Challenging Dogma - Spring 2008

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

Wednesday, April 23, 2008

Scare Tactics: Shortcomings of the National Breastfeeding Awareness Campaign—Tara Lukens

Breastfeeding provides many advantages for infants, mothers, and society (1). Infants benefit from breastfeeding due to its advantages for growth, immunity, and development while mothers gain health and psychological benefits. Society acquires economic benefits within families, the health care system, and the workplace (2). However, despite such benefits, the United States currently maintains one of the lowest rates of breastfeeding in the developed world (3). In an attempt to counter such low rates, the National Breastfeeding Awareness Campaign (NBAC) was launched by the U.S. Department of Health and Human Services (DHHS). This national public health campaign aims to increase the number of women who breastfeed with a focus on increasing the number of mothers who breastfeed exclusively for 6 months (4). In accordance with Healthy People 2010 objectives, the DHHS aspires to increase breastfeeding rates in the early postpartum period to 75% and those at 6 months to 50% by the year 2010 (5).
It first attempted to do this by informing mothers of the benefits associated with breastfeeding, which was mirrored in its slogan stating, “Breast is Best.” Unfortunately this campaign was found to be ineffective in changing behavior. As a result, the DHHS launched its new campaign in conjunction with the Ad Council in 2004. This new campaign aims to encourage breastfeeding by informing mothers of the consequences associated with not breastfeeding (3). In accordance with their new message, the NBAC changed its slogan to “Babies Were Born to be Breastfed” (6). This alteration in framing, however, did not address underlying flaws in their campaign. The change in framing by the NBAC in 2004 was ineffective, and potentially counterproductive, to their goal of increasing the duration of breastfeeding by mothers.
The NBAC relies on the false belief that knowledge leads to intention, which ultimately results in behavior.
The idea that knowledge leads to intention, which ultimately results in behavior can be found in the Health Belief Model (HBM), which is one of the oldest individual behavior theories used in public health. This model is based on the notion that people make decisions by rationally weighing the perceived costs and benefits of a behavior. This weighing by the individual, then produces a tip towards an intention and, ultimately, results in the corresponding behavior. Programs formed utilizing the HBM attempt to influence an individual’s decision by providing them with information (7). In an effort to utilize this approach, the NBAC provides its audience with the knowledge of the risks associated with, otherwise known as a perceived cost of, not breastfeeding. In doing so, the NBAC tries to influence individuals by tipping the scale towards breastfeeding, otherwise known as the desired behavior.
The problem with such an approach arises from the fact that these intention-behavior models are based on information derived from correlational studies (8). Correlational studies do not present a clear causal relationship. This is mainly due to the fact that many correlational studies use cross-sectional designs, which collect data from only one point in time (9). This makes it impossible to determine whether the intention or the behavior came first. Consequently, such correlational studies cannot rule out the possibility that the behavior resulted in the intention (8). Cross-sectional designs are also prone to self-representational biases which may inflate the strength of the intention-behavior relationship. Furthermore, correlational designs are liable to be subjected to a third, unmeasured variable that may potentially cause the intention and the behavior. This would mean any correlation found between the two would be misleading (8). Such variables, when considering the intention to breastfeed and breastfeeding exclusively for six months, may include economical and societal forces.
Despite fundamental problems with their model of behavior change, the NBAC continues to rely on the false belief that knowledge leads to intention, which ultimately results in behavior. Upon the launch of its new campaign in 2004, the DHHS admitted the fact that many women already know that breastfeeding is beneficial for their babies and that this knowledge did not result in a change of behavior (3). Yet, rather than modify their approach, the NBAC simply changed the message from “Breast is Best” to “Babies Were Born to Be Breastfed” (3). In doing so, it shifted the focus from the perceived benefits of breastfeeding to the perceived costs of not breastfeeding. This modification of the information is the only major change in the campaign despite the fact that the DHHS admitted that knowledge did not have an affect on behavior. Consequently the new campaign will most likely be ineffective in increasing exclusive breastfeeding. This is due to the fact that it continues to rely on the unreliable relationship between knowledge, intention, and behavior.
This campaign targets mothers as the main determinant of child health and fosters negative emotions within and towards women who fail to breastfeed.
In using an individual-based model as a part of its public health intervention, the NBAC must have a target for its advertising. Despite the fact that the campaign states that it targets mothers, fathers, employers, co-workers, childcare providers, and health care providers (10) a look at its television ads easily suggests otherwise. For example, in one commercial a pregnant woman mounts a mechanical bull with the help of two other pregnant women and then proceeds to ride the mechanical bull (10). There are no employers, fathers, co-workers, health care providers, or childcare providers present or even mentioned in the commercial. In fact, the only people who are not pregnant are located in the hazy, dark background. Other ads presented by the campaign also fail to perceptibly include these target populations. In fact, only the radio ads of this campaign manage to allude to the fact that other people may play a role in breastfeeding besides the mother. However, this indication is limited to the fact that a male voice is utilized in the commercial. By predominantly featuring women in their ads the NBAC targets mothers as the main determinant of child health. This is due to the fact that the campaign consistently utilizes the pronoun “you” in their advertising. If mothers are the only people directly connected to these commercials, whether it is due to the presence of mothers in the commercial or their ability to breastfeed, the message is markedly directed towards mothers.
In targeting women, the NBAC exploits the assumption about the responsibility of mothers in protecting their children from harm, which promotes social stigma. This is due to the fact that, in addition to targeting women, the ad campaign presents the information about breastfeeding in terms of risk which is commonly misconstrued by the public (11). One commonly misinterpreted concept is the fact that probabilities are not equivalent to certainties (12). Consequently, after being informed that breastfeeding lowers the risk of ear infections, for example, many people may interpret the message as breastfeeding prevents ear infections. By utilizing a common misapprehension, the NBAC defines risk as preventable and, accordingly, the mother’s responsibility (13). If it is the mother’s responsibility to protect her child from harm and risks such as ear infections can be prevented, as is implied by the NBAC, the mother may be viewed as negligent or even reckless if she fails to breastfeed. Such a view helps to foster social stigma towards mothers. The campaign ads further utilize the misapprehension of risk by equating the risks of not breastfeeding to the risks a pregnant woman faces while engaging in dangerous, irresponsible acts. In doing so, the advertising of the NBAC aims to manufacture fear in order to increase breastfeeding rates.
However, not all women are capable of breastfeeding exclusively for six months due to physical, social, or economic reasons. These women essentially become an agent of risk to their own children, because such difficulties to breastfeeding are not even addressed in the campaign (14). This can potentially lead to feelings of guilt or inadequacy since they cannot provide their baby with the best source of nutrition. Such emotions reduce maternal confidence and, ultimately, self-efficacy towards breastfeeding. These are important factors in breastfeeding duration (15) and early discontinuation of breastfeeding (16). A woman with low self-efficacy will decrease her efforts to breastfeed or promptly settle for solutions that are only mediocre when faced with difficulties (17). Consequently, by targeting mothers and attempting to motivate them with fear and stigma, the NBAC is counterproductive in their goal to increase the duration of breastfeeding by mothers.
The NBAC fails to adequately address plausible external influences on breastfeeding behavior in their campaign.
By utilizing an individual-focused model for their advertising, the NBAC was limited in its ability to effectively address environmental factors (18). Environmental factors related to breastfeeding include breastfeeding legislation, welfare reform, workplace support, social support, and cultural norms (1). These factors present barriers to breastfeeding and are the reason many women do not initiate or discontinue breastfeeding (16). Moreover, social and economic forces affect the health choices of people more than health warnings do (19). Consequently, it is important to identify environmental factors that influence the ability and willingness of women to breastfeed in order to effectively increase the rates of breastfeeding initiation and duration.
Unfortunately the ad campaign focuses on the consequences of, rather than the barriers to, breastfeeding. This becomes obvious when a television commercial of the NBAC is compared to a television commercial of the Australian Breastfeeding Association (ABA) which aims to protect and promote breastfeeding (20). An example ad by the NBAC involves two pregnant women log rolling as part of a television broadcast followed by a black screen stating, “You wouldn’t take risks before your baby’s born. Why start after” (10)? The television ad of the ABA, on the other hand, features a male businessman eating in a toilet stall and ends by saying, “You wouldn’t eat here. So why should a baby?” This message directly targets the social stigma associated with breastfeeding in public, which is an external barrier to breastfeeding.
Such an ad would be very applicable to women in the United States where there is also stigma associated with breastfeeding. Women face negativity from a variety of sources including partners, relatives, friends, bosses, coworkers, and society in general (1). In fact, only thirty-nine states have laws that specifically allow women to breastfeed in any public or private location (21). Furthermore, although such laws may protect the rights of mothers to breastfeed in public places, it does not necessarily reflect the public’s perception of breastfeeding. For example, in 2006 a woman threatened to sue Toys ‘R’ Us, because she was harassed by five employees stating that her breastfeeding in the store was inappropriate given all the children in close proximity (22). This incident occurred in New York, which is one of the thirty-nine states that has a law stating the right of women to breastfeed in public places. Such social stigma plays an important role in breastfeeding behavior, because the attitudes of mothers are significantly influenced by those of peers, family members, professionals, and society in general. Furthermore, attitude towards breastfeeding is a main indicator of a mother’s decision to breastfeed (23). Mothers with moderate to poor emotional support have been shown to be less likely to maintain their breastfeeding three months post partum (24). Consequently, social stigma is a key influencing factor on breastfeeding initiation and duration.
By not addressing such factors and potentially causing reduced confidence due to the promotion of social stigma, the NBAC may potentially hinder its own progress. This is in view of the fact that decreased self-efficacy is directly related to the effort exerted in the face of difficulties (23). If barriers to behavior remain up, mothers with low-self efficacy will easily abort their breastfeeding efforts. In fact, despite a steady increase in breastfeeding initiation, exclusive breastfeeding rates have changed little since 1990 (23).
In attempting to motivate mothers to breastfeed by emphasizing the risks of not breastfeeding the NBAC is inherently flawed. By utilizing methods mirrored in the HBM the campaign relies on false associations, targets mothers while simultaneously subjecting them to feelings of inadequacy and blame by society, and fails to take into consideration main interpersonal and environmental factors regarding the behavior. Consequently, the revision of their campaign was ineffective, and potentially counterproductive, to their goal of increasing the duration of breastfeeding by mothers.
A better approach to increasing both initiation and maintenance rates may involve using risk awareness in conjunction with addressing barriers. Consequently, a more appropriate model of change for the NBAC to center its interventions around may be the theory of social ecology. This theory addresses behavior change as being influenced by factors in five categories: intrapersonal, interpersonal, institutional, community, and public policy. By encompassing all of these aspects, the theory of social ecology puts less weight on the individual to modify behavior and more stress on environmental influences. In doing so, the theory minimizes the blame associated with a person’s lack of effort or failure to change behavior (18). Since economic and social forces affect health choices made by people more than health warnings (19), the NBAC may be able to more effectively increase rates of breastfeeding initiation and exclusive continuation for six months by utilizing this model. This theory may also be advantageous in other public health campaigns using the HBM as a basis for their intervention. After all, when it comes to changing behavior, knowledge is simply not enough (1).
1. Kotan, S.E. Predictors of breastfeeding intention among low-income women. The Florida State University College of Nursing. 2007.
2. U.S. Department of Health and Human Services. HHS blueprint for action on breastfeeding, Washington, D. C.; U.S Department of Health and Human Services, Office on Women’s Health, 2000.
3. Public service campaign to promote breastfeeding awareness launched. HHS Press Release 4 June 2004.
4. Haynes, S.G. National Breastfeeding Awareness Campaign: Babies Were Born to be Breastfed! Department of Health and Human Services.
5. Healthy People 2010. Increase the proportion of mothers who breastfeed their babies.
6. Kukla, R. Ethics and ideology in breastfeeding advocacy campaigns. Hypatia. 2006; 21.1:157-181.
7. Edberg, M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
8. Webb, T. L. Does changing behavioral intentions engender behavior change? A meta-analysis of the experimental evidence. Psychological Bulletin. 2006; 132:249-268.
9. Simon, S. Stats: What is a Cross-Sectional Design? Children’s Mercy Hospital and Clinics.
10. Peters, K. Babies were born to be breastfed. Wet Set Gazette. 24 Nov. 2004.
11. Wolf, J.B. 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.
12. Angell, M. and Kassirer, J.P. Clinical research—What should the public believe? The New England Journal of Medicine. 1994. 331:189-190.
13. Armstrong, E.M. Conceiving risk, bearing responsibility: Fetal alcohol syndrome and the diagnosis of moral disorder. Journal of the American Medical Association. 2005; 293:627-8.
14. International Formula Council. Research Update. International Formula Council. 2007.
15. Blyth, R., Creedy, D.K., Dennis, C., Moyle, W., Pratt, J., De Vries, S.M. Effect of maternal confidence on breastfeeding duration: An application of breastfeeding self-efficacy theory. Birth. 2002. 29:278-284.
16. Creedy, D.K, Dennis, C., Blyth, R., Moyle, W., Pratt, J., and De Vries, S. M. Psychometric characteristics of the breastfeeding self-efficacy scale: data from an Australian Sample.
17. Bandura, A. Human agency in social cognitive theory. American Psychologist. 1989. 44:1175-84.
18. Choi, K., Gust, A.Y., and Kumekawa, E. HIV prevention among Asian and Pacific Islander American men who have sex with men: A critical review of theoretical models and directions for future research. AIDS Education and Prevention. 1998: 10: 19-30.
19. Wolf, J.H. Low breastfeeding rates and public health in the United States. American Journal of Public Health. 2003; 93:2000-10.
20. Australian Breastfeeding Association. General Information. Australia: Australian Breastfeeding Association.
21. 50 State Summary of Breastfeeding Laws. Denver, CO: National Conference of State Legislatures.
22. Goldstein, J. NYCLU threatens to sue Toys ‘R’ Us over treatment of a breastfeeding shopper. New York Sun Times 15 Sept. 2006.
23. Harris, A.H.S., Thoresen, C.E., Lopez, S.J. Integrating positive psychology into counseling: Why and (when appropriate) how. Journal of Counseling & Development. 2007. 85:3-13.
24. Hoddinott, P., Pill, R., Hood, K. Identifying which women will stop breast feeding before three months in primary care: a pragmatic study.

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  • At April 24, 2008 at 1:45 PM , OpenID Sunkistraindrops said...

    Hey Tara,

    Your paper sounds really good and professional! When I compared it to my own, I reliazed that mine was all over the place, but yours actually flowed really well and it was clear. Nice Work!



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