Improving HPV Vaccine Intervention through Social Science Theory- Alexandra Hulme

Public Health Problem

In June of 2006, the FDA approved the vaccination Gardasil for females between the ages of 9-26 to protect against types 6,11,16 and 18 of the Human Papillomavirus (HPV) that indicate an association to genital warts and cervical, vulvar and vaginal cancers, respectively (1). This vaccine was a game changer in the medical field as it was the first of its kind to show 100% efficacy in preventing cancers, in this case those caused by those strains of HPV (2). While it usually takes 10-15 years for cervical cancer to develop from first HPV infection, the best time to vaccinate is before a female’s first sexual experience, due to the high prevalence of HPV: 39.6% in women ages 14-19 and 49.3% in women ages 20-24 (3). The lag time between infection and development of cervical cancer and the high prevalence rates, and the nature by which HPV is contracted - typically sexual interaction - makes it a very unique vaccine to promote and support.

Merck, the developer of Gardasil, employed several campaigns to promote Gardasil, including an unbranded educational, pre-release campaign, the “One-Less” campaign and the “Tell Someone” campaign (A. Mueller, personal correspondence, 7 March 2011). All of these campaigns had to promote the vaccine to a wide aged cohort, because the vaccine was suggested for women ages 9-26. This makes its universal acceptance difficult because the way in which these target audiences need to be addressed, especially in relation to such a polemic topic. By 2008, 37% of the 9-26 female population had received the vaccine (3), but there was still reluctance in widespread acceptance of the vaccine. This paper will provide three critiques of the current HPV prevention campaign and then provide three suggestions for improved interventions to increase both awareness and acceptance of the vaccine.

Critique # 1

Failure of the Health Belief Model

The GARDASIL campaign was heavily grounded on two un-branded campaigns that served to educate the public about HPV, its connection to cervical cancer and new technologies that are being developed to prevent the disease. These campaigns were successful in increasing awareness and knowledge to both mothers and young adults, showing an increase from 5% awareness to over 50% awareness of the link between HPV and cervical cancer (4). The objectives here fall in line with the Health Belief Model approach to public health campaigns, that focus on increasing knowledge to affect an individual’s perceived susceptibility to contracting a disease and the perceived severity of the outcome (5). As an individual starts to perceive an increased risk of the negative outcome, they will then rationally do what is needed to protect themselves (6). In the case of GARDASIL vaccination, the idea was to increase perceived susceptibility to HPV and cervical cancer and then the women, with their newfound education, would take the appropriate steps towards vaccination. This approach however is flawed; an individual’s health decision is not rational, and the balance between costs and benefits do not always dictate intention to act and behavior. The health belief model has little strength in accounting for the variety of behaviors that are related to attitudes and beliefs, because there are a variety of forces that can influence and individual’s behavior (7). While education is an important component in any public health campaign, especially when there was little previous knowledge about the connection between HPV and cervical cancer and the susceptibility to such diseases, a successful campaign cannot depend on education alone.

Merck highlights young adult females as one of the primary target groups for the campaign and vaccination (A. Mueller, personal correspondence, 7 March 2011). They were the center for many focus groups and education campaigns to improve their education on the subject of HPV and cervical cancer in an attempt to get them to seek out the vaccine. A large flaw in this approach is the assumption that just because people have knowledge they will act in a responsible manner to mitigate the threat (perceived severity and susceptibility to HPV and cervical cancer). This increased knowledge was shown to be successful, but did little to influence their perceived susceptibility, even though they are at a high risk due to their sexual behavior (8). As a behavioral economist, Dan Ariely and others have demonstrated, humans are not the rational, predictable creatures that the Health Belief Model would like to believe they are. People are influenced by stereotypes, labels and expectations, which changes their behavior and causes them to act differently based on cultural expectations (9). In most situations when something is considered dangerous, such as risky sexual behavior, there is a tendency to want to continue with that behavior, because the consequences of one’s actions are not usually considered in the moment, nor is one’s intention to act an automatic stimulus for expected behavior. Education and awareness of a disease does not automatically result in change behavior and increased used of the HPV vaccination.

Specifically in this campaign, more emphasis was placed on GARDASIL as a preventative vaccine for cervical cancer, instead of its clinical prescription as a vaccine for HPV. In an attempt to be less controversial for the mother’s of young girls (a target audience), the anti-cancer campaign was more effective than an HPV driven campaign and increased the mother’s perceived threat and susceptibility for their daughters (10). This push to educate mothers, focused on mother’s telling or taking their daughters to get vaccinated and not on creating an incentive or reason YAFs to get vaccinated. Eliminating the connection between HPV and cervical cancer discouraged YAFs from getting the vaccine, because even though they had information from the campaign, it was not appropriate for their needs or demographics. (4,10, 8). The campaign failed in its education campaign because it limited what information was transferred to target audiences, not that it lacked the knowledge to educate their audiences. This element played into the ineffectiveness of the education campaign because while there was increased knowledge, individuals behave irrationally and could not connect their actions and perceived risks indicated to them to change their behavior.

Critique # 2

Limitations of Social Norms and Sex

The connection between HPV and cervical cancer and the need to spread the message to such a large target audience (girls 9-26 years old, FDA recommendation), posed a daunting question for promoters. Researcher Suellen Hopfer comments that this vaccine posed a “new challenge in health message design because promotion of the vaccine raises questions inextricably linked the sexual health and cancer – both topics that are culturally sensitive and taboo” (11). In following the social norms theory we know that people’s behavior is largely driven by social norms, but it is hard to know what the norms are. The current social norms that dictate our society downplay the discussion of sex and sexually transmitted diseases, though HIV/AIDS has probably improved the situation. Because of this sexual taboo, the discussion of HPV as a sexually transmitted infection was heavily downplayed in the campaign (10). The campaign focused on parents and getting mothers to take their younger daughters to get vaccinated, but for many, thinking about the future sexual activity of their daughters is not something which they regularly consider (A. Mueller, personal correspondence, 7 March 2011). Thus, the campaign focused on promoting GARDASIL as a cervical cancer vaccine, so as not to be so divisive with parents and thoughts of their young daughters being sexually active, if not now then in the future (12).

In devising a campaign that emphasized the prevention of cervical cancer, the marketers were able to heavily bypass that conversation and successfully appeal to the mothers of the girls on the younger end of the target audience. This approach maximized the threat of cervical cancer and HPV to adolescents, while minimizing those who were most at risk (10). Merck recognized the limitations that our cultural sensitivity would do to the appeal of an HPV vaccine if it were marketed as such (4). While this aspect allowed it to draw in a large population of younger girls, who were brought to get vaccinated by their mothers, the campaign’s focus on cervical cancer ignored and isolated young adult females (YAFs), limiting the effectiveness of the campaign on that age demographic (13).

Because the campaign focused on cervical cancer, the social norm regarding HPV vaccination in YAFs was very seldom looked at. Following the social norms theory, social norms affect human behavior, but there was little arena for the discussion of what the social norm is, within the context of HPV and who was getting or not getting vaccinated. Hopfer discovered that is hard to reach college age women because it is hard to know the types of messages they receive in regards to such stigmatizing topics like HPV (11). The failure of the campaign directed at YAFs was so unsuccessful that Merck ended up pulling the funding for that entire component of the campaign (A. Mueller, personal correspondence, 7 March 2011). It was clear in focus groups that YAFs knew about their risks and did not react, they did not relate to cervical cancer message tilt of the marketing campaign, which was guided by the social norms of our times.

Critique # 3

Lack of Self-Efficacy and the failure of the Theory of Planned Behavior in HPV Vaccine Interventions

The existing campaign encouraging HPV vaccination provides lots of information to potential vaccine candidates, but does little to account for their actual intention to change their behavior in regards to safer sex and getting the HPV vaccination to prevent an HPV infection or cervical cancer. The Theory of Planned Behavior, developed by Ajzen and Fishbein, is the weighing two things against each other: outcome expectancies of the behavior and perceived norms, which lead to and dictate intention to act, which will lead to behavior (6). Included is also the component of self-efficacy of perceived behavioral control: a person’s belief that they are capable of doing a behavior, which is another influential element in the process to actually performing a certain behavior. An appeal to one’s self-efficacy in actually changing their behavior is thus necessary for any successful campaign.

However, the current HPV intervention is unsuccessful at appealing to this need and desire. By simply providing information to the targeted demographic about the dangers of HPV or cervical cancer, little connection is being made to the individual and their ability to change their behavior. Ajzen’s theory proposes that perceived behavioral control can influence behavior directly and that those with higher perceived control are more likely to form intentions to perform a particular action than those who perceive they have little or no control (14). Media campaigns, like GARDASIL, predominantly addressed the mother of adolescents, to get the vaccine for their daughter, but ignored the needs of the adolescents or young adult females themselves in seeking their own change in behavior (13). In following the theory of Planned Behavior, this does not allow the individual the opportunity to weigh the outcome expectancies or perceived norms themselves which will lead to intention and behavior change.

Researcher M.C. Yzer and colleagues analyzed several safer sex campaigns and their effectiveness on self-efficacy, along with other variables (15). They found that planned behavior in relation to safer sex (which also relates to HPV transmission) actually changed people’s behavior. However, their results show that these changes dropped, when the mass media campaigns dropped, indicating the need for campaigns to maintain high levels of determinants of safer sex, because they are effective for stabilizing and enhancing determinants of safer sex behavior (15). This demonstrates the ability of and need for campaigns that do not just inform, but that show individual’s their ability to change what they do and how they behave for the better, in a demographically specific environment.

Because the HPV intervention does not emphasize and individual’s power or control, but depends on that of her mother or peer, she is unable to take the necessary steps towards behavior change, driven by her own self-efficacy. As shown in another study on condom use, chronic perceptions of HIV risk are minimally linked to preventative behavior (14). This shows, that even with all the information promoting the dangers of not getting the vaccine and the potential consequences, those who are at risk or believe they are risk, are not likely to change their behavior because of that perception.

It is not just the knowledge that is necessary, but also the tools to enact that knowledge which will lead to greater self-efficacy and behavior change. The GARDASIL campaign fails to address this need of self-efficacy, though that is usually an important factor in mediating the relationship between knowledge and behavior (16). The ‘One Less’ campaign focused on an individual joining a movement and deciding for themselves to be one less person who gets cervical cancer, it did not take the next step in showing their target audience how to actually take that step, and make that change for themselves. It empowered through knowledge, but not through action and behavior. Had the campaign focused on improving confidence in the ability to enact healthy behaviors, then the desired change would follow, because the campaign would focus on efficacy expectations not just information dissemination, as was shown to work in a study on exercise behavior. This study also showed that those with greater levels of self-efficacy engage more often in and tend to stick to a regular schedule of physical activity, indicating the importance of regular reminders and campaigns to maintain behavior change, similar to the results of the safe sex campaign study (15,16).

In failing to appeal to what Ajzen’s theory of planned behavior proposes: perceived behavioral control can influence behavior directly (14), the current HPV intervention is inadequate. In 2008, only 25% of US females 13-17 had received the started the vaccination, though HPV prevalence in the 14-19 year age group is 39.6% (2). The study showed that while 90% of adolescents and young woman understand that the best time to get vaccinated is before their first sexual experience, and that they show high levels of acceptance of the vaccine, actual vaccination rates are low (2). The information from the campaign is reaching its audience, but is not influencing their behavior, and that is the most key factor because, it is only behavior change that will improve the health of targeted demographic.

INTERVENTION #1

Redirecting the Campaign – Beyond Education

The Health Belief Model is limited in its effectiveness and as a result GARDSASIL’s campaign is flawed. Education campaigns need to value how the message is developed and administered to the target audience. The campaign should focus on psychology of persuasion and entice people to get the vaccine, not just through education, but by promising them something more exiting in return for an intentional behavioral change (having protected sex and getting vaccinated). The promise of the campaign needs to come from a messenger that the YAF population likes, focusing on similarity and familiarity to develop a meaningful association between the audience and the message. The manner in which the request is structured can and should be tied to a specific, stored trigger and thus direct the individual to the action that is desired (17). Understanding that education will not change or influence an individual’s behavior because she is predictable yet irrational, the campaign should play into these characteristics to increase success and the ownership of their decision, their body and the value of preventing HPV and cervical cancer. Increasing the value of the vaccine for YAFs is very important because, as it stands now, there is a limited connection in the campaign to something to which they can relate: STIs and unprotected sex. When individuals engage in unhealthy behaviors they own and value their actions, so to change their behavior they need to exchange it for something of higher value. In the case of HPV vaccine, they need to appeal to a value that is higher then health. The campaign could appeal to a cleaner, less risky sex life or focus on the portrayal of a more glamorous life after getting the vaccine and having protected sex, instead of just increasing the education component and pushing the prevention of cervical cancer.

INTERVENTION # 2

Challenging Social Norms

Without information guiding the social norms of the young adult female cohort, intervention strategies will continue to be ineffective. Research has shown that social influences were key correlates to vaccine decisions (18, 11 ,19), but research regarding what the social norm is and who can influence those is the first step in creating a more successful intervention campaign. A new direction is needed, one that normalizes vaccination within the YAF population and uses peer-led campaigns to encourage future vaccination. This new approach takes advantage of the research findings of (19) who found that the social norm of the HPV vaccination (peers also going to get the vaccine) had the strongest influence on being vaccinated. Additionally, when widespread acceptance of the vaccine is emphasized it will promote further acceptance by others (13).

On college campuses or in workplaces that are predominantly staffed with young adult females, interventions that focus on promoting a unified front of acceptance for the vaccine – a normalized behavior – will continue to reach a wider audience. Showing that more of one’s peers are vaccinated or in the process of getting vaccinated, will push those who are undecided or unsure of what others may think, to do the same, increasing the acceptance for all. Shifting the media campaign that showed mothers can do this and adolescent girls getting vaccinated, to more young adult females (an older age demographic than adolescents) who got vaccinated or are talking with their friends that got vaccinated in a collegiate environment. Another approach would be to increase the distribution of information on the number of women within the targeted age demographic who already got vaccinated. Since it is something that is not easily discussed, showing how commonly accepted vaccination is, will decrease the idea of the HPV vaccine as a taboo subject and will normalize both its discussion and the acceptance of the vaccine. By changing the social norms of our society, behavior change will also be initiated. This part of the program is less education based and more grounded in awareness and discussions of typically culturally taboo subjects of sexually transmitted infections.

INTERVENTION # 3

Improving Self Efficacy

It has previously been shown that improving one’s self-efficacy will lead to greater health outcomes, something the current HPV intervention does not do. A new way of approaching self-efficacy is to address the barriers that people perceive when they try to get about getting the vaccine or take the first step to change their behavior (14). This idea includes addressing factors such as insurance coverage, history of STI, doctor/family recommendation (2). For example, by limiting the price of the vaccine or making insurance companies cover the vaccine, which is roughly $360 for a full series of three shots (1), women will feel more in control and able to actually change their behavior.

Focusing on the previous similar achievements of an individual can also make improvements to the intervention, because prior performance accomplishments are typically a dependable source of efficacy expectations if they are based on one’s own personal experience (16). The intervention could draw attention to the success of other vaccination campaigns and the frequency with which people seek the flu vaccine or the Hepatitis B vaccine. By demonstrating to the candidates that they have already taken a similar step towards a similar goal in the past, will be motivation and proof, that they are capable of similar behaviors, even if they address another area of health.

Furthermore, reviewing pre-action behaviors can also improve self-efficacy. In a study that looked at condom use and safe sex practices, those who had condoms available and had talked to their partner about using a condom were more likely to use a condom as the “event was under personal control of the client” (14). In relation to HPV vaccination, this could include discussing with peers and family members beforehand, but also looking at choices that those in targeted age demographics have successfully completed beforehand. Since, uptake with YAFs is lower than expected, targeted campaigns that show their self-efficacy and success in moving away from their families, starting a job or going to college, making independent choices about eating, smoking, drinking, sexual, physical behavior, will prove to them they have done something similar before and are capable of doing it again (16).

CONCLUSION

As a result of the variety of ways in which health campaigns can be designed and disseminated, there are different ways to then also critique and improve. The three critiques above all address different aspects of the current HPV vaccination campaigns from the perspective of the health belief model, social norms theory and theory of planned action, respectively. While they pin point and target to whom the information is given, how the information is given and what the information and campaign addresses, the final goal is to increase acceptance of the HPV vaccine, specifically for the young adult female population. Different individuals with different goals and support devise campaigns such as these and therefore, there is no one right answer. However, using social science theories that are grounded in successful evidence-based approaches can only lead to the future success of public HPV vaccination campaigns.

REFERENCES

1)U.S. Food and Drug Administration. Gardasil. (2011). www.fda.gov

2) Gamble, Heather, Klosky, James L., Parra, Gilbert R., Randolph, Mary E. (2010). Factors Influencing Familial Decision-Making Regarding Human Papillomavirus vaccination. Journal of Pediatric Medicine, 35(7) 704-715.

3) Centers for Disease Control and Prevention. Vaccines and preventable disease: HPV vaccination. (2011). www.cdc.gov

4) Herskovitz, B. (2007). Brand of the year. www.pharmaexec.com

5) Cameron, K. (2007). A practitioner's guide to persuasion: An overview of 15 selected persuasion theories, models and frameworks. Patient Education and Counseling, 74, 309-317.

6) Freudenberg N, G. S. (2008). The impact of corporate practices on health: Implications for health policy. Journal of Public Health Policy, 29, 86-104.

7) Salazar, M. (1991). Comparison of four behavioral theories. AAOHN Journal, 39, 128-135.

8) Lopez, R., & McMahan, S. (2007). College women's perception and knowledge of human papillomavirus (HPV) and cervical cancer. Californian Journal of Health Promotion, 5(3), 12.

9) Ariely, Dan. (2008). Predictably Irrational. New York: Harper Collins.

10) Rothman, S. M., & Rothman, D. (2009). Marketing HPV vaccine: Implications for adolescent health and medical professionalism. Journal of American Medical Association, 302(7)

11) Hopfer, S., & Clippard, J. R. (2011). Women's HPV vaccine decision narratives. Qualitative Health Research, (21), 262. doi:10.1177/1049732310383868

12) Dederer, C. (2007, February 18, 2007). Pitching protection, to both mothers and daughters. The New York Times.

13) Marlow, L. A. V., Waller, J., & Wardle, J. (2007). Parental attitudes to pre-pubertal HPV vaccination. Cancer Research UK Health Behaviour Unit, Department of Epidemiology and Public Health, UCL.

14) Albarracin, D., Johnson, B. T., Fishbein, M., & Muellerleile, P. A. (2001). Theories of reasoned action and planned behavior as models of condom use: A meta-analysis. Psychological Bulletin, 127(1), 142.

15) Yzer, M.C., Siero, F.C., Buunk, B.P. (2000). Can public campaigns effectively change psychological determinants of sager sex? An evaluation of three Dutch campaign. Health Education Research, 15 (3), 339-352.

16) Rimal, R. N. (2001). Longitudinal influences of knowledge and self efficacy. Journal of Health Psychology, 6(31) vaccination. (2011). www.cdc.gov

17) Cialdini, R. (2007). Introduction and chapter 1: Weapons of influence. Influence: The psychology of persuasion (pp. xi-xiv, 1-16). New York: Harper Collins.

18) Allen, J. D., Othus, M. K. D., & Shelton, Rachel C., et al. (2010). Parental decision making about the HPV vaccine. Cancer Epidemiology, Biomarkers and Prevention, (19), 2187.

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.

REFERENCES
1. Allen J, Hector D. Benefits of breastfeeding. NSW Public Health Bull. 2005 Jan 1;16(4):42-46.

2. Bartick M, Reinhold A. The Burden of Suboptimal Breastfeeding in the United States: A Pediatric Cost Analysis. Pediatrics. 2010 May 1;125(5):e1048-1056.

3. Healthy People - About Healthy People 2010 [Internet]. [cited 2010 Nov 27];Available from: http://www.cdc.gov/nchs/healthy_people/hp2010.htm

4. 16 Maternal, Infant, and Child Health [Internet]. [cited 2010 Nov 27];Available from:http://www.healthypeople.gov/document/HTML/Volume2/16MICH.htm#_Toc494699668

5. Fitzgerald Health Education Associates, Inc. Healthy People 2010 Breastfeeding Objectives Revised [Internet]. [cited 2010 Nov 27];Available from: http://fhea.com/breastfeeding/december2007.pdf

6. Breastfeeding: Data: Report Card 2010: Outcome Indicators | DNPAO | CDC [Internet]. [cited 2010 Nov 27];Available from: http://www.cdc.gov/breastfeeding/data/reportcard2.htm

7. Breastfeeding: Data: NIS | DNPAO | CDC [Internet]. [cited 2010 Nov 27];Available from: http://www.cdc.gov/breastfeeding/data/NIS_data/

8. State Health Department Launches Breastfeeding Campaign [Internet]. [cited 2010 Nov 27];Available from: http://www.health.state.ny.us/press/releases/2010/2010-09-09_breastfeeding_campaign.htm

9. New York State Department of Health. Breastfeeding…For My Baby…For Me Campaign [Internet]. [cited 2010 Dec 8];Available from: http://www.health.state.ny.us/community/pregnancy/breastfeeding/campaign/

10. Edberg M. Essentials of Health Behavior: Social and Behavorial Theory in Public Health. 1st ed. Jones and Bartlett; 2007.

11. Siegel MM. Marketing Public Health: Strategies to Promote Social Change. 2nd ed. Jones & Bartlett Publishers; 2007.

12. Marks DF. Health Psychology in Context. Journal of Health Psychology. 1996 Jan 1;1(1):7 -21.

13. parentalleaveA131.pdf [Internet]. [cited 2010 Nov 27];Available from: http://www.iwpr.org/pdf/parentalleaveA131.pdf

14. Mandal B, Roe BE, Fein SB. The differential effects of full-time and part-time work status on breastfeeding. Health Policy. 2010 Sep;97(1):79-86.

15. Grier S, Bryant CA. SOCIAL MARKETING IN PUBLIC HEALTH. Annu. Rev. Public. Health. 2005 4;26(1):319-339.

16. McCracken GD. Culture and consumption II: markets, meaning, and brand management. Indiana University Press; 2005.

17. Salazar MK. Comparison of four behavioral theories. A literature review. AAOHN J. 1991 Mar;39(3):128-135.

18. Dillard JP, Shen L. On the Nature of Reactance and its Role in Persuasive Health Communication. Communication Monographs. 2005;72(2):144.

19. International Code of Marketing of Breast-milk Substitutes 1981 [Internet]. [cited 2010 Dec 5];Available from: http://www.who.int/nutrition/publications/code_english.pdf

20. QF_Newsletter_2006n1_July.pdf [Internet]. [cited 2010 Dec 5];Available from: http://www.babyfriendly.ca/ClientData/Modules/Challenge/newsletter/QF_Newsletter_2006n1_July.pdf

21. Merewood A, Grossman X, Cook J, Sadacharan R, Singleton M, Peters K, et al. US Hospitals Violate WHO Policy on the Distribution of Formula Sample Packs: Results of a National Survey. Journal of Human Lactation [Internet]. 2010 9 [cited 2010 Dec 5];Available from: http://jhl.sagepub.com.ezproxy.bu.edu/content/early/2010/09/22/0890334410376947.full.pdf

22. Bauer UE, Johnson TM, Hopkins RS, Brooks RG. Changes in Youth Cigarette Use and Intentions Following Implementation of a Tobacco Control Program. JAMA: The Journal of the American Medical Association. 2000;284(6):723 -728.

23. About the BFHI [Internet]. [cited 2010 Dec 6];Available from: http://www.babyfriendlyusa.org/eng/01.html

24. Sesame Street - Buffy Nurses Cody [Internet]. 2010 [cited 2010 Dec 5]. Available from: http://www.youtube.com/watch?v=7-L-Fg7lWgQ&feature=youtube_gdata_player

25. Henderson L, Kitzinger J, Green J. Representing infant feeding: content analysis of British media portrayals of bottle feeding and breast feeding. BMJ. 2000 Nov 11;321(7270):1196 -1198.

26. Rogers EM. Diffusion of innovations. Simon and Schuster; 1995.

27. Stuart-Macadam P, Dettwyler KA. Breastfeeding: biocultural perspectives. Transaction Publishers; 1995.

28. Bandura A. Social learning theory. Prentice Hall; 1977.

29. Balasubramanian SK. Beyond Advertising and Publicity: Hybrid Messages and Public Policy Issues. Journal of Advertising. 1994 Dec;23(4):29-46.

30. United States General Accounting Office. FOOD ASSISTANCE Information on WIC Sole-Source Rebates and Infant Formula Prices May 1998 [Internet]. [cited 2010 Dec 5];Available from: http://www.gao.gov/archive/1998/rc98146.pdf

31. Roe B, Whittington LA, Fein SB, Teisl MF. Is There Competition between Breast-Feeding and Maternal Employment? Demography. 1999 May;36(2):157-171.

32. report.pdf [Internet]. [cited 2010 Nov 27];Available from: http://www.hsph.harvard.edu/globalworkingfamilies/images/report.pdf

33. Pear R. New Health Initiatives Put Spotlight on Prevention [Internet]. The New York Times. 2010 Apr 4 [cited 2010 Dec 8];Available from: http://www.nytimes.com/2010/04/05/health/policy/05health.html

34. Andrews M. In All Those Pages, a Surprise or Two [Internet]. The New York Times. 2010 Mar 29 [cited 2010 Dec 8];Available from: http://www.nytimes.com/2010/03/30/health/30fine.html?scp=6&sq=breastfeeding%20working%20moms%20healthcare%20bill&st=cse

35. Kocieniewski D. Breast Pumps Lack Tax-Sheltered Status in Health Law [Internet]. The New York Times. 2010 Oct 26 [cited 2010 Dec 8];Available from: http://www.nytimes.com/2010/10/27/business/27breast.html?_r=2&emc=eta1