In 2008, the Government of New Zealand funded the Ministry of Health (MoH) to develop and implement a national breastfeeding promotion campaign. The campaign was based on formative research and designed to target groups with disparately low breastfeeding rates such as the Māori and Pacific people in New Zealand–in 2006, only 45% of Māori babies and 48% of Pacific babies were fully and exclusively breastfed at 3 months, compared to 60% for non-Māori and non-Pacific populations. Even more concerning, the research undertaken to inform the national breastfeeding promotion campaign found that exclusive breastfeeding prevalence at 3 and 6 months of age had even decreased slightly in the past 3 years for Māori and Pacific populations.
Following the campaign, the prevalence of exclusive breastfeeding at three months in the Māori population continued to hover at 45%, and the Pacific population had likewise not seen change. The results nationally showed a small increase (< 5%) in exclusive breastfeeding prevalence over this time period (2009-2015) for three-month and six-month infants. This case study also demonstrates the importance of long-term, multi-faceted promotion campaigns that target underserved populations.
Description & Context
In 2008, breastfeeding was featured in the Ministry of Health’s (MoH) Healthy Eating - Healthy Action (HEHA) strategy and implementation plan that focused on obesity prevention (1). The HEHA had three relevant initiatives: a breastfeeding social marketing campaign, breastfeeding action plans for District Health Boards (DHBs), and breastfeeding workforce development (3). The following year, the MoH sponsored GSL (a marketing company) to launch its own independent breastfeeding social media campaign (1,4). This social media campaign created “Breastfeeding NZ” communities on Facebook and Twitter (1). The Twitter feed featured questions from members of the public, publicity for upcoming breastfeeding events, health information from the Ministry of Health, and breastfeeding stories from real mothers (1,5). YouTube videos covering breast attachment, early initiation of breastfeeding, common challenges, returning to work, and the role of fathers and family members in supporting breastfeeding mothers, were also posted (1). Breastfeeding NZ on YouTube quickly gained more than 120,000 views in just three weeks – achieving the spot for the most popular channel in New Zealand during the last week of October that year (1). The Facebook community group reached more than 1,200 members in the first week alone (1). The MoH also sponsored a series of ads displaying mothers breastfeeding in non-home settings such as the library, work, or on a bus, to normalize breastfeeding in public (6). At the bottom of each ad sits the campaign’s powerful statement of purpose: “Wherever they’re heading, a healthy start in life will help them get there. In the community and workplace, breastfeeding is natural. Perfectly natural.”
The final step in the social media campaign was the launching of a blog that served as a platform to increase the engagement between the wider campaign and the social media community with in-depth campaign updates, advice on breastfeeding topics, information and advice from stakeholder groups (Plunket, La Leche League, Women’s Health Action), breastfeeding stories from real mothers, and video logs from the campaign’s celebrity advocates describing their breastfeeding journeys (1).
The number of followers on the Breastfeeding NZ twitter reached over 1,000, however, it has been inactive since 2015 (5). In 2012, a report on the government use of social media, particularly the Breastfeeding NZ Facebook campaign, stated it had attained a community of over 10,000 people and continued to grow (8).
Furthermore, the report stated increased engagement with the Facebook page in the past four years with 17,330 stories created about the page among other indicators (8). Despite the momentum, the Facebook page has been deleted as well as the YouTube videos–perhaps due to a change in government, the end of the contract with GSL,
or due to a conclusion of a ‘short-term’ campaign. This is a major setback, as while promotion campaigns can be short-term, the New Zealand MoH national breastfeeding promotion campaign had clearly built a community that would have continued to be receptors of appropriate breastfeeding information, likely bringing more of their fellow mothers into the social media groups.
In 2007, the “Comprehensive Plan to Inform the Design of a National Breastfeeding Promotion Campaign,” based on in-country research and an extensive literature review, was produced for the Ministry of Health (2). The plan highlighted the enablers and barriers to breastfeeding in New Zealand, the key messages that should be disseminated, the priority groups to be targeted, and the comprehensive approach the campaign should take (2). Below are key findings and methods the plan took.
The process used to develop the plan involved:
- Undertaking focus group research among target and priority groups
- Analyzing findings from the literature review
- Reviewing theories to structure research findings
- Applying standard program planning processes
- Consulting with key Ministry of Health personnel
The plan developed three dimensions of support for breastfeeding (tangible, emotional, informational) that could be translated into traditional Pacific and Māori models of health.
Tools available for the proposed breastfeeding promotion campaign:
- Influencing legislation
- Influencing environmental change
- Community development and engagement
- Awareness raising and advocacy
- Health education and training
- Mass communications
- Management, planning and evaluation
- Social marketing
- Facilitation and networking
Lessons from social marketing with Pacific and Māori populations, key to understanding how to reach the target population, included:
- The importance of Māori and Pacific clinical and community leadership
- Early engagement with Māori and Pacific stakeholders/communities and strong involvement of Māori and Pacific peoples in campaign planning and development
- Use of existing Māori and Pacific community networks
- Recognition of motivators and emotional drivers specific to Māori and Pacific peoples
- Use of culturally-specific sites such as marae, kura kaupapa, or Pacific churches, with use of culturally appropriate processes.
The plan recommended a two-stage approach:
1. Health Systems: Focusing on meeting with stakeholders and disseminating basic campaign information such as key messages, PowerPoint presentations, newsletters etc.
2. Family/whānau and community/workplaces: Using a mix of paid advertising, public relations, and community development approaches to reach target populations. Ensuring that specific advertising and PR strategy is developed for each audience.
Finally, the core principles underpinning the plan:
- Ensure that infants have the best possible start in life
- Ensure that outcomes from the campaign will be equitable, particularly among priority groups
- Facilitate Māori and Pacific health advancement
- Recognize that breastfeeding sits within a wider context of whānau ora (family health)
- Pragmatism: recognize small achievements (any shift towards improving breastfeeding rates is positive)
- Avoid stigmatizing women who do not breastfeed
The Ministry’s Health Eating – Healthy Action campaign featured breastfeeding in 2008 through three initiatives (3):
- Breastfeeding Social Marketing Campaign – this mass-media and advertising campaign featured television, radio, and magazine advertising that disseminated messages encouraging family and friends to support their women to breastfeed for as long as possible (3).
- Developing Breastfeeding Action Plans for District Health Boards – The action plans developed included ways to support and advocate the Baby Friendly Initiative, as well as how to facilitate and coordinate an infant feeding health promotion strategy in their respective regions (3).
- Breastfeeding Workforce Development – Previous research indicated the dire need for trained healthcare professionals to give breastfeeding advice, as well as ensuring the training was consistent and addressing common problems and solutions. Once the Ministry of Health updated training guidelines, courses would be developed for health care professionals, specifically Māori and Pacific health care practitioners and workers (3).
The New Zealand Ministry of Health’s independent breastfeeding social media campaign began in 2009 by creating television, radio, and magazine advertisements to help build awareness of the benefits of breastfeeding. The following year after initial success, they strove to maintain this newfound connection with breastfeeding mothers, extending into the home and growing community support (8). This second phase of the program included images of breastfeeding women on billboards, online and print advertising, promotion and distribution of an informational DVD, and, most importantly, the use of social media outlets such as Facebook, Twitter, and YouTube (8).
Focusing on the Facebook campaign, the page managers were breastfeeding experts who were also skilled in social media use. They were instructed to respond to questions posted on the Facebook page regarding breastfeeding, as well as informational facts about breastfeeding (8). In addition, using the information gained from the formative research, particularly with the engagement with stakeholder groups, the Ministry of Health compiled a list of topics for the community managers to post on the page (8). These posts “further stimulated discussion and feedback from the target audiences”, and importantly, kept people revisiting the page, building the sense of an online community and disseminating knowledge at a rapid pace (8).
To increase the action on the page, a competition called, “Looking Good Baby,” called for mothers to post photographs of them breastfeeding with the babies (8). Mothers posted across the country and eight regional winners were selected by members of the page (8). After the first two years of the Facebook launch, the page had developed a strong community.
Evidence of Implementation Strategy
A 2009 report to update the government on the status of Healthy Eating Healthy Action states the National Breastfeeding Promotion Campaign had successfully completed phase one and was entering phase two, going beyond the mothers’ immediate family to focus on promoting and supporting breastfeeding in healthcare facilities and retail settings such as supermarkets (9). The report also states that under the guidance of the National Breastfeeding Advisory Committee, a three-part seminar series was developed and presented via videoconference facilities that year. This seminar series provided HEHA managers the chance to bring together Pacific and Māori breastfeeding community stakeholders in order to hear from experts and community members on the best methods for the promotion and support of breastfeeding (9). Specifically in Southland, the report gives three different instances of breastfeeding promotion materials in regional newspapers (9).
Cost and Cost-Effectiveness
HEHA was funded by the government of New Zealand. In 2007, HEHA reported that $12.45 million was approved for funding HEHA Community Action Projects, breastfeeding, workforce development, and public health units and non-government organizations for nutrition and physical activity services (3). Not all of the $12.45 million went to breastfeeding but the proportion that did (not reported) went to fund their three breastfeeding initiatives: (3).
The use of mass media for health advocacy and promotion purposes has been reported as cost-effective in changing health behaviors (10). The MoH reported spending less than $200,000 a year on the Breastfeeding NZ Facebook campaign (8). This includes the salary of the page managers and many other resources developed alongside the Facebook page to support breastfeeding mothers including promotional material such as informational DVDs (8). In fact, the most expensive part of a promotion campaign may be the formative research done beforehand to inform the campaign; financial resources will be needed to hire research consultants, host meetings, and for the collection of in-country data through surveys, interviews, and other methods. However, the return on these investments is high, as using an evidence-based approach ensures proper targeting.
Perceptions and Experiences of Interested People
A case study by the New Zealand Government Information Services on New Zealand’s use of social media for breastfeeding promotion states the Facebook page was successful (8):
“The Facebook page works because it supports women in their own environment and according to their own time constraints. It offers credible content, support from other breastfeeding women and celebrates their shared experiences”
Feedback on the page was very positive–posts by community members were grateful for the breastfeeding advice given and support from other women members (8). An article from a parenting website on the New Zealand national breastfeeding promotion campaign praised the ads displaying mothers breastfeeding in public settings, agreeing with the campaign’s statement of purpose that breastfeeding gives babies a healthy start in life and is perfectly natural (6).
The case study reported key lessons learned; they reported an “excellent relationship” with their contracting company, GSL, and cited contracting outside expertise as an effective way to add to the success of the campaign (8). Monitoring, such as by full-time page managers on the Facebook page, was crucial to keeping the social media sites active (8). These page managers were also key in disseminating breastfeeding information and initiating conversations among community members (8). A final lesson learned reported was to commit to the promotion campaign in the long-run, something New Zealand failed to do. For instance, the Breastfeeding NZ Facebook page was able to gain a strong following over a period of four years, but unfortunately, it is not continued today (8).
Benefits and Potential Damages and Risks
- There is a risk in contracting with an outside actor because at the end of the contract, the promotion methods will not be sustained. This appears to be the case in New Zealand, as the Facebook Page and Blog are dormant or deleted. The Ministry of Health’s contract with GSL ended in 2013 (4). Individuals must be employed to continue/maintain the promotion methods, assuming responsibility from the external contracting company.
- There is risk of failure in reaching the intended audience depending on the avenues of communication in the country. This may have happened in New Zealand, whose target populations, the Māori and the Pacific communities, did not see an increase in exclusive breastfeeding rates while the nation as a whole did. Furthermore, these stagnant breastfeeding rates occurred despite formative research to develop the campaign to target these populations. Thus, countries must consider multi-faceted approaches to increase target population breastfeeding rates; alongside promotion through media, direct community outreach through community health workers may be better if the target population is a minority or rural group.
- As evidenced in New Zealand, the country can lose support and strength for a breastfeeding promotion campaign if the promotion is a subset of another campaign, such as HEHA in New Zealand’s case.
- 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. In addition, promotion campaigns that utilize social media must ensure constant monitoring so all posts by the public are appropriate and in-line with the goal of the campaign to promote breastfeeding.
- Resources for a professional, commercial-style campaign could be scarce (ie skilled personnel to undertake formative research, technical professionals to develop the material, lack of personnel to serve as social media managers that also have expertise in breastfeeding topics).
Scaling Up Considerations
- 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.
- It is good to note the wide array of media the New Zealand national breastfeeding promotion campaign utilized–print ads, Facebook, Twitter, YouTube, and blogs. It is important for a country to survey its main modes of communication, as well as the target population’s main mode of communication (which may be different than the national), and disseminate promotional material appropriately to reach the target population. For instance, television was not a mode of communication used widely by the New Zealand national breastfeeding promotion campaign, while the Internet and social media was clearly targeted.
- As mentioned, it is important for the promotion campaign to commit to the long-term. There is a risk in contracting with an outside actor because at the end of the contract, the promotion methods will not be sustained. This appears to be the case in New Zealand, as the Facebook Page and Blog are dormant or deleted. The Ministry of Health’s contract with GSL ended in 2013 (4). Individuals must be employed to continue/maintain the promotion methods, assuming responsibility from the external contracting company.
Barriers to Implement
- Formulating an appropriate and convincing campaign with the intended message is a difficult process that requires time, 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.
- 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. It is important that formative research inform countries the most cost-effective way to reach the target population.
- There may be a conflict of interest between the national government and the outside actor, for instance, the marketing group the New Zealand Ministry of Health contracted. Their interest may focus more on profit rather than the importance of the health message. It is crucial that the goals of the promotion campaign are clearly stated by stakeholders and agreed upon by the contracted company so that ultimately the company produces materials that meet the expectations and needs of the national government.
- Any national promotion campaign must involve multiple avenues of outreach. A campaign that simply focuses on social media avenues such as Facebook, Twitter, YouTube, and blogging may miss crucial populations that do not own or have access to computers or phones with Internet. This may have been the case in New Zealand, as the general public’s exclusive breastfeeding rates rose slightly, while the Māori and Pacific populations had stagnant breastfeeding rates.
- While promotional 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.
- WHO, UNICEF. (2014). The Who/UNICEF Baby Friendly Hospital Initiative Documents for Aotearoa New Zealand 2014. Retrieved from https://www.babyfriendly.org.nz/fileadmin/documents/Baby_Friendly_in_an_National_and_International_Context.pdf
- Quigley and Watts General. (2007). Comprehensive Plan to Inform the Design of a National Breastfeeding Promotion Campaign. Retrieved from https://www.health.govt.nz/system/files/documents/publications/comprehensive-plan-inform-design-national-breastfeeding-campaign.pdf
- New Zealand Ministry of Health. (2008). Healthy Eating – Healthy Action Oranga Kai – Oranga Pumau: Progress on Implementing the HEHA Strategy 2008. Retrieved from https://www.health.govt.nz/system/files/documents/publications/heha-progress-dec08.pdf
- GSL Promotus. Breastfeeding NZ. Retrieved from http://gslpromotus.co.nz/portfolio/breastfeeding/
- Twitter. Breastfeeding NZ. Retrieved from https://twitter.com/breastfeedingnz
- Chua, J. M. (2009). “New Zealand Launches National Breastfeeding Promotion Campaign.” Inhabitots. Retrieved from https://inhabitat.com/inhabitots/new-zealand-launches-national-breastfeeding-promotion-campaign/
- Royal New Zealand Plunket Society Inc. (2017). Breastfeeding Data: Analysis of 2010-2015 Data. Retrieved from https://www.plunket.org.nz/assets/PDFs/Breast-feeding-Data-2010-2015.pdf
- New Zealand Department of Internal Affairs. (2012). Social Media in Government Ministry of Health Case Study: Breastfeeding NZ on Facebook. Retrieved from https://webtoolkit.govt.nz/files/Social-Media-in-Government-Case-Study-Ministry-of-Health-v1.0.pdf
- Randall, P. and Gordon, R. (2009). “Report to the Community and Public Health Advisory Committee: Healthy Eating Healthy Action.” Retrieved from https://www.southerndhb.govt.nz/files/20090812160054-1250049654-6.pdf
- Wakefield, M. A., Loken, B., and Robert C. Hornik. “Use of Mass Media Campaigns to Change Health Behaviour.” Lancet 376.9748 (2010): 1261–1271. PMC. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4248563/
- Theodore, R., McLean, R. and TeMorenga, L. (2015). “Challenges to Addressing obesity for Māori in Aotearoa/New Zealand.” Australian and New Zealand Journal of Public Health, 39: 509–512. Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/1753-6405.12418/full