May 14, 2017

Ms. Ann Henderson and Ms. Carol Jue

Monadnock Understands Childhood Hunger (MUCH) Coalition

Dear Ms. Henderson and Ms. Jue,

I am respectfully requesting, from the Monadnock Mobile Milk program in coordination
with Cheshire Medical Center and Keene State College Dietetic Internship, for a grant of $500
from the Monadnock Understands Childhood Hunger (MUCH) Coalition. The Mobile Milk
program provides breastfeeding education to prenatal and postpartum women through a text
messaging system, GroupTexting.com. The program was recently implemented in May 2017 and
is still in the beginning stages. This grant would be used toward the continuation of the Mobile
Milk Program in order to increase the breastfeeding rates within the Monadnock region.
Enclosed you will find our grant proposal to further support the need for this funding.
The Mobile Milk program and members of Cheshire Medical Center-Dartmouth Hitchcock
sincerely hope that your MUCH Coalition will act favorably upon the request for this much
needed financial support to continue the program.
Sincerely,

Marissa Schriver
Keene State College
Dietetic Intern
 I. Statement of the Problem
It is recommended that breastmilk be provided as the main source of food for babies during
at least the first six months of their life and intended to be continued throughout the first year of
life. Breastmilk contains essential nutrients needed for optimal growth and development, reduces
risk of allergies and illness, creates a bond between mother and baby, reduces the mothers risk
of certain cancers and many more. Despite all of these benefits, the rates of women exclusively
breastfeeding at both six and 12 months are not where they should be. The U.S. National
Breastfeeding rates as of 2013 are 76.5% at initiation, 49% at six month and 27% at 12 months
(1). More specifically, the breastfeeding rates within Cheshire County as of 2015 are 92% at
initiation and 72% at discharge from the hospital. While these rates are higher than the national
rates, they still arent as high as they could be, especially at discharge. There currently is a lack
of research to compare the rates of breastfeeding at six and 12 months within Cheshire County,
however, it can be assumed that if there was a 20% decrease in rates just from initiation to
discharge, there would be an even greater decrease in the long-term.
One of the main concerns regarding this issue is why are mothers choosing not to breastfeed?
What are the barriers that they are facing and how do we alleviate them? We know from research
conducted in the Monadnock Region by Keene State College that WIC mothers face barriers
such as lack of reliable transportation, lack of access to services, lack of a support system, etc.
The Mobile Milk program aims to address this issue by providing instant breastfeeding education
at your fingertips via text message. This program delivers breastfeeding education to those
enrolled in the program through 2-3 text messages per week during the last five months of
pregnancy or four months post-delivery.
In order to address the issue of lack of access to reliable services due to multiple barriers, we
chose to utilize a text messaging based system to connect mothers to pertinent information and
healthcare providers without having to leave their homes. Based on research conducted by the
Pew Research Center, as of 2016, 95% of U.S. adults use a cell phone (2). These results also
concluded that there was 100% cell phone usage in adults aged 18-29 years old and 99% usage
in those aged 30-49 years old. In those with an annual income of <$30,000, they found 92% cell
phone usage as well. These results are applicable to our target population as that is the age range
of most of our participants and seeing such a high cell phone use percentage within the lowest
socioeconomic class illustrates that our program can be accessed by those of almost all
socioeconomic classes. There are currently several text message based health education
programs in effect, but the one most relevant to our program is text4baby, delivering a wide
range of pregnancy- related information on a larger scale. A study of text4baby conducted by
California State University San Marcos found that participants utilizing this program had
increased access to healthcare information, communication with medical providers, health-
related knowledge and willingness to make healthy choices (3). A study conducted by George
Washington University found that participants felt 3X more prepared for pregnancy,
breastfeeding and becoming a mom as well (3). These studies, as well as others, illustrate how
texting based programs are essential to reach diverse and underserved populations to address
present issues.
 II. Objectives of Proposal
To increase the opportunity for women from varying socioeconomic classes to have
immediate access to breastfeeding education by continuing the Monadnock Mobile Milk
Program. In order to support this program, we will need financial assistance from a funding
source to continue the annual membership with the GroupTexting.
III. Design
The Mobile Milk program is a breastfeeding education program that delivers educational
content via text messages. It began in 2014 by a Keene State College dietetic intern in
coordination with Rudolph Fedrizzi, MD of Cheshire Medical Center/Dartmouth-Hitchcock
(CMC/DH) and has been continued on by other interns each year. This program has been in
beginning stages since this time, but, we were finally able to launch the program this past May
2017. The program is marketed towards mothers who are ~20 weeks pregnant or who are
postpartum. The text messages provided information that is generalized to any stage of
pregnancy or post-delivery so that enrollment is open to mothers at any point during these stages.
Enrollment is free and the participants are made aware of the program at their 20 week
healthcare provider appointment or via flyers displayed in various locations around town. Once
enrolled, participants will receive 2-3 text messages per week for five months during their
pregnancy and four months post-delivery. The messages contain educational information about
breastfeeding, while providing the contact information for lactation consultants at CMC/DH who
would be willing to answer any of their further questions if need be.
This program is being run via GroupTexting.com. This platform allows us to enter the text
messages into their system as we wish and schedule the days in which we would like them to be
sent to participants. We currently have the messages being sent automatically, however, if we
would like to include the option of tow-way texting, a staff member would have to be hired to do
so. This platform also allows us to monitor the contacts being added in or option out of the
program, edit/ add text messages, respond to text messages that are sent back, control our
payment plan and offers 24/7 customer service support if needed.
The program began based on the funding from a grant awarded to us by the Advocates for
Healthy Youth in 2015. In order to continue utilizing and progressing with this program, we
would require further grant funding as the previously awarded grant money has been used to its
capacity. If awarded this grant, it will be used toward the maintenance and continuation of the
Mobile Milk program. More specifically, it will be used for annual payment required by
GroupTexting.com. Our current plan allows us to send 1,000 text messages per month for the
cost of $49 per month, yielding a net cost of $588 per year. Purchasing a program that allows for
1,000 text messages to be sent per month allows us to enroll a total of 125 women into our
program, either prenatal, postpartum or both. This also leaves an opportunity for text message
expansion. For example, if we would like to add text messages tailored to those supporting the
women while breastfeeding, we could do that as well. This could be done by controlling the
amount of mothers enrolled in the established group, based on the text message content of a
potentially new group.
 The Mobile Milk program began as a collaboration between Keene State College Dietetic
Interns, graduate students going on to pursue a career as a Registered Dietitian, and Rudolph
Fedrizzi, MD of Cheshire Medical-Center/ Dartmouth Hitchcock. It is intended that this
relationship continue, however, if the expansion of this program exceeds the dietetic interns
scope of practice, a new staff member may be required to take over. The staff member whom
would be best fit for this job would be a Registered Dietitian, as this program is focused on
evidence-based practice to treat a nutrition-related problem.
IV. Time Frame
The project has already been implemented but will require monthly maintenance and an
evaluation every 6 months.
Monthly Maintenance:
Monitor the amount of people who have opted in and out of the program within the month,
based on contact information found via GroupTexting account. Monitor and edit the text
messages to ensure that they are being sent on an automated, two text per week basis. Further
editing of text messages or the addition of new messages may be necessary.

Months 6 and 12
Staff member working with the program will be required to conduct a survey at 6 months and
1 year of program implementation. The link to the survey can be sent out via text message or
at a breastfeeding educational class given at Cheshire Medical Center (see below).

V. Evaluation
Once the program has been implemented for at least six months, an evaluation will be
carried out and then regularly on a six month basis. This program can be evaluated in three
different ways. One way in which it can be evaluated is through monitoring participant opt-in
and out of the program via the GroupTexting account. GroupTexting offers online regulation
of add-ins and cancelations, making it easier to regulate. This evaluation factor will help us
determine what percentage of the population we have reached at the time of measurement,
Another way the program can be evaluated is through a breastfeeding education class
given at Cheshire Medical Center (CMC). CMC offers a variety of classes for prenatal or
postpartum mothers to attend and address a variety of topics. The dates of these educational
classes vary, but usually occur on at least a monthly basis. Whomever the staff member
working with Rudy, either dietetic intern or RD, will attend one of these classes to assess
enrollment into the program based on a series of questions that will be prepared beforehand.
Questions asked could include, who has signed up for the program, whether or not the
audience has heard of the program, etc. Education about the program can be given depending
on audiences prior knowledge of Mobile Milk. This would offer direct, person-to-person
assessment without the hassle of trying to gather a focus group.
The third form of assessment would be via text message survey. The staff member
will create an online assessment survey that will be sent out in a weekly text message for
 participants to take part in. This is an effective way to analyze the feedback from all mothers
who may not be able to attend classes at the hospital. After the results have been finalized,
the staff member will analyze them to assess the current success of the program and where
improvements should be made.
VI. Budget
Who** Hours Rate/HR Total____
Registered Dietitian 72 $28 $2,016
Dietetic Intern ~120 FREE FREE
What Amount Individual Cost Total____
GroupTexting Program Fees 12 months $49 $588

Total Cost/ year $2,604

**Staff member hired to monitor and evaluate the program can either be a Registered Dietitian
OR Dietetic Intern, depending upon program need.
 Resources
1. Breastfeeding Report Cards. (2015). Retrieved March 24, 2016, from
http://www.cdc.gov/breastfeeding/data/reportcard.htm
2. Pew Research Center. (n.d.). Mobile fact sheet. Retrieved May 8, 2017, from Pew
Research Center website: http://www.pewinternet.org/
3. Text4baby. (n.d.). Text4baby data and evaluation (US Department of Health and
Human Services, White House Office of Science and Technology Policy, US
Department of Defense Military Health System, US Department of Agriculture,
US Consumer Product Safety Comission, Voxiva, Inc., & Zero To Three, Ed.).
Retrieved May 8, 2017, from text4baby website:
https://partners.text4baby.org/