Why Lincoln University’s Bold Attempt to Help Reduce the Prevalence of Obesity on Campus and in the African-American Community has Great Intentions but a Misguided Approach - Rahotep Alkebulan

Introduction

It is no secret that preventable diseases such as heart disease, diabetes, and lung cancer disproportionately affect African-Americans.   The prevalence of stress, poor diet, lack of exercise, alcohol use, and smoking in the Black community has been largely responsible for the heavy disease burden African-Americans face as well as poor access to quality health services.  According to the American Diabetes Association, 4.9 million or 18.7% of all African-Americans aged 20 years or older have diabetes and are 50% as likely to develop diabetes-related blindness compared to whites (1).     On average, African-Americans are twice as likely as whites to have diabetes (2).  The US Department of Health & Human Services has statistics that reveal African-American women having the highest rates of being overweight or obese compared to other groups with approximately four out of five African-American women being overweight or obese.  In 2011, African-Americans were 1.5 times as likely to be obese as whites (2).

Therefore, it was commendable when historically black college Lincoln University voiced concern about “the high rates of obesity and diabetes, especially in the African-American community” (3) and decided to intervene to reduce the prevalence of obesity on campus and in turn in the overall African-American community.  However, the methods used to accomplish this worthy objective stirred up some controversy.  The University enacted a mandate that requires incoming students to submit their calculated BMI Score and those with a BMI of 30 or greater would be required to take and pass a “Fitness for Life” class in order to graduate.  The class would entail physical activities as well as information on nutrition, stress, and sleep.  University officials such as James L. DeBoy, chairman of Lincoln's department of health, physical education and recreation have emphasized that “students are not required to lose weight or lower their BMI; they must only pass the class through attendance and participation” (3).

The intent of Lincoln University’s policy to address obesity in the African-American community is noble; however, the means used to fulfill this mission have the potential to do more harm than good.  The singling out the ‘fat’ incoming freshmen for enrollment in a fitness class violates many established principles of social science and theory.  Lincoln University officials should be applauded for bringing the issue of rampant obesity in the African-American community on the agenda and for taking aggressive action, but their tactics to address the issue must be scrutinized and reconstructed in order to become more effectual.  Lincoln University must empower its student with the tools to become self-efficacious, remove the negative labels placed on obese students, and address the environmental factors in the vicinity of the university that could contribute to the perpetuation of unhealthy lifestyle choices.  Since Lincoln University is “committed to maintaining a nurturing and stimulating environment for learning” as delineated in its mission statement, the university should empower every student with the tools to incorporate healthy lifestyle changes into their daily lives by creating a university environment conducive to the health of its students.  

The Negative Labeling Potential

The intent of Lincoln University’s intervention is to identify obese individuals entering the university who are at high risk of future health complications and require them to enroll into a healthy living class to reduce their future risks.  The problem is that they are selecting a certain population and labeling them with the socially undesirable name ‘fat’ and thereby subjecting them to shame, humiliation, and isolation.  Labeling theory posits that the self-identity and behavior of individuals may be determined or influenced by the terms used to describe or classify them (4).  Furthermore, the person labeled incorporates the label into their concept of themselves (5).  In other words, the person cannot think of themselves outside of the label that has been assigned to them and fulfills the prophecy of that label.  In regards to labeling individuals as fat, particularly children and young adults, the evidence is clear: it does more harm than good.  Researchers at UCLA found that 10-year-old girls told that they were ‘fat’ by those close to them were more likely to be obese at 19 than those who were never told they were fat, regardless of what they weighed at the beginning of the study(6).  It seems as though individuals who are told that they are fat internalize that identity, causing them great pain and to quell it they often turn to food which perpetuates the vicious cycle.

So it seems as though Lincoln University did a great disservice to their incoming students by labeling them before they even get on campus as fat, especially the young women.  Since this is a historically black university, many students entering Lincoln University will be Black students seeking to escape the label of being a “Black student” that may have been automatically given to them at their predominantly white high schools.  Many students who attend historically black colleges (from experience) are seeking to just be a ‘regular’ student in a predominantly Black setting to escape the responsibility of having to be the spokesperson for the race.  Therefore, as the obese Black students enter Lincoln University they will simultaneously lose and gain a label.  Studies have proven that many Blacks people have internalized racism, particularly Black women which have lead to negative health outcomes (7-13).  It becomes troubling to consider the harm this policy could do in adding to the burden of labels of its incoming students who are statistically more likely to be obese.  

Potential to Induce Strong Psychological Reactance

Human beings generally enjoy the freedom of choice in selecting participation in activities.  Whenever somebody threatens this choice or a human being’s autonomy they are risking psychological reactance.  Psychological reactance is an aversive affective reaction in response to regulations or impositions that impinge on freedom and autonomy (14, 15).  Psychological reactance elicits a response that seeks to restore autonomy, so if you try to force something upon somebody they are likely to counter by doing the opposite of what’s expected from them.  This effect may be greater when promoting health behavior change in college students (16).  Therefore, Lincoln University mandating that students must take a fitness class in order to graduate is likely to elicit psychological reactance because they are forcing students to take a class against their will.  When young adults go off to college they relish the opportunity to exercise their new found freedom and autonomy away from the home where they can independently choose their major and which classes to take.  However, if the university now requires students to take a class based on their BMI score then this is likely to generate a strong emotional response that will seek to establish autonomy.   Students may then become more obstinate in their health habits and refuse to incorporate the lifestyle suggestions into their life simply because the choice was taken out of their hands.  This form of rebellion may sabotage the intervention and actually cause people to gain weight rather than lose it.  To demonstrate the phenomena of psychological reactance in this instance, one student enrolled in the class told reporters in a press release that right after she gets out of the Fitness for Life class she goes directly to ‘The Grill’ to eat fried chicken (17).

No Change in Lincoln University

After reading all the press releases on this controversial issue I did not come across any evidence that the university itself changed the campus environment to become more conducive towards health.  Instead, the university expected students enrolled in the class to make all the changes and invest themselves into being healthy.  The university did not announce that they were changing the food choices being offered which include selections from KFC and ‘The Grill’ which features fried mozzarella sticks, quarter-pounders, hot dogs and Jamaican beef patties (17).     The university also did not reveal that they were remodeling the gym to accommodate more students; a sentiment that was expressed in a press release from a young man stating “If they want us to lose weight, expand the gym, don't tell us we won't graduate (17)."  The university is sending a mixed signal when it proclaims they are interested in the health of the students but are not willing to invest the necessary resources to create an environment where students have healthy food choices and adequate exercise equipment.  If the students were to see that the university was exerting the same effort and commitment they expected of them in the fitness classes, then it would create a more favorable environment to practice healthy behaviors.

Alternative Strategy

Utilizing the tools social science theory gives us, the first step of the new intervention would be to require every student regardless of BMI score or waist circumference to participate in the Fitness for Life class.  Secondly, the course would focus on fostering overall well-being and health rather than isolating obesity as the main culprit.  This would ensure that all facets relevant to the health of college students are addressed such as alcohol and drug abuse, mental health and healthy relationships (18).  The class would still have as a central theme of aerobic exercise because a significant amount of college students do not (19).  However, the course would emphasis the behaviors that are going to be continued after the course’s completion.  The current invention is overly focused on the issue of obesity because it is an easy target but there are other important health issues that affect students regardless of the BMI score.  Thirdly, the course component would be accompanied by changes to the university itself, namely making the availability of healthy food on campus the norm and not the exception.  To make exercise more feasible this intervention involves establishing a partnership with a local gym so that students will have the necessary infrastructure to work out.  This would likely fit the university’s budget while expand exercise equipment to students.  With this intervention in place the methods would support the goals of an overall healthier campus.

How the Proposed Intervention Mitigates the Current Flaws

The first step of including all students in the intervention would eliminate the stigmatizing label that was unceremoniously given to those with BMI’s over 30.  This would essentially remove both the label and the shame from having to take the class while creating an inclusive environment where all are trying to incorporate healthy behaviors.  No longer would students have to walk around in embarrassment with everybody knowing that they had to take, as one student enrolled in the class at Lincoln University put it, the “fat people class”.  In essence, everybody would be labeled which would cancel out the detrimental effects of the negative label of being in the “fat people class”.   Inclusion of all students in the class also corrects a potentially serious consequence of singling out obese individuals.  When Lincoln University selectively chose obese individuals for behavior change modification, they simultaneously validated ‘skinny’ students’ health behaviors even if they were unhealthy.  Only enrolling obese individuals into the class relays the message that only they have to change their habits while everybody can remain the same.  Under this premise the conveyed message is as long as you are not obese then you are healthy—clearly erroneous and unconstructive.  Encompassing all students in the class removes the potential for reinforcing negative health practices while sending the message that all students’ health, regardless of BMI, can improve.

The inclusion of all students would also significantly reduce the risk of psychological reactance.  Although collectively the students’ choice would be taken away in deciding if they want to take the class or not, at least everybody on campus would have to ‘suffer together’.  The resentment of being singled out would arguably be the biggest source of emotional opposition, so if that component was removed then the potential for psychological reactance would be drastically lowered.  For example, I attended a historically black university and one of the requirements for everybody was to take and pass a swimming class to counter the stereotype that Black people cannot swim.  Since this was a university-wide requirement, there were minimal complaints because we all had to take the course in something we could all agree was important.  At first it seemed unreasonable that everybody had to take the course but once the time came everybody participated and made the most out of the situation.  I suspect the same thing would take place if everybody at Lincoln University were required to take the course.  To further decrease the possibility of psychological reactance, the alternative intervention would incentivize accomplishing health goals such as losing weight or lowering blood pressure by offering legitimate prizes.  Because the intervention is taking away the students’ autonomy, it is imperative that we give them the possibility of gaining something so that they are not ‘gaining their freedom back’ through psychological reactance, but rather are regaining that sense of autonomy by achieving their health objective.  This would transform the class from being one where people would go through the motions to striving to accomplish their health goals. The class would no longer be one that they have to take but one that they get to take.

Finally, the third part of the alternative intervention which involves the University making changes to the food available and improving access to gym facilities would signal Lincoln University’s commitment to the health of their students.  Lincoln University would be holding itself accountable without expecting the students to be the only ones to change.  This would create more buy in from the students and would likely lead to healthier behavior due to the environment now being more suitable for healthy behaviors.  If the students see that the University is changing for the better then it could inspire them to do the same.

Conclusion

The prevalence of diabetes and obesity in the African-American community calls for immediate action to address the serious epidemic.  However, reasoned action that is predicated on sound social science theory must be applied before rushing into the fray.  Lincoln University’s attempt to reduce obesity and its associated complications on campus and within the greater community must be acknowledged for its impassioned approach to a serious problem.  However, singling out ‘fat’ individuals in such a way may cause more harm than good according to social science theory.  It adds negative labels to a demographic of people who already carry the burden of negative labels which increases the likelihood of psychological reactance to the intervention.  Thus individuals may resent being labelled and react against the intervention by fulfilling the prophecy of a fat person.  This could be in direct defiance of the university who itself has not committed to ensuring the most favorable conditions of health on campus.

Addressing the flaws of the intervention involves obligating every student on campus to participate in the Fitness for Life course.  Instead of socially isolating and labeling obese individuals, this creates an environment of solidarity where the health needs of all students are addressed together.  Including everybody and infusing incentives for participating in the class eliminates the stigmatizing label of being in the “fat people class” while increasing students’ willingness to participate.  This coupled with the University changing its policy on food selection and exercise capacity will create an environment where together the University’s staff, administrators, and students are all invested in the health and well-being of the campus and greater community.   

References

1. "Treatment and Care for African Americans - American Diabetes Association®." American Diabetes Association. N.p., 12 Nov. 2013. <http://www.diabetes.org/living-with-diabetes/treatment-and-care/high-risk-populations/treatment-african-americans.html>.
2. "We're in!." OMH Content. N.p., 25 Apr. 2014. Web.  <http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=3&lvlid=62>.
3. Landau, Elizabeth. "College's too-fat-to-graduate rule under fire." CNN. Cable News Network, 30 Nov. 2009. Web. <http://www.cnn.com/2009/HEALTH/11/30/lincoln.fitness.overweight/index.html?iref=24hours>.
4. "Labeling theory." Wikipedia. Wikimedia Foundation, 18 Apr. 2014. <http://en.wikipedia.org/wiki/Labeling_theory>.
5. "Definition of Labeling Theory | Chegg.com." Definition of Labeling Theory | Chegg.com. N.p., n.d. Web. <http://www.chegg.com/homework-help/definitions/labeling-theory-49>.
6. Deborah Netburn April 28. "Girls called 'too fat' are more likely to become obese, study finds." Los Angeles Times. Los Angeles Times, 28 Apr. 2014. <http://www.latimes.com/science/sciencenow/la-sci-sn-girls-too-fat-obese-20140428,0,4057459.story>.
7. "Brown v. Board at Fifty: “With an Even Hand”Brown v. Board of Education of Topeka, Kansas." Brown v. Board of Education of Topeka, Kansas. Library of Congress, n.d. Web. <http://www.loc.gov/exhibits/brown/brown-brown.html>.
8. Butler, Cleve, Eugene Tull, Earle Chambers, and Jerome Taylor. "Internalized racism, body fat distribution, and abnormal fasting glucose among African-Caribbean women in Dominica, West Indies.." National Center for Biotechnology Information. U.S. National Library of Medicine, 21 Aug. 2005. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2594102/>.
9. Harper, S. R. (2006). Peer support for African American male college achievement: Beyond internalized racism and the burden of ‘acting White.’ Journal of Men’s Studies, 14(3), 337-358.
10. Chambers, Earle C., et al. "The relationship of internalized racism to body fat distribution and insulin resistance among African adolescent youth." Journal of the National Medical Association 96.12 (2004): 1594.
11. Tull, Eugene S., et al. "Relationships between perceived stress, coping behavior and cortisol secretion in women with high and low levels of internalized racism."Journal of the National Medical Association 97.2 (2005): 206.
12. Tull, Eugene S., and Earle C. Chambers. "Internalized racism is associated with glucose intolerance among Black Americans in the US Virgin Islands."Diabetes Care 24.8 (2001): 1498-1498.
13. Paradies, Yin. "A systematic review of empirical research on self-reported racism and health." international Journal of Epidemiology 35.4 (2006): 888-901.
14. Psychological reactance theory. (n.d.). . Retrieved May 1, 2014, from http://www.psych-it.com.au/Psychlopedia/article.asp?id=65
15. Dillard, J. P., & Shen, L. (2005). On the nature of reactance and its role in persuasive health communication. Communication Monographs, 72(2), 144-168.
16. Engs, R., & Hanson, D. J. (1989). Reactance theory: A test with collegiate drinking. Psychological Reports, 64(3c), 1083-1086.
17. Pilkington, E. (2009, December 5). Success at fat-fighting Lincoln University hinges on BMI test. The Guardian. Retrieved May 1, 2014, from http://www.theguardian.com/world/2009/dec/04/lincoln-fat-graduate-obesity
18. Wyckoff, W. (2010, September 1). 5 Big Health Issues On Campus. NPR. Retrieved May 1, 2014, from http://www.npr.org/blogs/health/2010/08/31/129562240/top-5-college-health-issues-this-year
19. Kwan, M. (2012, January 1). Physical Activity and Other Health-Risk Behaviors During the Transition Into Early Adulthood. . Retrieved May 1, 2014, from http://www.ajpmonline.org/article/S0749-3797(11)00743-4/abstract

“Breast is Best,” But Not Against All Odds: A Critique of The National Breastfeeding Awareness Campaign – Anna Goldenheim

Introduction to Breastfeeding As An Important Public Health Issue

Breastfeeding is becoming an increasingly important public health issue. The American Academy of Pediatrics recommends that women breastfeed their infants for at least 6 months, citing both short- and long-term medical and emotional benefits for mom and baby.(1) Research shows that, in addition to other benefits, breastfed infants have lower rates of ear infections and diarrhea,(2), respiratory illness,(3), and obesity,(4) while women have lower rates of breast and ovarian cancer.(5,6) However, according to the 2013 CDC Breastfeeding Report Card, only 49% of women are still nursing at 6 months, of which 16.4% are doing so exclusively (without formula supplementation).(7) As such, improving breastfeeding rates and duration are important public health goals for women, babies, and society overall.

Introduction To The National Breastfeeding Awareness Campaign

Recognizing the need to address breastfeeding as a public health imperative, The National Breastfeeding Awareness Campaign (NBAC) was launched in 2004 by the United States Department of Health and Human Services’ Office on Women’s Health (OWH).(8) The campaign sought to achieve two main goals: first, increase the proportion of mothers who exclusively breastfeed their babies (from 69% to 75% during months 0-6 and from 33% to 50% during months 6-12) and second, increase general awareness of breastfeeding and its benefits.(8)

The campaign had both media and community outreach components. For its media component, the OWH collaborated with the Ad Council to develop materials for television, radio, newspapers, magazines, mass transit shelters, billboards, and Internet. Their intended target audience was first-time mothers and fathers who have no experience with breastfeeding. The OWH website publishes several of the materials used in their media campaign including links to print, radio, and television segments.(8)

Print Ads

The OWH website publishes three versions of their print ads. All are depictions of breasts using non-breast materials. In the first, there are two dandelions with pink centers used in association with the message “Breastfeed for 6 months. Help reduce your child’s risk for respiratory illness;” in the second, two otoscopes are used in conjunction with the message “Breastfeed for 6 months. Help reduce your child’s risk of ear infections;” and in the third, there are two scoops of ice cream, each with its own bright red cherry, and the message “Breastfeed for 6 months. Help reduce your child’s risk for childhood obesity.”(8)

Television Ads

The website also publishes two television ads, one featuring a very pregnant woman riding a bull and one featuring two very pregnant women participating in a log roll. “You wouldn’t take risks before your baby is born,” they say. “Why start after?”(8)

Radio Ads

Finally, the website publishes two radio ads. One is an R&B song in which the risks of not breastfeeding are soulfully swooned. The refrain, which repeats several times, is “you got to know the facts, lady.” The other is a country song, which sings “when it came to increasin' disease resistance, that woman could lactate like nobody's business,” in reference to the country singer’s “mama.”

            Despite its best intentions to increase breastfeeding rates in new mothers, NBAC’s method of doing so was deeply flawed. With messages like “You wouldn’t take risks before your baby is born—why start after?” and “Help reduce your child’s risk of disease X,” NBAC highlights the bad things that can happen to babies who are not breastfed and places the burden on women to fix them. These messages are a textbook representation of a campaign based on the Health Belief Model (HBM).(9) The HBM suggests that a person’s likelihood to adopt a new health behavior depends on two factors: first, the individual’s belief in a personal (or in this case, her child’s) threat of disease or illness; and second, an individual’s belief that the new health behavior will actually make a difference. As such, NBAC seeks to convince new mothers not only that their children are at risk for developing countless numbers of terrible diseases (e.g. obesity, diabetes, asthma, and ear infections), but also that breastfeeding will miraculously make these things go away.

NBAC plays to several strengths of the HBM, most notably in its use of “perceived susceptibility,” “perceived severity,” and “perceived benefits” to convince mothers that breastfeeding will help reduce the likelihood of serious illness in their children. However, there are also many weaknesses to using this model, both in terms of its application to this particular campaign and because of weaknesses inherent to the model itself.

In this paper, I will identify three major flaws of the NBAC because of its use of the Heath Belief Model: first, I will critique its failure to account for individual attitudes and beliefs that may influence a woman’s decision to breastfeed; second, I will critique its exclusion of non-health related reasons, in particular social barriers, for not breastfeeding; and third, I will critique its exclusion of environmental and economic factors that prohibit breastfeeding success. Following the critique, I will present features of an alternative campaign that may be better tailored to the diverse needs of new moms learning to breastfeed in the United States.

Critique #1. The NBAC Fails To Account For Individual Beliefs and Attitudes That May Be Barriers To Breastfeeding Success

            Ask any woman who has attempted to breastfeed her infant and she will tell you that it is hard work. Despite its being a “natural” behavior, breastfeeding is rarely a naturally innate skill. Nevertheless, this campaign addresses neither the challenges that individual women face with breastfeeding (10) or the feelings that many women experience when they struggle to succeed.(11) It wrongly assumes that breastfeeding success is independent of a woman’s personal experience, beliefs about breastfeeding, self-perception of success, or self-confidence in adequately nourishing her child. This assumption is problematic for several reasons.

            First, according to Ruowei Li et al. in their article “Why Mothers Stop Breastfeeding: mothers’ self-reported reasons for stopping during the first year,” the number one reason why women stop breastfeeding is the perception that their infant is not satisfied by breast milk alone.(12) As a result, many women introduce formula or food within the first few months because they are worried that their child is hungry. The earlier these supplements are introduced, the more likely a woman’s breast milk supply will suffer as her baby’s demand, supplanted by other sources of nutrition, will decrease.

            Second, Li et al. point out that Hispanic mothers and mothers with annual incomes <350% of the federal poverty line are among the more likely to stop breastfeeding before their peers.(12) While there are certainly environmental and economic factors for this discrepancy that are addressed later in this paper, these research findings support the campaign’s lack of emphasis on the individual beliefs and attitudes of populations needing the most help. For example, NBAC claims that they are targeting African-American mothers, a population with comparatively low breastfeeding rates,(7) through their use of a black woman on the mechanical bull and the “soul music” radio segment.(8) However, their efforts are misguided. “Deploying black women and symbols likely to resonate with African Americans represent a use rather than an understanding of cultural particularity,” writes Joan Wolf in her paper, “Is Breast Really Best? Risk and Total Motherhood in the National Breastfeeding Awareness Campaign.” “It was the outcome of market research (focus groups) that sought to determine how best to sell a product (breast-feeding) more than an effort to understand the ‘diverse values, beliefs, and cultures in the community.’”(13)

            Ultimately, perhaps in a well-intentioned effort to make its ads as broadly appealing as possible, the NBAC fails to account for the fact that women have deeply unique breastfeeding experiences that are highly informed by individual beliefs and attitudes. While this variation may be due to a variety of factors, addressing the individual needs of cultural groups needing the most support would be a good place to start.

Critique #2. The NBAC Fails To Account For Social Barriers To Breastfeeding

            Despite the fact that breastfeeding is becoming a more socially acceptable activity, women perpetually face societal barriers that hinder their breastfeeding success. Among these are negative reactions to public breastfeeding,(14) resistance to accommodating women’s nursing needs in the workplace,(15) hyper-“sexualization” of female breasts,(16) and male reactions to breastfeeding.(17) The NBAC avoids the social context of nursing entirely in its print and television ads, and touches upon it only briefly in its radio segments. Excluding any discussion of the social barriers that women face while attempting breastfeeding is a major flaw in the NBAC overall.

            The NBAC puts a lot of pressure on individual women to make the right choice for their babies, but no pressure on society to support them in this endeavor. They compare the health implications of not breastfeeding to that of riding a mechanical bull or log-rolling while heavily pregnant. This is not only an unfair comparison (there is no comparable danger in giving infants formula), but also one in which women are expected to succeed against all odds. It fails to account for the fact that unlike the woman who chooses to mount the bull, a woman most likely chooses not to breastfeed because of obstacles that are likely completely out of her control. Two of the most significant obstacles that NBAC excludes are societal reactions to women who breastfeed in public and lack of accommodations for nursing women in the workplace.  

In their paper “Men and Infant Feeding: Perceptions of Embarrassment, Sexuality, and Social Conduct in White Low-Income British Men,”(Henderson et al., 2011) Henderson et al. observe that “perceptions of breastfeeding as a sexual activity and the dominant mass media emphasis on breasts as a sexual site may present additional obstacles to breastfeeding.” While this study was conducted in Britain, it is definitely applicable to similar obstacles that women face in this country. Whether it intends to or not, NBAC does address some of the prevailing male perceptions of breastfeeding by using male vocalists in both of its radio ads. Both the country and soul segments feature male vocalists singing the praises of the breastfeeding women in their lives: the country song says, “Mamma's nursin' helped raise a healthy family. There's nothin' she wouldn't do, she helped us kids get through, with less risk for ear infections and respiratory illnesses,” while the soul song says, “wonderful woman, if you do breastfeed, our little baby will be at less risk of respiratory illnesses.” It is refreshing to hear a male not only profess his understanding of breastfeeding’s benefits, but also express gratitude for the work women do for their children.

While this is certainly a strong first-step, NBAC’s message is likely far too subtle to inspire real social change. Henderson et al. assert that for real changes in perception to happen, both pre- and peri-natal education should target men directly. Only then can many of the deeply entrenched problems generated by historical views of sexuality and masculinity be addressed.

Critique #3. The NBAC Fails To Account for Economic and Environmental Barriers to Breastfeeding

            There is a wide variation in breastfeeding rates between racial and socioeconomic groups in this country.(18) Much of this variation can be attributed to discrepancies between levels of social support, healthcare provider guidance, quality of maternity- and postpartum-care, and hospital engagement in breastfeeding (e.g. breastfeeding initiation delays, provision of pacifiers, promotion of formula, etc.).(18) These discrepancies are especially pronounced when comparing resources available to different racial groups and to populations in poorer or wealthier parts of the country. Therefore, for many women attempting to breastfeed, there can be any number of insurmountable economic and environmental barriers to success.

            Recognizing that African-American women have some of the lower breastfeeding rates in this country, the NBAC tailored part of its campaign for this audience. Nevertheless, as noted above, its methods for doing so fall short of reaching not only African-Americans, but also many of the other most vulnerable populations at risk for breastfeeding failure. The CDC recommends that public health measures to promote breastfeeding target black mothers in rural areas, mothers younger than 20 years old or who have not completed high school, and enrollees in the WIC program. In addition, they emphasize the importance of supporting women’s efforts not only to initiate breastfeeding, but also to continue for as long as possible.(18)

            Dr. Miriam Labbok, Professor of Maternal and Child Health at the University of North Carolina and Director of the Carolina Global Breastfeeding Institute points out that women who receive WIC are at a particular disadvantage because they are recipients of free formula for 3 out of 4 weeks each month.(19) In an interview I conducted with her on March 3, 2014, she said, “WIC really threw out a wrench by giving out free formula.”(20) She argues that this money could be much better spent on counseling and supporting new moms who otherwise have very little economic, community or social encouragement. WIC, she says, is doing the poorest women in this country a huge disservice. The NBAC fails to account for the vulnerabilities of this population and others facing similar economic and environmental burdens. Relying too heavily on the tenets of the HBM, its ads do not address the needs or concerns of women facing some of the most substantial barriers in this country.

Introduction To An Alternative To The National Breastfeeding Awareness Campaign

            Based on the above critique, the NBAC could improve its impact by changing the content, target audiences, and method of delivery of its messages. Of the many improvements it might pursue, there are three in particular on which I would like to focus. While I do not expect any of these suggestions to fix the campaign or universally increase breastfeeding rates in this country, I do hope that they will offer alternatives for targeting some of the root causes of the breastfeeding problem. First, NBAC should further investigate the individual beliefs and attitudes that hinder women’s breastfeeding success and address some of these sentiments in their ads. These individual beliefs should be addressed not only in the context of the obstacles women “in general” encounter, but also in terms of the obstacles that specific socioeconomic and racial groups encounter. Second, NBAC should contextualize its ads in contemporary society and address some of the social barriers that women face. To do this, NBAC must address sexuality, male-female dynamics, public breastfeeding, and workplace accommodations. Third, NBAC should design its campaign to focus not only on generating passive awareness, but also encouraging active participation via social networks.

Intervention #1. Acknowledgement And Incorporation Of The Diversity Of Breastfeeding Experiences Into The NBAC Campaign

            As detailed above, the NBAC assumes that when given the right information, women will make the right choice. Armed only with the knowledge that breastfeeding will decrease the likelihood of ear infections, respiratory illnesses, and childhood obesity, women are expected to just pick up their babies, put them on their breasts, and go. This is an unreasonable expectation given the many physical, emotional, personal, environmental, and economic challenges that women face. The NBAC can do a better job of addressing these individual beliefs and attitudes in two ways. First, I think NBAC and women would be well-served by acknowledging that breastfeeding is hard work for everyone. It is a skill that needs to be learned, despite the assumption that it is “natural” and therefore “second-nature.” One Canadian breast-feeding ad(21) treats this issue particularly well. Showing a woman struggling to learn a new language, it says “it takes time…to learn a new language. Why would breastfeeding be any different?” This ad is particularly powerful in the way that it normalizes the feelings of uncertainty and frustration many women experience when first starting to breastfeed their baby. Whether discouraged by pain, fearful that they are not providing adequate nutrition, or confused about the lactation process in general, women need to be encouraged by the fact that they do not struggle alone. The success of this ad is predicated on The Social Norms Theory(22), which states that correcting misperceptions will result in an increase in the desired behavior. In this way, this ad can be used to establish the social expectation that breastfeeding is challenging for everyone.

This message would be further bolstered by tailoring the ads to specific populations so that the message is broadened to say not only “we are all in this together,” but also that “breastfeeding is hard for people like you and me.” This could be achieved using African-American, Hispanic, and visibly poor women in these ads, as opposed to the obviously white, affluent woman sitting in a café in Nova Scotia in the Canadian ad above.

Intervention #2. Incorporation Of The Social Context Of Breastfeeding Into The NBAC Campaign

            The NBAC is also undermined by its trying to advocate for breastfeeding in a social vacuum. Ironically, none of the ads shows a woman actually breastfeeding her baby, but more importantly for this argument, there are no ads featuring women breastfeeding in a park, or in a mall, or at a restaurant—all images that could potentially inspire not only more breastfeeding in public, but also social acceptance of women who choose to do so. In keeping with the Social Norms theory again, this breastfeeding flashmob(23) video clip from the show, The New Normal, humorously addresses this issue. It features a woman at a restaurant who, in the process of breastfeeding her baby, is challenged by a male employee. He is reproached by a large group of women who parade around the restaurant with their babies. While promotion of breastfeeding as a socially normal activity is an imperative for improving breastfeeding rates in this country, one of the risks of the Social Norms approach is using sources that are either unreliable or lacking credibility. Therefore, any use of humor for the purposes of advancing awareness should be used judiciously.

            As discussed above, another social barrier that many breastfeeding women encounter are negative reactions from men.(17) As such, media campaigns that target men and their relationships with breastfeeding women are an important step in advancing breastfeeding as a social norm. Despite listing it as one of its goals, the NBAC does not make a deliberate effort to deliver its message to men aside from using male vocalists in its songs. However, if men don’t support breastfeeding women, societal change will continue to be slow. One campaign, Project Breastfeeding(24) is trying to address this issue directly. The project has created a photographic series of men, many of them shirtless, holding babies and children in the breastfeeding position and the underlying message, “I would if I could.” The project slogan states: “Destigmatize public breastfeeding. Educating Men. Empowering Women. Our goal and mission statement is simple, we need to normalize breastfeeding once again.” In this way, this project is targeting men and encouraging their participation in support of breastfeeding woman. While in many ways, this campaign is a beautiful application of the Social Norms theory, some men may react poorly to such an alternative message, particularly as it blurs the line between typical gender roles and responsibilities.

Intervention #3. Using Social Networks to Increasing NBAC’s Impact

            Finally, in addition to modifying the content of its ads, the NBAC could be strengthened through application of the Social Network theory to its intervention. Research such as that performed by Drs. Nicholas Kristakis and James Fowler at Harvard Medical School supports that groups of interconnected people can have either positive or negative effects on individual health.(25) The impact of these networks on breastfeeding women has also been demonstrated in research citing “new moms groups” and the effect of family members, friends, co-workers, and partners as important factors for whether a new mother succeeds with breastfeeding.(26,27) With the growing influence of social networks such as Facebook, more and more people are seeking “community” on the Internet and new mothers—tired, anxious, and isolated at home—are certainly among those who do.

The First 6 Weeks is a breastfeeding organization in Canada that has recognized this fact. As part of its campaign, it has assembled a collection of stories about women’s breastfeeding experiences during the first 6 weeks of their babies’ lives. The stories range from “Breastfeeding is the most amazing thing that ever happened to me,” to “I tried and failed.” Not only is this campaign reaching out to women during the time they are most likely to quit, they have created a collection of stories that brings women together in this shared experience. In keeping with the tenets of the Social Network theory, I think that both of these campaigns, NBAC and First 6 Weeks, would be additionally strengthened by directing women to online support groups and chat rooms where they could discuss their experiences in real time.

Conclusion

According to NBAC, its campaign did not “fail.” Awareness about breastfeeding and its health benefits definitely increased (28); however, there are no data to show either that more women are actually breastfeeding or that these breastfeeding efforts will be sustained. In order for these changes to happen, a different approach needs to be taken. Yes, women are the only people who have the physical means to breastfeed, but they can’t do it alone. Until society embraces breastfeeding not only as a public health imperative, but also as a social norm, there will always be opportunities for improvement.

References

1.         American Academy of Pediatrics. AAP Policy on Breastfeeding and Human Milk.

2.         Scariati PD, Grummer-Strawn LM, Fein SB. A longitudinal analysis of infant morbidity and the extent of breastfeeding in the United States. Pediatrics. 1997 Jun;99(6):E5.

3.         Beaudry M, Dufour R, Marcoux S. Relation between infant feeding and infections during the first six months of life. J Pediatr. 1995 Feb;126(2):191–7.

4.         Gillman MW, Rifas-Shiman SL, Camargo CA Jr, Berkey CS, Frazier AL, Rockett HR, et al. Risk of overweight among adolescents who were breastfed as infants. JAMA J Am Med Assoc. 2001 May 16;285(19):2461–7.

5.         Do Carmo França-Botelho A, Ferreira MC, França JL, França EL, Honório-França AC. Breastfeeding and its relationship with reduction of breast cancer: a review. Asian Pac J Cancer Prev APJCP. 2012;13(11):5327–32.

6.         Luan N-N, Wu Q-J, Gong T-T, Vogtmann E, Wang Y-L, Lin B. Breastfeeding and ovarian cancer risk: a meta-analysis of epidemiologic studies. Am J Clin Nutr. 2013 Oct;98(4):1020–31.

7.         Centers for Disease Control. Breastfeeding Report Card. Atlanta, GA; 2013.

8.         Haynes S. Breasteeding: National Breastfeeding Campaign [Internet]. WomensHealth.gov. 2010 [cited 2014 Apr 29]. Available from: http://www.womenshealth.gov/breastfeeding/government-in-action/national-breastfeeding-campaign.html

9.         Janz NK, Becker MH. The Health Belief Model: A Decade Later. Health Educ Behav. 1984 Mar 1;11(1):1–47.

10.       Brown A, Raynor P, Lee M. Healthcare professionals’ and mothers’ perceptions of factors that influence decisions to breastfeed or formula feed infants: a comparative study. J Adv Nurs. 2011 Sep;67(9):1993–2003.

11.        Otsuka K, Dennis C-L, Tatsuoka H, Jimba M. The Relationship Between Breastfeeding Self-Efficacy and Perceived Insufficient Milk Among Japanese Mothers. J Obstet Gynecol Neonatal Nurs. 2008 Sep 1;37(5):546–55.

12.       Li R, Fein SB, Chen J, Grummer-Strawn LM. Why mothers stop breastfeeding: mothers’ self-reported reasons for stopping during the first year. Pediatrics. 2008 Oct;122 Suppl 2:S69–76.

13.       Wolf J. Is Breast Really Best? Risk and Total Motherhood in the National Breastfeeding Awareness Campaign. J Health Policy Polit Law. 2007 Aug;32(4):595–636.

14.       Trocola M. Breastfeeding in Public [Internet]. La Leche League International. 2005 [cited 2014 Apr 29]. Available from: http://www.lalecheleague.org/nb/nbnovdec05p238.html

15.       United States Department of Labor. Break Time for Nursing Mothers Provision [Internet]. Fair Labor Standards Act Mar 23, 2010. Available from: http://www.dol.gov/whd/nursingmothers/Sec7rFLSA_btnm.htm

16.       Victoria’s Secret [Internet]. Victoria’s Secret. 2014 [cited 2014 Apr 29]. Available from: www.victoriassecret.com

17.       Henderson L, McMillan B, Green JM, Renfrew MJ. Men and infant feeding: perceptions of embarrassment, sexuality, and social conduct in white low-income British men. Birth Berkeley Calif. 2011 Mar;38(1):61–70.

18.       Centers for Disease Control and Prevention. Racial and Socioeconomic Disparities in Breastfeeding -- United States, 2004. MMWR Morb Mortal Wkly Rep. 2006 Mar 31;55(12):335–9.

19.       WIC Benefits and Services [Internet]. [cited 2014 Apr 30]. Available from: http://www.fns.usda.gov/wic/wic-benefits-and-services

20.      Labbok M. Personal Interview. 2014.

21.       Nova Scotia Health Promotion and Protection. First 6 Weeks [Internet]. Available from: http://www.first6weeks.ca/

22.       Siegel M. SB721: Lecture 5. Bakst Auditorium; 2014.

23.       Buecker B. Dairy Queen. The New Normal. Los Angeles: NBC; 2013.

24.       Project Breastfeeding [Internet]. 2013. Available from: www.projectbreastfeeding.com

25.       Christakis NA, Fowler JH. The Collective Dynamics of Smoking in a Large Social Network. N Engl J Med. 2008;358(21):2249–58.

26.       Dunn RL, Kalich KA, Henning MJ, Fedrizzi R. Engaging Field-Based Professionals in a Qualitative Assessment of Barriers and Positive Contributors to Breastfeeding Using the Social Ecological Model. Matern Child Health J. 2014 Apr 17;

27.       Oakley LL, Henderson J, Redshaw M, Quigley MA. The role of support and other factors in early breastfeeding cessation: an analysis of data from a maternity survey in England. BMC Pregnancy Childbirth. 2014;14:88.

28.      Haynes S. National Breastfeeding Awareness Campaign Results [Internet]. Office on Women’s Health; 2010 [cited 2014 Apr 29]. Available from: http://www.womenshealth.gov/breastfeeding/government-in-action/national-breastfeeding-campaign.html