Review a Grant RFP – links and documents provided
Statistically it has been proven that women on WIC do not breastfeed their children as much as other populations. Our Breast is Best program aims to increase rates of Breastfeeding within women on WIC in Christian County to help ensure their children can have the most beneficial start to life through all of the many proven benefits of breastfeeding. breastfeeding.

Breast is Best RDF

Breast is Best Foundation

1245 Street Name

Bowling Green, KY 42101

Anella Higgins, Grants Management Specialist

Department of Health and Human Services

CDC Procurement and Grants Office

2920 Brandywine Rd, MS E09

Atlanta, GA 30341

To Whom This May Concern,

Our agency is interested in giving children the best, healthiest life possible all the way from the start. We know that the best way to promote a healthy immune system as well as healthy growth and weight in a growing infant is breast feeding. The children of WIC women consistently have the lowest rates of breastfeeding.

This program is a multi-level intervention within Christian County, KY that not only works with the target population directly, but with those in their surrounding environment who frequently work with those on WIC. Breast is Best will implement an educational program to increase awareness of this issue within those community members, will help to increase the perception of importance of this issue within WIC women, and the entire Christian County community itself.

Breast is Best looks to hire on a lactation specialist to work specifically with WIC women to promote breastfeeding within the population. Breast is Best also will help to decrease limitations that WIC women may have with breastfeeding by purchasing an ample number of hospital grade breast pumps to allow these women to have access to these products that they may not financially have been able to prior. Breast is Best will hire on peer counselors to assist these women if they have any questions or need outside support in their decision to breastfeed.

This program works to increase the likelihood of those on WIC to breastfeed their children to their babies can have the best start possible. Breast is Best appreciates your consideration of this grant application, and looks forward to hearing from you.

Sincerely,

Lauren Graves, Mackenzie Perkins, and Mary Walsh (Breast is Best Board of Directors)

Table of Contents

Section

Page Location

Statement of Need

Cover

Cover Letter

1

Table of Contents

2

Abstract

3

Program Plan

4

-Brief History

4

-Literature Review

5

-Breast is Best Program

6

-Summary of Activities

9

-Program Evaluation Plan

11

-Process Evaluation

12

-Outcome Evaluation

13

-Impact Outcome Evaluation

13

Work Plan

13

-Mission

13

-Goals and Objectives

14

-Partnerships and Collaboration

15

Timeline

16

-Proposed Plan for Evaluation

16

Monitoring and Evaluation

17

-Evaluation Plan

17

-Collaboration with CDC

18

Staffing

18

Budget

20

-Personnel Budget

20

-Itemized Budget

22

Appendices

24

-Appendix A: Task Timeline

24

-Appendix B: Timeline of Program and Evaluation

28

-Appendix C: Works Cited

31

Abstract

Breastfeeding is one of the best ways to promote an infant’s health from their very first day of life. Unfortunately, rates of breastfeeding are not as high as would be best for growing infants, especially so within the population of WIC women. Consistently WIC women have the lowest rates of breastfeeding for multiple reasons. The multi-level program (Breast is Best) looks to not only assess the community of Christian County, Kentucky to understand their knowledge level and perceptions of breastfeeding, but it will also implement a knowledge based and access based approach to promote breastfeeding within Christian County’s WIC women. Breast is Best will hire a Lactation specialist to work specifically with WIC women regarding breastfeeding. Breast is Best will also purchase hospital grade breast pumps to be rented by these WIC women to increase access to these expensive products. Breast is Best plans to also hire peer counselors who are also on WIC who breastfed their child to work with these WIC women to provide support and a source of information in case they need it. Breast is Best also plans to educate core members of the community who work directly with WIC women such as WIC based health department employees, doctors, nurses (etc.) to increase awareness of breastfeeding with this community so they can help to promote breastfeeding with these women as well. Breast is Best works to not only increase a knowledge base of WIC women, but those who work directly with them, and helps to break down barriers that may be preventing these women from breastfeeding. This program’s aim is to increase breastfeeding in WIC women and to increase the overall health of WIC women’s baby’s health.

Program Plan

Brief History

Breastfeeding is considered by the CDC to be the highest level of prevention a mother can take in protecting her infant and keeping him/her healthy. The American Academy of Pediatrics (AAP) states that breastfeeding is the preferred feeding method for all infants for the first six months of life (AAP, 2012). The AAP’s policy statement includes that breastfed children benefit in growth, health, development, and multiple other potential outcomes (AAP, 2012). New research is continuously found on the importance and necessity of breastfeeding. With this new research, health care professionals are critical in assisting and supporting women in breastfeeding initiations and the promotion of further longevity of breastfeeding. The breastfeeding benefits the mother and child’s health but can also have financial benefits on society as a whole. Concurrent with the Healthy People 2020 objectives, the United States is committed to increasing the proportion of infants who are breastfed to 81.9% in the early postpartum period, 60.6% 6 months postpartum, and 34.1% 1 year postpartum (United States Department of Health and Human Services, 2011). According to the Health People 2020, the United States’ baseline for breastfeeding was 74.0% in early postpartum period, 43.5% 6 months postpartum, and 22.7% 1 year postpartum (United States Department of Health and Human Services, 2011).

Breastfeeding is valuable for mothers, children, families and communities. For children, breastfeeding reduces the risk of contracting a variety of different illnesses. Reduction in the risk of acute otitis media, non-specific gastroenteritis, severe lower respiratory tract infection, atopic dermatitis, asthma, obesity, type 1 and type 2 diabetes, childhood leukemia, sudden infant death syndrome, and necrotizing enterocolitis within breastfed children in developed countries (Ip, Chung, Raman, Chew, Magula, Devine, Trikalinos, & Lau, 2007). With the reductions in sudden infant death syndrome and other potential life-threatening diseases, one can infer that breastfeeding will reduce infant mortality rates. For mothers who chose to breastfeed, there was a reduced risk of type 2 diabetes, breast cancer, and ovarian cancer (Ip et al., 2007).

Kentucky is reported to be one of the lower breastfeeding states in the nation (CDC, 2010). On the CDC’s Outcome Indicator for breastfeeding in 2012, Kentucky was at 59.4% for women who have ever breastfed (once or more), 27.3% breastfeeding at 6 months, and 10.8% breastfeeding at 12 months (CDC, 2012). Breastfeeding rates can be affected by several factors such as race and socioeconomic status. Within Kentucky, there is a significant difference between race and breastfeeding rates; for Hispanic women, breastfeeding was 65.8% at initiation, 32.3% 6 months postpartum, and 10.8% 1 year postpartum (CDC, 2010), White, non-Hispanic women, breastfeeding was 54.8% at initiation, 26.1% 6 months postpartum, and 12.7% 1 year postpartum (CDC, 2010), and Black, non-Hispanic women, breastfeeding was 36.4% at initiation, 11.1% 6 months postpartum, and 2.8% 1 year postpartum (CDC, 2010). Women whom were recipients of WIC (Women, Infants and Children) had lower breastfeeding rate at 66.1% than those not on WIC but eligible (76.5%) and those that were not eligible for WIC at (82.2%) (CDC, 2010). Mother’s education and age also affect the breastfeeding rates with increase education and age leading to higher rates of breastfeeding at initiation.

The breastfeeding initiation rate among many counties in the state of Kentucky falls drastically below the 50% mark and in Christian County, Kentucky particularly the initiation rate is at a 39.9% (Bailey, 2012). With this initiation in this county being extremely low compared to other counties in the state, it was decided that the women and infants in this county would benefit greatly from a breast feeding initiation program. Many statistics show that breast feeding is least common among mothers who fall in the lower socio-economic status. Therefore instead of just concentrating on all women in Christian County, Kentucky, we have specifically decided to target women who are accepted and certified into the federal Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

At the local level, breastfeeding initiation rates are higher in northern and western Kentucky (Bailey, 2012). Within western Kentucky, some counties are below 50% initiation rate. Among these counties includes Christian County at 39.9% initiation rates (Bailey, 2012). Within the WIC participation in Christian County, 14% of WIC mothers fully breastfed their child and 10.9% of WIC mothers partially breastfed their child (USDA, 2013). In Christian County 24.9% of WIC mothers breastfed. WIC mothers in Christian County are the target population for the intervention to increase breastfeeding rates.

Literature Review

Ruowei, Fein, Chen, and Grummer-Strawn conducted a study to focus on the various reasoning of why women to stop breastfeeding and at what point within their infant’s first year of life. Data was collected by administering questionnaires through the mail to roughly 1323 mothers , the questionnaire consisted of 32 reasons for their decision to stop breastfeeding and the participants were asked to rate the importance of each question. The results of the study showed that the number 1 reason the mother stopped breastfeeding was she felt as if the breast milk alone did not satisfy her infant, the 2nd reason indicated in the results showed that the mother ‘s concern for her infant’s nutrition and lactation had increased at the infant’s age of 2 months, and the top 3rd reason indicated in the results that mothers stopped breastfeeding in the third month because they felt their infant began self-weaning including statements such as; the baby lost interest in breastfeeding, or the baby began to bite (Ruowei, Fein, Chen, & Grummer-Strawn, 2008).. The author’s reported that this information is vital to health professionals indicating that there are many perceived barriers for breastfeeding mothers. It is also acknowledged in the text that infants and children who are not breastfed have increased health issues such as hospitalization for respiratory infections, pneumonia, and asthma, they are twice as likely to suffer from diarrhea, increased chances of becoming overweight during their childhood, and have increased chances of developing ear infections. Many factors are associated with breastfeeding rates, such as environmental support, psychological support, and hospital practices (Ruowei, Fein, Chen, & Grummer-Strawn, 2008).

Authors Anderson and colleagues conducted a study to determine the effectiveness of utilizing peer counselors to promote exclusive breastfeeding among low-income and inner city women. Women who live in inner cities and are low income in Hartford, Connecticut are less likely to breastfeed than those who have a higher income and live in a rural or suburban area (Anderson et. al, 2005). The intervention promoted exclusive breastfeeding with the use of peer counselors; there were 3 prenatal home visits, daily perinatal visits, 9 postpartum visits, and telephone counseling as needed (Anderson et. al, 2005. The results of the study indicated that with a well-planned and implemented breastfeeding support program provided at the hospital and with peer counselors are effective and improved the rates of exclusive breastfeeding among women who lived in inner cities and had low incomes (Anderson et. al, 2005). The authors recognize that currently there is quite a bit of literature that supports breastfeeding, as well as education provided by public health professionals, and other health care service, yet the breastfeeding rates remain low among low income women, but more strategies should be developed such as the community based peer counseling intervention to increase the breastfeeding rates. Breastfeeding provides the infant with developmental benefits, decrease likelihood of acute and chronic diseases, and has immunologic benefits, and has social economic and environmental benefits to both the infant and society (Anderson et. al, 2005).

Breast is Best Program

This program’s strategy works along with the previously stated AAP guidelines to help in promoting, supporting, and protecting breastfeeding mothers who give birth in Christian County (AAP, 2012). The AAP explains that breastfeeding should be encouraged through education, positive societal outlook, and continued research (AAP, 2012). Our plan for increasing breastfeeding in Christian County for WIC women includes pre-program data collection, programming through peer counselors, hiring of a lactation specialist for the Christian County Health Department specifically for WIC women, and training programs on breastfeeding for healthcare professionals within Jennie Stuart Medical Center, Christian County Health Department WIC staff, and other relevant professionals. This program works to not only educate women in Christian County on the multiple health benefits for mother and child through breast feeding, as well as helping to create a more educated environment around these women to assist in supporting these women in their choice to breastfeed.

The program works to promote breastfeeding in women through raising awareness in the community of the lack of breastfeeding in the population and the need to increase these rates between mother and child. We will do this through public service announcements, and we will also promote our program through this. Community support is a huge factor when it comes to women deciding whether or not they will breastfeed their children. The US Surgeon General in 2011 made a call to action specifically relating towards breastfeeding. In this document, it was stated that only 43% of Americans believed that women should have the right to breastfeed in public places (US, 2011). Helping to show the community that breastfeeding is important for mother and child, as well as working with PSA’s to promote not only the idea of breastfeeding but stressing the importance of it as well.

A preliminary survey will be given to identify Christian County’s specific barriers to and will allow the program to address them head on. Assessing the community helps to know their perspectives on many different levels, as well will survey not only our target community, but those who work directly with this community including doctors and nurses in maternity areas in hospitals, WIC women, WIC staff in the Christian County Health Department, lactation specialists, health educators, and other community members residing in Christian County. This survey will assist in knowing which barriers we will have to prioritize in spearheading in our program. Without the survey, it is unclear whether or not this program would be effectively addressing the most prominent issues within its target community.

The “Breast is Best” will assist in the hiring of a lactation specialist that is specifically designated to work directly with mothers who are currently on WIC. The lactation specialist will be responsible for meeting with the expectant mother on their enrollment into WIC prior to giving birth to discuss the option of breastfeeding. The lactation specialist will then be responsible for meeting with the mother postpartum if the woman has chosen to breastfeed. This is because Christian County does not currently have a lactation specialist that works solely with WIC women, although breastfeeding services are currently being offered through Christian county’s health department for women who seek these services out such as breastfeeding classes, and in person as well as telephone breastfeeding counseling. Having a WIC designated lactation specialist helps with targeting our focus community, and it helps in the respect that the current on-staff lactation specialist is not overwhelmed with the new responsibilities our program will entail.

“Breast is Best” also works with peer counseling of WIC women interested in breastfeeding to help guide and support these new mothers. In the previously stated surgeon general’s Call To Action, it states that “Peer-counseling programs that provide breastfeeding support for low-income women who are enrolled in or eligible for WIC have been found to be effective at both agency and individual levels in improving breastfeeding rates” (US, 2011). Including this peer counseling (consisting of volunteers within the Christian County area that are interested in promoting breastfeeding and assisting new mothers with this process) in our program will assist in answering questions that new mothers may have, and provide an example on a peer level that these new mothers can look up to for support.

The next portion of this program consists of providing hospital grade medical pumps for new WIC mothers who have experienced issues with their baby latching during attempts at feeding their child. In the Surgeon General’s Call To Action it states, “High-quality lactation programs go beyond just providing time and space for breast milk expression, but also provide employees with breastfeeding education, access to lactation consultation, and equipment such as high-grade, electric breast pumps” (US, 2011). If women have trouble with their babies latching and feeding, then they can at least pump milk not only at home, but at work as well to provide their child with essential nutrients. It is shown that, “…in the United States, a majority of mothers have returned to the workplace by the time their infants are six months old” (US, 2011), and if these women are already having trouble with their babies latching, returning to work is likely to lower their levels of self-efficacy towards being able to maintain breastfeeding. Providing pumps to these women can help to extend the time period that their children are breastfeeding, and to help mothers feel that this is indeed doable.

Our program will also train those who work directly with Christian County’s WIC mothers, such as doctors, nurses, WIC staff, and the health department to be able to assist with women who have questions about breastfeeding. The Surgeon General’s Call to Action to Breastfeeding states, “hospitals, clinicians in the community, and community organizations typically lack systems to help connect mothers to skilled persons who can offer support for breastfeeding” (US, 2011), and through the training of those who work with WIC women on many different levels helps to ensure that there are multiple people that can offer support for those who are breastfeeding. Doing this also helps to promote breastfeeding itself, and it helps in relation towards stressing the importance of breastfeeding for the health of the child. If these health professionals aren’t prioritizing breastfeeding in their minds to know how to answer questions of mothers needing to know how to breastfeed their child, it may make a statement to these patients that breastfeeding really isn’t that essential in the health of the child.

Our training of these individuals includes both in-house trainings at their place of employment, as well as outside training that is provided through take home materials that those being trained will look over and study, and then be tested on at a later time. This allows for training that goes further than what can be squeezed into a typical work day, and takes on the Red Cross’ training ideas that allow for both in person training as well as at home training too. Having multiple different training methods being implemented allows for those with different learning styles to absorb the material in a way that best fits the way they learn, and allows for there to be a more all-encompassing training program.

Through working with both the internal barriers such as women’s knowledge or both how to breastfeed, and external barriers such as ease of access to peer counselors in their area, and those in their environment including their doctors’ and nurses’ knowledge level and ability to give support works to effectively improve upon these women’s ability and levels of self-efficacy regarding breast feeding. Working to break down the barriers that may be keeping these WIC women from breastfeeding and building support systems that may not have been there in the past targets the specific reasons why these WIC women aren’t breastfeeding, and through our survey we will put the most emphasis on what needs to be prioritized. This program should effectively target the exact reasons why women aren’t breastfeeding and help to improve their rates directly.

Summary of Activities

The Christian County Breastfeeding initiation program among WIC participants is composed of several phases. It is important to note that the overall goal of the breast feeding initiation, is to improve infant health (morbidity and mortality), through breast feeding and increase the support and encouragement of breast feeding among CCHD WIC staff, health educators, lactation specialist, community members, and hospital staff. The initial phase of the initiation will begin with the issuing of surveys for WIC participants and for the nurses who work within the maternity department in the hospital. The purpose of the surveys, interviews, and focus groups that are given to the WIC participants, is to gain a clear understanding of how WIC participants perceive breast feeding (positive or negative), identify their perceived barriers, identify and understand their current knowledge and education concerning breastfeeding, and to learn about past their past experiences with breast feeding if any. The primary purpose of the surveys and interviews given to the WIC and maternity nursing staff is to identify their prospective on breast feeding and the promotion of breastfeeding within their professional environment and determine areas of weakness, barriers, and the needs for the professional environment, considering they have much interaction with the patients.

Mothers who intend on breast feeding their child many times in the initial stage have great difficulty in properly breast feeding (or having their infant latch on to the breast), therefore the program is designed for the CCHD to employ a well-trained Lactation Specialist. This Lactation Specialist (LS) is exclusively for WIC participants. It is the responsibility of the LS to assist women who are on WIC within twelve hours of delivery, the LS is required to stay in the room with the mother for two entire feeding sessions or until the mother is comfortable with doing it without assistance. The WIC appointed LS will also be required to attend follow-up WIC appointments to address questions and concerns that the mother may have about breast feeding. During the follow-up appointment, this will be the opportunity for the LS to give the mother positive reinforcement concerning her decision to breastfeed and reassuring her of the benefits that breastfeeding will have for her child.

The third component of the breast feeding initiation will be peer counseling by the CCHD within the program. The health educators have the responsibility of providing information classes regarding breastfeeding promotion and awareness to WIC expectant or lactating mothers. Health educators will be the facilitators of the peer-counseling meeting and the actual peer counselors will consist of volunteer women, who has successfully breastfed in the past and is willing to provide positive feedback and support to the mothers who may have some doubts about breast feeding or those mothers who would like to have social support from someone who has made it through their current situation. The peer counselors will be able to relate to similar barriers that the women are currently facing and help them overcome them learn how to overcome in different ways. Considering that peer counseling is a crucial part of initiation and success of the program, care recruiting and consideration will be taken in selecting the peer counselors. It is the goal recruit peer-counselors who were successful in their breastfeeding and have a passion for getting other women to breastfeed. The breastfeeding peer counselor volunteer position will be posted on the CCHD website and applications will be available, there will be interviews conducted to decide which peer-counselors that will be involved in the program.

The fourth and final stage of the breast feeding initiation is to make available hospital grade breast pumps for the mothers who have attempted to breastfeed their infant with no success, but still has the desire to keep her child on breast milk. The breast pumps are not given to the mothers but loaned to them and must be returned at the child’s first birthday. In order to insure the efficiency of the breast pump, the mother will be required to bring her breast pump to her follow up WIC appointments. Although the initiation supports and encourages the mother’s to work at getting their child to latch there are some cases, where it just doesn’t work, which is why it the breast pump is considered the last result. The mothers who wish to receive a breast pump must have a recommendation from the WIC LS, which will verify that this mother has taken every action possible to breastfeed and has reached out to the LS on several attempts for assistance.

In order for the breast feeding program to be successful, it is important that we have the support and encouragement of all the medical professionals that have direct contact with our WIC participants. A hospital breast feeding initiation will be implemented to prepare and train staff members on multiple levels to assist in the success and efficiency of the breast feeding initiation program. The program will mandate the training of physicians, nurses, WIC staff, and the CCHD staff to increase their ability to educate the public and on the benefits of breast feeding when given the opportunity. Requiring this training will refresh the health professionals and staff on the importance of breastfeeding and give them the ability to answer various questions related to breastfeeding on all different levels. Educating the health professionals and staff on the barriers that many women face while breast feeding will help them develop a better understanding on their patients and give them the opportunity to respond accordingly.

There will be a training process for the health educators, which will involve an in-house and education seminar delivered by a certified breastfeeding educator who will work face-to-face with the trainees. Materials for the training will be available online and in paper for those who are required to go to the program and who must successfully complete the exam. The fact that many health professionals obtain prior health education knowledge and training having the opportunity to complete the certification online and on their own time will be just as effective to what is being taught and tested on in a class. Mandating breast feeding training and certifications of health professionals will ensure that the WIC women that give birth in Christian County will have will have multiple resources in obtaining information regarding breast feeding and support.

The Breast is Best program will coordinate, collaborate, and meet the requirements of the Baby Friendly USA initiation criteria. The training/continuing education for the hospital staff in labor and delivery, maternity ward, and the WIC staff will meet the requirements of the Baby Friendly USA as well. The Breast is Best Program will follow these Baby Friendly USA guidelines:

Requirement 1: Have a written breastfeeding policy that is communicated to all healthcare staff.

Requirement 2: Train all healthcare staff in the skills necessary to implement this policy.

Requirements 3: Inform all pregnant women about the benefits and management of breastfeeding.

Requirement 4: Help mothers initiate breastfeeding within one hour of birth.

Requirement 5: Show mothers how to breastfeed and how to maintain lactation even if they are separated from their infants.

Requirement 6: Give infants no food or drink other than breastmilk unless medically indicated.

Requirement 7: …

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