Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Monday, April 21, 2008

“Babies Were Born To Be Breastfed" Campaign Fails to Capture the Complexity of the Issue for First Time Parents – Sara Hoffman

The National Breastfeeding Campaign does not effectively support or promote breastfeeding practices among new mothers and their families. This paper will provide a brief background on the importance of breastfeeding and the creation of the National Breastfeeding Campaign. Using McGuire’s Communication/Persuasion Matrix, it will then analyze the campaign and demonstrate its three main weaknesses: using a patronizing source, not segmenting the audience and delivering a message that lacks empowerment.

Breastfeeding is Best
Breastfeeding can be an amazingly profound experience for both mother and child. Breast milk is nutrient-rich and provides passive immunity, giving a child a healthy start in life (17, 18). Few dispute the overall importance of breastfeeding, as research demonstrates that for both health and economic reasons, breastfeeding is the best choice for a family. Babies who are exclusively breastfed for six months are less likely to develop common health problems such as ear infections, diarrhea and respiratory illnesses. Babies who are breastfed face lower risk for chronic diseases as well, such as diabetes, celiac disease, inflammatory bowl disease, childhood cancer, allergies and asthma (12, 14, 17-19). Mothers also receive benefits from breastfeeding beyond bonding with their babies, including positive hormonal, physical and psychosocial effects. Additionally, breastfeeding delays menstruation and fertility, increases self-confidence and may even reduce the risk of breast and ovarian cancer (14, 17). Economically, breastfeeding is a much cheaper option than formula. Plus, considering the health benefits outlined above, fewer visits to the doctor can be cost saving (14, 17).

Despite the overwhelming evidence that breastfeeding is the best choice to make for a baby, there are still women and families who “choose” not to breastfeed their babies. Reasons for not breastfeeding include cultural and economic factors, employment, and being physically unable to breastfeed (2, 4, 6, 8-10). Data taken in 1998 showed:
• Only 64% of women tried to breastfeed in the early postpartum period
• By 6 months, only 29% were still breastfeeding
• At 1 year, only 16% were still breastfeeding (7, 12).
Healthy People 2010 has outlined a goal for improving rates of breastfeeding; namely, to increase mothers who initiate breastfeeding to 75%, who exclusively breastfeed through 6 months to 50%, and who continue up to 1 year to 25% (7, 17).

National Breastfeeding Campaign
In 2004, in response to these statistics and to further the Healthy People 2010 goal, the Office of Women’s Health (OWH), a division of the US Department of Health and Human Services (DHHS), sponsored the National Breastfeeding Campaign (NBC) (12). The NBC targeted first-time mothers and fathers who would otherwise not have chosen to breastfeed their baby (12). The campaign claimed to be “aimed to empower women to commit to breastfeeding and to highlight new research that shows that babies who are exclusively breastfed for six months” have increased health benefits (3, 12). OWH collaborated with Ad Council, a private, non-profit marketing company, to develop the slogans “Babies were Born to Be Breastfed” and “You’d never take risks before your baby is born. Why start after?” DHHS called the messages “empowering and compelling” (3, 12). The campaign included radio and television public service announcements, print ads in magazines, pamphlets, billboards and posters, as well as a breastfeeding help line service (12). The purpose of the campaign messages was to spread awareness about the positives aspects of breastfeeding and encourage more women to breastfeed (3, 12).

However, affecting behavior change is more complex than providing information and relying on individuals to make rational decisions and changes regarding their behaviors, especially with respect to their health. Accordingly, public health messages often fail in effecting behavior changes (11). McGuire’s Communication/Persuasion Matrix provides a detailed framework for planning a communication action plan to initiate attitude and behavior changes. He outlines five specific elements of a strong communication plan: source, audience, channel, message and destination (11). Drawing from McGuire’s theory, along with the basic principle of “audience segmentation” in Marketing Theory and the self-efficacy principles outlined in the Social Cognitive Theory of behavior change, this paper will show that--despite slightly increased numbers of new parents trying to breastfeed their children--the NBC could have been a much stronger campaign.

Use of a Patronizing Source
The OWH and Ad Council did not consider choosing a good source for the National Breastfeeding Campaign, the first aspect outlined in McGuire’s Communication Persuasion Matrix. The perceived communicator of any message will be the first contact for the audience, so recognizing how individuals will react to that source is essential. Matching the characteristics of the source to the target audience will make a message more openly received and accepted. Characteristics of the perceived source’s demographics include age, race, gender, and socioeconomic status (11). These factors impact persuasiveness by creating the sense of a connection for the audience based on perceived trustworthiness and intent (11). The source of the message is not the same as the funding agency.

The message from the OWH would be more powerful if presented from a source within the target audience itself. The target audience will better relate to a message perceived to be coming from within their peer group than one that seems condescending or directed at them (11, 16). Unfortunately, the message “Babies are Born to be Breastfed” is delivered from the all-knowing standpoint of the government and not from within the audience. To match the source appropriately to the audience, it is imperative that the target audience itself be identified, as is analyzed below.

Non-Segmented Audience

A campaign message must be targeted at a specific group of people with particular needs in order to be successful, which the NBC did not do. McGuire’s Theory refers to target members as “receivers,” and in Marketing Theory they are called the “audience” (11, 16). If the audience is well-defined first, the campaign message can be designed to clearly target those individuals. The message disseminator should consider identified characteristics including demographic variables, cultural experiences, socioeconomic status, educational level, work environment and family (11). Unfortunately, the NBC message is a “one-size-message fits all” because the target is not defined enough to be effective. The message is aimed at the general public, the majority of which is not effected by breastfeeding.

Marketing Theory basics that are used in commercials and product advertisements should also be applied to public health campaigns. Audience segmentation is a central principle of Marketing Theory, and describes how the target audience is broken up so that the message can be directed appropriately (16).

The audience of the NBC is not segmented; rather, the message seems to be intended for the general public. Even the explicitly stated aim of the campaign was to influence first time parents, which is too broad a category and a group that may not have come across the campaign or associated with it (12).

According to author Michael Siegel, in Marketing Public Health, the most important and useful way to initially segment an audience is by current behavior, the “doers” and “non-doers” (16). Otherwise, an intervention may target unnecessary people, namely those who already engage in the target behavior. In the case of the NBC, the lack of audience segmentation means that the message seems to target women who are already breastfeeding--and will therefore not benefit--at the same time as it alienates women who cannot physically breastfeed. Further, targeting first time mothers, as the campaign claims to do, the NBC does not consider differences in SES, education, cultural differences in breastfeeding practices in the United States, race, ethnicity and immigration status, all of which influence a woman’s ability and her choice to breastfeed. Women face different obstacles depending on their personal situations (2, 4, 6, 8-10).

By clearly segmenting and defining target receivers, a message can be created for the audience that it will process actively as opposed to passively (13). It is imperative to target individuals with whom the message resonates--breastfeeding and pregnant women--so that they will be motivated to seek out more information on the topic and the support they need to implement a breastfeeding plan for their family (13).

In addition, the channels through which a message is sent correlate with the lifestyles of the target audience: what television channels they watch, where they work and what they read. Since the NBC fails to segment the audience, it is not possible to tell whether the methods match the goal of the campaign.

Message Lacks Empowerment
Message content and construction for a campaign were not considered in the National Breastfeeding Campaign (11). It is important to decide how the message should be made “emotionally” or “rationally” appealing (16). Generally, emotional appeals are more effective. Specifically, positive emotional appeals are stronger than negative ones or those that initiate fear to produce behavior change (16, 19). Often public health campaigns, like the NBC, try to scare women into breastfeeding their babies by highlighting the dangers of non-compliance. Acting Assistant Secretary of Health Christina Beato, M.D. says: “These new public service announcements speak to parents clearly about the consequences of not breastfeeding, which may help encourage more mothers to initiate and continue to breastfeed exclusively for six months” (3). On the contrary, focusing solely on the negative consequences will alienate mothers rather than make them feel at ease and prepared for breastfeeding.

The words through which the NBC is attempting to “empower” women to breastfeed (the message itself) are ultimately flawed. If women cannot breastfeed, whether they want to or not, they will not. McGuire’s Theory cautions that the unintended effects of a message need to be considered so the campaign does not become a counterproductive exercise (11). The NBC could potentially create shame or guilt among women who are either physically unable to breastfeed or feel like they cannot breastfeed because of cultural, economic or logistic barriers (14). A strong message should be conscious of and avoid the negative consequences that could result.

Based on the alienating message and unclear destination, the NBC fails to incorporate principles of self-efficacy. Self-efficacy comes from Albert Bandura’s Theory of Planned Behavior model and is defined as: the concept of encouraging people to make a change not by telling them simply to do something, but by teaching them how to do it and making them believe that they are capable (15). While the NBC may attempt to be dramatic in order to attract media attention, it could be a more effective public health campaign if it promoted or initiated self-efficacy.

The NBC message “Babies were born to be breastfed” does not empower women to overcome obstacles of breastfeeding, nor does it offer substantial alternatives or provide suggestions for support. The “choice” to breastfeed is affected by so many parts of a woman’s life that she may not control, including her workplace, where she lives and how many other children she cares for, among other things (2, 4, 6, 8, 9, 20). The NBC oversimplifies why women do not breastfeed, ignoring that fact that for some of them, it does not feel like a choice.

The National Breastfeeding Campaign does not clearly target a specific audience or effectively promote or support breastfeeding for new mothers. The message is not empowering; on the contrary, it makes women feel guilty if they are unable to breastfeed.

There is a plethora of evidence that breastfeeding is the best alternative for both a mother and her baby. The advantages range from increasing the health of baby and mother to being the most economical option. In order for public health to encourage these health advantages to play out, campaign messages must be directed at alleviating the specific barriers of each audience. The OWH could help further the 2010 Healthy People goal to increase the number of women who initiate and continue breastfeeding with a more effective campaign design.

It is evident when teasing apart the components of the NBC and comparing them to the 5 elements that McGuire’s Communication/Persuasion Matrix recognizes as strong and effective, that the National Breastfeeding Campaign could have been more successful. The source of the message was external and, rather than inspiring, may have been perceived as patronizing, therefore alienating prospective families from breastfeeding. A clearly identified target audience was lacking and the message was unable then, to recognize and support women based on particular characteristics that can include differences in SES, education, race, culture and ethnicity. The message itself must also recognize the nuances of the target audience and promote breastfeeding by encouraging the self-efficacy of women by making them believe they can overcome their own barriers and take the necessary steps toward making it a reality. It may be true that babies were born to breastfeed, but making the choice to is often more complicated for many families who would benefit more from education and support rather than hearing about the negative consequences of not breastfeeding.

1. Breastfeeding Report Card, United States – 2007: Outcome Indicators.
2. Celi A, Rich-Edwards J, Richardson M, Kleinman K, Gillman M. Immigration, Race/Ethnicity, and Social and Economic Factors as Predictors of Breastfeeding Initiation. Arch Pediatrics Adolescent Medicine 2005; 159; 255-260.
3. DHHS Press Release June 4, 2004.
4. Forste R, Weiss J, Lippincott E. The Decision to Breastfeed in the United States: Does Race Matter? Pediatrics 2001; 108; 291-296.
5. Haynes S. National Breastfeeding Awareness Campaign Results: Babies Were Born to Be Breastfed! U.S. Department of Health and Human Services, Office of Women’s Health. 2005.
6. Heck K, Braveman P, Cubbin C, Chávez G, Kiely J. Socioeconomic Status and Breastfeeding Initiation Among California Mothers. Public Health Reports 2006; 121; 51-59.
7. Increase the proportion of mothers who breastfeed their babies.
8. Kelly Y, Watt R, Nazroo J. Racial/Ethnic Differences in Breastfeeding Initiation and Continuation in the United Kingdom and Comparison With Findings in the United States. Pediatrics 2006; 118; e1428-e1435.
9. Li R, Grummer-Strawn L. Racial and Ethnic Disparities in Breastfeeding among United States Infants: Third National Health and Nutrition Examination Survey, 1988-1994. Birth 2002; 29; 251-257
10. Li R, Ogden C, Ballew C, Gillespie C, Grummer-Strawn L. Prevalence of Exclusive Breastfeeding Among US Infants: The Third National Health and Nutrition Examination Survey (Phase II, 1991-1994). American Journal of Public Health 2002; 92; 1107-1110.
11. McGuire W. Theoretical Foundations of Campaigns (pp.43-66). In: Rice R, Atkin C, eds. Public Communication Campaigns (2nd ed.) Newbury Park, CA: Sage Publications, Inc., 1989.
12. National Breastfeeding Awareness Campaign – Babies Were Born to Be Breastfed.
13. Parrott R. Motivation to Attend to Health Messages: Presentation of Content and Linguistic Considerations. (pp. 7-23). In: Maibach E, Parrott R, eds. Designing Health Messages: Approaches From Communication Theory and Public Health Practice. Thousand Oaks, CA: Sage Publications, Inc.,1995.
14. Rabin R. Breast-feed or Else. New York Times, June 13, 2006.
15. Salazar MK. Comparison of four behavioral models. AAOHN Journal 1991;39:128-135.
16. Siegel M, Doner L. Marketing Public Health: Strategies To Promote Social Change. Gaithersburg, MD: Aspen Publishers, Inc., 1998.
17. U.S. Department of Health and Human Services. HHS Blueprint for Action on Breastfeeding. Office of Women’s Health. Washington, D.C., 2000.
18. Wolf J. Low Breastfeeding Rates and Public Health of the United States. American Journal of Public Health 2003; 93; 2000-2010.
19. Wolf J. Is Breast Really Best? Risk and Total Motherhood in the National Breastfeeding Awareness Campaign. Journal of Health Politics, Policy and Law 2007; 32; 595-636.
20. Visness C, Kennedy K. Maternal Employment and Breastfeeding: Findings from the 1988 National Maternal and Infant Health Survey. American Journal of Public Health 1997; 87; 945-950.

Labels: , ,


Post a Comment

Subscribe to Post Comments [Atom]

<< Home