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5 Responses and Concluding Remarks At two different times during the workshop—in the morning, after the first two panels, and in the afternoon, after the third panel—the committee asked an expert to reflect on what he had heard and to identify themes. Laurence Grummer-Strawn, who responded to the first two panels, is chief of the Centers for Disease Control and Prevention (CDC) Nutrition Branch and is recognized internationally for his work on breastfeeding policy, among other topics. The second responder was William Smith, editor of Social Marketing Quarterly, who has more than 40 years of experience in behavior change, social marketing, and community building. At the end of the day, workshop chair Rafael Pérez-Escamilla offered some common messages and challenges to conclude the workshop. RESPONSE TO PANELS 1 AND 2: BREASTFEEDING MARKETING IN THE NEW ENVIRONMENT Respondent: Laurence Grummer-Strawn Grummer-Strawn thanked the panelists for pulling together a large amount of literature into the short presentations required by time con- straints. He said that he had captured eight main messages from the first two panels: 1. Breastfeeding has increasingly become the norm. Rates of breast- feeding at six months have nearly doubled since 1997 when Lov- ing Support began, and a majority of WIC mothers are initiating 75

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76 UPDATING THE USDA NATIONAL BREASTFEEDING CAMPAIGN breastfeeding. This fact, he said, changes the dynamics of the con- versation a WIC staff member is likely to have with a WIC par- ticipant from one that encourages a mother to breastfeed who has reservations and questions about it to a conversation that supports the mother’s choice to breastfeed. There may not be a huge change in the number of women breastfeeding, Grummer-Strawn said, but the nature of the dialogue has changed. However, he noted that WIC breastfeeding rates, while increasing, still lag behind the national average. 2. The environment to support breastfeeding has improved consid- erably. Looking at such factors as state legislation and policies, increases in Baby-Friendly Hospitals and International Board Certi- fied Lactation Consultants (IBCLCs), and other trends, one can see these positive trends as evidence of a far more supportive environ- ment than existed 14 years ago. 3. The same barriers exist that have existed for the last 25 years. In 1985 recommendations from the Surgeon General’s Workshop on Breastfeeding focused on work, public education, professional education, the healthcare system, support services, and research— issues that are still relevant today. This is because while the trends are positive, as noted above, they remain insufficient. For example, there are just over 100 Baby-Friendly hospitals, and they account for only 4 percent of the births in this country. 4. Society’s beliefs about breastfeeding have not changed much, at least on such issues as breastfeeding in public and the benefits of breast milk versus formula. Grummer-Strawn shared some data from Porter Novelli’s HealthStyles surveys (http://www.cdc.gov/ breastfeeding/data/healthstyles_survey/survey_2007.htm#) on pub- lic attitudes about breastfeeding in 1999, 2003, and 2007. In 2007 respondents actually felt a little less comfortable than those in 1999 when seeing women breastfeed in public. Similarly, Grummer- Strawn noted that the two-year National Breastfeeding Awareness Campaign did not show any significant changes in beliefs about breastfeeding. 5. How breastfeeding messages are framed is more important than the content of the message. Grummer-Strawn suggested that those designing the new campaign should read a paper by the Berkeley Media Studies Group entitled “Talking about Breastfeeding: Why the Health Argument Isn’t Enough” (Dorfman and Gehlert, 2010). According to the paper, current breastfeeding frames in the media include the beliefs that good mothers breastfed their babies and that breastfeeding is a natural thing to do that has be going on for generations but also that mothers need experts to show them how

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77 RESPONSES AND CONCLUDING REMARKS to breastfeed properly. The Berkeley group suggested alternative frames: Successful breastfeeding requires support, breastfeeding benefits women’s health (not just children’s), and well-supported breastfeeding improves everyone’s well-being. 6. Effective marketing must appeal to emotions, experience, and mo- tivations, not just provide information. Often, Grummer-Strawn said, WIC counseling is aimed at providing information about the benefits of breastfeeding, yet, he noted, literature on social market- ing and communication indicates that decisions are not generally made on the basis of breastfeeding’s benefits. 7. Communications channels have changed rapidly, and there are completely different ways to communicate with audiences than ex- isted 14 years ago. With those changes has come a population that is technology-dependent. Grummer-Strawn said that he learned at a recent conference that the main resource people rely on to learn a new behavior is YouTube. New technology has also led to the democratization of information. Grummer-Strawn said that infor- mation leaders are no longer deciding what information the public should have, but rather the millennial population will search for the information they want, access the information that appeals to them, and ignore what does not. 8. Millennial women want to be unique. They have an expectation of personalized messages and want to be recognized as a diverse population and as multidimensional people. Grummer-Strawn said the message he heard from the panelists was that millennial women want to be addressed not only as mothers but also as people who have careers, friends, and families because it is all part of who they are. They also want to be involved in the communication process, “pulling” messages of interest rather than having the messages pushed out at them. RESPONSE TO PANEL 3: WHERE TO GO FROM HERE Presenter: William Smith After the third panel, William Smith, editor of Social Marketing Quar- terly, observed that while many good ideas were presented in the workshop, they were offered without much priority-setting. One way to move forward would be to consider what unique contributions the U.S. Department of Ag- riculture (USDA) can make to support breastfeeding through an evidence- based social marketing campaign and to leverage resources. For example, rather than creating a social media strategy to compete with existing and successful initiatives, the USDA could determine how to leverage or support

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78 UPDATING THE USDA NATIONAL BREASTFEEDING CAMPAIGN these existing efforts. Smith also suggested sorting through all the data ac- cumulated from various sources because, he said, “You don’t know what it all means.” He suggested that the book How Doctors Think (Groopman, 2007) provides useful suggestions for how to look at data objectively and avoid confirmation bias seeping in. Overall, Smith encouraged participants to recognize their successes. He reminded them that within a decade after World War II, millions of women had turned their backs on breastfeeding and were using formula. Now, breastfeeding is again promoted as a social norm, and 75 to 80 percent of women are at least initiating breastfeeding. “Stop talking about women who aren’t breastfeeding and talk about the women who are,” he said. “You have created a norm.” Smith proposed moving away from focus groups and using observation studies. He noted that many presenters talked about the fact that WIC is not reaching mothers during the critical 72-hour window after the mother gives birth. What can WIC do to help mothers get through that time? Smith suggested gathering real metrics about what these new mothers are experi- encing. What really happens during that period that is so critical? How do they feel? What is happening with their husbands or their other children? First-hand information could provide WIC with a huge opportunity during these 72 hours. Smith discussed imagery in several ways. First, he suggested making WIC participation exciting, almost like being a member in an organization. Concerning the public’s images of breastfeeding, he noted that a search on “breastfeeding” in Google came up with pages of women breastfeeding in fields or other idealized settings, but not in public around other people. Images of breastfeeding in public, such as in the workplace, could help minimize the embarrassment that many women still feel. The current WIC website emphasizes the WIC program, with less focus on women and little mention of or images from the Loving Support brand. In contrast, private companies tend to focus their sites around women, and some government agencies, such as CDC and the Health Resources and Services Administration, have also successfully developed people-centered websites. Smith singled out Weight Watchers as an example of a website that focuses on success, belonging, and being challenged to succeed. Smith suggested developing a brand extension, perhaps “Loving Support Plus,” to use going forward. Following a very traditional social marketing and marketing technique, new elements could be added to the current campaign. Smith said that, based on what he heard during the workshop, pri- orities for the future might include celebrating WIC women; updating the market research; targeting that 72-hour critical period; and creating on a

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79 RESPONSES AND CONCLUDING REMARKS brand extension that focuses on breastfeeding duration and workplace and public place feeding. CONCLUDING REMARKS Presenter: Rafael Pérez-Escamilla Rafael Pérez-Escamilla wrapped up the workshop by repeating a num- ber of comments and insights he said he had heard during the day. First, though, he described a project in which he had been involved in Hartford, Connecticut. He had developed messages based on his own preconceived notions. Fortunately, he said, a colleague reminded him that he had to heed what the target audience—in this case mostly Puerto Rican women—were identifying as barriers to breastfeeding, not what he assumed from his own experience in Mexico. In line with that lesson, he noted that it is important to consider market segmentation and also to remain objective and to be unbiased even when the “right” answer seems obvious. He also noted that the campaign he was involved in was more successful because of a partner- ship, in this case with the Hispanic Health Council and Hartford Hospital (Stopka et al., 2002). Other points from the workshop that Pérez-Escamilla said he felt would be useful to the Food and Nutrition Service (FNS) included the following: • Deciding the scope of the campaign: An overwhelming amount of information about potential activities and approaches was pre- sented throughout the day. The first task for USDA is to decide the scope for the campaign: whether to focus on social marketing and the 4 P’s or to mount a well-focused health communication effort. The amount of funding will help decide the scope. • Defining the outcomes—initiation, duration, exclusivity: Exclusiv- ity is important, but it is a challenge if there is not a very well- coordinated system with peer counselors and better connections with hospitals. Adding a focus on exclusive breastfeeding to Loving Support would require addressing factors that include targeting mothers within the first few days after they give birth, training for medical students, and understanding the health implications of complementary feeding. • Market segmentation: A variety of different factors should be taken into account: ethnicity, whether a mother has already given birth or if this is the first time, the age of the mother, acculturation, and so on. Pérez-Escamilla recommended considering the Stages of Change model in planning the campaign.

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80 UPDATING THE USDA NATIONAL BREASTFEEDING CAMPAIGN • Research into specific and contextual issues: Research about so- cial media and the image of the WIC program can help the cam- paign. How, for instance, do participants and potential participants perceive the program? What is the explanation for WIC-eligible women who choose not to participate? What is the impact of the new food package as an incentive? Deciding whether to frame the issue so as to motivate women to breastfeed versus warning them against formula feeding is deserving of a good amount of research. The book Nudge (Thaler and Sunstein, 2008) suggests changing the “default systems” so that people gradually adopt more health- ful behaviors; this would be a useful way to discuss how far to go in promoting breastfeeding and discouraging formula feeding. • Evaluation: Formative, process, and outcome evaluations are all crucial, Pérez-Escamilla said. The formative evaluation will offer information about the needs and the wants of the target commu- nities. Concerning process evaluation, if the campaign is not user- friendly, it will be very difficult to move forward. • Monitoring tools: Good tools are in place from the CDC, the Food and Drug Administration, and other sources. They can help document feeding practices, hospital policies, and other important information, but better coordination across information systems is needed. CLOSING DISCUSSION The workshop ended with a few minutes of general discussion. The topics included • Motivational interviewing: A participant suggested using this tech- nique, in which the participant is guided to reach his or her own conclusion about the target behavior. Saluja said that the technique has been part of the WIC program for some time. • “Hot” and “cold” states in marketing: Smith suggested that this concept may be useful in thinking about breastfeeding. In this case the “cold” state would be the situation in which the mother is pregnant and is thinking about breastfeeding, and the “hot state” would be the period right after she gives birth. The challenge is how to prepare her for the hot state. • Reaching out to policy makers and other key players: A participant said that it is very important to engage with stakeholders at the community, state, and federal levels. As the participant put it, “A very important piece of this next generation of Loving Support is getting “loving support” from some other people—policy makers

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81 RESPONSES AND CONCLUDING REMARKS at the state level, at the federal level, and at the community level. They need to know the concepts and the successes of WIC.” Pérez- Escamilla agreed, mentioning the role that advocacy groups play in Brazil in reaching policy makers. They could do things that the government could not do, he said. • Viability of counter-marketing: Several participants asked whether a campaign to support breastfeeding should take cues from the anti-tobacco campaign. Smith suggested focusing on what is hap- pening with breastfeeding, not on demonizing choices. Pérez-Escamilla said he wanted to close by highlighting the very rel- evant issue of finding out how best to “nudge” women away from formula into breastfeeding. “It is a very complex matter,” he said, “but I think there are some good signs on the horizon.” He thanked the participants and panelists on behalf of the planning committee and the Institute of Medicine staff and expressed the hope that USDA/FNS benefited from the discussion. REFERENCES Dorfman, L., and H. Gehlert. 2010. Talking about breastfeeding: Why the health argument isn’t enough. Berkelely Media Studies Group 18. http://www.bmsg.org/pdfs/BMSG_ Issue_18.pdf (accessed June 17, 2011). Groopman, J. 2007. How Doctors Think. New York: Houghton Mifflin. Stopka, T. J., S. Segura-Perez, D. Chapman, G. Damio, and R. Pérez-Escamilla. 2002. An in- novative community-based approach to encourage breastfeeding among Hispanic/Latino women. Journal of the American Dietetic Association 102(6):766–767. Thaler, R. H., and C. R. Sunstein. 2008. Nudge: Improving Decisions about Health, Wealth, and Happiness. New Haven, CT: Yale University Press.

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