1. Evaluation of the National Breastfeeding Awareness Campaign Suzanne G. Haynes, Ph.D. –DHHS OWH Anne Merewood, M.P.H., IBCLC- BMC Jana Chaudhuri, Ph.D.-BMC Sara Fein, Ph.D.- FDA

2. Campaign Overview Campaign ran from June,2004 to April,2006 Goal: To portray breastfeeding as normal, desirable, and achievable Slogan: Babies were Born to be Breastfed Target: First-time or African American moms Message: Recast breastfeeding benefits to the Consequences of not breastfeeding for ear infections, respiratory illness, diarrhea, and maybe obesity Behavior change: Build Confidence in women and increase bf rates at 1 & 6 mos

3. TelevisionRadio

5. Campaign Evaluation IFPSII fielded one year into the campaign Campaign ad recall questions included in Prenatal questionnaire Respondents shown ad inserts with words removed for TV and Print ads: Have you recently seen an ad that shows…. Radio ads were described Health Belief Model used for analysis plan Outcomes: Perceived susceptibility, confidence, and breastfeeding rates at >1,>3, >6 months

6. Health Belief Model Cues to Action: media campaign Perceived susceptibility to disease - risk Demographics Perceived threat of disease Likelihood of behavioral change Self-efficacy Perceived benefits Perceived barriers

7. Measures Used in the Campaign Evaluation Analysis Concept in Health Belief ModelMeasure Cues to adoption of breastfeedingWhether mother lived in a CDP; whether the mother had seen or heard the TV, radio, print ads Perceived susceptibility to diseaseConsequences of not breastfeeding, including the risk of ear infections, respiratory illnesses, diarrhea, and obesity Perceived benefitsInfant formula not as good as breast milk; babies should exclusively breastfeed for six months Perceived barriersEmbarrassment about breastfeeding in public; lack of support of family or health professionals Self-efficacyConfidence in ability to breastfeed DemographicsAge; education; ethnicity; parity (first-time mom or not); PIR level; state of residence’s bf rate Behavioral changeInitiate breastfeeding; exclusively breastfeeding to 3 & 6 months; breastfeeding to 3 & 6 months

8. 0 5 10 15 20 25 30 Percentage Proportion Who Saw or Heard the Ads (4902)(4861) Billboard, Print, Internet (4881) Any Print (4879) Any TV (4875) Any Radio Any Ad

9. Exposed to the Campaign by Demographic Characteristics Demographic Characteristics N Ad Aware % P-Value Mother’s Race/Ethnicity P<.001 White386324.8 Black30035.0 Hispanic33530.5 API13630.9 Other12028.3 Enrollment in WIC P<.001 Not enrolled 325422.0 Enrolled163934.8 Mother’s Education P<.001 Less than high school 20538.1 High school graduate 85130.4 Some college 175724.3 College graduate plus 146519.9

10. Exposed to the Campaign by Demographic Characteristics (cont’d) Demographic Characteristics N Exposed % P-Value Mother’s Poverty Index Less than 100 92634.6P<.001 100 to 184 127830.2 185 to 349 168622.2 Greater than 350 101220.9 Mothers Parity P<.001 No other babies 152029.1 1 other baby 184325.6 2 or more babies 135822.8 State Breastfeed Rate - 2004 P<.001 Low174930.1 Medium174025.2 High141323.1

11. Proportion who Agree that if a Baby is Breastfed She/he will be Less Likely to Get ill or Become Obese by Exposure to Campaign (3588) (1287) Respiratory Illness (p =.003) (3585) (1286) Diarrhea (p =.006) (3586) (1285) Become Obese (p=.04) (3583) (1283) Ear Infections (p =.006) Percentage 0 10 20 30 40 50 60 70 Campaign Exposure Not Exposed Exposed

12. Perceived susceptibility Breastfed > 1m (%) Breastfed > 3m (%) Breastfed > 6m (%) Exclusively breastfed >3 m(%) Breastfed babies are less likely to get ear infections – Agree 81.064.749.225.8 Disagree/Not Sure 51.436.023.88.9 Risk Ratios 1.61.82.12.9 P Adjusted* <.001 <.001<.001<.001 Breastfed babies are less likely to get respiratory illnesses –Agree 81.765.550.026.0 Disagree/Not Sure 50.134.422.38.5 Risk Ratios 1.61.92.23.1 P Adjusted* <.001<.001<.001<.001 Breastfeeding Rates by Agreement With Perceived Susceptibility

13. Breastfeeding Rates by Agreement with Perceived Susceptibility Perceived susceptibility Breastfed > 1m (%) Breastfed > 3m (%) Breastfed > 6m (%) Exclusively breastfed >3 m(%) Breastfed babies are less likely to get diarrhea - Agree 84.168.253.227.0 Disagree/Not Sure 57.040.927.312.6 Risk Ratios 1.51.71.92.1 P Adjusted* <.001<.001<.001<.001 Breastfed babies are less likely to become obese - Agree 87.472.458.231.7 Disagree/Not Sure 60.443.829.412.6 Risk Ratios 1.41.72.02.5 P Adjusted* <.001<.001<.001<.001

14. Agreement with Benefits, Barriers, and Confidence t Breastfeeding by Ad Recall Health Belief Model Not Exposed Exposed P-Value Adj* Perceived benefits Infant formula is as good as breast milk (disagree) 58.457.7NS Babies Should be exclusively Breastfed for first 6 months (agree) 45.750.3<.001 Confidence Confidence in ability to breastfeed 67.566.4NS Perceived barriers Social support: Percent of the following people who do not support breastfed only Baby’s father Baby’s father49.949.6NS Mother’s mom Mother’s mom63.361.1<.001 Mother-in-law Mother-in-law75.269.0<.001 Mom’s doctor Mom’s doctor58.552.6<.001 Baby’s doctor Baby’s doctor64.660.6<.001 Embarrassed to breastfeed in presence of close friends 66.465.2NS Embarrassed to breastfeed in public 19.718.7NS

15. Duration and Exclusivity Not Exposed Exposed P Value Adjusted* Breastfed >1 month 71.467.8.65 Breastfed >3 months 55.950.1.35 Breastfed >6 months 41.735.4.27 Exclusively breastfed >3 months 20.816.1.90 *Adjusted for mother’s age, education, race, parity, WIC participation, CDP area and state breastfeeding category (low, medium, or high) in 2004 Breastfeeding Rates by Ad Recall

16. Conclusions One out of 4 mothers was exposed to the campaign, comparable to other surveys The campaign reached proportionally more of the targeted mothers: first-time, black, low SES, or poor moms, and residents of low B.F. states Awareness of campaign ads was significantly associated with increased risk perceptions for four health outcomes Support for mixed feeding or formula feeding was less in grandmothers and doctors when the mother had heard or seen campaign ads. No such association was observed for fathers. Mothers who agreed with risk statements were twice as likely to breastfeed at 6 months Mothers who agreed with risk statements were 2-3 times more likely to exclusively breastfeed for 3 months Exposure to the campaign ads, per se, was not associated with breastfeeding rates at any time interval or exclusivity at 3 months

17. Discussion The campaign did not change BF rates because : It reached the population of pregnant women traditionally less likely to breastfeed More time (at least by 2010) would be needed to change BF rates-22 months not enough for any successful Ad Council campaign 40% of mothers still agreed or were neutral that Infant formula is as good as breast milk Formula industry outspent us: $80 Million in 2004 and 2005 in advertising VS our $30 million donated media Marketing alone can’t change behavior without the help of family members, hospitals, health professionals, and worksites

18. Risk Reduction Estimates for Breastfed Infants From the April, 2007 AHRQ Evidence Based Review 72% reduction in lower respiratory tract diseases 64% reduction in gastrointestinal infections 50% reduction in acute otitis media 42% reduction in atopic dermatitis 40% reduction in Type 2 diabetes 36% reduction in SIDS 19% reduction in childhood leukemia

19. Risk Reduction Estimates for Breastfeeding Mothers From the AHRQ EBR 28% reduction in breast cancer 21% reduction in ovarian cancer 12% reduction in Type 2 diabetes