Implementation of Business Case for

Breastfeeding in Hampton Roads

Amy Paulson, MPH, AE-CCINCH Director/Instructor

EVMS Department of Pediatrics

Creating Mom-Friendly Worksites

Weight of the State Conference, April 12, 2013

Consortium for Infant and Child Health(CINCH)

Child health coalition with 200+ members serving Hampton Roads, VA

EVMS is CINCH’s lead agency

Mission: Engaging the community to improve children’s health in Hampton Roads

Focus: Obesity, Respiratory Health, Access to Care, Healthy Communities

Approach: Policy, Systems, Environmental Change

Learning Objectives1. Identify four components of comprehensive worksite

lactation support programs 2. Identify three approaches to employers regarding

establishing lactation support programs for employees. 3. List at least three factors businesses must consider in

establishing lactation support programs for employees4. Introduce a mechanism to evaluate a community level

BC4BF project

Primary Goal: Implement worksite lactation support programs with at least 10 employers in South Hampton Roads, Virginia (VDH funding for one year)

Evaluate organizational changes Coalition building for breastfeeding promotion Community Dialogues on breastfeeding & working Use Business Case for Breastfeeding Toolkit

Components: Private Space, Flexible Breaks, Education and Support

September 2010 - October 2011 & July 2012 - present

Business Case for Breastfeeding Project

Worksite Lactation Support Program Components

Private Space

Flexible Breaks

Education

Support

Outreach Approaches

1. Target mid-size to large employers of women of childbearing age

2. Recruit participation of ‘partner’ organizations first (i.e., “low hanging fruit”)

3. Direct contact by phone, email, in person 4. Healthcare Reform seminars, Workplace

Wellness conference

Implementation Approaches

1. In-person consultation & site visit at workplace to introduce BC4BF toolkit & Project

2. Lactation Assessment Form3. Free technical assistance4. Eligibility criteria for limited-time Incentives

1. Lactation Program Assessment2. Lactation Support Policy3. Designated Lactation Area4. Procedures5. Company-wide Promotion6. Employer Spotlight

Eligibility Criteria for Incentives

The “Sell” - Benefits to Business

Compliance with FLSA Wellness Initiative

increased productivity decreased absenteeism improved staff morale cost savings

Competitive Employee Benefit Community Role Model

Healthy BabyHealthy Mom

Healthy Business

Human Resources Considerations

Accommodating flexible breaks and addressing ‘extra’ time needed in policies

Identifying private spaces & access options Options for room furnishings and equipment

maintenance Promoting the Lactation Support Program with new

and existing employees Long-term sustainability

Policy Example: REST PERIODS, MEAL PERIODS AND BREAKS FOR NURSING MOTHERS

C. Break Time for Nursing Mothers.1. In accordance with the Fair Labor Standards Act (FLSA), EVMS

provides employees who have need to express breast milk with the following:

a. Two 15 minute paid breaks for every four hours of working time, which would replace any other paid break time normally granted during the employee’s shift. For those employees scheduled to work a shift in excess of 8 hours, one additional paid 15 minute break may be provided;b. Any additional unpaid breaks as needed to express breast milk (employees must clock out when using unpaid time); and

c. A private location, other than a bathroom, to express breast milk upon written request to Human Resources. Please contact Human Resources for the location of your Department’s lactation space or more information.

2. Employees intending to express breast milk at work must notify their immediate supervisor, each shift, and schedule breaks to express milk to best accommodate the employee and the Department workflow.

3. Breaks for nursing mothers will be provided for up to one year after the birth of a child.

4. Expressed breast milk must be stored in personal coolers.

Policy Example, cont.

Lactation Rooms and Signage: Educational Institution Setting

Lactation Rooms and Signage: Educational Institution Setting

Lactation Room: Hospital SettingBefore After

Lactation Room – Military Setting

Before After

• Implementation support useful for large and small employers• Interest from an external catalyst can accelerate internal

compliance & advance comprehensiveness of LSP• Employers gain LSP expertise quickly with BC4BF Toolkit

resources• Importance of flexibility and adaptation as no two situations are

identical, even within a large parent organization (e.g. hospital system)

• Emphasize WIN-WIN-WIN: Healthier babies, employees, business bottom line

Implications for Implementing

Health Reform

Challenges

Competing demands – low priority Contentment with status quo Eligibility Criteria too demanding? Brief project timeframe Identifying an effective champion Additional policy/protocol needed for room & pump

management (i.e., cleaning, storage, maintenance)

Successes

• 17 businesses were at least minimally engaged• 16 participated in face-to-face consultations• 15 completed baseline Lactation Assessment Form• 14 made implementation progress during project

timeframe• 13 affected by 8 drafted/adopted policies• 14 created/upgraded 17 lactation rooms• Over 6,200 women impacted across worksites

Evaluation Challenges• Short term project• Not research

• Scientific rigor limited• IRB – Determination of non-research• Use of incentives helped motivate protocol compliance

• Lactation Assessment Form set-up and completion• Piloting – was useful for e-format• Timeliness – not all completed at most optimal start time• No formal post-test

Lactation Assessment Form (LAF)

General information about business/worksite e.g. type, size, role of respondent

Human Resources e.g. # women of childbearing age, pregnancy and

breastfeeding rates, absenteeism, etc. Company Policies

e.g. general lactation support, leave, return to work, insurance coverage

Lactation Program Components e.g. Infrastructure, breastfeeding options, funding,

resources, etc.

The Businesses/Employers

Lactation Program Assessment Descriptive ResultsBusiness Size n = 15 %Small (1-99 employees) 3 20%Mid-sized (100-499 employees) 4 27%Large (500 or more employees) 8 53%

Estimated Potential Impact Count Range

Female Employees, age 16-44 >4,61915 to 842Male Employees age 16-44 1,353 3 to 233New Babies - Annual Estimate 213 1 to 50

The Businesses/Employers

Lactation Program Assessment Descriptive Results

Policy and Insurance Items Count Percent

Lactation Policy Status

No Previously Existing Policy 8 53%

Previously Existing Policy 7 47%

Unwritten and/or Unofficial 11 73%

Maternity Leave Policy

FMLA 13 87%

Disability Insurance 2 13%

The Businesses/Employers

Breast Pump Equipment Employees Receive Count %None, employees use their own 9 60%Purchased hospital-grade electric pump 1 7%Rented hospital-grade electric pump 1 7%Portable pumps 0 0%Other 3 20%Unknown 1 7%Breast Milk Storage Employee provided cooler 11 73%Company provided cooler 0 0%Small designated refrigerator 3 20%Public shared refrigerator 7 47%Other 2 13%

Evaluation Measures – Likert-Type Scales

1. Level of Engagement with the Project2. Stage of Change – TransTheoretical Model of

Behavior Change adapted for organizations3. Comprehensiveness of Lactation Support

Program Components4. Level of Policy Development5. Changes in Physical Environment6. Changes in Social Environment

BC4BF Evaluation Ratings Engagement (E) of businesses/employers with

BC4BF Project Minimal = 1: intention, support letter, BC4BF training Engagement = 2: onsite consult, lactation area analysis Moderate = 3: commitment to enhance LSP, LAF

completed High = 4: written policy, equipped lactation area,

procedures, promotion

BC4BF Evaluation Ratings

Stage of Organizational Change (TTM) Precontemplation = 1: non-issue Contemplation = 2: awareness, FLSA compliance, value

as family support, considering feasibility Preparation = 3: exploring issue, timeline, info gathering Action = 4: facilities, policy, champions, signage, promo Maintenance = 5: ongoing champion, eval & monitoring,

integration into way of doing business

BC4BF Evaluation Ratings

Implementation/Level of Comprehensiveness of Lactation Support Program (Comp) Unsatisfactory: No Lactation Support = 1 Satisfactory: Basic Model (2 required items) = 2: breaks

and non-restroom space; plus privacy, locks, chair, pump, table; and flexible break scheduling

Superior: Basic Model plus (3 or more items) = 3: written policy, education, peer support, enhanced (baby onsite, paid breaks, footstool, recliner, fridge, etc.)

BC4BF Evaluation Ratings

Policy (P): CHANGE Rating Not Identified as a problem = 1 Problem identification gaining agenda status = 2 Policy formulation and adoption = 3 Written policy and implementation = 4 Policy evaluation and enforcement = 5

BC4BF Evaluation Ratings

Physical Environment (PE): CHANGE Rating No elements in place = 1 Few elements in place = 2 Some elements in place = 3 Most elements in place = 4 All elements in place = 5

BC4BF Evaluation Ratings

Social Environment (SE): CHANGE Rating No support or negative support in place = 1 Neutral or some support emerging = 2 Positive support, some encouragement for using

BF facilities = 3 Active support, absence of criticism = 4 Enthusiastic support communicated = 5

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

1

1.76470588235294 1.70588235294117

1.294117647058821.58823529411765

2.52941176470588

3.647058823529413.94117647058823

2.88235294117647

3.52941176470588

4 3.94117647058823

Results: Baseline and Post Interven-tion Comparison of Means, p = <

0.0001

Baseline

Post-Interven-tion

(E) (TTM) (Comp) (P) (PE) (SE)

Case Example: EVMS Large Employer - > 500 580 women aged 16 – 44, 233 males Estimated 50 annual pregnancies Breastfeeding rates unknown No lactation support policy at baseline, new policy needed Provides FMLA and disability Health insurance provides “Expectant Mother” programs Employee health unit domain Personal office available $500 start up available Employees’ own pump/cooler pack Newsletter and website

1

2

1 1 1

2

4

5

3

4

5 5

Case Example, EVMS: Evolution Pre - Post

Baseline Post Intervention

Engage SOC Comp Policy PhysEnv SocialEnv

Case Example: EVMS Established 5 lactation rooms Plans to establish more rooms in all buildings

on campus

Next Steps

Seek financial support to continue promotion, coordination and technical assistance

Outreach to more businesses Expand coalition component Expand support for parents Promote breastfeeding-friendly community Monitor health impacts Publicity and BIB awards (Business Investment in Babies)

Acknowledgments• Elise Wallace, MPH – Project Manager• Cheza Garvin, PhD – Evaluation Director• Natasha Sriraman, MD, MPH, IBCLC – Medical Director• Liz Flight, RN, IBCLC – Informal Consultant• Liz Marshall, MPH – Volunteer• Business Partners• Employer Champions• Professional groups and coalitions• Other Volunteers & Staff support

Support• Virginia Department of Health’s CHAMPION Program

(Commonwealth’s Healthy Approach and Mobilization Plan for Inactivity, Obesity and Nutrition)

• American Recovery & Reinvestment Act (ARRA) Communities Putting Prevention to Work

• Eastern Virginia Medical School

• National Association of Chronic Disease Directors/CDC Action Communities for Health, Innovation and Environmental Change Grant (ACHIEVE)

Resources• Business Case for Breastfeeding:

http://www.womenshealth.gov/breastfeeding/government-in-action/business-case-for-breastfeeding/

• Fact Sheet #73: Break Time for Nursing Mothers under the FLSA : http://www.dol.gov/whd/regs/compliance/whdfs73.htm

• AIA Lactation Room Design form: http://www.aia.org/aiaucmp/groups/ek_public/documents/pdf/aiap037226.pdf

• Sample policy development guide: http://www.cdph.ca.gov/programs/breastfeeding/Documents/MO-BF-WorkPolicy.pdf

Questions?Amy Paulson, MPH, AE-C757-668-6426CINCH@evms.edu www.cinchcoalition.orgwww.facebook.com/cinchcoalitionTwitter @CINCHCoalition www.facebook.com/healthyhr

Thank you