A Critique of the National Breastfeeding Awareness Campaign: Three Ways in Which the Campaign was Flawed- Rachel Bernier

Introduction

Breastfeeding is increasingly regarded to benefit the baby, mother and society. Breastfeeding benefits are so apparent that Healthy People 2o1o prioritized increasing breastfeeding rates as one of their goals (1). Additionally, the American Academy of Pediatrics highlighted the benefits of breastfeeding in its policy statement, “Breastfeeding and the use of human milk”(2). Studies show that infants who are breastfed have fewer occurrences of infectious disease, obesity, asthma, and several other health related outcomes (2). Breastfeeding also benefits the mother. Mothers who breastfeed are more likely to have a longer duration of time between the births of their children. They tend to have decreased bleeding after giving birth and a decreased risk of breast and ovarian cancers (2). Breastfeeding mothers benefit society because they are not producing waste from formula containers and infants who are breastfed are sick less often, resulting in lower health care costs (2). Furthermore, when an infant is sick less often, parents miss fewer days of work since they do not have to stay home to take care of a sick baby (2). Ultimately, Wolf (2007) states, “Human milk is the ‘gold standard’ when it comes to feeding babies” (3).

The Office of Women’s Health, a branch of the U.S. Department of Health and Human Services, launched the National Breastfeeding Awareness Campaign (NBAC) in June 2004 (4) . The campaign’s goal was to target first time mothers and African American mothers and convince them to breastfeed their infant (4-5). The campaign, and more specifically the media outreach campaign, consisted of several public service announcements in the form of television advertisements, radio advertisements, and print advertisements. The advertisements can be seen on the U.S. Office of Women’s Health website http://www.womenshealth.gov/breastfeeding/government-in-action/national-breastfeeding-campaign/#materials. The print advertisements displayed images of dandelions, ice cream or otoscopes and stated that babies should be breastfed exclusively for six months to reduce their risk of respiratory illness, obesity, and ear infections (4). The television ads showed either a pregnant woman log rolling or a pregnant woman riding a mechanical bull. The text on both television ads said “you wouldn’t take risks before your baby’s born, why start after” (4). The radio advertisements had two styles: a soul music song and a country music song (4). In each song, a man sang about the benefits of breastfeeding (4).

The NBAC intended to increase breastfeeding based on evidence suggesting healthier outcomes in breastfed babies, but the campaign had several flaws. First, the NBAC failed to address the barriers to breastfeeding that keep some mothers from breastfeeding their newborn baby. Second, the campaign did not address the fact that breastfeeding is not a social norm in this society, and is rarely portrayed in the media. Lastly, the National Breastfeeding Awareness Campaign did not deflect psychological reactance in their audience. The people used to deliver this message were not similar to the target audience.

Campaign did not address barriers to breastfeeding

The National Breastfeeding Awareness Campaign provided information regarding the many benefits of breastfeeding throughout their advertisements, but they failed to address the barriers to breastfeeding. Women may encounter several barriers, making breastfeeding difficult or inconvenient and this may cause these women not to breastfeed. A workplace that is not accommodating to breastfeeding mothers is an example of an environmental barrier that might discourage a woman from breastfeeding (5). A mother’s social group (family and friends) can be another barrier to breastfeeding if they are unsupportive of her decision to breastfeed (5). Since some women have difficulty breastfeeding, being surrounded by unsupportive people may discourage her from breastfeeding. Wolf (2007) states that the NBAC was not intended to be “supporting, or otherwise being sensitive to the concerns of women but rather an attempt to manufacture and exploit fear among pregnant women and new mothers” (3). The campaign provoked fear in women instead of addressing the barriers women may be facing.

Based on Bandura’s Social Learning Theory, public health campaigns must take into account the environment of the targeted individuals. The Social Learning Theory acknowledges that the environment plays a role in an individual’s decision to change a behavior or not (6). Moreover, the Social Learning Theory suggests that self-efficacy is a necessary component for a successful behavior change (6). An individual will not attempt a new behavior if they do not believe that they are capable of performing it (6). According to Grusec, people can gain self-efficacy “from observation of what others are able to accomplish” (6). However, women exposed to the NBAC were unable to achieve self-efficacy concerning breastfeeding in the workplace since the NBAC did not portray this in the ads. The NBAC failed to address the environment in the campaign and therefore mothers were unable to achieve self-efficacy.

Bronfenbrenner’s Ecological Perspective Theory also supports that it is critical to address the environment when trying to change a behavior (7 -8). This theory suggests that living conditions, neighborhoods and communities, institutions and social policies all play a role in one’s decision to change a behavior (7-8). The NBAC did not specifically influence multiple factors affecting a mother’s ability to breastfeed, specifically the workplace or social environment. A campaign that fails to address factors like the one’s included in the Ecological Perspective Theory will be unsuccessful in changing a behavior. The Ecological Perspective Theory shows that the NBAC campaign only focused on changing an individual’s “intrapersonal level factors” (8). The theory describes some of the intrapersonal factors as knowledge, attitude and beliefs (8). However, a crucial aspect of the theory is that a behavior is influenced by multiple levels of influence including not only intrapersonal level, but also interpersonal level and community level factors (8). The NBAC only addressed intrapersonal level factors (ie. Education) and therefore was unsuccessful.

Campaign did not address that breastfeeding is not a social norm

The National Breastfeeding Awareness Campaign was a media campaign, but it did not portray breastfeeding as a social norm or acknowledge that breastfeeding is not seen in the media in this society. The NBAC did not use any advertisements showing women breastfeeding, typical for today’s media. Television rarely depicts breastfeeding; babies are most often with a bottle. Many women feel uncomfortable breastfeeding in public because breastfeeding is not a social norm. Breastfeeding an infant can become quite challenging if a woman is uncomfortable to breastfeed in public. Since the NBAC did not acknowledge that breastfeeding is not a social norm in this society, the campaign was not as successful as it could have been.

According to the Social Learning Theory, people do what they see other people doing, often referred to as modeling (6). However, the NBAC advertisements did not actually depict women breastfeeding. Instead, the ads displayed women participating in log rolling, women riding a mechanical bull, and images of dandelions, ice cream and medical equipment (otoscopes). This campaign did not demonstrate the act that NBAC was established to encourage. This campaign suffered from this particular failure because people are likely to act in ways that they see other people acting. Since women are exposed to more images of babies being fed bottles than they are of babies breastfeeding, its sensible that breastfeeding is not more common. According to modeling, women who viewed the NBAC ads were more likely to ride mechanical bulls and participate in log rolling than they were to breastfeed (6).

Schultz et al (2007) suggest that social norms are an incredibly strong indicator of behavior (9). Many successful public health campaigns have recognized this and adopted a campaign method called social-norms marketing (9). Social-norms marketing campaigns work to impact the true social norms of a behavior instead of merely educating people on the benefits of the behavior (9). According to Schultz et al, people overestimate how common undesired behaviors are and they compare their own behaviors to those of their peers (9). Therefore, campaigns led by the social-norms marketing approach show people that a behavior is more common than they may have thought. This information causes people to be more likely to adopt the suggested behavior (9). However, the NBAC did not affirm breastfeeding as a social norm or convince people that it is more prevalent then they may think. Ultimately, the targeted women were unlikely to embrace the behavior of breastfeeding since they were not reassured that it was socially acceptable.

The Theory of Planned Behavior recognizes that people consider how they will be perceived by others before behaving in a particular manner (8). Not everyone supports breatfeeding, which is evident since it is not portrayed in the media and not always welcomed in public settings. Many women are influenced by the opinions that individuals in their lives hold concerning breastfeeding. According to the Theory of Planned Behavior, if these women do not feel that breastfeeding will be perceived positively by others, they will not breastfeed (8). The National Breastfeeding Awareness Campaign had insufficient results because their ads did not address this.

Campaign did not deflect reactance by having the message delivered by someone similar to the target audience

The National Breastfeeding Awareness Campaign’s goal was to increase the breastfeeding rates in first time mothers and in African American mothers (5). However, the advertisements did not suggest that these particular groups of women were the target of the intervention. When the recipient of a behavior change message believes that the message is threatening their freedom they display reactance and do the opposite of the message or merely ignore it (11). One way to avoid Psychological Reactance is by having the message delivered by someone with similarities to the recipient of the message (10-11). The NBAC’s advertisements were not delivered by a messenger similar to the target audience. The print ads were not even depictions of people, they were objects. The radio ads were delivered by singing men and the television ads were delivered by pregnant women partaking in strange activities. The NBAC did not display any breastfeeding mothers. Based on the Psychological Reactance Theory this may have caused reactance in the women viewing the ads and caused them to not breastfeed.

The Social Learn Theory also suggests that the role of the messenger is crucial (6). The theory acknowledges that the source of a message must be in some way attractive to the audience of the message (6). If the deliverer of the message is not attractive to the audience then they must possess a form of power that compels the recipient of the message to be interested (6). The audience will lack attention if a message is delivered without a powerful or attractive messenger. It can be argued that individuals are attracted in some way to people that have similar characteristic as themselves (12). Since the NBAC failed to use a source of the message that had similarities to the recipient of the message, the recipients were not receptive.

Additionally, individuals are more likely to try a behavior that they can picture themselves doing (13). This is referred to as self-referencing (13). Since the NBAC’s advertisements did not display breastfeeding women with similarities to the target audience, the target women were unable to self-reference. Because these women were unable to imagine themselves breastfeeding when viewing the ads, they were unlikely to breastfeed as a result of the ads (13). The campaign failed to include characters in the ads that the viewers could relate to, this was extremely apparent in the radio ads, which were sung by men.

The article “Is Breast Really Best? Risk and Total Motherhood in the National Breastfeeding Awareness Campaign,” suggests that the NBAC’s attempt to target African American women was unsuccessful (3). The campaign tried to target these women by using an African American woman in one of the television ads and by the genre of music in the radio ads (3). While the NBAC’s intention may have been the opposite, Wolf’s suggestions raise questions about stereotyping. Ultimately, the campaign would have been more successful if it had put in a much greater effort to learn about the culture of their target populations (11). If the NBAC researched the cultures of their target audience it would have been able to use people to deliver the message that were similar to the target audience, this would have deflected reactance (11).

Proposed Intervention

The National Breastfeeding Awareness Campaign had several flaws that reduced its success, but the motivation for the campaign was very important. The U.S. Office of Women’s Health was aware that increasing breastfeeding rates would benefit babies, mothers and society. According to Merewood and Heinig (2004), one goal of Healthy People 2010 was for 75% of mothers to initiate breastfeeding and for 50% of mothers to breastfeed their baby for six months (5). However, the NBAC was not able to increase the breastfeeding rates to the desired values. A more thorough intervention will need to be designed in order for breastfeeding rates to increase in the targeted population, striving for the Healthy People goal.

In order to reach women who were uninfluenced by the NBAC, a new intervention will be designed to promote breastfeeding in first time mothers and African American mothers. The new intervention will be multi faceted with the goal to provide mothers with the necessary support, education and convenience that is needed to breastfeed. One aspect of this intervention will be implemented during prenatal care and early pediatric doctor’s appointments. This will offer women a way to obtain knowledge concerning the importance of breastfeeding and the technical support to breastfeed successfully. The mother’s primary support group (family and friends) will also be educated at these doctors’ visits so that they can offer the breastfeeding women as much support and encouragement as possible. Additionally, mothers will be provided with a peer-support group of other breastfeeding women. The new campaign will also include workplace policy changes to make breastfeeding more convenient for working mothers. Furthermore, the new campaign will use advertisements depicting breastfeeding women. Each aspect of the new campaign will help the campaign be more successful than the NBAC.

Addressing Environmental Barriers to Breastfeeding

The National Breastfeeding Awareness Campaign was flawed in that it failed to address the barriers to breastfeeding, but this will be fixed in the new intervention. The new intervention will provide benefits to workplaces that accommodate breastfeeding mothers. Based on the Social Learning Theory, if there are environmental barriers to a behavior, individuals will not do this behavior (6). This suggests that barriers to breastfeeding in the workplace must be eliminated in order for working mothers to breastfeed. By offering benefits to employers that make the workplace conducive to breastfeeding, working mothers will realize that they are able to breastfeed and work. This realization or feeling of self-efficacy is highlighted by the Social Learning Theory as a necessary component for an intervention (6).

Similarly, family and friends can act as barriers to breastfeeding for some women. The NBAC did not educate the family and friends of a breastfeeding mother about the importance of being supportive. As described by the Ecological Perspective Theory, behavior is influenced by family, friends and peers (8). If a mother’s primary support group is not in favor of breastfeeding, why would the mother breastfeed? The new intervention will provide the mother’s support group with an educational experience to help them support the breastfeeding mother. This will occur during the doctor’s visits. Once these people learn about their role in the breastfeeding process, they will be able to support the mother and breastfeeding will be more successful. Ultimately, the new intervention will aim to eliminate barriers to breastfeeding in both the workplace and in a mother’s social environment.

Campaign will aim to make breastfeeding a social norm

The new intervention will strive to make breastfeeding a social norm in this society since the NBAC did not do so. According to the Social Learning Theory, people model the behavior that they see others doing (6). The NBAC did not model breastfeeding in any of the advertisements, which made women unlikely to breastfeed. The new campaign will accomplish modeling by including television advertisements that display mothers breastfeeding in various locations, for example in a restaurant, at home, on a bus, etc. By displaying mothers’ breastfeeding in the ads, mothers will see that it is socially acceptable to breastfeed, even in public. Also, the media will be urged to show breastfeeding as opposed to bottle feeding in movies, television shows and in commercials. The campaign will offer increased air time to media companies that incorporate breastfeeding. This will increase the frequency of breastfeeding modeling that women are exposed to.

Additionally, the NBAC did not acknowledge that free formula is distributed by maternity clothing stores, hospitals and formula companies. This undermines the social norm of breastfeeding, making formula seem more popular. Schultz et al (2007) state that people overestimate how many individuals partake in an undesired behavior (9). Schultz et al would argue that women believe that breastfeeding is less common than it really is and by dispensing free formula this idea is reinforced (9). The new campaign will discourage hospitals from providing free formula to mothers unless a mother and physician decide together that breastfeeding is not best in her particular situation. Mothers will believe that breastfeeding is common if free formula distribution is reduced.

Furthermore, the Theory of Planned Behavior suggests that people consider how they will be perceived by others before deciding to act themselves (8). Since the NBAC did not strive to make breastfeeding a social norm, women were unaware of how individuals would perceive their decision to breastfeed. The new campaign will make breastfeeding a social norm and therefore women will be more reassured that if they breastfeed, others will support their decision.

Campaign will deflect reactance by having the message delivered by someone similar to the target audience

The National Breastfeeding Awareness Campaign failed to use a source of the message that had similarities to the recipient of the message. The implications for this were that the lack of similarity induced reactance to the message (11). Silvia (2005) conducted a study in which he found that when the communicator of the message is dissimilar to the recipient of the message, there is a “boomerang effect” (11). This suggests that people did the opposite of a message since the message was not delivered by someone similar to themselves (11). Additionally, if the audience can not relate to the messenger, the individuals targeted by the campaign are unable to self-reference (13). However, the new campaign will include a peer-support group, which will allow women to learn about the importance of breastfeeding from their peers. Women who take part in a peer support group will be able to interact with other women who have actually breastfed. The peers could be neighbors, co-workers or friends. Women interacting with their peers while learning about breastfeeding will be more likely to comply with the message (11).

Additionally, having a group of peers who are also breastfeeding mothers will allow the target audience to engage in self-referencing and imagine themselves breastfeeding (13). Burnkrant and Unnava (1995) state that self-referencing can be accomplished in a campaign that “addresses the audience directly and introduces experiences to which it can relate” (13). Not only will these women be able to self-reference as a result of the peer group, they will also become aware of the commonality of breastfeeding. While the NBAC did not deliver the message of their campaign by someone similar to the target audience, the new intervention will do this through the use of peers. Since the peers will share similarities with the targeted mothers, they will be able to contribute experiences that the targeted mothers can relate to. This will ultimately work in a persuasive way to promote breastfeeding and increase compliance (13).

Conclusion

The suggested intervention will be more successful than the National Breastfeeding Awareness Campaign in increasing breastfeeding rates because it takes into account flaws of the NBAC. First, many women face barriers to breastfeeding including lack of support from friends and family and also unaccommodating work environments. The new intervention addresses the environmental barriers in order to increase one’s feeling of self-efficacy (6-8). Second, breastfeeding is not a social norm in the United States society. The new intervention works to make breastfeeding become a social norm so people do not worry about how they will be perceived by others when breastfeeding (6-7). Also, people model the behavior they see; by seeing breastfeeding more often women will be more likely to model this behavior (6-7). Lastly, people are more likely to adopt a behavior change that is suggested to them if the message is delivered by someone similar to the recipient of the message (10-11). The new intervention recognizes this and delivers the message through peers. Using peers also allows mothers to self-reference and imagine that breastfeeding is something they are capable of doing (13).

The new intervention will incorporate improvements making it more successful than the National Breastfeeding Awareness Campaign’s attempt at increasing breastfeeding rates. The NBAC had several flaws that are corrected for in the new intervention and some of these concepts are recognized by the American Academy of Pediatrics (AAP) in its policy statement, “Breastfeeding and the use of human milk” (2). The AAP recognizes that a campaign’s promotion of breastfeeding must encourage breastfeeding to be a “cultural norm” (2). They also state that breastfeeding must be supported by families and society (2). The AAP believe that employers must provide “appropriate facilities and adequate time in the workplace” for breastfeeding mothers (2). Based on these recommendations by the AAP, it is clear that the National Breastfeeding Awareness Campaign was not sufficient in promoting breastfeeding. However, the proposed campaign recognizes the necessary aspects of breastfeeding campaigns as described by the AAP, and therefore will be more successful than the NBAC.

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