Saturday, December 15, 2012

Breastfeeding-Promotion Requires Acknowledgement of Perceptions of and Barriers to Control: A Critique of the “Latch On NYC” Initiative – Marita Hatton

Several national and international institutions have championed the issue of breastfeeding for its short-term and long-term health benefits to both mothers and infants (1-2). The positive immunological and anti-inflammatory properties of breastmilk are well supported by research in the field and can contribute to a lower risk of certain kinds of infections in infants, such as ear, gastrointestinal, and respiratory infections (1). Health benefits for breastfeeding mothers include a lower risk of certain cancers, such as ovarian cancer (1). In addition to the health benefits, experts also tout the psychosocial (i.e., bonding), economic, and environmental benefits of breastfeeding (1). Economic benefits include not only the direct benefit related to averting the significant cost of formula, but also long-term indirect benefits of lower health care costs as a result of reduced illnesses and improved health conditions for mother and infant (1). The benefits of breastfeeding are generally proportional to the duration of breastfeeding, and the WHO recommends a goal of exclusive breastfeeding for at least the first 6 months and continued breastfeeding up through 2 years (2).
In many developed and developing countries, breastfeeding rates and durations have declined due to a variety of cultural and economic reasons (2). In the US, rates of breastfeeding have increased since the 1970s, when the proportion of women breastfeeding was at an all-time low, but the prevalence of breastfeeding at different times in an infant’s first year of life is still lower than the Healthy People 2010 goals (1). In May 2012, Mayor Michael Bloomberg and the New York City Health Commissioner Thomas Farley announced the “Latch On NYC” initiative to boost rates and durations of breastfeeding within the city (3-5). The initiative had two main components: a request for NYC hospitals to pledge to limit certain formula distribution practices, and a public awareness campaign regarding the health benefits of breastfeeding (4). Specifically, hospitals pledged to enforce NY State’s hospital regulation of only supplementing breastfeeding infants with formula when medically indicated and documented in the medical record, to restrict and track infant formula distribution, and to end the distribution and display of promotional infant formula materials (3). Although this initiative incorporated several of the goals in WHO’s “Ten Steps to Successful Breastfeeding,” it failed to consider the impact of a presented threat to a woman’s choice of whether or not to breastfeed, the barriers to perceived control of breastfeeding success, and the cultural norms surrounding breastfeeding in NYC (2). In light of these critical issues, the Latch On NYC initiative is limited in its potential for success as a public health intervention.
Critique #1: Latch On NYC Presented a Perceived Threat to a Woman’s Choice
One highly visible flaw of the Latch On NYC campaign is that it generated a very vocal and polarized reaction in the popular press, especially among female journalists and bloggers (7-11). Articles with titles such as “Sucking the choice out of parenting” and “Back Off of the Mamas, Mayor Bloomberg!” clearly depict some of the outrage in response to the announcement of the initiative (7-8). Such potential for negative responses could have been predicted if considering the Theory of Psychological Reactance (6). This theory, as posited by Jack W. Brehm in the 1960s, describes how people often react to a perceived threat to freedom or choice by explicitly taking an action that reinstates that freedom (6). If, for example, a person had three possible choices of how to spend their time on a given afternoon, if one of these choices is suggested to be taken away, it actually increases the person’s interest in that option, as they are motivated to reestablish the freedom of choice they had previously experienced. Thus, the person is effectively resistant to the persuasive suggestion and can be pushed toward an opposite stance. Brehm describes how individuals will demonstrate more of the negative reactance response if a large portion of their choices are threatened or eliminated, or if the threat has a substantial likelihood of being carried out (6). He also delineates how justification and legitimacy can help to mitigate the reactance response, as long as the reasons are sufficiently compelling (6).
Unfortunately, the focus of the Latch On NYC campaign on formula distribution practices in hospitals implied a direct threat to a woman’s choice of whether to breastfeed or formula-feed her newborn. Many female journalists in particular responded with outrage to this perceived threat to freedom, and others responded by championing the right to formula-feed and emphasizing the practical benefits (7-8, 12). This psychological reactance was further exacerbated by the impression of Mayor Bloomberg as having radical health policies and by the fact that the message came from the Mayor and the NYC Health Commissioner, both of whom are men and thus could have no direct experience with the factors and difficulties associated with the decision to breastfeed. One journalist wrote “We can’t imagine the mayor making these decisions for us…because obviously they’re none of his business” (7). Reports that the mayor was requiring hospitals to keep formula under “lock and key” implied the very real and severe threat to choice that Brehm emphasized as stimulating high levels of reactance (6-7). The attempts to use justification based on the health benefits of breastfeeding failed to be compelling because they came from men, and again the impact was high levels of psychological reactance (6, 8).
The Latch On NYC campaign attempted to address the public display of reactance by publishing more documentation on the initiative and creating a “Myths & Facts” document to try to address some of the negative press (5). However, as journalists and bloggers continued to emphasize, the program was trying to revoke some of the inflammatory wording, such as “lock and key,” while the key program components on restricting access to formula remained (13). In reality, these after-the-fact messages have had little power to influence the public perception of the initiative following the vocal outrage. Because it failed to recognize the significant potential for psychological reactance to the message, the Latch On NYC initiative is severely hampered in its ability to affect change in the rates of breastfeeding.
Critique #2: Latch On NYC Did Not Address Barriers to Perceived Control of Breastfeeding
            Although the WHO and the Baby Friendly Hospital Initiative emphasize important breastfeeding-promoting practices in hospitals and other maternity facilities (2, 14-15), and this was the emphasis of the Latch On NYC campaign, practices in these environments are only influencing the very beginning of breastfeeding. In light of the struggle for continued duration of breastfeeding beyond the hospital, other experts and US agencies also stress the barriers and perceived barriers that exist outside of the hospital environment (1, 16). The US Surgeon General’s report lists barriers that include poor family and social support, embarrassment and lactation problems, and issues with employment and child care, in addition to the barriers related to health care services (1).
Perceived behavioral control is an element described in the Theory of Planned Behavior, or TPB (17). The TPB is an individual-oriented health behavior theory that was developed to assess ones attitudes toward health behaviors and their resulting behavior intentions and actions. In the precursor model, the Theory of Reasoned Action, the key components influencing a person’s reasoned decision to act in a certain manner include their attitudes toward the expected outcome and the social norms regarding others’ perception of the behavior (17). The TPB builds on this precursor model in that it recognizes that real-world barriers can interfere with an individual’s ability to act in a certain way, even if that individual has very strong intention and motivation toward that behavior. Circumstances may severely limit the ability of an individual to achieve that behavior, as in the case of transportation issues prohibiting someone from seeking proper preventative medical care for a chronic disease. In the TPB, the element of perceived behavioral control includes what an individual believes about factors that will limit or enable her, as well as how much power that individual believes she has to overcome such barriers to action (17).
Perceived behavioral control and self-efficacy, or the confidence in an ability to perform a behavior, have been demonstrated as important elements in health-related behaviors such as seeking screening for skin cancers or successfully achieving a vaginal delivery (18-19). In the case of breastfeeding, women can have many perceived and actual barriers to control of realizing successful behavior. Mistry et al. describe the multi-faceted social, economic, and cultural determinants of early childhood health that are in place in the workplace, home, health care, family, neighborhood, and religious institutions and the ways these can be influenced by both private and public sector policies and programs and by strengthening the capacities of families and communities (16). The USDA’s Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), which provides nutritious food to low-income pregnant women and young children, underwent several changes in 2009 that incentivized especially exclusive and also partial breastfeeding (20). These public policy changes, combined with extensive participant education to support breastfeeding, were successful in improving the rates of exclusive breastfeeding at 2 and 6 months in a study in California (20), highlighting the success of strategies that aim to eliminate financial barriers.
Several studies also emphasize the importance of the workplace environment in facilitating successful breastfeeding (21-23). Exclusive breastfeeding rates are persistently low among women who work full-time (21), a reflection of barriers related to time, workplace facilities, and economics, among others. In the US, the Family Medical Leave Act guarantees 12 weeks of job-protected unpaid leave (16), whereas in countries such as Canada, recent changes improved on a compensated job-protected maternity leave of 6 months to up to 1 year in most provinces (23); the benefit improvement resulted in an additional 40% of women achieving the goal of exclusive breastfeeding at 6 months. Letters to the Editor in the New York Times and research studies interviewing women describe hostile workplace environments that are not supportive of women who need time and space to pump in order to sustain breastmilk after returning to work (11, 22). Such workplace barriers involve actual time and space issues, especially for women in administrative or manual positions, but they also involve the perceived control over such situations, which is something that can be addressed through proper coaching and supportive breastfeeding education (22).
Although the Latch On NYC initiative had purported aims to increase the duration of breastfeeding, it did not provide solutions outside the hospital environment, including in the workplace. As a result, women still have a perceived lack of control over some key factors influencing their ability to successfully exclusively breastfeed up to 6 months. Because the initiative does not give women this necessary control, its potential to achieve the targeted durations of breastfeeding are considerably hindered.
Critique #3: Latch On NYC Did Not Address Cultural Norms Surrounding Breastfeeding in NYC
Although the health benefits of breastfeeding are widely known in the US, the social and cultural norms are often not conducive to breastfeeding. Reports have described how public perception is not receptive to breastfeeding in public in many situations (1, 11, 25-26). Breastfeeding mothers are quite sensitive to their appearances when needing to breastfeed in public (26). There are instances when women are asked to leave or refrain from breastfeeding in public locations (27). Additionally, studies describe how ridicule from friends and family and unsupportive health care providers can also frame and dominate the social and cultural context of breastfeeding (25). In the US, despite the efforts to educate the public of the health benefits of breastfeeding, bottle-feeding is still viewed by many as the accepted social norm (1).
DeFleur described in his Cultural Norms Theory how an individual’s behavior is usually strongly influenced by social or cultural norms, and in turn how the media can be used to influence and change the social norms (24). Norms are described as the “general rules that are understood and followed by all members of a group” (24). Individuals that fail to adhere to these norms are subject to negative sanctions and may feel like social outcasts (24). In the case of breastfeeding, the cultural norms in large US cities like NYC dictate that breasts should not be visible when breastfeeding in public, or in some cases taken further to mandate that it should not be at all obvious that one is breastfeeding or even that it should not take place at all in public (11, 25-26). Even if workplaces provide a private space to breastfeed or pump breastmilk, coworkers, especially males, can portray negative reactions before or after, making breastfeeding women uncomfortable (22). Finally, these social pressures can persist even among family and friends, wherein a woman is uncomfortable when needing to breastfeed at another’s house. The influence of social norms can be so significant that a woman might stop breastfeeding to avoid social stigma, even if she feels great guilt and deprivation from the knowledge that she is potentially negatively impacting the health or enjoyment for herself and her infant (25). The fact that a threat of social sanctions outweighs the guilt over breastfeeding cessation illuminates the power of social norms and emphasizes their important place under consideration in public health interventions.
Despite its goal to lengthen the duration of breastfeeding among women giving birth at NYC hospitals, the Latch On NYC initiative failed to consider that cultural and social norms are a key factor influencing the continuation of breastfeeding beyond the hospital environment, and that currently such norms can discourage breastfeeding behaviors. The only widespread public ads included in the initiative were posters displayed in subway stops depicting the health benefits of breast milk versus formula (4). Such ads focus on education and do not address the cultural norms of breastfeeding in NYC. A well-rounded campaign that incorporates media components aimed at shifting cultural norms of breastfeeding would have a much greater chance of success in achieving its goals.
Proposed Intervention
            If a different US city aimed to achieve goals of increased breastfeeding prevalence and duration, they could certainly learn from the shortcomings of the Latch On NYC program to develop a similar intervention but one with a much greater likelihood of achieving successful outcomes. My proposal for such an intervention would incorporate several key strategies. First, to avert psychological reactance, the initiative would have a visible female leader and would emphasize the goal of supporting breastfeeding mothers, while simultaneously limiting the impression of being an anti-formula initiative (29). The initiative would still incorporate a call-to-action for hospitals, but it would ask them to pledge to help breastfeeding women by upholding state regulations to support women seeking exclusive breastfeeding, unless medically indicated and recorded in the medical chart (a statement that does not explicitly mention formula at all). A hospital-based education component for mothers undergoing prenatal and postnatal care would still be vital to provide these women with the information they need to succeed. In addition, to address the perception of workplace barriers to control of breastfeeding action, the revised initiative would include a call-to-action to employers (21-23). This would ask employers to also pledge to help breastfeeding women, by providing private and clean rooms for breastfeeding or pumping and by accommodating women with the time to take at least two 20-minute breaks for breastfeeding or pumping within a workday. Taken one step further, the workplace component could also create a Baby-Friendly Workplace recognition system that awards employers with gold, silver, or bronze qualifications based on a variety of breastfeeding-promoting benefits such as compensated maternity and/or paternity leave, lengths of job-protected leave available, accommodations such as part-time, flexible, or work-from-home hours, and physical facilities and time allotted for breastfeeding or pumping breaks. This system would provide clear recognition for businesses that excel in these categories and motivation to improve benefits and the workplace environment. Finally, to begin to influence the cultural norms surrounding breastfeeding, the advertising campaign would focus less on the health benefits and more on ways to shift cultural perceptions of where breastfeeding can take place. For example, ads would use visual images of breastfeeding women and statements such as: “You have decided to breastfeed your baby, and these city employers will support you along the way,” or “You have decided to breastfeed your baby, and you are free to do so in all city-owned public parks and facilities.” Social media strategies and partnerships with so-called “lactivists” would help to further shift cultural norms through mass gatherings of breastfeeding women in public spaces to focus media and public attention on the issue of breastfeeding acceptance and norms (32).
Defense #1: Proposal would Limit Perceived Threat to a Woman’s Choice
The described proposed intervention would use similarity to limit psychological reactance and framing to focus the issue so as to limit the perceived threat to a woman’s freedom of choice over whether or not to breastfeed (29, 33). This would represent a marked improvement over the Latch On NYC initiative, which instigated an outcry that was completely predictable according to Brehm’s theory on the reaction to a threat or elimination of choice (6). Brehm described how reactance could be mitigated through compelling justification or legitimacy (6). Silvia emphasized the potential for similarity as a tool to create legitimacy and thereby mitigate reactance (29). The lack of similarity was plain and apparent in the Latch On NYC campaign, but the proposed use of a female advocate, especially one who does not appear self-righteous in her promotion of breastfeeding, is a simple way to make considerable strides with regards to similarity. Within the concept of similarity, Silvia describes how liking the messenger can help to improve reception of and compliance with the message (29). Here, choosing a woman who has perhaps herself struggled with breastfeeding due to issues of support would help to improve her likability and the ability of other women to relate and thus respond.
The perceived threat to freedom of choice can also be potentiated through the use of framing tactics (33). Framing represents a powerful mechanism to highlight how a proposed behavior aligns with strong core values (33, 34). The Latch On NYC initiative created trouble when it described placing limits on formula distribution, which directly relays a threat to a woman’s infant feeding options and control (4, 7). Careful initiative wording and promotional materials would ensure that the intervention is described less as a breastfeeding-vs.-formula battle and more as a women’s rights and breastfeeding support initiative. An increased emphasis of the educational component provided by hospitals and lactation consultants to educate and assist women with the initiation and continuation of breastfeeding will provide further framing of the initiative as one that will help mothers to achieve control rather than limit their choices. This aligns with the views of Gallagher et al., who describe positive and gain-framed messages as having a much greater likelihood for success at impacting attitudes and behavior (34), especially for preventative health behaviors. Taken together, these components of the proposal would reduce the perceived threat to a woman’s freedom of choice over whether or not to breastfeed.
Defense #2: Proposal would Address Perceived Workplace Barriers to Control of Breastfeeding Action
Through its substantial efforts emphasizing the workplace environment as well as the hospital environment, the proposal would tackle the issue of perceived barriers to control of breastfeeding action, as employment and workplace factors represent a significant unaddressed barrier cited by many women (11, 21-23). Simply vocalizing the issue of workplace practices in support of breastfeeding may help companies to come forward and may help women to feel more confident in facing the obstacles associated with returning to work after a maternity leave and trying to maintain breastfeeding. According to the TPB, this could feed into the element of perceived behavioral control by increasing the amount of power an individual believes she has to overcome such barriers to action (17). It has been shown that supportive breastfeeding education, especially focused on strategies for maintaining breastfeeding after returning to work, can help to improve a woman’s perceived control over such situations (22).
In addition to giving women have an increased sense of power over the situation, the Baby-Friendly Workplace recognition system could motivate companies to actually change and improve the real workplace barriers to breastfeeding, such as allowing appropriate time and space for women to breastfeed or pump breastmilk while at work and providing improved maternity and paternity leave policies or flexible work options. Improving the length or compensation of job-protected leave has been definitively identified to improve the rates of sustained breastfeeding at key timepoints, such as the 6 months recommended by WHO (2, 23). Making concrete improvements to at-work facilities would also further improve the perceived control of continuing breastfeeding after returning to work (17). These measures would help to create changes in a key environment that women often cite as being a barrier to achieving continued breastfeeding for the recommended durations (11, 22) and would address the perceived workplace barriers to control of breastfeeding action (35).
Defense #3: Proposal would Start to Shift Cultural Norms Regarding Breastfeeding
By embracing an advertising focus on a topic other than the health benefits of breastfeeding and partnering with social media strategists to promote the awareness of breastfeeding in public, the proposal includes components that start to shift the prevailing cultural norms surrounding breastfeeding (1, 11, 25-26). This is in recognition of the fact that social pressures are strong and can outweigh inner pressures of guilt or regret (25). Interventions that try to address cultural norms also have an advantage in that they seek to change the actions and behaviors of many people at the same time, rather than focusing one-by-one on individuals, and so they could potentially create change much more rapidly by encouraging people to “follow the herd” (28). Media and advertising can be used to accomplish such goals of influencing social norms (24), and the ads included in the proposed initiative try to achieve this by focusing less on health beliefs of breastfeeding and more on the normalcy of breastfeeding in public. Breastfeeding activists, or so-called “lactivists,” embrace the importance of social norms and try to shift cultural views by using public displays of breastfeeding, and such group events or “nurse-ins” have been carried out in the US and abroad (27, 31-32). In recognition of the potential impact of such events, the proposal includes plans to partner with lactivists using such staged group events or social media to shift the cultural norms. Taken together, these strategies try to combat the issue of social norms regarding breastfeeding and give the proposed initiative much stronger footing compared to the NYC initiative.
Upon careful examination, the Latch On NYC campaign was shown to have critical flaws in that it failed to consider the psychological reactance to a perceived threat to a woman’s choice, the perceived and actual workplace barriers to a woman’s control of breastfeeding success, and the cultural norms surrounding breastfeeding in NYC. Although these flaws limit the potential for success for this initiative, they illuminate the possibilities for improvement in a redesigned health intervention proposal designed with the same goal: to increase the rates, exclusivity, and duration of successful breastfeeding. The redesigned intervention uses similarity and framing to mitigate the perceived threat of control, awareness and motivation to promote changes in workplace barriers to breastfeeding, and advertising and public activism to shift the cultural norms.  By addressing the shortcomings and failed assumptions of the flawed intervention, the redesigned proposal has a much greater chance to affect change in US breastfeeding practices.

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