Tuesday, December 21, 2010

Social Marketing Principles and the NY State Dept of Health's Television PSAs for Breastfeeding Promotion - Cathleen Prata Cisse

Breast milk is the optimal way to feed a baby and has numerous advantages for both mother and child. Evidence shows that breast milk provides benefits beyond nourishment. Breast milk protects against ear, gastrointestinal, and respiratory infections. Other evidence suggests that breast milk decreases the risk of sudden infant death syndrome, asthma, allergies, and obesity (1). It also protects mothers from maternal depression and decreases her risk for ovarian, endometrial, and breast cancers (1). A recent study revealed that 13 billion dollars could be saved if 90% of mothers breastfed according to the World Health Organization’s (WHO) guidelines of exclusive breastfeeding until 6 months (2). These costs include only the direct and indirect costs of caring for children suffering from illness and disease possibly prevented by exclusive breastfeeding (2). Savings could be substantially increased when factoring in the cost to manufacture, purchase, and distribute infant formula. Yet, despite these savings, the government does little to increase the rates of breastfeeding. Goals are set, but campaigns to promote breastfeeding are not compelling enough to illicit behavior change. This paper will explore the flaws behind a recent social marketing campaign to promote breastfeeding, as well as the government’s lack of true initiative to increase the rates of breastfeeding in the U.S.

Healthy People 2010
Prior to the start of the 21st century, the Department of Health and Human Services developed “Healthy People 2010”, a list of health objectives to improve the quality of life and prevent disease in 28 areas of public health (3). Despite the potential that breastfeeding has to prevent illness and disease, it came as 1 of 23 total subheadings under focus area number 16: Maternal, Infant and Child Health (4).
The Centers for Disease Control’s (CDC) National Health Statistic Center (NCHS) is responsible for monitoring national progress towards the goals of Healthy People 2010 (3). In 2000, the objectives for percentage of breastfeeding by the year 2010 were set at 75% for breastfeeding initiation, 50% at 6 months, and 25% at 1 year (5). Although breastfeeding has increased, changes have not been dramatic and only the target for breastfeeding initiation has been met (6). In 2006, targets were added for exclusive breastfeeding at 3 months (60%) and exclusive breastfeeding at 6 months (25%) (5). A year later, these targets were considered an overestimation and reduced to 40% and 17% (5). Perhaps the change was made to make it appear that Healthy People was more successful at reaching their targets. At the time the objectives were changed, exclusive breastfeeding rates were 33% (3 months) and 13% (6 months) (7).

In September 2010, the New York State Department of Health (DOH) introduced the “Breastfeeding…For my Baby, For Me” (8). The campaign consists of several TV commercials, online ads, and ads on buses and bus shelters throughout the state of New York. It seems that the DOH attempted to apply social marketing to its campaign when designing the commercials for this campaign. Although, the campaign had positive attributes and some may applaud the mere fact that more attention is being given to breastfeeding, their application of social marketing is flawed and this component of their campaign will fall short of eliciting a substantial increase in breastfeeding rates. The campaign is not compelling because a) it is based on antiquated health behavior theories that have shown to be ineffective, b) it unsuccessfully employs social marketing theory and c) it tries to create a norm that does not exist, is unattractive for some, and is unachievable for many women due to our current government policies.

Health Belief Model
The first commercial in the series shows a 4 or 5 year old boy standing in front of a white backdrop, music is played and words appear on the screen, “No ear infection. No fever. Will go to school today”. His mother then enters the scene and more words appear on the screen, “Will go to work today.” A voiceover of a woman tells us that breastfed children have stronger immune systems and other health advantages (9). This type of commercial stems from the Health Belief Model. According to the Health Belief Model people are likely to engage in an action based on the perceived severity of not taking action and the perceived benefits of taking the action. The model theorizes that people need cues to action and that they are more likely to engage in the action if they have a high level of self-efficacy, a belief that they are capable of performing the behavior (10). The limitations of this behavior model are that it only targets individuals, tries to promote breastfeeding based on the core value of health, and it does not take the social environment into account.
The commercial tries to persuade the mother to breastfeed based on the core value of health, which is ultimately the value and belief of those promoting the campaign, the DOH. This type of persuasion is flawed because campaigns true to the social marketing theory do not assume that they should change the consumer to conform to what the marketer’s core value (11). Rather the most successful marketing campaigns match their product to the values and beliefs of their target audience (11). Breastfeeding promotion campaigns that do not target the values and beliefs of expectant mothers and their families will continue to fail to increase rates of breastfeeding because they are based on the health benefits of the behavior rather than the benefits in the self-interest of mothers and families (11).
Most importantly, this commercial fails to convince women to breastfeed because it treats mothers as “contextless individuals” without any outside factors that affect the decision to breastfeed (12). However, this is not the case. Breastfeeding does not come easy for women in the United States.
The federal Family and Medical Leave Act (FMLA) ensures that employees, who work for a firm employing at least 50 people, receive up to 12 weeks of unpaid leave due to the worker’s own disability or illness (including pregnancy and childbirth) with a guarantee of return to the same, or an equivalent, job (13). According to a study published in 2010 in Health Policy, women who expected to return to work full-time were less likely to initiate breastfeeding than mothers who did not expect to return to work full-time (14).
Instead of looking at low breastfeeding rates as a problem stemming from government policy and law, the commercial’s use of the Health Belief Model targeted at women addresses the problem from a downstream approach. The commercial puts all of the responsibility on women to decide to breastfeed without taking into consideration the factors around her that do or do not support breastfeeding. The commercial literally shows the mother having made their decision in a vacuum, as she stands with her son in front of a white background.

Social Marketing Theory
Research suggests that public health interventions could be more successful by using social marketing theory’s ‘4 Ps’ – product, price, place, and promotion – to repackage , reposition, and reframe public health messages (11,15). Based on this theory, public health interventions must a) offer a benefit that promises to satisfy the needs and wants of the target audience, b) take the cost or sacrifice needed to gain the benefit into consideration from the consumer’s point of view, and c) provide convincing evidence that the promised benefit is worth the cost or sacrifice (11,15).
A second commercial of the “Breastfeeding…For my Baby, For me” series, a woman holds up a pair of maternity pants and claims to have lost 40 pounds because “I breastfed my baby!” She then continues to dance around with her baby while music plays and viewers are told that “breastfeeding burns up to 500 calories a day, that’s like 2 hours of aerobic exercise. So while it’s good for your baby, breastfeeding is also great for your body. Breastfeeding for my baby, for me” (9).
Although regaining control of your body by returning to your previous weight is a benefit that appeals to the target audience, this message is poorly delivered and not convincing. There is no evidence that this woman actually breastfed. According to Mcguire’s source-attractiveness model, the effectiveness of a message depends on “familiarity”, “similarity”, and/or “likeability” (16). Mcguire theorized that the odds of the messenger being seen as a credible source are increased by the target audiences similarity to and attraction to the person delivering the message (16). Based on this model, the woman in the DOH’s breastfeeding commercial will not convince women to breastfeed. We see her only after she has lost the supposed weight dancing around the room with a child who appears not to be her own. It is obvious that the child is being distracted and looking at something else to keep her happy during filming. Again, she is in front of a white back drop, insinuating that this woman does not live in the same world of the viewer who faces many challenges to breastfeeding. This woman fails to convince the viewer because she is more actress than mother.

Theory of Reasoned Action and Psychological Reactance
A third commercial shows a grandmother looking at an old photo album. She tells the viewer that although she formula fed her children, she is proud of her daughter for breastfeeding (9).
The commercial uses one component of the Theory of Planned Behavior to promote breastfeeding. The theory is based on the premise that a person’s intentions to practice a behavior are influenced by whether or not important people in their lives approve or disapprove of the behavior (17). In this case, the woman’s mother, a very important person in most women’s lives, is supporting her daughter’s choice to breastfeed. However, the way the grandmother frames her support could invoke psychological reactance. She states that she formula fed her own children, but now she “knows better” and supports her daughters decision to breastfeed by saying, “She’s determined to breastfeed and I say more power to her” (9).
Psychological reactance theory posits that people will do anything to regain or maintain control of their freedom, which is defined as actions, emotions and attitudes, if it is threatened (18). Forces exerted on an individual that could possibly compromise his/her ability to exercise their freedom constitutes a threat (18). Psychological reactance occurs when a freedom is threatened or completely eliminated. Being in this state motivates a person to reclaim their freedom and the easiest way to this is by engaging in the threatened action, emotion, or attitude, which in this case would be choosing infant formula to feed your child (17). Although the commercial tried to influence a new mother to breastfeed by showing support from the people important in her life, it is not dynamic enough of a commercial to do anything more than subtly tell a woman that she should breastfeed and that others are better to judge how she should feed her child. The grandmother also says that because her daughter is breastfeeding, that her granddaughter will be healthier. This may be true, but it is another way that the commercial is threatening a woman’s choice to decide how to feed her child by telling her that if she uses formula, her child will not be healthy.

Concern for Replication
The New York State DOH has done a huge amount of work to promote breastfeeding, and their efforts should be applauded. However, a concern that one might have is that other state programs will try to replicate only the commercial aspect of their campaign without recognizing the other strategies the New York State DOH has used to increase breastfeeding rates; such as introduction of new laws, the creation of curriculum to teach breastfeeding in primary schools, a peer counseling program and the development of guidelines for healthcare providers to assist mothers in breastfeeding. If a state’s DOH or other government programs try to use these commercials, they will fail to increase breastfeeding rates. Furthermore, any increase in breastfeeding rates seen in New York will not be attributed to these commercials because they rely heavily on individual level behavior change models that assume people are rational and that the context of their environment does not influence people’s decision to engage or not engage in a behavior.

A counteractive marketing strategy
In 1981, the WHO and the United Children’s Fund (UNICEF), created the International Code of Marketing of Breast milk Substitutes in order to protect and promote breastfeeding as a critical element of primary health care. The code’s principle aim is to ensure “the proper use of breast milk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distributi0n” (20). The code outlines recommendations regarding the marketing of breast milk substitutes and infant formula. The code states that for all products within the scope of this code “there should be no advertising or other form of promotion to the general public”, “manufacturers and distributors should not provide, directly or indirectly, to pregnant women, mothers or members of their families, samples of products”, and “there should be no point-of-sale advertising, giving of samples, or any other promotion device to induce sales directly to the consumer at the retail level, such as special display, discount coupons, premiums, special sales…” (19). Additionally, the code states that “informational and education materials, whether written, audio, or visual, dealing with the feeding of infants and intended to reach pregnant women and mothers of infants and young children…should not use any pictures or text which may idealize the use of breast-milk substitutes” (19).
Despite the recommendations of the code, 91 % United States hospitals still distribute formula sample packs, give coupons directly to the consumer to induce retail sales, and show pictures and text that in venerate formula-feeding. They are allowed to do this because although the United States finally endorsed the code in 1994, they have taken no measures to actually enforce the code (20). Although, there is a movement to discontinue the distribution of formula sample packs in hospitals (21), there is nothing to stop the formula companies from continuing this practice in other venues that expectant mothers frequent. Breastfeeding can be difficult, especially without the correct support and advice from experts. When formula companies use hospitals and health care professionals to market their products, they set a woman up to fail and undermine her right to breastfeed.
It took the United States 13 years to actually sign the International Code of Marketing of Breast milk Substitutes, so we cannot wait for the government to enforce it. Rather we must create public health campaigns that are strong enough to counteract the messages being sent by formula companies. A counteractive marketing campaign, similar to the “truth” campaign must be developed to expose the manipulative marketing practices of formula companies.
The “truth” campaign combined elements of several theories: framing, diffusion of innovation, psychological reactance, and branding. The campaign started as a pilot program on tobacco control in Florida from 1998-2000 (22). During the two years of the campaign, the prevalence of frequent cigarette use declined by almost 50% among middle school students and 23% among high school students (22).
In the year 2000, Healthy People 2010 set goals to increase breastfeeding rates by the year 2010 (4). The Baby Friendly Hospital Initiative (BFHI) was started to help reach the new goals. The BFHI consists of 10 steps a hospital can take to “assist hospitals in giving mothers the information, confidence, and skills needed to successfully initiate and continue breastfeeding their babies or feeding formula safely, and gives special recognition to hospitals that have done so” (23). Yet, despite these goals, rates for “any breastfeeding” post-partum have only increased by 6% (70.9 to 75) and from 34.2% to 43% for 6 months and 15.7% to 22.4% at 12 months (4, 6, 7). Furthermore, the rates of introducing formula before 2 days and 3 or 6 months failed to decrease and remained stagnant for the period of 2003-2010 (7). In 2006, increasing exclusive breastfeeding at 3 and 6 months was added to the goals (5). Since then rates have only remained the same or in the case of exclusive breastfeeding at 6 months, decreased (6). Although BFHI has helped increase rates of “any breastfeeding”, it must be noted that the increase was over a period of 10 years as opposed to the rapid declines of smoking seen over 2 years in the “Truth” campaign. In order to effectively campaign for increased breastfeeding, strategies must be changed to 1) make breastfeeding the norm, (2) induce psychological reactance against infant formula feeding companies, and (3) garner support to lobby the government to implement necessary laws and public policy that give women the right to breastfeed.

Sesame Street, Diffusion of Innovation, and Social Modeling
In 1977, a Sesame Street segment shows a woman breastfeeding and a curious Big Bird asking many questions. It only lasts 57 seconds and the woman explains that this is the way that some mothers feed their babies. The segment ends with Big Bird saying, “You know, that’s nice” (24). It is a simple message that normalizes breastfeeding.
Today, scenes like this one, of real moms who breastfeed, are rarely seen on television. A Pub Med search of breastfeeding in the United States media returned no relevant results. However, a study done by researchers in the UK has shown more references to bottle feeding than breastfeeding (25). The study analyzed 13 British newspapers, health and parenting television programs, and a selection of news bulletins, soap operas, medical drama series, and daytime non-fiction programs. Of the 235 references to breast or bottle-feeding in the news, there were 194 references to bottle-feeding and only 41 to breastfeeding. Almost half of the comments were about breastfeeding problems and provided no solutions, yet there was no mention of difficulties with bottle feeding. Breastfeeding was rarely seen on television and in 170 of the scenes showed either someone preparing formula or bottle feeding. The study also reported that “bottle feeding was associated with ‘ordinary’ families whereas breast feeding was associated with middle class or celebrity women” (25). It is highly probable that the same type of results would be found in the U.S.
Yet, if public health media campaigns developed media based on the diffusion of innovation theory and social modeling theory, rather than the Health Belief or Theory of Reasoned Action models, considerable changes in breastfeeding rates could be made in a short amount of time.
Diffusion of Innovations is the process by which a “new innovation is communicated through certain channels over a period of time among the members of a social system” (26). It is possible that people have known about an innovation for some period of time, but may not have made a favorable or unfavorable decision about it (26). In order to help people make a favorable opinion about breastfeeding, Public Health campaigns must reframe the issue of breastfeeding return to strategies that normalize breastfeeding. When reframing the issue, the Public Health community must be very cautious not to induce feelings of guilt in the non-breastfeeding mother (27). Campaigns around guilt for choosing to use infant formula to feed your baby will incite controversy and distract from the real issues of legislation and infant formula marketing strategies that impede on a woman’s ability to breastfeed. Social Modeling Theory should be used to avoid the debate over such feelings of guilt.
Social modeling is based on the principle that people are persuaded to practice certain behaviors if they see other people practicing them (28). Television and film should be used to promote breastfeeding by offering story lines to dispel, rather than perpetuate, the myths associated with breastfeeding. This is similar to the practice of product placement that many corporations use to market their product. Storylines could provide realistic scenarios of the challenges women face when breastfeeding and solutions. Positive outcomes should be used as they are more likely to facilitate learning and practice of the behavior (29). A variety of characters that women feel they can identify with should also be used because women are more likely to practice behavior that they see characters they can relate to and want to be like practicing these behaviors (29). Furthermore, using characters that women can relate to shows that the decision to breastfeed is made in the context of the society we live in. By showing characters in television and film, women will have the chance to be educated about breastfeeding without being told what they should or should not do.

Promoting breast milk as a brand
According to Grier and Bryant, marketing may be one of the most effective behavior promotion strategies for three reasons: 1) “unlike education, it alters the behavioral consequences rather than expects individuals to make a sacrifice on society’s behalf”, 2) it makes the health behavior being promoted more advantageous by communicating “the more favorable cost-benefit relationship to the target audience”, and (3) it recognizes that different strategies need to be used when “societal goals are not directly and immediately consistent with people’s self interest” (15). In order to increase breastfeeding rates, it is necessary that such an approach be taken.
A campaign that redefines the act of breastfeeding as a new product and offers benefits that meet women’s needs must be created. The campaign must deliver a promise to clearly show the benefits that can be offered by breastfeeding. In order to do create a promise, women’s needs must first be defined by women themselves. Formative research must be done to identify and understand the needs and wants of expectant mothers and their families (11). The designers of the campaign should not assume that they know or can guess the wants and needs of their audience. Qualitative research techniques should be used to collect data from mothers who are breastfeeding, are not breastfeeding, have breastfed, and wanted to breastfeed, but were unable to. Research should be done using participants from all racial, ethnic, and socio-economic backgrounds. Literature reviews of past research should be carried out, as well.
The most effective campaigns have been able to target the core values in the U.S., “freedom, independence, autonomy, and control” (11). The women’s response from the research should be analyzed based on the core values and answer the question: What aspects of breastfeeding or not breastfeeding appeal to women’s core values? The campaign should be developed and created based on the answer to this question.
Once formative research is done a campaign can be based around these core values. Strategies used by formula companies to manipulate mothers into depending on the use of formula should be exposed in order to create a movement of women who no longer let formula companies take their freedom to breastfeed away from them. For example, the campaign should let women know that formula companies are able to give so much of their product away because the cost of manufacturing is so low (30). Thus, the rebates they give at the beginning of a pregnancy end up paying for themselves later when the mother now depends on formula because she no longer has enough milk. The formula companies know that breastfeeding will be difficult if a baby is given a bottle before he learns how to properly at latch-on to the breast. Furthermore, the more a woman breastfeeds, the more milk she makes. If a mother supplements with formula, her body will make less milk.
In addition to the schemes formula companies use to convince women to feed infant formula, the campaign should include the risks and inconveniences of infant formula. Some examples that could be used are that it costs more money, more time is spent sterilizing and cleaning bottles, and there have been a number of recalls of infant formula (27).
The campaign could be called “Defending my baby, defending myself”. A commercial similar to the Gardisel “One Less” campaign should be used. It should show women of different ages, race and ethnicities, and socio-economic status stating why “their brand”, breast milk, helps them defend their baby’s health. Key messages of why “their brand” is better should be based on the the appealing aspects of breastfeeding and negative aspects of formula feeding women reported during formative research. Much like the Gardisel commercial, information about breastfeeding and any contraindications can be provided throughout the commercial, but the main message will be to target the core values of expectant mothers.

Changes in government
Although, the two mentioned marketing strategies have great potential to increase breastfeeding. Truly dramatic changes will not be seen until the government makes serious changes in policies regarding women’s rights after giving birth. If the government truly wants to increase breastfeeding, they should recognize its benefits by enforcing the WHO International Code of Marketing of Breast-milk substitutes, making sure that the BFHI extends beyond the hospital through the distribution of handheld breast pumps, increasing women’s access to lactation consultants, and providing women with paid maternity leave.
The government should protect families from the marketing strategies employed by formula companies. Lawmakers should enforce the recommendations of the International Code of Marketing of Breastfeeding by turning them into law and sanctioning those who violate the recommendations.
The BFHI is in place to initiate breastfeeding, but due to the rebates provided by formula companies, initiation does not last very long. The government should implement a program for the distribution of free handheld breast pumps and referrals to lactation consultants upon post-delivery discharge. Women should also see a lactation consultant before she leaves the hospital and be offered subsequent visits with a lactation consultant that is covered by health insurance. This should be the standard procedure at every hospital in the United States.
In the U.S., women are not paid to be home after giving birth, they often cannot afford to stay home and return to work earlier than the allotted 12 weeks. Evidence shows that the most significant negative effect going back to work had on breastfeeding was a return to work prior to 10 weeks after birth. The same study found that for every week a mother delayed returning to work, duration of breastfeeding increased by 0.5 weeks (31). Despite these statistics the United States still remains one of the two developed countries not to offer any paid maternity leave. Australia also does not offer paid leave, but women are allowed to take up to one year off from working (32). Changes must be made to Family Medical leave act that offer woman paid maternity leave for at least 6 months.

A large part of the new health care bill is to prevent disease and promote healthy behaviors (33). There is a provision in the low that mandates employer with more than 50 employees to allow women unpaid breaks to express breast milk (34). Yet, despite these changes, the federal government still does not completely recognize the benefits of breastfeeding. Recently, the Internal Revenue Service, part of the Executive Branch of the U.S. federal government, “ruled that breast-feeding does not have enough health benefits to qualify as a form of medical care” and will therefore not reimburse mothers for the costs of breast pumps, unless medically necessary, or visits to a lactation consultant (35). Without breast pumps it would be very difficult for mothers who, return to work, to breastfeed because they depend on breast pumps to extract milk that they can refrigerate and feed to their baby later (35). It is a necessity. So, at the same time the government appears to support and promote breastfeeding, they also send a clear message that it is still not the norm.
Given that the government continues to send conflicting messages that undermine advocacy efforts to promote breastfeeding, the Public Health community must do more to encourage breastfeeding in the general population. If we continue to rely on campaigns based on individual behavior and rational thinking rather than creating social media campaigns based on American core values, we will not reach the goals set for Healthy People 2020. By not achieving the goals set by Healthy People 2020, the American people will continue to lose 13 billion dollars spent to treat adverse health conditions that could be prevented through breastfeeding.

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