Assessing the Needs of Physicians and Providing Resources to Address Barriers to Breastfeeding Initiation and Duration

State: CO Type: Promising Practice Year: 2015

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Background/Purpose: In today’s society, the decision to breastfeed is influenced by many factors, including information given by physicians. The benefits of breastfeeding are well documented, and public health agencies have a responsibility to inform and support residents in their breastfeeding efforts, in hopes of a healthier tomorrow.  Tri-County Health Department (TCHD) looks for ways to collaborate with physicians in helping mothers to achieve breastfeeding success.  The aim of this survey was to find out how TCHD could assist physicians in patient support and employee education about breastfeeding.

Methods: Two-hundred surveys were mailed to randomly selected obstetrician and gynecologists (n=100), family practice physicians (n=50), and pediatricians (n=50) within the Tri-County jurisdiction (Adams, Arapahoe, and Douglas counties).  A small incentive was offered for survey completion and two follow-up mailings were sent.  Large clinics and hospitals were eliminated to prevent duplication.

Results:  One hundred eleven surveys were returned, yielding a 55.5% response rate.  For patient education, most physicians preferred handouts or pamphlets and fact sheets (n=85, 82.5%), web links to instructional videos (n=43, 41.7%), and referral sheets for community-based lactation support (n=43, 41.7%). In terms of staff education, most physicians also preferred handouts or pamphlets (n=46, 45.1%), and lunch and learn events (n=42, 41.2%), breastfeeding websites (n=41, 40.2%), and web-based training (n=34, 33.3%). Some physicians reported time limits during each patient’s visit (n=84, 84.0%) as the most common barrier in providing breastfeeding education, while others needed more information about available resources (n=61, 65.6%) and indicated they had limited training in breastfeeding management (n=48, 52.2%).

Implications: The top selected breastfeeding resources were identified and provided on a newly developed Breastfeeding Resources for Health Care Providers webpage with quick links to information tailored to meet needs identified in the survey. The webpage also contained information about TCHD programs and free trainings available to help build partnerships between physicians and the health department. Conducting follow-up networking meetings with physicians who completed the survey served to market the website and strengthen partnerships. By providing tools and education to physicians in Adams, Arapahoe, and Douglas counties for both patient and staff education, we hope to increase breastfeeding initiation and duration rates in our local population. 

 

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Tri-County Health Department
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Assessing the Needs of Physicians and Providing Resources to Address Barriers to Breastfeeding Initiation and Duration
Brief description of LHD – location, demographics of population served in your community. Tri-County Health Department (TCHD) was established in Colorado in 1948 and is an experienced provider of public health services. TCHD serves approximately 1.4 million people in Adams, Arapahoe and Douglas Counties, comprising nearly one-quarter of Colorado’s population. The population of the TCHD region is extremely diverse—very urban areas as well as suburban and rural areas, with residents in very low-income and very high-income communities.  TCHD’s mission is to promote, protect and improve the lifelong health of individuals and communities in Adams, Arapahoe and Douglas Counties through the effective use of data, evidence-based prevention strategies, leadership, advocacy, and partnerships. Describe the public health issue. The public health issues that this project addressed were decreasing childhood obesity and chronic disease through promoting breastfeeding. While the benefits of breastfeeding are well documented, including protection from childhood obesity, only 58% of Colorado mothers are still breastfeeding at six months postpartum and only 29% are breastfeeding at 6 months.[1] This falls below the Healthy People 2020 goals of 60.6% of women breastfeeding at 6 months and 34.1% breastfeeding at 12 months. In 2008, 15% of Colorado children ages 2-14 were overweight and 14% were obese.[2] Colorado needs to more effectively address childhood obesity prevention and increasing breastfeeding duration through physician support can play a key role in combating this public health issue. Goals and objectives of proposed practice. The goal of this project was to improve the quality of breastfeeding information and support provided by health care providers in the TCHD jurisdiction through partnerships with TCHD. Objective 1: By August 31, 2013, create and pilot test a need assessment survey with a minimum of five members of the target population to determine how TCHD can assist physicians in patient support and employee education about breastfeeding. Objective 2: By December 31, 2013, survey a minimum of 150 randomly selected obstetrician and gynecologists, family practice physicians, and pediatricians to determine current breastfeeding support practices, resources, common barriers and needs.   Objective 3: By September 30, 2014, create or provide, based on results from the needs assessment survey, a minimum of one breastfeeding resource for physicians, their health care clinic staff, and their patients.   Objective 4: By October 31, 2014, complete networking meetings with a minimum of two health care provider clinics in Adams, Arapahoe and Douglas counties to build community partnerships. How was practice implemented/activities. After receiving community needs assessment and survey implementation training, the TCHD dietetic interns completed a literature review to identify existing successful collaborations between health departments and health care provider offices.  A needs assessment survey was created, pilot tested and distributed to randomly selected physicians within the TCHD jurisdiction. Based on survey results, the top selected breastfeeding resources for physicians, their health care clinic staff, and their patients were provided to physicians.   Results/Outcomes; Were all of the objectives met?; What specific factors led to the success of this practice? The project successfully met all goals and objectives. Several factors led to the success of the project. Completing a comprehensive needs assessment survey with the target population allowed for resources to be tailored to current needs and increased the use of TCHD as a breastfeeding resource. Using a webpage increased project reach and provided easy access to direct information links decreasing the time barrier physicians face in providing information to patients. The emphasis on building community partnerships built in project sustainability and strengthened the network of breastfeeding support for women in the community. Public health impact of practice. Because needs specific to the target population were identified and tailored materials were provided to meet these needs, the project has great potential to improve the support TCHD area physicians provide to patients to improve breastfeeding rates and decrease childhood obesity. Increasing physician knowledge, skills and attitudes toward breastfeeding, including increasing access to resources, is highlighted as a successful strategy to increase breastfeeding rates in The CDC Guide to Strategies to Support Breastfeeding Mothers and Babies. Furthermore, building collaborative relationships aligns with the 2011 Surgeon General’s Call to Action to Support Breastfeeding which calls for the creation of community networks to provide access to breastfeeding support for mothers once they leave the hospital. Website for your program, or LHD. The TCHD website address is www.tchd.org [1] National Immunization Survey (2007), Centers for Disease Control and Prevention, DHHS.[2] Colorado Physician Activity and Nutrition Program. (2009), The Weight of the State: Report on Overweight and Obesity in Colorado. Colorado Department of Public Health and Environment.
Statement of the problem/public health issue. The public health issues that this project addressed were decreasing childhood obesity and chronic disease through breastfeeding promotion. Babies who are fed formula have higher risks of obesity, diabetes, respiratory and ear infections and sudden infant death syndrome, and often have higher medical costs due to more doctor visits, hospitalizations and prescriptions.[1] The risk of childhood obesity is one-third greater for children who never have been breastfed compared to children who have been breastfed.[2] Respiratory problems, endocrine disorders, cardiovascular risk factors and psychiatric disorders are common medical problems in obese children.[3] In 2008, 15% of Colorado children ages 2-14 were overweight and 14% were obese.[4] While the benefits of breastfeeding are well documented, only 58% of Colorado mothers are still breastfeeding at six months postpartum and only 29% are breastfeeding at 6 months.[5] This falls below the Healthy People 2020 goals of 60.6% of women breastfeeding at 6 months and 34.1% breastfeeding at 12 months. The breastfeeding initiation rates in Adams, Arapahoe and Douglas Counties are 90%, 94% and 91% respectively. However, duration rates fall quickly with only 64-68% of women in our three counties continuing breastfeeding for more than nine weeks.[6] In Colorado, there are few programs available for the prevention and treatment of childhood obesity and families often turn to their physicians for support and advice. Breastfeeding is associated with lower rates of obesity, but physicians receive little training in this area. In 2005, TCHD surveyed physicians and found none of the physician offices offered breastfeeding training for staff.  This theme was upheld in the current physician needs assessment survey where physicians reported needing more information about available resources (n=61, 65.6%) and indicated they had limited training in breastfeeding management (n=48, 52.2%). What target population is affected by problem (please include relevant demographics)?; What is target population size?; What percentage did you reach? The target population for this project was all Family Medicine, Pediatric, and Obstetrical/Gynecological (OB/GYN) physicians with a practice address located in Adams, Arapahoe, or Douglas Counties. Physicians were identified in the Peregrine Database, a commercial database of physicians, and were exported to a Microsoft Access program.  Physicians with more than one practice location were identified, and de-duplicated.  For each physician with one or more addresses, one address was randomly selected and the others removed.  In order to focus on community based providers, physicians with practice locations at the Anschutz medical campus in Aurora (University of Colorado Hospital and Children’s Hospital), were also removed from the sampling frame.   This resulted in a database of 793 physicians in which each physician was only listed once with a community-based address.  From this database, 25% of the community providers (100 OB/GYN physicians, 50 Pediatric and 50 Family Medicine physicians) were randomly selected to complete the survey using the random number function in Microsoft Excel. Of the total 200 surveys distributed, 111 responses were received yielding a 55.5% response rate. Fifty-one responses were from OB/GYN physicians, for a 51% response rate for the specialty (51/100); 38 family physicians responded for a response rate of 76.0% (38/50), and 22 pediatricians responded for a response rate of 43% (22/50). The majority (n=70, 63.6%) of the respondents were in group practice. Seventy-seven percent (n=85, 77%) of respondents indicated that a majority of their patients were not on medical assistance programs, such as Medicaid or Child Health Plan Plus. What has been done in the past to address the problem? Over the past decade, TCHD has sought out ways to collaborate with community partners to help women achieve breastfeeding success.  In 2004, TCHD completed a needs assessment survey with physicians in our jurisdiction who served a large population of clients who participate in the Special Supplemental Food and Nutrition Program for Women, Infants and Children (WIC) to elicit what nutrition materials they were currently using in their practice and what was needed for patient education. The two broad categories identified by physicians as a need for intervention were breastfeeding and childhood obesity.  The following year in 2005, the project continued with TCHD conducting a follow-up survey focused on refining the types of breastfeeding and childhood obesity materials desired and the form in which the physician offices would prefer to receive the information. Breastfeeding and child healthy weight materials were identified (pamphlets, resource lists, and assessment tools) and placed in a kit with hanging file folders of information. Kits were distributed at 21 physician offices at a lunch presentation which highlighted how using the materials could save provider time, improve patient care, and promoted TCHD services. A WIC registered dietitian presented the materials at the physician offices where she would serve as the liaison, attending regularly scheduled networking meetings to maintain and strengthen the community partnerships built as a result of the project. In a six-month follow-up survey, over 50% of the offices reported accessing the kit at least once a day for patient education. This project entitled Marketing Nutrition to Physicians received a NACCHO model practice award in 2007. However, a variety of factors caused the kits to become obsolete. With improvements in technology, many physicians began using computers during patient visits and printing handouts as needed for education. Staff turnover at TCHD resulted in decreased in-person contact with physician offices reducing utilization of TCHD as a community breastfeeding resource.  Another way TCHD has collaborated with community partners to help women achieve breastfeeding success is through offering a two-part basic breastfeeding training to providers.  In 2012 and 2013, a TCHD Lactation Specialist held networking meetings with 20 hospital and health care clinics to discuss ways to collaborate effectively to improve breastfeeding support. Lack of breastfeeding training was identified as a need in these meeting so TCHD developed a free basic breastfeeding training which was completed at six health care provider offices. Why is current/proposed practice better? A new creative approach was needed to bring TCHD to the forefront again as a breastfeeding resource. Completion of the physician breastfeeding needs assessment project has led to the creation of a Breastfeeding Resources for Health Care Providers webpage on the TCHD agency website. Using a webpage to provide tailored breastfeeding resources is more effective than the previous kit project in many ways. First, using a webpage expands the project reach to all physicians in the TCHD jurisdiction creating a large network of support for women. Second, TCHD serves a large geographic area covering three counties where physician offices vary in size, culture and needs, and each individual office can use the webpage materials as works best for their office to meet the needs of a wide variety of staff and patients. Finally, using a webpage simplifies the process of keeping resources and materials current, is sustainable with minimal staff and financial resources, and use is easy to evaluate. Is current practice innovative? How so/explain? This project used the framework outlined in MAP-IT: A Guide to Using Healthy People 2020 in Your Community. Using this framework, conducting a needs assessment survey, and creating a resource webpage are not new to the field of public health but this particular approach has several unique aspects. First, according to the literature review, this is the first survey to investigate current practice, knowledge, and comfort concerning breastfeeding support and barriers amongst Colorado physicians. Second, while other physician resources exist, including webpages listed in the NACCHO toolkit, our project is unique in that it provided breastfeeding materials tailored for physicians working with families of all income levels with an emphasis on building community partnerships with these physicians to improve patient care. Needs assessment survey questions were centered on resources needed, but also gathered physician ideas on how they could work in collaboration with TCHD to support women in the community. When physicians accessed the webpage, they not only had access to requested resources but were exposed to information about TCHD programs and staff contact information. Networking meetings helped to solidify community partnerships and have served as a way to market and solicit ideas for the webpage. Many existing webpages have links to other sites which must be navigated further to find needed information. A third way this project is innovative is that the TCHD webpage provided information as a direct link to increase ease of access and counteract the barrier of physician’s limited time to provide breastfeeding information to patients. As being a local health department with limited resources, we have limitations on what can be created and offered to physician offices. Researching and providing access to existing resources and modifying existing TCHD programs, such as converting trainings into lunch and learn sessions, was an effective way to share resources. Another unique aspect of this project is that the TCHD webpage has a resource area for patients and a resource area for physicians and their staff. This aided physicians in both educating patients and improving staff knowledge to improve services. Finally,  conducting the needs assessment project with the help of dietetic interns was an innovative way to fulfill a portion of the internship training competencies and provided the health department with an economical way of completing the needs assessment survey process. Is the current practice evidence-based? Support for increasing breastfeeding rates as a strategy to combat childhood obesity and improve the health of the nation is referenced in several Morbidity and Mortality Weekly Recommendations and Reports (MMWR). Recommendations include increasing exclusive breastfeeding rates and decreasing disparities in breastfeeding initiation and duration and exclusive breastfeeding among subgroups such as African American women. As outlined in the U.S. Department of Health and Human Services Blueprint for Action on Breastfeeding, areas to target include maternity care practices, interactions with health-care professionals, and workplace support.[7] Another MMWR report stated that although there is no single solution to increasing support for breastfeeding women, the 2011 Surgeon General's Call to Action to Support Breastfeeding outlines a number of actions aimed at increasing societal support for women who choose to breastfeed.[8] Strategies to increase breastfeeding support include improving maternity care practices and increasing education for health care professionals. Guidelines in the National Guideline Clearinghouse are specific to increasing breastfeeding rates including the 2013 Academy of Breastfeeding Medicine Clinical Protocol #14 entitled Breastfeeding-friendly physician office: optimizing care for infants and children. A CDC Vital Signs report recommended that physicians need to learn how to counsel mothers on breastfeeding during prenatal visits and support breastfeeding in the hospital and at each pediatric doctor's visit until breastfeeding stops. It is also recommended that physicians work to coordinate lactation care between the hospital and community resources such as local health departments. [9] [1] CDC Vital Signs, August 2011, National Center for Chronic Disease and Prevention and Health Promotion, Division of Nutrition, Physical Activity, and Obesity.[2] Arnez, S, Ruckerl, R, Koletzko, B, von Kries, R. (2004) Breastfeeding and childhood obesity – a systematic review. Int J Obes Relat Metab Disord. Pps  1247-1256.  [3] American Academy of Pediatrics. (2003) Policy Statement on the Prevention of Pediatric Overweight and Obesity, Pediatrics, Pps. 424-430.[4] Colorado Physician Activity and Nutrition Program. (2009), The Weight of the State: Report on Overweight and Obesity in Colorado. Colorado Department of Public Health and Environment.[5] National Immunization Survey (2007), Centers for Disease Control and Prevention, DHHS.[6] Colorado Pregnancy Risk Assessment Monitoring Systems Statistics (2010), CDPHE.[7] Breastfeeding Trends and Updated National Health Objectives for Exclusive Breastfeeding --- United States, Birth Years 2000—2004, August 3, 2007 /  56(30);760-763.[8] Progress in Increasing Breastfeeding and Reducing Racial/Ethnic Differences — United States, 2000–2008 Births, February 8, 2013 / 62(05);77-80.[9] CDC Vital Signs, August 2011, National Center for Chronic Disease and Prevention and Health Promotion, Division of Nutrition, Physical Activity, and Obesity.
Nutrition, Physical Activity, and Obesity
Goals and objectives of practice.; What did you do to achieve the goals and objectives?; Steps taken to implement the program.; Any criteria for who was selected to receive the practice? The goal of this project was to improve the quality of breastfeeding information and support provided by health care providers in the TCHD jurisdiction through partnerships with TCHD. Internal collaborations within the health department and community collaboration played a part in completing all four objectives. Objective 1: By August 31, 2013, create and pilot test a need assessment survey with a minimum of five members of the target population to determine how TCHD can assist physicians in patient support and employee education about breastfeeding. The project began on September 1, 2103 when an internal TCHD planning committee met and created a plan to reestablish collaborative relationships with physicians in Adams, Arapahoe, and Douglas Counties and improve the network of breastfeeding support available to women in the community.  The committee members were from two TCHD divisions, the Nutrition Division and the Epidemiology Planning and Communication Division. Members from the Nutrition Division included the TCHD Dietetic Internship Program Director, the TCHD Breastfeeding Coordinator, and three dietetic interns. The committee also included an experienced TCHD Population Health Epidemiologist. A partnership was created with the TCHD Dietetic Internship Program Director to train the TCHD dietetic intern class on community needs assessments and survey implementation. This training has become a part of the internship curriculum. All incoming dietetic interns will be trained and play a role in both future community assessments and updating breastfeeding resource materials for physicians. All work completed by dietetic interns is guided by TCHD professional staff and approved by TCHD Division Directors.   Three dietetic interns completed a literature review to identify existing successful collaboration programs between health departments and health care provider offices. The internal TCHD planning committee created a 16 question physician needs assessment survey with both multiple choice and open response formats. The survey included questions regarding demographics of the physician’s practice, at what time during pregnancy and post-partum they counsel women regarding breastfeeding, patients’ common problems and addressing breastfeeding complications, how comfortable they felt with breastfeeding, barriers to support, and what materials they wish to have for breastfeeding support. TCHD partnered with two experts in the field of lactation in our jurisdiction along with five members of the target population to review the survey and provide comments on content and format.  Objective 2: By December 31, 2013, survey a minimum of 150 randomly selected obstetrician and gynecologists, family practice physicians, and pediatricians to determine current breastfeeding support practices, resources, common barriers and needs. Our Office of Emergency Preparedness provided access to the Peregrine Database, a commercial database of physicians. In order to focus on community-based providers, physicians with practice locations at the Anschutz medical campus in Aurora (University of Colorado Hospital and Children’s Hospital), were removed from the sampling frame.  From this database, OB/GYN  (n=100), Family Medicine (n=50), and Pediatric physicians (n=50) were randomly selected using the random number function in Microsoft Excel. The only criteria necessary for participation in the project was to be a physician with a practice address in Adams, Arapahoe or Douglas Counties. All surveys were mailed, in a series of 3 mailings.  1) Original paper survey, cover letter, and pre-stamped return envelope mailed October 18, 2014 with a $5 Starbucks gift card used as a thank you and incentive for survey completion, 2) A reminder post card, sent on October 28, 2014, and 3) The final mail-out, sent out November 12, 2014, was a replacement survey, with cover letter, and pre-stamped envelope mailed to physicians who had not yet responded.  Physicians had the option of completing the paper survey and mailing it back to the TCHD office, or to enter the survey into Survey Monkey® (available at https://www.surveymonkey.com/). Objective 3: By September 30, 2014, create or provide, based on results from the needs assessment survey, a minimum of one breastfeeding resource for physicians, their health care clinic staff, and their patients.   Based on results from the needs assessment survey, the top selected breastfeeding resources for physicians, their health care clinic staff, and their patients were placed on a Breastfeeding Resources for Health Care Providers webpage launched on the TCHD agency website on September 1, 2014. Since its launch, 72 individuals have accessed the page for information or resources.      The Epidemiology Planning and Communication Division assisted with project evaluation and analyzing the results of the survey.  The TCHD Website Team assisted with evaluating use of the Breastfeeding Resources for Health Care Providers webpage and the evaluation is ongoing. Objective 4: By October 31, 3014, complete networking meetings with a minimum of two health care provider clinics in Adams, Arapahoe and Douglas counties to build community partnerships. Health care provider staff from two offices met with TCHD lactation staff to network and discuss how best to work together to meet the breastfeeding support needs of women residing in Adams, Arapahoe and Douglas Counties. TCHD has learned from past efforts that face-to-face meetings help maintain community partnerships. These meetings began in June 2014 and will be on-going.   What was the timeframe for the practice? The project began September 1, 2013 and concluded October 31, 2014. The needs assessment survey was administered between October 18, 2013 and December 1, 2013. The Breastfeeding Resources for Health Care Providers webpage launched on the TCHD agency website on September 1, 2014. The networking meetings took place between June 1, 2014 and October 31, 2014. Were other stakeholders involved?; What was their role in the planning and implementation process? Building collaborative relationships between TCHD and physicians in Adams, Arapahoe and Douglas Counties was a main focus of the project. Physicians played a key role in survey development and describing the current landscape of breastfeeding support available for women in the TCHD community. Survey responses identified what support is currently provided, common patient questions and concerns, common barriers to providing support and needs regarding breastfeeding information and resources. This information determined what resources were included on the webpage. Involving the target audience in the determining the webpage content increases the likelihood they will utilize the resource. What does the LDH do to foster collaboration with community stakeholders?; Describe the relationships and how it furthers the practice goal.   Collaborative relationships should continue to form as physicians become more aware of TCHD programs and services through webpage use and contact the health department for information. Physician offices that have completed the established two-part basic breastfeeding training (which is now marketed on the website as a free lunch and learn option) have developed strong working relationships with TCHD lactation staff. Due to the large reach of this project, we believe that there is potential for the development of many future partnerships. Regular networking meetings with TCHD area hospitals and health care clinics with TCHD lactation staff to discuss needs and resources are scheduled to continue in 2015. Another way that TCHD fosters collaboration with this project’s target population and other community partners is through participation on community committees. TCHD staff have consistently played an active role in several committees that promote breastfeeding, such as the Colorado Department of Public Health and Environment Breastfeeding Advisory Committee, the Colorado Breastfeeding Coalition, Diabetes Prevention Program State Committee, Early Childhood Overweight Prevention in Early Care and Education Settings, State Coalition on Childhood Obesity Prevention, and the internal TCHD breastfeeding task force which coordinates breastfeeding activities between TCHD divisions. TCHD also serves as a resource for other local health departments interested in learning about their communities. Since the completion of the needs assessment survey, the survey questions and results have been utilized by Denver County WIC, who designed a similar survey for assessing breastfeeding training needs for physicians within the Denver County jurisdiction. TCHD hopes other agencies throughout Colorado will use information from this project as a resource since use of the same questions in other surveys could allow for combined results and coordinated training responses. Partnering with physicians, sharing expertise in breastfeeding support and promotion with health care providers at committee meetings, and sharing best practice projects and lessons learned with other local health departments all contribute to this project’s goal of improving the quality of breastfeeding information and support provided by health care providers in the TCHD jurisdiction through partnerships with TCHD. Any start up or in-kind costs and funding services associated with this practice?; Please provide actual data, if possible. Else, provide an estimate of start-up costs/ budget breakdown. The start-up costs for this project consisted of printing, mailing costs and the incentive. TCHD and health care provider time for planning, implementation and evaluation was provided in-kind. The expenses for this project were paid for through the TCHD Nutrition Division’s Community Nutrition Program budget. The total cost of the project was $1,355.33 which included $4.35 for one and a half reams of paper, $184 for the initial mailing of 200 surveys with two stamps, $62.28 for one box of 500 #10 envelopes, $1,000 for 200 $5 Starbucks gift cards, $49.50 for the mailing of 150 reminder postcards, and $55.20 for the mailing of 120 follow-up surveys with one stamp.  
What did you find out? The needs assessment survey yielded some interesting information. A full analysis of the survey results is available at http://www.tchd.org/508/Breastfeeding-Resources-for-Health-Care-. The highlights include: When asked the time at which breastfeeding was discussed with patients during maternal visits, the most common time was after delivery while still at the hospital (n=72, 69.2%), followed by 6 weeks postpartum (n=65, 62.5%), and 3rd trimester (n=58, 55.8%). Other times were 1st trimester (n=34, 32.7%), 2nd trimester (n=29, 27.9%), respectively. For pediatric visits, “3 to 5 days of age” was the most common time period (n=52, 50.0%) at which breastfeeding was discussed, followed by “2 weeks to 1 month of age” (n=51, 49.0%) and “2 months” old (n=46, 44.2%), respectively. Although breastfeeding discussion decreased as infants grew older, 26.9% (n=28) of respondents still talked to their patients about breastfeeding when infants reached 12 months of age. Looking at the responses from OB/GYN, Family Practice, and Pediatricians combined, the two most necessary topics for patient education reported were 1) what to expect in the first week (n=57, 55.3%) and 2) how to know if infant is getting enough milk (n=55, 53.4%), followed by 3) Breastfeeding myths (n=40, 38.8), 4) Prevention of sore nipples (n=37, 35.9%), 5) What to expect in the first month (n=35, 34.0%), and 6) Breastfeeding benefits (n=31, 30.1%). The rankings are similar when looking at OB/GYN separately from Family Medicine and Pediatric physicians. This indicated that the most necessary topics for patient education are the same among different practices. Provided with a list of nine potential breastfeeding topics that TCHD could provide education for physicians’ office staff, the most desired topics were listed in the following descending order: 1) solutions to common breastfeeding concerns (n=75, 74.3%), 2) proper latch and positioning technique (n=56, 55.4%), 3) milk production/supply (n=44, 43.6%), 4) sore or cracked nipples (n=35, 34.7%), 5) drug safety while breastfeeding (n=27, 26.7%), 6) breastfeeding benefits (n=20, 19.8%).  When physicians were asked how comfortable they were when addressing breastfeeding concerns with patients, on a scale of 1-5 from very uncomfortable (1)  to very comfortable (5), 68.7% of all physicians selected a score of 4 or 5 indicating that they are comfortable when discussing breastfeeding topics. After analyzing our data, there is a clear difference between the comfort level of Family Practice and Pediatric physicians compared to OB/GYNs.   The vast majority (83.9%) of Family Practice and Pediatric physicians indicated that they were comfortable addressing breastfeeding concerns by selecting a score of 4 or 5 compared to 60% of OB/GYN physicians who signified that they were comfortable. This finding was statistically significant (X2= 9.6, 2.d.f., p<0.01).  For patient education, most physicians preferred handouts or pamphlets and fact sheets (n=85, 82.5%), web links to instructional videos (n=43, 41.7%), and referral sheets for community-based lactation support (n=43, 41.7%). In terms of staff education, most physicians also preferred handouts or pamphlets (n=46, 45.1%), and lunch and learn events (n=42, 41.2%), breastfeeding websites (n=41, 40.2%), and web-based training (n=34, 33.3%). Some physicians reported time limits during each patient’s visit (n=84, 84.0%) as the most common barrier in providing breastfeeding education, while others needed more information about available resources (n=61, 65.6%) and indicated they had limited training in breastfeeding management (n=48, 52.2%). To what extent were your objectives achieved?; Please re-state your objectives from the methodology section.; Did you evaluate your practice?; List any primary data sources, who collected the data, and how (if applicable).; List performance measures used.; Include process and outcome measures as appropriate.; Describe how results were analyzed.; Were any modifications made to the practice as a result of the data findings? The goal of the project was to improve the quality of breastfeeding information and support provided by health care providers in the TCHD jurisdiction through partnerships with TCHD. The objectives for this project were achieved in full and the project was evaluated. Objective 1: By August 31, 2013, create and pilot test a need assessment survey with a minimum of five members of the target population to determine how TCHD can assist physicians in patient support and employee education about breastfeeding. Performance Measure: A needs assessment survey was created and reviewed by seven members of the target population. The primary source of data for this objective was the creation of the 16 question paper and Survey Monkey needs assessment survey and review comments from members of the target population. Dietetic interns collected the review comments supervised by the TCHD Dietetic Internship Director, the TCHD Breastfeeding Coordinator, and the TCHD Population Health Epidemiologist. The survey was sent out for review to two physicians, Dr. Marianne Neifert and Dr. Maya Bunik, both well-known in the Denver areas as experts in the field of lactation. Five additional members of the target population also reviewed the survey and provided comments. All comments were provided in written form. Comments were summarized by the dietetic interns and modifications were made to the survey questions and format to assure the desired information was being collected.     Objective 2: By December 31, 2013, survey a minimum of 150 randomly selected obstetrician and gynecologists, family practice physicians, and pediatricians to determine current breastfeeding support practices, resources, common barriers and needs.   Performance Measure: The needs assessment survey was distributed to 200 randomly selected OB/GYN, family practice physicians, and pediatricians with a practice address in Adams, Arapahoe, or Douglas Counties. Of the total 200 surveys distributed, 111 responses were received yielding a 55.5% response rate. Fifty-one responses were from OB/GYN physicians, for a 51% response rate for the specialty (51/100); 38 family physicians responded for a response rate of 76.0% (38/50), and 22 pediatricians responded for a response rate of 43% (22/50). The primary data source for this objective was the paper or Survey Monkey needs assessment survey.  Dietetic interns collected and evaluated the data supervised by the TCHD Dietetic Internship Director, the TCHD Breastfeeding Coordinator, and the TCHD Population Health Epidemiologist. Prior to the first mail out, Microsoft Excel spreadsheets were created for the dietetic interns to record responses as they arrived through the mail and Survey Monkey website.  Data was collected from the months of October 2013 through December 2013 by checking https://www.surveymonkey.com/ and the appropriate mailbox at noon every day. Paper surveys received by mail were entered into Survey Monkey the same day.  Surveys completed through Survey Monkey originally, were noted of and captured in Excel. Two Excel datasheets were created separating OB/GYNs from Family Medicine and Pediatric physicians.  The Excel worksheets were divided into 11 columns identifying the physician by a unique ID number, their specialty, last name, first name, street, city, state, reply method (either paper survey or an online survey), date the survey was received in office, and if the survey was entered into Survey Monkey (with the processer’s initials).  For extra precaution in data entry, paper tracking sheets were also used.  Survey ID number, initials of processor and date were listed as the surveys were received. Data were analyzed in Survey Monkey and also exported to Microsoft Excel.  For each close-ended question, the frequency of responses was tabulated using the number of physicians who answered the question as the denominator. Objective 3: By September 30, 2014, create or provide, based on results from the needs assessment survey, a minimum of one breastfeeding resource for physicians, their health care clinic staff, and their patients.   Performance Measure: Breastfeeding resources identified in the survey for physicians, their health care clinic staff and their patients provided to all physicians with a practice address in Adams, Arapahoe or Douglas Counties, including all who responded to the survey, through the creation of a Breastfeeding Resources for Health Care Providers webpage. The primary data source for this objective was the creation of the resource webpage for physicians. The TCHD Website Team collected data on webpage use, including number of individuals accessing the webpage and resources viewed, through TCHD agency website reports. Since its launch, 72 individuals have accessed the Breastfeeding Resources for Health Care Providers webpage site for information and resources. Since the webpage contains evidenced-based breastfeeding information and trusted resources, the more health care providers that access the site, the higher the quality of breastfeeding information and support that will be provided to women residing in Adams, Arapahoe and Douglas Counties. The webpage was launched on September 1, 2014 and information from TCHD agency website reports was gathered and compiled for evaluation. Use and feedback regarding the webpage will continue to be solicited and monitored on a regular basis and modifications to the webpage will be completed as needed. Objective 4: By October 31, 2014, complete networking meetings with a minimum of two health care provider clinics in Adams, Arapahoe and Douglas counties to build community partnerships. Performance Measure: The completion of two networking meetings held with the St. Anthony North Nurse Family Partnership program and the Lactation Program staff at University Hospital.    The primary source of data for this objective was tracking the number of completed networking meetings held with health care provider groups. A TCHD IBCLC recorded meeting minutes and listed ideas shared during the meeting for collaboration to improve breastfeeding information and support provided to mothers. Comments and ideas from the meetings were summarized by a TCHD IBCLC and information learned was discussed with additional TCHD lactation staff. Ideas will be implemented as able to strengthen working relationships and community partnerships. One modification made to the networking meeting component was for TCHD lactation staff to meet with a designated individual at a physician office that could discuss collaboration ideas and share information with the rest of the staff if scheduling difficulties prevented meeting with a group of health care providers from the office.    Continued evaluation and follow-up surveys with physicians will determine the extent to which use of the Breastfeeding Resources for Health Care Providers webpage, lunch and learn trainings, and networking meetings improved the quality of breastfeeding information and support provided by health care providers in the TCHD jurisdiction. The number of individuals accessing the website, the number of networking meetings held, and the number of partnerships built will continue to be tracked.    
Lessons learned in relation to practice. All of the project objectives were met and lessons were learned during the process. One lesson learned when implementing a needs assessment survey is to choose the target population carefully. Since the focus of the survey was on community-based physician practices, surveys were not sent to physicians who had offices at University Hospital or Children’s Hospital.  This unintentionally decreased the number of practices surveyed who had a high percentage of low income patients or patients on Medicaid. Using an experienced population health epidemiologist to create survey questions and having members of the target population review the survey prior to mass distribution assured accurate and relevant information was collected. Administering the survey to randomly selected health care providers with a practice address in Adams, Arapahoe or Douglas Counties helped eliminated bias. Offering multiple ways to complete the survey, using an incentive, and providing reminders all improved the survey response rate. Lessons learned in relation to partner collaboration. A lesson learned in relation to partner collaboration is that physicians have busy schedules and it can be difficult to schedule lunch and learn sessions or networking meetings. Finding a contact in the office with authority over office schedules is helpful or meeting with the office manager to discuss collaboration who can then share information at a later time with the entire staff.  Another lesson learned is meeting with health care providers in person significantly strengthens the collaborative relationship. Did you do a cost/benefit analysis? A cost/benefit analysis was not a component of the project. Is there sufficient stakeholder commitment to sustain the practice? The comprehensive needs assessment completed at the beginning of the project helped assure physician commitment to use the webpage and will aid in sustainability. Successful collaborative relationships have been established as a result of the project, such as relationships with Nurse Family Partnership programs and local hospitals, and there is a potential to develop many more due to the large project reach. As more physicians use the website, schedule lunch and learn trainings, and participate in networking meetings, more partnerships should form, thereby increasing the network of breastfeeding support. Continuing to solicit input and ideas from the target population during networking meetings and through follow-up surveys will assure the webpage is meeting current needs will help maintain these relationships. Networking meetings should be an easy and effective way to continue to market the website and keep TCHD in the forefront as a community breastfeeding resource.  Two health care provider offices have already contacted TCHD for additional breastfeeding information and resources. Describe sustainability plans. This project can be sustained with minimal resources and TCHD administration supports the project as being in-line with the vision and mission of the health department and our new Strategic Plan. Keeping the webpage current and on-going evaluation of content and use has been added to the TCHD Breastfeeding Coordinator job description. Networking and building community support is already a function of the TCHD IBCLC position. TCHD received a grant from the Colorado Department of Public Environment to fund webpage marketing efforts and staff time for webpage development. Marketing included each physician receiving a mailing with a promotional poster, a summary of the survey results and a flyer advertising the new webpage. Information about the webpage has been shared with all WIC staff working in the state of Colorado and marketing efforts will continue through TCHD social media and distributing the webpage marketing flyer at all networking and community meetings. Giving health care providers easy access to evidenced-based information and trusted resources tailored to meet their needs has the potential to increase the number of women who receive best practice breastfeeding support. This will lead to more mothers meeting their breastfeeding goals, higher breastfeeding rates, and improved maternal and infant health with lower rates of childhood obesity and chronic disease.  
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