Improving Documentation Practices for Breastfeeding Peer Counselors

This past summer I had the pleasure of implementing my Applied Learning Experience (ALE) with the Massachusetts Women, Infants, and Children (WIC) program, which is a supplemental nutrition program funded through the United States Department of Agriculture Food and Nutrition Services that aims to safeguard the health of low income women and children. While there are over 100 WIC offices across the state, I carried out my ALE from the state office housed within the Massachusetts Department of Public Health in Boston. My preceptor, Rachel Colchamiro, is the state's WIC Nutrition Coordinator and was instrumental in the development and implementation of this project.

My ALE consisted of a quality improvement project for the Breastfeeding Peer Counselor program. The program is one of WIC's strategies to achieve its goal of improving the nutritional status of infants by allowing WIC-eligible women who are pregnant or breastfeeding to be paired with a Peer Counselor. The Peer Counselors are former WIC participants who are hired to support current participants in setting and achieving breastfeeding goals.

WIC's effort to promote and support breastfeeding is significant because breastfeeding is widely acknowledged to be the healthiest nutritional choice for infants. Breastfeeding contributes to various health, emotional, and economic benefits for both mothers and infants.1 However, breastfeeding rates are found to be lower among WIC participants as compared to the national average.2

Peer Counselors offer support to WIC participants through in-person meetings in a WIC office setting, as well as via phone, text, and email. After meeting with or contacting participants, Peer Counselors are responsible for documenting their services using an electronic Management Information System (MIS) called Eos. Documentation helps ensure the quality of services by helping Peer Counselors keep track of what has and has not been working for participants in terms of breastfeeding.

Although Peer Counselors are trained to use the Eos system for documentation, my ALE project grew out of the observation by the state WIC office that there has been inconsistent documentation of services across Massachusetts in recent years. The WIC state office is concerned with documentation of Peer Counselor services not only because documentation helps ensure the quality of services provided, but also because it creates a written record of all Peer Counselor activities. This written record is useful in regards to planning and funding efforts on the state level.

The specific aims and objectives of my ALE involved identifying barriers and facilitators to Peer Counselor documentation. By reaching out to Peer Counselors and other key informants within the WIC program, I set out to understand the experience of documentation. I worked toward my project aims and objectives by conducting focus groups with Peer Counselors, in-depth interviews with WIC Breastfeeding Coordinators, and an online survey that was distributed to all Peer Counselors in the state.

In hindsight, the most poignant moment of my ALE was conducting focus groups with Peer Counselors from across the state of Massachusetts. Fortuitously, during the first week of the ALE implementation semester, the peer counselors held a retreat. I used this opportunity to ask them about their experiences with documentation and the Eos system. I took away more than just valuable information for my report. Having the opportunity to meet Peer Counselors from different offices across the state allowed me to hear first-hand and understand the passion that the women have for the work that they do. This helped me frame my ALE early on as a project that aimed to make the documentation process easier for Peer Counselors, and shift my mindset away from being too highly critical.

Over the course of my ALE, I found that many of the inconsistencies in documentation stemmed from the mobile nature of the Peer Counselors' work. Peer Counselors are typically expected to document their services while in the office where they have access to a computer. However, most Peer Counselors exceed expectations by contacting breastfeeding mothers all hours of the day via phone calls, texts, and emails. Peer Counselors do not always have access to Eos when they have contacts with participants, creating a lag time between contact and documentation. This is one of the greatest barriers to documentation that I found.

In summarizing my findings and recommendations for my preceptor at WIC, I kept in mind the passion that the Peer Counselors have for their work, which I experienced during the focus groups. The ALE resulted in recommendations for improving the Eos system, looking into mobile solutions for documentation, and modifying the training manual for Peer Counselors. I am grateful to my preceptor and all of the WIC staff who were supportive of this project, and look forward to seeing how WIC utilizes the findings from this ALE.


1. American Academy of Pediatrics. (2012). Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics, 129. doi: 10.1542/peds.2011-3552.

2. Hedberg, I. (2013). Barriers to Breastfeeding in the WIC Population. The American Journal of Maternal and Child Nursing. 38(4), 244-249.