Challenging Dogma - Fall 2008

Wednesday, December 17, 2008

Critique and Reformulation of the Proposed 2004 Department of Health and Human Services Breastfeeding Campaign – Ellenor Barish

Breastfeeding in Modern America

The American Academy of Pediatrics (AAP) and the World Health Organization (WHO) agree that breastfeeding is the best method of feeding for most infants and the current AAP recommendation is to breastfeed for at least the first year of life (1, 2). Though both organizations cite certain medical reasons to discourage breastfeeding, the majority of women can breastfeed successfully and safely. Despite physical capacity and overwhelming scientific evidence in support of breastfeeding, less than 70% of American women initiate breastfeeding and less than 20% of American women meet the AAP recommendation to breastfeed to one year (3).
The United States government considers low rates of breastfeeding a significant enough public health issue to include breastfeeding among its Healthy People 2010 (HP 2010) initiatives. Objective 16-19 is to “Increase the proportion of mothers who breastfeed their babies (3).”[i] Specifically, the goals are to increase the proportion of women who initiate breastfeeding from 64% (1998 baseline) to 75%, to increase the proportion who breastfeed for 6 months from 29% to 50%, and to increase the proportion of those still breastfeeding at one year from 16% to 25%. Toward these ends, the Centers for Disease Control (CDC) recommends educating parents and health care providers, changing hospital policies, increasing social support, and encouraging media portrayals of breastfeeding as normal.

In response to the HP 2010 objectives, the Department of Health and Human Services (DHHS) embarked upon the development of an advertising campaign aimed specifically at increasing breastfeeding rates (4). The advertisements highlighted the health risks of not breastfeeding and used startling imagery – insulin vials and asthma inhalers topped with rubber nipples. (See Appendix.) After extensive lobbying by baby formula manufacturers, these startling images were replaced with more innocuous ones.

In this paper I will argue that the original DHHS campaign was destined to fail and thus, may have actually benefited from the interference of the formula industry. A number of issues are raised by these advertisements. First, they seem to be based on behavioral psychology premises that ignore the true reasons why women do not breastfeed. Second, the campaign wrongly appeals to fear. Finally, the campaign uses inappropriate imagery and sends unclear messages about breastfeeding and in doing so risks alienating potential breastfeeders.

Reliance upon the Health Belief Model

The strategy behind these advertisements appears to rely heavily upon the Health Belief Model (HBM). This construct was first proposed in the 1950’s when researchers found that in order to make health decisions people essentially weighed the benefits of participation against the barriers to participation (5, 6). In order to determine whether action would provide any benefit, a person would consider their susceptibility to the illness and the severity of the illness. Barriers to action would be any negative consequences person anticipates as a direct result of an action. These might include cost, inconvenience, and physical pain. Once the person had weighed the benefits against the barriers, an intention would be formed which would dictate that person’s behavior (7, 8). Clearly, the outcome of this process would depend in part on the subject’s level of knowledge regarding the benefits of the proposed behavior.

In the case of the DHHS breastfeeding campaign, the proposed behavior is breastfeeding. The aim of the campaign is to educate the public about the role of breastfeeding in preventing illnesses such as asthma and diabetes. The considerable risks presented in the advertisements are intended to outweigh any perceived barriers to breastfeeding. In theory, this doesn’t sound like a terrible approach. However, there are a number of problems inherent in using the HBM. First, because barriers may be very specific to each individual, campaigns based on the HBM are inclined to focus on increasing knowledge about the more subjective benefits of the behavior in question. The assumption is that women do not breastfeed because they do not know that it is beneficial for their babies. In fact, a study of low income mothers’ attitudes and beliefs regarding breastfeeding shows that over 56% of mothers who feed their babies formula recognize that breastfeeding help “a lot” in protecting babies from diseases. The majority of mothers who use formula also know about nutritional and bonding benefits of breastfeeding. However, fewer than 17% of these mothers said that any of these factors was important in choosing a feeding method (9).In a study of adolescent mothers, nearly 75% of those who had considered breastfeeding but decided to bottle feed said that they could not breastfeed and return to school or work (10). Nearly the same proportion said that bottle feeding was more convenient than breastfeeding. Only about 12% said that formula was healthier than breast milk. Thus, for a 16-year-old girl, the possible risk of diabetes or asthma may seem insignificant in contrast with the prospects of social isolation, joblessness, and poverty that might follow from a failure to complete high school. She may see breastfeeding as incompatible with education and choose the latter in hopes of providing a better future for herself and her child – asthmatic, diabetic, or otherwise.

These studies show that the use of HBM premises is not appropriate for the issue at hand. The majority of women are not deciding to bottle feed due to lack of knowledge or due to incorrect information. That decision appears to be based on environmental and social factors that the HBM – and by consequence, these advertisements – ignores. As the study of adolescent mothers demonstrates, these factors may interrupt the progression from intention to behavior which is taken for granted by the HBM.

A common criticism of the HBM is that it leads to a “blame the victim” mentality because it focuses so strongly on the individual’s role in forming and acting upon a decision (11). This can certainly be seen in the case of the DHHS breastfeeding campaign. Women with low income and poor social support may be those least likely to breastfeed and often with good reason: victims of physical and sexual abuse often have difficulty allowing the intimate contact that breastfeeding demands; those with HIV/AIDS are discouraged from breastfeeding in this country as the virus can be transmitted through breast milk; women who do not feel empowered in the workplace may be unable to safely express and store breast milk (12, 13). None of these barriers is the fault of the woman, yet the DHHS advertisements will likely contribute to feelings of guilt, stigmatization, and low self esteem among these populations. This unintended outcome is not only counter-productive but also detrimental to society.

Appeal to Fear

An important premise of the HBM is that people must be made aware of the risks and benefits of the proposed action. As a result, there are two framing options for an HBM proponent: a framework of hope and a framework of fear. This campaign relies on the latter, using a construction that stresses the dangers of not breastfeeding a child: “Babies who aren’t breastfed are up to 250% more likely to suffer respiratory diseases;” and “Babies who aren’t breastfed are up to 40% more likely to suffer type 1 diabetes.” The developers of this campaign could just as easily have written that babies who ARE breastfed are LESS likely to be affected by those health problems. Clearly, they were aware of the intense drive a parent has to protect his or her child – everyone knows not to stand between a mother bear and her cub.
Indeed, fear can be a very powerful tool in shaping behavior. However, experts suggest that fear is only useful in specific situations. Witte’s Extended Parallel Process Model (EPPM) aims to predict the outcomes of fear appeals (14). According to this model, there are three possible outcomes based on the relevance of the threat, the effectiveness of the recommended response, and the person’s self-efficacy with respect to the recommended response. Thus, in order to be effective, a fear appeal must convince the audience that: they are susceptible, the response will work, and that they are capable of implementing the response.

The DHHS breastfeeding advertisements do not meet the requirements of the EPPM. They do acknowledge the first premise of the model – that one must believe he is susceptible. In providing statistics, the advertisements attempt to impress upon the public that the threat is real. However, this approach assumes that the viewer will (or even can) read the fine print and relies on the fact that the viewer understands statistical analysis. Even if both of these criteria are met, the viewer may not be particularly impressed by the numbers. A doubling – or even tripling – of the risk for respiratory disease may not be particularly salient for a person who does not know a lot of people with respiratory disease and thus believes the incidence to be quite low in the general population. The advertisements do far worse in addressing the efficacy of the response. The negative construction – “Babies who AREN’T breastfed…” – does not allow for the direct presentation of the efficacy of breastfeeding in preventing a given disease. That connection must be deduced by the viewer. Furthermore, the desired response, “Breastfeed exclusively for 6 months,” is only stated in the smallest print of the advertisement and it is separated from the fear statement. As a result, the viewer may not even be sure how to respond to the threat if in fact she is convinced of her baby’s susceptibility.

Finally, the advertisements do nothing to address a mother’s self-efficacy. Women commonly cite the concern that they will not be able to produce enough milk for their babies as a barrier to breastfeeding, and thus a detractor from self-efficacy (15). The tag line, “Babies were born to be breastfed” speaks only to the child’s ability to nurse which is not a common concern. Thus, even if the advertisements are somehow able to achieve the first two requirements of a successful fear campaign, the third may prove to be the campaign’s downfall. A failure in meeting the third requirement of the EPPM may have ramifications beyond the success of the advertisement at hand. Witte proposes that the viewer may engage in denial, defense avoidance, or reactance in order to reduce her fear (13). As a result, a woman who is exposed to this campaign but lacks self-efficacy with respect to breastfeeding may react negatively to future breastfeeding campaigns and interventions even if they are not based on a fear response, reducing the likelihood of behavior change (16).Because fear is a powerful emotion, it can be a useful tool in shaping behavior. However, inappropriate or ineffective use of fear may be detrimental in shaping behavior. The DHHS advertisements’ fear messages are not composed in a way that is likely to increase breastfeeding rates and may even result in declines in breastfeeding. Clearly, the fear strategy may not have been the best choice for this campaign.

Unclear Message

As described above, the images and text used in these advertisements appear to be intended to inform and to invoke fear. Those misguided intentions are not the only flaws of this campaign. Communications expert Paul Martin Lester states that, “Well-crafted images with their inherent emotional qualities can produce all the motivational changes desired of customers by advertisers when carefully combined with well-chosen words (17).” In this section I will discuss some of the problems with the images, words, and the combination of the two. The antithesis of Lester’s statement, they result in an unclear message that does not support the objectives of the campaign.

First, the images are certainly provocative – provocative enough to mobilize the formula industry’s lobbyists. However, these images do not necessarily lead to the intended interpretation. Obviously, the creators thought the public would be shocked to imagine a baby sucking on an inhaler or insulin vial. However, a person might think the advertisements are publicizing advances in treatment for childhood diseases, particularly if he or she is not able to read the text due to a language barrier, illiteracy, vision impairment, or simply logistics (a moving subway, for example). That person might think, “Thank goodness treatments exist for childhood diseases;” or, “How sad that breastfed babies can’t take these important medicines.” These reactions may seem far-fetched, but they are certainly within the realm of possibility.

Another problem with the imagery is that it does not discriminate between types of bottle feeding. The implication is that feeding a baby anything in a bottle will have the same detrimental health consequences. A mother who only feeds her baby breast milk but uses a bottle may think she is putting her baby at risk. Similarly, a mother who supplements breastfeeding with formula feeds may believe her baby is at risk. These mothers may be persuaded that the damage is done so they might as well give their babies formula. As a result, these women may stop breastfeeding earlier and may be less likely to breastfeed future children. The text of the advertisements is also problematic. The first line states that “Babies who aren’t breastfed…” are more likely to suffer from diseases. Does that mean that any amount of breastfeeding protects babies equally? If so, women who initiate breastfeeding in the hospital may feel they have done what is needed to protect their children and will feel comfortable switching to formula feeds. The second line of text does say to breastfeed exclusively for six months, but this reads more like a suggestion than a means to an end.The Healthy People 2010 goals behind the initiation of this campaign are to increase breastfeeding rates and duration. Unfortunately, the images and text are contradictory and certainly are not prescriptive enough to suggest a clear course of action. Mothers are likely to be left wondering… If I cannot breastfeed for at least six months, should I even bother? Does any amount of breastfeeding count? As a result, these advertisements may actually bring about reduced rates of breastfeeding initiation and reduced duration.

The formula industry saves the day?

The proposed breastfeeding awareness campaign is misguided and counter-productive. It relies on inappropriate behavioral models, unsuitable motivational strategy, and ambiguous imagery and text. The formula companies were apparently outraged at the characterization of formula feeding in the proposed DHHS campaign. Their resulting actions to have the campaign “toned down” brought about a reformulation of the campaign in which dandelions and ice cream sundaes replaced the insulin bottle and asthma inhaler and the risks of not breastfeeding were reframed as benefits of breastfeeding. Though these advertisements lack the shock value of their earlier incarnations, they may have been less hurtful to the mission and to society if not more successful in increasing breastfeeding statistics. Ironically, the formula industry’s actions may actually have been beneficial to the breastfeeding movement.
Make it Work

I have presented some of the reasons why the original 2004 DHHS breastfeeding campaign was destined to fail. In the next section of this paper I will propose an alternative marketing strategy for bringing about in increase in breastfeeding rates. Instead of relying on the Health Belief Model, this strategy will employ Social Marketing Theory. It will also appeal to the audience’s desires, rather than their fears. Finally, it will deliver a clear and cohesive message.

Social Marketing Theory

As noted above, most women are aware of the benefits of breastfeeding. Thus, the Health Belief Model does not appear to be applicable to the problem of low breastfeeding rates. A more effective strategy would rely on Social Marketing Theory. This theory describes the use of commercial marketing practices to bring about social behavior change (18). Extensive effort and investment has been made in the commercial sector to determine what motivates people to change purchasing behavior. Public health professionals should take advantage of the work that has been done in this area in bringing about health behavior change. Even if the audience is not buying anything, they do have to buy in. Three specific areas of marketing theory that are very useful in public health interventions are segmentation, formative research, and exchange.

When designing an intervention, it is important to determine which segment of the population will be targeted; not all segments are motivated by the same things. A review of 2005 breastfeeding data reveals that women identifying themselves as non-Hispanic blacks or African Americans have the lowest breastfeeding initiation rates and breastfeed for shorter durations: 59% initiate (compared to national average of 74%), 26% are still breastfeeding at 6 months (vs. 43%), and 12% continue through 12 months (vs. 21%). Women under 20 years of age have even lower rates (51%, 19%, and 9.2% respectively). These groups also have the lowest rates of exclusive breastfeeding at 3 and 6 months (19). As a result, young black/African American mothers appear to be a prime target segment for a breastfeeding intervention.
Now that the target has been identified, formative research must be conducted to identify the barriers to breastfeeding and motivating factors among this population. The research tool must be carefully selected and designed. For example, because survey questions are pre-formulated and often closed-ended they may miss important issues that qualitative interviews and focus groups are able to identify. Furthermore, the person conducting the interview or focus group must be well-trained in interviewing as well as cultural sensitivity. Fortunately, a great deal of research has already been done in the area of barriers to breastfeeding among groups that include large proportions of young African American mothers. These studies have identified common deterrents to breastfeeding: fear of pain or embarrassment; lack of family or social support, role models, and confidence in the ability to produce enough milk; and the challenges of breastfeeding upon returning to school or work

The next step is to offer an exchange (25). The formative research above identified what mothers need in order to breastfeed. Next, it is important to identify what these mothers – and their significant others – want. This could be accomplished by performing more research as above. For example, it might be informative to ask what young pregnant women are looking forward to or what their hopes are for the postpartum period. Using existing research may also be helpful. In the development of an anti-tobacco campaign, researchers found that young African American females want role models their age while young African American males would be responsive to a superstar like Michael Jordan (26). Looking at existing successful marketing campaigns directed at the target populations would also be useful.

Have No Fear

As discussed above, appeals to fear are dangerous and often counter-productive. My strategy will rely on promising the audience what they want and need instead of frightening them into submission. Research cited above has identified some important motivators for the target audience: social support, role models, self confidence. General aspirations of the target population might also be seized upon.
Few would argue that most consumers want to be attractive and happy. In fact, research shows a correlation between attractiveness of a spokesperson and persuasive ability for male and female consumers (27). However, the body consciousness of adolescents in general and of the post-partum woman in particular must be taken into account when selecting images so as not to alienate or discourage the target audience (28, 29). Dove’s 2005 “Real Women” campaign is an example of how attractiveness might be portrayed in a realistic and attainable nature (30).
The ad campaign I propose will take into account the needs and desires of young African American mothers as well as those of their partners and their own mothers. These ideas will be incorporated so as to suggest an exchange: if you breastfeed (or support a breastfeeder), you will feel attractive, popular, and proud.

A Clear and Positive Message

The proposed DHHS campaign did not present a clear message about the intended behavior change. Contrary to the DHHS advertisements that implied that women who do not breastfeed are making a conscious decision to harm their babies, the message I hope to convey is that breastfeeding is worthwhile and is possible for the majority of women and their families. Each advertisement will be from the perspective of a different interested party: pediatrician, grandmother, father, mother, and baby, highlighting why or how breastfeeding makes sense for that person. The implication will be, “You can do it!” The immediate goal of the campaign is to increase breastfeeding rates and durations among those exposed to the advertisements. The long-range goal is to alter social norms so that breastfeeding will become the default feeding choice for future generations of mothers.

The Campaign: Breastfeeding Works

Now that I have identified the target audience, selected some motivating factors, and formulated a message, I will present the campaign itself: Breastfeeding Works. All of the people featured in the advertisements will be black or African American and will be “real” people. That is, they will not appear in designer clothing or look like they have spent the entire day at the beauty salon. They will be attractive, but will remind us of our best friend, neighbor, or coworker. These advertisements will appear in outdoor locations as “outdoor” (billboards, subway, bus shelter) has been identified as the most effective form of advertising for young African Americans (31). Finally, as suggested in Healthy People 2010 these advertisements will incorporate images of breastfeeding women (3).

The Pediatrician
Headline: Breastfeeding Works
Image: Doctor in a lab coat with her arm around a young mother breastfeeding and infant.
Text: …for my patients. It helps reduce the risk of ear infection, asthma, and diabetes which means they spend less time at my office and more time being kids. Give your baby breast milk for at least a year. For more information on how breastfeeding can work for you, visit or call 1 800 FEEDING.

The Grandmother
Headline: Breastfeeding Works
Image: Proud grandmother holding hands with her daughter who is breastfeeding an infant.
Text: …for my baby and my grandbaby. Of course, I’m delighted to hold little (name) when he’s all done eating! Give your baby breast milk for at least a year. For more information on how breastfeeding can work for you, visit or call 1 800 FEEDING.

The Father
Headline: Breastfeeding Works
Image: Proud young father in sports attire with arms around the mother and their baby who is nursing.
Text: …for my baby and his mom. And I can help by making sure she has plenty to drink and a comfortable place to relax. Give your baby breast milk for at least a year. For more information on how breastfeeding can work for you, visit or call 1 800 FEEDING.

The Mother
Headline: Breastfeeding Works
Image: Four young mothers nursing their babies.
Text: …for us. We asked for a room at school where we can pump and store breast milk during the school day… and we got one! Give your baby breast milk for at least a year. For more information on how breastfeeding can work for you, visit or call 1 800 FEEDING.

The Baby
Headline: Breastfeeding Works
Image: Close up of an infant nursing. Mother’s face is not visible.
Text: …for me. When I’m six months old I’ll get to try some new foods, but for now breast milk is perfect. Give your baby breast milk for at least a year. For more information on how breastfeeding can work for you, visit or call 1 800 FEEDING.

The above advertisements refer viewers to a web site where information would be provided regarding the breastfeeding guidelines, benefits of breastfeeding, proper breastfeeding technique, how family members can help, strategies for gaining support at work and school, acquiring breast pumps, and how to introduce solid foods. There would also be links to local support groups and lactation consultants.
This campaign provides support for mothers who are considering breastfeeding but also potentially engages their doctors, mothers, and partners to encourage and support them in doing so. It also presents helpful and positive information about breastfeeding. The people in the advertisements are attractive and look like members of the target community which will increase the audience’s likelihood of identifying with them and emulating their behavior. Employing Social Marketing Theory, using positive imagery, and presenting a clear and consistent message will result in a more successful campaign than that proposed for the DHHS in 2004. However, the work does not stop there. Careful and intelligent design and management of the website and telephone line are also imperative in achieving the campaign’s goals. Constant monitoring and evaluation of the program’s impact will help to inform future campaigns and interventions. The results will be well worth the effort when eventually breastfeeding is the accepted norm and the expected method of feeding in all communities.

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