Table 2 Description of the intervention programme

Development and implementation

For the adaptation of the previous successful breastfeeding intervention done by Nilsson and colleagues (2017) in hospital setting, an assessment of the needs of families following discharge from hospital after birth and until six months postpartum was carried out. Programme objectives corresponding to findings from the needs assessment formed the basis of the adaptation. In the adaptation process, a participatory approach including health visitor representatives from each of the intervention municipalities was chosen to enhance ownership, to match the organisational structure of the setting (the Danish Health visiting programme), and to ensure implementation in the intervention municipalities. The final intervention programme consisted of a breastfeeding programme for parents and a related training programme for health visitors. In December 2021, 210 health visitors from the 11 intervention municipalities completed a preparatory 3.5-h e-learning course, and in March 2022 they participated in the 15-h physical attendance interactive training programme supported by a written manual. Following training, the health visitors immediately initiated implementation of the programme in their municipalities

Topics in the training programme for health visitors

• Current evidence-based knowledge about breastfeeding, including:

  - Anatomy of the breast and physiology of lactation

  - Preparing for breastfeeding

  - Breastfeeding positions

  - Suckling technique

  - Alleviating breastfeeding problems, for example by strengthening parents’ action competence

  - Breastfeeding as a joint parenting task

  - The social context of the parents and its’ influence on breastfeeding

• Tailoring communication

• Breastfeeding self-efficacy – how to improve and support parents’ self-efficacy

Objective of the parental breastfeeding programme

To support parents who want to breastfeed in establishing effective breastfeeding by improving health visitors’ and parents' breastfeeding knowledge, and enhancing parents’ self-efficacy, and action competency through a focus on four simple key principles and tailored information

Content of the parental breastfeeding programme

The programme consists of four key principles:

• Skin-to-skin contact as much as possible during the first week while the mother and father are awake [43]

• Frequent breastfeeding defined as a minimum of eight times including identifying the infant’s cues for being ready for breastfeeding and signs of getting enough milk [44, 45]

• Proper positioning of the mother-infant dyad including introducing the parents to laid-back breastfeeding and focus on the mothers’ experience of pain and relaxation as guidelines for positional changes [46, 47]

• Acknowledgment of the mother and the father as equal parents with different roles in relation to breastfeeding [48]

The parents’ breastfeeding self-efficacy and breastfeeding knowledge is intended to be supported by the communication based on Bandura’s theory of self-efficacy and the related four sources to increase self-efficacy: 1) Mastery experiences, 2) Vicarious experience, 3) Social persuasion, and 4) Emotional arousal [42]. Kreuter’s theory of tailoring knowledge to the specific needs of the individual [49] is furthermore included to address findings from the needs assessment [30]

Supportive health educational materials include:

• A dialogue sheet

• A pamphlet with visuals for the changes in colour of a healthy infants’ stool during the first week

• A postcard with the four key principles

• A website with written knowledge, videos, podcasts, a quiz about breastfeeding aimed at preparing parents for breastfeeding, and furthermore a trouble shooting guide