Challenging Dogma - Spring 2008

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

Friday, April 18, 2008

Loving Support Might not be Enough: A Critique of a Breastfeeding Promotion Campaign Marketed Through the Theory Of Planned Behavior – Reagan Kane

Low breastfeeding rates persist in certain populations despite the obvious benefits to both the child and the mother. Breast-fed infants develop an enhanced immune system and have a decreased risk of childhood obesity and several chronic diseases (1). Breastfeeding positively impacts the mother by facilitating uterine recovery and in developing a bond with the newborn, among many other benefits (1). Evidence shows that 59.7% of women with higher incomes breastfed in the hospital and 21.6% continued to breastfeed at six months. Compare this to women of lower incomes, where 46.6% breastfed in the hospital and a mere 12.6% breastfed at six months (2-3). There is an obvious need to increase these rates among women of low income.
Despite the scientific knowledge of the benefits of breastfeeding, there are many other factors that will influence a woman’s decision. These include social, cultural, and psychological factors. As a health behavior, breastfeeding is guided not necessarily by empirical evidence from years of research, but by underlying attitudes, skills, beliefs, and perceptions of what others think (4). Many people close to the mother will have strong opinions of breastfeeding. Equally as important as a strong opinion in the decision to breastfeed is a neutral attitude among physicians and nurses (4).
The Supplemental Nutrition Program for Women, Infants, and Children (WIC) uses the “Loving Support Makes Breastfeeding Work” (LSMBW) campaign to encourage women of low income to breastfeed their infants. While it is national in scope, it is implemented through state agencies. The campaign goals are well laid out and include: encourage WIC participants to initiate and continue breastfeeding; increase referrals to WIC for breastfeeding support; increase general public acceptance and support of breastfeeding; and provide technical assistance to WIC State and local agency professionals in the promotion of breastfeeding (2).
The way health care professionals attempt to achieve these goals is not effective. A series of videos are shown and pamphlets are given out, each tailored to a specific goal (2). But how can breastfeeding in this population increase simply by watching a video and reading a pamphlet? The campaign borrows on many ideas of the Theory of Planned Behavior, and falls short in empowering women of low income to initiate breastfeeding in the hospital and continue past discharge and in to the real world.
Health Care System and Self Efficacy
Self efficacy is the expectancy related to an individuals belief that he or she can execute the actions necessary to achieve a goal (in this case, breastfeeding) (5). If self efficacy does not exist regarding a certain behavior, no motivation to do the behavior will be allocated to it. Whatever health behavior that is being targeted by the intervention will not change if the predicted self efficacy toward the behavior in a population is miscalculated. Self efficacy is malleable, and can be positively influenced. In the case of breastfeeding initiation and continuation, it can be influenced by supportive, knowledgeable, and encouraging health care providers (5).
At the individual level, LSMBW assumes that self-efficacy will result from being counseled on the benefits of breastfeeding during prenatal visits and at the hospital with the use of the campaign’s materials. This, of course, can not happen unless health care providers feel comfortable and confident to dispense breastfeeding promotion information and support. Unfortunately, many health care providers do not feel confident with their knowledge of breastfeeding, or fail to even mention it as an important issue (6). One of the main reasons mothers of lower income status will not be able to achieve self efficacy (as is one of the program’s assumptions) is the lack of follow-up and support from the medical field.
Many women enrolled in WIC report that lack of support or even a neutral attitude about breastfeeding by a health care provider greatly influenced their decision to not breastfeed (6). One study found that one third of physicians and nurses did not encourage their patients to breastfeed, or missed key opportunities to support and follow-up with patients (1).
The LSMBW campaign attempts to remedy this situation by distributing a Breastfeeding Resource Guide to providers, publishing articles describing the program in state professional newsletters, and implementing a training program called “How to Support a Breastfeeding Mother” that hospitals and clinics can participate in. These steps seem rather short-sighted; if, in fact, the goal is to give women confidence to breastfeed, education must start in medical or nursing school on the importance of breastfeeding education and support.
The Social Network and Perceived Norms
Social networks have always played an important role in determining what constitutes appropriate behavior. These social beliefs can determine whether breastfeeding is perceived as good or bad, and how long is appropriate. Social norms can be particularly important to a first time mother who is more likely to ask for advice and consider other’s opinions (4). The Theory of Planned Behavior explicitly defines social norms as the perceived social pressure to perform or not perform a behavior (5). In regards to breastfeeding, and especially in low income women, those most important in influencing social norms are the woman’s mother, grandmother, and significant other (4).
Therefore, family support is critical in the role of breastfeeding. The perceived norms in low income families are actually to not breastfeed. It is seen as embarrassing, inconvenient, and discouraging to the father’s involvement with the child (7). Also at the social network level is the woman’s occupation and the professional support given. Two thirds of working mother’s of low income return to work within six months post-delivery. They are also more likely to have a job that makes breastfeeding rather difficult, whether it is because of the type of job or the fact that there is no on-site child care (1).
LSMBW focuses mainly on the mother and changing her perceived norms (although not very successfully). However, one of their key messages is “the involvement of family and friends to make breastfeeding a success” (2). Much like the material given to the new mother, the campaign attempts to educate fathers and other family members via a two page informational pamphlet. If the LSMBW campaign wants to change an entire social network’s beliefs about breastfeeding in order to help the mother, it almost certainly will take more than an informational pamphlet for this to happen.
Among the WIC women who do initiate breastfeeding, one of the major barriers for the continuation of breastfeeding is their occupation and the lack of professional support. Studies have shown that women who return to are at a higher risk of discontinuing breastfeeding than those who do not return to work (2,7). Women of low income are more likely to need to return to work within three to six months post-partum compared to their higher income counterparts. The campaign put together a presentation, in the form of a CD, that they can distribute to employers entitled “Creating a Breastfeeding Friendly Workplace: Loving Support Makes Breastfeeding Work” (8). There is no literature that supports this presentation as having the ability to change the perceived norms and attitudes of the workplace or employers, thus, low income women are left to advocate for themselves.
Shortcomings of the Theory of Planned Behavior
LSMBW based partially upon the Theory of Planned Behavior does not consider many variables which affect breastfeeding initiation and continuation. Mother’s health, lifestyle, and education, as well as previous breastfeeding experience should be considered but are not a part of the intervention model. All of these variables could certainly affect breastfeeding initiation outside the hospital, and need to be taken into account when designing a program.
Among the most predictive lifestyle factors that influence breastfeeding are education, age at first birth, and marital status. WIC participants are, on average, less educated, younger at first birth, and less likely to be married or have the father living in the home (9). The interaction between lifestyle factors most associated with WIC participants and health behavior is a controversial and much debated issue. There have been somewhat inconsistent results as to what can best predict health behaviors (9). Still, it has been considered that these factors can contribute to the decision to not breastfeed (1). One survey found that these factors made WIC certified women half as likely to initiate breastfeeding (8).
Although strengths of these results can vary, lifestyle factors and health behaviors are all extremely important to consider. Breastfeeding promotion might need to start even before pregnancy, to focus on these issues so that future mothers are more likely to breastfeed their infants. Unfortunately, room for these issues, and others like them, have been left out of LSMBW and many other health behavior intervention programs.
There are so many obvious benefits to breastfeeding, and very few (and rare) drawbacks. Rates are far from the Healthy People 2010 goal of 75% of women initiating breastfeeding, especially for low income women (10). The field of Public Health has attempted to increase these rates, as evidenced through the LSMBW campaign. However, the designers of these campaigns are not focusing on the beliefs and attitudes that need to change in order to accomplish the programs goals. Moreover, the campaigns do not always focus on the correct people, including the father of the child and the woman’s mother and family. There is room for improvement in the health care system if women are supposed to feel confident to breastfeed. In addition, assumptions made on the social network and the society levels need to be examined in a new and creative way to allow for a breastfeeding-friendly community. Until then, a large amount of low income women and their children will not have the benefits breastfeeding brings.
1. Khoury A, Moazzem S, Jarjoura C, Carothers C, Hinton A. Breastfeeding Initiation in Low Income Women: Role of Attitude, Support, and Perceived Control. Women’s Health Issues. 2005. 15: 64-72.
2. WIC Learning Center. 2007. Available at Accessed February 21, 2008.
3. USDA National Breastfeeding Promotion Campaign: Loving Support Makes Breastfeeding Work. 2005. Available at
Accessed February 21, 2008.
4. Swanson V, Power K. Initiation and Continuation of Breastfeeding: Theory of Planned Behavior. Journal of Advanced Nursing. 2005. 50(3): 272-282.
5. Vancouver J, More K, Yoder R. Self Efficacy and Resource Allocation: Support for a Nonmotonic, Discontinuous Model. Journal of Applied Psychology. 2008. 93(1): 35-47.
6. Mitra K, Khoury A, Carothers C, Foretich C. The Loving Support Breastfeeding Campaign: Awareness and Practices of Health Care Providers in Mississippi. Journal of Obstetrics, Gynecologic and Neonatal Nursing. 2003. 32(6): 753-7
7. Racine E, Frick K, Guthrie J. Individual Net-Benefit Maximization: A Model for Understanding Breastfeeding Cessation among Low-Income Women. Maternal and Child Health Journal. 2008. Online but not yet published.
8. Smith, C. Multimedia Review: Creating a Breastfeeding Friendly Workplace: Loving Support Makes Breastfeeding Work. Journal of Human Lactation. 2006. 22: 459-461.
9. Lantz M, House JS, Lepkowski JM, Williams DR, Mero RP, Cheng J. Socioeconomic Factors, Health Behaviors, and Mortality: Results from a Nationally Representative Prospective Study of US Adults. Journal of the American Medical Association. 1998. 279(21): 1703-1708.
10. Wolf J. Low Breastfeeding Rates and Public Health in the US. American Journal of Public Health. 2003. 93(12):2000-2010.

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  • At April 23, 2008 at 10:11 AM , Anonymous Jackie said...

    Also of interest is that there is an "informational CD" that women with "unfriendly" breastfeeding environments are supposed to hand to their employers. This might be effective in a large cooperation, where you could send the CD to HR, but how would this work in the sort of situation that many of these mothers are in? Are they supposed to give it to the manager at the retail store? Could you even imagine how embarassing that might be for someone in an already fragile situation?

    Along the same lines, what is a new father going to do with a two page informational packet? "Hey honey, it says here in this bullet point..."

    Without back up social support, it seems like a pamphlet and a CD for the employeer don't give the mother much to stand on.


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