Epidemiologic studies have proven the
numerous advantages of breastfeeding over using formula—including health,
nutritional, economic, social, immunologic, developmental, social and
environmental benefits (1). Breastfeeding reduces a mother’s risk of breast and
ovarian cancer and reduces a baby’s risk of ear, respiratory and
gastrointestinal infections, reduces rates of hospitalization, asthma, and
promotes maternal bonding and optimal growth (2).
Despite these known benefits,
breastfeeding rates after six –months and at one year of age are low, compared
to public health goals in the United States. The National Immunization Survey
of 2001-2002 estimates that more than 71.4% of children nationwide were
breastfed at some point; however, that rate drops to 16.1% by one year of age (3).
Unfortunately, these rates are lowest among individuals with the greatest risk
of poor maternal and child health outcomes: those women of low income, low
socioeconomic status, low educational attainment, and non-Hispanic black women
(3). With these disparities in mind, New York City developed a hospital-based
breastfeeding-only program, namely “Latch On”.
This program is a hospital-based initiative that focuses on
reducing distribution of promotional infant formula and a public awareness
campaign, to inform women of the benefits of breastfeeding (2). This public
health awareness campaign takes form in posters in subways and hospitals (2). The
program in New York City also asks that hospitals put away formula, take down
formula advertisements, and advertise the health benefits of breastfeeding
throughout the hospitals (2). It requires that new mothers ask for formula from
the nurses instead of being given promotional material automatically. Nurses
are required to discuss the benefits of breastfeeding with new mothers. By reducing
formula distribution and increasing knowledge about the benefits of
breastfeeding, the “Latch On” program intends to increase exclusive
breastfeeding rates. (2).
Currently 28 hospitals in the area have signed on to
participate. The initiative focuses on two main health beliefs—women need
accurate information in order to make the right decisions about breastfeeding
and through reduction in distribution of promotional formula, breastfeeding
initiation and duration rates will improve (2).
While the Latch On approach has many positive aspects to it,
which are backed by research and evaluation, the program has received a lot of
backlash from the public.
On Initiative even had to publish a “myths and facts” memo in order to quell
some of the many myths that had arisen surrounding the program. Some of the
myths included in this publication were: “formula was being put under lock and
key”, “formula feeding will be forbidden in some fashion”, and probably most
importantly, “Latch on NYC is taking away and/or jeopardizing a woman’s right
to choose how to feed her baby” (2).
In this critique, I will focus on three
aspects of the Latch On campaign that failed when considering social and
behavioral sciences. Firstly, the campaign assumes individual level factors are
sufficient to promote breastfeeding. Secondly, the Latch On campaign ineffectively
uses core values. Thirdly, the campaign does not use effective communications
strategies, including failure to avert psychological reactance.
Critique 1: Individual Level Factors are
Mayor Bloomberg’s Latch On Initiative assumes
that individual level factors are sufficient to promote change. This construct
led policymakers to create the Latch On Program, which provides information to
new mothers about the benefits of breastfeeding through posters, information
from hospital nurses and limits access to formula. However, the framework of
the social determinants of health explains how social and community influences,
living and working conditions, and general socioeconomic, cultural and
environmental conditions also influence health behaviors (4).
Interventions that focus entirely on
individual behavior change can be ineffective because they fail to consider the
cultural, sociopolitical and economic contexts of individual health experience
and behavior (5,6).
Even if women leave the hospital without
formula and a wealth of knowledge about the benefits of breastfeeding, individual
level interventions are not sufficient to promote change, as there are other
factors women face once they leave the hospital that may or may not allow them
to breastfeed. According to the literature, factors that influence the length
and duration of breastfeeding include employment status (7), social support,
self-efficacy, and breastfeeding experience (8). Assuming that informing women
that they should breastfeed and making formula harder to obtain in the hospital
setting does not in any way help women overcome these external factors. The
breastfeeding prevalence data reveals that these external factors are not being
considered. The major issue in the United States today is the continuation of
exclusive breastfeeding, not necessarily initiation. As the data shows, 71.4%
of children received breastfeeding initiation, which is a fairly substantial
percentile. The problem is the sustainability of breastfeeding—the breastfeeding
rate drops to 16.1% by one year of age (3). The American Academy of Pediatrics
highly recommends exclusive breastfeeding through the first six months and
continued breastfeeding through at least one year of age in order to ensure the
health benefits (1).
Ultimately, the flaw in this campaign is
assuming that individual level factors are exclusively influencing health
behavior—that is, women will breastfeed if they leave the hospital without
formula and with knowledge about the benefits. Breastfeeding is a very
difficult process and there are many barriers beyond simply those assessed in
considering only individual level factors, the Latch On program ignores the
context beyond the hospital setting; they assume that women choose not to
breastfeed because they don’t know the benefits. Stress, lack of social support,
and work schedules are just some of the contextual factors that play a role in breastfeeding
decisions (7,8). Ultimately, all women need support beyond the day of birth to
ensure adequate breastfeeding practices. Simply de-promoting formula use and
increasing knowledge are not sufficient.
Critique #2: Ineffective
Use of Core Values
The second critique of this campaign
is the use of health as the main core value. When developing a campaign, the core values of
the messages must be consistent with American values (9). Powerful American
values include individual freedom, freedom speech, and protection against
racial discrimination (9) and not health. Framing an issue accurately for
public approval is a very important component of public health campaigns (9).
In this particular campaign, the interventionists failed at framing Latch On
effectively to the public.
A public health frame is strong if
it has a strong core position, utilizes metaphors, catch phrases, symbols, and
most importantly, a powerful core value (9). The tobacco industry is one such
example of a campaign that has been very successful due to the nature of its
core values. Despite the known negative health consequences of smoking, cigarette
campaigns have been successful because they appeal to freedom, autonomy, individual
rights, and economic opportunity (9). Tobacco control campaigns that have
utilized the core value of health have been less successful (9).
To the left is a poster used in the
campaign (10). You can see here that the main core value used is health—breast
milk reduces a baby’s risk of ear infection, pneumonia, and diarrhea.
Throughout reading the promotional materials, I did not come across any
metaphors used in the campaign. The main symbol is the baby/infant, and the
catch phrases are “Latch On”, and “breast milk is best for you’re your baby”.
In the press release for this
initiative, the State Health Commissioner, Nirav Shah, is quoted as saying,
“Mothers who choose to breastfeed their baby are making a healthy choice for
their child and themselves” (2). The Latch On initiative is focused solely on
health as a core value, which ultimately is ineffective with the public. The
framing of this particular initiative created backlash because it did not
utilize core values that are important to Americans including freedom, justice,
and liberty (9).
Critique 3: Failure of Health Communication Strategies
On also failed at utilizing effective communication strategies including
failure to consider psychological reactance theory and failure to utilize an
particular initiative took away freedom by limiting new mother’s access to
formula. By putting away formula, and requiring that women request it from the
nurse, women felt that their individual freedoms were being limited. One particular
myth that spread rapidly was that the initiative was “jeopardizing a woman’s right to choose
how to feed her baby” (2). This type of reaction is a result of the
Psychological Reactance Theory, which states that any pervasive message may
cause an individual to feel that their personal freedom or personal choice has
been threatened (11,12). There are four main elements to psychological
reactance theory: freedom, threat to freedom, reactance and restoration of
freedom (11). In this case, the freedom is to receive formula in the hospital;
the threat is the removal of the formula; the reactance is the anger that results;
and the restoration of the freedom stage is when women go out and buy the
formula to reestablish their freedom.
This type of reaction has also been
referred to as the Boomerang Effect (12). Warnings, among other types of public
health campaigns, sometimes produce opposite effects of those intended (12, 13).
One particular example of a public health campaign that produced boomerang, or
opposite effects, is the minimum age for alcohol beverages (12). Research has
revealed that increasing the legal age for drinking to 21 years of age may
actually have increased underage drinking (12).
In public health, policymakers should
never limit individual freedoms if they want their interventions to be
successful (11). Taking away formula
only makes women want formula more, due to Psychological Reactance Theory.
reactance also may have occurred because of the lack of similarity of the
communicator to the targeted audience. Studies have shown that threats only
cause the boomerang effect when the communicator’s similarity was low or
unknown (14). When people are similar to the communicator, they agreed with the
message of the campaign, regardless of threat to freedom (14). Public health
campaigns can avoid reactance if they elect a communicator who is similar to
the targeted audience. The Latch On campaign does not employ these
communication principles. The messengers for this particular campaign are Mayor
Bloomberg, the Health Commissioners, and ultimately nurses and doctors. For
pregnant and nursing women, they need a spokesperson of whom is similar to
them—another mother or a peer. By using health officials and figureheads, the
Latch On program ideology was not relatable to their target audience. As a
result, their target audience—new mothers—rejected the program.
Introduction to New
I propose a new intervention to
replace the Latch On campaign, which I believe will eradicate the three areas
where Latch On failed—lack of consideration of factors beyond the individual in
determining breastfeeding outcomes, ineffective use of core values, and lack of
health communication strategies. Instead of focusing on knowledge and formula
access, New York City public health officials should focus on antenatal
breastfeeding support. The data shows that the greatest area of need is
breastfeeding continuation, with only 16% of women breastfeeding their babies
through year one in the United States (3). I propose allocating funding to antenatal
breastfeeding peer education and group support in New York City hospitals. This
particular intervention will resolve the three failures of the original
campaign, by considering the context of breastfeeding, not just individual
level factors; by utilizing effective core values including individual freedom;
and avoiding psychological reactance through providing choices and a messenger
similar to the audience.
Support #1: Breastfeeding
Support, Improving the Context
of focusing on individual level knowledge and access to formula, the Latch On
Campaign should improve antenatal breastfeeding support, through both support
groups and peer education. Social support is highlighted as one of the most
significant predictive factors of breastfeeding initiation and lengthened
duration among low-income women (8)—not knowledge or access to formula, as the
Latch On Program advocates. In this study on low-income women, breastfeeding
experience, self-efficacy, support from the father and support from a grandmother
were all statistically significant correlates to lengthened breastfeeding
duration and better outcomes (8). Support is imperative to breastfeeding
success long term, not simply knowledge.
Social support is powerful in public
health. One particular prenatal care intervention, namely the Centering
Pregnancy program, is one such example that employs social support as a
mechanism to improve outcomes. For Centering Pregnancy, group prenatal care
resulted in lengthened gestation and increased birth weight (15).
Relationship-centered care empowers women to advocate for themselves and others
and gives them a social network of who can serve as a safety net and a sounding
board. The Centering Pregnancy prenatal
model of group-centered support groups can be applied to the antenatal period
as well. The United Nations Children Fund and the World Health Organization published
the 10 steps to successful breastfeeding (16, 19). The tenth step is “foster
the establishment of breastfeeding support groups and refer mothers to them on
discharge from the hospital or clinic” (16). Breastfeeding support groups are
an imperative piece to improving breastfeeding outcomes outside of the
Breastfeeding peer counselors are another component of
antenatal support. Breastfeeding peer
counselors are defined as “local community women who have
experienced breastfeeding success, have been trained in breastfeeding
management, and work with women of similar cultural, demographic, and socio-
economic characteristics to promote positive breastfeeding outcomes” (17). Training women to aid other women with
breastfeeding practices has been employed and effective in a variety of
developing countries, but few in the United States (17, 20, 21). A literature
review conducted by the National Institutes of Health revealed that
breastfeeding peer counselors improve breastfeeding initiation, duration, and
exclusivity and decreased rates of infant diarrhea (22). Studies have also
concluded that breastfeeding peer counselors are effective with low income,
minority women, who have some of the lowest rates of breastfeeding in the
United States (17).
Combining the principles of peer
education and group-centered support could help improve breastfeeding outcomes—especially
for women who might not have the best context—perhaps without a supportive
partner, family, safe neighborhood, among others. The creation of antenatal support
groups and peer counselors could help improve breastfeeding outcomes through
improving self-efficacy, knowledge, and social support for mothers. Women who
are supported in their breastfeeding process will more likely succeed in
persevering through the trials and tribulations of parenting and ultimately
have a better chance of breastfeeding through the first year of their child’s
life. Instead of taking away formula and focusing on knowledge, funding in New
York City should be allocated to antenatal breastfeeding support. Instead of putting away formula, nurses could
offer a breastfeeding peer educator and/or group-centered support for women in
each hospital in New York City. Immediately from the start, new mothers could
have a support system that is offered to them in the hospital immediately when
their baby is born. If framed and marketed effectively, this new program could
be very effective.
Support #2: Effective
Framing and Use of Core Values
health as the main core value was entirely ineffective in the Latch On
Campaign. As a result, we need to re-frame and re-package the new breastfeeding
peer counseling campaign. Public health officials need to frame this campaign
as a women’s choice, not a loss of freedom. Freedom and liberty are powerful
core values in the United States (9), thus, any such campaign that takes away
freedoms (i.e. takes away formula), will be ineffective (11,14). In addition to
using powerful core value, public health officials need to employ effective
metaphors, symbols, and catch phrases in the new frame.
Instead of framing health as the
core value, employing liberty and justice as core values could be effective.
Formula companies can be packaged as the enemy—their promotional strategies are
infringing upon a mother’s right to choose between breastfeeding and formula.
Because every hospital is covered in advertising and mothers are given formula
right from the start, women are not given the opportunity to choose whether they
want formula or not. Women have the right to reject the promotional strategies
of formula corporations, and choose whether they want to breastfeed or not. It
is one’s civil liberty to decide how they will feed their children and formula
companies, like tobacco companies, are targeting new mothers, without the well
being of their babies in mind. Women can make the choice to choose the peer
educator and group support over formula. The “the evil formula companies” frame
employs the core values of freedom and justice, which are more effective core
values than the heath frame used in the Latch On campaign.
Metaphors, Symbols, and
order to make this new frame truly effective, public health officials need to
create metaphors, symbols, and catch phrases to support the frame. Metaphors
and symbols should be recognizable and important to the American public in
order to be effective (9). Some potential catch phrases examples include:
mom’s back in charge”
“Taking the profit out of birth”
“It is our civil right to protect our
“Take control of your baby’s outcomes.
Work with a breastfeeding peer educator”
“She’s been through it before. She can
help you get through it, too.”
Some important symbols to employ are
pictures of all kinds of women who serve as breastfeeding educators—of varying
ages, ethnicities and races--in order to appeal to the entire NYC population of
women. Posters should be available in multiple languages and focus on women’s
rights and self-empowerment.
This campaign will be more
successful than Latch On because of the reframing, use of more effective core
values, and appeal to the audience at risk.
Support #3: Using Effective
The new campaign reduces psychological
reactance because women have options. They have the option to choose between
formula, or a peer educator and support groups. Giving women the option to
choose increases their freedom, instead of decreasing it. By giving women
options, psychological reactance is avoided. Women have the option to choose
formula, but they also have the option to work with a breastfeeding peer
educator and enroll in a breastfeeding support group.
Similarity of the messenger to the
audience is an important component of avoiding psychological reactance (14).
Breastfeeding peer educators work with women from their own community, who are
similar to them in cultural, demographic, and socio-
economic characteristics (17). Because this program utilizes peers, who
are similar to the women they serve, psychological reactance is also avoided.
Another pitfall of the Latch On campaign
was using the Health Commissioner and Mayor as the spokespeople for the
campaign. Given the nature of psychological reactance, the spokesperson for the
new campaign should be a mother who breastfeeds, who is relatable to the
audience. Having a celebrity endorse a campaign makes it newsworthy and often
more effective (18). It could be potentially effective to use a celebrity
mother as the spokesperson for this new campaign in New York City.
The Latch On campaign, although well
intentioned and backed with research, did not consider the predictable
irrationality of human behavior and social and behavioral sciences. The program
fails in three main ways. Firstly, breastfeeding outcomes are not attributed
solely to individual level factors. Stress, lack of social support, poverty,
working conditions all are factors that influence breastfeeding (8)—not simply
knowledge. Secondly, the program uses health as a core value, which is very
weak (9). Thirdly, the campaign produces psychological reactance, due to the
limiting of access to formula and the dissimilar spokespeople.
A potentially effective intervention
for the low breastfeeding rates at 6 months and one year is breastfeeding peer
counselors and group support sessions. Funding should be allocated to training
breastfeeding peer counselors and organizing these group sessions. Nurses in
hospitals should offer this program to all new mothers in the obstetrics
department. This way, women can leave the hospital with a support system that
can help them breastfeed. This type of program is backed by a variety
research—peer educators and group support sessions are successful at improving
initiation and duration of breastfeeding outcomes (16, 17, 20, 21, 22).
This new campaign corrects the errors
made by the Latch On Campaign, through the use of social and behavioral
sciences. Breastfeeding peer counselors and group support groups will resolve
the three failures of the original campaign, by considering the context of
breastfeeding, not just individual level factors; utilizing effective core
values including individual freedom; and avoiding psychological reactance
through providing options and a spokesperson who is similar to the targeted
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Labels: Aging and Health, Breastfeeding, Health Communication, Maternal and Child Health, Nutrition, Red, Women's Health