MetroWest's Fat Chance at Fighting Childhood Obesity- Maithili Davada

Introduction

Due to economic inequalities many people around the world suffer from starvation and malnutrition; meanwhile many others suffer from obesity and the health and social problems associated with it.(1) Obesity is an issue that concerns not only adults but children, too.(1) Childhood overweight and obesity are issues of growing concern in the United States. According to a survey conducted by the National Health and Nutrition Examination Survey (NHANES), in 2003-04, 17 percent of children and adolescents ages 2-19 years were overweight. (2,3)

The MetroWest Kids campaign, launched by the MetroWest Community Health Care Foundation, aims at decreasing the prevalence of childhood obesity. The campaign includes local billboards, print advertising, a website (metrowestkids.org) that tries to provide useful tips for parents, kids and schools.

However, firstly, the campaign not only fails to inspire self-efficacy and provide positive reinforcement, but also ends up traumatizing the kids and assigning stigma to obesity. Secondly, the suggestions made on the website fall into the most common fallacy of using only individual level factors, and they do not play on group dynamics and they lack practicality, also, some of the suggestions are unsafe. Finally, the intervention also does nothing to address important environmental factors like availability and affordability.

“Fat Chance!” Fat chance of losing weight?

Bandura’s Social Cognitive Theory states any change in human behavior is influenced by: environmental, social and individual factors. Self-efficacy is one of the individual level factors explained in the theory. Self-efficacy is an individual’s confidence, faith, belief in their ability to successfully complete any behavior. Reinforcement is one of the environmental factors. Reinforcements may be in the form of positive or negative response to their behavior.(7,9)

Their billboard says “fat chance” and shows the chubby feet of an overweight child standing on a scale. Unfortunately, it conveys a message of doom and gloom and hopelessness as opposed to inspiring hope and determination to fight the battle against childhood obesity. According to Catharine Curran-Kelly, an assistant professor of marketing at the University of Massachusetts at Dartmouth, the billboards instill fear in people who do not have the problem, and parents whose kids are obese tend to argue against it.(4) The parents’ response may be one of righteous indignation.

Not only are these billboards nonproductive, they may also be counter-productive. “They traumatize the very children they're trying to help," said Peggy Howell, a spokeswoman for the California-based National Association to Advance Fat Acceptance, a group that works for social acceptance of overweight people. According to her, the image on the billboard results in further bullying of obese kids by their peers, and provides reinforcement of this kind of negative behavior.(5) Competition, teasing and bullying are major barriers for students to be physically active during physical education class, on sports teams, and before and after school activities. (6) Thus the billboard not only causes internal and emotional trauma to the kids, but it also results in them being bullied, which results in harming self-efficacy. This is especially the case when it comes to obese children, resulting in them not participating in the above activities and leading a sedentary life resulting in further weight gain. Being bullied and teased results in negative reinforcement and hence lack of participation of obese kids in these activities. That reinforcement plays a major role in bringing about behavior modification is well-explained by Bandura’s Social Cognitive Theory (SCT). (7,9) Thus, the billboard not only results in negative reinforcement of healthy behavior in obese children, it also adds to the problem by causing positive reinforcement to bullying and as a result traumatization of these kids by their peers, which also negatively affects their sence of ‘self’, self-worth and self-efficacy.

That stigma negatively affects the self-esteem of individuals which also affects their self-efficacy is supported by several theories, which include social comparison theory (8,10), and social identity theory.(8,11) Even though the billboards are aimed at parents of obese children, the children themselves see them, too. The billboards assign stigma towards obesity resulting in harm to self-esteem of these children. This in turn has a negative effect on self-efficacy which, according to the social cognitive theory, is an important factor in enabling positive behavior change. (7,9) Dr. Gordon Cochrane, a registered psychologist, supports this idea. He presents the idea that an enhanced sense of self worth and self-efficacy give a person enough faith in themselves to follow healthy behavior and achieve an ideal weight and as a result overcome obesity. (12) Thus, by stigmatizing obesity, not only does the intervention fail to encourage and promote self-efficacy; in fact, it negatively affects the self-esteem and self worth of these children and as a result negatively affects their self-efficacy.

Are some of the options really safe or feasible?

Social norms and the social network, that an individual belongs to, play a major role in affecting behavior change. This idea is supported by the Social Expectations Theory and the Social Network Theory, respectively.(7,13,14) The intervention does not address these factors and focuses only on individual activities.

The MetroWest Kids website lists a few suggestions to help increase activity levels of kids. Some of the activities that the website suggests are not practical or safe and none of them take into account the effect of social norms, group dynamics and herd mentality. Although the website itself has a lot of useful information, sitting in front of the computer and reading information does not get kids to indulge in any physical activity. Also, the activities listed on the website are all solitary, so even if kids do follow them, they might eventually get bored of those activities and fall back into their old sedentary lifestyle. Furthermore, these activities do nothing to change the social norms, which according to the social expectation theory are an important factor affecting behavior change.(7,13) According to the social network theory, behavior change occurs and is maintained in groups(7,14), and none of the activities mentioned on the website are group activities.

One of the activities mentioned is going for a walk, but kids are in school all day and by the time they get back home and eat, it is already dark outside and if they live in an unsafe neighborhood, they cannot possibly go out. Some of the other activities suggested include rearranging the furniture, crawling under the table, setting up an obstacle course in the house, etc. These activities are not only disruptive to the parents but may also result in the kids hurting themselves. Another suggestion was to get off the bus a few stops before the destination which could prove to be dangerous in a high crime neighborhood; it also may lead to vehicular accidents if the kids are not cautious enough while crossing the road.

The intervention fails to bring about a change in the social norms, or target groups and social networks and does not take into account group dynamics and herd mentality. Behavior of most kids and adolescents today is influenced by the very factors that the intervention fails to address, according to the social expectations theory(7,13) and the social network theory(7,14) respectively.

What is MetroWest Kids doing to help with the real issues of environment, availability and affordability?

Additionally, the intervention does nothing about the environment and practical roadblocks such as lack of availability and affordability of healthy food and/or safe as well as affordable places to do physical activities like riding bikes or walking. The locations for parks and recreational areas provided on the website are few and far away from most places like Boston, Dorchester, Roxbury, Quincy etc. For most people these might be the only places where they can go for physical activities due to constraints such as living in an unsafe neighborhood or inability to afford the high membership fees for gyms, especially in these difficult economic times.

Also, processed and fast foods are cheaper and more easily available than healthy foods. Wherever we go, we are surrounded by vending machines and franchises like Dunkin Donuts, McDonald’s, Wendy’s, etc., which provide cheaper and tastier alternatives to the expensive salads. Also, most salads available at these places contain cheese or some kind of creamy dressing. According to the SCT another major factor affecting individual behavior is the environment surrounding them.(7,9) Additionally, the low-socioeconomic areas have fewer and costlier grocery stores compared to the high socio-economic areas and suburbs where most of the relatively cheaper chain stores are located. The intervention fails to take any measures that address these problems.(15)

According to a study, conducted in 2000, the quality of the food served, easy access to non nutritious snacks, limited time for lunch period are the major factors affecting the food choices made by high school kids. Many of the students and staff members complained that the cafeteria food was too greasy. Moreover, they felt that presence of snack carts and vending machines influenced students’ food choices. It was noted by many of the staff members that students are less likely to select nutritious foods for lunch in the presence of these other attractive non nutritious options in their environment.(6) One of the students made a very interesting statement which emphasizes the role that the environment surrounding an individual plays in their decisions. She said, "How Can We Stay Healthy when you’re Throwing All of this in Front of Us?" with reference to the food choices available at their high school.(6) Although high school cafeterias have begun to offer some healthier foods, many continue to sell sodas and fries. If you were an average American teenager, given a choice between fries or salad and soda or milk, what would you choose? Besides, the intervention does nothing to provide positive reinforcement to consume healthy foods, which according to SCT is an important aspect in enabling positive health behavior change. (7,9)

Introduction

Childhood obesity is a serious issue and requires a multilevel intervention that targets the environment of the kids on the whole, including their home, school and social environment. It should provide them with the confidence, self-efficacy and positive reinforcement required to enable them to make the necessary lifestyle modification in order to combat obesity.(7,9) According to The Social Expectation Theory(SET), behavior change occurs in groups and an individual’s behavior is largely dependent on the social norms that dictate the social environment.(7,13) It is important to understand that intention may not lead to behavior changes unless individuals also have a positive environment and access to healthy and affordable food and a safe place to exercise.

Intervention

Most of the requirements needed to fight the battle against childhood obesity can be met by schools. Schools can provide a safe environment for the kids to stay active in by arranging non-competitive after-school activities like aerobics, yoga, dance, and martial arts. They should make it mandatory for every student to be enrolled in at least one of these activities, regardless of whether or not they are obese so as to avoid stigma to obesity. To make sure that the obese kids do not get teased or bullied, they should start with the basics and go at a pace everyone can keep up with.

Schools could organize discussion sessions for parents and kids together, as well as just for kids, where they can promote self efficacy and provide positive reinforcement for these kids. Another purpose of these meetings would be to encourage parents to bond among themselves and exchange ideas on how to support their kids and provide their kids with appealing healthy food at home. In addition, the school can organize a monthly talk given by a formerly obese, now well balanced and successful peer or role model followed by an interactive discussion session. The school should encourage the students to host a social event that serves only healthy food and has fun activities, at the end of each semester. Instead of vending machines with junk food and sodas, they could have, carrot sticks, cherry tomatoes, apples, grapes, bananas and juices at an affordable price. School cafeterias and social events should have healthy food, too.

The intervention that I propose is based mainly on Bandura’s SCT and also derives support from the Social Expectation Theory and some published articles.

Self-efficacy and positive reinforcement

The above intervention promotes self-efficacy and provides positive reinforcement, which are key factors affecting behavior change in an individual according to Bandura’s Social Cognitive Theory.(7,9)

The after-school activities promote self-efficacy by showing the students that they are capable of doing these activities despite obesity. Also, being able to successfully learn these activities enhances their sense of ‘self’. On the other hand, competitiveness negatively affects physical activity.(16) Thus it is essential to keep the activities non-competitive to avoid bullying and make the activities non-stressful and fun. The monthly talks are aimed at promoting self-efficacy and providing positive reinforcement using modeling (behavior of others) and vicarious learning (consequences of others’ behavior), as suggested by SCT.(7,9)

The end of the semester social also raises self-efficacy by giving students the confidence that comes from successfully organizing the event, and it makes them aware of their behavioral capabilities, which is one of the individual-level factors influencing behavior change according to the SCT.(7,9)That self-efficacy is an important factor affecting behavior change is supported by Dr Gordon Cochrane, a registered psychologist. (12)

The weekly parent meetings educate parents on how to support their kids emotionally and help them build confidence, self efficacy and provide positive reinforcement, which are key factors influencing behavior change according to SCT.(7,9)

Safe environment and non-competitive group activities

Unlike the Metrowestkids campaign, which focused on individual-level activities and did not provide practical options for activities, this intervention provides a safe environment for the kids to come together and participate in non-competitive, fun activities and to host group discussions. The Metowestkids campaign suggested that the kids walk to school, which could be dangerous for them. For example, Bauer, Yang and Austin reported that various staff members of a school observed and were worried about incidents in which students were approached by strangers while walking to school. As a result, the administrators discouraged parents from letting their kids walk to school. They said the high density of car traffic further compromised the safety of these kids.(6,16) Since the activities suggested by the current intervention happen at school, after school, students are spared the risk and expenses of travelling and trying to find a safe place to carry out these activities.

According to the Social Expectation Theory, individual behavior is driven by each person’s desire to conform to social norms. (7,13) Norms may be established and/or changed over time. This process can occur in three ways: “top-down influences, including official edicts and role models; bottom-up influences in which local customs and practices coalesce into norms; and lateral influences in which established norms from one type of interaction are transferred to related types of interactions.”(17) All the kids are required to participate in these activities, and physical activities are promoted by the role-models during the monthly discussion sessions (top-down influence), and it is an established norm that rules are followed (lateral influence). Additionally, some kids might be interested in these activities and will encourage their friends also to get involved in all these activities (bottoms-up influence). Hence, it is only a matter of time before being active becomes a social norm.

Adressing availability and affordability

The most important roadblock in fighting the battle against obesity is the lack of availability and affordability of healthy food and a safe place for physical activities. Also, the presence of unhealthy temptations all around us prevents us from making healthy choices easily and quickly. (6,16) This is especially the case for kids who are less aware of the serious consequences of these choices.

Replacing the unhealthy options in school vending machines with healthier affordable options takes away the temptation and increases the availability of healthy food. A study published by the Society of Public Health Education quoted some students as saying that “if the cafeteria offered fruits and vegetables in greater quantity and quality, they would choose to eat them instead of the less nutritious entrees or snack foods”(6). Providing healthy choices at school ensures that students have at least one healthy meal a day, regardless of what is available at their individual homes. Additionally, the weekly meetings for parents are aimed at encouraging healthy food choices at home and educating parents on what is healthy. Having kids present at these meetings could give them a chance to express their opinion in these matters too, and help them communicate their suggestions and choices.

The after school activities also provide a safe non-expensive place and environment for the kids to stay active and bond and explore options that would otherwise not be available or affordable, like yoga and aerobics. This is especially important in these difficult economic times.

Conclusion

The suggested intervention is based partly on the SCT and SET, and provides a feasible way to combat childhood obesity. The habits we develop during the formative childhood years last us a long time. If we make sure that this generation of kids develops healthy habits at an early stage and incorporates these habits of eating healthy and staying active into the social norms, we are on our way to winning the battle against obesity.

Conclusion:

The MetroWest Kids Campaign, like most other Public health campaign fails to rise above the individual level factors influencing behavior. Even while addressing only individual level factors they fail to address important individual level factors like self-efficacy and positive reinforcement. They do not take into account that an individual is affected by, the social norms and the environment surrounding them. It does nothing to increase the availability of healthy food. It also fails to address the issue of affordability, of both healthy food and a safe place to exercise, especially in these difficult economic times.

References:

1. Nestle Marion. The Ironic Politics of Obesity. Science; 2/7/2003, Vol. 299 Issue 5608, p781.

2. CDC’s National Centre for Health Statistics. Prevalence of Overweight among Children and Adolescents: United States, 2003-2004.

http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overweight/overwght_child_03.htm

3. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA 295:1549-1555. 2006.

4. Manuse Andrew J. Obesity billboard idea yanked. The MetroWest Daily News. Posted Jan 31, 2007 at 12:38 AM. Last update Jan 31, 2007 at 04:47 PM

http://www.metrowestdailynews.com/homepage/8998967371255250943

5. Reuell Peter. MetroWest 'fat' ads attract the ire of national obesity tolerance outfit. The MetroWest Daily News. Posted Feb 13, 2007 at 11:23 PM. Last update Feb 14, 2007 at 11:48 AM.

6. Bauer Katherine W., Yang Wendy Y. and Austin Bryn S. "How Can We Stay Healthy when you’re Throwing All of this in Front of Us?" Findings from Focus Groups and Interviews in Middle Schools on Environmental Influences on Nutrition and Physical Activity. Health Education and Behavior. 2004; 31; 34.

7. Edberg M. Essentials of health behavior:Social and behavioral theories in public health. Sudbury, Ma : Jones and Bartlett Publishers.

8. Crocker Jennifer and Major Brenda, Social Stigma and Self-Esteem: The Self-Protective Properties of Stigma. Psychological Review, Vol 96(4), Oct 1989. pp. 608-630

9. Bandura A. Social Foundation of Thoughts and Action. Englewood Cliffs, NJ: Prentice Hall; 1986.

10. Festinger, L. (1954). A theory of social comparison processes. Human Relations, 7,71-82.

11. Tajfel, H., & Turner, J. C. (1986). The social identity theory of intergroup behavior. In W, Austin & S. Worchel (Eds,), The social psychology of intergroup relations (pp. 7-24). Monterey, CA: Brooks/Cole.

12. Cochrane Gordon. Role for a sense of self-worth in weight-loss treatments: Helping patients develop self-efficacy. College of Family Physicians of Canada. Can Fam Physician. 2008 April; 54(4): 543–547.

13. Hornick, Robert. Alternative Models of Behavior Change. Annenburg School for Communication, Working Paper 131, 1990, p 5/6

14. Barnes JA. Class and communities in a Norwegian island parish. Human Relations. 1954;7:39-58.

15. Chung C., Myers, S. Do the poor pay more for food? An analysis of grocery store availability and food price disparities. The Journal Of Consumer Affairs.(1999)Pg 276.

16. Olga López de Dicastillo. Promotion of physical activity and healthy food quality food, easy access to non-nutritious food, and choices was hampered by competitiveness, lack of time constraints. Evid. Based Nurs. 2004;7;123

http://journals.bmj.com/cgi/reprintform

17. Edited by Durlauf Steven N., Blume Lawrence E. New Palgrave Dictionary of Economics, Second Edition.

Humor is Not Enough: The Failure of the “Babies were Born to be Breastfed Campaign” – Laura Dodge

Introduction

The benefits of breastfeeding are enormous. For infants, breast milk contains all the necessary nutrients in the correct proportions, and also contains antibacterial factors and protective immunoglobulins, both of which are absent from formula (1). Early benefits of breastfeeding include decreased mortality in preterm infants, as well as reduced infant morbidity from gastro-intestinal, respiratory, urinary tract, and middle-ear infections (2). Impacts on maternal health include lower incidences of breast cancer, ovarian cancer, and hip fractures in women who have breastfed, compared to women who have not breastfed (2).

Despite these many health benefits, only 12% of mothers in the United States meet the World Health Recommendation of exclusively breastfeeding until six months of age (3). This public health challenge has been widely recognized in the United States. Healthy People 2010 seeks to “increase the proportion of women who breastfeed their babies” to 75% in the early postpartum period, 50% at six months of age, and 25% at twelve months of age (4). Looking at national proportions of women who breastfeed, but not necessarily exclusively, provisional data from 2005 reports that 74% of women breastfeed in the early postpartum period, 43% breastfeed at six months of age, and 21% continue to breastfeed at twelve months of age (5). Increased breastfeeding is also a major program area of the Center for Disease Control and Prevention’s State-Based Nutrition and Physical Activity Program to Prevent Obesity and Other Chronic Diseases.

In order to increase the proportion of women in the United States who breastfeed, a major media campaign was launched with the tagline “babies are born to be breastfed.” While this effort focused on an important public health issue, the campaign itself was fatally flawed in three main ways. First, it failed to address the structural barriers to breastfeeding, such as lack of support from the medical community, employers, and society in general. Second, the campaign took a “one-size-fits-all” approach, without tailoring the message to certain high-risk groups. Finally, and perhaps most importantly, the campaign failed to provide women with tools to overcome these barriers and make breastfeeding a viable option in their lives. The campaign will be redesigned as a three-pronged approach: one prong will focus on alleviating structural barriers, the second prong will diversify the message to appeal to high-risk groups, and the final prong will modify each message to include resources that can be used individually. Instead of being based on the Health Belief Model, as the original campaign was, the redesigned campaign will be based on Social Norms Theory and the Theory of Planned Behavior.

About the Campaign

The “Babies Were Born to be Breastfed” campaign was launched June 4, 2004 by the US Department of Health and Human Services (HHS) Office on Women’s Health, in conjunction with the Advertising Counsel (6). The campaign designed provocative and attention getting public service announcements, featuring posters containing images that were reminiscent of breasts and nipples, and television ads that showed heavily pregnant women engaging in risky behaviors such as log rolling and mechanical bull riding. Dr. Cristina Beato, a member of the campaign team, explained “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” (6). By telling women “you wouldn’t take risks before your baby’s born; why start after?” the campaign emphasizes the health risks of not breastfeeding. This is consistent with one of the aims of the Health Belief Model (HBM), which seeks to increase the perceived susceptibility to the disease as well as the perceived severity of the disease (7). This campaign is trying to increase women’s perceived severity of not breastfeeding their infants. The HBM assumes that women are in control of their own lives and are the sole decision makers about their health behaviors. However, using the HBM as a basis for this national campaign was a fatal flaw because it failed to recognize the existence of more important group-level factors.

The Campaign Failed to Acknowledge of Structural Barriers to Breastfeeding
Lack of Support from the Medical Community

In line with the Health Belief Model, the “Babies were Born to be Breastfed” campaign holds women to be individually responsible for failing to breastfeed their babies. In doing so, it disregards the complexity of the situation. The first few hours after birth are critical to breastfeeding initiation. As almost all infants in the US are born in hospitals, the hospital is a crucial influence on breastfeeding initiation (8). Many women rely on support from hospital staff when starting to breastfeed because a majority of new mothers find the initiation process to be difficult (9). If the hospital staff is unable or unwilling to assist new mothers in breastfeeding their infants, the mothers may give up. This is especially discouraging in light of hospital policies that allow free formula samples to be given out on Labor and Delivery, which have a disproportionately negative impact on women who are particularly vulnerable, including first-time mothers, minorities, and women with less education (10). Women who have just given birth are often physically and emotionally tired, and if the hospital does not assist a woman in initiating breastfeeding, a woman is more likely to look to infant formula as an attractive and convenient alternative. In this respect, the campaign fails to provide women with the tools and resources needed to encourage breastfeeding when support from the medical community is lacking.

Here, the campaign will be modified to promote institutional changes through meetings with high-level hospital administrators. This portion of the campaign will not be publicly visible, but will encourage hospitals to adopt on components of the Baby Friendly Hospital Initiative, which a Cochrane review found to result in greater breastfeeding (11). The campaign will emphasize the potential for lowered health care costs resulting from increased rates of breastfeeding among its patients (12). In addition, the components of the Baby Friendly Hospital Initiative will be low-cost to the hospital, and will include assisting mothers to begin breastfeeding within 30 minutes of birth, rooming-in, and not giving out pacifiers or free formula samples (11). Because the costs are low and the potential benefits are high, hospitals will be interested in implementing the changes promoted by the revised campaign (12).

Discouragement from Employers of Working Mothers

The second area of structural barriers that the “Babies were Born to be Breastfed” campaign does not address is the difficulty working mothers face when they return to the workforce. Approximately 70% of employed mothers with children under the age of three work full time (13). Of these women, one third of them return to work within three months of giving birth, and two thirds return within six months of giving birth (13). Working outside of the home is related to decreased duration of breastfeeding and also less frequent initiation, probably because of the multiple barriers that exist in the workplace (14). These barriers include a lack of flexibility in the daily work schedule to allow for milk expression, lack of accommodation to pump or store milk, concerns about lack of support from employers and colleagues, and real or perceived low milk supply (15-17). All of these barriers are structural in nature, and none are under individual control. Individual women cannot be reasonably expected to change these situations alone, and the “Babies were Born to be Breastfed” campaign is unable to help them. In fact, the campaign has the potential to make mothers feel guilty that they are not breastfeeding, when in fact they are up against institutional-level barriers they have no reasonable amount of control over.

Here the campaign will be modified with ads targeted to employers based on the Theory of Social Norms (18). These ads will feature breastfeeding as a normal and healthy behavior in an attempt to make breastfeeding seem like a practice worthy of workplace support. In addition, the ads will inform employers that breastfeeding results in lowered health care costs, which may benefit the employer’s bottom line (12).

Lack of Community Support for Breastfeeding

The third area that the “Babies Were Born to be Breastfed” campaign fails to address is the difficulties associated with breastfeeding outside the home, due to lack of support in the community. Many women feel uncomfortable breastfeeding away from the home, which is unsurprising (19). Although breastfeeding in public is legal in all 50 states, many breastfeeding women have been asked to leave stores and restaurants for being “indecent,” and many worry about being charged with indecent exposure (20). Resources exist for breastfeeding mothers that explain their rights, and have suggestions for what to do in situations where they are unfairly asked to leave a public place. Unfortunately, the campaign does not provide women with similar resources. Gaining public acceptance and support for breastfeeding should be a priority for breastfeeding advocates, because normative health beliefs are heavily influenced by one’s environment (18). An environment that is accepting of public breastfeeding is itself likely to encourage more women to breastfeed. The awareness that the campaign is trying to raise surrounds the health dangers of not breastfeeding, and unfortunately, this is unlikely to positively influence society’s view of breastfeeding in public. Again, the campaign is hobbled by the HBM by focusing on the individual. Without an effort to increase public support for breastfeeding away from the home, it is unlikely that large gains will be made in the proportion of mothers who breastfeed their infants.

The campaign will be revised to include a component of Social Norms Theory to normalize breastfeeding. Celebrity supporters should be sought out to assist in the campaign, such as actor Angelina Jolie, who was photographed breastfeeding one of her newborn twins for the November 2008 cover of W Magazine (21). Public figures who treat breastfeeding as a normal activity can help to change the collective perception of it from something embarrassing to something admirable.

The Campaign was “One-Size-Fits-All”

Certain groups are much less likely to breastfeed than others. Women who are younger, less educated, and have lower incomes are less likely to initiate breastfeeding and more likely to discontinue breastfeeding early, than their older, more educated, and wealthier peers (22). In the United States, being under the age of 20, having a high school education, and living below 100% of the federal poverty level are all associated with a rate of roughly 8% exclusive breastfeeding at six months of age (22). This rate increases to roughly 60% for any breastfeeding at six months of age (22). Maternal age of 30 and above, being a college graduate, and living above 350% of the federal poverty level, on the other hand, are each associated with rates of exclusive breastfeeding at six months of age of roughly 16%, which increases to nearly 80% for any breastfeeding (22). However, the “Babies Were Born to be Breastfed” campaign made no distinction between any groups. Although the campaign sought wide appeal through its humor and provocative nature, it would have benefited the campaign to tailor its message to sub-populations, instead of assuming that every individual is just like every other individual. At-risk groups such as young women, less-educated women, and low-income women are the most in need of intervention and have the potential for greatest success.

To address this issue, the campaign will be modified to target these specific populations through diverse messages in a range of locations. For instance, younger and less educated women will be targeted with ads placed in schools and youth centers. Breastfeeding will be presented to low-income women as a free alternative to formula feeding, as well as a way to lower health care costs (18). These ads will be located in public agencies that assist low-income women, as well as community health centers and supermarkets. By making the message relevant and accessible, women are more likely to listen to the message and make the proposed behavior change.
The Campaign Failed to Provide Women with Tools to Change their Behaviors
One of the claims of the “Babies were Born to be Breastfed” campaign was that it “will provide women with the information and the motivation to breastfeed (23).” While information alone can be empowering, sometime it is not enough to tell women what they should be doing without showing them exactly how to do it. Because most women already know that breastfeeding is better than bottle-feeding, the women who do not breastfeed may already feel inadequate and guilty (23). This campaign could have easily made them feel more hopeless and inadequate by not providing them with any guidance on how to change their behavior.

It is puzzling that resources were not provided in this campaign, since study staff did seem to be aware of the need for increased information and encouragement. Acting Assistant Secretary of Health, Dr. Cristina Beato, acknowledged “new parents are often discouraged from breastfeeding because of confusion about duration and doubts about their ability” (23). It is unclear how study staff expected the campaign to affect these doubts about personal ability. The Health Belief Model does not take self-efficacy into account, unlike the Theory of Reasoned Action and the Social Cognitive Theory (24,25). Women who lack a sense of self-efficacy about breastfeeding would not have benefited from the campaign because the campaign did nothing to increase their confidence in their abilities.

Previous breastfeeding campaigns were successful in educating the public about the health benefits of breastfeeding, and this campaign is simply a renovated continuation of those efforts. This failure is a result of basing the intervention on the Health Belief Method. Because the HBM is concerned with changing perceptions of severity and susceptibility, it neglects the how of behavior changes, as well as how attitudes play into decision-making regarding health behaviors, and the importance of self-efficacy in making changes to health behaviors. Even if women’s perceptions of severity are heightened by this campaign, they are left alone in deciding exactly how to incorporate the change into their lives.

The revised campaign will use the Theory of Planned Behavior to address the important concept of self-efficacy (24). As the original campaign correctly acknowledged, confidence in the ability to breastfeed will have a large impact on whether or not a woman actually breastfeeds. The revised campaign will touch on the first two prongs and seek to show women the how in addition to the why. First, it will provide resources for women who encounter barriers to breastfeeding at an institutional level. Pamphlets will be developed to inform women of barriers in the hospital, which they may not be aware of. These materials will educate women about hospital policies and encourage them to speak with the hospital staff about their desire to breastfeed, which may result in greater rates of breastfeeding initiation. The pamphlets will be distributed to medical offices and childbirth education centers. Additional materials will be developed to inform women of their right to breastfeed in public. The materials will give sample responses that women can use if someone asks them to leave a public space because they are breastfeeding. By providing with concrete examples that can improve self-efficacy, women may be more prepared to defend themselves against these barriers. Online and telephone resources will also be listed where women can find support from other breastfeeding mothers, as well as lodge complaints about businesses that are not breastfeeding-friendly. All of these resources will be printed on all of the campaign posters, regardless of the target population, because each target population can benefit from the full use of these resources.

Second, the revised campaign will not chastise women for “risking” their baby’s health, which is patronizing and may actually reduce self-efficacy. Instead, the campaign will provide women with contacts for groups that provide breastfeeding support, such as La Leche League. When available, local organizations where women can find peer support will also be provided. These resources will help women make breastfeeding a realistic part of their lives, instead of scolding those who are unable to breastfeed or have been discouraged by institutional barriers. These resources will also be printed on all the campaign posters and materials.

Conclusion

Undoubtedly, breastfeeding needs to be encouraged. However, the “Babies Were Born to be Breastfed” campaign is an example of how not to structure a national campaign to boost the proportion of breastfeeding mothers. By focusing on individual factors, the campaign neglects the larger structural factors that act as enormous barriers to women, including lack of support from the medical community, employers, and society in general. These structural factors are critical barriers to breastfeeding. In addition, by not tailoring the message to high-risk groups, the campaign missed out on the huge gains that could have been made in these populations. Finally, and perhaps most importantly, the campaign failed to truly empower women to breastfeed by not giving them the tools they needed to be successful. Because it was based on the Health Belief Model, this campaign is subject to the shortcomings on the model as a whole. By turning away from the influence of the Health Belief Model to instead focus on Social Norms Theory and the Theory of Planned Behavior, the campaign will be able to address institutional barriers, target specific at-risk populations, and improve individual self-efficacy. It will do this through targeted campaigns to the medical community, marketing of new social norms to society, tailoring the message to specific populations, and improving self-efficacy through the provision of resources. Breastfeeding is an important public heath challenge that has the potential to benefit greatly from a thoughtful and effective campaign.

References
(1) Dodds J, Laraia B. Issues in maternal and child health nutrition. In: Kotch JB, editor. Maternal and child health: Programs, problems, and policy in public health. 2nd ed. Boston: Jones and Bartlett Publishers; 2005. p. 432-439.
(2) Britton C, McCormick FM, Renfrew MJ, Wade A, King SE. Support for breastfeeding mothers. Cochrane Pregnancy and Childbirth Group Cochrane Database of Systematic Reviews 2007: 3.
(3) Centers for Disease Control and Prevention. Breastfeeding Among U.S. Children Born 1999—2005, CDC National Immunization Survey. http://www.cdc.gov/breastfeeding/data/NIS_data/index.htm.
(4) U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2010.
(5) Centers for Disease Control and Prevention. Breastfeeding among US children born 1999-2005, CDC National Immunization Survey. http://www.cdc.gov/breastfeeding/data/NIS_data/index.htm
(6) U.S. Department of Health and Human Services Press Office. Public service campaign to promote breastfeeding awareness launched. June 4, 2004. News release.
(7) Rosentstock IM. Historical origins of the health belief model. Health Educ Monogr 1974;2:328-335.
(8) Shealy KR, Li R, Benton-Davis S, Grummer-Strawn LM. The CDC guide to breastfeeding interventions. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2005.
(9) Taveras EM, Li R, Grummer-Strawn LM, et al. Mothers’ and clinicians’ perspectives on breastfeeding counseling during routine preventive visits. Pediatrics 2004;113(5):E405-11.
(10) Donnelly A, Snowden HM, Renfew MJ, Woolridge MW. Commercial hospital discharge packs for breastfeeding women (Cochrane review). In: The Cochrane Library, Issue 2, 2004. Chichester, UK: John Wiley & Sons, Ltd.
(11) Fairbank L, O’Meara S, Renfrew MJ, Woolridge M, Snowden AJ, Lister-Sharp D. A systematic review to evaluate the effectiveness of interventions to promote the initiation of breastfeeding. Health Technology Assessment 2000;4(25):1-171.
(12) Pugh LC, Milligan RA, Frick KD, Spatz D, Bronner Y. Breastfeeding duration, costs, and benefits of a support program for low-income breastfeeding women. Birth 2002 Jun;29(II): 95-100.
(13) U.S. Department of Labor. Women’s Jobs: 1964-1999. Washington, DC: U.S. Department of Labor, Women’s Bureau, 1999.
(14) Fein SB, Roe B. The effect of work status on initiation and duration of breastfeeding. American Journal of Public Health 1998;88(7):1042-6.
(15) Corbett-Dick P, Bezek SK. Breastfeeding promotion for the employed mother. Journal of Pediatric Health Care 1997;11(1):12-9.
(16) Frank E. Breastfeeding and maternal employment: two rights don’t make a wrong. Lancet 1998;352(9134):1083-4.
(17) McLeod D, Pullon S, Cookson T. Factors influencing continuation of breastfeeding in a cohort of women. Journal of Human Lactation 2002;18(4):335-43.
(18) Berkowitz AD. Application of social norms theory to other health and social justice issues. In: Perkins HW, editor. The Social Norms Approach to Preventing School and College Age Substance Abuse: A Handbook for Educators, Counselors, and Clinicians. San Francisco: Jossey-Bass Publishers, 2003.
(19) Li R, Fridinger F, Grummer-Strawn LM. Public perceptions on breastfeeding constraints. Journal of Human Lactation 2002;18(3)227-35.
(20) National Conference of State Legislatures. 50 states summary of breastfeeding laws. http://www.ncsl.org/programs/health/breast50.htm
(21) W Magazine, November, 2008.
(22) Centers for Disease Control and Prevention. Breastfeeding Among U.S. Children Born 1999—2005, CDC National Immunization Survey. http://www.cdc.gov/breastfeeding/data/NIS_data/index.htm
(23) U.S. Department of Health and Human Services Press Office. Public service campaign to promote breastfeeding awareness launched. June 4, 2004. News release.
(24) Ajzen I. From intentions to actions: a theory of planned behavior. 1985, In Kuhl J, and J. Beckman (Eds.), Action-control: From cognition to behavior (pp. 11- 39). Heidelberg, Germany: Springer.
(25) Bandura A. Organizational Application of Social Cognitive Theory. 1988, Australian Journal of Management, 13(2), 275-302.

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
(20-24).

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 www.breastfeedingworks.org 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 www.breastfeedingworks.org 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 www.breastfeedingworks.org 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 www.breastfeedingworks.org 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 www.breastfeedingworks.org 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.

REFERENCES
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2. Global strategy for infant and young child feeding. World Health Organization. Geneva, Switzerland. 2003.
3. U.S. Department of Health and Human Services. Healthy People 2010. 2nd ed. With Understanding and Improving Health and Objectives for Improving Health. 2 vols. Washington, DC: U.S. Government Printing Office, November 2000, p. 16-46.
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13. AAP Committee on Pediatric AIDS. Human milk, breastfeeding, and transmission of human immunodeficiency virus in the United States. Pediatrics 1995;96:977-979.
14. Witte K, Allen M. A meta-analysis of fear appeals: implications for effective public health campaigns. Health Educ Behav 2000;27:591-615
15. Carothers C. Best Start’s 3-step counseling strategy. Paper presented at the meeting of the International Lactation Consultant Association 2005 Conference: Breaking the Barriers to Breastfeeding; Research, Policy, and Practice, Chicago, IL.
16. Brown SL. Emotive health advertising and message resistance. Australian Psychologist 2001;36(3):193-199.
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19. National Immunization Survey, Breastfeeding among US children born 1999-2005. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/breastfeeding/data/NIS_data/index.htm.
20. Wiemann CM, DuBois JC, Berenson AB. Strategies to promote breast-feeding among adolescent mothers. Arch Pediatr Adolesc Med 1998;152:862-869.
21. Wambach KA, Koehn M. Experiences of infant-feeding decision-making among urban economically disadvantaged pregnant adolescents. Journal of Advanced Nursing 2004;48(4):361-370.
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Tackling Childhood Obesity in Schools: The Failures of the Social Expectations Theory and How to Overcome Them– Akshar Patel

In America, childhood obesity is an increasingly growing concern and is proven by the fact that currently 16-18% of children and adolescents are obese and 34% are at risk, this is an 11% increase from the 1970’s (1,2). Obesity in children becomes ever challenging as those afflicted grow up to become obese adults. Cardiovascular disease, high blood pressure, and Diabetes Type II are all problems which arise due to obesity in adults and have been documented to be present in children who suffer from obesity (3). The United States has started to realize that obesity is rapidly becoming a problem in adults and especially in children and as a direct result, a variety of school based interventions have been created; BMI report cards, increasing physical activity, and changing the food available inside of public schools are just a few of the interventions which have been performed. These intervention share one main thing in common, they will all fail, or as discovered, children will go into remission once the intervention has been completed (4).

Due to the fact that they encompass a wide range of groups and are recognized to be a microcosm of the larger world around them, primary and middle schools have been established as a pivotal place to base interventions. The two types of obesity interventions that have designed are: primary, which try to prevent or lessen the effect of obesity, and secondary, which strive in helping maintain weight for obese children (5). Primary schools do not face many problems as the student body is not as deeply fragmented as the middle schools; here the dominating jocks, cheerleaders, and lowly geeks interact together and form a small social community whose actions are interconnected and influenced by factors such as puberty. I will be arguing the obvious, that the numerous interventions that have been proposed and conducted try and incorporate the social expectations theory but fall short in living up its’ definition. Social expectations theory states that individuals will act based on what the social norms prescribe as the acceptable way to act (6). Current interventions of changing foods, increasing physical activity, and promoting parental interaction (7,8) are modeled with the social norms of adults in mind, children and teenagers might share some of the norms, but they act by trying to associate the action with it’s acceptability to their peers.

Eating right does not mean being right

Kids do not have healthy eating on their minds, and let’s face the facts, nor do most adults. At risk kids, ages 6-13, are concerned about having fun or are in the center of teenage life and not thinking about what they will be having for dinner, for that is a problem best left to parents who have enough problems to deal with which will be discussed later. The norms of educated adults and dieticians call for heavily regulating what children are eating so that obesity can either be prevented or maintained. Schools were the chosen point because norms can be tried to be altered on a large scale. Grown ups typically have a method of going about doing things and often it is exactly like the lineage before them: we simply dictate what we want children to do. In a perfect world, this would work out completely fine, but kids have their own social norms, and one of them is to not always listen to what is directed towards them. This can create a problem if schools have lectures and classes about healthier eating habits, students will be less apt to pay attention or retain any information being conveyed, because teenagers hate being told what to do.

The removal of soda and food vending machines from hallways has already been implemented or is currently underway in most schools. This intervention was developed with the hope that throngs of students would be forced to buy healthier drinks, or single serving food packets (5,7) as they found an increasingly amount of less junk food available in the lunch lines. However, even though this intervention was shown to slightly decrease the consumption of unhealthy foods; many children were still bringing the products from home. By trying to rid of vending machines we are simply trying to change the social norms of teenagers into making them believe that it is ok to eat healthier foods. An idea which is unfathomable for school kids everywhere. The average student eats one to two meals supplied by schools; lunch is guaranteed, unless brought from home and thus unregulated and breakfast which can be healthy but is often served with sugary cereals (9). By supplying one healthy meal we are implementing a diet upon the kids since the dinner portion is not controlled by schools; studies have been conducted to test the effectiveness of such interventions, and have found inconclusive evidence of healthy eating interventions lowering obesity rates in children and some studies have even shown to promote weight gain from enforcing a diet (8,10).

This method of trying to change the social norms of eating habits in school kids was not implemented in the best way and is reflected with the inconclusive results. This failure can be attributed to two reasons: incorrect use of the Social Expectations Theory and overlooking a powerful factor. This factor is a lot more powerful than policy making and it is the power that the media holds. The media, if utilized properly, can be used to implement Marketing, Advertising, and Agenda Setting Theory at one time and quickly change social norms held by any group of people. This is exactly what the fast food industry has done. The commercials they have in the mainstream are more appealing than looking at the menu in a cafeteria. After school is dismissed, kids are left on their own until dinner time. At home, elementary school children might have snacks that may or may not be healthy. The situation is different for at risk middle schoolers, who with freedom and their allowance money can easily act on their cravings (11). Instead of eating a healthy meal at school, more and more teenagers are opting for the delicious but deadly Big Mac, items such as these are marketed to an extent (12) where children’s norms have been changed to promote eating at fast food restaurants; thus contributing to the rising problem of obesity and also unraveling the school based food program. The fast food industry has easily been able to change the social norm of children, for them fast food is the like advertising Gatorade, very easy. Fast food is quick, cheap, and delicious; there is no regard for the calorie count or the health effects of obesity simply because kids feel that it is not a problem that they have to worry about (11).

Physical Activity: Not just for athletes

Recess is the highlight for most children in primary school, and with good reason. As a kid, after a stressful morning of class all you want to do is run around outside and let off some pre-teen stress. For those in middle school, this is easier said than done. Middle schools do not have recess; instead they have replaced recess with Physical Education (PE), or recess in a structured environment.

As the obesity epidemic affects more children, schools are following a study (13) that provided inconclusive data for extending PE and weight loss. As an idea, extending PE looks to be well thought out; after all, what kid does not want to play games and hang out instead of sitting in class? The answer is simple, take a look into the bleachers and you will be easily able to spot them. It is one thing to appeal to the social norms of playing sports and having fun in teenagers, however when you try to mandate and get every student to participate, it is bound to fail. Those that can be found sitting in the bleachers are often the afflicted and the target of the intervention. The reason that they are sitting and not participating in the sport of the week is for the simple and small fact of not having developed the skills of playing sports, and instead of embarrassing themselves have opted to sit and take a mediocre grade. Although we can mandate physical activity and playing sports along with being active may completely be within the social norms, kids can not be forced into actually partaking in the exercise, especially obese children who have developed norms different then their peers. Interventions increasing requirements for physical activity do not take this into account and can fail (13,14). However, for the individuals that do participate in the activity, small effects can be observed as long as they keep up the exercise.

The beauty of school based physical activity is that it can be expanded out of the confines of the four walls of school. Students are encouraged to join school or city sport teams. This offers another way for kids who have developed athletic skills to keep exercising, and those who have not to try and get involved; although most often they tend to avoid these sport teams as well. One of the other factors that affect the success of this intervention is the neighborhood children come from. Low-income families typically live in the darker side of the city, and it might not always be safe for kids to cross the street and play a game of basketball, instead a safer alternative can be playing sports on the new Xbox 360 or watching TV (15). In conclusion, although intervening and increasing the amount of physical activity taking place in school using the Social Expectations Theory, we have completely disregarded the fact that athleticism is a developed talent and part of growing up is becoming absorbed into a clique where playing sports is just not the social norm. We have targeted the wrong social norm.

We’re in this together: the need for increased parental influence and involvement

Children can be compared to trees, as both need roots to survive. Without roots, trees will die off and in children values and knowledge will fail to be imparted. Due to this, parents are very important in determining the outcome of an obesity intervention. Studies have shown that if the grandparents and parents of children under 10 are obese, then the chances of obesity in the children is doubled when compared to non obese families (16,17) According to the social norms of parenting, parents should be present to take care of their children; this as we will see is not always the case, especially in low income families.

School based interventions, which are striving to change many norms that children currently have, relied heavily on parental involvement. Schools can only be held responsible for a small fraction of a child’s health and it is parents who hold the majority stake in the investment so they must be active in their child’s upbringing and health. However, this social norm is sometimes unattainable for some families located low on the socio-economic ladder. These parents are not able to feed their kids healthy foods everyday, most are working multiple jobs to help clothe, keep their children healthy, and put any food on the table (15). Most times when parents choose to work over dinnertime, fast food or ordering pizza becomes more of a decision. This applies not just too low income families but those that are in the middle class as well. The stigma of fast food as fast and filling, as also been established within the mindset of adults, and is attributed to adult obesity. In the context of this analysis, if parents are working longer hours everyday and do not have time to prepare healthy food, fast food becomes a viable alternative and unravels any forward process attained by school based interventions.

Looking ahead

Social Expectations Theory tells us that individuals act as a cohesive group, and will base their actions and thoughts around if their peers will find it acceptable. The loss of incorporating this teaching into a real world setting and forgetting children and adults have different norms has led to and will lead to a failure of school based interventions to stop and prevent childhood obesity. We in the public health field have tried to push our thoughts and norms onto kids that are not concerned about the same problems; the strategy of simply filling cafeterias and vending machines is a short term approach and completely disregards what kids eat after they leave the confines of the building.

A successful approach should not mirror present approaches, trying to change the social norms of pre-teens and teenagers to reflect what educated adults this is not right. Interventions should be addressed similarly to the “Truth” campaign in Florida, what the fast food industry is currently doing, and keeping the idea that parental involvement is crucial to the success of studies. The Florida and industry campaigns successfully utilized Marketing, Advertising, and Agenda Setting Theories; if these were applied to childhood obesity correctly, there would be a significant increase in success.

New interventions to fix past mistakes

The first steps that must be undertaken if we are to slow down and reverse the rate of childhood obesity, is to change the way children and adults view and act within their respective norms. Children can no longer be led to believe that junk food is the easier alternative to healthy eating, adults must not be allowed to dictate their views upon the younger generation, doing so only increases the rate of failure. Using the ideas and foundations of Social Expectations Theory in order to address the effects of obesity has so far, for the most part led to failure.

One way to address the failures of the theory in terms of childhood obesity is to patch up and strengthen the weakness mentioned earlier. A second method is to incorporate Marketing, Advertising, and Agenda Setting Theory to the same extent that fast food companies have done in order to ‘serve billions worldwide’, as McDonalds puts it. Children have been exploited through the use of these theories and it is time that we use the same weapons in order to protect them from further harm. The way these theories work are by determining what the consumer wants and then packaging and advertising the item (in our case fast food) back to the population (18). Once this happens, the issue that is always advertised and displayed in the media is the problem or item in question (19). Decreasing the growth of childhood obesity will save millions of dollars in the future for treating illnesses such as hypertension, cardiovascular problems, and Type II Diabetes (3).

The majority of interventions must focus on primary and middle school education. It is at these levels that children are most susceptible to the media, and also for forming bad habits such as unhealthy eating (20). By the time children reach high school, the majority of the damage has been done, and habits that were formed will continue into adulthood. Younger children are more likely to be affected by adult interventions, as they have not fully developed the need to rebel against the parental and authoritative adults.

Keeping kids healthy: a balance between dictatorship and friendship

Schools are the perfect place to conduct obesity interventions. The small community of children function as a smaller part of the adult world, and different models of interventions can be made for each subgroup of the population. These institutions are set up as a dictatorship, the principal and teachers dictate what the students should do; something that carries into every interaction a teacher and pupil have. This carries over into lectures that are given to middle school students about healthy eating; instead of learning about how to eat healthy, the students are simply told why it is good for them and told what to eat.

If interventions are meant to succeed, teachers need to become friendlier when addressing problems such as obesity in the classroom. Instead of lecturing to middle school pre-teens about what they should eat, more emphasis should be placed on not just the nutrition behind healthy eating and why it is important, but the lessons should become hands on. Students can be placed into groups, or ‘families’ and each are in charge of preparing a recipe of healthy meals. In this way, not only do the students learn about why healthy eating is beneficial, but they began to learn more about what healthy meals should consist of.

One of the biggest issues mentioned earlier is the removal of vending machines from schools. The machines were removed from schools to help lower the consumption rate and lower obesity as a result of buying the unhealthy products. A better method to go about this process would have been to allow both types of healthy and unhealthy vending machines to exist, but charge a much lower rate for the goods in a healthier machine. This method allows for children to somewhat make their own choices, however if the product is much more than one is willing to pay, the runner up looks even better. In this way, instead of boycotts of unwanted machines occurring, students would slowly develop a liking to the cheaper healthier foods.

Only six to seven hours of one day is spent inside the confines of school, the rest is spent at home, where the television is always on. This invention is one of the greatest culprits of childhood obesity. The commercials by the fast food industry are more numerous and appealing due to the new types of burgers, and the inclusion of a toy. One way to reverse this trend of commercials on the air is to have public service announcements in the form of the Truth campaign. The issue should link fast food companies and tobacco companies together, and talk about how fast food companies, are getting children addicted slowly and affecting health over a longer period of time. Another example on how to use Advertising and Marketing theory is to have short clips on making healthy snacks using the same ingredients that can be used to make junk food.

Physical Activity: making sure it’s done right

Recess is everyone’s favorite memory of early schooling. It was a chance to run around in the fresh air, not having to worry about class or the fact that you forgot your homework at home. During those early years, physical activity and fitness are not on a kid’s mind, however recess allows for excess energy and calories to be burned off and fights weight gain.

Once middle school came, recess was snatched away and replaced with a period called Physical Education (PE). It became known as structured recess with the catch being that you had to play the game of the week, and be graded on participation. Teams were decided on not how much you wanted to play, but what your peers thought of your athletic skills and how likely you were to help the captain win. Instead of being put through the humiliation of being picked last, one is more likely to skip PE or do something requiring less activity. This is not something we need in America, where the average person is told to exercise for 30-60 minutes three to five times a week (21).

There are two options that we can choose from. Option one brings back the dream of recess; in this version, PE is eliminated and everyone is allowed to play from many games. This allows for groups to decide on what they want to play and activities that are based on ones talents can be decided to be played. The second option is to allow PE to exist but in a manner which helps build up athletic skill. Those that often skip out on PE lack the skills that are required to play many of the sport games. Furthermore, teams should not be decided by a captain, but instead arranged so that individuals who are athletic are teamed up with those that are not.

Outside of schools, physical activity can take place in neighborhoods. Children have the option of joining city teams outside of school; others might want to play in the local park but are hindered by the lack of safety surrounding parks. In lower income neighborhoods; parks and recreation areas are places where gangs and other unsafe practices may congregate. This creates an atmosphere that parents do not want their children to experience and will not allow their children to go outside. If these areas have better lighting and more is done to ensure that the neighborhoods are safe; parents would be more willing to allow their children to play in the park. This would increase the amount and duration of activity that every child has a chance to partake in.

Teamwork: getting parents involved

One of the major reasons for the failure of current interventions is the lack of parental commitment. As stated earlier, low income parents often work at more than one job or multiple shifts. As a result, children are left with money for fast food. Barring large amounts of money being handed to low-income families; there is not much that can be done about the fact that parents have to work.

There are two things that can be done to help promote healthy eating at home in low and middle income families, the first is to send pamphlets and videos home to parents to view on healthy eating. The second, and more effective method, would be to encourage parents to cook meals in advance. Cooking meals in advance allows for healthier eating, because instead of eating fast food, children or parents can come home and warm up the prepared food.

…And that’s a Wrap

In conclusion, although primary and secondary school based interventions are being conducted; more often then not, they will fail. The failure is partly due to the fact that differences in norms of children and adults, nor the fact that parents may not always be a good mediator of keeping up the intervention at home, are not taken into account. Adults often dictate and do not think as a child, this alienates interventions from addressing the issues that would help enhance the chance of success of the specific intervention. By addressing these simple issues, and following the ideas that were suggested, the goal of curbing the rate of childhood obesity can be greatly enhanced.

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