Dear all:

First, here in NY City, the ads for many health issues are completely in your face.  They 
have shown a mother dying of lung cancer with tubes up her nose worrying about her 
daughter, followed by her daughter mourning her loss after her death and similar 
commercials with those suffering from the effects of their cigarette smoking.  The latest 
is this full jar of black liquid that equates the amount of toxic fluids you accumlate in your 
lungs in a year.  Along with these ads I have seen other ads suggesting where to get 
help.  So it is the punch in the nose followed by the hand reaching out to help.

I think Diane Weisseninger has the right approach.  Having watched a shift in 
international nutrition in our approaches from the lame tired old nutrition education 
messages where mothers were told the "right way" to feed their infants in a boring group 
session with unattractive posters - there was a shift in approach with some innovative 
programs using MULTIPLE approaches.

I don't think I can remember all the five or six P's or S's or other categories used by the 
social marketing organizations - but here's what I remember of the list:

1) Legislation --- some things won't happen without protective legislations.  For example, 
for iodine deficiency --- if you want to ensure that salt is iodized to levels that 
compensate for soil erosion that has made it impossible to get enough iodine from food 
sources --- you have to legislate and back it up with checks on the iodine content from 
the source to the consumer.  And our breastfeeding equivalent is the WHO Code.

2) Product placement --- this means that the "product is accessible" and visible.  For 
instance, if you want people to use a product it is not on the top shelf or tucked away in 
the corner, it is in a highly visible area where everyone can see it and get it.  If schools 
have candy dispensers and soft drinks in their cafeterias as opposed to fresh fruits and 
bottled water --- what foods do you think kids will eat?  Why do you think candy is placed 
at the check out counter at the level that a toddler can reach from the shopping cart? So, 
this means the baby should be in the room with mom if she has a hospital delivery and 
the formula bags should not be there.  As well as, breastfeeding in public should be 
widely practiced and promoted with images so everyone gets over their early training 
that it is the equivalent of elimination.

3) Service delivery --- this means that you have adequate and appropriate help with the 
product.  For instance, if you live in an area of the world where you have to travel 25 
miles on foot or hope you have enough saved to rent a donkey drawn cart, you are 
unlikely to seek health care services unless you are on death's doorstep.  If you have just 
had a C-section, don't own a car, are afraid of germs on the subway and the ground is 
covered with freezing slush, you are unlikely to drag yourself out for a breastfeeding 
support group that is 50 blocks away.  If you don't have enough money (or think you don't 
have enough money) then you are unlikely to call someone in to help.  If, on the other 
hand, you have a health care system that sends someone to your home on the third or 
fourth day that is well trained in how to assist breastfeeding, it is going to make it much 
easier to overcome difficulties in learning how to breastfeed.  If I had Bill Gate's money I 
would spend some of it right now on retraining the staff in many Manhattan hospitals out 
of the RAM method of shoving the head into the breast and have enough trained LCs in 
the city so that every mother would get a visit on the third or fourth day at home if she 
wanted it.

4) Support structures --- here is where Richard Manoff made a light bulb go off in my 
head.  He listed all the things mothers were supposed to do in developing areas to protect 
their infants from illness and death on UNICEF's list. Even though I was single at the time, 
it really clicked in how impossible that was for that mother to do without help. If a mom 
has to walk 15 miles to collect water and to collect firewood as well, she is not going to 
have the energy to boil the contaminated water before her family drinks it, let alone cook 
up fresh complementary food for her toddlers three to four times a day. If a father 
makes all the purchasing decisions and eats all the iron-rich sources of food because that 
is the cultural norm, a mother may not be able to reduce her anemia during pregnancy.  
If he is convinced that buying liver snacks for his pregnant wife will make his wife less 
tired, he may see the value and she may have a better chance at survival during and 
after delivery.  If Manhattan fathers are taught how to make a mother comfortable when 
she is learning how to breastfeed --- how to massage her tense shoulders, prop up a 
wrist that is headed into carpal tunnel territory from the "death grip" on her baby's head, 
bring her glasses of water and tasty snacks --- think how much easier that will make it 
for her to learn how to assist her baby to breastfeed and not decide to delegate her 
mothering to a baby nurse. 

5) Channels of communication ---- it is very important to identify the many different 
channels of communication.  It is not enough to have one channel.  Some of us are only 
working through one channel of one on one contact.  Some of us also do classes and have 
another means of communication.  Some work in public health and have various media 
sources at our disposal.  All of these channels should be accessed to reach women AND 
the influencers around her.  Some of the best social marketing messages I have seen in 
developing areas have NOT targeted the mother herself.  An example would be "Friends 
don't let Friends drive drunk".

I'm sure I am missing many points that a social marketing would have at the tip of their 
tongue but I will jump to TIPS which I have mentioned before.  I found it shocking at first.  
Nutritionists tend to get very preachy about the "RIGHT" foods to eat.  This approach 
doesn't usually work.  TIPS means "trials of improved practices" and this is what I often 
see good lactation consultants do.  We all know the "ideal" ---- that rosy picture of what 
we would like to see for all mothers.  Yet, mothers may cling to societal misinformation 
despite our best efforts at providing "evidence" or "logic" to convince her to do otherwise.  
So, we strive for improved practices on her part in a back and forth dialogue.  It will not 
be perfect, it will not be the ideal, it may not be what we would have hoped --- but we 
acheive more than would have happened without the dialogue and back and forth over 
what the mother is capable of doing or "thinks" she is capable of doing.

I'm sure someone who has kept up with social marketing strategies could do this topic 
more justice --- so feel free to pipe up with your comments.

Best, Susan Burger

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