The National Breastfeeding Awareness Campaign: Failure to Contextualize Individual Behavior Change – Eloesa McSorley

In June 2004, the Office of Women’s Health, as part of the US Department of Health and Human Services (USDHHS), launched the National Breastfeeding Awareness Campaign (NBAC). The campaign was a result of directed funding to increase the proportion of women who initiate breastfeeding with their first infant and who exclusively breastfeed during the first six months post partum (1). This objective was articulated in Healthy People 2010 as to increase the percentage of women that breastfed in the early postpartum period from 64% (1998 baseline) to 75% by 2010 (2). Additionally, objectives of percentage increases were put forth for the rate of breastfeeding at 6 months (from 29% to 50%) and at 1 year (from 16% to 25%) (2).

With these goals in mind, the USDHHS Office of Women’s Health produced the HHS Blueprint for Action on Breastfeeding (3). The report evaluated the state of breastfeeding in the United States and established four specific goals that would lead to fulfillment of the Healthy People 2010 objective (3). With the charge of the report the Office of Women’s Health established the National Breastfeeding Awareness Campaign. The overall goals of the Campaign were those established in the Healthy People 2010 document (1). The campaign had two main components: a nationwide media outreach campaign and sixteen community based demonstration projects (1). Both components sought to increase rates of breastfeeding through empowering women to commit to breastfeeding (4). The Office of Women’s Health worked with the Ad Council to create and disseminate the campaign which ran through April 2006 (5).
The campaign, though well crafted and supported by valid and thorough scientific research, failed to fulfill its goals. I argue that this is partially due to three problems in t he campaign. First, the campaign failed to include all relevant information necessary for women to make an informed decision regarding the decision to breastfeed, in particular information regarding infant formula. Second, the campaign failed to consider all of the stages of change that a woman would go through to initiate and continue breastfeeding. And finally, the campaign only sought to address women themselves, ignoring others that may influence a woman’s decision and capacity to breastfeed, and failing to appropriately contextualize the health behavior.

I. Failure to fully implement the Health Behavior Model

The nationwide media outreach component of the NBAC sought to recast the benefits of breastfeeding to have a greater perceived consequence (4). The health related behavioral principals that underlie this campaign strategy come from the Health Belief Model (HBM) (5). The HBM views health related behavior change as related to an individual’s perception of the severity of risk associated with not changing behavior, along with perception of their individual susceptibility to the risk (6). Additionally, the HBM posits that people will also consider the potential benefits of implementing a behavior change and the likelihood that they can implement the change (i.e. what barriers they face to changing) (6). A critical flaw of implementation in the nationwide campaign was that the campaign only told half of the story about risk, and therefore failed to fully implement the HBM, underutilizing its potential for change in this situation.

The NBAC used a strategic implementation of framing via the print portion of the nationwide media outreach campaign to invite expectant mothers to think about breast-feeding as a risk reduction strategy (i.e. to think about not breastfeeding as imposing a risk upon a child). They cleverly used images associated with the risk being addressed portrayed in such a way as to represent breasts. Two dandelions were used to represent a possible decrease in respiratory illness in breastfed babies, ice cream scoops with cherries on top represented a decreased likelihood of childhood obesity in children exclusively breastfed for the first six months of life, and otoscopes represented a decrease in the likelihood of childhood ear infections obtained by exclusive breastfeeding (1). Public Service Announcements (PSAs) designed for television portrayed pregnant women engaging in activities that would be universally understood to carry a substantial risk of injury to a fetus, such as log rolling and riding a mechanical bull, and were accompanied by the text, “You wouldn’t take risks before your baby was born. Why start after. Breastfeed exclusively for 6 months.” (1) Both media campaigns were clever, catching and humorous. Additionally, they both encouraged further inquiry into the subject.

However, these ads were created and disseminated in the context of a moms and future moms having a perception of breastfeeding as the “ ‘ideal,’ not the standard” (6). This begs the question: what, then, is the standard? Of course, the answer to this is that the majority of those mothers that are not exclusively breastfeeding their infants up to six months or a year postpartum, are feeding them infant formula. Knowing this, a goal of the campaign was to establish breastfeeding as the standard, as opposed to the ideal (6). The statements about risk that are included in the print and TV ads are lacking the essential information that increased risk is not only associated with women not breastfeeding, but, logically, with women instead using baby formula as a primary source of nutrition for their infants. There have been many critiques made of the Health Belief Model, one being that it assumes that individuals act rationally and empirically when presented with a risk benefit analysis of potential health behavior implementation (7). However, before addressing such an aspect of a public health intervention based on the HBM, one must observe a well constructed intervention based on the HBM in the first place. NBAC not only omits discussion and information about risks associated with using baby formula, they also fail to embrace an opportunity to remove clout from (or insert uncertainty into) the perceived benefits of using baby formula. By leaving this out of its ad campaign, the NBAC fails to give consumers of the ads adequate information about risks and benefits of breast feeding in contrast to the risk and benefits of the oft used replacement, baby formula.

Of course, the NBAC does imply that breastfeeding is associated with health benefits and reduced risks to health compared to baby formula, simply by addressing the risks associated with not breastfeeding. Doing this does, in a sense, tie risks to formula feeding, but by addressing formula feeding in this indirect way, it places the context in which a mother makes a decision to breastfeed or formula feed, unrelated to a risk/benefit analysis, in a neutral place. The environment in which mothers make these decisions is far from neutral. Barriers to breastfeeding have been cited by a variety of studies and include social environment, conflicts with employment, inadequately trained hospital support staff, among others (8-10, 3). These types of barriers can and are being addressed through media campaigns, changes to policy in work settings and training programs. Such interventions all have to do with creating an environment in which a mother feels that it is both the right choice and the accessible choice to breastfeed (3). However, the other side of the environment in which a mother initiates and continues to breastfeed or does not, is one that is heavily influenced by the marketing and influence of formula companies that exploit the existence of the barriers stated above in order to make formula feeding an acceptable and an easy choice.

The infant formula is an $8 billion a year industry, and as it is an industry, there is strong investment in seeing that products are consumed (11). Formula companies use both direct to consumer advertising, as well as advertising and distribution of free samples in hospitals and other birthing environments. Without getting into business ethics or the impact of consumer or doctor marketing, what makes the story of the influence of the infant formula industry on the NBAC campaign unique is the emergence of information that the industry, upon reviewing the original marketing plans of the Ad Council, exerted pressure and influence to have certain ads withdrawn that did more directly address breastfeeding in comparison to formula feeding (12). In particular, original manifestations of the ads were to include specific statistics about increased risk associated with formula feeding and also were to include information on leukemia and diabetes (12). The change in stance of the NBAC only goes to highlight that an understanding was at hand about the strength of a message making a comparison between the benefits and risks and breastfeeding versus infant formula. To water down the message is to remove agency from expectant mothers in their capacity to make decisions, all else equal, given the most complete information.

II. Implementation strongly addressing only initial stages of change

Ideally, the transtheoretical of behavior change can describe the process that a woman may go through in her decision to breastfeed if she is exposed to the NBAC. In her stage of precontemplation, she doesn’t know how she will feed her infant after it is born, perhaps she hasn’t really thought about it yet. She may then be exposed to a television or print ad produced by the campaign and may gradually move into the contemplation stage, wherein she decides that she will breastfeed her baby. Next she maybe will tell her partner, her doctor and her family of her plans, perhaps buy a breast pump – this is all part of the preparation stage. Immediately post-partum, a woman would, ideally, initiate the action and begin breastfeeding her child. She would then maintain this behavior through at least the first six months post partum (7).

The NBAC has two distinct, but related goals. It aims to increase the proportion of women who breastfeed and it aims to increase the proportion of women who breastfeed exclusively for the first six months postpartum (1). Paramount to the fulfillment of these goals is that women initiate breastfeeding immediately postpartum (13). The concern with the implementation of a campaign the focuses exclusively on awareness is that it envisions its primary effect to be had on women in either the precontemplation or contemplation stage. It doesn’t address aspects of planning or steps that a women might take to plan for breastfeeding. It doesn’t address the myriad of elements that go into the crucial moment that a women “decides” to breastfeed her baby immediately post-partum. And it doesn’t address ways in which women can continue to breastfeed, considering the environment in which breastfeeding is going to realistically be carried out.

In terms of addressing the initiation of breastfeeding immediately postpartum, though a new mother may be aware of the benefits of breastfeeding, and the risk associated with not breastfeeding, the risk benefit equation that she is theoretically weighing is considered at a key moment defined by the extremely emotionally and physically demanding act of giving birth. There is a likelihood that she will cease to think rationally about the decision in that moment, and “decide” to not breastfeed. Or, she may even think very rationally and consider how exhausted she is, how there are no nurses around to help her breastfeed, how, perhaps, despite all those adds about risk and not breastfeeding, she is a new mom and doesn’t know how to breastfeed and is worried she may do it wrong. The NBAC campaign relies solely on the idea that mothers will be so concerned with the potential risks of not breastfeeding that they will do whatever is necessary to initiate breastfeeding. The campaign, self-styled as an awareness campaign, fails to give moms ideas for how to begin breastfeeding, ignoring a preparation stage. It also fails to address the importance of initiation in the first moments of a child’s life, an aspect crucial to mothers moving into the action, and then maintaining the health behavior.

III. Changing the perception of breastfeeding among many social levels

By implementing a risk-based awareness approach to its campaign, the primary target of the NBAC is expectant mothers. In making expectant mothers the primary target of the campaign, the framers of the campaign are making an assumption that mothers are the people that would 1) be most concerned with their expected child’s health and well being, 2) be the individuals who will carry out the act of breastfeeding and 3) initiate the act of breastfeeding in a self-determined way, according to their will. Secondary to targeting mothers, the ad campaign attempts to indirectly address co-parents, recognizing that the father, in particular, plays an important role in a mother’s decision to breastfeed (5). By changing the perception of breastfeeding from the “ideal” to the “standard,” the campaign attempts to establish and normalize breastfeeding as the standard for the co-parent, thereby fostering a sense of acceptance and support among in the family structure so that mothers will feel comfortable breastfeeding (5).

This aspect of the campaign speaks to individual behavior change alongside a primary interpersonal relationship that will affect child-rearing choices. However, it does not address other relationships and obstacles that a mother contends with when evaluating support for her decision and capacity to breastfeed. Specifically, the ad campaign does not do enough to normalize breastfeeding at all levels of the socio-ecological framework, nor does it do enough to disrupt a static notion of breastfeeding as tied to limiting perceptions femininity and motherhood.

The socio-ecological framework acknowledges that the social environment is made up of multiple levels of influence that effect health behavior, including intrapersonal, interpersonal, institutional or organizational, community and public policy factors (14). The NBAC targeted its efforts to the intrapersonal and interpersonal level of this framework, and largely ignored addressing efforts and awareness at the institutional/organizational, community or public policy level. This is particularly damaging to a breastfeeding awareness campaign, because there are a variety of environments that a women could potentially breastfeed in, in which she is discouraged from doing so due to social norms. Additionally, by only targeting the intrapersonal and interpersonal relationships that could affect a mothers decision or capacity to breastfeed, the ad campaign does not create sufficient space in which it could have begun to restructure notions that are held about breastfeeding and notions and images that are portrayed related to breastfeeding throughout society. In their study on the factors that determined infant-feeding practices, McIntyre, Hiller and Turnbull (1999), found that a primary reason that women gave for not breastfeeding was potential embarrassment. The HHS Blueprint for Action on Breastfeeding noted that efforts were needed to address the social perceptions of breastfeeding and the subsequent social support that mothers had in their endeavor to breastfeed. The NBAC, despite its clever tactic for the print portion of the campaign, may even reinforce the idea that breastfeeding is something to be done in private, that breasts, as a vehicle for infant sustenance, should be hidden. By using images that are not, in fact, breasts and by removing women completely from its print campaign, the NBAC reinforces the idea that breastfeeding itself is too lewd, too exposed, to convey in a print advertisement.

Related to the fact that the campaign only addressed intra- and interpersonal aspects of behavioral influence, is the fact that the campaign does not attempt to change normative ideas about breastfeeding generally, nor ideas that are tied to limited and limiting notions of motherhood specifically and of womanhood, more broadly. By placing the onus of responsibility in breastfeeding initiation on the mother and by excluding direct images of women breastfeeding, the campaign reinforces a notion that breastfeeding is an exclusive act between mother and child and an act that is private, and should be kept private. While on the surface, it is true that the actual act directly involves two parties, the mother and the baby, reinforcing this notion of exclusivity and privacy recalls generations of public images related to breastfeeding that portray breastfeeding as a concealed, near spiritual act, that essentializes motherhood as something characterized by the intense caring and nurturing feelings that we expect mothers to have towards their babies when engaged in this act. As Rebecca Kukula notes, the imagery shows “mother and infant…locked into a dyadic and private relationship of mutual attention that excludes the rest of the world” (15). The portrayal of this relationship (or the fact that the NBAC campaign recalls it) reinforces ideas about motherhood and femininity that do not coincide with the complex world that mothers live in where they may have to breast feed at work, in a store, or while doing another task that any woman has the capacity to be involved in. The idea that breastfeeding is the be all end all of womanhood and of motherhood needs to be challenged. Furthermore, the fact that humor is tied into the imagery of breasts, simultaneously makes breasts themselves more one dimensional (i.e. private) and also reinforces social norms about objectivity related to breasts that create social spaces hostile to breastfeeding, viewed as part of female sexuality, in the first place.

Proposed intervention:

The National Breastfeeding Awareness Campaign had many strengths, but ultimately was lacking in key areas that would have given it more widespread and significant success. There are specifics ways in which amplification and adjustment of the campaign could be implemented to addresses the specific areas of weakness critiqued above. For a proposed intervention, I will focus on such amplification as opposed to designing a multifaceted campaign that could address not only awareness and understanding of breastfeeding, but also policy implementation that would facilitate and encourages breastfeeding among women in hospitals and in places of employment, acknowledging that for uptake of breastfeeding on a larger scale, such policies are essential (3). Directly answering the critiques discussed above, I put forth three suggestions for amplification and adjustment to the campaign. First, the campaign should include information about risk reduction via breast feeding compared to baby formula, while also removing neutrality from baby formula and the baby formula industry and placing it within the context of a business with a target audience. Second, the campaign should increase ad space and information to hospitals where women are giving birth. This will also increase campaign exposure to key individuals that will influence a mother’s decision and capacity to begin breastfeeding, so that she will have more potential to implement early initiation – a predictor for future breastfeeding and exclusive continuation of breastfeeding. Finally, the campaign should broaden its scope to target diverse members of the community through portrayal of diverse manifestations of motherhood and breastfeeding. These three amplifications and adjustments to the NBAC would build upon it s original structure to have a more widespread effect on changes in behavior and attitudes related to breastfeeding.

Defense I: Acknowledging alternatives to breastfeeding

If as a premise for changing behaviors related to breastfeeding, we assume that giving individuals (mothers in particular) information about the risks and benefits of breastfeeding, it is essential that we not withhold information critical to making an informed decision. By framing the issue of providing nutrition and sustenance narrowly to include only breastfeeding, the NBAC fails to acknowledge the oft used alternative, which is using baby formula. The new campaign should not only compare health outcomes, in a direct way, of breastfeeding versus formula feeding, but should also portray information about motives of formula feeding companies (i.e. profit).

In a study by Nommsen-Rivers, Chantry, Cohen and Dewey, comfort with the notion of formula feeding was the strongest (negative) predictor in a mother’s intention to breastfeed, compared to exposure to breastfeeding, comfort with ideas of breastfeeding and breastfeeding self-efficacy (cite). Specifically, Afriacn-American women were more comfortable with formula feeding and less comfortable with breastfeeding than their white and Hispanic counterparts (16). This is of particular importance, as African-American women are much less likely to breastfeed than other racial and ethnic groups, showing lower rates of both initiation and continuation (13).

Comfort with formula feeding can be disrupted by portraying scientifically supported information about the increased risks associated with formula feeding. Additionally, apart from increased risk to a child’s long term health, neutrality can be taken away from formula feeding by directly addressing the business aspect of the formula industry. This could be done in a clever way, comparing the for-profit aspects of formula feeding to the non-profit aspects of breastfeeding. Or the fact that the formula industry is an $8 billion dollar industry could be contrasted with the money and resources that go into the “breastfeeding industry.” This could be done directly by talking about the amount of money and resources that go into the actual campaign alongside other campaigns and maternal health interest groups, or it could be done indirectly by making a comparison to the “production capacity” of a woman’s breasts.

Defense II: Targeted timing and support of intervention

The second adjustment to the campaign would be to increase ad space to places that women are giving birth so as to target women closer to the moment of parity, and to target health care professionals that are an important source of support for women that may breastfeed. Additionally, the campaign should address behavioral change methods not only related to risk, but also related to action and continuation.

While increasing awareness of breastfeeding and of risks associated with not breastfeeding does directly address individuals in the precontemplation and contemplation stages of change, and even indirectly will affect people in further stages and in relapse, more decisive messages need to be implemented to prepare women to breastfeed, to move women into action, and to encourage continuation. Information should be provided to women regarding how she might feel when she first gives birth, and relative to that, how important it is to initiate breastfeeding as early as possible, if not immediately. Included in this information should be data on why breastfeeding in the first days of newborn life is particularly important for continued health and well-being (3).

Continuation of breastfeeding is already somewhat addressed in the current campaign, making a point of stating that breastfeeding should be done exclusively in the first 6 months of life (1). Continuation is very dependent on a mother’s work environment and support system (3). While these aspects can be addressed through policy in initiatives, continuation can also be addressed by including information in ads about how women can integrate breastfeeding into their lives: perhaps showing an actual picture of a women breastfeeding while working, or of a breast pump and some line of text about how giving babies breast milk can manifest in diverse ways.

Defense III: Normalizing of breastfeeding among all community members

A critical fault of the NBAC is that it does not appropriately or adequately consider the social context in which women breastfeed and as such does not attempt to change social norms about breastfeeding. As discussed above, the campaign only attempts to influence behavior change at intrapersonal and interpersonal levels, ignoring that these behaviors, especially significant with behaviors related to breastfeeding, are influenced by all levels of a socio-ecological model.

Particularly useful to an evaluation of current breastfeeding imagery and social perception of breastfeeding and to the development of new campaigns that attempt to change norms is the implementation of theory related to gender and power. In applying the theory of gender and power to a health behavior, we are drawn to consider what the risk factors are, created by historically unequal and differential perceptions of gender related to power, for a woman to engage in “harmful” health behavior (17). In other words, what are the factors that women face, determined by unequal power structures, that put her at an increased risk to not breastfeed? This, of course, has been stated in more benign ways, usually within the context of discussing barriers to breastfeeding. However, it is critically important to break down these barriers with an understanding of their social and historical roots in the relegation of women to a domestic sphere, the view of women as solely mechanisms of reproduction only, and sexism and objectification of women’s bodies. While this is no small task, a breastfeeding campaign that considers such a strategy could begin to reshape how society at large, and mother’s in particular, think about breastfeeding.

The sexual division of labor is particularly important in considering a women’s capacity to breastfeed in that policy may not be in place to allow her to breastfeed. The baseline from which policy is created is one in which the normative action by employers is not to consider roles of parenthood that women take on in the professional sphere, because they have historically been placed in a domestic sphere. While policy implementation is important, more significant is changing perceptions of breastfeeding as private and domestic to normal, diverse and professional. The campaign can address this by showing images of women using a breast pump at work. This could influence not only women in their self-efficacy to continue breastfeeding, but also workers at large to feel normal about such an action.

It will be important to show all types of women breastfeeding in a variety of situations. Kukla points out that two authoritative sources on breastfeeding, the American Academy of Pediatrics breastfeeding guide (AAP 2002) and the book What to Expect When You’re Expecting (Murkoff et. al 2002), are both resources that do not include images of women of color breastfeeding. Furthermore, images usually associated with breastfeeding show women that are “able-bodied, conventionally pretty and feminine, normally shaped… and endowed with normal-sized breasts” (15). This is especially shocking given the low rates of breastfeeding among African-American women, and reinforces the idea that if you are not the normative image of femininity or of a mother, then perhaps breastfeeding is embarrassing. An ad campaign needs to balance its message of breastfeeding as important to the health of the mother and the baby while not making it the defining characteristic of motherhood or womanhood, to give it weight, but in the context of the complex personal and social material that make up every woman. To understand how to change concepts of breastfeeding, the context of breastfeeding must be understood: both the physical reality (breastfeeding in work cloths or while engage in other activity) and the theoretical interpretation (as part of a social environment influenced by gendered power relationships and sexism). Then the portrayal of breastfeeding must reflect this reality, the ideal being that the health behavior can be achieved in the context, thereby changing the context.

Works Cited

1. Office of Women’s Health. National Breastfeeding Campaign. Washington DC: US Department of Health and Human Services. http://www.womenshealth.gov/breastfeeding/programs/nbc/#a
2. U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, DC: U.S. Government Printing Office, November 2000.
3. U.S. Department of Health and Human Services. HHS Blueprint for Action on Breastfeeding. 1ed. Washington, DC: U.S. Department of Health and Human Services, Office on Women’s Health, 2000
4. Office of Women’s Health. Presentation on Breastfeeding Campaign with Campaign Research Findings. Washington DC: US Department of Health and Human Services. http://www.womenshealth.gov/breastfeeding/programs/nbc/results/index.cfm
5. Haynes, SG. (2006, April). Breastfeeding and Public Opinion: Before and After the Launch of the National Breastfeeding Awareness Campaign. Presented at the 134th Annual Meeting and Exposition of the APHA, Boston, MA.
(accessed from http://apha.confex.com/apha/134am/techprogram/paper_123944.htm)
6. Rosenstock IM. Historical origins of the health belief model. Health Education Monographs 1974; 2:328-335.
7. Salazar MK. Comparison of four behavioral theories. AAOHN Journal 1991; 39:128-135.
8. McIntyre E, Hiller JE, Turnbull D. Determinants of infant feeding practices in a low socio-economic area: Identifying environmental barriers to breastfeeding. Australian and New Zealand Journal of Public Health 2008; 23 (2): 207-209
9. Barber-Madden R, Petschek MA, Pakter J. Breastfeeding and the working mother: Barriers and intervention strategies. Journal of Public Health Policy 1987; 8 (4): 532-541
10. Dobson B and Murtaugh MA. Position of the American Dietetic Association: Breaking the barriers to breastfeeding. Journal of the American Dietetic Association 2001; 101 (10): 1213-1220
11. National Resources Defense Council. Issues: Health; Healthy Milk, Healthy Baby. Washington, DC: National Resources Defense Council. http://www.nrdc.org/breastmilk/formula.asp
12. Peterson, M (2003, December 4). The media business: Advertising; Breastfeeding ads delayed by a dispute over content. New York Times. Retrieved from http://www.nytimes.com/2003/12/04/business/media/04adcol.html?pagewanted=1
13. Centers for Disease Control and Prevention. (2010). MMWR weekly: Racial and ethnic differences in breastfeeding initiation and duration, by state – National Immunization Survey, United States, 2004-2008. Retrieved April 28, 2010 from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5911a2.htm
14. Schneider MJ. Introduction to Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2006.
15. Kukla R. Ethics and ideology in breastfeeding advocacy campaigns. Hypatia 2006; 21(1): 157-180.
16. Nommsen-Rivers LA, Chantry CJ, Cohen RJ, Dewey KG. Comfort with the idea of formula feeding helps explain ethnic disparity in breastfeeding intentions among expectant first-time mothers. Breastfeeding Medicine 2010; 5(1): 25-33.
17. Wingood GM, DiClemente RJ. The theory of gender and power: A social structural theory for guiding public health interventions (Chapter 3). In: DiClemente RJ, Crosby RA, Kegler MC, eds. Emerging Theories in Health Promotion Practice and Research: Strategies for Improving Public Health. San Francisco, CA: John Wiley & Sons, Inc., 2002, pp. 313-346.

Works Consulted

-Bakalar, N (2010, April 19). Despite advice, many fail to breastfeed. New York Times. Retrieved from http://www.nytimes.com/2010/04/20/health/20stat.html
-Chatterji P and Brooks-Gunn J. WIC participation, breastfeeding practices, and well-child care among unmarried, low-income mothers. American Journal of Public Health 2004; 94(8): 1324-1327
-Fein SB, Labiner-Wolfe J, Shealy KR, Li R, Chen J, Grummer-Strawn LM. Infant feeding practices study II: Methods. Pediatrics 2008; 122: S28-S35
-Grummer-Strawn LM and Shealy KR. Progress in protecting, promoting, and supporting breastfeeding: 1984-2009. Breastfeeding Medicine 2009; 4: S31-S39
-Merewood A and 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
-Wolfe JH. Low breastfeeding rates and public health in the United States. American Journal of Public Health 2003; 93(12): 2000-2010

The Promotion of Breastfeeding and Impact on the Proportion Who Breastfeed: A Critique of the National Breastfeeding Campaign - Courtney Porter

Upon giving birth, mothers need to decide whether to breastfeed or to utilize formula in order to provide their baby with nutrition. Unless the mother suffers from one of the rare circumstances in which it would not be recommended, the optimal decision would be to breastfeed. According to research, benefits of breastfeeding can be seen within both the baby and mother (1-3). Breastfeeding is also economically beneficial as it costs less for families than paying for formula (1, 3).

The benefits of breastfeeding for a child are wide spread and seem to continue throughout development. Within the first several days after birth, the breast milk is considered colostrum, which has a different composition than mature breast milk (4). Colostrum contains a high concentration of vitamins, minerals, and antibodies, such as zinc, sodium, potassium, fat-soluble Vitamin A, and carotenoids. In addition the substance assists in the establishment of the bifidus flora within the digestive tract and may boost the development of the immune system.

In part due to colostrum, initial benefits of breastfeeding include lower rates of contracting and dying from otitis media, respiratory tract infections, bacteremia, diarrhea, botulism, urinary tract infections, necrotizing enterocolitis, and bacterial meningitis as compared to infants who are not breastfed (1, 3). Research supports more chronic benefits of breastfeeding as well, including reduced risk of obesity, insulin-dependent diabetes mellitus, ulcerative colitis, Crohn’s disease, hypertension, and allergic diseases (1-3). Children who have been breastfed also scored higher on motor and intellectual development assessments (1).

In addition to being beneficial for the child, breastfeeding can also benefit the mother. According to various research studies, “initiation of breastfeeding immediately after delivery stimulates the release of oxytocin, a hormone that helps to contract the uterus, expel the placenta, and reduce postpartum bleeding” (1). Women who breastfeed are able to lose the weight they gained during pregnancy quicker than those that do not (3). Breastfeeding decreases the risk of breast cancer before menopause and ovarian cancer (1, 3). It also delays the re-onset of ovulation which therefore increases the time between pregnancies.

Despite all of the short-term and long-term benefits of breastfeeding, all mothers who are able to breastfeed do not make the decision to do so. In 2003 as determined through the National Immunization Survey, the national rates of breastfeeding in the early postpartum period, at six months, and at 12 months were 72.6 percent, 39.1 percent, and 19.6 percent, respectively (5). The percent of mothers exclusively breastfeeding (without supplementing with formula, water, glucose water, etc.) at three and six months were 29.6 percent and 10.3 percent, respectively.

In order to increase the rates of breastfeeding, the United States Department of Health and Human Service’s Office of Women’s Health (OWH) in collaboration with the Advertising Council developed a National Breastfeeding Campaign (7). The goals for the campaign were based upon the Healthy People 2010 targets. The Healthy People 2010 Objective 16-19 goal was to “increase the proportion of mothers who breastfeed their babies: in early postpartum to 75 percent, at 6 months to 50 percent, at 12 months to 25 percent, exclusively through 3 months to 40 percent, and exclusively through 6 months to 17 percent” (6). The campaign focused on increasing the rate of breastfeeding in the early postpartum period to 75 percent and the rate at six months to 50 percent as well as emphasizing the importance of exclusively breastfeeding for at least six months (7). Though they wanted to increase breastfeeding within all mothers, the target population was first-time mothers who would not typically choose to breastfeed. The campaign was launched in June 2004 and ran until April of 2006 with a media campaign that included television ads, print ads, billboards, and radio spots

Critique of the National Breastfeeding Campaign

As discussed earlier, the benefits of breastfeeding make it the optimal choice for the infant and the mother. As the optimal choice, all women who are able to breastfeed should be doing so. Therefore, breastfeeding should be promoted and supported as the optimal choice in order to increase the proportion of able mothers who breastfeed. An effective public health intervention would achieve that goal and increase awareness about the benefits of breastfeeding. Though the National Breastfeeding Campaign was created with this goal in mind, it failed to do so. Three factors contributed to this failure, which were its basis on fear appeals and a negative approach, its failure to address other factors that cause women to not breastfeed, and its failure to market an appealing behavior besides health.

I. Based on Fear Appeals and Negative Approach

As part of the National Breastfeeding Campaign, two television advertisements were utilized to promote breastfeeding exclusively for six months. Within both commercials, women in their final trimester of pregnancy are engaging in behaviors dangerous to the health of the fetus. In one, two women are competing in a log rolling contest and working vigorously to remain on the log. “You wouldn’t take risks before your baby’s born” (7) comes across the screen and then “why start after” (7). Shortly after the text disappears, one of the women fall into the water as you hear the crowd gasp. The following announcement is then made: “recent studies show babies who are breastfed are less likely to develop ear infections, respiratory illnesses and diarrhea. babies were born to be breastfed” (7). In the other commercial, the same text and verbal announcements are made. Rather than seeing two pregnant women engaging in a log rolling contest, you experience a woman who appears to be in her final trimester of pregnancy riding a mechanical bull at a bar setting. The lady rides triumphantly for a short time before falling off to which the audience gasps and then cheers to her jumping up exuberantly.

Utilized in both commercials was a negative, fear-based appeal as the approach. The commercials leave one feeling as if not breastfeeding is as risky and harmful to an infant as a log rolling contest or riding a mechanical bull would be to a fetus. It paints such a negative picture of not breastfeeding that it incites fear and anxiety in the audience.

Recently, this method has become a popular approach used by social marketing campaigns. These commercials and others that utilize a similar approach use shocking visuals in hopes of gaining the attention of the targeted audience and stimulating them to alter their behavior in the desired way (8-11). Though focus groups have supported that they grab the attention of the audience, the commercial may leave the viewer feeling disturbed, fearful, and anxious.

For breastfeeding, generating anxiety within mothers is especially troubling as “breastfeeding is undermined by internalized stress” (12). Therefore if the fear appeal approach works as desired it may make it harder for women to breastfeed rather than to achieve its goal of increasing the proportion of women that breastfeed. In addition to feeling anxiety about breastfeeding, several studies have supported that maladaptive responses may be caused by fear appeals. According to the research, these responses are a coping method for the disagreeable feelings that arise as a result of seeing the negative, fear appeal. Some maladaptive responses are “avoiding or tuning out the message, blunting (failing to process the salient threat part of the message), suppression (failing to relate the threat to oneself), and counterargumentation (summoning arguments against the message’s veracity)” as determined by various studies (10). Rather than making the decision to breastfeed, the campaign may have caused women to become increasing afraid of harming their fetus or to not be able to realize that the risks associated with not breastfeeding was relevant to them.

II. Failure to Market Appealing and Desired Behavior

Also a part of the National Breastfeeding Campaign was several print ads used to promote exclusively breastfeeding for six months. An example ad shows two scoops of ice cream in a dish with cherries on top of each in order for them to resemble breasts. The text along the bottom of the advertisement reads “breastfeed for 6 months. You may help reduce your child’s risk for childhood obesity” (7). Each of the ads differed in the visual and the benefit stated, but followed the same general concept. Though different visuals and statistics are shown in each advertisement, the benefit of health is the sole promise marketed within each print ad.

As argued by the Marketing Theory, public health practitioners often try to market what they determine to be what the targeted audience should want and need (13). As with the case of the National Breastfeeding Campaign, improved health is often what the public health community determines to be important regardless of the little to no demand for it. In contrast to selling what the public health community believes is important; the Marketing Theory argues the need to take a different approach.

According to the theory, the steps of successfully marketing for a public health problem are the following: “(1) identifying the needs, wants, and core values of the target audience to define the product as beneficial to that audience; and (2) packaging and positioning the program or policy so that it reinforces the core values of the target audience” (13). The National Breastfeeding Campaign fails to base the two components of marketing campaign, its promise and the support for the promise, on these steps. Within its print ads, it solely markets health and utilizes data to market that promise which has been shown to be ineffective and unconvincing.

The campaign fails to provide the audience with a desirable behavior to change for. Framing should have been utilized in order to provide the audience with that desirable behavior. Without appropriate framing, the campaign failed to go beyond the health benefits to marketing for core values of Americans, such as freedom, autonomy, independence, family, and virility.

III. Failure to Address Other Factors

In addition to inappropriately utilizing a negative, fear appeal and failing to appeal to a desirable behavior, the National Breastfeeding Campaign failed to address other factors that influence whether a women breastfeeds or not. The campaign framed the issue to be a simple decision that mothers make or a simple weighing of the costs and benefits of breastfeeding. Research and data have shown that other factors contribute to the initiation and continuation of breastfeeding including socioeconomic status, race/ethnicity, age, and education level (5, 14).

According to the National Immunization Survey (NIS), in 2003 the rates of initiating breastfeeding, breastfeeding at six months, and breastfeeding at 12 months was lowest in non-Hispanic blacks as compared to other race/ethnicities (5). The rates of breastfeeding increased as the age of the mother increased as well as when the maternal education level increased. Similarly an increase can be seen corresponding to an increase in poverty income ratio with 63.4 percent of mothers at less than 100 percent poverty level ever breastfeeding as compared to 81.7 percent of mothers at more than or equal to 350 percent poverty level ever breastfeeding in 2003 (5).

In addition to sociodemographic characteristics influencing breastfeeding, the amount of family and community support plays a role in the decision to breastfeed. Family members and partners having a negative attitude about breastfeeding was considered a barrier to breastfeeding (15). Societies that were supportive of mothers and had generous maternity leave mandates had higher rates of breastfeeding, as supported by cohort studies (16). Other employment supports such as providing breaks for breastfeeding and making the work environment more friendly for women who breastfeed as well as allowing for more part-time work increased the proportion of women who breastfed.

Another societal factor that undermines breastfeeding attempts is the financial support given to hospitals and clinics by formula companies. Unless the hospital is denoted as a baby-friendly facility, formula companies provide hospitals with samples that are given to the mothers of newborns upon discharge and have advertisements throughout hospital facilities. In addition to the formula, the take-home gift bags given to parents are often sponsored by formula companies and include the products of the company (3, 12, 15).

“The campaign placed the burden of change on individual women rather than on the medical and cultural practices and societal structures that undermine their breast-feeding intentions and success,” argues Judy M. Hopkinson of Baylor College of Medicine (12). It is reasonable to assume that framing the issue in this way to put the entire burden on the mothers leads to more guilt in the mothers. Many times when a woman is unable to or does not breastfeed it is not simply a matter of knowing the benefits and weighing the pros and cons. As discussed, many other factors influence the behavior that were not addressed in the campaign. The campaign focused too much on the behavior of the individual rather than the societal and environmental structural factors.

Proposed Intervention for the National Breastfeeding Campaign

As the best nutritional option for an infant, breastfeeding should be performed whenever it is possible and feasible for the mother to do so. Though it is the optimal choice, the rates of breastfeeding in the early postpartum period, at six months, and at 12 months and the rate of exclusively breastfeeding for the first six months and 12 months of the infant’s life are lower than desired (as known by lower rates than the Healthy People 2010 targets).

The National Breastfeeding Campaign attempted to decrease the discrepancy between the national rates and the Healthy People 2010 targets, especially within the population of first time mothers who would not typically breastfeed. As with any public health intervention, the National Breastfeeding Campaign was not without flaws. As discussed earlier, three of the shortcomings are the following: its basis on fear appeals and a negative approach, its failure to address other factors that influence whether or not a mother breastfeeds, and its failure to market a desirable message besides health. Using an ecological approach that utilizes a positive message and incorporates principles of the Marketing Theory, the three shortcomings can be addressed.

I. Utilize a Positive Approach

As described previously, the two television commercials that were part of the campaign utilized shocking visuals in order grab the attention of the targeted audience. Though the commercials may have gained the attention of the audience, it also may have left them feeling fearful, anxious, and guilty. It may also have resulted in maladaptive responses being created in order to cope with the unpleasant feelings resulting from the shocking visuals. In some situations fear appeals may be an effective approach, but anxiety and stress undermine breastfeeding which undermines the campaign.

As opposed to the negative, fear appeals utilized in the National Breastfeeding Campaign, a positive approach and positive labeling should be used. The commercial and print ads should frame breastfeeding as positive and natural, as recommended by the Department of Health and Human Services (17). Within the Breastfeeding: HHS Blueprint on Action on Breastfeeding the Department of Health and Human Services recommends a “media campaign which presents images of breastfeeding as the normal way to feed infants in most places women and their infants go” (17).

The most effective way to utilize positive emotional appeal should be determined through focus groups of pregnant women and mothers. Possible positive emotions that can be used are compassion, joy, humor, and empathy (8). As supported by research, these emotions may be able to grab the attention of individuals who were overly familiar with similar campaigns and therefore no longer pay attention as well as to allow individuals who did not consider the issue relevant to them to reconsider this idea.

II. Incorporates Marketing Theory Principles

The print advertisements, which were described earlier, marketed the benefit of health as being an outcome of breastfeeding. According to the Marketing Theory, public health practitioners often attempt to market what they believe to be important for the society, such as health. As is often the case with solely marketing improved health as the benefit of a policy or program, the product that the public health community believes society should want has little or no demand within society.

Utilizing principles of the Marketing Theory, the proposed intervention would sell core values rather than just the benefit of improved health. By marketing core values, the deepest aspirations that people have would be sold. The core values would provide enough incentive for individuals, especially mothers, to change their current behavior. These core values include family, America, freedom, youth, virility, strength, an identify, fun, happiness, laughter, and joy. In order to support these core values being marketed, visual images will be utilized. This is vastly different from the statistics and data that supported the promise of health within the National Breastfeeding Campaign. The visual images should be supportive, positive, and show the audience that the promise being made is real. As discussed previously, the media campaign should utilize images that portray breastfeeding as a natural, desirable, and achievable behavior.

III. Address Other Factors, Such As Societal and Environmental Factors

The National Breastfeeding Campaign was an individual-level approach that did not address other factors that influence whether or not a mother breastfeeds. Based on statistics and research, socioeconomic status, race/ethnicity, age, education level, family support, and community support play a role in whether or not a mother initiates breastfeeding and continues to breastfeed. As the campaign did not address any of these many factors and focused the burden on the individual mother, feelings of guilt may have arisen in mothers who wanted to breastfeed and were not able to or mothers who did not want to breastfeed due to societal and/or environmental factors.

Utilizing a broad, population (group)-level approach such as an ecological approach, the proposed intervention would be able to address the societal and environmental factors that influence initiation and continuation of breastfeeding. An ecological approach takes a comprehensive perspective (18). While it continues to consider the relationship between mother and infant as well as family, the approach also considers the community, healthcare delivery system, societal and cultural influences (the mesosystem and exosystem of the family). To implement an ecological approach, many layers of interventions would need to occur simultaneously and throughout several sites. In addition to simultaneous implication, it is necessary to have frequent and open communication with all individuals involved in the implementation of the layers of intervention in order to seamlessly provide the services and supports of the program.

Included in the ecological approach would be the promotion of the Baby Friendly Hospital Initiative (BFHI) (19). Within the United States, the BFHI is organized through Baby-Friendly USA and is sponsored by the United Nations Children’s Fund (UNICEF) as well as the World Health Organization (WHO). This initiative aims to provide mothers with support, information, skills, and confidence in their ability to initiate and continue breastfeeding. In order to become certified as a Baby-Friendly Hospital, the facility must go through the “Ten Steps to Successful Breastfeeding” (19). These steps include educating pregnant women about the benefits of breastfeeding, allowing babies to remain in the same room as mothers, and assisting the initiation of breastfeeding within one hour of birth. Hospitals must also discontinue receiving free samples and other financial assistance from formula companies.

Another aspect of an ecological model would be to encourage (or even require) employers to create an environment that is friendlier to employees engaging in breastfeeding. Some policies to create such an environment would include providing breaks for breastfeeding and allowing for more part-time work. Employers would support and promote breastfeeding among their employees.

Conclusion

With the many short-term and long-term benefits for the infant and the mother, breastfeeding is the best choice of nutrition for infants. In order to promote breastfeeding among mothers, especially first-time mothers who would otherwise not engage in the behavior, the United States Department of Health and Human Service’s Office of Women’s Health (OWH) in collaboration with the Advertising Council developed a National Breastfeeding Campaign. The campaign ran two television commercials, circulated print advertisements, put up billboards, and held radio spots for two years, but suffered from shortcomings. Three of those shortcomings were the following: its basis on fear appeals and negative approach, its failure to market an appealing and desirable behavior, and its failure to address other factors that influence whether or not a mother breastfeeds. Utilizing an ecological approach that incorporates a positive message and principles of the Marketing Theory, the three shortcomings can be addressed and overcome.

REFERENCES

1. Leon-Cava N, Lutter C, Ross J, Martin L. Quantifying the Benefits of Breastfeeding: A Summary of the Evidence. Washington, D.C.: Pan American Health Organization (PAHO), 2002.

2. Grummer-Strawn L, Mei Z. Does Breastfeeding Protect Against Pediatric Overweight? Analysis of Longitudinal Data From the Centers for Disease Control and Prevention Pediatric Nutrition Surveillance System. Pediatrics 2004;113:81-86.

3. American Academy of Pediatrics. Breastfeeding and the Use of Human Milk. Pediatrics 2005; 115:496-506.

4. Huffman SL, Zehner ER, Victora C. Can Improvements in Breast-Feeding Practices Reduce Neonatal Mortality in Developing Countries? Midwifery 2001: 17:80-92.

5. Centers for Disease Control and Prevention. Breastfeeding: Data and Statistics|DNPAO|CDC. Atlanta, GA: Center for Disease Control and Prevention. http://www.cdc.gov/breastfeeding/data/index.htm

6. Centers for Disease Control and Prevention. Breastfeeding Report Card—United States, 2009. Atlanta, GA: National Center for Chronic Disease Prevention and Health Promotion, 2009.

7. Department of Health and Human Services. National Breastfeeding Campaign. Washington, DC: Department of Health and Human Services. http://www.womenshealth.gov/breastfeeding/programs/nbc/.

8. Lewis IM, Watson B, White KM, Tay R. Promoting Public Health Messages: Should We Move Beyond Fear-Evoking Appeals in Road Safety? Qualitative Health Research 2007; 17:61-74

9. Guttman N, Salmon CT. Guilt, Fear, Stigma and Knowledge Gaps: Ethical Issues in Public Health Communication Interventions. Bioethics 2004; 18:531-552.

10. Hastings G, Stead M, Webb J. Fear Appeals in Social Marketing: Strategic and Ethical Reasons for Concern. Psychology & Marketing 2004; 21:961-986.

11. Wolf JB. Is Breast Really Best? Risk and Total Motherhood in the National Breastfeeding Awareness Campaign. Journal of Health Politics, Policy and Law 2007;32:595-636.

12. Hopkinson JM. Response to “Is Breast Really Best? Risk and Total Motherhood in the National Breast-Feeding Awareness Campaign. Journal of Health Politics, Policy and Law 2007;32:637-648.

13. Siegel M, Lotenberg LD. Marketing Public Health—An Opportunity for the Public Health Practitioner In: Siegel M, Lotenberg LD, eds. Marketing Public Health: Strategies to Promote Social Change. Sudbury, MA: Jones & Bartlett, 2007.

14. Celi A, Rich-Edwards J, Rishardson M, Kleinman K, Gillman M. Immigration, Race/Ethnicity, and Social Factors as Predictors of Breastfeeding Initiation. Archives of Pediatric & Adolescent Medicine 2005;159:255-260.

15. Arora S, McJunkin C, Wehrer J, Kuhn P. Major Factors Influencing Breastfeeding Rates: Mother’s Perception of Father’s Attitude and Milk Supply. Pediatrics 2000;106.

16. Scott J, Binns C, Oddy W, Graham K. Predictors of Breastfeeding Duration: Evidence From a Cohort Study. Pediatrics 2006;117:646-655.

17. Department of Health and Human Services. Breastfeeding: HHS Blueprint on Action on Breastfeeding. Washington, DC: Department of Health and Human Services, 2000.

18. Tiedje L, Schiffman R, Omar M, Wright J, Buzzitta C, McCann A, Metzger S. An Ecological Approach to Breastfeeding. The American Journal of Maternal/Child Nursing 2002;27:154-161.

19. Baby Friendly USA. Baby Friendly Hospital Initiative in the US. Sandwich, MA: Baby Friendly USA. http://www.babyfriendlyusa.org/eng/01.html.

The Coalition for Healthy Children’s Reliance on Individual Behavior Change and Social Marketing to Combat Childhood Obesity - Virginia Lijewski

The Coalition for Healthy Children is an Ad Council initiative whose goal is to “help address the obesity crisis that confronts our nation and its children” with a mission to “provide clear, consistent, research-based messages to children and parents on the importance of practicing a healthier lifestyle and offer them the means to do it” (1). They feel fighting the childhood obesity epidemic can be achieved by communicating directly to children, and their parents, about the importance of physical activity and healthy eating. They have crafted five main messages to promote healthy lifestyles: 1) physical activity; 2) food choice; 3) food portions; 4) balance between food and activity; and 5) role modeling.

The five basic messages are broken down into messages tailored to kids and to parents. Messages to kids are 1) Physical activity: Be a player. Get up and play and hour a day; 2) Balance: Eat well. Play hard. Make it balance; 3) Food choices: Are you eating a home run or a strikeout?; 4) Food portions: The amount counts. Keep portions under control. Messages to parents are 1) Encourage your kid to be a player. Get up and play an hour a day; 2) food choice: Tell your kids to eat well, play hard, and make it balance; 3) Food choices: is your kid eating a home run or a strikeout? 4) food portions: The amount counts. Keep portions under control; and 5) Set the example: When it comes to activity and eating right kids take their lead from you.

Organizations and companies have the options to become members of the Coalition for Healthy Children and help in the promotion of the campaign’s health messages. By becoming a member of the Coalition, these groups have made a commitment to incorporate the “strategic messages” into their marketing materials including advertisements, packaging, websites, and in-store promotions (1).

The Ad Council’s Coalition for Healthy Children is using social marketing strategies to deliver their health messages to children and adults. Social marketing has been defined as “the design, implementation, and control of programs seeking to increase the acceptability of a social idea or practice in a target group” (2) Social marketing tactics persuade an individual to change their behavior in order to improve their own health and often work to alter an individual’s perceptions and attitudes about their health (3).

Traditional social marketing campaigns, like that of the Coalition for Healthy Children, develop a short-lived mass advertising campaigns to encourage individuals to exercise more and eat more fruits and vegetables. The Coalition for Healthy Children focuses on the individual as being in complete control of his or her health and ignores the social, environmental, and economic causes of childhood obesity. The campaign recognizes the important role parents play in the health of their children but it fails to provide parents with the tools they need to make a positive change in their child’s health. Obesity disproportionately effects minority populations who have limited access to healthy foods and places to engage in physical activity. The campaign fails to acknowledge the racial and ethnic health disparities that exist and does not target a particular population nor does it try to reduce disparities in health and access to health promoting activities.

Critique 1: Providing parents with the tools needed to promote healthy behaviors in their children

Parents play a vital role in the health of their children and are critical to the success of any intervention to combat childhood obesity. The Coalition understands the important role parents play in the health of their child and through their targeted messages advise them to be a role model for healthy behavior, to play with their children and hour a day, encourage their kids to eat smaller portions and healthy foods, and convince them that being healthier now will pay off in the end. The Coalition however, does not provide parents with the tools they need to make a positive change in their child’s health.

Research has been done to determine the barriers parents face in helping their child eat healthy and be more physically active. The main barriers that have been identified are family schedules, lack of money/transportation, safety, and availability and desirability of healthy foods. Hectic family and work schedules and the convenience and accessibility to unhealthy foods lead parents to make unhealthy food choices for their families. There is a lack of desirability among children for healthy foods, which also makes it hard for parents to encourage healthy eating in their children (4).

A study by Tyler and Horner (5) analyzed an intervention aimed at collaboration between parents, children, and medical providers. Through discussions with parents and children, the medical providers created individualized health plans for each family. The most frequent barriers parents reported were a lack time and safe recreational facilities for their children to play. Most parents understood that their children needed to become more physically active and eat healthier foods but did not know how to implement a healthier lifestyle into their family’s routine. The intervention’s focus was on helping parents make positive changes in their children’s health by providing them with ideas and strategies to improve their families’ health.

Interventions designed to increase physical activity may be more effective if they are designed to accommodate the multiple competing demands of a family and provide affordable and diverse activities that families can do together (6). Parental involvement in obesity prevention programs has been proven to be effective in reducing the rates of childhood obesity (7) but telling parents what to do through health messages isn’t enough. Parents already know the importance of physical activity and healthy food choices but need to be provided with the tools required to accommodate lifestyle change. Effective interventions should provide parents with the ability to work around the barriers they face by encouraging families to work together to improve their health and come up with create ways to be active together.

Critique 2: Failure to consider social determinants of health

The Coalition for Healthy Children’s campaign fails to acknowledge the lack of resources available to certain subsets of the population. They encourage individual behavior change without recognizing that minorities groups, and people in disadvantaged populations, disproportionately lack access to the resources they need to create personal change.

The highest rates of obesity occur in the most disadvantaged populations, including minority groups, and populations with the highest poverty rates and least education (8). Socioeconomic status has been viewed as one possible explanation for the disproportionate rates of obesity among these populations (9). Studies evaluating the effects of socioeconomic status and health have found that poor health is directly correlated to low socioeconomic status. Improvement in health of disadvantaged people includes providing material conditions for good health and a control of life circumstances or empowerment. In the United States material conditions for good health include things like the availability of healthy foods and opportunities for exercise. Empowerment is both an individual and community level phenomenon and at the community level involves securing resources for health (10).

Some research suggests that racial and ethnic disparities in obesity rates can be explained by a lack of access to activity- friendly environments. Rates of physical activity among youth are higher in communities where there are sidewalks, parks, and indoor recreation facilities (11). Access to supermarkets is associated with improved dietary quality, higher intake of fruits and vegetables, and lower rates of obesity. There is a disparity in access to these resources among predominantly white neighborhoods and those of minority populations. High income and white communities tend to have more access to sources of healthy foods and places to engage in physical activity. Low-income communities, and communities with a high percentage of racial and ethnic minorities, tend to have less access to supermarkets and a higher availability of corner convenience stores and inexpensive high-calorie foods (12). The Coalition for Healthy Children fails to recognize that people may have a hard time making a positive health change because they lack access to the resources they need to improve their health. The Coalition is not addressing the larger social issues that may be part of the cause of childhood obesity rates. Instead, the Coalition is sending health messages to children and parents encouraging them to make a change without addressing the specific needs or the barriers to health.

Critique 3: Individual approach

The Coalition’s strategy for achieving its goals is through sending messages to children and parents about health behaviors and physical activity. By creating targeted messages the Coalition is fostering the notion that eating healthy and being more physically active is all within an individual’s control. The Coalition is ignoring the social, economic, and environmental factors that also contribute to obesity and lack of physical activity in children.

Historically, obesity as been blamed on the individual and it is still the case today that a failure of personal responsibility is thought to be the its cause (13). The concept of personal responsibility, especially for one’s health, is highly ingrained in American society and can even be seen in the political structure of the United States (14). While taking personal responsibility for one’s health can lead to positive changes in behavior and heath, emphasizing this as the only way to achieve optimal health can foster victim blaming. Victim blaming occurs when someone is blamed for his or her ill health and negative characteristics are ascribed to the person because they did not make the positive health behavior changes expected by society (14). Societal focus on the individual diverts attention from the social influences that affect health.

Individual level approaches to health behavior change have been criticized in recent years and the field of public health has begun to shift its focus from the individual to the group level. Group level approaches to behavior change emphasize that an individual’s behavior is the result of one’s intentions and abilities to act on those intentions. Factors acting on the individual level like self-efficacy, confidence, and personal beliefs, determine an individual’s intention. Factors acting in the wider environment like access to healthy food and socioeconomic status, determine whether a person acts on their intentions (15). Focusing on group level interventions requires creating environments that will foster behavior change.

People seek good health and the ability to pursue it; however, traditional individual level approaches to behavior change do not capture the importance of both needs. Rugar (16), in an attempt to shift the focus from the individual to the group, defined the concept of health capability. Health capability incorporates the conditions that affect one’s health as well as the person’s ability to make healthy choices; it is the ability to be healthy. Individual health capability is dependent on how someone’s external environment enhances or detracts from his or her health.

Intervention

The Coalition for Healthy Children uses a social marketing approach in an attempt to communicate health messages to parents and children about the importance of eating healthy and exercising. Their goal is to reduce obesity on the individual level; however, by doing so they neglect the environmental causes of childhood obesity. Current social science research has shown “diet and physical activity interventions that build knowledge, motivation, and behavior change skills in individuals without changing the environments in which they live are unlikely to be effective” (17). An individual can make the choice to be more physically active and eat healthier foods but they cannot act on these decisions if their wider environment is preventing them from living a healthy lifestyle. An intervention designed to address an individual’s barriers to health behaviors would be a more effective approach to reducing the rates of childhood obesity. In designing an intervention it is important to understand the population being targeted and the specific needs of the communities within that population to enable the individual to make personal changes in his or her health. I propose an intervention that corrects the shortcomings of the Coalition for Healthy Children’s campaign to combat childhood obesity by using the combined concepts of social marketing, community organization, and policy change. By incorporating these approaches, the intervention can address the environmental and societal barriers that children and their parents face, sustain a level of personal accomplishment, and address the disparities in health that are the underlying cause of childhood obesity.

Socioeconomic status is a strongly correlated with health and interventions created to focus on changing disparities in health, especially those that disproportionately effect minorities and low-income populations, will have the greatest population benefit. Achieving social and economic change would require major societal change and interventions aimed at addressing social determinants of health need the support of the government and society. A successful intervention should include government and policy makers and should work to promote change in the social system in the United States.

The Health Impact Pyramid is one example of how public health is trying to shift its attention to the population and not the individual to make positive health changes. At the base of the pyramid are efforts to address socioeconomic factors (i.e. poverty and education levels), followed by public health interventions that change the context for health to make individuals’ default decisions healthy (i.e. clean water, safe roads), then long-lasting protective interventions (i.e. immunizations), clinical interventions, and at the top counseling interventions. Public health interventions at the base of the model require the least individual effort and have the greatest population impact. The focus of public health interventions should be at the first and second levels of the pyramid (18).

Parents play a vital role in the success of childhood obesity prevention interventions but they cannot help their child if they are not provided with the information necessary to assist them in making healthy decisions for their family. A good example of a current campaign that involves parents and provides them with the appropriate tools to make a positive change is the “Let’s Move” campaign (19) created by First Lady Michelle Obama. The campaign’s website provides links to services and resources parents can use to make a positive change in their child’s health (20). Part of the campaign’s website focuses on access to affordable healthy food which provides links to the National Policy and Legal Analysis Network to Prevent Childhood Obesity (21) where parents can learn how to increase the access to fresh fruits and vegetables in their particular neighborhood, the Farmer’s Market Coalition (22) where parents can learn how to start a farmer’s market in their community, and the Food Trust (23) where parents can learn what community and school-based access plans there are in their community. The intervention combines individual approaches with group level approaches by providing individuals with the tools they need improve not only their health, but also the health of their family their community. The “Let’s Move” campaign also focuses on making broader social changes through the use of policy changes and government initiatives. The campaign highlights the Healthy Food Financing Initiative, which as part of the president’s 2011 budget, will put $400 million dollars a year towards increasing access to healthy foods in underserved areas (20) By combining the efforts of individuals, communities, and the government, “Let’s Move” has the potential to reduce health disparities related to access to healthy food as well as reduce the rates of childhood obesity.

Several ecological models combining public health, health psychology, consumer psychology, and urban planning, have identified four types of food environments (community, consumer, organizational, and information) that should be understood when trying to reduce obesity in minority populations (17). Community food environments refer to places where food can be obtained (grocery stores, restaurants, etc). Consumer environments refer to what people are exposed to; more specifically the availability, prices, and promotions of certain foods. Information environments include places in the built environment (school and work) that directly and indirectly encourage unhealthy eating habits and sedentary lifestyles and do not encourage healthy eating behavior (24). Schools are one type of information environment that can easily be changed to promote positive health behaviors. Schools are a major setting in a child’s life and should become active in developing obesity prevention programs. Communities, schools, and governmental agencies should work together to design and implement obesity prevention programs (25).

By changing the environments in which children interact through a combination of efforts, positive health behaviors, like increased physical activity and healthy eating habits, can be formed. Interventions aimed at addressing the barriers individual’s face in access to healthy food and the health disparities that exist in the United States would be more effective in combating childhood obesity. A successful intervention should combine the concepts of social marketing, policy change, and community change that will allow the individual (both parents and children) to make the necessary steps to improve their health.

References

1. The Advertising Council Inc. (2008). Coalition for Healthy Children. http://www.healthychildrencoalition.org/

2. Goldberg, Marvin E. (1995). Social Marketing: Are we Fiddling while Rome Burns? Journal of Consumer Psychology 4(4), 347-370

3. Yancey, AK, Cole, BL., Brown, R, Williams, JD. Hillier, A, Randolph, KS, Ashe, M, Grier, SA, Backman, D, and McCarthy, WJ. (2009). A Cross-sectional Prevalence Study of Ethnically Targeted and General Audience Outdoor Obesity-Related Advertising. The Milbank Quarterly 87(1), 155-184.

4. Power, TG, Bindler, RC., Goetz, S, and Daratha, KB. (2010). Obesity Prevention in Early Adolescence: Student, Parent, and Teacher Views. Journal of School Health 8(1), 13-19.

5. Tyler, Diane and Horner, Sharon. (2008). Collaborating with Low-Income Families and Their Overweight Children to Improve Weight-Related Behaviors: An Intervention Process Evaluation. Journal for Specialists in Pediatric Nursing 13(4), 263-274.

6. Thompson, J.L., Jago, R., Brockman, R., Cartwright, K., Page, A.S., Fox, K.R. Physically Active Families- de-bunking the myth? A Qualitative Study of Family Participation in Physical Activity. Child: Care, Health, and Development 36(2), 265-274.

7. Kitzmann, KM, Dalton, WT, Stanley, CM, Beech, CM, Reeves, TP, Buscemi, J, Egli, CJ, Gamble, HL, Midgett, EL. (2010). Lifestyle Interventions for Youth Who are Overweight: A Meta-Analytic Review. Health Psychology 29(1), 91-101.

8. Flegal, Katherine M., Margaret D. Carroll, Cynthia L. Ogden and Clifford L. Johnson. 2002. "Prevalence and Trends in Obesity Among US Adults, 1999-2000." Journal of the American Medical Association 288(14): 1723-1727.

9. LaVeist, Thomas, A. (2005). Minority Populations and Health: An Introduction to Health Disparities in the United States. Preventing Chronic Disease: Public Health Research, Practice, and Policy 2(4).

10. Marmot, Michael. (2006). Health in an Unequal World. The Lancet 368.

11. Whitt-Glover, Melicia C, Taylor, Wendell C, Floyd, Myrone F, Yore, Michelle M, Yancey, Antronette K, and Matthews, Charles E. (2009). Disparities in Physical Activity and Sedentary Behaviors Among US Children and Adolescents: Prevalence, Correlations, and Intervention Implications. Journal of Public Health Policy 30, 309-334.

12. Odoms-Young, AM, Zenk, Shannon and Mason, M. (2009). Measuring Food Availability and Access in African-American Communities. Implications for Intervention and Policy. American Journal of Preventative Medicine 36, 145-149.

13. Schwartz, Marlene and Brownwell, Kelly D. (2007). Actions Necessary to Prevent Childhood Obesity: Creating the Climate for Change. Journal of Law, Medicine, and Ethics 35(1).

14. Brownwell, Kelly D. (1991). Personal Responsibly and Control Over Our Bodies: When Expectation Exceeds Reality. Health Psychology 105(5), 303-310.

15. Maziak, Wasim and Ward, Kenneth. (2009). From Health as a Rational Choice to Health as an Affordable Choice. American Journal of Public Health 99(12), 2134-2139.

16. Ruger, Jennifer Prah. (2010). Health Capability: Conceptualization and Operationalization. American Journal of Public Health 100(1), 41-49.

17.Sallis, James F. and Glanz, Karen. Physical Activity and Food Environments: Solutions to the Obesity Epidemic. The Milbank Quarterly 87(1), 123-154.

18. Frieden, Thomas R. (2010). A Framework for Public Health Action: The Health Impact Pyramid. The American Journal of Public Health 100(4), 590-595.

19. U.S. Department of Health and Human Services. “Let’s Move” (January 2009). http://www.letsmove.gov/

20. U.S. Department of Health and Human Services. (2009).“Access to Affordable Healthy Food.” http://www.letsmove.gov/accessing/index.html

21. National Policy and Legal Analysis Network to Prevent Childhood Obesity. (2010). http://www.nplanonline.org/nplan/products/8-steps-more-fruits-vegetables

22. Farmer’s Market Coalition. (2008). http://www.farmersmarketcoalition.org/resources/

23. USDA Supplemental Assistance Nutrition Program. The Food Trust (2004). http://www.thefoodtrust.org/php/about/OurMission.php

24. Wechsler, H., Devereaux, RS, Davis, M, and Collins, J. (2000). Using the School Environment to Promote Physical Activity and Healthy Eating. Preventative Medicine 31, 122-134.

25. Li, Ji and Hooker, Neal. (2010). Childhood Obesity and Schools: Evidence from the National Survey of Children’s Health. Journal of School Health 8(2), 96-103.