Healthy

Start Toolkit

Funding Requested: $8,080
Project Duration: 8 week Intervention, 1 year data collection period
Project Director: Julianne Borba
Address: 68 Corey Rd, Aromas, Ca 95004
Phone: (831) 809-8570
Email: jtellesborba@gmail.com
Created by: Kern County Breastfeeding Coalition
Potential Funding Agency: Coalition for Healthy Communities




Abstract:

This intervention aims to increase the proportion of Hispanic and Latino
women located in Kern County who exclusively breastfeed for 6 months. This will be
accomplished through the delivery of bilingual breastfeeding education classes to
maternity ward staff currently working at Kern County Medical Center. A two-
month educational seminar and training program will take place. Pre and post
breastfeeding knowledge will be evaluated through surveys and the in-hospital
breastfeeding rates will be collected and analyzed for a year following completion of
the program. These surveys will determine if the educational program results in
increased knowledge among hospital staff and breast-feeding rates will be
compared to prior hospital data in order to determine if increasing staff and health
care provider's knowledge and training has a notable impact on patient's exclusive
breastfeeding rates.

Needs Assessment:
Exclusive breastfeeding has the ability to increase the well-being of mothers,
infants, children, and families. It has been shown to result in superior nutritional,
psychological, and economic benefits. The Department of Health and Human
Services have set a Healthy People objective of increasing the proportion of infants
who are breastfed exclusively through the first six months of their lives from 14.6%
in 2008 to 25.5% in 20201. Raising the rate by nearly 11% can not only save money
in medical costs but it can also improve both mothers and childrens nutritional
status. It is estimated that the lives of 1,000 children and $13 billion a year could be
saved if 90% of babies in the US are exclusively breastfed for the first 6 months of
their lives2. Minority groups, a lack of education, and low-income mothers/families
are all factors associated with low exclusive breastfeeding rates. These risk factors
are evident in a large portion of Kern Countys population, making it a high priority
population of interest.3,4
Latinos are both the largest and fastest growing minority in the US,
comprising about 17% of the population6. In California, Latinos comprise 38.2% of
the population and in Kern County they comprise an even higher percentage.
Latinos and Hispanics comprise nearly 50% of the Kern County population and have
been shown to have a 22.5% lower exclusive breastfeeding rate in hospitals than
whites do5. Due to the high percentage of Latinos and Hispanics and the lower
exclusive breastfeeding rate among them, increasing the exclusive breastfeeding
rate among the Hispanic and Latino population in Kern county should be a
prominent public health concern.

According to 2012 data from the California Department of Public Healths

Maternal Child Adolescent Health department, Kern Countys exclusive
breastfeeding rate was 50.2% compared to Californias overall exclusive breast-
feeding rate of 62.6%.2,5 Hispanics in California showed a 56.2% exclusive breast-
feeding rate compared to the 45.6% in Kern County, which ranks 43rd /50 in
exclusive breast-feeding rates among counties 5. Due to the fact that Kern County
has one of the highest Hispanic and Latino populations and is among the lowest
ranking countries for exclusive breastfeeding rates, it should be of high priority for
public health interventions.
Breast-feeding can protect the health of both mother and infant. The
biological, immunological, and nutritional components of breast milk build a strong
foundation of lifelong health8. Human milk provides all the essential nutrient
requirements including water, vitamins, minerals, carbohydrates, proteins, fat,
digestive enzyme, and hormones for infants 6 months and younger which aids in
child development as well as providing immuno-protective support.6 Infants who
are breastfed have been shown to have lower rates of GI problems, lower risk of ear
infections, improved cognitive development, lower obesity risk, and lower
prevalence of type II diabetes.7 Breastfeeding provides many maternal benefits as
well. Not only does it typically shorten the time it takes mothers to return to their
pre-pregnancy weight, it also decreases maternal risk of ovarian and breast cancer,
type II diabetes, and postpartum depression.8,9 These health benefits demonstrate

the importance of increasing breastfeeding rates and educating mothers so they can
make informed decisions.
In addition to health benefits, breastfeeding also proves to have a number of
economic benefits. Commercial formula feeding has been shown to increase
healthcare spending by $331-$475 per never breastfed infant during the first year10.
Breastfeeding mothers and families have far fewer financial expenses than those
who opt for formula feedings. Not only do they save money on the supplemental
formulas themselves but they also save money on medical bills associated with the
improved health benefits of breastfeeding.

New mothers face many challenges when it comes to exclusively breast-

feeding. The likelihood of a mother to stick with exclusive breast-feeding for 6

months depends on factors that start during the first few hours after giving birth
and extend several months after.11 Many mothers are too exhausted from labor to
try breast-feeding right away so often times the hospital staff provide the mother
with formula rather than urging them to breast feed. Other inhibitory factors
include separating mother from child after birth, delaying the first feeding, and
failing to provide the proper skilled support11. Hospitals often provide
supplemental formulas regardless of whether or not the mother plans to breast-feed
their infant. Breast-feeding is a natural process but a mothers experience in the
hospital can dictate her ability to follow through with her decision to breast-feed
her baby.11
Even more challenges arise for low-income mothers, who make up a large
percentage of the Kern County.12 The low exclusive breastfeeding rates in Kern

County are likely related to the high percentage of residents living below the
poverty line. In 2011, 30.8% of the Latino and Hispanic population in Kern County
were living below the poverty line, about 126,545 people.6,12 Low socioeconomic
status may lead to inflexible work hours and busy schedules that make exclusive
breast-feeding extremely challenging. Low-income status can also result in lack of
maternity leave depending on the job situation as well as poor lactation
accommodations11,12. These mothers need programs, support, and resources to
overcome these barriers in order to increase breastfeeding rates.
The rate of babies breastfed at 6 months increased from 35% in 2000 to 49%
in 2010.13 Though weve seen increases in the prevalence of breast-feeding, less than
half of these mothers were still breast-feeding at 6 months indicating the need for
some sort of additional continual support3. The Kern County Breastfeeding
Coalition serves to promote, support, and protect breastfeeding through initiatives
like the Baby Friendly Hospital Initiative which promotes exclusive breastfeeding
while infants are in the hospital14. The annual California Breastfeeding Summit
gathers to address issues like workplace accommodation laws, hospital maternity
policies and practices, and how to bridge the gap between lactation services prior to
and post hospital experiences15,16. These programs are playing a part in the
combined effort necessary to reach the Healthy People 2020 objective, though
additional efforts need to be made.
Benefits of breastfeeding demonstrate the value of interventions that
promote the initiation, exclusivity, and duration of breastfeeding rates. Further

actions need to be made in order to effectively increase the exclusive breastfeeding

rates among Hispanics and Latinos in Kern County. Peer intervention programs
need to be acknowledged by public health programs as a means to improve
exclusive breastfeeding rates among the low-income Latino population.17
Research has indicated that less than half of maternity ward hospital staff
have received any sort of breastfeeding education during their formal or continued
education.8 In addition, the information they provide to patients regarding matters
of breastfeeding is often inaccurate, showing a need to bridge the education gap.
Public health officials should acknowledge peer intervention programs as a means
of improving exclusive breastfeeding rates among the low-income Latino
population. Therefore hospital staffs should be properly educated and trained on
breastfeeding and lactation related issues in order to provide the proper support to
their patients.
Previously conducted research has shown the effect of hospital staffs
knowledge and training on breastfeeding rates, but it has also shown the impact of
the mothers perceptions of prenatal physicians and hospital staffs attitude on
breastfeeding .13 Its been determined that a perceived neutral attitude toward
breastfeeding by medical staff members is associated with mothers who chose not
breastfeed beyond 6 weeks.13 Providing medical personnel with the proper
education may increase their awareness and a more positive attitude toward
breastfeeding which will come across to patients and play a role in their decision.
Education among maternity ward staff has showed a positive impact but at least 18
hours of education and training was proven to be most effective.14 The more

intensive and thorough the training among professionals the more effective as far as
increasing breastfeeding knowledge and skills among personnel and better
equipping maternity wards with a stronger breastfeeding support system.

Goals and Objectives:

The goal of this intervention is to increase the breastfeeding related

knowledge among hospital staff in order to provide better support for patients and
increase the prevalence of Hispanic and Latino women in Kern County who
exclusively breastfeed for 6 months.
The educational seminar will include medical Spanish language instruction, evaluate
the effectiveness of classroom learning, and will cover the following topics:

-Social, cultural, and physiological aspects of breastfeeding

-Health benefits to both mother and child
-Initiation of lactation
-Overcoming common barriers/problem related to breastfeeding
-Continual lactation support strategies
-Sources for further support

Methods:
-Educational seminar and training program:
The breastfeeding classroom training will be a total of 24 hours over a 2-
month span and will take place in a conference room at Kern County Medical center.
The staff will choose from two different schedule options in order to accommodate

their work and personal schedules. They will be given the choice of attending
either Wednesday or Saturday seminars from 12-3pm for 8 weeks. These lessons
will be given by a locally hired lactation consultant and shall cover the previously
stated criteria.
-Language Instruction:
Language instruction will total 12 hours and be provided to staff members by
a Spanish instructor from Bakersfield College. The instructor will accompany a
lactation consultant with whom they will collaborate to comprise a list of
breastfeeding terminology and phrases that will aid the staff. Pronunciation
exercises and classroom instruction will be the basis for participant training. These
Spanish lessons will follow weekly breastfeeding seminars and run from 3-4:30pm
on Wednesdays and Saturdays (staffs choice).

Participants:
My proposed intervention will focus on maternity ward staff members as
participants (nurses, nurse practitioners, nurse midwives, physician assistants, and
doctors) employed by Kern County Medical Center. Training will be required and
will take place from October 1st to November 31st of 2014.
Kern County Medical Center will make the training program mandatory for
relevant medical personnel and provide the location for the lactation seminars as
well as the resources needed like projectors, tables, desks, chairs, ect.

Evaluation:

-Summative: The lactation consultant and language instructor will observe and
monitor participants level of understanding and engagement throughout the
intervention in order to determine what types of improvements can be made in
order to make the program more successful in the future.
-Formative: Kern County Medical Center already tracks patients exclusive
breastfeeding rates so this data will be collected from previous years as well as the 2
year span following the newly implemented training program in order to determine
the success of the intervention on breastfeeding rates among Hispanic and Latino
women in Kern County. Hospital staff participants will be given a test both before
and after the seminar to assess their breastfeeding knowledge and bilingual
capabilities. The lactation consultant and language instructor will develop and
perform these breastfeeding tests to determine whether an improvement in staff
knowledge has taken place.
-Impact: By collecting these results, we will be able to determine whether the
intervention has increased the breastfeeding knowledge among maternity ward
staff members and, if it did, whether the increased knowledge of the staff led to an
increase in exclusive breastfeeding rates among Hispanic and Latino women in Kern
County.

Sustainability:
This knowledge can benefit the hospital staff and caregivers throughout their
entire careers, allowing them to help educate and counsel new mothers on
breastfeeding. It has the ability to empower new mothers in making and carrying

out the decision to exclusively breastfeed for the duration of 6 months. Increasing
the exclusive breastfeeding rates can help protect newborns from diseases and
health conditions as well as providing health benefits to the new mothers. The
knowledge and training attained by the participants of this intervention can
continue to be passed to new hospital staff during job training and can be used to
make improvements to future Healthy Start Toolkit programs in the future.
Community Participants:

Kern County Medical Center: The hospital is enthusiastic about the project

and has agreed to make the program a required part of training for its maternity
ward staff (including nurses, nurse practitioners, nurse midwives, physician
assistants, and doctors) The hospital offered the use of their on site conference
rooms and educational materials like tables, chairs, desks, projectors, and white
boards free of charge for the training sessions. The hospital agreed to provide us
with the results of the breastfeeding rates they continually track.

APPENDIX I--Budget Narrative
Direct Costs:
A. Salaries and wages
a. Project Director: $28/hr; 9hrs/week; 8 weeks/yr- Total= $2,016
b. Lactation Consultant: $40/hr; 9hrs/week; 8weeks/yr- Total= $2,880
c. Spanish Instructor: $35/hr; 3hrs/week (includes time outside of class
preparing lessons etc); 8weeks/yr- Total= $840
i.

Total= $5,736


B. Materials and Supplies
a. paper, notebooks, pens, pencils, printing pamphlets & instructional
materials
b. total= $350
C. Indirect Costs
a. hospital staff time (required part of training)
b. conference room and materials (donated by hospital)
D. Total Direct Costs (Items A and B): Total= $6,086
Total Direct Costs and Indirect Costs=$6,086


APPENDIX II- Time Frame
Task
Time to Complete
Contact Kern County
Medical Center and
Community College
Spanish departments
Conduct interviews and
hire the lactation
consultant and Spanish
instructor
Email/notify hospital staff
about the mandatory
training
Enroll staff in one of two
training schedules (staffs
choice)
Create PowerPoint
lectures, and classroom
activities
Obtain classroom
materials: pens, paper,
pencils, etc

3 months prior to

Personnel Responsible
Program director

intervention
2 months prior to

Program director

intervention
1 day

Program director

1 week

Program director

2 weeks

Lactation Consultant and

Spanish instructor

2 day

Program director,
Lactation consultant, and
Spanish instructor

Create pre and post

classroom intervention
tests

1 month prior to start of

Classroom training

2 months

intervention

Program director,
Lactation consultant, and
Spanish instructor

Lactation consultant and

Spanish instructor
Lactation consultant and
Spanish instructor
Program director

Pre/post classroom
2 days (1st and last day of
intervention tests
intervention)
Assess data and
1 week after the 1 year
evaluations
data collection period




References
1. Healthy People 2020 breastfeeding objectives. Healthy People Web site.
www.HealthyPeople.gov. (search MICH-21) Accessed April 11, 2014.

2. Breastfeeding report card - United States. Centers for Disease Control and
Prevention (CDC) Web site.
http://www.cdc.gov/breastfeeding/data/reportcard.htm. 2011. Accessed April 12,
2014.

3. Healthy People 2020 breastfeeding objectives. Healthy People Web site.
www.HealthyPeople.gov. (search Kern County) Accessed April 11, 2014.

4. Chapman DJ, Perez-Escamilla R. US national breastfeeding monitoring and
surveillance: current status and recommendations. J Hum Lact. 2009;25:13950.
Accessed April 13, 2014

5. AAP (American Academy of Pediatrics): Breastfeeding and the use of human milk:
policy statement.

6. Petrova A, Ayers C, Stechna S, Gerling JA, Mehta R. Effectiveness of exclusive
breastfeeding promotion in low-income mothers: a randomized controlled study.
Breastfeed Med. 2009;4:639. Accessed April 13, 2014

7. The Baby-Friendly Hospital Initiative guidelines and evaluation criteria for
facilities seeking Baby-Friendly Designation. Baby-Friendly USA Web site.
http://www.babyfriendlyusa.org/eng/docs/2010_Guidelines_Criteria_Rev%2011_2
8_11.pdf. 2010. Accessed April 12, 2014.

8. Forster DA, Mclachlan HL. Breastfeeding initiation and birth setting practices: a
review of the literature. J Midwifery Womens Health. 2007;52(3):273-280.

9. Apostolakis-kyrus K, Valentine C, Defranco E. Factors associated with
breastfeeding initiation in adolescent mothers. J Pediatr. 2013;163(5):1489-1494.

10. Myers JA. Improve breastfeeding rates by increasing health care providers
knowledge and attitude. Ky Nurse. 2013;61(1):5.

11. Vittoz JP, Labarere J, Castell M, Durand M, Pons JC. Effect of a training program
for maternity ward professionals on duration of breastfeeding. Birth.
2004;31(4):302-307.

12. Whaley SE, Koleilat M, Jiang L. WIC infant food package issuance data are a valid
measure of infant feeding practices. J Hum Lact. 2012;28(2):134-138.

13. Digirolamo AM, Grummer-strawn LM, Fein SB. Do perceived attitudes of
physicians and hospital staff affect breastfeeding decisions?. Birth. 2003;30(2):94-
100.

14. Ward KN, Byrne JP. A critical review of the impact of continuing breastfeeding
education provided to nurses and midwives. J Hum Lact. 2011;27(4):381-393.