Sunday, December 12, 2010

Learning to Market Breastfeeding–Olga Yevtukhova

Breastfeeding is a natural way to feed a newborn. The American Academy of Pediatrics (AAP) recommends that women exclusively breastfeed their infants for the first six months of the baby’s life, and continue breastfeeding until 12 months of age (5). The AAP advises that breastfeeding has numerous health benefits for the child, such as reduced incidence of infectious disease, respiratory infections, otitis media (ear infections), diarrhea, type I and type II diabetes, asthma, and obesity (5). Mothers also experience health benefits from breastfeeding their babies. Studies have shown that breastfeeding women experience a faster return to pre-pregnancy weight, improved bone remineralization post-partum, and a reduced risk of ovarian and breast cancers (5). A recent study has showed that women with a family history of breast cancer were 59% less likely to develop breast cancer themselves if they breastfed their children (9). Increased breastfeeding also leads to community benefits that would decrease annual costs of up to $3.6 billion in the United States (5). These cost reductions would come from decreased expenses for government support programs for low-income expecting mothers and newborn children, reduced parental absenteeism from work, and the accompanying loss of income and decreased environmental burdens due to a lowered consumption of formula (5).
The 2010 Centers for Disease Control and Prevention (CDC) Breastfeeding Report Card across the United States showed that 3 out of 4 new mothers in the U.S. now start breastfeeding (3). However, American mothers don’t breastfeed their children as much as the experts would like. Rates of breastfeeding at 6 and 12 months and rates of exclusive breastfeeding at 3 and 6 months remain stagnant and low (3). This demonstrates that even though new moms intend to breastfeed and try to breastfeed, they do not follow through for the recommended amount of time, which is 6 months. The CDC posits that is because new mothers are not getting the breastfeeding support the need, and New York’s statistics are only marginally higher than the national average - 4.6% higher in response to “Ever Breastfed” and “Breastfeeding at 6 months” and only 2.5% higher in response to “Breastfeeding at 12 months” (4). On the other hand, the state of Ohio has fared much worse. As of 2010, only 64.8% of the mothers “Ever Breastfed”, about 10% less than the national average (3). The rate of mothers breastfeeding at 6 months is 4.5% less than the national average, and at 12 months, the two rates begin to look more similar, with only a 2% less mothers breastfeeding at 12 months in Ohio than takes place on average across the United States. Thus, while neither New York nor Ohio is able to encourage mothers to continue to breastfeed for an entire year, most of the expecting mothers in Ohio do not attempt breastfeeding at all.
In April 2010, the Ohio State Department of Health began a public health campaign to promote breastfeeding that drew a great deal of attention through its state program, “Help Me Grow”. The goal of the ad campaign was to show that breast milk is the perfect food for babies that promotes the bond between a mother and child (17). Several posters and billboards have been installed in major cities and to be visible from highways as new parents drive, using the slogan “Breast Milk Satisfies”. There are two types of billboards. One portrays a satiated, rosy-cheeked white toddler, the other a younger African-American baby with milk dripping from the corner of its mouth. Both of the kids look contended, fully and quite a bit glazed over. A spokesperson for the campaign said that the ads were meant to mimic “Got Milk?” print ads, a campaign used by milk processors and dairy farmers to promote drinking cow’s milk. The “Got Milk?” campaign featured numerous celebrities from the fields of sports, media, entertainment and popular culture, including film and fictional characters holding a glass of milk and sporting a milk mustache (16). The Ohio State Department of Health received a lot of criticism for the public for the campaign, calling disturbing, distasteful and even racist (17).
In September 2010, hundreds of miles away, the New York State Department of Public Health (NYSDPH) launched a very different public health education campaign to encourage women breastfeed their babies and to educate them about the benefits of breastfeeding (1). The campaign cost $1.6 million and was funded by an award from the U.S. Department of Agriculture, in recognition of New York’s Women, Infants, and Children (WIC) nutrition program is one of the 10 in the nation with the highest breastfeeding rates (1). The NYSDPH ad targets low-income new and expectant mothers (who qualify for assistance with the cost of groceries through WIC) and attempts to educate them about the benefits of breastfeeding for mothers and their babies. Another goal of the campaign was to address the support that breastfeeding mothers need – from family, employers, health care providers, and the community. In an effort to improve breastfeeding rates, the NYSDPH campaign was designed to support the new mother’s decision to breastfeed and address any breastfeeding concerns (2).
The campaign was short and focused, and ran for about 2 months. It featured TV spots, online ads and ads on buses across the State of New York. The slogan of the campaign was “Breastfeeding… For my Baby. For Me.” The print ad was a picture of a young, good-looking African-American woman breastfeeding her baby, gently holding its little fist, with the slogan printed in small print across the bottom. The TV-ad campaign, however, featured four Public Service Announcements (PSAs) that aired across the state. The first PSA shows a woman who is dressed in business casual and her 5-8 year old child with his backpack on. “No ear infection, no fever, will go to school today” are the words that are displayed next to him. Next, his smiling mother walks up to him. The words appear, “will go to work today”.
The second PSA focuses on an immediate result rather than on long-term health benefits. This PSA looks like an advertisement for a weight loss program, showing a woman dancing happily, bragging about losing 40 pounds, and crediting breastfeeding rather than Jenny Craig, Weight Watchers or NutriSystem. She holds up her old “mom” jeans and boasts that she is down to a “size 8.” At the end of this attention-grabber, the friendly announcer comes on in the background and lets the watchers know that breastfeeding burns up to 500 calories a day – which is like 2 hours of aerobic exercise a day – and while it’s good for the baby, it’s great for the mother! Below, I will argue that while the immediacy and tangibility of quick post-partum weight loss may be more convincing than an abstract Health-Belief Model based promise of future health benefits, like lower rates of heart disease later in the baby’s life. However, this campaign seems to be playing on post-pregnancy body insecurities, framing breastfeeding as a dieting plan, with the mother’s weight loss taking precedence over any other benefits.
The last PSA shows an African-American mother flipping though baby pictures of her daughter, talking about her support for her daughter’s decision to breastfeed. The mother says that when she was bottle-feeding her daughter they didn’t know any better, but her daughter intends to breastfeed her infant, and the mother says, “More power to her.”
I will argue that both of these campaigns have failed to fulfill their goals. First, the Ohio campaign failed to correctly implement the marketing model. Second, these campaigns are not effective in increasing the social acceptance of breastfeeding. Third, these campaigns failed to increase the breastfeeding self-efficacy of mothers and portray the benefits of the behavioral change as outweighing the costs.

The campaigns failed to correctly utilize marketing theory.

Both the New York and Ohio campaigns are stark examples of a failed application of marketing theory. Marketing theory is grounded in principles of exchange, self-interest, behavior change, competition, segmentation and building relationships (21). The aim of marketing goes far beyond presenting the product, its benefits and specifications to a set of potential purchasers. The goal of marketing theory is to create a demand for a product by making a promise that a core value, need or desire, which would otherwise remain unmet, will be fulfilled with the purchase of the product (10). A successful public health intervention marketing strategy would incorporate all the same strategies that commercial marketing uses and apply it in socially beneficial ways. The first step behind marketing theory is gathering data about the market group, the second step is determining the target group’s needs and desires (11, 12). The goal of the market research is to gain an understanding of the target audience, know its demographic characteristics (age, education, values) and behavioral characteristics (needs, desires and wants). This allows the marketers to make predictions about the target group’s behavior and ultimately influence it (12). Planning the presentation of the advertisement, developing the “product” and how it is framed, implementing and continually assessing the performance of the campaign are the final steps (11, 12).
The Ohio campaign seemed to have blindly focused on the desire of a mother to see her child happy, well-fed and fulfilled. Taking a cue from the “Got Milk?” ads they mimicked the milk mustache on the faces of the celebrities and replaced that with breast-milk dribble on the face of a baby. However, Ohio missed the point. The “Got Milk?” print ads channeling the glamour of the celebrities and associating it with a commodity like milk. Here, the baby looks glazed, ravenous and messy – some of the comments found by Fox Toledo, a local news station commented that the baby looked like a “vampire” with “all the drool . . . dripping off his chin.” (22). Moreover, the color choices picked for the print ad were not ideal – some observers noticed that the milk dripping off the face of the African American baby did not look white, which led to conjectures of racism on part of the Ohio State Department of Health and comments such as, why is the African American baby drinking chocolate breast milk? This approach violated many marketing principles. Ohio’s proposed exchange of the satisfaction of breast milk in return for the convenience and habit of bottle-feeding took into consideration the happiness of the baby but did not address the self-interest of the mothers or their support networks. If a mother believes that formula is essentially nutritionally equivalent to breast milk, there is no reason she cannot satisfy her baby without the difficulties and inconveniences of breastfeeding. The concept of self-interest dictates that the only perceived costs and benefits that matter are the ones of the customer – the customer in this intervention is the mother of the baby (19). Here, the mother bears all the burdens and incurs all the costs of the transaction, in addition to giving up her value that she is already taking good care of her infant and the baby is “satisfied.” The child benefits in the short-term, but there is no indication that a baby would be satisfied with a breast-milk substitute. Other benefits for the child are not indicated, but generally, in social marketing, the benefits are difficult to measure and not visible until long into the future (23).
The New York State campaign handles this angle significantly better – it introduces into the mix the idea that a mother will immediately benefit from the breast-feeding through weight loss. However, the campaign simply does not go far enough. A large part of the reason that advertising and marketing is so successful is because of the thorough research of the target audience and continual re-evaluation of the campaign after implementation as to its effectiveness. The New York campaign only lasted for a mere two months, which did not provide sufficient time to assess the results and change tracks if necessary. Again, the campaign does not truly apply marketing theory, but mimics the form of a weight-loss commercial instead of the function. The advertisement is a humorous spin on a Jenny Craig commercial instead of truly targeting the core values of youth and beauty.

The Campaigns Ignore Barriers to Breastfeeding.

Both the Ohio and New York State breastfeeding campaigns targets individual behavioral change that affects a child-rearing choice. Even though the New York campaign is the better of the two, it still does not meet one of its main intended goals – increasing support that a new mother needs to improve her ability to breastfeed her baby. The ad campaign simply does not go far enough to make breastfeeding an acceptable social norm across the socio-ecological framework. In fact, it further entrenches breastfeeding as tied to perceptions of motherhood, sexuality, and femininity. Finally, it further reinforces stereotypes associated with being an expecting or new mother.
There are a number of systemic impediments to breastfeeding. Although breastfeeding is natural, it is not an easy skill to learn for first-time mothers. Many mothers do not have access to skilled assistance in the first weeks after birth to help them with the mechanics and logistics of breastfeeding (8). Some pay for expensive lactation consultants, but that is not a resource that is available to the majority of the population, and especially not to low-income women.
Today, we live in a society where a mother who wants to continue breastfeeding exclusively faces difficult choices. She may have to breastfeed at work, in a store, or in a restaurant. Life does not stop merely because a woman gives birth. In the US, women are entitled to three months of unpaid maternity leave under the law. Paid maternity leave is merely a benefit that is offered by a small proportion of employers. Many women cannot afford to stay out of the workforce much longer. One third of women return to work after three months, and two thirds return within six months of giving birth (24). The sharp drop-offs in exclusive breastfeeding at three and six months of age closely reflect the demands and practices of the labor market: most mothers can no longer breastfeed full time when they return to work (13). If a mother wants to breast feed for the length of time that the guidelines suggest, she is relegated to pumping breast milk for up to nine months, storing it, and feeding it to her baby out a bottle. Not all women are even able to pump milk at work, which is necessary to maintain supply. Only twelve states have enacted laws relating to breastfeeding in the workplace. For example, New York law mandates that employers provide mothers with reasonable unpaid break time to pump breast milk at work, and requires that they provide a private place in which to do so (23). Ohio does not. Women with lower incomes are more likely to hold lower-wage jobs with no breaks allowed for nursing or breast-pumping, with no facilities to store the expressed milk.
What’s worse, even while breastfeeding, it is considered to be inappropriate, shameful and embarrassing to expose a woman’s breasts in public (24). Only 26 states address the issue of breastfeeding by exempting the practice of public breastfeeding from criminal law (14). In a 2002 study of U.S. adults, researchers found that 27% of the subjects found breastfeeding in public to be embarrassing (20). A 2004 study done by the Centers for Disease and Prevention (CDC) showed that 37% of adult respondents agreed with the statements that “mothers who breastfeed should do so in private places only” (21). One of the factors that were found to discourage low-income women from breastfeeding were the perceptions of social disapproval of breastfeeding in public and reports of ridicule from friends (25).
The best way to change an individual’s behavior is to change social norms, that is, the customary codes of behavior in a culture that guide behavior (26). Studies have shown that it is a lack of observable models that leads to a neutral or negative attitude about breastfeeding. If a young person was not breastfed or exposed to breastfeeding, they were less likely to breastfeed her child in the future or to support their partner in breastfeeding their child (30). Neither the Ohio nor the New York campaigns model breastfeeding behavior to their target audiences. They leave it to the imagination of the viewer to determine what happens between a mom and a hungry baby. Also, they target soon-to-be mothers rather than younger men and women in their formative years, whose guidelines for social norms have not yet ossified.
Additionally, women need close support of their families. Studies have shown that if a woman’s partner, husband and/or mother do not support her decision to breastfeed, she is unlikely to do so (13). Ohio’s campaign completely fails at building a support coalition for the breastfeeding mother. One of the New York State ads begins going in the right direction, where a mother expresses her support for her daughter’s commitment to breastfeed her baby. A sense of acceptance and support among the family may make the mother feel comfortable breastfeeding and encourage a new mother to begin to or to continue to breastfeed her baby. However, New York’s problem is not with initiating breastfeeding – it is encouraging women to continue breastfeeding the infant through 6, and even 12 months of the age. The support of her mom, no matter how empowering, would not be sufficient to maintain that behavior for such an extended period of time.
Furthermore, the campaigns ignore cultural norms and the cultural differences in breastfeeding practices. The African American culture tends to emphasize involvement of the family rather than having the mother bond exclusively with the newborn. Thus, if a mother chooses to bottle-feed instead of nursing, the whole family may be involved rather than just the mother. (8) This is particularly important because African-American women show lower rates of breastfeeding initiation and continuation than women of other ethnic groups (27). This may be due to a complex set of cultural reasons that includes a lingering perception of formula as a sign of prestige and a history of African-American domestic servants serving as wet nurses (8).
The print ad of the New York State’s Campaign is the only component of either of the two campaigns that addresses social perceptions of breast feeding. It portrays an image of a woman with one semi-exposed breast, locked in the contemplation of her nursing baby. However, the campaign needs to take an extra step. These images are idealized portrayals of a nursing mother, trapped in a purple billboard far away from world. The campaign does not attempt to change normative ideas about breastfeeding, and only addresses interpersonal aspects of behavior. The images of women breastfeeding are excluded from the TV advertisements. They do not integrate the breastfeeding woman into society. This reinforces the notion that breastfeeding is an ideal act to be aspired to, that is private and exclusive between the mother and the baby and does not take place in the everyday world. Images associated with breastfeeding typically show healthy women, conventionally attractive and feminine, normally shaped, and with normally shaped breasts (22). The New York campaign continues to reinforce these stereotypes. Two out of three TV spots they use attractive, healthy, thin, young white women with blonde hair. Even so, the commercials do not elevate the prestige of breastfeeding practice or show it either esteemed, sophisticated, attractive or glamorous. Related to the fact that the campaign only addressed intra- and interpersonal aspects of behavioral influence, is the fact that the campaign does not attempt to change normative ideas about breastfeeding generally, nor ideas that are tied to limited and limiting notions of motherhood specifically and of womanhood, more broadly. Instead, the “Jenny Craig”-like breast-feeding TV advertisement reinforces that a woman needs to lose weight after her pregnancy and appear more physically attractive to her partner.

The campaigns may lead to a rejection of the message due to reactance.
Finally, government-sponsored interventions may induce reactance because mothers may not trust the source of the information. Studies have shown that each infant in the WIC program that was breastfed as opposed to formula fed saved WIC about $478 in formula and administrative costs during the first six months of life (25). In the New York State campaign clearly identifies WIC as the source of information. Women may perceive the breastfeeding campaign as seeing the government simply trying to cut its costs due to a limited budget. They would not be entirely wrong – some of the benefits of breastfeeding have been overblown. Many of the studies that AAP relied on in issuing its statement confuses association with causation: thus, even the authors of the research warn that breastfeeding may only be a part of a package of skills, abilities and emotional attachments that mark families whose infants do better rather than the effects of breastfeeding or breast milk per se (31). This in turn may lead to reactance on part of the women, that is, when their sense of freedom and autonomy is threatened, they may react with a rejection of the intervention (32). One way to diminish reactance is through diffusion theory – by increasing similarities between the target audience and the person sending the message (28). Social groups are more likely to change their behavior when the information is presented by someone who is similar to them and someone who comes from inside the community. It does not help the cause of the New York State campaigns that the women featured in two out of three ads do not physically resemble their target audience (one is dressed professionally in work pants and jacket, the other an attractive blonde white woman).

The campaigns fail to portray the perceived benefits of breast-feeding to outweigh the perceived costs.

A number of studies have shown that generally, young women have an overall positive attitude about breastfeeding and believe that it is natural and healthy (14, 15). However, they did not have a common acceptable language for describing breastfeeding and seemed confused about the process. Many did not intend to undertake it personally for a number of reasons. First, they tended to view breastfeeding as inconvenient, a private activity, only allowed in certain contexts.
The Ohio breastfeeding campaign is geared towards the individual mother, telling her that breastfeeding is beneficial because it leads to a satisfied baby. However, motivating a mother to modify her intended behavior remains an unmet challenge in Ohio State. Studies have shown that there are four motivational facts that can be influenced by coaching, experience and education: 1) Perceived chances of success, 2) perceived benefit of the goal, 3) perceived cost, and 4) inclination to keep the old habit (15). People ultimately decide whether to adopt or reject behavior based on the balance of the appraisal of the perceived costs and benefits. The Ohio breastfeeding campaign fails to address the perceived chances of success and perceived costs altogether. The only benefit that is vaguely addressed is the satisfaction of the baby (“Breastmilk Satisfies”). The campaign encourages breastfeeding of babies to ensure a full, happy and satisfied baby. The questions of perceived costs to the mother are side-stepped altogether. Nevertheless, these will be present in the mind of the woman who is making the decision. The perceived costs are the comfort and convenience of the mother, who may be embarrassed by the idea of breastfeeding in public. Going back to work has significant social value.
Furthermore, based on the Social Cognitive Theory, a person’s decision to engage in a particular behavior is influenced by their self-efficacy, that is, the belief in your capacity to organize and execute the course of action necessary to produce the result. Shortly, self-efficacy is the extent to which a person believes that they can be successful in performing a given task or completing an action (33). A person with a high level of self-efficacy is likely to put forth more effort and to persist longer at a task than those with low self-efficacy.
Even though the women targeted by the Ohio campaign now know that breast milk “Satisfies,” that is, the benefit of breastfeeding, the campaigns fail to acknowledge the momentous difficulty of the task of breastfeeding for six to twelve months. Research has shown that a lack of confidence is associated with a shortened duration of breastfeeding, and perceived capability and confidence has a strong influence on initiation and self-efficacy (29). In order for women to maintain breastfeeding for an extended period of time, they need to believe that they will be successful in doing it. Women need to see role models that are similar to them that successfully perform the behavior. Unfortunately, for many new mothers today, the only image they may have of the act of breastfeeding may come from a National Geographic documentary or a museum; it is not something that is frequently captured in popular culture. Neither the Noew York nor the Ohio campaigns really address this. The Ohio campaign fails to frame the issue in a way that would lead women to believe that they can initiate and maintain breastfeeding. Showing images of an overfed, satiated baby does not frame the issue in a way that gives the mother control and a set of choices.

Proposed Intervention

There is a great deal of strong evidence that breastfeeding is the best way to feed a baby. However, in order to increase breastfeeding initiation and 12- month maintenance rates, a new kind of campaign is necessary. This would be a multi-prong approach that does not merely tout the medical benefits of breastfeeding. First, the campaign should use an educational approach focusing on educating about the benefits and challenges of breastfeeding. However, this should not target current or expecting mothers, but be made part of sexual education in high schools. This approach should not follow the flawed Health Belief Model, which fails to address environmental and social influences of behavior, but instead present breastfeeding role models to the children to encourage future mothers to adopt the behavior and their future partners to be supportive of it. Diffusion theory is an important tool that would decrease the women’s reactance by increasing the similarities between the target audience and the person sending the message. One aspect of that would be using people that look like members of the target community to appear in print and TV advertisement. Rather than scaring women with the risks of feeding formula, women need to feel that the benefits of breastfeeding outweigh the costs. Other advertisements would portray breastfeeding as glamorous, something that celebrities, fashion models do to improve their figures. It is not enough to simply copy the outward appearance of an advertising campaign. It is necessary to fully implement marketing theory to appeal to the core values of beauty, happiness, vigor, youthfulness and glamour. Campaigns would also feature women breastfeeding in public and at work and talk about how they made breastfeeding “work” in conjunction with living their lives and returning to their jobs. This would help women build confidence and improve self-efficacy. In order to improve the perceived benefits of breastfeeding, one angle to pitch is the convenience of breastfeeding, showcased in a campaign that contrasts the stories of two moms. One mom wakes up and staggers, bleary eyed, at 3 a.m. to warm up a bottle in a water bath is portrayed as tired and careworn the next day. The other mom happily naps as her infant nurses at her side and is refreshed the next day.
However, true social change and removal of barriers calls for more than advertising. Additional legal change is also necessary across the country in order to make every community breastfeeding-friendly. Women who breastfeed in public areas need to feel comfortable without fear of harassment. Incentives need to be passed for employers to make it good business sense for employers to support lactating mothers who return to work. Employment guarantees need to be put in place for low-income women who may feel pressure to return to work. In order to enable mothers to breastfeed their children they need across-the-board social support from both their families, partners and the healthcare system – for example, by increasing the number or post-partum nurses who assist new mothers. A helpful tactic to implement would be to send a nurse to visit the mother at home to teach breastfeeding techniques a week after birth. Free formula should be eliminated, except for those mothers who cannot breastfeed for medical reasons. Only then will breastfeeding rates for babies at 6 and 12 months substantially increase.

REFERENCES

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2 Comments:

At December 12, 2010 at 8:57 PM , Blogger Samual said...

Its a great Blog.Chinese Marketing outsourcing is its low cost online business services as well as manufacturing, which are predicted to remain low for a good time in future also. The great assets of educated labour, which are available at low cost,

 
At December 13, 2010 at 3:08 PM , Anonymous Anonymous said...

Why is this not tagged for "breastfeeding"?

 

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