Systems-Based Approach to Facilitate Lactation Support throughout the Community.

State: CO Type: Model Practice Year: 2020

Jefferson County Public Health (JCPH) is a nationally accredited health department comprised of more than 180 employees who work to address our county's most pressing health issues — from food insecurity, to housing and homelessness, to mental health and substance misuse. By working with and through the community, we create conditions for all people to achieve the best health possible.  According to 2017 U.S. Census estimates, Jefferson County's population is 574,613. The population includes 25% under the age of 18, 40% from 18 and 44, and 35% older than 45. Children age six and under are approximately 6.5% of Jefferson County's population (69% non-Hispanic White, 22% Hispanic, 1.1% Black, 2.7% Asian, Pacific Islander, American Indian or Alaska Native) (Data Census Bureau, 2017).

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 describe difficulties accessing lactation care, insufficient support after immediate postpartum, language barriers, and lack of advocacy for workplace accommodations, especially low-wage workplaces.

We are in year 1.5 of a three-year plan in which JCPH will:

  1. Increase the number of environments that have supportive lactation policies and practices.
    1. Engage 60 child care providers in education/support to attain Breastfeeding Friendly Certification.
    2. Engage 10 medical offices in skill-based lactation training for Lactation Friendly Recognition.
    3. Engage 10 public spaces and worksites to attain Lactation Friendly Recognition.
  2. Build community connections to provide culturally-responsive and effective breast/chest feeding support.
    1. Offer 70 hours of lactation, child development, emergency preparedness as part of a culturally-congruent lactation training pathway.
    2. Certify 10 Spanish-speaking lactation counselors as a platform for CLC or IBCLC certification.
    3. Offer trainings to Family, Friend and Neighbor (FFN) and licensed child care to meet the requirements for Breastfeeding Friendly Certification.
  3. Establish emergency preparedness plan focused on infant and child feeding (IYCF-E) and mental health. 
    1. Develop plan for IYCF-E as an official appendix of the Public Health Emergency Operations Plan Emergency Support Function 8 Annex.
    2. Offer bilingual IYCF-E Training to lactation professionals and counselors. 
    3. Develop shelter kits, materials, and linguistically and culturally responsive messaging.

This model is an intentional effort to connect and leverage Jefferson County Public Health (JCPH) initiatives and develop partnerships with community members and leaders for increased capacity and sustainability. In 2018, the Women, Infant and Children's program (WIC) and Maternal Child Health teams formed a cross-divisional Milk Power Team with the mission More Milk for More Babies. The Milk Power Team established partnerships across community, health, education, and government to strengthen continuity of care and family supportive environments.

By December 2019, the outcomes are:

  1. 39/60 child care settings certified, including 5 large centers.
  2. 6/10 medical offices focused on those with low-income- in process of Recognition.
  3. 3/10 worksites/public spaces recognized (25 in progress).
  4. 35/70 hours of lactation training offered.
  5. 12/10 Spanish-speaking, Latinx lactation counselors certified.
  6. 8/5 Certified Lactation Educator (CLE) in medical offices.
  7. IYCF-E Plan fully adopted.
  8. 16 Lactation counselors and professionals are trained in IYCF-E.
  9. IYCF-E materials, messaging and kits developed (4 languages).

Objectives have been met or are in process. Ongoing assessments and community engagement practices continue to inform strategies and priorities, advising new objectives or adjustments to meet community needs effectively.

The factors that led to success include:

  1. Use of broader meaning of lactation as a developmental process. Inclusive narrative informed by infant mental health practices.
  2. Established partnerships for shared learning and benefit. Communities' experiences inform our strategies.
  3. Grant coordinator role as a mobilizer leading goal alignment, support efforts of community engagement with Latino community, and support for partnerships' structure. 
  4. Model designed to increase the long-term capacity of people working with families instead of becoming a parallel or independent process with short-term deliverables. 
  5. High lactation initiation rates; supportive legislation and community awareness.

    The public health impact includes:

  1. Increased lactation knowledge at community level, community connectedness, and access to lactation care through authentic partnerships with Latino leaders.
  2. Supported families with infants and young children in emergency situations.
  3. Feeding practices at child care settings are supportive of child-development and infant mental health.
  4. Improved health outcomes for workforce due to supportive policies and practices.
  5. Improved lactation practices and referrals in medical settings.
  6. Improved long term health outcomes population-wide due to supportive and coordinated lactation initiatives across systems.

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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:

  1. Recognizes community as a unit of identity.
  2. Builds on strengths and resources within the community.
  3. Facilitates a collaborative, equitable partnership in all phases of research, involving an empowering and power-sharing process that attends to social inequalities.
  4. Fosters co-learning and capacity building among all partners.
  5. Integrates and achieves a balance between knowledge generation and intervention for the mutual benefit of all partners.
  6. Focuses on the local relevance of public health problems and on ecological perspectives that attend to the multiple determinants of health.
  7. Involves systems development using a cyclical and iterative process.
  8. Disseminates results to all partners and involves them in the wider dissemination of results.
  9. Involves a long-term process and commitment to sustainability.
  10. Openly addresses issues of race, ethnicity, racism, and social class, and embodies cultural humility.”
  11. 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

Detailed description of goals and objectives

Goal 1: In three years, increase the number of environments that have lactation related policies and supportive practices.

  1. In partnership with JCPH's Environmental Health-Child Care Inspections team, Child Care licensing through the Department of Human Services (DHS), TRIAD the Early Childhood Council for the counties of Clear Creek, Gilpin, and Jefferson, Jefferson County Child Care Association (JCCCA) and Adelante Lactation Counselors engage 60 child care including, Spanish and English-speaking Family, Friend and Neighbor (FFN) and license home child care providers trainings, to receive education and support to attain Breastfeeding Friendly Certification.
  2. In partnership with JCPH WIC team, engage 10 medical offices to receive recognized skill-based lactation training and support to attain Lactation Friendly recognition.
  3. Engage 10 government agencies and other public spaces, as well as worksites (focused on those with low-income wages) to receive support and meet requirements to attain Lactation Friendly Recognition.

Goal 2: In three years, build capacity in community settings to provide high-quality, culturally-appropriate, and effective breast/chest feeding support

  1. Partner with the Adelante Network, the Latino Network for Health and Education, to develop, implement, and evaluate a culturally-congruent lactation training pathway. Ensure Adelante Lactation Counselors receive 70 hours of lactation, child development, emergency preparedness, and leadership/facilitation/communications education as part of lactation counselor curriculum.
  2. Provide at least 10-15 lactation counselors training to host support groups in community settings and sustain breastfeeding- friendly recognition programs for child Care providers, medical offices, and public spaces.
  3. Ensure that Breastfeeding Friendly Certification is embedded in the Child Development Associate (CDA) curriculum taught by Providers Advancing Student Outcomes (PASO) at the Colorado Statewide Parent Coalition (CSPC) for sustainability of Breastfeeding Friendly Certifications program for FFN providers.

Goal 3: Jefferson County will develop an emergency preparedness plan focused on infant and child feeding and mental health support for families expecting and with young children in emergency situations. 

  1. Develop bilingual training plans and offer Safe Infant Feeding in Emergencies Training to lactation professionals and supporters. 
  2. The plan for Infant and Child Feeding In Emergencies is an official appendix of the Public Health Emergency Operations Plan Emergency Support Function 8 Annex.
  3. Develop culturally and linguistically responsive messaging for social media and communications, materials and kits for shelters and families.

How did we archive goals:

As an overview, our general process followed four steps:

  1. Establish a collaborative process with community, stakeholders, and internal teams.
  2. Listen, connect, align, adapt, and support partners to develop shared goals, implementation and evaluation processes. CBPR principles support our efforts to authentically connect and seek alignment with community members and groups.
  3. Integrate lactation promotion and support strategies into programs that:
  • are already working with families
  • are spaces where families are
  • are places where people who work directly with families are or learn.

4. Seek to create sustainability through policy, process, and practice change.

Whenever possible, we use the Cancer, Cardiovascular and Chronic Pulmonary Disease (CCPD) Grant funds through the Advancing Breastfeeding in Colorado (ABC) Project and county funds to support incentives and remove barriers for community members to participate. ABC works with local and regional partners to create a seamless system of culturally relevant lactation support, effect policy change, and develop breastfeeding friendly environments throughout Colorado. We also seek start-up funds specific to some areas of work to leverage resources.

Timeline and processes

2017   Pre- work: Connection and Alignment

  • Establishment of Milk Hour, a JCPH Lactation Learning Collaborative. This involved an informal space to connect our internal work and align agency-wide goals.
  • Pilot a Breastfeeding Friendly Child Care Certification process. In partnership with TRIAD, JCCCA, and Environmental Health – Child Care Inspections team, MHC team connected with child care centers and licensed in-home child care providers. This pilot included outreach, training, site visit, incentives, recognition, and promotion.
  • Application to CCPD Grant for Breastfeeding Coordination as a part of a regional initiative.

2018    Formalization and Expansion

  • Hire a JCPH's Breastfeeding Coordinator through CCPD Regional grant/ABC Project. In Jefferson County, this supports:
  • Implementation and expansion of Breastfeeding Friendly Child Care Certification and the addition of Worksite, Medical Offices, and Public Places Lactation Friendly Recognition processes.
  • Establishment of formal agency-wide initiative and cross-division collaboration.
  • The Milk Power team is established including members of Maternal Child Health, WIC and Nutrition Services, and Healthy Eating Active Living teams and is facilitated by JCPH - CCPD Grant coordinator. The mission is More Milk for More Babies.
  • Continuation and formalization of Breastfeeding Friendly Child Care Certifications process across child care centers and licensed home providers.
  • Partnership with TRIAD's Health in Early Childhood Collaborative to bring lactation friendly training to rural areas of Clear Creek and Gilpin counties, as well as additional training and outreach into Jefferson county child care locations. This included meetings with program directors, quality coaches, and providers to identify priorities and shared goals.
  • MCH Coordinator and ABC Coordinator host trainings for home visitation programs: Nurse-Family Partnerships, Healthy Start at Home, Human Services Collaboration Program, WIC staff, and JCPH Clinic's staff so they are aware of current lactation laws, referral processes and resources available for families in the community. Those internal programs reach over 6,000 families yearly.

2019   Established Community Partnerships

  • Spanish-speaking, Latino communities - partnership with the Adelante Network.
    • Four hours of facilitated lactation discussion and training to 24 FFN providers and community leaders for Breastfeeding Friendly Child Care Certification.
    • Following the interest of some participants, nine of them received training on basic lactation management and the Breastfeeding Friendly Certification process to became Promotoras de Lactancia. They reached out to other FFNs and certified 17 FFN providers over the summer.
    • Continuous interest led to the development of Spanish- Lactation Curriculum and formation of Adelante Consejeras de Lactancia (Lactation Counselors). Fourteen counselors started the program, currently 12 are still involved.
    • Adelante Lactation Counselors became recognized by the International Breastfeeding Lactation Examiners (IBLCE) as lactation counselor organization to provide a platform for volunteers interested in continuing lactation support at community level. Also gained membership to United States Breastfeeding Committee (USBC).
    • Adelante Lactation Counselors receive 20 hours of lactation education, plus opportunity to participate in Leadership and Communications cohort training (30 hours) and Patient Navigator (Phase 1) Training (30 hours).
    • Five Spanish-language community support groups are established.
    • We host monthly evaluation and planning meetings with Adelante Lactation Counselors and develop strategic plans. They receive reflective consultation to support their mental health a they provide support to community members.
    • The Adelante Lactation Counselors program is currently a shared project of JCPH and the Adelante Network. The Lactation Counselors include community members, JCPH nurse, WIC dietitian, and MCH Specialist/IBCLC as part of the team.
    • The Adelante Network Strategic Plan includes the establishment of a Lactation Consultants Cooperative in 2022.
  • Medical Offices, Worksites, and Public Spaces Lactation Friendly Recognition. 
    • Currently, six medical offices have begun the program with two completing most of the six steps. Four of them serve primarily Medicaid members. Four of them received support for staff to participate in Certified Lactation Education (CLE) training. The recognition involves the following process:
      1. Connection and information delivery
      2. Self-assessment and review of current practices
      3. Action plan development and training needs identification
      4. Policy and space change
      5. Implementation and recognition             
      6. Evaluation
    • The two smaller pilot worksites fully certified are Evergreen Bread Lounge and Bakery and Boettcher Mansion. Jefferson County Public Health updated its policy and became Lactation Friendly Recognized. Government agencies with great number of employees are in the process of recognition. They follow a similar process to medical offices without the additional training requirements.
  • Child Care Certifications
    • Expansion of Healthy Preschool Partnership (HPP), a collaborative agreement between JCPH, TRIAD and Culture of Wellness in preschools that works to promote and support each agency in planning for long-term sustainability of the Breastfeeding Friendly Child Care Certification for licensed centers and home child care providers. This collaboration includes focus on childhood workforce's short and long-term health, mental health and wellness.
    • MCH coordinator completed training with 122 child care providers in the Denver Metro Area and under-resourced rural areas of Clear Creek and Gilpin Counties. In addition, information regarding full training and certification were presented to large groups of child care professionals at the Colorado Association of Family Child Care Annual Conference, the Rocky Mountain Early Childhood Conference, and JCCCA. JCPH outreach has helped to connect and launch work with home providers in El Paso and Arapahoe counties. In addition to in-person training, 177 providers have accessed the online training.
    • Child Care Certifications include: 5 large child Care centers, 17 FFN providers, 17 licensed home child care providers. The estimated reach is 228 children.  Many more child Care centers, provider, and FFNs have received the lactation training, but they have not committed to certification yet. We trust that the trainings have raised awareness and will lead to more certified programs in the future. The process to become certified involves:
      1. Participation in one-hour training (in person, online through licensing, and one-on-one).
      2. Complete self-assessment
      3. Action plan development
      4. Policy and space change
      5. Implementation and recognition      
      6. Evaluation (participants receive a package with lactation information to share with families, a decal to display, certificate, books, toys, rocking chair (if needed), and other items as needed).
  • Emergency Preparedness Plan is developed and adopted.
    • This initiative emerged after experiencing a snow storm in which we connected with several families that are part of the Adelante Network. We realized that we needed to have a plan to support families with young children immediately. Working with EPR and community members, and due to the availability of county funds at that point, we were able to mobilize resources, order kits, and host the initial facilitated training/discussion. We intentionally connected with experts from Puerto Rico, New Orleans, and Seattle to consult as well as local emergency response experts.
      • IYCF-E Plan is development and embedded into current EPR response plans.
      • 7 Shelter and 20 family kits developed.
      • Informational materials developed in 4 languages.
      • Pilot training for lactation first responders.
      • Second training (coming in February 2020).
      • Messaging for social media and community partners development (2020).
      • Community trainings in partnership with Adelante Network (2020).
  • Pilot of NICU2HOME under program for Children and Youth with Special Health Care Needs focused on infant development and community connections to lactation and mental health support for families with premature and medically complex babies.
  • Nutrition Services opens Breastfeeding Clinic to all families on a sliding scale fee. Due to underutilization it is not available anymore and focus has shifted to holding groups in the community.
  • Jefferson County Board of Health issued Breastfeeding Proclamation in August.

While all community members, agencies, or organizations could be part of the program, our work has focused in establishing partnerships with community organizations/groups working with families from under-resourced communities (in particular Latino/Spanish-speaking), medical providers who work with low-income communities, public spaces with greater impact (government agencies, schools, libraries), child care centers with high attendance of children with low-incomes, and in-home or FFN providers. The CBPR principles have been used primarily in our work with the Adelante Network and IYCF-E projects. 

Partnerships Developed

Latino/Spanish-speaking Community

Adelante, the Latino Network for Health an Education, is a network of community members and organizations working together with the vision to create a society where each family has the tools and power to raise their children healthy and happy, direct the creation of community services, and be valued as the experts in the health, education, and wellbeing of their families. Adelante is an initiative of CSPC and JCPH and part of the Networks of Opportunities for Child Wellbeing through Vital Village at Boston Medical Center. It was funded by the Robert Wood Johnson Foundation from 2018-2019. The network continues their work and has expanded our of the county, being supported by a variety of organizations and the powerful leadership of community members.

The partnership with the Adelante Network has grown and evolved as leadership and decision making is shared. This is an ongoing JCPH partnership that continues to expand across different areas of Latino health and education. JCPH plays the role of a partner and supportive platform as community members identify areas of greater need and explore solutions to issues they recognize. This supports the goals of sustainability and authentic partnerships in which JCPH's work is informed and evaluated directly by those receiving the services.

Community members from the Adelante Network have been involved in planning and implementation of:

  • FFN trainings and certifications – Role: team members.
  • Lactation Counselor Curriculum development – Role: full participants and authors. This training was both, content delivery and content co-creation to embed cultural components.
  • Decision making about future trainings and educational pathway to reach IBCLC certification- Role: team members of Adelante Lactation Counselors.
  • Community groups establishment- Role: team members of Adelante Lactation Counselors.
  • IYCF- E pilot training – Role: participants. This training was both, content delivery and content co-creation. Small group of Adelante Lactation Counselors will be adapting this training to be delivered to others and creating a community version.
  • Lactation Certification Integration into PASO Program – Role: team members of Adelante Lactation Counselors and PASO coaches.

Child Care Professionals

Established partnerships with Jefferson County Child Care Association (JCCCA), TRIAD, The Health in Early Childhood Collaborative, Colorado Associacion of Child Care (CAFCC) and Culture of Wellness in Preschool (COWP). 

JCCCA is a nonprofit association that supports family child care home providers by enhancing and promoting professionalism through education, networking, and other valuable resources and activities. JCCCA has been a strong partner that promotes the certification among their members and hosts yearly trainings.

TRIAD is composed of public and private stakeholders engaged in collaborative planning and decision making to improve quality, access, and equity outcomes for young children. TRIAD offers child care centers information and support to obtain the Certification through their quality coaching process. 

CAFCC is an organization whose goals include the education of family child care providers and offers educational opportunities throughout the state to increase quality care. CAFCC provides high standards and open communication among child care providers, parents and government agencies. The CAFCC aims to increase the understanding of family child care within the state. CAFCC has been a strong partner that promotes the certification among their members and hosts yearly trainings.

COWP is a comprehensive and collaborative early childhood obesity prevention program, which aims to promote a culture of wellness” in preschool settings by increasing fruit and vegetable consumption and physical activity levels. All program components are evidence-based or promising practices. CPWP has been a strong partner that promotes the certification among their partners and hosts yearly trainings.

Medical Offices

JCPH has partnered with Lutheran Medical Center, our local Baby-friendly Hospital and medical offices in the community. Medical office recognitions involve an ongoing trusting relationship and troubleshooting. 

Currently, six medical offices have completed most of the program. Four of them serve primarily Medicaid members. Four of them received support for staff to receive Certified Lactation Education (CLE) training. Two other medical offices are in the process. Participants receive funding to adapt spaces or have high-quality pump available to employees. It has been a complex process to support each facility's needs and embed staff trainings and lactation referral resources into practices and electronic medical records. Their role has been the promotion of the new practices internally in their work-flow, adoption of referral process in their medical health records, as well as informing our team about potential barriers and solutions.

Worksites and Public Spaces

JCPH has been working collaboratively with worksites, especially large government agencies that have a greater impact in community practices. The two smaller pilot worksites fully certified are Evergreen Bread Lounge & Bakery and Boettcher Mansion, and our own Jefferson County Public Health (180 employees). In the process of completing certifications are: Jeffco Public Schools (500+ employees), Jefferson County Public Libraries (165 employees), Jefferson Center (450 employees), Jefferson County Human Services (JCHS), City of Wheat Ridge (200 employees), City of Wheat Ridge Rec Centers (100 employees), Jefferson County Human Services, McClain High School, Free Horizon Montessori School, Edgewater Elementary, and Connects Workspace.

Similar to medical offices, the collaboration and engagement of stakeholders depends on the needs of each agency or business in the recognition process. These worksites are unique because through their policy change they are implementing practice and cultural change for their internal staff while simultaneously adapting spaces and policies to be lactation friendly to community members, clients, visitors, and patrons. The adoption of lactation friendly policy at county-level public school has a direct impact on individual schools' ability to adopt lactation friendly-policies; indeed, one of the Title 1 schools is already working to be the first elementary school recognized as lactation friendly. Jefferson County Libraries has eleven locations across the whole county and serves thousands of families in a year. As they remodel one location annually, they plan to incorporate lactation spaces in their new libraries as well as adapting spaces in the others. It also matches their family place certified locations. McClain High School is a unique school; they have a child care center on site and serve non-traditional students including those that are raising children, are expecting, or experience homelessness.

The partnership established with these worksites are unique in nature and seek to build their capacity to increase knowledge, connections, and policies for long term sustainability of the cultural changes that they experience.

Estimated Budget

Star-up funds:

$5,000 in start-up costs for computer equipment and staff onboarding – 2018.

$3,000 in start-up funds for Emergency Preparedness Kits – 2018.

The CCPD grant (ABC project) funds three years for a total of $390,000 and  cover:

  • A full-time 1.0 coordinator/project manager (40 hours/week).
  • 18% of a WIC Registered Dietitian/IBCLC time to support medical offices.
  • 2% of a WIC Registered Dietitian/CLC to support Spanish community breastfeeding counselors.
  • 2% of Maternal Child Health Supervisor.
  • 2% of Communication Team's time to support resource creation and social media promotion.
  • Site incentives for lactation spaces, training costs for community and site lactation trainings.
  • Stipends for community leaders that provide FFN support for certifications.

In-kind contributions

MCH/Title V and County Funds:

  • 50% of MCH Coordinator to support Child Care Certifications.
  • 30% MCH Specialist to support Child Care Certifications for Spanish-speaking FFNs, partnerships with Adelante Network, Adelante Lactation Counselors Program.
  • 2% Maternal Child Health Supervisor.


  • 85 hours of EPR Coordinator
  • 20 hours EPR Training Coordinator

We have also receive in-kind contributions of space for trainings, materials, coaching, lactation expertise shared by professionals, and volunteer hours of community members and colleagues.

Most of the objectives have been met or are in process:

Increase the number of environments that have supportive lactation policies and practices.

Engage 60 child care providers in education/support to attain Breastfeeding Friendly certification.

Over 45 reached, 29 certified including:

5 childcare centers, 17 FFN providers, 7 licensed home child care providers

In-person trainnings to 122 across the Denver Metro area, Gilpin, and Clear Creek counties. 177 have accessed the training on-line.

Engage 10 medical offices in skill-based lactation training for Lactation Friendly recognition.

Six medical offices begun the program. Two almost completed all requirements.

8 medical offices staff have attend CLC training.

Engage 10 public spaces and worksites to attain Lactation Friendly recognition

Eleven public spaces and worksites have started the program, over 25 have been reached out to. Three worksites are currently recognized.

Child care trainings and certifications evaluations describe great appreciation for the information and skills provided. The data has been collected through pre-post surveys and anecdotical evidence.

For some child care providers this has been a refresher, for many others, this is an opportunity to learn new skills. In general, they are supportive of breast/chest feeding and appreciate the opportunity to have knowledge and connections that would support the families of children under their care. Childcare providers have shared their own experiences with lactation which allows to support and reaffirm their experience and role, enhance information, and debunk myths. Work with FFNs has been a great way to partner with community leaders who are usually not connected to the work of Public Health they have embraced their supportive role and have informed many of the next steps taken in the certification processes.

Public Spaces and Worksite recognitions have been well received, especially in government agencies. Many organizations already have supportive policies, adding the Lactation Friendly Recognition allows them to operationalize some of the arrangements they had already in place or formalize more protections for families. Anecdotal reports describe the process as simple and support provided by coordinator effective. They appreciate the incentives. There is an evaluation survey after completing process, but the data is not currently available due to recognitions being recent. There are planned follow-up surveys in the first year and future low-cost opportunities to sustain practices.

Medical Offices is a complex process. The program seems to require much more attention and resources than expected. Incentives for space remodel, CLC and CLE training opportunities are supportive of medical offices engagement. We do not have much data related to this area of work but are working alongside medical office champions to develop relevant mechanisms to capture stories and quantitative data.

Build community connections to provide culturally-responsive and effective breast/chest feeding support.

Offer 70 hours of lactation, child development, emergency preparedness as part of a culturally-congruent lactation training pathway.

16 hours of Adelante Lactation Counselor training and 4 hours of biliangual Safe Infant Feeding in Emergencies completed. Additionally, 4 hours of Breastfeeding Friendly Certification,  21- hour cohort of Communication and Leadership in Spanish, and 30 hours of Health Navigation Training in Spanish trough University of Colorado Patient Navigation Network.

Certify 10 Spanish-speaking lactation counselors as a platform for CLC or IBCLC certification.

14 started the program; 12 continue participating in monthly meetings, group support, and lactation trainings. IBLCE recognition is formalized to receive clinical hours through volunteer work. Progress in developing hours of lactation education and initial partnership development for required college level courses. Counselors participate in USBC workgroups.

Offer trainings to English and Spanish Family, Friend and Neighbor (FFN) requirements for Breastfeeding Friendly Certification.

24 participants in 4 hours group training, 6 participants in small group 1-hour training. 3 participants in individual training.  17 Spanish-speaking FFN are certified. Adelante Lactation Counselors will continue the program in 2020.

Participant evaluations describe satisfaction and engagement with trainings offered. Spanish-speaking participants describe great commitment to breast/chest feeding a limited access to other resources. Nature of FFN providers job involves continuous follow-up and connection in bigger aspects of maternal child health work. The trainings will become embedded in quarterly trainings offered by JCPH and CSPC to create ongoing opportunities for support.  The data has been collected through pre-post surveys and anecdotical evidence.

Establish emergency preparedness plan focused on infant and child feeding (IYCF-E) and mental health. 

  1. Develop plan for IYCF-E as an official appendix of the Public Health Emergency Operations Plan Emergency Support Function 8 Annex.

Completed and adopted.

  1. Offer bilingual IYCF-E Training to lactation professionals and counselors

16 participants. Next training will happen in February.

  1. Develop shelter kits, materials, and linguistically responsive messaging for communications.

Seven shelter kits and 20 family kits are completed.  Materials are developed. Messaging for social media and text will be developed in 2020.

Community members are exploring to host community conversations around emergency preparedeness in 2020.

The evaluations and post-engagement of lactation first responders has been outstanding. Their reports describe appreciation for the information shared, lactation techniques, and the opportunity to be part of a multicultural cohort. The data has been collected through pre-post surveys and anecdotical evidence.


We have different layers of evaluation processes depending on the projects and partners. The idea is that each of these areas of work are assessed and modified to transfer and become part of our partners priorities supported by JCPH.


  • ABC grant coordinator collects data thought team members reporting and training participants evaluation forms. ABC grant coordinator works under and reports to MCH Supervisor.
  • Trainings Evaluation:
    • After each training participants fill out an evaluation.
    • Depending on the training or project, they may also receive follow-up emails.
    • Engagement in cohort training modules is assessed by continuous participation.
    • We assess number of participants and engagement.


  • The regional CCPD grant contracts with Colorado Health Institute (CHI), as a fiscal sponsor and evaluator, to assess process and outcome measures. JCPH ABC coordinator reports to CHI quarterly. Number of certification, recognitions, trainings and anecdotical evidence are agglomerated for regional grant reporting.
  • The Adelante Network reports monthly to the Network of Opportunities for Child Wellbeing, thought their grant at Vital Village with the Boston Medical Center. Adelante Lactation Couselors report monthly to Adelante Network Council.
  • MCH grant reports to the Colorado Department of Public health and Environment on a quarterly basis.

Performance measures used:


# of participants in training

# of child care, worksites, public spaces, medical offices reaching milestones in process of certification/recognition (training, materials received, policy completion, recognition received, evaluation completed).

# of families reached

# of employees in worksite

# of medical office providers in training


# of certifications/recognitions

# of Lactation Counselors in program

# of kits for shelters and families 

# of hours of trainings provided

# of community groups hosted

# of participants in groups

# of calls requesting lactation support

IYCF-E Plan adoption

Individual Trainings evaluations include questions about:

  • Likelihood of using new skills in practice
  • Degree of interest of new information received
  • Relevancy of information
  • Quality of simultaneous interpretation and translation of materials
  • Open feedback

Description of evaluation components

The Milk Power team meets quarterly and review progress under each of the areas of work. The data is analyzed by quarterly reporting through CCPD grant - ABC Project and MCH grant. Adelante Lactation Counselors meet monthly hosting small groups discussions and reflection processes, they use 90 Days- challenge planning and evaluation processes and report to Adelante Network Council. Trainings evaluation data is reviewed after each session and adjustments made.


Modifications have been made in pretty much all areas of work due to data findings and ongoing cycles of reflection and evaluation. For example, (1) Spanish-language community groups start was delayed so Adelante Lactation Counselors could connect with community members and gain more confidence before offering groups in the community, (2) in addition to first responders training, the team is considering some direct community outreach to increase awareness about the safety of using shelters in emergency situations for immigrant families, (3) shelter and individual family kits were modified after receiving feedback from participants at IYCF-E training.

This project has expanded and grown due to the engagement of community members and stakeholders in planning, implementation, and evaluation. A significant modification across all initiatives has been to develop stronger dissemination mechanisms and enhanced communitications to promote lactation champions, partners, etc. in ways that are valuable to them, beyond our grant reporting requierements. For example, FFN providers wantes a certification ceremony at a community event.  We have added planned social media and communications messaging to be culturally and linguistically relevant, so community members feel ownership and are sharing the messaging (especially for licenced child care providers as this is a way to promote their business).

Another modification across all our initatives has been to welcome and expand our work to other counties in the state. While resources are limited, we support our organizational partners by sharing knowledge and resources to areas of Colorado that they consider important for their work. TRIAD works in three counties, so we have offered trainings to all of those areas as well. We open trainings to people coming from other counties, even if they could be available locally to them, and help to build partnerships and community members with other local health departments. We have learned that families do not see county or city bounderies, but they see friendships and respect, so we embrace their vision of what a community is and where they feel they belong.

Finally, another modification we have embraced due to data findings is to expand the focus of lactation. Early in the process, FFN providers told us that families do not clasify their members by age, so our initial narrative on children younger than 2 was not relevant. We learned that we have to talk about child health and development, reach out to families of all structures, includying extended family. To learn and discuss potential services for young children, we needed to hear about the frustrations of their caregivers, and usually grandparents have great insight.

Shared-leadership partnerships with stakeholders and community members requires listening intentionally and the ability to be flexible to adjust plans accordingly.  A fundamental part of the success of implementing this cross- sector practice was the previous development of trusting relationships and partnerships with our community. This may require advocating for a whole-agency approach to authentic community engagement, which involves shared-practices across divisions and partners, and funding that secures time and resources.

Using practices focused on community-based participation, we came to understand:

  • The complexity and the priorities of our community members and stakeholders, so we could be better and effective partners to support their projects and needs. Limiting our role to just lactation certifications, or just trainings on the topic of lactation would have been detrimental to the relationship. Often, we needed to move out of our scope to support a variety of projects, which we defined as expansions. An example of this was the work of the MCH Coordinator supporting child care providers and the Sheriff Office to host an Active Shooter training.
  • Our community and stakeholders are experts in the implementation of this project. Through this process, we moved from a model of consultation (i.e., working with a few childcare providers to develop the process for certifications) to a model of shared leadership (i.e., working alongside with Latino FFN providers and leaders to develop a culturally- centered lactation curriculum). If we had used a pre-made curriculum the content and approach would not have resonated with our community members. We needed to listen first to identify knowledge gaps and values leading to believes and behaviors around breast/chestfeeding.
  • Community members can easily identify the gaps in services and can often identify potential solutions. While we come with theorical frameworks so predominant in public health, community members can describe the impact of the gaps in services much more effectively because they live them daily. Collaboration leads to mutual learning and work that expands and energizes itself. 
  • Cultural humility and appreciation are essential for authentic relationships. Openly addressing issues of race, ethnicity, racism, and social class is fundamental to identifying training needs, develop opportunities, and inform policy. We cannot take care of breast/chestfeeding if we don't take care of the whole family and community, and demonstrate respect for their history, lived experience, and their dignitiy.
  • We have a significant opportunity to build sustainability by enabling community leaders with knowledge and decision power, so families can have a direct source of information, connection, and support in their communities. Our role could be strengthening the screening and referral processes so if children need a specialist or clinical help, families can navigate easily and receive quality services. The Adelante Network and MCH team works directly with the LAUNCH Together initiative to strengthen our systems of screening and referrals in Jefferson County, so children can receive support in a timely manner and with cultural competencies. Our health department could be a platform to support the leadership of community members and their health and wellbeing goals across this and other initiatives.

Sustainability plans

Sustainability plans are being developed and updated constantly. There is significant commitment internally in JCPH, among stakeholders, and community members.

As a summary:

  • Most of the work is wrapped and already connected to broader areas of maternal child health for sustainability, resource leverage, and ongoing partnerships (EPR, TRIAD, Wellness in Preschools, Libraries, School District, Adelante Network, etc.).
  • There is potential regionally/statewide agreement for coordinated communication, toolkits updates, sharing support for sites across counties when possible, and supporting regional trainings through the ABC initiative with CDPHE coordination.
  • MCH staff has the capacity to support continuing the Milk Hour, JCPH Lactation learning Collaborative, IYCF-E and community trainings. This will provide opportunities for ongoing networking and connection with lactation professionals and lactation counselors locally and in the region.
  • The Colorado Breastfeeding Coalition and RAISE Colorado play a key role in advocacy at the state level (i.e. student lactation rights, family leave) that supports our local on-the-ground work with sites, providers, and community. JCPH and Adelante Network members participate in those coalitions already.
  • Expansion of Healthy Preschool Partnership (HPP) supports planning for long-term sustainability of the Breastfeeding Friendly Child Care Certification for licensed centers and home child care providers. 
  • Jefferson County Board of Health and City of Lakewood issued Breastfeeding Proclamation in August. Through MCH and Adelante Lactation Counselors will continue reaching our cities in the county to promote and support maternal child health, including lactation environments.

Depending on the specific area of work, stakeholders, and partnerships, the sustainability plans include:

Increase the number of environments that have supportive lactation policies and practices.

Engage 60 child care providers in education/support to attain Breastfeeding Friendly certification.

Opportunities to embed Breastfeeding Friendly Child Care certification process into Title V MCH funds. For licensed centers, certification can be sustained through statewide licensing/Environmental Health/Colorado Shines. TRIAD and other partners can also embed educational pieces in their current educational offerings.

Currently, Colorado Department of Health and Environment (CDPHE) has free online modules that meet the educational requirements for certification (English and Spanish). We are supporting CDPHE and Healthy Child Care Colorado to develop a statewide child care designation model.

Engage 10 medical offices in skill-based lactation training for Lactation Friendly recognition.

Possibility to sustain a small portion of WIC Lactation Supervisor's time to support Lactation Friendly Recognized medical offices.

Model needs to be streamlined for more offices to take part and for staff time to be most effective. Need funding/support.

Engage 10 public spaces and worksites to attain Lactation Friendly recognition

Promising work through government agencies and County Human Resources.

Potential to sustain a portion of coordinator time to support worksites, but the sheer number in our county combined with the lack of an existing workplace wellness structure makes impact limited.

Build community connections to provide culturally-responsive and effective breast/chestfeeding support.

Offer 70 hours of lactation, child development, emergency preparedness as part of a culturally-congruent lactation training pathway.

This is part of MCH Specialist role as co-coordinator of the Adelante Network. Bilingual WIC Dietitian and Program for Children and Youth with Special Health Care Needs (HCP) nurse provide support and training to lactation counselors as well. Potential to partner with Gina Penka, from Community Lactation Action project, to transcreate 45 hour curriculum to offer statewide to Latinx communties.

Certify 10 Spanish-speaking lactation counselors as a platform for CLC or IBCLC certification.

The Adelante Network Strategic Plan for the next three years includes the formation of a Latina Lactation Consultants Cooperative as one of their health strategies. The Adelante Network and Colorado Statewide Parent Coalition will sustain this work in partnership with JCPH – educational component.

Offer trainings to English and Spanish Family, Friend and Neighbor (FFN) requirements for Breastfeeding Friendly Certification.

Partnerships with Colorado Statewide Parent Coalition and PASO program for FFN Breastfeeding Friendly Child Care Certification sustainability.

Establish emergency preparedness plan focused on infant and child feeding (IYCF-E) and mental health. 

Develop plan for IYCF-E as an official appendix of the Public Health Emergency Operations Plan Emergency Support Function 8 Annex.

Completed and adopted. This will continue under JCPH Emergency Preparedness team in coordination with MCH Specialist and Coordinator to provide trainings and activate lactation first responders in case of an emergency.

Offer bilingual IYCF-E Training to lactation professionals and counselors

MCH funds will support lactation trainings, including IYCF-E.

Develop shelter kits, materials, and linguistically responsive messaging for communications.

Shelter and family kits are completed. EPR budget will support purchasing in the future. Messaging for social media and text will be developed in 2020 and be ready in case of need. The messaging may need to be reviewed and updated once a year. MCH grants and partnership with Adelante Lactation Counselors will support this process.  

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