation Research Logic Model (IRLM). Explanatory mixed methods were utilized to triangulate findings from semi-structured interviews and qualitative document review to identify barriers and facilitators to implementation, as well as strategies used to address barriers and leverage facilitators. Interviews were conducted in 2022–2023 with patients, providers, nurses, and clinical leaders at the tertiary perinatal center and affiliated outpatient clinic where the ci-BPC program was implemented, and analyzed using directed content analysis with the Consolidated Framework for Implementation Research (CFIR) and Expert Recommendations for Implementing Change (ERIC) framework. Documents included publications, meeting minutes, workflows, protocols, correspondences, quality improvement data, electronic medical records, job descriptions, and grant applications from 2015 to 2024. Saturation of themes was achieved with 10 clinical team and 18 patient interviews and qualitative document review. Implementation barriers included patient education needs, insufficient staff capacity to provide breastfeeding care, and lack of continuity between inpatient and outpatient service lines. The ci-BPC model addressed these barriers and achieved implementation outcomes with position criteria that prioritized experience and shared traits with patients that supported acceptability and effectiveness; a multidisciplinary leadership team guiding implementation that aided adoption and feasibility; clinical integration via specialized workflows, EMR access, and ongoing training and communications that supported adoption, fidelity, and feasibility; and a dedicated physical workspace for outpatient counseling that supported feasibility and fidelity. Use of the IRLM demonstrated how implementation strategies leveraged existing facilitators and overcame barriers at the individual, team, and system level and to achieve program effectiveness and implementation outcomes. These findings can inform future implementation of ci-BPC, and other clinically integrated perinatal community health worker models, with evidence-based strategies for implementation.