A Model Practice must be responsive to a particular local public health problem or concern. An innovative practice must be -
Please state the Responsiveness and Innovation of your practice
Jefferson County experiences high rates of breast/chest feeding initiation, but sharp decreases in duration (especially among communities of color and low-income families) which suggests that support for continuation of breast/chest feeding is lacking. Community members have shared stories of difficulties accessing lactation care, insufficient support after immediate postpartum, language barriers, and lack of advocacy for workplace accommodations, especially low-wage workplaces which explain the decrease in lactation rates. Moreover, stigma and uninformed practices such as introduction of formula or early solids, and misconceptions about quality of milk, lactation management, or protections to breast/chest feeding parents limit the success of families who are committed to provide human milk to their babies.
Jefferson County is located near the center of the state along the Front Range of the Rocky Mountains, adjacent to the state capital of Denver. U.S. census estimates in 2017 identify the population of Jefferson County at 580,233 making it the fourth-most populous county in Colorado. The population includes 25.30% under the age of 18, 8.10% from 18 to 24, 32.10% from 25 to 44, 24.90% from 45 to 64, and 9.60% who were 65 years of age or older. The median income for a family was $67,310. About 3.40% of families and 5.20% of the population were below the poverty line, including 5.80% of those under age 18 and 5.10% of those age 65 or over.
In Jefferson County, children age six and under make up approximately 6.5% of Jefferson County’s population. Of all children in Jefferson County, 69.2% identify as non-Hispanic White, 22.6% identify as Hispanic, 1.1% identify as Black, 2.6% identify as Asian or Pacific Islander, and 0.1% identify as American Indian or Alaska Native, with 5.9% identify as two or more races[i].
The average number of births between 2012- 2013 was 5,717 with 73% of babies born to families who identify as non-Hispanic White, 19.3% of births to families who identify as Hispanic, 1.3% identify as Black, 3.8% identify as Asian Pacific Islander, and 0.7% as American Indian or Alaska Native. Children living in households with Supplemental Security Income (SSI), cash public assistance income, or Food Stamp/SNAP benefits accounted for the 11.7% of children[ii]
The target population is families of children younger than 2, which is estimated to be 15,869 children. An additional focus are children whose parents identify as Hispanic/Latino and whose income is below poverty rate, which is estimated to be approximately 3,500.
Our work has reached about 20% of the target population through different initiatives.
- From medical offices participating in the Lactation Friendly Recognitions, which includes Certified Lactation Counselor (CLC) trainings, practice change, and informational materials, we have reached approximately 400 families. The medical practices involved serve families who have a low-income.
- Child Care Certifications have reached 288 children. This includes child care centers working with families with low-income, licensed home child care providers, and Family, Friend, and Neighbor (FFN) providers.
- Worksites has reached 1,000 employees across 10 employers, including Jeffco Public Schools, Jefferson County Public Libraries, and Jefferson County Human Services which has a significative ripple effect.
- Emergency preparedness has impact in the whole population through awareness and emergency response planning.
- Through partnership with our Breastfeeding-Friendly Certified local hospital, we have indirectly reached about 3,305 of children younger than 2.
- Through training and referral processes with home visiting programs, WIC, and clinic staff we have indirectly reached: WIC - 5,397 children; home visitation - 520 families, and clinic - 4,500 (between family planning and West Points program).
In the past, our lactation services were provided predominantly through WIC and home visitation programs. Now, in addition to these direct services, JCPH uses Community Based Participatory Research (CBPR) principles as an evidence-based strategy to build and sustain community partnerships and create a lactation-friendly culture from an ecological perspective. JCPH does not do research but uses the principles of CBPR as a framework for developing authentic and sustainable community partnerships.
While CBPR as a research approach is not new to the field of public health, using CBRP principles to guide work is rarely seen in local public health agencies. At the core of this practice, JCPH demonstrates appreciation for community expertise and creates co-learning spaces where we experience how communities navigate the systems of care to identify breakdowns and build solutions together. We have learned that, amid many challenges, families may not see lactation as their priority, but when we approach lactation in the context of community needs and opportunities in everyday life, families highlight its importance. In partnership with community members and using culturally and linguistically competent practices, we develop effective strategies to improve lactation rates, increase child development knowledge, and support mental health for the whole family. This community partnerships’ systems-based approach expands previous lactation efforts and builds sustainability for a cultural shift across different aspects of maternal child health.
Additionally, CBPR principles enhances our coordination and alignment as an agency. In 2017, an internal learning collaborative group was started with the intention of convening JCPH staff from different divisions and programs to learn lactation-specific content and share experiences working with families in direct services and population work. This initiative has advanced JCPC staff’s capacity and commitment to see their role as lactation supporter across their functions and gain deeper understanding of family’s lactation ecosystems. This internal collaboration has improved informal and formal coordination across divisions and programs, and the development of cross- disciplinary team projects inclusive of community members.
Externally, through a partnership with the Adelante Network, JCPH worked with community members in the development, implementation, and evaluation of trainings and certifications for FFN child care providers. Using the Breastfeeding Friendly Child Care Toolkit (developed by the Colorado Department of Public Health and Environment, CDPHE) our team and community members created a process to train and certify FFNs, so they could receive information and connections to support child development and healthy feeding practices. This felt imperative knowing that Jeffco Public Schools estimates that 50% of children in the county are not in licensed child care facilities, but with their families or under FFN care. Most parents choose FFN care due to flexibility of schedules (working evening, night or weekend shifts), trust in providers, language and physical accessibility, and cost efficiency. Working with already trusted community leaders in lactation strategies place knowledge and connections directly in the family’s closest environment. Not only they know how to access care, they also have an advocate in their own community.
CBPR principles involves an iterative process of improvement and innovation. For example, with the realization that the county did not have an Infant and Young Child Feeding in Emergencies Preparedness Plan (IYCF-E), JCPH formed a cross divisional team to develop a relevant and community-centered plan. This included embedding IYCF-E into current emergency response system to facilitate volunteer recognition and access to resources, training and coordination of bilingual volunteers (English and Spanish), and shelter kits and materials in four languages. Community IBCLCs, lactation counselors and supporters, and JCPH staff from three divisions came together to a facilitated discussion and training to identify different scenarios and priorities, as well as to inform the roles of the first cohort of lactation first responders. The IYCF-E plan has been now incorporated as an official appendix of the Public Health Emergency Operations Plan Emergency Support Function. English and Spanish-speaking lactation first responders, and family and shelter lactation support kits are ready to deploy as needed. Adelante Lactation Counselors are currently exploring strategies to build awareness and trust with Latinx, Spanish-speaking communities and guarantee community participation in case of an emergency. Finally, JCPH is working with regional partners and supporting other counties in Colorado to develop their own plans based on their systems of emergency response and local community needs.
Lastly, another example of the innovation potential of CBPR and the impact of a systems-based approach is the current partnership with the PASO program (Providers Advancing Student Outcomes). PASO is a program under the Colorado Statewide Parent Coalition (CSPC), a non-profit, grassroots organization that is the only Child Development Associate (CDA) credential provider in the state. PASO participants who earn their CDA can work as staff in child care centers, open their own child care facility, or seek licensure if desire. The PASO program has trained over 1,200 child care providers in the last 10 years and about 80 child care providers went through their program in 2019. The goal of this partnership is to embed the lactation education modules for Breastfeeding Friendly Child Care and visits/incentives support into their curricular program for long-term sustainability. While currently only offered in Spanish, PASO will be piloted in English and with a focus on African-refugee experience in 2020.
CPBR principles are an innovative practice in public health because it creates co-learning, collaborative spaces where partners share power and control over decisions. While JCPH has limited staff capacity and resources, our community members and partners have a significant opportunity to incorporate a lactation and child development framework into their work across sectors and systems. CBPR holds the promise of sustainability by elevating community capacity to lead the work.
Community-based participatory research (CBPR) is a well-known framework for community engagement. CBPR is a research approach designed to ensure and establish structures for participation and collaboration among the communities affected by the issue being studied, representatives of organizations, and researchers[iii]. Its aim is to achieve social change to improve health outcomes and eliminate health disparities [iv].
CBPR principles (1) demonstrate respect for community autonomy; (2) elicit ideas from community members for potential health interventions; and (3) strengthen the capacities of participants to gain control over the conditions that affect health[v].
The eleven key principles of CBPR are:
- Recognizes community as a unit of identity.
- Builds on strengths and resources within the community.
- Facilitates a collaborative, equitable partnership in all phases of research, involving an empowering and power-sharing process that attends to social inequalities.
- Fosters co-learning and capacity building among all partners.
- Integrates and achieves a balance between knowledge generation and intervention for the mutual benefit of all partners.
- Focuses on the local relevance of public health problems and on ecological perspectives that attend to the multiple determinants of health.
- Involves systems development using a cyclical and iterative process.
- Disseminates results to all partners and involves them in the wider dissemination of results.
- Involves a long-term process and commitment to sustainability.
- Openly addresses issues of race, ethnicity, racism, and social class, and embodies “cultural humility.”
- Works to ensure research rigor and validity but also seeks to ”broaden the bandwidth of validity” with respect to research relevance[1] [2] [3].
[1] Israel, Barbara, Amy J. Schulz, Edith A. Parker, and Adam B. Becker. 1998. REVIEW OF COMMUNITY-BASED RESEARCH: Assessing Partnership Approaches to Improve Public Health. Annual Review of Public Health, 19:173–202.
[2] Israel, Barbara A., Chris M. Coombe, Rebecca R. Cheezum, Amy J. Schulz, Robert J. McGranaghan, Richard Lichtenstein, Angela G. Reyes, Jaye Clement, and Akosua Burris, 2010. “Community-Based Participatory Research: A Capacity-Building Approach for Policy Advocacy Aimed at Eliminating Health Disparities.” American Journal of Public Health 100, no 11 (November): 2094- 2002. doi: 10.2105/AJPH.2009.170506
[3] Minkler, Meredith, Analilia P. Garcia, Victor Rubin, Nina Wallerstein, 2012. Community-Based Participatory Research: A Strategy for Building Healthy Communities and Promoting Health through Policy Change. Policy Link Report. School of Public health, University of California, Berkley.
[i] Data Census Bureau.
[ii] DiversitydataKids. The Heller School for Social Policy and Management, 2019.
[iii] Blumenthal, Daniel S., 2011. “Is Community-Based Participatory Research Possible?” American Journal of Preventive Medicine 40, no 3 (March): 386–389. doi:10.1016/j.amepre.2010.11.011.
[iv] Israel BA, Schulz AJ, Parker EA, Becker AB, Allen AJ, Guzman JR. Critical issues in developing and following community based participatory research principles. In: Minkler M, Wallerstein N (editors). Community-based participatory research for health (pp. 53-76). San Francisco: Jossey-Bass; 2003.
[v] Montoya, Michael J., and Erin E. Kent, 2011. “Dialogical Action: Moving from Community-Based to Community-Driven Participatory Research.” Qualitative Health Research 12, no 7: 1000 - 1011. DOI: 10.1177/1049732311403500