explanatory case study methodology

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Continuing to enhance the quality of case study methodology in health services research

Shannon l. sibbald.

1 Faculty of Health Sciences, Western University, London, Ontario, Canada.

2 Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.

3 The Schulich Interfaculty Program in Public Health, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.

Stefan Paciocco

Meghan fournie, rachelle van asseldonk, tiffany scurr.

Case study methodology has grown in popularity within Health Services Research (HSR). However, its use and merit as a methodology are frequently criticized due to its flexible approach and inconsistent application. Nevertheless, case study methodology is well suited to HSR because it can track and examine complex relationships, contexts, and systems as they evolve. Applied appropriately, it can help generate information on how multiple forms of knowledge come together to inform decision-making within healthcare contexts. In this article, we aim to demystify case study methodology by outlining its philosophical underpinnings and three foundational approaches. We provide literature-based guidance to decision-makers, policy-makers, and health leaders on how to engage in and critically appraise case study design. We advocate that researchers work in collaboration with health leaders to detail their research process with an aim of strengthening the validity and integrity of case study for its continued and advanced use in HSR.

Introduction

The popularity of case study research methodology in Health Services Research (HSR) has grown over the past 40 years. 1 This may be attributed to a shift towards the use of implementation research and a newfound appreciation of contextual factors affecting the uptake of evidence-based interventions within diverse settings. 2 Incorporating context-specific information on the delivery and implementation of programs can increase the likelihood of success. 3 , 4 Case study methodology is particularly well suited for implementation research in health services because it can provide insight into the nuances of diverse contexts. 5 , 6 In 1999, Yin 7 published a paper on how to enhance the quality of case study in HSR, which was foundational for the emergence of case study in this field. Yin 7 maintains case study is an appropriate methodology in HSR because health systems are constantly evolving, and the multiple affiliations and diverse motivations are difficult to track and understand with traditional linear methodologies.

Despite its increased popularity, there is debate whether a case study is a methodology (ie, a principle or process that guides research) or a method (ie, a tool to answer research questions). Some criticize case study for its high level of flexibility, perceiving it as less rigorous, and maintain that it generates inadequate results. 8 Others have noted issues with quality and consistency in how case studies are conducted and reported. 9 Reporting is often varied and inconsistent, using a mix of approaches such as case reports, case findings, and/or case study. Authors sometimes use incongruent methods of data collection and analysis or use the case study as a default when other methodologies do not fit. 9 , 10 Despite these criticisms, case study methodology is becoming more common as a viable approach for HSR. 11 An abundance of articles and textbooks are available to guide researchers through case study research, including field-specific resources for business, 12 , 13 nursing, 14 and family medicine. 15 However, there remains confusion and a lack of clarity on the key tenets of case study methodology.

Several common philosophical underpinnings have contributed to the development of case study research 1 which has led to different approaches to planning, data collection, and analysis. This presents challenges in assessing quality and rigour for researchers conducting case studies and stakeholders reading results.

This article discusses the various approaches and philosophical underpinnings to case study methodology. Our goal is to explain it in a way that provides guidance for decision-makers, policy-makers, and health leaders on how to understand, critically appraise, and engage in case study research and design, as such guidance is largely absent in the literature. This article is by no means exhaustive or authoritative. Instead, we aim to provide guidance and encourage dialogue around case study methodology, facilitating critical thinking around the variety of approaches and ways quality and rigour can be bolstered for its use within HSR.

Purpose of case study methodology

Case study methodology is often used to develop an in-depth, holistic understanding of a specific phenomenon within a specified context. 11 It focuses on studying one or multiple cases over time and uses an in-depth analysis of multiple information sources. 16 , 17 It is ideal for situations including, but not limited to, exploring under-researched and real-life phenomena, 18 especially when the contexts are complex and the researcher has little control over the phenomena. 19 , 20 Case studies can be useful when researchers want to understand how interventions are implemented in different contexts, and how context shapes the phenomenon of interest.

In addition to demonstrating coherency with the type of questions case study is suited to answer, there are four key tenets to case study methodologies: (1) be transparent in the paradigmatic and theoretical perspectives influencing study design; (2) clearly define the case and phenomenon of interest; (3) clearly define and justify the type of case study design; and (4) use multiple data collection sources and analysis methods to present the findings in ways that are consistent with the methodology and the study’s paradigmatic base. 9 , 16 The goal is to appropriately match the methods to empirical questions and issues and not to universally advocate any single approach for all problems. 21

Approaches to case study methodology

Three authors propose distinct foundational approaches to case study methodology positioned within different paradigms: Yin, 19 , 22 Stake, 5 , 23 and Merriam 24 , 25 ( Table 1 ). Yin is strongly post-positivist whereas Stake and Merriam are grounded in a constructivist paradigm. Researchers should locate their research within a paradigm that explains the philosophies guiding their research 26 and adhere to the underlying paradigmatic assumptions and key tenets of the appropriate author’s methodology. This will enhance the consistency and coherency of the methods and findings. However, researchers often do not report their paradigmatic position, nor do they adhere to one approach. 9 Although deliberately blending methodologies may be defensible and methodologically appropriate, more often it is done in an ad hoc and haphazard way, without consideration for limitations.

Cross-analysis of three case study approaches, adapted from Yazan 2015

The post-positive paradigm postulates there is one reality that can be objectively described and understood by “bracketing” oneself from the research to remove prejudice or bias. 27 Yin focuses on general explanation and prediction, emphasizing the formulation of propositions, akin to hypothesis testing. This approach is best suited for structured and objective data collection 9 , 11 and is often used for mixed-method studies.

Constructivism assumes that the phenomenon of interest is constructed and influenced by local contexts, including the interaction between researchers, individuals, and their environment. 27 It acknowledges multiple interpretations of reality 24 constructed within the context by the researcher and participants which are unlikely to be replicated, should either change. 5 , 20 Stake and Merriam’s constructivist approaches emphasize a story-like rendering of a problem and an iterative process of constructing the case study. 7 This stance values researcher reflexivity and transparency, 28 acknowledging how researchers’ experiences and disciplinary lenses influence their assumptions and beliefs about the nature of the phenomenon and development of the findings.

Defining a case

A key tenet of case study methodology often underemphasized in literature is the importance of defining the case and phenomenon. Researches should clearly describe the case with sufficient detail to allow readers to fully understand the setting and context and determine applicability. Trying to answer a question that is too broad often leads to an unclear definition of the case and phenomenon. 20 Cases should therefore be bound by time and place to ensure rigor and feasibility. 6

Yin 22 defines a case as “a contemporary phenomenon within its real-life context,” (p13) which may contain a single unit of analysis, including individuals, programs, corporations, or clinics 29 (holistic), or be broken into sub-units of analysis, such as projects, meetings, roles, or locations within the case (embedded). 30 Merriam 24 and Stake 5 similarly define a case as a single unit studied within a bounded system. Stake 5 , 23 suggests bounding cases by contexts and experiences where the phenomenon of interest can be a program, process, or experience. However, the line between the case and phenomenon can become muddy. For guidance, Stake 5 , 23 describes the case as the noun or entity and the phenomenon of interest as the verb, functioning, or activity of the case.

Designing the case study approach

Yin’s approach to a case study is rooted in a formal proposition or theory which guides the case and is used to test the outcome. 1 Stake 5 advocates for a flexible design and explicitly states that data collection and analysis may commence at any point. Merriam’s 24 approach blends both Yin and Stake’s, allowing the necessary flexibility in data collection and analysis to meet the needs.

Yin 30 proposed three types of case study approaches—descriptive, explanatory, and exploratory. Each can be designed around single or multiple cases, creating six basic case study methodologies. Descriptive studies provide a rich description of the phenomenon within its context, which can be helpful in developing theories. To test a theory or determine cause and effect relationships, researchers can use an explanatory design. An exploratory model is typically used in the pilot-test phase to develop propositions (eg, Sibbald et al. 31 used this approach to explore interprofessional network complexity). Despite having distinct characteristics, the boundaries between case study types are flexible with significant overlap. 30 Each has five key components: (1) research question; (2) proposition; (3) unit of analysis; (4) logical linking that connects the theory with proposition; and (5) criteria for analyzing findings.

Contrary to Yin, Stake 5 believes the research process cannot be planned in its entirety because research evolves as it is performed. Consequently, researchers can adjust the design of their methods even after data collection has begun. Stake 5 classifies case studies into three categories: intrinsic, instrumental, and collective/multiple. Intrinsic case studies focus on gaining a better understanding of the case. These are often undertaken when the researcher has an interest in a specific case. Instrumental case study is used when the case itself is not of the utmost importance, and the issue or phenomenon (ie, the research question) being explored becomes the focus instead (eg, Paciocco 32 used an instrumental case study to evaluate the implementation of a chronic disease management program). 5 Collective designs are rooted in an instrumental case study and include multiple cases to gain an in-depth understanding of the complexity and particularity of a phenomenon across diverse contexts. 5 , 23 In collective designs, studying similarities and differences between the cases allows the phenomenon to be understood more intimately (for examples of this in the field, see van Zelm et al. 33 and Burrows et al. 34 In addition, Sibbald et al. 35 present an example where a cross-case analysis method is used to compare instrumental cases).

Merriam’s approach is flexible (similar to Stake) as well as stepwise and linear (similar to Yin). She advocates for conducting a literature review before designing the study to better understand the theoretical underpinnings. 24 , 25 Unlike Stake or Yin, Merriam proposes a step-by-step guide for researchers to design a case study. These steps include performing a literature review, creating a theoretical framework, identifying the problem, creating and refining the research question(s), and selecting a study sample that fits the question(s). 24 , 25 , 36

Data collection and analysis

Using multiple data collection methods is a key characteristic of all case study methodology; it enhances the credibility of the findings by allowing different facets and views of the phenomenon to be explored. 23 Common methods include interviews, focus groups, observation, and document analysis. 5 , 37 By seeking patterns within and across data sources, a thick description of the case can be generated to support a greater understanding and interpretation of the whole phenomenon. 5 , 17 , 20 , 23 This technique is called triangulation and is used to explore cases with greater accuracy. 5 Although Stake 5 maintains case study is most often used in qualitative research, Yin 17 supports a mix of both quantitative and qualitative methods to triangulate data. This deliberate convergence of data sources (or mixed methods) allows researchers to find greater depth in their analysis and develop converging lines of inquiry. For example, case studies evaluating interventions commonly use qualitative interviews to describe the implementation process, barriers, and facilitators paired with a quantitative survey of comparative outcomes and effectiveness. 33 , 38 , 39

Yin 30 describes analysis as dependent on the chosen approach, whether it be (1) deductive and rely on theoretical propositions; (2) inductive and analyze data from the “ground up”; (3) organized to create a case description; or (4) used to examine plausible rival explanations. According to Yin’s 40 approach to descriptive case studies, carefully considering theory development is an important part of study design. “Theory” refers to field-relevant propositions, commonly agreed upon assumptions, or fully developed theories. 40 Stake 5 advocates for using the researcher’s intuition and impression to guide analysis through a categorical aggregation and direct interpretation. Merriam 24 uses six different methods to guide the “process of making meaning” (p178) : (1) ethnographic analysis; (2) narrative analysis; (3) phenomenological analysis; (4) constant comparative method; (5) content analysis; and (6) analytic induction.

Drawing upon a theoretical or conceptual framework to inform analysis improves the quality of case study and avoids the risk of description without meaning. 18 Using Stake’s 5 approach, researchers rely on protocols and previous knowledge to help make sense of new ideas; theory can guide the research and assist researchers in understanding how new information fits into existing knowledge.

Practical applications of case study research

Columbia University has recently demonstrated how case studies can help train future health leaders. 41 Case studies encompass components of systems thinking—considering connections and interactions between components of a system, alongside the implications and consequences of those relationships—to equip health leaders with tools to tackle global health issues. 41 Greenwood 42 evaluated Indigenous peoples’ relationship with the healthcare system in British Columbia and used a case study to challenge and educate health leaders across the country to enhance culturally sensitive health service environments.

An important but often omitted step in case study research is an assessment of quality and rigour. We recommend using a framework or set of criteria to assess the rigour of the qualitative research. Suitable resources include Caelli et al., 43 Houghten et al., 44 Ravenek and Rudman, 45 and Tracy. 46

New directions in case study

Although “pragmatic” case studies (ie, utilizing practical and applicable methods) have existed within psychotherapy for some time, 47 , 48 only recently has the applicability of pragmatism as an underlying paradigmatic perspective been considered in HSR. 49 This is marked by uptake of pragmatism in Randomized Control Trials, recognizing that “gold standard” testing conditions do not reflect the reality of clinical settings 50 , 51 nor do a handful of epistemologically guided methodologies suit every research inquiry.

Pragmatism positions the research question as the basis for methodological choices, rather than a theory or epistemology, allowing researchers to pursue the most practical approach to understanding a problem or discovering an actionable solution. 52 Mixed methods are commonly used to create a deeper understanding of the case through converging qualitative and quantitative data. 52 Pragmatic case study is suited to HSR because its flexibility throughout the research process accommodates complexity, ever-changing systems, and disruptions to research plans. 49 , 50 Much like case study, pragmatism has been criticized for its flexibility and use when other approaches are seemingly ill-fit. 53 , 54 Similarly, authors argue that this results from a lack of investigation and proper application rather than a reflection of validity, legitimizing the need for more exploration and conversation among researchers and practitioners. 55

Although occasionally misunderstood as a less rigourous research methodology, 8 case study research is highly flexible and allows for contextual nuances. 5 , 6 Its use is valuable when the researcher desires a thorough understanding of a phenomenon or case bound by context. 11 If needed, multiple similar cases can be studied simultaneously, or one case within another. 16 , 17 There are currently three main approaches to case study, 5 , 17 , 24 each with their own definitions of a case, ontological and epistemological paradigms, methodologies, and data collection and analysis procedures. 37

Individuals’ experiences within health systems are influenced heavily by contextual factors, participant experience, and intricate relationships between different organizations and actors. 55 Case study research is well suited for HSR because it can track and examine these complex relationships and systems as they evolve over time. 6 , 7 It is important that researchers and health leaders using this methodology understand its key tenets and how to conduct a proper case study. Although there are many examples of case study in action, they are often under-reported and, when reported, not rigorously conducted. 9 Thus, decision-makers and health leaders should use these examples with caution. The proper reporting of case studies is necessary to bolster their credibility in HSR literature and provide readers sufficient information to critically assess the methodology. We also call on health leaders who frequently use case studies 56 – 58 to report them in the primary research literature.

The purpose of this article is to advocate for the continued and advanced use of case study in HSR and to provide literature-based guidance for decision-makers, policy-makers, and health leaders on how to engage in, read, and interpret findings from case study research. As health systems progress and evolve, the application of case study research will continue to increase as researchers and health leaders aim to capture the inherent complexities, nuances, and contextual factors. 7

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To the editor:.

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Explanatory Case Study Design—A Clarification

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Megan Anne Simons, Jenny Ziviani, Explanatory Case Study Design—A Clarification, Journal of Burn Care & Research , Volume 32, Issue 1, January-February 2011, Page e14, https://doi.org/10.1097/BCR.0b013e3182033569

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For the purpose of clarity for the readership, we wish to address the description of the explanatory case study design (ECSD) as a qualitative research method in the invited critique to our original article. 1 Yin, 2 the primary source for ECSD, described case study as suitable when the number of variables of interest exceeds the number of data points (i.e., participants). He has positioned the case study as a stand-alone method, in which the collection of both quantitative and qualitative data is appropriate. 3 We agree that within a qualitative research paradigm, the sample size of seven participants 1 would likely be insufficient to satisfy the sampling strategy. However, ECSD is “driven to theory.” 3 , p. 1212 The use of multiple case studies (as in the original study) is deemed the equivalent of multiple experiments. 2 Generalization from the case studies is accomplished using replication logic derived from theoretical propositions (hypotheses) or theories about the case. Results are considered even more potent when two or more cases support the same theory but not an equally plausible, rival theory. 2 The problem of generalizing from case studies is the same as generalizing from experiments—where hypotheses and theory are the vehicles for generalization. 3 With this point of clarification, we acknowledge that the findings from the original study are limited to children with lower injury severity (when measured as %TBSA) within a shortened timeframe postburn injury (6 months).

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Case Studies

Case studies are a popular research method in business area. Case studies aim to analyze specific issues within the boundaries of a specific environment, situation or organization.

According to its design, case studies in business research can be divided into three categories: explanatory, descriptive and exploratory.

Explanatory case studies aim to answer ‘how’ or ’why’ questions with little control on behalf of researcher over occurrence of events. This type of case studies focus on phenomena within the contexts of real-life situations. Example: “An investigation into the reasons of the global financial and economic crisis of 2008 – 2010.”

Descriptive case studies aim to analyze the sequence of interpersonal events after a certain amount of time has passed. Studies in business research belonging to this category usually describe culture or sub-culture, and they attempt to discover the key phenomena. Example: “Impact of increasing levels of multiculturalism on marketing practices: A case study of McDonald’s Indonesia.”

Exploratory case studies aim to find answers to the questions of ‘what’ or ‘who’. Exploratory case study data collection method is often accompanied by additional data collection method(s) such as interviews, questionnaires, experiments etc. Example: “A study into differences of leadership practices between private and public sector organizations in Atlanta, USA.”

Advantages of case study method include data collection and analysis within the context of phenomenon, integration of qualitative and quantitative data in data analysis, and the ability to capture complexities of real-life situations so that the phenomenon can be studied in greater levels of depth. Case studies do have certain disadvantages that may include lack of rigor, challenges associated with data analysis and very little basis for generalizations of findings and conclusions.

John Dudovskiy

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Home » Explanatory Research – Types, Methods, Guide

Explanatory Research – Types, Methods, Guide

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Explanatory Research

Definition :

Explanatory research is a type of research that aims to uncover the underlying causes and relationships between different variables. It seeks to explain why a particular phenomenon occurs and how it relates to other factors.

This type of research is typically used to test hypotheses or theories and to establish cause-and-effect relationships. Explanatory research often involves collecting data through surveys , experiments , or other empirical methods, and then analyzing that data to identify patterns and correlations. The results of explanatory research can provide a better understanding of the factors that contribute to a particular phenomenon and can help inform future research or policy decisions.

Types of Explanatory Research

There are several types of explanatory research, each with its own approach and focus. Some common types include:

Experimental Research

This involves manipulating one or more variables to observe the effect on other variables. It allows researchers to establish a cause-and-effect relationship between variables and is often used in natural and social sciences.

Quasi-experimental Research

This type of research is similar to experimental research but lacks full control over the variables. It is often used in situations where it is difficult or impossible to manipulate certain variables.

Correlational Research

This type of research aims to identify relationships between variables without manipulating them. It involves measuring and analyzing the strength and direction of the relationship between variables.

Case study Research

This involves an in-depth investigation of a specific case or situation. It is often used in social sciences and allows researchers to explore complex phenomena and contexts.

Historical Research

This involves the systematic study of past events and situations to understand their causes and effects. It is often used in fields such as history and sociology.

Survey Research

This involves collecting data from a sample of individuals through structured questionnaires or interviews. It allows researchers to investigate attitudes, behaviors, and opinions.

Explanatory Research Methods

There are several methods that can be used in explanatory research, depending on the research question and the type of data being collected. Some common methods include:

Experiments

In experimental research, researchers manipulate one or more variables to observe their effect on other variables. This allows them to establish a cause-and-effect relationship between the variables.

Surveys are used to collect data from a sample of individuals through structured questionnaires or interviews. This method can be used to investigate attitudes, behaviors, and opinions.

Correlational studies

This method aims to identify relationships between variables without manipulating them. It involves measuring and analyzing the strength and direction of the relationship between variables.

Case studies

Case studies involve an in-depth investigation of a specific case or situation. This method is often used in social sciences and allows researchers to explore complex phenomena and contexts.

Secondary Data Analysis

This method involves analyzing data that has already been collected by other researchers or organizations. It can be useful when primary data collection is not feasible or when additional data is needed to support research findings.

Data Analysis Methods

Explanatory research data analysis methods are used to explore the relationships between variables and to explain how they interact with each other. Here are some common data analysis methods used in explanatory research:

Correlation Analysis

Correlation analysis is used to identify the strength and direction of the relationship between two or more variables. This method is particularly useful when exploring the relationship between quantitative variables.

Regression Analysis

Regression analysis is used to identify the relationship between a dependent variable and one or more independent variables. This method is particularly useful when exploring the relationship between a dependent variable and several predictor variables.

Path Analysis

Path analysis is a method used to examine the direct and indirect relationships between variables. It is particularly useful when exploring complex relationships between variables.

Structural Equation Modeling (SEM)

SEM is a statistical method used to test and validate theoretical models of the relationships between variables. It is particularly useful when exploring complex models with multiple variables and relationships.

Factor Analysis

Factor analysis is used to identify underlying factors that contribute to the variation in a set of variables. This method is particularly useful when exploring relationships between multiple variables.

Content Analysis

Content analysis is used to analyze qualitative data by identifying themes and patterns in text, images, or other forms of data. This method is particularly useful when exploring the meaning and context of data.

Applications of Explanatory Research

The applications of explanatory research include:

• Social sciences: Explanatory research is commonly used in social sciences to investigate the causes and effects of social phenomena, such as the relationship between poverty and crime, or the impact of social policies on individuals or communities.
• Marketing : Explanatory research can be used in marketing to understand the reasons behind consumer behavior, such as why certain products are preferred over others or why customers choose to purchase from certain brands.
• Healthcare : Explanatory research can be used in healthcare to identify the factors that contribute to disease or illness, as well as the effectiveness of different treatments and interventions.
• Education : Explanatory research can be used in education to investigate the causes of academic achievement or failure, as well as the factors that influence teaching and learning processes.
• Business : Explanatory research can be used in business to understand the factors that contribute to the success or failure of different strategies, as well as the impact of external factors, such as economic or political changes, on business operations.
• Public policy: Explanatory research can be used in public policy to evaluate the effectiveness of policies and programs, as well as to identify the factors that contribute to social problems or inequalities.

Explanatory Research Question

An explanatory research question is a type of research question that seeks to explain the relationship between two or more variables, and to identify the underlying causes of that relationship. The goal of explanatory research is to test hypotheses or theories about the relationship between variables, and to gain a deeper understanding of complex phenomena.

Examples of explanatory research questions include:

• What is the relationship between sleep quality and academic performance among college students, and what factors contribute to this relationship?
• How do environmental factors, such as temperature and humidity, affect the spread of infectious diseases?
• What are the factors that contribute to the success or failure of small businesses in a particular industry, and how do these factors interact with each other?
• How do different teaching strategies impact student engagement and learning outcomes in the classroom?
• What is the relationship between social support and mental health outcomes among individuals with chronic illnesses, and how does this relationship vary across different populations?

Examples of Explanatory Research

Here are a few Real-Time Examples of explanatory research:

• Exploring the factors influencing customer loyalty: A business might conduct explanatory research to determine which factors, such as product quality, customer service, or price, have the greatest impact on customer loyalty. This research could involve collecting data through surveys, interviews, or other means and analyzing it using methods such as correlation or regression analysis.
• Understanding the causes of crime: Law enforcement agencies might conduct explanatory research to identify the factors that contribute to crime in a particular area. This research could involve collecting data on factors such as poverty, unemployment, drug use, and social inequality and analyzing it using methods such as regression analysis or structural equation modeling.
• Investigating the effectiveness of a new medical treatment: Medical researchers might conduct explanatory research to determine whether a new medical treatment is effective and which variables, such as dosage or patient age, are associated with its effectiveness. This research could involve conducting clinical trials and analyzing data using methods such as path analysis or SEM.
• Exploring the impact of social media on mental health : Researchers might conduct explanatory research to determine whether social media use has a positive or negative impact on mental health and which variables, such as frequency of use or type of social media, are associated with mental health outcomes. This research could involve collecting data through surveys or interviews and analyzing it using methods such as factor analysis or content analysis.

When to use Explanatory Research

Here are some situations where explanatory research might be appropriate:

• When exploring a new or complex phenomenon: Explanatory research can be used to understand the mechanisms of a new or complex phenomenon and to identify the variables that are most strongly associated with it.
• When testing a theoretical model: Explanatory research can be used to test a theoretical model of the relationships between variables and to validate or modify the model based on empirical data.
• When identifying the causal relationships between variables: Explanatory research can be used to identify the causal relationships between variables and to determine which variables have the greatest impact on the outcome of interest.
• When conducting program evaluation: Explanatory research can be used to evaluate the effectiveness of a program or intervention and to identify the factors that contribute to its success or failure.
• When making informed decisions: Explanatory research can be used to provide a basis for informed decision-making in business, government, or other contexts by identifying the factors that contribute to a particular outcome.

How to Conduct Explanatory Research

Here are the steps to conduct explanatory research:

• Identify the research problem: Clearly define the research question or problem you want to investigate. This should involve identifying the variables that you want to explore, and the potential relationships between them.
• Conduct a literature review: Review existing research on the topic to gain a deeper understanding of the variables and relationships you plan to explore. This can help you develop a hypothesis or research questions to guide your study.
• Develop a research design: Decide on the research design that best suits your study. This may involve collecting data through surveys, interviews, experiments, or observations.
• Collect and analyze data: Collect data from your selected sample and analyze it using appropriate statistical methods to identify any significant relationships between variables.
• Interpret findings: Interpret the results of your analysis in light of your research question or hypothesis. Identify any patterns or relationships between variables, and discuss the implications of your findings for the wider field of study.
• Draw conclusions: Draw conclusions based on your analysis and identify any areas for further research. Make recommendations for future research or policy based on your findings.

Purpose of Explanatory Research

The purpose of explanatory research is to identify and explain the relationships between different variables, as well as to determine the causes of those relationships. This type of research is often used to test hypotheses or theories, and to explore complex phenomena that are not well understood.

Explanatory research can help to answer questions such as “why” and “how” by providing a deeper understanding of the underlying causes and mechanisms of a particular phenomenon. For example, explanatory research can be used to determine the factors that contribute to a particular health condition, or to identify the reasons why certain marketing strategies are more effective than others.

The main purpose of explanatory research is to gain a deeper understanding of a particular phenomenon, with the goal of developing more effective solutions or interventions to address the problem. By identifying the underlying causes and mechanisms of a phenomenon, explanatory research can help to inform decision-making, policy development, and best practices in a wide range of fields, including healthcare, social sciences, business, and education

Advantages of Explanatory Research

Here are some advantages of explanatory research:

• Provides a deeper understanding: Explanatory research aims to uncover the underlying causes and mechanisms of a particular phenomenon, providing a deeper understanding of complex phenomena that is not possible with other research designs.
• Test hypotheses or theories: Explanatory research can be used to test hypotheses or theories by identifying the relationships between variables and determining the causes of those relationships.
• Provides insights for decision-making: Explanatory research can provide insights that can inform decision-making in a wide range of fields, from healthcare to business.
• Can lead to the development of effective solutions: By identifying the underlying causes of a problem, explanatory research can help to develop more effective solutions or interventions to address the problem.
• Can improve the validity of research: By identifying and controlling for potential confounding variables, explanatory research can improve the validity and reliability of research findings.
• Can be used in combination with other research designs : Explanatory research can be used in combination with other research designs, such as exploratory or descriptive research, to provide a more comprehensive understanding of a phenomenon.

Limitations of Explanatory Research

Here are some limitations of explanatory research:

• Limited generalizability: Explanatory research typically involves studying a specific sample, which can limit the generalizability of findings to other populations or settings.
• Time-consuming and resource-intensive: Explanatory research can be time-consuming and resource-intensive, particularly if it involves collecting and analyzing large amounts of data.
• Limited scope: Explanatory research is typically focused on a narrow research question or hypothesis, which can limit its scope in comparison to other research designs such as exploratory or descriptive research.
• Limited control over variables: Explanatory research can be limited by the researcher’s ability to control for all possible variables that may influence the relationship between variables of interest.
• Potential for bias: Explanatory research can be subject to various types of bias, such as selection bias, measurement bias, and recall bias, which can influence the validity of research findings.
• Ethical considerations: Explanatory research may involve the use of invasive or risky procedures, which can raise ethical concerns and require careful consideration of the potential risks and benefits of the study.

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Globally, mothers have identified work as one of the main obstacles to exclusive and continued breastfeeding. The support a woman receives in her workplace in terms of workplace arrangements can be critical to enable women to continue breastfeeding. This study aimed to develop and assess the face validity of a practice model to support exclusive and continued breastfeeding in workplaces in the Western Cape, South Africa.

An explanatory, sequential, mixed-method research design, was conducted (June 2017 to March 2019) in three distinct phases. Phase one employed a quantitative, descriptive, cross-sectional study design. Phase 2 used a qualitative, multiple case study. Phase three involved the development and face validity of a practice model to support exclusive breastfeeding in workplaces. The face validity included two Delphi rounds for experts to provide input on the draft practice model. This paper will only report on phase 3 of the study. The practice model was developed, drawing on the analysis of data from phases one and two and using programme theory approaches and a logic model.

The practice model was positively perceived. Participants viewed it as informative, well designed and easy to follow, even for those not knowledgeable about the subject. It was viewed as an ideal tool, if accompanied by some training. Participants were positive that the model would be feasible and most commended the tiered approach to implementation. They felt that workplaces would be more open to a step-by-step approach to implementation and if only a few activities are implemented it would be a start to make the work environment more conducive for breastfeeding employees. There were mixed opinions regarding commitment; a few participants mentioned commitment as a challenge they anticipated in the male-dominant environments in which they worked. The provision of space for breastfeeding at the workplace was also highlighted as a potential challenge.

Conclusions

Advocacy around creating an enabling workplace environment for breastfeeding is needed. The practice model has the potential to be internationally relevant, locally applied and may be of particular use to workplaces that want to initiate and/or strengthen breastfeeding support.

Returning to work is often considered an obstacle to exclusive and continued breastfeeding. It is a major reason for mothers not breastfeeding, or for ceasing to breastfeed early. Several factors may influence the duration of breastfeeding once the mother returns to full time employment. For instance, workplace support in terms of providing breastfeeding time and space, support at home and in the community, the attitudes of employers and colleagues towards breastfeeding employees and employment conditions and workplace arrangements. For many mothers, the lack of workplace support for breastfeeding makes working incompatible with breastfeeding [ 1 ].

The creation of an enabling workplace environment for breastfeeding may assist mothers to continue breastfeeding. Enabling interventions operate to remove structural and societal barriers that interfere with a mother’s ability to breastfeed optimally [ 2 ]. Globally, workplace support for breastfeeding is progressively seen as a cost-effective investment to increase employee morale, minimize absenteeism and reduce staff turnover [ 2 , 3 ]. Workplace interventions like providing lactation rooms and breastfeeding breaks are low-cost strategies [ 2 ] that can improve the duration and continuation of breastfeeding globally and in South Africa.

South Africa is a upper middle income country with low exclusive breastfeeding (EBF) rates. In South Africa only 32% [ 4 ] of infants under the age six months are exclusively breastfed, contrary to the recommendation that children under six months be exclusively breastfed. The percentage of children exclusively breastfed also decreases with age from 44% of infants age 0–1 month to 24% of infants age 4–5 months. Twenty five percent of infants under six months are not breastfed at all [ 4 ]. Mixed feeding before six months is a well-documented social norm in South Africa, closely related to beliefs that breastmilk is insufficient to nourish a child [ 5 ]. Multi-level barriers to EBF exist in South Africa. At an individual level milk insufficiency beliefs and incompatibility of EBF with schooling and employment. At a community level, norms around mix feeding including traditional and cultural beliefs that exist within communities that inform mothers infant feeding decisions [ 5 ]. Mothers face pressure to adhere to family traditions and decisions relating to infant feeding [ 5 ]. Also, with the high level of fathers being absent in many households, buying commercial milk formula is one way that families pressure males to take responsibility [ 6 ]. With this backdrop and the growing number of women in their childbearing years taking up employment, it is essential that support for breastfeeding in the workplace is reinforced and that institutional workplace challenges are addressed.

Workplace breastfeeding support and promotion models, interventions and case studies have been reported in other contexts like Thailand, Indonesia, United States, Bangladesh and Kenya [ 7 , 8 , 9 , 10 ]. In South Africa the South African National Department of Health (NDOH) developed a guidance booklet supporting breastfeeding in the workplace a guide for employers and employees [ 11 ]. However, to date, in South Africa there is no practice model to guide employers in supporting breastfeeding in the workplace with a set of comprehensive programme activities to implement, links and access to national and international resources and visually depicting the underlying theory of the programme. Owing to the gap in the literature the objective of this study was to develop and test the face validity of a practice model to support EBF in designated workplaces (employers who employ 50 or more employees) [ 12 ] in the Breede Valley sub-district, Western Cape Province in South Africa.

Providing workplaces with a validated tool to create an enabling workplace environment for the practice of breastfeeding, may ensure that infants are provided with exclusive and prolonged breastfeeding. This, in turn, may contribute to infants receiving the highest, most attainable standard of feeding with numerous health benefits.

To inform the development of the practice model, an explanatory, sequential, mixed-method research study was adopted. The research was conducted in Worcester, Breede Valley sub-district in the Western Cape Province, South Africa. The setting was selected based on designated workplaces being present in Worcester area that represent linkages with various levels, namely local, regional as well as national (retail stores and large commercial food companies).

The research was conducted in three distinct phases (Fig.  1 ). Phase one employed a quantitative, descriptive cross-sectional study design, using an online survey to assess current breastfeeding support practices and has previously been reported [ 13 ]. Phase 2 was a qualitative, multiple case study. Data was collected at nine purposively selected workplaces from the manufacturer, retail and public sector, using focus group discussions (FGDs) with employees and in-depth interviews with managers. FGDs were also conducted with employed breastfeeding mothers from designated workplaces who exclusively or predominantly breastfed their children for any period up to six months. This paper will elaborate only on phase three of the study, the model development and face validation phase. The research received ethical approval (S17/04//089) from the Stellenbosch University Health Research Ethics Committee.

Phases of the research study

Review of the evidence regarding workplace breastfeeding interventions and breastfeeding outcomes

A critical review of the literature in the field of workplace breastfeeding support interventions and breastfeeding outcomes were conducted. A search was conducted on PubMed using the following key words: (breastfeeding OR breast feeding OR lactation) AND (work OR workplace OR employment) AND (intervention OR support) AND (duration OR continuation OR exclusive OR rates). The literature consulted included published articles from 2008 through 2019 listed in PubMed. The PubMed search article titles was assessed. Sixteen selected article abstracts, and full text were further screened of which seven were excluded (two was qualitative studies, three was systematic reviews and two were excluded as the main outcomes measured were not breastfeeding duration, continuation and exclusivity). This yielded a total of nine articles included. Amongst the material a review article [ 14 ] on worksite lactation accommodation was found. The review article was reviewed, and five similar articles as yielded by the selected PubMed search article was found. From the critical review of the literature, it was concluded that workplace breastfeeding interventions and support services are responsive to breastfeeding outcomes and practices in terms of increased rates of breastfeeding duration, continuation and exclusivity [ 7 , 14 , 15 , 16 , 17 , 18 , 19 , 20 ]. There is a lack of randomised control trials relating to breastfeeding support in the workplace as most studies extracted reflected cross-sectional surveys. Not all studies consistently found significant associations with all breastfeeding interventions and breastfeeding outcomes assessed. This can be attributed to possible confounding variables that may have been present e.g. lack of family support, cultural and maternal belief of the mother, the mother`s low self – efficacy for breastfeeding.

Identifying main elements from phase one and two for inclusion in the practice model

Phase one and phase two were analysed, interpreted and the main issues arising were identified for inclusion in the model. Phase one analysis involved statistical analysis of the quantitative data. Phase one findings revealed that provision of a private space for breastmilk expression was uncommon [ 13 ]. Allowing time for breastfeeding and promoting breastfeeding amongst the employees were also not commonly practiced [ 13 ]. The provision of breastfeeding time in South Africa is recommended according to the Basic Conditions of Employment Act, Code of Good Practice on the Protection of Employees during Pregnancy and After the Birth of a Child Sect. 5.13 [ 21 ]. Needs identified by managers related to physical space, a regulatory framework, communication, education and information. From phase one of the study, the following pertinent issues raised were taken up in the practice model: provision of breastfeeding time and private space, education and communication.

Phase two analysis of the FGDs with employees and in-depth interviews with the managers involved content analysis using the Atlas ti programme. Phase two findings revealed the absence of private space and time for expressing breastmilk as major challenges for women returning to work. The lack of communication between employers and employees regarding their needs, policies regulating their return from maternity leave, as well as unsupportive attitudes on the part of staff and co-workers were highlighted. The employed mothers who successfully combined breastfeeding and work had a strong belief in the benefits of breastfeeding and this motivated them to continue breastfeeding with work. Therefore, the provision and promotion of breastfeeding time and space as well as communication (conducting a return-to-work consultation after maternity leave) were included in the practice model. Also included in the model were addressing unsupportive attitudes and increasing belief in breastfeeding among employees by enhancing knowledge of the benefits of breastfeeding and the recommended breastfeeding time through education. Conducting a needs assessment amongst women to assist managers with planning and coordination was also taken up in the practice model.

Integrated programme theory and program logic models to draft the practice model

A programme theory describes how and why a programme is supposed to work [ 22 ]. The process of developing a programme theory promotes evidence-based thinking and provides a clear understanding of how change will occur. It also describes the beliefs and assumptions that underlie the choice of activities, thereby making the results more credible [ 22 ]. By reviewing the literature, the underlying linkages and secure evidence of the mechanism of change that would lead to improved breastfeeding duration and EBF rates amongst employees could be explained. The process involved moving continually between theory and practice to develop the practice model programme theory. A logic model is a commonly used tool for illustrating an underlying programme theory. The logic model was selected for the mentioned reason and also as the logic model would provide stakeholders with an easy-to-follow clear visual representation and clear specific guidance in terms of what needs to be provided (input and responsibilities) and the potential gains it holds. The following components are included in a programme logic model 1) Inputs: any resource or material used by the programme to enable its activities e.g. private hygienic space with resources 2) Activities: any services or treatments provided by the programme e.g. engage in interpersonal communication a return to work consultation 3) Outputs: amount of activity provided, described in quantifiable terms e.g. number of employees aware of breastfeeding space 4) Outcomes: any characteristics of the participants that, according to the programme theory, are expected to change as a result of the participants’ receiving services e.g. improved staff wellness and better work life integration practice 5) Impact: the ultimate intended change e.g. cost saving in terms of retaining staff [ 23 , 24 , 25 ].

Delphi rounds

A list of experts in the fields of infant feeding, breastfeeding, human resources management (private and public sectors), academia, child health and behavioural and organizational development was developed. The experts met the requirements of having knowledge and experience of breastfeeding, infant feeding, or human resource management in an organization. An email was sent to the experts to invite them to take part in the study as an expert panel member. Sixteen experts were invited and 11 (69%) participated in the two modified Delphi rounds. The Delphi process and rounds allowed the researcher to gather the opinions of a panel of experts without having to bring them together physically, thereby saving time, cost and effort. The process is free from social pressure and individual dominance and conducive to independent thinking and the gradual formulation of judgement. Of the 11 expert members, ten were female and one male. Four of the expert members were from the academic/research sector and three were International Board-Certified Lactation Consultants. The remaining expert members comprised a provincial health department official, a UNICEF nutrition specialist, one human resource practitioner from the private sector and one from a provincial organizational development department, industrial psychologist.

A graphic designer assisted with the drafting and refining of the practice model. The first version of the practice model was supported by an additional one-page information sheet providing guidance as to the inputs and activities that the employer must provide and perform. The Delphi round one questionnaire consisted of open-ended questions relating to the elements in the developed practice model: inputs, activities, outputs, outcomes, linkages/connections between inputs, activities, outputs and outcomes, strengths, weaknesses, achievability/realistic to implement, challenges, design, use of wording and any recommendations and improvements. Content analysis techniques was used to the open-ended input by grouping similar items together and summarizing the comments received. These were discussed by the research team. Thereafter the practice model was amended. Under the inputs, the identification of a breastfeeding champion, including trade unions, lactation consultants and breastfeeding counsellors as well as other international toolkits was added. Two activities were added to the model: one was maternity leave provision, as this was believed to contribute to the achievement of the stated long-term outcome of increased breastfeeding duration. The provision of antenatal education by the employer was removed and changed to the inclusion of time for pregnant employees to participate in antenatal visits/classes/clinics, which was added under the education heading. Granting pregnant women time off to participate in antenatal preparation is included in Sect. 5.12 of the Code of Good Practice on the protection of employees during pregnancy and after the birth of a child [ 21 ]. Listed activities linked to legislation was highlighted with the text “legal obligation /recommendation to provide”. Also, additional long-term outcomes were added, and more images included under impact.

The improved, second version of the model was sent to the experts. A set of questions mostly using scoring/ranking techniques was used to gain consensus on the amended practice model inputs, activities and outcomes and the connections between them. The round two questionnaire consisted of ten questions relating to the importance of the input and activities used in the model on a one-to-five rating scale of 1 = least importance and 5 = high importance. Also, ten four-point Likert-scale statements and four four-point rated (poor, fair, good, excellent) questions relating to the overall design. To determine the importance of the inputs, a mean score and mean percentage score for each stated input were calculated (Fig.  2 ). Inputs and activities were judged less valid if there was less consensus on their importance. For the input and activity variables, a mean score of 70% (3.5 out of 5) was deemed to be valid for inclusion in the practice model. Therefore, funding for a lactation consultant was removed and a written breastfeeding policy statement as well as the provision of maternity leave benefits were both added to the model, as both scored an overall percentage of 93% (4.65/5).

Score percentage rating for the inputs and activities in the practice model

After the input from the Delphi round two, the final amendments to the model were made. Following on, the practice model face validity was tested by presenting it to the to the nine workplaces that participated in phase two, during four focus group discussions and one in-depth interview. These participants ( n  = 16) included human resource practitioners ( n  = 5), occupational health nurses ( n  = 2), social workers ( n  = 2) managers ( n  = 6) and personal assistant ( n  = 1). The majority of the participants was from the public sector ( n  = 8), manufacturing sector ( n  = 5) and retail sector ( n  = 3). The Atlas ti programme was used to analyse the qualitative data. The analysis was mainly deductive (having a pre-prepared structure), but also partly inductive, in terms of which emerging themes were built and developed.

The practice model (Fig.  3 ) projects a simple logic model flow, making clear connections within the proposed theory of change. The programme theory is based on the Theory of Planned Behaviour [ 25 ] which states that three categories of belief guide human action-oriented behaviours: the outcomes of performing the behaviour (behavioural beliefs – what you feel, think, and the importance of the behaviour = attitude), the expectations of significant others (peers, supervisors) in relation to the behaviour (referent beliefs, how others view the behaviour = subjective norm) and the presence of factors that facilitate or hinder the behaviour (control beliefs = perceived behavioural control).

Workplace breastfeeding support practice model

The programme theory in the practice model relies on working mothers’ attitude towards breastfeeding and the uptake of available breastfeeding accommodation (space and time) at the workplace. The uptake of available breastfeeding accommodation depends on a working mother’s intention to combine breastfeeding and work. Intention is influenced by the working mother’s belief in her ability to successfully combine breastfeeding and work (self-efficacy) and her motivation to do so (control belief). It is also influenced by the working mother’s attitude towards breastfeeding and, more specifically, breastfeeding for an extended period (behavioural belief), as well as by the support she receives from workplace supervisors, peers and co-workers (referent belief) [ 25 ].

The theory of change hinges on the following change mechanism as depicted in Fig.  3 short term outcomes, leading to the medium term and long-term outcomes: when workplace breastfeeding support is provided in terms of space, time and support (i.e. education, peer support, communications and policies), employees’ breastfeeding knowledge will increase and foster positive attitudes towards breastfeeding and breastfeeding employees. It will also increase self-efficacy and the motivation to combine breastfeeding and work, which strengthens the intention to combine breastfeeding and work, leading to increased utilization of the available breastfeeding accommodation (space). This may ultimately lead to increased breastfeeding duration and EBF rates among employees. The literature indicates the connection between the implementation of a workplace breastfeeding support programme and significant higher breastfeeding rates after implementation [ 7 ] as well as the positive correlation between the duration of breastfeeding with the level of workplace support, sufficient time and availability of appropriate space at work to express breastmilk [ 18 ]. Organizational support (Odds Ratio = 1.80) increases the odds of EBF by nearly twofold [ 20 ].

Input by employer

The practice model starts off by identifying the critical elements required from the employers. Commitment by organizational leaders, leadership, planning and co-ordination were identified as key elements for the model to succeed.

Responsibilities/activities by employer

The model flows from left to right, starting with the model inputs and responsibilities/ activities that should emanate from the employer. Among the activities and inputs included in the practice model, the elements of time, space and support are paramount. These three elements have been regarded in the literature as the critical elements of a breastfeeding friendly workplace since 1993 [ 26 ]. The activities included in the practice model can be viewed in the below Table  1 . These activities scored more than 70% by the experts in the second Delphi round and meant consensus for inclusion in the practice model.

The model also expands on the expected outcomes, which were based on the literature review and the programme theory of change. The six listed activities included in the practice model are intended to lead to short-term, early changes (i.e. creation of a supportive breastfeeding environment, increased breastfeeding knowledge, increased motivation and self-efficacy to practice EBF and combine breastfeeding and work), which in turn set in motion changes in the medium term (i.e. increased intention to combine breastfeeding and work, increased utilization of breastfeeding accommodation, positive attitudes towards breastfeeding and breastfeeding employees). This is expected to result in the long-term outcomes of increasing breastfeeding duration and exclusivity rates for the first six months of babies’ lives among employees.

Outputs quantify the services provided and describe what the specific activities will produce. The set indicators for each activity were developed by the researcher with inputs form the expert panel members during the two Delphi rounds. The outputs for each activity are portrayed in Fig.  3 , which guides the monitoring aspects of the model. A potential challenge with measuring the outputs and the outcome may include the additional administrative load in monitoring the various aspects.

Impact is the fundamental intended or unintended change occurring in organizations, communities or systems as a result of programme activities within seven to ten years [ 23 ]. The impacts in terms of societal gains (healthy children lead to a productive society) and workplace gains (cost saving in terms of retaining female staff and decrease absenteeism, positive public image) are made explicit in the model.

The model is accompanied by a three-page information sheet providing further explanations on the inputs and activities /responsibilities that needs to be provided by the employer and links to various resources that can assist with the support process.

Qualitative results of the face validity of the practice model

To determine the face validity of the practice model after the two Delphi rounds, four FGDs and one in-depth interview were conducted. Participants ( n  = 16) had sufficient opportunity to review the practice model, as the protected document was emailed a few days prior to the discussions to enable participants to engage with the content. The Human Resource practitioners, managers` and occupational health nurses of the nine participating workplaces were invited to attend a focus group discussion in February or March of 2019. Gaining the input of the stakeholders was deemed important in order to gauge the end user’s perception of the model. The input of stakeholders in the development and the face validity of the model serves to improve the quality and also encourage the use of it [ 24 ].

Three main themes were established namely, perceptions of developed practice model, challenges to implementation of the practice model and suggested changes to the model.

The practice model was positively perceived by the majority of the participants. The participants viewed it as informative, well designed and easy to follow ‘ the layout is good’,  ‘It`s clearly set out and understandable` . The model was viewed as an ideal tool, if accompanied by some training of how to apply and use it. Participants were positive that implementation of the model was achievable. The model was regarded as informative and insightful, even for someone who are not knowledgeable about the topic. Participants felt the model provided a basic guideline of how to implement breastfeeding support in the workplace.

‘It’s an incredible model … but we know that we must make place for breastfeeding, we know that there are certain laws, but we don’t necessary do it and we don’t know how. So this is actually the how ….` HR manager, manufacturer, male

The tiered approach (selecting a few activities to pilot first) was perceived as the best way to approach implementation. Participants felt that workplaces would be more open to a step-by-step approach.

‘… for management to get into the idea… if it’s in steps then I think they will be more open to the idea.` HR manager, manufacturer, female

In terms of the three-page information sheet some participants felt at first glance that there was a lot of information to process. Others considered the information sufficient. Most participants appreciated the degree of detail in the information sheet and described it as informative, clearly set out and reader friendly.

‘So I think that it’s good that the explanations is there. Because we are being told: “consult people”, but then you are, where should I begin, who must I look for, who else must I approach?` HR manager, retail, female

Commitment on the part of organization leaders, an important element mentioned in the model, was viewed as critical for the model to succeed. There were mixed opinions regarding commitment; a few participants mentioned commitment as a challenge they anticipated in the male-dominant environments in which they worked.

‘You need the commitment from the leaders or the management team to buy into this model, to have things in the workplace like that. So, I think that is aimed …. Most of them at our company are men so they don’t usually understand the importance of breastfeeding and things like that. So, I think that to me will be a challenge.’ HR manager, manufacturer, female

Others stated that their workplace would commit to something like that, as it stands to benefit both employees and the employer. It is therefore essential that organizational commitment be developed for successful breastfeeding support. Other challenges that workplaces may experience with implementation of the model was voiced as the provision of space within their work environments.

This study aimed to develop and assess the face validity of a practice model to support EBF in designated workplaces at district level. A similar Australian-based study also developed a good practice model to evaluate the effectiveness of comprehensive primary health care in local communities [ 27 ]. This research employed a similar methodology of combining programme logic and theory-based approaches, drawing on the literature and conducting interviews to draft the practice model. Another study set out to develop a generic community health worker (CHW) logic model, proposed a theoretical causal pathway to improved performance [ 28 ]. The researchers described their model as a practical tool that offers guidance for continuous learning about what works. The value of the logic model for CHWs was that it can aid planning, draw attention to certain elements of design that are sometimes overlooked, contribute to consensus building to facilitate communication and a shared understanding of what is needed, and it can be used as a guide for improving programme implementation [ 28 ]. The reported value of the logic model for CHWs can similarly apply to the value of the practice model developed in this study, which is also based on a programme logic model.

The six activities included in the practice were providing the recommended breastfeeding time and flexibility (allow 2 × 30 min breaks per day until infant is 6 months old), promotion of breastfeeding space, time accommodation and breastfeeding policy, education of all male and female staff at all levels of the organization and providing pregnant women time to attend antenatal clinic visits, interpersonal communication (antenatal and return-to-work consultation) regarding organizational policies, breastfeeding time, and the mother’s needs, facilitation or referral to peer support group or mentor and provision of the legislated four months maternity leave. The implementation of these selected activities and workplace interventions and the impact on breastfeeding outcomes are well documented. Research reveals that women with access to breaks and space are 2.3 times more likely to EBF at 6 months [ 29 ] and women with an independent breastfeeding room in the workplace are less likely to discontinue breastfeeding [ 30 ]. Qualitative research found interpersonal communication as important to enhance workplace breastfeeding support [ 31 ]. A review article highlights the positive relationship between providing maternity leave and breastfeeding duration [ 32 ]. Furthermore, the literature reveals that a workplace environment that included supervisor and peer support, quiet space other than a bathroom and the frequency of breastfeeding in the workplace showed significant positive correlations ( r  = 0.26, p  = 0.01) with a longer duration of EBF [ 12 ].

Also, the literature shows that a combination of different interventions physical resources (e.g. space) organizational resources (e.g. flexible breaks) education resources and workplace support (e.g. by establishing policy and encourage support from managers and co-workers) leads to more comprehensive breastfeeding support programmes [ 33 ]. However, the comprehensive approach is still uncommon [ 34 ]. The practice model suggests a comprehensive set of activities to be implemented.

To achieve equitable work environments, interventions should focus at the three ecological layers namely individual, interpersonal, and organizational [ 34 ]. The workplace is an organizational level in which institutional support for breastfeeding mothers can be fostered. This support interacts with individual level factors linked to breastfeeding intentions and self-efficacy. Organizational support in terms of promoting lactation rooms and flexible time to express breastmilk, is associated with longer breastfeeding duration [ 34 ]. Interpersonal factors are also important and includes support from co-workers. An effective way to promote organizational support is imparting knowledge among coworkers [ 34 ]. When evaluating the activities in the practice model it addresses these three ecological layers through education of all staff, institutional support in terms of space, time and policies which links to individual factors of intention and self-efficacy.

The practice model is distinctive as it showcases the activities and their potential pathways of change. A systematic review highlighted that interventions and their impact pathways need to be better understood and documented [ 34 ]. The systematic review suggested further studies on the adaption of workplace interventions for firms of different types and size. The practice model addresses this, as it was mainly developed for workplaces with more than 50 employees from the manufacturing, retail and public sectors.

A participatory action research study was conducted in Thailand to develop a workplace breastfeeding support model for employed lactating mothers [ 7 ]. This study compared breastfeeding rates before and after implementation of the breastfeeding support campaign. The Thailand model was also based on the three core elements of time, space and support. The process undertaken to develop the Thailand model included the creation of a breastfeeding support committee, breastfeeding support activities and educational materials for breastfeeding support campaigns in the workplace. Similarly, this practice model incorporates engagement with trade unions, human resources managers, line managers and consulting breastfeeding professionals. The implementation of the Thailand model consisted of breastfeeding education and support by nurses, midwives and/or lactation consultants as part of the breastfeeding support campaign at the workplace. Breastfeeding education and support from health professionals started from the third trimester of pregnancy and continued during hospitalisation, after giving birth, during the four- to six-week post-partum follow-up visit, one-two weeks before resuming employment, and continued after the mother’s resuming employment through at least six months. Similarly in the current study, the aspect of breastfeeding education for all levels of male and female staff was included as an activity in the practice model. The practice model additionally included facilitation and/or referral to peer support groups as part of the support. The Thailand model proved to be effective, as the breastfeeding rates after implementation were significantly higher for both EBF and any breastfeeding at six months, at levels of 0.004 and 0.033 respectively. The employed lactating mothers had a positive psychological experience from combining breastfeeding with work, and members of the committee reported positive attitudes towards breastfeeding and themselves felt good about supporting lactating workers [ 7 ].

A study by Basrowi et al. (2018) in Indonesia similarly to the current study, used the aspect of expert consensus on developing a workplace-based lactation promotion model. A three-round online survey using Delphi approach was conducted. The seven dimensions, i.e. policy and regulation, facility, education material, target participants, promotion approach, human resources, and time was highlighted as the most important actions to promote lactation in the workplace. In the final round, “maternity leave of 3–6 months” and “employees have the right to breast-pumping every 3 h” ranked as the two most important indicators regarding policy and regulation. Having a dedicated lactation room was the highest ranked indicator regarding facility dimension. Regarding education materials, benefits of breastmilk for babies ranked as the highest indicator. The top management in the company and lactation counsellor are the two highest-ranked indicators in human resources dimension. For the delivering methods dimensions, social media and interactive counselling were the two highest ranked indicators [ 8 ]. The dimensions highlighted in this study has several links with the developed practice model. The links relates to importance of breastfeeding time, providing the maternity leave period, space/facility, involvement of education, using interactive communication and the importance of top management and lactation counsellors.

A study by Garvin et al. (2013) in Southeastern Virginia aimed to assist workplaces in developing lactation support using the business case for breastfeeding resource toolkit [ 9 ]. This one-year project educated 20 businesses about breastfeeding support in the workplace and engaged 10 businesses to implement the business case for breastfeeding. The aim was to assess sustainability via documented policy and environmental changes as well as integration of the lactation support programme into the businesses infrastructure. The results indicated out of 17 businesses that engaged with the project 14 significantly increased their stage of change, development of a lactation support programme, written policies and physical and social environment changes ( p  < 0.001). A brief follow-up also indicated that all 14 businesses sustained the programme eight months after the program ended with increased stages of change, policy enforcement and physical environment ( p  < 0.05). This resource toolkit provided an effective approach in assisting and maintaining lactation support programmes in workplaces across several cities in Virginia. Similar to the Garvin et al. study there is also potential to conduct similar research in the South African context. By providing workplaces with education and training relating to the developed practice model and assessing the progression of the stages of change, physical and social environment with the aim to determine if the approach would be effective in establishing support in the workplace.

The United Nations Childrens Fund (UNICEF) Bangladesh and Kenya workplace breastfeeding case study, similar to the practice model activities of the current study, included interpersonal communication, pre-maternity leave and a back-to-work preparatory consultation. Workplace dialogue was included to sensitize employees and promote available breastfeeding breaks and space accommodation. The lessons learned from the Bangladesh case study were about the importance of involvement from leadership as well as commitment from the business to initiate the programme [ 10 ]. The practice model starts off by identifying the critical elements, with leadership and commitment considered important elements for the practice model to succeed.

A report by World Health Organization and UNICEF relating to breastfeeding family-friendly policies sets out a call for action: advocacy within business is needed and workplace policies must be adapted and strengthened. The report mentions that technical assistance is needed to build workplace capacities to implement such policies [ 35 ]. The practice model addresses these aspects through providing workplaces with practical guidance in how to build workplace capacities to support breastfeeding.

A recommendation is for a campaign for the endorsement of the practice model by all government departments in the Western Cape. The South African NDOH should consider recognition for workplaces that support breastfeeding. Government could for example provide tax breaks as an incentive for employers to create breastfeeding facilities. Furthermore, the NDOH should ensure the distribution, awareness and marketing of the breastfeeding in the workplace toolkit and guide for employers and employees. Much more advocacy around this aspect is needed.

In terms of the results and outcomes of this research, using a sequential mixed-method approach proved to be helpful in bridging the gap between research knowledge and the creation of an action-orientated model to help create a supportive workplace environment for breastfeeding. Limitations in terms of the model development process relates to the extensive logistical arrangements to set up a suitable date and time for the FGDs for the participants with high-ranking positions. The Delphi experts also held high ranking positions and were employed in occupations that are very demanding. The two Delphi rounds took three months of periodic interaction to complete. Participant fatigue was sensed, and no further rounds were therefore conducted. Another limitation can be that the research did not engage organizational change theory to develop the model in conjunction with the programme theory used. A challenge of the model may be that it may be too ambitious for some workplaces to implement. Other potential barriers to implementing the model may be the commitment from leaders may be lacking due to breastfeeding not being a priority in the organization, the male dominant work environments that do not prioritize female needs and breastfeeding. Also not able to identify a breastfeeding champion to drive the process in the workplace and providing the space for breastfeeding and the associated infrastructure. To overcome these potential challenges advocacy in workplaces around the importance and benefits of workplace breastfeeding support is needed.

The practice model was positively perceived. Participants viewed it as informative, well designed and easy to follow, even for those not knowledgeable about the subject. It was viewed as an ideal tool, if accompanied by some training. Participants were positive that the model would be feasible and commended the tiered step by step approach to implementation. Challenges related to commitment from management, especially in the male dominant environments as well as the provision of a breastfeeding space. There is a need for greater advocacy around creating an enabling workplace environment for breastfeeding. If employers implement concerted activities according to the practice model, it may go a long way to assist employed mothers with EBF and longer breastfeeding duration. It additionally holds the potential outcomes for the employee in terms of increased morale, improved staff wellness and better work life integration, which benefits the workplace in terms of cost saving relating to retaining skilled female staff, decreased absenteeism and increased productivity. The practice model has the potential to be applicable nationally and relevant internationally. The model can be locally applied and may be of particular use to workplaces that want to initiate and/or strengthen breastfeeding support. Future research should explore the piloting of the practice model within the three workplace categories (i.e. retail, manufacturing and public) and exploring the perceptions of employees and employers before and after the implementation of the intervention and to evaluate the effect on breastfeeding outcomes. Research on the impact of the recommended breastfeeding time on organizational workplace practices and policies is also needed. Exploring the experiences of breastfeeding mothers employed in the informal sector is also recommended, as these mothers presumably face similar but unique challenges.

Availability of data and materials

No datasets were generated or analysed during the current study.

Abbreviations

Exclusive breastfeeding

Focus group discussions

National Department of Health

United Nations Children Fund

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Acknowledgements

We thank all the participants and expert panel members who participated in the study.

This work was supported by National Research Foundation, Thuthuka Funding for author L Daniels (Reference number TTK170419227683). The co-authors have no financial support to disclose.

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LD developed the protocol for the research study, undertook data collection with the assistance of a research assistant and a fieldworker, captured the data, analysed the data with the assistance of a statistician, interpreted the data, developed and finalized the practice model and drafted the article. Co-authors, XM and LDP, provided input at all stages of the research, revised the protocol, provided input on analysis and interpretation and reviewed the article. All authors contributed to critically reviewing the article and gave final approval of the manuscript.

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Correspondence to Lynette Carmen Daniels .

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The study was approved by the Health Research Ethics Committee of Stellenbosch University (S17/04//089). Written informed consent was obtained from all participants involved in the study.

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Daniels, L.C., Mbhenyane, X.G. & Du Plessis, L.M. Development of a workplace breastfeeding support practice model in South Africa. Int Breastfeed J 19 , 32 (2024). https://doi.org/10.1186/s13006-024-00638-9

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Received : 14 December 2023

Accepted : 19 April 2024

Published : 06 May 2024

DOI : https://doi.org/10.1186/s13006-024-00638-9

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