Friday, December 17, 2010

Critique of New York State Department of Health and WIC Breastfeeding Intervention - Ellen LaRoche

Over the past decade, breastfeeding has grown in popularity as the choice feeding method for newborns. New research has shown the breastfeeding offers many health advantages over formula feeding, both for the mother and the infant. Society had become more accepting of breastfeeding as well, by offering family rooms in public restrooms, providing women returning to work with private areas to pump, and designing high quality and stylish nursing tops. The current trend in breastfeeding, however, has not been as successful among low income mothers as it has been with their higher SES counterparts. In September 2010, The New York State Department of Health decided to work with New York’s WIC branch to launch a $1.6 million public health education campaign promoting the benefits of breastfeeding and encouraging new mothers to choose to nurse(6). This campaign, entitled “Breastfeeding...For My Baby, For Me” is a combination of print and television advertisements, along with WIC resources, aimed mostly at mothers in low-income areas to give them the support necessary to breastfeed their newborns (6). Not only does it provide extra immune support for the baby, but it is also substantially less expensive than choosing formula. When analyzing the campaign as a whole, it appears as though not one single social or psychological theory was used. There were elements of the Theory of Reasoned Action, Marketing Theory, and Psychological Reactance Theory. When looking at the campaign as a whole, there were many flaws, which may have hindered the success of the promising initiative.

Critique 1: Ineffective use of Psychological Reactance Theory

The Psychological Reactance Theory was created by Jack Brehm in 1966. The main concept behind this theory is a loss of personal freedom. Reactance occurs when an individual feels as through their personal freedom is being taken away from them and they try to reagin that freedom (8). When an individual feels as though their right to behave a certain way is being threatened, they will choose to behave in a way opposite of what is being suggested. This is known as the Boomerang effect (11). Essentially, when an individual is told that they cannot have something, it makes them want it more. An example of this theory is how once a commercial is deemed inappropriate for television and taken off the air, it goes viral on the internet and become much more popular.

When planning an intervention using the Psychological Reactance Theory, it is most important to reduce the level of possible reactance within the intervention. That is, make the intervention as non-threatening as possible to the target audience. Similarity has been identified as a very important factor affecting the level of reactance (9). In a study done by Paul J. Silvia, participants were read an essay that did or did not pose threats to their individual freedom (11). When the person reading the essay was identified as sharing the same age, name, or birthday with the participant, the boomerang effect was much lower than when there was no similarity at all. Participants felt less threatened by an interviewer that shared a trait with them. Furthermore, when the interviewer had a high level of similarity to the participant, the level of agreement regarding a threatening or non threatening letter was the same. It can be interpreted that similarity not only reduces reactance, but it also improves the level of compliance by the consumer.

The New York State Breastfeeding campaign took the idea of reactance into consideration when planning the commercials that would air on local television channels throughout the state. A series of four commercials were released promoting the benefits of breastfeeding for both the mother and the child. Two of these commercials were controversial because they focused entirely on the increased caloric burn that results from breast feeding, which leads to weight loss for some women(5). The third commercial in the series focused on the positive impact that breastfeeding has on a child’s immune system, leading to fewer sick days for both the child and their mother. The fourth commercial identified the change in trends from bottle feeding to breastfeeding over the past twenty years(5). Three out of the four commercials backed up the claim that breastfeeding is better for the mother and the child with facts. When evidence is provided to back up a claim, consumers feel less of a threat to their personal freedom and are less likely to experience reactance. Each commercial featured mothers providing the supporting evidence that backed up the breastfeeding recommendation. By using mothers, instead of experts or doctors, the commercial became more relatable. In that sense, the NYS Department of Health used similarity to their advantage to reduce reactance.

Similarity was also where the campaign fell short. The creators of the commercials failed to consider the target audience when selecting the women to represent mothers in each commercial. NYS Department of Health and WIC were hoping to target women living in low income neighborhoods. Three out of the four commercial’s featured white women, who appeared to be from a high socioeconomic background. The lack of diversity within the commercials decreases the level of similarity to the women living in the targeted areas. As a result, women may experience a higher level of reactance from these commercials than if each commercial was represented by a different race(9,11) .

Critique 2: Ineffective use of Theory of Reasoned Action

The Theory of Reasoned action is a conventional model used to asses behavior change on an individual level. It was founded by 1975 by Martin Fishbein and differs from many of the other conventional models of individual behavior change because it focuses on the intention to change. The theory states that people will perform a given action if they believe that they should (1). An underlying consideration of this theory is that people act in rational ways, thinking before they act. According to the Theory of Reasoned Action, when considering whether or not to adopt a certain behavior, an individual will consider two determinants. The first is whether or not they, themselves believe the action to be good or bad. The second is the attitudes and beliefs of those surrounding them, also known as subjective norms(7).

The Theory of Reasoned Action is a logical choice when planning a behavioral intervention involving the decision of whether or not to breastfeed. A woman must put a lot of thought into how they choose to feed their newborn because that decision has an impact on every aspect of their life. That requires rational thought. The series of commercials within the New York State Department of Health campaign do a good job of showing some important benefits of breastfeeding, such as how it boosts the child’s immune system, leading to fewer sick days for that child and therefore fewer days the mother has to take off from work to care for her child. Throughout the campaign, in both print and on television, four different women are featured promoting the benefits of breastfeeding. This helps to show pregnant women that many other women made the decision to breastfeed and it has had a positive outcome on their lives. In this sense, issue is framed in a positive light, thus improving the target audience’s attitude regarding breastfeeding. A positive attitude will increase the individual’s intention to perform a given behavior (7).

The second factor that influences an individual’s behavioral intention, normative beliefs, is where this campaign fell short. Normative beliefs refer to the individual's perception of the opinions of important people in their lives regarding the behavior in question (1). With an issue, such as breastfeeding, which can be controversial at times, it is important that a woman feels supported by her peers, her community, and her family. By featuring a clip at the end of each commercial about community resources at the local WIC chapter and portraying the opinion of other mothers, the community and peers are represented. One commercial features a mother sharing a story of how proud she is of her daughter for being so determined to breastfeed her child, thus instilling the support of parents onto the expectant mothers. While the series of commercials do a good job of showing that females support the decision to breastfeed, they do not attempt to show the opinions of fathers or husbands. Most pregnant women have a partner in their life to share the responsibility of raising the child with, and his or her opinion is important to the expectant mother. This ad campaign makes no attempt to show that men support the choice to breastfeed. In this situation, the absence of male input could appear as disapproving to a woman making the decision. If she does not believe that one of the most important people in her and her child’s life does not support her choice to breastfeed, her intention to choose breastfeeding over bottle feeding will decline.

Critique 3: Ineffective use of Marketing Theory

Marketing theory takes into account the concept of commercial branding and applies that to a particular public health behavior. Similarly to commercial branding, it is the main goal of public health branding to build a relationship between the target audience and the health behavior at hand. Public health branding differs from commercial branding in that it is promoting a specific health behavior and the long term health benefits, where as commercial branding is selling an object or service (2). When building a public health brand, it is important to consider the target audience. One of the main determinants as to whether or not a brand succeeds is the audience’s trust in the message (3). The position of the brand needs to be aimed towards that target group, focusing on the most relevant issues to that particular audience, in order to be most successful in building a brand image.

New York state and WIC have been working together for many years to build a strong breastfeeding promotional brand. The USDA Food and Nutritional Service Northeast Regional Administrator James C. Arena-DeRosa recently commended the NYS Department of Health and WIC by saying "It's admirable that New York State WIC took this opportunity to continue to build upon its successes in promoting breastfeeding and that it continues to provide the information and support WIC mothers and their families need to successfully breastfeed." (5). It is clear the New York state has done a good job at laying the ground work for building a successful breastfeeding brand. The most recent campaign, however, failed to adjust to the needs of the target audience.

The main “consumer” for this campaign was “new and expectant mothers, primarily in lower-income areas”. The aim of the four television commercials released by this appeared to focus more on upper-middle class mothers. Two of the PSA’s focus only on the weight loss benefits of breastfeeding, while the third focuses on immune system benefits to the child and fewer sick days from work for the mother. The fourth PSA is nostalgic and supportive but gives very little information about the benefits of breastfeeding for the mother or the child. Although these commercials may have been effective in the promotion of breastfeeding to middle class women, low-income women may struggle to relate. A woman will be much less concerned with returning to her pre-gravid weight when she is struggling financially. One message that is never mentioned in any of the PSA’s is that unlike baby formula, which has become extremely expensive, breastfeeding is free. With a need for diapers, clothing, and medical bills, having a newborn is extremely expensive and can be daunting for women without financial security. By promoting the cost difference between breastfeeding and formula feeding, low-income mothers may be more willing to choose breastfeeding.

Another way in which this breastfeeding campaign fails to consider the target audience and therefore represents an ineffective application of Marketing Theory is that it does not consider the diversity of the target population. Low-income areas have much higher amounts of racial diversity. The PSA’s released wold have been more effective in reaching the desired group of women if they had been multiracial. These commercials also lacked diversity in age. Three out of the four commercial consisted of Caucasian women looking to be in their thirties while the fourth commercial featured and African American grandmother. Teenage pregnancy is common within the target audience. A sixteen year old Latino girl is not going to relate well to a perky 30-something blonde woman talking about how much weight she lost from breastfeeding. It also may send the wrong message that WIC is only for the type of woman represented in the PSA’s, when WIC actually aims to help those in greater need. This breastfeeding campaign lacks relevance to its target audience of low-income women. As a result, they may lose trust in the message and the agencies supporting the message and ultimately weaken the public health brand.

While looking closely at New York State and WIC’s recent public health campaign that was hoping to support and promote breastfeeding among low-income mothers from the perspective of three different social or behavioral science theories, it was clear that the audience was not the main focus when preparing the campaign materials. Although low-income mothers were stated as the target audience in the press release, the campaign design was focused more on the production of commercials that would be relatable to upper-middle class women. The commercials and advertisements lacked racial diversity and failed to address issues of concern relating to the target audience. This limited the potential of the campaign.

Proposed Intervention

The New York State Department of Health and the New York State WIC chapters put together a very positive campaign promoting breastfeeding. The campaign was well rounded and included four television commercials, one print advertisement, and website which provided access to numerous resources. Although there were numerous flaws to this particular campaign, the overall concept was strong. It is important to spread the word about the benefits of breastfeeding for the mother and for the child, so the title of the campaign “Breastfeeding...For My Baby, For Me” is appropriate. Since New York State has been successfully promoting breastfeeding through numerous campaigns for years now, it is appropriate to look at this is as an opportunity to create a brand. The target audience in the this situation would be low-income expectant mothers, their families, and also their community as a whole. Taking a cue from the Theory of Reasoned Action, a behavioral intention is much more likely to be made by an individual if it is considered to be “good” by all key people in that individual’s life (1). It is extremely important to the success of this campaign that this campaign be accessible and relatable to the target demographic. As a result, the three main changes that need to be made to this campaign involve producing more print ads to reach more people, include more diversity within the advertisements, and focus the messages of the advertisements on the major concerns of the target audience.

Change #1: More print ads

As stated in the press release, New York State was planning on presenting the advertisements on buses and in bus shelters. These are two great locations to present information, but unfortunately, there was only one print ad prepared for the entire campaign and this advertisement does not provide any information about breastfeeding. Print ads placed in strategic locations around town are more appropriate for this target audience, as they may not have televisions in their homes or may not have time to watch television. It is important to place the ads where the consumer will be. Billboards would be a good way to reach a large amount of people. Placing advertisements in and around hospitals and free clinics or anywhere else that the women of the community may be going to receive pre-natal care would be good locations because it would guarantee that women see those advertisements at least once during their pregnancy. Also, by strategically placing these advertisements near health care providers, it would expose women to the idea of breastfeeding while they are already on the way to their obstetrician. That would give the physician the opportunity to bring up breastfeeding and promote the numerous benefits. Prior exposure to the topic may also inspire some questions about the topic, which the expectant mother can ask at their appointment. Postcards should be made as well with a print ad on one side and a list of local and online resources for women considering breastfeeding for their child on the other. These postcards can be handed out at doctors appointments, with any visit to a WIC center, or with any SNAP (food stamps) promotional material.

Change #2: Messages that cater to the target audience

With an increase in the number of print ads, there needs to be more than just one print ad. The original print ad for this campaign featured a mother breast feeding her child with the title of the campaign, “Breastfeeding...For my Baby, For Me” in the bottom corner. By switching the main focus of this campaign from television advertisements to print advertisements, the impact that the message being portrayed needs to be stronger. These print advertisements should to supply the viewer with enough information to persuade them to at least consider choosing breastfeeding over bottle feeding. When information is presented as a statistic, it is often overlooked. Based on the Law of Small Numbers, people struggle to relate to facts (10). Information has more of an impact on the consumer when it is presented as a story or memory. Facts can also be more threatening than personal statements, thus increasing the possible feeling of reactance towards the message.

The print advertisements for this campaign will feature both women alone and women with their families (whether it be with their partners, children, or parents) saying why they chose to breastfeed. By including family members in the campaign, it will show that they support the decision and therefore increase the likelihood for a positive behavioral intention by the mother (7). These quotes will be based on benefits of breastfeeding that are the most relatable to the target audience. In order to develop of strong brand and have the most significant impact, the messages of the campaign need to be relevant to the target audience. While increased caloric burn may be important to some women, there are more important benefits that will appeal to the low-income audience. It is important to remember that benefits to the baby and to the mother need to be included in the advertisements, as this is the basis of the campaign. Some benefits of breastfeeding that will be featured in the campaign include the fact that it is free and requires no preparation, breastfed children are less likely to become overweight throughout their lifetime, increased immunity for the child, mother-child bonding, and lowers the risk for certain types of cancers and type 2 diabetes in mothers(5). The fact the breastfeeding is free is appealing to low-income households because they may be on a tight budget to begin with and baby formula is very expensive. The risk of childhood obesity is much higher in low SES neighborhoods, due to poor access to healthy foods and safe outdoor environments. Increased immunity for the child means that there will be fewer sick days and doctor visits for the child. Decreased risk of certain long term disease such as cancers and type 2 diabetes for the mother will mean that she will be around to spend more time with her children while also having to spend less time and money at the doctors office.

Change #3: More diversity

While choosing more relevant messages will make the pro-breastfeeding campaign more relatable to the target audience, the women featured in the campaign need to be more similar to those in the target audience. The information being portrayed in the print advertisements will have a stronger impact if it is being presented by a diverse collection of women. Each ad should feature of woman of a different race or ethnicity. The advertisements should also feature women of different ages. Based on the Psychological Reactants Theory, a message will induce a lower level of reactance if the subject in the advertisement is similar to the subject that the advertisement is hoping to influence (4). The target audience will feel less threatened by an ad featuring a person similar to them as opposed to an advertisement featuring an authority figure or person sharing no similarities with that audience (9). Since low income neighborhoods are much more diverse, it is important to represent that throughout the campaign. Often times people in low-income neighborhoods may have immigrated from another country and may not speak or read english very well. Some neighborhoods may be predominately Spanish speaking, and in that case, some of the advertisements would be translated so that the message can reach the maximum number of people. In It is also important to represent all types of family structures in the campaign.

Racial diversity is important to the campaign because it will increase relevance of the message being portrayed to the target audience and therefore strengthen the brand. Family diversity is also an important factor to be considered when designing the ad campaign. Since some of the print advertisements will feature women and their families, it is important to embrace the ever-changing family structure. Now, more than ever, a family is not only represented by mother, father, and child. There are same-sex families, single-mother families, and extended families. As a result, it is important to represent multiple family structures to increase the amount of similarity to the target audience. Not only will this help to reduce reactance, but it will also show that key people in women’s life support their decision to breastfeed. This will lead the mother to have a more positive attitude towards breastfeeding, according the the Theory of Reasoned Action (1).

When creating a public health brand, it is important to consider the target audience. By building trust between the campaign and the key demographic, a strong brand image will follow (3). New York State’s recent breastfeeding campaign was a positive one, but it was slightly flawed. The most significant flaw was the overall lack of focus on the target audience. The base of the campaign was strong, so the details were modified by taking into consideration the Theory of Reasoned Action’s concept of Normative beliefs, The Psychological Theory of Reactance and similarity, and The Law of Small Number. These social and behavioral theories helped to make the breastfeeding campaign more relevant to the target audience, allowing them to better relate to the messages being portrayed. This new and improved will have a stronger influence on the consumer and lead to spread in the trend of breastfeeding over bottle feeding into the low-income neighborhoods of New York State.


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