Thursday, May 6, 2010

A Closer Look at the 2003-05 National Breastfeeding Campaign, Babies Were Born to Be Breastfed: Would It Have Worked? - Cristina Deis

A Critique of the National Media Campaign to Address Breastfeeding

The debate over breastfeeding has been heated in the United States for over one hundred years. Among the lowest in the world, the US has set breastfeeding goals through the Healthy People 2010 outline. National goals are set for seventy five percent of mothers to initiate breastfeeding, fifty percent breastfeeding at six months, and twenty five percent breastfeeding at twelve months. Unfortunately, when measured in 2002, rates of exclusive breastfeeding were less than forty six percent during the hospital stay, and less than thirty three percent at six months. Additionally, increased evidence speaking to the cost savings associated with breastfeeding continued to accumulate. David Satcher, United States surgeon general released the formal Blueprint for Action on Breastfeeding in 2000 (1). To support those measures, the Office of Women’s Health (OWH), an agency within the Department of Health and Human Services, was given the charge of creating a public health campaign for breastfeeding, the first of its kind since 1911 (2). They raised $40 million to launch a national media campaign called Babies Were Born to Be Breastfed (BWBBB) to increase exclusive breastfeeding. The campaign quickly gained media coverage as formula companies were affiliated with the head of the American Academy of Pediatrics and the head of the Health and Human Services. Original media ads showed strong negative images associating formula feeding with poor health outcome. Formula company lobbyists were able to influence public health professionals to change the ads. After a controversial debate over the content of the ads, the campaign eventually utilized television, radio, Internet, and print advertising to spread its message from 2003 to 2005. In the end, after the media ads aired, the proportion of mothers who breastfed in the hospital decreased from seventy percent in 2002 to 63.6 percent in 2006 (1). Some experts believe that the strong arm of the formula companies watered down the public service messages, leading to an ineffective media campaign. I would offer that the formula companies were not the only contributing factor to the failure of the breastfeeding campaign. In fact, even without the negative influence of the formula companies, I believe the Babies Were Born to Be Breastfed media campaign would have done equally poor, if not worse because of the inappropriate framing of the situation, the lack of branding, and the lack of strong financial backing.
With the backing of the surgeon general, and the recent release of the Agency for Healthcare Research and Quality report on breastfeeding, the United States Department of Health and Human Services’ Office on Women’s Health decided to launch a national media campaign that encourages first-time mothers to breastfeed exclusively for six months. The committee began on the right tract, conducting formative interviews with 36 focus groups and input from the USDA’s Breastfeeding Promotion Consortium and the US Breastfeeding Committee (3,4). Additionally, ads were created using risk-based social marketing strategies to change behavior. The Ad Council decided to frame the campaign in a risk-based way to address the misconceptions that breastfeeding was a “supplement” to a standard diet of baby formula. Although not explicitly stated, committee members based the media campaign on the assumption that the problem was individual mothers not having the right information. Similar to the Health Belief Model (HBM), organizers identified women who were susceptible as mothers, and emphasized the severity of consequences if they did not breastfeed. Based on that, public health practitioners assumed that women would rationally weigh the cost and benefits of breastfeeding, have a new intention to breastfeed, which according to the HBM results in behavior change (5). Originally, before the ads became watered down secondary to corporate influence, the images were primarily negative, with the emphasis of educating individual mothers on the risks of not breastfeeding. There were no testing of ads in target audience groups to measure for psychological reactants (6), so it is unclear if ads created a similar phenomenon as the national youth anti drug media campaign (7) by inadvertently restricting mothers freedom to choose breast to bottle.
The national committee did a good job to identify contributing factors to why women do not breastfeed, however the original frame of the campaign was doomed to fail. The campaign was framed around the individual using an inappropriate behavioral model, the focus was on risk and not benefit, and no big promises were made. We know that physiologically, the way an issue is framed has an impact on human behavior (8). The BWBBB campaign places the responsibility to breastfeed in the hands of the individual. This paradigm is used in a number of traditional behavioral models including the Health Belief Model, Theory of Reasoned Action, and Theory of Planned Action. The individualistic view spurs from the US cultural emphasis on individual mastery, coping, and control (9). Women who are at risk due to socioeconomic status, health status, or some other factor run the risk of falling behind if their skills are not up to par. Additionally, assumptions made about individual beliefs and the translation into behavior is not observed in the field (10). Formative interviews gave researchers insight into how individual women may not breastfeed, however it failed to look at outside barriers that may contribute to diminished breastfeeding. Using the individual frame shifts responsibility and blame onto women to breastfeed without providing her support or a social environment that encourages and nurtures breastfeeding. BWBBB emphasizes mother’s duty to her child but does not account for outside influences such as family support, employment support, and social support.
In addition to using the individual as the basis for a campaign, public health practitioners decided to take a risk-based approach in the BWBBB movement. The notion of emphasizing the benefits was thought to be ineffective by public health personnel (3), as they thought the main problem was the misinformation about breastfeeding. Ogilvy would argue that essential to a great campaign is a large promise (11). The BWBBB made no large beneficial promises that the general public could hold on to. They isolated women who chose not to breastfeed or could not breastfeed. Although they did focus groups to determine preconceived notions of breastfeeding, they did not run test pilots to verify that there was not an opposite and unintended affect due to reactance (6). The success of risk-based campaigns based on one of the traditional models has been dismal and inconclusive at best (10).
The inappropriate frame used by the national campaign was compounded by the fact that there was no brand associated with the campaign. Ogilvy argues “golden rewards await the advertiser who has the brains to create a coherent image, and the stability to stick with it over a long period”(11). A brand has been described as a set of associations linked to a name, mark, or symbol associated with a product (12). Branding is important in creating a relationship between the consumer and the product (12). In this case, breastfeeding is seen as something that mothers need to worry about. There is no sense that breastfeeding is something that a woman should be proud of or strive for. As highlighted in the Best for Babe campaign website, one of the many challenges to breastfeeding is the lack social acceptance (13). In the home, frustrated partners may succumb to bottle feeding to quite baby, with family; relatives may not have breastfed and so are not supportive or cannot offer advice. Barriers extend into the workplace where women are forced to pump in broom closets or break rooms or not at all because of space or management issues. Additionally, breastfeeding is frowned upon in public in the US. A brand would be a way of labeling breastfeeding and associating it with something good. It would be similar to priming, in which a media campaign with a strong brand could bring feelings of health, wellness, and vitality when walking past a breastfeeding mother. By having a strong brand associated with breastfeeding and all the benefits, a brand primes the public with feeling of encouragement and support for breastfeeding mothers as opposed to disgust and withdrawal. By setting people up with a preconceived idea of breastfeeding, when they see a breastfeeding mother they will likely behave in a manor consistent with their previous ideas.
Florida’s “truth” campaign sites one of the major reasons for the success was the ability to make “truth” a brand (14). For the individual, especially among the youth, branding serves as a means of defining one’s identity. By making breastfeeding a brand, more people would be more likely to support it. People would be able to visually express their support and identify themselves as breastfeeding advocates. Increasing social awareness through visual media has been shown to be successful in increasing breastfeeding initiation and duration rates and increasing perceptions of community support (15). The CDC Guide to Breastfeeding Interventions sites the use of social marketing as a key component of changing the social norms of breastfeeding (16). They site the Four Ps as being important to a good campaign: product, price, place, and promotion. Not only has the BWBBB not addressed the price of breastfeeding (emotional, psychological, physical and social), but also they are lacking in the forth P of promotion. By not giving consumers a brand to hold onto, to wear on their shirt, they are missing an entire key component to creating true behavior change.
Finally, Ogilvy argues that facts are important to a successful media campaign. With breastfeeding, there is no long a call for more research because it would be considered unethical to conduct case control studies. The evidence is too great. There is a clear benefit of breastfeeding to infant, mother, and community. By branding this information, Blitstein and colleagues would argue that it increases the perceived value of the breastfeeding in the mind of the public (17).
The last component of the BWBBB national media campaign that lead to poor outcomes was the inadequate funding. After the recommendation was made by the surgeon general to increase breastfeeding awareness through the Blueprint for Action on Breastfeeding, the Office on Women’s Health partnered with the nonprofit Ad Council to fund thirty million dollars in media time (1). The Ad Council used the typical model and distributed the public service announcement to twenty eight thousand media outlets throughout the country, airing commercials during donated media time. The campaign was scheduled to run between 2003 and 2005. Although thirty million dollars in media time and forty million dollars total over three-year period seem adequate, to counter the national breastfeeding campaign, formula companies are said to have spent over fifty million dollars in one year (1).
In the Florida “truth” campaign, Hicks sites real money as the number one factor for success (18). The Florida youth anti-tobacco campaign was a two year two hundred million dollar campaign. That is equivalent of thirteen million dollars a year spend versus one hundred million dollars spent. The anti-tobacco group sited that not having the restraints of limited funding allowed them to utilize tools of modern marketing, work with exclusive directors, and carry out research to target teen sector. Above all else, the “truth” campaign reports the increased funding had the biggest effect on the media. The “truth” annual budget for television media was fifteen million dollars compared to ten million dollars a year of donated airtime. The funding allowed the “truth” campaign to air during time slots of high viewership as opposed to traditional midnight slots reserved for public service announcements. The campaign aired on MTV and ran during the Superbowl (18). For the BWBBB this could have helped increase awareness through more television airtime. Additionally, appropriate funding could have lead to more time spent on cultivating a logo or brand.
Money for a breastfeeding campaign must also be used to address outside influences that women may have acting a barriers to breastfeeding. Using funds to create audits of employment sites to verify they have appropriate room for women to breastfeed. Spending is needed on focus groups that target non-breastfeeding mothers, both men and women. This is critical to understand what target points to emphasize in creating a breastfeeding campaign focused on changing social norms around breastfeeding.
Overall, although the formula companies played a central role in diluting the message by public health practitioners, the way the campaign was framed, the lack of a brand, and the lack of adequate funding ultimately lead its failure.
An Alternative Approach to Creating a Media Campaign for Breastfeeding
The Department of Health and Human Services was on the right track with its goal of changing social norms around breastfeeding through a massive media campaign. The Best for Babe Foundation, created in 2007 by Bettina Lauf Forbes and Danielle Rigg, whose mission is to “Give breastfeeding a makeover and to beat the booby traps, the barriers to breastfeeding success” (13). Part one of the mission is to make breastfeeding a brand in the mainstream market in hopes of elevating the cause to the level of other national campaigns such as the (Red) campaign. The second part of the mission is to move the focus of breastfeeding away from mother, as seen in the BWBBBB campaign, and onto barriers to breastfeeding. The founders cleverly coined the term booby traps as the culprit responsible for the low rates of breastfeeding in the US. As with the Department of Public Health, their program sprout up in the wake of low US breastfeeding rates, increasing evidence of cost savings, and most importantly maternal and child health. To meet the original request of the Department of Health and Human Services, I would draw on many of the key elements of the Best for Babes campaign to create the most effective and long lasting media campaign targeted at change the social norms around breastfeeding. My main focus for a media campaign would be creating the right frame, adopting a brand, and obtaining adequate funding.
The Best for Babes campaign does a great job of moving away from the individual and changing the focus onto barriers associated with not breastfeeding. To supplement this underlying theme, I would incorporate social expectation theory and try to target the general population. This model focuses on social norms and moves away from changing beliefs or attitudes. Examples of this can be seen with smoking in bars and restaurants (19). As with smoking, the goal was to change social norms, not individual feelings about smoking. Similarly, with breastfeeding, the goal is to reverse the socially unacceptable nature of breastfeeding in the US. Part of this will be done through ads targeting families and communities. The other part of it will be to create a task force to make sure that the requirements for a suitable breastfeeding station are enforced. By enforcing the law, communities are normalizing breastfeeding. They are reframing the issue and understanding it as a community norm not a mother problem. The other thing that I would add to the Best for Babes campaign was to promise big. This is not hard as the benefits of breastfeeding really are health, vitality, and wealth. Breastfeeding reduces cardiovascular risk in mother, reduces numerous morbidities with baby and has been shown to save the US as a whole millions. In creating my media campaign I would show images of ethnically diverse families and communities that are healthy and prosperous. I would not focus on mothers or infants but rather focus on small family units. The law of small numbers implies that people don’t understand statistics and to use them is a waist of time (20). Instead, I would use personal family units were people could see themselves in image. Furthermore, the law of optimistic bias says that people tend to underestimate risk that applies to them. When the BWBBB put up images and risks associated with not breastfeeding, the law of optimistic bias predicts a feeling of ‘it is not going to happen to me,’ which might have been reflected in the decrease seen in breastfeeding from 2002 to 2006. To counter this effect, the individual family unit among an intimate community setting would be ideal. As Ogilvy recommends, include facts. I would include the benefits of breastfeeding however I would avoid using numerical comparisons and would stick to generalized concepts. The Best for Babe campaign includes a small script at the bottom of their main poster that says: Every day and in emergencies, breastfeeding saves lives. It goes on to say more about getting hospital, pediatrician, employer and insurers involved. Although this last part is important, the general message is life. Breastfeeding gives community a better life. I would flash short highlights of benefits including health affects averted and money saved, but my lasting and consistent message would be something short like ‘Breastfeeding for Tomorrow’ to emphasize the critical affect it has on the future.
As with framing, the Best for Babes campaigns major strength is a brand that is catch, sexy, and modern. Best for Babes is short and to the point. The double meaning for Babes is intelligent. The signature overlapping Bs is a trademark that supporters can wear and associate with breastfeeding, health, and vitality. The image of a slender silhouette with large breasts, highlighting the nipples as letters in the slogan “stimulus package” or “Life-saving devices” is funny, catchy, and true. The campaign has also created a sense of sexiness and strength by recruiting actresses and leading women to act as ‘champions’ for the campaign. The combined effect is giving women who want to breastfeed something to be proud of. The image of the sexy silhouette, combined with the information reinforced through television, radio, posters, etc cause society to change the perception of a breastfeeding mother. She is cared for and nurtured rather than shunned. The expectation will shift from whether moms will breastfeed to how long. I would keep the Best for Babes brand and logo. I would shorten the subscript and make it a consistent message. The script between the breasts is one of the best parts of the image as it can be updated and modernized with the changing mainstream shifts.
Lastly, unlike the BWBB campaign that spent thirty million dollars over three year, I would recommend an intense and evolving campaign over 5 years. The “truth” campaign had over fifteen million dollars a year specifically for TV media. Under 2010 Health Reform, the federal government has pledged to expand and sustain funding for prevention and public health programs. I would recommend receiving funding to total five hundred million dollars over the course of five years from various different coalitions. Breastfeeding is key in reducing disparities, improving maternal health, and economically benefiting our country. Each of the different funds set up are to have increases, some of which are effective this year. I would divide the cost among the Prevention and Public Health fund, Childhood Obesity Demonstration Project, Community Transformation Grants, Maternal Infant and Early visitation programs, and Personal Responsibility Education funds (21). Funding is taken from different groups that do not all are directly related to breastfeeding. However, for a five year period, making a real shift in social norms and should be supported by everyone, especially those who will see improvements in their outcomes as a result of breastfeeding. Alternative funding will spur from high profile individuals, such as actresses who become champions. Additionally, a key component in maintaining ongoing funding is by creating a partnership with current existing resources. Many breastfeeding coalitions currently have a fund specifically for advertising. Their money may not seem to stretch, but the combination of breastfeeding coalitions throughout the country supporting a national campaign to change social norms could raise enough money to sustain the active campaign well beyond five years.
Finally, to ensure a welcome reception to the national breastfeeding campaign, I would want to spend a substantial portion of the budget toward running focus groups to see how people in the community are reacting to the media campaign. The national youth anti-drug media campaign (7) was a failure in part because the ads had the opposite effect on y0uth, something they could have figured out had they run focus groups.
Overall, I believe that to make a serious attempt to increase the exclusive breastfeeding rates in the United States, it is critical to change social norms around breastfeeding and support mothers. The Department of Health and Human Services began that mission by creating a Blueprint for Action to Breastfeed and supporting the Office of Women’s Health to steer a national committee. Although derailed by the formula companies, the original media campaign may not have had better results than the one that ultimately came out. The lack of appropriate framing, branding, or financial support were major barriers to the campaign’s success.
In looking forward to new interventions, campaigns like the Best for Babes campaign are major improvements and starting points for creating effective and long lasting national breastfeeding campaigns. Framing breastfeeding as being the choice for better life and supported by the community is optimal. Shifting the focus away from the mother and onto the community distributes accountability. Furthermore creating a lasting brand that can reflect the promise made by breastfeeding is important. The phrase Booby Traps is a trademark brand that directs blame to outside factors preventing women from breastfeeding. Finally, to seriously have a lasting effect, continuous funding needs to be provided to ensure a high quality, evidence based campaign that is dynamic and meets the needs of consumers.
References
1. Kaufman M, Lee C. HHS Toned Down Breastfeeding Ads. The Washington Post. 2007: 1-7.
2. Merewood A, Heinig J. Efforts to promote breastfeeding in the United States: Development of a national breastfeeding awareness campaign. Journal of Human Lactation. 2004: 20(2): 140-145.
3. Massachusetts Breastfeeding Coalition. Ethical conflicts delay the national breastfeeding campaign. 2004. http://massbreastfeeding.org/news/#ethics
4. Siegel M. The importance of formative research in public health campaigns: an example from the area of HIV prevention among gay men (Appendix 3A). In: Siegel M, Doner L. Marketing Public Health: Strategies to Promote Social Change, 2nd edition. Sudbury, MA: Jones and Barlett Publishers, 2007, 73-78.
5. Salazar MK. Comparison of four behavioral theories. AAOHN Journal. 1991; 39:128-135.
6. Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology. 2005; 27:277-284.
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9. Marks DF. Healthy psychology in context. Journal of Health Psychology. 1996; 1: 7-21.
10. Ogden J. Some problems with social cognition models: a pragmatic and conceptual analysis. Health Psychology. 2003; 22: 424-428.
11. How to build great campaigns (Chapter 5). In: Ogilvy D. Confessions of an advertising man. New York: Atheneum, 1996. 89-103.
12. Evans WD, Hasting G. Public health branding: Recognition, promise, and delivery of healthy lifestyle (Chapter 1). In: Evans WD, Hastings G, eds. Public Health Branding: Applying marketing for social change. Oxford University Press, 2008. 3-24.
13. Best for Babes: Giving breastfeeding a makeover. 2007-2010. http://www.bestforbabes.org/
14. Hicks JJ. The strategy behind Florida’s “truth” campaign. Tobacco Control. 2001; 10: 3-5.
15. Khoury AJ, Moazzem AW, Jarjoura CM, Caro C, Hinton A. Breastfeeding initiation in low income women: role of attitudes, support and perceived control. Women’s Health Issues. 2005; 15(2): 64-72.
16. Shealy KR, Li R, Benton-Davis S, Grummer-Strawn LM. The CDC Guide to Breastfeeding Interventions. Atlanta: US Department of Health and Human Services, Center for Disease Control and Prevention. 2005.
17. Blitstein JL, Evans WD, Driscoll DL. What is a public health brand? (Chapter 2). In: Evans WD, Hastings G, eds. Public Health Banding: applying marketing for social change. Oxford: Oxford University Press, 2008. 25-41.
18. Hicks JJ. The strategy behind Florida’s “truth” campaign. Tobacco Control. 2001; 10: 3-5.
19. Siegel M. Marketing social change: an opportunity for the public health practitioner (Chapter 3). In: Siegel M, Doner L. Marketing public health: strategies to promote social change (2nd edition). Sudbury, MA: Jones and Barlett Publishers, 2007. 45-71.
20. Tversky A, Kahneman D. Belief in the law of small numbers. Psychological Bulletion. 1971; 76: 105-110.
21. Johnson K. Health reform: meaning for girls and women. News on Preconception Health and Health Care. 2010. 1-8.

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1 Comments:

At May 6, 2010 at 4:57 PM , Anonymous Best for Babes said...

Thank you so much for this great critique! You captured exactly what Best for Babes and Frank About Women intended to create, an ad campaign that inspires and empowers moms! Now, just to get your article into the hands of those who hold the pursestrings . . .

 

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