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3
Lessons Learned from Other Social
Marketing and Breastfeeding Campaigns
Karen DiMartino, marketing and media manager for the Massachusetts
Department of Public Health WIC Nutrition Program, served as modera-
tor for the second panel. The goal for this panel was to learn from other
social marketing campaigns what has worked and what has not worked in
their campaigns. R. Craig Lefebvre began by first presenting an overview
of social marketing and how it differs from health communications. As an
example of social marketing, Faye Wong discussed VERB™, a multiyear
campaign that promoted physical activity in youth ages 9 to 13. Suzanne
Haynes explained the National Breastfeeding Awareness campaign, which
the U.S. Department of Health and Human Services undertook to promote
breastfeeding among first-time parents. Carole Peterson presented ideas
from innovative breastfeeding promotion campaigns in state WIC programs
across the country, focusing on Colorado, Missouri, Texas, and California.
In the last presentation, Rafael Pérez-Escamilla highlighted the lessons
learned from the Brazilian National Breastfeeding Promotion Program,
which resulted in an increase in the median duration of breastfeeding from
less than 3 months to more than 10.
WHAT IS SOCIAL MARKETING?
Presenter: R. Craig Lefebvre
R. Craig Lefebvre, a national expert in social marketing and professor
at the University of South Florida, distinguished social marketing from a
health communication approach. Social marketing is broader than health
33
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34 UPDATING THE USDA NATIONAL BREASTFEEDING CAMPAIGN
communications and can potentially have a greater impact on changing be-
haviors. He said that people often confuse the two approaches. To explain
health communications, he referred to the Centers for Disease Control and
Prevention (CDC) “wheel” (see Figure 3-1). The approach involves analyz-
ing and segmenting target audiences, identifying message concepts, selecting
communication channels, and creating and pretesting message materials.
But, Lefebvre said, “When we’re thinking about breastfeeding, we need
to think about a lot more than what our materials look like and what our
communications look like.” And that brought him to an explanation of
social marketing.
Social marketing starts with an understanding of a target audience’s
1. Review
Background
Information
10. Feedback
2. Set
Communication
Objectives
9. Assess
Effects
Formative
8. Implement
Outcome Research
Communication
Evaluation
Strategies
3. Analyze and
Consumer
Segment Target
Process
and Audiences
Evaluation
7. Develop
Promotion
Evaluation
Plan
6. Create 4. Identify Message
Messages/ Concepts and Pretest
Materials
and Pretest
5. Select
Communication
Channels
Fig 3-1.eps
FIGURE 3-1 Health communication approach.
SOURCE: Roper, 1993. Reprinted with permission from the Association of Schools
of Public Health. March–April 1993. 108(2):181. Copyright © Association of
Schools of Public Health. All rights reserved.
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35
LESSONS LEARNED
The Audience BENEFIT
Desired Behavior
• Determinants
• Context
• Consequences
ESSENCE: Behaviors,
Products, and Services
[BPS]
The Marketing Mix
• Brand
BPS
• Relevance
• Design and features
• Positioning
Price
• Incentives and costs
Place
• Access and opportunities
Promotion
• Communications and
experience
FIGURE 3-2 The social marketingig 3-2.eps
F idea, with audience at the core.
SOURCE: Lefebvre, 2011. Reprinted with permission from the Journal of Social
Marketing 1(1):54–72. Copyright © Emerald Group Publishing. Limited all rights
reserved.
benefit: in this case, the benefit of engaging in breastfeeding. In order to
market to a specific audience, one needs to understand how people perceive
the benefit. Depicted graphically (see Figure 3-2), the benefit to the audience
is at the center of the social marketing construct. Then, by considering the
audience, one should identify the desired behavior to work toward, includ-
ing the determinants of whether the desired behavior will take place or
not, the context, and the consequences of doing or not doing the behavior
(the next circle out from Audience Benefit in Figure 3-2). Consideration
of brand, relevance, and positioning comes after understanding the deter-
minants, context, and consequences of the desired behavior, product, or
service (the next concentric circle in Figure 3-2). Finally comes the design
of the marketing mix, or the “4 Ps” (product, price, place, and promo-
tion). Lefebvre noted that the WIC program has an enormous amount of
resources and an array of factors, such as incentives, costs, and opportu-
nities, that can be considered as stakeholders focus on how to improve
breastfeeding rates and duration. Communications is just one piece of the
overall social marketing idea.
A meta-analysis of more than 400 health communications campaigns
(Snyder, 2007) identified characteristics that make some campaigns more
effective than others. First, promoting the adoption of healthier behaviors
or substitutions is more effective than trying to stop or prevent unhealthy
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36 UPDATING THE USDA NATIONAL BREASTFEEDING CAMPAIGN
ones. Habitual behaviors are difficult to modify. Behavior change should be
an explicit goal or objective, and formative research should be conducted
and used in design and planning. Other characteristics of effective health
communications campaigns indicated by the meta-analysis are direct com-
munications with homogeneous population groups (rather than communi-
cating through intermediaries), multiple executions of messages, frequency
of exposure to the messages, media multiplexity, and sustained activity. A
5 percent change in behavior could be reasonably expected if a campaign
has the elements in place to be effective, which, Lefebvre said, is why it is
important to move to marketing.
One issue considered by marketing is how to design—or redesign—
products and services. Lefebvre suggested a number of questions that need
to be addressed in considering how best to market Loving Support: How
should services be redesigned so that they start appealing to different seg-
ments of people to whom Loving Support may not be appealing right now,
including those who come in and try WIC services only to leave after a few
weeks or a few months, or those who stop breastfeeding for a variety of
reasons? How should product and service innovations be introduced? How
should new opportunities be created for women to be exposed to breast-
feeding information, services, and support products?
When marketing and communications are used in concert, the impact
can be greater than when one relies on communications alone, as has been
demonstrated in such areas as nicotine replacement therapy, child safety
seats, recreational safety helmets, and condom use. The Community Preven-
tive Services Task Force (Community Guide Branch/CDC, 2011) recently
reviewed the role of marketing in improving these and other health behav-
iors and found that marketing can result in an average 8.4 percent increase
in people who engage in the healthy behavior. The task force found that
successful campaigns applied the “marketing 4 Ps” by offering the prod-
uct at a free or reduced price, distributing it in accessible and convenient
locations, and promoting it through mass and multiple channel delivery to
increase awareness of, demand for, and appropriate use of the product. Al-
though the review addressed only products, Lefebvre said he felt its lessons
could be extended to services.
According to Lefebvre, one of the values of the task force study is that
it provides a science-based recommendation for the use of social marketing
in the area of public health as compared with a communications approach
alone. Another study (Sorensen et al., 2011) also provides evidence of how
the 4 Ps can be used to move someone from not thinking at all about a
healthy behavior (in this case, Pennsylvania farmers’ use of a rollover bas-
ket to improve tractor safety) to action. In this study the biggest increase
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37
LESSONS LEARNED
in usage came for the group in which all aspects of a social marketing
campaign were used.
Questions to Ponder
As an example of a different way of thinking, Lefebvre asked the group
to consider the role of mobile phones. The “old way” of thinking about
mobile phones in a campaign would be to send out messages to the target
audiences. Instead, he challenged participants to consider other, more inter-
active applications. The beer company Stella Artois has an application for
mobile phones in which people can locate the nearest locations that serve
its product. “Imagine if a woman could do that for WIC clinic products
and services,” he suggested.
Lefebvre said that it is important for social marketing campaign plan-
ners to involve the target audience in creating program content. He con-
cluded by posing a series of questions for participants to consider when
contemplating how to move a breastfeeding promotion campaign forward:
• Could breastfeeding patterns be designed to fit people’s lives?
• What if a social change movement could be successful with little
or no promotion?
• How can WIC cocreate value with the people served by the program?
• How can learning and change be made into a social event?
• How can a move be made to solve puzzles and create patterns of
change?
OVERVIEW AND LESSONS LEARNED
FROM THE VERB™ CAMPAIGN
Presenter: Faye L. Wong
The VERB™ It’s What You Do campaign, which ran from 2002 to
2006, was designed to increase and maintain physical activity among
“tweens,” defined for the purpose of the campaign as youths from 9 to 13
years of age. Faye Wong, chief of the Program Services Branch in the CDC
Division of Cancer Prevention and Control and the former director of the
VERB™ campaign, summarized the lessons from this social marketing
campaign that could potentially apply to promoting breastfeeding.
The campaign vision was for youth to lead healthy lifestyles. Wong
emphasized that the focus was deliberately on physical activity and not
on nutrition, obesity, or other related issues and that the 9- to 13-year-old
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38 UPDATING THE USDA NATIONAL BREASTFEEDING CAMPAIGN
BOX 3-1
Know Your Product!
Selling Physical Activity
It’s not a physical product → It’s an experience
For kids, it’s not about a rational need → It’s about an emotional desire
It shouldn’t just inform → It creates affinity, a feeling of belonging
It shouldn’t preach → It should self-motivate
SOURCE: Wong, 2011.
age group was defined as the primary audience, with parents, teachers, and
youth leaders as secondary audiences.
Building on Lefebvre’s discussion of marketing versus communications,
Wong said that the campaign had four interlinking components—market-
ing (mass media, public relations, and edutainment), partnerships, research
and evaluation, and community events. In terms of the “4 Ps,” the product
was physical activity and the price1 was the benefits and costs of being
physically active. According to Wong to sell physical activity as the product,
tweens have to see the benefit (what will I get out of it? e.g., time outside
with my friends) and be willing to pay the cost (what do I have to give up?
e.g., time playing video games). Further, she said the cost would be too high
if tweens felt the benefit was not of value to them.
Wong continued the place in the “4 Ps” was the different places where
tweens could be physically active and the promotion involved messages, de-
livery channels, campaign strategies, and tactics that ranged from contests
to kid-friendly partnerships.
VERB’s main lesson was that it is important to frame messages with
words and images that appeal to the target audience, based on audience
research. For example, the campaign learned to sell physical activity as a
fun experience to do with friends (see Box 3-1) rather than to rely on such
messages as the need to exercise to avoid heart disease or other messages
that might resonate with older audiences.
Audience research is critically important in planning a campaign, Wong
stressed. Without it, one does not really know what the product is, what
1 “Price refers to the cost or sacrifice exchanged for the promised benefits. This cost is always
considered from the consumer’s point of view. As such, price usually encompasses intangible
costs, such as diminished pleasure, embarrassment, loss of time, and the psychological hassle
that often accompanies change, especially when modifying ingrained habits” (Grier and Bryant
(2005).
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39
LESSONS LEARNED
its price should be, or what the barriers and motivations are. The VERB™
campaign team, including CDC staff and contractors, conducted extensive
research both before and continuously throughout the campaign, in addi-
tion to performing an ongoing evaluation. That research informed them
that the messages should relate to such things as “play, discover, being
positive, try and try again, explore, fun, and laugh.”
The VERB™ campaign developers also recognized the importance of
creating a brand—in this case, a kid’s brand for having fun. They had a
big brand idea based on the fact that there are 7,000 action words or verbs
in the dictionary. The message the developers created was that children
should try a new action. Specifically, Wong said, the message was “Find
a verb that motivates you and is yours,” such as run, jump, bounce, kick,
toss, or dance. The VERB™ brand became visible in places that reached
tweens—the child’s media (TV, radio, magazines) targeted to them, shop-
ping malls, schools, community-based organizations that offered a place
to play, sports arenas, and so on. The campaign was implemented with a
surround strategy, which Wong described as meaning that wherever chil-
dren are—at home, at school, or somewhere in their communities—they
are exposed to the VERB™ brand. To strengthen the strategy and ensure
consistency, partners and communities that participated in the campaign
were given guidelines that described the VERB™ brand’s purpose and at-
tributes (Asbury et al., 2008). The campaign created a multiethnic, “true
to the VERB™ brand” campaign.
The campaign had four phases,2 each with a distinct objective:
• Phase 1: Build awareness and affinity for the brand: “What is our
VERB?”
• Phase 2: Motivate tweens to incorporate physical activity into their
everyday lives.
• Phase 3: Motivate tweens to play anytime, anywhere, anyway.
• Phase 4: Ignite kids’ desire to play.
In Phase 4, the objective was to have children so eager to play and
undertake physical activity that they would think, as Wong phrased it, “I
cannot not play.” Phase 4 was carried out with the Yellowball campaign—
distributing 500,000 branded, bright yellow balls, each imprinted with
its own number (Figure 3-3). Tweens played with a ball, passed it on to
another child, and went online at VERBnow.com to share their experi-
2 For a more detailed explanation of the 4 phases see Huhman, M., J. M. Berkowitz, F. L.
Wong, E. Prosper, M. Gray, D. Prince, and J. Yuen. 2008. The VERB™ campaign’s strategy
for reaching African American, Hispanic, Asian, and American Indian children and parents.
American Journal of Preventive Medicine 34(6):S194–S209.
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40 UPDATING THE USDA NATIONAL BREASTFEEDING CAMPAIGN
FIGURE 3-3 Phase 4: The VERB Yellowball™ Campaign.
SOURCE: Yellowball. Reprinted from “New media and the VERB campaign: Tools
to motivate tweens to be physically ig 3-3.eps Huhman, 2008, Cases in Public
F active,” by M.
Health Communication & Marketing, 2, p. 134. Copyright 2008 by the Public
Health Communication & Marketingbitmap Reprinted with permission. All rights
journal.
reserved.
ences about how they played with their specific ball. Children were not
just reading or hearing about the VERB™ brand, but literally touching it
and playing with it.
Activities during the 4 years of the campaign also included a designated
“National Day of Play” (June 21, the day with the most daylight), contests
and promotions by media partners, summer tours around the country in
“branded” vans, and other special events. Funding for the campaign ended
in 2006. Several locations, including Kentucky and Iowa, continue to plan
and offer a VERB™ Summer Scorecard Program in communities, even five
years after the national campaign ended.
Results and Lessons Learned
Wong reviewed the results as measured throughout the VERB™ cam-
paign. After Year 1, various effects in free-play physical activity were seen
in sub-populations, notably younger tweens (age 9 and 10) and girls. In
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41
LESSONS LEARNED
years 2 and 3, effects were found for the entire target population for free-
time physical activity. In Year 4, the level of exposure of tweens to VERB™
was significantly associated with physical activity on the day before the
survey and with each of the psychosocial variables, with 72 to 74 percent
awareness. The more a tween was exposed to the campaign, the more
physical activity he or she was likely to perform.
Wong concluded by offering eight lessons from the VERB™ campaign
that may be applied to the Loving Support campaign:
• Develop clear, focused campaign goals.
• Develop a logic model.3
• Plan using the 4 P’s of social marketing to design an audience-
driven intervention.
• Consider a branding approach, with instant association of the
brand to the message and with interactions by the audience with
the brand.
• Build in multiple and reinforcing strategies.
• Plan for sustainability.
• Take risks to make a difference.
• Continuously evaluate and refine the campaign.
LESSONS LEARNED FROM THE NATIONAL
BREASTFEEDING AWARENESS CAMPAIGN, 2004–2006
Presenter: Suzanne G. Haynes
The National Breastfeeding Awareness Campaign (NBAC) was de-
signed to promote breastfeeding among first-time parents, both mothers
and fathers, who would not normally breastfeed their babies. The campaign
was planned in 2003, launched in 2004, and continued until 2006. Suzanne
Haynes, senior science advisor for the Department of Health and Human
Services Office of Women’s Health and the NBAC campaign manager, said
that the lessons learned from the campaign have implications for the WIC
campaign.
The first lesson that Haynes discussed related to that target audience of
first-time parents. In choosing them as the target audience, NBAC decided
it would not consider pediatricians, obstetrician/gynecologists, family prac-
titioners, nurses, hospitals, and worksites as primary target audiences, but,
she noted, all of these others have a huge influence on parents’ decisions.
These groups were NBAC research and publicity partners, and Haynes
3 As noted by Wong, the development of the VERB™ logic model was not discussed during
her presentation.
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42 UPDATING THE USDA NATIONAL BREASTFEEDING CAMPAIGN
recommended they also be targeted as audiences in any new campaign
because of their influence. The WIC campaign, she said, must go beyond
social marketing to parents and be comprehensive, multi-modal, and multi-
sectoral (or, referring to a CDC term discussed more fully in the next panel,
socio-ecological) in order to be successful.
The overall goals of NBAC were to increase the proportion of mothers
who breastfeed their babies in the early postpartum period to 75 percent
and to increase breastfeeding at 6 months postpartum to 50 percent by
2010. The campaign also aimed to empower women to commit to breast-
feeding. In retrospect, Haynes said, the goal to increase breastfeeding at
6 months was unrealistic for a two-year campaign. Reaching that goal
would take 10 years, with messages reevaluated every 2 years. In her opin-
ion, empowerment must come from other aspects of a mother’s surround-
ings that cannot be addressed in social marketing campaigns.
Focus Group Research
Haynes said that NBAC conducted the largest qualitative study to date
to explore the process that successful breastfeeding mothers, who partici-
pated in focus groups, used in deciding to breastfeed. Twenty-four focus
groups were held in 2002 in Chicago, San Francisco, and New Orleans.
They included women of a range of ages and socioeconomic groups, Afri-
can Americans and Caucasians, and pregnant, breastfeeding, and formula-
feeding mothers.
The research identified two processes associated with successful breast-
feeding. The first was what Haynes termed “confident commitment.” In
the prenatal period, all groups voiced a lack of confidence in the process
of breastfeeding. Most said they would “try” to breastfeed, although few
said they “definitely would.” Pregnant women’s confidence in their ability
to breastfeed was affected by such concerns as whether they could suffi-
ciently nourish and satisfy their babies and whether they would be able to
cope with the discomfort or inconvenience. Commitment refers to making
breastfeeding work despite challenges or a lack of support. Taken together,
“confident commitment” relates to self-efficacy. Breastfeeding mothers had
been confident in the process and committed to making it work. Based on
an analysis of the focus groups’ responses, Avery et al. (2009) concluded
that women who believe that their bodies can produce milk of sufficient
quality and quantity to nourish their baby and that their babies are capable
of latching and feeding properly and who view breastfeeding as a learned
process may be more successful than those who see breastfeeding as natural.
Haynes suggested that the WIC campaign focus on instilling “confident
commitment” by reconceptualizing breastfeeding as a learned skill. Draw-
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LESSONS LEARNED
ing from the focus groups, she noted that women did not know that they
had to learn how to breastfeed.
The second important issue related to successful breastfeeding identi-
fied by focus group participants was workplace accommodations, in that
confusion about how to breastfeed at work can result in the decision to
wean. When a woman returned to work often determined when she would
stop breastfeeding. Haynes noted that mothers’ apprehension about how
to breastfeed at work suggests that dialogue with the business community
is needed, which would be a possible role for WIC.
Components of the Campaign
The NBAC consisted of a media campaign, community-based demon-
stration projects (CDPs), and a breastfeeding help phone line and website.
The Advertising Council selected NBAC for official sponsorship and
assisted with multimedia ads and public service announcements (PSAs).
The Office of Women’s Health worked in close coordination with the Ad
Council to produce ads for television, radio, the Internet, bus stop shelters,
newspapers, magazines, and billboards. It received $30 million in free
advertising in two years, although, as Haynes noted, the formula industry
spent $80 million in advertising during that same period. One challenge was
that baby magazines that ran paid advertising from the formula industry
did not run the PSAs, and NBAC did not have the funds to purchase ads
to run in these magazines. On the other hand, radio, newspapers, other
magazines, and billboards did run a large percentage of the PSAs.
A high number of women said they saw the NBAC PSAs, Haynes
said, and African American mothers were more aware of the ads than
many other groups. WIC mothers were clearly exposed to the campaign,
with 34.8 percent of WIC participants reporting seeing some part of the
campaign, compared to 22 percent among non-WIC participants. Among
mothers with less than a high school education, 38.1 percent were aware
of the ads, which was the highest percentage among the different levels of
education. About 30 percent of pregnant women across the country saw
the campaign. Billboards were the most popular vehicle, and “Babies were
Born to be Breastfed” was the most popular message that came out of the
campaign.
In the NBAC’s second component, 18 CDPs throughout the country
implemented the campaign at the grassroots level. Funds went to increase
existing services, provide outreach, train healthcare providers in breast-
feeding, implement the media aspect of the campaign locally, and track
breastfeeding rates. Grantees included breastfeeding coalitions, hospitals,
universities, state health departments, and other organizations, and par-
ticular attention was paid to grantees in the Southeast. An evaluation of
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44 UPDATING THE USDA NATIONAL BREASTFEEDING CAMPAIGN
TABLE 3-1 Breastfeeding Rates by Ad Awareness and CDP Area
Breastfeeding
Duration and Not Aware Aware Not
Exclusivity (%) (%) P Value CDP Area CDP Area P Value
Breastfed 70.6 66.2 0.02 68.3 78.5 < 0.001
> 1 month
Breastfed 41.2 34.7 0.002 38.8 45.4 0.01
> 6 months
Exclusively 41.4 16.3 < 0.001 19.6 24.1 0.04
breastfed
> 3 months
Exclusively 3.4 3.1 NS 3.2 4.5 NS
breastfed
> 6 months
SOURCE: Haynes, 2011.
breastfeeding rates after the campaign showed that women who were aware
of the ads actually had lower breastfeeding rates than those who were not
aware of it. In light of this, Haynes said that some might conclude that the
campaign failed, but she disagreed with that conclusion, noting toward
its end the campaign did reach a higher proportion of women who are at
higher risk of not breastfeeding, e.g., low-income African American women.
However, the campaign did not last long enough (two years) to make a sub-
stantial change in breastfeeding rates. Furthermore, marketing campaigns
alone cannot change behavior without the help of the community, including
family members, hospitals, health professionals, and worksites. Bolstering
her point, Haynes noted that the CDP areas that provided on-the-ground
support had higher breastfeeding rates at various stages (Table 3-1) recom-
mended that the WIC campaign incorporate a way to reach out to the com-
munity and bring in the resources of breastfeeding coalitions, hospitals, and
other organizations. She also suggested drawing from the Infant Feeding
Practices Survey and other research to conduct a detailed analysis on WIC
versus non-WIC mothers.
The third component of the campaign was a breastfeeding helpline
and website. The National Women’s Health Information Center created
and maintains these resources to help mothers with common breastfeeding
questions and challenges. Trained information specialists answer calls and
e-mails in both English and Spanish. They receive about 500 calls a month,
while the website gets 500,000 users. Haynes attributed the difference both
to the role of the Internet and to the fact that the phone system operates
only during weekday office hours. She recommended 24-hour phone sup-
port in the future.
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LESSONS LEARNED
Self-efficacy
Demographics
Perceived benefits
Perceived barriers
Likelihood of
Perceived
Perceived threat
behavioral change
susceptibility to
of disease
disease-risk
Cues to Action: media campaign
FIGURE 3-4 Health Belief Model.
SOURCE: Adapted from Champion and Skinner, 2008. Permission to reprint from
John Wiley & Sons.
The campaign was based on the Health Belief Model, which is based
on the theory that self-efficacy, perceived benefits, and perceived barriers all
affect the likelihood of behavior change (Figure 3-4). Haynes suggested that
the next campaign 3-4 on self-efficacy in order to increase women’s confi-
Figure focus
dence in their commitment to breastfeeding, i.e., “confident commitment.”
BREASTFEEDING BEST PRACTICES IN FOUR STATES
Presenter: Carole Peterson
Carole Peterson, chairperson of the National WIC Association (NWA)
Breastfeeding Committee, said that the workshop planning committee, of
which she was a member, realized that there is little evidence about what
is working in WIC clinics. She was asked to speak about the efforts of
WIC programs in four states: Colorado, Texas, Missouri, and California.
Although her presentation did focus on these four, she noted that WIC
programs in other states are also developing many innovative efforts to
support breastfeeding.
Loving Support is the basis of the state programs. However, Peterson
said, many states have gone beyond Loving Support in supporting breast-
feeding. Thus the National WIC Association has developed six steps to meet
breastfeeding goals in WIC clinics (see Box 3-2). The steps are intended to
position WIC as a “go-to” place for breastfeeding support and to create a
goal of exclusive breastfeeding for WIC mothers. Peterson said that states
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46 UPDATING THE USDA NATIONAL BREASTFEEDING CAMPAIGN
BOX 3-2
The NWA Six Steps to Achieve
Breastfeeding Goals in WIC Clinics
1. Present exclusive breastfeeding as the norm for all mothers and babies.
2. Provide an appropriate breastfeeding friendly environment.
3. Ensure access to competently trained breastfeeding staff at each WIC site.
4. Develop procedures to accommodate breastfeeding mothers and babies.
5. Mentor and train all staff to become competent breastfeeding advocates and/
or counselors.
6. Support exclusive breastfeeding through assessment, evaluation, and
assistance.
SOURCE: NWA, 2011.
that have adopted these steps have increased their breastfeeding rates and
serve as examples of what WIC can do to support exclusive breastfeeding.
Colorado
Colorado focused on training and working with hospitals. A three-day
training session in lactation management was developed for WIC-registered
dietitians, nurses, and select educators, of which about 45 percent had at-
tended at the time of the workshop. The training is on the effective assess-
ment of participants and counseling of those identified as high risk based
on the Colorado WIC Program’s breastfeeding Nutrition Risk Factors for
Breastfeeding listed in the Nutrition Risk Factor Module that is part of the
state’s Level I WIC certification (Colorado WIC, 2011). Colorado WIC
also promotes exclusive breastfeeding in the first month through the new
food package; in addition, infants not receiving formula receive a voucher
imprinted with “Thank you for breastfeeding.” As of June 2009, Colorado
WIC’s policy is to not provide formula to infants younger than one month
of age except for medical reasons or the mother’s intent to wean. Intense
follow-up allows supervisors to see if the policy is followed by agencies
throughout the state.
Through the Colorado Can Do 5! Initiative, WIC staff promote five
actions at every opportunity: (1) infants are breastfed in the first hour after
birth; (2) the infant stays in the same room as the mother; (3) infants are
fed only breast milk and receive no supplementation; (4) no pacifiers are
used; and (5) the staff gives mothers a phone number to call for help with
breastfeeding. These five actions are listed on a crib card provided to preg-
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LESSONS LEARNED
nant women by WIC staff. (A crib card is a card placed in the baby’s crib
listing the baby’s and mother’s names; the baby’s date of birth, weight, and
length; and the doctor’s name. See http://www.coloradoaap.org/Crib%20
Cards%20for%20Web08.pdf.) The card used by the Colorado WIC Pro-
gram is for use in the hospital to indicate that the baby is to be breastfed.
This approach is based on a population-based study that found that imple-
menting these five practices significantly increased breastfeeding duration
rates regardless of maternal socioeconomic status. Overall, Colorado has
seen a decrease in the issuance of formula since these measures began.
Texas
Texas is an example of a state WIC program working with a range of
partners, including hospitals and worksites. Hospitals can earn the Texas
Ten Step designation through a series of measures that are less rigorous than
a Baby-Friendly designation but that still support breastfeeding. A website
provides expectant mothers with a list of these hospitals as well as with
information and resources about breastfeeding. Across racial and ethnic
groups, more mothers are exclusively breastfeeding at Baby-Friendly and
at Texas Ten Step hospitals than at other hospitals in the state. WIC also
works with the Texas Mother-Friendly Worksite Program. In this program,
the Department of State Health Services designates businesses as Mother-
Friendly if they take certain steps to accommodate breastfeeding.
Missouri
Missouri has launched numerous best-practice interventions to sup-
port breastfeeding. There are more than 100 peer counselors throughout
the state, and the number of International Board Certified Lactation Con-
sultants (IBCLCs) has more than tripled, from 20 to 65, over the past
few years. A 45-hour course was developed to train additional IBCLCs.
Missouri also set up local breastfeeding coordinator mentors, recognizes
breastfeeding-friendly WIC clinics, and partners with breastfeeding coali-
tions. A “Show Me 5” tool kit was created to assist hospitals in supporting
breastfeeding initiation and continuation. All agencies have experienced an
increase in breastfeeding rates, but the agencies with peer counselors and
IBCLCs had the greatest increase. Missouri plans to assist more WIC staff
to become IBCLCs.
California
Peterson discussed three efforts in California: (1) strengthening coun-
seling, (2) improving clinic flow, and (3) convening diverse stakeholders.
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48 UPDATING THE USDA NATIONAL BREASTFEEDING CAMPAIGN
California now hires peer counselors (PCs) for their passion and then edu-
cates them for the requisite knowledge. The PCs facilitate Moms2Moms
groups and are available to mothers 24 hours a day. A training curriculum
addresses emotional reasons why mothers stop breastfeeding. Training to
increase the number of IBCLCs was stepped up. The IBCLCs train staff at
the local level and support the peer counselors and other staff working with
high-risk mothers.
At WIC clinics decisions about providing formula are now made with a
lactation specialist, who can often resolve an issue preventing breastfeeding,
rather than at check-in or at the front desk. The new food package is being
promoted as an incentive to begin and continue exclusive breastfeeding, and
Peterson said it has been working.
The California Breastfeeding Summit was held in January 2011. More
than 300 hospital administrators, managers, health professionals, and pol-
icy makers gathered to discuss practical strategies to establish policies and
strengthen community partnerships.
Common Threads in All Four States
Peterson suggested that successes in the four states have some elements
in common:
• Human milk as the norm—and, indeed, Peterson said, these states
made it a priority
• Increased staff professional training
• Increased numbers of peer counselors and IBCLCs
• Cooperation with hospitals
• Encouragement of Baby-Friendly initiatives
Addressing the knowledge gaps that impede further progress, as were
brought up in the discussion after the first session, Peterson said that WIC
programs suggested there be a mentorship component to training. WIC staff
learn what to do in a training situation but often ask, “What do we do
when a mother walks in to the clinic and we are not sure how to identify
her problem?”
In summary, the states that are implementing the NWA six steps and
working toward the NWA strategic plan are increasing their breastfeeding
rates and duration. Although this observation is not based on research,
Peterson suggested that the U.S. Department of Agriculture could encourage
other states to adopt the six steps because states that have followed these
guidelines have had increases in breastfeeding initiation and duration rates.
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49
LESSONS LEARNED
BRAZILIAN NATIONAL BREASTFEEDING
PROMOTION PROGRAM
Presenter: Rafael Pérez-Escamilla
The panel’s final presentation focused on Brazil’s National Breastfeed-
ing Promotion Program. Over a period of 25 years Brazil increased the me-
dian length of breastfeeding from 2.5 to 10 months. Rafael Pérez-Escamilla,
the planning committee chair and a professor at Yale University, discussed
the program, drawing on a publication that described it (Rea, 2003). Ac-
cording to Pérez-Escamilla, the key to the program’s success was its inter-
sectorial coordination4 (see Figure 3-5) across programs, institutions, and
strategies, which he referred to as the “social glue” which was created early
on and which still exists today for breastfeeding and for many other social
programs. He also stressed the length of time it took for the program to
achieve results—more than two decades.
The program began in 1980, after many years in which little improve-
ment had been made in increasing median breastfeeding duration. The goal
of the launching phase was to mobilize stakeholders, such as politicians,
journalists, and other decision makers and opinion leaders. Well-known
pediatricians delivered the messages that “Breastfeeding saves money” (as
this was during a time of economic crisis) and “We know what works to
promote breastfeeding.” At that point the Ministers of Health and Social
Development approved the launching of the National Breastfeeding Promo-
tion Program.
From 1981 to 1986, in a phase that Rea refers to as “social commu-
nication” in her article, improvements began to appear. The goals of the
phase were to generate a social movement through key stakeholders and
to develop and launch well-designed mass media campaigns. The first such
campaign took place in 1981; its main message was to breastfeed for at
least 6 months. Stakeholders included members of various civic, social,
community, faith-based, and mother support groups. These people were
reached through TV and radio as well as through printed collateral on lot-
tery tickets, utility bills, and bank statements. Newspaper articles targeted
opinion leaders, and articles in professional journals and meetings were
developed for health practitioners and academics, particularly members of
the Brazilian Association of Obstetrics and Gynecology and the Brazilian
Association of Pediatrics.
A second phase in 1982 to 1983 built on lessons learned. It used forma-
tive research to determine what should be said now that people had been
4 Different sectors of society working together toward a common goal in a well coordinated
manner.
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50 UPDATING THE USDA NATIONAL BREASTFEEDING CAMPAIGN
Advocacy
Social
Political Will
Participation
Intersectorial
Research and
Coordination
Evaluation
Mass
Media
Training
Policies and
Legislation
FIGURE 3-5 Intersectorial coordination as the “glue” in a campaign.
SOURCE: Pérez-Escamilla, 2011. Fig 3-5.eps
generally sensitized. This campaign had pretested messages for mothers,
such as “Continue breastfeeding; every woman can”; “You can produce
enough milk”; and “Your breasts will not drop if you breastfeed.” The cam-
paign also urged mothers to “Make up your own mind” in recognition of
the bias of many pediatricians for formula. A popular soap opera included
pro-breastfeeding messages and celebrities appeared in TV PSAs in further
attempts to reach the intended audience.
Pérez-Escamilla reported that Brazil essentially followed a social mar-
keting framework after 1983, applying the 4 P’s in an integrated manner.
Efforts ranged from helping to develop and then enforcing the WHO Inter-
national Code for Marketing of Breast-Milk Substitutes, to promoting the
Baby-Friendly Hospital Initiative (although Brazil’s high rates of Caesarean
sections has meant a lower number of hospitals that qualify), and to sup-
porting community-based approaches. Changes in legislation were needed,
such as those related to maternity leave and the work environment. The
country now has one of the most extensive human milk bank networks in
the world, which it has used to promote the social and economic value of
breastfeeding.
Conclusions and Implications for Loving Support
Social marketing played a key role in the Brazilian Breastfeeding Pro-
motion Program and its impact on breastfeeding. Possible reasons for its
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51
LESSONS LEARNED
success include its targeting of multiple stakeholders with effective mes-
sages and dissemination channels in a well thought-out program based on
social marketing. Pérez-Escamilla noted that Brazil also took advantage of
the global consensus on the need to reverse the decline in breastfeeding.
Furthermore, the program is still ongoing, rather than ending as a discrete
activity.
Pérez-Escamilla said that political support will be of key importance
in moving forward with the Loving Support campaign. Although Loving
Support should take advantage of strong support from the Surgeon General
and First Lady Michelle Obama, political support for the program should
transcend individual presidential administrations. Public opinion can shape
that political support. As the Brazilian program shows, sustainability de-
pends on a strong and well-coordinated national promotion program, with
intersectorial coordination providing the glue. Messages must resonate
across different stakeholders, may need to change over time, and must reach
diverse audiences, including family members, different racial and socioeco-
nomic groups and ages, and communities.
GROUP DISCUSSION
Presenter: Karan DiMartino
In keeping with the format of the workshop, moderator Karan
DiMartino took written questions from the audience and directed them to
the speakers. The issues included the following:
• Definition of social marketing in the context of updating Loving
Support: Suzanne Haynes said that social marketing is important,
but that other elements are also needed, and she agreed with the
need for what Wong called a “surround campaign” in VERB™.
For breastfeeding this might include ways to reach out not only to
mothers, but also to workplaces, hospitals, and health care provid-
ers, among others. Lefebvre urged the group not to carry out just
a health communications campaign.
• Breastfeeding after C-sections: The rate of Caesarean sections is
high in Brazil—as much as 36 percent in public hospitals and more
than 80 percent in private hospitals (Barros et al., 2011), according
to Pérez-Escamilla. C-sections are generally considered a risk factor
for a poor breastfeeding outcome. However, as shown in Brazil,
breastfeeding can still succeed after a C-section if the hospital sup-
ports it. In fact, one beneficial consequence of a C-section is that
women stay in the hospital longer so their milk may come in before
they are discharged.
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52 UPDATING THE USDA NATIONAL BREASTFEEDING CAMPAIGN
• Budget and political considerations: Wong said that VERB’s budget
averaged about $60 million per year ($125 million in the first year,
with lesser amounts in subsequent years). Thus, as she noted, the
VERB™ campaign staff had the resources to follow the appropri-
ate social marketing methods from the beginning, although she
stressed the importance of paying attention to the 4 P’s no matter
the size of budget available for a campaign. The chair of the House
Appropriations Committee, the Honorable John Porter, was con-
cerned about children’s poor health behaviors and strongly believed
in supporting long-term health, and he championed VERB’s fund-
ing. It became difficult to sustain the high level of appropriations
support when he was no longer in office. Wong also observed that
the campaign’s direct focus on children made it difficult for adults
to understand and support what VERB™ was doing initially; this
changed as VERB™ became more broadly known and evaluation
results became available. This experience, she said, illustrates the
need to build support early in order to weather changes in the
political climate. Even though some people felt the campaign was
too expensive compared to the typical low-budget public health
campaign, she said that the cost paled in comparison to the adver-
tising and marketing budgets of such companies as McDonald’s
and Coca-Cola. Haynes observed that political cycles often mean
that leaders come in and favor their own programs—which is one
of the impediments to a 10-year campaign.
• Acknowledging difficulties in breastfeeding: The panelists discussed
presenting breastfeeding as “easy and normal” versus acknowl-
edging difficulties. Wong suggested testing the messages in focus
groups or through other research. Lefebvre said that audience
segmentation should help identify the messages needed, explaining
that different sets of expectations will exist concerning this issue
and that these different expectations will need to be acknowledged
in order for the mothers to believe the message. Haynes noted
that the original title of an NBAC publication was “Easy Guide
to Breastfeeding” but that when focus groups said they did not
consider breastfeeding easy, the title was changed to “Your Guide
to Breastfeeding.” Pérez-Escamilla said that segmentation is a chal-
lenge and noted that even within the Latino community people
are from many different countries and have different levels of
acculturation.
• Building on and sharing existing research: A participant suggested
that sharing findings from states’ formative and outcome evalu-
ations, which often are not published, can maximize the dollars
spent on research. Haynes suggested holding a conference to bring
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53
LESSONS LEARNED
together research and researchers from different states. A par-
ticipant suggested using research to develop a script for providers
similar to the 5-2-1-0 message for obesity (5 or more fruits and veg-
etables; 2 hours or less recreational screen time; 1 hour or more of
physical activity; 0 sugary drinks and more water and low-fat milk
[http://www.letsgo.org]), which is a public education campaign
designed to develop awareness of the daily guidelines for nutrition
and physical activity.
• Reaching the healthcare delivery system: The nonprofit Wellstart
International played a large role in Brazil in building capacity for
lactation management. Brazil made breastfeeding education for
health care providers a large part of its program.
• Building a brand: The VERB™ campaign staff talked to many chil-
dren in order to build the brand, Wong said. Three different brand
concepts developed by an advertising agency were tested with
children and mothers in order to receive their input. According to
Wong, a brand is more than a slogan—it is the promise made to
the target audience. Go back to the target audience for its views,
Wong said, rather than substituting one’s own opinions. With re-
spect to VERB™, the target audience was tweens; adults see the
world differently than tweens. Lefebvre reminded participants that
they should consider the important benefits to focus on are those
identified by the audience, not by the campaign developers. He
said that the questions addressed in developing the Loving Support
brand should include such things as, What does this brand mean
to women? and, Does it need to be refreshed, updated, or does a
new brand need to be developed?
• Ongoing use of the name “Loving Support”: The panelists were
asked if the title “Loving Support” should change. Generally, pre-
senters were not wedded to the title but also did not feel it should
change just for the sake of something new. Lefebvre said it depends
on what the audience says. Peterson agreed, observing that states
often do Loving Support–type activities without using that title.
Haynes suggested that the word “support” is important and that
it helps build mothers’ confidence. Pérez-Escamilla said that while
he thought the research supports the term, he wondered why the
logo does not include a woman breastfeeding a baby. Wong said
that, as someone who does not work in promoting breastfeeding,
the brand struck her as aimed more at the people providing support
rather than at women who may be breastfeeding or are going to
breastfeed.
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54 UPDATING THE USDA NATIONAL BREASTFEEDING CAMPAIGN
REFERENCES
Asbury, L. D., F. L. Wong, S. M. Price, and M. J. Nolin. 2008. The VERB™ campaign: Ap-
plying a branding strategy in public health. American Journal of Preventive Medicine
34(6):S183–S187.
Avery, A., K. Zimmermann, P. W. Underwood, and J. H. Magnus. 2009. Confident commit-
ment is a key factor for sustained breastfeeding. Birth 36(2):141–148.
Barros, A. J., I. S. Santos, A. Matijasevich, M. R. Domingues, M. Silveira, F. C. Barros, and
C. G. Victora. 2011. Patterns of deliveries in a Brazilian birth cohort: Almost universal
Caesarean sections for the better-off. Revista de Saúde Pública 45(4):635–643.
Champion, V. L., and C. S. Skinner, 2008. The Health Belief Model. In Health Behavior and
Health Education: Theory, Research, and Practice, 3rd ed., edited by K. Glanz, B. K.
Rimer, and K. Viswanath. San Francisco, CA: John Wiley & Sons. Pp. 45–65.
Colorado WIC (Colorado Department of Public Health and Environment/Nutrition Services/
WIC Program). 2011. Colorado WIC Growing Healthy Families: Nutrition Risk Mod-
ule. http://www.cdphe.state.co.us/ps/wic/Resources/NRFModule%20061311%20AH.
pdf (accessed August 12, 2011).
Community Guide Branch/CDC (Centers for Disease Control and Prevention). 2011. Health
communication & social marketing: Health communication campaigns that include
mass media & health-related product distribution. http://www.thecommunityguide.org/
healthcommunication/campaigns.html (accessed June 14, 2011).
Grier, S., and C. A. Bryant. 2005. Social marketing in public health. Annual Review of Public
Health 26:319–339.
Haynes, S. G. 2011. Evaluation of the National Breastfeeding Awareness Campaign: Implica-
tions for the WIC campaign. Presented at the Institute of Medicine Workshop on Updat-
ing the USDA National Breastfeeding Campaign, Washington, DC, April 26.
Huhman, M. 2008. New media and the VERB campaign: Tools to motivate tweens to be phys-
ically active. Cases in Public Health Communication & Marketing 2:126–139. http://
www.gwumc.edu/sphhs/departments/pch/phcm/casesjournal/volume2/invited/cases_2_08.
pdf (accessed August 22, 2011).
Lefebvre, R. C. 2011. An integrative model for social marketing. Journal of Social Marketing
1(1):54–72.
NWA (National WIC Association). 2011. Six steps to achieve breastfeeding goals for WIC
clinics. http://www.nwica.org/sites/default/files/WIC_2011_SixSteps_FINAL.pdf (ac -
cessed August 4, 2011).
Pérez-Escamilla, R. 2011. The Brazilian National Breastfeeding Promotion Program: Social
marketing lessons learned. Presented at the Institute of Medicine Workshop on Updating
the USDA National Breastfeeding Campaign, Washington, DC, April 26.
Rea, M. F. 2003. A review of breastfeeding in Brazil and how the country has reached ten
months› breastfeeding duration. Cadernos de Saúde Pública 19 (Suppl. 1):S37–S45.
Roper, W. L. 1993. Health communication takes on new dimensions at CDC. Public Health
Reports 108(2):179–183.
Snyder, L. B. 2007. Health communication campaigns and their impact on behavior. Journal
of Nutrition Education and Behavior 39(2 Suppl.):S32–S40.
Sorensen, J. A., P. L. Jenkins, M. Emmelin, H. Stenlund, L. Weinehall, G. B. Earle-Richardson,
and J. J. May. 2011. The social marketing of safety behaviors: A quasi-randomized
controlled trial of tractor retrofitting incentives. American Journal of Public Health
101(4):678–684.
Wong, F. L. 2011. Overview and lessons learned from the VERB campaign. Presented at the
Institute of Medicine Workshop on Updating the USDA National Breastfeeding Cam-
paign, Washington, DC, April 26.
