Qualitative as well as descriptive data from the monthly reports are reported under the themes of ‘bonding’, ‘bridging’ and ‘linking’ social capital. A selection of quotes have been utilised to illuminate the issues being raised, together with the code HP (to refer to a maternity or health visiting professional), CP (to refer to a community professional, e.g. Children’s Centre Workers), P (to refer to the infant feeding coordinator, lactation consultants or commissioner), PS (to refer to VCs/peer supporter) and M (mother). The term ‘participant’ is used to refer to insights generated across the different participant groups. In the occasions where the findings relate to a particular group, this has been made explicit in the text.
Bonding social capital
Bonding social capital typically refers to close connections and strong bonds between individuals in closed networks to, ‘bring together people who are like one another in important respects’ ( p.11).
Bonding social capital was evident within the peer support service through the regular communication and opportunities for social occasions amongst all members of the service. All VCs contacted their assigned volunteers on a monthly basis to collect data for the monthly reports, to provide information on local activities or training events and to provide on-going and informal supervision. Volunteers had the mobile number of the VCs and were encouraged to contact them when needed. The peer support service also had an active Facebook account where issues and events were shared. Mentoring and support was provided by VCs when volunteers were undertaking new tasks, for example providing shadowing opportunities for those who wished to run breastfeeding groups or offer support in the neonatal unit. At Christmas, all volunteers were bought a gift and/or invited to attend a social event to say ‘thank you’; with picnics and other social occasions (involving wider family members) organised on a more ad-hoc basis. While data on the number of volunteers involved in these activities were not recorded, these insights indicate that the service had created a range of formal and informal connections and support between its members. The positive value placed on these networks and personal contacts was highlighted by the volunteers, ‘makes you feel like you’re connected to something’ and the VCs:
We do have get togethers, so they can all meet up, just like friends really and let them know as well that they are appreciated. (PS_1)
In order to maintain the volunteers’ ‘bond’ with the peer support service, on-going assessments were undertaken between the VCs and the individual peer supporters to ensure that their skills, interests and capacity was suitably matched to their volunteering roles. For example, some volunteers worked on the breastfeeding helpline(s) as this suited their availability, whereas others chose to work directly with women, or in groups at times that fitted with their childcare needs or other work commitments:
And I could volunteer in the evening to go on the ward but evenings, I was just a bit of a washout really. I thought, I’m not going to be any good talking to a mum who’s all emotional because I’m feeling like that myself…so I’ve kind of been somebody who the Coordinator could [say] can I phone you if I’ve got too many people to phone and can you do some phone support? And I’ve been very happy to do that. (PS_11)
Another aspect of bonding social capital was evident in the relationships forged between women and peer supporters. The peer support service was set up to provide proactive on-going contacts between women and peers across the peri-natal period, e.g. antenatal clinics, the postnatal ward and in the community. Early opportunities for contact were perceived to be important by the participants to provide reassurance, ‘knowing that there was going to be support there’ and to build connections and familiarity with women and their families:
I know the Star Buddies are trying to build up the antenatal, so they do have contact with women antenatally, which does seem really positive, getting to know somebody before they’ve even made the decision how they’re going to feed their baby. (HP_2)
According to Woolcock and Sweetser  bonding social capital relates to connections with individuals who are ‘like you’ (p. 26). This was evident in this study as women reported how the peer supporters were mothers ‘like them’ which enabled connections through shared understanding and experiences. The women explained that the supporters ‘know what they’re talking about because they’ve done it themselves’. They also highlighted the personal qualities of the peer supporters, characterising them as reliable, ‘dedicated to what they do’,’enthusiastic’, ‘good at talking to people’, ‘friendly’ and ‘approachable’. It was these qualities and what women identified to be the ‘time’ and ‘reassurance’ offered by the peer supporters as well as the ‘non-judgemental’ and flexible based tailored support they received that enabled a ‘trust’ based relationship to be formed. This was commonly expressed by women in terms of the safety and reliability of ‘knowing that I could phone somebody’ or ‘just having someone there’ when they needed it most.
Breastfeeding groups were offered in all locality areas (n = 6) with a total of 1,011 group sessions run over the evaluation period, supported by 2,429 volunteer hours. Attendance at the groups was generally high, and the peer supporters attributed this success to practical and psychological barriers to access being addressed. For example, crèche facilities were provided at the groups for older children and peer supporters would meet and accompany women to the groups. This thereby provided women with the reassurance of a ‘familiar face’ in an unfamiliar setting. Individuals from across the participant groups emphasised how the breastfeeding groups played an invaluable role in linking and bonding new mothers to each other, thereby creating new and significant social contacts;’I’ve met some really good lifelong friends’. Women were also identified to have formed their own social networks outside of the group environment:
There’s a group of mums now, they keep accessing the sensory room together, but they’ve met in the centre [breastfeeding group]. (CP_12)
Bonding social capital is believed to enable individuals to come together to collectively resolve problems and achieve outcomes of mutual benefit . This was evident in the mother-to-mother relationships that provided reassurance and support from those who had had ‘the same problems’ and which in turn helped to increase the women’s motivation, confidence and capacities to resolve their own breastfeeding challenges; ‘if it wasn’t for the group I wouldn’t have carried on feeding’:
Because to start off with I didn’t know how long I was going to last for, it was hard work, you were up all night, it wasn’t as easy as what you thought it was going to be. So I spoke to those other mums that had done twelve months and you just thought, yes there is other mums out there that breastfeed for a long time. (M_1)
While bonding social capital is generally perceived to be more apparent within homogenous groups , some professionals highlighted how the service had created new communities of breastfeeding women which crossed previous social boundaries:
Its social groups as well that you wouldn’t, they would never have put themselves with each other. And the little group that comes to X, they’re the most diverse group of ladies, girls whatever, four of them there are. You would never have put them as friends out of there, but it’s because they’ve all got this natural link. (CP_12)
Bonds that are forged between individuals in a community can lead to mutually beneficial collective action . In this study, some of the women reported how their positive experiences of peer support had fuelled a desire to provide the same for others:
I wanted to give something back because she’s [peer supporter] been really good. So she’s put me in touch, I’m now on the course to do the [peer support training] for the Breastfeeding Network (M_1)
Bridging social capital
Bridging social capital concerns more distant connections between people, and relates to weaker ties across individuals at a same level of hierarchy, such as those from different interests or backgrounds [56,57]. In this theme we report on how the peer supporters forged links with those from different ethnic, economic and professional backgrounds. As well as how ‘being known’ in the community led to a diffusion and dissemination of breastfeeding information and support across the community.
Bridging social capital was apparent through the service actively recruiting volunteers from Eastern European (e.g. Bulgarian, Czechoslovakian and Polish) and Spanish backgrounds and engaging with outreach workers to provide support to women from different ethnic backgrounds:
Well luckily there is a volunteer from that community [Polish] so we can use her when we need [. . .]. There’s also a large population that have just arrived from Eastern Europe [. . .] and there’s a whole load that have come over from Hungary, Czechoslovakia, that area. And again, we employ a Czechoslovakian girl in our staff, and she set up a group for Eastern European families. (PS_2)
However, some on-going challenges in reaching certain ethnic groups were reported:
Chinese really stick to themselves and don’t really want the support, so you can’t really get in there. And other Asians, again it’s difficult, they don’t tend to come out the house anyway and they always have their sisters and mothers in their own group. They’re always invited to [breastfeeding groups] but it’s a bit difficult to draw them in. (PS_1)
Engagement with Children’s Centre staff, meant that the peer supporters were able to build links with ‘hard to reach’ families and young mothers who are known to be those who are less likely to breastfeed . For example, volunteers attended Young Parents groups at the Children’s Centres and provided support at a supported accommodation centre for homeless young people and families. While these relationships may not equate to the ‘bonding’ social capital created amongst women who actively engaged with peer support, the service had created opportunities to connect with the more marginalised populations in the community.
The opportunity to form links in order to identify and understand cultural differences in health behaviours was considered essential within the peer support service; ‘they [Eastern European women] believe smoking is OK but they won’t smoke and breastfeed’. However, many of the peer supporters emphasised a need for on-going communication with local women as well as professionals to ensure that their service was appropriate and responsive for all those residing within the community:
You have to find what works with the people you’re working with and everybody’s different, every area is different. […]. Because as the years go by people change and how they want it changes, so it’s keeping on top of that. (PS_2)
Bridging social capital involves connections between individuals who are ‘not like themselves’ (e.g. non breastfeeding mothers) to open up new opportunities, span social boundaries and provide connections to their current networks [56,57,59]. As wider social networks are known to have a significant impact on women’s decisions and experiences of infant feeding , the peer support service involved partners and other family members in antenatal workshops, breastfeeding groups as well as during home visits. Peer supporters explained the need to include ‘their [the woman’s] support system,’ as they ‘all need to understand how it works and what’s going to happen and what’s going on and why it’s a good thing’ so that they can best support the mother. The peer supporters reported how they took ‘every opportunity’ to engage with fathers and wider social networks through encouraging ‘mums to bring grandmas’ and ‘getting as many of the family’ involved because ‘that makes a huge difference’. A grandmother peer support training course was provided in one of the localities. Breastfeeding groups also coincided with antenatal clinics in community locations. This was perceived as important to enable pregnant women to observe breastfeeding and promote their self-beliefs and self-efficacy for breastfeeding, and corresponds with the ‘Apprentice Model’ described by Hoddinott and colleagues .
Bridging social capital was also demonstrated through the peer support service being involved in various promotional and awareness-raising activities in their localities. These activities were designed to ‘reach out’ to other women, families as well as wider community members. For example, volunteers were involved in breastfeeding-related community events, e.g. the ‘Milk Run’  and the ‘Big Latch On’ event  as well as local Carnival and Baby and Toddler shows. The roles and activities of the volunteers had also featured in local news articles and via radio interviews [62,63]. Furthermore in order to try address some of the wider cultural challenges, educational activities (n = 8, 18 volunteer hours) had been provided at primary schools (4–11 years), high schools (11–16 years) and colleges (16–18 years) to promote positive breastfeeding attitudes and beliefs in the next generation of parents.
While on and off ‘duty’ peer supporters wore their Star Buddies T-shirts in order to promote breastfeeding and their service. In turn, this led to impromptu contacts in terms of peer supporters being approached by mothers, fathers as well as other community members in local and informal settings, e.g. the school playground, shopping centres, leisure clubs, fish and chip shops and by a postman when delivering a parcel; with some 549 contacts of this nature recorded over the evaluation period. The fact that the peer supporters were recognised as a means of support, together with opportunistic opportunities to ‘get information out there to people in lots of different places’ were felt important ‘to normalise breastfeeding’. It also meant that women and others could gain guidance and support that they may not have been aware of, or had access to:
In a supermarket a grandma stood behind me in the queue and she said my daughter in law is having real problems [. . .] so I gave her the number of X [National Breastfeeding Helpline] (PS_Group interview)
These occasions of informal, flexible support were believed to have created a ‘flow’ of information, a ‘ripple’ effect as awareness and access to support resonated across the community.
Linking social capital
Linking social capital relates to vertical interactions between individuals and people in positions of power. The key difference between linking and bonding/bridging social capital is that it concerns relationships between those who are not necessarily on an equal footing [64,65]. Linking social capital is perceived to be important due to its capacity to connect individuals, and enable access to knowledge and resources to those in authority [64,65]. In this theme we describe how the peer supporters engaged and formed relationships with health, political, community, commercial and statutory sectors to disseminate knowledge and awareness of breastfeeding and peer support, to gain access to women and to promote a positive attitude to breastfeeding throughout the community.
Linking social capital was evident through the peer support service lobbying local politicians and council members for one of their localities to become the first’Breastfeeding Welcome’ town in the UK; with signage to this effect displayed on the town’s perimeter . Vertical relationships were also forged with local businesses to encourage them to become a ‘Breastfeeding Friendly’ establishment. Businesses deemed to be breastfeeding friendly are those where breastfeeding women and young children are welcomed and where women can feel comfortable breastfeeding. Breastfeeding women were subsequently aware of this endorsement through a sticker being visibly displayed in the window of the premises and details listed on a local website. One mother who was initially reticent to feed in public reported how she had been able to overcome her concerns after being told about the ‘cafes, that signed on the breastfeeding support’ and noted how in those places ‘they’re quite happy for you go and do it. [breastfeeding]’ As breastfeeding in public has been identified as a key barrier to breastfeeding continuation  these links provided important resources for breastfeeding women, as well as being perceived to help ‘promote a breastfeeding culture’.
Volunteers also identified how they wore their uniform when accessing professionals for their own healthcare needs e.g. dentist, General Practitioner. They considered how this had enabled promotion and ‘cascading’ of information across these professional groups as well as to wider community members; ‘chemist keeps telling me how she tells people about who I am and where we are’.
So I saw my doctor as a personal thing for me and she said, “Oh you do something around breastfeeding don’t you?” So I don’t know whether, again, that makes any difference in her other role, but maybe a mum goes to her and says, oh I’m finding it hard and she might go, oh well I know that there’s a group. (PS_6)
The peer support service had formed links and relationships with those in authority (e.g. maternity and early years staff) through regular meetings, multi-agency workshops and update events. These opportunities had subsequently enabled the service to gain access to statutory and more formal activities and structures of women-centred support. Examples within the monthly reports concerned volunteers running an infant feeding session as part of the midwifery led antenatal education classes within selected areas (n = 89 sessions delivered). Volunteers also worked alongside a range of statutory and informal professional-run activities and groups, i.e. baby clinics, antenatal clinics, baby groups, lactation consultant-led breastfeeding group, young mother’s groups, toddler groups, baby massage groups and weaning talks. The peer supporters also held or facilitated breastfeeding events within the Children’s Centres, e.g. during National Breastfeeding Week, at Halloween, Harvest, Christmas and Mother’s Day. Overall a total of 378 sessions/events of this nature were provided over the evaluation period, supported by 1,629 volunteer hours. All health/community professionals had been provided with the mobile numbers of the VCs for referral/contact purposes, with 269 health and 88 community professional referrals received during the evaluation period.
As reflected by Hofmeyer & Marck, the exchanges of information and resources as well as efforts at cooperation, coordination, and mutual assistance between professionals and the peer support service meant that women were able to proactively access information and support via multiple locations and opportunities . Furthermore, women were able to find out about the peer support service from different health and community practitioners, through written material developed in conjunction with professionals as well as via personal contacts with other mothers and peer supporters: ‘I phoned them actually because I got the telephone number off a friend’.
Chang et al. reflects on how social capital encompasses social interaction, trust and shared vision, which subsequently forms the preconditions for knowledge sharing . The on-going contact with professionals across the geographical area was perceived as invaluable in terms of enabling professionals to ‘recognise what we [peer support service] do and having more respect for it’:
I think at first the health visitors were the hardest but now they’re great. Because it’s showing them how you can help them as well, that you’re there to support them, that’s what it’s about. (PS_2)
The volunteers would often re-contact the referring professional after contact had been made with the woman. These feedback sessions were believed to be important to provide re-assurance that contact had been made and to raise awareness of the capabilities of the service:
I had one on Friday that came through, went out on Friday night to see the mum, baby with tongue-tie, referred her to tongue-tie clinic, phoned the health visitor back which is a health visitor I had never dealt with before and told her what had happened, what I’d seen and that I had referred the lady through already and she was like “oh my gosh that’s great have you done that, do I not have to do anything”. Sometimes, the health visitors and midwives don’t know we can do stuff like that. (PS_Group Interview)
The social interactions through professionals observing women-peer interactions (e.g. at clinics or during home visits) and ‘free flow of information’ between the peers-professionals was believed to have enhanced the professionals’ confidence and trust in the service. A number of the professionals considered peer support to be an ‘integral part of my practise’:
And, of course, if I was to look at people like X [VC], I just absolutely know that she’s going to be there. I can ring her, she’s always supportive of me, she’ll ring back, she’ll feedback and I know that my client’s going to get a really good service. So I can’t wish for more really. (HP_5)
Linking social capital in terms of enabling additional knowledge and resources from those in authority [64,65
], was also evident through the volunteers making referrals or sign-posting women into other professional-based or specialist services, e.g. fire brigade, benefits advice, birth afterthoughts, speech therapists and tongue-tie clinics:
I instantly got on to the sign language and they got lessons for her and its things like that. Fire, safety in the home, we do that, get the fire brigade round, link that in. (PS_2)
It is important to note however that linking social capital was not without its challenges. There were occasions where some professionals raised concerns about a perceived ‘lack of communication’ with the peer support service and how information was ‘not flowing very well’ in regard to individual cases:
I think the general thing is that there is no liaison going on at all. The peer supporters, the way it works, have a good relationship with the mother, which is good. But when there are difficulties with feeding, that’s when it would be really helpful to have the good communication and information sharing. (HP_11)
In turn, these communication difficulties appeared to lead to ‘insecurity’ amongst some of the professionals, together with a desire to ‘find smoother ways of working together’. A few of the professionals also highlighted tensions in inconsistent advice across the peer-health-community professionals and the potential negative impact on women’s self-efficacy to breastfeed:
One mum in particular reported so much conflicting advice between different midwives, the peer supporter and then myself. So she said, “look, you know, I’ve been told several different things, I just want to know which one’s right”. (HP_15)
Some peer supporters expressed concerns about ‘step [ping] on other peoples [professionals] toes’ whilst supporting mothers. While these boundaries were often successfully negotiated, in other situations ‘tension between what the Star Buddies, midwives and health visitors are doing’ was evident. This issue tended to occur when there was an overlap in service ‘you don’t want two [Star Buddy and professional) people going in supporting’ and concerns that women would feel ‘bombarded’. Some professionals also felt that the agenda of the peer supporters was different to their own. Concerns were raised that as peer supporters were ‘limited to promoting breastfeeding’, this could be internalised by women as ‘pressure’. The peer supporters perceived focus on ‘exclusive’ breastfeeding irrespective of weight gain was also believed to be at odds with the professionals ‘overall health’ agenda:
There’s been a few instances where really the babies have needed a top up as well because they’ve lost so much weight, but they haven’t been advised to do that because, obviously, it’s not really down to the peer supporters to do that. (HP_6)