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A literature review of global social marketing campaigns to improve breastfeeding rates

21 May 2021

Ayelet Levi-Brown and David Pontin carried out a literature review to appraise a social marketing campaign that raised breastfeeding rates. Health visitors can use this model to scrutinise local campaigns.

What factors influence mothers in the UK and Ireland to wean their infants before six months of age?

Authors:

Ayelet Levi-Brown, health visitor at Cardiff and Vale University Health Board. 

Professor David Pontin, Aneurin Bevan chair of community health, Faculty of Life Science & Education, University of South Wales.


Research summary

  • Health visitors need a robust social marketing campaign to break down social barriers, and upscale infrastructure to support mothers to achieve breastfeeding goals.
  • This literature review examines how a social marketing campaign could support health visitors to increase local breastfeeding rates.
  • Social marketing benchmark criteria – essential to a social marketing campaign – include retraining health workers, delivering coherent health messages and an all-media platform advertising campaign.
  • The UK government has overlooked the social marketing of breastfeeding as an intervention to improve rates, but now evidence from the developing world has been examined, and some campaigns are emerging in Scotland and Wales. 
  • Lessons from the LINKAGES campaign – which has been successful in Madagascar, Bolivia and Ghana – should be implemented for those campaigns to succeed.
  • The most successful models have used existing resources and innovation to ensure cost-effective use of assets.

Normalising breastfeeding is everybody’s responsibility. Health visitors need a robust social marketing campaign to help them break down social barriers, and upscale infrastructure to support mothers to achieve their breastfeeding goals (Unicef, 2016). This literature review found a social marketing model (the LINKAGES campaign) that worked well and improved breastfeeding rates in three countries. The interventions used in the social marketing campaign have been critiqued and evaluated to identify what factors contributed to its success. Social marketing benchmark criteria are an essential part of a social marketing campaign (Andreasen, 2002). They include retraining health workers, delivering coherent health messages and an all-media platform advertising campaign.

Following the success of the social marketing model worldwide, Yale and Kent universities (Kendall, 2018; Pérez-Escamilla et al, 2018) developed the model into a global campaign, Becoming Breastfeeding Friendly. This is currently being implemented by the Scottish and Welsh governments (Scottish Government, 2019; Welsh Government, 2019). The social marketing model suggests that a good campaign needs to be a long-term study that incorporates several hospital and community interventions (Quinn et al, 2005). Social marketing is a complex process. It is important that studies identifying as social marketing adopt the social marketing benchmark criteria as a behaviour change model (Andreasen, 2002). Social marketing when used to its full extent offers the potential to increase rates of breastfeeding.


Introduction

Stage one of this literature review took place in 2015 with the aim of identifying social marketing campaigns that set out to raise breastfeeding rates. One social marketing campaign stood out from the others as it was published in great detail. It was a longitudinal study, and its sample was a meaningful one of 10.5 million people. Stage two of the review took place in 2020 and looked at current UK progress and whether the devolved governments and public health services have learnt from scaling-up efforts around the globe.

The review compares the campaigns’ strategies and messages in addressing barriers to breastfeeding in the social/political/health agenda. This is vital as parents are influenced by many factors before they meet HVs (Unicef, 2013). The review used the social marketing benchmark as guidance for a good campaign as it addresses behaviour change. Barriers to breastfeeding can be at the individual level (Hamlyn et al, 2002) and also the social, cultural and socioeconomic level (Dyson et al, 2006; Renfrew, 2006; Rempel, 2004; Nicoll and Williams, 2002). The multifactorial nature of the barriers to successful breastfeeding makes it a complex task to untangle.

Important campaigns such as Unicef’s Call to Action (2016) and 1001 Critical Days (Burstow et al, 2014) highlight the greatest barriers to optimal breastfeeding in developed countries today. In the UK there is a need for more commitment from the devolved governments, and for investment in breastfeeding interventions. Call for Action identifies social pressure and lack of support as the main barriers to women choosing to breastfeed. This diverts the responsibility from mothers to political forces (Rollins et al, 2016). The debate about barriers and interventions sometimes shifts the focus away from the lack of governmental motivation and commitment; for example, at an event to support breastfeeding only 35 Westminster MPs attended out of 650 (Unicef, 2017). 


Study aim

Breastfeeding is the most bioavailable, eco-friendly, effective and economic nutrition for human beings (Wambach and Riordan, 2015). In the past century, there was a significant decline in the number of women who achieved their breastfeeding goal. As a result, globally, 600,000 babies die and $340bn annually is lost (Walter et al, 2019). The UK has one of the lowest rates in the world of exclusive breastfeeding at six months (Victora et al, 2016). Breastfeeding has been high on the UK public health agenda; however, finding the right intervention to reverse the low rates has been a struggle around the globe. 

Unicef breastfeeding standards (2013) underpin HV support for mothers to breastfeed successfully. The Healthy Child Wales Programme (Welsh Government, 2016) places HVs in Wales in a central position to regularly visit mothers at home before and after birth to give vital information and practical advice on breastfeeding, building strong relationships with their babies, and give mothers emotional support as they adjust to their role (NMC, 2004). NICE (2021) guidance states that health professionals who support mothers should use the Baby Friendly Initiative as a minimum standard and implement a well evaluated programme. Many studies show that health professionals alone can’t increase population breastfeeding rates where breastfeeding is no longer seen as the norm (Theurich et al, 2019; Rollins et al, 2016; WHO, 2014).

This literature review examines how a social marketing campaign could support HVs to increase breastfeeding rates in their locality. Social marketing campaigns have been effective at reducing the rates of smoking, increasing awareness and protection against HIV, and highlighting and achieving other health and safety goals. 


Method

Stage one of the literature review took place in 2015. It involved searching psychology, business and health literature databases, as the social marketing of breastfeeding is a topic found in these areas (Schmidt, 2013). Therefore, the following databases were searched: CINAHL, MEDLINE, PubMed, PsycInfo, ASSIA, Business Source Premier, MIDIRS and Ovid (see Table 1).

 

Table 1: Databases searched and keywords used 

Table 1

 

The search terms used were ‘breastfeeding’, ‘marketing’, ‘social marketing’, ‘campaign’, ‘health promotion’,’ public health’ and ‘strategies’. Such a large search yielded thousands of articles. Scanning the titles revealed that most of them did not relate directly to the review focus. The search terms were then limited to breastfeeding (‘breast feeding’, ‘breastfeeding’ and ‘breast-feeding’) and social marketing (‘social marketing’, and ‘social and marketing’). Only a few articles were excluded because they were in languages other than English, or older than 19 years. 

The refined search yielded more relevant results for breastfeeding marketing campaigns and returned hundreds of articles. Duplicates (due to using multiple databases) were discarded, and after reading through the titles first, and reading the abstracts only if they directly studied social marketing of breastfeeding, a selection process was established. Seven articles were finally selected for the review, but only three (only one of which was UK-based) examined a social marketing campaign that followed the National Social Marketing Centre criteria with rigour. The remaining studies followed parts of a campaign or concentrated on a very small group of participants.

At stage two, the same databases were searched with the same keywords but limiting the time period from 2015 to 2020. The search was widened, and references followed up in the lactation literature and social media forums, discussing the issue with experts in the field. Some useful articles and studies highlighted current efforts around the globe to upscale breastfeeding promotion efforts. The focus remained on the UK, and the Becoming Breastfeeding Friendly campaigns in Scotland and Wales were selected.


Results

In stage one, the LINKAGES social marketing campaign stood out as it yielded significant results in Madagascar, Bolivia and Ghana (see Table 2). It was highly successful because it applied the recommended social marketing benchmark criteria to all areas of critical influence: media, health organisations, education, counselling and businesses. It was invested in by governments and aid agencies. The long-term study had commitment from all stakeholders for 10 years. Stage two of the literature review found that since LINKAGES took place, projects all around the globe had implemented its recommendations, and the term ‘social marketing’ had changed to ‘scaling up’. One of the main messages from the LINKAGES campaign was ‘doable actions’.

Table 2: Results of social marketing campaign in Ghana, Bolivia and Madagascar (Quinn et al 2005)

 

Stage two looked at new developments. It seems there is not one blueprint in Europe that informs government strategy to upscale breastfeeding social marketing campaigns. Owing to inconsistent funding in Sweden, Croatia and Spain, there was inconsistent support for breastfeeding and poorer outcomes. In the UK, efforts have been made to upscale breastfeeding support in all areas. Scotland has initiated the Becoming Baby Friendly programme which is based on the scaling-up model (Pérez-Escamilla et al, 2012). It is utilising the Breastfeeding Gear Model (eight essential elements to scaling up policies and programmes – see Figure 1) and scoring 54 benchmark criteria; however, it is not based on the social marketing benchmark criteria. This model has been adapted by Kent and Yale universities and scrutinised for use (Kendall et al, 2017). 

 

 

Wales has launched the All-Wales breastfeeding five-year action plan to have more babies breastfed for longer (Welsh Government, 2019). It is also based on the Kent/Yale model, but it lacks commitment by not having a dedicated social marketing campaign for breastfeeding, and relies on information-giving and targeting mothers alone. It is also using a campaign that primarily promotes healthy nutrition (‘10 steps to a healthy weight programme’). It appears that the Welsh Government is not committed to the idea of a social marketing campaign, because it is still looking for evidence that such campaigns can change behaviour. However, the evidence clearly shows how a social marketing campaign raises the rates of breastfeeding (Quinn et al, 2005) – see Table 3.

Table 3: Linkages elements of behaviour change (Quinn et al, 2005) based on the social marketing criteria

Table 3


Discussion

Stage two of the literature search showed that, since 2010, extensive scaling-up campaigns have been introduced in 28 countries, with varying degrees of success. Success in countries with prolonged investment and commitment (eg Brazil) was greater than in countries with short-term and partial investment (eg Mexico) (Pérez-Escamilla et al, 2012). Education, counselling, and advertising were key factors in this success (see Table 4). 

Table 4: The impact of reduced commitment and reduced efforts (Pérez-Escamilla et al, 2012)

 

In Europe, each country has used a different mix of interventions, investment was lacking, messages were inconsistent, and results were unreliable (Theurich et al, 2019) – see Table 5. Scotland and Wales are adapting the Yale Becoming Breastfeeding Friendly campaign, which is an example of the Breastfeeding Gear Model (Pérez-Escamilla et al, 2012), in partnership with the Centre for Health Services Studies at Kent University (Kendall et al, 2017).

Table 5: Inconsistent usage of resources in Europe (Theurich et al, 2019)


Recommendations

UK HVs need a social marketing campaign to help them support the breastfeeding dyad and break down barriers to successful breastfeeding. This will help bring about a sustainable culture that understands, supports and nurtures mothers and babies. The benefits and gains of breastfeeding are well known; however, the knowledge and motivation to invest and push all arenas in the direction that a global strategy recommends are not yet happening. 

A study that evaluates a robust social marketing campaign such as LINKAGES that has been successful in the developing world is needed in the UK. Some actions and steps have been implemented in the past few years in Scotland and Wales to follow these principles. However, full commitment from devolved governments to invest in all geographical areas and sectors to follow the recommended gears model and benchmark is still needed. A recent Unicef review of Ghana (Unicef, 2018) shows that lapsing into retrieving funds from initiatives and interventions can result in inconsistent messages and put health professionals in the difficult position of delivering a programme that seems incoherent against national priorities.

Social marketing principles promote coherent and homogenous messages across all sectors so that breastfeeding may win in the competitive market of infant feeding. The most successful campaigns used existing resources and innovation to ensure cost-effective use of assets (Forrestal et al, 2015; Sheriff and Hall, 2011; Quinn et al, 2005).


Conclusion

For years, the social marketing of breastfeeding as an intervention to improve rates has been overlooked by the UK government. Now that evidence from the developing world has been examined, some campaigns are emerging in Scotland and Wales. It is paramount that lessons from the successful LINKAGES social marketing campaign should be implemented for those campaigns to succeed (see Table 6). There must be commitment for continued investment in research, evaluation, professional upskilling and an all-media advertising campaign. Neglecting to learn from the evidence will fail mothers, babies and professionals who rely on these interventions to succeed. 

Table 6: Elements identified at the LINKAGES project (Quinn et al, 2005) and adapted to the Yale University and York University ‘gear model’ (Kendall 2019, Pérez-Escamilla et al, 2018)

 

More importantly, if HVs want to be an active part of scrutinising a local government campaign, they need to understand the principles of a successful social marketing model. 


References

Andreasen AR. (2002) Marketing social marketing in the social change marketplace. Journal of Public Policy Marketing 21(1): 3-13.

Burstow P, Field F, Leadsom A, Lucas C. (2014 ) The 1,001 critical days: the importance of the conception to age two period: a cross-party manifesto. See: bit.ly/Burstow_1001 (accessed 28 April 2021).

Dyson L, Renfrew MJ, McFadden A et al. (2006) Promotion of breastfeeding initiation and duration. Evidence into practice briefing. See: bit.ly/Dyson_promotion (accessed 26 April 2021).

Forrestal S, Briefel R, Mabli J. (2015) WIC Breastfeeding policy inventory. See: bit.ly/Forrestal_WIC (accessed 26 April 2021).

Hamlyn B, Brooker S, Oleinikova K et al. (2002) Infant feeding 2000. See: bit.ly/Hamlyn_infant_feeding (accessed 26 April 2021). 

Kendall S. (2018) Becoming Breastfeeding Friendly. See: bit.ly/Kendall_BBF (accessed 26 April 2021).

Kendall S, Merritt R, Eida T. (2017) Becoming Breastfeeding Friendly. A guide to global scale up. Centre for Health Service Studies: University of Kent. See: bit.ly/Kendall_BBF_Britain (accessed 26 April 2021).

NICE. (2021) Postnatal care. See: nice.org.uk/guidance/ng194 (accessed 26 April 2021).

Nicoll A, Williams A. (2002) Breast feeding. Archives of Disease in Childhood 87: 91-2.

NMC. (2004) Standards of proficiency for specialist community public health nurses. See: bit.ly/NMC_standards_proficiency (accessed 26 April 2021). 

Pérez-Escamilla R, Hromi-Fiedler AJ, Gubert MB et al. (2018) Becoming Breastfeeding Friendly Index: development and application for scaling-up breastfeeding programmes globally. Maternal and Child Nutrition 14(3): e12596.

Pérez-Escamilla R, Curry L, Minhas D et al. (2012) Scaling up breastfeeding promotion programs in low and middle-income countries: the ‘breastfeeding gear’ model. Advances in Nutrition 3(6): 790-800.

Quinn V, Guyon AB, Schubert JW, Stone-Jimenez M, Hainsworth MD, Martin LH. (2005) Improving breastfeeding practices on a broad scale at the community level: success stories from Africa and Latin America. Journal of Human Lactation 21(3): 345-54.

Rempel LA. (2004) Factors influencing the breastfeeding decisions of long-term breastfeeders. Journal of Human Lactation 20(3): 306-18.

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Sherriff N, Hall, V. (2011) Engaging and supporting fathers to promote breastfeeding: a new role for health visitors? Scandinavian Journal of Caring Sciences 25(3): 467-75.

Theurich MA, Davanzo R, Busck-Rasmussen M et al. (2019) Breastfeeding rates and programs in Europe: a survey of 11 national breastfeeding committees and representatives. Journal of Pediatric Gastroenterology and Nutrition 68(3): 400-7.

Unicef. (2018) Ghana: infant and young child nutrition. See: bit.ly/Unicef_Ghana_nutrition (accessed 28 April 2021).

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Walters D, Phan L, Mathisen R.  (2019) The cost of not breastfeeding: global results from a new tool. Health Policy and Planning 34(6): 407-17.

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