Be A Star
Commissioned by Central Lancashire Primary Care Trust (PCT), in partnership with Little Angels breastfeeding peer support organisation and The Hub social marketing agency, Be A Star promotes breastfeeding amongst 16- to 25-year-old mothers.
It does this by celebrating mothers who breastfeed as ‘Stars’ and supporting them through the breastfeeding process, via peer support and improving understanding and acceptance of breastfeeding within the community. Local breastfeeding mums are transformed to look like models, celebrities, singers and actresses, and star in a campaign to make breastfeeding glamorous, sexy and appealing to the target audience.
Be A Star first launched in Central Lancashire in March 2008 and has since been rolled out to 14 other PCTs throughout England.
- From March to May 2008, breastfeeding initiation rates (among 18- to 25-year-olds) in Central Lancashire increased from 52 per cent to 63 per cent
- This increase was also seen in the particularly deprived Preston locality in Central Lancashire
- Three ‘Stars’ have been trained as peer-to-peer supporters and one enrolled on a midwifery course within six months of involvement
Despite overwhelming evidence that supports the numerous health benefits of breastfeeding to both mother and child, many women do not choose to breastfeed. In particular, both nationally and locally in the UK, breastfeeding rates dip dramatically amongst those aged 25 and below.
According to national breastfeeding statistics (Infant Feeding Survey 2005):
- 76 per cent of all women in the UK initiate breastfeeding
- 51 per cent of mothers aged 20 and under initiate breastfeeding, and 67 per cent of mothers aged 20 to 24 initiate breastfeeding
For the Preston locality of Central Lancashire, the rates were even lower:
- 66 per cent of all women initiate breastfeeding
- 52 per cent of 18- to 25-year-olds initiate breastfeeding (lower in the most disadvantaged communities)
In response to this, the breastfeeding task group at Central Lancashire Primary Care Trust (PCT) wanted to develop a targeted campaign to increase breastfeeding amongst 16- to 25-year-olds in the PCT area, with a particular focus on young mums from deprived areas. Initial ideas involved developing some radio adverts and discussions were had with Rock FM. Following insight gathered by Central Lancashire PCT through focus groups with young mothers and their peer network, and the successful bid for £10,000 of Neighbourhood Renewal Funding, it was decided that a social marketing approach should be taken. This funding was used to commission The Hub social marketing agency, in collaboration with Little Angels breastfeeding peer support organisation, to develop a campaign.
As the project began, Little Angels facilitated engagement with three further PCTs (Blackburn with Darwen, East Lancashire and Bolton) to secure a total pooled funding of £52,000. Although the Be A Star campaign was rolled out across all these PCT areas, this case study focuses on the originating work in Central Lancashire.
A Working Group was set up to develop the campaign. Members included a project lead, Glenis Tansey (public health specialist), PCT breastfeeding coordinators, and peer support managers from external providers (Little Angels and Breastfeeding Network).
The Working Group reported to the Breastfeeding Steering Group, chaired by Glenis, and which included PCT breastfeeding coordinators, peer supporters, and members from the acute trust, voluntary sector and PCT public health.
The project was informed by and developed to contribute to a range of national and local policy drivers:
- Government target set in 2003 for PCTs to increase the number of women starting to breastfeed by 2 per cent each year
- Public Service Agreement 12: improving health and wellbeing for children and young people
- Public Service Agreement 18: reducing health inequalities
- North West Breastfeeding Framework for action (NHS North West 2008)
- Maternity Matters (Department of Health 2007)
- Every Child Matters (Department for Education and Skills 2003)
- Choosing Health (Department of Health 2004)
- National Service Framework for children, young people and maternity services (Department of Health 2004)
- UNICEF Baby Friendly Initiative
- Central Lancashire PCT Strategy
- PCT Breastfeeding Strategy
- PCT Weight Management Care Pathway/Strategy
- Vital Signs Target of increasing breastfeeding duration at six to eight weeks
Putting the customer first was essential to Be A Star, which was informed at all stages by the opinions and experiences of local, young breastfeeding mums.
Information was originally gathered through focus groups in December 2007, which Central Lancashire PCT ran with young mothers and their peer networks. The Hub interrogated these findings and conducted further desk research, as well as research with key breastfeeding stakeholders, such as peer-to-peer support workers, infant feeding co-ordinators, midwives and health visitors.
This scoping phase allowed the project creators to understand:
- The young women’s world and their role in it
- How they see themselves as women
- Their attitudes and that of their influencers towards breastfeeding and bottle feeding
- The influence of partners, peers and parents in their lives
- Appropriateness of current service provision in relation to feeding
- Attitudes and perceptions of key stakeholders in relation to current and future services
A number of key insights were gained from the focus groups, desk research and stakeholder expertise:
- The young women do not believe breastfeeding is for people like them – It is for ‘yummy mummies’
- They are interested in and influenced by glamour, brands, image and celebrity, but are fickle about celebrity – stars are here today gone tomorrow. They cannot identify their ‘issues’ with those of celebrity mums
- They cannot identify with national campaigns
- They do not wish to expose themselves in front of their parents. Mothers and their immediate network see breastfeeding as ‘weird’, incestuous, embarrassing – something that is uncomfortable to see
- Breastfeeding in public is not accepted within their community – Trust networks are incredibly strong and many girls do not travel far outside of their community
- The babies’ fathers, mum’s friends and her own parents are key influencers
- Support from each other helps them continue feeding
- There is confusion about what is best – The target audience does seek advice and is receptive
- They can feel isolated and seek refuge online where support is not available at home
- Self-esteem is an issue
A range of barriers to breastfeeding were identified through the project’s research phase:
- ‘I wasn’t breastfed, it’s not a done thing in my family’
- ‘It’s something earth mothers or hippies do’
- Fear of failure
- ‘It limits my life - I can’t drink, smoke or take medicine when breastfeeding’
- ‘My boobs are mine and my partners – they’re for sex, not for babies’
- ‘What if my baby gets hungry when there’s nowhere private to feed him/her’
- Bottle feeding’s easier
- ‘I want my body back as soon as possible’
The interventions would need to minimise these barriers and maximise the benefits as part of the exchange process. While these were all identified as crucial factors, the key incentive for behaviour change would be an emotional, value-based one. Health messages about breastfeeding are generally familiar to young mums. However, on their own they are not enough to shift attitudes and perceptions. More important would be to emphasise young, breastfeeding mums as achievers, doing a brilliant job for their baby:
‘Breastfeeding is your achievement – your baby will get the best start in life because of you – it’s something amazing that only you can do.’
The focus groups and meetings with Little Angels peer supporters and breastfeeding coordinators also identified the following factors as competing for mums’ attention and intention to breastfeed, which would need to be addressed by any campaign developed:
- Vast marketing budgets of formula companies – TV/press and advertising in Emma’s diary, in Bounty packs and, in some areas, in doctors surgeries
- Lack of identification with national marketing material, resulting in lack of knowledge about health benefits – For example, assumption that bottle-feeding is the healthiest option because of the benefits listed on the tin
- In many cases, lack of support from peers, family and partners – Some girls' support networks actively discourage them from breastfeeding, seeing it as something ‘unnatural’ or ‘gross’
- Issues around body image, style and vanity
Based on national and local evidence, Be A Star sought to prioritise the following segments:
- 16- to 25-year-old mums, white and mixed race ethnicity, in low paid or no employment
- Their peers
- Their partners
- Their families
Be A Star aimed to increase initiation of breastfeeding amongst mothers aged 16 to 25. However, the breastfeeding steering group also identified that the work should be particularly targeted at young mothers from deprived areas. Consequently, the project initially focused on four deprived wards (Ingol, Brookfield, Fishwick and St Matthews) to reach 300 mums and their trust networks. Based on each mum having three key figures in their trust network, this equates to a target group of around 900 people.
An initial multi-agency planning day was hosted to discuss the findings from the research and to brainstorm campaign ideas. This event included representatives from the PCT, peer supporters, health visitors, as well as the local radio station that would later host radio adverts developed for the campaign.
Creation of Be A Star branding and campaign
Following this initial planning day, and based on the initial research phase, The Hub created three concepts. These were pretested with the target audience before the Be A Star approach was selected for development, which was the approach clearly favoured by the target audience. Small amendments were made based on comments from the target audience and stakeholders before the final branding and materials were produced.
The Be A Star branding and materials were based on the findings that young pregnant women were attracted to celebrity culture and the glamorous lifestyles that went along with this, yet they were also more likely to respond to real situations and real people. Subsequently, the Be A Star branding and imagery shows real young mums breastfeeding, styled in a variety of glamorous celebrity roles. The visual materials aim to create the image of breastfeeding as something cool, glamorous, stylish and something to be proud of. They also aim to assert young women’s independence and provide positive role models to show young women that breastfeeding is ‘for them’.
“The insight we had showed that there wasn’t much information out there aimed at our target audience. It was all aimed predominantly at white, middle-aged, middle-class women. Our young women weren’t engaged with that information. Our insight showed that our women were really into glamour, into celebrity culture, it’s obviously inspiring to be something like a singer, a rock star, or an actress. We liked the idea of using real women, as the evidence confirmed that people will listen more and respond more to real situations and real people, rather than the lady in the fussy white towel which makes breastfeeding look so clinical.” (Glenis Tansey, Public Health Specialist)
Young mums already involved in the young mums groups and the peer support network were invited to be involved in the Be A Star campaign by becoming one of the ‘Stars’ and having a glamorous photo shoot.
The budget did not allow for four separate strands to be designed for each segment (young mums, peers, partners and families), so Be A Star used the eyes and voices of partners, family members and babies to describe the breastfeeding mother, thus appealing to all of the target audiences.
For instance, posters read:
‘Look at my daughter, she’s an inspiration: she’s absolutely besotted with that baby and it makes me so proud to be her mum’
‘Look at my mum, she’s amazing: from the second I was born she’s loved me with everything she has. And by choosing to breastfeed she’s protecting me against diabetes and reducing her chances of getting breast cancer’
Radio ads were also developed, which feature the voices of proud partners, parents and grandparents, praising their girls and describing the amazing thing they are doing by breastfeeding.
To overcome other barriers to breastfeeding identified by young mums in the scoping phase, the campaign had to be supported by further interventions. Consequently, a strong service delivery arm was developed to sit alongside the marketing materials, whereby Little Angels and Breast Mates peer supporters would provide in-home support for breastfeeding mothers and a 24-hour, on-demand helpline. This means that at any time of the day or night, girls or their partners or peers can reach a trained and accredited peer supporter for immediate help, encouragement and advice.
For those localities that do not have a 24-hour helpline, a two-way SMS system would be set up to provide 24-hour advice and support to mothers via text in the 12 weeks following hospital discharge.
A website and blog were developed to provide support, information and signposting for women, partners and families on a range of breastfeeding and wider issues.
A stakeholder and communications plan and dedicated materials called ‘Create a Star’ were developed to gain buy-in amongst health and maternity professionals, encourage the recruitment of new breastfeeding mothers, and increase the reach and sustainability of the campaign.
Due to the tight timescales for the work leading up to the launch of the campaign, daily updates were sent by The Hub and Little Angels peer support to the project manager to ensure deadlines would be met and everything would be ready for a coordinated delivery. Progress was regularly fed back to the breastfeeding task group at Central Lancashire PCT and the breastfeeding coordinators from the three other PCTs.
The Be A Star brand and materials were launched in March 2008, alongside the peer support and training for health and maternity professionals. Leaflets, posters and postcards were displayed at children’s centres, libraries, colleges, schools, leisure centres, GP surgeries, shopping centres, bus stops and telephone kiosks. Roll out of the marketing materials was coordinated with the eight-week radio campaign aired on local stations Rock RM, Magic and 2BR. This was timed to lead up to the World Breastfeeding Awareness Week in May.
“We were pretty coordinated in how we circulated the supporting materials – we linked them up with breastfeeding awareness week, they went out to acute trusts, it was supported by peer supporting on the wards, we had the hospital engaged – putting up the posters, handing out the leaflets.” (Glenis Tansey, Public Health Specialist)
The materials and visuals were seen to be a great success, prompting much discussion and praise. In particular using the voices of family members and peers on the posters and radio adverts was seen to be crucial, as this really helped to address some of the perceived barriers identified during the scoping phase.
"The babies' fathers, the mums' friends and her own parents are far more influential with this group than anything or anyone else. We identified real barriers to breastfeeding because of attitudes and cultural perceptions, so using the voice of people in the materials worked really well." (Glenis Tansey, Public Health Specialist)
One element of the campaign that had been discussed during the development stage was a viral campaign, including a video to be launched on YouTube. Unfortunately due to a number of issues around which music and soundtrack could be used, this did not go ahead as planned.
One unexpected success that came out of the work in Central Lancashire was that one of the three ‘Stars’ who was brought on board to be a peer-to-peer supporter and featured in the marketing materials enrolled on a midwifery course within six months of being involved in the campaign. Her desire to take this path came as a result of her experiences supporting other mums to breastfeed.
Breastfeeding initiation rates within 18- to 25-year-olds increased from 52 per cent in March 2008, prior to the launch of the campaign, to 63.6 per cent (April 2008) and 63.0 per cent (May 2008). Breastfeeding initiation rates for all mums in the locality also increased from 66 per cent to 71.5 per cent (May 2008).
After the initial campaign burst, breastfeeding initiation rates amongst 18- to 25-year-olds decreased (although never below the pre-campaign levels) and then increased again to 56.3 per cent (2009 average) and 57.8 per cent (2010 average).
Breastfeeding initiation rates within 18- to 25-year-olds increased from 52 per cent in March 2008 to 63.6 per cent (April 2008) and 63.1 per cent (May 2008). Breastfeeding initiation rates for all mums in Central Lancashire also increased from 66 per cent in March 2008 to 70 per cent in May 2008.
Further results include:
- Empowerment, with three ‘Stars’ becoming peer-to-peer supporters and one enrolling on a midwifery course
- Positive feedback of mums’ experiences following access to peer support and the online blog
- By November 2010 there had been 65,552 visits to the Be A Star website
- Extensive media coverage, regional, national and international
A tight original budget, combined with short delivery timeframe, meant that the first phase of Be A Star was not evaluated as soundly as hoped. However, as the project has now been commissioned for further roll-out in other PCT areas, much clearer evaluation mechanisms have been integrated from the start, including collection of the following data:
- Breastfeeding initiation figures per ward, per PCT, for the target age group specifically, pre- and post-intervention
- Breastfeeding initiation figures, per ward, per PCT, for all age groups, pre- and post-intervention
- Breastfeeding figures at six weeks for the target age group, pre- and post-intervention
- Breastfeeding figures at six weeks for all age groups, pre- and post-intervention
- Number of calls to the 24-hour helpline, before and after campaign launch
- Number of peer-support visits, pre- and post-intervention
- Website data, such as the number of hits on the website and number of posts on user blogs
Following the original Be A Star project in Central Lancashire, Blackburn with Darwen, East Lancashire and Bolton, the campaign has been rolled out to 11 other PCT areas during 2008 to 2010:
- NHS Barnsley
- NHS Blackpool
- NHS Cumbria
- NHS Doncaster
- NHS North Lancashire
- NHS North Yorkshire and York
- NHS Rotherham
- NHS Salford
- NHS Solihull
- NHS Tower Hamlets
- NHS Wirral
When implementing these further executions of Be A Star, The Hub conducts primary, qualitative research with pregnant women and bottle-feeding mothers from the target audience and their influencers – namely grandparents, friends and, crucially, partners. This has included self-completion questionnaires, focus groups, dyads and depth interviews. In addition to research with primary audiences, insight has been gathered with stakeholders via focus groups and tele-depth interviews.
Based on this further research, Be A Star has since incorporated material produced specifically for partners, as well as a pack for retailers to become ‘breastfeeding friendly’:
- For dads – Materials have been developed for fathers to be distributed at the 20-week scan or the nearest midwife visit following the scan. A dedicated section – ‘Dads and breastfeeding’ – has been added to the campaign website and tailored support for fathers is now available via the 24-hour helpline.
- For retailers – Packs for retailers have been developed to encourage them to become ‘breastfeeding friendly’, which includes: a letter (from the NHS to the retailer) to introduce the scheme; window and till stickers to demonstrate to customers that they are part of the scheme; and A4 Be A Star posters and A6 postcards to promote the message to the community in the premises.
A Be A Star ‘knowledge sharing hub’ is being developed for all localities to share learning and best practice and encourage active participation in online networking through the Be A Star blog.
In Central Lancashire, the cost of renewing the Be A Star intellectual property rights license has been built into the budget for breastfeeding, to ensure that the posters and branding can be continued to be used by Central Lancashire PCT. The breastfeeding peer support continues to be implemented alongside this.
“Plan, plan, plan! Have clear budgets, clear timeframes, and just invest lots in planning.” (Glenis Tansey, Public Health Specialist)
Due to tight budgets, the focus groups in Central Lancashire were undertaken by the PCT. However, The Hub was not furnished with transcripts from these focus groups, since these were unavailable due to the informal nature of the research. This delayed the insight gathering and mining until further research was undertaken by The Hub.
Robust research conducted in new localities, in combination with shared learning, ensures campaign efficacy and supplies baselines against which to evaluate at key milestones.
“We would have absolutely loved to have had the time and the budget to do a lot more focus groups. So we had to be quite resourceful – we used existing networks, existing data, did a bit of profiling with Mosaic, and did testing with focus groups in existing networks.” (Glenis Tansey, Public Health Specialist)
Linking the campaign objectives to partners' strategic aims helped facilitate smooth and immediate stakeholder buy-in, which was vital given the tight timeframes. Pooling of insight, theory and experience overcame issues with informal audience insights, and the innovation and creativity of the campaign was embraced by all partners.
With more time, the team would have engaged more with district councils, retailers, cafes and other community venues to create more breastfeeding-friendly places and to help normalise breastfeeding.
Lines of communication were strong. However, formalisation of roles, responsibilities and milestones prior to the original campaign launch by the first four PCTs could have been improved. Since the original launch, steering groups of multi-partner agencies have been established to formalise roles, share objectives and gain buy-in from the start.
Timescales for the initial launch were incredibly tight, putting pressure on partners (there was a five week turn-around). This resulted in lack of formalisation of partner roles, leading to confusion amongst stakeholder groups as to their role at times. The timescales and budget restraints meant that The Hub was also unable to host or attend further focus group sessions.
Develop a formal evaluation plan from the beginning and build in proxy indicators. An evaluation budget was not available at time of launch, therefore results pulled together by The Hub had to come from outside of the campaign budget.