The Dangers of ‘Fat Shaming’ and Parent-Child Interventions: Rethinking Obesity Interventions- Emily Hall

There is no denying that obesity has become a public health epidemic that needs immediate attention, especially among America’s youth. Currently, 1 in 3 children ages 11-19 are overweight or obese and nearly 1 in 6 children are obese with a BMI above the 95^th percentile of the CDC’s recommended growth charts (1). Overweight and obese children are at an increased risk for many health conditions such as cardiovascular disease, type-2 diabetes in addition to various psychological problems related to the social stigma of being overweight (2- 241S). It is also likely for many children that these health problems will continue into adulthood: overweight children have a 70% chance of becoming obese adults, which rises to 80% if 1 parent is overweight or obese (1).

In order to counteract this dangerous trend, several public health organizations have designed interventions to highlight how parental obesity is related to childhood obesity. However, many of these programs rely on a tactic known as ‘fat shaming’ which relies on the stigma against obesity as motivation for children (and their parents) to adopt healthier lifestyles and lose weight (3-4). Examples of such anti-obesity campaigns include Georgia’s Strong4Life campaign (4) and Blue Cross and Blue Shield of Minnesota’s ‘Better Example’ campaign (5). Both have sparked national debates over the use of fat shaming in their TV and billboard advertisements. Anti-obesity campaigns focusing on the parent-child relationship and using weight stigma as a call to action are detrimental to obesity interventions since they do not take into account the entire ecological model of health promotion, are based on changing attitudes through the Theory of Reasoned Action, and rely on fat shaming to create positive behavior change when in reality it leads to psychological reactance.

Individual-level Interventions and the Ecological Model of Health Promotion

           

Applied to health promotion by McLeroy et al., ecological models of behavior describe the individual, social and environmental factors that contribute to an individual’s actions (6-351). Although individual factors play a role in the model, social and environmental influences are shown to be greater predictors of behavior. Individual-oriented behavior change interventions, such as child anti-obesity campaigns that use fat shaming, often lead to victim blaming and inaction (6-352). Social and environmental forces maintain and reinforce unhealthy eating behaviors, so intervening only on an individual level ineffective (6-353) and ignores many of the group-level factors contributing to the problem.

            The levels of influence identified within McLeroy et al.’s ecological model for health promotion are intrapersonal factors, interpersonal processes, institutional factors, community factors, and public policy (6-355). Anti-obesity campaigns based on fat shaming are only utilizing intrapersonal and interpersonal factors, as they are specifically aimed at changing the behavior of obese children and their parents (5). Since they are focused on intervening on the individual level, these campaigns assume that the direct causes of behavior come from within the individual or familial influence rather than the larger social and political environment. Concerning most health behaviors, motivation to act is not only the result of an individual’s knowledge and attitudes about health but influence from outside environmental forces out of the individual’s control (6-356).

            This is especially true of the convergence of environmental and social influences that have led to obesity epidemic in the U.S. Rather than just the result of individual lifestyle choices, the growing rate of weight gain can also be attributed to a series of environmental influences stemming from widespread lifestyle changes. These include the overall reduction in physical activity and increase in the availability of inexpensive, energy dense foods (7-853).

For example, obesity rates in the last 30 years have risen in tandem with the increase in restaurant portion sizes. Items at restaurants, especially at fast food establishments, have gotten 2 to 5 times larger since the 1980s. Studies conducted in natural eating environments have illustrated that when presented with a small and large portion choice, individuals are more likely to choose the larger portion (7-905). The amount of food offered to an individual as a portion has a great influence on their caloric intake, which in turn impacts their weight. Children are particularly susceptible to weight gain due resulting from this trend of increasing portion sizes: children with higher BMIs consume portions up to 100% larger than those routinely eaten by children with lower BMIs (8-907).

Changes in overall eating habits of Americans have greatly contributed to the rising trend of childhood obesity. Consuming meals made outside the home is very common due to an increasing number of both two income and single parent households and expansion of the restaurant industry. The increase in portion sizes at restaurants is attributable in part to consumer demand for economic value leading to fast food establishments offering larger portions of calorie dense food for lower costs as a marketing strategy (8-908).

The rise in fast food consumption among families is also attributable to the changes in economic structures and workplace expectations that have occurred in the last two generations—the “9 to 5” workday is disappearing, leaving parents with less time to prepare meals for their children. This emphasis on high productivity in the workplace has also left many adults without the time to engage in physical activity for themselves or encourage it among their children. It is clear that current social norms encourage obesity and are influential forces dictating individual health behaviors (7-854).

Anti-obesity interventions that focus only on individuals and their interpersonal interactions, such as those between parents and their children, fail to address the influences that higher level factors have on health behaviors. According to the ecological model of health promotion, at the community level resources available for health services or encouraging healthy lifestyles may be limited (6-364) and therefore dictate an individual’s eating habits more than personal food preference. This model also states that community power dictates the public agenda and those with the most severe health problems are often have the least access to participating in the community and influencing the agenda. McLeroy et al. describes these disenfranchised groups as the poor, uneducated, unemployed and those with socially stigmatized medical conditions (6-365). 

Across the U.S., childhood obesity is growing the fastest among low income households where levels of parental education are also low, although this relationship is moderated by ethnicity (9-5). Therefore, disregarding the amount of community power that these families wield as compared to more educated and affluent community members has led to interventions that are ineffective due to their ignorance of the community power structure (6-365). The stigmatization of obesity seen in the Strong4Life and Better Example campaigns marginalizes obese children even further (10), making the intervention not only unsuccessful in provoking community level change but may even be harmful to the parents and children whose health they are trying to improve.

Appealing to Parents through the Theory of Reasoned Action

            The Theory of Reasoned Action uses social psychology to explore the relationships between an individual’s behaviors, beliefs, attitudes and intentions. It states that behavioral intention is the most important predictor of action. In this theory, intention is influenced by an individual’s attitude towards performing a behavior and by subjective norms about the behavior within the individual’s peer group. The Theory of Reasoned Action also assumes that all other factors that could influence behavior are experienced only through the model and cannot predict behavior independently. This includes environmental or cultural factors (11-16).

            Blue Cross Blue Shield Minnesota’s ‘Better Example’ campaign uses the Theory of Reasoned Action through trying to change parents’ attitudes towards certain lifestyle habits, such as eating large portions of fast food, and the negative impact that they have on their children. The slogan used in many of their commercials, “Today is the day we set a better example for our kids,” (5) also illustrates that this campaign seeks to address the subjective norms that overweight parents with children who are overweight or obese have about their eating habits and how it influences their children. Through attempting to change parents’ attitudes about how their behavior impacts their children, this campaign seeks to influence their intentions and therefore their health behaviors.

            One flaw in the Theory of Reasoned Action is its emphasis on intention leading directly to behavior. This emphasizes individual cognition above environmental influence when making decisions (11-16). The Theory of Reasoned Action also assumes that individuals systematically process and the information that is presented to them and make decisions based on a rationed thought process (12-253).  When applying these assumptions to other health behaviors such as HIV prevention, research has shown that being informed about protection had little impact on changing the rate of unprotected sex among homosexual men. Instead, socioeconomic status and perceived severity of illness were the biggest predictors of using protection when engaging in risky sexual activity (12-254).  Therefore, individual attitudes and beliefs alone cannot be depended upon to lead to behavioral change, since much of behavior is influenced instead through the social structures that govern everyday actions (12-255).

Similar to the impact of individual attitudes on HIV prevention behavior, parental attitudes towards obesity are not the greatest predictors of a healthy lifestyle for their children that include a balanced diet and adequate physical exercise. Even a person’s food preference is a result of their socioeconomic and cultural environment rather than individual, rational thought considering nutritional benefits and potential impact on weight (13-250S). The externality theory of obesity, supported by many behavioral researchers,  states that obese individuals are more susceptible to overeating since they are more receptive to external cues rather than internal cues such as lack of hunger or attitudes about food consumption (13-251S).

 The Theory of Reasoned Action also postulates that external factors only impact behavior through an individual’s attitudes (11-6), which is clearly illustrated to be false concerning overeating behavior and other activities that lead to obesity. A study conducted by Craeynest et al. on the attitudes of obese and non-obese children concerning food intake and physical activity concluded that obese children did not have a negative attitude towards healthy food or physical activity. However, when given the opportunity they ate larger portions of food and engaged in sedentary activities more often than the non-obese participants. This illustrates the discrepancy between the attitudes of obese children and their behavior (14-1118), which cannot be accounted for by the Theory of Reasoned Action. Since childhood obesity is not only the product of individual or parental attitudes towards a healthy lifestyle (6-356), basing an intervention on this theory will not lead to a substantial change in obesity rates among children or their parents.

Fat Shaming and Psychological Reactance

            Both the Strong4Life and Better Example campaigns have been criticized for fat shaming, or using the societal stigma against being overweight as motivation for parents and children to adopt healthier lifestyles (3-4). Supporters of these campaigns claim that obesity is such a serious and prevalent problem that parents and children need to be confronted with these realities through any means possible (5). However, a recent analysis of anti-obesity public health campaigns conducted at Yale University has determined that weight stigma is not an effective tool for encouraging weight loss. Instead, promoting the stigmatization of obese individuals leads to serious psychological health problems, exacerbates health disparities, and discredits effective obesity interventions (15-1) through provoking psychological reactance.

Psychological reactance results from being pressured by social influence to act in a certain way, which threatens individual autonomy. In response to this perceived threat, individuals feel the need to respond reactively or against the message of the influence to restore their personal freedom (16-277). Fat shaming invokes psychological reactance through stereotyping overweight individuals as lazy, unsuccessful, unintelligent, and lacking in self-discipline as an incentive to change their behavior. A psychologically reactive response ensures that the opposite happens: overweight individuals who are targeted by weight stigmatizing anti-obesity ads actually increase the risk of unhealthy behaviors. This often results in further weight gain and therefore poor physical health outcomes, but also adverse psychological outcomes (15-1). Anti-obesity campaigns that highlight personal responsibility for weight gain have also been shown to be received negatively by the targeted audience rather than inspire motivation for change (15-5).

            Georgia’s Strong4Life campaign has generated significant controversy for its use of fat shaming, with TV ads using dialogue such as, “Being fat takes the fun out of being a kid,” and “It’s hard to be a little girl if you’re not,” and featuring images of overweight and obese children (10).  As discussed in Fat Shame: Stigma and the Fat Body in American Culture, weight stigmatization is especially detrimental to the psychological health of women and girls due to historical gender norms. According to Western cultural ideology, women are weak and lacking in self-discipline as compared to men and are therefore more susceptible to individual blame for being overweight (3-49).The ads used by the Strong4Life campaign perpetuate this idea, presenting images of children, many female, who look depressed and isolated. As Farrell stated to CNN, “[These ads] teach us that we should feel sorry for fat kids and that it’s normal to tease and abuse them” (10).   

            The prejudice against overweight individuals resulting from weight stigma may further marginalize populations that already suffer discrimination due to their race or socioeconomic status. One result of weight stigmatization has been the avoidance of doctors and healthcare providers by obese individuals (17-89). Obesity contributes to many chronic conditions that need significant medical treatment (2-241S), and stress responses to stigmatization can exacerbate these conditions (17-89), so fat shaming is doubly detrimental to overweight and obese individuals. Rather than perpetuating weight stigma, anti-obesity campaigns should focus on creating an atmosphere of empowerment that inspires the target audience to engage healthier behaviors (15-1).

Rethinking Anti-Obesity Campaigns: An Alternative Approach           

In order to combat all of the downfalls of parent-child focused obesity interventions that use fat shaming, many changes need to be made to the theoretical basis and execution of these campaigns. First, the parent-child obesity problem should be addressed in the context of the community while utilizing the upper levels of the ecological model of health promotion. Instead of using an individual level theory such as the Theory of Reasoned action, advertising theory provides the means to present an obesity intervention to parents that makes behavior change look attractive and beneficial. Lastly, instead of using ‘fat shaming’ to encourage behavior change, an effective intervention presents concrete lifestyle change ideas and messages of empowerment for the target audience to use to their benefit.

Community Level Interventions and the Ecological Model of Health Promotion

            There are a multitude of benefits to planning public health interventions at a community level, as the community has often played a central role in public health planning (6-362). Communities include “mediating structures’” such as informal social networks, churches and other voluntary associations that provide social identity to individuals and are an important influence on behavior. McLeroy et al. emphasize the importance of community social structures, asserting that without the support of these mediators convincing individuals to change their behavior is nearly impossible (363). As stated earlier, community structure also dictates the power that certain groups may have to change their behavior which needs to be taken into account when planning public health campaigns and interventions (364).

            Since the current obesity epidemic is being driven primarily by environmental influences (7-853), a community level intervention can better address these factors and their impact on the target population of obese parents and children. Therefore, an intervention aimed at decreasing the prevalence of obesity should begin a long-term campaign for social change that will result in large enough political and economic incentives to change the environment to be more conducive to healthy lifestyle choices. At the same time, the current needs of the growing population of obese parents and children can be addressed through providing individuals with strategies to resist environmental factors that contribute to weight gain (854).

             Some proposed interventions to combat the influence of increasing portion sizes available in fast food and the popularity of sedentary behavior (7-905) as part of a comprehensive anti-obesity include encouraging mindful eating, increasing physical activity and other changes. These methods can be used by entire families, but must be supported by the community in order to be successful (18-71). Communities that already have public spaces such as parks or gardens can encourage an increase in community activity through well designed signage (18-72) or organizing events such as walking clubs with free participation. In addition, community level interventions can advocate for an expansion of nutrition labeling on fast food since many parents are unaware of the contents of what they and their children are eating or the exact caloric content (18-73).

Incorporating Advertising Theory into Anti-Obesity Campaigns

            The two flaws in the Theory of Reasoned Action that make it a poor basis for an anti-obesity campaign is that it assumes that intentions lead directly to behavior and that decisions to change behaviors are shielded from outside environmental forces (11-16). As illustrated by the failure of Georgia’s Strong4Life and Minnesota’s Better Example campaign to lead to actual behavioral change (5), appealing to individual intentions is not an adequate technique to decrease the prevalence of obesity in the U.S. Using a different approach, advertising theory allows anti-obesity campaigns to reach a larger number of people and influence their behavior on a population level.

This is done with presenting the target audience with what they want, or a “promise” that the idea that is being sold will fulfill their desires (20-3). To utilize this idea within anti-obesity campaigns, public health practitioners should realize that the “promise” that individuals are seeking is not health but rather freedom from the burden of being obese (3-4). The target audience of obesity interventions rate public health messages that do not mention the word ‘obese’ or ‘fat’ as more motivating than those that invoke personal responsibility for weight gain, which illustrates the desire for freedom from this stigma (15-5).

Obesity interventions can provide the promise of freedom from the constraints of excess weight by crafting advertisements that focus on the positive promotion of behavioral changes such as eating healthier foods and engaging in regular physical activity (15-6). If presented through actors that appear carefree and happy while doing these and other healthy lifestyle activities, preferably with their family members, obese parents will not only be more motivated to change their behavior, but they will also feel less stigmatized by the intervention (15-6).

The use of advertising theory rather that the Theory of Reasoned Action in anti-obesity campaigning skirts the issue of ignoring environmental influences on behavior and harnesses an important resource that has been traditionally used to promote obesity epidemic rather than prevent it from growing. Analyses of television ads created to sell fast food products to children have concluded that over 50% of the commercials feature high fat, high sugar, and high sodium content foods (19-409). These advertisements have been shown to contribute to the obesity epidemic through reinforcing unhealthy eating habits and making the consumption of larger portion sizes appear to be the social norm (19-411).  If advertising theory is a powerful enough tool to contribute to the rise in obesity rates, it can be harnessed by public health interventions to promote the opposite through “selling” healthy lifestyle changes.

Empowerment and Avoiding Psychological Reactance

            The use of fat shaming in anti-obesity interventions is damaging to the mental health of both parents and children (15-1) and should be abandoned by public health practitioners entirely as a tactic to motivate healthy behavior. Children especially should not be stigmatized through anti-obesity advertisements, as these were found to cause the most extreme negative response to weight loss and diet change messages (15-7) In fact, the public health community should work to eradicate prejudice against overweight and obese individuals to ensure that they feel confident that they can change their lifestyle (15-6). Health practitioners are not immune to the societal stigma against obesity, which impacts the quality of care given to individuals that they deem as ‘fat’ (17-89).

            The link between body size and social standing is especially important to consider when addressing the obesity epidemic, as the experiences of how overweight and obese individuals experience discrimination due to their size have a great impact on how they view their health and ability to change (3-3). Fat shaming is not the result of the health dangers associated with being overweight, but the social connotations associated with fatness: laziness, greed, stupidity, ugliness etc. This has led a cultural stigma against fatness that often supersedes discussion about obesity’s impact on an individual’s physical health (3-4).  It is a societal misconception that obesity is solely the result of poor individual lifestyle choices. Media outlets that perpetuate this idea do not motivate positive behavior change, as discussed earlier, but contribute to the barriers that make fighting obesity a difficult challenge for public health practitioners (17-90).

An approach to anti-obesity interventions that is not supportive of  fat shaming can work against the detrimental impact of weight stigma and also reduce the amount of psychological reactance experienced by the target audience (15-1).  Psychological reactance can also be lessened through communicating the desired message to the target audience through individuals that are similar to the audience, and therefore are perceived as more credible (16-277). Similarity between the communicator and the audience has been shown to not only increase the positive force towards compliance but also reduce the negative force of resistance that leads to reactance (16-278).

Therefore, anti-obesity interventions focusing on families should communicate its messages through actors who are overweight or obese but have chosen to adopt lifestyle changes to improve the health of their families. These could include paying closer attention to nutrition labels and utilizing community spaces for family physical activities (18-72). Featuring resources within community also illustrates that obesity is a problem that impacts the entire community rather than targeting isolated individuals.

Yale University’s analysis of anti-obesity campaigns suggests that best received messages were multivariate, or suggested a multitude of behavior changes to be adopted on a community rather than individual level (15-6). Through combining the use of actors similar to the target audience to deliver positive messages of empowerment, anti-obesity interventions can be used not only to encourage healthy behaviors but also work against weight stigma. This will hopefully begin to reduce the physical, psychological and societal barriers against weight loss experienced by overweight and obese individuals.

            As the rate of obesity continues to rise steadily in the U.S. among children and adults (1), anti-obesity campaigns are a necessary vehicle to providing health education and motivation for lifestyle change on a community level. However, public health interventions should avoid the mistakes made by Georgia’s Strong4Life and Minnesota’s Better Example campaigns (5), including focusing only on the parent-child relationship, depending on the Theory of Reasoned action to cause behavior change, and relying on fat shaming as inspiration for transformation. This approach can be remedied through adopting community-level intervention techniques as described by McLeroy et al.’s ecological model of health promotion (6-355), using advertising theory to promote a healthy lifestyle as the means of gaining freedom from stigma, and using empowerment and rather than shaming as the primary motivation for behavior change.

        REFERENCES

(1) American Heart Association. Statistical Fact Sheet 2012 Update: Overweight & Obesity. Dallas, TX: American Heart Association, 2011. http://www.heart.org/idc/groups/heart-public/@wcm/@sop/@smd/documents/downloadable/ucm_319588.pdf

(2)Decklebaum, R. and Williams, C. Childhood Obesity: The Health Issue. Obesity Research 2001; 9(4S): 239-243S.

(3)Farrell, A. Fat Shame: Stigma and the Fat Body in American Culture. New York, NY: NYU Press, 2011.

(4)Children’s Healthcare of Atlanta. Strong4Life. Atlanta, GA: Children’s Healthcare of Atlanta. http://strong4life.com/

(5) Abrams, L. Think of the (Fat) Children: Minnesota’s ‘Better Example’ Anti- Obesity Campaign. The Atlantic, September 24, 2012. http://www.theatlantic.com/health/archive/2012/09/think-of-the-fat-children-minnesotas-better-example-anti-obesity-campaign/262674/

(6)McLeroy, K., Bibeau, D., Steckler, A, and Glanz, K. An Ecological Perspective on Health Promotion Programs. Health Education Quarterly 1988; 15(4):341-377.

(7)Hill, J., Wyatt, H., Reed, G., and Peters, J. Obesity and the Environment: Where Do We Go From Here? Science 2003; 229:853-855.

(8)Ledikwe, J., Ell0-Martin, J., and Rolls, B. Portion Sizes and the Obesity Epidemic. Portion Sizes and the Obesity Epidemic. Paper presented at the “Modifying the Food Environment: Energy Density, Food Costs, and Portion Size” Symposium held by the American Society for Nutritional Sciences. Washington DC: April 19, 2004.

(9)Ogden, C., Lamb, M., Carroll, M., and Flegal, K. Obesity and Socioeconomic Status in Children and Adolescents. Hyattsville, MD: U.S. Department of Health and Human Services, National Center for Health Statistics, 2010.

(10)Grinberg, E. Georgia’s childhood obesity ads aim to create movement out of controversy. CNN, February 7, 2012. http://www.cnn.com/2012/02/07/health/atlanta-child-obesity-ads/index.html

(11)National Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice. Bethesda, MD: National Cancer Institute, 2005. http://www.cancer.gov/cancertopics/cancerlibrary/theory.pdf

(12) Kippax, S. and Crawford, J. Flaws in the Theory of Reasoned Action (pp. 253-271). In Terry, D., Gallois, C., and McCamish, M., eds. The Theory of Reasoned Action: Its Application to AIDS-Preventative Behavior. Tarrytown, NY: Pergamon Press, Inc., 1993.

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(15) Puhl, R., Peterson JL., and Luedicke, J. Fighting obesity or obese persons? Public perceptions of obesity related health messages. International Journal of Obesity 2012; 1-9.

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Is Strong4Life Strongly Flawed? A Critique of Georgia’s campaign to end childhood obesity – Ashley Floreen

 

            One of the greatest public health issues today is the growing rate of childhood obesity in the United States.  Within the past thirty years, the obesity rate has nearly tripled, resulting in 17% of children and adolescents meeting the criteria for obese (1).

In 2011, the Strong4Life campaign was initiated by the Children’s Healthcare of Atlanta to combat the growing childhood obesity epidemic in Georgia.  According to Strong4Life, nearly 40% of children in Georgia are obese and are now at risk for diseases such as hypertension and Type II Diabetes that were previously only seen in adult populations.  The Strong4Life campaign addresses the dangers of childhood obesity by providing ways to decrease obesity by promoting healthy eating habits, increasing exercise, and offering support to families (2).

However, in addition to its website, Strong4Life launched numerous advertisements on television and on billboards which shamed obese children and parents.  One ad, featured in black and white, has a child named Bobby sitting across from his mother who is also obese, and asking “Mom, why am I fat?” The mother says nothing.  A billboard shows a photo of an obese young girl with the message “WARNING. It’s hard to be a little girl if you’re not” (3).  While there are numerous sides to this particular public health campaign, the advertisements and billboards carry a flawed message because they do not recognize a number of issues: perceived dangers and risks associated with obesity, how behavior is influenced by a child’s environment, a positive role model for children, and the importance of providing solutions for childhood obesity and a pathway to success. 

Perceived Dangers of Childhood Obesity

Strong4Life claims that 75% of Georgia parents do not recognize their child as obese (2).  Although that statement of truth is effective for raising awareness of the issue, it fails to explain the health risks that accompany obesity.  As a result, the population may not believe they are at risk for obesity and therefore will not take action to prevent this condition or reverse the effects if they have already been diagnosed.  This theory is known as the Health Belief Model, which originated from a failed tuberculosis screening in the 1950s sponsored by the United States Public Health Service.  The screening was free and conveniently located directly in neighborhoods across America, yet very few people actually took advantage of this service.  Godfrey Hochbaum, a USPHS social psychologist, developed the Health Belief Model after discovering that people were more likely to get screened if they believed they were at risk of contracting tuberculosis and that there was a benefit to getting an early diagnose.  It now comprises of six major components: Perceived Susceptibility, Perceived Severity, Perceived Benefits, Perceived Barriers, Cues to Action, and Self Efficacy (4).

The Strong4Life ads and billboards completely disregard this theory.  For example, the ad with Bobby facing his mother contains nothing of perceived susceptibility because it does not show the child or parent feeling at risk for being classified as obese, nor does it discuss the perceived severity of obesity, in that neither child nor parent acknowledges any consequence of being obese.  Additionally, the audience does not gain any perceived benefits because no positive outcomes of losing weight are discussed, nor do they recognize any perceived barriers because no negative consequences of not losing weight are mentioned (4).  The ad ends with Bobby and his mother simply staring at each other, with no motivating event that would suffice as a cue to action to change the behavior that led them to become obese.  It also lacks self-efficacy, or the mother and son’s belief that they could actually change their behavior. On the contrary, the silence at the end of the ad suggests the disease is so depressing and severe that the child and his mother are beyond help. 

Environmental Factors

Another flaw to the Strong4Life billboards and ads is the lack of understanding as to why so many children in Georgia are obese.  Without acknowledging the underlying reason for the disease, it is nearly impossible to change the behavior needed to reverse the effects of obesity and halt this epidemic.  According to the Ecological Perspective, a person’s behavior both affects and is affected by many levels of influence.  Additionally, behavior is shaped by and shapes the social environment of the person, or reciprocal causation.  Five levels of influence were created by McLeroy and colleagues, defined as: Intrapersonal Level, Interpersonal Level, Institutional or Organizational Factors, Community Level, and Public Policy (5). 

At the intrapersonal level, an adolescent may feel ashamed of her weight and know that she should change her eating habits.  However, she may also be afraid to make this step because she knows it will require more work to prepare healthy foods and she will miss the comfort of her favorite junk foods.  At the interpersonal level, she sees all of her classmates eating the same school lunches in the cafeteria, who tell her they do not think she needs to eat differently because they all eat the food she does and are not worried about their health. 

At the organizational level, her mother may be the only caretaker for her and she does not have time to go grocery shopping because she is working two jobs to support her family.  Additionally, the local supermarket may be located in an unsafe neighborhood and it is not wise for the young adolescent to walk to the store herself to buy healthy food.  Researchers found that the average BMI was higher for those living in disadvantaged neighborhoods or whose supermarket was located in a disadvantaged neighborhood (6).  Moreover, there may not be any safe parks for her and her friends to go to for exercise after school, if her state is experiencing budget cuts.  This public policy limits the likelihood in which she is able to increase her daily physical activity.  

Another example of environmental issues responsible for childhood obesity revolves around peers.  According to the Social Norms Theory, a person’s behavior is influenced by their perception of how others in their social circle behave (7). If fifteen year old Susie sees all of her friends eating pizza and fries for lunch every day at school and they are also overweight, Susie will believe this is normal.  Fortunately, the good news is that based on the Social Norms Theory, people can just as easily be taught to partake in healthy behavioral choices if those around them do the same (7).  If Susie and her friends learn in health class about the importance of eating fruits and vegetables and exercising on a daily basis, they will likely feed off of each other’s positive behavior and increase the likelihood of maintaining their new lifestyle. 

The ability for humans to conform to social influences, even when they know people are not doing what is right or healthy (choosing soda over water, pizza over salad) was illustrated by social psychologist Solomon Asch.  Asch conducted a series of experiments to determine this theory.  When given a test, without the judgment or influence of others, participants gave the correct answers.  However, when others gave an incorrect answer, participants also gave an incorrect result nearly one-third of the time, against their better judgment (8).  This phenomenon can also be applied to making healthy choices.  If a person is in line at the cafeteria and knows that bottled water is the best choice for him, but he sees everyone in front of him choosing soda, he is more likely to fall under the social influence of others and be nudged to choose soda over water, despite his awareness of the calories and sugar he would consume with soda. 

Lack of Positive Role Models

There is no doubt surrounding the notion that people model their own behaviors after those around them.  In Strong4Life’s commercial of the mother and her son, it is clear that the obese mother leads the audience to believe that the boy is fat because she herself is fat.  This is the opposite role model which that should be featured.  Instead of having a healthy physician or a soccer coach as model to explain to the child why he is obese and set goals to improve his health, the public only sees an obese parent, highlighting the mother as the cause of the problem instead of offering healthy role models. 

Albert Bandura recognized this concept and created the Social or Observational Learning Theory in the 1960s.  One of the main concepts in this theory is the idea of imitation combined with reinforcement (9).  For instance, if a child sees his mother eating ice cream to relieve her stress after a busy day at work, the child is likely to imitate his mother and also use food to comfort his stress.  Strong4Life uses this theory in a negative way not only in the commercial described above, but on a billboard featuring a boy and stating “He has his father’s eyes, his laugh, and maybe even his diabetes” (10). This automatically assumes children will inherit the same diseases as their parents, if their parents are overweight.  Although it is a risk factor, the focus should not be giving up on our nation’s youth and letting them become obese.  Instead, it should re-direct its focus to producing positive role models who practice healthy behaviors to teach families how to change their lives and improve their health.

No Plan of Action to Change Behavior

Another flaw in the Strong4Life billboards and ads is the lack of a plan to help people make lifestyle changes slowly.  For obese individuals and families, it is crucial that they understand this is not a diet, this is a new way of life.  The Stages of Change Model, founded by Prochaska and DiClemete, illustrates this theory quite well.  This model is based on comparing the experiences of smokers who quit on their own without professional help and smokers who receive treatment to stop smoking.  The main belief is that changing behavior is not a process that happens overnight (5).  Instead, it explains how there is a process to adapting a new lifestyle which occurs in stages.  The first stage is precontemplation, during which the person has no intent to take action to change his behavior within six months.  The second stage is contemplation, in which the person does intend to take action within six months.  In the third stage, preparation, the individual plans to change his behavior within thirty days and is making a plan to follow through on this new path.  The fourth stage, action, occurs when the individual has changed his behavior for less than six months.  In the final stage, maintenance, the individual has successfully changed his behavior for longer than six months (5). 

The Stages of Change Model is not a straight path to success.  Instead, it shows that the process of achieving a new lifestyle takes many steps and can often include relapsing to a previous stage (a woman starts eating McDonald’s again, a smoker who has not smoked in three months lights up with friends at a bar one night).  A billboard featuring an obese child with the statement “Big bones didn’t make me this way. Big meals did” (10) offers no explanation or hope that this child, or any child, could change their behavior.  There are no facts about his weight resulting in hypertension or the benefits of eating fresh fruits and vegetables to improve his cholesterol.  There is no motivation for the young girl to make specific plans in order to contemplate losing weight to prevent other kids from teasing her.  Bobby’s mother does not help him develop an action plan or create goals to help them both eat less and increase physical activity.  While one tagline mentions the dangerous relationship between diabetes and obesity, none of the statements offer social support or feedback when a setback occurs or reinforce goals already met.  Additionally, they do not provide hope that maintenance is even plausible, given that one ad states “Fat kids become Fat adults” (10).  This particular slogan completely undermines everything in this model and simply assumes children will be heavy throughout their entire lives and nothing can be done to change this fact. 

Additionally, this theory believes individuals in an audience can be at different stages.  For example, a thirteen year old girl may know she is obese and has heard the dangers from her pediatrician and is going to her first appointment with a nutritionist next week when she sees these billboards on her way home from school.  She suddenly feels hopeless and eats two large candy bars to console herself and begins to lose faith that she can successfully change her behavior.  Across the street, an eight year old boy named Joe, whose father is also obese, views the ad with Bobby and his mother and realizes that if nobody is telling Bobby to change his behavior, and he has obese parents like him, there is no reason Joe should change his behavior either.  Tina, meanwhile, is eleven years old and has lost fifteen pounds in the past five months and is on her way to achieving her goal of losing twenty five pounds by her twelfth birthday in eight weeks.  Where are the models for her to look at who are making similar healthy choices and who can offer encouragement to keep her on the right track?   Without a clear message showing children at different stages of weight loss and choosing healthy options, the campaigns will not invoke the results intended. 

Intervention to a New, Healthy Lifestyle

A new way to combat the alarming increase in childhood obesity is to frame the message in a way that teaches families how to change their lives, not shaming them into the dark.  My intervention is to create a new campaign which highlights healthy choices such as choosing fruits and vegetables, increasing physical activity, showing the importance of families eating meals together, and having a success story in a popular role model share her experience with children so they can model their behavior after her, as well as setting small goals families can achieve together with tips to maintain their new lifestyle.

The Strong4Life ads and billboards were created in black and white, undertook a negative tone in the messages displayed, and were seen as stigmatizing obese children and blaming their parents for failing to look out for their health.  However, one study found that public health obesity campaigns were most likely to see positive results from those that focused on promoting healthy eating through fruits and vegetables as well as promoting multiple positive health behaviors.  On the other hand, people responded negatively to campaigns which stigmatized obesity (11).  This study shows the importance of framing the issue of obesity not as something to be ashamed of, but merely a problem that can be improved upon by making small changes to everyday living. An additional study further proved the dangers of stigmatizing obese people in that it poses a significant risk to their psychological health and may even interfere in obesity prevention programs (12).

Instead of having a billboard featuring a child in a black and white photo looking ashamed of her weight and not having a happy childhood, the billboard will feature a picture of children of all different ethnic backgrounds enjoying a picnic and eating fruits, vegetables, and drinking water, not sugary drinks.  The slogan will read “Healthy Food Choices Makes Happy Kids”.  This ad frames healthy behaviors in a way that results in happy children.  Instead of negatively stigmatizing obesity and blaming parents for not caring about their children’s health, this ad connects healthy with happy, leading parents to see that their children will actually be happier and feel better about themselves if they consume healthy foods.

Regarding advertising on television, instead of having a son and his mother staring at each other in the dark, not knowing why they are obese, an ad could feature a group of boys of all shapes and sizes attending a basketball clinic with Michael Jordan.  According to Dr. Seigel’s lecture on October 4^th regarding the Communication Theory, familiarity is a major component of a successful campaign.  If a celebrity whom the audience is familiar with is the messenger, the message of the campaign will be more effective because that person will be more influential.  Moreover, the recipients of the message must like the person delivering the message in order for the campaign to be effective.  Additionally, showing children of all sizes shows how this ad applies for everyone and not solely overweight children.  As noted in the Stages of Change Model, children could be just beginning to make changes in their lifestyle or they could be having their first day of a sports clinic.  Michael Jordan could remind them of the importance of keeping active so they can keep up with him on the basketball court.  This increases a general healthy behavior which applies to children of all sizes, whether they are obese or not and promotes a healthy lifestyle for everyone.

Another ad could feature a group of young teenage girls in a community drama club. Some are eating healthy snacks while talking to their friends.  The teacher could announce the special mentor for the day is here, and the girls gather around in awe as Jennifer Hudson walks in.  Jennifer became a spokeswoman for Weight Watchers and has shed 80 pounds.  She is not only a celebrity, but she is a success story for lifestyle behavior changes that have paid off.  Jennifer states in article for Good Housekeeping “The only way you can sustain a permanent change is to create a new way of thinking, acting, and being” (13).  Jennifer is likely in the maintenance stage in the Stages of Change, as her weight has been kept off for over two years.  She could act as a positive role model for young people to aspire to when looking to change their current eating habits and recognize the achieving and maintaining a healthy weight is possible.  Jennifer would speak to the adolescents about how important it is to eat well so they can perform their best and improve their health while increasing self-esteem.  By having a male role model (Michael Jordan) and a female role model (Jennifer Hudson) children of both genders are able to relate to a healthy individual to further their changes of emulating the healthy celebrity’s behavior. Furthermore, the messages from Michael Jordan and Jennifer Hudson are positive messages and meant to empower young people to make healthy decisions.  This is crucial in the success of a campaign, as it gives the freedom and power to the audience, not invoking a response to being told what is best for them. 

Another advertisement could feature a young mother sending her smiling children off to school with water bottles.  She will say “Did you know fruit juice and sugary beverages are the number one reason for childhood obesity? I didn’t, until our pediatrician’s office gave us this list of healthy behaviors when our son’s weight increased this year.  Instead of drinking juice which contains excess sugar and calories, my kids drink water at school, and they love their new colorful water bottles.  Plus, you will not believe all the money I save at the Piggly Wiggly each week!”  This advertisement follows the Health Belief Model in that it recognizes a common problem (excessive consumption of sugary drinks) followed by an action cue to solve the problem by switching to water, and illustrates self-efficacy in that it is a normal mother who became aware of an issue and easily solved the problem. 

The choice of language in a public health campaign is crucial for appealing to a targeted audience.  By using words such as “did you know” instead of telling people what to do by forcing facts and regulations at people, it follows the Psychological Reactance theory by not confronting the consumer or taking their freedom away. As Paul Silvia notes in Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance, people will react by trying to regain control if any source of such freedom is removed (14).  Florida’s “Truth” campaign exemplifies this theory, in that the tone of the message matters greatly.  Youth did not want to be told that smoking is as simple as choosing life over death, nor did they wish to be bombarded by messages of what to do.  Instead, they wanted to be presented with the facts and left to make decisions on their own (15).

My campaigns will feature positive messages from both celebrities, which increase the influence of the product (healthy lifestyle) to the audience, and average citizens of Georgia, or peers, who also carry weight in convincing others to follow their lead and do what is best for their health.  The people of Georgia will feel empowered by these billboards and advertisements  to make healthy decisions but also realize that these many small changes in behavior are not simply steps to losing weight, they are steps towards a longer, brighter, and healthier future, allowing themselves the ability to follow their dreams and not succumb to the weight of obesity.

References

1)   Centers for Disease Control and Prevention. Overweight and Obesity: Childhood Overweight. Atlanta, GA: Centers for Disease Control and Prevention.

http://www.cdc.gov/nccdphp/dnpa/obesity/childhood/index.htm

2)     Strong4Life. The Facts. Atlanda, GA. Children’s Healthcare of Atlanta. http://strong4life.com/pages/about/aboutDetailPage.aspx?articleid=0&sectionid=facts

3)   Teegardin C. Grim Childhood Obesity Ads Stir Critics. The Atlanta Georgia- Constitution. Atlanta, GA. 2012. http://www.publichealth.uga.edu/hpb/news/grim-childhood-obesity-ads-stir-critics

4)   Edberg M. Individual health behavior theories.  (pp. 35-49). In: Edberg M. Essentials of Health Behavior. Social and Behavioral Theory in Public Health. Sudbury, MA. 2007

5)   Theories and Applications (pp.10-21). In Theories at a Glance. A Guide for Health Promotion Practice. NIH Publication, 2005; No. 05-3896.

6)   Inagami S, Cohen DA, Finch BK, Asch SM. You Are Where You Shop: Grocery Store Locations, Weight, and Neighborhoods. American Journal of Preventative Medicine. 2006; 31(1):10-7.06.

7)     Best Practices: Social Norms. http://wch.uhs.wisc.edu/13-Eval/Tools/Resources/Social%20Norms.pdf

8)     Thaler R, Sunstein C. Following the Herd (pp. 53-71). In: Nudge. Improving Decisions about Health, Wealth, and Happiness. Yale New Haven Press. New London, CT. 2008.

9)     DeFleur M, Ball-Rokeach S. Socializing and theories of indirect influence (pp. 203-227). In: Theories of Mass Communication 5^th Edition. White Plains, NY: Longman Inc., 1989.

10)  Victory: Strong for Life Billboards Coming Down. 2012. http://www.mamavation.com/2012/02/victory-strong-4-life-billboards-coming-down.html

11)                  R Puhl, JL Peterson and J Luedicke. Fighting Obesity or Obese Persons? Public Perceptions of Obesity Related Messages. International Journal on Obesity. 2012; 1-9.

12)  Puhl, R Obesity Stigma: Important Considerations for Public Health. American Journal of Public Health. 2010; 1019–1028.

13)  Jennifer Hudson’s Weight-loss Wisdom. Good Housekeeping. http://www.goodhousekeeping.com/family/celebrity-interviews/jennifer-hudson-diet-tips#category1-3

14)                 Silvia P. Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance. Basic and Applied Psychology 2005; 27(3), 277-284.

15)                  Hicks J. The Strategy Behind Florida’s “truth” Campaign. Tobacco Control 2001; 10:3-5.

Breastfeeding Initiatives: Banning Formula is not the Answer – Kayley Pettoruto

Introduction

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.

The Latch 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 Insufficient

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 this intervention.

 By 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

            Latch On also failed at utilizing effective communication strategies including failure to consider psychological reactance theory and failure to utilize an effective messenger.

This 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.

            Psychological 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 Campaign

            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

            Instead 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 hospital.

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

            Using 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.

Core Values

            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 Catch Phrases

            In 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:

 “Putting mom’s back in charge”

“Taking the profit out of birth”

“It is our civil right to protect our babies”

“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 Communications Strategies

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.

Conclusion

            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 audience. 

References

  

1.       American Academy of Pediatrics Policy Statement. Breastfeeding and the use of human milk, section on breastfeeding. Pediatrics 2005; 115(2): 496-506.

2.       New York City Department of Health and Mental Hygiene. Latch On New York City. http://www.nyc.gov/html/doh/html/ms/latchonnyc.shtml.

3.      Li R, Darling N, Maurice E, et al. Breastfeeding rates in the United States by characteristics of the child, mother, or family. Pediatrics 2005; 115(1): e31-e37.

4.      Dahlgren G., Whitehead M. Policies and Strategies to Promote Social Equity in Health. Stockholm: Institute for Futures Studies, 1991.

5.      Marks, D. Health psychology in context. Journal of Health Psychology 1996; 1(1): 7-21.

6.      McKinlay, JB, Marceau, L.D. Upstream health public policy: lessons from the battle of tobacco. International Journal of Health Services 2000; 30(1): 49-69.

7.      Anderson-Kosmala, J. Breastfeeding works: the role of employers in supporting women who who wish to breastfeed and work in four organizations in England. Oxford Journal of Public Health 2006; 28(3): 183-191.

8.     Mitra AK, Khoury AJ, et. all. Predictors of breastfeeding intention among low-income women. Maternal and Child Health Journal 2004; 8(2): 65-70.

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