Please complete the highlighted sections in the signature paper.

Running head: Signature assignment: Breastfeeding Promotion 1

Signature assignment: Breastfeeding Promotion 9

Signature Assignment: Breastfeeding Promotion

National University

(NEED TABLE OF CONTENTS)

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Introduction & Needs Assessment

Breastfeeding is an important element for the growth and development of a child. It provides unmatched health benefits for babies. Because breast milk is uniquely tailored to meet the health needs of a growing baby, it is considered the clinical gold standard for infant feeding and nutrition. According to United States Department of Health and Human Services, when you breastfeed a baby, you have given that baby a healthy start to life which can last for lifetime (US DHHS, 2019). Some of the additional benefits of breastfeeding are for mothers and include lowering a mother’s risk of high blood pressure, type 2 diabetes, ovarian cancer and breast cancer.

Public Health Problem

The benefits of breast feeding to infants, children and mothers have been extensively reported. Both the American Academy of Pediatrics and the Centers for Disease Control and Prevention recommend infants are exclusively breastfed for about the first 6 months with continued breastfeeding while introducing complementary foods for at least 1 year (CDC, 2020). In spite of the benefits of breastfeeding to both the infant and mother, 2 out of 3 mothers fail to follow the guidelines. This rate that has not improved in 2 decades. Infants who receive formula feedings are at higher risk for: acute otitis media (ear infections), asthma, diabetes (type 1 and 2), eczema, lower respiratory tract infections, obesity and infections in the digestive tract. Some studies suggest that just one formula feeding can change a baby’s normal intestinal bacteria. Breast feeding also lowers an infant’s risk of Sudden Infant Death Syndrome (SIDS.). CDC reports that low rates of breastfeeding add more than $3 billion a year to medical costs for the mother and child in the United States.

Target Population

The target population is expecting and new mothers ages 20-29 living in San Diego county who plan to return to work within 6 months of delivery.

Program Planning Model

The PRECEDE-PROCEED model was selected because it is very robust with hundreds of published papers citing evidence of its usefulness in improving health outcomes.

Relevant Primary Data Source

Key informant interviews were completed with breastfeeding experts. The first expert, Karen Berlin, is an RN-C from the Neonatal Intensive Care Unit (NICU) at Santa Barbara Cottage Hospital in Santa Barbara, California. Her NICU is a Level 3 NICU, capable of providing the highest level of care for premature and critically ill newborns. Santa Barbara Cottage Hospital has achieved Magnet status. The hospital is a Baby Friendly accredited facility, as well. Ms. Berlin has worked as a full-time RN-C for 19 years. In addition to providing care to newborns, she provides lactation consulting services to mothers that come to spend time with their babies in the NICU. Ms. Berlin believes that low rates of breastfeeding is a major health issues in her community. She sees young, low-income mothers impacted the most. These mothers need more education about how to breastfeed, along with emotional and financial support. She expressed a desire to see more areas for mothers to comfortably and privately breastfeed when they go out because many women are reluctant to openly breastfeed in public.

(Need 2-3 more paragraphs summarizing your key informant interviews)

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Relevant Secondary Data

(Need relevant secondary data, include race/ethnicity, statistics about the occurance of illness/death breastfeeding has been shown to reduce).

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Needs Assessment

Pregnant women and new mothers are eager to learn about breast feeding, as evidenced by the multi-billion dollar breastfeeding accessory market in the United States. Be that as it may, breastfeeding initiation and establishment are not as easy as anticipated for a significant percentage of women. According to the CDC, in 2017, only 58.3% of 6 month old babies and only 35.3% of 12 month of babies were breastfed. There are numerous risk factors for breastfeeding problems. The more risk factors present, the greater likelihood breastfeeding problems will arise. It’s important to recognize these risk factors because once they’re identified, interventions can be initiated to promote successful breastfeeding. Risk factors for potential breastfeeding problems are divided into 3 categories: genetic/biological risk factors, behavioral risk factors, and environmental risk factors.

Genetic/Biological Risk Factors

Genetic and Biological risk factors are not as easy to modify and in some rare situations, they can make it impossible for a mother to breastfeed. The majority of the conditions in this group cause the mother’s milk production to be very low. They can also lead to pain for the mother. The identified genetic/biologic risk factors are:

· Advanced maternal age (35 years and older)

· A history of breast surgery (reduction/augmentation)

· Maternal health problems such as breast cancer and treatment, HIV, active tuberculosis, depression, endocrine disorder (thyroid, diabetes) hypertension, obesity, malnutrition, infections in pregnancy (taxoplasmosis, hepatitis, varicella, parvovirus, rubella, cytomegalovirus, herpes simplex, syphilis) and anemia prior to or after delivery

· Congenital breast anomalies (tuberous breasts, inverted or flat nipples)

· Infertility and subsequent intervention/treatment

· Pain management during labor such as epidural and other medications

· Structural anomalies with the infant’s mouth (cleft lip or cleft palate)

· Multiple births

Behavioral Risk Factors

Many behavioral risk factors can be easier to modify. For example, if a mother isn’t eating enough calories or drinking enough water, improving her nutrition and hydration can lead to better supply of breast milk.

· Poor nutrition or hydration

· Late or lack of prenatal care

· Lack of attendance at a prenatal breastfeeding class

· Substance use or abuse, including tobacco and alcohol

· Plan to return to work within 6 months postpartum

Environmental Risk Factors

Environmental risk factors can cause mothers to prematurely discontinue breastfeeding. Providing a safe and supportive environment for mothers and their children is the first step to correcting these. Environmental risk factors include:

· Minimal social support

· Interpersonal violence or other home stressors

· Unsupportive work policies and lack of parental leave

· Unsupportive hospital practices and policies

The extensive list of risk factors, many of which cannot be altered or easily altered by the mother, helps explain why breastfeeding rates are below the current recommendations. In fact, sixty percent of mothers do not breastfeed for as long as they intend to. Despite the fact that a few risk factors, such as HIV infection, will make it impossible for a woman to breastfeed, the majority of risk factors can be addressed. When appropriate interventions are made, nearly all mothers can successfully breastfeed.

Conclusion/Program Focus

Risks factors tend to occur at higher rates in younger mothers aged 20-29. This may explain why younger mothers are less likely to breastfeed than mothers aged 30 years and older (CDC). Women who made the decision not to breastfeed or to discontinue breastfeeding prematurely reported the reason for the decision largely fell into 3 categories: (1) lack of information about infant nutritional benefits and maternal benefits (2) lack of knowledge or skill to breastfeed (appropriate positioning, latching, etc…), (3) lack of personal and professional support.

The program will focus on providing services to mothers 29 and younger who plan to return to work within 6 months of delivery. Program services will primarily focus on educating expecting and new mothers about the infant nutritional benefits and maternal benefits of breastfeeding, as well as teaching how to breastfeed. The program will also provide direct support to new mothers in the hospital (checking positioning, attachment, suckling, providing positive encouragement and reassurance, helping mothers with common breastfeeding issues). In addition, the program will provide emotional and social support for mothers through a support group, led by a breastfeeding expert, where mothers can ask questions about breastfeeding as well as enjoy the friendship and support of other moms. A secondary focus of the program will be to provide referrals for mothers in need of financial or nutritional assistance. Lastly, because most women 20-29 who have a baby will return to the workplace within 6 months, and only 51% of employers have worksite lactation support programs, according to the Society for Human Resource Management, the program will focus on teaching mothers’ their rights with respect to expressing breastmilk at work, and how to be effective self-advocates for their right to do so. The program will be known as Best Start for Mothers and Infants Breastfeeding Support Program. It will be implemented at the Sharp Mary Birch Hospital for Women and Newborns in San Diego, California.

Program Planning

Goal Statement

Participants will show increased rates of initiation, duration and exclusivity of breastfeeding as a result of receiving services and support through the Best Start for Mothers and Infants Breastfeeding Support Program.

Process Objectives:

· Prior to program implementation, program planners will request authorization from the executives at Sharp Mary Birch Hospital for Women and Infants to implement the program.

· During program pilot testing, the program facilitators will receive a “good” rating or better from 75% of the participants.

· Prior to the start of the program, the program staff will deliver all program materials, including the breastfeeding organizer/journal, to all people who registered for the program.

Activities & Strategies for Reaching Process Objectives

Prior to the start of the program, planners will ensure that adequate resources are available, including personnel, time and money. Permission will be obtained from all necessary individuals. After that, a group of volunteers will be recruited to field test the program and will rate their experiences and attitudes towards the program. Changes may be made to reflect feedback and lessons learned during the field test. Then program staff will begin to deliver all program materials to all of the people who registered for the program.

Impact Objective: Learning Objective

Objectives fall into 3 categories:

Knowledge Objectives

· When classes are completed, 100% of participants will gain knowledge about the infant nutritional benefits of breastfeeding, as evidenced by a passing score on an exit-test.

· When classes are completed, 100% of participants will gain knowledge about the maternal health benefits of breastfeeding, as evidenced by a passing score on an exit-test.

· When classes are completed, 100% of participants will gain knowledge about common breastfeeding issues, including engorgement, cracked or sore nipples, and mastitis, as evidenced by a passing score on an exit-test.

· When classes are completed, 100% of participants will gain knowledge about some common risk factors for breastfeeding problems and what should be done, as evidenced by a passing score on an exit-test.

· When classes are completed, 100% of participants will be able to summarize their rights under the Patient Protection and Affordable Care Act, that requires most employers, with few exceptions, to offer a breastfeeding employee reasonable break times to pump for up to 1 year after her baby is born and a place other than a bathroom to comfortably, safely, and privately express breastmilk.

· When classes are completed, 100% of participants will be able to summarize the programs that provide financial and nutritional assistance for low income.

Attitude Objectives

· When classes are completed, 100% of participants will begin to develop a positive attitude with regard to breastfeeding and will be able to defend their personal reasons for breastfeeding.

· When classes are completed, 100% of participants will begin to develop a positive attitude with regard to requesting accommodations to express breastmilk at work and be able to do so in a simulated role-play activity.

Skill Development Objectives

· When classes are completed, 100% of participants will demonstrate skills to successfully breastfeed their baby, including how to hold baby while breastfeeding, getting baby to latch, and when to breastfeed, using a training manikin/doll.

Activities & Strategies for Reaching Learning Objectives

Participants will attend 3 classes. A pre-test will be given to determine participants current level of knowledge. Objectives will be shared with participants. In each class there will be presentations, discussions and Q&A session. Guest speakers will attend. A pediatrician will cover the benefits of breastfeeding for infants. An OB-GYN will cover the benefits of breastfeeding for the mother, as well as risk factors for breastfeeding problems. A lactation consultant will teach the class how to breastfeed and what to do if a common problem is experienced. A human resource specialist will give a presentation about mother’s rights when they return to work. Mothers who successfully continued to breastfeed after returning to the work-place will also be guest speakers, to share their inspirational breastfeeding experience stories. A social worker will give a presentation and answer any questions about financial and nutritional aid available. The program facilitator will encourage participants to ask questions and elicit feedback.

Impact Objective: Behavioral Objective

· After completing courses, 100% of those who participate will drink an optimal amount of water per day, 90% of the time, to remain well hydrated, healthy and to maintain good levels of milk supply after delivery. (“Optimal” is an individualized number and will be calculated in class.)

· After completing courses, 100% those who participate in the program will consume an optimal amount of calories per day, 90% of the time, to remain well-nourished and maintain good levels of milk supply after delivery. (“Optimal” is an individualized number that will be calculated in class.)

· After completing courses, 100% of those who participate in the program will take a pre-natal vitamin daily, 90% of the time.

· After completing courses, 100% of those who participate in the program will adhere to putting baby to breast or to pumping breastmilk at least every 3 hours to maintain good levels of milk supply.

· After completing courses, 100% of those who participate in the program will engage in a stress-reduction activity lasting a minimum of 30 minutes, 6 out of 7 days per week.

Activities & Strategies for Reaching Behavioral Objectives

After registering for the program, participants will receive a pregnancy organizer/journal. The journal will contain the main points covered in the classes about nutrition, health benefits, and how to breastfeed. It will contain formulas to determine their optimal individual caloric and fluid needs. Class facilitator will ensure that each participant has correctly calculated their needs based on the provided formulas. It will also contain a place to record what they eat to ensure they’re meeting their caloric needs to develop an adequate milk supply. It will contain a place to record their fluid intake, to ensure they’re remaining hydrated, a check-box for daily prenatal vitamins, and a place to record what they’re doing every day to take care of themselves/reduce stress. The organizer/journal is intended to be useful and motivational. When classes begin, participants will learn how to fill them out and be encouraged to self-track progress on goals.

Impact Objective: Environmental Objectives

· Following completion of the classes, 90% of those who participate in the program will attend one at least 1 support group meeting.

Activities and Strategies for Reaching Environmental Objectives

The program will provide emotional and social support for mothers through a support group. The group will be held in person once per week. In addition, a virtual support group meeting will also be held every week, for those who prefer virtual. A lactation consultant will facilitate the meeting. Mother’s will be encouraged to share what they’ve struggled with and what they have learned. Mothers can also ask questions about breastfeeding as well as enjoy the friendship and support of other moms in the group.

Outcome Objectives

The outcome objectives represent a 10% increase from current rates in the general population.

· 94.1% of those who participate in the program will initiate breastfeeding.

· 56.9% of those who participate in the program will breastfeed their baby exclusively through 3 months.

· 68.3% of those who participate in the program will breastfeed their baby at 6 months.

· 35.6% of those who participate in the program will breastfeed their baby exclusively through 6 months.

· 45.3% of those who participate in the program will breastfeed for 1 year.

Health Promotion/Education Materials

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Marketing

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Timeline

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Program Evaluation

Process Activities

A Gnatt chart will be used to measure the extent to which the program was delivered as planned. Attendance records will be kept for all classes and support group meetings. Those who participate in the program will be asked how they were referred to the program to determine if the program’s recruitment was adequate, and how it can be improved. Surveys will be sent via email to a representative sample of the priority population to determine if the reach of the program was adequate. Attendance records will be compared to findings on the programs reach to arrive at a conclusion about the program’s response. Lastly, a focus group will convene discuss findings on the program’s fidelity, dose, recruitment, reach and response. The group will be tasked with uncovering context, or the presence of any confounding factors, or naturally occurring events in the same environment that may affect program participation and results.

Process Measure/Data

(Need)

Impact Learning Objective Activities & Data

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Impact Behavioral Objective Activities & Data

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Impact Environmental Objective Activities & Data

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Outcome Design

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Outcome Measure/Data

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Reporting

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Reference

1). US DHHS (2019), Making the decision to breastfeed. Retrieved from https://www.womenshealth.gov/breastfeeding/making-decision-breastfeed

2). CDC (2020), breastfeeding. Retrieved from https://www.cdc.gov/breastfeeding/about-breastfeeding/index.html

3). country health ranking & roadmaps (2018), Breastfeeding promotion programs

4). Kenny, L. A. (2019). A needs assessment for breastfeeding students in higher education in the state of kansas (Order No. 27666750). Available from ProQuest One Academic. (2389213391). Retrieved from https://nuls.idm.oclc.org/login?url=https://www-proquest-com.nuls.idm.oclc.org/dissertations-theses/needs-assessment-breastfeeding-students-higher/docview/2389213391/se-2?accountid=25320

5). UNICEF. (2018). Infant and young child feeding. Retrieved from http://web.archive.org/web/20190515201253/https://data.unicef.org/topic/nutrition/infant-and-young-child-feeding/

5). Hassan, A. A., Taha, Z., Ahmed, M. A. A., Ali, A. A. A., & Adam, I. (2018). Assessment of initiation of breastfeeding practice in kassala, eastern sudan: A community-based study. International Breastfeeding Journal, 13 doi:http://dx.doi.org.nuls.idm.oclc.org/10.1186/s13006-018-0177-6

6). Stuebe, A. (2009). The risks of not breastfeeding for mothers and infants. Reviews in Obstetrics and Gynecology, 2(4), 222–231.

7). Girard, G. (2018). Breastfeeding and externalising problems: a quasi-experimental design with a national cohort. European Child & Adolescent Psychiatry, 27(7), 877–884. https://doi.org/10.1007/s00787-017-1085-9

8). Park, S., Kim, B., Kim, J., Shin, M., Yoo, H. J., & Cho, S. (2014). Protective effect of breastfeeding with regard to children's behavioral and cognitive problems. Nutrition Journal, 13 doi:http://dx.doi.org.nuls.idm.oclc.org/10.1186/1475-2891-13-111

9). Schwarze, C. E., Hellhammer, D. H., Stroehle, V., Lieb, K., & Mobascher, A. (2015). Lack of breastfeeding: A potential risk factor in the multifactorial genesis of borderline personality disorder and impaired maternal bonding. Journal of Personality Disorders, 29(5), 610-626. doi:http://dx.doi.org.nuls.idm.oclc.org/101521pedi201428160

10). Dorea, J. G. (2007). Maternal smoking and infant feeding: Breastfeeding is better and safer. Maternal and Child Health Journal, 11(3), 287-91. doi:http://dx.doi.org.nuls.idm.oclc.org/10.1007/s10995-006-0172-1

11). Mennella JA, Yourshaw LM, Morgan LK. Breastfeeding and smoking: short-term effects on infant feeding and sleep. Pediatrics. 2007 Sep;120(3):497-502.

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