Washington 'Steps' Up: A 10-Step Quality Improvement Initiative to Optimize Breastfeeding Support in Community Health Centers.

BACKGROUND: Breastfeeding initiation in Washington State (Northwest United States) is high, yet rates plummet by 3 months postpartum. In the United States, national quality improvement (QI) efforts to improve breastfeeding outcomes have largely focused on hospital maternity care practices through implementation of the Ten Steps to Successful Breastfeeding. This framework has not extended similarly to primary care clinics, a key site for supporting continued breastfeeding following hospital discharge. This article details a pilot effort with community clinics to implement 10 evidence-based steps to support breastfeeding in the clinic setting and to evaluate the process and outcomes. OBJECTIVE: A public-private-academic partnership developed and piloted a 10-step clinic breastfeeding support strategy and focused resources, training, and technical assistance on primary care clinics to help facilitate best-practice policy and environmental changes to improve clinic breastfeeding support. METHODS: Eight health centers, serving predominantly Latino and Native American communities, worked to systematically implement 10 evidence-based steps developed for the community primary care setting. An evidence table, self-assessment with scoring criteria, tool kit, and provider reference documents were developed to guide clinics. RESULTS: At baseline, clinics had 2 steps, on average, already in practice (range, 1-4 steps); by final assessment, an average of 7 steps was implemented (range, 5-9 steps). Within 6 months from pre-intervention to post, clinics fully operationalized between 2 and 7 steps. CONCLUSION: Catalyzing clinic QI efforts through an evidence-based 10-step model is an effective way to optimize primary care breastfeeding support and to strengthen the continuum of care for breastfeeding mothers and babies following hospital discharge.

A Community Health Clinic Breastfeeding-Friendly Pilot: What Can We Learn about the Policy Process?

BACKGROUND: Implementing evidence-based practices and policies for breastfeeding support in community clinics is a promising, but challenging, approach to reducing disparities in breastfeeding rates. OBJECTIVE: This study aimed to apply a policy process research framework to increase knowledge of factors that facilitate adoption and implementation of breastfeeding policy changes. METHODS: In 2013, Washington State piloted a process to encourage 8 clinics to adopt and implement steps to become breastfeeding friendly. Evaluation data were collected through interviews, project reports, training evaluations, and pre- and post-self-assessments of achievement of the steps. RESULTS: In 6 months, clinics increased the breastfeeding-friendly steps that they were implementing from a median (interquartile range) of 1.5 (0-3) to 6 (5-7). Improvements were most likely in the steps that required the fewest resources and administrative changes. Barriers to implementation included misperceptions about breastfeeding and breastfeeding support; lack of administrative "buy-in"; need for organizational changes to accommodate actions like monitoring breastfeeding rates and allowing providers training time; and the social-political climate of the clinic. Several factors, including actions taken by public health practitioners, enhanced the change process. These included fostering supportive relationships, targeting technical assistance, and providing resources for planning and training. CONCLUSION: This pilot project demonstrates that it is possible to make changes in breastfeeding support practices and policies in community clinics. Recommendations to enhance future work include framing and marketing breastfeeding support in ways that resonate with clinic decision makers and enhancing training, resources, and advocacy to build capacity for internal and external systems changes to support breastfeeding best practices.

A framework for developing evaluation tools used in Washington State's Healthy Communities projects.

Washington State's Healthy Communities pilot projects were developed to test approaches and recommendations of the Washington State Nutrition and Physical Activity Plan and to provide a statewide model for implementation. The Healthy Communities program included plans for ongoing process evaluation to ensure implementation. Two years into the first project, however, the evaluation team recognized that data for evaluation were inadequate to explain the experiences of the pilot community partnership. The team sought a framework through which to better understand how the community partnership functioned, including what worked well and how guidance and technical assistance could best be provided. The evaluation team identified the community health governance model of Lasker and Weiss through a literature search and applied this model to existing Healthy Communities project evaluation data. The team also designed a new survey tool based on the model and used it in the second pilot community. The new tool provides feedback to community partners to help guide project implementation and tests the applicability of a theoretical model to public health practice.