Challenging Dogma

...Using social sciences to improve the practice of public health

Friday, April 27, 2007

Why the National Breastfeeding Awareness Campaign will not Increase Breastfeeding Rates: A Critique Based on Social Cognitive Theory– Lauren R. Pino

Warning: Public health officials have determined that formula feeding is hazardous to your baby’s health.
There is no warning label like this affixed to cans of infant formula or tucked into the corner of magazine advertisements, at least not yet. Nevertheless, that is the explicit message of the National Breastfeeding Awareness Campaign (NBAC). In 2004, the Department of Health and Human Services Office on Women’s Health and the Ad Council launched a $40 million dollar national campaign encouraging first-time mothers to breastfeed exclusively for six months. With the tag line: “Babies were born to be breastfed,” this ongoing campaign aimed to empower women to commit to breastfeeding and to highlight research supporting the health benefits of breastfeeding. The NBAC employed communication techniques through a variety of channels, including public service announcements for television, radio, newspapers, magazines, mass transit, billboards and the Internet in an effort to increase breastfeeding rates. For example, the television announcements featured pregnant women engaging in dangerous sporting events, such as roller derby, with the voiceover: “You’d never take risks while you’re pregnant. Why start when the baby’s born? Babies who are exclusively breastfed for 6 months are less likely to develop ear infections, diarrhea, respiratory illnesses, and may be less likely to develop childhood obesity.”
According to the National Immunization Survey (2005), 21 states in the United States achieved the national Healthy People 2010 objective of 75% of mothers initiating breastfeeding; whereas 5 and 11 states achieved the objective of having 50% of mothers breastfeeding their children at 6 months of age and 25% of mothers breastfeeding their children at 12 months of age, respectively. Only 5 states — California, Hawaii, Oregon, Vermont and Washington — achieved all three of these Healthy People 2010 objectives (1). However, the American Academy of Pediatrics (AAP) recommends that an infant be breastfed without supplemental foods or liquids for the first 6 months of age (known as exclusive breastfeeding). Only one state — Oregon — achieved an exclusive breastfeeding rate of 25% or greater through 6 months of age. Apparently, the vast majorities of women in this country do not attempt to breastfeed or cease breastfeeding much earlier than the Academy of Pediatrics recommends. Why is this so? NBAC supporters believe that women bottle-feed because the general public assumes that infant formula is comparable to breast milk. However, according to the Centers for Disease Control HealthStyles Survey (2005), only 26.4% of respondents agreed that infant formula is as good as breast milk and 49.1% agreed that babies should be breastfed for at least six months (2). Contrary to the NBAC’s beliefs, the general public is aware of the benefits of breast milk over formula and many pregnant women intend on breastfeeding once their child is born. This illustrates that the act of breastfeeding depends not only on women’s knowledge, desire or intention to breastfeed, but also on additional internal and external factors. Numerous studies attest to this fact. O’Campo and colleagues examined the psychosocial, demographic, and medical factors associated with longer breastfeeding duration among 198 urban breastfeeding women (3). Of 11 psychosocial and demographic factors examined, the following 4 were the most significant influences on breastfeeding duration: normative beliefs, maternal confidence, social learning, and behavioral beliefs about breastfeeding. Clearly, multiple factors disrupt the intention—behavior pathway. However, the NBAC, like countless other breastfeeding promotion campaigns of its kind, neglects to consider this reality. The NBAC public service announcements previously described disregard self-efficacy and observational learning as significant factors affecting a woman’s decision to breastfeed. Finally, the NBAC shows no appreciation of the numerous social barriers to exclusive breastfeeding. Such barriers include: work environments with inadequate breast pumping areas and lack of support at home.
The NBAC will continue to fail because it does not consider the effect of self-efficacy on behavior. Bandura (4), who coined the term, defined an efficacy expectation as “the conviction that one can successfully execute the behavior required to produce outcomes.” Further, Bandura asserts that “outcome and efficacy expectations are differentiated, because individuals can believe that a particular course of action will produce certain outcomes, but if they entertain serious doubts about whether they can perform the necessary activities such information does not influence their behavior” (5). In his definition, Bandura clearly draws distinctions between perceptions of self and perceptions regarding the recommended behavior. Social science research supports Bandura's claim that when self-efficacy is low, people rarely attempt behavior change (5).
Further, self-efficacy judgments help determine not only whether we undertake particular activities, but also, the amount of effort we put into them, and the length of time we persist in striving for goals in particular situations (6). Therefore, a new mother with low self-efficacy will not attempt to breastfeed even if she believes that breastfeeding is best for her child. As such, if the new mother does attempt to breastfeed, it is highly unlikely that she will continue to do so exclusively for six months. For that reason, breastfeeding messages should not merely tell new mothers the risks of not breastfeeding, but rather, bolster their beliefs that they can successfully breastfeed. Techniques for bolstering self-efficacy include showing women that they are capable or demonstrating that breastfeeding exclusively for six months can be accomplished.
Additionally, Bandura asserts that somatic and emotional states such as anxiety, stress, arousal, and mood states provide information about efficacy beliefs (7). People can gauge their degree of confidence by the emotional state they experience as they contemplate an action. Strong emotional reactions to a task provide cues about the anticipated success or failure of the outcome. When they experience negative thoughts and fears about their capabilities, those affective reactions can themselves lower self-efficacy perceptions and trigger additional stress and agitation that help ensure the inadequate performance they fear (7). Thus, the NBAC will continue to fail because the campaign attempted to manufacture and exploit fear among new mothers. When new mothers associate uncomfortable images (log-rolling, bull-riding, etc.) and dismal clinical terms (ear infections, diarrhea, respiratory illnesses, etc.) with breastfeeding, they will be less likely to breastfeed.
Observational Learning
Moreover, Bandura affirms that people retrieve efficacy information by watching others, especially during times of uncertainty (8). Bandura contends that observation of behavior often outweighs verbal instruction as an influence on self-perceptions of competence and the internalization of morals and standards. However, people do not passively absorb all the standards of behavior to which they are exposed. Instead, the standards that are internalized are dependent on the degree to which the model is like oneself, the value of an activity, and one's perception of their degree of personal control over the behavior (8). Therefore, the public service announcements featured in NBAC that display physically fit, pregnant white women engaged in ridiculous stunts are not effective interventions if the primary goal of the campaign is to increase breastfeeding rates among women of color. Moreover, how could any woman, regardless of race, relate to images of women log-rolling? To increase breastfeeding rates in this country, public service announcements should include scenes of women incorporating breastfeeding into their daily routine. For example, images of a woman doing something one-handed while nursing her baby with the other, or of a woman nursing in her office before a meeting would have been influential models for women to emulate.
Social Challenges
The National Immunization Survey revealed that in 2005 a mere 8.8% of unmarried and 10.3% of socioeconomically disadvantaged women (pov-inc ratio< href=""> offers women an ample amount of breastfeeding support regardless of their social situation. I agree that the website offers practical advice concerning the physical challenges of breastfeeding (engorgement, sore nipples, etc.), however, the website halfheartedly addresses the social challenges for women, especially single mothers and the socioeconomically disadvantaged who do not have the comfort of living in a supportive, nurturing environment. For instance, under the heading Coping with Breastfeeding Challenges, the website encourages women to, “take as much time off work as possible, since it will help you get breastfeeding well established and also reduce the number of months you may need to pump your milk while you are at work” (9). How would a single mother, earning hourly wages, struggling to pay the bills benefit from that advice? Is she even guaranteed a quiet, comfortable office at work where she can pump in peace? Although the answers to these questions are quite obvious, proponents of the NBAC appear oblivious to these issues. Furthermore, although 35% of mothers in our society are single, the website encourages women to look to their baby’s father for social support (1). Under the heading, Feeding at Home, the website claims, “Fathers can play a major role in the breastfeeding experience by being sensitive to the mother’s needs and encouraging breastfeeding when the mother is feeling tired or discouraged”(9). Clearly the NBAC’s ignorance and overall disregard for the social challenges specific to these groups of women will lead to the campaign’s ultimate failure.
Final Thoughts
As public health professionals, it is critical that we address self-efficacy, observational learning, and social challenges as moderators in the pathway between intention and behavior. The NBAC, like so many other maternal and child health campaigns, is failing as an effective public health intervention because it did not integrate behavioral science theory into its campaign design.
1. Centers for Disease Control and Prevention. National Immunization Survey. 2005.
2. Centers for Disease Control and Prevention. HealthStyles Survey. 2005.
3. O'Campo P, Faden RR, Gielen AC, Wang MC. (1992) Prenatal factors associated with breastfeeding duration: recommendations for prenatal interventions. Birth. Dec;19(4):195-201.
4. Bandura. A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84, 191-215.
5. Bandura, A. (1978). The self system in reciprocal determinism. American Psychologist, 33, 344-358.
6. Bandura, A. (1997). Self-efficacy: The exercise of control. New York: Freeman Press.
7. Bandura, A. (2001). Social cognitive theory: An agentive perspective. Annual Review of Psychology, 52, 1-26.
8. Bandura A and Jourden FJ. (1991) Self-regulatory mechanisms governing social comparison effects on complex decision-making. Journal of Personality and Social Psychology, 60: 941-951.
9. Office on Women’s Health. The National Breastfeeding Awareness Campaign. The U.S. Department of Health and Human Services. Washington, DC.

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