Dakota County Public Health Department
Breastfeeding Friendly Health Departments
Dakota County and Minnesota population:
Dakota County, located in Minnesota, led the Breastfeeding Friendly Health Departments (BFHD) initiative. This effort was first implemented as a pilot in partnership with ten local health departments (LHD) representing urban, suburban, and rural populations of varying size. Now, the Minnesota Department of Health (MDH) has established a recognition program so additional health departments can reach designation as a BFHD. Dakota County is the third most populous county in Minnesota, with an estimated 405,088 residents. Of that population, an estimated 19% of residents are people of color. The county is part of the Minneapolis-St. Paul metropolitan region and maintains an equal land use mix of urban, suburban and rural.
Overview of the public health issue:
Research consistently shows that breastfeeding helps improve public health in a variety of ways. Health benefits are both immediate and lifelong for infants and mothers, and can even extend to the family unit. The economic saving potential from breastfeeding is large, making it an important preventive measure. Therefore, breastfeeding and optimal infant nutrition should be viewed as an important public health issue, and not just a lifestyle choice. Despite the many benefits, current research, and efforts by various groups, national and state breastfeeding rates remain low for initiation, duration, and exclusivity. The Minnesota Department of Health (MDH) states, â€¦if we are to extend breastfeeding duration and promote exclusivity in accordance with Healthy Minnesota 2020 goals, more needs to be done to provide a breastfeeding friendly environment outside of the hospitalâ€ (1).
Goals and objectives:
The goals of the Breastfeeding Friendly Health Departments project is to: Increase the capacity of metropolitan and rural health departments in Minnesota to promote breastfeeding in their communities. An additional goal of the pilot was to assess the usefulness of the Ten Steps, and that work was structured around twelve process objectives and ten outcome objectives, all of which were met. From the onset, this project included a strong partnership between Dakota County Public Health and the Minnesota Department of Health to assure the sustainability and usefulness of the BFHD Ten Step process.
Implementation and success:
The BFHD project was launched in 2012 with a needs assessment and implementation with pilot sites began in 2013. Each health department in the pilot designated a BFHD Champion, who worked towards implementing the Ten Steps over a six month period. Champions received five BFHD Tip Sheets to help with their work, were asked to participate in a webinar, and were given relevant resources, training and articles. Email communication and individual consultation was also provided to the Champions if requested.
The pilot effort was successful, with all ten LHDs reporting progress in building capacity to support and promote breastfeeding within their agency and community. This was measured by a self-appraisal at the initiation and conclusion of the pilot project. The process and success of the pilot was recognized as a Promising Practice by NACCHO in 2014.
Based on this success, the Minnesota Department of Health (MDH) established the process to designate LHDs as Breastfeeding Friendlyâ€. Local public health agencies and tribal health boards can now apply for recognition as a Breastfeeding Friendly Health Department at Bronze, Silver and Gold levels, depending on the number of steps met. To date, eleven health departments have been designated as Breastfeeding Friendly, with more currently pursuing designation.
Public health impact:
The BFHD initiative can positively impact public health in a few ways. The Centers for Disease Control (CDC) notes that, A woman's ability to initiate and sustain breastfeeding is influenced by a host of factors, including the community in which she livesâ€ (2). Providing clear steps for local health departments to follow can be used as a checklist to increase capacity within the community and achieve goals. By building capacity and infrastructure within LHDs, we can further ensure mothers and families are supported in the communities where they live, learn, work, and play. This is especially important for continuing the good work started after birth, in hospitals designated as Baby-Friendly. By wrapping mothers and families with supports at multiple touch-points, we can continue to promote and support breastfeeding and work towards the Healthy People 2020 breastfeeding goals. Increasing the percentage of women who breastfeed has immediate and lifelong positive impacts on the health of infants, mothers, families, and communities.
Dakota County Public Health website, search breastfeedingâ€: https://www.co.dakota.mn.us/
Minnesota Department of Health website: http://www.health.state.mn.us/divs/oshii/bf/healthdeptBFF.html
According to the Centers for Disease Control and Prevention (CDC), the protection, promotion and support of breastfeeding are critical public health needs. The public health community and breastfeeding advocates have been encouraged by successful breastfeeding promotion programs, policies, and system changes over the years. Many of these efforts have focused on hospital settings â€“ a key place for initiation. However, rates of breastfeeding remain below the Healthy People 2020 goals, locally and nationally. Healthy People 2020 has set targets for increasing both breastfeeding initiation and exclusivity; the target for breastfeeding initiation is 80 % and for exclusivity the target is 25.5%4. Minnesota has also chosen as a health indicator that by 2020 more Minnesota children are exclusively breastfed for six months (4).
The most recent Breastfeeding Report Card by the Centers for Disease Control (5) indicates that Minnesota is among a few states nationally who are meeting or exceeding the Healthy People 2020 breastfeeding goals. This very positive outcome results from the great work already accomplished in clinical and community settings to promote breastfeeding. However, there is still work to be done. Though the data shows high rates of initiation among Minnesotan mothers, this is not the case for exclusivity rates. Breastfeeding imparts the most benefit when women exclusively breastfeed their babies for at least six months, and continue through the first year. Also, rates remain low (for initiation and exclusivity) among certain populations within the state, including mothers involved in the Women, Infants and Children (WIC) program, African-American and Hispanic mothers, and mothers living in poverty. These disparities reflect a troubling trend nationally, but also an opportunity to build capacity at the local level to increase breastfeeding within these groups. Local health departments have a unique and important role to play in the promotion of breastfeeding for all women, and can be a key partner in the community for reaching specific groups.
The pilot period of the Breastfeeding Friendly Health Departments initiative involved ten local health departments (LHDs) of varying size and reach. Four of the LHDs (including the City of Bloomington Public Health) serve urban/suburban areas, and the remaining six LHDs serve rural counties. County populations ranged from 25,700 people (Lyon County) to 533,600 people (Ramsey County) (6). Dakota County, where this model was developed, is the third most populous county in the State of Minnesota. The size of the health department workforce ranges from six to 310 persons. The ten pilot sites were chosen through a convenience sample, specifically to represent a diverse mix of urban and rural counties with varying population needs. It is encouraging that success was seen across all ten of these LHDs.
What has been done:
The World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) started the Baby-Friendly Hospital Initiative (BFHI) in 1991. The program works within the hospital setting to encourage and increase breastfeeding. This is accomplished when hospitals implement, among other things, the Ten Steps to Successful Breastfeeding. Hospitals can be recognized as Baby-Friendly which indicates they provide a, â€¦comprehensive, detailed and thorough journey toward excellence in providing evidence-based, maternity care with the goal of achieving optimal infant feeding outcomes and mother/baby bondingâ€ (7). As of November, 2016, there are 388 hospitals and birthing centers in the U.S. designated as Baby-Friendly, including 11 in Minnesota.
In 2011, the Surgeon General released a Call to Action to Support Breastfeeding. In this report, communities are specifically discussed for their unique ability to either support or discourage breastfeeding. It also states that the various components of a community, including public health, â€¦can be crucial to a mother's success in breastfeedingâ€ (8). The Ten Steps for Breastfeeding Friendly Health Departments directly relate to the Action Steps outlined in this Call to Action report. Steps include supporting mothers through education and resources, building or strengthening community programs and policies, and training employers in the community on ways to support workplace lactation.
How BFHD is an improvement:
The Breastfeeding Friendly Health Department practice outlined here improves and expands upon previous breastfeeding friendly initiatives. The Ten Steps build a foundation of public health leadership in each community, to support and sustain breastfeeding. Although hospital practices that support breastfeeding are important, these practices alone are not sufficient for ensuring new mothers will breastfeed for the recommended six months (9). Research has shown that greater exposure to Baby Friendly practices would substantially increase the new mother's chance of breastfeeding beyond eight weeks (10). A common thread in the literature is the importance in establishing a network of partners that would work together in creative, innovative, and productive ways to protect, promote and support breastfeeding (11). Although a community-level approach to breastfeeding promotion is recognized in the literature, there is little reference to Breastfeeding Friendly Health Departments. Since implementation, the BFHD model and toolkit have been included in CDC communications (see resources section).
By building capacity among LHDs across the state, this model creates an important network of resources, leadership, and support for mothers in their community, after they leave the hospital setting. Working with local Champions also helps to establish a process to promote a positive breastfeeding culture within the health department, touching the various programs provided by the county or city. This creative approach to breastfeeding promotion utilizes proven practices, such as steps and a checklist, is guided by public health theory, and builds upon existing practices that have been successful in other non-public health settings (i.e. Breastfeeding Friendly Hospitals Initiative). An extensive toolkit has been created as a guide for LHDs, along with a clear application process and recognition program. These tools provide LHDs with the capacity to work towards a culture that supports breastfeeding, and the necessary resources to sustain positive changes.
Nutrition, Physical Activity, and Obesity
Collaboration with LHDs and stakeholders:
Local health departments across Minnesota played a key role in the development and implementation of this practice. Additional partners from the Minnesota Department of Health (MDH), the Minnesota Breastfeeding Coalition, and Dakota County WIC (Women, Infants, and Children) contributed to the collaborative nature of the program. A culture of teamwork and passionate participation from these partners was essential for success, and continues to provide a solid foundation as the program expands.
The pilot project for this practice was developed by Bonnie Brueshoff, Director of the Dakota County Public Health Department, to fulfill a requirement for a doctorate in nursing practice degree from the School of Nursing at the University of Minnesota. Brueshoff obtained institutional review board approval, conducted an extensive review of the literature, and designed the process based on Lippitt's phases of change approach. This theory suggests that the assessment, planning and implementing of change should involve those who are to be influenced by it.
The adoption of the BFHD model and recognition program by the Minnesota Department of Health (MDH) was done in collaboration with Dakota County, and included feedback from the pilot sites. The collaboration continues each year, as a committee made up of individuals from MDH, local public health, and the Minnesota Breastfeeding Coalition review applications for recognition as a BFHD. Health departments are then recognized during a state-wide community health conference, which further encourages this work to expand.
Goals and objectives:
The goal for the pilot project was to implement a quality and process improvement project Breastfeeding Friendly Health Departmentsâ€ (BFHD) to increase the capacity of local health departments to promote breastfeeding in communities. The established program works to build the capacity of local health departments and designate them as Breastfeeding Friendly. The objective of the toolkit for local health departments is to develop the capacity of local health departments to promote breastfeeding in communities through the implementation of the Breastfeeding Friendly Health Department Ten Step process.
The BFHD Ten Steps are:
1. Establish a designated individual or group to manage BFHD.
2. Have a written breastfeeding policy.
3. Coordinate support and promotion to establish breastfeeding as the normâ€ in the community.
4. Collaborate to assure access to breastfeeding classes.
5. Educate the community on breastfeeding support.
6. Encourage racially and ethnically diverse resources within the community.
7. Support mothers in initiating and maintaining breastfeeding for up to 12 months and beyond.
8. Encourage local public places to provide a breastfeeding friendly environment.
9. Select businesses each year and provide worksite lactation support training.
10. Facilitate access to information and training for childcare centers to support a breastfeeding mother.
Steps taken to implement the program:
At the start of the pilot project, a needs assessment of local health department staff indicated that the majority of respondents strongly agree that breastfeeding is a priority issue for the health department and that the BFHD process would increase the capacity of the health department to promote breastfeeding in the community. After this assessment, ten local health departments in Minnesota were recruited to join a six-month pilot of the process. Departments were chosen from a convenience sample during the Minnesota Breastfeeding Coalition annual conference, with special attention to a mix of urban, suburban, and rural sites. Each site identified a BFHD Champion from their staff. The use of champions in each LHD is based on the evidence that nursing champions are able to influence and implement evidence-based practices to advance positive patient, organizational and system outcomes (12).
Because the pilot project was so successful, in 2015 the Minnesota Department of Health (MDH) adopted the Ten Step process to designate additional health departments and tribal health boards in Minnesota as Breastfeeding Friendly. LHDs can complete some or all of the Ten Steps and apply for recognition at various levels â€“ The tiered approach recognizes that the process of changing organizational and community norms takes place over time:
? Bronze: demonstrated completion of Step One, Step Two, and any three additional steps, for a total of five steps
? Silver: demonstrated completion of the requirements for Bronze level recognition, plus completion of any two additional steps
? Gold: demonstrated completion of all Ten Steps
A Toolkit for Local Public Health and Community Partners was developed through leadership from Dakota County Public Health staff in 2014 to provide additional support and resources for LHDs pursuing recognition as a BFHD. This toolkit is distributed through the Dakota County and MDH websites and provides detailed evidence, steps, templates, and resources to encourage success in the application process. Clear checklists are also included to outline the path to success in each individual step.
Local health departments who are interested in becoming Breastfeeding Friendly can access materials, including the toolkit, on the MDH website. The application forms include checklists, and clearly outline ways to document and demonstrate ways the department has met each step. Applications are reviewed each August, and designation lasts five years. Departments can submit an application to renew or increase their status. After designation, the LDH receives a certificate and the BFHD logo to display and promote their status to partners and the public. Additional communication resources are also provided. An interactive map of Breastfeeding Friendly Health Departments is maintained on the MDH website, for use by partners and the public. All of the application tools and forms were creating by, or with, Dakota County and the pilot partners.
The resources for this project mainly consist of staff time, which is estimated to be a 0.2 FTE commitment. This includes time to complete the Ten Steps, apply for designation, evaluate outcomes, and maintain current information and resources. The initial pilot project provided staffing costs through Maternal and Child Health grant funds, WIC program funds, Statewide Health Improvement (SHIP) grant funds and/or county levy. The pilot project estimated the following total hours and pay for one BFHD Champion over six months, implementing each of the Ten Steps:
? 248 hours / six months
? $7,482.16 ($10,326.72 with benefits)
Outcome and evaluation:
All of the objectives for the initial pilot project were fully or partially met: the toolkit and expansion statewide are ongoing as additional LHDs pursue recognition as a BFHD.
1. By October 15, 2012 develop a draft of ten steps for BFHD.
2. On October 28, 2012 conduct needs assessment for BFHD.
3. By November 16, 2012 review and document needs assessment results, using information to recruit potential pilot sites.
4. By November 16, 2012 review feedback on proposed BFHD ten steps and make revisions.
5. By November 29, 2012 distribute recruitment letter to local health departments (LHDs).
6. By December 15, 2012 complete the selection of the 10 LHDs pilot sites for BFHD.
7. By January 5, 2013 initiate self-appraisal process with pilot sites.
8. By January 30, 2013 review and analyze pilot site self- appraisal results.
9. By February 15, 2013 provide BFHD overview and policy examples to pilot sites.
10. By March 31, 2013 distribute BFHD tool kit/resources for the 10 steps based on self-appraisal results.
11. By June 1, 2013 repeat self-appraisal process with pilot sites.
12. By July 1st, 2013, analyze the repeat self-appraisals and summarize results.
1. By June 1, 2013 increase the capacity of local health department to establish a designated individual/group to manage the BFHD tasks including policy review, development, staff orientation and education.
2. By June 1, 2013 increase the capacity of local health department to have a written breastfeeding policy that is routinely reviewed with department staff addressing all BFHD 10 steps.
3. By June 1, 2013 increase the capacity of local health department to coordinate breastfeeding support and promotion with other programs in the health department, private and public health care systems, and community organizations to establish breastfeeding as the normâ€ in the community.
4. By June 1, 2013 increase the capacity of local health department to collaborate with community partners to assure access to breastfeeding classes for prenatal women.
5. By June 1, 2013 increase the capacity of local health department to educate the community on breastfeeding support.
6. By June 1, 2013 increase the capacity of local health department to encourage racially and ethnically diverse resources within the community.
7. By June 1, 2013 increase the capacity of local health department to support mothers in initiating and maintaining breastfeeding up to 12 months and beyond.
8. By June 1, 2013 increase the capacity of local health department through community partners encourage local public places to provide a breastfeeding friendly environment for families.
9. By June 1, 2013 increase the capacity of local health department to select businesses each year and provide worksite lactation support training.
10. By June 1, 2013 increase the capacity of local health department to facilitate access to information and training for local childcare centers/providers/schools on how to support a breastfeeding mother.
The goals for the statewide recognition program, currently being implemented by MDH, and the Toolkit for Local Public Health are continuously in progress. The recognition program has been successful, as measured by the number of local health departments who have applied for designation as a BFHD. The statewide model and toolkit have been widely recognized and praised by organizations such as APHA, NACCHO, the CDC, and the Minnesota Breastfeeding Coalition. Joanne M. Wesley, Minnesota Breastfeeding Coalition 2016 Board Chair, said the Ten Step process was, â€¦well defined with evidence-Â-based rationale for implementationâ€ and praised the toolkit for creating awareness and assisting local health departments. Calondra D. Tibbs, Senior Advisor for NACCHO, noted the unique contributionâ€ of the toolkit to support local breastfeeding support.
The toolkit and Ten Step process have demonstrated success across diverse settings, including urban, suburban, and rural communities. A focus on culturally appropriate approaches is emphasized in Step Six (Encourage racially and ethnically diverse resources in the community), and the toolkit provides steps and templates to complete community assessments. All of this brings value and success to each LHD and the populations they serve.
Evaluation through appraisals:
Evaluation of the pilot project consisted of a self-appraisal survey, done by each BFHD Champion at the beginning and end of the six month period. The ten sites rated themselves based on progress with each of the Ten steps: yesâ€ for having a step completed, in progressâ€ if more activities for a step were underway, or noâ€ if a step had not been started. The analysis of the self-appraisals was completed comparing the responses of each site for each step using a scoring scale (2=yes; 1=in progress; 0=no) and determining the percentage of the increase.
Process objectives were tracked on a timeline, and were met or exceeded based on the specified target date. Only one process objective was partially met (#10): tip sheets and a webinar were delivered, but the toolkit was not developed and distributed until 2014. This was done so that recommendations from the pilot LHDs and MDH staff could be included. Outcome objectives were measured by self-report from the BFHD Champions. Each BFHD step had a score ranging between 0 and 2.0, and seven out of the ten steps showed statistically significant improvement.
In conclusion, the evaluation process showed widespread success for all of the pilot sites and all of the Ten Steps. The Champions found the resources useful and every participant reported that this project helped make progress in building capacity around breastfeeding within their agency. It is also noteworthy that the toolkit and model have been shared with other states, indicating the ability to transfer across local communities and states.
The sustainability of this project was secured through a partnership with the Minnesota Department of Health (MDH), who coordinates the recognition program statewide. Local health departments and tribal agencies can apply for Breastfeeding Friendly recognition through MDH. The MDH website also includes additional information about BFHD, the benefits of promoting breastfeeding in various settings, and links to the BFHD toolkit and resources. All of these things continue to grow the knowledge base and capacity of champions and local health departments.
Partnership with MDH also includes the successful funding of the Statewide Health Improvement Project (SHIP), which works through local health departments to influence policy, system, and environmental changes. SHIP funds work with LHDs across Minnesota to create, â€¦community-led improvements in healthy eating, physical activity, and reducing commercial tobacco useâ€ (13). One of the SHIP strategies requires LHDs to promote and support breastfeeding in child care, worksite and healthcare settings.
Sustainability is also built into the Ten Steps: one step requires the LHD to establish a breastfeeding friendly policy for their agency. The creation and adoption of such a policy provides a foundation, establishes leadership, and provides a commitment to the BFHD Ten Step process.
Finally, the model and successes have been shared as various State and National conferences, and staff will continue to share tools and resources as appropriate.
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