Evaluation of the Be a Star Campaign and its Role in Improving Breastfeeding Rates Among Young Women – Megan Scott

Introduction
Breastfeeding initiation is essential in order to confer vital antibodies to the infant in the first few days after birth, protecting him or her against infectious illness and disease (7). The benefits do not stop after the first week. Sustained breastfeeding has been shown to: allow for appropriate infant weight gain, lower the risk of childhood obesity, reduce allergies and lower the risk of illness, increase childhood bone density, reduce the risk of Sudden Infant Death Syndrome (SIDS), improve neurological and cognitive development, and improve vision (7). Breastfeeding also reduces the incidence of intestinal infections and gastroenteritis in infants. A study of infants who were admitted to the emergency room due to gastroenteritis and other intestinal infections revealed that of the 197 monitored infants, only one was breastfed. This illustrates the impact that breastfeeding can have on reducing the prevalence of gastroenteritis when compared with bottle fed infants (4).
Although breastfeeding initiation rates are near the national goal of 74%, women today are unlikely to continue breastfeeding exclusively for 6 months (6). The Healthy People 2010 goal for exclusive breastfeeding for six months is 50% and is not projected to be met. It has been shown that infants who are breastfeed exclusively for six months have improved health outcomes, yet only approximately 59.3% mothers with a poverty income ratio below 100% actually breastfed (9). These averages exclusively focus on breastfeeding initiation rates. The number of women who exclusively breastfeed for six months, as recommended by the American Academy of Pediatrics (AAP), drops to approximately 35%, and only 16% of women continued to breast feed exclusively for 12 months(5).
It has been shown that there is a sharp decline in breastfeeding rates between months three and five and that it is especially important to provide support and counseling during this interval (6). Exclusive breastfeeding is defined by UNICEF as feeding the baby no other form of milk or food for the first 4 months, and that breast milk be used at least one year (or until the infant is weaned) (5). The introduction of cow milk into an infant’s diet has been shown to result in an allergic reaction and stomach irritation every time the baby drinks. Young mothers are the least likely to initiate and sustain breastfeeding behavior’s and therefore more interventions need to be targeted at this population. In an effort to address the issue of breastfeeding in these young mothers, The Be a Star campaign was launched.
Be a Star (BAS) is a breastfeeding campaign that was launched in the United Kingdom in March of 2008. The campaign targets young mothers age 16-25 and aims to make breastfeeding more attractive within this age group. BAS decided to take an innovative approach to targeting young women by portraying local women breastfeeding their children while dressed like fashion models. The campaign chose multiple media outlets to convey the message to youth that breastfeeding makes you a star and is a positive thing. These media outlets included TV spots, radio broadcast commercials, internet, posters, and pamphlets (10). Posters portray local women who have been “glamorized” to look like fashion models breastfeeding their babies. Tag lines on the posters include “she may not be famous but she is a star,” “she may not be a singer but she’s a star,” and other similar lines (10). BAS is modeled around three social behavioral theories. The first is the Social Learning Theory (SLT). SLT is based on the idea that people are more likely to engage in a behavior that they see others doing (10-11). Therefore by showing young women that other women breastfeed, the creators of this program hope to engage young mothers and demonstrate that breastfeeding is a social norm. The second theory that this campaign was based upon was the Social Capital Theory (SCT) (10-11). SCT aims to redefine social norms and shift the balance of social capital. BAS specifically attempts to change the social norms surrounding breastfeeding by engaging fathers and other family members in the process by using informational pamphlets (10-11). The final theory that BAS was based on is the Value Attachment Theory (VAT). VAT attempts to attach a behavior to the population’s current value set. BAS tries to accomplish this by reframing the issue of breastfeeding as something glamorous and sexy.
While BAS offers many positive messages, this paper will demonstrate that there are three main flaws to BAS’ approach. Further, this paper will make suggestions to improve this campaign and offer an alternative approach to tackling the issue of breastfeeding.
The Be a Star Campaign is Not Relatable
This campaign seeks to demonstrate that breastfeeding is normal and that everyone is doing it, yet they choose to portray women in ways that makes them not relatable to everyday women (12). BAS specifically chooses small town women to be in their campaign, but because these women are portrayed as super models they become no longer relatable (12). The casual observer of the poster campaigns may not recognize that the woman being portrayed is a small town girl, but will notice the fancy clothes and the makeup the woman is wearing. The glamour of the image draws your eyes to the woman and the clothes allowing the baby to fade into the background and not be the center of focus. It is in this way that the message “breastfeeding is the best” is lost in translation. Social Marketing theory is rooted in the idea that people need to be able to relate to the message they are viewing if you want them to change their behavior (13-14). The idea of portraying small town women in ads is a great idea, however changing their image takes away from this. On an everyday basis most young women do not dress glamorously, wear a lot of makeup, and look fabulous when they are breastfeeding their child. Young mothers observing these ads could feel alienated and feel that if they do not look like the glamorous woman in the photo that they do not have the capability to breastfeed. The BAS campaign fails to recognize that self-efficacy is an important part of a woman’s decision to breastfeed (11, 12). In their attempt to appeal to young mothers by portraying breastfeeding women as stars, BAS could inadvertently impact a woman’s feeling of self-efficacy. If a woman views images of glamorous women breastfeeding and does not feel she looks like these women or is capable of looking like these women, she may decide she is unfit or unable to breastfeed.
BAS’ decision to portray women who are breastfeeding as stars implies those who choose not to breastfeed are not stars. It further implies that women who chose not to breastfeed are not glamorous and possibly not as pretty. Alienating mothers who are unable to overcome the necessary barriers to continue breastfeeding could have detrimental effects on these mothers. As the co- founder of the Best for Babes points out “We are too quick to judge women without respecting their circumstances or the obstacles they face (11).” Women who choose not to breastfeed are no different than women who do. Failure to recognize that many women face barriers that they cannot overcome or recognize that some women are incapable of breastfeeding altogether can have detrimental effects on how the public perceives women who do not breastfeed (11).
The Be a Star Campaign Offers a False Promise
BAS has taken a revolutionary step in reframing the issue of breastfeeding from one focused on health benefits to one focused on “sex appeal and glamour (12).” While these messages appeal to the younger crowd, this campaign offers a false promise to teen mothers that underestimate the difficulties associated with breastfeeding. The promise of the BAS ads and posters is that if you breastfeed you will be beautiful, glamorous, sexy, and a star. The problem is that breastfeeding is really not glamorous. It requires waking up at all hours of the night, eating certain foods, avoiding certain foods, taking time out of work etc. Breastfeeding is also very physically demanding on the mother (1-4). This campaign does not take into account that by promising women that they will feel beautiful and glamorous when they breastfeed, women may be disappointed. For example, a young mother who chooses to breastfeed for the first time in public may find herself met with stares and looks of disapproval from the crowd, which would conflict with the promise BAS provides. Further, BAS promises young women who choose to breastfeed that they will receive a glamorous reception, yet it is possible that young mothers feel they are limited in their ability to lead glamorous lives because they have to give up certain things to breastfeed their child (11, 12).
Ownership Theory and BAS
BAS does not adequately consider the role that Ownership Theory can play in a woman’s decision to breastfeed. Breastfeeding asks a young mother to give up social acceptance behaviors, such as smoking and drinking. Ownership theory recognizes that giving up a behavior, such as drinking in order to breastfeed your infant, may not be that simple. BAS fails to recognize that women who make the decision to breastfeed may forgo other alternatives. Further, breastfeeding requires a woman to dedicate time to either physically breastfeeding the infant or pumping her milk for later use. For a young adult this could be a significant decision. Continuing with the above example, a young mother who wishes to still remain a part of her group of friends and party on the weekend may feel restricted by breastfeeding. If she chooses to bottle feed her baby she can go out on the weekend, drink with her friends, and secure a babysitter, without worrying about contaminating her milk or taking the time to pump so the babysitter can feed the baby. Ownership theory is important consider because even if the behavior that is given up is not drinking a woman will have to give something up to be able to breastfeed. For example, a less drastic example is that drinking coffee while breastfeeding in not recommended this could be a huge barrier for many women. It is important to consider all of the alternate options that women might forgo in making this decision in order to adequately address their concerns. While these examples may seem crude it is important to consider all the barriers and reasons why a young mother may choose not to breastfeed her infant.
BAS Does Not Adequately Consider Environmental and Societal Barriers
BAS does not adequately address the many barriers that might prevent women from being able to breastfeed, including jobs, school, physical taxation, inconvenience, and social unacceptability. Failure to recognize and adequately address the many barriers that prevent women from choosing to breastfeed significantly hinders the success of this program. It is suggested that BAS increase the number of resources available to women to address the barriers that many women face. More information could be included on the website addressing issues around commonly observed barriers. Right now the campaign does offer ways to avoid being seen in public, but it focuses just on shopping malls and restaurants. Young women do not spend all of their time shopping and eating at restaurants. The campaign fails to recognize the alternate locations and complications that young mother might face when trying to breastfeed. BAS offers little or no information to young mothers about how to continue to breastfeed if they are still in school or working. A typical sixteen year old girl would still be in high school and faced with many challenges if she decided to remain in school and care for her child. Feeling like a star, when you have a child in high school may not be enough to convince a young mother that she needs to keep breastfeeding. The fact that a young mother, who remains in school, may not be given enough “free” time to pump her milk, or even have access to a pumping machine on school facilities, is an important barrier to consider. BAS does not adequately address the barriers that young mothers may experience in their work place settings. Many young mothers do not have steady jobs that pay benefits that would allow you to take the breaks necessary to pump milk.
BAS attempts to address the social stigma surrounding breast feeding by engaging fathers and providing peer support groups to women. The literature used to target men however, does not efficiently target the proposed audience. Literature includes similar photos and text that appear on the promotions used to target the young women, which could reduce their appeal to the men, they are targeting (12).
Also, this campaign offers the opportunity to gather information directly from young women who have joined the BAS blog. Asking women directly what barriers they face and tailoring the information on the website to the women’s concerns will further increase the effectiveness of this campaign.
Proposed Intervention
In order to increase the breastfeeding rates among young mothers, a new program could be implemented that synthesizes the effective components of existing campaigns and seeks to address the barriers that women face. Instead of portraying women as stars, the campaign will be based around a current campaign in California that portrays images of women in actual settings including coffee shops and libraries, breastfeeding their infant. These photos include tag lines like “future business entrepreneur getting an important order filled” or “future internet whizz kid busy downloading (8).” Portraying women in natural settings will increase the ability of other mothers to relate and increase the likelihood that they will feel they could be that mother. If women feel that they could be the mother being portrayed, they are more likely to engage in the behavior being suggested (14-16). By developing a photo campaign that matches the image of the mothers we are trying to target, we will likely increase the number of women who start breastfeeding. Also, like the BAS, these photos are not selling health which makes both of these approaches unique and effective. BAS is selling sex appeal, but because they go over the top, the message is lost in the fancy clothes and makeup. Our campaign will not be selling the health benefits of breastfeeding, but will be selling the “future” of your child. BAS is not completely flawed in its choice to portray young mothers as stars but this approach is insufficient. We can further increase the effectiveness of our campaign by using BAS’ approach, but by including the image of the actual mother alongside the photo of the glamorous model. While the image of the glamorized woman is powerful, BAS would be even stronger if they portrayed the image of the “real” mother alongside the “glamorized” mother. Paired with this we could offer the tag line “while you might feel tired, run down, and unable to continue, remember you are a star.” By including the image of the mother and baby in their normal environment, BAS would increase the likelihood that others will relate to the mother being portrayed. This new campaign would address the limitations of the BAS campaign by portraying women in a relatable way, and by strengthening the message that is being conveyed to young mothers.
Changing Societal Norms
As part of my new campaign, I will also work with well known celebrities who have breastfed, or are currently breastfeeding their babies in order to increase public awareness. I will have these celebrities appear on talk shows and on radio stations in order to increase awareness about breastfeeding and to change the perception of the practice. By getting people to talk about breastfeeding, and increasing the number of times people hear about it, the more likely it will begin to become accepted as an everyday practice (18-19). The role of social influencers has been demonstrated throughout history for a variety of public health measures (17). The most notable social change that was brought about by celebrity action is the movement against breast cancer. In The Politics of Breast Cancer, author Casamayou demonstrates that it was the social influence of Hillary Clinton, paired with the backing of the breast cancer movement by many prominent Hollywood stars, that created the optimal environment for the launching of a multi-billion dollar fundraising effort (17). The Warriors in Pink Campaign continues to utilize prominent figures to promote self-breast exams and to raise awareness about the fight for a cure (17). For example, the Warriors in Pink have teamed up with The Ford Motor Company and the cast of the television series Beverly Hills, 90210 to promote breast cancer awareness. The stars of the show are shown wearing Warriors in Pink T-shirts and are featured in commercials advocating for breast cancer awareness. A similar approach could be used to raise awareness about the importance of breastfeeding. The fact that youth already tune in weekly to watch shows like Beverly Hills, 90210 and Gossip Girl would increase the number of youth that could be reached with these pro-breastfeeding ads. Demonstrating to young women, and to society in general, that breastfeeding is a social norm, will increase the likelihood that new mothers will choose to initiate breastfeeding (18). BAS does not adequately address the issue of changing social norms around breastfeeding. According to Social Expectations Theory and Psychological Reactance Theory individual perception of social norms directly impacts the individual’s decision to engage in the ascribed behavior (18, 19). Based on these theories, in order to increase the number of women who initiate breastfeeding, changes will need to be made to reduce the negative reactions that society has surrounding observing breastfeeding in public. Working directly with celebrities and well known companies will increase public exposure to the issue of breastfeeding and begin to change the societal norms surrounding the issue.
More needs to be done on a policy level to change the employer-employee relationship surrounding breastfeeding. If employers are regulated to allow women the breaks necessary to pump milk, it is likely that there will be an increase in the number of women who are able to continue to breastfeed. While employers may argue that they are losing productivity, a counter argument would be that smokers are allowed to take smoke breaks and there is no health benefit associated with smoking, whereas breastfeeding has a documented health benefit (7). A study conducted in England found that 80% of the women who completed their survey stated that they wanted to continue to breastfeed when they returned to work (20). Further, the study found that 90% of women surveyed had no idea what their current employer’s breastfeeding policy was (20). Finally, 90% of women surveyed stated that they felt employers should do more to support breastfeeding (20). Women suggested the inclusion of facilities to express and store milk, allowing women to take rest breaks during working hours, and allowing women to work flexible schedules as methods to promote sustained breastfeeding (20). Increasing the number of employers who support a woman’s decision to breastfeed improves the chances that women will choose to continue to breastfeed when they return to work.
Part Three- Mentors
The third component of this program will be the implementation of peer mentors in hospitals to aid with the breastfeeding process. Studies have shown that women who are paired with peer mentors and feel that they have someone to support them during the breastfeeding initiation process are more likely to choose to breastfeed (14-16). Further, studies have shown that by developing a mother’s intent to breastfeed early in the pregnancy, the more likely she is to initiate and sustain breastfeeding (12-16). A study in the Netherlands demonstrated that a woman’s intent to breastfeed was a significant indicator of her actually initiating breastfeeding behaviors (16). Young mothers (16-25) will be indentified by their obstetrician and referred into the program when they are three months pregnant. Mothers will be matched with peer mentors of a similar age who breastfed their children. Matching mothers with mentors of a similar age and who have undergone the same hardships and experiences that the mother is currently facing will increase the mother’s ability to relate to her mentor. The ability to relate to the mentor will likely increase the mother’s feelings of self-efficacy because she has someone to relate with. These mentors will be trained to work with mothers and to provide them information about the common barriers and difficulties associated with breastfeeding and how to overcome them. Mentors will be available to mothers throughout the pregnancy and up to a year after birth. It is hoped that by pairing the young mothers with someone who has had similar experiences they will be able to ask the questions they need and feel supported in their choice to breastfeed.
BAS offers peer support groups but does not adequately address issues surrounding the self-efficacy of the mother to continue breastfeeding when bombarded with the many barriers that new breastfeeding mothers face (12-14). The institution of peer mentors allows each mother to have someone they can speak to directly about the barriers they are facing.
Conclusion
In conclusion the BAS campaign has three main faults, including 1) it is not relatable to young women, 2) it offers a false promise, and 3) does not adequately address the social and environmental factors that influence a woman’s decision to breastfeed. Implementation of an alternate program that seeks to change social norms by raising awareness about breastfeeding within the general public, pairing women with peer mentors to support them through the decision process, and changing the face of the campaign, will improve the effectiveness of the BAS campaign. More needs to be done to raise awareness amongst employers and to create work environments that facilitate a woman’s decision to breastfeed.











References
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Breast is Best?: Why the National Breastfeeding Campaign Falls Short in its Promotion of Breastfeeding

I. Introduction
Both the World Health Organization and the American Academy of Pediatrics recommend exclusive breastfeeding for an infant’s first 6 months of life and then continued breastfeeding with supplemental foods until at least 12 months (1, 2). However, in the United States, only 73.9% of women initiate breastfeeding, and only 43.4% of infants are still breastfed at 6 months of age (4). Even more startling is that only 13.6% are exclusively breastfeed to 6 months post partum (4). Furthermore, only 22.7% of mothers continue breastfeeding to 12 months post-partum (4). The government initiative “Healthy People 2010” strives to increase breastfeeding so that 75% of babies are breastfed early post partum, 50% are breastfed at 6 months post partum, and 25% at one year (3).
Breastfeeding has important implications on both maternal and infant health, making it an important public health issue. Breast milk contains antibodies, providing immune support and protecting infants from a wide range of infections (5, 6). Breast milk also coats and protects the infant’s digestive tract (5). Breast milk has been linked to lower rates of ear infections, respiratory infections, diarrhea, asthma, obesity, diabetes and SIDS in infants (5-10). In terms of maternal health, breastfeeding has been associated with a reduced risk of ovarian and breast cancers, a quicker return to pre-pregnancy weight, less postpartum bleeding, quicker involution of the uterus and delayed return of the menstrual cycle (5, 6, 11-15). Furthermore, breastfeeding promotes bonding between mother and infant and is cost saving compared to formula-feeding (5, 16).
The National Breastfeeding Campaign was initiated by the United States Department of Health and Human Services in an effort to promote breastfeeding to first-time parents (17). The Department of Health and Human Services worked with the Advertising Council to develop a media campaign that was launched in 2004 and lasted until 2006 (17). The campaign materials included three print ads which portrayed pictures of dandelions, ice cream scoops, or otoscopes, each of which looked similar to a pair of breasts (Figures 1-3). Each image then contained a statement saying “breastfeed for six months” followed by a brief corresponding message about breastfeeding being linked to a reduction in respiratory illnesses, obesity, or ear infections (17). This paper will address the shortcomings of this campaign and propose interventions that address those shortcomings.

II. Critique of the National Breastfeeding Print Ad Campaign
I contend that the print ads of the National Breastfeeding Campaign have three major flaws. First, this campaign is based on the Health Belief Model and does a poor job conveying disease susceptibility and severity. Second, this campaign does not recognize the importance of social networks and does nothing to change the social norms surrounding breastfeeding. And third, this campaign fails to address social or environmental issues that influence breastfeeding.

A. Poor Use of Model and Framing
The print ads of the National Breastfeeding Campaign convey one message: breastfeeding is a health benefit. As demonstrated by the Marketing Theory, a good marketing campaign is not based on the product, but rather what the intended consumer wants (18). The Marketing Theory maintains that good marketing campaigns will have two parts: a promise and support for the promise (18). For the campaign to be successful, the “promise” needs to be a core value. Health is not a core value and is not enough of a reason to incite behavior changes. Furthermore, using statistics as a support to the promise is weak and ineffective (18). Studies have shown that breastfeeding is not influenced by health care providers or health facts (19). Despite this, the National Breastfeeding Campaign used health to promote breastfeeding by using health as the core value in the Health Belief Model.
The Health Belief Model (HBM) is based on the framework that people make decisions about health behaviors after weighing the perceived benefits and barriers of those behaviors resulting in an intention of a behavior and then a behavior (20). According to the HBM, the perceived benefit of a behavior is influenced by perceived susceptibility and perceived severity to an outcome that the behavior is intending to prevent (20). In this case, the HBM suggests that when making a decision about breastfeeding women would weigh their perception of the benefits of breastfeeding against their perception of barriers to breastfeeding to reach a decision. Influencing their perception of benefit is the perception of susceptibility and severity of outcomes that would occur if they did not breastfeed. These ads do nothing to address the barriers associated with breastfeeding and, I believe, do a poor job at conveying susceptibility and severity. I contend that the ads are framed in a way that actually minimizes the susceptibility of illnesses.
The National Breastfeeding Campaign ads attempt to provide women with information on susceptibility and severity of respiratory infections, obesity, and ear infections that could arise from not breastfeeding. However, the ads, which are each similar to this one highlighting ear infections, read: “Breastfeed for Six Months. Help Reduce Your Child’s Risk for Ear Infections” (17). The message does not convey an infant’s susceptibility of ear infections regardless of their breastfeeding status and also does not convey the severity of ear infections (or respiratory illness or obesity). Furthermore, by framing it as a reduction of the potential poor health outcome, I think these ads make breastfeeding seem like “extra credit” or a “bonus.” In reality, breastfeeding is natural and healthy and should be viewed as the primary feeding option as opposed to being viewed as an added benefit. As demonstrated people have an aversion to loss (21). This ad campaigned is not framed as a “loss” but rather as a “gain.” The campaign promotes that the child will gain better health if breastfed and thus makes breastfeeding seem like a “bonus” because it is implying you can make your child healthier than the norm. This de-values the importance of breastfeeding.
Aside from the National Breastfeeding Campaign doing a poor job utilizing the HBM, I think that using the HBM itself was a poor model choice. The HBM is an individual level model and fails to account for other societal or environmental factors. It also assumes that “intention” influences behavior and that decisions are static (20). Studies have shown that breastfeeding is heavily influenced by outside factors and that an intention to breastfeed does not always result in breastfeeding (19). Factors influencing the decision to breastfeed are addressed in depth in section C.

B. Failure to Address Social Norms or Networks
Another failure of the print ads of the National Breastfeeding Campaign is that they do nothing to address the social norms surrounding breastfeeding. The ads also fail to incorporate the importance of social networks on breastfeeding. The National Breastfeeding Campaign is an individual level campaign intended to affect individual behaviors. However, it has been demonstrated that social support has a significant effect on breastfeeding (5, 6, 19, 22, 23). There are certain areas and cultures where breastfeeding is more accepted and more predominant it is more of a norm in those areas and cultures leading more women to breastfeed (4, 24, 25). As women become more acculturated in American society they become less likely to breastfeed (24, 25). This indicates that breastfeeding is not the social norm in the United States and that our current norm is negatively associated with breastfeeding.
Studies have shown that women that have support from their families are more likely initiate and continue breastfeeding (5, 6, 19, 22, 23). Similarly, women that have peer support are more likely to breastfeed and more likely to breastfeed for a longer duration (23). Furthermore, community support also has a positive effect on breastfeeding (19, 22, 23). Women often expect breastfeeding to be easy, when in reality it can be quite difficult. Without the proper support system in place, many women that had intended to breastfeed will give up (22). The Health and Human Services Blueprint for Action on Breastfeeding calls for a social marketing media campaign that portrays breastfeeding as the “normal” form of infant feeding (5).
The National Breastfeeding Campaign does not try to promote breastfeeding through any sort of social network or social norm. As mentioned in part A, I believe that the ads portray breastfeeding as a “bonus.” This attitude continues to reinforce that breastfeeding is not the social norm in the United States.

C. Failure to Address Social or Environmental Issues
I think that the predominant failure of the National Breastfeeding Campaign is its failure to address the social and environmental factors that influence breastfeeding. The decision to breastfeed is not solely based on knowledge that breastfeeding is beneficial and studies have shown that a wide range of factors beyond social norms and social networks affect breastfeeding (24-27). If these barriers are not addressed, the promotion and distribution of breastfeeding knowledge is essentially useless.
Studies have shown that lower levels of education and lower socio-economic status are related to lower rates of breastfeeding (24-27). Race is also a predictor of breastfeeding: African American are less likely to breastfeed than white women and Hispanic women are less likely to breastfeed than non-Hispanic women (23, 26). Age is another predictor of breastfeeding (24). As discussed in the previous section, family support, community support and role models play an important role in the initiation and continuation of breastfeeding (24-27).
Full-time employment has been linked to lower rates of initiation and continuation of breastfeeding (5, 6, 19, 22, 23). Studies have shown that women are unsure of how to balance employment and continued breastfeeding (27, 28). There are currently no national policies regarding breastfeeding or expressing milk and the workplace (5). Furthermore, if women feel that their employer does not support breastfeeding or feels that her career may be jeopardized by taking the time to do so, she will be less likely to breastfeed (5).
Common practices that are widely accepted also have negative impacts on breastfeeding. For example, it is a common practice for hospitals to distribute gift bags to new mothers that contain samples of infant formula. Studies have found that mothers that receive these samples are less likely to breastfeed than mothers that don’t (29-31). These samples can undermine a woman’s milk supply and inadvertently imply a hospital endorsement of formula feeding (31).
By failing to address these barriers to breastfeeding the National Breastfeeding Campaign ads are failing to address the main reasons that women do not breastfeed.

III. Proposed Intervention
My proposed intervention for the National Breastfeeding Campaign is an ecological model that addresses social norms and incorporates principles of the Marketing Theory.

A. Incorporation of the Principles of the Marketing Theory
The proposed intervention will use Marketing Theory to convey the ultimate goal of initiation and continuation of breastfeeding. Instead of using health as the outcome it will promote known core values in a two pronged approach. To convey the benefits to infants the proposed intervention will use core values of family, happiness, and “the American Dream.” It will also promote sex appeal to portray and “sell” maternal benefits. As demonstrated, health is generally not one of the most important values to people (18). The altered campaign will no longer use statistics and science as the support and will instead use images that convey the new core values. As shown, the majority of women already know the benefits of breastfeeding and these statistics on campaign ads do not influence decisions about breastfeeding (18).
The proposed intervention will also re-frame the issue so that breastfeeding is not viewed as “extra credit.” It is important to portray breastfeeding as natural and as the first choice (5)

B. Address Social Norms and Networks
The proposed intervention will work with local communities to create support groups and to increase awareness of breastfeeding. It will work to promote breastfeeding within communities and social networks and will also work to change the social norm. The use “opinion leaders,” or community members that will vocalize their support of breastfeeding, is an important way to encourage breastfeeding and to establish it as a social norm (32, 33). It is important to use a diverse group of opinion leaders so that many different women can identify with them (32).
The Diffusion of Innovations Theory maintains that if enough people adopt the new behavior a “tipping point” will be reached and that behavior will become the new norm (33). The “Be a Star Campaign,” a breastfeeding campaign in England, is an example of a campaign that is working to change social norms (34). It uses local mothers as examples and promotes the fact that they are breastfeeding. My proposed intervention will encourage local governments to begin programs consistent with this concept and will also work to change the social norms on a national level by exemplifying well know figures that breastfeed their children. Both the social norm theory and the theory of innovation maintain that as breastfeeding becomes the social norm, more women will initiate and maintain breastfeeding practices (32, 33).

C. Use of an Ecological Model
For this breastfeeding campaign to be successful, I think that it is extremely important to incorporate a multi-level intervention using an ecological model. Ecological models address many different levels of an issue including: intrapersonal, interpersonal, institutional, community and policy levels (35). If the major social and ecological factors that influence breastfeeding are not addressed it will be very difficult to accomplish higher rates of breastfeeding (27, 35). In my opinion, a woman can know all the facts about breastfeeding but without support and regulations that make it possible for her to breastfeed, she still might not be able to breastfeed even if it is her intention.
Starting at the broadest level, my proposed intervention will encourage governments and individual hospitals to institute policies promoting the idea of the “baby friendly hospitals” by banning the practice of infant formula distribution to new mothers by hospitals (36). The campaign will address the institutional level by encouraging businesses to develop policies and practices that support and promote working mothers that breastfeeding. In its “Blueprint for Action on Breastfeeding,” the Department of Health and Human Services has outlined many different ways that businesses can do this including the establishment of rooms designated for breastfeeding or expressing milk and refrigerators for storing breast milk (5).
The intervention will promote support at the community level as discussed in section B by working to change the social norms surrounding breastfeeding by utilizing social networks. The intervention will also work to encourage family support by targeting social networks. Studies have shown that if a woman’s family, and especially her partner, support breastfeeding she is much more likely to breastfeed. The proposed intervention will also work on the individual level, portraying widely held core values.
IV. Conclusion
Breastfeeding is a significant issue with critical public health implications both short term and long term. While the National Breastfeeding Campaign marketing ads might influence some individuals it is unlikely that it will have any population level effect. The failure of this campaign to social norms and networks along with its failure to address other social and environmental factors critically impairs it from having a meaningful effect. By incorporating a multi-level intervention that encompasses changes on the political, community, institutional (work place), interpersonal and intrapersonal levels, this campaign is much better suited to realize its goals of the promotion of breastfeeding.

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