National WIC Breastfeeding Promotion Project
National WIC Breastfeeding Promotion Project repositioned the traditional health benefits of breastfeeding to emphasize a new product benefit - familiar bonding from birth. The emotional price of breastfeeding was identified as embarassment and conflicts with active lifestyles. To reduce these prices, a counseling program was developed to help mothers work through individual constraints. The place strategy targeted hospital environments as well as homes. It focussed on key intermediaries such as professional associations. Media as well as grassroots advocacy comprised the bulk of the promotion strategy with media stressing a congratulatory tone and communicated through family spokespersons. Breastfeeding rates in hospitals went from 57.8% to 65.1% after a year of the programs operation.
Though there has not yet been a national study conducted to evaluate the results of the National WIC Breastfeeding Promotion Program in each of the ten pilot states, a summative evaluation of the program's impact in the State of Iowa was completed, and several other pilot states are currently assessing their individual campaigns. Preliminary results from the Iowa study show evidence of the program's success in both breastfeeding rates and changed attitude and awareness toward breastfeeding. The Iowa evaluation was based on the Ross Six Months Mothers' Infant Feeding Survey and a separate mail survey of WIC participants immediately before the campaign and four months afterward.
Increased breastfeeding rates: Based on the data from the Ross Breastfeeding 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 the public information component of the National WIC Breastfeeding Promotion Project's "Loving Support Campaign" was to encourage the spouses, relatives, and friends of pregnant women to provide support for breastfeeding. Results of the survey indicated that support for breastfeeding increased in every relationship category.
The WIC Program
Created in 1972, WIC (the Special Supplemental Nutrition Program for Women, Infants, and Children), is a federal program under the USDA designed to provide nutrition education, supplementary foods, and referrals for health and social services to economically disadvantaged women who are pregnant, postpartum, or are caring for infants and children under five. Administered in all of the fifty-five U.S. states and territories and in 33 Indian tribal organizations (ITOs), the WIC program is credited with reducing infant mortality and morbidity, improving the health outcomes of its participants, and reducing health care costs. WIC operates through a network of 88 state agencies and 2,200 local agencies, and provides services to more than 7.4 million program participants per month in 10,000 clinic locations.
National WIC Breastfeeding Promotion Project
Among its many programs and services, the WIC provides support, education, and promotion for breastfeeding. In 1989, Congress began designating a specific portion of each state's WIC budget allocation to be used exclusively for the promotion and support of breastfeeding among its participants. More than five years after the government started supporting promotional efforts, however, breastfeeding rates among participants of the WIC program were found to be considerably less than segments of the population in higher socio-economic levels. During this time, 59.7% of infants in the United States were breastfed at birth and 21.6% at six months postpartum compared to only 46.6% and 12.7% respectively among infants in the WIC program.
In September of 1995, Best Start Social Marketing, a non-profit social marketing organization based in Tampa, Florida, submitted an unsolicited proposal to the United States Department of Agriculture's Food and Nutrition Service (FNS) to request funding and assistance in developing a comprehensive, national breastfeeding promotional campaign through the WIC.
During the fall of that year, Best Start staff, together with representatives of the FNS and members of the WIC's breastfeeding promotion consortium, instituted the National WIC Breastfeeding Promotion Project and outlined the program's objectives, targeted populations, and pilot locations. The four goals that were established for the program included: increasing breastfeeding initiation rates; increasing the rate of breastfeeding duration among WIC participants; increasing referrals to the WIC program for breastfeeding support; and increasing the general public's knowledge and support for breastfeeding.
In order to maximize the impact for each of the program's objectives, the targeted population for the campaign was organized into three separate audiences. The primary target audience was composed of pregnant Anglo, African, and Hispanic American women who were either enrolled as WIC participants or who met the income eligibility requirements (annual income below 185% of the US poverty guidelines). The secondary audience consisted of individuals who might influence the primary target population, such as the mothers, husbands and boyfriends of pregnant women, prenatal health care providers, and WIC staff. The general public was also included as the tertiary audience in order to affect change in the established social norms and prevailing public perception regarding breastfeeding.
The campaign planners chose ten pilot states to conduct research and demonstrate the initial WIC Breastfeeding Promotion Project. The selected states included: Arkansas, California, the Chickasaw Nation, Iowa, Mississippi, Nevada, New Jersey, New York, Ohio, and West Virginia.
With the parameters of the program established, formal development of the campaign began with the collection of consumer information needed to segment the population, identify important factors limiting breastfeeding, and to define the methodology to effectively promote breastfeeding. Some of the important research objectives included: (1) identifying the perception of breastfeeding and bottle-feeding held by the primary and secondary target groups; (2) identifying the factors that motivate and deter the primary target group from breastfeeding and the secondary and tertiary target groups from encouraging women to breastfeed; and (3) identifying effective information channels and spokespersons for promoting breastfeeding among WIC participants.
Between December of 1995 and May of 1996 qualitative and quantitative research data was collected from the ten pilot states through a series of observations, interviews (personal and telephone), surveys, and focus groups using the primary and secondary target audiences. The qualitative data that was collected was then used to identify other potential research areas and to help develop a comprehensive survey instrument. This 53-item questionnaire was administered to 292 WIC participants in twelve prenatal clinics representing a diverse group of ethnicities, a variety of caseload sizes, and a mixture of urban, suburban, and rural communities.
Marketing Plan Development
Results from the formative research that was conducted were used to develop a marketing plan for the WIC Breastfeeding Promotion Program. With the broad set of data collected from the surveys and interviews, program strategists established detailed objectives and goals for the project, the specific audiences and behaviors to be targeted, and the strategies for addressing the factors associated with promoting breastfeeding. The marketing plan was created using the conceptual framework of the 4 Ps (product, price, place, and promotion), and included a specific strategy for each area to distinguish the product (breastfeeding) from its competition (formula bottle-feeding).
The "product strategy" defined breastfeeding by describing both the health and the emotional benefits, and by emphasizing the special, loving bond the mother will share with her child. In contrast to the traditional public health approach of addressing breastfeeding as a medical health decision, breastfeeding was repositioned as a way for a family to establish a special relationship with their child from the very onset of its life. With the slogan "Loving Support Makes Breastfeeding Work," program materials were created to explain the supportive role family members and friends can play in encouraging a new mother to breastfeed.
Another key component of the marketing plan was its "pricing strategy," which entailed minimizing or eliminating the deterrents or "perceived costs" of breastfeeding for new and prospective mothers. The strategy called for targeting the women who doubted their breastfeeding ability or who felt breastfeeding was embarrassing or conflicted with their active lives and relationships. To address these perceived costs, public education materials were created for each targeted group of women, and a counseling program was developed for health care providers to assist them in identifying common misperceptions and helping mothers work through them.
Placement and Promotion Strategy
"Placement strategy" for the program focused on reaching the various environments in which mothers and their friends and relatives obtain infant care information. Education materials were developed to reach mothers and relatives in their homes; and together with the World Health Organization and the UN Children's Fund, Best Start program staff took steps to make hospital environments more supportive of breastfeeding mothers. Partnerships with other breastfeeding promotion organizations and professional associations were established through the FNS' Breastfeeding Promotion Consortium to further institutionalize and disseminate the program.
The program's "Promotion Strategy" entailed promoting the WIC breastfeeding project using a variety of methods and through a broad range of outlets, including: legislative, policy, and organizational development; media and grassroots advocacy; professional training and education, peer counselor programs, and direct marketing and advertising. The strategy also called for developing a campaign message that would use emotional appeal, convey a positive, congratulatory tone, and would be communicated through family spokespersons.
Program Launch and Implementation
During the summer and fall of 1996, Best Start brought together the campaign's strategies and concepts, contracted with an advertising agency, and finalized the structuring of the program. Pretesting of all of the campaign's messages and materials was also conducted in several pilot states during this time to determine which marketing concepts were most effective in reaching the target audiences. When the program and campaign strategies were finalized, the initial set of marketing and media materials were developed and included: three bilingual (English and Spanish) television commercials, three bilingual radio commercials, outdoor billboards, nine bilingual posters, nine bilingual educational pamphlets, and several information and resource guides and WIC staff kits.
To ensure effective coordination and implementation of the program's many elements at the state and local levels, a comprehensive training conference was held for WIC staff members from the 10 pilot states. The conference sessions included presentations and seminars covering a broad range of topics including: research results and their implications for breastfeeding promotion; working with the media and utilizing the marketing/media package; community and team building; and nontraditional communication methods. Additional breakout sessions allowed for skill development and team planning; and by the conclusion of the conference, WIC staff 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). As part of the program's implementation plan, Best Start Social Marketing 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.
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