Step 1.1 Write a problem statement.

Starting in 1989, Congress designated a specific portion of each state’s Special Supplemental Nutrition Program for Women, Infants and Children (WIC) budget allocation to be used for the promotion and support of breastfeeding among WIC participants. More than five years after the government started supporting promotional efforts, breastfeeding rates among WIC participants were considerably lower than for women of higher socioeconomic levels. In 1995, 59.7 percent of infants in the U.S. were breastfed at birth while only 46.6 percent of infants in WIC programs were. At six months postpartum, the rates were 21.6 percent nationally and only 12.7 percent for WIC-enrolled infants.

In September 1995, Best Start Social Marketing, a non-profit social marketing organization based in Tampa, Florida, was funded by the U.S. Department of Agriculture (USDA), which administers WIC, to develop a comprehensive, national breastfeeding promotional campaign through WIC.

Step 1.2 List and map the causes of the health problem.

Several studies have identified why there are lower initiation and earlier cessation rates than the national average among WIC participants. Of course, women in WIC face barriers similar to many American women. These include:

• Misinformation, embarrassment, lack of confidence or desire, bad previous breastfeeding experience
• Lack of support from family members or other mothers (i.e., support group)
• Lack of support and helpful information/assistance from their doctors
• Hospital policies of offering free infant formula, separating mother and baby, discharging mother and baby early or inadequately following-up about breastfeeding progress after discharge
• Lack of support in the workplace (limited leave, lack of breastfeeding/breast milk expression/childcare facilities)

Step 1.3 Identify potential audiences.

Planners initially decided to target women enrolled in WIC who had not made a firm commitment to breast or bottle feed and, therefore, were open to considering breastfeeding. Research showed that most of these women would answer “breastfeed” to a closed-ended question—how do you plan to feed your baby?—but were not firmly committed. This group was the primary audience population that Best Start Social Marketing later segmented further based on their perceived costs of breastfeeding. The secondary audiences were people who influenced these women to breastfeed or not.

Step 1.4 Identify models of behavior change and best practices.

Best Start had the advantage of lessons learned from its previous USDA work on breastfeeding promotion. In addition, Best Start looked at several behavior-change models—including the Health Belief Model, Stages of Change and Social Learning Theory—and decided to use elements of several models to guide program development.

The Health Belief Model would help identify the perceived benefits and barriers to breastfeeding. The WIC participants who considered breastfeeding would be “contemplators” according to the Stages of Change. The importance of motivation, modeling, self efficacy, and outcome expectations would be consistent with the Social Learning Theory. (see Theory at a Glance)

Step 1.5 Form your strategy team.

During the fall of 1995, Best Start staff met with the USDA’s Food and Nutrition Service (FNS) representatives and members of their Breastfeeding Promotion Consortium to begin planning the program. Consortium members were instrumental in strategy planning and implementation, selection of pilot sites, and in program promotion.

Assistance from a wide variety of federal agencies, professional organizations, including the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, was invaluable to planning and dissemination. The strategy team also consulted with breastfeeding promotion organizations (including the International Lactation Consultants Association, La Leche League, U.S. Breastfeeding Committee) throughout the planning and program implementation.

Step 1.6 Conduct a SWOT analysis.

Step 2.1 Define your research questions.

Formative research aimed to collect consumer information needed to segment the population, identify important factors limiting breastfeeding, and define the methods to effectively promote breastfeeding. Some of the research objectives included:

• identifying the perception of breastfeeding and bottle-feeding (formula) held by the audiences,
• identifying the factors that motivate and deter the target audience group from breastfeeding and influencing audiences from encouraging breastfeeding, and
• identifying effective information channels and spokespersons for promoting breastfeeding among WIC participants.

Step 2.2 Develop a market research plan.

The market research plan was a mix of qualitative and quantitative data:

• Participant observation in five pilot states
• 122 in-depth interviews with WIC participants and 62 in-depth interviews with WIC employees
• 12 focus-group interviews with WIC participants and 1 panel discussion with health care providers
• 45 telephone interviews with secondary target audience members
• 292 WIC participants in 12 WIC and prenatal clinics completed a 53-item survey instrument.

Step 2.3 Conduct and analyze market research.

Data were collected in pilot states from December 1995 through May 1996 and analyzed during the summer of 1996. Qualitative research results were used to identify areas that merited further exploration and to develop the 53-item quantitative survey instrument. Clinics were selected that represented urban, suburban and rural communities. Within these sites, programs were selected that represented small, medium and large caseloads and access to Anglo, African American, Hispanic/Latino and Native American populations. All women served in the clinics on data-collection days were invited to participate in the survey. Fewer than 5 percent refused to participate.

Step 2.4 Summarize research results.

Data collected from focus groups and interviews were compiled into a research report that became the basis for the campaign. The report included a summary of:

• Women’s knowledge and perceptions of breastfeeding and contraindications;
• Factors that motivate women to breastfeed;
• Factors that deter women from breastfeeding;
• Family members’ perceptions of breastfeeding benefits and contraindications;
• Factors that motivate WIC personnel to promote breastfeeding; and
• Factors that deter WIC personnel from promoting breastfeeding.

Highlights from the research conducted with WIC participants, WIC employees and other health care providers are described below:

WIC participants: Mothers’ infant-feeding decisions were balanced between the benefits and costs of breastfeeding and how these compared to its competition, bottlefeeding (formula). Compared with infant formula, breastmilk was considered by most to provide better nutrition and better protection from illness and a closer maternal-infant bond. For many women, the enjoyment they expected to experience and the special time they associated with breastfeeding were breastfeeding’s most important benefits.

Although most women were attracted to the benefits breastfeeding offered them and their babies, many were deterred by the sacrifices they would have to make if they breastfed. They worried that breastfeeding would create many embarrassing moments when they would be required to nurse in front of others or open them to criticism from friends or relatives who viewed breastfeeding in a sexual light. Some women worried that the additional time it takes to nurse a baby would conflict with work, school, or social life; and some women worried that their boyfriends or husbands, mothers, and other close relatives would feel “left out” of the feeding experience and fail to bond to their baby. Other “costs” associated with breastfeeding were the pain associated with nursing, changes nursing mothers would have to make in dietary and health practices, and anxiety about their ability to product the quality and quantity of breast milk needed to meet their child’s nutritional needs.

In addition to the unfavorable ratio between benefits and costs, women’s infant-feeding decisions reflected their lack of self-efficacy as potential breastfeeders and a lack of support from relatives, friends, and some health providers.

WIC employees. The vast majority of WIC nutritionists and clerical staff felt that breastfeeding support and education are important components of the WIC program. Most enjoyed the one-on-one interaction that breastfeeding education afforded them, and many expressed a sense of achievement and satisfaction with their roles as breastfeeding advocates. Clerks in some agencies were actively involved in breastfeeding support. In agencies where training had not been offered to clerical staff, some clerks expressed an interest in receiving breastfeeding training so that they could play a more active role in promoting breastfeeding.

WIC employees also talked about numerous problems that offset the benefits to be gained from breastfeeding promotion: time required to promote breastfeeding, (a precious commodity in many agencies where staff shortages and other competing demands make it difficult to allocate sufficient time to educational activities) and lack of administrative support for breastfeeding promotion. Employees working in communities with low breastfeeding rates were also frustrated by clients’ lack of receptivity to breastfeeding promotion activities. Finally staff members’ efforts to promote breastfeeding were hampered by external factors, including a perceived lack of support from health care providers and hospitals, direct competition from formula companies, and negative portrayal of breastfeeding by the media.

Other health care providers. Most health care providers believed breastfeeding promotion efforts had improved greatly, but felt a consistent effort to encourage and support breastfeeding was missing in most communities. They also pointed out that breastfeeding instruction and support during the critical postpartum period were lacking in most areas.

Step 3.1 Select your target audience segment(s).

From a pool of 33 applicants, the campaign planners chose 10 pilot sites: New York, Ohio, Iowa, New Jersey, Nevada, Arkansas, California, Mississippi, West Virginia, and the Chickasaw Nation in Oklahoma. The sites were selected to include each of USDA’s eight geographic regions and to reflect ethnic diversity. The planners also selected sites with a range of existing programs and activities and breastfeeding rates. (Mississippi had the lowest breastfeeding rates in the country while Iowa had fairly high rates and an infrastructure.)

The primary target audience was further refined to include pregnant Anglo, African American, Native American*, and Hispanic/Latino women who were enrolled in WIC or were eligible for WIC (low income). The target audience was segmented based on perceived costs of breastfeeding—embarrassment; fear of being tied to the baby and conflict with work, school, or an active social life; fear of not being able to nourish or nurse adequately; fear of jeopardizing relationships with the grandmother or father of the baby or other network ties; lack of support or encouragement from family and friends.

Secondary audiences consisted of those influencing the target audience, such as mothers of the pregnant women, fathers of the baby, prenatal health care staff and WIC staff. The general public was also designated as an influential tertiary audience because social norms related to breastfeeding, especially in public settings, were found to play an important role in women’s infant-feeding decisions.

* Native Americans were added in the second round of material development.

Step 3.2 Define current and desired behaviors for each audience segment.

See Table of Audiences, Current Behaviors, and Desired Behaviors.

Step 3.3 Describe the benefits you will offer.

Step 3.4 Write your behavior change goal(s).

More pregnant women enrolled in WIC and those eligible for WIC will initiate breastfeeding in exchange for developing a loving bond and joy they will share with their babies.

More pregnant women enrolled in WIC and those eligible for WIC will continue breastfeeding for longer periods of time in exchange for maintaining the loving bond and joy they share with their babies.

More friends and family members of WIC participants will support breastfeeding in exchange for the feeling that they have participated in giving the baby a good start in a strong family.

Step 3.5 Select the intervention(s) you will develop for your program.

Project research identified a number of barriers to breastfeeding. Materials and messages were based on these barriers:

• Embarrassment
• Competing demands on mother’s time (work, school, active social life)
• Confidence in ability to nurse and nourish
• Need for social support and encouragement from baby’s father and grandmother, family and friends

Product
The marketing plan for the National WIC Breastfeeding Promotion Program was organized with an emphasis on positioning or defining breastfeeding so it was clearly distinguished from the product’s competition—bottle feeding (formula).* The product strategy called for an emphasis on the close, loving bond and special joy that breastfeeding mothers share with their babies. Although breastfeeding’s health advantages would be mentioned in some materials, the product strategy emphasized the emotional benefits breastfeeding offers because these most clearly distinguished it from bottle feeding. Breastfeeding was positioned as a way families can realize their dreams of establishing a special relationship with their children. The campaign slogan—“Loving Support Makes Breastfeeding Work”— and program materials emphasized the role family members and friends play in mother’s ability to breastfeed. This strategy represented a significant departure from more traditional public health approaches to breastfeeding promotion in which breastfeeding was positioned as a medical choice by demonstrating the health benefits it offers mothers and babies. In addition to being the campaign slogan, “Loving Support” would eventually become the brand under which all campaign activities would be organized.

*The national WIC program dictates that formula be provided to women who do not breastfeed to ensure infants receive more than cow’s milk. Thus, the use of formula was not directly discouraged by the campaign.

Price
The pricing strategy was a central component of the marketing plan, with “price” being the perceived cost to breastfeeding—embarrassment, conflicting with work, school or social schedules, and/or jeopardizing their relationships with the father of the baby, mothers, friends and family. The marketing plan focused on ways to lower these “costs” or make them more acceptable. A key tactic for realizing the pricing strategy was a three-step counseling training designed to teach health providers to identify patients’ perceptions of breastfeeding’s costs and help lower them. Public information and consumer education materials were developed for each target segment to influence attitudes about breastfeeding and correct common misperceptions about the “price” of breastfeeding. While some of the educational materials did address the nutritional aspects of breastfeeding as well as breastfeeding skills, a strong family bond was still the core message.

Place
The placement strategy focused on the multiple settings in which women and their social network members seek information about infant feeding, where they actually made decisions about breastfeeding, and where they encountered barriers. For example, Best Start Social Marketing staff began working closely with the Baby Friendly Hospital Initiative, an international breastfeeding promotion program developed by the United Nations Children’s Fund and the World Health Organization, to create hospital environments that fully support breastfeeding mothers. Public information materials were developed to reach women in their homes where they can discuss breastfeeding with relatives and friends. Media advocacy and policy development were also used in many pilot states to promote policies supportive of breastfeeding in workplaces and pass legislation permitting breastfeeding in public settings. Best Start also established a hotline (800-275-4975) for lactation consultants and other breastfeeding professionals to receive technical assistance. Other hotlines already existed for breastfeeding mothers.

Promotion
The promotional strategy used multiple approaches to create a supportive public norm for breastfeeding. These included legislation, policy development and organizational change, professional training and provider’s kit, peer counselor programs, curriculum development, consumer education, public relations, direct marketing, advertising (television and radio), face-to-face communication, media advocacy, and grassroots advocacy. Materials were produced in English and Spanish. Sites were encouraged, when possible, to purchase advertising time to ensure message placement rather than relying on public service ads (PSAs). Message design guidelines were prepared to assist the creative team in developing communication materials. These guidelines recommended an emotional appeal with an upbeat, congratulatory tone, a slice-of-life or vignette presentation, and the use of families as spokespersons. The guidelines were based on market research findings. When asked about who they would most readily believe, the women said they would trust people like themselves—working women who represent various racial and ethnic backgrounds.

See Table of Audiences, Objectives, Strategy, and Tactics.

Step 3.6 Write the goal for each intervention.

Best Start’s goal was to develop a comprehensive, integrated program with elements that could be used separately by each of the pilot sites. The interventions were developed to work separately or together with the overall goal of increasing breastfeeding initiation and duration among WIC participants in each of the pilot site programs. Possible goals for the intervention could be:

• Counseling services: Help mothers work through individual costs to breastfeeding.
• Print materials: Provide take-away guidance for pregnant women and new mothers to use as reminders of benefits, techniques, where to go for help.
• Mass media: Create a positive, supportive, public environment for breastfeeding; reinforce women’s individual decisions to breastfeed.
• Training materials and sessions: Help WIC personnel become familiar with the goals, design and materials of the project; educate on three-part counseling strategy to help identify individual breastfeeding cost issues and how to overcome them.
• Policy advocacy: Change laws about public breastfeeding and workplace policies to increase support for breastfeeding mothers in public places and on the job.

Step 4.1 Select members and assign roles for your planning team.

In addition to Best Start Social Marketing staff, members of the strategy team including USDA’s Food and Nutrition Service (FNS) representatives, members of its Breastfeeding Promotion Consortium, and representatives of the pilot sites helped plan the program interventions. Best Start contracted with Altman, Meder, Lawrence, Hill, an advertising agency, to design public information messages and prepare consumer education materials. An instructional designer assisted with the development of the three-step counseling program.

Step 4.2 Write specific, measurable objectives for each intervention activity.

While each of the pilot sites tailored the interventions for the given situation, below are sample objectives for some of the activities.

Counseling
In six months, 50% of pregnant women enrolled in WIC will report receiving one-to-one counseling from WIC staff about breastfeeding.

Training
By 1997, 100 health care professionals will be trained to deliver patient education on the basics of lactation, breastfeeding counseling, and lactation management.

Advertising
By December 1997, 3 television and 3 radio spots recorded in English and Spanish will be produced and placed where WIC mothers and their family and friends are likely to see and hear them.

Step 4.3 Write program plan, including timeline and budget, for each intervention.

The program was initially a three-year effort in ten pilot sites. Additional sites were added later. Each state used their own breastfeeding set-aside funds to support the project and had the authority to determine how the program would be managed and delivered based on available funding and infrastructure. As part of the program's implementation plan, Best Start Social Marketing received approximately $516,000 to work closely with the 10 pilot states for 18 months to provide materials and technical assistance with marketing and team and consensus building.

In general, the sites followed this timeline.

Step 4.3.a Plan new or improved services.

A three-step counseling training was a key tactic to help health providers identify patients’ perceptions of breastfeeding’s costs and help lower them. The training was designed by an instructional designer based on past trainings and was tested and revised over time.

Step 4.3.b Develop or adapt a product.

Best Start also established a hotline (800-275-4975) for lactation consultants and other breastfeeding professionals to receive technical assistance. Other hotlines already existed for breastfeeding mothers.

Step 4.3.c Plan a strategy for policy change.

Media advocacy and policy development were used in many pilot states to promote policies supportive of breastfeeding in workplaces and pass legislation permitting breastfeeding in public settings.

Step 4.3.d Plan communication intervention/promotion activities.

The promotional strategy used multiple approaches to create a supportive public norm for breastfeeding. These included public relations, direct marketing, and advertising (television, radio, outdoor). Materials were produced in English and Spanish. Sites were encouraged, when possible, to purchase advertising time to ensure message placement rather than relying on public service ads (PSAs).

Step 4.4 Pretest, pilot test, and revise as needed.

To assure that the advertising agency clearly understood the target audiences, the WIC culture, and appropriate communication approaches and channels, Best Start project staff formally presented the research findings along with the following design strategies:

• Type of appeal: emotional;
• Manner: slice of life/demonstration;
• Tone: upbeat, warm and congratulatory; and
• Spokesperson: originally families.

During the summer of 1996, the agency developed five campaign concepts. One concept was eliminated in staff review because it was not consistent with the marketing strategy and minor adjustments were made to the other four before “testing boards” (conceptual visual presentations representing each approach) were prepared for pretesting. The concepts were tested through more than 100 interviews with the primary and secondary audiences in Florida (where Best Start is located). Two concepts were selected for further development based on target audience response.

In the second round of testing, the campaign messages were revised and pretested in five pilot states and Florida. In both rounds of pretesting, individual interviews were used to encourage frank appraisals of the materials by respondents and to avoid “group think” response bias sometimes associated with focus group pretesting. Revisions and pretesting continued until it became clear which concept worked most effectively with all the target audiences.

As a result of testing, the “Loving Support Makes Breastfeeding Work” concept was selected as the campaign theme because it best captured the necessity of family and friend support for a mother to initiate and maintain breastfeeding. The advertising agency rewrote the concept to incorporate some of the more attention-getting aspects of the other concepts, e.g., having a baby as the narrator.

In the final round of testing, Best Start tested the campaign prototype materials with other existing materials that would be used. The Breastfeeding Promotion Consortium (USDA, FNS) also reviewed all content and materials.

Step 4.5 Summarize your program plan and review the factors that can affect it.

Intervention plans focused on the multiple settings in which women and their social network members seek information about infant feeding. The final campaign theme, “Loving Support Makes Breastfeeding Work”, was used in a coordinated fashion to build a comprehensive campaign for maximum impact. “Loving Support” became the brand around which other components revolved. The original media and materials were designed to reach WIC mothers, their support network, health practitioners and WIC employees as well as the general public and worksites. These included:

• Three 30-second television commercials in English and one spot in Spanish
• Three 60-second radio commercials, two in English and one in Spanish
• Outdoor advertising boards, in English and Spanish
• Nine posters, targeting the primary ethnic groups in WIC (English and Spanish)
• Nine educational pamphlets, targeting the primary ethnic groups in WIC (English and Spanish)
• A motivational/information booklet for WIC staff
• A breastfeeding resource guide
• A breastfeeding promotion guide
• WIC staff support kit pocket folder to hold breastfeeding resource guide and motivational booklet for WIC staff.

Although coordination is important for any program, social marketing projects demand careful sequencing of a wide variety of activities: professional training, materials distribution, public information, public relations and often, public policy formation. A key element of the National WIC Breastfeeding Promotion project was training of WIC staff members who would implement the program at the state and local level. A training conference was held for teams from the 10 pilot sites and other interested WIC programs. The conference agenda included presentations on:

• Research results and their implications for breastfeeding promotion
• Media package (TV, radio, billboards)
• Working with the media
• Methods for tapping nontraditional communication channels
• Community-building skills
• Team building

Breakout sessions for skill development and team planning sessions were held to allow state WIC programs to develop work plans for their states. When attendees concluded the conference they left with an outline of a state plan for implementation.

In addition to the pre-launch training conference, Best Start was available to each of the pilot sites to provide technical assistance.

Factors that did or could have affected the program were a lack of funding for evaluation of all 10 pilot sites, decrease in state or local WIC commitment to the effort, existing legislation regarding public “nudity.”

Step 4.6 Confirm plans with stakeholders.

Throughout the strategy and initiative development, Best Start maintained contact and consulted with a variety of federal agencies, professional organizations, national organizations (and their local chapters). As implementation of the program approached, Best Start representatives began a concerted effort to present the initiative at conferences and national meetings of stakeholder and partner organizations. Outreach and communication with stakeholders was conducted at a variety of levels: national, state, community and organizational.

Nationally, Best Start staff met with USDA’s Food and Nutrition Service (FNS) Breastfeeding Promotion Consortium to build partnerships needed to institutionalize and sustain the program. Assistance from a wide variety of federal agencies, professional organizations ( e.g., the American Academy of Pediatrics, American College of Obstetricians and Gynecologists) and breastfeeding promotion organizations (e.g., International Lactation Consultants Association, La Leche League, US Breastfeeding Committee proved invaluable in producing additional program materials and disseminating the program outside the WIC community.

Best Start reached out to other organizations and networks to increase reach. For example, Best Start staff began working closely with the Baby Friendly Hospital Initiative, an international breastfeeding promotion program developed by the United Nation’s Children’s Fund and the World Health Organization.

Step 5.1 Identify what information needs to be collected.

A program evaluation was planned to track:

• Breastfeeding initiation
• Breastfeeding duration
• Support of family and friends

Step 5.2 Select the key evaluation questions.

Step 5.3 Determine how the information will be gathered.

The USDA requires an annual report on breastfeeding activities but formal evaluation of the pilot sites was not a requirement of participation. Because of budgetary restrictions, many of the sites did not conduct formal evaluations—in some cases, evaluation would have cost more than the interventions.

Summative evaluations of the program's impact in the states of Iowa (See Iowa’s initiative and evaluation report) and Mississippi were completed. Several other pilot sites are currently assessing their individual campaigns. Preliminary results from both Iowa and Mississippi show evidence of the program's success in both increased breastfeeding rates and changed attitude and awareness toward breastfeeding.

Iowa’s Evaluation Model
In Iowa, to assess the project’s impact on WIC participants’ breastfeeding rates, perceived social support, and exposure to media messages, a baseline survey was mailed to a random sample of 1,000 postpartum breastfeeding women and 1,000 postpartum non-breastfeeding women enrolled in the Iowa WIC program in July 1997, immediately prior to the media campaign’s launch in August. The 1998 post-campaign survey used a separate sample of 1,000 breastfeeding and 1,000 non-breastfeeding WIC participants. In both administrations, respondents received a questionnaire, cover letter, sweepstakes postcard and a business reply envelope for return of the questionnaire. One week later, a reminder letter was sent and three weeks after the initial mailing, a second mailing of the questionnaire was sent to non-respondents.

Potential respondents were provided an opportunity to have their names chosen in a cash sweepstakes if they returned an enclosed postcard for this purpose (cash prizes were $100, $75, $50, and $25). Slightly more than half (56 percent) of the mailed baseline surveys were returned. The return rate for the post-campaign survey was 62.9 percent. The survey examined:

• Breastfeeding initiation and duration rates
• Reasons for weaning, if applicable
• Exposure to information about breastfeeding from media channels used in the campaign
• Perceived social support (e.g., from WIC, health providers, baby’s father, mother, friends)
• Attitudes and knowledge about breastfeeding
• Demographic information

In addition to the questions included on the baseline survey, several questions were added to the post-campaign survey to explore:

• Exposure to newspaper articles about breastfeeding
• Participants feelings about breastfeeding through a fill-in-the-blank question (Breastfeeding makes me feel _______ because_______).

Mississippi’s Evaluation Model
Researchers at the University of Southern Mississippi evaluated the Mississippi effort. The overall objectives were to assess the impact of the campaign on: 1) breastfeeding rates among low-income women and 2) provider and community support for breastfeeding. The study included a qualitative phase (focus groups with WIC clients and WIC clinic staff) and a quantitative phase (a statewide survey of low-income, postpartum women) and was approved by the University of Southern Mississippi’s Human Subjects Protection Review Committee. (Link IRB document) In addition, the state WIC program conducted a statewide survey of health providers and a survey of state WIC agencies.

Focus Groups with WIC Clients
Nine focus groups with pregnant, postpartum breastfeeding, and postpartum non-breastfeeding WIC clients were conducted in 1999, including one group in each of the state’s nine public health districts. The focus groups assessed the impact of the campaign on 1) knowledge of benefits of breastfeeding; 2) community support and barriers to breastfeeding; and 3) provider support. District breastfeeding coordinators recruited participants. The groups were held at accessible community sites during convenient hours. Participants received a stipend of $20, and refreshments and childcare were provided. A professional facilitator moderated the groups using a discussion guide. The discussions were taped, transcribed, analyzed, and integrated with the field notes into a report. The nine reports were analyzed for cross-cutting issues and themes.

Focus Groups with WIC Clinic Staff
Two focus groups with WIC clinic staff from across the state, including nurses, nutritionists, and clerical staff, were conducted in 2000. The focus groups assessed the implementation of the campaign from the perspective of clinic staff. A professional facilitator moderated the groups using a discussion guide. The discussions were taped, transcribed, and integrated with the field notes into a report. The two reports were analyzed for cross-cutting issues and themes.

Survey of Low-income Postpartum Women
Study design: A quasi-experimental, post-intervention only, study design was used. Pretest numbers were garnered from the existing Ross Six-Month Infant Survey/ Mother’s Survey in 1995 and 1997 and used as proxy data. The intervention group included low-income postpartum women served by seven public health districts that had fully implemented the campaign. The comparison group included low-income postpartum women served by two public health districts that only implemented the public awareness component of the campaign.

Survey instrument: A two-page self-administered questionnaire was developed, pilot tested with 30 low-income, postpartum women, revised, and finalized. The questionnaire collected data about exposure to and ratings of different breastfeeding promotion activities, provider and community support for breastfeeding, infant feeding methods, and socio-demographic characteristics. The questionnaire was printed on color paper and mailed with a personalized cover letter and a return envelope to sampled women.

Survey design: A mail survey of low-income, postpartum women was conducted July 2000. The survey assessed: 1) exposure of low-income women to campaign activities; 2) perceptions of support for breastfeeding; and 3) breastfeeding rates. The target population for the survey was all low-income women who had a live birth in Mississippi in the spring of 2000. The sampling frame was the state Newborn Screening Database, which collects data on all deliveries, except home deliveries. The database is part of a statewide surveillance program and collects data on infant’s health, demographic characteristics, mother’s contact information, and Medicaid number, if any. In addition, a stratified random sample of 1,200 postpartum women on Medicaid was selected, including equal numbers in the intervention and comparison strata.
Women not responding within two weeks received a second mailing. Trained interviewers conducted telephone follow-up with women not responding to the mailings. Participants received $5 for their time.

Step 5.4 Develop a data analysis and reporting plan.

Because each of the pilot sites was a separate and independently run program, there was not a specific, uniform data analysis and reporting plan developed for the project.

Iowa’s Reporting Model
Survey responses were entered using SPSS statistical software, using the double entry feature to identify and correct errors. After the data were checked and cleaned, frequency distributions, Chi-Square, and logistical regressions were performed using SPSS.

Based on the data from the Ross Six-Month Infant/Mother’s Survey, there was an observed increase in the rate of breastfeeding as a result of the WIC Breastfeeding Promotion Project. Prior to the start of the program, breastfeeding rates for mothers while in the hospital had been at 57.8 percent. Six months after the campaign's start rates increased to 64.4 percent, and a year after the start they increased to 65.1 percent. The rates for women still nursing six months after birth also increased. Before the start of the campaign, women still breastfeeding was at 20.4 percent. Six months after the start of the campaign, rates increased to 29.3 percent, and to 32.2 percent a year after the program's start.

Increased breastfeeding support from relatives and friends: A major objective of "Loving Support Makes Breastfeeding Work” was to encourage the father of the baby, mothers, relatives, and friends of pregnant women to support breastfeeding. Results of the survey indicate that support for breastfeeding increased in every relationship category.

• Support from the pregnant woman's mother increased from 35.2 percent to 53 percent.
• Support from the pregnant woman's husband or boyfriend increased from 47.7 percent to 53 percent.
• Support from the pregnant woman's friends or other relatives increased from 48.8 percent to 51.1 percent.
• Support from the pregnant woman's prenatal health care provider increased from 62.4 percent to 83.8 percent, and from WIC employees from 81.9 percent to 92.5 percent.

Mississippi’s Reporting Model
Data were entered and analyzed using SPSS. Frequencies of all variables were generated. Characteristics of women in the intervention and comparison groups were examined using chi-square and t-tests, as appropriate.

Findings from the focus groups and survey indicate that the Loving Support campaign in Mississippi was successful in increasing breastfeeding rates and public awareness and acceptance of breastfeeding. Surveyed women reported high levels of exposure to Loving Support print and media materials and high levels of provider support for breastfeeding. There was room, however, for increasing support from physicians and hospital nurses. Relative to the comparison districts, the intervention districts were more likely to use lactation specialists/peer counselors, breastfeeding videos, breastfeeding classes, and nursing rooms. The intervention districts also experienced larger increases in community support for breastfeeding and breastfeeding rates.

Breastfeeding initiation rate for Medicaid infants for 2000 (37.5 percent) was similar to the rate reported by the Ross Six-Month Infant Survey/ Mother’s Survey for Mississippi WIC infants for the same year (38.3 percent). The Mississippi researchers also used Ross data to examine breastfeeding rates in 1995 (two years before the campaign), 1997 (the year the campaign was kicked-off), and 1999 (two years after the campaign). In-hospital breastfeeding rates for Mississippi WIC infants were 27 percent in 1995, 29 percent in 1997, and 37 percent in 1999. Breastfeeding rates at 6 months for Mississippi WIC infants were 5 percent in 1995 and 7 percent in 1997 and more than doubled to reach 15 percent in 1999. Similar trends were observed for rates for all infants, suggesting that the campaign may have promoted breastfeeding in the non-WIC population as well. Overall, the data indicates that Loving Support in Mississippi effectively increased knowledge of and positive attitudes towards breastfeeding as well as increased the initiation and the duration of breastfeeding.

The Mississippi results are limited in two ways. First, it was not feasible to collect pretest data from the intervention and comparison groups. Researchers did not expect this to affect the conclusions of the study, because there is no evidence to suggest that the two groups had different breastfeeding rates at baseline. Second, the survey measured breastfeeding rates at four-months postpartum, although rates are typically measured at six-months postpartum. The Mississippi researchers decided to contact the women earlier during the postpartum period, because the state WIC population is mobile, and addresses collected at the time of delivery expire quickly.

Step 6.1 Prepare for launch.

Each site was responsible for its own implementation of the program, based on funding available in that state or territory. Best Start provided sites with media placement recommendations for advertising and public service placement options. Campaign materials were shipped in July 1997 for the project launch. The project kicked off August 1, 1997, nationwide during World Breastfeeding Week with print material and media ads.

To ensure effective coordination and implementation of the program's many elements at the state and local levels, Best Start held a comprehensive training conference for the 10 pilot sites in April 1997 Sites could determine who to send to the conference. Iowa, for example, sent a team of five (three local WIC agency staff members and two state WIC staff members). By the conclusion of the conference, attendees had developed detailed implementation plans for each of their respective states.

The National WIC Breastfeeding Promotion Project was officially launched in Washington, DC with a national press conference during World Breastfeeding Week (August 1-7, 1997). The adaptable program materials were identical for each pilot site, however, individual sites had the authority to determine what and how the materials would be used. Those determinations were generally guided by available funding and program management, which varied from site to site. As part of the program's implementation plan, Best Start worked closely with the 10 pilot states during the campaign's first 18 months by providing technical assistance with marketing and team and consensus building.

Preparation for Campaign—Iowa example
In addition to the national training, Iowa prepared for the launch with a series of training and outreach efforts including:

Hold informational meetings. Getting the word out on the project was the main focus after returning from the training conference in Virginia. Contacts were made within the Iowa Department of Public Health (IDPH) as well as groups outside the department. Within the department, presentations were made to the director and his staff, at several bureau staff meetings, and to new public health nurses. Outside the IDPH, presentations were made at the Iowa Lactation Task Force Meeting, Networking For Iowa Breastfeeding Coalitions Meeting, Child and Adult Care Food Program Meeting, and the Breastfeeding Peer Counselor Train-the-Trainer Conference.

Train local staff. The training that took place in Iowa for the project occurred over the Iowa Communication Network (video teleconference) on July 1, 1997. Local WIC staff, public health nurses, and members of local breastfeeding coalitions participated.

Provide materials. The Iowa WIC program sent all local agencies print materials developed for the campaign. The materials included posters, pamphlets and staff support kits.

Inform stakeholders. The project summary was mailed to various groups and individuals in Iowa including the Iowa Chapter of the American Academy of Pediatrics Breastfeeding Coordinators, Infant Mortality Prevention Project Coordinators, La Leche League leaders, International Board Certified Lactation Consultants, Iowa State University Extension nutrition and health field specialists, Maternal Child Health Advisory Council and Local breastfeeding coalitions. A newsletter article about the project also was submitted to various Iowa organizations to be included in their summer or fall 1997 newsletters. Organizations that published an article included the Iowa Dietetic Association, Child and Adult Care Food Program, Maternal and Child Health Program, and Iowa Chapter of the American Academy of Pediatrics.

Prepare staff for 800-number calls. The Iowa WIC 800 number appeared as a tag on all TV, radio, and outdoor advertisements for the campaign. In anticipation of calls that might be received in response to these messages, several tools were developed. The following table shows the tools that were developed and their intended use.

Step 6.2 Execute and manage intervention components.

Local WIC staff managed the interventions at the state and local levels. Best Start worked closely with the 10 pilot sites during the campaign’s first 18 months by providing technical assistance with marketing and team and consensus building.

State Example: Iowa

1998 Media Campaign
The campaign in 1998 focused on Des Moines, Council Bluffs, and Davenport for radio, television and billboard ads. Des Moines was chosen for its population density. The Council Bluffs/Omaha and Davenport markets were chosen because they included the largest remaining cities not part of the 1997 campaign. Counties covered in 1998 served about 53 percent of the WIC caseload.

Radio ads ran for 2 weeks (March 16 – 29) for a total of 212 spots. A total of 349 television ads were aired over a 3 to 6 week period (March 16 – April 26) depending on the media market. Billboards were displayed for four weeks (late March to late April) with 38 boards in use. The media budget for 1998 was $90,000.

Newspaper public service announcements (requiring no payment for publication), developed by Best Start Social Marketing, were sent to all the weekly and daily papers in the state for publication during World Breastfeeding Week in August, 1998. However, fewer than 20 of the PSAs were used due to newspapers’ dwindling PSA budgets.

State Example: Mississippi

Campaign Implementation
With the country’s lowest breastfeeding rates at the start of the campaign, the Mississippi WIC Program developed a comprehensive plan to implement the Loving Support campaign. The plan addressed specific needs within the state, including the identified barriers to breastfeeding (embarrassment, time/social constraints, lack of social support, and nursing skills/nourishment). The campaign became part of an ongoing state program of breastfeeding promotion and support.

Mississippi’s Loving Support program included five major components. All components were implemented in seven of the state’s public health districts. Only one component (public awareness) was implemented in the remaining two public health districts.

Staff Communication: Planners provided orientations to decision-makers and staff in 48 local health departments and nine community health centers. Breastfeeding management training was also provided to clinic staff. The orientation included brainstorming on ways to make the clinic environment more breastfeeding-friendly, which resulted in the establishment of nursing rooms and supportive activities. Staff Support Kits and Loving Support banners, posters, pamphlets, and signs were delivered to all WIC clinics. Newsletters updated staff on the project.

Patient and family education: Campaign materials were widely used. Pamphlets were distributed to WIC pregnant and breastfeeding clients. Flyers were inserted in WIC food packages. Coloring contest sheets for children were posted in the community. Posters were hung in WIC clinics and other community settings. WIC peer counselors and lactation specialists were trained in the Best Start Three-Step Counseling Strategy and hosted special activities, including baby showers, receptions for breastfeeding mothers, activities for children, and classes for family members. A video, Breastfeeding: Another Way of Saying I Love You, was also developed to reinforce the Loving Support message and address barriers. The video was effective in improving WIC clients’ perceptions of breastfeeding. The WIC program expanded the breast pump loan program to provide personal mini electric pumps to working mothers.

Public Awareness: The public awareness campaign included statewide Loving Support television and radio spots, newspaper ads in community papers, billboards in high population areas, and displays at malls, fairs, and other community events. WIC lactation specialists and peer counselors visited media channels, delivered press packets, and encouraged feature articles on breastfeeding. Media activities continued annually. (This was the only program component delivered in the nonintervention health districts.)

Health Professional Outreach: Hospitals and health professionals received mailings announcing the project and articles for state medical publications and hospital newsletters. The Breastfeeding Resource Guide was distributed to providers. A training program, How to Support a Breastfeeding Mother, was developed as part of a Breastfeeding Clinic Environment Project funded by a USDA Special Project Grant. Fourteen WIC clinics participated in this project and received mini-grants to make their environment more breastfeeding-friendly and offered breastfeeding training to all their staff. The clinic environment project was effective in improving breastfeeding knowledge, attitudes, and practices of clinic staff (4). The training was then provided to more than 1,400 staff in 34 of the state’s 52 delivering hospitals.

Community Outreach: Community-based activities included visits to malls and businesses to encourage the opening of nursing rooms, breastfeeding fashion shows at the mall, and breastfeeding activities at the local zoo, ballpark, and department stores. Staff developed training programs for childcare centers, worksites, and churches In addition, staff helped organize the Mississippi Breastfeeding Coalition, which worked in collaboration with WIC to develop a community-based “Breastfeeding-Friendly Site Project” to recognize churches, businesses, childcare centers, and clinics providing breastfeeding support.

Step 6.3 Execute and manage the monitoring and evaluation plans.

While Best Start provided technical assistance in program implementation, monitoring and evaluation, the individual sites were responsible for monitoring and evaluating their own programs. Data from the Ross Six-Month Infant Survey/Mother’s Survey show that in the states implementing Loving Support, breastfeeding initiation and duration is increasing. Overall, the data from Mississippi, the only state with a quasi-experimental evaluation design, indicates that Loving Support effectively increased knowledge of and positive attitudes towards breastfeeding as well as increased the initiation and the duration of breastfeeding.

For a sample of a state-based evaluation, see Iowa’s initiative and evaluation report.

Step 6.4 Modify intervention activities, as feedback indicates.

Reports from state WIC agencies identified two important problems. Resolution of these problems required Best State to return to the beginning of the social marketing process and application of the same steps, this time with the assistance of a large network of program partners.

First, even before the program was fully implemented, it became clear that efforts to reach an important secondary audience—prenatal health care providers working outside the WIC setting—were unlikely to succeed without materials targeted to their special needs. To fill this gap, the Health and Services Administration’s Maternal and Child Health Bureau (HRSA/MCHB) funded the Physicians and Health Care Providers Breastfeeding Promotion Kit to help these providers participate in the program. Research conducted with this group was used to develop marketing concepts and subsequent materials for pretesting and revision. The completed kit included: program information and materials that allowed health providers to participate in the program; patient education materials, outreach assistance resources to promote breastfeeding and help women manage lactation more effectively. MCHB distributed copies of the kit to MCH-funded programs, a wide variety of professional organizations (e.g., American College of Obstetricians and Gynecologists and American Academy of Pediatrics) and other MCH-targeted populations.

The second problem was the program’s failure to reach Native Americans and other ethnic groups not originally targeted. To address this problem, USDA contracted with Best Start Social Marketing to develop and distribute material interventions for Native American populations.

An important goal in social marketing programs is sustainability of program initiatives. To achieve its optimal impact, a social marketing project such as the National WIC Breastfeeding Promotion Program, requires ongoing and long-term implementation, evaluation and adjustment. Two aspects of program implementation have helped institutionalize the program in ways that make it more easily sustained:

First, although USDA funded the program development, state WIC programs purchased program materials and supported state and local breastfeeding promotion activities from recurring funds in their budgets. This strategy encouraged states to take a greater role in the process of implementation and to see this as a continuation of their existing efforts.

Second, Best Start was designated as the distribution and clearinghouse for program materials, making it easier for a wide variety of organizations to participate in the National WIC Breastfeeding Promotion Program and freeing the program from federal funding cycles and other limitations. Additionally, Best Start continues to provide technical assistance to state and local programs throughout the U.S. By 2003, more than 72 of 88 state, intertribal, or territorial organizations of the WIC program were using the campaign materials as part of their breastfeeding promotion efforts.

Best Start published the program strategy and the formative research findings in a peer-reviewed journal (Lindenberger & Bryant, 2000).

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