Portsmouth Promotes Breastfeeding

1. Portsmouth Promotes Breastfeeding Using Social Marketing to increase breastfeeding continuation rates in Portsmouth April – Sept 2009 Amanda Malthouse Specialist Practitioner – breastfeeding Portsmouth City tPCT

2. Portsmouth Promotes Breastfeeding Project Aims • Increase % of mothers continuing to b/f at 6-8 weeks, exclusively or with formula • Establish the motivation for 35% of mothers to continue to breastfeed beyond 6-8weeks • Establish the obstacles in continuing to breastfeed after 6-8 weeks

3. Portsmouth Promotes BreastfeedingLocal breastfeeding rates

4. Portsmouth Promotes Breastfeeding Quotation Specification: • Background – demographics / statistics • Aims and objectives of b/f strategy group • Overview of request • Project deliverables: secondary and primary research evaluated in order to gain clear audience segmentation to target health inequalities • To provide behavioural analysis and insight for a clear understanding on how to apply exchange via an appropriate intervention and marketing mix • To capture competition • Final report • Payment

5. Portsmouth Promotes Breastfeeding Target audience • In the brief, the target audience was identified as women within Portsmouth City of all ages and social economic class who have initiated breastfeeding. • Forster recommended that some elements of the research would focus on specific wards within Portsmouth that were identified through the secondary research as facing greater health inequalities

6. Portsmouth Promotes Breastfeeding The following wards in Portsmouth City were identified as a focus for the primary research: • Charles Dickens, Paulsgrove, Cosham, St. Thomas, Fratton • These are some of the most deprived areas of the country, and have been identified as having existing or future health problems by ACORN data and have a high proportion of the ‘at risk’ clusters of the Change4Life segmentation

7. Portsmouth Promotes Breastfeeding Ethical issues • research is not NHS research if women recruited via posters / direct approaches rather than as NHS patients • therefore no NHS REC review is required.  • b/f is a sensitive issue therefore suggested that questionnaires / interview schedules were carefully scrutinised.  • Given that some women might be breast feeding and experiencing problems and others might be planning to breastfeed but have questions to ask, it was suggested that sources of help were identified at the group meetings / interviews

8. Portsmouth Promotes Breastfeeding Stakeholder interviews • Participants were self selecting and included: • 12 in-depth interviews conducted • Midwives • Health Visitors • Nursery nurse • Voluntary sector breastfeeding supporters • Pharmacist

9. Primary research methodology Qualitative • Focus groups • In-depth interviews • Self-selected in response to posters and flyers displayed in Children’s Centres and distributed by health professionals • Research groups held primarily at Children’s Centre Quantitative • 124 women with a child under the age of three • On street interview at key public locations across Portsmouth • Focus on specific deprived areas • 10 minutes in length

10. Portsmouth Promotes Breastfeeding Focus Groups • Four focus groups took place in Children’s Centres based in the wards outlined above. • Participants included: • Mothers aged under 25 who have bottlefed • Mothers aged under 25 who have breastfed • Mothers aged over 25 who have bottlefed • Mothers aged over 25 who have breastfed • Focus group respondents were self-selected by responding to posters displayed in Children's Centres. The groups were held at Children’s Centres or similar venues where the women feel comfortable, and an approved discussion guide was used to run the session.

11. Portsmouth Promotes Breastfeeding Paired interviews • Eight friendship/family in-depth interviews were conducted with women, in addition to the focus groups • These interviews focussed on younger mothers, but were influenced by findings from the focus groups to address any issues requiring further in-depth understanding. • The format was based on the discussion guides used for the focus groups, but probed certain areas in more detail. • Interviews took place with a combination of breast and bottlefeeders. As with the focus groups, all participants self nominated

12. Portsmouth Promotes Breastfeeding Street questionnaires: • 100 women with children under the age of five were asked to participate in a 10 minute street questionnaire. • This will verify if the results of the qualitative research are reflected in the general population’s opinions and experiences. • Researchers were stationed at key public locations across the City, with a focus on the areas detailed above. • A questionnaire was specifically prepared for this element of the research and signed off by the client prior to use.

13. Key findings High levels of understanding of benefits of breastfeeding Behaviour highly influenced by family and friends Sufficient information available although clear signposting would be welcomed Encouragement not coercion from professionals desired Support during initial 48 hours critical to breastfeeding adoption Perception that too few staff/too busy Health visitors praised but often too little too late Women report ‘resorting’ to a bottle to help manage tiredness, desire to go out and family pressure Strong bonding and high reliance between members of support groups 6 weeks critical milestone – either as legitimate time to give up, or after which breastfeeding truly established Breastfeeding in public high impact on continuation. Insufficient public places Returning to work not a significant barrier Portsmouth Promotes Breastfeeding

14. Inside the head of the breastfeeding maintainer Highly Committed to Breastfeeding Less Committed Trialists Adopt a ‘try it and see’ attitude Entirely pragmatic Don’t put themselves under too much pressure Give themselves fall-back option of bottle-feeding if necessary This group of maintainers tend to find breastfeeding easy or have problems which are easily resolved They feel they are taking the easiest route for them – least hassle Practical, relaxed and not particularly emotional • Women who experience minimal problems will sail • through, usually enjoying breastfeeding • BUT • For others problems perceived more as ‘challenges’ • to be overcome (with help) • Tend to have supportive families/partners • Pain part of ‘total experience’/Element of • ‘rites of passage’ • Their ‘Breastfeeding Story’ unfolds like their ‘Birth Story’ in a like-minded group – though need support • Proud of their ‘battle scars’ • - worn as a ‘badge of honour’ amongst peers • Can be a highly emotional group • Triumph over Adversity

15. Breastfeeding maintainers: Key motivators to continuation Rational health benefits strong peer networks

16. Inside the head of the lapsed initiator Highly Committed to Breastfeeding Less Committed Trialists Adopt a ‘try it and see’ attitude Entirely pragmatic Don’t put themselves under too much pressure Give themselves fall-back option of bottle-feeding if necessary This group of Maintainers tend to give up very quickly if breastfeeding becomes painful/problematic This group often says they had to give up as not producing enough milk/had a hungry baby Practical, accepting and not particularly emotional May put themselves under enormous pressure Often have supportive families/partners (though not always) Accept pain/problems as part of ‘total experience’ BUT For this group problems become insurmountable Mastitis/bleeding nipples + exhaustion leads to crisis point Need more help May introduce bottle in desperation (family intervention?) and baby will refuse breast Often a highly emotional group Failure/Guilt

17. Lapsed initiators: Key barriers to continuation Rational can get more help if bottle-feed BF does not allow bonding for father Introduced bottle in desperation – now baby prefers it BF in public too embarrassing/difficult I am not producing enough milk overwhelmed by problems hungry baby/ needs more than I can give just too ill/ run down to continue baby not gaining enough weight - I had no choice lack of support at home too painful - bottle-feeding doesn’t hurt

18. Early days - cycle of failure lack of one-to-one breastfeeding help in hospital poor positioning and low confidence soreness/ bleeding nipples introduce formula – often as last resort gaps between home visits – problems worsen Baby crying - PANIC feelings of failure and exhaustion

19. First few days at home Up to 6 weeks Beyond 6 weeks Pregnancy Birth/In hospital Basic feeding facts Encouragement not coercion Peer educators Promoting group involvement Step-by-step guidance during first feeds Stay with mother Not just ‘latch’ Preventative advice Signposting to sources of help Information about managing baby as needs change Ongoing encouragement needed Preventative advice Regular visits/contact Information about managing baby as needs change Promoting group involvement Summary of key times for support Feeding in public Move to solids

20. Example bubble drawing • The vast majority of participants allocated feelings of embarrassment to the friend

21. Creative 1: Be A Star

22. Positives Positive message Inspiring - be a star Nice words from baby Negatives Unrealistic (too young, too thin, too glam, high heels) Baby looks too big Doesn't show bonding Response They look miserable and they’re not looking at their babies It should show women of all different sizes and races Its too trashy, she doesn’t look like a mum I like the words there…that you’ve loved them since they were born

23. Creative 2: Best Beginnings

24. Positives Modern Young Like the bra! Negatives Too much skin Babies position is wrong Unrealistic image Too sexy Response What about the bond between the baby and mum? That’s not how you feed with the whole boob out – and they’re not breastfeeding boobs! I can see it’s trying to make it relevant to more people, trendy

25. Creative 3: NHS

26. Positives Image of a young girl is good Realistic Discreet Believable Negatives Not very eye catching Text is quite small Response Oh I’ve seen these before, they’re up everywhere The teenager is a positive role model The park bench is normal – the sort of place I go

27. Creative 4: Forster mock-up

28. Positives Natural images Realistic Believable message Negatives Message could be misleading Response It’s not always convenient or fast! It’s nice to see mum & baby together, she looks proud and happy These are the best images – I like the way she is looking down at her baby The café looks like a normal environment

29. Portsmouth Promotes Breastfeeding Recommendations: • Consider establishing audience insight panel (e.g. 6-8 local women) with whom ideas can be discussed and feedback obtained • Introduce a generic brand to tie in all existing and planned activity • Ensure consistent use of encouraging and non-judgmental tone across all face to face communications and printed materials (promoting choice not coercion) • Develop new communication materials

30. Portsmouth Promotes Breastfeeding • Identify and ‘sign-up’ local authority, retail and attraction outlets to welcome breastfeeding women and provide appropriate facilities libraries, department stores, supermarkets, cafes, primary schools, GP clinics • Produce ‘Breastfeeding Welcome’ directory: online and print • ‘Incentivise’ breastfeeding in public, eg, sign-up cafes to provide freebie at certain times of the day • Undertake year-round proactive and reactive media relations not just during NBFAW

31. Portsmouth Promotes Breastfeeding Advertising: • Utilise public facing channels such as washroom posters, inside bus advertising, • Capitalise on ‘owned’ channels across Council and tPCT venues, vehicles, personnel Reaching influencers: • Consider specific focus for promotional activities (e.g. during NBAW) to target mothers, grandmothers and sister of pregnant women and new mothers • Specific focus on ‘What you can do to help’ highlighting the ways they can support a breastfeeding mother Early Days • Increase frequency and duration of visits in first 48 hours • Establish widespread use of peer supporters on wards • Ensure delivery/ward midwives have up to date information on post-natal support groups to signpost to women

32. Portsmouth Promotes Breastfeeding • Maintain and extend post-natal new mother support groups across city • Provide inclusive groups as well as breastfeeding specific groups • Extend provision of peer support across the city • Introduce text messaging service to new mothers • Send regular messages providing women with encouragement and ‘permission’ to get in touch if they have problems • Promote support group times/locations • Extend provision of POPT service • Use real life women as case studies in communication materials: ensure positive, realistic, representative • Include specific mention of breastfeeding when health visitors undertake development checks (to help influence behaviour of potential future babies)

33. Portsmouth Promotes Breastfeeding GP TARGET session Nov 2009 A captive audience! Amanda Malthouse Specialist Practitioner – Breastfeeding Portsmouth City tPCT

34. Portsmouth Promotes Breastfeeding • Your starter for 10! • How many more calories does an artificially fed baby consume than a breastfed baby within the first 8 months of life?

35. Portsmouth Promotes Breastfeeding Artificially-fed infants consume 30,000 more calories than breastfed infants by 8 months of age. That’s about 120 chocolate bars! Riordan et al, Breastfeeding & Human Lactation, Jones and Bartlett 1999

36. Portsmouth Promotes Breastfeeding For every month that a baby is breastfed there is an associated 4% reduction in obesity risk WHY? • Behaviour • Nutrition • Growth acceleration

37. Portsmouth Promotes Breastfeeding Themes of presentation: • Link b/f with reduced incidence of obesity • Cost of obesity to NHS • National drivers, national and local targets • Policy messages and government commitments • Stats – national &local • Details of Strategy Group • BFI 7 point plan • Social marketing slides

38. Portsmouth Promotes Breastfeeding What will Baby Friendly Initiative Accreditation mean to YOU?

39. Portsmouth Promotes BreastfeedingThree Legged Stool WHY? Knowing that breastfeeding is good WHERE? Being able to breastfeed within a supportive culture HOW? Having the skills to maintain breastfeeding

40. Portsmouth Promotes Breastfeeding Workshop • Choice of 5 – 6 GP’s signed up, 8 turned up! • Joint session with Wendy Jones – re: thrush and mastitis / prescribing issues • “Goody bag” IF they attended workshop • Encouraged other practices to sign up for “in house” workshop

41. Portsmouth Promotes Breastfeeding • Workshop 5 Breastfeeding • Why did you choose this workshop and what had you hoped to learn? • Useful for triage - symptoms of mastitis • To help answer questions from mums in triage and at 1st Immunisations • (x3) To help with feeding problems and pathways available • A patient at our practice felt that we had not followed local guidelines for thrush • What useful information have you gained from this workshop? • (x2) Signs of thrush and mastitis • Support and contact numbers • (x3) Treatment guidelines for mastitis & thrush • Excellent handout pack with contact info

42. Portsmouth Promotes Breastfeeding • Good care based scenarios and clinical advice • Excellent information on how to support mums when breastfeeding • Mastitis patients will improve in 12 hours with drawing milk • Overall Feedback • Will you do anything differently as a result of what you have learnt today? • (x4) Ensure awareness within practice of treatments / pathways available • Promote Breastfeeding more • (x2) Disseminate breastfeeding information • Make adjustments to our new breastfeeding room • Change my treatment of mastitis • Offer patients informed advice • Conduct self-directed study • (x2) More confident in referral