Friday, December 17, 2010

Liquid Gold and Social Networks: A Critique Based on the Health Belief Model and Theory of Planned Behavior - Danit Kaya


Roman goddesses, Egyptian princesses, Jewish warriors, Islamic prophets, French monarchs and British peasants are all intimately linked by one particular life sustaining practice, one that had until recently fallen out of favor and is beginning to experience a noteworthy revival. The practice of wet nursing, when a woman other than an infant’s biological mother provides nourishing milk to that infant, has been a practice that seems to pre-date written history. There are numerous reasons why women have chosen to use wet nurses: the mother had passed in childbirth, was too weak to breastfeed, had an illness, wanted to conceive again (breastfeeding suppresses ovulation), or had multiple children at once and needed help in feedings (1, 2). Cross nursing is a similar practice wherein another woman temporarily nurses a child that is not her own, usually while the mother is away for a few hours.

By the 18th century, the tradition of wet nursing began to fall out of fashion in Europe since it impeded fertility and royal families sought out large families. As royal families hired wet nurses to feed their newborn children, the practice was adopted by other well-to-do families and nursing one’s own child became viewed as a practice of the poor (1). More recently, in the United States in the mid-1950s, as affluence increased and marketing of infant formula became prevalent, wet nursing and even mother-child nursing declined in popularity. In an overall cultural context where women’s bodies are viewed more often as objects of sexual desire than potential sources of nourishment for young children, breast feeding remains a practice that can incite discomfort and repulsion. As University of Chicago political theorist, Iris Marion Young wrote, “Breasts are a scandal because they shatter the border between motherhood and sexuality” (3). Social responses to breast feeding and wet nursing often reflect this ambiguity.

Amidst a conversation about breast feeding and wet nursing, Shell Walker, a midwife and mother in Phoenix, Arizona, wondered aloud to her friends, “Hey why don’t we just become wet nurses? Instead of ‘Meals on Wheels’, we can call our business ‘Eats on Feets’ (4). She began a Facebook page in July 2010 by that title and established it as a free, community-based breast milk sharing network where mothers can match themselves to women who either have excess or are in need of this liquid gold for their infants (4). In October 2010, Emma Kwasnica, a mother and informed choice advocate in Montreal, Canada partnered with Walker to globalize the network. Today, only weeks after the beginning of Kwasnica’s partnership with Walker, a simple search for Eats on Feets (EOF) on Facebook indicates that there are over 100 EOF group pages including: all American states, Canadian provinces, Australia, France, Guam, Malaysia, Argentina, Senegal, the Netherlands, Italy, Singapore and Japan. The explosion of this milk sharing network across the globe is evidence that Walker and Kwasnica have given voice to a growing and passionate movement of mothers who are all seeking to participate in the same behavioral and social practices.

The public health and medical communities readily acknowledge the benefits of breast feeding. When mothers exclusively breast feed, studies have shown a significant reduction for newborns in hospitalization for gastroenteritis, sepsis and respiratory infections. In theory, when six months of exclusive breastfeeding is followed by another six months of continued breastfeeding, 13% of all child deaths could be prevented for children under five years of age (2). Breastfeeding has also been indicated to support healthy cognitive function and reduce cholesterol and BMI levels in older children. It has been shown to aid in the recovery of the mother, facilitate a return to pre-pregnancy weight, prevent anemia, serve as a natural contraceptive, reduce the risk of osteoporosis and ovarian cancer and foster a close mother-child bond (2).

Yet because of a concern over the possibility of infectious disease transmission between mother and child via breast milk, a network such as this one, may pose a concern for public health professionals working towards the prevention of mother to child transmission (PMTCT) because the potential milk donors in this network are not required to be screened for infectious diseases, such as hepatitis, HIV or syphilis. Since the Eats with Feets phenomena has just recently begun, now could be a critical time for public health professionals to enter into this conversation in a way that is contemporary, approachable and reasonable so as to inform mother’s decisions about breast feeding and milk sharing.

Current Approach

The creation of Eats on Feets is too young for there to be an official public health intervention already, but the approach that public health and medical professionals will take is already becoming clear and predictably similar to most unsuccessful public health interventions of the past. Seeing as this movement was globally launched in Canada, Health Canada, the federal department tasked with encouraging health for Canadians, has already released a statement directed at Eats on Feets, similar networks and potential participants. Released on November 25, 2010, it claims:

“Obtaining human milk from the Internet or directly from individuals raises health concerns because, in most cases, medical information about the milk donors is not known. The Canadian Pediatric Society does not endorse the sharing of unprocessed human milk. There is a potential risk that the milk may be contaminated with viruses such as HIV or bacteria which can cause food poisoning, such as Staphylococcus aureus. In addition, traces of substances such as prescription and non-prescription drugs can be transmitted through human milk. Improper hygiene when extracting the milk, as well as improper storage and handling, could also cause the milk to spoil or be contaminated with bacteria and/or viruses that may cause illness... Unprocessed human milk should not be shared” (5).

Although this information is factually correct, the department of health is unlikely to dissuade a significant number of mothers who are already interested in milk sharing from participating in this network with this fact based message. The Canadian Pediatric Society as well as independent physicians have also mirrored the messages of Health Canada. Dr. Sharon Unger, a neonatologist at Mount Sinai Hospital in Toronto, said in a statement to the media, “I think it’s dangerous. I completely understand why women do it, but you really don’t know what you’re’s very unsafe” (6). Though Unger acknowledges that there are perceived benefits to participation in milk sharing, she does little to provide compelling immediate alternatives.

Health Belief Model and Perceived Susceptibility - Critique Argument 1

Of all the traditional theories used most commonly by public health professionals, the Health Belief Model (HBM) is the oldest and most broadly implemented model in the field (7). Originated by Irwin Rosenstock, Godfrey Hochbaum and Stephen Kegels, social psychologists working for the United States Public Health Service (USPHS) in the 1950s, it was developed to create a guideline that explained perturbing behavior. In the 1950s and 1960s, the USPHS attempted to screen people in free mobile clinics for tuberculosis, cervical cancer, dental disease, rheumatic fever, polio and influenza in order to detect asymptomatic diseases early on (8). Yet, despite the ease of access to these screening sites at no cost, people did not respond to these screening opportunities in large numbers. Social psychologists created a theory, which came to be known as the Health Belief Model, delineating four key influences on human behavior. They were: perceived susceptibility, perceived seriousness, perceived benefits of taking action and perceived barriers to taking action (8). By 1988, two additional components were added to this model: cues to action - something that gives an individual a push to act - and self efficacy - an individual believing that they are capable of acting (7). Together, these six elements have comprised the guidelines upon which a majority of public health interventions have been developed.

The first factor of the HBM, perceived susceptibility, postulates that if an individual recognizes the subjective risks of contracting a condition, an individual will begin to change their behavior (8). This model is clearly an assumption of Health Canada’s approach. As their statement expresses, “There is a potential risk that the milk may be contaminated with viruses such as HIV or bacteria which can cause food poisoning” (5). By making such a blanket, albeit accurate statement, Health Canada has assumed that the mere knowledge of risks involved in milk sharing is sufficient to increase perceived susceptibility and in turn change the behavioral decisions of nursing mothers. Yet, studies conducted after the conception of the HBM have concluded that this assumption is a fatal flaw of many public health interventions (9, 10, 11). Knowledge of susceptibility is rarely enough to spur behavior change alone.

Moreover, even if mothers acknowledged the potential for mother to child transmission of infectious diseases via milk sharing, they are unlikely to recognize that this outcome could happen to their child just as easily as it could happen to another woman’s infant. This is largely due to the Optimistic Bias Theory which will be discussed later in this analysis. Put simply, it states that although people may have an accurate perception of a particular risk, they do not believe that it applies to them. Neil Weinstein, professor of human ecology at Rutgers University, and his colleagues studied this perception in smokers. The study determined that while they recognized a 43% overall increased risk of developing lung cancer for smokers, they believed their personal risk of developing lung cancer to be only 29% (12). Although knowledge is influential is curbing dangerous health behaviors, unless a public health approach presents that knowledge in a personalized manner, the approach will likely have little success.

Health Belief Model and Perceived Benefits - Critique Argument 2

Another component of the Health Belief Model is perceived benefits of taking action. If an individual perceives that a particular behavior will be beneficial, that will serve to spur behavior change. As an individual level model, this component of the HBM is frequently flawed when applied to public health interventions. According to this theory, once an individual accepts her susceptibility to a disease or condition, the direction of her action is influenced by her beliefs about the effectiveness of alternative behaviors (8). In other words, if she perceives that there is a benefit to taking action or refusing to take action, the HBM states that this will push her to act accordingly. Notably, the individual’s beliefs about the effectiveness and benefit of an action, not the objective facts about the action’s effectiveness guide individual behaviors in this model.

In the context of Eats on Feets, this component of the Health Belief Model has two potential perceived benefits. The first is the perceived benefit of breastfeeding the child. As was stated earlier, physicians and public health professionals readily acknowledge the biological and emotional benefits of exclusive breastfeeding, including: better immune function, less hospitalization, increased cognitive function and improved health of the mother(2). By joining the Facebook Eats on Feets network, mothers from 100 different regions confirm that they too share this perception. On the other hand, Health Canada and the Canadian Pediatric Society clearly assume the third component of the HBM in their message:

Parents made aware of the possibility for their children to receive human donor breast milk along with all of the perceived benefits and potential risks [emphasis added]...They may then make an informed decision as to the best feeding plan for their baby (13).

Health professionals seemingly strike a balance between infant formula and informal milk sharing networks by encouraging the use of human milk banks. Yet in Canada, there is only one milk bank located in Vancouver. It cannot meet the demand for one of the large regional hospitals, Sunnybrook, let alone individual requests (6). In fact, Sunnybrook Hospital complements its supply of human breast milk from the United States. Although there were twenty-three milk banks in Canada, all but the one in Vancouver were shut down amidst the fears of HIV transmission in the 80s. In early November, the Canadian Pediatric Society called for an increase in the number of milk banks nationwide, particularly for premature and sick newborns (14). This leaves little room of real alternatives for mothers desiring to feed their otherwise healthy infants with human breast milk. Furthermore, the cost of human breast milk from milk banks can be nearly $100US each day, with a charge of $3/ounce plus shipping and handling (15). This cost is out of reach for many families.

Theory of Planned Behavior and Subjective Norms - Critique Argument 3

Another individual level model, upon which many public health interventions and approaches rely is the Theory of Planned Behavior (TPB). Developed in 1975 by Martin Fishbein and expanded in 1985 by Icek Ajzen, this theory focuses on the rational, cognitive decision-making processes. Specifically, TPB found behavioral intentions to be more predictive of actual behavior than attitudes alone. The components of this theory were: attitude (individual beliefs about what will happen), subjective norms (beliefs about what other people will think), behavioral intention (intention to perform a behavior), perceived behavioral control (beliefs about factors that will affect ability to perform behavior) and perceived power (belief about how much power individual has to perform behavior). A model based on rational processes, it does allow for some irrationality in that it accounts for the influence of subjective social norms upon individual behavior.

Health Canada’s approach to the Eats on Feets global milk sharing network utilizes the Theory of Planned Behavior in its public messaging, with a focus on subjective norms. This component states that beliefs about whether influential people approve or disapprove of a behavior will be key determinants in the eventual behavior choice. Individuals are motivated to act in a way that gains the approval of others, often by conforming to those perceived norms. (Note: my previous paper’s discussion about the False Consensus Effect and perceived norms expands on this dynamic issue). Health Canada states: “Breastfeeding promotes optimal infant growth, health and development and is recognized internationally as the best method of feeding infants. However, unprocessed human milk should not be shared” (5). By stating that there is international recognition and acceptance of breastfeeding of infants, Health Canada affirms what mothers participating in Eats on Feets have already recognized: breastfeeding is the optimal source of nutrition for an infant. While promoting the use of breast milk, they shun the practice of informal milk sharing, attempting to create a new social norm or taboo. However, the effect is one of mixed messages. If Health Canada aims to promote breast feeding, while discouraging milk sharing, it would serve them well to offer alternatives.

The social norms surrounding breastfeeding in developed nations are rife with controversy. When asked about cross nursing on Good Morning America, Morgan McFarland, a mother who engages in milk sharing said,

“I think it’s just not been our social some cultures it is, and you think nothing of nursing your neighbor’s child if something happened or your sister’s baby if she had to go to work. That would be completely normal” (16).

In developed nations, public breastfeeding is often shunned as immoral and nursing a child once the child gets older, can be looked upon as scandalous. This is mostly true in nations where the maternal instinct is conflated with the sexual instinct. McFarland’s friend and cross nurser echoed,

“A lot of people are uncomfortable hearing about nursing at all. They assume that anything that has to do with breasts has to be sexual. I guess it’s bad enough if you’re doing it with your own child, then you add in another child to the mix and they’re really concerned about it. It’s feed babies, that’s what they’re for” (16).

For an issue that evokes such visceral reactions, Health Canada’s mixed messaging is likely to have a negative effect on the behavior of women already participating in Eats on Feets. Communications strategists must recognize that while social norms have a tremendous influence on individuals, those norms tend to change from one population subset to another and messaging should be tailored to this population explicitly.

Facebook Ads and Virtual Resource - Proposed Intervention

The most significant steps for the creation of a new public health intervention may be viewed as three fold: establishing a explicit goal or outcome for the intervention, using subtle or overt strategies which successfully achieve that goal and knowing the audience targeted by the intervention. Most of this is lacking in Health Canada’s approach toward Eats on Feets. Though the goal of their statement was to stop mothers from participating in informal milk sharing networks, the theories behind the message were flawed and likely create a muddled and counterproductive effect.

Moreover, though the population of women participating or considering participating in this network may be diverse, they all have tangible commonalities, including a reliance upon a social networking site for community, recent childbirth, young families and a desire to breastfeed their newborns. These factors must be recognized and embraced if a public health intervention directed toward these women is to succeed. This could be done through a targeted social media campaign, focusing on Facebook users who have joined Eats on Feets. This population is likely to be comprised of women in their late 20’s who are vocal and potentially strong influencers of other women in their physical and virtual communities (17).

A campaign could be developed that creates Facebook ads which target women who have certain words on their profiles, including breastfeeding, informal milk sharing, Eats on Feets, birthing, conscious living, midwifery, lamaze, motherhood, babies, informed choice, home birthing, unassisted childbirth, grassroots, environmentalism, and natural parenting. A more thorough investigation into pivotal keywords could be useful to assure the intervention successfully reaches as many women of the target population as possible. Seeing as Facebook ads are fairly small, the advertisement would have limited room to catch the attention of mothers interested in informal milk sharing. In contrast to goal of Health Canada and the Canadian Pediatric Society, which is to forbid women from engaging in a behavior, this intervention would recognize and support women already joining this community.

Rather than telling them what they should not do, the goal of the intervention would encourage mothers to respectfully screen the donors and educate them on how to flash pasteurize human milk. This could be done with images of a nursing baby, a smiling child, or familiar cartoon figures with the alternating titles “Flashing, Naturally,” “Behind the Screens,” “Liquid Gold,” “Formally, Informal,” or “Flash Mob Babies”. The purpose of these proposed titles would be to capture the attention of mothers who are actively practicing or considering informal milk sharing through networks such as Eats on Feets. Formatted as a Facebook ad, a subtitle would accompany this series of ads with basic and appealing information, such as “Stay healthy and happy when milk sharing with these simple tips.” A much more detailed website would follow once a Facebook user clicked on the advertisement. Requiring little up front capital, this website would have easy to read and visually appealing information about various resources for pregnant and nursing women, including a few particularly moving testimonials from mothers describing their concern about safety and consequent decision to screen. It would have images of young women and various ethnicities looking at their cellphone screen with a child nearby, sitting at the computer with a baby on their lap, close-up shots of smiling mothers and children and other such images which would seem familiar and approachable to these women. Alternating with these pictures would be a bottle being flash pasteurized, a woman getting her blood drawn and two women talking to each other with steaming mugs of tea looking at a checklist on the table. Finally, there would be a YouTube-style commercial on the site with a simple message about donor screening and flash pasteurization. Young women would be featured in this video, so as to encourage the familiarity of the message source.

Optimistic Bias and the Law of Small Numbers - Intervention Defense 1

Neil Weinstein, professor of human ecology at Rutgers University wrote about optimistic bias in his 1980 study conducted on undergraduate students. Asking study participants to compare their own chance of various life events to those of their peers, Weinstein and his colleagues noted that participants often thought themselves much more likely to have positive life events and more unlikely to have negative outcomes as compared to their peers. Participants believed that their chances of liking their post-graduate job, owning their own home and having a starting salary greater than $10,000 was more likely for them. However, they also believed that they were less likely than their peers to have a drinking problem, attempt suicide, or be divorced a few years after being married (10). While people may have an accurate objective perception of risk, they think that their personal chance of that risk is much lower than they should reasonably expect.

This tendency can be a positive social force, encouraging people to have unreasonably cheery outlooks even in the face of evidence to the contrary. However, the effect can be most damaging when individuals do not recognize the likelihood of their own risk. The optimistic bias theory can counter the effects of the perceived susceptibility model in the Health Belief Model by recognizing that even in the face of overall perceived susceptibility, individuals may not act unless they belief they are truly personally at risk.

The proposed intervention creates a sense in which the risk of disease transmission seems more likely by featuring video testimonials from mothers of similar ages. By identifying a few key stories about mothers who participate in milk sharing only when they have screened the donors and pasteurized the milk, mothers who are considering joining informal milk sharing networks, such as Eats on Feets, will be encouraged to equate the network with a need for screening. This approach works in tandem with the Law of Small Numbers. In their 1971 study at Hebrew University, Amos Tversky and Daniel Kahneman observed an effect in which individuals regard small samples of the population as highly representative of the entire population for all significant characteristics (9). As a result of these generalizations, individuals develop skewed perceptions of reality and risk probability. By creating a visually appealing online resource, the video testimonials would harness the power of the Law of Small Numbers. Telling a few compelling personal stories about healthy infants and donor screening will likely break through the optimistic bias effect and change perception of personal susceptibility to disease transmission. The ultimate goal of this intervention would be furthered, not by discouraging women from participating in informal milk sharing, but by linking milk sharing to donor screening and pasteurization.

Cognitive Dissonance and Commitment Theory - Intervention Defense 2

While the Health Belief Model, and therefore Health Canada’s approach, relies heavily upon an individual mother’s perceived benefits, it does not take into account that those perceptions are heavily influenced by her feelings of commitment to her community. If mothers join Eats on Feets’ informal milk sharing network, feelings of commitment and belonging take a key role in her experiences within this network. This is largely due to Leon Festinger’s Cognitive Dissonance Theory, which explains how individuals reconcile internal psychological conflicts following a decision (18). Dissonance occurs when one internal belief is inconsistent with another belief. In order to reduce sources of dissonance, individuals either change an element to make the two beliefs more consonant, add additional consonant elements to change the ratio of consonant-to-dissonant beliefs or alter the significance of the cognitions(18). When an individual mother feels committed to an action or a community, she is more likely to over inflate the significance of exclusive breastfeeding and deflate that of screening. Unless donor screening and flash pasteurization are viewed as linked to the informal milk sharing community, mothers are likely to find screening dissonant with their belief in the overall benefits of breastfeeding.

The proposed intervention would work to eliminate cognitive dissonance by recognizing the community that these mothers have joined and encouraging that sense of community, both in the Facebook advertisements and the online website. A sense of community in other aspects of the ads and website, such as offering a monthly rendezvous for nursing mothers in the area and local family-friendly activities would support the sense of community for these mothers. If donor screening and flash pasteurization are promoted in this setting, it is likely to be viewed as an addition to the informal milk sharing community, rather than a threat. Instead of relying on a mother’s perception that screening donor milk is beneficial as the Health Belief Model does, the intervention appeals to her sense of commitment to a community she has already joined and encourages healthy behavior from within the community.

Familiarity and Theory of Psychological Reactance - Intervention Defense 3

Although the strategy is used often in public health interventions, messages that are dictated by public health departments and ministries of health lack a commonplace familiarity. As a result, decisions influenced by social norms can appear elitist and out of touch with the target population. The Theory of Planned Behavior does recognize that decisions can be influenced by subjective norms. Yet, as utilized by Health Canada, it embraces only one venue for engaging and challenging those norms: influential physicians or public health appointees. Though physicians are often a tremendous source of influence for individuals, especially young mothers, when an individual mother engages in a behavior that may be thought of as somehow counter to the advice of the physician, a mother may not consult the physician for further advice on the matter (19). The sphere of influence of a physician or prominent public health figure can only extend to matters a nursing mother feels comfortable addressing. If a physician further confirms the impressions of a nursing mother that informal milk sharing is not medically sanctioned, a conversation about the importance of screening potential donors and flash pasteurization may never occur.

If a message about donor screening and flash pasteurization were to come from within the milk sharing community as well as from medical professionals, the effect of familiarity would be induced. According to Communication Theory, if an individual delivering a message is relatable, the individual receiving the message is more likely to accept the message as positive and beneficial (20). This works in tandem with the Theory of Psychological Reactance, wherein individuals react to perceived threats of freedom or control by asserting the freedom that has been threatened. Communication theory is one method in which psychological reactance can be minimized.

In 2005, Paul Silvia and his colleagues at the University of North Carolina conducted a study wherein threats were made to the freedom of study participants by communicators who were either similar or dissimilar to themselves (21). Similarity was achieved by communicators having the same first name, birthday and moral values as the study participants. As expected, when there were low threats to freedom, participants agreed with similar communicators more than those with dissimilar communicators (t=5.90 vs t=4.95, respectively). Yet even during high threats to freedom, participants still agreed more with the similar communicator than with a dissimilar one (t=6.18 vs t=4.19, respectively) (21).

Curbing the effect of psychological reactance by using communication theory enhances the potential success of the proposed public health intervention. By featuring mothers of similar ages and ethnic backgrounds, a message about screening milk for infectious diseases and flash pasteurization of all milk would come from a similar and familiar source. Even mothers who are skeptical of the medical establishment, would be encouraged to embrace these behaviors, seeing other women who believe in similar social norms actively advocating for these safety measures.

Closing Discussion

It becomes clear that although Health Canada’s approach to Eats on Feets is medically sound, it is unlikely to deter a large number of women from informal milk sharing, especially if they have already demonstrated a commitment to breastfeeding. While Health Canada and the Canadian Pediatric Society may think that they will discourage this movement by calmly presenting facts to the nation, the theory of communication, optimistic bias, psychological reactance, cognitive dissonance and the law of small numbers all present models to the contrary. Health Canada must develop a campaign based on these theories, if they are to successfully prevent mother to child transmission of diseases through informal milk sharing networks.


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2. Petrova, Mihaela and Kamburov, Victor. Breastfeeding and chronic HBV infection: Clinical and social implications. World Journal of Gastroenterology, 2010; 28: 16(40):5042-5046.

3. Young, Marion I. Throwing like a girl and other essays in feminist philosophy and social theory. Indianapolis, IN: Indiana University Press, 1990.

4. Eats on Feets. World's Largest Breast Milk Sharing Network Spreads Across Facebook: "Eats On Feets" Goes Global, Press Release. Montreal, Canada, November 2010.

5. Health Canada. Health Canada Raises Concerns About the Use of Unprocessed Human Milk. Ottawa, Canada: Health Canada, November 2010.

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11. Ayanian, John Z. and Cleary, Paul D. Perceived Risks of Heart Disease and Cancer Among Cigarette Smokers. Journal of American Medical Association. 281(11) March 17, 1999. Pp. 1019-1021.

12. Weinstein, Neil D, Marcus, SE, Moser, RP. Smokers’ Unrealistic Optimism about their Risk. Tobacco Control 2005; 15:55-59.

13. Canadian Pediatric Society. Human milk banking. Canada: Canadian Pediatric Society.

14. Canadian Pediatric Society. Donations of human milk could help sick, hospitalized newborns. Ottawa, Canada: Health Canada, November 2010.

15. Mother’s Milk Bank. Frequently Asked Questions. San Jose, CA: Mother’s Milk Bank.

16. Good Morning America. Cross-Nursing. New York City, NY: Good Morning America, 28 July 2008.

17. Personal Correspondence with Emma Kwasnica, co-founder of Eats on Feets.

18. Cameron, Kenzie A. A Practitioners Guide to Persuasion: An Overview of 15 Selected Persuasion Theories, Models and Frameworks. Patient Education and Counseling 74, 2009. Pp. 309-317.

19. Shealy, Katherine R. Characteristics of Breastfeeding Practices Among US Mothers. Pediatrics 2008; 122; S50-S55.

20. Ariely, Dan. Predictably Irrational. New York City, NY: Harper Perennial, 2008.

21. Silvia, Paul J. Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance. Basic and Applied Social Psychology, 27 (3) 2005. Pp. 277-284.

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