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 moderator 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



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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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43 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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45 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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47 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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