Challenging Dogma

Sunday, May 6, 2012

Shocking Parents into Compliance: A Critique of the City of Milwaukee’s Safe Sleep Advertising Campaign – Emily Jansen

Introduction: Infant mortality and unsafe sleep deaths in Milwaukee

The City of Milwaukee Health Department (MHD) has dedicated substantial effort toward reducing the city’s high infant mortality rate, a complex public health issue marked by stark racial and socioeconomic disparities. The infant mortality rate is a ratio of the number of infant deaths within the first year of life per 1000 live births. In 2009, the infant mortality rate in Milwaukee was 11.1 infant deaths per 1000 live births (1). Among black infants, the rate was 14.7 per 1000, while Non-Hispanic white infants fare much better with a rate of 5.9 per 1000 (1).
A growing body of research explores the distal risk factors contributing to the racial disparities in the infant mortality rate nationwide. Lu et al. posit that differential exposure to stressors such as racism among African-American mothers, and the cumulative impact of those stressors over time, may help explain the disparity (2). More proximate risk factors contributing to infant mortality include prematurity and low birth weight, birth defects, and SIDS/unsafe sleep.
Analyzing data from Milwaukee’s Fetal Infant Mortality Review, the MHD found that of the 51 infant sleeping deaths that occurred during the 2008 and 2010 period, 35% were attributed to “positional or mechanical suffocation, overlay or as undetermined,” and 63% “were classified as SIDS or SUDI (Sudden Unexpected Death in Infancy)” (3). Importantly, many of the infant sleeping deaths shared one or more unsafe sleep risk factors. Unsafe sleep risk factors included bed sharing, items in the baby’s sleeping area such as bumpers or pillows, prenatal smoking, postnatal exposure to second-hand smoke, as well as caregiver use of alcohol or drugs (3). The racial disparities persist in unsafe sleep deaths: according to the MHD, “46% of Milwaukee births were to Black mothers, yet Black infants represent 60.8% of all sleep-related deaths” (3). Armed with data, the MHD launched an awareness-building campaign to reduce preventable unsafe sleep deaths.
The entire campaign consisted of public installations, facilitated discussions, commercials and radio spots. It also included a shocking advertising campaign designed by Serve Marketing and launched in early November of 2011. The ad depicts a sleeping infant beside a large knife with the headline, “Your baby sleeping with you can be just as dangerous,” followed with the message, “Babies can die when sleeping in adult beds. Always put your baby to sleep on his back, in a crib. If you can’t afford a crib, call (414) 286-8620” (4). (A large image of the ad can be viewed here) (5). Mayor Tom Barrett and Commissioner of Public Health Bevan K. Baker unveiled the campaign in tandem with an announcement of the city’s goals to reduce the racial disparity in infant mortality by 2020 (5). The campaign soon caught national attention and provoked a lot of criticism from a diverse array of organizations and individuals.
The ad campaign is flawed in three important respects. First, it relies on the notion that emphasizing the perceived threat of unsafe sleep will compel behavior change. Second, the campaign creates psychological reactance among co-sleeping advocates by threatening their freedom to co-sleep. Third and finally, the designers fail to apply basic advertising and marketing theory in the design and delivery of the advertising campaign. This paper will discuss each critique in turn, and will provide a counterproposal for an improved public health intervention addressing unsafe sleep deaths in Milwaukee.
Critique 1: The advertising campaign relies on the notion that emphasizing the perceived threat of unsafe sleep will compel behavior change.

The belief that alerting people to the gravity of a public health problem will persuade them to change their behavior is based in part on a theory called the Health Belief Model (HBM). Originally, the model emerged as an explanatory framework to describe what influenced an individual’s use of health screening and treatment services (6). The HBM proposes that individuals make decisions to change health behavior by weighing the perceived benefits against the perceived costs or barriers to taking action (7). The model suggests that an individual’s perception of the severity of and susceptibility to poor health influence the perceived benefits of taking a course of action to protect health (8). If the benefits outweigh the costs, an individual must then be moved by a cue to action (e.g. media information) to change behavior (8). The most current iteration of the model adds self-efficacy as a predictor of behavior. Self-efficacy is the belief in one’s own capability to take action or influence their circumstances (8).
            The safe sleep ad campaign attempts to influence behavior by emphasizing the perceived severity of unsafe sleep, and the likelihood of infant death. The imagery of the ad also attempts to increase the perception of susceptibility by highlighting the dangerousness of the seemingly innocuous adult bed. It also offers parents a beneficial alternative by providing parents a phone number to call to get a free crib, potentially eliminating one of the perceived barriers to safe sleep practices. The ad as a whole may be though of as a cue to action to create behavior change.
The Health Belief Model has clear theoretical limitations that in turn limit the utility of this campaign. First, it assumes that knowledge influences behavior and that individuals make decisions rationally, based on evidence (7). In doing so, it fails to acknowledge the social aspects of behavior, or the ways individuals perform behaviors without any intentionality or cues to action. Second, it fails to acknowledge the social-ecological factors and various destabilizing forces that may contribute to unsafe sleep and subsequent death. In other words, the HBM does not allow for an integrative understanding of the “risk factors of the risk factors,” including systemic barriers, lack of social support, and poverty. This is evident in the way the campaign reduces the public health problem to the assumed irresponsibility of a parent. Finally, the ad campaign proscribes co-sleeping, and urges parents to follow the guidance of the experts. As articulated by Linda Thomas in her critical feminist critique of the HBM, “The HBM and other theories using the traditional research process do not allow for reciprocal or equal participation” (9). As a result, the ad campaign does not provide any substantive pathway for self-efficacy or self-esteem.
Critique 2: The ad campaign creates psychological reactance among co-sleeping advocates

Developed by Dr. Jack W. Brehm, the theory of psychological reactance involves an individual’s perceived behavioral freedom, or “the freedom to choose when and how to behave”(10). According to the theory, when a message or a person threatens an individual’s behavioral freedom, an individual will react by trying to restore their freedom (10). Dillard et al. suggest that messages that authoritatively proscribe behaviors without any support instill a great degree of reactance, which may take the form of an individual intentionally performing the forbidden behavior (11).
In the case of Milwaukee, the current advertising campaign and previous challenges to co-sleeping created substantial psychological reactance among co-sleeping advocates. Advocates contend that conflating co-sleeping with unsafe sleep is inaccurate, and argue that co-sleeping can be done safely when parents take the proper precautions (12). They also argue that the campaign glosses over the range of co-sleeping arrangements, including bed-sharing, bedside bassinets, and room sharing. Most importantly, advocates felt their freedom to perform a behavior they held to be beneficial and healthful to their child was threatened, and acted out accordingly.
            Advocates and community members created a Facebook page protesting the advertising campaign, which peaked at a modest membership of about 700 people. (The page can be viewed here: Campaign Against Milwaukee's Co-sleeping Campaign) (13). Members encouraged one another to post their own co-sleeping pictures, a fascinating product of the psychological reactance created by the campaign. Two members even rewrote the advertisement. One member offered a critical commentary of the implication of the campaign: "Is this what you meant..." (13). Another took a more humorous approach, cropping out the knife and writing from the perspective of the baby: "I swear..." (13).
            From the Milwaukee Health Department to Serve Marketing, all parties involved in the design and dissemination of an awareness campaign must anticipate and minimize the opportunity for psychological reactance. The failure to minimize reactance to the safe sleep campaign undermined the persuasiveness of the message, and produced a vocal opposition movement that extended beyond the target audience.  Formative research and message testing help to reduce psychological reactance, and generally yield a more durable and effective campaign.
Critique 3: The advertising campaign assigns blame and violates the basic tenets of marketing and advertising theory  

The complementary disciplines of advertising and marketing have demonstrated strength in influencing consumer behavior and selling commercial products. Within the past 40 years, champions of social causes and public health issues have used the techniques of these two disciplines to influence health behavior. However, many public health advertising campaigns, including the Milwaukee safe sleep campaign, betray the basic principles informing advertising and marketing theory.
David Ogilvy, one of the most prominent advertising executives in the history of the field, described the core components of advertising as consisting of research and the positioning or framing the product. On consumer research, he writes:
Find out how they think about your kind of product, what language they use when they discuss the subject, what attributes are most important to them, and what promise would be most likely to make them buy your brand. (14)

Similarly, Phillip Kolter and Gerald Zaltman began articulating the application of marketing concepts to social causes in the early 1970s, pioneering what is now commonly referred to as social marketing. In their landmark article, “Social Marketing, An Approached to Planned Social Change,” Kolter and Zaltman contextualized marketing as fundamentally about exchange and understanding the target audience (15). Kolter and Zaltman suggested that applying the principles of formative research and designing campaigns around the target audience’s “wants, attitudes, and behaviors” would yield more effective results in creating social change (15).
While the campaign may elicit initial shock, it is not clear that it will change behavior. On a superficial level, the promise of the ad is an accusation of child abuse, and the core value is fear. The foremost message is that co-sleeping with a child is no different than intentional endangerment of a child with a knife. The sub-headline that provides a resource for free cribs is almost imperceptible next to the provocative image and the headline.
Community leaders and Serve Marketing cited the need for a shocking advertising campaign to wake parents up and educate them about the risks. JS Online reporter Crocker Stephenson quoted the director of Serve Marketing as saying, "You've got to make people uncomfortable," and "If it reduces infant death, it's worth it" (4).
One of the best measures of a campaign’s reach may be the insight provided by formative research, and after the campaign’s release, the response of community members.  While some individuals thought its shock would be effective, many did not understand the campaign’s intent and felt offended by the content. Dr. Patricia McManus, Executive Director of the Black Health Coalition, captured some of the public sentiment in her editorial in the Milwaukee Courier. She describes how many people did not understand the campaign and asked her for comment. She writes:
People are confused, they are offended, but, more importantly, they are not clear on the intent of the message, because unlike the view of those responsible for the ads, they do not see themselves as uncaring monsters that do not care about their children. (16)

Based on feedback from community members, Dr. McManus adds that like the broader community, African American mothers and grandmothers who participated in the focus groups convened by Serve Marketing also did not understand the intent until Serve Marketing “explained it to them” (16). Clearly, the target audience does not identify with the message. Likewise, instead of designing a campaign around the target audience’s needs and beliefs, Serve Marketing and the Milwaukee Health Department are “marketing in reverse” by relying on the shock value of the campaign.
Just as advertising and marketing may persuade a large segment of the population to change their behavior and attitudes, it may also have the opposite effect. As succinctly summarized by David Ogilvy, “The wrong advertising can actually reduce the sales of a product” (14). This campaign reflects poor framing of the issue, which many community members interpret as a critical indictment of the target audience. Moreover, the campaign does not provide other substantive strategies for minimizing risk, and labels parents as child abusers instead of partners with a vested interest in keeping their child healthy.
Counterproposal for a more effective intervention

It is understandable why the City of Milwaukee Health Department chose to target unsafe sleep deaths: in a field where complexity and co-morbidity create tremendous challenges in reducing health disparities, targeting an issue which on the surface appears to be completely controlled by behavior was arguably the easiest target. However, isolating unsafe sleep as the most preventable form of infant mortality is illusory: unsafe sleep and infant mortality share common complexity when one examines the more distal risk factors contributing to unsafe sleep environments. Poverty, lack of social support, systemic barriers, and racism all influence the more proximate risk factors that create an unsafe sleep environment. Furthermore, an overemphasis on unsafe sleep death overlooks the fact that ultimately, all infant mortality is preventable.
To improve the existing advertising campaign, this paper offers a three-tiered counterproposal with a broader focus on racial disparities in infant mortality. This paper proposes an awareness campaign that promotes existing home visiting programs and material resources such as free cribs. Rather than focusing exclusively on modifying parent behavior, an improved campaign must address the more distal contributors to infant mortality in a way that affirms and includes parents. First, the campaign must be built around programs that promote self-efficacy and draw upon the wisdom of African American community leaders.  Second, promotional materials associated with the campaign must apply insight from Framing and Labeling Theory to generate persuasive messages that respect families. Finally, the awareness campaign must apply marketing and advertising theory to create a campaign that provides a framework for long-term disparity reduction.
Proposal 1: Move beyond the prescriptive Health Belief Model and build the awareness campaign around programs that already promote self-efficacy

Nationally, home visitation has emerged as an important strategy to help reduce infant mortality and improve the economic self-sufficiency of families. Evidence suggests that home visiting programs also increase social support, hypothesized to be a protective factor for a range of adverse health outcomes (17, 18). The home visiting programs Milwaukee currently offers include: Empowering Families in Milwaukee, Nurse-Family Partnership, and Parents Nurturing and Caring for their Family (18). Empowering Families and Nurse-Family Partnership provide longer-term services than the latter program. The programs have different eligibility requirements, and a targeted advertising campaign could help support women and their families in getting in touch with the resources they need.
Home visitation has the benefit of incorporating the social aspects of behavior change in its very design. Public health nurses, social workers, and paraprofessionals develop a relationship with families, and act as liaison to other social services (19). They also provide valuable guidance on parenting, accessing childcare, and facilitate goal setting with regard to education and employment (19). In this way they have the capability to look at the social-ecological forces shaping maternal and child health, and provide a framework to enhance maternal self-efficacy.
Working in partnerships organizations like the Black Health Coalition, the Milwaukee Health Department could identify community leaders to promote the programs, and educate the community informally about the range of services available to them. The use of community health workers has an empirical basis in Natural Helper Models of health communication. As defined by Eng et al., “Natural helpers are particular individuals to whom others naturally turn to for advice, emotional support, and tangible aid”(20). Partnerships with natural helpers provide important insight into the risk and protective factors that inform infant mortality as well as the day-to-day realities of community members. It also encourages dialogue, rather than a top-down approach to addressing health disparities.
Proposal 2: Use Framing Theory and Labeling Theory to reduce psychological reactance

Framing emerged as a theoretical concept rooted in cognitive science with extensive application in political science and mass communications (21). Political scientists Dennis Chong and James N. Druckman define framing as “the process by which people develop a particular conceptualization of an issue or reorient their thinking about an issue” (22). Framing also refers to the strategic presentation of an idea in a way that draws upon existing cognitive associations and biases in the target audience (21). By evoking a particular “frame” or way of thinking, a message provides the contextual basis for interpretation.
As an issue is framed, it may generate or reinforce labels ascribed to individuals. Labeling Theory explores stigmatization and tendency of individuals to categorize others as “deviant” (23). More specifically, Labeling Theory explores the ways in which labeling constructs the subjective identity of the labeled person as they internalize or reject their negative label (23). Poor framing and negative labels may result in a great degree of psychological reactance, as evidenced by the response of co-sleeping advocates. By moving the conversation from safe sleep to home visiting utilization, the health department can avoid clashes with co-sleeping advocates who feel threatened by the message.
This framing of the Milwaukee safe sleep campaign also contributes to the labeling of the target audience as indifferent and ignorant (a label too often associated with minority and low-income communities). In order to build a more effective advertising campaign, the Milwaukee Health Department should concentrate on framing the utilization of home visiting services in a way that empowers, strengthens and supports families.  Core values emphasizing the freedom and autonomy provided by home visiting services may prove beneficial.
Most importantly, families must be recognized as allies rather than adversaries by the health department, and equal participation must be encouraged. The Black-White disparity needs to be understood holistically, not reduced to an issue of unsafe sleep in the Black community. As articulated by Dr. McManus:
There is no doubt that the impacted community must also be engaged; the black-white infant death gap is too great for the disparity to be lost in the politics of things. But let the engagement be respectful with the belief that the African American community has a problem, but is not the problem” (16).

The Milwaukee Health Department (MHD) should anticipate that some community members might find home visiting to be stigmatizing. By using Labeling Theory to their advantage, the images of home visiting could convey community resilience and capabilities. Recruiting community members who can provide testimonials about their experiences with home visiting may help normalize and reduce any stigma associated with the programs. In order to refine their message, the Milwaukee Health Department should test the frames they generate in consultation with focus groups from the community.
Proposal 3: Apply insight from advertising and marketing theory in the design of all advertisements and promotional materials associated with home visiting

The original safe sleep campaign had two core assumptions that guided its execution: First, it assumed that parents did not understand the risks of safe sleep and needed information to change their behavior. Second, it assumed that parents needed to be made uncomfortable for them to understand the risks of unsafe sleep. Notably, this is not the first “shock campaign” on infant mortality that the city commissioned. Released in 2009, the previous campaign shows an image of a bed with a headboard that looks like a tombstone. The tombstone reads, “For too many babies last year, this was their final resting place” (24). (The image can be viewed: here) (24). The Milwaukee Health Department keeps returning to the same well of ideas for information, and will inevitably keep coming up short if it fails to apply the guiding principles of advertising and marketing theory.
In order to maximize the advertisement’s effectiveness and reach, the Milwaukee Health Department and the agency designing the ad must engage with the community and design the campaign around the community’s wants and needs. Using qualitative and formative research, the Milwaukee Health Department will discover what is important to the community, how the community contextualizes the problem of infant mortality, how they feel about home visiting, and what images and ideas resonate with them most.
The best advertisement promoting home visiting will follow directly from the insight provided by community members during formative research and message testing. Any messages that offend the audience or proscribe behavior should be avoided and discarded. The target audience should be able to identify with the message, and the message should affirm the audience, not criticize them. By focusing the campaign around home visiting access, the campaign will indirectly address the risk factors that contribute to unsafe sleep deaths, without explicitly mentioning them.
The shock advertisement approach used in Milwaukee’s safe sleep campaign is not a viable long-term solution to reducing infant mortality in Milwaukee. Intentionally or not, the advertisement blames parents for unsafe sleep deaths and fails to highlight the supports and strategies available to families to eliminate these tragedies. By developing an advertising campaign around the promotion of home visiting and other material resources, the Milwaukee Health Department can affirm parents and learn from them. Emphasizing models like the Natural Helper Model to encourage self-efficacy, applying framing and labeling theory, and constructing a campaign using advertising and marketing theory all promise to produce a message that captures community attitudes and responds to their wants and needs. The only way strategies to reduce unsafe sleep death will prevail is if families are truly understood as partners and experts in their own lives. Supporting community-driven programs and utilizing community-based participatory research provide a meaningful pathway to reducing infant mortality.
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