Challenging Dogma - Spring 2008

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

Friday, April 18, 2008

The National Breastfeeding Campaign: A Dubious Attempt At Moving Beyond The Health Belief Model – Kerin Arora

Prior to the launch of the National Breastfeeding Campaign, Babies Were Born to Be Breastfed in 2004, the rate of children having ever been breastfed in the United States was 71%. However, the rate of exclusive breastfeeding drops precipitously to 42.5% at 3 months and a mere 13% at 6 months (1). The fact that over two thirds of children were breastfed at some point is evidence for the notion that women are aware breastfeeding is beneficial to the health of their children. The benefits of breastfeeding for both the mother and infant are numerous. For example, breastfeeding has been shown to aid in a child’s healthy brain development thereby helping children attain their cognitive milestones at age appropriate times (2). In addition breastfed babies have healthier immune systems leading to fewer ear infections or gastrointestinal problems than babies who are fed infant formula (3). Also, mothers who breastfeed have lower incidences of ovarian and premenopausal breast cancer as well as a reduced risk of postpartum bleeding (4). Finally from an economical perspective, six months of exclusive breastfeeding has been found to save families nearly $500 when compared to families of formula fed infants (5). Unfortunately, despite the many benefits of breastfeeding, exclusive breastfeeding rates beyond 3 months of age are low (1). Reasons for the significant drop in breastfeeding rates have been studied. One such study found that the main predictors of continued breastfeeding were: 1. The mother’s perception of the father’s attitude toward breastfeeding 2. Time required to breastfeed or pump breast milk, and 3. Adequacy of the mother’s milk supply (6).
In order to improve breastfeeding rates, the campaign, Babies Were Born to Be Breastfed was launched nationally. The campaign is comprised of television advertisements, radio announcements and posters to support breastfeeding. In attempt to move beyond the traditional Health Belief Model of past public health campaigns, Babies Were Born to Be Breastfed employs social science principles that draw upon emotion rather than rationality. Regrettably, the progressive, emotion-centered campaign will still likely fail to improve breastfeeding rates for the following reasons: 1. The campaign capitalizes on fear to convey its message. 2. The campaign’s television component may be too extreme to elicit a serious response from its viewers. 3. The campaign fails to incorporate a model of self-efficacy into its approach.
The problem of employing fear as a tactic for behavior change
The message portrayed in the Babies Were Born to Be Breastfed campaign attempts to scare women into breastfeeding their infants. The television ad flagrantly urges that a lack breastfeeding will significantly harm a child. The two ads consist of pregnant women partaking in risky behaviors. In one ad, a woman is riding a bull while pregnant and in the second ad, women are partaking in a log-rolling competition while pregnant. As the commercial progresses, the message stating “you wouldn’t take risks before your baby’s born, why start after” appears on the screen (7). This commercial attempts to frighten new mothers to comply with breastfeeding without positively supporting them alongside. Instilling fear in a population has been shown to be ineffective at eliciting behavior change unless a component of support and self-efficacy is addressed (8). In the television ad, the fearful images are not coupled to positive and supportive images of breastfeeding. Instead, the viewers are only left with unsettling and frightful images of pregnant women bull riding or log-rolling.
The fear tactic as a motive for behavior change is effective when employed correctly (9). For example, fear can be a good motivator to stop unhealthy behavior if the consequences of the unhealthy behavior are shown. If similarities between the audience and the fearful example can be drawn, then eliciting fear can be an effective choice. However, Babies Were Born to Be Breastfed does not draw upon fear in a way such that the audience can relate to that fear. Without a clear relationship between the audience and the fearful tactic established, the use of fear as an instrument of behavior change fails (9). If instead of the frightful log-rolling image, the commercial portrayed a formula fed baby with chronic ear infections, perhaps the fear tactic would have been more plausible.
Although there are distinct situations when employing fear tactics can be beneficial, with regards to highly emotional situations, positive and supportive imagery has been found to be a more effective means to behavior change (10-12). Since pregnancy and motherhood are emotional times, it is reasonable to believe new mothers will be more inclined to breastfeed from positive breastfeeding imagery than from the use of fear as a motivator.
The faults of the campaign’s extremism
It is plausible to believe pregnant women log-rolling or riding mechanical bulls is beyond the comprehension of most expecting mothers. These images may perhaps be too extreme to be believable thereby forcing viewers to disregard the message entirely. When a relationship or similarity cannot be drawn between one’s own life and the message conveyed, changing behavior to follow the conveyed message is difficult (9). In this particular campaign, it is hard to fathom that expecting mothers will associate themselves with the women engaging in the risky activities shown in the television commercials. The disengagement between the audience and the ad may leave the audience feeling that they can ignore the message because they do not associate themselves with the women portrayed on television.
In addition to women ignoring the message because it is not relatable to their lives, the extreme scenarios depicted in the commercials may also cause women to become defensive against the campaign and breastfeeding as a whole. The campaign implies women who do not breastfeed are exceedingly dangerous to their babies. However, the level of risk associated with log-rolling while pregnant greatly exceeds the level of risk associated with nourishing infants with formula. By utilizing this extreme analogy, women who don’t breastfeed are left feeling like unfit mothers (13). This feeling of inadequacy can lead to defensive behavior (14). Unfortunately, defensive behavior may lead to a conscious decision to not follow the advice of the particular program and instead continue defending one’s own stance (14). If women become defensive against the commercial and breastfeeding, the entire campaign is at risk of being ineffective.
The campaign leaves women without a sense of self-efficacy
Lastly, in addition to the extremism and fear tactics of Babies Were Born to Be Breastfed, the campaign falls short most egregiously by neglecting the concept of self-efficacy. Public health messages targeting smoking cessation, increased exercise, contraception, and alcohol abuse have all shown success when encouraging a sense of self-efficacy in their target audience (15). Because self-efficacy has been an integral component of the success of myriad public health interventions, it is likely that promoting self-efficacy in the public health campaign, Babies Were Born to Be Breastfed would also be beneficial. However, the campaign neglects to include ways to promote self-efficacy and is therefore at risk of becoming a public health failure. If instead, the campaign empowered women who would consider breastfeeding by highlighting the notion that breastfeeding is possible for both women in the workforce and women in the home, the campaign is likely to have more positive effect. In addition to instilling a sense of self-efficacy among women who can breastfeed, Babies Were Born to Be Breastfed should also incorporate empowerment and self-efficacy in persons unable to breastfeed. However, this population of soon-to-be parents is ignored in the campaign.
Instead of empowering persons unable to breastfeed, Babies Were Born to Be Breastfed is entirely insensitive and neglects this population completely. According to the World Health Organization (WHO), women with diseases that can be transmitted through breast milk such as HIV are discouraged from breastfeeding when infant formula is readily available (16). In addition, adoptive parents or single father families do not have the option of breastfeeding their infants. After viewing the television ads for Babies Were Born to Be Breastfed, this subset of new parents is left without any sense of self-efficacy. Instead of encouraging this population to seek alternatives to infant formula such as wet nurses or milk banks, the campaign may leave these people feeling hopeless. The lack of self-efficacy may again lead to defensive behaviors similar to the effects of negative extremism (14). By augmenting the campaign and adding a segment sensitive to the needs to non-breastfeeding parents, a sense of empowerment and self-efficacy could be instilled in that population .
The national breastfeeding campaign, Babies Were Born to Be Breastfed will likely become an unsuccessful public health intervention due to its blatant disregard for any sort of positive imagery. The campaign focuses on fear instead of empowerment, negative extremism instead of the positive health outcomes of breastfeeding, and finally low self worth instead of self-efficacy. Alternate approaches could have been successful by highlighting and reinforcing the benefits of breastfeeding with an educative component. In addition, a campaign aimed at changing the social norms of breastfeeding by aiming to make breastfeeding more socially acceptable may also have been more effective than the current negative campaign. In order to make breastfeeding more socially acceptable, perhaps images of actual women breastfeeding their infants may be a better first step than frightening images of women partaking in unsafe behaviors. Finally, to establish a successful campaign, insight into the reasoning behind a lack of long term breastfeeding should have been examined. For example, the time required to breastfeed and the baby’s responses to the breast are key indicators of continued breastfeeding (6). This campaign neglected to take these factors into account and instead chose to frame new mothers in a negative light. A simple focus group of mothers could have easily alerted the campaign’s organizers to the pitfalls of the campaign and it is a shame focus based research was not conducted prior to the campaign’s launch.
Li R, Darling N, Maurice E, Barker L, Grummer-Strawn L. Breastfeeding Rates in the United States by Characteristics of Child, Mother, or Family: The 2002 National Immunization Survey. Pediatrics 2005; 115:31-37
Anderson J, Johnstone B, Remley D. Breast-feeding and cognitive development: a meta-analysis. Am J Clin Nutr 1999; 70:525-535
Heinig M. Host defense benefits of breastfeeding for the infant: effect of breastfeeding duration and exclusivity. Pediatr Clin North Am 2001; 48:105-123
Heinig M, Dewey K. Health advantages of breastfeeding mothers: a critical review. Nutr Res Rev 1997; 10:35-56
Montgomery D, Splett P. Economic benefit of breast-feeding infants enrolled in WIC. J Am Diet Assoc 1997; 97:379-385
Arora S, McJunkin C, Wehrer J, Kuhn P. Major Factors Influencing Breastfeeding Rates: Mother’s Perception of Father’s Attitude and Mild Supply. Pediatrics 2000; 106:67-71
US Department of Health and Human Services. National Women’s Health Information Center. Washington D.C.
Job S. Effective and Ineffective Use of Fear in Health Promotion Campaigns. Am J Public Health 1988; 78:163-167
Witte K, Allen M. A Meta-Analysis of Fear Appeals: Implications for Effective Public Health Campaigns. Health Educ Behav 2000; 27:591-615
Finkenauer J. Scared Straight and the Panacea Phenomenon. Englewood Cliffs, NJ. Prentice Hall 1982
Carr E, Dunlap G, Horner R, Koegel R, Turnbell A, Sailor W et al. Positive Behavior Support: Evolution of an Applied Science. Journal of Positive Behavior Interventions 2002; 4:4-17
Michael J. Positive Psychology and the Distinction Between Positive and Negative Reinforcement. Journal of Organizational Behavior Management 2005; 24:145-153
Wolf J. Is Breast Really Beast? Risk and Total Motherhood in the National Breastfeeding Awareness Campaign. Journal of Health Politics, Policy and Law 2007; 32:595-636
Asforth B. Defensive Behavior in Organizations: A Preliminary Model. Human Relations 1990; 43:621-648
Strecher V, DeVellis B, Becker M, Rosenstock I. The Role of Self-Efficacy in Achieving Health Behavior Change. Health Education and Behavior 1986; 13:73-92
World Health Organization. HIV and Infant Feeding. Geneva, Switzerland

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  • At May 1, 2008 at 6:55 AM , Anonymous PAB said...

    "Instead of encouraging this population to seek alternatives to infant formula such as wet nurses or milk banks..."
    I've often wondered why milk banks are almost never mentioned. In fact, I hadn't even heard of them until my roommate (a Breastfeeding Coalition employee) mentioned them. I think in this respect, educating the public could prove to be a successful campaign strategy.


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