Promotion of Breastfeeding on a Large Scale with Alive & Thrive’s Mass Communication Campaign

From 2009-2014, the Alive & Thrive (A&T) project used mass communication within Ethiopia, Bangladesh, and Viet Nam to rapidly deliver breastfeeding and complementary feeding messages to families with children under two years of age. These national mass media campaigns used broadcast, out-of-home, and digital channels to reach over 10 million families and were based on strong formative research. Impact evaluations found that 85% of mothers from the targeted areas reported exposure to an A&T message. The breastfeeding promotion campaigns also changed social norms and behaviors quickly: 66% of mothers exposed to the campaign agreed exclusive breastfeeding was the norm compared to 47% of those not exposed and, during the first campaign year, A&T reported that exclusive breastfeeding prevalence rose 22%. Overall, the programs in Viet Nam, Bangladesh, and Ethiopia were a huge success–the rate tripled to 57% in Viet Nam, and to more than 80% in Ethiopia and Bangladesh in the program areas compared to non-program areas, where the exclusive breastfeeding prevalence remained low at 20%, 52%, and 55% for Viet Nam, Ethiopia, and Bangladesh respectively.

Quantitative evidence from A&T’s mass media campaign shows that behavior change is greater when the promotion campaign has a multifaceted approach; in areas only affected by mass communication, exclusive breastfeeding prevalence increased 25%, while in areas where interpersonal counseling was available along with mass communication efforts, the rate increased 34%. Countries or organizations running national promotion campaigns should consider using multiple avenues to promote breastfeeding. In addition, while promotion messages should target a specific audience to be most effective, multiple messages and delivery methods (ie different languages, different actors) should be developed in order to reach all segments of the concerned population with the appropriately-formatted message. Tailoring the messages to different groups ensures equality in outreach and maximizes uptake.

Main Components

The following are the different strategies used in each of the three countries, Viet Nam, Bangladesh, and Ethiopia, for Alive & Thrive’s (A&T) breastfeeding promotion campaigns.

Viet Nam

Within Viet Nam, A&T first sought to identify and evaluate existing materials, messages, and media outlets with reference to infant feeding practices, formula, and other nutrition products (7). This media audit covered radio, internet, TV, newspapers and magazines, cinema, advertising spend, top selling brands, and media penetration (7). Ad expenditure data was obtained from TNS, a syndicated research company. This research monitored the number of child and infant foods advertisement placements on TV, radio and print media and tracked areas where most of the budget was spent on which media, on which time belt and the most popular channels. Messages analysis was done by MediaBanc, a communications tracking organization (7). They monitored all paid placements, radio, and print media, including editorial coverage and promotions offered. These were then analyzed by the type of campaigns, key messages, and reason to believe each piece of communication. The key findings were (7):

• TV remained the main channel for communication due to the 99% household penetration nationwide, followed by print, whose impact and influence is strong in Ho Chi Minh City and Hanoi.
• Internet usage saw tremendous growth particularly with the younger target audience (late teens and young adults).
• Cost of radio was competitive but remained largely a medium for rural areas due to lack of TV programming in these areas.

The advertising strategies of infant formula manufacturers helped A&T to “market” breastmilk in an emotional and effective way (5). Marketing for infant formula in Viet Nam is pervasive, so A&T purchased airtime rather than depend on free or “public service announcement” coverage. However, even though they were outspent by infant formula companies on advertising by 13 to 1, they managed to win back some of the “market share,”, increasing rates of exclusive breastfeeding for the first 6 months from a pre-campaign rate of 26% to 48% nationally following a year of the mass media intervention (5).

For more information on A&T’s six steps to design their mass media campaign, see the EBB: Alive & Thrive’s National Advocacy Strategies. Data showed that giving water was a large threat to exclusive breastfeeding in Viet Nam. Thus, a small doable action was to promote through mass media “do not give your baby water for the first 6 months”.

Bangladesh

In 2010, the International Food Policy Research Institute (IFPRI) conducted a baseline household survey in Bangladesh with a sample of 2,000 households that had children below 24 months of age (8). The survey looked at infant and young child feeding (IYCF) practices, including mothers’ knowledge, health worker interactions, and media habits. The media survey found that TV should be the main channel for high reach/coverage on a national scale, as 68% of households watched TV at least once a week, irrespective of economics or education (8). However, the media survey also showed that media habits change rapidly, so A&T hired external media companies to track TV viewing habits, via devices embedded in homes, to keep abreast of these changing habits (8). This information, along with routine A&T surveys and two more IFPRI surveys, enabled A&T to assess the level of coverage of their TV spots and the public’s level of recall of the key messages.

The Bangladesh IYCF Alliance had identified the priority behaviors that this media campaign was designed to help improve. A&T next utilized a process called Concept Testing in order to design a culturally appropriate TV media campaign (9). Similar to product testing processes, Concept Testing allows researchers to try out a variety of emotional appeals on the audience they are trying to reach, while still being entertaining and ultimately making the message stick. Importantly, the concepts were tested before the TV scripts were finalized through target audience interviews that garnered feedback on the appeals/emotion of the script, memorability of the facts, credibility of the behavior presented, and any other changes the participant recommended in the script (9,10). An example of a script before and after Concept Testing shows the process shortened the total number of words spoken, introduced different actors outside of the family unit (such as a health worker and doctor), and moved from many factual, lengthy sentences to simple, to-the-point, and natural conversations (11).

Ethiopia

In Ethiopia, A&T contracted Howard Delafield International (HDI), a marketing and communications consulting firm, to develop material for their IYCF communication and marketing campaign (12). HDI began with a desk review of all existing IYCF research and identified gaps in available information (12). Next, they ran focus groups and in-depth interviews with mothers, fathers, mothers-in-law, health workers, CHWs, and religious, tribal, and women’s associations leaders. The topics covered included (12):

• Motivating and enabling factors
  • Identified through the use of concept boards
• Family-level dynamics and decision making
  • Explored the role of various family members in decision making and child care
  • Explored women’s access to information and resources
• Community-level dynamics and decision making
  • Roles of community leaders, school teachers and other educated persons, community institutions such as self-help associations, women’s associations, etc.
• Local anecdotes, folklore, folk tales and songs
• Mobile phone usage patterns, particularly among health workers and men
• Identification of media opportunities such as near markets or health centers Information about lifestyles, media habits, knowledge, awareness and practices, motivators for behavior, and psycho-social and physical hurdles to correct IYCF practices were gathered (12). Using this information, HDI and the local A&T team developed communication materials and tools which they then pretested with mothers, mothers-in-law and health workers for overall appeal, appropriate imagery, memorability, relevance, comprehension, and believability (12). Ultimately, a radio and TV campaigned was launched focusing on seven feeding actions to strengthen the IYCF community outreach efforts, particularly through radio outside those program areas (13).

Evidence of Implementation Strategy

Evaluation and re-planning was a key final step in A&T’s mass media campaigns in order to ensure the placement of media was optimized to reach the large target population (4). Clearly, their strategy was successful; in areas where A&T evaluated its impact with the mass media campaign, 85% of mothers interviewed reported exposure to an A&T message (4). A&T’s mass media breastfeeding promotion campaign also changed social norms and behaviors quickly: 66% of mothers exposed to the campaign agreed exclusive breastfeeding was the norm compared to 47% of those not exposed and during the first campaign year, and exclusive breastfeeding prevalence rose 22% nationally (4). A&T reports that exposure to TV spots alone accounted for an additional 149,000 exclusively breastfed babies in Vietnam in 2012 (4). Overall, the programs in Viet Nam, Bangladesh, and Ethiopia were a huge success–increasing exclusive breastfeeding rates in just five years; the rate tripled to 57% in Viet Nam, and to more than 80% in Ethiopia and Bangladesh in the program areas compared to non-program areas, where the exclusive breastfeeding prevalences remained low at 20%, 52%, and 55% for Viet Nam, Ethiopia, and Bangladesh respectively (15, 16, 17, 18).

However, quantitative evidence from A&T’s mass media campaign claims that behavior change is greater when the promotion campaign has a multifaceted approach; in areas only affected by mass communication, exclusive breastfeeding prevalence increased from 25%, while in areas where interpersonal counseling was available along with mass communication efforts, the rate increased 34% (4). In addition, an independent study that interviewed over 11,000 Vietnamese mothers found that mass media alone (consisting of two A&T 30 second commercials promoting breastfeeding) was not effective in increasing exclusive breastfeeding prevalence alone but with other intervention strategies had an effect (6). It is therefore important that any national promotion campaign use multiple avenues to promote breastfeeding.

Cost and Cost-Effectiveness

Alive & Thrive reports that across the three countries, mass media comprised 27% of the total costs of the program–much less than the total costs for scaling up interpersonal counseling (4). Furthermore, mass media reaches a large proportion of the population quickly and is clearly cost-effective when the nation has national broadcast stations in place (4).

Perceptions and Experiences of Interested People

Alive & Thrive reports crucial lessons learned from its mass communication breastfeeding promotion program including the necessity of the message to be clear and require little interpretation by the viewer and that, positively, mass media has the ability to reach nearly the entire population to change social norms and behavior quickly (4). Most importantly, A&T cites the importance of a comprehensive program beyond just mass communication to make larger impacts in IYCF practices (4). Overall, the programs in Viet Nam, Bangladesh, and Ethiopia were a huge success, increasing exclusive breastfeeding rates in just five years (15). The rate tripled to 57% in Viet Nam, and more than 80% in Ethiopia and Bangladesh in the program areas compared to non-program areas, where the exclusive breastfeeding prevalences remained low at 20%, 52%, and 55% for Viet Nam, Ethiopia, and Bangladesh respectively (15, 16, 17, 18).

A study by Sanghvi et al. cites that the Alive & Thrive program in Bangladesh led to rapid and significant improvements in infant and young child feeding (8). The authors praise the extensive formative research done beforehand that was used to tailor messages to the local context (8).

Benefits and Potential Damages and Risks

• There is risk of failure in reaching the intended, large audience depending on the avenues of communication in the country.
• There is a risk of failure of the mass media campaign in promoting the uptake of the intended message and thus behavior change in the target audience due to the campaign’s content, style, or other factors such as the belief in the credibility of the media.
• Resources for a professional, commercial-style campaign could be scarce (ie technical professionals to develop the media ad, insufficient purchased airtime). The mass media outlet may be crowded, meaning that purchased spots may not be able to air at the appropriate times or stand out to reach the target audience (5).

Scaling Up Considerations

• It is important that any promotion campaign have a multifaceted approach; quantitative evidence from A&T’s mass media campaign claims that behavior change is greater with interpersonal counseling and mass communication rather than mass communication alone. For instance, in areas only affected by mass communication, exclusive breastfeeding prevalence increased from 25%, while in areas where interpersonal counseling was available along with mass communication efforts, the rate increased 34% (4).
• It is essential that any mass media health message be pre-tested and based on formative research to ensure uptake by the target population. The message should be culturally appropriate and specific to the target population.

Barriers to Implement

• Determining funding sources to cover the costs of creating a national promotion campaign, let alone a mass media campaign, can be difficult for a country. All three national programs presented were due to the efforts of an outside actor, Alive & Thrive, who was funded by the Bill & Melinda Gates Foundation. Smaller mass media campaigns may be more plausible for national governments to fund.
• In the case of A&T, there may be a conflict of interest between the national government and the outside actor. It is crucial that, if an outside actor is a participant in the national promotion campaign, they cooperate and partner with in-country organizations and actors to build a sustainable relationship.
• Formulating an appropriate and convincing campaign with the intended message is a difficult process that requires time and pre-testing and formative research. If a country lacks the technical skill and funds for these prerequisites, an inappropriate or inadequate message/campaign may be disseminated.

Equity Considerations

• Any national promotion campaign must involve multiple avenues of outreach. A campaign that simply focuses on disseminating TV messages may miss crucial populations that do not own or have access to televisions.
• While promotion messages should target a specific audience to be most effective, multiple messages and delivery methods (ie different languages, different actors) should be developed in order to reach all segments of the concerned population with the appropriately-formatted message. Tailoring the messages to different groups ensures equality in outreach.

References:

1. Alive and Thrive. (2017). About Us. Retrieved from http://aliveandthrive.org/about-us/
2. Alive and Thrive. (2017). Retrieved from http://aliveandthrive.org/
3. Alive and Thrive. (2017). Technical Focus: Breastfeeding. Retrieved from http://aliveandthrive.org/technical-focus/breastfeeding/
4. Alive and Thrive. (2014). Mass Communication: Infant and Young Child Feeding at Scale. Retrieved from http://aliveandthrive.org/wp-content/uploads/2014/10/Mass-Communication-Brief-2014.pdf
5. Alive and Thrive. (2015). Strategic Design of Mass Media: Promoting Breastfeeding in Viet Nam. Retrieved from http://aliveandthrive.org/wp-content/uploads/2014/11/eMag-VN-Mass_Media-FINAL-Update-Feb-2015.pdf
6. Naugle, D. A. (2016). The Evaluation of a Mass Media Campaign to Promote Exclusive Breastfeeding in Vietnam. University of Pennsylvania. Retrieved from https://repository.upenn.edu/cgi/viewcontent.cgi?article=3697&context=edissertations
7. Alive and Thrive. (2009). Media & Communication Audit To Identify Current Advertising /Marketing Trends and Spends, Messaging and Landscape. Retrieved from http://aliveandthrive.org/wp-content/uploads/2014/11/Media-review-Vietnam-Ogilvy-4.16.09.pdf
8. Sanghvi, T., Haque, R., Roy, S., Afsana, K., Seidel, R., Islam, S., . . . Baker, J. (2016). Achieving behaviour change at scale: Alive & Thrive's infant and young child feeding programme in Bangladesh. Maternal & Child Nutrition, 12(S1), 141-154.
9. Alive and Thrive. (2015). Step-by-Step Guide to Concept Testing. Retrieved from http://aliveandthrive.org/wp-content/uploads/2014/11/Toolkit-R2A-Step-by-step-guide-to-concept-testing.pdf
10. Alive and Thrive. (2012). Pretesting Materials Discussion Guide. Retrieved from http://aliveandthrive.org/wp-content/uploads/2014/11/Toolkit-R2A-Pretest-instrument_0.pdf
11. Alive and Thrive. (2012). Improving a TV Spot by Pretesting a Script. Retrieved from http://aliveandthrive.org/wp-content/uploads/2014/11/Toolkit-R2A-Before-and-after-scripts.pdf
12. Howard Delafield International, LLP (HDI) Marketing and Communications. (2011). Initial Insight Mining and Pretest Research for Alive & Thrive Ethiopia. Retrieved from http://aliveandthrive.org/wp-content/uploads/2014/11/Insight-Mining-and-Pretest-Research-Report-Ethiopia-2011.pdf
13. Alive and Thrive. (2017). Alive & Thrive Countries: Ethiopia. Retrieved from http://aliveandthrive.org/countries/ethiopia/
14. Bill & Melinda Gates Foundation. (2009). Annual Budget 2009. Retrieved from https://www.gatesfoundation.org/Who-We-Are/Resources-and-Media/Annual-Reports
15. Alive and Thrive. (2017). Alive & Thrive Announces New Funding to Expand Global Nutrition Impact. Retrieved from http://aliveandthrive.org/alive-thrive-announces-new-funding-to-expand-global-nutrition-impact/
16. WBTI. (2015). Country Report: Vietnam. Retrieved from http://www.worldbreastfeedingtrends.org/GenerateReports/report/WBTi-Vietnam-2015.pdf
17. WBTI. (2015). Country Report: Bangladesh. Retrieved from http://www.worldbreastfeedingtrends.org/GenerateReports/report/WBTi-Bangladesh-Report-2015.pdf
18. WBTI. (2013). Country Report: Ethiopia. Retrieved from http://worldbreastfeedingtrends.org/GenerateReports/report/WBTi-Ethiopia-2013.pdf