Folic Acid Supplementation in Spanish-Speaking Populations: A Critique on the CDC Folic Acid Campaign – Laura Fuerstman

Introduction

One of the greatest achievements in the reduction of birth defects has been the discovery of the link between folic acid deficiency and increased risk for neural tube defects (NTDs). (1) NTDs are a classification of birth defects that result from the incomplete closure of the neural tube during the third and fourth week of embryonic development. (1) NTDs have a wide range of severity, depending on size and location of the defect. Classic forms of spina bifida often leave an individual paralyzed; severe forms of anencephaly cause an absent brain and an unviable fetus. (1)

In the late 1980s, researchers discovered a correlation between maternal serum deficiency of folic acid and an increased incidence of NTDs. (1) In order to be preventative, adequate serum levels of folic acid must be achieved before and maintained during the development of the fetal neural tube. (1) Studies showed that supplementation with folic acid reduce the risk of NTDs by 50-70%. (1) This finding led to an imminent recommendation by the CDC in 1992 that all women of childbearing age should have a minimal intake of 400mg of folic acid daily. (1) The continuing CDC campaign that followed includes raising awareness of folic acid, promoting folic acid supplementation to women of childbearing age, and mandating folate-fortified foods, including breakfast cereals and breads. (1)

The Hispanic population in the United States has an increased prevalence of spina bifida compared to the general population. (2) The CDC folic acid mandate has been successful in reducing the overall prevalence of spina bifida, however, the prevalence of this birth defect in the Hispanic population has remained the same. (3) The etiology of this increased prevalence has not been studied, but may be attributable to an underlying genetic predisposition for NTDs in this ethnic population, an inadequate dietary intake of folic acid, and increased number of unplanned pregnancies. A study in California suggests that Hispanic women have reported lower folic acid intake (30%) than their White counterparts (50%). (4) Aware of these ethnic differences, the CDC and local public health authorities have placed additional focus on the Hispanic population as part of the continuing campaign to promote folic acid intake for the prevention of NTDs. (5)

The effort to date that CDC has put forth to increase folic acid intake in the Hispanic population has merely included translating into Spanish various CDC lay campaign materials on the importance of folic acid intake prior to. (6) The “Before You Know You’re Pregnant” and “Before you Know It” campaign posters have previously been studied in a controlled research study, however, these posters and other materials have not been scrutinized on the basis of their ability to change beliefs based on social behavior science theory. (7) While the English versions have their flaws to begin with, the translated versions take an additional hit, based on cultural differences, in their ability to have their desired effects.

Critique #1: Reliance on the Health Belief Model

The Health Belief Model (HBM) is a classic behavioral theory that predicts the likelihood that an individual will engage in a positive health promotion behavior by weighing the benefits and barriers of engaging in the action. (8) Important factors in this equation are the individual’s perceptions of perceived susceptibility and perceived severity of the disease, which contribute to the overall threat of the disease, and the drawbacks to engaging in the health behavior, which may include discomfort, cost, and inconvenience. (8) The HBM often serves as a foundation for designing and evaluating public health campaigns and is the likely model used by CDC to increase folic acid awareness and consumption in both the general United States population, as well as the growing Hispanic subpopulation. (9) The general strategy of the CDC Folic Acid campaign is to prevent NTDs by presenting the threat of such birth defects and informing how folic acid supplementation is a positive health behavior that can prevent such conditions.

Regardless of what the true nature of the increased incidence of NTDs among Hispanic women is – whether it is genetic predisposition or the lack of knowledge about NTDs and folic acid– increasing awareness regarding the public health issue is the first step. This might not be so farfetched in this population, as qualitative research using interviews has suggested that Hispanic women do not receive adequate knowledge in their home countries about the prevention of NTDs with folic acid supplementation. (9) The CDC took the logical step and translated their English campaign materials into Spanish. If these materials are readable and accessible in various public settings, then surely they have the capacity of increasing the perceived the threat of NTDs.

Strictly sticking to the HBM, there are two problems with the “Before You Know You’re Pregnant” and “Before you Know It” campaign posters (see English and Spanish versions below), which are representative of other CDC Folic Acid campaign materials. (6) The first is the failure to increase the perceived threat. The terms neural tube defects, spina bifida, and anencephaly are never explicitly stated in either of these posters. The preferred phrase, “serious birth defects of the baby’s brain and spine,” is ambiguous, subjective, and does not concretely convey the potential severity of the these birth defects. Just as some individuals may personally label cleft lip as a “serious” birth defect and not actually perceive it as severe, they may be imagining a condition of similar magnitude. These posters fail to accurately describe the potential of children with NTDs to have severe disabilities, be handicapped and require the use of a wheelchair, or perhaps not even develop a brain. The perceived susceptibility is also not acknowledged in any of the translated material. Usually we see some form of statistics, which would include the overall incidence of babies to have a NTD. Not only is this number omitted in these posters, but there is not even the mention that there is a higher rate of NTDs in Hispanic women in the translated version. The combination of these factors does not provide a particularly high perceived threat of NTDs.

The second failure of the using the HBM approach is that an increase in perceived threat of NTDs does not necessary lead to the desired behavior, which is an increase in folic acid intake. In fact, a research study in Hispanic communities showed that knowledge about the link between folic acid and pregnancy or birth defects does not result in daily supplementation. (10) This can be attributed to the inattention to barriers of folic acid intake. Sources of folic acid that are recommended in these materials are multivitamins and enriched foods, such as cereal, bread, and pasta. In fairness, these are the most robust sources of folic acid available to the majority of the United States population; however, they are likely not as appealing to many Hispanic women. In addition, the cost of vitamins being is potentially prohibitive. It has also been documented that many Hispanic women believe that vitamins cause you to have an increased appetite and gain weight. (9, 11) This potentially causes negative social reinforcement both from the fear of “becoming fat,” but also perhaps the fear of social derision if peers discover you are taking vitamins. Other barriers include the smell or taste of vitamins, difficulty making it a habit or remembering to take them, and an upset stomach. (9,11) Additionally, the foods fortified with folic acid that are listed and currently available are not as likely to be a part of the diet of many Hispanic individuals in the United States. To the credit of the CDC, current efforts are underway to mandate fortification of processed foods, such as those made with masa corn flour, that are regularly consumed by Hispanic Americans. (5)

Critique #2: Communication of Risk Leads to Optimism Bias

One of the biggest challenges faced by CDC in the folic acid campaign is the striking statistic that 49% of all pregnancies in the United States are unplanned. (12) At 54%, this number is slightly higher for Hispanic women and leads to a higher rate of unintended births than White women: 40 per 1,000 vs. 17 per 1,000. (12) In other words, among women of childbearing age, 4% of Hispanic women will have unintended pregnancies compared to just 1.7% among White women. (12) The concern surrounding such a high percentage of unintended pregnancies is important to the folic acid campaign because most of those women who did not plan to become pregnant will not realize that they are pregnancy until they have missed their first menstrual period. By this point in gestation, the fetus has already begun crucial development of the neural tube and it is likely too late to prevent NTDs with folic acid supplementation. Serum levels of folic acid must be adequate prior to pregnancy in order to have the 50-70% chance of preventing a NTD. (1) Logically, a campaign would want to target women before they become pregnant.

The approach that a campaign uses to address the health of women who are at risk for an unplanned pregnancy is a sensitive topic. Almost all of the CDC Folic Acid campaign materials broadcast the above statistic that roughly 50% of pregnancies are unplanned. Perhaps it is a scare tactic that is intended to evoke an internal dialogue that goes something like, “Oh, I’m at risk for getting pregnant by accident. In that case, I should take folic acid so that the baby I didn’t plan to have doesn’t have a neural tube defect.” The more plausible effect, however, is the elicitation of optimistic bias, in which individuals have the tendency to underestimate their personal chances of negative outcomes and overestimate their personal chances of positive outcomes, despite the fact that they have just been given the overall chances of the group to which they belong. (13) In the case of unplanned pregnancies, a woman who views the 50% statistic will optimistically say to herself, “Well, I’m not part of that 50% and my chances of getting pregnant by accident are actually much lower.” Consequently, the intended health outcome of the campaign material immediately becomes useless to this woman as she processes in her mind, “If I’m not going to have a baby, I don’t need folic acid.”

Optimism bias also accounts for the above stated failure of the HBM in achieving a substantial level of perceived susceptibility of personal risk to have a baby with a NTD. Every healthy couple has a chance of having a child with a NTD or other birth defect, regardless of their personal medical or family history, an important fact that the campaign posters fail to explicitly point out. Women, therefore, may perceive their own risk as even lower than the general population if they themselves are healthy, have healthy family and friends, and especially if they have previously had children who are healthy. A woman may feel that she is already in control of the chances of having a child with a birth defect if she is already taking measures to ensure her own health and experiences healthy adults and children around her who do not have NTDs. This illusion of control is classically part of optimism bias. (14)

Studies have shown that even when Hispanic women do take folic acid supplements in the form of prenatal vitamins or multivitamins during pregnancy, they have a tendency to discontinue use after the birth of their child. (7) One cannot ignore the fact that it is undoubtedly difficult for a woman to grasp whether or not her use of folic acid before and during her recent pregnancy actually prevented a potential NTD. But part of the internal reasoning for this action lies in optimism bias: they have just experienced the birth of a healthy baby, which decreases their personal perceived risk of having a child with a NTD, despite the fact that the overall risk remains the same. The CDC campaign fails to bluntly inform women that her risk is the same as every other woman and does not decrease if she has had healthy pregnancies unless she gets enough folic acid. Additionally, the translation of the CDC Folic Acid campaign material verbatim into Spanish passes up the opportunity to point out that Hispanic women are actually at an increased risk for NTDs. This fact has the potential to garner the attention of Hispanic women and reduce optimism bias by providing information that is more meaningful to the woman.

Critique #3: Cultural Disparities Invoke Psychological Reactance

People do not like to be told what to do – especially by authority figures. One of the core values held by individuals is the sense of freedom and control of one’s own actions. When someone is told what to do, they have a psychological and physiological response to the message that results in the very opposite behavior. (15) This psychological reactance is familiar response to public health messages. How does this apply to folic acid, which seems like a pretty simple and benign beneficial health behavior? Lack of folic acid supplement is not labeled as a risky behavior and is not necessarily a rebellion against authorities if not everyone needs to ensure adequate daily folic acid intake.

The source and delivery method of the folic acid message, however, can greatly instill a psychological reactance in particular populations. This is where the CDC Folic Acid campaign runs into trouble. Research by Silvia found that the source of message greatly impacts psychological reactance and, consequently, the degree to which an individual will agree with the given message. (15) Broadly speaking, people are less likely to experience psychological reactance in response to those who are similar to them (i.e. peers) and more likely to agree with the message provided; in contrast, individuals are more likely to experience psychological reactance and therefore less likely to agree with messages provided by those who are less similar (i.e. authority figures). (15)

The CDC is generally regarded as a trusted source of health information. However, we cannot ignore that it is part of our central government, and not everyone holds the government in high regards. Immigrant populations, which include many Hispanic populations, are at risk for distrust of the government and the CDC may be viewed as part of this distrusted authority. With the CDC proud to plaster their logo over all printed material, it is obvious who the message is coming from. Hispanic women have stated that information about folic acid supplementation and NTDs is knowledge that they want, but they prefer to receive such information from their community members and local health care provider, i.e. people who are most similar to them and who are trusted figures. (7)

Additionally, the CDC fails again in the translation of their campaign posters. Visuals can be effective modes of communication in campaign posters. The “Before You Know You’re Pregnant” campaign poster strategically uses several images of average women in order to influence the source of the message, i.e. peers rather than authority. These are women who represent the majority of the United State population that should be taking folic acid: young, married, and Caucasian. The perception that the average women appearing on these posters have the knowledge about folic acid is intended to reduce psychological reactance and increase the degree to which the viewer agrees with the message and ultimately takes her folic acid! The CDC fails to change these pictures in the translated versions. The image of a Caucasian woman in a white wedding dress may not best represent the peers of an immigrant Hispanic woman.CDC brochure tells the story of “Emma,” a young woman who carefully plans her pregnancy, takes the recommended amount of folic acid, and has a healthy child. (6) The translated Spanish version fails to change the spelling of “Emma” to “Ema,” the Spanish version. It may seem like a minor detail, but it can drastically decrease the perceived of the message source. The dismissal of such considerations on behalf of the CDC is likely to induce psychological reactance in the Hispanic population. Again, the source of the message may be a dissimilar and even disrespected population in the eyes of a Hispanic woman. Such psychological reaction, consequently, diminishes the effectiveness of the message regarding folic acid and NTDs for a Hispanic woman and the likelihood that she will engage the desired health behavior.

Intervention Strategies

Basic information about the link between folic acid intake and NTDs is essential to raise awareness about this relatively new finding and recommendation. Various campaigns, including the CDC Folic Acid campaign, that employ a traditional HBM, have been effective in motivating many women of child-bearing to ensure adequate folic acid supplementation. (16) The CDC has not been as effective in reaching certain populations at risk, including younger women at risk for unplanned pregnancies and the Hispanic population. (3, 16) Strategies that target the Hispanic populations are outlined below, and, with minor tweaks, are applicable to other populations.

Strategy #1: Change the Source of the Message

As stated above, the source of any public health message is essential to the success of a campaign. The various flaws in simply translating English Folic Acid materials into Spanish have been described and we now know that one of the keys to success is to have the message appear to come from people who are more similar to our target audience. (15) Our goal is to reduce psychological reactance to the folic acid message and ultimately increase folic acid intake. We can achieve this by discarding the authoritative components of the majority culture and utilize the peers of the Hispanic community as well as public figures and pop stars.

There are potential pitfalls when choosing icons, because the larger Hispanic population in the United States is comprised of several smaller groups, based on country or region of emigration. Hispanic women have pointed out that care should be taken to avoid exemplifying a specific Hispanic group, such as Mexican-Americans or Cuban Americans, that may be identified by language dialect or specific phrases, mannerisms, or general outward appearance. (17) Instead, using individuals with unidentifiable origins has the effect of reaching a larger sector of the Hispanic population. In essence, using a nondescript representative, we are further decreasing any potential of psychological reactance that may arise between Hispanic subgroups.

Additionally, research has already been done on focus groups of Hispanic women to find out where they want to hear these messages. They want to hear this information at Women and Infant Care and medical clinics, grocery stores, churches, community members, and media outlets, such as the Internet, magazine, and television. (7) These are trusted outlets that we must take advantage of when considering the placement of printed campaign materials.

The CDC does recognize the need to involve influential community members and spokespeople when planning a folic acid campaign. (18) “Preventing Neural Tube Birth Defects: A Prevention Model and Resource Guide” offers this important token of wisdom for those who are planning a local folic acid campaign. (18) It would have been helpful if they had followed some of their own advice when developing their own materials! Changing the source of the message, as we will see below, is this first step towards greatly improving the positive effects of other strategies. We cannot expect to increase awareness of NTDs and the benefits of folic acid unless our audience is listening.

Strategy #2: Increase Risk Perception

The HBM states that increasing threat of a disease is an essential part of motivating individuals to engage in positive health behaviors. Women of childbearing age must understand that their risk of having a child with a NTD is real and applies to them and not just to other women. The goal is not to make them understand their actual risk of having a child with an NTD, which, according to 2002 data, is .00041% for spina bifida alone in the Hispanic population, but rather to raise the perception of the risk high enough that it motivates them to want to reduce that risk. (2) Increasing this threat should be accomplished by increasing awareness of the severity of the disease, as well as increasing personal susceptibility of the disease.

We know that many forms of NTDs, including spina bifida occulta, are quite mild and may not be associated with any symptoms or disabilities; however, we are more concerned with more severe, debilitating forms. Communication of the potential severity of information in some manner rather than labeling it as an ambiguous “severe birth defect” is important to increasing the perceived severity of the condition. Perhaps the CDC is afraid to plaster information regarding the most severe forms of NTDs, which include anencephaly, or the absent development of the brain, and myelomeningocele, which include involvement of the spinal nerves. A simple method to achieve this goal is to provide a brief description, similar to the previous sentence along with the image of a child in a wheelchair. With the exception of one lengthy brochure, Healthy Mothers have Healthier Babies with Folic Acid: Emma's Story, the CDC folic acid campaign materials advertise images of healthy children, communicating that this is the goal of folic acid supplementation. (6) Showing the image of a disabled child has more potential effect because of the law of small numbers. (19) By providing only examples of the potential health threat, the chance of a NTD is overrepresented in the eye of the viewer and consequently perceived as an increased threat.

The law of small numbers should be expanded to media outlets by providing additional examples. The story of a nondescript Hispanic family that has a child disabled by a NTD should be developed along with a simple message coming from this family about the benefits of Folic Acid supplementation. Essential to this message would be the communication from the mother that her chance of having the a child with an NTD is the same as the chance of the woman viewing receiving the message, thereby breaking down the optimism bias. This story can be utilized in a series of pamphlets and posters available for view in common public areas, such as the local grocery stores, medical clinics, and community centers, as well as television and radio advertisements to air on Spanish language networks. Again, the use of such a story employs the law of small numbers by overrepresenting the actual risk of NTDs. We are also starting to break down the optimism bias

Strategy #3: Promote General Health, not Pregnancy Health

One of the major challenges that folic acid campaigns face is reaching out to the very women who are at most risk – those 50% who have unplanned pregnancies. It is certainly a powerful statistic that drives the need for folic acid and NTD campaigns. What we have learned, however, is that you cannot show that number and scare women into believing that they could be part of that statistic.

The first step to address this problem is just to omit this information about unplanned pregnancies. Leaving information is not straightforward lying; it’s simply not telling the whole story. It serves to weaken the association between folic acid and pregnancy. If we omit this information, we eliminate the optimism bias that relegates the need for folic acid in the eyes a woman who is not intending to become pregnant. Weakening the association between pregnancy and folic acid is exactly what we want to do for part of this new intervention approach. It turns out that folic acid is believed to be beneficial for the prevention of a multitude of other health condition, including heart disease, stroke, and cancer. (20) Everyone could use a little more folic acid and as we know, many processed foods are already fortified with folic acid and many multivitamins contain an adequate amount of this vitamin.

The next big step is to break down the barriers to daily use of multivitamins by Hispanic Americans that the HBM predicts will decrease the likelihood of engaging in this positive health behavior. Again, these barriers include prohibitive cost, lack of routine, distaste for vitamins, and social stigma linked to the false belief that vitamins make you gain weight. (9,11) Use of vitamins needs to perceived as a cultural norm, or a general practice that is adopted by all members of a given population, in order for this population to change their overall behavior. (21) Various strategies need to be employed to create this new social norm.

We can start to create the perception of a social norm using media. A partnership can be created with the Hispanic television industry, which would show characters of all ages in popular television programs taking their morning multivitamin and perhaps discussing their benefit and even joking about the myth that vitamins make you fat. A partnership can also be created with school districts to identify teenage peer leaders who can model behavior and spread the message about their own benefits of multivitamins, including information most relevant to these kids, such as increased energy and performance in sports or dance classes, and improved concentration in school. One particularly strategy that can be taught to these kids is to use rebellion against to their advantage. Parents can try to feed their kids what they want and authorities can try to preach to kids about what to eat, but if we assume that kids are going to eat what they want to eat, multivitamins can be reframed as method of rebellion and used as the anti-junk food. Again, it is of upmost importance in each of these strategies to utilize individuals who are viewed as similar to the individuals we are trying to reach and well respected.

Conclusion

We have made great strides in discovering the benefits of folic acid and preventing many cases of neural tube defects. The current strategies that have gotten us this far are not adequate to reach certain at-risk populations, including Hispanic American women. The future of this campaign must pay close attention to who is delivering this message and ensure that is it a nonthreatening message with accurate, real information that promotes the wellbeing of all.

References

1. Centers for Disease Control and Prevention. Recommendations for the Use of Folic Acid to Reduce the Number of Cases of Spina Bifida and Other Neural Tube Defects. Atlanta, GA: Center for Chronic Disease Prevention and Health Promotion, 1992. http://www.cdc.gov/mmwr/preview/mmwrhtml/00019479.htm

2. Williams LJ, Rasmussen SA, Flores A, Kirby RS, Edmonds LD. Decline in the prevalence of spina bifida and anencephaly by race/ethnicity: 1995-2002. Pediatrics. 2005;116(3):580-586.

3. Centers for Disease Control and Prevention. Racial/ethnic differences in the birth prevalence of spina bifida - United States, 1995-2005. Atlanta, GA: Center for Chronic Disease Prevention and Health Promotion, 2009. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5753a2.htm

4. Centers for Disease Control and Prevention. Trends in folic acid supplement intake among women of reproductive age – California, 2002-2006. Atlanta, GA: Center for Chronic Disease Prevention and Health Promotion, 2009. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5642a3.htm

5. Centers for Disease Control and Prevention. CDC Grand Rounds: Additional Opportunities to Prevent Neural Tubes Defects with Folic Acid Fortification. Atlanta, GA: Center for Chronic Disease Prevention and Health Promotion, 2010. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5931a2.htm

6. Centers for Disease Control and Prevention. Folic Acid Publications. Atlanta, GA: Center for Chronic Disease Prevention and Health Promotion, 2010. http://www2.cdc.gov/ncbddd/faorder/orderform.htm

7. Mackert M, Kahlor L, Silva K, Padilla Y. Promoting folic acid to Spanish-speaking Hispanic women: evaluating existing campaigns to guide new development. Women & Health 2010; 50(4):376-395.

8. Rosenstock IM. Historical origins of the health belief model. Health Education Monographs 1974; 2:328-335.

9. Mackert M, Kahlor L, Silva K, Padilla Y. Promoting folic acid to Spanish-speaking Hispanic women: evaluating existing campaigns to guide new development. Women & Health. 2010;50(4):376-395.

10.                   Prue CE, Hamner HC, Flores AL. Effects of folic acid awareness on knowledge and consumption for the prevention of birth defects among Hispanic women in several U.S. Communities. Journal of Women’s Health. 2010;19(4):689-698.

11.Centers for Disease Control and Prevention. Folic Acid and Birth Defects Prevention: Focus Group Research and Materials Pre-Testing with Hispanic At-Risk Women. Atlanta, GA: Hispanic Executive Summary, 2000.

12. Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health. 2006;38(2):90-6.

13. Weinstein ND. Unrealistic optimism about future life events. Journal of Personality and Social Psychology 1980; 39:806-820.

14. Langer EJ. The illusion of control. Journal of Personality and Social Psychology 1975; 32:311-328.

15.Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology 2005; 27:277-284.

16. Centers for Disease Control and Prevention. Use of Supplements Containing Folic Acid Among Women of Childbearing Age - United States, 2007. Atlanta, GA: Center for Chronic Disease Prevention and Health Promotion, 2008. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5753a2.htm

17. Quinn GP, Thomas KB, Hauser K, Rodríguez NY, Rodriguez-Snapp N. Evaluation of educational materials from a social marketing campaign to promote folic acid use among Hispanic women: insight from Cuban and Puerto Rican ethnic subgroups. Journal of Immigrant and Minority Health. 2009;11(5):406-414.

18. Centers for Disease Control and Prevention. Preventing Neural Tube Birth Defects: A Prevention Model and Resource Guide. Atlanta, GA: Center for Chronic Disease Prevention and Health Promotion, 2009. http://www.cdc.gov/ncbddd/orders/pdfs/09_202063-A_Nash_Neural%20Tube%20BD%20Guide%20FINAL508.pdf

19. Tversky A, Kahneman D. Belief in the law of small numbers. Psychological Bulletin 1971; 76:105-110.

20. Office of Dietary Supplements, National Institute of Health. Dietary Supplement Fact Sheet: Folate. National Institute of Health, 2010. National Institute of Health http://ods.od.nih.gov/factsheets/folate/

21. DeFleur ML, Ball-Rokeach SJ. Theories of Mass Communication (5^th edition), Chapter 8 (Socialization and Theories of Indirect Influence), pp. 202-227. White Plains, NY: Longman Inc., 1989.

Alcohol Consumption during Pregnancy: A Critique on Alcohol Warning Labels – Diana Toledo

Introduction
Alcohol consumption during pregnancy is a major public health concern. According to the Centers for Disease Control and Prevention, data collected from the Behavioral Risk Factor Surveillance System (BRFSS) surveys indicates that there has been no change in alcohol use during pregnancy from 1991 to 2005 (1). This study found that approximately 1 in 8 women (or 12%) drank alcohol during their pregnancy (characterized by having at least one alcoholic beverage in the past 30 days). Approximately 1 in 50 women reported drinking alcohol in a binge-like manner during their pregnancy (characterized by at least one occasion of consuming five or more alcoholic beverages in the past 30 days). This study also found that the sociodemographic factors predicting any amount of alcohol use during pregnancy were: aged 35–44 years (17.7%), college graduates (14.4%), employed (13.7%), and unmarried (13.4%).
Alcohol consumption during pregnancy is strongly associated with a spectrum condition known as Fetal Alcohol Spectrum Disorder (FASD). FASD is an umbrella term that encompasses any of the characteristics seen in infants who have been exposed prenatally to alcohol. These characteristics being any and all of the following: pre- and postnatal growth retardation, central nervous system involvement resulting in neuropsychological impairment (ranging from learning disabilities to more severe mental retardation), seizures, and specific craniofacial anomalies (2). The estimated prevalence of Fetal Alcohol Spectrum Disorders is approximately 1 in 100 (3). This incidence rate is higher than Autism Spectrum Disorders (3-6 in 1,000) and Down syndrome (1 in 733), both of which are not preventable (4). However, this condition can be prevented and more robust interventions need to be implemented.
The current intervention for decreasing alcohol consumption during pregnancy in the United States is the use of alcohol warning labels on beer, wine, and spirits. This intervention was implemented after two decades of controversy, when the Alcohol Beverage Labeling Act of 1988 was passed (5). The current warning label states the following:
GOVERNMENT WARNING: (1) ACCORDING TO THE SURGEON GENERAL, WOMEN SHOULD NOT DRINK ALCOHOLIC BEVERAGES DURING PREGNANCY BECAUSE OF THE RISK OF BIRTH DEFECTS. (2) CONSUMPTION OF ALCOHOLIC BEVERAGES IMPAIRS YOUR ABILITY TO DRIVE A CAR OR OPERATE MACHINERY, AND MAY CAUSE HEALTH PROBLEMS.

Critique Argument #1
My first critique will focus on the public health approach that supports the use of health warnings. Alcohol warning labels were implemented on the basis of the Communication Persuasion Model; a model that was specifically tailored and applied to health warning messages in 1980 by William McGuire. He proposed that the intervention would include input variables and output variables. The input variables include: the source, the message, the channel, the receiver, and the destination. The output variables specifically include 10 processes that facilitate the persuasion effect on the individual level. These 10 processes are: exposure to label, attend to the message, react affectively, understand the information, believe the message, store the information from the message after initial exposure, retrieve information upon moment of action arrives, decides on the action to take, behaves according to the decision, and the behavior should be anchored by the beliefs of the message (3).
The initial input variable is the source of the message, or who it is coming from. For the alcohol warning labels, the message is clearly stated that it is coming from the Surgeon General him/herself. The Surgeon General is unknown to most people, however the idea is that this person has authority over others and has validity in informing pregnant women not to drink. It is not uncommon for people to show resistance when given health advice from an authoritative figure; an example of this being a patient refusing to follow a certain diet advised by their physician.
The message itself is directive and may cause a significant amount of psychological reactance in their audience. Women who read this may instinctively think that their behavioral freedom is being threatened; thus motivating them to avoid any further loss of their freedom. Their extent of motivation is affected by the importance of the free behavior (the importance of drinking alcohol) (6). The channel or vehicle that this message is presented is by a written label on bottles of alcohol that are purchased from a liquor store or vendor. The print, font, and style of the message are often small and disguised by the rest of the label on the alcoholic beverage, almost like the manufacturing company does not want people to see or notice the labels.
As far as the receiver (or intended audience) and the destination of the message, the information is only being presented to the buyer of the alcohol. Once at a venue, the container of the alcohol may be discarded while the contents are put in glasses or the containers may be shared. Also, the intended audience will never see a warning label if they are purchasing their alcohol at a restaurant or bar, where drinks are (mostly) served in glasses.
According to the output variables, the Communication Persuasion Model is assuming too much. They are assuming that a person will have exposure to the label (which is not necessarily true), that they will take in the message, and that they will have a strong emotional reaction to it that will enforce them to discontinue or prevent drinking during pregnancy. They also assume that the emotional affect will cause the individual to have a strong enough belief in the contents of that message and will change behavior. In essence, the theory is assuming that belief or intention directly leads to a behavior change, which is strongly unsupported for drug and alcohol issues. In essence, this model is based on the individual level and assumes that behavior is planned and rational.

Critique Argument #2
My second critique will focus on the label itself. The alcohol warning label that has been placed on every domestic and imported alcoholic container since 1988 is nothing short of inconspicuous. Typically, the message is written in fine print and illegible on bottles and cans. The location of the message tends to be on an obscure place of the container, such as the back or side of the bottle. Since alcoholic beverages are typically served cold, condensation that accumulates on these containers has the potential to rub the paper label off, making paper a poor choice in material for such an important message.
Public opinion supports my thoughts on the label itself. According to a national survey that was conducted by the Center for Science in the Public Interest (CSPI) in 2001, most Americans do not notice or read the alcohol warning labels. Three out of four alcohol consumers agree that the labels “sometimes appear in the least prominent place on containers, making them difficult to notice or read”. According to the survey: 63% of alcohol consumers say that they never notice the warning label; only 21% say that they are familiar with the information on the warning message; close to 90% say that placing the warning label in a more prominent spot on the front of alcohol containers and/or having labels printed in red or black print on a white background surrounded by a lined border would make them more noticeable and readable (7).
The design and implementation of these warning labels could hardly be worse. In a way, the labels seem to be designed to go unnoticed and ultimately fail.
The labels are also not reaching many alcohol consumers. Those who only purchase their alcohol at bars or restaurants are not coming into any contact with the message on alcohol containers. This is because most drinks at these establishments are served in glasses and not in their original bottle or can. This is also true for events, such as holiday parties, where alcohol is typically served in something other than the original container, an example being drink from a punch bowl (with unknown amounts of alcohol).
The content of the message itself is very strong and directive. The wording is forward and has an accusatory tone. People are typically not persuaded by strong, directive language because many like to feel like they have control over their own decisions and do not need advice from a higher authority, such as the Surgeon General. The strength of the language on the message is likely creating a counter-intuitive effect on alcohol consumption.

Critique Argument #3
My third critique will focus on effects of the label and attenuation of it over time. These warning labels have not changed since their implementation in the late 1980s. They have the same message (word for word); they essentially have the same font, as well as the same style. For a habitual alcohol drinker, these labels have become commonplace and attenuation of them has led to the message being overlooked.
Research has suggested that general awareness of adverse effects being associated with alcohol consumption during pregnancy has increased. However, this general awareness has attenuated over time and has not proven to be completely effective on reducing alcohol consumption during pregnancy (8).
Another study focused on researching whether multiple exposures to health messages influenced behavior change around drinking during pregnancy. They found that those who were exposed multiple times (1, 2, & 3 times) to three different messages with distinct approach around alcohol consumption during pregnancy were more likely with each exposure to converse about the issue with someone. Also, actual reduction in the amount of alcohol consumed during pregnancy was only observed after two or more messages were exposed (9). This research reinforces the idea that one exposure to the same message strategically located where few ever see it is not enough to instill any changes to behavior.
Findings have also suggested that warning labels in general have induced counter-productive influences. One study found that alcohol warning labels actually caused a boomerang effect in that alcohol consumers perceived greater benefits from having alcohol due to the presence of a warning label (10). Another study found that warning labels surrounding violence preceding a television show produced a counter-productive effect, adding to the suggestion that warning labels may do more harm than good (11).
Another study found that health messages with strong arguments and directive language may not be persuasive or change attitudes surrounding the content of the message. They found that messages with strong statements are less likely to be seen as believable or credible, and are more likely to be viewed as implausible (17). Also, the believability of the message does not necessarily change if the message is coming from an authoritative figure, such as the Surgeon General.

Proposed Intervention
There is no question that other interventions need to be implemented to reduce or eliminate alcohol use during pregnancy; the greater effect being to reduce the incidence rate of Fetal Alcohol Spectrum Disorder. My proposed intervention consists of an elaborate media campaign that sells the core value of control to women of child-bearing age. The campaign will involve multiple types of media: television commercials, magazine ads and articles, billboard ads, and radio public service announcements. This concept is supported by the idea that multiple message exposures and the use of different strategies increase the likelihood of awareness and behavior change (9). The idea of using the concept of control is because it is a core value to many people. Once that control is perceived as lost, then an individual will be motivated to restore that sense of control (6). According to the Illusion of Control, people tend to think that they have more control in situations and over certain life events than they actually do (12). By advertising the stories of those who thought they had control over their alcohol consumption during pregnancy and lost control over their chance at having a healthy baby will impact individuals who believe moderate alcohol intake is not harmful during pregnancy.
A typical campaign television commercial will involve no statistics or numbers on the incidence of Fetal Alcohol Spectrum Disorder or the rate of alcohol consumption during pregnancy (although both are alarmingly high). These commercials will give the picture of a real family with a real story and issues that they face around the diagnosis FASD in a child. The main focus of the campaign will be on mothers who drank light to moderate amounts of alcohol without contemplating or realizing that those alcohol levels could still present long term effects for their child.
The typical story will start with the mother talking about the complications at birth and the differential diagnoses that were suggested by a number of specialists; discussing the loss that the family experienced when they learned that their newborn was not healthy. At this point, the mother can talk about how she thought she had taken proper precautions and done everything right by taking prenatal vitamins, eating healthy, and exercising. Then, the story will lead into the actual diagnosis of FASD and hearing the news that alcohol during the pregnancy caused these issues at birth and will continue to cause issues for the developing child and adult. Toward the end of the commercial, the mother will talk about the light drinking she had done (an example being two glasses of wine per week) during her pregnancy and how she thought she was in control of the situation. In this part, it will be important for the mother to elaborate on her lack of knowledge that such low levels of alcohol can still have serious repercussions and implications for the fetus, for example “I just didn’t know that a few glasses of wine per week could cause these problems for my baby” or “I thought I was in control of my alcohol intake during my pregnancy, but I just didn’t know the risk I was taking”. Although the commercial should not be heavy on the guilt that the mother may be feeling, it can allude to some of those ideas with phrases like “My child will now have challenges during development because of something I could have easily prevented.”
Similar quotes (like the ending quote from my “commercial”) can be used to make a magazine ad very powerful. The campaign can be advertised in women’s health magazines, motherhood and parenting magazines, black health magazines, Spanish language magazines, etc. These magazines will specifically target the intended population, increasing awareness, increasing exposure, and promoting behavior changes. Similarly, billboards will be placed in busy, well populated areas, while radio public service announcements can be played on all radio stations that reach women of child-bearing age from all ethnic backgrounds.

Defense of Intervention Section #1
My first defense will focus on the core value of control and the use of one emotionally charged story. Advertising theory relies on the concept of a promise, typically the promise that a core value will be met. In the marketing paradigm, the needs and wants of the audience are met by the core value that is at the root of the promise that is made through the advertisement. Marketing does not actually change the needs and wants of the audience, however it convinces them that their needs and wants will be met by the achievement of the core value (13).
In this campaign, the needs and wants of the audience are to have a healthy baby with long term wellbeing. The way to achieve this need is to promote the idea of control. If a woman controls her alcohol consumption during pregnancy and brings the volume to zero, then her control over having a healthy pregnancy and baby is significantly increased compared to before.
A good method of promoting the core value of control and giving that “jolt” to women who are pregnant or thinking about becoming pregnant is the telling of one story or case. The law of small numbers suggests that people have a distorted perception of statistics and tend to overestimate small sample sizes (12). One real story with one real affected child that discusses the implications of alcohol intake during pregnancy can have a jolting impact on the population. The story should not include numbers or statistics, as that would cloud the actual message. Although numbers like “1 in 12 women drink alcohol during pregnancy” and “Fetal Alcohol Spectrum Disorder occurs in 1 in 100 live births” are powerful, they are not as influential of one story with one name and face. Also, pregnancy can be a good time for a “jolt” because there is a heightened sense of emotion around the pregnancy and more chance of quitting cold turkey.

Defense of Intervention Section #2
My second critique will focus on women’s response to emotional advertisement. The intended population for this campaign is women of child-bearing age. Although the multi-media approach will likely reach both genders and all age groups, the targeted audience is women 18 to 40 years of age. This is because women are in control of what they consume during their pregnancies. Women tend to have stronger responses to emotional advertisement; this may be especially true during pregnancy when emotional states are higher.
In general, women tend to be more attuned with their emotions and put their insights at higher value (14). Studies have found that women self-report having more frequent and more intense emotional responses and experiences than men (15).
Women also have a strong response to the sense of guilt. The guilt that women feel after an event is focused on a specific behavior or action. Feelings of tension, remorse, and regret over one event are characteristics of guilt (16). Demonstrating the feelings of parental guilt surrounding Fetal Alcohol Spectrum Disorder in the proposed campaign has the potential to instill behavior change in women to control for future sense of guilt.
Defense of Intervention Section #3
My third defense will focus on the impact of presenting more realistic information throughout the campaign. Alcohol warning labels are not informative enough to gain the acknowledgement that they should have. The only comment of fetal alcohol effects is the mention of the too general term “birth defects”. What are these birth defects? Are there any long term effects? If there are no physical birth defects, are we in the clear? These questions are important in fully understanding the issues that surround Fetal Alcohol Spectrum Disorder.
Describing the birth history in the commercials, from having birth defects (like postnatal growth retardation, low birth weight, small head size, and heart problems) to not having any signs at birth will be important in educating the public on what FASD actually is. Detailing the possible seizures in childhood, as well as the learning difficulties and disabilities that arise once a child is in a school and learning setting will be essential in driving the point that FASD does not need to be present at birth for it to impact the rest of the child’s life (2).
In a way, the alcohol warning labels are misleading the public by mentioning the term “birth defects” since many issues do not arise until later in childhood. A campaign showcasing these effects will educate people on the actual risks that alcohol during pregnancy causes.

Conclusion
Experiences in the prenatal genetic counseling clinic have taught me that many women think that light to moderate drinking (one-two glasses of wine per sitting) is reasonable to do during a pregnancy. The thought among many of these women is that Fetal Alcohol Spectrum Disorder only occurs in babies that are exposed to very high levels of alcohol in utero. Although we give them a disclaimer that there is no safe level of alcohol consumption during a pregnancy, they tend to be set in their ways and thoughts by the time we see them in clinic. In my opinion, the issue of light to moderate alcohol intake during pregnancy needs to be addressed before women even become pregnant or enter child-bearing years. By having a campaign that is multi-media and targeting the core value of control, many more women would have a more concrete ideology that any alcohol intake equates to the possibility of FASD effects in their child.

Resources
(1) CDC. Alcohol Use Among Pregnant and Nonpregnant Women of Childbearing Age --- United States, 1991--2005. MMWR 58(19); 529-532.

(2) Hankin, Janet R., (1993), The Impact of the Alcohol Warning Label on Drinking during Pregnancy, Journal of Public Policy & Marketing, Volume 12, Issue No 1, Pages 10-18.

(3) O’Connor, Mary J., (2007), Brief Intervention for Alcohol Use by Pregnant Women, American Journal of Public Health, Volume 97, Issue No 2, Pages 252-258.

(4) Rutter, M., (2005), Incidence of autism spectrum disorders: changes over time and their meaning, Acta Paediatrica, Volume 94, Issue No 1, Pages 2-15.

(5) Graves, Karen L., (1993), An Evaluation of the Alcohol Warning Label: A Comparison of the United States and Ontario, Canada in 1990 and 1991, Journal of Public Policy & Marketing, Volume 12, Issue No 1, Pages 19-29.

(6) Brehm, Jack, W., (1966), A Theory of Psychological Reactance. Academic Press.

(7) Center for Science in the Public Interest. Alcohol Labels Go Unnoticed, Poll Finds. Washington, DC. http://www.cspinet.org/booze/batf_labels2001_press.htm

(8) MacKinnon, DP., (1995), Review of the effects of the alcohol warning label, Alcohol, Cocaine, and Accidents: Drug and Alcohol Abuse Reviews 7. Totowa, NJ: Humana Press, Pages 131-161.

(9) Kaskutas, LA., (1994), Relationship between cumulative exposure to health messages and awareness and behavior-related drinking during pregnancy, American Journal of Health Promotion, Volume 9, Issue No 2, Pages 115-124.

(10) Snyder, LB., (1992), Caution: Alcohol Advertising and the Surgeon General’s Warning may have Adverse Effects on Young Adults, Journal of Applied Communication Research, Volume 20, Pages 37-53.

(11) Bushman, BJ., (1996), Forbidden Fruit Versus Tainted Fruit: Effects of Warning Labels on Attraction to Television Violence, Journal of Experimental Psychology: Applied, Volume 2, Pages 207-226.

(12) Siegel, M., Social and Behavioral Sciences for Public Health Lecture, November 18, 2010.

(13) Siegel, M., Social and Behavioral Sciences for Public Health Lecture, October 28, 2010.

(14) Feldman Barrett, Lisa, (1998), “Are Women the ‘More Emotional’ Sex?” evidence form Emotional Experiences in Social Context, Cognition and Emotion, Volume 14, Pages 555-578.

(15) Dube, Laurette, (1998), Capturing the Dynamics of In-Process Consumption Emotions and Satisfaction in Extended Service Transactions, International Journal of Research in Marketing, Volume 15, Pages 309-320.

(16) Niedenthal, PM., (1994), If only I weren't" versus "If only I hadn't": Distinguishing shame and guilt in counterfactual thinking, Journal of Personality and Social Psychology, Volume 67, Pages 585-595.

(17) Petty, RE., (1986), The elaboration likelihood model of persuasion, Advances in Experimental Social Psychology, Volume 19, Pages 123-205.

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).

NEW YORK STATE BREASTFEEDING MEDIA CAMPAIGN
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.

CONCLUSION
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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