Advance Provision of Emergency Contraception and its effects on Prevention of Unintended Pregnancies- Diego Martinez-Vasquez,M.D

Modern contraceptive methods represent more than a technical advance: they are the instrument of a true social revolution—the "first reproductive revolution" in the history of humanity, an achievement of the second part of the 20th century, when modern, effective methods became available. Today a great diversity of techniques have been made available and—thanks to them, fertility rates have decreased from 5.1 in 1950 to 3.7 in 1990. As a consequence, the growth of human population that had more than tripled, from 1.8 to more than 6 billion in just one century, is today being brought under control (1).

The most recent cycle of the National Survey of Family Growth demonstrates that, despite a reduction in unintended pregnancies among adolescents, college-educated, and higher-income women, 49% of all pregnancies in 2001 (3.1 million) were unintended. Of these unintended pregnancies, 42% ended in abortion. Furthermore, 48% of unintended pregnancies occurred in women who were using contraception during the month of conception (2, 3).

Unintended and teenage pregnancies (49%) are major public health concerns in the United States (see above). Emergency contraception (EC) is used to prevent pregnancy after failure of a contraceptive method or after unprotected intercourse. EC can prevent pregnancy when taken within 120 hours of unprotected intercourse (4). Several types of EC regimens exist, including an estrogen-progestin combination (sometimes called "combined regimen" or "Yuzpe regimen"), levonorgestrel alone (plan B), and mifepristone.

Some clinical trials have been studied the benefits of providing EC in and advance manner (AEC) to facilitate females in their use (4). The idea begin was to determine if when giving AEC can reduce the rates of unintended pregnancy when compared to regular EC. These clinical trials did not showed any benefit in reducing unintended pregnancies in females who received AEC compared to EC.

Contraceptive counseling. A Healthy People 2010 objective is to increase the rate of intended pregnancy to at least 70% of all pregnancies (5). One approach to reducing rates of unintended pregnancy is providing contraceptive counseling during primary care visits. The National Survey of Family Growth defines birth control counseling as “counseling about whether to use birth control methods, how to get them, information about different methods, and how they are used.

EC for a woman, who has unprotected intercourse, requires several steps to reduce the risk of unintended pregnancy. She must perceive that her risk of pregnancy is real and must be motivated to prevent it. She must be aware that a post-coital contraceptive method exists that could reduce her risk of conception. She also must have specific knowledge about how to obtain it and time its administration. She must have access to it, including a place to get it, a way to pay for it, and the time to invest in getting it. Any of those steps can be barriers to actually using emergency contraception after unprotected sex.

One of the current and likely been a very significant barrier to making EC part of routine contraceptive counseling is that providers are unlikely to initiate discussions regarding EC or offer an advance prescription (AEC). One particular barrier to the provision of EC information may be lack of a standardized manner in which to deliver information and the option for EC. Major health organizations and groups, such as the World Health Organization, American College of Obstetrics and Gynecology and the International Consortium for Emergency Contraception, have guidelines regarding key points to be included in EC counseling. However, despite increases, knowledge is still limited and EC provision does not occur in a majority of visits(6).

Contraceptive counseling is defined as a form of interpersonal (as opposed to public) communication. It includes information-giving as well as opportunities for clients (patients) to express their concerns, values, and preferences and to ask questions. Information may be provided through multiple communication channels, and using multiple channels may have a synergistic impact, with written or video material reinforcing oral communication. In health care settings, counseling may include face-to-face discussions between the patient and her provider; group discussions; peer counseling; telephone hot lines or information resource lines; print or video materials made available in information kiosks or resource centers; and telephone or mail follow-ups or reminders. In the case of contraceptive counseling, the goal is to empower women to prevent unintended pregnancy (1, 2, 6).

Counseling is conceived as having three dimensions: 1) exposure refers to whether or not any counseling occurs through any communication channels; 2) content refers to the information imparted during counseling; and 3) personalization refers to the degree to which women’s needs and preferences are addressed. Little research on U.S. populations has addressed the relationship between counseling and contraceptive adoption or continued use (7).

The plausibility of the hypothesis that counseling is associated with contraceptive use is supported by evidence that provider counseling influences women’s use of other preventive tests and interventions. Studies of mammography screening find that one of the most common reasons reported by older women for not obtaining mammograms is that their physicians did not recommend it.

Theories of health behavior attempt to explain how individuals adopt or fail to adopt health-promoting behaviors (e.g., exercise, smoking cessation, use of screening mammography) or maintain those behaviors over time. Theories such as the health belief model, the theory of planned behavior, and the transtheoretical model provide a basis for examining the relationship between contraceptive counseling in the health care setting and contraceptive behavior. These theories recognize that knowledge alone is not sufficient to motivate individuals to adopt health-promoting behaviors and that factors such as values, expectations, and social influences also are important determinants of health behaviors. In addition, these theories draw attention to intervening steps between the acquisition of information and health-promoting behavior, such as building self-efficacy and forming behavioral intent.

The function of counseling in the health care setting can provide information and help clarify the options available to the individual, thus empowering individuals to make informed decisions with respect to their health. Counseling can help alleviate fears about specific options or reduce anxiety about social consequences of options, thus addressing some of the nonrational components of health decision making. Providing information and enabling individuals to cope with their concerns help build self-efficacy for behavior change. Counseling also can help individuals move from one stage of behavior change to another—for example, from the precontemplation stage, in which there is no intent to take action, to the contemplation stage, when an intent is formed to change behavior in the near future—or to maintain a health behavior once adopted.

Increase risky sexual behavior, increasing the risk of pregnancy or sexually transmitted diseases. Several studies have looked into AEC in effort to circumvent some of these obstacles. (8, 9). The studies showed that there is no evidence that suggests that providing AEC causes adolescents to have more unprotected intercourse or less consistent contraceptive use. Indeed, contrary to many health care providers and the public's views, the AEC group participants reported significantly higher condom use. The problem with this studies is that these studies failed to showed reduction in unintended pregnancies when compared to standard access situations (defined as routine contraceptive counseling, provision of information on emergency contraception, or emergency contraception on request) (4).

These trials share a common weakness. Reported information on use of emergency contraception, frequency of unprotected intercourse, and changes in contraceptive patterns was of unknown validity. Since these self reports lacked objective verification, this information should be viewed with caution. Objective evidence indicates that self reports on use of contraceptives other medications are inaccurate, and that self-report of unprotected intercourse is inferior to other ascertainment methods. Some degree of underreporting of pregnancies may have occurred in both the advance provision and control groups in these trials, particularly those trials using only self-reported data. Unintended pregnancies terminated by induced abortion are routinely underreported. However, results from the trials relying on pregnancy testing were consistent with results from the trials using self-reports of pregnancy(4).

None of the adequately powered trials showed difference in pregnancy rates, despite increased use, multiple use and faster use of AEC (4).

This conclusion conflicts with earlier optimistic projections of the potential public health impact of improved access. This intervention could have failed because the way women perceives pregnancy risk or because concerns about side effects, and inconvenience(10, 11).

Health care coverage or insurance. Although men and women have some similar challenges with regard to health insurance, women face unique barriers to becoming insured. More significantly, women have greater difficulty affording health care services even once they are insured. On average, women have lower incomes than men and therefore have greater difficulty paying premiums. Women also are less likely than men to have coverage through their own employer and more likely to obtain coverage through their spouses; are more likely than men to have higher out-of-pocket health care expenses; and use more healthcare services than men and consequently are in greater need of comprehensive coverage. Moreover some females don’t have coverage of prescription contraceptives. The direct medical costs of unintended pregnancies were US$5 billion in 2002 and direct medical cost savings due to contraceptive use were US$19 billion (12, 13).

In summary, advance provision of emergency contraception does not decrease unintended pregnancies nor increase sexual risking behaviors or sexual transmitted diseases. In order to decrease unintended pregnancies using advance provision of emergency contraception, routine and consistent counseling by health providers (physicians, pharmacists, nurse practitioners and physician assistant) in emergency contraception has to be provide to any female who is sexually active. Health behavior models like the health belief model, the theory of planned behavior, the transtheoretical have to be use in combination to assess the specific needs of each patient. Health coverage and insurance has to be taken in account when prescribing or recommending AEC. Overall not having access to medical coverage directly impacts the availability of physicians and health care providers. Moreover new programs have to be implemented to increase access of this population to health care.

Finally more studies need to be performed to asses the use of advance provision of emergency contraception. These studies need to be conducted looking at counseling and behavior model as described above. Nevertheless new programs that facilitated easy access to AEC for uninsured sexually active females have to be implemented through out the federal or state level.

References:

1. Benagiano G, Bastianelli C, Farris M. Contraception today. Ann N Y Acad Sci 2006;1092:1-32.

2. Chandra A, Martinez GM, Mosher 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 23 2005(25):1-160.

3. Martinez GM, Chandra A, Abma JC, Jones J, Mosher WD. Fertility, contraception, and fatherhood: data on men and women from cycle 6 (2002) of the 2002 National Survey of Family Growth. Vital Health Stat 23 2006(26):1-142.

4. Polis CB, Schaffer K, Blanchard K, Glasier A, Harper CC, Grimes DA. Advance provision of emergency contraception for pregnancy prevention (full review). Cochrane Database Syst Rev 2007(2):CD005497.

5. Services DoHAH. Healthy People 2010; 2007 October.

6. Petersen R, Albright JB, Garrett JM, Curtis KM. Acceptance and use of emergency contraception with standardized counseling intervention: results of a randomized controlled trial. Contraception 2007;75(2):119-25.

7. Pisaniello ML. Importance of counseling patients about contraception. Am Fam Physician 2007;75(5):624; author reply 624.

8. Gold MA, Wolford JE, Smith KA, Parker AM. The effects of advance provision of emergency contraception on adolescent women's sexual and contraceptive behaviors. J Pediatr Adolesc Gynecol 2004;17(2):87-96.

9. Raymond EG, Stewart F, Weaver M, Monteith C, Van Der Pol B. Impact of increased access to emergency contraceptive pills: a randomized controlled trial. Obstet Gynecol 2006;108(5):1098-106.

10. Adler NE. Contraception and unwanted pregnancy. Behav Med Update 1984;5(4):28-34.

11. Moreau C, Bouyer J, Goulard H, Bajos N. The remaining barriers to the use of emergency contraception: perception of pregnancy risk by women undergoing induced abortions. Contraception 2005;71(3):202-7.

12. Lindrooth RC, McCullough JS. The effect of Medicaid family planning expansions on unplanned births. Womens Health Issues 2007;17(2):66-74.

13. Trussell J. The cost of unintended pregnancy in the United States. Contraception 2007;75(3):168-70.

Got Fear?: The Failures of The Health and Human Services Campaign to Overcome the Barriers to Breastfeeding – Elmy Trevejo

The benefits of breastfeeding have been well documented for years. It is believed that breastfeeding saves 5-6 million children’s lives annually. According to the Lancet Child Survival Series, it is estimated that 1.3 million additional lives could be saved annually if women were enabled to achieve six months exclusive breastfeeding with continued breastfeeding thereafter (6). Infants that are not breastfed have decreased survival rates due to physical conditions such as NEC (necrotizing enterocolitis), diarrhea, respiratory illnesses, sepsis, and pneumonia. Bottle fed infants are more likely to suffer from otitis media, atopic dermatitis, gastroenteritis, and asthma (5,6,11). Other studies have found that infants that are bottle-fed may be more susceptible to increased cardiac risk factors such as obesity, diabetes and childhood leukemia (6). The benefits to the mother are quite substantial as well, and include decreased risk of breast cancer, ovarian cancer, and type two diabetes mellitus. There is also an association between breastfeeding and decreased cases of post partum depression (6, 12).
“ ...[Breastfeeding] represents the normal and expected way to feed infants and young children, yet continues to suffer from cultural and commercial barriers that make it difficult for mothers to adhere to the medical recommendations to breastfeed exclusively for six months, and to continue breastfeeding with appropriate complementary foods for one year and beyond (15, p. 552).”

Breastfeeding rates in the United States are considerably lower than in other parts of the world. The American Academy of Pediatrics recommends that women breastfeed for >12 months, and thereafter for as long as mutually desired (13). The latest data compiled by the Center for Disease control states that in 2004, the rates for breastfeeding early postpartum, at six months, and at twelve months was 73.8, 41.5, and 20.9, respectively. US Healthy People 2010 target is to increase the proportion that breastfeed their babies at birth to 75% and for six months to 50% (12). As a public health initiative the Department for Health and Human Services developed a marketing campaign to address this growing public health crisis.

The campaign featured two television ads, radio spotlights, and print media coverage. The commercials, which aired from June of 2004 to December of 2005, became the center for significant controversy due to the manner in which HHS targeted the audience. The first commercial shows two women, late in their pregnancies, in a logrolling competition. A message is briefly displayed on the screen that states, “You wouldn’t take risks with your baby before their born. Why start after?” The logrolling women are then back on the screen, and a voiceover states that studies show that babies that are breastfed for six months are less likely to develop ear infections, respiratory illnesses, and diarrhea. The end of the commercial shows the final message, “Babies were born to be breastfed.” The second commercial that HHS created depicted a woman in her third trimester being helped on top of a mechanical bull, and riding it until she falls off. The same message is displayed, “You wouldn’t take risks with your baby before their born. Why start after?” The same voice over is heard that quickly states some of the benefits of breastfeeding. In this paper, I am going to discuss the reasons that the HHS campaign for breastfeeding failed to be an effective public health initiative. The Health and Human Services campaign failed to be an effective public health initiative because it 1) uses a scare tactic/bullying approach, 2) fails to address the barriers that new mothers face that may hinder their compliance, and finally 3) the campaign fails to address the growing duality that exists between women and their bodies in American culture.

The Health and Human Services campaign uses a scare tactic approach towards breastfeeding
This tactic is discussed in the Protection Motivation Theory developed by Rogers in 1983. Protection motivation theory was first developed within the framework of fear-arousing communication. As stated by Boer and Seydel, protection motivation is the result of the threat appraisal and the coping appraisal. The appraisal of the health threat and the appraisal of the coping responses result in the intention to perform adaptive responses (protection motivation) or may lead to maladaptive responses. Protection motivation is a mediating variable whose function is to arouse, sustain and direct protective health behavior. It facilitates the adoption of adaptive behaviors and can best be measured by behavioral intentions (2). The HHS campaign uses this tactic in order to “frighten” their audience. The assumption is made that if knowing that one is causing harm to their child, mothers will be more apt to adopting breastfeeding practices. This is the major flaw in the campaign. The campaign uses callous blaming in order to get the audience’s attention. The message that is portrayed is that women who choose not to breastfeed are essentially harming their children, and goes as far as to compare it to dangerous activities such as mechanical bull riding, and logrolling. Although the message is supposed to be humorous, the underlying message is riddled with blame and has a tone of judgment that is not effective.

The campaign, in essence, labels women that bottle-feed as “bad mothers” or mothers that do not care about the well being of their children. The strategy used was designed to notify the public that on all counts breastfeeding is better for infants. The problem is that the campaign assumes that people are unaware of this. Studies have shown that when asked, non breastfeeding mothers state that they are aware that breastfeeding is superior to bottle-feeding, but the barriers that they faced to breastfeed outweighed the potential benefits. As stated by the HHS in June of 2004, “Research has shown that many women know that breastfeeding is the best nutrition for babies. This knowledge has not translated into changed behaviors, and breastfeeding rates have hit a plateau.” Pregnancy and birth are highly stressful and anxiety provoking events for most women, and instead of trying to empower and encourage women to embrace breastfeeding for the numerous benefits that it has, the HHS campaign bullies women into feeling like “incompetent mothers,” if they choose not to breastfeed.

The Campaign fails to address professional and social barriers
Another issue that I have with the HHS campaign is that it fails to address any of the barriers that women face when making the decision to breastfeed or bottlefeed. One of the biggest barriers that women face is related to lack of support in the workplace, and shortened maternity leave. One third of mothers return to work within three months of having a baby, and two thirds return within six months from birth (14). As stated by C. Barona-Vilar, “Among employed women, structural support linked to working conditions has a decisive role on breast-feeding election and duration. Duration of breastfeeding tends to be longer when maternity leave is longer, especially among women with higher professional qualifications and permanent contracts. Among women with lower professional qualifications, and women whose high level of precarious work and low income converges, breast-feeding duration is substantially reduced (1)” The United States guarantees three months of unpaid maternity leave. When compared to other countries, this is appalling. In Norway, more than 97% of women breast-feed their infants during the immediate postpartum period, 80% continue at 3 months, 20% breast-feed beyond 12 months. Women can take maternity leave for 42 weeks with full pay or for 52 weeks with 80% pay. After returning to work, they are entitled to 1-1 ½ hour breaks each day to feed their infant (13). Many women are forced back into the workplace early because they are unable to go without the additional income, adding another layer of complexity to breastfeeding their infants.

Another complaint that new mothers have is regarding the stigmas regarding workplace pumping. As suggested by Caroline Jane Gatrell, “mothers face hostility if they breastfeed infants, or express milk, within workplace spaces. Consequently, shortened breastfeeding duration rates among employed mothers have attributed to organizational discouragement (3). It was originally suggested by Witters-Green that even where employers are aware of the issues, they fail to offer suitable spaces for breastfeeding. This is partly for cost-related reasons but also because employers are ‘discomfitted’ and ‘offended’ by the idea of breastfeeding mothers (14). There are false perceptions regarding breastfeeding in the workplace. Women often choose not to continue breastfeeding after returning to work, because of the way they feel their coworkers will react (8). In this country, breastfeeding has become something that should be hidden and done discretely, in order to keep everyone comfortable, instead of acknowledging it as a natural and biological necessity. Some women even feel that if they were to breast feed or expel milk at work, their professional life would suffer from negative consequences. Without addressing these concerns, the message of the HHS campaign is useless. It is easy for the campaign to blame women for their inability to care for their infants appropriately, but we as a society need to change policy and the workplace environment to assist and encourage women to feel that breastfeeding is socially acceptable.

The Campaign fails to acknowledge the dichotomy between breastfeeding and sexuality
It is well known that in Western cultures, breasts have become increasingly oversexualized. The social norm has changed the focus of the breast from its biological function to a sexual male fetish. As stated by Iris Young in her essay, Breasted Experience, “To be understood as sexual, the feeding function of the breasts must be suppressed, and when the breasts are nursing they are desexualized. A great many women in this culture that fetishizes breasts are reluctant to breastfeed because they perceive that they will lose their sexuality. They believe that nursing will alter their breasts and make them ugly and undesirable (17, p. 199).” This process may contribute to the reason women choose not to breastfeed. If women are afraid that by breastfeeding they are in essence “desexualizing” themselves, they are less likely to adopt the behavior. They are more likely to view the behavior in a negative way. The dichotomy that prevails creates a disassociation for most women. Although they want to do their best by providing nutrients for their infant, it puts their own sexual identity at risk.

According to Dettwyler, a well-known breastfeeding advocate, she states that the sexualization of women’s breasts underlies the taboo against breastfeeding in public. “It is ironic that breastfeeding an infant in public is still widely frowned upon, denying the natural function of the breasts at the same time as objectifying them for the sexual gratification of men” (3, p. 204). Women are concerned that they will no longer be considered attractive to their male partners. A survey conducted by Ward in December 2006, found that men were more likely to endorse traditional gender ideologies that portray men as sexually driven, and women as objects of sexual desire. It was difficult for men to accept the duality of female sexuality, and the biological need to provide nutrition for their infants. “These findings support the notion that traditional masculine ideation focuses on the sexual aspect of women’s breasts and bodies, thereby making it more difficult for men to embrace the reproductive functions (16).”

The failure of the HHS campaign is that it does not acknowledge that this duality exists. As long as women’s bodies are objectified to the degree seen now, it will be extremely difficult to change breastfeeding compliance rates without addressing the root issue. In our society, we do not object to media shots of women in skimpy outfits that accentuate their breasts, but we become very uncomfortable with the image of a woman nursing. Western culture continues to see the breast as an object for sexual gratification, and has made any other views of the breast perverse. The Health and Human Services campaign fails to broach the social stigma that our culture has towards a “desexualized” breast. It fails to acknowledge the dichotomy, and therefore cannot be effective in persuading mothers to breastfeed.

In conclusion, the Department of Health and Human Services breastfeeding campaign fails to be effective due to its judgmental and “bullying” strategy. To combat this public health issue, we cannot alienate and label women as inadequate mothers without addressing the social and professional reasons that contribute to the decision making process. The fire and brimstone campaign approach to breastfeeding is insulting and fails to encourage women to adopt the behavior. Instead of focusing on changing policy and also trying to address the manner in which women now objectify themselves, the health and human services campaign puts the blame and focus on the individual mother. It is obvious that this issue is multi-layered, and must be addressed in that manner, as well.

References
1. Barona-Vilar, C., et al., A Qualitative Approach to Social Support and Breast-feeding decisions, Midwifery (2007) 1:1-8.
2. Boer, H., Seydel, E. Protection Motivation Theory. (95-120) In M. Connor and P. Norman (Eds.) Predicting Health Behavior. Buckingham: Open University Press, 1996.
3. Dettwyler, K., Biocultural Perspectives. Beauty and the Breast: The Cultural Context of Breastfeeding in the United States (1995) 167-216.
4. Gatrell, Caroline. Secrets and lies: Breastfeeding and professional paid work. Social Science and Medicine (2007) 65:393-404.
5. Jacknowitz, A., Increasing Breastfeeding Rates: Do Changing Demographics Explain Them?. Women’s Health Issues (2007) 17: 84-92.
6. Johnston-Robledo, Ingrid. Indecent Exposure: Self-objectification and Young Women’s Attitudes Toward Breastfeeding. Sex Roles: A Journal of Research (2007) 56: 429-437.
7. Labbok, M. Breastfeeding: A woman’s reproductive right. International Journal of Gynecology and Obstetrics (2006) 94: 277-286.
8. Khoury, A., Moazzem, S., Jarjoura, C., et al. Breast-Feeding Initiation in Low-Income Women: Role of Attitudes, Support, and Perceived Control. Women’s Health Issues (2005) 15: 64-72.
9. Kukla, R., Ethics and Ideology in Breastfeeding Advocacy Campaigns. Hypatia (2006) 21: 157-180.
10. Li, R., Fridinger, F., Grummer-Strawn, L. Public Perceptions on Breastfeeding Constraints. Journal of Human Lactation (2002) 18(3): 227-235.
11. Marshall, J., Godfrey, M., Renfrew, M. Being a ‘good mother’: Managing breastfeeding and merging identities. Social Science & Medicine (2007) 65: 2147-2159.
12. Miracle, D., Fredland, V. Provider Encouragement of Breastfeeding: Efficacy and Ethics. Journal of Midwifery & Women’s Health (2007) 52(6): 545-548.
13. Raju, Tonse. Continued Barriers for Breast-Feeding in Public and the Workplace. The Journal of Pediatrics (2006) 148: 677-679.
14. Ryan, A., Zhou, W., Arensberg, M. The Effect of Employment Status on Breastfeeding in the United States. Women’s Health Issues 2006; 16:243-251.
15. Walker, M., International Breastfeeding Initiatives and their Relevance to the Current State of Breastfeeding in the United States. Journal of Midwifery & Women’s Health (2007) 52: 549-555.
16. Ward, L. Breasts Are for Men: Media, Masculinity Ideologies, and Men’s Beliefs About Women’s Bodies., Sex Roles (2006) 55: 703-714.
17. Young,I. Breasted Experience: The Look and the Feeling (189-209). In: Throwing Like a Girl and Other Essays in Feminist Philosophy and Social Theory. Indianapolis, IN: Indiana University Press (1990).

“The Fear Factor”, How The Breastfeeding Advocacy Campaign Failed Through Manipulation – Regina Njoroge

In June 2004, the U.S. Department of Health and Human services Office on Women’s Health and the Ad Council launched a national campaign encouraging first time mothers to breastfeed exclusively for six months. The campaign’s tagline was “Babies were born to be breastfed.” The overall goal of the campaign was to increase the proportion of mothers who breastfeed their babies exclusively in the early postpartum period to 75% and those within 6 months postpartum to 50% by the year 2010 (1-2). Exclusive breastfeeding according to the World Health Organizations (WHO) definition is feeding an infant only breast milk without any additional food or drink (3). Besides trying to raise breastfeeding initiation rates, the campaign stressed the negative effects of not breastfeeding such as lower respiratory tract infections, middle ear infections, eczema, childhood obesity and Type 2 diabetes among others.

The main theme of DHHS campaign was to focus on the consequences of not breastfeeding rather than on the benefits. This was based on the assumption that, once the mothers know the risk they are taking by not breastfeeding, they will automatically take action and chose to breastfeed. However, results from the National Immunization Survey (NIS) show that the strategy has failed. An August 2007, MMWR report shows that while more women are choosing to initiate breastfeeding, the percentage of those who continue to breastfeed exclusively for three months is very low. Rates for exclusive breastfeeding through ages 3 months and 6 months among infants born in 2004 were 30.5% and 11.3%, respectively, below target (4). Based on this data one can conclude that The DHHS “babies were born to be breastfed” campaign is a flawed public health intervention.

The campaign fails to address the social perception of the act of breastfeeding in the general public
The campaign assumes that knowledge of the risk factors associated with not breastfeeding will lead to behavior change. It fails to acknowledge the subjective norm principle of the Theory of Planned Behavior (TPB). The subjective norm is the belief that others expect one to perform or not to perform a behavior, and the motivation to comply with these expectations. According to the TPB, if people evaluated a suggested behavior as positive (attitude), and if they think their significant others wanted them to perform the behavior (subjective norm), this results in a higher intention (motivation) and they are more likely to perform the behavior (5).

The “Babies were born to breastfeed” campaign fails to recognize that there are many prevailing social and cultural norms that contribute to a woman’s choice on whether to breastfeed or not. Research has shown that infant feeding decisions are most often made prior to pregnancy or during the first trimester. The decision is based more on the socio-cultural environment that the woman is in other than on individual choice or preference (6-7). Similarly, a woman’s social network can significantly contribute to either making breastfeeding successful or difficult. Studies on women who initiate breastfeeding at birth have shown that encouragement from parents and relatives is significantly associated with breastfeeding patterns of mothers (8-9). The campaign addresses the issue of breastfeeding as an individual decision that a mother has to make and fails to consider the social network that surrounds the pregnant woman, such as husbands, parents, grandparents, friends and employers among others.

The campaign does not try to improve the social acceptability of breastfeeding in public. The sexual perception of breastfeeding in the United States also plays a prominent roll in a woman’s decision to breastfeed. While the act of breastfeeding was once a natural biological act, in today’s society particularly in the US, the social and sexual significance of the female breast rivals, if not exceeds, its biological significance (10. In North America and in many other westernized countries woman's breasts are a taboo; they are supposed to be hidden. Exposing a woman's breasts in public is considered shameful and inappropriate ("indecent exposure") even while breastfeeding (11-12). As a result women have been thrown out of restaurants, airplanes and business premises and accused of indecent exposure because they were nursing their babies. Such incidences indicates that some people still perceive breastfeeding as an indecent, disgusting, animalistic, sexual, and possibly even perverse act (10). Such incidences have a very strong impact on a woman’s decision to breastfeed, because they send the message that women who chose to breastfeed in public risk facing discrimination or evoking negative emotional reactions. As a result, even women who breastfeed may have difficulties doing it exclusively because of other people's attitudes towards them.

Another issue that the DHHS campaign fails to address is the social obstacles that women face when they go back to work. In the united State, women are entitled to only 3 months of unpaid maternity leave. Studies show that one third of women return to work within three months, while two-thirds return within six months of having a baby. Many of these women are forced to return to work because they are unable to go without the additional income (13). The decision to work while breastfeeding is a complex one, according to Dr. Frances Biagioli of Oregon Health and Science University, new mothers must negotiate the emotional distress of leaving a baby behind, social aspects such as a fear of leaking, lack of an appropriate space to pump (other than a bathroom stall), finding time for breaks and fatigue (14). Consequently, breastfeeding is discontinued. The campaign approach was unfair to women who choose to or have to go back to work by suggesting that they are putting their child in danger by not breastfeeding when it's so difficult to breastfeed exclusively and work. There should have been more focus on working with employers to provide more work place support to breastfeeding mothers such as, paid maternity leaves, lactation rooms and flexible schedules.

The Media Ads were contradictory to the campaign slogan
The television ads failed to address why breastfeeding is important and what its benefits are for the baby and the mother. One television ad has a scene at a ladies nightspot, with music playing in the background and a crowd cheering as a pregnant woman rides on a mechanical bull. As she is thrown off the bull, a message appears on the screen “you wouldn’t take the risk before your baby is born, why start after?” A second advertisement shows two women competing in a log rolling game. As one of the women plunges into the water, again the message appears on the screen “you wouldn’t take the risk before your baby is born, why start after?” Both ads conclude with a voice- over quickly stating, “Recent studies show babies who are breastfed are less likely to develop ear infections respiratory illnesses and diarrhea; Babies were born to be breastfed” (15). According to the Ad council, these new Public Service Announcements (PSAs) should speak to parents clearly about the consequences of not breastfeeding, which may help encourage more mothers to initiate and continue to breastfeed exclusively for six months. This effort fails to effectively apply the power of persuasion in changing behavior. According to researcher Ruth Faden of John Hopkins University “persuasion succeeds by improving and not by undermining a person’s understanding of her situation”. Faden notes that public health uses communication of information to mold behavior for the purpose of promoting social and individual welfare. She proposes that information must be packaged to enhance rather than cripple understanding (16). The DHHS TV ads serve to mislead women about the true risk of not breastfeeding by setting up inappropriate comparisons. The suggestion that mechanical bull riding while pregnant is comparable to not breastfeeding your child during the first six months is misleading. The idea of a pregnant woman going out on a ladies night and riding a mechanical bull portrays an irresponsible woman who would take risk to harm her child in order to pursue her own pleasure. Comparing the danger of riding a mechanical bull to formula feeding grossly misrepresents non-breastfeeding women as equally negligent and irresponsible.

The ads also portray women’s failure to breastfeed not only as an extremely risky choice, but also as a completely voluntary individual choice, similar to log rolling or mechanical bull riding. The message ignores the fact that there are women who may not have a choice to breastfeed, such as women with HIV infection, women on interacting medication, or women who might risk domestic violence. Telling these women that they are harming their child by not breastfeeding feeding leaves them with feelings of failure, shame, self-blame.

The fear appeal message failed to promote self-efficacy in pregnant women and new mothers
Based on The Social Cognitive Theory, a person’s decision to engage in a particular behavior is highly influenced by his or her self-efficacy; the belief in one's capabilities to organize and execute the courses of action required to produce given attainments, or the extent to which a person believes they can master or be successful in performing a task (17). Generally, people with a high level of self-efficacy are more likely to expend more effort, and persist longer in a task than those with low efficacy (18). Even though the DHHS acknowledges that women already know the benefit of breastfeeding, it fails to acknowledge that most women perceive breastfeeding as a difficult task. Hence, they lack the confidence that they can actually do it successfully. Knowing that breastfeeding a baby reduces the risk for several diseases might motivate one to initiate breastfeeding. However, for women to maintain breastfeeding practices, they need to feel that they can actually be successful in doing it. Studies have shown that lack of confidence is associated with a shortened duration of breastfeeding (8). The campaign could have focused more on how to breastfeed successfully rather than focusing exclusively on the harms of not breastfeeding.

Additionally, focusing on the harms of not breastfeeding could serve as a turn-off to low-income and minority women, who are the very group that the campaign was trying to target. According to the MMWR report, low breastfeeding rates persist among mothers who are low income, black, young or with low education (19). It is important to note that this group has in many cases been labeled for making bad health choices such as smoking while pregnant, use of illicit drugs, and poor diet. Hence, a fear appeal message could actually do more harm than good by decreasing their sense of self-efficacy to breastfeed. The fear appeal theory postulates that utilizing a message that instills a sense of fear and dread in the audience has the exact opposite effect that it intends. That is, it completely turns the recipient off, not only to hearing the message, but also to heading the content or advice contained within that message (20). Targeting this group of women calls for a more positive message, that would improve and not undermine self-efficacy.

Conclusion
The DHHS breastfeeding promotion campaign should start by acknowledging that most women are aware of the benefits of breastfeeding. However, the decision to breastfeed has many intertwined layers of emotional, social, economic factors that need to be addressed. The campaign should adjust the content of the promotional materials to take into consideration social issues such as support from family and friends, the acceptability of breastfeeding in public places and employer support. Additionally, the content, manner, and tone in which the promotional messages are conveyed should be positive and seek to empower pregnant women and new mothers. If these issues are not addressed with a positive tone, the DHHS campaign is unlikely to substantially increase breastfeeding rates. The current approach is more likely to instill fear and guilt other than change behavior.

References

1. US Department of Health and Human Services: HHS blueprint for action on breastfeeding. Office on Women's Health, 2000.
2. US Department of Health and Human Services. Healthy People 2010 midcourse review. Washington, DC: 2005. Available at http://www.healthypeople.gov/data/midcourse
3. World Health Organization. Promoting proper feeding for infants and young children. Geneva. 2004. Available at http://www.who.int/nutrition/topics/infantfeeding/en/
4. Centers for Disease Control and Prevention. Breastfeeding Trends and Updated National Health Objectives for Exclusive Breastfeeding: United States, Birth Years 2000—2004. Atlanta, GA: Mortality and Morbidity Weekly Report, 2007.
5. Ajzen, I. From intentions to actions: A theory of planned behavior (pp. 11-39). In Kuhl, J.& Beckman, J. n ed. Action-control: From cognition to behavior. New York: Springer-Verlag, 1985.
6. Baranowski T, et al: Social support, social influence, ethnicity and the breastfeeding decision. Journal of Human Lactation 1992; 8: 122–124.
7. Bentley et al. Sources of Influence on Intention to Breastfeed Among African-American Women at entry to WIC. Journal of Human Lactation 1999; 15: 27-34.
8. Ertem IO, Votto N, Leventhal JM. The timing and predictors of the early termination of breastfeeding. Pediatrics 2001; 107: 543-548
9. Baronna-Vilar, C., et al. A qualitative Approach to Social Support and Breastfeeding decisions. Journal of Midwifery 2007; 1: 1-8.
10. Forbes, G.B et al. “Perceptions of the woman who breastfeeds: the role of Erotopia, Sexism, and attitudinal variables”. Sex Roles: A Journal of Research 2003; 49: 379-388
11. Dettwyler, K. "Beauty and the Breast: The Cultural Context of Breastfeeding in the United States." Sexuality and Breastfeeding. Journal of Human Lactation 1995; 11: 263
12. Latteir, Carolyn. Breasts: The women’s perspective on an American Obsession. Haworth Press Inc, 1998.
13. Ryan, A. et al. The Effect of Employment Status on Breastfeeding in the United States. Women’s Health Issues 2006. 16: 243-251.
14. Bhatia, J. Breastfeeding Push Turns to Workplace Obstacles. Women’s eNews, New York: 07/13/2006.
15. US Department of Health and Human Services: National Breastfeeding awareness Campaign-Babies were born to be breastfed. Washington, DC: Office on Women's Health, 2000. Available at http://www.4women.gov/breastfeeding/index.cfm?page=Campaign
16. Faden, Ruth R. Ethical issues in government-sponsored public health campaigns. Health Education Quarterly 1987: 14: 27–37.
17. Wikipedia. Self-efficacy. Wikipedia Foundation Inc. http://www.en.wikipedia.org/wiki/Self-efficacy.
18. Schunk, D.H. Goal setting and self-efficacy during self-regulated learning. Educational Psychologist 1990. 25: 71-86
19. Centers for Disease Control and Prevention. Racial and socioeconomic disparities in breastfeeding in the U.S. Atlanta GA: MMWR 2006.
20. Ruiter A.C. The Role of Coping Appraisal in Reactions to Fear Appeals: Do We Need Threat Information? Journal Health Psychology 2003; 8: 465-474

“Fat Chance:” The MetroWest Community Health Care Foundation’s Flawed Childhood Obesity Public Education Initiative – Leslie Judge

The prevalence of overweight and obesity in the United States is rising. In 2005, nearly 21 percent of Massachusetts adults were obese (defined as a body mass index [BMI] >30), while nationally, the rates of obesity are even higher (1). Paralleling the rate of concern over adult weight issues, child and adolescent obesity (defined as >95^th percentile according to CDC weight-for-height charts) has become a pressing public health concern. Since 1980, rates of overweight have doubled for children and tripled for adolescents (2). Nationally, 17.1 percent of children aged 6-19 were overweight in 2006 (approximately 9 million children) (2). The problem of childhood obesity is especially concerning because it threatens the physical health of our nation’s youngest citizens. Being overweight increases a child’s risk of developing Type 2 diabetes and the symptoms of cardiovascular disease at a younger age (2). In addition, the likelihood that other conditions, like asthma, sleep-apnea and depression may develop is increased if a child is overweight (2).

In an effort to combat the rising rates of childhood obesity, many public health initiatives have arisen, employing various methods to address the problem. One such initiative was started by the MetroWest Community Health Care Foundation (MCHCF) of Framingham, Massachusetts, in January of 2007. The campaign consisted primarily of billboards and television advertisements, targeted at parents to address the issue of childhood obesity. One billboard, which featured the image of a child’s chubby legs and feet on a scale stated, “Fat chance: Obese children are a good bet for Type 2 diabetes, heart disease, stroke, cancer, sleep-apnea and depression” (3). Another billboard depicted an overweight child from the back and included text asking, “If that’s your kid, what are you waiting for?”(3) The television commercial featured an overweight child snacking and playing video games, while parents danced around the child, in an effort to symbolize parents, ‘dancing around the issue’(3). The media campaign was designed to catch the eye of parents. As Dr. Jerry Wortzman, chairmen of pediatrics at the MetroWest Medical Center stated, “…the campaign is directed at parents, not children…issues surrounding food are mainly controlled by parents. They buy the groceries” (4).

The MCHCF failed to consider several factors when designing their public health initiative. Although the campaign was directed at parents, the derogatory images displayed in the media campaign were easily visible to children, increasing the likelihood that overweight children would self-identify with the negative images portrayed. In addition, the campaign used fear and blame as methods to motivate parents, and therefore decreased their self-efficacy. Finally, by using deprecating images of children, the initiative to raise awareness of childhood obesity only served to further stigmatize the population it was seemingly designed to help. The childhood obesity public education initiative, launched by the MetroWest Community Health Care Foundation (MCHCF), was flawed because it failed to take into account basic social and behavioral science principles.

Labeling Theory: The obese label decreases self-efficacy

The MCHCF’s public education initiative to raise awareness of childhood obesity was flawed because it supported the Labeling Theory. Although the campaign was directed at parents of overweight children, the billboards were displayed on highways where they were easily viewed by children and potentially missed by driving adults. These billboards labeled overweight children as the object of ridicule and deemed them socially unacceptable. Depicting overweight children in this negative manner only served to increase the likelihood that overweight children would identify with the socially unacceptable label of ‘obese,’ which decreased self-efficacy among this population (5, 6).

The Social Cognitive Theory (SCT) was developed by Albert Bandura in the 1960s and was based on the earlier Social Learning Theory to explain behavior (6). The Social Learning Theory is based on the concept that individuals learn by modeling the behaviors of others. Bandura took this theory one step further and added the concept of self-efficacy to create the Social Cognitive Theory (6). The concept of self-efficacy is defined as a person’s belief that they have the ability to perform a behavior (6). In essence, the SCT presumes that individuals learn by observing and modeling the behavior of others, but ultimately an individual’s behavior is influenced by whether or not they believe they can do that behavior.

An individual’s self-efficacy is challenged by the concepts developed in Labeling Theory. Labeling Theory explains the behavior of an individual as the result of their identification or ‘label’ as a member of a particular group. An individual’s identification as a member of a particular group allows that person to adopt the characteristics as defined by membership in the group, and therefore influences the person’s behavior (5). Labels come with their own connotations; some positive and some negative. Often times, labels are used in society to stereotype people and deem them “socially unacceptable.” Applying negative labels to members of a group decreases their self-efficacy and encourages society to further stigmatize that group (5). As Link and Phelan state in their article entitled Stigma and its Pubic Health Implications, “…when people are labeled, set apart, and linked to undesirable characteristics, a rationale is constructed for devaluing, rejecting, and excluding them” (5). If an individual is identified with a particular label, for instance “obese” or “fat”, and believes the negative characteristics that society uses to define that label like, “lazy”, “ignorant”, “ugly” and “undesirable”, than a person may identify themselves with these characteristics and adopt these shameful attributes (5).

In an article examining the stigma of overweight in U.S. culture, Crocker and colleagues identify stigmatizing conditions as labels that, “…lead to the rejection of individuals because those individuals have an attribute that compromises their humanity in the eyes of others” (7). Crocker et al goes on to talk about the fact that although there are numerous conditions for which a person may be stigmatized in society, including racial or ethnic group membership, religious affiliation, physical handicaps and sexual orientation, the stigma of being overweight may be the most debilitating (7). Unlike some conditions that are deemed socially unacceptable but can be concealed from others, like sexual preference, overweight is immediately visible to society. Further blurring the lines between stigmatized groups is the fact that overweight and obesity is more prevalent in certain ethnic and racial populations, particularly among African Americans and Mexican Americans (7). In addition, unlike other stigmatizing conditions like physical handicaps or being seen as ‘poor’ or ‘disadvantaged’ which might elicit sympathy or understanding, Crocker states that, “people who are overweight elicit almost uniformly negative responses from others”(7). In this way, being overweight in society packs a double punch. Being overweight is viewed as, “…both an abomination of the body that elicits immediate negative responses from others on the basis of aesthetically displeasing qualities, and a character stigma that carries with it shame and guilt of self-blame for a moral failure (8).

Applying labels to groups does not encourage the individuals within that group to change in order to avoid the label. In fact, the result of labeling is quite the opposite. According to Allon, overweight people tend to interpret their social experiences in terms of their weight and are more likely than members of other stigmatized groups to see their weight as the cause of their social outcomes, particularly negative outcomes (8). Overweight individuals are much more likely to blame themselves for the negative reactions their weight provokes from society rather than blaming the prejudice that society condones against the overweight (8). As Allon states, “…consequently, overweight persons may be vulnerable to depressed affect and low self-esteem” (8).

If we apply the label of “obese” to children the effects are just as harmful as in their adult counterparts. In a study that evaluated the contributions of weight, skin tone, peer teasing, and parental appraisals of a child’s size to self-esteem in African American children ages 5-10, Young-Hyman et al found that being overweight was associated with low self-esteem and increased body size dissatisfaction (9). In addition, parental perception of child’s size as “heavier than average”, and the child’s own skin tone dissatisfaction were also associated with low self-esteem in the children studied (9). Young-Hyman found that heavier children were also more apt to act out in school or be reported as having behavioral and psychosocial problems (9). Overweight children in this study also reported that weight-related peer teasing was especially hurtful, and direct correlations were observed between the amount of teasing a child experienced and their decreased self-esteem (9). Several other studies in children from various ethnic and racial groups have reported similar findings in the relationship between obesity and decreased self-efficacy regarding weight in children and adolescents (10-12). The result of declining self-efficacy in children is especially problematic because their experiences in childhood largely shape their perceptions of their abilities as they move towards adulthood (10-12).

Billboards touting the MCHCF’s anti-childhood obesity message were displayed prominently on highways and busy streets in suburban Massachusetts. Although the MCHCF’s campaign was directed at parents of overweight children, the billboards were displayed in locations where they were easily viewed by children and potentially missed by driving adults. As one resident of Natick, Ma noted, “I don’t know where they got the idea that kids can’t see these billboards…fat kids are already teased mercilessly” (3). In addition, television commercials were shown during regular nightly programming and on weekend afternoons, which are both times that children are likely viewers. These billboards and TV ads contributed to the social labels of overweight children by portraying them as socially unacceptable and undesirable. Depicting overweight children in this negative manner, and in locations clearly viewed by the children themselves only served to increase the likelihood that overweight children would identify with the socially unacceptable label of “obese,” which decreased self-efficacy among this population.

The Blame Game: Decreased self-efficacy in parents of overweight children

As previously discussed, the concept of self-efficacy states that a person’s ability to perform a behavior is directly impacted by their belief that they can do the behavior (5). The MCHCF’s public education initiative was flawed because it did not take into account the concept of self-efficacy as defined by the Social Cognitive Theory. Placing blame for the rising childhood obesity epidemic on the shoulders of parents only served to decrease self-efficacy among parents of obese children. Billboards that asked, “If that’s your kid, what are you waiting for?” and a television commercial that featured an overweight child snacking and playing video games, while parents danced around the child, in an effort to symbolize parents, ‘dancing around the issue’ unfairly targeted parents. Parents were ridiculed as the cause of the problem, making parents feel shunned and outcast by a society that favors thinness.

Blaming parents for their child’s overweight decreases the self-efficacy of the parents in addressing the problem. Attributing blame, in an effort to inspire feelings of shame, fear and guilt to motivate parents was the strategy that the MCHCF hoped to employ. However, utilizing fear of their child’s overweight and its potential health implications to motivate parents was not an effective strategy. As noted by Vedantum in a Washington Post review of current research on effective motivation strategies to influence health behaviors, “scaring people about the health risks of smoking and obesity…is an ineffective way to change their behavior…giving people the confidence that they can make such changes is far more effective, according to an analysis of hundreds of research studies involving 47 different kinds of behaviors” (13). The article noted that in contrast to motivational strategies that used positive messages to increase self-efficacy, “…public interest methods that seek to induce fear, guilt, or regret were ineffective” (13).

In addition to being a poor strategy for motivation, creating feelings of fear, guilt and shame in the minds of parents of overweight children might actually contribute to the decreased health of the children. The vilification of parents potentially decreases the likelihood that overweight children will receive appropriate medical care. Research supporting this concept has not been documented in parents of overweight children to date but the phenomenon has been considered in parents who smoke around their children and it can be argued that the situations have many similarities. As parents of overweight children are often deemed “abusive” or “neglectful” for allowing their children to eat too much or remain sedentary, parents who smoke around their children are also considered to be “bad parents” for exposing their children to potentially harmful cigarette smoke (14-15).

With the recent attention on the effects of secondhand smoke on children, parents who smoke around their kids have been blamed for increased rates of childhood asthma and ear infections and threatened with policies that would make their conduct unlawful (14). Similarly, the mother of an eight year-old British boy was recently threatened with removal of the child from her care because his obesity was deemed to be her fault for “allowing” him to gain so much weight (16). Laws and policies put in place to seemingly “protect” children might not achieve their desired outcomes. As Siegel argues in his blog from 2006, “…imposing criminal or even civil penalties, referring parents who smoke around their children to authorities, or treating smoking around children as a form of child abuse, we would actually be imposing a huge barrier to children’s access to appropriate medical treatment for conditions that are associated with secondhand smoke exposure” (14). Siegel goes on to compare this problem to that of the children of illegal immigrants. It is well-documented that many immigrant families are reluctant to seek proper medical care because they fear the discovery of their “illegal” status and the potential for deportation (14, 17). In the same way, it can be argued that blaming parents for their child’s overweight might decrease the likelihood that parents would take their overweight child to the physician. In this way, overweight children are placed at greater medical risk if parents believe that they will be judged or criticized at the pediatrician’s office if their child presents with a weight-related problem like Type 2 diabetes or high blood pressure.

Flawed Purpose: Perpetuating prejudice against overweight individuals

In addition to being an ineffective motivational strategy to parents and a method of decreasing self-efficacy in both parents and their overweight children, the MCHCF’s public education initiative was flawed because it contributed directly to the ongoing prejudice against overweight individuals. The use of negative images to portray overweight children on billboards and on television only contributed to the idea that it is acceptable in present culture to ridicule people based on their weight. In this way the public education initiative to raise awareness of childhood obesity only served to further stigmatize the population it was seemingly designed to help.

In an article examining childhood obesity in a societal context, Schwartz and Puhl state, “the societal message about being fat in the 21^st Century is clear: it is bad to be fat. But why is it bad? Clearly, there are serious medical consequences of obesity…However, obese people are not discriminated against because they are medically compromised. They are stigmatized because their obesity is viewed as a reflection of poor character” (18). Schwartz and Puhl go on to discuss the manner in which overweight children are increasingly becoming the objects of ridicule. They cite prejudiced attitudes from other children that lead to bullying and on a daily basis, in addition to the more covert stigmatization that overweight children face from teachers, doctors and parents (18).

The stigmatization that overweight people face from parents, health professionals, and in the academic setting is particularly astounding. A study of obese college-aged females reported that once in college, female obese students receive less financial support from their parents than their non-obese peers receive, even when parents have similar income, family size, and number of children (19). Negative attitudes about obese patients have been documented among physicians, nurses, and medical students (20). Common perceptions among health professionals include beliefs that obese patients are, “unintelligent,” “unsuccessful,” “weak-willed,” and “lazy” (20). This prejudice may lead to poor medical care for obese patients as physicians admit not intervening as much as they should with obese patients simply because weight loss counseling is “inconvenient” (20). The same study found that nurses were hesitant to “touch” obese patients and 24% of nurses described obese patients as “repulsive” (20). At the college level, educational discrimination based on weight has also been documented (20). Obese students are less likely to be accepted to college than average-weight students, despite having equivalent application rates and academic performance (20).

What is perhaps more concerning is the fact that negative attitudes towards overweight children are learned at a young age. One study found that pre-school children aged 3-5 years old judged an overweight child to be a “mean” and a “less desirable playmate” than another child of average weight (21). The study found that 3 year-olds associate overweight children with the traits of being “mean”, “stupid”, “ugly”, “selfish”, “lazy”, “stupid”, “dishonest”, and “subject to teasing”, while average weight children were considered, “clever”, “healthy”, “attractive”, “kind”, “happy”, “popular” and “desirable playmates” (21). Another study looked at the negative stereotyping associated with overweight among fourth– and sixth-grade students (21). The study found that these children endorsed negative stereotypes of both children and adults who were overweight (22). The beliefs of the fourth- and sixth-graders were also assessed about the controllability of obesity and overweight. The study found that most fourth- and sixth-graders believed that obesity was under personal control and that this belief was positively associated with negative stereotyping (22).

The attitudes expressed by the preschool and middle-school children in these studies are a product of social norms that are widespread in current culture. The early stigmatization of overweight children may explain their lower self-esteem and greater shame, humiliation compared with normal-weight children (23). To make matters worse, the level of negativity in the way overweight children are viewed by their peers, increases as children get older, suggesting a steady rise in the ridicule and prejudice experienced by overweight children throughout their development (23). One study conducted by Adams and colleagues observed the way that parents may subtly convey their stereotypic beliefs about obese children at home (24). In the study parents were given three pictures of children (an average-weight child, a handicapped child, and an obese child) and asked to tell a story about each picture to their own child. In the stories, the parents portrayed the obese child as having the most negative attributes and lowest self-esteem of all three children (24). In addition, there were striking differences in the rate of successful outcomes at the end of the stories. The obese child had 0% successful story outcomes while the handicapped child had 85% successful story outcomes and the average-weight child had 45% successful story outcomes (24). This study supports the idea that parents communicate with their children in ways that endorse stereotypes about obese children. It also shows that parents themselves house the stereotypes that may potentially influence their own treatment of obese children in addition to their children’s treatment of obese children in society.

It is clear from current research that there is a connection between depression and childhood obesity (10-12), but researchers have not clearly determined a path of causality between the two factors. Are overweight children more prone to depression considering the social stigmatization that confronts them on a daily basis, or are depressed children more prone to obesity due to their poor self-esteem and lack of self-efficacy? This is a question that continues to be hotly debated. What can be unequivocally determined is that overweight children are the objects of ridicule, and these children do have higher rates of depression and poor self-esteem than normal-weight children (10). The MCHCF’s public education initiative was flawed because it contributed directly to the ongoing prejudice against overweight children. The use of derogatory pictures to portray overweight children on billboards and on television only added to the negative and prejudicial images present in current society that condone discrimination based on weight. In this way the public education initiative to raise awareness of childhood obesity only served to further stigmatize the population it was seemingly designed to help.

Conclusions

The MCHCF failed to consider several factors when designing their public health initiative. Although the campaign was directed at parents, the derogatory images displayed in the media campaign were easily visible to children, increasing the likelihood that overweight children would identify themselves with the negative images portrayed. In addition, the campaign used fear and blame as methods to motivate parents, and therefore decreased their self-efficacy. Finally, by using deprecating images of children, the initiative to raise awareness of childhood obesity only served to further stigmatize the population it was seemingly designed to help. The childhood obesity public education initiative, launched by the MetroWest Community Health Care Foundation (MCHCF), was flawed because it failed to take into account basic social and behavioral science principles.

References

1. The Massachusetts Health Policy Forum. Overweight and Obesity in Massachusetts: Epidemic, Hype or Policy Opportunity? Boston, MA: The Massachusetts Health Policy Forum, 2007.
2. National Conference on State Legislatures. Childhood Obesity – 2006 Update and Overview of Policy Options. Washington, DC: National Conference on State Legislatures. http://www.ncsl.org
3. Haneisen R. The politics of fat. The Framingham Tab. February 16, 2007
4. Drake J. Obesity ads aim to jolt parents. The Boston Globe. January 28, 2007.
5. Link BG, Phelan JC. Stigma and its public health implications. Lancet 2006; 367:528-529.
6. Edberg M. Social cognitive theory (pp. 51-61). In Edberg M: Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
7. Crocker J, Cornwell B, Major B. The stigma of overweight: Affective consequences of attributional ambiguity. Journal of Personality and Social Psychology 1993; 64:60-70.
8. Allon N. The stigma of overweight in everyday life (pp.130-174). In: Woldman B.B., ed. Psychological aspects of obesity. New York, NY: Van Nostrand Reinhold, 1982.
9. Young-Hyman D, Herman-Wenderoth L, Bozylinski K. Obesity, Appearance, and Psychosocial Adaptations in Young African American Children. Journal of Pediatric Psychology 2003; 28: 463-472.
10. Mustillo S, Worthman C, Erkanli A, et al. Obesity and psychiatric disorder: developmental trajectories. Pediatrics 2003;111: 851-859.
11. Sheslow D, Haasink S, Wallace W, DeLancey E. The relationship between self-esteem and depression in obese children. Ann NY Acad Sci. 1993;699:289-291.
12. Csabi G, Tenyi T, Molnar D. Depressive symptoms among obese children. Eat Weight Disord. 2005;5:43-45.
13. Vedantam S. Fear is a weak motivator. The Washington Post; A02:September 29, 2006.
14. Siegel M. Making it unlawful to smoke around children could have detrimental effect on childrens’ health, especially among disadvantaged populations. The Rest of the Story: Tobacco New Analysis and Commentary (blog). May 22, 2006. Available at: http://tobaccoanalysis.blogspot.com/2006/05/in-my-view-making-it-unlawful-to-smoke.html.
15. Davison K.J,Birch L.L. Weight status, parent reaction, and self-concept in five-year-old girls. Pediatrics 2001;107: 46-53.
16. Bannerman L. Go on a diet or be taken into care, 14-stone boy is told. The Times: February 26, 2007.
17. The Access Project and the National Health Law Program. Immigrant access to health benefits: a resource manual. Washington, DC: National Health Law Program, 1999-2000.
18. Schwartz MB, Puhl R. Childhood obesity: a societal problem to solve. International Association for the Study of Obesity 2003; 4: 57-71.
19. Crandall CS. Do parents discriminate against their heavy-weight daughters? Pers Soc Psychol Bull. 1991;21:724-735.
20. Puhl R, Brownell KD. Stigma, discrimination, and obesity (pp 109-110). In: Fairburn CG, Brownell KD, eds. Eating disorders and obesity: A comprehensive handbook. New York, NY: Guilford Press, 2002.
21. Cramer P, Steinwart T. Thin is good, fat is bad: How early does it begin? J Appl Dev Psych 1998;19:429-451.
22. Tiggermann M, Anesbury T. Negative stereotyping of obesity in children: The role of controllability beliefs. J Appl Soc Psych 2000; 30:1977-1993.
23. Latner JD, Stunkard AJ. Getting worse: The stigmatization of obese children. Obes Res 2003; 11(3): 452-456.
24. Adams GR, Hicken M, Salehi M. Socialization of the physical attractiveness stereotype: Parental expectations and verbal behaviors. Int J Psychol 1988;23:137-149.