accelerating mch impact: integrating direct services with policy,...

Accelerating MCH Impact: Integrating Direct Services

with Policy, System, and Environmental Approaches

AMCHP Webinar

Monday, November 18, 2019

Speakers

Dena Herman, PhD, MPH, RDAdjunct Associate Professor, UCLA Fielding School of Public Health, Department of Community Health Sciences; Director,

Partners in Excellence for Leadership in MCH Nutrition Training Program; Professor, California State University Northridge

Angie Tagtow, MS, RD, LDFounder & Chief Strategist, Äkta Strategies, LLC; Doctoral Candidate, University of Illinois at Chicago, School of Public

Health; Former Executive Director, USDA Center for Nutrition Policy & Promotion

Leslie Cunningham-Sabo, PhD, RDNProfessor, Department of Food Science and Human Nutrition, Colorado State University

Objectives

At the end of this session, attendees will be able to:

Describe the benefits of integrating direct services and policy, system, and environmental approaches to address Title V MCH priorities;

Identify opportunities for building MCH workforce and/or agency capacity to advance policy, system, and environmental approaches; and

Reflect on a case study of how Title V MCH agencies have applied individual and policy, system, and environmental change approaches to their strategic plans, needs assessments, and operations.

Western MCH Nutrition Leadership NetworkDr. Dena Herman, University of California Los Angeles

Western MCH Nutrition Leadership NetworkThe Western Partners MCH Nutrition Leadership Network (NLN) members are state and regional Title V and public health nutrition leaders from the 13 Western states, including Hawaii, Alaska and Inter-tribal Councils.

The NLN began in 1999 and has State members in Regions: VI, VII, VIII, IX, and X.

NLN Purpose: provide leadership training for nutritionists in leadership positions, as well as networking, promoting CE , and supporting TA and opportunities for collaborative learning to strengthen the practice of public health nutrition across the western region.

The Western MCH Partners include nutrition faculty at the following universities: CSU, OHSU, and UW and collaborations with ASU and UCB.

Childhood Obesity Prevention Enhancement Project

Scope: State health departments are charged with addressing childhood obesity, yet often lack resources, skills, and training needed to address multifactorial issues to reduce/prevent obesity at the systems level

Aim: Provide comprehensive I+PSE training to enhance the viability and sustainability of state program efforts to reduce childhood obesity

Process: Provide I+PSE training and TA for 4 western state MCH nutrition teams that result in comprehensive, tailored strategic plans

Teams: California, Oregon, Washington, Winslow Indian Health Care Center (Arizona)

Complete Online Module (1 hr)

Participate in Group & Individual Discussion &

Technical Assistance (1-2 hrs)

Apply Information to Team Strategy

Plan (1 hr)

Chris Mornick, MPH, RDN

Nutrition CoordinatorWashington State Department of Health

Robin Stanton, MA, RDN, LD

MCH Nutrition LeadOregon Health Authority

Suzanne Haydu, MPH, RD

Nutrition & Physical Activity CoordinatorCalifornia Department of Public Health

Nicole Lawrence, MPH, CHES, RDN, LDN

LCDR USPHS , Supervisory DietitianWinslow Indian Health Care Center (AZ)

2018-2019 Childhood Obesity Prevention Enhancement Project Team Leads

MCH Nutrition Training Fact Sheet

Available at https://mchb.hrsa.gov/training/documents/fs/factsheet-NUTRITION.pdf

The State of Nutrition & Health in the U.S.Angie Tagtow, Äkta Strategies, LLC

Current Eating Patterns in the United StatesPercent of the U.S. Population Ages 1 Year and Older Who are Below, At, or Above Each Dietary Goal or Limit

Note: The center (0) line is the

goal or limit. For most, those

represented by the blue sections

of the bars, shifting toward the

center line will improve their eating

pattern.

Data Source: What We Eat in

America, NHANES 2007-2010 for

average intakes by age-sex group.

Healthy U.S.-Style Food Patterns,

which vary based on age, sex, and

activity level, for recommended

intakes and limits.

Adapted from Figure 2-1 (page 39), U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th Edition. December 2015.

Leading Causes of Death in the US, 1980 & 2017 (adapted from the National Center for Health Statistics, 2018)

Rank

1980 2017

Cause of Death # Deaths Cause of Death # Deaths

All causes 1,989,841 All causes 2,744,248

1 Diseases of heart 761,085 Diseases of heart 635,260

2 Malignant neoplasms 416,509 Malignant neoplasms 598,038

3 Cerebrovascular diseases 170,225 Accidents (unintentional injuries) 161.374

4 Unintentional injuries 105,781 Chronic lower respiratory diseases 154,596

5 Chronic obstructive pulmonary diseases

56,050 Cerebrovascular diseases 142,142

6 Pneumonia and influenza 54,619 Alzheimer’s disease 116,103

7 Diabetes mellitus 34,851 Diabetes mellitus 80,058

8 Chronic liver disease and cirrhosis 30,583 Influenza and pneumonia 51,537

9Atherosclerosis 29,449

Nephritis, nephrotic syndrome, nephrosis

50,046

10 Suicide 26,869 Intentional self-harm (suicide) 44,965

GDP & National Health Expenditures in the US1960, 1980 & 2017 (adapted from the National Center for Health Statistics, 2018)

1960 1980 2017

Amount (billions)

Gross Domestic Product (GDP) $542.4 $2,857.3 $19,485.4

National Health Expenditures $27.2 $255.3 $3,492.1*

National Health Expenditures as Percent of GDP 5.0% 8.9% 17.9%

Health Expenditures Per Capita $146 $1,108 $10,739

* 34% private health insurance, 20% Medicare, 17% Medicaid, 10% Out-of-pocket

Conformance with Healthy Eating Patterns Reduces Health Care Costs

A daily increase of 2 cups of fruits and vegetables consumed would save an estimated $32 billion in health care expendituresa

A 20% increased conformance to a healthy eating pattern as measured by HEI-15 would save an estimated $31.5 billion in health care expendituresb

An 80% increased conformance to a healthy eating pattern as measured by HEI-15 would save an estimated $55.1 billion in health care expendituresb

Rinehardt S. Delivering on the Dietary Guidelines. How Stronger Nutrition Policy Can Cut Costs and Save Lives. 2019. Washington, DC: Union of Concerned Scientists.

Scrafford G. Bi X, Multani J, Murphy M, Schmier J. Barraj L. Health economic evaluation modeling shows potential health care cost savings with increased conformance with healthy dietary patterns among adults in the United States. J Acad Nutr Diet. 2019; 119(4): 599-616.

“This modern public health world that we are quickly

moving into, one in which public health as the local

governmental institution has a responsibility and an

opportunity to lead our collective impact around improving

the public’s health. This is a multi-sectoral approach that

takes the opportunity to address environmental, systems

and policy-level change.”

Dr. Karen DeSalvo

Former HHS Assistant Secretary for Health

October 26, 2015

CDC. The Public Health System and the 10 Essential Public Health Services. Available at https://www.cdc.gov/publichealthgateway/publichealthservices/essentialhealthservices.html

Core Functions & Essential Public Health Services

Nested Systems

https://www.cdc.gov/publichealthgateway/publichealthservices/essentialhealthservices.html

The Public Health System

Where’s the food?

CDC. The Public Health System and the 10 Essential Public Health Services. Available at https://www.cdc.gov/publichealthgateway/publichealthservices/essentialhealthservices.html

Maternal and Child Health

Bureau

To improve the health and well-being of America's mothers, children, and families.

We envision an America where all children and families are healthy and thriving, and where each child has a fair shot at reaching their fullest potential.

HRSA Maternal & Child Health Bureau. About the Maternal and Child Health Bureau. Available at https://mchb.hrsa.gov/about

Maternal and Child Health

Maternal/ Women’s

Health

Perinatal/ Infant Health

Child Health

Adolescent/ Young Adult

Children with Special Health

Care Needs

Cross-Cutting SystemsMCHB

Strategic Framework

WorkforceResearch

Adapted from Carolyn Gleason, Title V Block Grant Project Officer, Division of State and Community Health, MCHB, Overview of the Title V Block Grant Program. MCH Nutrition Grantee Conference Call. October 7, 2019

Oscar Fleming W, Apostolico A, Mullenix A, Starr K, Margolis L. Putting implementation science into practice: Lessons from the creation of the National Maternal and Child Health Workforce Development Center. Matern Child Health J. 2019; 23:722-732. https://doi.org/10.1007/s10995-018-02697-x

MCH Workforce Development Training & Technical Assistance Implementation Drivers Framework

Systems Science

A transdisciplinary study of interactions, and the degree of those interactions, among components. This includes identifying the intended and unintended consequences of those interactions.

Applies theories and models from various sciences (biological, social, economic, environmental) to analyze and solve problems.

Formulates multidimensional/holistic approaches or representations of different systems to effectively solve problems and avoid negative consequences.

Angie Tagtow, Scholar-in-Residence, Green Mountain College, Masters in Sustainable Food System Program, 2018

Do Systems Approaches Have a Role in Title V MCH?

Systems Science

Systems Thinking

Systems Practice

I

Direct Services - Evidence-based interventions directed to individuals and families that support increased knowledge and positive behavior changeIndividual

I+P


Organizational & Community Policy – Changes to procedures or organizational practices

Public Policy - Changes to or creation of laws, ordinances, resolutions, mandates, regulations or rules

Policy

I+PS




Policy

Infrastructure & Operations - Changes to infrastructure that impacts all elements of an organization, institution, or framework

*Result of individual, policy PLUS environmental changes

Systems

“I+PSE”




Policy

Infrastructure & Operations - Changes to infrastructure that impacts all elements of an organization, institution, or framework

*Result of individual, policy PLUS environmental changes

Systems

Built Environment - Modifications to physical spaces and settings in organizations, institutions, or public areas

Natural Environments – Changes to ecological resources, landscapes and ecosystems that impact soil, water, energy, climate, biodiversity, and energy

Environment

Policy

System

Individual (Direct

Services)

Environment

Building Blocks for Optimal Impact

Benefits of I+PSE

Tackle wicked problems

Reciprocal support

Multisectoral and interdisciplinary

Multi-level action

Applicability and adaptability

Iterative

Community and population benefits

Operationalize and institutionalize

Individual Behavioral Change Theories

Health Belief Model

Health Promotion Model

Integrated Theory of Health Behavior Change*

Self-Regulation Model

Social Cognitive Theory*

Theory of Planned Behavior

Theory of Reasoned Action

Transtheoretical Model (Stages of Change)*

Social Cognitive Theory (Social Learning)

Adapted from Bandura, A. Social foundations of thought and action: A social cognitive theory. 1986. Prentice-Hall, Inc.

Behavior

Environmental Factors

Personal Factors (cognitive, affective,

biological events)

Observation

Integrated Theory of Health Behavior Change

Knowledge & Beliefs

Condition-specificKnowledgePersonal Perceptions

Self-efficacyOutcome ExpectancyGoal Congruence

Social Facilitation

InfluenceSupport

EmotionalInstrumentalInformational

Self-Regulation Skill & AbilityGoal SettingSelf-Monitoring Reflective ThinkingDecision-MakingPlanning and Plan EnactmentSelf-EvaluationManagement of Emotional Response

Outcomes -Proximal

Engagement in Self-Management Behavior

Outcomes -Distal

Health Status

Adapted from Ryan P. Integrated theory of health behavior change. Background and intervention development. Clin Nurs Spec. 2009; 23(3):161-172.

Transtheoretical Model – Stages of Change

Adapted from Prochaska J, DiClemente C, Norcross J. In search of how people change: Applications to the addictive behaviors.American Psychologist. 1992;47, 1102-1114. PMID: 1329589.

Precontemplation

Contemplation

Preparation

Action

Maintenance

1

2

3

4

5

System Change Theories & Conceptual Frameworks

Community Organization Model

Culture of Health Framework*

Diffusion of Innovation Theory

Life Course Theory*

Organizational Change Model

PRECEDE-PROCEED Framework

Social Determinants of Health*

Social-Ecological Model*

Increase focus on community and population

health

Culture of Health Framework

From Vision to Action. A Framework and Measures to Mobilize Health. Robert Wood Johnson Foundation. 2015. Available at https://www.cultureofhealth.org/content/dam/COH/RWJ000_COH-Update_CoH_Report_1b.pdf

Florida Health. Programs and Services. Women’s Health. Life Course Theory. Available at http://www.floridahealth.gov/programs-and-services/womens-health/florida-life-course-indicator-report/life-course-theory-1.html

http://www.floridahealth.gov/programs-and-services/womens-health/florida-life-course-indicator-report/life-course-theory-1.html

Helman H, Artiga S. Beyond Health Care: The Role of Social Determinants of Health and Health Equity. Kaiser Family Foundation. 2015. https://www.kff.org/disparities-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/

Social Determinants of Health

Social Ecological Model

FIGURE 3-1. A Social-Ecological Model

for Food and Physical Activity

Decisions (page 65), 2015-2020 Dietary

Guidelines for Americans.

Data Source: Adapted from: (1) Centers

for Disease Control and Prevention.

Division of Nutrition, Physical Activity, and

Obesity. National Center for Chronic

Disease Prevention and Health Promotion.

Addressing Obesity Disparities: Social

Ecological Model. Available at:

http://www.cdc.gov/obesity/health_equity/a

ddressingtheissue.html. Accessed October

19, 2015. (2) Institute of Medicine.

Preventing Childhood Obesity: Health in

the Balance, Washington (DC): The

National Academies Press; 2005, page 85.

(3) Story M, Kaphingst KM, Robinson-

O’Brien R, Glanz K. Creating healthy food

and eating environments: Policy and

environmental approaches. Annu Rev

Public Health 2008; 29:253-272.

Public Health Services for MCH Populations: Title V MCH Services Block Grant

Direct

Services

Enabling Services

Public Health Services & Systems

MCH Block Grant Services Program, Title V, SEC. 501 (a) (1) (A-B)

Appropriations to states ”to improve the health of

all mothers and children.”

Applying Theory to PracticeI+PSE Conceptual Framework for Action

Spectrum of Prevention

The Spectrum of Prevention: Developing a Comprehensive Approach to Injury Prevention. The Prevention Institute. Available at http://www.preventioninstitute.org/component/jlibrary/article/id-105/127.html

Modified Spectrum of Prevention

Enhancements• Re-order• Action verbs• Added “Modify

Physical Spaces & Natural Settings”

• Changed ‘Influence’ to ‘Inform Policy and Legislation’

• Colors• “I+PSE Conceptual

Framework for Action”

Tagtow, A. I+PSE Conceptual Framework, Western Region MCH Nutrition Learning Network Annual Training. May 2017.

Strengthen Individual Knowledge & Skills

Promote Community Education

Educate Providers

Foster Coalitions & Networks

Change Organizational Practices

Modify Physical Spaces & Natural Settings

Inform Policy & Legislation

Strengthen Individual

Knowledge & Skills


Educate Providers

Foster Coalitions &

Networks

Change Organizational

Practices



Enhancingpersonal, individual, or household’s decision-making and capability of participating in or benefitting from healthy eating and active living

Reach groups of people with information and resources by promoting healthy eating and active living

Inform and educate providers or intermediaries who transmit information about healthy eating and active living to others

Foster relationships and cultivate multisector collaborations by convening individuals and groups around healthy eating and active living

Revise or adapt policies, regulations, and procedures within institutions that support healthy eating and active living

Design physical spaces and natural settings within institutions or public environments that support healthy eating and active living (behavioral design/built environment)

Develop strategies to change laws, regulations, and public policies (local, state, federal) that support healthy eating and active living

Application: Healthy Eating & Active Living (HEAL)

A. Tagtow, MCHB Childhood Obesity Prevention Enhancement Project, 2019

I+PSE Conceptual Framework for Action




Educate Providers









Educate Providers





Context/Capitalo Healtho Social/Culture o Economic o Environmental o Political






Educate Providers







Systemic Transformation

Adaptive Organization

Collective Action

Sustained Impact

Adaptive Leadership





Educate Providers







Systemic Transformation


Collective Action

Sustained Impact

Strategic Communication

Nurturing an Adaptive Culture

Adaptive Leadership

Mobilize people to tackle tough challenges and to thrive

Establish an iterative process using previous wisdom and experience

Use diversity to create collective intelligence

Integrate action learning and systematic reflection

Build upon and support evidence-based practice


Addresses all issues, regardless of the sensitivity (“elephants”)

Shares responsibility for the organization’s future

Values independent judgment

Builds leadership capacity

Institutionalizes reflection and continuous learning

Allows for innovation, experimentation, and risk of failure

Heifetz R, Grashow Al, Linsky M. The Practice of Adaptive Leadership. Tools and Tactics for Changing Your Organization and the World. 2009. Cambridge Leadership Associations: Boston, MA.

Strategic Communication

Intentional Coordination

Management/Organizational

Marketing

Public Relations/Media

Technical

Social Marketing

Informing and Educating

Political

Principles

Accessible

Actionable

Credible and Trusted

Relevant

Timely

Understandable

Hallahan K, Holtzhausen D, van Ruler B, Vercic D, Sriramesh K. Defining Strategic Communication. International Journal of Strategic Communication. 2007; 1(1):3-35.

WHO. WHO Strategic Communications for Effective Communications. (2017). Available at https://www.who.int/mediacentre/communication-framework.pdf.

Know Your Audience!

Downstream

Putting the I+PSE Conceptual Framework for Action to Work



Educate Providers





“Downstream”

• Communication• Training & Technical

Assistance• Program Planning

(Logic Model)• Local Coalition

Building• CHNA HIP• Monitoring &

Evaluation

“Upstream”

• Communication• Performance

Measures• Agency Strategic

Planning• Monitoring &

Evaluation• Staff Competencies• Partnerships• Funding

Adapted from Raskind I, Chapple-McGruder T, Mendez D. et al. MCH workforce capacity: Maximizing opportunities afforded by a changing public health system. Matern Child Health J. 2019;23:979. https://doi-org.proxy.cc.uic.edu/10.1007/s10995-018-02728-7

Systems Integration

Health in

All Policies

Assessing array of factors that influence

public health problems

Understanding relationship between new policy and public

health problems

Evidence-Based Decision-Making

Evidence-Based

Public Health

Finding evidence on public health efforts

that work

Applying evidence-based approaches to

solve public health issues

Change Management &

Adaptive Leadership

Implementation of the Affordable Care

Act

Managing change in response to dynamic

evolving circumstances

Anticipating the changes in your

environment that may influence your work

MCH Workforce Capacity Core Training Areas

Trends in Public Health Practice

Associated MCH Job Skills

NLN Obesity Enhancement Project OutcomesDr. Leslie Cunningham-Sabo, Colorado State University

Results of Childhood Obesity Prevention Project

Recap of childhood obesity prevention project with 4 teams

Evaluation processes

Summary notes from CoP and individual TA sessions

Surveys and interviews with teams

Review of team’s strategic plans and other developed products

Outcomes – All Teams

Advance from their (different) starting places

Gained knowledge and value for I+PSE approach

Engaged stakeholders (upstream, downstream, outside agency)

Developed MCH strategic plan incorporating I+PSE

Challenges

Competing priorities for self and others

Changing mindset to incorporate I+PSE into current work

Communicating I+PSE to others

Example: Oregon Public Health Department

Population/Audience Title V grantees (local and health agencies)

Project Goals1. Promote community education and educate providers on I+PSE

approaches

2. Foster communities of practice at the local level

3. Support partner engagement through existing coalitions to expand reach of I+PSE strategies


I + PSE Framework (definition) Activities Partners Engaged Inputs OutputsShort-term Outcomes

Success (Mid- and Long-term

Outcomes)

Measurements & How Shared

Strengthen Individual Knowledge & Skills/ Professional Development

Enhance personal, individual, or household's capability of healthy eating and active living

Deepen I + PSE knowledge & skill of staff through Systems Approaches for Healthy Communities Modules (professional capacity building)

MCH Title V priority leads; Center Director; Public Health Division staff in PHD Director’s office; SNAP-Ed Advisory Group partners

Staff from MCH section, Center Director and PHD Director’s office; Systems Approaches for Healthy Communities modules

Adoption of modules for community partners

Module series scheduled for local grantee partners & promoted by Title V leads and staff in Director’s officeWithin PHD form Community of Practice (or some similar type of support) to spread PSE approaches into work

Modules completed by local grantee partners

Increased knowledge about I + PSE approaches that are incorporated into Title V priority workstreams

# of individuals who completed modules

# of priorities with PSE approaches included in guidance documents; priority strategies in guidance documents have PSE approaches identified using Spectrum of Prevention frame


Reach groups of people with information and resources to promote healthy eating and active living

Incorporate nutrition, food security, breastfeeding and physical activity into Title V needs assessment process

Title V needs assessment work group

Title V program lead and research analyst staff

Needs assessment a.k.a. Partner Survey includes opportunity for input for state Title V program on breastfeeding, physical activity, nutrition, food security and obesity; survey is qualitative; survey assesses public health system needs

Survey results informs state Title V program priorities for next 5 years; survey elicits responses on nutrition topics; results shared with stakeholders

Nutrition topics identified as important issues for state Title V program to address, especially as part of SDOH upstream interventions

Survey results analyzed for breastfeeding, physical activity, nutrition, food security and obesity; results shared widely

Specific to Title V MCH


I + PSE Framework Activities Partners Engaged Inputs OutputsShort-term Outcomes


Outcomes)


Educate Providers

Inform providers or intermediaries who will transmit skills and knowledge of healthy eating and active living to others

Promote and facilitate Title V local grantees participation in Systems Approaches for Healthy Communities; support or lead community of practice for specific priorities:-draft meeting invitation to preview modules-develop elevator speech about public health, nutrition, I + PSE approaches-get buy-in at meeting

Title V staff; local Title V grantees including tribes

Staff from MCH section and Director’s office; Systems Approaches for Healthy Communities modules

Module series scheduled; Community of practice topics identified and scheduled

Title V grantees participated in modules and in a community of practice

Increased knowledge and application of I + PSE approaches into local Title V plans; guidance documents for Title V priorities incorporate I + PSE strategies for local level action;Increased understanding how I + PSE supports addressing SDOH

# grantees / # individuals per grantee participated;# & type of community of practice formed


Convene groups and individuals around healthy eating and active living to meet broader goals and greater public health impacts

Leverage existing partnerships to participate in Title V needs assessment process

Engage with Northwest Portland Area Indian Health Board (NWPAIHB) to learn how to engage with and support needs of tribes in breastfeeding and food security work using I + PSE approaches

Nutrition Council of Oregon (NCO); SNAP-Ed Advisory Group; Oregon WIC program; NWPAIHB

Nutrition Council of Oregon (NCO); SNAP-Ed Advisory Group; Oregon WIC program

NWPAIHB staff and tribal breastfeeding coalition lead

Title V Nutrition Consultant staff; share Systems Approaches for Healthy Communities license to interested partners

Needs assessment completed by partners

Partners request access to I + PSE modules

Contact (meetings, email, etc.) between Title V Nutrition Consultant and Tribal members

Partners participate in I + PSE modules and share / promote within their networks

Increased understanding of tribal needs related to breastfeeding and food

Increased coordination or integration among SNAP-Ed, WIC and NCO partners of I + PSE approaches

Strengthen relationships and shared understanding

# partner licenses shared

# of contacts



I + PSE Framework Activities Partners Engaged Inputs OutputsShort-term Outcomes


Outcomes)



Adapt regulations and procedures by shaping norms that support healthy eating and active living

Local Title V action plans incorporate PSE approaches in addition to the individual approaches

Title V local grantees Title V staff Title V priorities have guidance documents

Title V grantee yearly action plans and reports

Guidance documents from Title V priority leads include application of PSE approaches at local level

Grantee action plans and reports include PSE approaches in addition to individual approaches

Increased understanding of PSE enhancing individual approaches and ability of local grantees to incorporate PSE into Title V plans

Evaluate Title V grantee plans (breastfeeding, food security) by spectrum of prevention approaches each year


Change physical spaces or setting within organizations or larger public environments that support healthy eating and active living

NA-Existing policies and practices are in place at OPHD to support healthy meetings, wellness at work, expression of breast milk, active transport

NA NA NA NA NA NA


Develop strategies to change laws, regulations, and policies that support healthy eating and active living

Develop 2 White Papers (i.e. policy brief) on Breastfeeding and Food Security highlighting I + PSE approaches, illustrating nutrition is one of foundations for addressing SDOH

Title V staff; Title V local grantees; PHD internal partners (e.g. WIC); PHD external partners

Title V staff; student intern and preceptor to evaluate data

Title V grantee stories, data, testimonials gathered from all annual plans and reports 2015-2019

2 white papers developed

Increased understanding of nutrition I + PSE as foundational in addressing SDOH;Briefs used to inform / change policies and practices around breastfeeding and food security at state and local level

Brief developed, shared widely with internal partners and external stakeholders


Thank You!

Q & A

Contacts: Dr. Dena Herman, [email protected]

Ms. Angie Tagtow, [email protected]

Dr. Leslie Cunningham-Sabo, [email protected]

accelerating mch impact: integrating direct services with policy,...

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