Why Learn More? The Critique of National Heart Lung and Blood Institute’s Campaign to Improve the Lives of Individuals with COPD – Stanislav Henkin

            Chronic obstructive pulmonary disease (COPD), a disease characterized by airflow limitation that is not completely reversible, is the third leading cause of death and one of the top three causes of disability in the United States (1). While the rate for the other top causes of mortality (cardiovascular disease, stroke, and cancer) has been declining in the past 5 years, the mortality rate for COPD has been fairly stable (2). Well-identified risk factors for COPD include cigarette smoking, environmental and occupational exposure to toxic chemicals or gases, recurrent infection, and genetic factors; the most common symptoms consist of cough, wheezing, chronic mucus production, and breathlessness (2). The prevalence of COPD (11.8 million) has been stable for the past 10 years (3). Even though COPD has been previously viewed as a disease of men who smoke (4), women have had a significantly higher prevalence of COPD than men in the past 10 years – 6.1% of women compared to 4.1% of men, with women aged 65-84 having the highest COPD prevalence. Importantly, while the mortality rate due to COPD has slightly decreased for men in the past 9 years, the rate has not significantly changed for women, with 60,000 men and 65,000 women dying from COPD in 2007 (3). Racial and economic factors also play a role in the disease occurrence, as Puerto Rican and non-Hispanic white individuals have a higher prevalence of COPD than other individuals of other races; similarly, persons whose income is less than 100% of the poverty levels report higher COPD prevalence than individuals with higher income levels (3).    

            Sadly, the majority of individuals who are at risk for developing COPD have not heard of this debilitating disease and often overlook its symptoms, resulting in delayed diagnosis (4). To promote early diagnosis and aid in prevention of disability and mortality, the National Heart Lung and Blood Institute (NHLBI) launched a campaign in 2007: “COPD Learn More Breathe Better.” The campaign has three main goals: 1. “Increase awareness of COPD as a serious lung disease,” 2. “Increase understanding that COPD is treatable,” and 3. “Encourage people at risk to get a simple breathing test and talk to their doctor” (5). The campaign targets men and women over 45 years old who have risk factors for developing COPD – i.e. current or former smokers, individuals with a history of environmental exposure to harmful chemicals or second-hand smoke, and those with a genetic mutation that predisposes them to early development of COPD (4, 5).

            In its campaign materials, NHLBI reports that 12 million Americans are currently diagnosed with COPD while 12 million more may be undiagnosed (5). Through radio and print public service announcements, fact sheets, and educational videos, NHLBI encourages individuals with COPD symptoms to speak to their doctors and to ask about spirometry testing. Additionally, more than 20 partners, including American Academy of Family Physicians and Kaiser Permanente, have joined NHLBI in promoting the campaign to its members and staff.  One of the partners, the COPD Foundation tours health fairs, senior expos, community venues, and country music festivals, offering information provided by NHLBI in conjunction with free spirometry testing  (4). The spokeswoman for the campaign, Grace Koppel, has appeared on numerous TV and radio shows, including The View, Good Morning America, and The Diane Rehm Show, to promote the campaign and to encourage individuals at risk for COPD to talk to their physician (5). While the campaign has been running for the past five years and the awareness of the disease has increased, many individuals at risk never talk to their physician about their symptoms and thus remain undiagnosed (6). These facts are suggested by the stable prevalence of COPD over the last 10 years (3). This critique will examine the underlying issues that may be holding back the success of the campaign, including focus on individual behavior change, lack of promoting self-efficacy, and not understanding its target population. Ultimately, this paper will suggest methods to improve these limitations and to increase the success of the campaign.

Critique 1 – Focus on Health Belief Model

            The “Learn More Breathe Better” campaign is geared towards individuals at risk for COPD by trying to increase awareness and understanding of COPD and encourage individuals to talk to their primary care physician and get tested.  The campaign is modeled on the Health Belief Model, the oldest and most widely used model in public health, which focuses on the individual. The proponents of this model theorized that health behavior is motivated by six factors: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cue to action, and self-efficacy (7). The campaign describes to each individual the risk factors for COPD (smoking, environmental exposure, genetic factors) as well as the benefits of COPD diagnosis (breathing better). The perceived barrier is assumed to be absence of awareness about COPD, and the cue to action includes public radio announcements, advertisements in magazines and newspapers, and other outreach materials as previously described. The campaign assumes that by increasing awareness and understanding of the disease, people will have self-efficacy to talk to their physician and receive testing. Essentially, the success of the campaign is based on the rational thought process of individuals: “Since I am now aware of COPD and understand the disease, I will speak to my doctor.” Even though the Health Belief Model is a reasonable model for simple individual decisions, it has not shown to be as successful with complex decision making where conclusions may not be rationally made by weighing the risks against the benefits (8).

            The Health Belief Model focuses on individual rational choices, and therefore it does not take into account social and environmental factors (7). These factors are especially important in this campaign since significantly more individuals of lower socioeconomic status are at risk for COPD than others (3). Low socioeconomic status, both at individual and neighborhood-level, is generally associated with increased smoking prevalence (9) and individuals in this group may not be willing to quit smoking because of the neighborhood cultural standards (10). Additionally, individuals who may be exposed to harmful chemicals at work may not be able to avoid these chemicals because they need to stay at the job financially support their families. Unfortunately, previous use of newspaper advertisements encouraging COPD testing in a low socioeconomic status population has shown to be severely ineffective, with low recall of advertisements and extremely limited reach to the targeted high-risk individuals (11). 

Critique 2 – Low Self-Efficacy of High Risk Individuals       

            If a person decides to act after going through the individual components of the Health Belief Model, self-efficacy is necessary to complete the desired action. Even though self-efficacy is a component of the Health Belief Model, it is better described as part of the Social Cognitive Theory, which explores interactions between people, their environments, and behavioral factors. The theory postulates that health behavior is affected by three factors: self-efficacy, goals, and outcome expectations (12). The concept of self efficacy is especially important in this model as well as decision making. Bandura describes the importance of this concept: “Efficacy beliefs are the foundation of human agency. Unless people believe they can produce desired results and forestall detrimental ones by their actions, they have little incentive to act or to persevere in the face of difficulties…Such beliefs influence whether people think pessimistically or optimistically and in ways that are self-enhancing or self-hindering” (13). Self-efficacy (perceived control over COPD diagnosis and management) has been previously associated with positive behavior change, such as improved self-management of COPD (14-15). Creating sufficient self-efficacy may be done through remembering past personal accomplishments, verbal persuasion by others, and self-evaluation of one’s personal emotional state (16).

            With respect to the NHLBI campaign, it is important to examine how self-efficacy influences decisions about undertaking COPD risk factors and following up with a physician for appropriate testing. Low self-efficacy has been shown to predict smoking relapse in former smokers (17). Additionally, research has suggested that women, due to past socialization experiences, have lower self-efficacy than their male counterparts (18).  Other research has demonstrated that individuals of lower socioeconomic class also have lower self-efficacy, which may be mediated by their occupational conditions (19). High self-efficacy may be especially important in individuals at risk or already diagnosed with COPD because it is independently associated with prolonged survival (20).

            While the campaign provides each individual with many facts about COPD risk factors and diagnosis, it does nothing to empower individuals and increase their self-efficacy to make a change in their lives. Previous programs that have employed education as a primary means of improving breathing difficulty for individuals with COPD showed no improvement in self-efficacy from preprogram to 6 months after the end of the education program (21). This fact is especially troubling considering that the groups that have the highest risk of COPD (e.g. women and individuals of lower socioeconomic status) have low self-efficacy in general. Consequently, the campaign’s shortcoming to improve the self-efficacy of individuals who evidently need such improvement results in its inability to enact long-term change and achieve its main goals.

Critique 3 – Failure to Consult the Population at Risk in Design and Implementation of Campaign

            Even though COPD is highly prevalent, many individuals who are diagnosed and are symptomatic have low knowledge of COPD and are undertreated (22). One would expect that program developers would consult those individuals who are most at risk for COPD and are thus the most important targets for the intervention. However, NHLBI makes no mention of conducting pre-intervention research on its target population. After the intervention was implemented, a focus group with 13 individuals (6 females, 9 smokers, and 8 individuals diagnosed with COPD) was conducted a year later. Only one of 13 individuals in the group had previously heard of the campaign and no one had heard of Grace Koppel, the spokesperson for the campaign. Importantly, all individuals in the focus group mentioned lung cancer as the most important “lung disease,” but were unable to connect other diseases that might affect the lungs, such as COPD, with this label (23). With this information, it seems as though the campaign missed its target population likely correlating with its choice of spokesperson, who did not resonate with any individuals; and failure to mention lung cancer in any of its materials. The targeted individuals are less likely to follow the advice of a spokesperson who they do not know or with whom they do not identify themselves, even if the spokesperson appears on national television. Lung cancer should have been mentioned in the educational materials – ignoring the most significant “lung disease” in the eyes of the audience is not the way to educate individuals on another important lung pathology. Those who developed the educational materials could have used lung cancer as a way to frame the magnitude of COPD and show how it is a higher predictor or mortality and morbidity in the target population.

            In its educational videos, the information is narrated by a Caucasian male who is described as: “He is male around the age of 45 to 55. He is a “NASCAR dad”-type of guy, plain spoken and liable, dressed in khakis and plaid shirt” (24). It seems as though the only descriptive category that the developers got right in this video is the age. It is understandable that the host should appear as someone who is easy to be liked; however, the program developers could have chosen someone who is easy to like but also connects to the target population.  It appears that this host is part of a higher socioeconomic status, which may appear as patronizing to women and individuals of lower socioeconomic class. It is doubtful that this educational video was tested with the population that should be targeted the most. Thus, the failure of the program to appeal to its most important population undoubtedly played a role in its limited success.

Alternative Model – Expanding “Learn More Breathe Better”

            Evidently, the limitations of the campaign described above have been holding it back from reaching its true potential – not only increasing awareness, but namely encouraging individuals at risk to receive testing and thus obtain early treatment, which has extreme potential at improving outcomes, such as quality of life (25). Attempting to improve patient knowledge with the health belief model or without underlying theory in mind has been unsuccessful in improving outcomes (26). In turn, a successful program would combine knowledge while increasing self-efficacy, and successfully framing the intervention to the target population after doing rigorous pre-program research to discover the factors that govern the behavior of the target group (27). By focusing on group level intervention, improving self-efficacy, and targeting the population most at risk, the alternative intervention can be far more successful.

Intervention 1 – Focus on Group Level Intervention

            Focusing on group level intervention rather than on individual health behaviors can increase the success of this campaign. Individual models cannot explain group behaviors as beliefs of individuals do not sum up to beliefs of a group. An example is the Abilene paradox, which explains that a group of individuals may collectively make a decision contrary to the decision that a single individual would have made (28).  Since an important limitation of the health belief model is its assumption of rational behavior, the group model takes advantage of its assumption that behavior may not be planned and the decision to act is due to context and environmental circumstance of the targeted group.

            Group behavior may be modified with the use of the advertising theory, especially if applied in the right way to the target population. The theory states that successful advertising lays out a promise to the consumers with support and simultaneously appeals to core values and emotions of the target population (29). Advertising on television and radio may be especially successful as individuals have reported higher credibility of advertisement that appear on television and radio rather that in print (30). Importantly, the advertisement should have an explicit conclusion and should show how the product will improve the groups’ lives rather than leaving it for the individual to draw their own conclusion (29). In this case, the advertiser, which could be NHLBI or any of its partners, must advertise a promise – not having trouble breathing, being able to more spend time with family and friends (especially in neighborhoods that have characteristics of the target population), and being able to work without disability. The advertisements must back up these promises with support. Providing straight statistics (i.e. COPD is fourth leading cause of death and leading cause of disability) will not appeal to the emotions of the group (29). Instead, the advertisements should show a specific story of an individual at risk or with COPD and employ a catch phrase that is easy to remember (i.e. I learned to breathe better!).

Obviously, since appealing to the core values is an important component of a successful advertisement, pre-program research must assess the most important core values of the target population. Core values may be different for each population and the program implementers should assess as many different groups of people as possible in order to examine which core values permeate through all groups as well as which values separate one group from another. By conducting careful research, advertisements targeted toward specific populations may be created and shown on channels and radio stations that provide the greatest exposure. Television and radio advertisements take precedence over print advertisements. Ultimately, this proposed intervention of employing the advertisement theory is an key aspect to improve the previous public service announcements and educational videos that were based on the Health Belief Model.

Intervention 2 – Improving Self-Efficacy, “Yes I Can!”

            Providing individuals with knowledge without improving their self-efficacy has shown limited improvement in COPD outcomes (27). An individual’s perception of self-efficacy will determine whether he motivates himself and participates in the behavior that is advertised (31). Influencing and improving self efficacy can be achieved through an individual’s past experiences as well as current psychological status, witnessing the experience of others, and the power of persuasion (13).

            In this part of the intervention, showing the experience of others and employing persuasion in advertisements may also improve psychological state of the target individual in the group and thus enact the behavior. As previously stated, it is important for an advertisement to show true experiences of other individuals who are most similar to the target group. By illustrating the experience of individuals who have faced similar problems (both health and “life” problems) and how they have effectively overcome many of these challenges by going to their physician and getting tested for COPD, the individual who views this commercial should have an increased belief that he can achieve the same success by copying the behavior shown. The same individual who appears in an advertisement may use persuasive comments to improve the viewer’s self-efficacy; an example of such comments includes “Yes, I can! I learned to breathe better, and have shown many of my friends and family how they could do the same!” By appealing to the emotions of the group with individual stories and showing how enacting the behavior may reduce the stress in their lives (i.e. “Since I’m breathing better, I can work more hours or spend more time with my family”), the psychological status of the viewer may be improved.

            An additional component that may be used to improve self-efficacy is creation of self-help groups in the neighborhoods of target populations. Self-help groups have been shown to improve self-efficacy (31-32). The advertisement may show an individual participating in a self-help group and providing support as to how the self-help group helped achieve the promise. At the end of the commercial, information about the group may be provided (i.e. when and where a group meets). Employing several different strategies to improve self-efficacy by using the advertisement theory, the campaign will not only reach a larger target audience but will also be more successful to promote the desired behavior.

Intervention 3 – Know your population!

            Unlike the health belief model that tries to enact change in one individual at a time, the advertisement theory takes advantage of needs and desires of a group to endorse behavior change. It is extremely important for the program and advertisement developers to understand their target population in order to appeal to their basic core values. Pre-intervention research must delve into the experiences and desires of the target group.

The limited success of the current campaign is in part due to its inability to connect with the population. In a focus group, none of the participants had heard of Grace Koppel, the spokesperson for the COPD campaign (23), who has appeared on CBS Evening News, the View, and Good Morning America (5) to promote the campaign. Even though Mrs. Koppel is a woman with COPD, it is unclear if women of lower socioeconomic status, the group that is most at risk, can view a connection between themselves and the spokesperson; or if the target population even watches these television shows. In fact, the majority of the View audience is middle-class women who are housewives and retirees; most of these viewers also do not watch evening news (33). Consequently, the population that was reached the most was probably of higher socioeconomic class. Even though some of this population may be at risk or have COPD, it should not be the most targeted population. In fact, reaching out to this group may have created a larger “knowledge” gap between the populations, unethically depriving the target population of knowledge they must have in order to enact behavior change (34).  Campaign implementers should conduct several pre-program focus groups with the stakeholders and members of the target population to determine: 1) with whom do you connect (i.e. a celebrity, politician, etc); and 2) what channels and television shows do you tend to watch the most. In order to achieve successful exposure of the campaign, it should be known on which channels, shows, and times the advertisements would be most viewed by the target population.

The same idea also pertains to the choice of the narrator on educational videos. The individuals must be asked which characteristics connect them to the people that they see on television and in movies. The described attributes of the individual should be portrayed in both the educational videos as well as the advertisements. These features will make the videos and advertisements seem more realistic, which was one of the stated limitations of the current campaign (23). Accordingly, by truly understanding the target population, the disseminated advertisements, videos, and information would be more appealing and have a better chance to promote the desired behavior change.

Conclusion

            Considering that COPD is the third leading cause of death in the US and the mortality of women with COPD steadily rising, successful intervention to combat this public health issue is needed. NHLBI has undertaken an important campaign to improve the lives of individuals at risk or with COPD; unfortunately, their goals have come up short. The partnership of NHLBI with numerous foundations and associations shows that the campaign has an ability to reach a large audience. However, several factors have held back its success, including a focus on the health belief model, the inability to increase self-efficacy, and not understanding its target population. Still, not all is lost. The campaign may be improved by focusing on group level change through the advertising theory, promoting self-efficacy in its advertisements, and conducting rigorous pre-intervention research in order to understand its target population. By advancing the campaign with these improvements, it should be more successful in combating COPD morbidity and mortality. There is too much at stake for NHLBI to stay idle – millions of people are waiting to be diagnosed and treated. If COPD is to be conquered in the future, this public health campaign cannot fail now.

REFERENCES

1. Minino AM, XU JQ, Kochanek KD. Deaths: Preliminary data for 2008. National Vital Statistics Report 2010;59.
2. Mannino DM, Homa DM, Akinbani LJ, et al. Chronic obstructive pulmonary disease surveillance – United States, 1971-2000. MMWR 2002;51:1-16.
3. Akinbami LJ, Liu X. Chronic Obstructive Pulmonary Disease Among Adults Aged 18 and Over in the United States, 1998-2009. NCHS Data Brief 2011;63.
4. Carlin BW. Chronic Obstructive Pulmonary Disease: “Learn More, Breathe Better.” J Cardio Rehab Prev 2007;27:311-313.
5. US Department of Health and Human Services, National Institutes of Health. COPD: learn more, breathe better. www.learnaboutcopd.org. Accessed April 15, 2012.
6. US Department of Health and Human Services, National Institutes of Health. COPD awareness continues to rise, new NIH survey finds: Yet many at risk do not talk to their doctor about symptoms. http://public.nhlbi.nih.gov/newsroom/home/GetPressRelease.aspx?id=2818. Accessed April 16, 2012.
7. Edberg M. Chapter 4: Individual Health Behavior Theories (p35-49). In:Edberg M. Essential of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
8. Ogden J. Some problems with social cognition models: a pragmatic and conceptual analysis. Health Psychology 2003;22:422-428.
9. Cohen SS, Sonderman JS, Mumma MT, et al. Individual and neighborhood-level socioeconomic characteristics in relation to smoking prevalence among black and white adults in the Southeastern United States: a cross-sectional study. BMC Public Health 2011;11:877.
10. 10. Ross CE. Walking, exercising, and smoking: does neighborhood matter? Soc Sci Med 2000;51:265-274.
11. 11.  Jose RJP, Roberts J, Bakerly ND. The effectiveness of a social marketing model on case-finding for COPD in a deprived inner city population. Prim Car Resp J  2010;19:104-108.
12. National Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice (p9-21). Part 2. Bethesda, MD: National Cancer Institute, 2005;NIH Publication No. 05-3896.
13. Bandura A. Social cognitive theory: an agentic perspective. Annu Rev Psychol 2001;52:1-26.
14. Bandura A. Health promotion by social cognitive means. Health Educ Behav 2004;31:143-64.
15. Dowson CA, Town GI, Frampton C, et al. Psychopathology and illness beliefs influence COPD self-management. J Psychosom Res 2004;56:333-340.
16. Bandura A. Self-efficacy: the exercise of control. New York: WH Freeman and Company, 1997.
17. Baer JS, Holt CS, Lichtenstein E. Self-efficacy and smoking reexamined: Construct validity and clinical utility. Journal of Consulting and Clinical Psychology 1986;54:846-852.
18. Hackett G, Betz NE. A self-efficacy approach to the career development of women. Journal of Vocational Behavior 1981:18:326-339.
19. Gecas V, Seff MA. Social Class, Occupational Conditions, and Self-Esteem. Sociological Perspectives 1989;32:353-364.
20. 20. Kaplan RM, Ries AL, Prewitt LM, et al. Self-efficacy expectations predict survival for patients with chronic obstructive pulmonary disease. Health Psychology 1994;13:366-368.
21. Scherer YK, Schmieder LE, Shimmel S. The effects of education alone and in combination with pulmonary rehabilitation on self-efficacy in patients with COPD. Rehabilitation Nursing: the Official Journal of the Association of Rehabilitation Nurses 1998;23:71-77.
22. Barr RG, Celli BR, Mannino DM, et al. Comorbidities, Patient Knowledge, and Disease Management in a National Sample of Patients with Chronic Obstructive Pulmonary Disease. Am J Med 2009;122:345-355.
23. Parker DA, Goldman RE, Eaton CB. A Qualitative Study of Individuals at Risk for or Who Have Chronic Obstructive Pulmonary Disease: What Do They Understand About Their Disease? Lung 2008;186:313-316.
24. US Department of Health and Human Services, National Institutes of Health. COPD: learn more, breathe better educational video. www.nhlbi.nih.gov/health/public/lung/copd/what-is-copd/transcript_video.htm.  Accessed April 20, 2012.
25. Ramsey SD, Hobbs FDR. Chronic Obstructive Pulmonary Disease, Risk Factors, and Outcome Trials: Comparisons with Cardiovascular Disease. Proc Am Thorac Soc 2006;3:635-640.
26. Monnikhof EM, van der Valk PD, van der Palen J, et al. Self-management education for chronic obstructive pulmonary disease. Cochrane Database of Syst Rev 2003;CD002990.
27. Harris M, Smith BJ, Veale A. Patient education programs – can they improve outcomes in COPD? Int J Chron Obstruct Pulmon Dis 2008;3:109-112.
28. Harvey JB. The Abilene Paradox: The Management of Agreement. Organizational Dynamics 1988;17-43.
29. Nan X, Faber RJ. Advertising Theory: Reconceptualizing the Building Blocks. Marketing Theory 2004;4:7-30.
30. 30. McGuire WJ. The Nature of Attitudes and Attitude Change (pp.136-314). In: Lindzey G, Aronson E, eds. The Handbook of Social Psychology, volume 3. Reading, MA: Addison-Wesley, 1969. 
31. Lestari CUP. Improving self-efficacy in the search for cost-effective solutions – the Indonesian experience. Diabetes Voice 2008;53:13-15.
32. Sobral DT. Improving learning skills: a self-help group approach. Higher Education 1997;33:39-50.
33. Chozick A. Obama on the “The View.” The Wall Street Journal 2010 (July 26). http://blogs.wsj.com/washwire/2010/07/26/obama-on-the-view/. 
34. Guttman N, Salmon CT. Guilt, fear, stigma and knowledge gaps: ethical issues in public health communication interventions. Bioethics 2004;18:531-552.

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.

Conclusion

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.

REFERENCES

1. City of Milwaukee Health Department. Infant Mortality. 2012. Available at: http://city.milwaukee.gov/Infant-Mortality. Accessed April 14, 2012.

2. Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective. Matern Child Health J. 2003;7(1):13–30.

3. Anon. Safe Sleep Brief: 2008-2010 Data Analysis. City of Milwaukee Health Department; 2012:1–2. Available at: http://city.milwaukee.gov/Safe-Sleep-for-baby. Accessed April 13, 2012.

4. Stephenson C. Milwaukee Co-sleeping Ad Stirs Nationwide Debate. JS Online. 2011. Available at: http://www.jsonline.com/news/milwaukee/milwaukee-cosleeping-ad-stirs-nationwide-debate-4m33572-133987863.html. Accessed April 14, 2012.

5. Herzog K, Stephenson C. City’s provocative new safe sleep ad - JSOnline. News and Opinion Blog. 2011. Available at: http://www.jsonline.com/blogs/news/133537793.html. Accessed April 21, 2012.

6. Rosenstock IM. Why people use health services. Milbank Mem Fund Q. 1966;44(3):Suppl:94–127.

7. Siegel M. Traditional Models of Individual Behavior Change: Are they Helping or Constraining Us? – I. 2012.

8. Rosenstock IM, Stretcher VJ. Cambridge Handbook of Psychology, Health and Medicine. 1st ed. (Baum A, Newman S, Weinman J, West R, McManus C, eds.). Cambridge University Press; 1997.

9. Thomas LW. A critical feminist perspective of the health belief model: Implications for nursing theory, research, practice, and education. Journal of Professional Nursing. 1995;11(4):246–252.

10. Brehm JW. A theory of psychological reactance. Academic Press; 1966.

11. Dillard JP, Shen L. On the Nature of Reactance and its Role in Persuasive Health Communication. Communication Monographs. 2005;72(2):144–168.

12. McKenna JJ, Gettler LT. Can co-sleeping be done safely? | Yes: Preserve beneficial sleep practice  - JSOnline. JS Online. 2010. Available at: http://www.jsonline.com/news/opinion/82299907.html. Accessed April 25, 2012.

13. Anon. Campaign Against Milwaukee’s Co-Sleeping Campaign. Facebook. 2012. Available at: https://www.facebook.com/pages/Campaign-Against-Milwaukees-Co-Sleeping-Campaign/293528054002264. Accessed April 25, 2012.

14. Ogilvy D. Ogilvy on Advertising. 1st Vintage Books ed. Vintage; 1985.

15. Kotler P, Zaltman G. Social Marketing: An Approach to Planned Social Change. Journal of Marketing. 1971;35(3):3–12.

16. McManus P. The City’s Infant Mortality Ads: Does the Ends Always Justify the Means? Milwaukee Courier Weekly Newspaper. 2011. Available at: http://milwaukeecourieronline.com/index.php/2011/11/25/the-citys-infant-mortality-ads-does-the-ends-always-justify-the-means/. Accessed April 25, 2012.

17. Manne S. Coping and Social Support. In: Handbook of Psychology. John Wiley & Sons, Inc. 2003. Available at: http://onlinelibrary.wiley.com.ezproxy.bu.edu/doi/10.1002/0471264385.wei0903/abstract?userIsAuthenticated=false&deniedAccessCustomisedMessage=. Accessed April 26, 2012.

18. Anon. Home Visits for Moms and Babies. City of Milwaukee Health Department. Available at: http://city.milwaukee.gov/Nurse-Home-Visits. Accessed April 26, 2012.

19. Anon. States and the New Federal Home Visiting Initiative: An Assessment from the Starting Line. Washington, DC: Pew Center on the States: The Pew Charitable Trusts; 2011:1–36. Available at: http://www.pewstates.org/research/reports/the-case-for-home-visiting-85899373065.

20. DiClemente RJ, Crosby RA, Kegler M eds. Emerging Theories in Health Promotion Practice and Research. 2nd ed. Jossey-Bass; 2009.

21. Lakoff G, Dean H, Hazen D. Don’t Think Of An Elephant!/ How Democrats And Progressives Can Win: Know Your Values And Frame The Debate: The Essential Guide For Progressives. Pap/DVD. Chelsea Green; 2005.

22. Chong D, Druckman JN. Framing Theory. Annual Review of Political Science. 2007;10(1):103–126.

23. Thoits PA. Resisting the Stigma of Mental Illness. Social Psychology Quarterly. 2011;74(1):6–28.

24. Stephenson C. City Health Officials Launch Safe-sleep Campaign as Another Infant is Found Dead. JS Online. 2009. Available at: http://www.jsonline.com/news/milwaukee/80213217.html. Accessed April 26, 2012.