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An innovative community-based approach to encourage breastfeeding among Hispanic/Latino women

      At Hartford Hospital, located within a predominantly Hispanic/Latino section of Hartford, Connecticut, Rafael Perez-Escamilla and colleagues found that approximately 60% of the low-income women (eligible to receive government assistance) who deliver in its maternity ward initiate breastfeeding, but more than half discontinue breastfeeding by 2 months postpartum (
      • Perez-Escamilla R.
      • Himmelgreen D.
      • Segura-Millan S.
      • Gonzalez A.
      • Ferris A.M.
      • Damio G.
      • Bermudez-Vega A.
      Prenatal and perinatal factors associated with breast-feeding initiation among inner-city Puerto Rican women.
      ). These breastfeeding rates are below national goals as defined by the Department of Health and Human Services’ Blue-print for Action on Breastfeeding (
      ). In the same study, the main reason found among Hispanic/Latino women for not breastfeeding, or stopping breastfeeding prematurely (before 6 months after birth), was embarrassment in public (
      • Perez-Escamilla R.
      • Himmelgreen D.
      • Segura-Millan S.
      • Gonzalez A.
      • Ferris A.M.
      • Damio G.
      • Bermudez-Vega A.
      Prenatal and perinatal factors associated with breast-feeding initiation among inner-city Puerto Rican women.
      ) . All of the mothers in this study who breastfed their children also reported using formula in varying quantities.

      1. Social Marketing

      The Hispanic Health Council (HHC) is a community-based social services organization located in Hartford that serves Hispanics/Latinos and other low-income groups. The council, in collaboration with the University of Connecticut Family Nutrition Program for Infants, Toddlers, and Children, developed a social marketing campaign to increase breastfeeding in the Hispanic/Latino community. Social marketing campaigns have been utilized in several communities throughout North America to promote breastfeeding. The State of Ohio's “Best Start” campaign (
      • Hartley B.M.
      • O’Connor M.E.
      Evaluation of the “Best Start” breast-feeding education program.
      ) was associated with a doubling of the breastfeeding initiation rate in an economically disadvantaged population over the course of one year. Our campaign aimed to duplicate the success of the Ohio campaign.

      2. Gathering Information

      We used a rapid assessment procedure (
      • Scrimshaw S.C.M.
      • Hurtado E.
      ) that included a variety of qualitative methods—approaching people for interviews on the street, in-depth interviews, and focus groups conducted at the HHC— to identify the primary sources of support for women who have previously breastfed, as well as the barriers to breastfeeding. We used a “baby stroller intercept” method in a predominantly Hispanic/Latino neighborhood to stop and question mothers (N=43) pushing baby strollers with infants and toddlers (<2 years of age). We asked mothers whether they breastfed, what were their sources of emotional support if they did breastfeed, and what were the barriers if they didn’t breastfeed.
      Fourteen of the 43 women we interviewed on the street agreed to in-depth interviews at the HHC, conducted in Spanish and English. We asked detailed, open-ended questions about prenatal and postpartum advice and support, as well as infant feeding practices and perceptions related to the advantages and disadvantages of breastfeeding, formula feeding, and weaning. At the end of each interview, we showed participants a number of sample print, radio, and television social marketing ads and asked them their opinions and suggestions relating to each ad. Matrix rankings were used to obtain participants’ perceptions of images, messages, overall appearance, and cultural sensitivity of the ads. Three focus groups composed of clients and staff members of HHC also reviewed the sample ads. A breastfeeding advisory group, composed of community stakeholders that included Hispanic/Latino community members, social service providers, social marketers, and health professionals then reviewed research findings and final ads. The campaign was initially expected to last 2 months, but with extra funding from Hartford Hospital, it was able to continue a total of 4 months.

      3. Key Findings

      ■ Primary obstacles to breastfeeding included: embarrassment about breastfeeding in public, pain during breastfeeding, the baby's rejection of the breast or preference for formula, insufficient milk, convenience of formula for mother, and the mothers’ dislike of breastfeeding.
      ■ Primary sources of breastfeeding support included: relatives (mother mentioned most often), health care providers, and breastfeeding peer counselors.
      ■ Among participants in street interviews that named a peer counselor as a source of support, 50% breastfed their babies for at least 6 months (P<05).
      ■ When asked what was most important in a breastfeeding social marketing campaign, participants preferred ads with: pictures of family members, including extended family, surrounding the breastfeeding mother; images of young mothers breastfeeding discreetly; pictures of ethnic minority families; pictures of mothers breastfeeding in public places; and TV spots with a picture of an infant with a child's voice narrating the advantages of breastfeeding to expecting or indecisive mothers.

      4. The Social Marketing Ads

      Given that a general lack of support for breastfeeding was found among families in which the mother did not breastfeed, the primary goal of the campaign was to promote a positive environment for breastfeeding within the Hartford community. Thus, the slogan of the campaign became “Breastfeed with Pride: At all times, in all places.” We created a bilingual newspaper ad designed for a newspaper with a large Puerto Rican readership; one 60-second Spanish language radio public service announcement created with the expertise of a local marketing firm; one 30-second TV public service announcement purchased from “Best Start”; a fotonovela (story told with photographs) that portrays the breastfeeding challenges and successes of a Hispanic/Latino family (distributed through HHC prenatal and postnatal services); and a bus billboard ad placed on the exterior and interior of 30 community buses.

      5. Program Budget

      The budget for the entire social marketing campaign was $29,115. Printing 30 “queen-sized” bus billboards cost $2,458, and bus space rental totaled $10,296 for four months. Posters, placed inside 30 buses for three months, cost $1,021 for printing and $990 for bus space rental. Copyright permission for the television public service announcement (PSA) cost $589 and airtime for 144 spots on a local Spanish-language channel totaled $4,200. Production of the radio PSA cost $2,975, and airtime for 250 spots on a local Spanish-language radio station totaled $5,250. Fifty additional spots were aired for free as a courtesy of the radio station. Finally, a quarter-page newspaper ad was run eight times in a local newspaper at a cost of $1,336. Graphic design for bus billboards and newspaper ads was completed by HHC staff at considerable savings.

      6. Applications

      Culturally appropriate social marketing campaigns are important to consider when developing nutrition interventions targeting behavior change. Rapid assessment procedures—street interviews, in-depth interviews, focus groups, and matrix ranking—make these campaigns affordable for agencies where funding is limited.

      References

        • Perez-Escamilla R.
        • Himmelgreen D.
        • Segura-Millan S.
        • Gonzalez A.
        • Ferris A.M.
        • Damio G.
        • Bermudez-Vega A.
        Prenatal and perinatal factors associated with breast-feeding initiation among inner-city Puerto Rican women.
        J AM Diet Assoc. 1998; 98: 657-663
      1. HHS Blueprint for Action on Breastfeeding. US Department of Health and Human Services, Office on Women's Health, Washington, DC2000
        • Hartley B.M.
        • O’Connor M.E.
        Evaluation of the “Best Start” breast-feeding education program.
        Arch Pediatr Adolesc Med. 1996; 150: 868-871
        • Scrimshaw S.C.M.
        • Hurtado E.
        Rapid assessment procedure for nutrition and primary health care. UCLA Latin Center Publications, Los Angeles, CA1987