A social marketing approach to breast-feeding in public places and at work breast-feeding in public places

Terry Blair-Stevens and Sarah Cork outline the findings of a social marketing project designed to ensure that policies, practices and facilities support breast-feeding in public and at work

Terry Blair-Stevens BSc MSc Applied Psychology MSc Public Health Public Health Programme Manager Brighton and Hove City Teaching Primary Care Trust and Brighton and Hove City CouncilSarah Cork BA(Hons)
Managing Director, Brilliant Futures Senior Lecturer, School of Business, University of Brighton
ABSTRACT
A public health project is described which used social marketing philosophy and techniques to find out how to help facilitate breast-feeding in public places and for mothers returning to work.As part of a strategy to increase local breast-feeding rates, Brighton and Hove Healthy City Partnership, representing the local Primary Care Trust, City Council and the business, academic and voluntary sectors, worked with a social marketing consultancy. The consultancy carried out a literature review and qualitative research that used creative engagement methods to consult with local people. The consultations were with key stakeholders, mothers, and groups traditionally less interested in the subject of breast-feeding, such as employers, elderly people, teenage boys, and fathers. The qualitative research generated in-depth insight and soundly-based, practical recommendations for facilitating breast-feeding. The social marketing approach helped to establish that any ensuing policies and practices would be acceptable to a wide range of the local population. Journal of Family Health Care 2008; 18(5): 167-170

Key points

_ To improve local breast-feeding rates, Brighton and Hove Primary Care Trust (PCT) and City Council worked with a social marketing consultancy on a project to make it easier for mothers to breast-feed in public places and when returning to work
_ The project team used a strategic social marketing approach to gather insight that would be used to drive change in policies, services, attitudes and behaviour
_ A consultation was held which aimed to get local people to "have your say, your way"
_ Creative research methods were used to ensure active representation from a wide-ranging spread of the population. A targeted approach was used, using specialists in engaging with hard-to-reach audiences
_ Results suggested that there is a gap between the perceived acceptance of breast-feeding in public and what is accepted in reality
_ Little has been done to tackle social and cultural views of breast-feeding in public, and changes will be required to make breast-feeding the accepted feeding norm
_ Using the project's results and recommendations, Brighton and Hove PCT and City Council will develop policies, facilities and practices to enable mothers of all ages and socio-economic groups to breast-feed in public and at work if they wish
_ Encouraging respect and understanding for others was identified as a key to success, e.g. by educating the wider population, including employers, businesses and school pupils about the benefits and normality of breast-feeding and the need to support it, and advising mothers on breast-feeding "discreetly"

Introduction
 

Part of the Government's commitment to reduce health inequalities is to increase breast-feeding rates, especially among women from disadvantaged groups1. In Brighton and Hove the local breast-feeding target is to increase the rate of breast-feeding by 2% - measured by the numbers of mothers breast-feeding at six weeks after the baby's birth - with a proportionately higher increase in disadvantaged areas2.
This article describes a social marketing project designed to try to improve breast-feeding rates by making it easier for women to breast-feed in public and when returning to work. It explains the methods used for the research, the key findings and the recommendations for the next steps. It is hoped that the initiative will help midwives, health visitors and other health and local authority professionals to develop projects to support breast-feeding. We want mothers to feel able to breast-feed their babies in our city's workplaces and public spaces - including our famous pier! (Figure 1).

Breast-feeding rates in Brighton and Hove  

In 2007/08, 80.3% of mothers, for whom feeding status was recorded, initiated breast-feeding3 in the city, a figure that fell short of the 84.5% planned target for that year. In the same year, of those mothers for whom feeding status at six weeks was known, only 49% were breast-feeding (exclusive and mixed feeding)*. At the time of the project, Brighton and Hove was one of 88 English local authorities receiving Neighbourhood Renewal Funding to tackle deprivation and improve opportunities in disadvantaged areas identified by low scoring on the Index of Multiple Deprivation (IMD). The prevalence of initiation of breast-feeding varies between neighbourhoods from 28% to 80.6%.

The social marketing project  

As part of local efforts to improve local breastfeeding rates, Brighton and Hove's Healthy City Partnership developed a project to make it easier for mothers from all age groups and socioeconomic backgrounds to breast-feed in public and when returning to work. Difficulties in breastfeeding away from the home or at work were identified in the national Infant Feeding Survey 20054 as actual or perceived barriers to breastfeeding, especially for younger mothers and those from lower socio-economic groups. Brighton and Hove's Healthy City Partnership consists of representatives from Brighton and Hove Primary Care Trust (PCT), the City Council, local neighbourhood and community groups and voluntary organisations, and the local business and academic sectors. The aim of the partnership is to work together to steer efforts to make the city a healthy place for everyone. For the breastfeeding project, the Healthy City Partnership worked with a social marketing consultancy, Brilliant Futures.
We adopted a social marketing, insight-driven approach, i.e. one based on gaining insight into what moves and motivates mothers and other members of the public (see Box). The NHS actively promotes the concept of social marketing in public health and we considered that by adopting this approach we were more likely to engage effectively with the people of Brighton and Hove and produce policies that would be relevant and acceptable to them.

breast-feeding in publicConsultation and research

In addition to traditional research methods, innovative techniques were used to find out what local people think and feel about breast-feeding. We included groups that have traditionally been hard to interest in the subject, such as employers, elderly people, teenage boys, and fathers. We also ensured that we achieved an ethnic mix within all the groups targeted according to their present behaviour and attitudes towards breast-feeding. The research findings highlighted the different attitudes that exist towards breast-feeding in public and confirmed the national statistics4 that younger mothers from working class backgrounds are less likely to breast-feed than their older, more middleclass and professional counterparts. Shops and shopping malls were cited as not providing enough appropriate and comfortable places to breast-feed. As one young mother said: "Who wants to eat in a toilet?" Employers were criticised for not providing places at work where breast milk could be expressed and stored. The marketing consultancy's insight-driven social marketing approach (see Box), which used secondary and primary research across various literature sources and differing audiences, has helped the Healthy City Partnership to identify:
_ barriers to breast-feeding
_ the benefits sought by mothers and partners
_ how Brighton and Hove can provide an environment that will encourage and support breast-feeding in public and when mothers return to work. As a result of the research, we are in a better position to develop policies, practices and facilities which will respond to the real needs of people living and working in the city.

The approach breast-feeding in public places F2

The social marketing consultancy used a strategic social marketing approach to gather understanding and insight that would be used to drive change in policies, services, attitudes and ultimately in behaviour. A targeted approach was adopted, working in partnership with experts who specialise in engaging with hard-to-reach audiences.
The project team decided to make the approach part of a wider local consultation called "Best for Babies", which encouraged the public to have their say on making Brighton and Hove a better and more baby-friendly place for babies to grow up. This was launched at an event at Brighton's landmark Dome (Figure 2). The consultation engaged all parts of the population in the first instance, before going further with particular targeted groups into the area of breast-feeding in public and when returning to work.

Strategy for the consultation

Our strategy in holding the consultation was:
_ To use a mix of research methods targeted at different audiences and with the objective of achieving maximum engagement with them
_ To consult and work with local partners and other projects to ensure that our target audiences were not being "over-consulted". We checked that we were not in competition with other activities that might get in the way of the public engaging with us and our messages
_ To tie in with another of the PCT's breastfeeding projects to ensure that we communicated a consistent message to our target audiences
_ To create a transparent, dynamic platform (including meetings and websites) for views, attitudes and ideas to be shared. This encouraged an ongoing live debate and generated recommendations based on insight into the public's views
_ Used creative and innovative research methods to maximise engagement with our target audience and generate interest from the local media.

Research methods  

In addition to a full literature review, we used different qualitative research methods to appeal to different audiences and ensure that we reached those who might be hard to engage. The key focus of the consultation was to ensure that residents were invited to "have your say, your way". Table 1 shows some of the qualitative research methods used.breast-feeding in public places T1

Key findings from the literature review

A time-limited review of international literature was undertaken, which consolidated the key findings on breast-feeding in public and when returning to work. This shaped the online survey and other engagement techniques. Key data was sourced from the National Social Marketing Centre (NSMC), Infant Feeding Survey 20054, Brighton and Hove Breastfeeding Scoping Report 2007, Improving Infant and Young Child Feeding Practices in Brighton and Hove, academic sources, media and online sources.
The literature review revealed that while there is a large amount of research into breast-feeding generally, there is little existing research into breast-feeding in public and when returning to work. However, key themes emerged from the literature reviews, and we shall be exploring these further in a local context. While the literature review revealed that the public seem to find breast-feeding in public acceptable, our primary research suggests there is a gap between what is perceived as acceptable and what is accepted in reality.

Key findings from the qualitative research

Key themes emerging from the qualitative research we undertook included:
_ Little has been done to tackle the social and cultural views of breast-feeding in public, and changes will be required to make breastfeeding the accepted feeding norm
_ The importance of role models in increasing the uptake of breast-feeding among younger groups and lower socio-economic groups
_ The need to provide more baby-friendly venues and settings to make it easier to breast-feed in public
_ The need for a list or directory of cafés, pubs, restaurants that are breast-feeding friendly
_ The belief that workplaces have a duty to support mothers when returning to work, and that workplace policies need to be drawn up to provide explicit support for breast-feeding mothers
_ There is a need to communicate with employers about the benefits to themselves and society of supporting employees who are breast-feeding
_ Any policies or practices that are developed must respect the sensitivities and feelings of those who are not comfortable with breastfeeding in public
_ Breast-feeding mothers need to be taught how to breast-feed discreetly in public. While there was overwhelming support for breastfeeding in public settings, many mothers as well as others stated that this should be done discreetly
_ Better facilities need to be provided that not only support breast-feeding in public but help with the general practicalities of parenting babies and children when outside the home. These should take into account accessibility, cleanliness, safety, nappychanging facilities that include toilets for older children and mothers, and family rooms where fathers can look after children when out shopping
_ The feeling of vulnerability that younger mothers have when on the receiving end of disapproval from onlookers
_ Nurseries need to provide storage for expressed breast milk. Options should be explored to fund this
_ There needs to be a campaign to communicate the benefits of supporting breast-feeding in public.

Outcomes  

The qualitative research has generated valuable in-depth insight. Brighton and Hove PCT and City Council will now be working with the target audience and key stakeholders to generate facilities and practices to support breast-feeding. Specifically, we aim to enable and encourage mothers of all ages and from all socio-economic groups to breast-feed with confidence, with respect for others and in a way that suits them, both in public and when returning to work. The project has also helped us to open a dialogue with key influencers and stakeholders and gain their support. We hope to work with these groups to develop the next steps. 

 breast-feeding in public places T2
Recommendations  

The recommendations in Table 2 are based on  findings from all the research methods. We advise that all potential interventions should be designed in conjunction with stakeholders and the various target audiences, and be tested before being rolled out.

The consultation has included identifying and talking with key stakeholders and influencers, and we recommend that any steering group includes representatives from these groups to develop a consumer-focused approach. The recommendations are based on a social marketing model to provide short- and long-term operational and strategic options.

References   
1. Department of Health. Breastfeeding and the NHS Priorities and Planning Framework 2003-2007 (modified February 2007). London: Department of Health. www.dh.gov.uk/  
2. Brighton and Hove City Primary Care Trust and Brighton and Hove City Council. Commissioning for Health. The Annual Report of the Director of Public Health, 2006.
3. Department of Health. www.dh.gov.uk/assetRoot/04/07/16/96/04071696.pdf. 2005 4 The Information Centre. Infant Feeding Survey 2005. London: The Information Centre, 2007. Available online at www.ic.nhs.uk (accessed 14 June 2008)

Further reading  

The Information Centre. Feeding outside the home (Chapter 9). In: Infant Feeding Survey 2007. London: The Information Centre. Available online at www.ic.nhs.uk Department of Health. Social Marketing. www.dh.gov.uk.uk/en/Publichealth/Choosinghealth/DH_066342 (last modified June 2007) (accessed 14 June 2008) NHS Networks. Social Marketing and Health - Concepts and Applications Explained. www.networks.nhs.uk/networks/page/229 (accessed 14 June 2008)

Further information

The project  

For more information about the project, please contact one of the following: Cat Tardiff, Communications Manager, Brighton and Hove City Teaching PCT. cat.tardiff@bhcpct.nhs.uk Sarah Cork, Managing Director, Brilliant Futures. Sarah@brilliantfutures.org or Susannah Hines. Susannah@brilliantfutures.org  Brilliant Futures Brilliant Futures is a social enterprise providing training, coaching, consultancy and community interventions to help promote behavioural change with social benefits. A percentage of Brilliant Futures' profits is used to help young people achieve healthy futures. Recent projects have included Brilliant Reading, a reading and confidence-building programme, and Healthy Enterprise, where children make and sell healthy snacks and drinks to their peers. Sarah Cork, the founder and managing director of Brilliant Futures, is a Senior Lecturer in Marketing at the University of Brighton. Website www.brilliantfutures.org E-mail info@brilliantfutures.org; Tel 0845 347 9355/01273 494999 

BOX:
The social marketing approach

What is social marketing?

The huge increase in lifestyle-related illnesses has led the Department of Health to develop more sophisticated and targeted approaches, including social marketing, to improving the nation's health and well-being. A national social marketing strategy was launched in 2006 to increase understanding of the role of social marketing and the capacity and skills needed for this approach. The aim of social marketing is to move people to action, not just give them information. It uses tools and techniques from commercial marketing to stimulate voluntary behaviour change, helping individuals to achieve and sustain positive and healthier lifestyles.
The success of social marketing is based on the principle of starting with the consumer. It involves developing a comprehensive understanding of real people in real situations, understanding what motivates them and then "selling" the benefits of particular behaviours to them in their own way and on their own terms. This is known as an "insight-driven" approach. It recognises that people do not exist in isolation, but in contexts where they interact with complex networks of key influencers and influences. Successful social marketing will therefore be consumer-led and customer-focused, which is why research and consultation are the key starting points for any successful project. Social marketing also recognises that there is no such thing as targeting the general public. Like commercial marketing, it uses techniques such as dividing the subjects into specific groups, characterised for example by socio-economic circumstances, gender or age. This practice is known as "market segmentation" and can be used to produce appropriately targeted communications and activities for a particular group.  

Some definitions of social marketing

"The systematic application of marketing alongside other concepts and techniques, to achieve specific behavioural goals, for a social or public good." French J, Blair-Stevens C. Big Pocket Guide to Social Marketing. (2nd edn.) London: National Social Marketing Centre, 2007, p. 35. www.nsmc.org.uk "…a programme planning process designed to influence the voluntary behaviour of a specific audience segment to achieve a social rather than a financial objective." Interview with Beverly Schwartz. Social Marketing Quarterly 2005; 11(3&4): 68-77 "…where marketing is used to help achieve and sustain positive behaviours for social good." French J, Blair-Stevens C. Big Pocket Guide to Social Marketing. (2nd edn.) London: National Social Marketing Centre, 2007, p. 35. www.nsmc.org.uk