Evaluation of a comprehensive loving support program among state women, infants, and children (WIC) program breast-feeding coordinators. (Original Article).

Background: Mississippi was selected as a pilot state in the national breastfeeding promotion campaign titled Loving Support Makes Breastfeeding Work (LSMBW). To reinforce the national LSMBW project, the Mississippi Women, Infants and Children (WIC) Breastfeeding Promotion Project Team developed a comprehensive program that included patient and family education, staff training, public awareness activities, health professional outreach, and partnerships with the community. The program also implemented a breastfeeding-friendly clinic environment project and a videotape project. This study was conducted to evaluate the impact of Mississippi's LSMBW activities among WIG breastfeeding coordinators in the United States.

Method: The cross-sectional study was performed with the use of a mailed, self-administered questionnaire.

Results: Representatives of 50 state WIC agencies returned the survey. Of these SO agencies, 36 (72%) had effectively used education materials created by the state of Mississippi. Breastfeeding coordinators reported that among the campaign activities, staff training, community outreach, and peer counseling were most beneficial. They also identified the videotape project developed by Mississippi as useful in addressing barriers to breastfeeding and in training support groups, staff, and health care professionals.

Conclusion: This study showed that Mississippi's outreach activities and motivational videotape had a positive impact on coordinators' promotion of breastfeeding.

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The American Academy of Pediatrics considers breast-feeding to be the optimal source of nutrition during the first year of life for all infants. (1) Despite the demonstrated benefits of breastfeeding, (2-5) breastfeeding rates in the United States continue to be low. (6) Rates are particularly low among participants in the Special Supplemental Nutrition Program for Women, Infants and Children (WIG) and among black women. (7,8) Rosenberg et al (9) reported a steady increase in the New York City breastfeeding rate to 58%, which might have been associated with a New York state regulation requiring that a. lactation coordinator be designated at each hospital. Health care workers, including staff and professionals who provide prenatal advice on breastfeeding, should be targeted to discuss the benefits of breastfeeding with their clients.

In 1997, Mississippi was selected as a pilot state in the Best Start/U.S. Department of Agriculture (USDA) national breastfeeding promotion campaign titled Loving Support Makes Breastfeeding Work (LSMBW). The national objectives of the campaign were to 1) increase rate of initiation and the duration of breastfeeding, 2) increase public awareness and acceptance of breastfeeding, and 3) increase referrals to WIC. (10) Best Start Social Marketing conducted formative research with WIG clients and staff in 10 pilot states, including Mississippi. To address the identified barriers, it developed a comprehensive array of materials, including a staff support kit, patient education materials, public awareness campaign materials, kits for health providers, and promotional items.

Nationally, the USDA's LSMBW campaign was implemented to some degree in all 50 states. Mississippi's implementation of the national campaign was a comprehensive statewide effort that included patient and family education, staff training, public awareness activities, health professional outreach, and partnerships with the community. The state developed additional materials to reinforce the LSMBW message, including training resources, a breastfeeding protocol manual, a resource guide, campaign buttons, and client education materials. The state's comprehensive implementation of the LSMBW program was nationally recognized as a model for breastfeeding promotion and resulted in significant increases in breastfeeding initiation and duration. (11)

In addition, the state of Mississippi implemented clinic environment and a videotape project to reinforce the national campaign and to address the unique barriers to breastfeeding identified in the campaign research. (12) The clinic environment project promoted breastfeeding-friendly clinics through staff training and changes in the physical environment of clinics. The videotape, titled Breastfeeding: Another Way of Saying "I Love You," featured a diverse group of WIG clients and their families and effectively addressed the three identified barriers to breastfeeding: embarrassment, time and social constraints, and perceived lack of social support. (13) Mississippi's implementation of the LSMBW campaign and special projects were evaluated independently and found to be successful overall in achieving their objectives. (11)

In this study, we evaluated the impact of Mississippi's LSMBW and related breastfeeding promotion activities among state WIG breastfeeding coordinators. Two factors drove this research. First, Mississippi was selected as a pilot state in the national campaign, and the evaluation finding was that its programs were effective in promoting breastfeeding. Second, a paucity of data exists regarding the level of awareness of breastfeeding promotion activities among WIG staff, and this research helped to fill this gap.

Methods

This study was conducted from December 2000 through March 2001. The target population comprised all 82 state WIG agencies in the United States, including the 50 state WIG programs and those affiliated with the Indian Tribal Organizations and Territories (eg, Puerto Rico). The mailing list of WIG agencies was available through the USDA. A self-administered questionnaire was developed and mailed to WIG breastfeeding coordinators. The questionnaire included questions about the respondent's awareness of information about Mississippi's breastfeeding promotion activities, the usefulness of the additional LSMBW materials created by Mississippi, the usefulness of other Mississippi outreach projects or activities, and the usefulness of Mississippi's breastfeeding promotion videotape. The Mississippi WIG Program provided a handbook to WIG agencies that outlined the state's implementation of the LSMBW campaign several months after the campaign kickoff in 1997. The handbook included campaign implementation ideas in four key sections: public awareness (media events and saturation through television, radio, newspapers, and billboards), client education, staff and health care professional outreach, and community outreach. The handbook also included sample materials developed by Mississippi to reinforce the campaign. In addition, a copy of the promotional videotape was sent to all state WIG directors. Mississippi WIG representatives and evaluation researchers had also presented their promotion activities and evaluation results at meetings of the National Association of WIG Directors, the International Lactation Consultant Association, the American Public Health Association, and other groups. The presentations addressed the LSMBW campaign, the clinic environment project, and the videotape project.

Results

Of the 82 surveys mailed, 50 were returned, for a response rate of 61%. Forty-three agencies (86%) were aware of Mississippi's breastfeeding promotion activities, and the majority of them (n = 26) had heard about the state's program through formal presentations at National Association of WIG Directors conferences during the previous 3 years. Other important sources of information included Mississippi's Nutrition Notes newsletter, the International Lactation Consultant Association, and other conferences. Of the 50 respondents, 36 (72%) had reviewed and used materials created by Mississippi to reinforce the LSMBW campaign. When asked to identify the LSMBW campaign implementation activities that were useful to them, 22% of respondents mentioned the staff training program, 19% mentioned the community outreach activities, and 11% mentioned the peer counseling program (Fig. 1). The breastfeeding coordinators were asked to identify other Mississippi outreach projects that were helpful to their states. More than one- half of the respondents reported positively on the videotape. Other projects identified by respondents were the clinic environment project, LSMBW door signs, the child care center training manual, "How to know your breastfeeding baby is doing well" cards, and the breast-feeding protocol manual. Forty-one agencies received copies of the videotape, and the majority (85%) of them found it to be effective in addressing barriers to breastfeeding. Of the 41 breastfeeding coordinators who had access to the videotape, 66% reported using it. The three most common uses of the videotape were showing it in classes and/or support groups, using it in training of staff or other groups, and providing it to health care professionals (Table 1).

Discussion

In this study, several materials created by Mississippi to reinforce the national LSMBW program were found useful and were being used by state WIG breastfeeding coordinators. This study identified two components of breastfeeding promotion activities as the most beneficial to state WIG agencies: training of WIG staff and community outreach. Previous research conducted in southern states had shown that staff members' inconsistent information and a perceived lack of support from health care professionals were important barriers to initiating and continuing breastfeeding among WIG clients, and that staff training was therefore necessary for breastfeeding promotion.(12)

A promotional videotape developed by Mississippi was found to be the most useful outreach activity in addressing barriers to breastfeeding. A recent study also showed that the videotape significantly improved women's perceptions regarding embarrassment as well as the time and social constraints against breastfeeding. (13) In terms of the lack of social support barrier, the videotape had a positive impact on participants' views that the baby's father encouraged breastfeeding, but it did not change their perceptions of support from female relatives and friends.

The study results identified some missed opportunities for breastfeeding promotion. For example, 32 of 82 eligible agencies did not respond to the survey. It is possible that nonrespondents could have been less active than respondents in breastfeeding promotion, leading to a response bias. If that is true, then our figures overestimate the level of adoption of Mississippi materials by WIG agencies. In our study, more than one-fourth of the respondents reported not using the campaign handbook created by Mississippi to implement the national LSMBW campaign. One explanation for the nonuse of the Mississippi materials is that they may not have been perceived to address needs of certain regions of the United States. In addition, it is possible that other states may have similar breastfeeding education or outreach programs already in place.

In this study, 35 (85%) of the 41 coordinators who had access to the videotape reported that it was an effective tool for breastfeeding promotion. This response confirms previous results about the importance of videotapes in breastfeeding promotion. (13,14) Furthermore, 19 (70%) of the 27 coordinators who reported using the videotape showed it early during pregnancy in prenatal classes and/or support groups. Several studies have indicated that videotapes should be used early during pregnancy and in conjunction with other breastfeeding promotion activities, because most mothers make their infant feeding decisions before pregnancy or during the first trimester of pregnancy. (15,16)

Conclusion

Mississippi's campaign activities to implement the national LSMBW program, including staff education and training, community outreach, and the promotion of an educational videotape had a positive impact on coordinators of the state WIG breastfeeding program. Additional in-depth data on the experiences of states are needed to further understanding of the utility of the LSMBW program and about barriers that states might encounter in implementing a breastfeeding promotion campaign.

Table 1

Usefulness of the Mississippi videotape project as reported by WIC
breastfeeding coordinators in 27 states (a)

                                        No. of
Variable                           responses (%) (b)

Show videotape in classes and/or        19 (70%)
support groups
Use in training of staff or other       16 (59%)
groups
Provide to health professionals          8 (30)
Lend to WIC participants                 5 (19)
Distribute to community groups or        5 (19)
in community locations
Give to pregnant or breastfeeding        1 (4)
WIC participants
Other                                    4 (15)

(a)WIC, Women, Infants, and Children program.

(b)The total percentage is greater than 100% because of multiple
responses.

Accepted May 14, 2002.

References

(1.) American Academy of Pediatrics Work Group on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 1997;100:1035-1039.

(2.) Dewey KG, Heinig MJ, Nommsen-Rivers LA. Differences in morbidity between breast-fed and formula-fed infants. J Pediatr 1995;126:696-702.

(3.) Montgomery DL, Splett PL. Economic benefit of breast-feeding infants enrolled in WIG. J Am Diet Assoc 1997;97-379-385.

(4.) Beaudry M, Dufour R, Marcoux S. Relation between infant feeding and infections during the first six months of life. J Pediatr 1995;126:191197.

(5.) Mitra AK, Rabbani F. The importance of breastfeeding in minimizing mortality and morbidity from diarrhoeal diseases: The Bangladesh perspective. J Diarrhoeal Dis Res 1995;13:l-7.

(6.) Ryan AS. The resurgence of breastfeeding in the United States. Pediatrics 1997;99(4):e12. Available at: http://www.pediatrics.org/cgi/content/full/99/4/e12. Accessed December 17, 2002.

(7.) Carmichael SL, Prince GB, Burr R, Nakamoto F, Vogt RL. Breastfeeding practices among WIG participants in Hawaii. J Am Diet Assoc 2001;101:57-62.

(8.) Misra R, James DC. Breast-feeding practices among adolescent and adult mothers in the Missouri WIG population. J Am Diet Assoc 2000;100:1071-1073.

(9.) Rosenberg KD, McMurtrie C, Kerker BD, Na Y, Graham EH. Breastfeeding initiation in New York City, 1979 to 1996. Am J Public Health 1998;88:1850-1852.

(10.) Social Marketing Institute. Success Stories: National WIG Breastfeeding Promotion Project (online document). Available at: http://www.socialmarketing.org/success/cs-nationalwic.html. Accessed December 17, 2002.

(11.) Khoury AJ, Hinton A, Mitra AK. Evaluation of Mississippi's Breastfeeding Promotion Program: Final Report to the US. Department of Agriculture Food and Nutrition Service and Mississippi's Women, Infants, and Children (WIG) Program. Hattiesburg, University of Southern Mississippi, 2001.

(12.) Best Start Social Marketing. National Breastfeeding Promotion Project Research Brief (National Agricultural Library Gall No. RJ216 B7436 1996). Tampa, FL, Best Start Social Marketing, 1996.

(13.) Khoury AJ, Mitra AK, Hinton A, Carothers C, Sheil H. An innovative video succeeds in addressing barriers to breastfeeding among low-income women. J Hum Lact 2002;1S:125-131.

(14.) Gross SM, Caulfield LE, Bentley ME, Bronner Y, Kessler L, Jensen J, et al. Counseling and motivational videotapes increase duration of breastfeeding in African-American WIG participants who initiate breast-feeding. J Am Diet Assoc 1998;98:143-148.

(15.) Houghton MD, Graybeal TE. Breast-feeding practices of Native American mothers participating in WIG. J Am Diet Assoc 2001;l0l:245-247.

(16.) Arora S, McJunkin G, Wehrer I, Kuhn P. Major factors influencing breastfeeding rates: Mother's perception of father's attitude and milk supply. Pediatrics 2000;106(5):e67. Available at: http://www.pediatrics.org/cgi/content/full/106/5/e67. Accessed December 17, 2002.

RELATED ARTICLE: Key Points

* Mississippi's breastfeeding promotional campaign activities for the national Loving Support Makes Breastfeeding Work program was found to be useful for other Women, Infants, and Children (WIC) programs across the United States.

* Staff training and community outreach activities were found to be most beneficial.

* Mississippi developed a motivational videotape that addresses barriers to breastfeeding.

* WIC programs are most likely to use the videotape for prenatal classes and/or support groups and for training of staff and health professionals.

* Mississippi's campaign activities had a positive effect on state WIG breastfeeding coordinators.

From the Center for Community Health, University of Southern Mississippi, Hattiesburg, MS; Best Start Social Marketing, Tampa, FL; and the Mississippi State Department of Health WIG Program, Jackson, MS.

Supported in part by Grant 59-3198-7-521 from the U.S. Department of Agriculture, Food and Nutrition Service. This article does not necessarily reflect the views or policies of the U.S. Department of Agriculture, nor does the mention of trade names, commercial products, or organizations imply endorsement by the U.S. government.

Reprint requests to Amal K. Mitra, MD, MPH, DrPH, Center for Community Health, University of Southern Mississippi, Box 5122, Hattiesburg, MS 39406-5122, Email: [e-mail]

Copyright [c] 2003 by The Southern Medical Association 0038-4348/03/9602-0168