Planned community Change:

1. Planned community Change: Improving Breastfeeding RatesKent County, Michigan Ferris State University NURS 340 – Summer 2012 Sharon Herring, Amy Long-Nelson, Suzanne Schlacht

2. Demographics: Kent County, Michigan Kent County Statistics • The county covers 864 square miles • Grand Rapids is the urban center of the county • Health care: 5 health care centers, 6 public health clinics • 2010 Population of 602,622 • Fourth largest population center in Michigan - 51% Female - Median age: 34 years • Racial diversity: - 84% White - 10.3 % Black - 9.9% Hispanic or Latino - 2.5% Asian

3. Health Problem Kent County Health Problem • Mothers in Kent County are less likely to breastfeed • Kent County 22.7% • Michigan 33.2% • Higher rate of births in teens age 15-19 • Kent County teen birth rate 42/1000 females • Michigan teen birth rate 35/1000 females • Rate nearly 2x that of national benchmark 22/1000 • Higher rate of mothers with less than 12 years of education • 18.9% Kent County • 15.9% Michigan • African American and Hispanic females in Kent county are more likely to receive Medicaid and have no or inadequate prenatal care • Inadequate prenatal care: White = 9.6% , Black =19.8%, Hispanic = 17.9% • Over 40% of mothers participate in WIC during pregnancy • More than 79% of infants in the Kent County WIC program are exclusively bottle-fed • (MDCH, 2010), (MPHI, 2012), (United States Department of Agriculture, 2011, p.38)

4. Analysis of the Problem • Kent County Breastfeeding rates are low compared to Michigan and the United States • Healthy People 2020 Objectives for Breastfeeding: • Increase the proportion of infants breastfed • Ever : Target = 81.9% • Exclusively through 3 months: Target = 46.2% • Disparities in breastfeeding rates identified in 2011 Surgeon General report • Less likely to breastfeed: • Low Income family • Education status less than high school diploma • Maternal age less than 20 • African American (Healthy People.gov, 2012), (U.S. Department of Health and Human Services, 2011).

5. Problem Statement There is a low rate of breastfeeding among Kent County, Michigan mothers related to risk factors of individual health and environment as demonstrated by… • High rate of teen births • High rate of mothers with less than 12 years of education • Over 40% of mothers participate in the WIC program • Kent County has a higher rate of residents who are enrolled in Medicaid than the state of Michigan • Health care disparities exist in minority population groups resulting in no or inadequate prenatal care • 18% of African American infants born in Kent County are born to mothers who are age 15-19 years (MDCH, 2010)

6. Relevant Change Model: HBM What change model would be effective for increasing breastfeeding in Kent County? • The Health belief model states that health related behavior depends on 4 things: • The perceived severity of the possible illness or physical change • The level of perceived susceptibility • The benefits of taking preventive or protective action • What stands in the way of taking action toward the goal of the healthy behavior? (Harkness & DeMarco, 2012)

7. Community Change Models The Social Ecological Model • Ecological Model: All behavior which occurs in individuals is interdependent with their environment. • Health promotion is targeted at “intrapersonal, interpersonal, organization, community and public policy” (Pender, Murdaugh & Parsons, 2011, p. 72). • Socio-ecological Model: An expansion of the ecological model The model states an improvement of health promotion strategies occurs when multiple interventions are applied which utilize a combination of behavioral and environmental approaches. • Both environmental and individual factors contribute to behavior change (Pender, Murdaugh & Parsons, 2011)

8. Community Change Models The Social Marketing Model • The Social Marketing Model utilizes a set of marketing philosophies to promote an idea, product or behavior. • Current media promotes bottle feeding as a norm and contains many messages of negativity related to breastfeeding

9. Evidence based barriers to breastfeeding • Barriers to breastfeeding • Lack of knowledge • Social Norms • Poor Family and Social Support • Embarrassment • Lactation Problems • Employment and Child Care • Health Services • Special population groups in which breastfeeding is contradicted (U.S. Department of Health and Human Services, 2011).

10. Current Community Resources • La Leche League of Grand Rapids • Four monthly meetings are held to provide information, advice and support for breastfeeding. • 3 Hospitals in Kent County • Provide childbirth classes which include breastfeeding • Support groups with a certified lactation counselor • Kent County WIC • Provides breastfeeding education • Breast pumps are available (accessKent.com, 2012)

11. Potential Partnerships and Community Resources • Community High Schools • Area Colleges and Universities • Churches • Grand Rapids African American Health Institute (GRAAHI) • Community Clinics and Doctor’s offices • Community Workplaces and Childcare Centers

12. Relevant Evidence Based Practice:Primary Prevention • Social Marketing • Utilizes principles of commercial marketing to change behavior • Evidence based success in improving breastfeeding rates • Media campaigns by the National WIC Breastfeeding Promotion Program in 10 states • Demonstrated improvement in breastfeeding and support

13. Relevant Evidence Based Practice:Secondary Prevention • Reducing barriers to breastfeeding -Peer Counseling using the Loving Support™ Model -Workplace policies which facilitate breastfeeding • Prenatal counseling and education -Breast feeding benefits -Management of breastfeeding • Maternity care practices must support the behavior -Breastfeeding training course offered by WHO -Encourage hospitals which have in-patient maternity care to adopt the “Ten Steps to Successful Breastfeeding” -Continuity of support with Certified Lactation Consults (Office on Women’s Health, 2000)

14. Evidence Based Practice-Summary • Media and Social Marketing • Peer Support • Support for Breastfeeding in the Workplace • Educating Mothers • Maternity Care Practices • Professional Support (Centers for Disease Control and Prevention, 2009)

15. Evidence Based Practice:Kent County • Kent County mothers have multiple risk factors which evidence based data demonstrates a low rate of breastfeeding • These groups are targeted in evidence based intervention based strategies which have resulted in improvements in breast feeding rates • Current evidence based intervention strategies can be utilized to target at risk population groups in Kent County

16. Interventions: HOW The project goal is to improve breastfeeding rates in Kent County, evidence based data demonstrates improvements utilizing multiple intervention strategies. • Identified Community Strengths • WIC • Area Hospitals • Universities and colleges • Potential Resources • Churches • Additional community organizations: Salvation Army, GRAAHI • Area public schools • Radio stations, local food markets • Fund Raising Events • Mom to mom sales

17. Interventions: WHO Target population • Pregnant females in Kent County identified most at risk • Age under 20, less than high school education, receiving Medicaid or WIC services • Secondary targets: As a community intervention you want to change the community health in the future Fathers, family units Educate in high school as part of the nutrition and parenting classes Childcare centers and workplace environments • Leaders and Partners • WIC nurses • Community health care professionals • Community partnerships

18. Interventions: WHY • Health Benefits • Infant: • Lower incidence of illnesses and infections including diarrhea, respiratory infections, otitis media and pneumonia • Evidence supports babies who are breastfed for 6 months are less likely to be obese • Less likely to have asthma or insulin dependent diabetes • Reduction in Sudden Infant Death Syndrome (SIDS) • Mother: • Decreased incidence of breast and ovarian cancer • Earlier return to pre-pregnancy weight • Lower risk for postpartum depression • Cost Benefits • Less cost related to medical care and purchasing formula (Office of the Surgeon General, 2011)

19. Interventions: WHAT • Breastfeeding promotion program for Kent County 1. Media Campaign: pamphlets, posters, tv, radio, social media Promote breastfeeding as a norm Promote education programs, access to information 2. Education : Multidimensional approach Mothers and fathers Health-care professionals Nutrition and parenting classes Workplaces 3. Support Identify at risk mothers early via emergency department collaboration Increase Community Peer to Peer Support Persons

20. Interventions: WHERE • Kent County Health Department Health Care Clinics • Area Hospital’s Birthing Centers • Kent County Emergency Rooms • Kent County OB and General Practitioner offices • Kent County Churches • Kent County High Schools and Alternative Education • Mom to Mom sales

21. Interventions: WHEN Components of strategic planning process • Assess: Identify needs, Identify community strengths and potential resources. • Foster community partnerships: Identify community stakeholders • Facilitate a planning workshop and develop a plan: Within 30 days • Develop a plan: Identify leaders and resources, develop Gannt charts, Review strategies and roles (monthly) • Implement the plan: Implementation target for 6 months after plan development. • Evaluate implementation: Regular on-going evaluations (90 days) • Review the plan: Evaluate data, review and update the plan components (6 months) (Thompson, Fawcett & Shultz, 2008)

22. Evaluation: Desired Outcomes • Increase the rate of mothers who initiate breastfeeding • Improved maternal knowledge of breastfeeding health benefits in high risk population groups • Improved knowledge of best breastfeeding practices healthcare personnel who care for mothers and infants. • Increase the number and knowledge of support persons available to mothers who plan to breast feed • Increase the percentage of mothers who receive early prenatal care • Identify mothers who are eligible for WIC and Medicaid early in pregnancy • Mothers will verbalize an improvement in barriers related to: • Workplace • Childcare

23. Evaluation: Time Frame • At risk mothers in Kent County will demonstrate a 20% improvement in breastfeeding rates within one year of initiation. • Evaluation 6 months after implementation will reveal an improvement in knowledge of breastfeeding in healthcare personnel • All birthing classes will provide breastfeeding education and resources within 3 months of program implementation. • Community stores will demonstrate a reduction in infant formula sales within one year of implementation. • There will be an increase in the number of employers that have worksite lactation support programs in Kent County within one year of implementation.

24. Evaluation: Method • Through Michigan Report Card 2020 Kent County will have an increase in the breastfeeding rates. • There will be an increase in the number of employers who offer breastfeeding rooms for moms in Kent County by 2020. • There will be increased number of competent healthcare professionals in Kent County by 2020.

25. Conclusion • In Kent County it is an important role and responsibility of clinicians, employers, communities, and government leaders to take on a commitment to enable mothers to meet their personal goals for breastfeeding. • In doing this we can increase the rates of breastfeeding for Kent County.

26. References • Centers for Disease Control and Prevention [CDC]. (2009). CDC Breastfeeding Guide to Interventions. Author. Retrieved from http://www.cdc.gov/breastfeeding/pdf/BF_guide_4.pdf • Department of Health and Human Services, Office on Women’s Health. (2000). HHS Blueprint for Action on Breastfeeding. Author. Retrieved from http://womenshealth.gov/breastfeeding/government-in-action/hhs-blueprints-and-policy-statements/ • Grand Rapids African American Health Institute [GRAAHI]. (2012). Strong Beginnings. (Author). Retrieved from http://www.graahi.org/Advocacy/StrongBeginnings.aspx • Healthy People 2020. (2012). Maternal, infant and child health. U. S. Department of Health and Human Services. Washington, DC. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx • Michigan Department of Community Health [MDCH]. (2010). Natality 2010. Author. Retrieved from http://www.mdch.state.mi.us/pha/osr/chi/births/frame.html • Michigan Department of Community Health [MDCH]. (2011). Breastfeeding initiation and three months exclusive duration, MI PRAMS 2004-2008.MI PRAMS Delivery,10 (1), (pp.1-4). Retrieved from http://www.michigan.gov/documents/mdch/PRAMS_Newsletter_January_2011_Final_358253_7.pdf

27. References • Michigan Public Health Institute [MPHI]. (2012). Kent County 2011 community health needs assessment and health profile (pp. 1-64). Published by Saint Mary’s Health Care, Grand Rapids, Michigan. Retrieved from http://www.mercyhealthsaintmarys.com/documents/GrandRapids/KentCoCHNA_Final(Website).pdf • Pender, N. J., Murdaugh, C. L. & Parsons, M. A. (2011). Health Promotion in Nursing Practice (6th ed.). Upper Saddle River, NJ: Prentice-Hall. • Shealy KR, Li R, Benton-Davis S, Grummer-Strawn LM.(2005) The CDC Guide to Breastfeeding Interventions. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention,. • Social Marketing Institute. (2012). National WIC Breastfeeding Promotion Project. Retrieved from http://www.social-marketing.org/success/cs-nationalwic.html • Thompson, J., Fawcett, S., Schultz, J. (2008). Differential effects of strategic planning on community change in two urban neighborhood coalitions. American Journal Community Psychology, 42;25 (38) DOI:10.1007/s10464-008-9188-6

28. References • United States Census Bureau. (2012). State and county quick facts. Author. Retrieved from http://quickfacts.census.gov/qfd/states/26/26081.html • US Department of Health and Human Services, Office of the Surgeon General. (2011). The surgeon general’s call to action to support breastfeeding. Author. Retrieved from http://www.surgeongeneral.gov/library/calls/breastfeeding/calltoactiontosupportbreastfeeding.pdf#page=67 • Department of Health and Human Services CDC. (2011). Breastfeeding Report Card –– United States, 2011. In CDC. Retrieved July 1, 2012, from http://www.cdc.gov/breastfeeding/pdf/2011BreastfeedingReportCard.pdf • United States Breastfeeding Committee. (2012). Breastfeeding Objectives. In Healthy People 2020. Retrieved July 20, 2012, from http://www.usbreastfeeding.org/LegislationPolicy/FederalPolicies/HealthyPeople2020BreastfeedingObjectives/tabid/120/Default