Milwaukee Campaign Against Sleeping with Baby – Natasha Neal

Infant Mortality in Milwaukee, Wisconsin
Milwaukee, Wisconsin has higher rates of infant mortality in comparison to other areas of the United States and other parts of the world. Infant mortality is the number of infants that die during their first year of life (1). Milwaukee’s African-American infant mortality rate is ranked higher than at least 35 other countries, including some developing countries (2). The top four reasons for infant death in Milwaukee are complications of prematurity; congenital abnormalities and related complications; sudden infant death syndrome (SIDS), overlay, and accidental suffocation; and infections (2). In particular, Wisconsin is a state with one of the largest differences in infant mortality based on race. The gap between non-Hispanic white infants and African-American infants is quite large: for every five white infants that die prematurely, 14 African-American babies die (1). Based on the list of most common deaths in infants, the only cause that is preventable after birth is SIDS, overlay, and accidental suffocation.

In order to address the dismal situation, the City of Milwaukee’s Health Department created a Safe Sleep Awareness Campaign, in which they discourage the practice of co-sleeping, and more specifically, babies and adults sharing the same bed (3). They have used posters, as well as radio and television advertisements to get their point across to the public. To view the public health campaign advertisements, visit http://city.milwaukee.gov/SafeSleep (3). The public has perceived these advertisements with mixed views as they depict a small baby sleeping in a bed next to a large knife. The poster states: “Your baby sleeping with you can be just as dangerous.” Some responses have been supportive towards catching parents’ attention on an important matter; however, others feel that the City of Milwaukee is demonizing parents. These posters were created with the intention of grabbing the attention of parents that may bed-share. It is very unlikely that parents that co-sleep are consciously putting their babies in harm’s way, explaining the negative reactions of some parents.

Problems with Milwaukee’s Campaign Against Co-Sleeping

Despite correctly identifying the large racial disparity in infant mortality, Milwaukee’s campaign is unlikely to be successful in closing this gap. The Health Department has chosen to focus on a much narrower health behavior in the hopes that it will significantly reduce the rates of infant mortality. The advertisements used in the campaign overlook four important social behavioral models: Labeling Theory, Optimism Bias, the Law of Small Numbers, and Psychological Reactance. Furthermore, The City of Milwaukee’s Health Department has done a poor job of approaching such a controversial, and poorly understood health behavior.

The Health Department has been quick to pinpoint bed-sharing as the form of unsafe sleeping practice that results in sudden infant death syndrome (SIDS) or sudden unexpected death in infancy (SUDI). However, based on a study released in 2011, the major risk factors for SIDS also include inadequate prenatal care, low birth weight, premature birth, short interval between births, and maternal substance abuse (4). It becomes clear that many of these factors are uncontrollable, and are often completely independent from whether an infant sleeps in the same bed as an adult or not, except for maternal substance abuse. Therefore, even infants that sleep in their own bassinet or crib are at risk of SIDS. In some unfortunate cases, despite parents following the safest child-rearing practices, an infant will still experience SIDS. In combination with the disparity in infant mortality between races, it encourages one to question whether an ethnic community in particular is engaging or has a history of increased risk factors, in addition to bed-sharing. It is important to examine the situation in relation to different races as one of the goals is to narrow the gap between infant mortality rates in Milwaukee.

Data included in the City of Milwaukee’s Fetal Infant Mortality Review (FIMR) also does not concretely support their view on targeting co-sleeping. The FIMR stated that Singapore had the lowest infant mortality rates, despite approximately 70% of the population engaging in bed-sharing, showing that bed-sharing can be practiced safely (5). Armed with this knowledge, one must ask what specifically, during bed-sharing, is the cause for increased infant mortality in the United States versus Singapore. Research has been conducted on this point, and it has been found that there are often other factors playing a role. For instance, the risk of infant death during bed-sharing often occurs if a parent also engages in smoking or alcohol abuse (6). In addition to this, in other countries where bed-sharing is the predominant form of sleep practice, it is important to be aware that in these countries, families often sleep on firm mats instead of softer mattresses (7). Therefore, it is a combination of the risks mentioned previously, including premature birth and maternal substance use, combined with bed-sharing, that can increase the risk of infant death.

Another critical consideration of this intervention is the message that public health officials want to send. Research has shown that the risk of SIDS increases when babies sleep in a different room from parents (8). Despite this known fact, the advertisements do not include information indicating that although bed-sharing should not occur, room-sharing is important to the health of infants. The advertisements, while depicting the dangers of bed-sharing, contain little information on how to mitigate the risks. This information only appears on the website, and yet there is no guarantee that parents will spend the time going to the website. All information must easily reach parents in order for individuals to make educated decisions. The City of Milwaukee also ignores the positives that have been identified in literature regarding bed-sharing. These positive elements include making breastfeeding easier, allowing babies and parents to get more sleep, ensuring mothers are more responsive to the needs of the infant, and the practice encourages bonding and security between parent and infant (7). By purposely omitting this information, the public may feel as though the City of Milwaukee’s Health Department is trying to deceive or manipulate their behavior. This may be especially likely to occur in parents that are well-versed in the sleeping practices of other non-Western cultures.

Due to the vast majority and somewhat contradictory information available in regards to bed-sharing and co-sleeping, it becomes apparent that education must be the first step to behavior change. Parents are unaware of the pros and cons of different sleep practices. As well, many parents are misinformed about the definition of co-sleeping; some believe that co-sleeping is defined specifically as the practice of sharing the same bed with a baby; however, this is not true (3). Having a baby sleep in a bassinet or crib next to the parents’ bed is also a form of co-sleeping. Some experts have begun referring to room-sharing versus bed-sharing in order to clarify the difference in the two practices (3). One problem with the campaign is that the ads do not clarify this distinction. Therefore, the overall impression parents may be getting is that their babies need to sleep in a completely different room.

Labeling Theory and Racism's Effect on Health Disparities

Milwaukee’s Health Department has been quick to identify the difference in infant mortality rates between African Americans and non-Hispanic whites (2). However, one major flaw in their intervention was the obvious avoidance of addressing these differences in their campaign, other than including two versions of their ads, one featuring a white infant and the other featuring an African-American infant (3). It is important to consider the reasons behind why the rates of infant mortality differ so drastically between the two races, even when all other factors are similar. It has been reported that an African-American woman with a college degree has poorer infant mortality rates compared to a white woman with only a high school education (1). One contributing factor to this phenomenon may be due to labeling theory, and its relation to race. Institutionalized racism may play a huge role in the differences in infant morality rates between white and African-American infants. Differences in race are especially important as the City of Milwaukee is dramatically racially segregated (9).

One study has looked at biological differences between people of different races in order to determine reasons for such dramatic differences in health disparities in different populations of people. One study was conducted in order to identify why blood pressure can differ so drastically between black and white individuals (10). Researchers Krieger and Sydney concluded that when examining blood pressure, it was important to take into account how discrimination may affect health (10). Similarly, it is important to take into account the biological differences of African-American women in comparison to white women. African-American women typically have babies with lower birth weights and are more often born prematurely (9). Institutional racism, a form of racism that is not necessarily obvious, can result in African-American women having increased stress levels, perhaps due to the expectation that discrimination will occur in everyday life events (11). Increased stress levels may then lead to increased risk of premature births and low birth weight. It is important to help these women that must live with institutional racism overcome the hardships they may face, especially during pregnancy.

One other study looked at the differences in infant mortality between African-Americans and white mothers in relation to sleeping position. The study identified that the sleeping positions varied distinctly between the two races. African-American infants were more likely to sleep in the prone position, or on their stomachs, rather than the nonprone position (on the back or side) (12). The prone position is more highly associated with SIDS. This could be one reason why the disparity in infant mortality exists between the two races. The study also went on to find that African-American mothers more often recalled or were incorrectly told by health professionals that the prone position should be used (12). Here we see a form of institutionalized racism that impacts the mothers of different races, as it is unlikely physicians were purposely suggesting unsafe sleeping practices.

A separate study found that interpersonal racial discrimination experienced by African-American women a year prior to birth as well as over a lifetime was a risk factor for premature birth (13). Nancy Krieger defines interpersonal racism as “directly perceived discriminatory interactions” (14). The City of Milwaukee should consider examining whether members of the African-American community experience higher levels of interpersonal racism, in order to prevent this from occurring. In the study conducted by Rankin, David, and Collins, they found that using active coping behaviors to deal with interpersonal racism could weaken the association between the risk factor and premature birth (13).

Understanding the differences between African-American women and white women is one way to focus Milwaukee’s intervention and an important factor in determining how to reduce the infant mortality rate. Milwaukee’s campaign does not inform women that babies born prematurely or with low birth weights are at higher risks for SIDS, and the necessity to take more precautions. The racial segregation in Milwaukee can further impact the situation as areas with high populations of African-Americans may have fewer resources for pregnant and new mothers, such as clinics, primary care offices, and prenatal classes.

Optimistic Bias and the Law of Small Numbers

The Health Department has overlooked the roles that the theory of optimistic bias in combination with the law of small numbers may play in this campaign. The Law of Small Numbers is the theory that people will often associate their risk with one positive case despite substantial information contradicting this (15). For example, a smoker will doubt that smoking increases the risk of cancer despite the vast evidence supporting this simply because they have a family member who smoked their entire life and never developed cancer. Optimism bias refers to the fact that an individual will know the risks of a particular behavior, but will underestimate their own risk (16). The campaign against bed-sharing emphasizes the dangers through the use of the knife and tombstones in the ads (3). While this may communicate the risk of bed-sharing with the public, individuals may believe that they will be the exception to the statistics. In the television ad depicting a mother that tosses and turns while sleeping, the overall impression is that bed-sharing may lead to a parent or adult suffocating their child. However, based on optimistic bias, people viewing the ad may think that while suffocation of a child may happen to others, it will not happen to them – they will be the exception to the rule (16). This becomes especially important for parents who already have had a child, and who practiced bed-sharing without any incidence of SIDS or SUDI. Based on their previous experience, they are likely to experience the law of small numbers, and be confident they can bed-share with smaller risks than the general public, although this may not necessarily true (17). Another factor to consider is the social networks of people, and the different sleeping practices friends and families engage in. One study found that at 2 weeks of age, 42% of parents shared a bed, at 3 months 34% shared a bed, and 28% at a year of age (18). These statistics show that bed-sharing is not rare and many people likely know of other parents that sleep in the same bed as their infants. The knowledge of others that have bed-shared successfully can lead people to believe in the Law of Small Numbers - that those people that have successfully practiced bed-sharing are in fact the norm. These individuals will question the veracity of the ads in conjunction with having an increased risk of infant death, especially if these parents believe that bed-sharing is a better parenting technique. Combined with optimistic bias, knowing others that successfully bed-share make it unlikely that these ads will be effective in changing the behavior of parents that co-sleep in the same bed, especially those that have never known someone whose child suffered from SIDS or SUDI.

Psychological Reactance and Pushback Against the Ads

It is very important to gauge how the public perceives the advertisements. Psychological reactance occurs when people feel their control is being taken away (19). It becomes particularly important in the issue of co-sleeping because parents have differing opinions on the pros and cons of bed-sharing based on the literature available and the cultural norms of different populations. Therefore, when advertisements tell people that their method of child-rearing is incorrect or unsafe and should not be practiced anymore, it is in effect taking away the freedom for people to decide how they want to raise their children, and what they believe is best for their child’s development. In a study conducted, investigators found that countercultural parents in the US were more likely to also be “pronatural.” This group of parents was interested in following “natural parenting” and often follows practices more common in non-Western countries, such as breast-feeding rather than formula use, bed-sharing, and using only organic foods (20). However, they may be unaware that in non-Western countries, firmer mats instead of softer mattresses are used. These parents believe that they are practicing the best form of parenting, and will therefore not heed the warning, and they will perceive a loss of control over their style of parenting. When people experience psychological reactance, they will often engage in the prohibited behavior much more strongly (19).

Solutions for Co-Sleeping and High Infant Mortality Rates

It is important to consider the root causes of high infant mortality. Despite perhaps not being the largest cause of SIDS and SUDI, proper co-sleeping may lower the rates of infant mortality in Milwaukee. However, identifying the differences in racial groups will also be impactful if addressed in the intervention. A new intervention is being proposed that will effectively remove the barriers in the already existing intervention.

The new intervention will consist of various different platforms: it will use television advertisements as well as offering educational programs in the community. This new intervention is based largely on three models useful for changing behavior: the Theory of Planned Behavior, Social Expectations Theory, and Advertising Theory. In combination, these will overcome the problems seen in Milwaukee’s current campaign, and will hopefully reduce the number of deaths that can be attributable to unsafe sleeping practice, as well as reducing the number of SIDS and SIDU deaths in general in Milwaukee.

New television advertisements will be created for the intervention. The advertisements will depict images of the important milestones in a child’s life: first birthday, first steps, first day of school, graduation, marriage, and then the birth of a grandchild. Following the images, a parent who experienced the death of an infant due to SIDS or SIDU will speak out. More specifically, the parent will emphasize the point that they were unaware of the importance of safe-sleep practices, that they missed out on so many of the milestones they expected to experience, and they will encourage parents to seek out new information regarding safe sleep practices. They will also suggest ensuring children sleep in an environment without blankets or pillows, to avoid the risk of suffocation, and that parents always place their babies on their back or supine position to sleep (8). If parents are concerned about moving in their sleep, the ad will go on to explain that the safest place for a child is in a crib or bassinet. However, it will emphasize the importance of infants sleeping in the same room as a parent.

In addition, the new intervention will have nurses available at churches, clinics, or community centers for expecting and new mothers. These nurses will be concentrated in African-Americans communities, where clinics and services may be harder to come by and where infant mortality rates are much higher – in particular, the zip codes of 53206, 53210, and 53233, which have the highest rates of infant mortality in Milwaukee (2). The nurses will act as educators, talking about the increased risk of SIDS for premature or low birth weight babies. They will ensure that African-Americans have strategies in place to deal with any type of discrimination they may face. They will describe common safe sleep practices outlined in the report by the American Academy of Pediatrics, such as always placing an infant in a supine position, using a firm mattress, avoiding pillows and blankets near the infant, encouraging breast-feeding, encouraging room-sharing over bed-sharing, and encouraging the avoidance of exposure to tobacco smoke, alcohol, and illegal drugs (8).

Finally, the City of Milwaukee should start a program where parents can donate cribs or bassinets once they are no longer needed. These will be provided to parents of newborns that are interested in room-sharing rather than bed-sharing, but that may not have the means to purchase these items.

Social Expectations Theory for Community-Based Interventions

The Social Expectations Theory suggests the importance of examining individuals based on the community they live in and the values they hold (21). As Milwaukee is racially segregated, this theory would be very helpful in addressing the differences in community norms and values. This theory, and its examination based on a community level, will help overcome weaknesses due to the Labeling Theory and racism. Do mothers in the African-American communities place more importance on bed-sharing or sleeping in the prone position? Does this belief stem from the norms and values of their culture? Is there a way to educate these mothers on safer methods of co-sleeping that may reduce risk of smothering and suffocation?

It is also important to focus on the issue of infant mortality among African-Americans in general, as this population has the highest rates of infant mortality in the city. The first step would be to identify the resources available to new and expecting mothers. Placing more resources in these lacking communities may have a profound effect on infant mortality. Finally, it will be important to examine the communities, and in particular, the African-American communities, for indicators of excess stress levels mothers may encounter due to discrimination and racism. If these two issues can be combatted, perhaps the number of premature or low birth weight cases will decrease. Following this identification, if the City of Milwaukee can take a more active role in the resources available to pregnant women combatting discrimination, perhaps Labeling Theory and racism can be overcome, in turn decreasing the number of cases of premature and low birth weight babies, and in turn decreasing the number of cases of SIDS or SIDU.

The Theory of Planned Behavior

The first step to effecting behavior change, especially in regards to a topic that individuals may not be familiar with, is education. Using the Theory of Planned Behavior, one can begin to develop a new intervention that may be more effective in reaching people that currently do not practice safe sleep techniques. The Theory of Planned Behavior is based on the fact that individuals weigh their attitudes and social norms against expected outcomes when engaging in a particular action (22). An important factor is their perceived behavioral control, also known as self-efficacy, in carrying out a particular behavior (22). This theory, with a focus on education, can be used to overcome optimism bias and the law of small numbers. In order for this to occur, it is imperative that individuals are educated on the safest sleeping practices for children from birth to the age of one.

If prenatal classes are available in the community and are well attended, the City of Milwaukee should ensure that expectant mothers are educated about safe sleeping practices during these classes. This allows mothers to be exposed to the information, and they can include it during their decision process. If prenatal classes are not offered, programs will be created in churches, community centers, and clinics in the community, which will be free of charge. By basing these educational events in a group setting, new social norms are being created around safe sleeping practices. These safe-sleeping practices can be geared towards room-sharing over bed-sharing.

The information presented in the sessions will include information about the pros of co-sleeping, the definitions of co-sleeping, room-sharing, and bed-sharing and the pros and cons of each. Classes will encourage parents to use bassinets or cribs that can be close to the bed, which are completely empty except for the mattress. For parents that are determined to bed-share, it is important to portray a safe way to do so – by placing blankets and pillows away from infants, by placing infants on their backs to sleep, and by ensuring that the parents are not restless sleepers that tend to move in their sleep. It is important, on the part of the educators, not to give the impression that parents are being told how to raise their children. By using education rather than commanding or ordering parents to engage in a particular behavior, we are allowing parents to make their own decisions on child-rearing practices. This will help mitigate psychological reactance because we are not taking away individuals’ sense of control (19). Instead, we are giving control to parents – they are now in control of making safe and smart decisions when choosing a particular sleep practice based on all of the information available.

One important addition to the Theory of Planned Behavior is the component of self-efficacy (22). Parents must be made to feel as though they can actually change their behavior and be successful. One barrier to self-efficacy in the context of room-sharing may be that the parent does not have access to a bassinet or a crib, due to financial circumstances. Therefore, this needs to be addressed in the intervention. It is unreasonable to institute a campaign encouraging mothers to practice safe-sleeping techniques if they are unable to afford the necessary requirements. The program involving crib and bassinet donations from the public will allow parents to obtain these needed items when financial limitations exist. By using donations, Milwaukee’s Health Department will not need to worry about financial constraints.

Advertising Theory and Connecting to the Community

Advertising theory should be considered when reaching out to the target population. Advertising theory is composed of three main components: the promise, core values, and support. These work together to reach the public on an emotional level (23). Therefore, advertisements need to be created which touch individuals on all three components. The promise the new set of advertisements will offer to viewers is the possibility of being a part of all important milestones in a child’s lifetime: first steps, first birthday, graduation, wedding, and the birth of their first child. These are all experiences that parents will treasure over the course of their child’s life, and will reach a wider target. These images will support the promise of experiencing life’s many milestones, and will play on the values of love, family, and aspirations. In order to overcome the law of small numbers, following the images, a parent will speak about how they missed out on all of these important life events because they were unaware of safe sleep practices, and therefore, they suffered the death of a child. They will show a picture of their baby that passed away due to SIDS. This overcomes the law of small numbers because people can now relate to someone who has experienced SIDS rather than knowing someone that has successfully bed-shared. Advertising Theory has proven successful in an intervention known as the Truth Campaign in Florida (24). This campaign was able to build a brand based on values, and resulted in decreased rates of high school and middle school students smoking (24). Similarly to this campaign, Milwaukee’s safe-sleeping campaign will place most attention on life’s important milestones for a parent, and the values of love and family, in order to connect with parents and change behavior.

Conclusion

Milwaukee is a city that is unique in its mortality rate differences based on ethnicity. It is critical to narrow the gap, and decrease the infant mortality rate. Milwaukee has correctly identified one potential area that may reduce the rates of infant mortality – the incidence of bed-sharing, but by basing their intervention on fear alone, they are unable to make an emotional connection with viewers that will encourage parents to change their behavior. Using the Social Expectations Theory, The Theory of Planned Behavior, and Advertising Theory for the basis of a new intervention, Milwaukee will be more successful in reaching their target population, and lowering the rates of infant mortality due to SIDS and SIDU.

References:
1. City of Milwaukee. Infant Mortality. Available at: http://city.milwaukee.gov/InfantMortality.htm. Accessed December 12, 2011.
2. City of Milwaukee Health Department. 2010 City of Milwaukee Fetal Infant Mortality Review (FIMR) Report: Understanding and Preventing Infant Death and Stillbirth in Milwaukee. Milwaukee, Wisconsin: City of Milwaukee Health Department; 2008.
3. City of Milwaukee Health Department. Safe Sleep for Your Baby. City of Milwaukee. Available at: http://city.milwaukee.gov/SafeSleep. Accessed December 14, 2011.
4. Athanasakis E, Karavasiliadou S, Styliadis I. The factors contributing to the risk of sudden infant death syndrome. Hippokratia. 2011;15(2):127-131.
5. Chng SY. Sleep disorders in children: the Singapore perspective. Ann. Acad. Med. Singap. 2008;37(8):706-709.
6. Lahr MB, Rosenberg KD, Lapidus JA. Bedsharing and maternal smoking in a population-based survey of new mothers. Pediatrics. 2005;116(4):e530-542.
7. Prato CC. The Family Bed: The Risks and Rewards of Co-Sleeping. Parenthood.com.
8. Task Force on Sudden Infant Death Syndrome. SIDS and Other Sleep-Relatd Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment. AAP. 2011;128(5):1341-1367.
9. Sims M, Rainge Y. Urban poverty and infant-health disparities among African Americans and whites in Milwaukee. J Natl Med Assoc. 2002;94(6):472-479.
10. Krieger N, Sidney S. Racial discrimination and blood pressure: the CARDIA Study of young black and white adults. Am J Public Health. 1996;86(10):1370-1378.
13. Harrell SP. A Multidimensional Conceptualization of Racism‐Related Stress: Implications for the Well‐Being of People of Color. American Journal of Orthopsychiatry. 2000;70(1):42-57.
14. Hauck FR, Moore CM, Herman SM, et al. The contribution of prone sleeping position to the racial disparity in sudden infant death syndrome: the Chicago Infant Mortality Study. Pediatrics. 2002;110(4):772-780.
11. Rankin KM, David RJ, Collins JW Jr. African American women’s exposure to interpersonal racial discrimination in public settings and preterm birth: the effect of coping behaviors. Ethn Dis. 2011;21(3):370-376.
12. Krieger N. Embodying inequality: a review of concepts, measures, and methods for studying health consequences of discrimination. Int J Health Serv. 1999;29(2):295-352.
15. Tversky A, Kahneman. Belief in the Law of Small Numbers. Psychological Bulletin. 1971;76(2):105-110.
16. Davidson K, Prkachin K. Optimism and Unrealistic Optimism have an Interacting Impact on Health-Promoting Behavior and Knowledge Changes. Personality and Social Psychology Bulletin. 1997;23(6):617 -625.
17. Weinstein ND. Unrealistic optimism about susceptibility to health problems: conclusions from a community-wide sample. J Behav Med. 1987;10(5):481-500.
18. Hauck FR, Signore C, Fein SB, Raju TNK. Infant sleeping arrangements and practices during the first year of life. Pediatrics. 2008;122 Suppl 2:S113-120.
19. Brehm J. Psychological Reactance: Theory and Applications. ACR. 1989;16:72-75.
20. Weisner TS. Culture, Development, and Diversity: Expectable Pluralism, Conflict, and Similarity. Ethos. 2009;37(2):181-196.
21. Flamand L. Social Expectation Theory | eHow.com. eHow. Available at: http://www.ehow.com/about_5474324_social-expectation-theory.html. Accessed December 13, 2011.
22. Icek A. The theory of planned behavior. Organizational Behavior and Human Decision Processes. 1991;50(2):179-211.
23. Evans WD, Hastings G. Public Health Branding. Oxford University Press; 2008. Available at: http://www.oxfordscholarship.com/view/10.1093/acprof:oso/9780199237135.001.0001/acprof-9780199237135. Accessed December 14, 2011.
24. HIcks J. The strategy behind Florida’s “truth” campaign. Tobacco Control. 2001;10:3-5.

Babies Are Born To Be Breastfed: A Critical Review-Geetika Kalloo

Introduction

Breastfeeding is a beneficial practice for both mothers and infants and has been the focus of several recent public health interventions.[1] The focus of this critique are two advertisements released by the Department of Health and Human Services’ in their National Women’s Health breastfeeding campaign. The first featured two pregnant women who are competing in a log rolling tournament. Viewers watch as one of the pregnant women displaces the other, sending her plummeting into the water. The final shot of the women is with one woman celebrating her victory and the other being pulled out of the water in apparent dismay at her loss (http://www.youtube.com/watch?v=wC1RAr52xFo).[2] The second advertisement is equally inappropriate. It features a pregnant woman at a “Ladies Night” in a rodeo bar. She is helped onto a mechanical bull by other pregnant women. She rides the bull with apparent glee for several seconds before she is thrown off. She jumps back up a big smile on her face (http://www.youtube.com/watch?v=WM8NLxCXlp0&NR=1&feature =endscreen).[3] Both of the advertisements have the same voiceover and visual word prompts. They first question in words after the initial shot of the pregnant women participating in risky behaviors: “You wouldn’t take these risks before your baby was born. Why start after? Breast feed exclusively for 6 months.” It then follows with a voiceover message which states “Babies who are breastfed were less likely to develop ear infections, respiratory illness, and diarrhea. Babies were born to be breastfed!” [2, 3]

It is generally acknowledged that breastfeeding is one of the most complete forms of nutrition for infants, breast milk provides many benefits to infants’ health, immune system, and development.[4] Breastfeeding is inimitable source of food for a baby, and though many formulas have attempted to copy its nutritional qualities none have been completely successful. Many studies have demonstrated that breastfed children have increased immunity against disease and infection in their early childhood when compared to children who are formula fed. They are also less likely to contract a variety of diseases later in life, including juvenile diabetes, multiple sclerosis, heart disease, and cancer.[5]

Additionally, breastfeeding is also beneficial for the mother. Women who breastfeed have a decreased chance of developing osteoporosis later in life, have lower risks of breast, uterine, and ovarian cancer, and are able to lose weight gained during pregnancy with greater ease. Breastfeeding can also serve as a cost cutting method for young families. It is considerably more cost effective than buying formula. It also avoids medical bills associated with early childhood illnesses that infants are at greater risk for if they are formula fed.[6] Therefore, the goal of the Women’s Health campaign is well intentioned, but the campaign itself fails to effectively inform the viewer of any of the above mentioned benefits and risks. In fact the only emotions that the two advertisements manage to incite in viewers are of disgust and ridicule.

These two advertisements fail to properly address any of the benefits associated with breastfeeding. Rather they rely instead on ludicrous imagery which fails to serve any purpose. The predominant fault of this campaign is that it misapplies or utilizes outdated multiple public health theories. In analyzing these two advertisements it is clear that the Department of Health and Human Services has attempted to utilize the Health Belief Model, Theory of Reasoned Action and Social Expectations Theory. All three are well established models of public health change. However, the manner in which they are applied is not conducive with the subject matter at hand and therefore the campaign is ineffective. In order to better elucidate the flaws of the intervention an in depth review of this breastfeeding campaign is warranted.

Critique Argument 1- The Health Belief Model

The first fault of the Woman’s Health campaign is its use of the Health Belief Model (HBM). The HBM is a psychological model which attempts to predict behaviors related to health. The underlying theory of this model states that individuals make decisions after taking time to understand the perceived costs and perceived benefits of the health behavior, in this scenario breastfeeding.[7] The implications of the perceived benefits or harms are determined by how susceptible the target audience believes they are to the dangers outlined, and how severe they think the repercussion of the “incorrect” action would be. This model believes that individuals weigh both sides of the issue and come to a rational conclusion regarding the health behavior with the best outcome.[8]

Firstly, this campaign fails to correctly utilize the HBM. In order for the viewer to ascertain the perceived harms and perceived benefits of breastfeeding, they must be provided with complete and accurate information about the behavior. Both advertisements provide limited information about the benefits of breast milk. In fact they simply state a reduced risk of three minor ailments, whereas the benefits of the breastfeeding are far greater than these paltry reasons. Furthermore, viewers are provided with no actual perceived risks. In order for the HBM to work most effectively complete information about breastfeeding must be presented to the viewers. Without this mothers will be unable to fully weigh the perceived benefits and harms of the behavior. [8]

The creators of this campaign rely on the ridiculous scenarios in order to present the perceived risks associated with not providing a child with breast milk. They attempt to liken the harms of not breastfeeding with a pregnant woman being thrown of a mechanical bull or almost drowning. The fact of the matter is that the majority of woman formula feed their child at some point. In fact a study found that only 45% of infants were exclusively breastfed one week after being born.[9] Therefore, individuals know from the experience of others that not providing breast milk does not have the same dangers as a serious accident during pregnancy. Thus most individuals who view this commercial would discredit the entire campaign because it does not provide a sufficient number of perceived benefits and unrealistic perceived harms. The HBM is completely knowledge based, and seeks to provide information to individuals in order for them to assess their situation and make an appropriate decision.[10] But the implications regarding breastfeeding in this campaign are blatantly false and thus it is unsuccessful in part because the model is misapplied. They fail offer accurate information for mothers to utilize in making this decision.

If this campaign had more accurately used HBM, it would still fail to effectively convey its message. HBM is not a suitable model for an intervention regarding breastfeeding. It is an individual based model and stresses personal responsibility for health behavior. These commercials rely on the fact that it up to the woman to choose to breastfeed her child. This may lead people to feel it is they “fault” if they cannot are not capable of completing the action. Yet some women have to go back to work or are unable to produce breast milk, which are not factors that they have any control over. These advertisements would alienate rather than inform those individuals and make the campaign less successful.[7] Furthermore, HBM based interventions have been shown to work less effectively with decisions that are taken daily such as smoking, eating nutritiously, and exercising. Breastfeeding can be counted among these daily decisions as mothers can switch to formula at any point should it become too inconvenient to provide milk themselves. HBM assumes that what a person values and beliefs are static from one day to another. There is a complexity in making day to day decisions that is not accounted for in the HBM.[11] A mother might provide milk for her child while she’s on maternity leave but once she gets back to work, her priorities and perceived benefits and harms regarding the situation change. The information provided in this campaign using the HBM is not sufficient to persuade women continue with this positive health behavior.

Critique Argument 2-Theory of Reasoned Action

The use of the Theory of Reasoned Action (TRA) in this intervention demonstrates that the creators believe that all individuals are rational and their behavior is determined by their intention to breastfeed. The TRA suggests that an individual’s behavior is determined by his intention to complete that behavior. Intention is defined as an individual’s readiness to perform a given health related action. An individual’s intention to complete an action is based on their attitudes towards that behavior, in our case breast feeding, as well as their perception of subjective norms associated with that activity.[12] Attitude in this scenario is derived from the sum and evaluation of an individual’s beliefs about breastfeeding. Subjective norms can be better understood as “the person's perception that most people who are important to him or her think he should or should not perform the behavior in question.”[13] The TRA component of this intervention is the explanation of positive outcomes for a child’s health to influence the attitudes of new mothers towards breastfeeding. They also attempt to use the mechanical bull riding and log rolling to demonstrate the subjective norms associated with formula feeding one’s child, in order to influence a woman’s intention to breastfeed her child.

As mentioned with the HBM critique this campaign fails to effectively provide many benefits or outline the harms associated with choosing to breast feed or formula feed. Therefore, TRA is not being properly utilized to influence the attitudes of the target audience or change how they view the subjective norms associated with this action. The campaign attempts to provide three potential health benefits to a child in comparison to a horrible accident to a pregnant woman. They expect women to evaluate the benefits and harms between the two scenarios. These advertisements may influence a woman’s attitude associated with log rolling during pregnancy or riding a mechanical bull, but the comparison is so ludicrous that it certainly will not change her attitude or influence her belief about how society views breastfeeding. Therefore this campaign fails to use TRA in order to change the intention of would-be mothers to breastfeed.

Furthermore, the use of the TRA in this particular scenario is flawed. “The aim of the TRA is to explain volitional behaviors. Its explanatory scope excludes a wide range of behaviors such as those that are spontaneous, impulsive, habitual, the result of cravings, or simply scripted or mindless. Such behaviors are excluded because their performance might not be voluntary or because engaging in the behaviors might not involve a conscious decision on the part of the actor."[14] Behaviors such as breastfeeding, which are habitual, do not fare well when targeted by a static model like the TRA because these decisions are not influenced by the same attitudes or subjective norms on a daily basis. It has also been shown that when a choice between alternatives exists, breastfeeding versus formula feeding, TRA functions much less effectively in creating intention. TRA functions best in a yes or no decision.[15] Therefore the TRA is not an appropriate mechanism to create the desired change in regards to breastfeeding.

Critique Reason 3- Misapplication of Social Expectation

This campaign relies most heavily on the Theory of Social Expectations. This paradigm relies on the fact that individuals’ behavior is dictated by social norms. Social norms are defined as the behavior patterns and expectation that people observe in the environment around them. Individuals comply with these behavioral patterns and beliefs without consciously engaging in them. In fact it has been "long argued that people tend to adopt group attitudes and act in accordance with group expectations and behaviors based on affiliation needs and social comparison processes, social pressure toward group conformity, and the formation and acquisition of reference group norms."[16] This implies that individuals generally prefer to conform to expectations of society rather than confront them. This is true regardless of whether these actions are concurrent with their belief systems, because most people place a high value on acceptance from their peers and society. Attitudes of groups can be changed en masse with first changing the behavior of the group and their beliefs regarding the action should follow suit.[17]

The Women’s Health campaign relies heavily on social expectations and norms surrounding motherhood. It appeals to the desire of women to be viewed as good mothers by society. As mentioned previously, the implications of the advertisements are that formula feeding your child is akin to log rolling or riding a mechanical bull whilst pregnant. The shock value of both these scenarios also attempts to elicit a reaction about the deviation from social norms. The commercials make it clear that it is not socially acceptable to participate in these risky behaviors during pregnancy. The intervention then attempts to draw a parallel between the disapproval that a woman would receive if she participated in these activities during pregnancy and if she chose to not breastfeed her child.

Social Expectations Theory is a perfectly legitimate model to use in case of a breastfeeding intervention. It is very likely that if women believed that society expected all mothers to breastfeed, we would see an increase the number of infants who exclusively given breast milk for the first 6 months of their lives. Unfortunately, this particular campaign blatantly misapplies this model. There is no doubt that the imagery in these advertisements will cause shock amongst the viewer. But because formula feeding is so common in society, women are fully aware that the social implications of not breast feeding one’s child are not as severe as those for willingly participating in the behaviors shown in these advertisements. In fact the stories presented in the Women’s Health Campaign only manage to reaffirm the societal condemnation regarding risky behavior and pregnancy. It fails to draw a parallel between those actions and breastfeeding. The social expectations paradigm is not at work within this campaign and only serves to add to the ludicrous nature of the commercial. Therefore their attempt at using Social Expectations Theory further adds to the ineffectiveness of this campaign.

Proposed Intervention

The goals of this campaign are quite noble and would benefit society greatly. In fact “widespread recommendations from health organizations encourage exclusive breastfeeding for six months.”[18] The Women’s Health Campaign would have been much more effective had they used different models to deliver their message. Therefore, the proposed intervention is a complete overhaul of the campaign presented by the Department of Health and Human Services. The goal behind the proposed intervention in to create change utilizing the irrational aspects of human nature, which studies have shown create greater change than those which are based on facts and statistics. This intervention is attempting to make group level change in behavior that will ultimately impact and change the attitudes that individuals have towards breastfeeding. This campaign will also be reliant of a series of commercials much like the Women’s Health intervention in order to reach the largest number of people. We will attempt to correctly apply Social Expectations Theory as well use Advertising Theory, Optimistic Bias and the Law of Small Numbers in order to produce the most effective campaign strategy. The target audience of this intervention are all women who are about become mothers and are physically capable of breastfeeding. My intervention techniques will positively enforce breastfeeding using stories that women can relate to and techniques that lead them to believe that breastfeeding is an expectation from all mothers.

Intervention 1- Proper Application of Social Expectation Theory

As mentioned in its critique Social Expectation Theory functions under the belief that norms outlined by society are the basis of how individuals determine what behavior is expected and acceptable in the environment in which they live. Social Expectations theory is a group level model which means that it attempts to make change by facilitating action amongst peer groups. Individuals can observe others in their environment participating in the positive behavior and follow suit whether or not their attitudes coincide with the actions they are taking.[17] Social expectations theory has been shown to be effective in several public health campaigns such as the use the seat belts in cars and the ban of smoking in Massachusetts bars and restaurants.[19]

In order to best use the Social Expectations paradigm with regards to breastfeeding we would focus on the positive health behavior that is expected of new mothers. Thus, rather than focusing on the disapproval one would receive for formula feeding their infant, the new campaign would focus on the respect and accolades one would receive for exclusively breastfeeding their child for six months. Our campaign would also emphasize the fact that the majority of mothers breastfeed with success, increasing the new mothers’ confidence that they could also complete this behavior.

The first series of advertisements of the new breastfeeding campaign would feature a variety of women from all different socioeconomic demographics breastfeeding children ranging from one to twelve months of age. Using a variety of women from different social demographic groups would emphasize the fact that individuals from all walks of life participate in this behavior. Enforcing the belief that breastfeeding is not specific to any particular group. We would show these actions occurring in a variety of “normal” places including at home, work, a park and other public places. The imagery would bring to light the fact it is easy and acceptable by society to breastfeed anywhere. All other individuals in the advertisement, who are present around the breastfeeding women, would have “Breastfed for X months” written on their shirts. The X would represent the number of months that the individual was supposedly breastfed. This would confirm that not only is it socially acceptable for new mothers to breastfeed but that also the majority of children are breastfed. Therefore utilizing the Social Expectations Theory in our campaign would encourage new mothers to believe that breastfeeding was the norm and increase the number of women who participate in this beneficial practice.

Intervention 2- Advertising Theory

Employing Advertising Theory to promote breastfeeding would significantly increase the effectiveness of the campaign. Advertising theory in public health implements the methods used by companies to sell products in endorsing positive health behaviors.[20, 21] Advertising theory uses print or TV media to tell a story with a promise of a positive health outcome and provide support, or evidence, for that promise. Both the promise and support are depicted through the imagery, dialogue or music in the advertisement, and attempt to elicit a response from the viewer based on their core values.[22] Core values can be defined as the deepest aspirations that individuals have, such as love, freedom, and independence etc. In the case of new mothers the proposed campaign will capitalize on the core value of maternal love and a mother’s desire to protect and nurture her child.[23]

Adoption of the Advertising theory is a more effective method of promoting breastfeeding than use of the Theory of Reasoned Action. The TRA believes that individuals behave in rational manner after weighing their personal beliefs and those of society, which has been demonstrated as an unsuccessful means of creating change in breastfeeding behavior. Advertising theory on the other hand capitalizes on the irrationality of individuals and the importance they place on their core values to effectively persuade them participate in positive health behaviors.[22] Unlike the TRA advertising theory does not rely on facts or statistics which are easy to disregard, but rather focuses on positive emotions to make promises that are easily relatable for the majority of people.[20]

The proposed campaign would also produce an advertisement in which mothers would we shown breast feeding their infants. The next shot would show the same woman twenty to thirty years later standing next to her son or daughter who in now the President of the United States, a famous scientist, or professional athlete etc. The promise of this campaign is that the benefits of breastfeeding are long reaching and promote development of the child so that they can grow up to accomplish great things. The support in these advertisements is provided the images of the aged mother standing next to her famous and successful child. The advertisement will be accompanied by a song that focuses on the beauty of the relationship between a mother and her child. This will emphasize the core value that is being expressed in the advertisement of maternal love. This commercial will provide essentially the same reasoning for breastfeeding as the Women’s Health campaign attempted with the use of the TRA, but this is more effective. Rather than stating bland facts, the new advertisement demonstrates the benefits of breast milk through compelling visual imagery. The use of advertising to convey a story, that takes advantage of core values and emotions of the audience, will lead to effective change in the perception of breastfeeding. This should result in an increased number of women participating in this positive health behavior.

Intervention 3- Utilizing Optimistic Bias and Law of Small Numbers

The final psychological models that the proposed campaign would utilize are the Optimistic Bias and the Law of Small Numbers. Optimistic bias theory states that when individuals are given facts and statistics about potential health risks they tend to believe that others fall within the risk but they are unlikely to be susceptible.[24] People generally over estimate the likelihood of positive outcomes and under estimate the chance of negative events. So individuals who are told that their children are at higher risk of disease if they are not breastfed are likely to consider this information more likely to be true for their peers rather than themselves.[25] Therefore, the information provided in the Women’s Health Campaign would be easily discredited by the viewer because they do not believe that they are susceptible to the harms outlined. Furthermore, the Law of Small Numbers explains that individuals are far more likely to believe a story told by one or a small group of individuals sharing personal experiences rather than a plethora of confusing statistics.[26]

The HBM provides facts and figures that attempt to explain the benefits and harms associated with breastfeeding. According to the Law of Small Numbers and the Optimistic Bias this method is ineffective in conveying information. Rather, it would be beneficial to provide an example of one woman who told her personal story regarding the positive impact that breastfeeding had on her child.[27] With this method it is possible to relay the same or even greater number of facts than presented in the Women’s Health campaign.

The new campaign would feature advertisements in which real mothers who had breastfed their children gave testimony to the fact that their children were far healthier than children who had been formula fed. Providing specific details about their experiences would make the stories seem more realistic and relatable for the target audience. This would in turn increase the validity of the advertisement. Utilizing a personal story, as suggested by the Law of Small Numbers, rather miscellaneous facts and statistics allows us to provide an increased amount of accurate information. Furthermore, this information is presented in a more appealing, relatable and effectual manner, and thus should persuade a greater number of women to breastfeed.

Conclusion

The new intervention is complete change from the campaign put forth by the Department of Health and Human Services. The proposed intervention attempts to make group level change utilizing Social Expectation Theory, Advertising Theory, and an understanding of the Optimistic Bias and Law of Small Numbers. Using these models allows us to put forth a campaign that is relatable and emotionally appealing for all women. It also emphasizes breastfeeding as a societal norm. Unlike the Women’s Health Campaign, our intervention does not rely on scare tactics, as those have been shown to be generally ineffective. This intervention attempts to modify behavior at the societal level, with an understanding that attitudes regarding breastfeeding will change as the practice becomes a usual occurrence amongst women.

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