1. Planned community Change:
Improving Breastfeeding Rates Kent County, Michigan
Ferris State University
NURS 340 – Summer 2012
Sharon Herring, Amy Long-Nelson, Suzanne Schlacht
Presentation: Planned Community Change: Improving Breastfeeding Rates in Kent County

2. Demographics: Kent County, Michigan
Kent County Statistics
The county covers 864 square miles
Grand Rapids is the urban center of the county
Health care: 5 health care centers, 6 public health clinics
2010 Population of 602,622
Fourth largest population center in Michigan
- 51% Female
- Median age: 34 years
Racial diversity:
- 84% White
% Black
- 9.9% Hispanic or Latino
- 2.5% Asian
Kent County is located in Western Michigan. Grand Rapids is likely the most familiar city in the county. Census data from 2010 reveals a population of 602,622 in Kent County. This makes Kent County the fourth largest population center in the state of Michigan. Analysis of the population characteristics of Kent County reveals the median age in Kent County is 34 years whereas Michigan’s is 39 years. In addition, Fifty one percent of the population in the county are female (MPHI, 2012). An examination of racial diversity reveals Kent County is predominantly white defining nearly 84% of the population, this is a higher proportion of population when compared to Michigan which is 80% (United States Census Bureau, 2012).

3. Health Problem Kent County Health Problem
Mothers in Kent County are less likely to breastfeed
Kent County 22.7%
Michigan 33.2%
Higher rate of births in teens age 15-19
Kent County teen birth rate 42/1000 females
Michigan teen birth rate 35/1000 females
Rate nearly 2x that of national benchmark 22/1000
Higher rate of mothers with less than 12 years of education
18.9% Kent County
15.9% Michigan
African American and Hispanic females in Kent county are more likely to receive Medicaid and have no or inadequate prenatal care
Inadequate prenatal care: White = 9.6% , Black =19.8%, Hispanic = 17.9%
Over 40% of mothers participate in WIC during pregnancy
More than 79% of infants in the Kent County WIC program are exclusively bottle-fed
(MDCH, 2010), (MPHI, 2012), (United States Department of Agriculture, 2011, p.38)
Statistical information from 2011, provided by Michigan Public Health Institute (2012), reveals Kent County mothers have a low rate of breastfeeding when compared to Michigan and the United States (MPHI, 2012).
Analysis of the characteristics of mothers in Kent County demonstrates a high rate of births in women under the age of 20, and a high rate of mothers with less than 12 years of education when compared to Michigan statistics. Kent County has a proportionally lower rate of African Americans and Hispanics than whites. However, both groups are more likely to receive Medicaid and less likely to receive adequate prenatal care (MPHI, 2012).
Although it is similar to the characteristics of mothers throughout Michigan, over 40% of the mothers in Kent County receive food and services from the Special supplemental Nutrition Program for Women, Infants and Children (WIC) (MDCH, 2010). Data from the United States Department of Agriculture (2011) reveals only 21% of mothers who participate in the WIC program either partially or totally breastfeed their infants.

4. Analysis of the Problem
Kent County Breastfeeding rates are low compared to Michigan and the United States
Healthy People 2020 Objectives for Breastfeeding:
Increase the proportion of infants breastfed
Ever : Target = 81.9%
Exclusively through 3 months: Target = 46.2%
Disparities in breastfeeding rates identified in 2011 Surgeon General report
Less likely to breastfeed:
Low Income family
Education status less than high school diploma
Maternal age less than 20
African American
(Healthy People.gov, 2012), (U.S. Department of Health and Human Services, 2011).
An evaluation of the maternal characteristics in Kent County reveals there is a multiplicity of disparities and barriers present which correlate with poor breastfeeding rates.
In 2011, a report by the United States Surgeon General identified disparities in breastfeeding rates. The report identified socioeconomic and race/ethnicity characteristics which affect breastfeeding rates.
Socioeconomic difference is demonstrated in studies of WIC program participants. The studies revealed mothers and infants who participated in the USDA WIC programs were less likely to be breastfed. As WIC eligibility is dependent upon income, this demonstrates a correlation of lower income with lower breast feeding. Education status and age were also identified as determinants to breastfeeding rates. Racial disparities are identified as breastfeeding rates for African Americans are approximately 35% less than whites, regardless of income or education status (p.7).

5. Problem Statement
There is a low rate of breastfeeding among Kent County, Michigan mothers related to risk factors of individual health and environment as demonstrated by…
High rate of teen births
High rate of mothers with less than 12 years of education
Over 40% of mothers participate in the WIC program
Kent County has a higher rate of residents who are enrolled in Medicaid than the state of Michigan
Health care disparities exist in minority population groups resulting in no or inadequate prenatal care
18% of African American infants born in Kent County are born to mothers who are age years (MDCH, 2010)
Kent County’s low rate of breastfeeding is related to individual health and environmental risk factors which are demonstrated to have a lower prevalence of breast feeding. Kent county has a high rate of teen births and mothers who have less than 12 years of education, both of these variables demonstrate a lower occurrence in breast feeding.
Studies have demonstrated mothers who participate in WIC and those who are insured by Medicaid are less likely to breast feed.
Early prenatal care has been demonstrated to improve the likelihood of breastfeeding through education and identification of resources, health care disparities exist in minority population groups in Kent County.

6. Relevant Change Model: HBM
What change model would be effective for increasing breastfeeding in Kent County?
The Health belief model states that health related behavior depends on 4 things:
The perceived severity of the possible illness or physical change
The level of perceived susceptibility
The benefits of taking preventive
or protective action
What stands in the way of taking action
toward the goal of the healthy behavior?
(Harkness & DeMarco, 2012)
Following the health belief model the perceived susceptibility is what the mother’s feel about the benefits of breastfeeding for their baby. The perceived severity relates to the knowledge and beliefs about breastfeeding. Perceived benefits would be the improvement of their baby’s health including a decrease in ear infections and decreased obesity rate. Finding what stands in the way of the mothers choosing breastfeeding over formula would include their personal beliefs and the beliefs of their family members. As seen in the chart, education an explanation of the benefits of breastfeeding from a healthcare provider assist in the mother coming to action on choosing breastfeeding.

7. Community Change Models
The Social Ecological Model
Ecological Model: All behavior which occurs in individuals is interdependent with their environment.
Health promotion is targeted at “intrapersonal, interpersonal, organization, community and public policy” (Pender, Murdaugh & Parsons, 2011, p. 72).
Socio-ecological Model: An expansion of the ecological model The model states an improvement of health promotion strategies occurs when multiple interventions are applied which utilize a combination of behavioral and environmental approaches.
Both environmental and individual factors contribute to behavior change
(Pender, Murdaugh & Parsons, 2011)
Community based models recognize the multiplicity of factors which effect individual health. Pender, Murdaugh & Parsons (2011) state community models include “the social, political, institutional, legislative and physical environments in which behavior occurs…” (p. 68). The community model which is applicable to changing breastfeeding rates in Kent County is the Socio-ecological Model. The socio-ecological model recognizes change is dependent on individual and environmental factors, and a combination of model strategies is needed to promote health behavior change.

8. Community Change Models
The Social Marketing Model
The Social Marketing Model utilizes a set of marketing philosophies to promote an idea, product or behavior.
Current media promotes bottle feeding as a norm and contains many messages of negativity related to breastfeeding
An additional community change model which can be used to promote breastfeeding rates in Kent County is the Social Marketing Model. The social marketing model utilizes both mass media and interpersonal communication to promote health behaviors. Media can have a strong influence on consumer perception of a health related behavior, particularly when targeted population groups are the focus. Social marketing is not the same as education, the goal of the marketing is to “…increase the attractiveness of the desired behavior”, (Pender, Murdaugh & Parsons, 2011), this approach leads to a desire to engage in or change a certain health behavior.

9. Evidence based barriers to breastfeeding
Lack of knowledge
Social Norms
Poor Family and Social Support
Embarrassment
Lactation Problems
Employment and Child Care
Health Services
Special population groups in which breastfeeding is contradicted
(U.S. Department of Health and Human Services, 2011).
When considering a change in health behavior, the community health nurse must realize barriers which may be encountered. The 2011 Surgeon General’s report identifies many barriers to breastfeeding: Lack of knowledge encompasses both the mother and the healthcare providers knowledge of health benefits and breastfeeding practices
As demonstrated in the pictures on the previous slide, social norms relate to a generalized public perception that bottle feeding is the “normal” way to feed an infant, and breastfeeding is not “normal”.
Family and Social support are identified as significant influencing factors. A woman who has friends or family members with positive breastfeeding experiences is more likely to breastfeed.
Embarrassment is another barrier. Women’s breasts are often connotated as sexual rather than nurturing. Breastfeeding is discouraged in public places, and women are encouraged to remove themselves from the public view when breastfeeding.
Lactation problems include pain, leaking and fear of inadequate milk production.
Employment and child care issues cause barriers to initiation as well as continuation of breastfeeding. Maternity leave is often inadequate and workplaces do not consistently provide for time or privacy to express milk.
Health care settings are often barriers as hospital policies and clinical practices in Obstetrics and Labor and Delivery settings often do not support evidence based best practice.
There are instances when breastfeeding may not be advisable or a women must stop breastfeeding. Some examples include mothers who have HIV, is addicted to illicit drugs, or is undergoing cancer treatment.

10. Current Community Resources
La Leche League of Grand Rapids
Four monthly meetings are held to provide information, advice and support for breastfeeding.
3 Hospitals in Kent County
Provide childbirth classes which include breastfeeding
Support groups with a certified lactation counselor
Kent County WIC
Provides breastfeeding education
Breast pumps are available (accessKent.com, 2012)
Kent County currently has several community resources for breastfeeding mothers which can be utilized to form partnerships to promote breastfeeding rate change. Area hospitals have a variety of birthing classes which include breastfeeding education and resources for lactation support. St. Mary’s Hospital has classes specific to breastfeeding and an outpatient lactation clinic. WIC has breastfeeding education, lactation support includes the availability of breast pump loans to mothers who demonstrate this need.

11. Potential Partnerships and Community Resources
Community High Schools
Area Colleges and Universities
Churches
Grand Rapids African American Health Institute (GRAAHI)
Community Clinics and Doctor’s offices
Community Workplaces and Childcare Centers
Health promotion can occur in multiple settings. Partnerships can be formed with community schools to initiate early education of the benefits of breastfeeding. There are 8 colleges and Universities in Kent County (MPHI, 2012), healthcare and education students could be recruited to promote breastfeeding education and gain valuable experience in exchange. Additional community organizations could include church groups. Church members may be available to provide personal experiences and support for young mothers. An additional identified potential partnership is the Grand Rapids African American Health Institute (GRAAHI). This is a non-profit organization which aims to improve access to health care and health information to African Americans during pregnancy and throughout early childhood (GRAAHI, 2012). Community childcare centers are also potential partners as an identified barrier to breastfeeding is returning to work and childcare.

12. Relevant Evidence Based Practice: Primary Prevention
Social Marketing
Utilizes principles of commercial marketing to change behavior
Evidence based success in improving breastfeeding rates
Media campaigns by the National WIC Breastfeeding Promotion Program in 10 states
Demonstrated improvement in
breastfeeding and support
Primary prevention strategies help avoid a health related problem or concern. Social marketing is an evidence based community change model which promotes individual and community attitudes toward a health related behavior. An evidence based example of the effectiveness of a media campaign is demonstrated in the Breastfeeding Promotion Program which was piloted in 10 states by WIC. The media campaign occurred over a three year period from The objectives were to market the product of breastfeeding, to reduce the perceived costs of embarrassment and inconvenience, and to promote with education in a place of the family and community. This promotion increased breastfeeding rates and increased support from relatives and friends (Social Marketing Institute, 2012).

13. Relevant Evidence Based Practice: Secondary Prevention
Reducing barriers to breastfeeding
-Peer Counseling using the Loving Support™ Model
-Workplace policies which facilitate breastfeeding
Prenatal counseling and education
-Breast feeding benefits
-Management of breastfeeding
Maternity care practices must support the behavior
-Breastfeeding training course offered by WHO
-Encourage hospitals which have in-patient maternity care to adopt
the “Ten Steps to Successful Breastfeeding”
-Continuity of support with Certified Lactation Consults
(Office on Women’s Health, 2000)
Secondary prevention interventions are those that target persons who have risk factors for the identified health risk. Evidence based data demonstrates a multitude of societal influences are present which influence breastfeeding practice. Congruent with the Socio-ecological model, personal and environmental factors affect breastfeeding rates.
Particularly in special population groups, such as African Americans and teen mothers, personal and social support is essential to breastfeeding.
The Loving Support Campaign by the USDA WIC programs demonstrates an improvement in breast feeding and initiation rates in at risk low income groups.
The Health Resources and Services Administration (HRSA) has a kit to promote employer support in breastfeeding called The Business Case for Breastfeeding: Steps for a Breastfeeding Friendly Worksite. Current evidence indicates breastfeeding continuation is dependent on workplace policies when the mother must return to work (Surgeon General, 2011).
The CDC identifies education as the “most effective single intervention for increasing breastfeeding rates..”. Studies have demonstrated the best strategy is to educate the mother during the prenatal period (CDC, 2009).
Early experiences with breastfeeding significantly impacts breastfeeding initiation and sustaining rates. Hospitals with maternity care units should have policies regarding breastfeeding knowledge and practices (Office on Women’s Health, 2000).

14. Evidence Based Practice-Summary
Media and Social Marketing
Peer Support
Support for Breastfeeding in the Workplace
Educating Mothers
Maternity Care Practices
Professional Support
(Centers for Disease Control and Prevention, 2009)
The CDC offers a guide to improve breastfeeding. The guide contains breastfeeding interventions which are evidence based. These interventions have been established by practice and theory and are designed to promote breastfeeding in target population groups.

15. Evidence Based Practice: Kent County
Kent County mothers have multiple risk factors which evidence based data demonstrates a low rate of breastfeeding
These groups are targeted in evidence based intervention based strategies which have resulted in improvements in breast feeding rates
Current evidence based intervention strategies can be utilized to target at risk population groups in Kent County
The best practice interventions provided by the CDC, can be applied to Kent County. The CDC guide states that none of the interventions are effective alone, rather, breastfeeding interventions are most effective when they are multifaceted.

16. Interventions: HOW
The project goal is to improve breastfeeding rates in Kent County, evidence based data demonstrates improvements utilizing multiple intervention strategies.
Identified Community Strengths
WIC
Area Hospitals
Universities and colleges
Potential Resources
Churches
Additional community organizations: Salvation Army, GRAAHI
Area public schools
Radio stations, local food markets
Fund Raising Events
Mom to mom sales
Need to create a community structure that promotes and supports mothers toward a decision to breastfeed. Current community organizations such as WIC, Le Leche and area hospitals have programs in place, however, breastfeeding rates remain low. Additional resources are needed to reach those mothers who are at risk. Several potential resources are identified which would require little monetary investment. Emergency departments could be utilized to identify at risk mothers early in pregnancy and facilitate entry to prenatal care as well as the WIC program if indicated. Members in church and ethnic organizations such as GRAAHI can be solicited and educated to provide peer to peer support for breastfeeding as well as to distribute educational materials. Education can also be distributed and posted at community events such as mom-to-mom sales.
Collaboration with community schools and colleges could provide an avenue for early education in nutrition and parenting classes.
Solicit area radio stations and television broadcasting to run ads such as those currently developed by WIC, distribution of posters which promote breastfeeding could be displayed in local food markets.
Promotion of the available resources would be a vital strategy in collaboration, so that all mothers are aware of all resources which are available to them. Mom to mom sales could be organized to raise funding, promote social awareness and to provide an avenue of distribution of education and resources available.

17. Interventions: WHO Target population
Pregnant females in Kent County identified most at risk
Age under 20, less than high school education, receiving Medicaid or WIC services
Secondary targets: As a community intervention you want to change the community health in the future
Fathers, family units
Educate in high school as part of the nutrition and parenting classes
Childcare centers and workplace environments
Leaders and Partners
WIC nurses
Community health care professionals
Community partnerships
The primary target population is easily identified as pregnant females with risk factors. An application of primary intervention must be included in interventions, to promote breastfeeding as a natural, normal way to feed infants, interventions must include the community as a whole. Fathers, families and friends are key in supporting mothers to breastfeed. Education of breastfeeding, rather than formula feeding in relation to nutrition and health benefits can begin in nutrition and parenting classes offered to high school students. Breastfeeding educational materials should be developed and distributed specific to childcare centers and workplace environments.
Forming a collaborative group, local WIC nurses, hospital lactation consultants, OB/GYN offices and area Le Leche members will be the key persons to organize, apply, track and measure intervention strategies. WIC nurses are experienced and knowledgeable as community health professionals and would play the lead role in the collaborative group. Potential community partners such as church groups, GRAAHI and the salvation army can assist with identification of mothers needs, education, distribution of resources, and fundraising activities. Area college students in nursing and education can assist with development of educational materials.

18. (Office of the Surgeon General, 2011)
Interventions: WHY
Health Benefits
Infant:
Lower incidence of illnesses and infections including diarrhea, respiratory infections, otitis media and pneumonia
Evidence supports babies who are breastfed for 6 months are less likely to be obese
Less likely to have asthma or insulin dependent diabetes
Reduction in Sudden Infant Death Syndrome (SIDS)
Mother:
Decreased incidence of breast and ovarian cancer
Earlier return to pre-pregnancy weight
Lower risk for postpartum depression
Cost Benefits
Less cost related to medical care and purchasing formula
(Office of the Surgeon General, 2011)
Why is breastfeeding important to the health of the community. Breast feeding has many health benefits for both the infant and the mother.

19. Interventions: WHAT Breastfeeding promotion program for Kent County
1. Media Campaign: pamphlets, posters, tv, radio, social media
Promote breastfeeding as a norm
Promote education programs, access to information
2. Education : Multidimensional approach
Mothers and fathers
Health-care professionals
Nutrition and parenting classes
Workplaces
3. Support
Identify at risk mothers early via emergency department collaboration
Increase Community Peer to Peer Support Persons
Media campaigns are identified as primary intervention strategies. Television commercials have been shown to improve attitudes toward breastfeeding as well as an increase in initiation rates. Posters, radio commercials and social media must present positive images of breastfeeding to counteract prior negative images and to normalize breastfeeding as opposed to formula. Nutrition and parenting classes can include breastfeeding education by a WIC nurse or certified lactation consultant.
Education can occur in a variety of settings, by a variety of resources. The most effective education has been demonstrated to occur in small group or one-one interactions such as those in prenatal classes and prenatal appointments. In addition to verbal interactions, LLLI Breastfeeding Answer Books should be distributed at first encounters in prenatal office visits and at public health care facilities.
Intra-partum education is also important, with emphasis on potential problems and identification of resources during the post-partum period. In addition to Lactation consultants each hospital should have nurses who care for mothers that are knowledgeable about early initiation of breastfeeding and demonstrate best practices such as rooming in, offering the breast within the first 30 minutes and no supplemental formula or water unless medically indicated.
WIC nurses and community partners can distribute educational resources and materials as well as exhibit posters at workplaces and childcare centers.

20. Interventions: WHERE Kent County Health Department Health Care Clinics
Area Hospital’s Birthing Centers
Kent County Emergency Rooms
Kent County OB and General Practitioner offices
Kent County Churches
Kent County High Schools and Alternative Education
Mom to Mom sales
The primary place of planning, interventions and evaluation occurs at Kent County Health Departments and Hospitals. Additional education and support is provided throughout the community. For example emergency room healthcare professionals will be vital to refer at risk mothers via an established direct phone number to WIC leader for appropriate referrals. Kent County Health Department Lactation Consultants and WIC leaders can conduct education programs and provide resources to physician offices, public schools, and community organizations.

21. (Thompson, Fawcett & Shultz, 2008)
Interventions: WHEN
Components of strategic planning process
Assess: Identify needs, Identify community strengths and potential resources.
Foster community partnerships: Identify community stakeholders
Facilitate a planning workshop and develop a plan: Within 30 days
Develop a plan: Identify leaders and resources, develop Gannt charts, Review strategies and roles (monthly)
Implement the plan: Implementation target for 6 months after plan development.
Evaluate implementation: Regular on-going evaluations (90 days)
Review the plan: Evaluate data, review and update the plan components (6 months)
(Thompson, Fawcett & Shultz, 2008)
Thompson, Fawcett & Schultz discuss strategic planning in community coalition teams. To keep focus on goals, responsibilities and accountability in the project, an action plan with clearly defined goals and timelines is vital. The components of the planning process are outlined above. The assessment and identification of community partnerships has been initiated in this plan. As it is a community action plan with multifaceted interventions would plan the program to be initiated over a minimum of two years, in incremental steps. The next step of planning would be to meet with identified community resources to discuss implementation plan components, specifically the who, what, and how components. This should be a meeting led and organized by the public health nurse with at least 6 hours of dedicated time for discussion and sharing of ideas. Within the next 30 days a formal plan should be developed by all members of the coalition with clear roles and timelines, a Gannt chart should be developed and socialized at this time.
Allowing for time to solicit potential community alliances and begin education of key members, an implementation date 6 months from development would be realistic. It would be important that the coalition continued to meet minimally once a month to share progress and identify barriers.

22. Evaluation: Desired Outcomes
Increase the rate of mothers who initiate breastfeeding
Improved maternal knowledge of breastfeeding health benefits in high risk population groups
Improved knowledge of best breastfeeding practices healthcare personnel who care for mothers and infants.
Increase the number and knowledge of support persons available to mothers who plan to breast feed
Increase the percentage of mothers who receive early prenatal care
Identify mothers who are eligible for WIC and Medicaid early in pregnancy
Mothers will verbalize an improvement in barriers related to:
Workplace
Childcare
The primary goal is to increase the rate of breastfeeding in Kent County. To accomplish this goals other outcomes must be achieved. The identified risks create barriers which must be reduced or eliminated. Mothers and the community must demonstrate an improvement of knowledge of breastfeeding health benefits as well as techniques. Mothers must have support persons available throughout her pregnancy and following. In addition mothers must be confident that efforts can be sustained with support in workplace environments and childcare centers.

23. Evaluation: Time Frame
At risk mothers in Kent County will demonstrate a 20% improvement in breastfeeding rates within one year of initiation.
Evaluation 6 months after implementation will reveal an improvement in knowledge of breastfeeding in healthcare personnel
All birthing classes will provide breastfeeding education and resources within 3 months of program implementation.
Community stores will demonstrate a reduction in infant formula sales within one year of implementation.
There will be an increase in the number of employers that have worksite lactation support programs in Kent County within one year of implementation.
Interim measures of implementation strategies occur at 3 months, 6 months and one year intervals. Examples would be in improvement of healthcare personnel knowledge evaluated using education tools and pre and post-tests. A way to measure the transition to an acceptance of breastfeeding as a norm would be a demonstrated improvement in breastfeeding rates as well as a reduction of formula sales in the community.

24. Evaluation: Method
Through Michigan Report Card 2020 Kent County will have an increase in the breastfeeding rates.
There will be an increase in the number of employers who offer breastfeeding rooms for moms in Kent County by 2020.
There will be increased number of competent healthcare professionals in Kent County by 2020.
These measureable goals will be met by 2020 as evidenced through Michigan Report Card and Health People 2020.

25. Conclusion
In Kent County it is an important role and responsibility of clinicians, employers, communities, and government leaders to take on a commitment to enable mothers to meet their personal goals for breastfeeding.
In doing this we can increase the rates of breastfeeding for Kent County.
There are many initiatives to encourage breastfeeding. It is important that in Kent County the community is in support of these initiatives. In the Surgeon General’s “Call to Action” it states “identifying the support systems that are needed to help mothers meet their personal breastfeeding goals will allow them to stop feeling guilty and alone when problems with breastfeeding arise.” (Surgeon General,2011)

26. References
Centers for Disease Control and Prevention [CDC]. (2009). CDC Breastfeeding Guide to Interventions. Author. Retrieved from
Department of Health and Human Services, Office on Women’s Health. (2000). HHS Blueprint for Action on Breastfeeding. Author. Retrieved from
Grand Rapids African American Health Institute [GRAAHI]. (2012). Strong Beginnings. (Author). Retrieved from
Healthy People (2012). Maternal, infant and child health. U. S. Department of Health and Human Services. Washington, DC. Retrieved from
Michigan Department of Community Health [MDCH]. (2010). Natality Author. Retrieved from
Michigan Department of Community Health [MDCH]. (2011). Breastfeeding initiation and three months exclusive duration, MI PRAMS MI PRAMS Delivery,10 (1), (pp.1-4). Retrieved from

27. References
Michigan Public Health Institute [MPHI]. (2012). Kent County 2011 community health needs assessment and health profile (pp. 1-64). Published by Saint Mary’s Health Care, Grand Rapids, Michigan. Retrieved from
Pender, N. J., Murdaugh, C. L. & Parsons, M. A. (2011). Health Promotion in Nursing Practice (6th ed.). Upper Saddle River, NJ: Prentice-Hall.
Shealy KR, Li R, Benton-Davis S, Grummer-Strawn LM.(2005) The CDC Guide to Breastfeeding Interventions. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention,.
Social Marketing Institute. (2012). National WIC Breastfeeding Promotion Project. Retrieved from
Thompson, J., Fawcett, S., Schultz, J. (2008). Differential effects of strategic planning on community change in two urban neighborhood coalitions. American Journal Community Psychology, 42;25 (38) DOI: /s

28. References
United States Census Bureau. (2012). State and county quick facts. Author. Retrieved from
US Department of Health and Human Services, Office of the Surgeon General. (2011). The surgeon general’s call to action to support breastfeeding. Author. Retrieved from
Department of Health and Human Services CDC. (2011). Breastfeeding Report Card –– United States, In CDC. Retrieved July 1, 2012, from
United States Breastfeeding Committee. (2012). Breastfeeding Objectives. In Healthy People Retrieved July 20, 2012, from