A Critique of Fetal Alcohol Spectrum Disorder Prevention Campaigns and Recommendations for Developing An Effective Alternative-Eve Wilder
Fetal Alcohol Spectrum Disorders (FASD), a group of medical and developmental conditions that occur in children whose mothers consumed alcohol during pregnancy, are the leading cause of preventable intellectual disability in the United States. (1) The effects of FASD, which range from mild to severe, include physical impairments such as abnormal facial features and low weight, behavior problems including Attention Deficit Hyperactivity Disorder, learning disabilities, vision or hearing problems, impaired central nervous system and intellectual disability. (2) The disorders that comprise the umbrella term “FASD” include, Fetal Alcohol Syndrome, the condition with the most severe impairments to health and cognition, Alcohol-Related Neurodevelopmental Disorder (ARND) and Alcohol Related Birth Defects (AEBD). In addition to serious, lifelong health and learning outcomes for children with FASDs, there are also consequences for families and society as a whole. In 2002, the estimated lifetime cost of care for one individual with a FASD was $2 million and the estimated cost to the U.S. for FAS alone totals $4 billion per year. (3).
Current incidence estimates of FASD range from .2 to 1.5 cases per 1,000 live births, but experts believe many more cases have gone undetected. (2) Population-based data collected by the Centers for Disease Control and Prevention (CDC) reveal that the rate of alcohol use among pregnant women has remained stable for the past 15 years. The Center’s most recent data report that 12.2%, or 1 in 8, pregnant women have consumed alcohol in the month preceding data collection. (2) The data also highlight that certain subgroups of women have higher rates of drinking during pregnancy. African American pregnant women drink at 5 times the rate than their White non-Hispanic counterparts. American Indian women also have higher rates of drinking during pregnancy than White non-Hispanic and Asian pregnant women. (4) Finally, low socio-economic status, low educational attainment, lack of prenatal care and mental illness have been identified as risk factors for consuming alcohol during pregnancy. (2)
Despite the ample existence of public health FASD prevention campaigns, the rate of women who report consuming alcohol during pregnancy has hovered around 12% for the past 15 years. (5) Both the federal and state governments have initiated FASD awareness campaigns. In 2002, the CDC funded 4 regional technical assistance centers dedicated to developing and disseminating FASD prevention messages educational materials, and Missouri, Minnesota and New Jersey are several examples of states that have launched FASD media prevention campaigns.
Although countless research dollars and public health practitioner hours have been dedicated to generating FASD prevention messages, there are three key reasons why these messages were not effective in reducing women’s alcohol consumption during pregnancy. First, existing campaigns are based on the health belief model, which evidence has proven to be ineffective in producing behavior change. Second, existing campaigns use fear-based or shock-value messages that trigger psychological reactance and have been demonstrated to be ineffective in changing behavior. Finally, existing campaigns don’t address, or attempt to counteract, the power and influence the alcohol industry’s marketing has on women of child-bearing age.
Critique of Fetal Alcohol Spectrum Disorder Prevention Campaigns
Critique 1: Use of the Health Belief Model
A principal reason federal and state FASD prevention campaigns did not successfully decrease the rate of women’s alcohol consumption during pregnancy is because the campaign messages were based on the health belief model. This individual level model assumes that health behavior is planned, determined by intent, and is based upon a rational weighing of the perceived benefits (the value of the new behavior in decreasing risk of developing new disease) and perceived barriers of adopting the behavior. (6) The FASD campaigns were based on the premise that when young women are give then facts and consequences about exposing a fetus to alcohol they would make the decision not to drink during pregnancy.
A FASD prevention campaign in Missouri featured a slogan stating, “Alcohol hurts unborn babies” and focused on the description of the birth defects associated with FASD. (4) In New Jersey, the “Be in the kNOw” campaign featured videos of health professionals answering youth’s questions about the harm of alcohol consumption during pregnancy and featured the slogan, “Think about it. Every time you drink alcohol, smoke or use drugs, so does your baby. Alcohol, cigarettes and drugs can harm your unborn child!” (1) Finally, a campaign in Minnesota focused on ensuring that women were aware of the hazards of drinking while pregnant, decreasing their attitudes supporting this behavior and increasing the perceived severity of the impact of alcohol on a developing fetus. (7) Evaluations of each of these campaigns revealed that while the target audience’s knowledge of the consequences of alcohol consumption during pregnancy increased, the audience did not report being less likely to use alcohol during pregnancy. (1) Population based data on the un-changed rate of alcohol use among pregnant women supports these results.
Recent research has proven the health belief model to be ineffective in changing most health behaviors, especially those that are complex like alcohol and food consumption or substance use. (8, 9, 10) First, the model does not effectively apply to decreasing alcohol consumption during pregnancy because almost 50% of all pregnancies in the U.S. are unplanned. (11) Many women don’t even recognize they are pregnant until the 4-6th week when it’s likely they’ve already consumed some alcohol. (11)
Secondly, several social and behavioral theories have explained the weakness of the health belief model. Because of “optimistic bias”, people believe that the poor outcomes of others are not relevant to themselves. (12) For example, smokers who are presented with lung cancer fatality statistics rarely believe they will become one of those statistics themselves. Also, the fundamental attribution error incorrectly attributes a person’s behavior to individual characteristics and ignores the significant influence of context and environment. (12) Finally, much evidence exists that behavior is not planned or rational and that intent does not determine behavior (13, 14).
Critique 2: Use of Fear-Based or Shock-Value Messages
Instead of utilizing effective behavior change models like Advertising and Marketing Theory, which appeal to universally held core values, many of the FASD prevention campaigns, both in the U.S. and internationally, employed fear-based messages, in addition to the health belief model, that trigger psychological reactance in the audience who is being targeted. (15) Psychological Reactance, first expressed by Brehm in 1977, describes when an individual feels his freedom is being threatened by being told to do something or not to do something, he acts to try to restore that freedom by doing the opposite of what he is told. Due to the effect of psychological reactance, fear-based messaging has proven to be unsuccessful in substance abuse and tobacco use prevention campaigns targeting youth, including graphic cigarette warning labels and “This is Your Brain on Drugs” campaign of the Partnership for A Drug Free America (16, 17).
Examples of FASD fear-based prevention messaging at the federal level include the Substance Abuse and Mental Health Services Administration’s (SAMSHA) FASD prevention materials, featuring the messages “Alcohol passes through the bloodstream and hurts and many as 1 in 100 babies each year” and “Your baby may never outgrow some of the problems caused by alcohol”. (SAMSHA, 2010) On the state level, the New Jersey “Be in the kNOw” campaign featured the message, “When we look at maternal and infant mortality, it becomes clear that having babies is a risky business”. (18) The Missouri FASD prevention campaign’s logo featured a picture of an African American female holding a liquor bottle that directed alcohol into her umbilical cord with her fetus saying, “None for me, Momma!” (4) Finally, in Italy, where alcohol consumption during pregnancy has been, and still is, more prevalent than in the U.S. a FASD campaign showed a photograph of a fetus floating in a glass containing an Italian cocktail with the message, “When mom drinks, baby drinks”. (19)
A 2010 study evaluated the efficacy of fear-based messages in decreasing alcohol consumption in pregnant women. In this research, college-age women were asked to read four different messages about FASD that either featured potential losses or fear-based messages, like “I wuz sposed to be a genuis” written in crayon by a disabled child, or potential benefits, like “Healthy Babies Need Everyone’s Support. Alcohol and Pregnancy Don’t Mix”. (20) The study found that the women reacted more strongly to the benefit messages and did not relate to the fear-based messages because they believed they would never drink during pregnancy. Messages featuring women they could identify with, where mothers were portrayed as responsible, were more effective than fear, statistics or abstract generalizations that women didn’t feel were relevant (20)
Critique 3: Ignores the Power and Influence of Alcohol Industry Marketing
A third and important reason previous FASD campaigns could not effectively decrease women’s alcohol consumption during pregnancy is because the campaigns disregarded the significant influence the alcohol industry has over young consumers, including women of child-bearing age. Youth are constantly bombarded with alcohol-friendly messages in their daily lives via the television, radio and print media. The Center on Alcohol Marketing and Youth reported that in 2003 Black non-Hispanic adolescents were exposed to more pro-alcohol than anti-alcohol messages in the media by a ratio of 200 to 1. (4)
Furthermore, the alcohol industry does not use ineffective behavior change theories, like the health belief model, to reach youth. Instead the industry is adept at using advertising and marketing theory to universally appeal to youth and generate competing messages, based on core values, about the effects of alcohol. (4, 21) As a result, the evidence concludes that exposure to alcohol advertising contributes to an increase in youth drinking. The alcohol industry also has vast resources at its disposal. In 2005, the alcohol industry spent $2 billion in advertising. (21) One study documented that for each dollar spent on alcohol advertising in a local retail store, youth increased their alcohol intake by 3%. (22)
Proposal of An Alternative FASD Prevention Campaign
Over the past 15 years, the steady rate of women’s alcohol consumption during pregnancy, and the significant disability children experience as a result, necessitate the development of a revised FASD prevention campaign. The prevention campaign proposed in this paper is based upon 6 effective alternative, group level models of behavior change, which address the flaws of the health belief model and fear-based messaging strategies and attempt to counter the influence of the alcohol industry. The behavior change models used to inform the proposed FASD prevention campaign include: Advertising Theory, Marketing Theory, Social Norms Theory, Communication Theory, the Law of Small Numbers and Cognitive Dissonance.
Description of Proposed Campaign:
The proposed FASD prevention campaign will be comprised of two television advertisements and several print media advertisements targeting women of childbearing age who reside in urban, low-income communities in Massachusetts. The first television ad will feature an actual mother, from a community similar to that of the target audience, who occasionally drank alcohol during her pregnancy because she was unaware of the consequences. In telling her personal story, the mother won’t focus on statistics of FASD or list the negative health consequences, but will focus on how this is a real problem that happens to real people. This mother’s persuasive, emotional personal story will portray how her life and her child’s life have changed. At the end of the ad the mother will make the request, “Don’t make the same mistakes I did. There are places you can turn to for support or to answer your questions” and provide women with the information for local FASD prevention resources.
The second advertisement will take a different approach. This advertisement will also feature mothers from a community similar to the target audience’s, but these mothers will be shown happily engaging, kissing and playing with their healthy babies, watching them reach their developmental milestones, like their first words or first steps, and then flash to the future where the child is pictured graduating high school. The ad will feature scenes outside on a sunny day at the park and at home with the family, set to the popular song, “These Are the Days” by Natalie Merchant. At the end of the advertisement, the message will read, “When you are pregnant, you are building the road your child will travel in her future. From her first steps, to her first steps on a college campus, you have the power to make sure that road does not have any bumps. Avoid drinking any amount or type of alcohol when you are pregnant”. After the message, the audience will be invited to go online to an FASD prevention website where they can join a pledge to reach a FASD-free future. The last line of the ad will read, “The power is in your hands” and flash to a picture of a black and white photograph of a mother’s hands cupped around a baby’s feet in the shape of a heart.
The print advertisements will be coordinated with the television ads. The goal of the print ads will be to create a community of women of childbearing age in the targeted area who are committed to an alcohol-free pregnancy and strong future for their children. This campaign will attempt to generate a sense of collectivism, empower women, and reject the manipulative and negative influences of the alcohol industry. The ads will feature photographs of strong, relatable women with text reading, “You can’t fool me!”, “I pledge to keep my baby safe by not drinking when I’m pregnant”, “Your industry profits are not more important that my baby’s future” and “Together we can prevent Fetal Alcohol Spectrum Disorder”. Several variations of this ad will exist, each one featuring a sound-bite about the alcohol industry’s wealth and attempt to control youth through advertisements. This prevention campaign will also adopt the logo of Alberta Canada’s FASD Awareness Day, a dreamcatcher. The dreamcatcher will serve as a symbol for the endless possibilities of a child whose development was not effected by alcohol. The dreamcatcher logo will appear on all campaign materials with the slogan, “See all your child’s dreams come true”.
Defense of Proposed FASD Prevention Campaign
Argument 1: Use of Effective, Group-Level Behavior Change Models
Alternative, group-level models of behavior change were chosen to guide the proposed campaign for three principal reasons. First, these models consider group dynamics, that being part of a group influences an individual’s behavior. Also, with group level models, an intervention can impact a large number of people at the same time. Second, alternative models are based on the premise that behavior is not planned, but rather based on visceral impulses and that people in a cold state over estimate their ability to control their impulses. (23) Finally, alternative, group level models consider that environment or context, not just individual characteristics, influence behavior.
Instead of simply listing negative health outcomes for children with FASD or FASD statistics, the proposed campaign attempts to elicit behavior change in several other distinct ways. First, the revised campaign employs the Law of Small Numbers in the first TV advertisement. This theory states that People’s mathematical understanding of probability is skewed by the context in which they perceive behaviors and their familiarity with the context. (24) Therefore, people’s perception of risk is distorted and they often don’t believe negative health outcomes are applicable to them. To counteract this phenomena, similar to the strategy used in a Massachusetts’ Tobacco Control advertisement featuring a mother who died at age 30 from smoking, the FASD campaign’s first TV ad uses a single, personal story of an individual the target audience can relate to and identify with. As in the Tobacco Control ad, the FASD ad shows women that FASD is something that can happen to anyone and shows women through images, not data, what the real consequences of drinking during pregnancy look like. By featuring a woman who could likely be the friend or sibling of the woman in the target audience, this advertisement also employs Communication Theory. This theory states that the most important factor in determining how effective a request will be is how much the audience likes and relates to the messenger.
Argument 2: Use of Advertising and Marketing Theory Not Fear-Based Strategies
Another strength of the proposed FASD prevention campaign is its foundation in Advertising and Marketing theories, two other group level behavior change theories. These theories have been effectively used for years by for-profit corporations to persuade consumers to purchase certain products by understanding that human behavior is not rational and that people are influenced by universally-held core values including freedom, family, love, belonging, and fairness. (25)
In the proposed campaign, instead of presenting women with facts about the horrible consequences of drinking while pregnant, the second advertisements shows women the alternative: a long lifetime of family, love and possibilities. By appealing to these core values, using persuasive images like playing in the park and symbols like the Natalie Merchant song, the advertisement is supporting its promise that there is great benefit to not drinking while pregnant. The print campaign also employs the use of marketing theory by using the dreamcatcher logo and creating the slogan, “See all your child’s dreams come true”. By creating a brand for the campaign, an identity is created that evokes what the campaign represents. With an established identity, women can be invited to join the movement for safe and healthy babies, which appeals to the core value of belonging.
By inviting the women to sign an alcohol-free pledge and join the movement, the campaign is also employing the principles of cognitive dissonance and ownership. Cognitive dissonance is an evidence-based theory that states that once someone behaves in a certain way, the person has to change his attitudes to reconcile them with the behavior no conflict exists between the two. (26) In the revised FASD campaign, instead of first attempting to change women’s knowledge and attitudes about drinking while pregnant, the advertisement is inviting women to experience an alternative behavior, which will then generate knowledge and attitudes against drinking while pregnant.
Argument 3: Uses Evidence-Based Strategies to Address Influence of Alcohol Industry
A final strength of the revised FASD campaign is its direct attack on the alcohol industry’s attempt to manipulate young consumers to behave in ways that are bad for their health. The print advertisements appeal to the principal of psychological reactance by informing women that their freedom to receive unbiased information about alcohol and their health is being threatened. The ads attempt to empower these women with strong messages like, “Your industry profits are not more important that my baby’s future”, and images and incite them to rebel against the influence of the alcohol industry.
Psychological reactance has been effectively used to counter industry influence in previous public health campaigns. Although the alcohol industry has already successfully saturated the advertising market and outnumbered public health messages with their pro-alcohol advertisements, the anti-tobacco Truth Campaign has demonstrated how public health campaigns can effectively combat the influence big, wealthy corporations have over health behavior. (27) The Truth Campaign used the theory of psychological reactance to its advantage by appealing to youth’s predilection towards rebellion. The messages of the truth campaign focused on how big tobacco corporations were using advertisements to manipulate youth into smoking and control their behavior. (28) An evaluation of the Truth Campaign determined that its messages effectively reduced smoking initiation among youth. (27)
A review of the literature reveals that previous FASD prevention campaigns can be strengthened and improved by employing group level, alternative models of behavior change instead of relying upon traditional models that have proven to be ineffective. It is hoped that after the proposed campaign is implemented, the current rate of women who consume alcohol during pregnancy will fall for the first time in 15 years, preventing thousands of children from experiencing the debilitating effects of Fetal Alcohol Spectrum Disorders.
1) Awopetu O, Brimacobe M, Cohen D. Fetal Alcohol Syndrome Disorder Pilot Media Intervention in New Jersey. Canadian Journal of Clinical Pharmacology. 2008; 15(1): e124-e131
2) Centers for Disease Control and Prevention. Alcohol use Among Pregnant and Nonpregnant Women of Childbearing Age --- United States, 1991-2005. Morbidity and Mortality Weekly Report. 2009; 58(19): 592-532
3) Lupton C, Burd L, Harwood R. Cost of fetal alcohol spectrum disorders. American Journal Genet C Semin Med Genet. 2004; 127C(1): 42-50
4) Mengel MB, Ulione M, Wedding D, Jones ET, Shun D. Increasing FASD Knowledge by a Targeted Media Campaign: Outcome Determined by Message Frequency. Journal of FAS International 2005;3:e13. Retrieved April 28, 20011 from http://www.motherisk.org/JFAS_documents/JFAS5000_e13.pdf
5) Sidhu J, Floyd R. Alcohol use among women of childbearing age--United States, 1991- 1999. MMWR. 2002;51(13):273-276
6) Rosenstock IM. Historical origins of the health belief model. Health Education Monographs 1974; 2:328-335
7) LaChausse RG. The Effectiveness of a Multimedia Program to Prevention Fetal Alcohol Syndrome. Health Promotion Practice. 2008; 9(3): 289-293
8) Thomas LW. A critical feminist perspective of the health belief model: implications for nursing theory, research, practice, and education. Journal of Professional Nursing 1995; 11:246-252
9) Hornik R, Jacobsohn L, Orwin R, Piesse A, Kalton G. Effects of the national youth anti-drug media campaign on youths. American Journal of Public Health 2008; 98:2229-2236
10) King DE, Mainous AG, Carnemolla M, Everett CJ. Adherence to healthy lifestyle habits in US adults, 1988-2006. American Journal of Medicine 2009; 122:528-534
11) Floyd RL, Weber MK, Denny C and O’Connor MJ. Prevention of Fetal Alcohol Spectrum Disorders. Developmental Disabilities Research Reviews. 2009; 15: 193-199
12) Maslow AH. A theory of human motivation. Psychological Review 1943; 50:376-396
13) West R, Sohal T. “Catastrophic” pathways to smoking cessation: Findings from national survey. BMJ 2006
14) DeMartino B, Kumaran D, Seymour B, Dolan RJ. Frames, biases, and rational decision-making in the human brain. Science 2006; 313:684-687
15) Bauer UE, Johnson TM, Hopkins RS, Brooks RG. Changes in youth cigarette use and intentions following implementation of a tobacco control program: Findings from the Florida Youth Tobacco Survey, 1998-2000. JAMA 2000; 284:723-728
16) Sabbane LI, Lowrey TM, Chebat JC. The Effectiveness of Cigarette Warning Label Threats on Nonsmoking Adolescents. Journal of Consumer Affairs. 2009; 43(2): 332-345
17) Orwin R, Cadell D, Chu A, et al. Evaluation of the National Youth Anti-Drug Media Campaign: 2004 Report of Findings. Washington, DC: Westat; 2006
18) Be in the kNOw. Retrieved from: www.beintheknownj.org
19) RASSEGNA STAMPA CAMPAGNA DI COMUNICAZIONE 2010 . Retrieved from: http://www.mammabevebimbobeve.it
21) Fleming K, Thorson E, et al., "Alcohol Advertising Exposure and Perceptions: Links with Alcohol Expectancies and Intentions to Drink or Drinking in Underaged Youth and Young Adults," Journal of Health Communication 9(2004): 3-29
22)Snyder LB, Milici FF, Slater M, Sun H, and Strizhakova Y. Effects of Alcohol Advertising Exposure on Drinking Among Youth. Archives of Pediatrics and Adolescent Medicine 160 (2006): 18-24
23)Ogden J. Some problems with social cognition models: a pragmatic and conceptual analysis. Health Psychology 2003; 22:424-428
24)Tversky A, Kahneman D. Belief in the law of small numbers. Psychological Bulletin 1971; 76:105-110
25) Ogilvy D. Confessions of an Advertising Man. How to build great campaigns (Chapter 5). New York: Atheneum, 1964, pp. 89-103
26)Festinger L. A theory of cognitive dissonance. 1957. Stanford, CA: Stanford University Press
27) Sly DF, Hopkins RS, Trapido E, Ray S. Inﬂuence of a counteradvertising media campaign on initiation of smoking: the Florida ‘‘truth’’ campaign. Am J Public Health. 2001;91:233–238
28) Hicks JJ. The strategy behind Florida’s “truth” campaign. Tobacco Control 2001; 10:3-5