Why Emergency Contraception has Failed to Decrease Unintended Pregnancy Rates – Is There a Better Solution? – Danielle Roncari

Introduction

Unintended pregnancies, including those that are mistimed, are a significant maternal and child health problem and comprise 49% of all pregnancies in the United States (1). Women with unintended pregnancies are more likely to recognize their pregnancies late, delay the start of prenatal care, and have unhealthy behaviors during their pregnancy (2). Consequences may also extend to the woman’s own health and socioeconomic status and to that of her family. To this end, family planning public health professionals have piloted many interventions to decrease the rate of unintended pregnancy. Programs ranging from comprehensive sexual education, in-depth contraceptive counseling, availability of emergency contraception (EC), increased contraceptive availability and increased use of long-acting reversible contraceptives (LARC) have all been advocated as potential solutions. Success, however, has been mixed. In particular, improved access to EC including over the counter status and advanced provision, has had little effect on decreasing rates of unintended pregnancy. While increasing the use of LARC may be a promising intervention to decrease these rates. Current use of LARC is extremely low and an effective public health intervention to increase use has yet been proposed.

In understanding why EC has met with such little success, it is important to understand how the method works. There are currently two methods of EC available in the United States, levonorgestrel and ulipristal acetate. Each method works most likely by preventing ovulation. As such, these medications are extremely time sensitive. If they are taken too remote from an episode of unprotected intercourse or after ovulation has already occurred, the potential window to prevent a pregnancy is lost. The levonorgestrel method is most effective within 72 hours of unprotected intercourse, but can be used up to 120 hours and ulipristal acetate can be used up to 120 hours (3 and 4).

In attempting to decrease unintended pregnancies, public health and medical professionals have developed many interventions to increase the use of emergency contraception. Among these interventions, have been advanced provision of emergency contraception and a policy change allowing the levonorgestrel method to be available over the counter to people age 17 and over with a picture ID. Both of these interventions have potentially increased access to the medication but have done little to actually decrease unintended pregnancy rates.

In a Cochrane Review of 11 randomized controlled trials of advanced provision of EC, pregnancy rates were unchanged with the intervention (5). While these results are disappointing, it is interesting to note that these studies did not show an increase in STI rates or frequency of unprotected intercourse among participants who had advanced provision of EC.

Emergency Contraception and the Health Belief Model

So why has improved EC access not decreased unintended pregnancy rates? The methods are effective, with efficacy ranging from 60% to 94% depending on when in the cycle it’s taken (3). One reason for its lack of effect is that EC was never designed to be a long-term method of birth control. It was intended to be a “back-up” method, something to be used for those times when a primary method either wasn’t available or had failed. Public health and family planning experts believed that EC could be a solution to a large number of unplanned pregnancies. However, in order for EC to prevent a large percentage of unintended pregnancies, improved access was necessary because of the time sensitive nature of the medication. Past efforts to improve this access have focused on obtaining over the counter status for EC as well as “advanced prescription” - providing patients with prescriptions or actual boxes of the medication at routine annual exams so it’s available “just in case.” The idea behind these interventions was that it was a lack of access that was preventing the widespread use of EC and hampering its ability to decrease unintended pregnancy rates.

Policies and programs to improve EC access can be attributed to adoption of the health belief model. At the core of the health belief model are the following principles: 1. An individual has a perceived susceptibility to a condition 2. An individual has a perceived severity of a condition and its potential consequences 3. There are perceived barriers by the individual to adopting a particular health behavior 4. There are perceived benefits for the individual to adopt a certain health behavior 5. The individual has confidence in his or her ability to take action and 6. The individual is exposed to factors that prompt action (6). Underlying these principles is the assumption that people behave rationally and are able to weigh the costs and benefits of a behavior in order to choose the appropriate course of action. For EC, this would mean that an individual would understand the negative consequences of unprotected intercourse, would understand the benefit of using EC and the minimal cost to using such a medication and would therefore choose to take the medication. The model also assumes that the individual after using EC would recognize that unprotected intercourse can lead to unintended pregnancy and thus after using EC would obtain more reliable contraception or abstain in the future to avoid this consequence.

We know, however, that EC has not had an effect on unintended pregnancy. It would appear that individuals have not used EC when needed and/or they have not followed up its use with a more long-acting method of contraception. There may be several reasons for this failure, both medical and behavioral. Focusing on behavioral patterns, the health belief model may be a poor choice to determine decision-making surrounding EC and may help explain why improved access interventions have not led to the desired outcomes.

The primary reason that the health belief model has poorly influenced EC use is people are not rational and do not make rational decisions, particularly when it comes to sexual intercourse. Inherent to this model, the individual must understand herself to be at risk of unintended pregnancy. Traditionally, unintended pregnancies are those that are unwanted or mistimed while intended pregnancies refer to those that occur at the “right time” or later than desired (7). These pregnancies, therefore, are caused by a behavior, sexual intercourse that by its very nature is often an unplanned, unintended, or unexpected event. Surveys of college and adolescent students corroborate this view.

College students report a high incidence of unplanned intercourse. In a survey of college students in 1991, 40.9% used either no contraception or withdrawal at first intercourse with 10.1% reporting they did not use contraception because they were not prepared (8). Results among adolescents are similar with 30-38% of adolescents reporting inconsistent contraceptive use (9). Furthermore, we know that 40% of unintended pregnancies are a result of inconsistent or incorrect use of a contraceptive method (10).

These results affirm that intercourse is often unplanned and to expect that people will plan to prevent the outcome of a very behavior that was not intended is unrealistic. And what we know about EC is that it only works if taken immediately after intercourse (or at the very least up to 120 hours after unprotected intercourse). EC is also only effective for a single act of unprotected intercourse; multiple acts will not be prevented by a single course of EC. Some degree of planning is therefore needed even with EC.

A second reason why the health belief model has not been an appropriate model for EC is the individual may have a perceived susceptibility to becoming pregnant that is not in line with scientific principles - the idea that “it won’t happen to me.” We know that EC only works for a single episode of unprotected intercourse. In reality, in a given cycle people may have many such episodes. However, the individual may take EC for one of those episodes and think that they are either protected or not susceptible with subsequent acts. They never follow through after the first episode and obtain more reliable contraception because they do not see the need or the risk in not doing so. In a randomized controlled trial of advanced provision of emergency contraception compared to no advanced provision, adolescent mothers in the intervention group were no more likely to begin another more effective method of birth control at 6 or 12 months (11).

Another reason that the health belief model has failed to be a successful model to predict behavior regarding use of EC is that while unintended pregnancy is something to be avoided by most public health professionals, individuals may not see avoiding this as a beneficial outcome. We know that for some people unintended pregnancy does not mean unwanted and about half of women with an unintended pregnancy choose to continue the pregnancy. Results from the NSFG report that among women who had an unintended pregnancy due to a contraceptive failure, 59% were unhappy or very unhappy about the pregnancy while 25% were happy or very happy (12). Trussell et al suggests that for some women: 1. Planning or intending to become pregnant may be different than wanting to be pregnant: 2. The concept of planning pregnancy may not have the same meaning for all women: and 3. Ambivalence towards pregnancy may lead to contraceptive failure (13).

And while finally, certainly improved access has decreased barriers to EC use, Many individuals may still perceive barriers to using it properly particularly because it has such a short window of action. For example, teenagers under age 17 still need a prescription to obtain EC, an individual may use her one pack of advanced provision and then never keep a second pack available and many pharmacies may refuse on moral objections to stock a medicine despite its over the counter status (14).

In summary, EC has failed as a public health intervention to decrease unintended pregnancies. There are many reasons for this failure and in particular, trying to promote the use of EC with the health belief model is particularly flawed because of the following faulty assumptions:

1. Sexual intercourse is a planned event and done rationally.

2. People have only 1 episode of unprotected sex per cycle and if they have greater than 1 episode, they will begin more effective contraception after using EC.

3. People recognize the negative health consequences of unprotected intercourse and because of these health consequences and their perceived susceptibility to pregnancy make the decision to take EC.

4. With over the counter status and advanced provision policies, individuals no longer face barriers to appropriate use.

Alternative Model to Decrease Unintended Pregnancy

Given that we know sexual intercourse to be an inherently irrational, unplanned behavior, an acceptable model to change behavior would not rely on the rationality of individuals. It would also make use of technologies that don’t require planning with each act of intercourse. LARC, in particular the Mirena and Paragard intrauterine contraceptives (IUCs) and the Implanon contraceptive implant, provide highly effective, temporary birth control that is not coitally dependent and is safe for most users. While technology has developed these highly effective, safe methods of birth control, they have not been widely accepted. New policies need to be developed to promote their use. Social network theory can provide a framework for improving utilization of these devices. Such an intervention based on this theory could use new social media such as Facebook and Twitter along with carefully designed advertisements tailored to at-risk populations that air both during network television shows that are popular with young adults and are printed in magazines read by young adults. This is in stark contrast to current media around these devices which typically depict women in their mid 30s with a family, certainly not the demographic most at risk of unintended pregnancy. These concerted media and online efforts would help spread the message through various social networks that these methods are safe and effective. As a result, use of LARC would increase.

Why hasn’t LARC been widely accepted? According to the National Survey of Family Growth, only 4.9% of reproductive aged women were using an IUC and only 0.08% of women were using an implant (15). Yet LARC is an excellent method of birth control in that it’s safe, doesn’t require the user to remember anything, and has very few contraindications.

In part, this low rate of use is secondary to myths surrounding these methods. Many reproductive aged women or their family members still remember an earlier IUC, the Dalkon Shield, which had higher failure rates than some of its predecessors, unacceptably high rates of septic abortion, hospitalization from severe pelvic inflammatory disease, resultant sterility and even death (16). Implanon conjures up images of Norplant, the preceding long-acting contraceptive implant that was introduced in the early 1990s. Norplant was immediately targeted to low-income women through the work of the Norplant Foundation, which provided 2.8 million Norplant devices a year to these women. Many states targeted low-income women and offered them financial incentives to use Norplant. In Kentucky, women were given $500 and an additional $50 a year for each year they continued to use Norplant. Louisiana paid women $100 per year to use the device. At the same time, women were not told about all of the side effects of the drug (17).

In order to combat some of the myths and fears surrounding LARC and gain more widespread acceptance, social networking theory may be an appropriate behavioral model to frame public health interventions. The theory takes advantage of the interconnectedness of individuals on many levels. In 1954, J.A. Barnes first proposed the concept of the “social network, ” which he described as patterns of connection including bounded groups (e.g. families, tribes) and social categories (e.g. race/ethnicity, gender) (18). This theory has been used to explain many behaviors including contraceptive use, alcohol consumption, obesity, and smoking. In a study assessing the prevalence of smoking of a 30+ year period among Framingham Heart Study participants, smoking cessation appeared relevant to one’s social network with smoking behaviors found more commonly among subjects interconnected by both close and distant social relationships. Furthermore, smoking cessation was more common among participants who had a sibling, spouse, friend, or coworker who had also quit smoking (19).

Today these connections have expanded to include online media such as Facebook, Twitter and MySpace, which have proven to be powerful tools to promulgate ideas and promote behaviors and products. Healthcare is just starting to use this media as well. As an example, one primary care practice in Brooklyn, called Hello Health, uses social media to take the place of many traditional health care roles. Patients can IM a question to the doctor, get an online “visit” for a problem and even read the physicians’ biographies on Facebook (20). In addition, peer-peer education is already occurring on many of these social networking sites. One study on the number of breast cancer groups on Facebook found 620 such groups with activities related to fundraising, awareness, service promotion, and patient/caregiver support. The support groups were the most popular sites on Facebook with the greatest number of posts (21). There remains tremendous opportunity to capitalize on the success of these media outlets to promote health behaviors.

Contraceptive use is particularly prone to influence by one’s social network. Often misconceptions, misperceptions as well as personal stories, dissatisfaction or satisfaction with a particular method are shared among people in the same social network (22). In some social networks, individuals may consider the advice regarding contraceptive effectiveness, side effects, safety and instructions for use to be more reliable coming from those in their network than from health care professionals. In a qualitative study of Latina females on their concerns about contraceptive side effects, women in the focus groups tended to value anecdotal information from peers over that of providers (23). In another qualitative study among a group of postpartum African American and Latina young women, the authors similarly found that the social network played a large role in family planning decision-making. Women often reported that while providers gave accurate information, the stories and experiences of women in their social circle had a more direct impact on their contraceptive choice (22). However, this information from their social network was also used in a positive way to encourage women to choose a more reliable method.

Given the influence that one’s social network has on contraceptive use and knowledge, this network could be exploited by public health professionals to increase use of LARC. If LARC were more commonly used, many of the reasons that improved EC access failed to decrease unintended pregnancy rates could be avoided. First, sexual intercourse is unplanned and often done irrationally. LARC, however, because it is long-acting does not require an individual to plan for each act of intercourse. It’s already in place even during unexpected sexual encounters. Second, EC only works with a single episode of unprotected intercourse. LARC is good for multiple acts without requiring any additional effort on the part of the user. Third, many people perhaps do not use EC because they do not believe in their own susceptibility to pregnancy or do not believe in the negative health consequences of unintended pregnancy. Likely, women’s belief in their susceptibility to pregnancy and their feelings regarding how a pregnancy may positively or negatively affect their lives may change several times during their reproductive life. With LARC, an individual needs to only recognize at one point in time that she is at risk of an unintended pregnancy and that this is not a desired outcome and subsequently visit a provider for a device. After this initial insertion, she needs to then consciously make a decision that an unintended pregnancy would not be a negative consequence and visit a health care professional for removal. In fact, in a study looking at interest in intrauterine contraception among seekers of emergency contraception or pregnancy testing, presumably a population that at the time of their clinic visit recognized the importance of avoiding pregnancy, 85% reported an interest in same-day insertion of an IUC (24). The challenge thus is to capture this group of patients at their most vulnerable time. And finally as compared to EC, while LARC may have a high upfront cost, once the device is inserted or implanted, there are no additional barriers. An individual does not need to visit a pharmacy, see a health care provider or pay any additional cost for effective contraception. In a research setting that eliminated many of these barriers to use of more effective methods, including provider misinformation and cost, 67% of subjects chose a LARC device (25).

LARC has many inherent advantages as a contraceptive method to decrease unintended pregnancy rates. It is safe, highly effective, doesn’t require repeated effort once in place and has no additional barriers to use once it is inserted. This is in contrast to EC, which is user-dependent and less effective. LARC, however, is infrequently used in the United States. The challenge to public health professionals is to develop innovative ways to increase utilization of these methods. Given the inherent unpredictability of sexual intercourse, constantly changing attitudes and emotions surrounding pregnancy, and a lack of understanding of the negative health consequences of unintended pregnancy, an intervention for increasing utilization based on the health belief model would be ineffectual. Furthermore, given that beliefs about fertility, childbearing and contraception are often tied to one’s cultural and social beliefs, social network theory may provide a more appropriate framework for an intervention to improve LARC uptake among at risk populations which would and thus decrease unintended pregnancy rates.

References

1. Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health 2006; 38:90-6.
2. Gipson JD, Koenig MA, Hindin MJ. The effects of unintended pregnancy on infant, child, and parental health: a review of the literature. Studies in Family Planning 2008; 29:18-38.
3. ACOG. Emergency contraception. Practice Bulletin 2010; 112:1-9.
4. Fine P, Mathe H, Grinde S, Cullins V, Morfesis J, Gainer E. Ulipristal acetate taken 48-120 hours after intercourse for emergency contraception. Obstetrics & Gynecology 2010; 115:257-63
5. Polis CB, Grimes DA, Schaffer K, Blanchard K, Glasier A, Harper C. Advance provision of emergency contraception for pregnancy prevention. Cochrane Database of Systemic Reviews 2007, Issue 2. Art. No.: CD005497. DOI: 10.1002/14651858.CD005497.pub2
6. National Cancer Institute. Theory at a Glance. A Guide for Health Promotion Practice. Theories and applications Part 2. NIH 2005.
7. Santelli J, Rochat R, Hatfield-Timajchy K, Gilbert BC, Curtis K, Cabral R, Hirsch JS, Schieve L. The measurement and meaning of unintended pregnancy. Unintended Pregnancy Working Group. Perspec Sex Reprod Health 2003;35:94-101.
8. Seventeen-year review of sexual and contraceptive behavior on a college campus. Hale RW, Char DF, Nagy K, Stockert N. Am J Obstet Gynecol. 1993 Jun;168(6 Pt 1):1833-7; discussion 1837-8.
9. National Campaign to Prevent Teen Pregnancy March 8, 2000. Risky business: a 2000 poll.
10. Homco JB, Peipert JF, Secura GM, Lewis VA, Allsworth JE. Reasons for ineffective pre-pregnancy contraception use in patients seeking abortion services. Contraception 2009; 80:569-74.
11. Belzer M, Sanchez K, Olson J, Jacobs AM, Tucker D. Advance supply of emergency contraception: a randomized trial in adolescent mothers. J Pediatr Adolesc Gynecol 2005; 18:347-354.
12. Chandra A et al. Fertility, family planning and reproductive health of US women: data from the 2002 National Survey of Family Growth. CDC. Series 23; Number 25, 2005.
13. Santelli et al, Trussell J, Vaughan B, Stanford J. Are all contraceptive failures unintended pregnancies? Evidence from the 1995 National Survey of Family Growth. Family Planning Perspectives 1999; 31:246-7.
14. Refusals by pharmacists to dispense emergency contraception: a critique. Wall LL, Brown D. Obstet Gynecol. 2006 May;107(5):1148-51.
15. Chandra A, Martinez GM, Mosoher WD, Abma JC, Jones J. Fertility, family planning, and reproductive health of U.S. women: data from the 2002 National Survey of Family Growth. Vital Health Stat 2005;23: 1–160.
16. Sivin I. Another look at the Dalkon Shield: meta-analysis underscores its problems. Contraception. 1993;48:1-12.
17. Roberts D. Killing the black body: race, reproduction and the meaning of liberty. New York; 1997.
18. Freeman L. The Development of Social Network Analysis. Vancouver: Empirical Press 2006.
19. Christakis NA, Fowler JH. The collective dynamics of smoking in a large social network. NEJM. 2008; 358:2249-58.
20. Hawn C. Take Two Aspirin And Tweet Me In The Morning: How Twitter, Facebook, And Other Social Media Are Reshaping Health Care. Health Affairs. 2009; 28:361-8.
21. Bender JL, Jimenez-Marroquin MC, Jadad AR. Seeking support on Facebook: a content analysis of breast cancer groups. J Med Internet Res. 2011; 13(1):e16.
22. Yee L, Simon M. The role of the social network in contraceptive decision-making among young African American and Latina women. Journal of Adolesc Health 2010; 47:374-80.
23. Gilliam ML, Warden M, Goldstein C, Tapia B. Concerns about contraceptive side effects among young Latinas: a focus-group approach. Contraception. 2004; 299-305.
24. Schwarz EB, Kavanaugh M, Douglas E, Dubowitz T, Creinin MD. Interest in intrauterine contraception among seekers of emergency contraception and pregnancy testing. Obstet Gynecol. 2009; 113:833-9.
25. Secura GM, Allsworth JE, Madden T, Mullersman JL, Peipert JF. The contraceptive CHOICE project: reducing barriers to long-acting reversible contraception. Amer J Obset Gynecol 2010; 203:115.e1-115.e7.

Increasing Breastfeeding Rates in the United States: A Mother’s Burden or a Needed Make-Over in Society? –Michelle Berardi

Breastfeeding is recognized worldwide as the most beneficial source of infant nutrition (1). The World Health Organization (WHO) recommends that infants be exclusively breastfed for the first six months of life to ensure that they grow and develop and achieve optimal health (2). Currently in the United States, 75% of infants were ever breastfed (3). This proportion is much lower than the percentages of infants in other developed nations. In Norway and Sweden, 99% and 98% of infants were ever breastfed, respectively (4,5). In Australia 88% of infants were ever breastfed (6). The disparities between the US and other developed nations are even more striking at six months. At six months, only 13.3% of infants in the US are exclusively breastfed, compared to Norway (50%), Sweden (53%), and Australia (47.1%) (3-6).

The United States’ Healthy People 2020 Objectives have set goals for the United States of 81.9% of infants ever breastfed and 25.5% exclusively breastfed at 6 months (7). The country’s current approach to this crucial public health issue is based on changing the behaviors of individual mothers. Pro-breastfeeding campaigns relying on extolling the benefits to infants and mothers if a mother chooses to breastfeed her child. The increase in breastfeeding initiation rates that the US has achieved in recent years indicates that mothers are making the choice to breastfeed. However, the low rates of breastfeeding duration indicate that barriers to continued breastfeeding cannot be overcome by an individual-level approach.

The Decline of Breastfeeding in the United States

Breastfeeding rates in the United States experienced a dramatic decrease in the twentieth century. In the 1920s and 1930s, evaporated milk became available as a substitute for breast milk (8). Evaporated milk was inexpensive and several clinical studies at the time claimed that babies fed evaporate milk formulas were as well off as babies who were breastfed (8). By the 1950s, over half of babies in the United States were fed evaporated milk formulas (8). In the late 1950s, Similac and Enfamil, two popular formula brands still manufactured and used today, entered the market and began to compete with evaporated milk formulas, quickly replacing them by the 1960s. By the early 1970s, over 75% of babies in the United States were fed commercially produced infant formulas (8). Aggressive marketing strategies by formula companies dramatically influenced the decrease of babies who were breastfed in the United States (8,9). These marketing strategies still exist today. One of Similac’s 2009 advertising campaigns for its Advance Infant Formula uses slogans such as, “You’ll feed his imagination, and we’ll help feed his immune system” (10).

The second wave feminist movement is often cited as a source of the decrease in breastfeeding rates in the United States (11). Women moved into the public sphere, embracing a definition of femininity that was not centered about motherhood (11). Formula became the way for a working mother to return to the workforce soon after the birth of her baby. Breastfeeding became something that confined a woman to her mother role and excluded her from participating in the workplace (11).

This movement also resulted in women celebrating breasts as sexual rather than maternal objects (11,12). In the United States, breasts are depicted as sexual objects rather than a means of providing nutrition to an infant. Some people get visibly uncomfortable around a woman who is breastfeeding. The idea of maternal sexuality makes many people uneasy, and thus when breasts are being used in a maternal situation like breastfeeding, there is much discomfort and controversy. For example, in the 1990s, Janet Jackson posed topless on the cover of Rolling Stone Magazine with her jeans unbuttoned and what appears to be male hands holding and covering her breasts (12, 13). The cover story is about Jackson embracing her sexuality. There was little to no public out-cry about this cover. However, in 2006, when BabyTalk Magazine published a cover with a nursing baby on a woman’s breast in an effort to promote breastfeeding, there was outrage (12,14). The public and the media have no problem depicting breasts in a sexual manner, but when they are presented in a maternal context, it is deemed inappropriate. The number one reason women who initiate breastfeeding cite for discontinuing is embarrassment in public when breastfeeding (15).

The declining rates of breastfeeding women in the United States throughout the 20^th century led to a diminishment in the social and familial support network for breastfeeding mothers. A woman born in the 1970s and 1980s is unlikely to have been breastfed by her mother or had her mother breastfeed any of her siblings (9). When these women have children of their own, they do not have the ability to seek support from their mothers and aunts and are therefore less likely to breastfeed their own children. Their friends are also unable to provide them with a support network. Therefore, a woman is less likely to initiate breastfeeding her own child. This perpetuates the already low levels of breastfeeding initiation.

Current Approaches: Targeting Mothers

The United States’ current approach to the promotion of breastfeeding has counteracted some of the reasons for the decline in breastfeeding practices in the twentieth century. However, not all of these barriers have been addressed adequately. The approaches taken in the health care system, the workplace, and the government are targeted towards individual-level efforts. These strategies place too much weight on the belief that a mother’s decision whether or not to breastfeed is due to her character and knowledge rather than her environment.

Discussing infant feeding options and infant nutrition are an important component to prenatal care (16). Physicians, midwives, and nurses are expected to recommend breastfeeding to their patients. In statements released by the American Academy of Pediatrics (AAP) and the American Congress of Obstetricians and Gynecologists (ACOG), these professional organizations issued recommendations for the support of breastfeeding as the optimal method of infant feeding (17,18). Providers are charged with informing their patients of the benefits of breastfeeding and encouraging mothers to breastfeed their babies for at least 6 months (17,18). This strategy relies on individual-level interventions to increase breastfeeding in the United States. Providers utilize the principles of the Health Belief Model (19) to encourage their patients to breastfeed their infants. By providing their patients with information on the benefits of breastfeeding and the potential risks of not breastfeeding, they assume that mothers will weigh these risks and benefits to make a rational decision to breastfeed. While this strategy may affect the intentions of mothers to breastfeed, it does not necessarily determine behaviors. This approach may partially explain why a large percentage of mothers initiate breastfeeding but do not continue.

In addition to utilizing the Health Belief Model, health care providers also employ the principles of the Theory of Planned Behavior to influence breastfeeding practices (20). Mothers respect the recommendations of their prenatal care providers and look to them for advice and guidance. By using an influential person to make recommendations encouraging breastfeeding, this strategy attempts to increase breastfeeding rates. However, this individual-level theory also assumes that the intentions of mothers to breastfeed determines their behaviors and neglects to account for social and cultural influences. While providers and other health professionals are valuable resources for increasing breastfeeding initiation and duration rates in the United States, attempting to affect change through individual patient-provider interactions is not efficient or effective.

There are several federal policies and programs aimed at increasing breastfeeding initiation and duration rates. Many states have statutes in place exempting breastfeeding mothers from being charged with “indecent exposure” if they are breastfeeding in public (21). While these laws protect mothers from being prosecuted on the basis of exposing their breasts while breastfeeding, they do not explicitly permit mothers to breastfeed in public. There are many examples of situations where breastfeeding women were asked to leave restaurants and other public places (9). There is no federal legislation granting mothers the right to breastfeed where ever they chose. This is indicative of the lack of federal and legislative support for breastfeeding and demonstrates lack of support from society as a whole for breastfeeding.

The United States Department of Agriculture, through its Women, Infants, and Children Food and Nutrition Service (WIC), has implemented policies, programs, and campaigns to encourage low-income mothers to breastfeed. Discounts on breast pumps, breast shells, and other nursing supplements as well as additional food package benefits and peer counselors are available for WIC participants who breastfeed (22). While these policies and programs remove some of the barriers to breastfeeding initiation and duration, they also fail to address some of the broader social barriers.

The Centers for Disease Control and Prevention (CDC) also issues factsheets and recommendations to encourage breastfeeding. Their objectives are targeted towards increasing mothers’ knowledge and education about the benefits of breastfeeding as well as encouraging providers and health care facilities to recommend and support breastfeeding (23). These methods employ the strategies of the Health Belief Model and the Theory of Planned Behavior, much like the approach taken by health care providers, and thus face similar challenges and have a limited effect on breastfeeding practices.

The Department of Health and Human Services (HSS) developed “Babies Were Born to be Breastfed,” a social marketing campaign to increase breastfeeding rates in the United States. This campaign used a variety of television, radio, and print advertisements to emphasize the risks of not breastfeeding. Pregnant women were the main targets of the campaign. In one of the television advertisements, a pregnant woman was depicting participating in Roller Derby, a dangerous and strenuous sport, while a voice-over asked, ““You’d never take risks while you’re pregnant. Why start when the baby’s born?”(24) These advertisements used fear to illicit behavior change. The strategy of this campaign was to utilize the Health Belief Model and overemphasize the risks of not performing the wanted behavior (breastfeeding). This approach also attempted to work on an individual level and failed to provide the necessary changes in social attitudes needed for the success of increasing breastfeeding rates.

The attitudes and beliefs of the American workforce also provide barriers to increasing breastfeeding initiation and duration rates in the United States. There is little support for women in the workforce who wish to breastfeed. The United States government mandates that 12 weeks of maternity and paternity leave be provided (25). This leave is unpaid. Often women cite the length of this period as being too short to initiate and sustain a breastfeeding regimen (11). In addition, very few work places provide nursing facilities and the appropriate accommodations for nursing mothers, especially for women who are paid hourly (25). Hourly workers have more difficulty finding time throughout the day to pump milk because they do not receive enough or lengthy breaks (25). There is also not often a place in which the nursing mother can go to pump breast milk in private; she is often forced to use the restroom (11, 25). Women who are salaried can more easily take the appropriate break time to pump (11). However, designated pumping facilities are often not available for their use either (11). Mothers with jobs in management or other similar higher positions are often able to utilize their private offices, but some still report feeling embarrassed or uncomfortable to be pumping breast milk while at work (11, 25). These women must also often approach their bosses and supervisors themselves in order to arrange for the appropriate accommodations. This places the burden of balancing work and breastfeeding on the individual and fails to address the larger social issues.

Taking the Social Route

While educating mothers and the public about the benefits of breastfeeding is important, strategies targeted primarily towards individuals are largely ineffective, especially in the context of breastfeeding, an issue with deep social influences. Through the creation of policies, programs, and regulations, the United States can incorporate breastfeeding back into the cultural norm. By utilizing strategies that embrace the more sophisticated psychosocial theories on human behavior, the United States can increase both breastfeeding initiation and duration rates.

The Baby-Friendly Hospital Initiative (BFHI) is an international program sponsored by WHO and UNICEF. The goals of BFHI are to support and encourage breastfeeding by recognizing hospitals and birthing centers that provide optimal levels of care for infant feeding (26). Hospitals and birthing center are assisted by BFHI in providing mothers with the information, support, and skills required to successfully breastfeed or, when necessary, formula feed their babies. The CDC recommends and recognizes the Baby-Friendly Hospital Initiative as an intervention that promotes breastfeeding and overall general good health of newborns and infants. International data supports the positive impact of BFHI on breastfeeding initiation and duration rates (27). As of March 31, 2010, there were less than 100 Baby-Friendly Hospitals in the United States (26). Hospitals and providers can encourage a shift in cultural norms by pushing for more hospitals and birthing centers in the United States to become Baby-Friendly. Baby-Friendly hospitals and birthing centers create an environment in which breastfeeding is the norm. As more and more hospitals and birthing centers become Baby-Friendly, more people in the United States are exposed to breastfeeding. Eventually, the adoption of breastfeeding as a social norm occurs. This strategy utilizes the concepts of the Diffusion of Innovations Theory (28) to change the behavior of a group, rather than an individual.

The federal government can also utilize strategies that target the behavior of groups in order to change the cultural norms for breastfeeding practices and increase breastfeeding initiation and duration rates in the United States. By creating federal laws that give women the right to breastfeed their infants and children in public, they influence the construction of societal ideals and norms. Congress should promulgate laws that make it illegal for a breastfeeding woman to be prohibited from any place on the basis of breastfeeding. Formal legislation on this matter will reflect to the public that breastfeeding is a priority for the health and well-being of children and mothers in the United States.

The United States Department of Agriculture, the Centers for Disease Control and Prevention, and the Department of Health and Human Services, instead of using interventions based on an individual level to educate and promote breastfeeding, should take advantage of prudent marketing strategies to influence cultural attitudes about breastfeeding. These government agencies should use their power and influence to bring the lack of support for breastfeeding mothers to the forefront of the public’s attention. By using Agenda Setting Theory (29), these agencies can help facilitate the creation of laws and regulations to support breastfeeding mothers and families.

In addition, these agencies can use Advertising Theory to develop an effective breastfeeding campaign. Advertising theory has three basic concepts: promise, support, and core values (30). By designing and implementing a social marketing campaign based on these tenets, the USDA, CDC, and HHS will be more successful in promoting breastfeeding and increasing breastfeeding initiation and duration rates in the United States. In order to effectively market breastfeeding, large promises should be made, visual images and sounds should be used as support for the promises, and core values must surround the advertisement. Advertisements depicting healthy, happy babies and mothers will appeal to the universal core values of family and love. Television, radio, and print advertisements that frame breastfeeding in a way that makes the practice a natural and “normal” part of everyday life would be the most successful because it would also utilize the principles of the Social Expectations or Social Norms Theory (31).

For example, a television advertisement could feature a man dressed in a cap and gown walking across a stage to accept his college diploma with the frame shifting to his mother in the audience, clapping, with teary eyes. In the next frame, we see a younger version of the mother contentedly breastfeeding an infant. Then there could be some text about breastfeeding supporting early brain development. This advertisement offers the promise of success and intelligence through breastfeeding. It supports these claims by showing the man receiving his degree and through the flashback of the mother breastfeeding her son as an infant. And the entire advertisement is surrounded by the core values of love, family, and power.

Interventions in the workplace must also be used to ensure that women who return to work after giving birth feel comfortable enough to continue breastfeeding. Laws at the federal level which influence leave for mothers and accommodations for nursing mothers in the workplace will help to increase breastfeeding duration rates. Federal laws mandating longer maternity leaves places more emphasis on the importance of families and will provide mothers with more support for continued breastfeeding. Companies should also adopt policies that create the appropriate for nursing mothers at all levels. Designated rooms with locks on the door that are not a part of women’s restrooms should be made available to nursing mothers to pump. In addition, pumping breaks as needed should be allowed. These policies and accommodations should already be in place without a new mother being required to request them, thus demonstrating the support of breastfeeding mothers in the workplace and signaling the cultural norms surround breastfeeding.

Society, Not Mothers

The United States’ current approach to increasing breastfeeding rates places an emphasis on changing the behaviors and attitudes of mothers. Interventions and strategies employed on the individual level have limited effectiveness in changing behaviors, especially in the long-term. The increases in breastfeeding initiation rates in recent years can be attributed to individual factors and the use of the Health Belief Model and the Theory of Planned Behavior. Statements from professional organizations like the AAP and ACOG have demonstrated the need and importance for physicians to support breastfeeding. Individual providers have worked to better inform and educate their patients about the benefits of breastfeeding and have encouraged mothers to breastfeed. The strategies employed by government agencies to warn mothers of the risks of not breastfeeding, such the campaign sponsored by HHS, have also used the Health Belief Model to convince mothers to breastfeed. However, the success of these strategies is limited in that mothers became more likely to initiate breastfeeding but quickly discontinued the practice when social support was lacking in places such as the workforce. When making a decision to breastfeed, an individual mother must consider factors beyond the risks and benefits of the practice.

The low proportion of women continuing to breastfeed their infants for the first 6 months of life is a result of the attitudes and views of breastfeeding in American culture and society. Many women who are mothers today were not breastfed by their own mothers. Therefore, they are missing need social support to breastfeed themselves. In addition, breasts are sexualized in the United States, making many women feel insecure, embarrassed, and uncomfortable with breastfeeding outside of their homes. This makes it difficult to return to work or to carry on one’s life following maternity leave. In order to increase breastfeeding duration rates, the United States must approach this issue with a social lens and work on changing the beliefs and attitudes of Americans in order to change social norms. The behavior of groups rather than individuals must be targeted. The implementation of the policies of the Baby-Friendly Hospital Initiative in more and more hospitals across the United States will help to create a cultural basis for breastfeeding and breastfeeding support. By bringing these issues to the forefront of the public’s concern, the CDC and WIC can help in pressuring Congress to create laws that protect and encourage breastfeeding mothers in public and in the workplace. In addition, the use of effective marketing strategies by government agencies when designing breastfeeding campaigns will also help to change social attitudes towards breastfeeding. In order to successfully increase breastfeeding rates in the United States, the broader social issues and the environment in which women breastfeed must be considered.

References

1. World Health Organization; UNICEF. Global strategy for infant and young child feeding. (2003) Available from: http://www.who.int/child_adolescent_health/documents/9241562218/en/index.html

2. World Health Organization. Statement: Exclusive breastfeeding for six months best for babies everywhere. (January 15, 2011) Available from: http://www.who.int/mediacentre/news/statements/2011/breastfeeding_20110115/en/index.html

3. Centers for Disease Control and Prevention. Breastfeeding Report Card, United States: Outcome Idicatiors.(2007) Available from: http://www.cdc.gov/breastfeeding/data/reportcard2.htm

4. Lande B et al. Infant feeding practices and assciated factors in the first six months of life: The Norwegian Infant Nutrition Survey. Acta Paediatrica, 2003, 92:152-161.

5. Sveriges officiella statistik och Socialstyrelsen. Amning och föräldrars rökvanor. Barn födda 2007 [Breastfeeding and smoking among parents of infants born in 2007]. Stockholm, Sweden: Sveriges officiella statistik och Socialstyrelsen, 2009

6. Donath SM, Amir LH. Breastfeeding and the introduction of solids in Australian infants: data from the 2001 National Health Survey. Australian and New Zealand Journal of Public Health, 2005, 29:171-175.

7. Healthy People 2020 Website: http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=26

8. Wolf, Jacqueline Don't Kill Your Baby: Public Health and the Decline of Breastfeeding in the Nineteenth and Twentieth Centuries (2001)

9. Hausman, Bernice L. Mother's milk: breastfeeding controversies in American culture (2003)

10. http://similac.com/baby-formula/similac-advance

11. Blum, Linda At the Breast: Ideologies of Breastfeeding and. Motherhood in the Contemporary U.S. (1999)

12. Bartlett, Alison. Breastwork: Rethinking Breastfeeding (2005)

13. Janet Jackson Rollin Stone Cover, Image. Available from: http://4.bp.blogspot.com/_v2p5nxaE2Dg/TIPlrqIEcNI/AAAAAAAAAC4/tjFBZAshZr8/s320/janetrollingstone.jpg

14. McNamara, M. “Breast-Feeding Cover Sparks Debate.” Associated Press. July 28, 2006. Available from: http://www.cbsnews.com/stories/2006/07/28/national/main1844454.shtml

15. Flower, K., Willoughby, M., Cadigan, R.J., Perrin, E.M., Randolph, G., & The Family Life Project Key Investigators. (2007). Understanding breastfeeding initiation and continuation in rural communities: A combined qualitative/quantitative approach. Maternal and Child Health Journal, 12(3), 402-414.

16. Archabald K, Lundsberg L, Triche E, Norwitz E, Illuzzi J. Women's Prenatal Concerns Regarding Breastfeeding: Are They Being Addressed? J Midwifery Womens Health. 2011 Jan;56(1):2-7.

17. American Academy of Pediatrics. Breastfeeding and the Use of Human Milk.Pediatrics (2005) 115:2,496-506. Available from: http://www.aap.org/advocacy/releases/feb05breastfeeding.htm

18. American College of Obstetricians and Gynecologists (ACOG). Committee Opinion, Breastfeeding: Maternal and Infant Aspects (2007). Available from: http://www.acog.org/from_home/publications/press_releases/nr02-01-07-1.cfm

19. Rosenstock, I. (1974). Historical Origins of the Health Belief Model. Health Education Monographs, 2, 328-35.

20. Ajzen, Icek. Understanding Attitudes and Predicting Social Behavior (1997)

21. National Conference of State Legislators Website: http://www.ncsl.org/default.aspx?tabid=14389

22. Food and Nutrition Servicees, Women, Infant,and Children Website: http://www.fns.usda.gov/wic/Breastfeeding/mainpage.HTM

23. Centers for Disease Control and Prevention Website, Breastfeeding: http://www.cdc.gov/breastfeeding/index.htm

24. Wolf, J. Is Breast Really Best? Risk and Total Motherhood in the National Breastfeeding Awareness Campaign. Journal of Health Politics, Policy and Law (2007) 32:4

25. Brown, C.A., Poag, S., Kasprzycki, C. (2001). Exploring Large Employers’ and Small Employers’ Knowledge, Attitudes, and Practices on Breastfeeding Support in the Workplace. Journal of Human Lactation, 17(1), 39-46.

26. Baby-Friendly Hospital Initiative Website: http://www.babyfriendlyusa.org/eng/index.html

27. Marchand MC, Laurent C, Lofgren K. BFHI (Baby Friendly Hospital Initiative)... standard of care in maternity. Arch Pediatr. 2010 Jun;17(6):804-5.

28. Introduction. In: Gladwell M. The Tipping Point: How Little Things Can Make a Big Difference. Boston: Little, Brown and Company, 2000, pp. 3-14.

29. McCombs, M.E. (1982). The Agenda-Setting Approach. In: Nimmo, D. & Sanders, K. (Eds.) Handbook of Political Communication. Beverly Hills, CA.: Sage.

30. How to build great campaigns (Chapter 5). In: Ogilvy D. Confessions of an Advertising Man. New York: Atheneum, 1964, pp. 89-103.

31. DeFleur ML, Ball-Rokeach SJ. Theories of Mass Communication (5th edition), Chapter 8 (Socialization and Theories of Indirect Influence), pp. 202-227. White Plains, NY: Longman Inc., 1989.

Have Knowledge, Will Behave? The ‘Learn The Signs. Act Early’ Campaign – Andrew Well

It is estimated that 16.8% of children have a developmental disability in the United States (1). Developmental disabilities have substantial consequences in both health and social outcomes. Children with these disabilities have 1.5 times more doctors visits, 3.5 times more hospital inpatient days, 2 times the number of school days missed, and 2.5 times the likelihood of repeating a grade when compared to children without these disorders (1). These disabilities include Cerebral Palsy, Learning Disabilities, Autism Spectrum Disorders (ASD), and others.

The prevalence of ASD in the population is 12.6 to 40 per 10,000 (2). The American Academy of Pediatrics recommends all children should be screened for ASD at 18 months of age (3). Identification and commencement of interventions before the age of 3 years has shown the greatest impact on improving the outcomes of developmental disabilities (4). However, despite the recommended screening and efficacy of early intervention, the mean age for initial evaluation for ASD is 48 months and the mean age at initial diagnosis is 61 months (5).

With this disparity in mind, the Centers for Disease Control and Prevention (CDC) launched the ‘Learn the Signs. Act Early’ campaign nationally in 2004. This campaign targeted three populations, parents, healthcare professionals, and early educators (6). The goal for the campaign was to close the time gap by educating these populations to identify delays earlier and react more quickly.

Learn the Signs. Act Early Campaign

The main thrust of the media campaign consisted of a public service announcement television ad, a radio ad, and print advertisements. These advertisements were produced in both English and Spanish (7). These media efforts were targeted at the parent audience (6). Parents, healthcare providers, and early educators were all targeted to receive resource kits that included facts on anticipated developmental milestones and what to do if there is a concern about development (6). The campaign also partnered with other organizations and corporations to further its message. For parents, the campaign partnered with WebMD.com, Babycenter.com, Lysol, and Autism advocacy groups (6). Professional groups, such as the American Academy of Pediatrics and the National Association of Child Care Providers, were partnered with to reach health care professionals and early educators (6).

Prior to developing campaign materials, the CDC preformed formative research. These activities included focus groups and analysis of relevant available surveys of parents, healthcare providers, and early educators (6). The CDC also utilized social marketing principles to determine target audiences (6). Social marketing involves three steps:

1. Segment the market using relevant factors

2. Evaluate each segment

3. Choose one or more markets for targeting during the campaign (8)

Formative Research Results

Surveys of parents found that 63% did not know what behaviors suggested a child may have autism and 57% did not know the best time to seek help for concerns (6). Physicians reported poor resources to be able to identify autism with less than half reporting proper resources to educate parents about developmental milestones (6). Only 27% of physicians reported that they believed physicians as a whole were well informed about developmental disorders (6). Early educators reported a general lack of knowledge of developmental milestones and a lack of resources to properly evaluate children and discuss concerns with parents (6).

Taking into consideration the data available, the CDC decided to use the Transtheoretical Model as the frame for the ‘Learn the Signs. Act Early’ Campaign (6). The Transtheoretical Model contains five steps:

1. Precontemplation

2. Contemplation

3. Preparation

4. Action

5. Maintenance (9)

This model postulates that an individual will work their way through each step of the model to alter a behavior and maintain the altered behavior. An individual can move forward and backward through the model. In other words, the model allows for regression of an individual. The model is designed to promote the evaluation of where an individual is currently in the model and target interventions to allow them to move forward through the steps.

Campaign Results

After the campaign had run for three years (2004-2007) new survey data was analyzed to determine the effectiveness of the campaign. The results in 2007 indicate a small number of statistically significant changes. However, while these changes reached statistical significance, they were only minor in their impact clinically. Only 34% of parents reported having heard of the campaign. Parents who knew the behavior most associated with autism increased from 37% to 52% and 42% answered ‘don’t know’ down from 57%. Sixty-six percent of parents reported looking for developmental milestones up from 51% and 42% endorsed that before two years of age was the opportune time for intervention, up from 22% (6).

Only 43% of pediatricians reported having heard of the campaign. A large increase was seen in physicians reporting adequate resources to educate parents (77% vs. 29%). Fewer physicians would advocate a ‘wait and see’ policy (19% vs. 30%). Those who were aware of the campaign were slightly more likely to evaluate for developmental delays regularly (71% vs. 61%), were more confident in discussing developmental milestones with parents (84% vs. 74%), and were more likely to be aware of resources available and treatment options (87% vs. 70%) (6).

No systematic evaluation had been performed to elucidate results in the early educator population.

Learn the Signs. Act Early Critique

As is clearly shown above, the campaign was mostly ineffectual particularly in changing parental behavior. The CDC included a few good aspects into the campaign; however, these were overshadowed by large failings in the theoretical design and implementation of the campaign. The CDC was insightful in using social marketing theory to attempt to develop their campaign. The overarching theoretical failure is utilizing the Transtheoretical Model. This model is developed to be used to assess and describe an individual (10). Applying this model to evaluate a population is difficult. This application, negates one of the strengths of the model which is an individualized intervention based on the individual characteristics. In determining a population intervention based on this idea already alienates a large portion of the population that is not currently in the stage of the Transtheoretical Model being targeted. Also, there is a fundamental flaw in the theory, which is assuming people act and think rationally and that all people must proceed through the steps in order to achieve success. The Transtheoretical Model has been shown to have no efficacy in smoking cessation (11-13), pregnancy and sexually transmitted infection prevention (14), and dietary intervention (15). Aside from these theoretical shortcomings, three implementation problems are described below.

One-Size Fits All – Critique #1

The first implementation problem was a one size fits all advertising campaign. There was really only one television commercial, one radio commercial, and one print ad, which were distributed in English and Spanish (7). These commercials did not have a breath of cultures encompassed into the campaign. It has been shown that individuals respond stronger to interventions that are specifically tailored to them (16). A study on a tailored intervention to reduce individuals dietary fat intake showed that those who received the tailored intervention information were more likely to remember receiving the information 4 months later, 72.9% vs. 33.3%, compared to a group that received information that was generic and not tailored (17). Those in the tailored intervention were more likely to have read the entire information sheet, 71.7% vs. 55.7% (17). The tailored group also had a greater response to the message decreasing their daily dietary fat intake more than the non-tailored group (17).

The impact of tailoring can be seen on functional MRI (fMRI) images. In a study on smoking cessation, smokers were shown three types of messages while their brain activity was being monitored by fMRI. The messages included an instructional or information based message, a motivational message and a personalized message (18). Each of the three messages showed activation in different portions of the brain. The instructional message activated the rules processing portion, the motivational message activated the anticipated reward processing regions, and the personalized message activated the self-related processing regions (18). Furthermore, it has been shown that increased activation of the self-related processing regions during a tailored intervention predicted smoking cessation at four month follow up (19).

When looking at the ads for this campaign, the print ad both in English and Spanish contain a picture of a Caucasian baby. The television ad features three mothers talking while their infants are playing on the floor. Two of these mothers were Caucasian and one was African American. Members of other races and ethnicities may not associate with these ads as well. Fathers will also not be engaged by this advertisement. The radio ad is more difficult to associate with culturally, however the ad features an interviewer talking with a child at a playground. Many families, especially inner city residents do not have access to playgrounds, thus they may associate less with this ad. The statistic that a one-size fits all approach in this campaign did not work is the low recognition rate after three years. With only 34% of parents reporting campaign recognition, the campaign was either not reaching the population, but more likely, large portions of the population were not associating with the ad campaign and thus not recalling the campaign.

No Promise – Critique #2

Successful product ad campaigns often sell their product by making a promise and backing it up. For example, Nike, in many of its advertisements, shows athletic individuals being successful while wearing their products. Their promise is improved athletic performance and they support that claim through visuals of people who fit this description. Targeted individuals’ self-interest is an important component and target in Marketing Theory (20). Beyond self-interest, successful marketing can be seen as an exchange (20). A successful exchange sets forth an explicit or implicit payback (promise) and the timing of the payback (20). An explicit promise with an immediate payback timing has been shown to be the most influential (20, 21). This influence is increased if there is greater involvement of the individual, such as tailoring the message in a way the individual can relate to easily (21). The results of the exchange are further reinforced if the exchange happens voluntarily as apposed to coercively, demandingly, or through fear (22). Unsuccessful public health campaigns typically neglect to address the costs and benefits for each said of the exchange (22). Instead, they typically focus on limiting the cost to the individual (22). A successful campaign will look to maximize the benefits each side receives from the campaign (22). The ‘Learn the Signs. Act Early’ advertising campaign fails to make any exchange and promise to the targeted individual. This problem of a lack of promise is shown in the statistic where knowledge of the main symptom of autism rose only to 52% from 37%. This indicates that many individuals are not integrating the message from the campaign, as there is no incentive for individuals to integrate the information.

Knowledge Is Enough – Critique #3

The ‘Know the Signs. Act Early’ campaign is essentially a knowledge dispersion campaign. The campaign views the lack of the desired behavior as a product of a lack of knowledge, that if the population only knew, they would change. This evokes the idea of the Health Belief Model (23). Much like the Transtheoretical Model, the Health Belief Model has large flaws. It also assumes that people think rationally and with the correct information and planning people will behave in a specific way (23). Simple knowledge dispersion has been shown to be an ineffectual process to produce behavior changes (20).

With knowledge also come other unwanted results, such as optimistic bias. Optimistic bias is the phenomenon where individuals will accurately if not overestimate the probability of a negative event happening to someone else while underestimating the probability of the same event happening to themselves (24). Optimistic bias has been shown to hold true across a wide range of situations including salary after graduation, smoking risk, and possibilities of one’s marriage ending in divorce (24, 25). Optimistic bias can also be observed on a fMRI. When subjects were asked to imagine a positive future event, the fMRI revealed activation in areas of the amygdala and in the rostral anterior cingulate cortex (26). Higher activation of the rostral anterior cingulate cortex was associated with higher optimism (26).

Along this line of thought, there is also the stigma surrounding the diagnosis of a developmental disability, especially autism, and the fear of a child being labeled (6). The CDC identified these worries as possible risks with the campaign (6). However, the CDC chose to try and mitigate this risk by not talking about it (6). The campaign’s lack of acknowledgement of this stigma and fear does nothing to try and alleviate parental concern. The campaign can pass as much knowledge to parents as possible, but if they are too worried or scared to act in accordance with the knowledge, their behavior will not change. A statistic to evaluate if this were the case would be to observe if more parents were actually scheduling and bringing their children in for developmental evaluations. This data is not available, but it is not a large leap to hypothesize that there was little change in this behavior over the three years of the campaign.

Looking Back

The ‘Learn the Signs. Act Early’ campaign began with a few solid and effective design strategies. However, the data obtained from this initial data was forced to fit an inappropriate health behavior model. The resulting campaign was implemented poorly and inefficiently which resulted in very little significant change in behavior and beliefs in the target population.

Looking Forward

This campaign attempts to intervene in a very important public health issue. With clear evidence supporting early intervention, before three years of age, in developmental delays, especially autism, there is great urgency to evaluate and diagnose these disorders as early as possible. Since there is the great need for intervention, the campaign, despite its shortcomings, should not be completely dismantled and forgotten about. There are a few changes that can be made to the campaign to address the current shortcomings and improve its efficacy.

The Tailored Look – Intervention #1

Research has shown that tailored messages cause more people to remember the message and more people to change their behavior in accordance with the message (16). It has also been shown that with increased tailoring of the message, more people will remember and act upon the message (16). Message tailoring must be included in to every aspect of the campaign. The easiest and least expensive place to start is the campaign website. Currently, it is an open website that is the same for everyone that logs onto it. To change this, the first time someone logs onto the site, they would be asked to answer a few simple questions about themselves. These questions would include information on gender, race, age, and profession (parent, educator, healthcare provider). From the answers to these questions, the website can be tailored to each individual who enters the site. This tailoring would include what types of information are available and how it’s presented (based on profession for example). Pictures can be tailored to the age, gender, and race of the individual. It has been shown that tailored pictures when placed next to text result in greater uptake of the information in the text when compared to non-matching pictures or general stock pictures not involving people (27).

Next, the print, radio, and television advertisements need to be tailored as well. These cannot feasible be tailored as much as the website, but more tailoring can be introduced beyond what is found now. The print advertisement would be the easiest to start with. Currently all print advertisements contain a picture of only a Caucasian baby. The picture of the baby could be changed out to infants of different races based on the demographics of the readership of the publication the advertisement will be in. It is difficult to tailor radio advertisements. Keeping the same current concept of an individual interviewing a child, different locations could be utilized for the interview. The current playground ad would be kept, but interviews could be held in locations such as a play date at someone’s home, or at a daycare. Lastly, there would need to be more than one television advertisement. The different advertisements would need to include mothers and children of different races and ethnicities. It would also be prudent to include advertisements that involved fathers.

With these simple tailoring efforts, it is conceivable that campaign recognition would increase. With this increased recognition, the hope would be an increase in the desired behavioral changes as has been shown previously with tailored interventions.

Promises, Promises, Promises – Intervention #2

The current campaign is very straightforward and blunt. It does not utilize any aspect of marketing or exchange theory in the design of its advertisements. These advertisements need to create a promise that is hinged on the central tenets of human nature. Two that should be specifically targeted are family and control. These two are very strong tenets and thus will create a more influential advertisement. While health is also a tenet, it has been shown to be relatively weaker and less influential. The advertisements could portray the model that if a parent closely monitors their child’s development and acts early to get them evaluated and initiate treatment, then they gain control over improving their child’s future and they improve their whole family’s quality of life. Control is also a powerful promise to promote as individuals who feel control or ownership over a thing or behavior place a higher value on it (28).

Done correctly, this promise creates an expectation for parents participating in the behavior. It sets up the promise as an incentive for participating in the behavior. This should create greater follow through by parents in being vigilant about paying attention for developmental delays and taking their children for evaluations when concerns arise.

Story Time – Intervention #3a

The current campaign focuses on giving facts and figures to parents. This is done with the premise that increasing parental knowledge will increase the desired behaviors. However, it has been shown that people are influenced more strongly when they are presented with stories (20). Use of stories in advertising also mitigates psychological reactance. Psychological reactance is the response to appose situations where they lose control or are being told what to do (29). These advertisements may be able to use psychological reactance in their favor, if not participating in the behavior can be portrayed as a loss of control.

This incorporates the previous two points. Again, these stories must be tailored to the audience for maximum effectiveness. This means the story and the person telling it must be relatable to the target audience. Bringing in the second point of promises, the story can be used to provide the evidence and support that the promise will happen if the behavior is followed.

For example, an advertisement that is to be delivered to a Hispanic population may include a television commercial in Spanish with a young happy Hispanic family with a child talking about how they noticed certain delays in their child’s development. They can go on to talk about immediately taking the child for evaluation and starting treatment. The conclusion of the commercial would be the family commenting on how much of an impact the treatment has made and how much it has improved their child’s life and his or her future possibilities.

By using stories to play to individuals need for control, these commercials are less likely to induce psychological reactance to the message. If anything,

Taking Down the Wall – Intervention #3b

The last shortcoming to address is how to handle the stigma and fear of a developmental diagnosis and labeling of a child. This is a very difficult barrier to develop a successful campaign around. This mentality is very deep seeded and is a very guttural response from parents. Since this is such a pervasive idea, the campaign cannot metaphorically burry its head in the sand and not address it. The campaign needs to address parental concerns head on. This must be done very tactfully or else the campaign risks alienating a large portion of the target population. This focus would almost certainly have to be a sub-campaign that focused only on the goal of demolishing the stigma and fear.

This portion of the campaign would need to use the same principles as described above. This would involve print, radio, and television advertisements that would again tell tailored stories. The focus of these stories would be shifted slightly to specifically focus on the diagnosis. An advertisement could contain a family who has a child diagnosed with autism. The family could talk about the improvements the child has made because they acted early and were not inhibited by the fear of the diagnosis. The advertisement would need to be explicit to show that the family overcame or did not cave in to the fear or perceived stigma of the diagnosis. If this fact is not placed in the forefront, it could be missed and the advertisement would be viewed as similar to the main campaign advertisements described above.

This portion of the campaign would hopefully empower parents to overcome their fears and to cast aside the perceived stigma surrounding autism and its diagnosis. They will instead hopefully realize that by overcoming this fear they are in fact doing what is best for their child. This again pulls back in the concept of control.

When All is Said and Done

The CDC’s effort to develop a campaign to promote early detection and intervention for developmental disorders was much needed. Even though the initial campaign missed the mark and was very ineffectual, it laid a groundwork from which a few changes can be made to create a more efficacious campaign. These new changes would without a doubt involve a greater cost than the original campaign. However, it would be better to develop and implement a few expensive campaigns that were very effective instead of running multiple less expensive campaigns that are mostly ineffectual.

The most distressing component in the initial campaign was the fact it completely ignored the fear and stigma surrounding developmental disability diagnoses. This shows a lack of willingness to tackle the tough questions and situations. Without breaking down that barrier, the effectiveness of even the best-designed campaign will have a limit to its effectiveness.

If these changes were to be made, this could be a very successful campaign for a very important public health need, a need that appears to be growing over time. Many more children would be evaluated and diagnosed early enough that treatment can result in the best outcomes possible for the child.

References

1. Boyle CA, Decoufle P, Yeargin-Allsopp M. Prevalence and Health Impact of Developmental Disabilities in US Children. Pediatrics 1994; 3:399-403.

2. Yeargin-Allsopp M, Rice C, Krapurkar T, et al. Prevalence of autism in an US metropolitan area. JAMA 2003; 289:49-55.

3. American Academy of Pediatrics. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. Pediatrics 2006; 118:405-420.

4. Dawson G, Osterling J. Early intervention in autism. The effectiveness of early intervention. Baltimore: Paul H. Brookes; 1997. P. 307-327.

5. Wiggins LD, Baio J, Rice C. Examination of the time between first evaluation and first autism spectrum diagnosis in a population-based sample. Journal of Developmental and Behavioral Pediatrics 2006; 27:S79-87.

6. Daniel KL, Prue C, Taylor MK, et al. ‘Learn the signs. Act early’: A campaign to help every child reach his or her full potential. Public Health 2009; 123:e11-e16.

7. Centers for Disease Control and Prevention. Learn the Signs. Act Early. Atlanta, GA: Division of Birth Defects, National Center on Birth Defects and Developmental Disabilities, Center for Disease Control and Prevention. http://www.cdc.gov/NCBDDD/actearly/multimedia/video.html

8. Kotler P, Lee N. Social marketing: influencing behaviors for good. 3^rd ed. Thousand Oaks, CA: Sage Publications: 2008.

9. Prochaska JO, Redding CA, Evers KE. The transtheoretical model and stages of change. Health behaviors and health education. San Francisco, CA: Jossey-Bass; 2002. p. 99-120.

10. Prochaska, JO.; DiClemente, CC. The transtheoretical approach. In: Norcross, JC; Goldfried, MR. (eds.) Handbook of psychotherapy integration. 2nd ed. New York: Oxford University Press; 2005. p. 147–171.

11. Riemsma, RP; Pattenden, J; Bridle, C; Sowden, AJ; Mather, L; Watt, IS; Walker, A. Systematic review of the effectiveness of stage based interventions to promote smoking cessation. BMJ 2003 May 31;326(7400):1175–7.

12. Aveyard, P; Massey, L; Parsons, A; Manaseki, S; Griffin, C. The effect of Transtheoretical Model based interventions on smoking cessation. Soc Sci Med 2009 Feb;68(3):397–403.

13. Cahill, K; Lancaster, T; Green, N. Stage-based interventions for smoking cessation. Cochrane Database Syst Rev. 2010 Nov 10;11:CD004492.

14. Horowitz, SM. Applying the transtheoretical model to pregnancy and STD prevention: a review of the literature. Am J Health Promot 2003 May–Jun;17(5):304–28.

15. Salmela, S; Poskiparta, M; Kasila, K; Vähäsarja, K; Vanhala, M. Transtheoretical model-based dietary interventions in primary care: a review of the evidence in diabetes. Health Educ Res 2009 Apr;24(2):237–52.

16. Kreuter MW, Strecher VJ, Glassman B. One size does not fit all: the case for tailoring print materials. Ann Behav Med 1999; 21(4):276-283.

17. Campbell MK, DeVellis BM, Strecher VJ, et al. Improving Dietary Behavior: The Effectiveness of Tailored Messages in Primary Care Settings. Am J of Public Health 1994; 84(5):783-787.

18. Chua HF, Polk T, Welsh R, et al. Neural responses to elements of a web-based smoking cessation program. Stud Health Technol Inform 2009; 144:174-178.

19. Chua HF, Ho SS, Jasinska AJ, et al. Self-related neural response to tailored smoking-cessation messages predicts quitting. Nat Neurosci. 2011 Apr; 14(4): 426-427.

20. Rothschild ML. Carrots, Sticks, and Promises: A Conceptual Framework for the Management of Public Health and Social Issue Behaviors. Journal of Marketing 1999 Oct; 63:24-37.

21. Samuelsen BM, Olsen LE. Promising Attributes and Experiences. Attitudinal Responses to Functional Versus Experiential Ad Claims and the Moderating Role of Involvement. Journal of Advertising 2010; 39(2):65-77.

22. Lefebvre RC, Flora JA. Social Marketing and Public Health Intervention. Health Education Quarterly. 1988; 15(3): 299-315.

23. Rosenstock IM. Why people use health services. Milbank Memorial Fund Quarterly 1966; 44(3): 94–127.

24. Weinstein ND. Optimism About Future Life Events. J Personality and Social Psych 1980; 39(5): 806-820.

25. Armor DA, Taylor SE. When Predictions Fail: The Dilemma of Unrealistic Optimism. Heuristics and biases: The psychology of intuitive judgement. 2002 Cambridge University Press.

26. Sharot T, Riccardi AM, et al. Neural mechanisms mediating optimism bias. 2007 November; 450: 102-105.

27. Center for Health Communication Research. CECCR – Eye Tracking. Unpublished Data. University of Michigan School of Public Health. http://chcr.umich.edu/what_we_do/projects/project.2008-05-08.0387818537/projects_results?status=active

28. Ariely D. The High Price of Ownership. Predictably Irrational. HarperCollins, New York. pp. 167-182.

29. Brehm JW. A Theory of Psychological Reactance. 1966 Academic Press.