Melda Çelik¹ and Sıddıka Yalçin¹

¹Department of Social Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey (Correspondence to M. Çelik: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ; This e-mail address is being protected from spambots. You need JavaScript enabled to view it ).

Abstract

Background: Social media posts that violate the International Code of Marketing of Breastmilk Substitutes (the Code) may influence societal opinions, views, attitudes, behaviours, and beliefs about breastfeeding, including among healthcare personnel who provide services to breastfeeding women and infants.

Aims: To investigate the literacy of healthcare personnel at Ankara Hacettepe University Hospitals, Türkiye, about the Code and their selection of social media posts about breastfeeding, after completing a breastfeeding counselling course.

Methods: This study included healthcare personnel who completed 2 breastfeeding counselling courses conducted at Hacettepe University in October 2018 and July 2019. They were asked to search for breast milk and breastfeeding on their favourite social media platforms, select 2–4 posts that attracted them, and evaluate the posts to know if they were supportive of breastfeeding. The counselling course facilitators assessed their responses.

Results: Twenty-seven nurses and 40 medical doctors participated in the study; 85.0% of them were female. The participants selected 82 (34%) posts from Instagram, 22 (9.1%) from Facebook, 4 (1.7%) from YouTube, and 134 (55.2%) from other social media platforms. The most common themes of the posts were benefits of breast milk, methods of giving breast milk, and use of infant formula instead of breast milk. The contents of the media were 68.2% (n = 165) favourable and 31.0% (n = 75) unfavourable to breastfeeding. The inter-rater reliability between the participants and facilitators was almost perfect (κ coefficient 0.83).

Conclusion: Sustainable support is needed in Türkiye to increase literacy among healthcare personnel about social media posts that violate the Code, especially those working at baby-friendly hospitals and those who care for breastfeeding mothers.

Keywords: breastfeeding, International Code of Marketing of Breastmilk Substitutes, healthcare personnel, literacy, social media.

Citation: Çelik M, Yalçin S. Literacy of healthcare personnel in Türkiye about the International Code of Marketing of Breastmilk Substitutes. East Mediterr Health J. 2023;29(5):335–342. https://doi.org/10.26719/emhj.23.048 Received: 04/05/22; accepted: 31/10/22

Copyright © Authors 2023; Licensee: World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction

Breastfeeding is the most suitable means of nutrition for all babies until the age of 2 years. Global strategies and targets to support breastfeeding for optimization of maternal and child health and nutrition have been determined by the United Nations Children’s Fund (UNICEF) and WHO (1). Increasing breastfeeding is an important public health goal (2). Successful breastfeeding requires support from family, friends, and healthcare personnel (3). The primary focus of breastfeeding support is on counseling, encouragement, and management of breastfeeding problems for nursing mothers (4,5). Support involves managing different lactation problems such as attachment and positioning of the infant or counselling mothers returning to work (4,6). Support can be psychological, physical, financial, or informative (7). For psychological support, such as social approval, the attitudes of close individuals such as partners are important.

Education and information for mothers, families, and healthcare personnel are critical to sustain the increasing trends in breastfeeding (2). After the Industrial Revolution in the mid-1900s, baby formulae began to be widely used, and advertisements that suggested formula milk was better than breast milk, and that formula-fed babies were healthier and more intelligent became widespread (2); however, infant mortality increased rapidly (3). At the 34th World Health Assembly in 1981, the International Code of Marketing of Breastmilk Substitutes was defined and approved by many countries, including Turkey. The Code includes all products, whether suitable or not (foods, herbal teas, fruit purees, etc.), that can replace breast milk or are used in the first 6 months of life, as well as bottles and pacifiers. The Code allows breast milk substitutes to be sold within a legal framework, but bans advertisements, distribution of free or promotional products, and any expressions on the product labels that support artificial nutrition as being “mother-like”. To be baby-friendly, hospitals must comply with the Code (1,3,6).

Continuation of breastfeeding is a complex process affected by many factors such as maternal antenatal care, back-to-work time, socioeconomic level, attitudes of families and healthcare personnel towards breastfeeding, as well as the social perspective on breastfeeding and how it is portrayed in the mass media (8,9). The current widespread use of social media and advertisements can positively and negatively affect attitudes, behaviours, beliefs, and social norms regarding promotion and support for breastfeeding, and many advertisements and posts on social media may not be compliant to the Code (3,10). Despite efforts to the contrary, artificial feeding continues to be advertised in the mass media, either directly or through the cross-promotion method. In Turkey, although advertising baby foods for use in the first 6 months is prohibited, advertisements are allowed for follow-on milk (for use after 6 months), provided that “mother-like” or similar words are not used on the product label. By using this method, companies package infant and follow-on formulae similarly, allowing cross-promotion (11). Therefore, healthcare personnel acting as consultants in the community need to be alert to advertising and cross-promotion on all media, especially social media, that may hinder the continuation of breastfeeding (3,6).

To overcome the unfavourable effects of social media, the healthcare system has an essential role in supporting and promoting breastfeeding. In the United States of America (USA), Lu et al. reported that mothers who were encouraged by nurses and physicians to breastfeed were 4 times more likely to initiate breastfeeding than mothers who were not encouraged, especially among those who were hesitant (12). In a survey among paediatric residents and practicing physicians in the USA, 70% stated that they needed to dedicate more time to patient communication and consultation to support breastfeeding mothers (13). Paediatricians seemed to have a particular need for education about breastfeeding management.

A study by Freed et al. on breastfeeding knowledge, attitudes, training, and experience among residents and practicing physicians in family medicine, obstetrics/gynaecology, and paediatrics in the USA showed that more knowledge on breastfeeding management was needed (14). Feldman et al. showed that, compared with the 1995 Periodic Survey of Fellows of the American Academy of Pediatrics, in the 2014 survey, more paediatricians reported that they recommended exclusive breastfeeding, which was aligned with Academy policy (15). The Turkey Demographic Health Survey showed that the exclusive breastfeeding rate for the first 6 months increased from 10.4% in 1993 to 40.7% in 2018 (16). In accordance with the Promotion of Breastfeeding and Baby-Friendly Hospital Program that has been conducted by UNICEF and the Ministry of Health since 1991 in Turkey (3), healthcare personnel were trained during a 4-day breastfeeding counseling course to increase the knowledge, literacy, and rates of breastfeeding in the community. After becoming consultants in breastfeeding, healthcare personnel try to assist mothers and babies with breastfeeding in perinatal and child health clinics (5). To increase breastfeeding rates, more support studies and interventions for mothers and healthcare personnel are needed in Turkey.

In this study, we investigated literacy about the Code among healthcare personnel who work in a baby-friendly hospital after they completed a breastfeeding counselling course, in relation to the effects of social media posts on support for breastfeeding. To our knowledge, there are limited data about the association between social media and breastfeeding in the literature.

Methods

Study participants

The participants included 27 nurses and 40 medical doctors (57 female, 85%) who frequently encountered pregnant or breastfeeding women, newborns, and infants while working at Hacettepe University Hospitals, Ankara, Turkey. The participants had completed the breastfeeding counselling course organized by the Social Pediatrics Department, Hacettepe University in October 2018 and July 2019. Nineteen of the 27 nurses were from paediatric and 6 from obstetrics and gynaecology inpatient and outpatient clinics. All 40 doctors were residents and 22 were from paediatrics, 13 from obstetrics and gynaecology, 3 from family medicine, and 2 from public health. Informed consent was obtained from all participants.

Breastfeeding counseling course

WHO and UNICEF launched the Baby-Friendly Hospital Initiative to motivate facilities providing maternity and newborn services worldwide to implement the Ten Steps to Successful Breastfeeding (17). Since 2000, the Department of Social Pediatrics has been conducting breastfeeding counselling courses compatible with the Baby-Friendly Hospital Initiative 3 or 4 times every year in Hacettepe University Hospitals (17). Each face-to-face course consisted of a theoretical part of 22 hours on 3 consecutive days and 1 day of clinical practice. The lectures were prepared using the official slide sets of the Turkish Republic Ministry of Health Breastfeeding Support Program, following WHO guidelines (17), and the training videos were shown on the official internet channel of the Global Health Media Project (18), a partner of UNICEF. Lectures were delivered face-to-face by the facilitators using PowerPoint presentations, demonstrations, and training videos in a meeting room.

The course covered the following subjects: benefits and mechanism of breastfeeding; counselling skills; antenatal, natal, and postnatal practices to support breastfeeding; assessing, assisting, and supporting breastfeeding; breast and nipple conditions; milk insufficiency; breastfeeding of low-birth-weight and sick infants; and implementing the Ten Steps and the International Code of Marketing of Breastmilk Substitutes (17). Interactive teaching techniques were used by asking questions and conducting case studies. During the clinical practice, the participants observed at least 10 breastfeeding mother–baby pairs, filled in the breastfeeding observation forms (17), and helped solve breastfeeding problems under the supervision of the expert facilitators.

Study design and procedures

This was a quantitative and pre-experimental 1-shot case study. In a 1-shot case study, participants are affected by the independent variable, and its effect on participants’ behaviour is measured and investigated and there is no control group. After the participants completed the breastfeeding counselling courses, we investigated the effect of the courses (independent variable) on the participants’ behaviour, attitudes, and literacy about breastfeeding by evaluating their Code literacy on social media, without a control group for comparison. We then performed a descriptive analysis.

The participants were asked to search for the terms breast milk and breastfeeding on their most commonly used social media platforms between 18:00 and 20:00 hours on the last day of the theoretical part of the course and choose 2–4 relevant posts that they found most attractive. They were asked to download or take a screenshot of the posts and print them on A4 paper and evaluate the posts for their favourability for breastfeeding in relation to the ideas, behaviours, or advertisements they contained. The posts that violated the Code and were noncompliant with the Ten Steps were considered unfavourable. The participants were asked to write only F for favourable, UF for unfavourable, or NC for no comment under the post, with no personal information on the papers or envelopes.

Two facilitators opened the sealed envelopes, and evaluated the submitted posts, using a checklist (Supplementary Table 1) that was prepared in accordance with previous studies (19,20). The facilitators classified the content of the posts as informative, supporting and making suggestions, problem reporting, experience sharing, problem solving, political attitudes, and advertisements (overt/hidden). They reached a consensus on the favourability of each post. The written assessments of the participants were then compared with those of the facilitators and the sources (Instagram, Youtube, Twitter, etc; unofficial or official) and characteristics (written or visual) of the posts were determined. Official websites belonged to organizations such as government agencies, hospitals, and associations with relevant activities on maternal and child health and breastfeeding. Unofficial posts with no official connection belonged to individuals, such as doctors, nurses, and activists.

Our study was reviewed and approved by Hacettepe University Non-Invasive Clinical Studies Ethics Committee (Acceptance number, date: GO 21/1200, 21 June 2021).

Statistical analysis

Descriptive statistical analysis was performed using SPSS version 23.0. The inter-rater reliability between the consensus of the 2 facilitators and the assessment of each participant for each post was analysed, and Cohen’s κ coefficient was calculated.

Results

The participants chose 242 posts with a median of 3 (2–4) per person. Approximately 49% (119) of the posts were from unofficial sites, 48% (116) from official sites, and 3% (7) from unknown sites. The participants selected 82 (34%) posts from Instagram, 22 (9.1%) from Facebook, 4 (1.7%) from YouTube, and 134 (55.2%) from other sources (internet news, personal/institutional blogs or websites, forums, etc.). The posts from unofficial sites comprised 73 (61.3%) from Instagram, 18 (15.0%) from Facebook, 4 (3.5%) from Youtube, 3 (2.0%) from Twitter, and 21 (17.0%) from other platforms. The posts from official sites comprised 56 (48%) from online newspapers, 36 (31.4%) from institutional websites, 10 (8.5%) from Instagram, and 4 (3.5%) from Facebook.

The most common contents were the benefits of breast milk (77, 32%), breastfeeding methods (40, 16.5%), and formula feeding (39, 16.1%). Other contents covered bottle use, duration of breastfeeding, breast milk sufficiency, breastfeeding in public, ways to increase breast milk, nutrition for nursing mothers, and social beliefs (Table 1). Among the posts, 110 (45.5%) were informative, 87 (36%) were supportive and made suggestions, and 47 (19.4%) contained advertisements (about formulae, bottles, pacifiers, etc.) (Figure 1). Thirty-one of the 47 posts contained overt advertisements and 16 contained hidden advertisements (Table 2).

One hundred and forty (57.8%) of the 242 posts had both written and visual content, 65 (26.6%) had only written content, and 37 (15.3%) had only visual content. Benefits of breast milk were mentioned in 79 (33%) posts; 45 (57.0%) of these posts had both written and visual contents, 26 (33.0%) had only written content, 8 (10.0%) had only visual content, and 74 (94%) posts were supportive of breastfeeding (Figure 2). Thirty-nine (10.7%) posts were about formulae; 26 (67%) of them supported formula use, 14 (53.0%) of which included both written and visual contents. Six (54%) of the posts with only written content did not support formula use. Of the 26 posts about bottle use, 19 (73%) were supportive, and nearly half (12,47%) of them had both written and visual contents.

The participants evaluated 80% (194) of the posts as favourable and 20% (48) as unfavourable regarding support for breastfeeding. One hundred and sixty-five (68.2%) of the social media posts assessed by the facilitators were favourable towards breasfeeding and 75 (31%) were unfavourable. The inter-rater reliability between the participants and facilitators was almost perfect (κ coefficient 0.83).

Discussion

We found that the most common social media posts that attracted healthcare personnel were about the benefits of breast milk, methods of giving breast milk, and use of formula instead of breast milk. Nearly half the posts selected by the participants were informative, others were supportive and made suggestions (36%), and some contained, mostly overt, advertisements (19.4%). Most of the posts selected had both written and visual contents (57.8%). The contents of most of the posts (68.2%) were assessed as favourable by the facilitators, which had a high inter-rater reliability with the participants.

Social media is frequently used by organizations and individuals to disseminate health-related messages and to create a forum for health information seekers. The main advantage of using social networks is that users can obtain health information and facilitate widespread interaction with other users (17). Pregnant women and nursing mothers frequently use social media for educational and social support regarding perinatal and parenting information, including breastfeeding (21,22). A considerable number of posts on social media platforms may positively influence breastfeeding (3,24), while others may be unfavourable (10). Qualitative studies on the use of social media groups by breastfeeding mothers have shown that social media can positively influence maternal behaviour, knowledge, and attitudes about breastfeeding (25).

Advertisements are frequently encountered on social media, and can influence social norms or general expectations of behaviour by suggesting that some behaviours are common and acceptable. This applies equally to breastfeeding and the use of breast milk substitutes. Content analysis of advertisements published in a popular parenting magazine in the USA between 1971 and 1999 revealed that whenever advertisements about bottle feeding, formula feeding, and solid foods increased, breastfeeding rates decreased thereafter (19). Formula feed manufacturers are increasingly using the internet, social media platforms, and mobile apps to market their products (26). Their unfavourable impact on breastfeeding has not been measured, but it is likely to increase as internet access, e-commerce, and network-based customer data mining become widespread and undersupervised.

A recent content analysis of breastfeeding promotion on Twitter found that 24% of 3972 tweets by 3798 users had pornographic content sexualizing breastfeeding (27). More tweets about evidence-based research findings were shared than non-evidence-based suggestions. The most common content was advertisements, followed by professional communications such as academic research, breastfeeding promotion and support, public breastfeeding advocacy, parent support groups, breastfeeding-friendly policies, and the International Code of Marketing of Breastmilk Substitutes. In our study, the participants mostly selected posts with informative content, followed by those supporting and making suggestions on breastfeeding, advertisements, and sharing experiences. This was probably because of the selective attention of the educated healthcare personnel in our study. Posts by the Australian Breastfeeding Association and 15 closed Facebook groups set up for breastfeeding mothers to provide support to their peers were evaluated in another study (20). Most (76%) of the queries were about breastfeeding management, breastfeeding and health, and breastfeeding and work. In our study, the most common content of the selected posts was about the benefits of breast milk (which correspond to breastfeeding and health), and breastfeeding methods and formula use (which correspond to breastfeeding management). Our results may have been because the participants were focused on the health benefits of breastfeeding after attending a course emphasizing this issue. If our participants had been breastfeeding mothers in a support group, they may have chosen posts mostly about breastfeeding management in line with their needs.

In a study analyzing YouTube videos on breastfeeding education, the most common content was breastfeeding techniques (63.2%) (28). Videos without subtitles or text may be most attractive to breastfeeding mothers because they only need to watch and listen. In our study, media with visual only content were the least selected, and those with both visual and written contents were the most selected, which was most likely because of the participants’ high educational level.

In our study, the majority of the commercial posts on social media that attracted the participants contained overt formula advertisements. Worldwide, healthcare personnel provide advice to mothers on infant nutrition and are seen as the most reliable sources of information (29,30). Therefore, it is crucial for healthcare personnel to counter social media posts promoting formula use and to support breastfeeding through evidence-based supportive information. There is clear evidence of

negative effects on exclusive breastfeeding when formulae are provided for free in maternity hospitals and encouraged by healthcare personnel (10). If healthcare personnel who encounter babies in hospitals are educated about breastfeeding, they can prevent promotional messages that contradict the International Code of Marketing of Breastmilk Substitutes. In our study, we observed that after attending the breastfeeding counselling course, the participants were able to evaluate the posts accurately and in accordance with the evaluation of the trainers.

The 1st International Breastfeeding Reality Congress organized in October 2019 in Ankara included the Advertisement and Community Promotion of Breastfeeding Workshop, which was attended by physicians, nurses, midwives, and media professionals (3). In the workshop report, the tasks that were determined to promote breastfeeding via social media were increasing media literacy among healthcare personnel, banning formula-related advertisements, regulating the control of unfavourable images, establishing breastfeeding groups, and enabling the participation of community leaders in breastfeeding promotion through social media (3).

There were some limitations to our study. The social media tools that the participants used were not standardized. The participants were given a limited time interval for social media scanning. We did not conduct any knowledge assessment before the course. As our study was a quantitative and pre-experimental 1-shot case study, the results were based on numerical data such as frequencies, and no control group was used. Therefore, the reasons, origins, and details of the experiences, opinions, and any cause–effect relationship could not be provided.

Conclusion

Our analysis showed a similar level of sensitivity to the unfavourable nature of social media posts on breastfeeding by the trainers and the participants. Our breastfeeding counselling course may have increased the literacy and sensitivity of the participants about unfavourable social media posts and advertisements about breastfeeding, although no evaluation was conducted before the course. To support breastfeeding in society, it is important to increase the literacy of healthcare personnel, especially those who work at baby-friendly hospitals and encounter breastfeeding mothers and their infants, about social media posts that violate the International Code of Marketing of Breastmilk Substitutes. Future studies could be conducted to better understand the attitudes, experiences, and opinions of healthcare personnel regarding breastfeeding, and emphasize the importance of the Code in breastfeeding support.

Funding: None

Competing interests: None declared.

Littératie des personnels de santé en Türkiye concernant le Code international de commercialisation des substituts du lait maternel

Résumé

Contexte : Les publications sur les médias sociaux qui enfreignent le Code international de commercialisation des substituts du lait maternel (le Code) peuvent avoir une incidence sur les opinions, les points de vue, les attitudes, les comportements et les croyances sociétales concernant l'allaitement, y compris parmi les personnels de santé qui fournissent des services aux femmes allaitantes et aux nourrissons.

Objectifs : Étudier la littératie des personnels de santé des hôpitaux universitaires Hacettepe à Ankara, en Türkiye, concernant le Code et leur sélection de publications sur les médias sociaux au sujet de l'allaitement, après avoir suivi un cours de formation en matière de conseil en allaitement.

Méthodes : La présente étude incluait les personnels de santé qui avaient suivi deux cours de formation en matière de conseil en allaitement dispensés à l'Université Hacettepe en octobre 2018 et juillet 2019. Il leur a été demandé de rechercher des informations sur le lait et l'allaitement maternels sur leurs plateformes de médias sociaux préférées, de sélectionner deux à quatre publications qui les avaient attirés et d'évaluer ces dernières pour savoir si elles étaient favorables à l'allaitement. Les animateurs du cours de formation ont évalué leurs réponses.

Résultats : Vingt-sept membres du personnel infirmier et 40 médecins ont participé à l'étude ; 85,0 % d'entre eux étaient des femmes. Les participants ont sélectionné 82 (34 %) publications sur Instagram, 22 (9,1 %) sur Facebook, quatre (1,7 %) sur YouTube et 134 (55,2 %) sur d'autres plateformes de médias sociaux. Les thèmes les plus fréquemment abordés dans ces publications étaient les avantages du lait maternel, les méthodes de lactation et l'utilisation du lait maternisé à la place du lait maternel. Le contenu des médias était pour 68,2 % (n = 165) favorable et pour 31,0 % (n = 75) défavorable à l'allaitement au sein. La fiabilité inter-examinateur entre les participants et les animateurs était presque parfaite (coefficient K 0,83).

Conclusion : Il est nécessaire de fournir un appui durable en Türkiye pour renforcer la littératie des personnels de santé concernant les publications sur les médias sociaux qui enfreignent le Code, en particulier ceux qui travaillent dans des hôpitaux « amis des bébés » et ceux qui s'occupent des mères allaitantes.

توعية العاملين في مجال الرعاية الصحية في تركيا بشأن المدونة الدولية لقواعد تسويق بدائل لبن الأم

ميلدا تشيليك، صديقة يالتشين

الخلاصة

الخلفية: قد تؤثر المنشورات على وسائل التواصل الاجتماعي التي تخالف المدونة الدولية لقواعد تسويق بدائل لبن الأم (المدونة) على آراء المجتمع ووجهات نظره ومواقفه وسلوكياته ومعتقداته بشأن الرضاعة الطبيعية، لا سيما في أوساط العاملين في مجال الرعاية الصحية الذين يقدمون الخدمات للنساء المرضِعات والرُضَّع.

الأهداف: هدفت هذه الدراسة إلى استقصاء مدى دراية العاملين في مجال الرعاية الصحية في مستشفيات جامعة هاسيتيب بأنقرة، تركيا، بالمدونة وقدرتهم على تقييم منشورات وسائل التواصل الاجتماعي المتعلقة بالرضاعة الطبيعية، بعد إتمام دورة إرشادية بشأن الرضاعة الطبيعية.

طرق البحث: شملت هذه الدراسة عاملين في مجال الرعاية الصحية أتموا دورتين إرشاديتين بشأن الرضاعة الطبيعية عُقدتا في جامعة هاسيتيب في أكتوبر/ تشرين الأول 2018 ويوليو/ تموز 2019. وطُلب منهم البحث عن موضوعَي لبن الأم والرضاعة الطبيعية على منصات التواصل الاجتماعي المفضلة لديهم، واختيار 2-4 منشورات تجذبهم، وتقييم هذه المنشورات لتحديد ما إذا كانت تدعم الرضاعة الطبيعية. وقيَّم منسقو الدورة الإرشادية إجاباتهم.

النتائج: شارك في الدراسة 27 ممرضة وممرضًا و40 طبيبة وطبيبًا، وكانت نسبة الإناث 85.0%. واختار المشاركون 82 منشورًا (34%) من إنستجرام، و22 منشورًا (9.1%) من فيسبوك، و4 منشورات (1.7%) من يوتيوب، و134 منشورًا (55.2%) من منصات التواصل الاجتماعي الأخرى. وكانت المواضيع الأكثر شيوعًا لهذه المنشورات هي فوائد لبن الأم، وطرق إعطاء لبن الأم، واستخدام المنتجات المركبة لبدائل لبن الأم. وكانت محتويات وسائل التواصل الاجتماعي مؤيِّدة للرضاعة الطبيعية بنسبة 68.2% (العدد = 165) وغير مؤيدة بنسبة 31.0% (العدد = 75). وكانت موثوقية التوافق في التقييم بين المشاركين والمنسقين تكاد تكون كاملة (معامل الموثوقية K 0.83).

الاستنتاج: ثمة حاجة إلى توفير دعم مستدام في تركيا لإذكاء الوعي في أوساط العاملين في مجال الرعاية الصحية بشأن منشورات وسائل التواصل الاجتماعي التي تخالف المدونة، لا سيما أولئك الذين يعملون في المستشفيات الملائمة للأطفال، وأولئك الذين يرعون الأمهات المرضعات.

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