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Table 1 The 7 Criteria of Complex Service Interventions and Their Evaluation Through Realist Reviews (after [21])

From: How do breastfeeding workplace interventions work?: a realist review

Criteria of complex service intervention and their evaluation through realist reviews

Application to workplace breastfeeding programs

1) Public health interventions hypothesize that after implementing an intervention, the condition will be improved. The review needs to closely follow those underlying theories.

Workplace breastfeeding programs are expected to improve breastfeeding rates among participating working mothers.

2) Public health interventions only accomplish their goals by active input from individuals. It is therefore essential to not only rely on controlled study designs but to also review the actions of involved stakeholders to be able to explain the success or failure of the intervention.

In order to have a successful workplace breastfeeding intervention, active input from several individuals is needed e.g. communicate the availability of a breastfeeding/lactation room, active support from co-worker to take over responsibility while the breastfeeding women is on her pumping break, etc.

3) Public health interventions involve a long and complex pathway which includes the operational changes needed to implement the intervention and the uptake and adherence to the program by the participants. Thus, the review needs to consider the entire implementation chain, determine the needed intermediate outputs for a successful final outcome and define processes and blockage points by including a variety of publication types.

In order to understand workplace breastfeeding interventions, the review needs to analyze who initiated the program, how it was developed, how it was implemented and who actively participated in the implementation and how as well as who adheres to the offered breastfeeding intervention.

4) Public health interventions are non-linear. The review therefore needs to determine and account for the different influences of the different parties by not only including controlled trials.

Within the implementation chain of a workplace lactation program, different stakeholders influence each other. Depending on their power, the workplace breastfeeding program differs e.g. workplace lactation programs might be more extensive if employee have strong representatives compared to situations in which the employers strictly follow governmental regulations.

5) Public health interventions are embedded in multiple social systems. Such differences are best uncovered by considering finding from qualitative study designs.

The wish for privacy in a lactation room in a woman dominated environment may be different then in a male dominated work environment.

6) Public health interventions differ depending on the context and the understanding of the implementing stakeholder. The review needs to help to understand what similar terms mean to different stakeholders by disentangling underlying implementation mechanisms and contexts behind interventions labelled the same way but in reality being different from each other.

A workplace lactation room can range from simply referring to an empty room vs. a fully equipped lactation room with an accompanying policy regulating breaktime and flexible working hours.

7) Public health interventions are open systems with feedback loops. Hence changes in overall environment as a result of interventions need to be considered across different contexts.

By successfully implementing a workplace lactation policy, the overall work-based environment may change and as a consequence, the policy itself strengthens.