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Moms Helping Moms Breastfeed – Peer Mentoring Program

State: MI Type: Model Practice Year: 2018

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Kent County Health Department
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Moms Helping Moms Breastfeed – Peer Mentoring Program
The Kent County Health Department (KCHD, accesskent.com/Health/health_department) serves more than 629,000 residents including 193,000 residents of the principal urban center the city of Grand Rapids. Kent County's population is approximately 83% white, 10% African American, and 10% Hispanic/Latino. A marked disparity in BF initiation and duration rates persists between whites and persons of color, especially African Americans. Breastfeeding initiation and duration data is not readily available at the population level but data from KCHD's largest home visiting (HV) program, the Maternal Infant Health program (3,944 clients, 27% African American, 49% White), for the five-year period 2009-14, indicates a BF initiation rate for Whites of 75% and 64% for African Americans. Among HV clients residing in the Grand Rapids' core city census tracts, the White initiation rate was 79% compared to 53% for African Americans. In 2016, KCHD initiated the Moms Helping Moms Breastfeed (MHMB) peer mentor program to address this BF disparity. The MHMB program had the following goals and objectives: 1. Address the historical, societal and social barriers that exist in BF support and success for African Americans. 2. Provide training and weekly support to 6 BF peer mentors, who will mentor at least 30 BF mentees by September 30, 2017. 3. By January 31, 2017, develop an improved referral policy to increase participation in the MHMB peer mentor program and the H.U.G.S. African American BF support group by KCHD WIC and HV program clients. 4. By September 30, 2017, at least 10 referred KCHD WIC clients will visit H.U.G.S. at least once. 5. By September 30, 2017, increase by 100% the average weekly participation in H.U.G.S breast-feeding support group. 6. Increase African American BF initiation rates by 15% and 3 and 6-month duration rates by 25% among WIC and MIHP clients who attend H.U.G.S. MHMB mentors and mentees were recruited through HV programs, H.U.G.S., and contacts of the MHMB coordinator and program mentors. Mentors received gift cards for every three completed encounters with mentees. Mentees were incentivized with BF pillows and other items to assist them in their BF experience. At least one of each three mentor-mentee encounters had to be a face-to-face interaction. Phone and text exchanges were the most common communication method among mentors and mentees. Mentors and mentees also had the opportunity to meet weekly at the H.U.G.S. BF support group. At the outset of the program, mentors participated in a one-day Breastfeeding from an African American Perspective training. In addition to training the mentors and maintaining regular communication, the MHMB coordinator also facilitated the H.U.G.S. meetings. The coordinator is a Certified Lactation Consultant with four breastfed children. Her presence at H.U.G.S. also provided an opportunity to share her knowledge and experience of BF with MHMB participants. Monitoring of program activities and achievement of outcomes was achieved by weekly documentation of mentor-mentee encounters. The encounter forms were provided through Survey Monkey or paper forms to accommodate mentors' preferences. Each week mentors were asked to provide data on number of encounters, issues discussed with mentees, BF barriers and successes, and BF milestones reached. Additional program data was gathered through the Intake/Discharge Form, an exit survey and focus group. The MHMB program met its participation goal by training 8 mentors, who in turn enrolled and assisted a total of 35 mentees. To increase referrals from the WIC clinics to the MHMB program and H.U.G.S., the only African American WIC Breastfeeding Peer Counselor was placed at the WIC clinic with the highest enrollment of African American clients. The Peer Counselor's outreach resulted in 9 successful referrals to MHMB and H.U.G.S., which was one referral short of the program objective. The presence of mentors and mentees at H.U.G.S. meetings increased previous H.U.G.S. participation by more than 100%. It was not possible to measure the MHMB program's impact in increasing BF initiation since all women involved in MHMB initiated BF; some, but likely not all, participants would have initiated BF without this assistance. Among all MHMB participants, 22% were BF partially at 3 months post-initiation and 15% at 6 months. Thirty-eight percent of participants breastfed exclusively for at least 3 months and 25% for at least 6 months. Data also was not available at the time of this model practice application to compare program outcomes with the percentage of African American WIC clients who initiated BF during the project evaluation period. From the program surveys and focus groups it was very commonly expressed that mentor encouragement and education was instrumental in mentees' successful BF experiences and BF duration/exclusivity.
It is commonly accepted that BF confers many benefits to mothers and infants, including: providing ideal nutrition for infants, benefits of colostrum in fighting off infections immediately after birth, reduced serious health risks in mothers such as Type 2 diabetes, breast cancer and ovarian cancer, building a stronger mother-infant emotional bond, and helping to stave off postpartum depression. Unfortunately, these benefits are not shared equally by all mothers as BF is a less common practice among certain racial/ethnic minorities including African Americans. The target population for this intervention was African American women enrolled in the KCHD WIC program or participating in a home visiting program in Greater Grand Rapids. Program flyers were distributed to WIC clinic supervisors and supervisors and staff of the two largest home visiting programs with KCHD involvement: The Maternal Infant Health Program, a state of Michigan program for Medicaid recipients, and Strong Beginnings, a federal Healthy Start program that utilizes community health workers. Since the MHMB program was dependent on volunteer mentors and many potential mentees were already receiving some form of BF promotion through WIC or a home visiting program, it was not expected that most eligible women would be interested in participating in MHMB. The program goal was to enroll 30 women who wished to increase the likelihood of a successful BF experience through a mentor relationship. During the 11-month implementation period, 35 mentees were enrolled and mentored by 8 volunteers. Mentors were African American women with a minimum of 6 months of successful BF. One of the important premises of this peer mentor program is that someone from your racial and socioeconomic background has an enhanced ability to coach your BF experience. In developing the Breastfeeding from an African American Perspective training, the presenters found historical and current indications that many or most African American women are not encouraged in their BF experience by their significant family members and friends. In fact, many African American women are discouraged from BF as this can still be viewed as a remnant from a time when slaves would only breastfeed the slave holder's children, or it is viewed a practice of the poor. While WIC and home visiting programs routinely provide BF education, this education is only one of a series of several maternal-child health topics discussed with clients. Furthermore, few home visiting clients receive the services of an African American peer, who is much more likely to understand and mitigate the unique circumstances that can defeat an African American woman in BF her infant. The WIC Breastfeeding Peer Counselor program offered at KCHD clinics has only one African American Counselor. Given the disparities in BF rates between African American and other races/ethnicities, it is apparent that current efforts to encourage BF in this population are not sufficient. The MHMB program joins a small number of other innovative, low-cost programs that utilize peer mentors to increase BF initiation and success rates. Other programs utilizing mentors are hospital-based, such as the EMPower Hospital initiative, which tend to be more resource intense than programs like MHMB since they often hire African American women to become BF peer counselors and then train them to become skilled lactation consultants employed by the hospital. MHMB is similar to other community-based initiatives, such as the Black Mothers' Breastfeeding Club®, that utilize support groups and one-to-one peer encounters to overcome BF barriers. MHMB may be unique in addressing the historical and social barriers that exist in BF support and success for African Americans. Breastfeeding research supports the use of peer mentors and support groups to increase initiation, duration and exclusivity rates among African Americans. The Loving Support Breastfeeding Peer Counselor program used by WIC to help clients reach their BF goals was developed by the USDA after a national study of best practices for peer counselor programs (Journal Human Lactation 26(3): 314-326. Donna J. Chapman, PhD., RD. August 2010). A study of the use of adult-based peer mentoring for promoting healthy behaviors found mentoring to be effective in breast feeding among low social economic status women (American Journal of Health Education, 45, 351-357. Petosa, R.L., & Smith, L.H. 2014). The impetus for MHMB was a 2016 NACCHO Reducing Disparities in Breastfeeding through Peer and Professional Support grant awarded to KCHD. The focus of this funding opportunity was to support peer and professional lactation support to predominantly African American or underserved communities. Following the NACCHO-funded six-month pilot project, KCHD secured funding from the Michigan Department of Health and Human Services to extend the MHMB program for an additional 11 months.
Nutrition, Physical Activity, and Obesity
Moms Helping Moms Breastfeed (MHMB) had the following goals and objectives: 1. Address the historical, societal and social barriers that exist in BF support and success for African Americans. 2. Utilize a MHMB coordinator to provide training and weekly support to 6 BF peer mentors, who will mentor at least 30 BF mentees by September 30, 2017. 3. By January 31, 2017, develop an improved referral policy to increase participation in the peer mentor program and H.U.G.S. African American BF support group by KCHD WIC and HV program clients. 4. By September 30, 2017, at least 10 referred KCHD WIC clients will visit H.U.G.S. at least once. 5. By September 30, 2017, increase by 100% the average weekly participation in H.U.G.S breast-feeding support group. 6. Increase African American BF initiation rates by 15% and 3 and 6-month duration rates by 25% among WIC and MIHP clients who attend H.U.G.S. The MHMB program was implemented from November 1, 2016 through September 30, 2017, after completion of a pilot project funded through NACCHO. MHMB participants—mentors and mentees—were recruited by community health workers through Strong Beginnings—a local maternal-infant peer support program—through H.U.G.S., and contacts of the MHMB coordinator and program mentors. Mentors and mentees needed to self-identify as African Americans. To become a mentor, women needed to be at least 18 years of age, have a minimum of 6 months successful BF experience, attend MHMB mentor training, undergo a criminal background check, attend the H.U.G.S. BF support group, and enroll 3-5 pregnant or post-partum (1-4 weeks) African American women as mentees. Mentors participated in the Breastfeeding from an African American Perspective training, which provided both education for promoting successful BF as well as an historical and social background on BF in the African American community. Mentors received gift card incentives for completing three visits with their mentees, for up to 12 visits. Mentees were incentivized with items to assist them in their BF experience (BF pillow, milk storage coolers, etc.). At least one of each three mentor-mentee visits had to be at the home or another venue that allowed face-to-face interaction. Phone and text exchanges were the most common communication method among mentors and mentees. Mentors and mentees also had the opportunity to meet weekly at the H.U.G.S. support group. In addition to training the mentors and maintaining regular communication, the MHMB coordinator also facilitated the H.U.G.S. meetings. This ongoing contact with mentors and mentees was necessary for the coordinator to sustain her knowledge of program implementation and needs. The coordinator is a Certified Lactation Consultant with four breastfed children and her presence at H.U.G.S. also provided an opportunity to share her knowledge and experience of BF with other mothers. The Kent County Health Department worked closely with Spectrum Health's Strong Beginnings HV program on this initiative. Strong Beginning's community health workers (CHW), employed by KCHD and Spectrum Health, assisted with recruitment of MHMB participants. Strong Beginnings also provided the Breastfeeding from an African American Perspective training. The H.U.G.S. support group is also coordinated by Strong Beginnings and this provided an established infrastructure for the MHMB program. To promote inter-department collaboration, KCHD distributed program flyers to staff of its home visiting programs and WIC clinics to promote the MHMB opportunity. Another collaborative strength of this program was the relationship built between the WIC Breastfeeding Peer Counselor and the contracted MHMB coordinator. Once the WIC Peer Counselor attended H.U.G.S. and had first-hand experience with the program, she was enthusiastic in referring her WIC clients to MHMB and attending H.U.G.S. meetings with them. In addition to partnerships in implementing MHMB activities, program planning and evaluation was assisted by the Grand Valley State University (GVSU) Nursing Department. A nursing instructor and two of her students knowledgeable about BF research provided valuable insight for planning MHMB program and evaluation activities. The total budget for the 11-month program was $47,380, of which $15,616 was provided as in-kind wages and supplies. The primary costs associated with operating MHMB included contract wages for the .25 FTE coordinator, the cost of incentive gift cards for mentors and mentee BF-related gifts, and training costs.
In addition to information on program outcomes gathered from the weekly mentor-mentee encounter forms, qualitative evaluation data was gathered through a focus group and survey of mentees' MHMB program experiences. This information will be summarized in a formal evaluation of the MHMB program being conducted by GVSU. In conducting the formal evaluation, GVSU will compare BF outcomes of program participants with a control group of African American WIC clients to determine if BF duration and exclusivity rates were significantly different between the two groups and whether the mentor program had a positive impact on mentee BF. The GVSU evaluation will also measure the level of participation in home visits and peer support groups by program participants and participant satisfaction with MHMB program activities. Primary data for program evaluation includes the weekly encounter forms, mentee surveys and focus group summary report. Secondary data on African American WIC clients' BF is being provided by the state of Michigan WIC data analyst. Goals and objectives for the MHMB program included: 1. Address the historical, societal and social barriers that exist in BF support and success for African Americans. 2. Utilize a MHMB coordinator to provide training and weekly support to 6 BF peer mentors, who will mentor at least 30 BF mentees by September 30, 2017. 3. By January 31, 2017, develop an improved referral policy to increase participation in the peer mentor program and H.U.G.S. African American BF support group by KCHD WIC and HV program clients. 4. By September 30, 2017, at least 10 referred KCHD WIC clients will visit H.U.G.S. at least once. 5. By September 30, 2017, increase by 100% the average weekly participation in H.U.G.S breast-feeding support group. 6. Increase African American BF initiation rates by 15% and 3 and 6-month duration rates by 25% among WIC and MIHP clients who attend H.U.G.S. The MHMB program surpassed its mentor and mentee participation goal by training 8 mentors, who in turn enrolled and assisted a total of 35 mentees. In order to increase referrals from the WIC clinics to the MHMB program and H.U.G.S., we placed the only African American WIC Breastfeeding Peer Counselor at the WIC clinic with the highest enrollment of African American clients. The Peer Counselor's outreach resulted in 9 successful referrals to MHMB and H.U.G.S., which was one referral short of the program objective. The presence of mentors and mentees at H.U.G.S. meetings increased previous H.U.G.S. participation by more than 100%. It was not possible to measure the MHMB program's impact in increasing BF initiation since all women involved in MHMB initiated BF; some, but likely not all, participants would have initiated BF without this assistance. Among all MHMB participants, 22% were BF partially at 3 months post-BF initiation and 15% at 6 months. Thirty-eight percent of participants breastfed exclusively for at least 3 months and 25% for at least 6 months. Secondary data was not available at the time of this model practice application to compare BF rates of MHMB participants with the control group of African American WIC clients. From the program surveys and focus groups it was commonly expressed that mentor encouragement and education was instrumental in mentees successful BF experiences and BF duration. Program modifications were implemented as a result of data gathered from the mentor-mentee encounter forms. The encounter forms were designed to be completed in the form of an online survey (Survey Monkey). However, it was difficult for several of the mentors to timely complete the forms using their smartphones. As a result, the surveys were printed and provided each week to the mentors by the MHMB coordinator. The data then had to be entered into the Excel file of weekly responses generated by Survey Monkey. Reviewing the encounter forms and speaking with mentors, it was also apparent that much of the communication among mentors and mentees was occurring through text messaging and phone calls, and less through home visits. Some mentees were not comfortable with having mentor visits occurring in their homes. To encourage face-to-face visits, gift card incentives were provided to mentees who were open to home visits or who were able to meet with their mentor in a neutral location such as a coffee shop.
Lessons learned related to Practice We learned that the MHMB mentors have adversities in their lives, much like the women they are mentoring, such as chronic health problems, family demands, job changes and unintended pregnancy. Two of the mentors had major health conditions that prohibited them from continuing. Due to these stressors, it was necessary to continually recruit new mentors. Mentors were asked to provide more than just BF support. They were often working with mentees with mental health issues, such as suicide ideation, and basic needs such as housing and food. The program provided over 10 hours of mentor training on the aspects of BF and mandated reporting, however no training was presented regarding other influences such as mental health. If the program continues, there are plans to have mentors attend training on Perinatal Mood Disorders, the Perinatal Mood and Anxiety Disorders Conference, and participate in Mental Health First Aid Training. The design of the MHMB program required periodic home visits in recognition that home visiting is a best practice. We learned that most mentees were very hesitant in having mentors come into their home. This created a barrier for face-to-face visits. Appointments were cancelled, delayed and often missed. To address this situation, mentors were able to provide a gift card to their mentees for the face- to-face meetings. The visits could occur in the home or a neutral venue such as a coffee shop. We learned from many mentees that without the support of their mentor they would have never succeeded in BF. The support from the mentor and the H.U.G.S. support group made all the difference in their duration success. And because of their success, they are telling their friends and family that they can breastfeed too. They are spreading the word on Facebook and other social media. This program began a culture shift in BF for the participating African American women. We heard from mentees, and it is a common experience in the African American community, that hospitals push formula to new mothers at discharge. They reported that nurses made them feel that their baby needs” formula due to weight, blood sugar levels, and their breastmilk not being sufficient. To create a greater understanding among providers about the BF practices of African Americans, more than 100 providers from WIC, federally qualified health center clinics, hospitals and home visiting programs were provided the Breastfeeding from an African American Perspective training, developed by Strong Beginnings. The training is provided by an African American International Board-Certified Lactation Consultant and a Certified Lactation Consultant. These women personally understand the barriers, beliefs and history that influence BF initiation. Some of the training evaluation comments revealed the importance of this topic. From a physician: This is excellent and will change my practice.” From a nurse: This should be offered every year for new staff.” And from a WIC staff: We need to be acting as bridges in getting African American women the support they need to breastfeed.” Lessons learned in relation to partner collaboration Ongoing collaboration was established to address health equity and social justice among KCHD, Strong Beginnings, and the Healthy Kent Infant Health Implementation Team. Healthy Kent is a KCHD-led community coalition focused on improving maternal-child health. Through these partners, the MHMB program addressed the racial disparity in BF rates by providing what helps African American families to breastfeed: warm and inviting support via providers who look like them and have similar life experiences; BF support groups specifically for women of color; and a mentor who is available when BF is challenging. Using an equity lens in the development of the program was critical to its success. A collaboration between KCHD and its WIC program provides a natural fit with the MHMB program but adjusting some WIC protocols was necessary. MHMB objectives included increasing referrals to the MHMB program from WIC and increasing participation in H.U.G.S. by WIC clients. However, Breastfeeding Peer Counselors did not have any first-hand experience with MHMB and traveling off-site is not a normal practice for them, so they were slow in referring clients to MHMB and the H.U.G.S. support group. A revised strategy encouraged the only African American WIC Breastfeeding Peer Counselor to attend H.U.G.S. and encourage her clients to participate in the MHMB program by meeting them at the weekly support group. Once this was implemented, referrals from WIC increased dramatically and mentors were at full capacity. Is there sufficient stakeholder commitment to sustain the practice? There has been overwhelming support to continue the MHMB program. At the state level, the Michigan Department of Health and Human Services' Breastfeeding Coordinator and the Michigan Breastfeeding Network have met with MHMB program staff and have been using their networks to explore further funding. In addition, Healthy Kent and KCHD are seeking bridge” funding to keep the program active until more secure funds can be found. The Grand Valley State University Kirkoff College of Nursing entered the MHMB program into a GVSU grant competition and was awarded the top prize of $3,000. The Kellogg Foundation has been funding BF programs in Michigan for populations of color. We plan to approach the Foundation when GVSU has completed the MHMB program evaluation.
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