Challenging Dogma - Spring 2011

Saturday, May 14, 2011

Why The Theory of Reasoned Action Is Not Helping Breastfeeding Rates in Low-Income Women: A Critique Using The Socio-Ecological Model-Natalie Butle

It has been firmly established in the medical community that breastfeeding is the best option for mothers and their children. The World Health Organization’s Healthy People 2010 has put forth the goal to have 50% of the population exclusively breastfeeding for 6 months (1). The benefits for children include strengthened immune systems, improved cognitive abilities, as well as decreased rates of asthma, obesity, and other chronic health programs. Mothers, in turn, benefit from decreased rates of breast cancer, better bonding with baby, and quicker return to pre-pregnancy weight, in addition to saving both time and money when compared to the preparation of formulas and bottles (2-6). Public health advocates urge all mothers to breastfeed if possible, and have created several programs to promote the benefits of this practice. Despite this effort, the United States lags behind other industrial countries. Statistically, only 33% of American mothers breastfeed for the first 3 months, and only 13.3% continue breastfeeding for the recommended 6 months (7).

WIC’s Approach to Improving Breastfeeding Rates

New York State’s Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program launched the “Breastfeeding…For My Baby…For Me” campaign in an attempt to increase poor breastfeeding rates (8). WIC is a state-funded nutritional program that supplies mothers and their children that are under 2 years of age with staple food items such as cereal, milk and bread. WIC also supplies baby formula for mothers with infants, much to the consternation of medical providers, who view this as a disservice to underserved populations. Researchers note that WIC recipients have some of the lowest breastfeeding rates in the United States, with low income, black non-Hispanic women having the lowest rates. WIC mothers have 58.8% imitation rates for breastfeeding, and 22.1% continuation for six months (9). In response, WIC has made strides to encourage breastfeeding for their clients in recent years, which would result in the increased health and well-being of families and decreased need for funding for baby non-breastmilk formulas. The “For My Baby...” campaign consists of Public Service Announcements (PSA’s), in the medium of print and television spots. WIC also has an online presence, providing information about the program, as well as a list of community services available through their website, including peer lactation counselors and links to other breastfeeding centers based out of the New York area. These PSA’s mention a variety of nutritional and physical benefits of breastfeeding practice for both mother and child, although there is no information to be found concerning an increase or decrease in the number of mothers that choose to breastfeed as an alternative to formula during this campaign.

Giving Mixed Messages About Importance

While the breastfeeding benefit data that is presented to new mothers is useful and encouraging, many social attitudes are not particularly supportive for the continuation of breastfeeding or breastmilk expression (also know as “pumping”). For example, the New York WIC website links to, which has the line “Breastfeeding for even one day is a very special gift for your baby” prominently displayed on the home page. This “special gift” references the colostrum that is initially produced in the first hours of a child’s life, which is nutrient- and calorie-packed (10). While this statement is true, it does not encourage the continuation of breastfeeding for six or more months, when most nutritional and emotional benefits are established for both mother and child. In contrast, this tagline creates a baseline of low expectations for mothers. The supplementation of formula also undermines the importance of breastfeeding, although it is unethical to not supply a necessary food to children. In response to this, WIC incentive packages are now offered to breastfeeding women to tweak this loophole (where breastfeeding women receive more variety and produce for their families). Studies have shown that the perceived benefits of better food choices outweigh the free cans of formula that are distributed in WIC food packages. The key, however, is also ensuring the WIC councilors receive incentives to having their clients sign up for this package (reinforcing the positive attitude towards breastfeeding by outsiders) (11).

High Reactance to Public Service Announcements

Another poorly executed aspect of this campaign is the fact that mothers, the intended audience can not relate to the women that are in these particular televised media spots, a concept that is a prime aspect of Psychological Reactance Theory. The concept of Reactance Theory states that people tend to do the opposite of what they are told, especially if the people telling them to do so are completely dissimilar to themselves. One television spot, for example, features a Caucasian woman, in her mid- to late-thirties, with a baby on her hip. She is very energetic, almost manically perky, and is discussing the amount of weight she has lost post-pregnancy. “How did I do it?”, she asks. “Breastfeeding my baby!” The ad comes off almost as a diet plan, extolling the amount of calories that are burned by breastfeeding, and there is humor in the PSA (showing maternity pants as the “before” look). The woman , however, seems to come from a different socio-economic status as the financially needy mothers that use WIC, as she is well dressed, seemingly well-rested, and well manicured. It is true that some mothers in the WIC program are probably focused on getting back to their pre-pregnancy weight, as the subjective norm of society encourages women to lose weight as quickly as possible after birth, as evidenced by numerous tabloid and gossip media publications showcasing “new mom” celebrities and their thin frames weeks after giving birth. Casting a Hispanic or African-American woman, however, could have made this message a bit more relatable to viewers and WIC recipients.

Another televised spot features a 50-something African-American woman, looking through a photo album, shaking her head to the fact that in her day of child rearing, bottle-feeding was “just the way it was”, while praising her daughter for making the “right” choice to breastfeed her child. This is another example of off-the-mark media spots, where the WIC program is not framing either of their spokespeople to be relatable to the population they are trying to reach. In this case, WIC users in New York tend to be young, African American women. The older woman in the ads creates reactance within the population WIC is trying to reach, which will in turn them off the mission to breastfeed their children, regardless of how healthy and beneficial it is. This maternal figure is an authoritarian figure, and while the message is one of support, her presence is condescending.

The print ad for this campaign, on the other hand, is better produced, with a young, African American woman in profile, with her child at the breast. These have been featured on buses and at public transportation stations, and is featured on the WIC website.

Limited Communication with the non-English-Speaking Population

Unfortunately, these previously-mentioned televised PSA’s are only offered in one language, English. The WIC website provides info for lactation support in three different languages (Chinese, English, and Spanish), but does not extend this info beyond the website. Printed ads featured on bus shelters and elsewhere were more in tune with the population, written in Spanish and featuring a Hispanic mother and baby, but because of this limited scope of advertising, the message was not extended beyond the immediate population that uses transportation.

Failure to Frame the Message

Finally, this campaign does not work because of the features it does not offer or say. For most underprivileged mothers, breastfeeding is simply not a viable long-term option because of the commitments of time that are needed and the physical requirement of being with the child (meanwhile, in the case of pumping, privacy is needed). While breastfeeding has long been touted as the best option, many mothers also do not have the proper education for breastfeeding techniques, such as positioning, nipple soreness, latching, nor the emotional support to sustain breastfeeding. Simply saying “Do this because it is good” does not mean that a population does not want to do this health behavior, or is not aware of this health behavior. Instead, society as a whole needs to be more supportive towards breastfeeding, providing education, privacy, and access to new mothers. The New York WIC programs offer peer counseling for mothers, for example, which is not mentioned on the televised commercials. Featuring this service in a campaign may encourage mothers to reach out for help if they know it is available, rather than having them hear what they should do.

This campaign seems to be centered on the Health Belief Model. In this individual health model, an adoption of a behavior is based on the factors of perceived susceptibility and severity of not adopting this behavior, and perceived benefits that come with adopting it, as well as self-efficacy, wherein a mother in this case believes in her ability to breastfeed, and the support to continue. All of this theory’s aspects are addressed by the WIC campaign, with the media messages and the availability of peer counselors. The campaign does not address the perceived barriers that a mother will face in adopting this behavior, such as losing her job or freedom due to the time and effort needed to breastfeed her baby for the recommended time. There is little focus on the external forces that influence individual behavior (12).

A New Approach

To retool a breastfeeding campaign from the public health campaign perspective, I would design another series of print and video media that addresses the stigma that comes with breastfeeding and the barriers to making this a normalized behavior. This new campaign would challenge these previously mentioned flaws and reshape the breastfeeding debate and related public health challenges facing society today. In addition, this new campaign would recharge the support offered by WIC by re-hauling the incentives offered to breastfeeding mothers, offering nipple shields, ointment, and information packets with breastfeeding “tips and tricks” to encourage proper latch and position techniques, in addition to the manual breast pumps that are already provided in WIC breastfeeding packages in lei of infant formula. These tools will help to support new mothers, who may be unable to access this equipment on their own. This new campaign, produced with WIC programs in mind, would not limit the populations that are being addressed to just mothers, but partners, employers, and younger, childless women as well, who will probably be faced with the choice to breastfeed or not in the next few years. By reformatting a breastfeeding campaign that is originally based on the Health Belief Model (which is dependent on individual behavior change, and can predict only the intent to breastfeed) to a socio-ecological model campaign, breastfeeding rates will increase across ages and races, thanks to the support systems that created for individuals, and the barriers that are overcome. This socio-ecological model has been studied with pre-natal care for low-income women, and is easily adaptable to the post-partum period. (13). Miriam Lobbok also details the benefits of the socio-ecological model in the breastfeeding community, stating that “four policy ‘pillars’ have been defined as a solid base for sustainable change…national/state government commitment, legislation and policy, health worker training and health system support, and family and community support. These pillars are the key arenas to changing the mindset of the community, and thus changing the social norm” (15).

The key to making this program different from other breastfeeding campaigns like WIC’s is by trying to fundamentally alter the discussion surrounding breastfeeding. Parents must be made aware of the federal and state-sanctioned rights that breastfeeding mothers have, which works at the public policy level. The social norms of breastfeeding that encourages mothers to breastfeed must change, and the practice must be continued through their child’s infanthood. A few campaigns have made strides towards this. The “Boob-olution” campaign, produced by during National Breastfeeding Month, encourages mothers to “whip ‘em out” and breastfeed, especially in public (16). This was done by gathering mothers of various races, sizes, as well as some celebrities, who humorously share anecdotes about their breastfeeding experiences, while listing the different names that they have given to their breasts. These ads de-stigmatize the shame that many women feel about feeding their child out in public.

Another effective intervention would be to reach out to working moms and parents that have outside commitments. This new intervention campaign will produce public service announcements (PSA’s) that portray mothers in the workplace, college campus, or any other general area that is visually realistic and appealing to new mothers who oftentimes are outside of the home during the day and juggle the roles of mother, employee, and student. The message of these PDA’s will also emphasize the breastmilk collection choices they have, such as breast-to-mouth and pumping (although formula supplementation is possible, it tends to result in decreased milk production and early weaning, and thus would not be encouraged). Making mothers and their partners aware of federally mandated laws for mothers will also raise awareness of policies within their own workplaces and community environment, giving a script for those who encounter opposition to this healthy and bonding experience.

The imagery and casting of these PSA’s is also important, and would show the audience mothers of all races with more than one child talking to the camera, making the characters more relatable to viewers. Print media commercials and visual ads will also feature the populations that they are addressing. These new PSA’s would feature these low-reactance actors and actresses giving quick tips for breastfeeding and encouraging women to seek help for any breastfeeding issues or questions they have, as well as with information on where to seek help. In another “reality TV” style of PSA, younger mothers of color, who utilize the WIC in the New York City area, will be featured discussing the benefits that they experienced while breastfeeding (whether it was weight loss or healthier children). This campaign will also reach out to young fathers who may need to support their partner’s decision to breastfeed. To make sure that this campaign resonates with viewers, reactance will be measured in a focus group before the program launches, to make sure that populations are receiving and positively responding to the messages that are being directed towards them.

Employing and utilize other mothers- peers- can provide the important emotional support roles that women need. This can be done by encouraging and emphasizing the peer lactation programs already available with the WIC program, and offering lactation support groups for new mothers, who may not have the support they need within their current social circles. As mentioned earlier, PSA’s, if cast well, can work in addressing fathers, encouraging them to support the breastfeeding decision that their partners have made.

New York’s WIC program campaign “Breastfeeding…For My Baby…For Me”, has good intentions of promoting breastfeeding for the woman that may be underprivileged. Some retooling is necessary, however, to truly reach out to the mothers and families that need this support the most. The campaign needs to move beyond the Health Belief Model, and be aware that the desire and intent to breastfeed is not enough to increase the rates of continuation. By adopting the methods of other campaigns, and expanding the reach of media, WIC will be able to support the women and children they serve, both nutritionally and emotionally. The socio-ecological model encompasses individual, social, and political interdependence and interaction, and will truly change the mindset surrounding breastfeeding.


  1. Department of Health and Human Services. Healthy People 2010: National Health Promotion and Disease Prevention Objectives. Washington DC: Department of Health and Human Services. 2000.
  2. Humphreys, A. S., Thompson, N. J. and Miner, K. R. Intention to Breastfeed in Low-Income Pregnant Women: The Role of Social Support and Previous Experience. Birth 1998; 25: 169–174.
  3. Chantry C, Howard C, et al. Full Breastfeeding Duration and Associated Decrease in Repertory Tract Infection in US Children. Pediatrics February 2006; Vol. 117 No. 2, pp. 425-432.
  4. American Academy of Pediatrics. Breastfeeding and the use of human milk. Pediatrics, 100 (6), 1035-1039.
  5. Singhal, A. and Lanigan, J. Breastfeeding, early growth and later obesity. Obesity Reviews 2007; 8: 51–54
  6. Dewey, K. Heinig, M., Nommsen, L. Maternal weight-loss patterns during prolonged lactation. American Journal of Clinical Nursing 1993; 58: 162.
  7. Center for Disease Control and Prevention. Breastfeeding Report Card, United States: Outcome Indicators. 2010. www.cdc.go/breastfeeding/data/reportcard.htm
  8. New York State Department of Health. Breastfeeding Promotion Program. “For My Baby, For Me Campaign”. New York. 2010.
  9. Munhall PL. Nursing Research: A Qualitative Perspective. Jones and Bartlett, 2007. Pages 332-341.
  10. New York State WIC Training Center. Breastfeeding Peer Counseling Program.
  11. Chiaravanont S, Keyes D. Effectiveness of Promotion Through Incentives on Duration of Exclusively Breastfeeding WIC Participants. Journal of the American Dietetic Association 1999; 99.
  12. Edberg M, PhD. Essentials of Health Behavior. Chapter 4 “Individual Health Behavior Theories”. Boston. Jones and Bartlett 2007.
  13. Sword, W. A socio-ecological approach to understanding barriers to prenatal care for women of low income. Journal of Advanced Nursing 1999; 29: 1170–1177.
  14. Labbok M. Transdisciplinary Breastfeeding Support: Creating Program and Policy Synergy Across the Reproductive Continuum. International Breastfeeding Journal. 2008.
  15. “Boob-olution Campaign”.

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