Enhancing Breastfeeding Among Refugee Women: A Quality Improvement Project

The World Health Organization (WHO) and American Academy of Pediatrics (AAP) recommend breastfeeding within the first hour of birth and exclusively for the first six months. Breastfeeding is crucial for infant health, reducing childhood infections, and supporting cognitive development. Despite high initiation rates in the U.S., breastfeeding is challenging for refugee mothers due to language barriers, lack of insurance, and cultural issues. In 2020, Utah's 6-month exclusive breastfeeding rate was 26.6%, higher than the U.S. average. However, refugee mothers face additional barriers, including language diversity and a lack of supportive clinical policies. Currently, the clinic selected for this project does not have a breastfeeding policy for pregnant or postpartum refugee mothers. This project was conducted at an urban family medicine clinic in Salt Lake City. The clinical team included residents, physicians, nurse practitioners, and medical assistants. The project provided a tailored education intervention and toolkit to address the barriers refugee women face in breastfeeding. Interventions: A pre-implementation survey assessed clinicians' comfort and knowledge about breastfeeding among refugee women. Training and a breastfeeding toolkit were provided. A post-survey assessed providers' knowledge, confidence, and the breastfeeding toolkit. A diverse group of clinicians attended the training (n=28). The participants were physicians (n=5), nurse practitioners (n=2), residents (n=7), and medical assistants (n=14). Survey results showed an increase in confidence, with 55.6 % (5/9) of participants expressing high confidence post-implementation compared to only 7.1% (1/14) in the pre-implementation survey. The breastfeeding toolkit enhanced clinician engagement and confidence in promoting breastfeeding among refugee women.

1 f Enhancing Breastfeeding Among Refugee Women: A Quality Improvement Project Sadiya M. Hassan, Jessica Ellis, and Diane Chapman College of Nursing: The University of Utah NURS 7703: DNP Scholarly Project III April 15, 2025 2 Abstract Background: The World Health Organization (WHO) and American Academy of Pediatrics (AAP) recommend breastfeeding within the first hour of birth and exclusively for the first six months. Breastfeeding is crucial for infant health, reducing childhood infections, and supporting cognitive development. Despite high initiation rates in the U.S., breastfeeding is challenging for refugee mothers due to language barriers, lack of insurance, and cultural issues. Local Problem: In 2020, Utah's 6-month exclusive breastfeeding rate was 26.6%, higher than the U.S. average. However, refugee mothers face additional barriers, including language diversity and a lack of supportive clinical policies. Currently, the clinic selected for this project does not have a breastfeeding policy for pregnant or postpartum refugee mothers. Methods: This project was conducted at an urban family medicine clinic in Salt Lake City. The clinical team included residents, physicians, nurse practitioners, and medical assistants. The project provided a tailored education intervention and toolkit to address the barriers refugee women face in breastfeeding. Interventions: A pre-implementation survey assessed clinicians' comfort and knowledge about breastfeeding among refugee women. Training and a breastfeeding toolkit were provided. A post-survey assessed providers' knowledge, confidence, and the breastfeeding toolkit. Results: A diverse group of clinicians attended the training (n=28). The participants were physicians (n=5), nurse practitioners (n=2), residents (n=7), and medical assistants (n=14). Survey results showed an increase in confidence, with 55.6 % (5/9) of participants expressing high confidence post-implementation compared to only 7.1% (1/14) in the pre-implementation survey. Conclusion: The breastfeeding toolkit enhanced clinician engagement and confidence in promoting breastfeeding among refugee women. 3 Keywords: Breastfeeding, Refugee Women, Culturally Appropriate Education, Quality Improvement, Healthcare Disparities, Infant Nutrition 4 Enhancing Breastfeeding Among Refugee Women: A Quality Improvement Project Problem Description Refugee people are individuals who have been forced to flee their home countries due to persecution, war, or violence (USA for UNHCR, 2025). Due to the circumstances of refugeeism, refugee mothers often have shorter breastfeeding durations compared to non-refugee mothers, despite healthcare recommendations for exclusive breastfeeding for the first six months (Hirani, 2024). They encounter language difficulties, lack health insurance, and may not have access to culturally and gender-sensitive healthcare services, all of which hinder their use of breastfeeding support services (Hirani, 2024). Cultural stereotyping and socioeconomic hardships exacerbate these challenges, leading to social, emotional, psychological, and physical stressors (Hirani, 2024). Refugee women frequently face contradictions and conflicts regarding breastfeeding (Hirani, 2024). Modern healthcare's imposition of medicalized "rules" over traditional knowledge may intensify maternal postpartum vulnerability, leading to feelings of inadequacy regarding breastfeeding (Dube et al., 2019). This cultural insensitivity can significantly impact breastfeeding practices, as observed in various studies (Dube et al., 2019). These challenges reflect the broader issues of uncertainty and fear among refugee women, who may be hesitant to allow healthcare professionals into their personal bodily space for breastfeeding assistance due to past traumas and oppression (Dube et al., 2019). Local Problem The Utah Department of Human and Health Services (2024) stated that Utah's rate for 6month exclusive breastfeeding in 2020 was 26.6%. Utah's rates were higher than the national average. However, breastfeeding for at least six months was more common among women who were White and non-Hispanic, Asian, college-educated, and women who were not enrolled in the 5 Women, Infants, and Children (WIC) program. In Utah, approximately 1,000 refugees are accepted annually (St. Mark's Family Medicine, n.d.). At the local clinic where this project was conducted, about 22% of patients prefer a language other than English, as detailed in Figure 1 (St. Mark's Family Medicine, n.d.). This language diversity contributes to barriers and disparities in breastfeeding support. Currently, the clinic does not have a breastfeeding policy for pregnant or postpartum refugee mothers. Available Knowledge The World Health Organization (WHO) and the American Academy of Pediatrics (AAP) recommend breastfeeding for optimal infant health (World Health Organization, 2025). These recommendations include initiating breastfeeding within the first hour of birth and exclusively breastfeeding for the first six months (World Health Organization, 2025). This is crucial for infant health and well-being, as breastfeeding reduces the risk of childhood infections and supports cognitive development (Hirani, 2024). The AAP also supports ongoing breastfeeding with the introduction of appropriate complementary foods at six months while continuing breastfeeding until the age of two years (Meek et al., 2022). Breastfeeding is common in low- and middle-income countries; however, practices are often inadequate due to early supplemental feeding and varying durations of exclusive breastfeeding (Walters et al., 2019). According to Walters et al. (2019), 595,379 children die globally each year due to a lack of breastfeeding. In the United States, more than 80% of new mothers initiate breastfeeding, and federal and state laws protect breastfeeding women (Meek et al., 2022). Refugee mothers face additional challenges, such as language barriers, lack of health insurance, and limited access to culturally sensitive healthcare. Food insecurities and the 6 distribution of commercial complementary foods also negatively impact breastfeeding efforts (Hirani, 2024). The common reasons mothers stop breastfeeding before the first year include lack of support, work or school obligations, the perception of inadequate milk supply, personal beliefs, financial hardships, inadequate healthcare support, inconsistent guidelines, and past traumas that hinder breastfeeding success (Hirani, 2024; Dube et al., 2019; Odeniyi et al., 2020) In Australia, African immigrant mothers retain some infant feeding practices from their home countries while adopting host-country practices, such as avoiding breastfeeding in public (Ware et al., 2021; Odeniyi et al., 2020). In the United States, breastfeeding rates are higher among non-Hispanic White populations compared to many minority groups (Ware et al., 2021; Odeniyi et al., 2020). Breastfeeding is often viewed as natural and typical for African mothers in high-income countries. Nevertheless, many introduce formula supplementation as early as three months, influenced by lifestyle changes and cultural beliefs. This trend is often driven by the false perception that formula feeding promotes larger babies, contributing to lower exclusive breastfeeding rates (Odeniyi et al., 2020). There are several international initiatives to support breastfeeding among refugee women. For example, UNICEF provides breastfeeding mothers with healthcare, nutrition, and psychosocial services in refugee camps and offers online patient education materials (UNICEF United Kingdom, 2019). Global Health Media is also an online resource for patients and providers, providing educational videos on breastfeeding in an international context (Global Health Media, 2025). These initiatives align with this project's goals and provide a supportive network for improving health outcomes for refugee women. 7 Rationale The framework used for this project is the Model Improvement project. This project is guided by the Johns Hopkins Evidence-Based Practice Model (Dang et al., 2022), which emphasizes a structured approach to implementing evidence-based interventions. This model ensured that the intervention aligned with the objectives and allowed for the measurement of meaningful outcomes. Throughout the intervention, Plan-Do-Study-Act (PDSA) cycles were employed to continuously gather and integrate feedback, ensuring the project progressed effectively. In the planning phase, clinicians were surveyed to assess their knowledge and comfort regarding breastfeeding education for refugee women, and existing educational materials were analyzed for cultural appropriateness. During the ‘do’ phase, a culturally tailored breastfeeding toolkit was developed and distributed to a family medicine clinic in an urban area of Salt Lake City, Utah. Additionally, the clinic staff were trained in using the toolkit, provided a list of breastfeeding resources, and given instructions on accessing them. We documented toolkit usage and collected feedback. During the study phase, the data were analyzed by assessing pre- and postimplementation survey results, toolkit usability, feasibility, and provider satisfaction, as well as identifying successes and areas for improvement. Finally, in the act phase, a post-survey was conducted to evaluate providers' comfort level with breastfeeding education, refine the toolkit based on feedback and data analysis, and address barriers to implementation to ensure the intervention achieved its intended outcomes. Specific Aims 8 This Doctor of Nursing (DNP) evidence-based practice change aims to mitigate breastfeeding disparities among refugee women by addressing the negative impact of racism, bias, and discrimination in healthcare delivery, thereby striving to repair historical injustices and improve health outcomes. Methods Context The project was conducted at a family medicine clinic in an urban area of Salt Lake City, Utah, primarily serving underserved populations, including refugee women. The clinical providers included five physicians, seven residents, two nurse practitioners, and fourteen medical assistants. The project duration was twelve weeks long. By providing tailored education, resources, and breastfeeding support, the project confronted the cultural, linguistic, and systemic barriers that refugee women faced. The project aimed to improve health equity by enhancing breastfeeding support for refugee women and addressing social determinants of health. Contextual factors such as language barriers and cultural differences may have impacted the project's success. This project aimed to increase breastfeeding support for refugee women by implementing a culturally tailored breastfeeding toolkit and evaluating its impact through a structured, two-phase approach. The Breastfeeding Toolkit included multilingual patient handouts, prenatal and basic breastfeeding information, pumping details, and a reference book. Dot phrases were developed to streamline documentation and address lactation concerns. The breastfeeding training consisted of three phases: an overview of breastfeeding benefits and barriers; information on proper latching techniques, pumping, and cultural considerations; and finally, an open discussion for clinicians. Intervention(s): 9 Phase One: Pre-Implementation Demographic information was collected through a pre-implementation survey, which also assessed breastfeeding knowledge, comfort levels, and clinicians' available resources. An education session for clinicians was developed, with a focus on breastfeeding support for refugee women. A breastfeeding toolkit was then developed to address cultural, linguistic, and systemic barriers for breastfeeding among refugee women. Dot phrases were developed to make documentation faster and more efficient for providers Phase Two: Intervention In phase two, an educational presentation and open discussion were conducted with clinicians to ensure understanding and foster active participation. The breastfeeding training was conducted in four structured steps: 1. Breastfeeding Overview: The first step included breastfeeding recommendations, benefits, prevalence, and the consequences of not breastfeeding. Additionally, it addressed the unique barriers refugee women face when breastfeeding (see Appendix A). 2. Latch and Breastfeeding Complications: The second step discussed proper latching techniques. Clinicians were shown an instructional video from Global Health Media on achieving a good latch and managing common breastfeeding complications (see Appendix B). 3. Pumping and Cultural Considerations: The third step focused on pumping, cultural beliefs that influence breastfeeding practices, trauma-informed approaches to breastfeeding, and strategies for supporting breastfeeding in public settings. 10 4. Discussion: The final step encouraged an open discussion among clinicians, allowing them to ask questions, share insights, and explore strategies for applying the training in their clinical practice. The Breastfeeding Toolkit was also presented at this training. The toolkit consisted of multilingual patient handouts from UNICEF and MedlinePlus. The languages included Arabic, Somali, Nepali, Bengali, Spanish, and Urdu. The written material included prenatal information on how to start breastfeeding, including diet, breastfeeding positions, latching and removing the baby from the breast, how often to breastfeed, and expected infant voids and stools. The other packets included basic breastfeeding information like waking the baby up for feeding, how long to feed the baby, and a feeding log. Pumping information was also included. A reference book with breastfeeding information was provided to the clinical staff, along with resources for patients and providers. Additionally, the dot phrases were presented to clinicians. Dot phrases (called 'smart phrases' or 'quick phrases') are prewritten templates or text shortcuts used in electronic health record (EHR) systems, such as Epic, to make documentation faster and more efficient. Recognizing the busy nature of this clinic and the additional challenges posed by language barriers, it was necessary to streamline the charting process for providers. To support this goal, dot phrases were developed addressing common lactation concerns, including their management, and key talking points for patient discussions. These phrases were designed to enhance clinician education while significantly reducing charting time. Phase Three: Post-Intervention Survey 11 A post-intervention survey was administered two weeks after the intervention to evaluate clinicians' attitudes toward the breastfeeding toolkit and training. The post-intervention survey focused on the usability, feasibility, satisfaction, and any barriers experienced by the clinicians. Study of the Intervention(s) The approach for assessing the interventions' impact involved pre- and post-surveys. Both the pre- and post-surveys used QR codes, allowing clinicians to access the surveys easily with their phones. The pre-test included questions to evaluate provider knowledge and confidence and included demographic questions. The post-survey included questions intended to gauge newly acquired provider knowledge and resources, assess the provider’s confidence, and determine the feasibility and acceptability of the breastfeeding toolkit. The 2-week post-survey contained open-ended questions about practice changes implemented since the training, allowing providers to give feedback on any missing components of the breastfeeding toolkit or any unnecessary resources included. The expected outcome was improved clinician knowledge and confidence in supporting breastfeeding among refugee women by increasing culturally appropriate education for providers., as well as evidence that clinicians found the toolkit useable and feasible. Measures To assess this quality improvement project, clinicians received a survey before and after implementing the breastfeeding toolkit. The study was conducted over three months, with weekly data collection using informal interviews and biweekly check-ins. Each survey was conducted using REDCap to ensure anonymity and accurate tracking. The surveys used a 5-point Likert scale and included open-ended questions to assess clinicians' knowledge, attitudes, and comfort with breastfeeding education. The pre-survey provided baseline data on clinicians' 12 attitudes and barriers, while the post-survey captured changes in attitude, confidence, and satisfaction with the breastfeeding toolkit. The intervention's effectiveness was measured through clinician confidence levels, material usage, and improvements in patient education quality. During the pre-implementation phase, demographic data was collected to aid the analysis. The clinicians’ feedback was analyzed to identify recurring issues and adjust the intervention using the Plan-Do-Study-Act (PDSA) method—weekly data collection allowed for rapid cycle changes and continuous improvement. Qualitative feedback from the medical director and content expert during the weekly check-ins provided insights into practical challenges and facilitators. The QI project emphasized flexibility, rapid feedback cycles, and ongoing communication. The expected outcomes from implementing the toolkit included increased clinician confidence and improved access to culturally tailored breastfeeding interventions. This was measured using the three measures for the project's success: feasibility, acceptability, and satisfaction. Feasibility data included provider attendance, training time, and schedule accommodation. Acceptability data gauged the usefulness of the training and toolkit. Effectiveness variables assessed awareness of resources, cultural differences, barriers, and confidence in providing culturally appropriate breastfeeding education. Analysis Pre- and post-surveys data included participant demographics and questions related to previous breastfeeding education and knowledge. The surveys featured both Likert-scale and open-ended questions. The pre-intervention and post-intervention surveys were analyzed using descriptive statistics. There were ten questions in both the pre- and post-implementation surveys. The Likert-scale questions offered a range of responses from "Disagree" to "Agree," with an option for "Neither Agree nor Disagree," and some questions used a "choose all that apply" 13 format. Qualitative and quantitative measures were employed to evaluate the impact of the breastfeeding toolkit. This approach enabled an assessment of the intervention's feasibility and usability and an evaluation of staff and provider practices, attitudes, and overall satisfaction with the toolkit. Ethical Consideration The University of Utah's Institutional Review Board (IRB) reviewed this project. It was considered exempt because it is a quality improvement project rather than research involving human subjects. The participants in the pre-and post-survey were clinicians at the site. Clinicians were allowed to remain anonymous when completing the pre-and post-implementation survey, which was securely stored using the RedCap system to ensure confidentiality. Participants were informed that the data collected would be used to develop a breastfeeding toolkit at the site. Throughout the project, careful attention was given to obtaining informed consent, maintaining confidentiality, and respecting the rights of participants. Results The surveys provided valuable insights into clinicians' experiences and perceptions regarding breastfeeding education for refugee women. The pre-intervention survey highlighted clinicians' comfort levels, knowledge of the barriers refugee women face, and the challenges in providing breastfeeding education. The post-intervention survey evaluated clinicians' attitudes toward the breastfeeding toolkit and training, focusing on usability, feasibility, satisfaction, and any barriers experienced. A total of 28 clinicians attended the breastfeeding education training, including physicians (n=5), nurse practitioners (n=2), residents (n=7), and medical assistants (n=14). Fourteen clinicians responded to the pre-survey, and nine completed the postimplementation survey. 14 Pre-intervention Survey A total of 14 (n=14) clinicians completed the pre-intervention survey, providing insights into their comfort levels, their knowledge of the barriers refugee women face, and the challenges clinicians encounter when providing breastfeeding education to refugee women. The survey included Likert-scale and open-ended questions about formal training and the primary challenges faced (see Appendix C). The pre-survey revealed that 57.1% (8/14) of respondents have 0-2 years of experience. An additional 21.4% (3/14) fell within the 3–5-year range, while only 7.1% (1/14) reported having 6-10 years of experience, and 14.3% (2/14) have over 10 years in practice (see Table 1). Clinicians were asked about refugee women's barriers to breastfeeding, and all participants (14/14) identified language barriers. Most clinicians noted inconsistent or inadequate support, 93% (13/14), while 71% (10/14) mentioned cultural differences. Limited access to healthcare was identified by 86% (2/14), traumas and mental health issues by 57% (8/14), and a lack of trust in healthcare providers by 42% (6/14). Finally, only 1 participant, 7% (1/14), identified gender differences as a barrier (see Table 2). Participants reported varying familiarity regarding refugee women's breastfeeding practices: 14% (2/14) reported being familiar with beliefs about colostrum, 29% (4/14) recognized the early introduction of foods/liquids, 64% (9/14) noted the cultural differences between breastfeeding in public versus private settings, and 50% (7/14) acknowledged the role of family/community in decisions. Familiarity with beliefs about maternal diet and religious influences on breastfeeding was lower at 36% (5/14) and 22% (3/14), respectively, highlighting a need for further targeted education (see Table 3). 15 Respondents rated their confidence in providing breastfeeding education. Only 7.1% (1/14) expressed high confidence, 35.7% (5/14) reported moderate confidence, and another 35.7 % (5/14) indicated low confidence. Additionally, 21.4 % (3/14) stated they had no confidence. This distribution suggests that more than half of the respondents would benefit from additional training and resources to improve their proficiency in delivering breastfeeding education (see Table 4). Lastly, most respondents expressed dissatisfaction when asked if they were satisfied with their current breastfeeding education. Most participants, 57.1% (8/14), disagreed with the statement, and an additional 14.3 % (3/14) somewhat disagreed. In contrast, 21.4% (3/14) remained neutral, and only 7.1% (1/14) somewhat agreed that they were dissatisfied with current breastfeeding education (see Table 5). Post-intervention Nine participants completed the post-intervention survey. This survey evaluated attitudes regarding the breastfeeding toolkit and breastfeeding training, focusing on usability, feasibility, satisfaction, and any barriers they experienced to using the breastfeeding toolkit (see Appendix D). Clinicians were first asked if they participated in breastfeeding training and discussion: 77.8% (7/9) participated in the breastfeeding presentation, and 22.2% (2/9) did not (see Table 6). Participants were asked whether their confidence in assessing and counseling patients on breastfeeding had increased: 55.6 % (5/9) agreed that it had, 22.2% (2/9) did not agree that their confidence had increased, 11.1 % (1/9) somewhat agreed, and 11.1% (1/9) was neutral (see Table 7). 16 Participants were asked whether they found the breastfeeding presentation helpful: 55.6% (5/9) agreed, 22.2% (2/9) did not agree that the presentation was helpful, 11.1% (1/9) somewhat agreed, and 11.1% (1/9) were neutral (see Table 8). Participants were asked whether they were satisfied with the breastfeeding education and toolkit: 56% (5/9) agreed, while 44.4% (4/9) were neutral (see Table 9). Participants were asked whether the breastfeeding presentation and toolkit were adequate: 44.4% (4/9) rated the presentation and toolkit as "very adequate,” 44.4% (4/9) remained neutral, and 11.1% (1/9) rated it as "somewhat adequate” (see Table 10). Clinicians were asked which resources from the breastfeeding toolkit they used. The most used resource was the patient handouts, selected by 55.5% (5/9) of clinicians. Additionally, 22% (2/9) of participants stated they used Global Health Media videos, providing visual guidance for breastfeeding. Another 22% (2/9) of participants reported using the dot phrases for common lactation concerns. Lastly, 22% (2/9) of participants used the reference booklet as a comprehensive guide for breastfeeding support (see Table 11). In the open-ended section of the post-survey, participants reported some challenges with the Breastfeeding Toolkit. Three clinicians reported they were unaware of where the patient handouts were placed, leading to missed opportunities to provide printed breastfeeding education materials to patients. Four clinicians said they knew where the handouts were but did not encounter pregnant or breastfeeding mothers too often. Additionally, some providers were unaware of the toolkit’s resources, such as videos on latching, addressing nipple pain, and improving insufficient milk supply. Several clinicians noted that, although they had not used the resources due to not seeing pregnant or breastfeeding patients, they did know how to access them if needed. For improvement, some clinicians suggested relocating the patient handouts to the main area where 17 other handouts are kept and clearly labeling them. Others recommended sending emails with the handouts so clinicians could access them more easily. Discussion Summary The results of this project demonstrate that the Breastfeeding Toolkit and education presentation were well received, with most participants reporting increased confidence in assessing and counseling patients on breastfeeding. Over half of participants (55.6%) agreed that their confidence had increased, and 55.6% communicated satisfaction with the breastfeeding toolkit. In addition, 44.4% of participants rated the breastfeeding presentation and toolkit as "very adequate," highlighting the relevance of the intervention to address the project's specific aims of enhancing breastfeeding support for refugee women. The toolkit also successfully addressed some cultural and systemic barriers that refugee mothers face when accessing breastfeeding support, as identified in the literature. A strength of this project was its focus on providing culturally tailored education and resources, including multilingual patient handouts, reference materials, and the provision of dot phrases, to encourage more straightforward and faster documentation. Interpretation The overall results were as expected. The breastfeeding toolkit and training proved feasible, usable, and effective in increasing clinician satisfaction. It also serves as a replicable approach to improving clinician confidence in providing breastfeeding support for refugee women. The use of culturally tailored resources and training has been emphasized in other studies as an effective method to address barriers faced by marginalized populations. When breastfeeding education incorporates the principles of social determinants of health—such as 18 access to healthcare, economic stability, language barriers, and community support—it has effectively reduced breastfeeding disparities rates among women of color (Rhodes et al., 2021). Providing culturally tailored education and practical resources, as was done in this project, can positively impact clinician engagement and patient outcomes, ultimately improving breastfeeding rates within the refugee population. Limitations Some challenges were encountered during the implementation of this project, particularly while creating patient handouts. Finding resources in all the languages commonly spoken by the clinic's patient population was challenging. Languages spoken included Pashto, Arabic, Spanish, Swahili, Dari, Farsi, Somali, Nepali, Kinyarwanda, and Burmese. Patient education materials were found in English, Arabic, Somali, Spanish, Nepali, and Bengali, but resources were unavailable for the remaining languages. Due to ongoing construction at the clinic, there were delays in incorporating the Global Health Media videos for patient viewing. These videos are valuable for providing health information in patients' native languages. We could not obtain usability data during this project's duration, but the clinic plans to utilize these videos in the future. Another evident limitation is the small sample size of this project and that two individuals who did not attend the training completed the post-survey. Conclusions Breastfeeding can be particularly challenging for many women, especially women of color, and this disparity hurts both their health and the health of their children. Research indicates that cultural competence training improves clinicians’ knowledge, attitudes, and skills, positively affecting their ability to provide care. Additionally, there is strong evidence that 19 cultural competence training enhances patient satisfaction, further improving the overall healthcare experience. Enhancing breastfeeding practices among refugee mothers requires comprehensive healthcare support, culturally tailored services, medical interpreters, babyfriendly initiatives, and targeted breastfeeding campaigns (Hirani, 2024). Based on this project, ongoing follow-up and collaboration among healthcare providers are essential for success. The sustainability of the toolkit was supported by the easy accessibility of the resources provided to the clinic, particularly the educational materials and videos. Nevertheless, further research in this area is necessary, as not all languages were represented, and clinicians still need additional resources to address language barriers. The next step would be to develop educational videos for patients, specifically those who cannot read in their native language, to further bridge these gaps in communication and support. 20 Acknowledgments I would like to acknowledge the following individuals for their contributions: The Medical Director of the clinic, Dr. Melanie Dance; Content expert, Dr. Daine Champman; Project Chai,r Dr. Jessica Ellis. Program directors, Dr. Jesscia Ellis and Dr. Erin Cole. The Salt Lake City Urban Family Medicine clinicians who participated in this project. 21 References Dang, D., Dearholt, S., Bissett, K., Ascenzi, J., & Whalen, M. (2022). Johns Hopkins evidencebased practice for nurses and healthcare professionals: Model and guidelines. ( 4th edition ed.). Sigma Theta Tau International. Dube, M., Gao, Y., Steel, M., Bromley, A., Ireland, S., & Kildea, S. (2019). Effect of an Australian community-based caseload midwifery group practice service on maternal and neonatal outcomes for women from a refugee background. Women & Birth, 36(3), e353e360. https://doi.org/10.1016/j.wombi.2022.10.004 Global Health Media. (2025). Breastfeeding attachment. https://globalhealthmedia.org/video/breastfeeding-attachment/ Hirani, S. A. A. (2024). Barriers affecting breastfeeding practices of refugee mothers: A critical ethnography in Saskatchewan, Canada. International Journal of Environmental Research and Public Health, 21(4), 398. https://doi.org/10.3390/ijerph21040398 Meek, J. Y., Noble, L., & Section on, B. (2022). Policy Statement: Breastfeeding and the use of human milk. Pediatrics, 150(1). https://doi.org/10.1542/peds.2022-057988 Odeniyi, A. O., Embleton, N., Ngongalah, L., Akor, W., & Rankin, J. (2020). Breastfeeding beliefs and experiences of African immigrant mothers in high-income countries: A systematic review. Matern Child Nutr, 16(3), e12970. https://doi.org/10.1111/mcn.12970 Rhodes, E. C., Damio, G., LaPlant, H. W., Trymbulak, W., Crummett, C., Surprenant, R., & Perez-Escamilla, R. (2021). Promoting equity in breastfeeding through peer counseling: the US Breastfeeding Heritage and Pride program. Int J Equity Health, 20(1), 128. https://doi.org/10.1186/s12939-021-01408-3 St. Mark's Family Medicine. (n.d.). Program highlights. St. Mark's Family Medicine. https://www.smfmr.org/highlights 22 USA for UNHCR. (2025). Who is a refugee? USA for UNHCR. https://www.unrefugees.org/refugee-facts/what-is-a-refugee/ UNICEF United Kingdom. (2019). Foreign language resources: Breastfeeding. https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/foreign-languageresources/ Utah Department of Health and Human Services. (2024, November 5). Complete health indicator report of breastfeeding at 3 months and 6 months. Public Health Indicator Based Information System (IBIS). https://ibis.utah.gov/ibisphview/indicator/complete_profile/BrstFeed6mos.html Walters, D. D., Phan, L. T. H., & Mathisen, R. (2019). The cost of not breastfeeding: global results from a new tool. Health Policy Plan, 34(6), 407-417. https://doi.org/10.1093/heapol/czz050 Ware, J. L., Love, D., Ladipo, J., Paddy, K., Starr, M., Gilliam, J., Miles, N., Leatherwood, S., Reese, L., & Baker, T. (2021). African American breastfeeding peer support: All moms empowered to nurse. Breastfeed Med, 16(2), 156-164. https://doi.org/10.1089/bfm.2020.0323 World Health Organization. (2025). Breastfeeding. https://www.who.int/healthtopics/breastfeeding#tab=tab_1 23 Tables and Figures Table 1 Years of clinician experience Years Experience (pre) Frequency Valid 0-2 years 8 Percent 57.1 3-5 years 6-10 years 10+ years Total 3 1 2 14 21.4 7.1 14.3 100.0 Valid Percent 57.1 21.4 7.1 14.3 100.0 Cumulative Percent 57.1 78.6 85.7 100.0 Table 2 Barriers refugee women face with breastfeeding Barriers Refugee Women Face (pre) Valid Language and Communication Barriers Cultural Differences Limited Access to Healthcare Trauma and Mental Health Issues Lack of Trust in Healthcare Providers Inconsistent or Inadequate Support Gender Difference Between Provider and Patient Total Frequency Percent Valid Percent 14 21.9 21.9 14 Cumulative Percent 21.9 10 12 15.6 18.8 15.6 18.8 37.5 56.3 8 12.5 12.5 68.8 6 9.4 9.4 78.1 13 20.3 20.3 98.4 1 1.6 1.6 100.0 100.0 100.0 24 Table 3 Clinicians' Familiarity with Refugee Women's Breastfeeding Practices Familiarity with Breastfeeding Practices (pre) Valid Beliefs about colostrum Early introduction of foods and/or liquids Breastfeeding in public vs private Role of family/community in decisions Beliefs about maternal diet and breastfeeding Religious influences on breastfeeding Total Frequency 2 4 Percent 6.7 13.3 Valid Percent 6.7 13.3 Cumulative Percent 6.7 A20.0 9 30.0 30.0 50.0 7 23.3 23.3 73.3 5 16.7 16.7 90.0 3 10.0 10.0 100.0 14 100.0 100.0 Table 4 Clinicians rate their confidence in providing breastfeeding education to refugee women. Rate your confidence in providing breastfeeding education Valid Frequency High confidence 1 Low confidence 5 Moderate confidence 5 No confidence 3 Total 14 Percent 7.1 35.7 35.7 21.4 100.0 Cumulative Valid Percent Percent 7.1 7.1 35.7 42.9 35.7 78.6 21.4 100.0 100.0 25 Table 5 Clinicians were asked about the breastfeeding education at the clinic and their satisfaction. I am satisfied with the current breastfeeding education we use Valid Frequency Percent Cumulative Valid Percent Percent 8 57.1 57.1 57.1 Neither agree nor disagree 3 21.4 21.4 78.6 Somewhat Agree 1 7.1 7.1 85.7 Somewhat disagree 2 14.3 14.3 100.0 Total Participants 14 100.0 100.0 Disagree Table 6 Post-intervention survey: Breastfeeding Education Attendance Frequency Valid No 2 Percent 22.2 Yes Total 7 9 77.8 100.0 Valid Percent Cumulative Percent 22.2 22.2 77.8 100.0 100.0 Table 7 Clinicians were asked about their confidence in counseling and assessing breastfeeding patients My confidence increased in assessing and counseling patients on breastfeeding Valid Frequency Percent Valid Percent Cumulative Percent Missing 2 22.2 22.2 22.2 Agree 5 55.6 55.6 77.8 Neutral 1 11.1 11.1 88.9 Somewhat agree 1 11.1 11.1 100.0 26 Total 9 100.0 100.0 Table 8 Clinicians were asked if they found the breastfeeding presentation helpful The breastfeeding presentation was helpful Valid Frequency Percent Valid Percent Cumulative Percent Missing 2 22.2 22.2 22.2 Agree 5 55.6 55.6 77.8 Neutral 1 11.1 11.1 88.9 Somewhat agree 1 11.1 11.1 100.0 Total 9 100.0 100.0 Table 9 Clinicians were asked if they were satisfied with the breastfeeding toolkit. I am satisfied with the breastfeeding toolkit Valid Frequency Percent Valid Percent Cumulative Percent Agree 5 55.6 55.6 55.6 Neutral 4 44.4 44.4 100.0 Total 9 100.0 100.0 Table 10 Clinicians were asked if the breastfeeding presentation and toolkit were adequate Adequacy of Breastfeeding Presentation/Toolkit Valid Frequency Percent Cumulative Valid Percent Percent 4 44.4 44.4 44.4 Somewhat Adequate 1 11.1 11.1 55.6 Very adequate 44.4 44.4 100.0 Neutral 4 27 Total 9 100.0 100.0 Table 11 Clinicians were asked what resources they used in the toolkit Resources Used Valid Patient Handouts Global Health Media Videos Quick Text for Common Lactation Concerns Breastfeeding Reference Booklet Total Frequency 5 2 Figure 1 Common language used at the site of the project Percent Valid Percent 55.5 45.5 22.2 18.2 Cumulative Percent 45.5 63.6 2 22.2 18.2 81.8 2 22.2 18.2 100.0 9 100.0 100.0 28 Appendix A Enhancing Breastfeeding Among Refugee Women: A Quality Improvement Project PowerPoint Education Provided to Clinicians: Pre-Implementation Toolkit 29 30 Appendix B Breastfeeding video https://globalhealthmedia.org/video/breastfeeding-attachment/ Clinician/patient resources booklet https://docs.google.com/document/d/1iYpdbw0Vr8kDsXpEc9YhOteERiQiS1qS/edit?usp=sharin g&ouid=102290168339817957881&rtpof=true&sd=true Dot Phases developed for clinicians https://drive.google.com/file/d/1T-vECxokHy5CG-dRoGSVT-FJKfP5Ba2t/view?usp=sharing 31 Appendix C Pre-intervention survey 32 33 Appendix D Post-intervention survey 34 35 Appendix E Executive Summary