Final Practicum Paper
Amber France
Department of Health Services
1 West Wilson
Madison, WI 53703
Practicum Supervisor: Kathryn Pederson
Concordia University, Nebraska
May 2015
Abstract
The practicum experience I chose was breastfeeding friendly childcare. During my practicum I developed a PowerPoint training on the 10 Steps to Breastfeeding Friendly Childcare to train the childcare providers. I also developed materials to supplement the training that would help the childcare providers meet the 10 steps. I then went into childcare centers and did the training and helped 16 centers become breastfeeding friendly. From there I trained 3 breastfeeding coalitions, as pilots to the project, and they implemented the training in their areas of the state. I then presented the information and results at numerous conferences throughout Wisconsin, as well as to North Carolina Department of Health Services where the work was highlighted during World Breastfeeding Week in August. I also developed a page on the Wood County Breastfeeding Coalition website so childcare providers could do the training online and get continuing education hours, and developed a train-the-trainer toolkit with all the necessary documents as attachments for the local coalitions or organizations implementing the training.
Introduction
The practicum project that I completed was to create training materials for the 10 Steps to Breastfeeding Friendly Childcare Toolkit that the Wisconsin Department of Health Services had created in 2009. The project was funded by an Investing Early Grant from the Celebrate Children Foundation. The purpose of the project was to increase the duration of breastfeeding by increasing the knowledge of breastfeeding among childcare provider staff and developing policies and environments that foster breastfeeding at the childcare center. The project included the development of a training PowerPoint, implementing the training in local childcare site (intervention sites), providing assistance to additional pilot sites, presenting the material to other coalitions/organizations, creating a web-based tool, and creating a train-the-trainer toolkit to be utilized statewide.
The 10 Steps to Breastfeeding Friendly Childcare Toolkit provides 10 steps which include environment and policy development, resources, and instruction on how to implement breastfeeding friendly practices. Being recognized as breastfeeding friendly means that all childcare staff is trained on breastfeeding friendly practices, the childcare center has created a policy that fosters a welcoming environment for breastfeeding, and they have met all 10 steps of the process. Prior to this practicum, childcare providers were able to get the 10 Steps to Breastfeeding Friendly Childcare Toolkit as a reference to become breastfeeding friendly but there was no formal process or recognition. As a result of the materials that were developed for this project, childcare providers are being formally recognized by going through an assessment and scoring process that is administered by local breastfeeding coalitions in conjunction with their local Child Care Resource and Referral office. Once the childcare providers meet the 10 steps and achieve a score indicating breastfeeding friendly status, they are recognized by the Wisconsin Department of Health Services and the Wisconsin Breastfeeding Coalition and put into a statewide registry that labels them as breastfeeding friendly. This information is all accessible to the community and those looking for childcare.
The Department of Health Services’ mission is “to support economic prosperity and quality of life, the Department of Health Services exercises multiple roles in the protection and promotion of the health and safety of the people of Wisconsin” (DHS, 2015). Along with their mission they have 11 guiding principles. The breastfeeding friendly childcare fits within all 11 guiding principles, and directly fits with the following principle, “we will promote quality health care delivery, protect the interests of citizens receiving services, and develop policies to reflect evidence-based standards of practice that promote optimal health” (DHS, 2015). The 10 Steps to Breastfeeding Friendly Childcare creates a support system for breastfeeding mother’s returning to work and encourages them to continue breastfeeding. In 2011, The Surgeon General’s Call to Action (2011) called on childcare providers to accommodate the needs of breastfeeding mothers and support her breastfeeding goals. It is public health’s responsibility to ensure resources and support are provided to childcare providers to make this initiative happen. My practicum project provides the tools necessary to educate, guide, and support childcare providers in this initiative.
Discussion
My role in the breastfeeding friendly childcare project was to develop materials to train childcare providers on the 10 Steps to Breastfeeding Friendly Childcare Toolkit. From there, the project grew tremendously. After successfully developing the materials and implementing within 16 childcare centers in Wood County, WI, I was then asked to train 3 breastfeeding coalitions around the state of Wisconsin to implement the work as a pilot in their areas. They also had great success and I was asked to speak at all the childcare provider conferences that took place in 2014 and also present the results at the Wisconsin Breastfeeding Coalition state summit. From there, interest grew and the Department of Health Services developed a team that included a representative from Child Care Resource & Referral, YoungStar, Department of Health Services, WIC, Wisconsin Breastfeeding Coalition, and me to discuss how the initiative could be spread statewide. It was decided that a train-the-trainer toolkit should be created. I will be presenting this toolkit in June 2015 at a statewide conference.
There was an initial grant awarded from the Celebrate Children Foundation to create these materials and help childcare providers become breastfeeding friendly. Much of this work can be done without funding, since most of it is education and policy development, so the initiative can easily be spread throughout the state. Some health departments around the state have written this work into their maternity child health objectives and are receiving some funding to help them with this work for staff time and materials. The objectives of the project included train 15 childcare sites on the Ten Steps to Breastfeeding Friendly Child Care Centers, implement community education plan and campaign to support breastfeeding friendly childcare centers in Wood County, and facilitate the adoption of evidence-based breastfeeding policies in 80% of facility-level intervention sites.
For objective 1, train 15 childcare sites on the Ten Steps to Breastfeeding Friendly Child Care Centers (Ten Steps), sixteen intervention sites were chosen, based on commitment and need, in Wood County. Each of the 16 sites received a mini grant of $1,000-1,500 to make small environmental changes in accordance with the Ten Stepsrecommendations, and to support continued participation throughout the duration of the project. In addition to conducting trainings on the Ten Steps, assistance was provided to the intervention sites. Expected support and consultation at each intervention site included, at a minimum, a site visit to assist with a baseline assessment, a mid-point check-in, and a final evaluation visit. Intervention sites were able to request and receive specific consultation as needed outside the required visits.
A binder was provided with sample policies, lactation room guidance, sample infant care plans, educational materials to have at the center for parents, etc. I trained 10health department and hospital staff who were trained as trainers for the Ten Steps to Breastfeeding Friendly Childcare Centers. Sixteen centers applied to become breastfeeding friendly and all centers and their staff were trained on the 10 steps. Each center had an individual trainer that worked with them and guided them through the process of meeting the Ten Steps. Each center had a one-on-one pre-assessment with the Ten Steps toolkit and BabyNAP SACC assessment tools. (The BabyNAP SACC was an assessment tool that I worked with the Go NAP SACC (2015) out of North Carolina to develop and implement a scoring system.) The centers then created an action plan off of the results of the pre-assessment and determined what items were needed to be purchased to help the center meet the Ten Steps. A grant proposal was created and reviewed and approved by the Wood County Breastfeeding Coalition. Materials were then purchased, or a check was given to the center with a request of all receipts in return. Each center was also given guidance on policy development. All policies were then reviewed and approved by the coalition leaders. A final assessment was completed using the same assessment tools during the pre-assessment to ensure all steps were now met. The following graphs show a baseline (initial assessment) and post-assessment results. The first is from the BabyNAP SACC assessment tool and based on a score of 30. The second shows each center’s pre- and post-assessment scores.
NAP SACC: Breastfeeding and Infant Assessment
Average Baseline: 18.2
Average Post: 24.8
Area Assessed / Baseline (3/2014) / Post (4-5/2014)BF Environment / 19.5 / 25.2
BF Support Practices / 21.3 / 26
BF Education & Prof Development / 11.6 / 24.2
BF Policy / 6.7 / 24
Infant Foods Served / 27.8 / 26
Infant Feeding Practices / 26.3 / 26
Infant Feeding Education & Prof Development / 19 / 22.8
Infant Feeding Policy / 14.7 / 23.3
NAP SACC: Breastfeeding and Infant Feeding
Individual Center Results
A ceremony was then held for the Center’s to be recognized as Breastfeeding Friendly. Each Center was represented and received a plaque with the 2 year recognition as Breastfeeding Friendly by the Department of Health Services and the Wisconsin Breastfeeding Coalition. Every 2 years the Center must go through re-assessment in order to maintain status. This must be tracked and maintained by the local health department or local breastfeeding coalition for the county the childcare provider is located.
An emblem was also created and given to each center to display on their website, flyers, and other materials.
For objective 2, implement community education plan and campaign to support breastfeeding friendly childcare centers in Wood County,building awareness and support amongst key stakeholders was crucial in creating lasting environmental changes and community linkages. In many cases, lack of knowledge regarding the many benefits of breastfeeding and lack of skill in employing evidence-based strategies negatively impacted breastfeeding outcomes. Each childcare center developed a resource guide and education plan designed to build linkages with parents, healthcare leaders, local media, and other local decision makers. I created a strategic direction in identifying priority audiences, selecting outreach strategies, and implementing educational activities in the community. Educational messages and materials related to evidence-based breastfeeding practices in childcare settings weredeveloped. A media campaign was created around breastfeeding friendly childcare centers by utilizing billboards, radio, and Facebook. A page on the Wood County Breastfeeding Coalition website for breastfeeding friendly childcare centers was created to provide flexibility to centers that are going through the training process. One requirement is that all staff must be trained. This allows staffs who were unable to be present during the time of face-to-face training still receive the training. Child Care Resource and Referral added breastfeeding friendly to their search criteria.
Ten billboards were put up in Wood County for 2 months during the rollout of this project and then neighboring counties who were interested in implementing the initiative did the same. I worked with a local billboard company to create the billboards and put up at a reduced cost.
This is a sample of Childcare Resource & Referrals search option:
The following is the website for the centers to receive online training:
For objective 3, facilitate the adoption of evidence-based breastfeeding policies in 80% of facility-level intervention sites,guidance was provided to each intervention site on how to create policies and effectively implement them. Building strong partnerships at the local level from the beginning of the project encouraged long-term, mutually-beneficial collaborations and integration of interventions into partners’ existing systems and operations. Model policies were provided to intervention sites. To ensure intervention sitesare actively utilizing their policy, the coalition continues to be actively involved with the Centers by offering continuing education on breastfeeding yearly and including Center directors on email lists. As part of the Ten Steps center staff must be trained within six months of hire and receive continuing education yearly. The coalition created online module trainings for the Ten Steps and a quiz that must be sent to the coalition upon completion to receive continuing education hours from The Registry.
The effects of the work surrounding breastfeeding friendly childcare will not be reflected on breastfeeding duration reports or even obesity reports for quite some time. However, the objectives of this project were met and were appropriate for addressing the problem, as over 100 childcare providers are now trained throughout Wisconsin and carrying out breastfeeding friendly practices. The project has grown tremendously and many key partners are being added continuously to carry out and grow this initiative.
Some barriers that I encountered during this project were the ability to effectively track breastfeeding friendly childcare status and ensuring all staff is trained continuously. Currently, there is no way of knowing if the childcare provider is actually carrying out breastfeeding friendly practices or if all staff are trained regularly, except for every 2 years when the breastfeeding coalition or local health department go in and do a re-assessment. However, with the addition of key partners such as YoungStar, Child Care Resource & Referral, and licensing this may be streamlined in the future.
Personal Assessment
This practicum project has really increased my understanding of how one concept, or aspect, in public health can ripple, causing an effect on so many other aspects of public health. My practicum project did just that. Breastfeeding is the normal way to feed an infant and provides essential nutrients for the infant, as well as immune properties (World Health Organization, 2014). Breastmilk provides the proper nutrients for healthy growth and development, and is the optimal source of infant nutrition (US Department of Health & Human Services, 2011). Breastfeeding not only provides the proper composition of nutrients, but also provides immunological benefits that protect the infant. However, so many mothers are choosing not to breastfeed their infants and so many childcare providers and businesses are not supporting breastfeeding. Breastfeeding has also been shown to decrease the risk of many chronic diseases such as obesity and type II diabetes (US Department of Health & Human Services, 2011). Lack of breastfeeding or support of breastfeeding is a public health issue, because breastfeeding has been shown to be a preventative factor for many of these illnesses and diseases.
Lack of support and education on breastfeeding are the most influential barriers to the decision to breastfeed or continue breastfeeding (US Department of Health Services, 2011). In order to address this, public health programs have been created to help impact breastfeeding initiation and duration. These programs include providing prenatal education classes, breastfeeding friendly business and child care education, and breastfeeding awareness and support campaigns. My practicum project has helped provide education to childcare providers to allow them to better support breastfeeding. This aspect of the practicum touches on health policy and management, as well as social and behavioral sciences. During the process of becoming breastfeeding friendly, policies are developed to support breastfeeding which will in turn improve the health status of our population. The practicum project is also dabbling into system-level changes, because we invited key partners to the table to make this a statewide initiative and a system level policy change.
This practicum project focused a lot on the social and behavioral sciences competency. The whole movement was to create a culture shift of the community. Learning positive breastfeeding behaviors and being able to positively support breastfeeding women impacts breastfeeding attitudes and beliefs in the community. The changes in attitudes and behaviors correlate with an increase in breastfeeding rates over time. Breastfeeding is associated with fewer ear infections, respiratory illnesses, bouts of diarrhea, hospitalizations, and decreased risk for asthma, allergies, and Sudden Unexpected Infant Death Syndrome (WebMD, 2015). According to WebMD (2015), breastfeeding also benefits mothers by burning extra calories, helping mothers return to their pregnancy weight quicker, decrease the risk of certain cancers and osteoporosis, and save time and money. All of these benefits of breastfeeding positively impact the health of the public. Breastfeeding leads to a decrease in illness and chronic diseases (Surgeon Generals Call to Action, 2011). This helps save in health care costs and allows employers to benefit by parent’s missing less days of work. As you can see, one small change has created a system-wide change from supporting mom in childcare to impact health care costs and increasing employee productivity.
Public health is such a multi-faceted field that this practicum project really touches on most of the public health competencies in some aspect. Epidemiology has been applied because we are trying to increase the duration of breastfeeding for maximum benefits to the infant and mother, which will ultimately decrease the risk of illness and disease. We look at the biostatistics to base our education off of what we are seeing in disease trends and what past studies have shown to be the benefits of breastfeeding longer.
The breastfeeding friendly childcare project touched on changes at the individual, community, and system levels. I learned so much about how to change the delivery of a message based on who you are speaking with. If you were working on an individual level, it was important to really focus on the present and how the changes would positively impact them and their families personally. If you were working on a community level it was important to show how the community was in support of one another and how the changes would impact the community as a whole, bringing opportunity and success to all. If you were working on the system level it was important to talk about policy changes and how they would impact all aspects including costs and employee/employer benefits. The greatest lesson I am taking from this practicum experience is that to make system level changes in public health you need to make many key partnerships and get the right people to the table. One person cannot make a difference by themselves in public health. It truly takes collective impact to make big changes.