COMMUNICATING ATTITUDINAL CHANGE THROUGH BREASTFEEDING PRACTICE MEDIA CAMPAIGN: REVIEW OF RESPONSES FROM NURSING MOTHERS IN AROCHUKWU, SOUTH-EAST NIGERIA

Studies have clearly shown that there are numerous health benefits accruing from breastfeeding, not only to infants but mothers also. However, adherence to breastfeeding practice remains a key challenge facing mothers and maternal health providers. The study which adopted survey research approach critically examined audience response to media campaign on the importance of breastfeeding in Arochukwu community of Abia State, Nigeria to determine the factors that actually militate against its practice as an ideal, healthy and accepted norm. Structured questionnaire was the principal instrument of data collection. A number of 185 respondents were randomly selected from seven health centers in the area, representing the population of the study. The data obtained were analyzed using tables and simple percentage calculation and graphs respectively to elucidate on the findings. Findings reveal that civilization/new cultural ideas were contributory to the decline in breastfeeding rate in Arochukwu. It was also found that there was a huge influence of the effects of social perception and lack of education resulting to mothers' neglect of breastfeeding practice in the area. Hence, the study concludes that the media and stakeholders in the health sector need to do more to effectively make mothers appreciate and appropriate the invaluable benefits of breastfeeding practice. It further recommends that conscious efforts should always be made by media campaigners to appropriately select and utilize suitable media channels for effective realization of objectives; more so, in the present context of addressing this key challenge of non-adherence to breastfeeding practice facing mothers generally, and particularly young mothers. © 2022 by the authors. Licensee ACSE,


INTRODUCTION
Breastfeeding (BF) has been identified in numerous studies as the optimal way to feed infants (Ibe & Nkanginieme, 1990). It no doubt plays a very important role in a child's growth and development besides contributing to the well-being of the mother and the mutual bonding between mother and child. Its rating as the most comprehensive nutritional source for infants cannot be overemphasized, due to breast milk's rich composition of essential fats, carbohydrates and proteins among other immunological factors that are necessary for the healthy development of the infant in its formative year in life (Ihudiebube-Splendor, Okafor, Anarado, Jisieike-Onuigbo, Chinweuba, Nwaneri, Arinze, & Chikeme, 2019). Uwakwe (1996) has highlighted on the significance of breastfeeding as a postnatal activity of utmost importance and interest to experts in paediatrics, nursing endocrinology, psychology, as well as anthropology; a significance that is no doubt premised on these experts' consideration of breastfeeding as the bes t source of infant nutrition and immunologic protection that also provides very remarkable health benefits to mothers. More so, new exciting observations about the bio-chemical, immunological, anti-allergic, emotional and economic benefits of breastfeeding have been emerging from across the globe as Lucas and Cole (1990) have noted; thus reinforcing not just the high value placed on breastfeeding practice, but also the renewed effort to arouse the

Problem Statement/Justification
There is no gain saying the fact that breastfeeding is ideal, and has proved to be vital in the formative stage of an infant. It is also a necessary prerequisite for the immunity and protection of the baby from possible health dangers and diseases. While its importance and benefits remain unarguable, a few worrisome questions need to be answered: To what extent has nursing mothers, especially in Arochukwu, tapped into these benefits of breastfeeding? How do these mothers view the act of breastfeeding their babies against the backdrop of prevailing dwindling perception of the importance of breastfeeding among mothers? It was based on the foregoing that the study sought response from mothers in Arochukwu on their perception of the media campaign on the importance of breastfeeding practice.

Objectives of the Study
The broad objective of this study is to determine audience response to media campaign on the importance of breastfeeding practice among mothers in Arochukwu. However, the specific objectives include to: i. Identify the roles of breastfeeding in the life of infants and mothers. ii.
Find answers to why the importance attached to breastfeeding in the time past has now dwindled. iii.
Identify the factors impinging on mothers' responsibilities to breastfeeding their babies. iv.
Ascertain audience response with regards to the importance of Breastfeeding (BF) practice, as well as v.
Identify the set of media that has mostly enhanced audience's understanding of the BF message?

LITERATURE REVIEW Overview of the Concept of Breastfeeding
The act of feeding a baby or young child milk from the breast of a lactating woman is known as Breastfeeding. On the part of the infant, it is simply to suck milk from the breast of the mother. More so, the basic definition of Breastfeeding divides it into two, "the full/exclusive" and "the partial breastfeeding". Full or exclusive breastfeeding means that no other liquid or solid is given to the baby, while partial breastfeeding refers to a situation where the baby receives some breastfeeds as well as other food or food-based fluids, such as formula milk or weaning foods. The World Health Organisation (2020) has described breast milk as the natural first food for babies which provides them all the energy and nutrients they needs for the first months of life; and further provides up to half or more of their nutritional needs in the second half of their first year, and up to one-third during their second year of life. The child receives breast milk, either directly from the breast or expressed. T he colostrums which is the initial milk produced in the first few days after delivery provides infants with their first immunisation against many bacterial and viral infections (Agho, Dibley, Odiase, & Mgbonmwan, 2011). The mature breast milk contains anti-infective substances which protect infants against common infections particularly diarrhea and respiratory tract infections (Ip, Chung, Raman, Chew, Magula, DeVine, Trikalinos, & Lau, 2007). Furthermore, breastfeeding, as Biancuzzo (1999) observes, boosts positive bonding between mother and child that cannot be realised through other supplementations. Apart from contributing to the mutual bonding between mother and child, breastfeeding is essentially important to their health too. Several studies have established breastfeeding's role in infant mortality red uctio n and risk o f obesity, morbidity fro m infectio n, enhancement of immunity as well as reduction of atopic disease Huffman & Combest, 1990;Lucas & Cole, 1990;Spady & Pabst, 1990;Victoria, 1997). Breastfeeding also contributes to mothers' health in many ways: post-delivery, birth control, reduced risk of postmenopausal osteoporosis, pre-menopausal breast cancer, ovarian cancer and auto-immune disease among others Chilvers, 1993).

Benefits of Breastfeeding
Breastfeeding, as WHO (2002) rightly observed, is not only an incomparable means of "providing ideal food for the healthy growth and development of infants"; but "it is also an integral pa rt of the reproductive process with vital implications for the health of the mothers" (p.5). Apart from certain medical conditions that may rule out breastfeeding either for the infant or on the part of the mother, its benefits cannot be overemphasized. So me of these benefits as UNICEF (2010, p.6) highlights include :

Those accruing to infants
i. The provision of adequate water for hydration. ii.
The provision of superior nutrition for optimum growth. iii.
Protection against infection and reduces overall child mortality. The biggest impact on reducing illness relates to diarrhoea, through two mechanisms: (a) reduced risk of bacteria from contaminated formula, other liquids and foods, and (b) transfer of antibodies through breast milk. iv.
The reduction of overall neonatal mortality by around 20% (early initiation of breastfeeding). v.
The promotion of bonding and development. vi.
Better cognitive development and IQ than in formula -fed children. vii.
Lower risk of chronic conditions such as diabetes, heart disease, obesity, certain canc ers etc. compared with formula-fed infants.
Those accruing to mothers i. (Early initiation) helps contract the uterus, expel the placenta and reduce bleeding. ii.
Helps mothers return more rapidly to their pre -pregnancy weight and a lower body mass index after 5−6 years. iii.
Lowers risk of pre-menopausal breast cancer and ovarian cancer. iv.
May delay return of fertility.

Theoretical Framework
The study was premised on the agenda setting theory of communication as formalized by McCombs and Shaw (1972). The theory describes the ability of the media to influence the salience of the topics on the public agenda (Nwosu, 2006). Hence, if a news item is covered frequently and prominently, the audience will regard the issue as more important. Agenda setting theory, in order words, lays emphasis on what the public thinks about as projected by the media (Nwogu, 1991;Shaw & McCombs, 1977), in all ramifications. In corroborating the importance of this vital role of the media, Chukwu-Okoronkwo, Okugo, Ihechu, and Okoronkwo (2019) stress that they do not only set public's agenda by shaping what people view as important, they also identify and define concerns, issues and problems in the society. Since, "media campaigns are central to people's ability to acquire knowledge for better health" (Wabwire, Nyambuga , & Yakub, 2016, p.40), the mass media play a vital role in communication for health and sustainable development by publicizing health information through health campaigns. However, in the context of this study, the term 'media' is considered from a broad communication approach, rather than the compartmentalized; this includes the electronic/broadcast comprising radio and television; the print, comprising newspaper, book and poster; and the human media (group and interpersonal) comprising antenatal channel; all of which provide relevant information aimed at conscientizing the people on the salient issue of the importance of breastfeeding practice. Hence, when these 'media' highlight the dwindling perception of the importance of breastfeeding among mothers during campaign awareness, they are also shaping and determining the importance for a positive and rapid response towards it. This can ultimately set the agenda for a change in attitude and perception of (lactating) mothers towards embracing the importance of breastfeeding in our communities, states, nation and the world at large. The agenda setting, therefore, reinforces the manifest influence of persistent 'media' content upon the pre-conceived consciousness of the (target) audience and its consequent response to the 'issue at stake'.

MATERIALS AND METHODS
Survey research approach is adopted in this study. Nwogu (1991) describes survey research method as such in which a group of people or items are studied by collecting and analyzing data from a few people or items considered as representative of the entire group. Nwosu (2006) stresses that survey must depend on samples of respondents and can be considered representative of the population. As a framework created to seek answers to research questions, structured questionnaire design is used as the major instrument of data collection. The structured close-ended questions were meant to enable respondents give straight forward and precise answers, rather than answering vaguely or inappropriately. This is basically targeted to facilitate easy recording, coding and analysis of data. The questionnaire was divided into two segments. While the first segment targeted responses on demographic statistics of respondents; the second segment sought to generate information geared towards providing answers to the research questions. To ensure an indebt study/analysis of audience response to media campaign on the importance of breastfeeding practice among mothers in Arochukwu, 220 (lactating) mothers were chosen from seven (7) health centers in Arochukwu community, representing the population of the study. These centers include: (i.) Arochukwu General Hospital [Ibom-Barracks] [Amannagwu]. The choice of these health centers as focal points in the study borders on accessibility of the target audience (nursing mothers); since they usually frequent the centers for their various prenatal and postnatal/postpartum medical attentions/check-ups. Out of a total number of 220 questionnaires distributed, 185 responses were duly and adequately returned. A breakdown of the population shows that 26 mothers were chosen from each of the six health centers, while 29 mothers were chosen from Arochukwu General Hospital (Ibom-barracks). The data in table 1 above on marital status shows that a majority of 158 respondents representing 85% of the population study are married; while 25 respondents representing 14% are single mothers. The remaining 2 respondents representing 1% are mothers that did not indicate their marital status. Therefore, it is evident from this result that the dominant respondents in this study are married.

RESULTS Demographic Data
On age distribution, data reveals that closely related number of 63 and 50 mothers representing 34% and 27% of the population study are within the age range of 32 -38 and 39 -44 years respectively; indicating, therefore, that the dominant age bracket of the research respondents are young mothers, which confirms the views of the EBF school of thought, La Leche League International (LLL), the oldest and largest breastfeeding support group in the world (Federico, 2017), that young mothers are the most dominant caregivers in the world. Unarguably, these groups of mothers have significant influence to the outcome of this study. Other significant age groups worthy of consideration as shown in the result are mothers within the age range of 45 years and above (these are 30 in number representing 16% of the population study) and those within 25 -31years (these are 24 in number representing 13% of the population study). While the later shows a group of very young mothers, the former shows a group of mothers with the needed experience for child or infant breastfeeding and upbringing. A number of 14 respondents representing 8% of the population study and 19 -24 years age bracket make up the age group of mothers with little or no experience of motherhood; and all this has so much implication for the study.
The occupational distribution of respondents shows that a dominant number of 118 respondents representing 64% of the population study are in the civil service; while 49 respondents representing approximately 26% of the population study are into trading. This clearly shows that majority of them are engaged in meaningful activities that would enable them foster for the well-being of their infants and family at large. On the other hand, 12 respondents representing approximately 7% of the population study are jobless and can be regarded as full house wives who depend on their husbands for the provision of child and family needs. Only 4 respondents representing 2% of the population study are students, while the remaining 2 respondents representing 1% percent of the population study did not indicate their occupational status.
On educational qualification, the result shows that a number of 72 respondents representing 39% of the population study possess either a diploma or NCE educational certificate; while 43 respondents representing 23% possess only secondary school certificate. 52 respondents representing 28% of the population study are mothers who possess a BA, BSC or HND certificate. 5 and 7 respondents representing 3% and 4% of the population study respectively have primary school and MSC/MA/PhD certificates respectively. 4 respondents representing 2% of the population study are mothers who acquired non-formal education. 2 respondents representing 1% of the population study are mothers who did not indicate their educational qualification. From the above table, it is apparent that almost 90% of the mothers have obtained at least one level of educational qualification or the other. This makes it easier to assume that they would be rationale or able to show a level of reasoning with regard to child breastfeeding practices. It therefore implies that the respondents only lack the necessary enlightenment since they have the capacity to read, write and listen to messages on issues regarding BF practice. This finding, however, does not agree with the views of Ogbonna, Okolo, and Ezeogu (2000) who opined that lack of education is a major factor contributory to low rate of EBF practice.

Response to Research Questions
The first research question raised the issue of the importance of breastfeeding to the infant. The result as shown in Figure 1 above reveals that an overwhelming 95% of the population study representing a total number of 176 respondents affirmed that breastfeeding is the ideal or main source of food for infants; while an infinitesimal 3% representing 6 respondents disagreed. The other 2% representing 3 respondents did not indicate their answer to the question at all. Analysis of the result clearly reveals that majority of respondents were in affirmation that breast milk is very much ideal for all infants, as rightly postulated by WHO (2002) and UN1CEF (2010).
Similarly, Figure 2 above shows that an overwhelming 86% of the population study representing a total number of 160 respondents affirmed that breastfeeding is as good to mothers as it is to their babies; while an insignificant 10% representing a number of 18 respondents disagreed to/with this. The other 4% representing a number of 7 respondents were rather uncertain, Yes and therefore, did not answer the question. This result goes a long way to confirm that as long as mother and child are concerned, breastfeeding has two-fold benefit; it is as good to the mother as it is to the child which corroborates the submissions of UNICEF (2010) and WHO (2002).
The result in Figure 3 above also shows that a majority 57% of the population study representing a total number 106 respondents affirmed that civilisation or new cultural ideas has taken a great toll on breastfeeding reduction rate; while the other 43% representing a number of 79 respondents were in opposition to the views of former. It is only obvious from the above statistics that majority of the mothers believe that civilisation or new cultural ideas has actually reduced breastfeeding rate among mothers in Arochukwu which also agrees with the postulation of Ogbonna, et al. (2000) that cultural factors actually militate against breastfeeding rate.
The result shown in Figure 4 above indicates that a dominant 57% of the population study representing a total number of 106 respondents agreed that the effect of social perceptions and lack of education has actually caused many women in Arochukwu to neglect breastfeeding practice. However, 34% of the population representing a number of 63 respondents disagreed with the former's view; while the other 9% representing a number of 16 respondents were rather irresolute about the answer. From the above result analysis, it is only clear that majority of the mothers subscribe to the influence of social perception and lack of education as constituting the reasons why women neglect breastfeeding practice, as highlighted by Andrea, Jaziel and Kelsie (2020) regarding breastfeeding trends, influences, and perceptions.
The result in Figure 5 above shows that an overwhelming 97% of the population study representing a total number of 180 respondents agreed that the media campaign contributed to their clear perception of the importance of Yes breastfeeding practice. On the other hand, an infinitesimal 2% representing a number of 4 respondents disagreed; while the other 1% representing one (1) respondent was rather uncertain. This finding is in tandem with the assertion of Wabwire, et al. (2016, p.40) that "media campaigns are central to people's ability to acquire knowledge for better health" and also reinforces the belief of the researchers that the media, indeed, have vital role to play in the campaign on the importance of breastfeeding practice. Figure 6 above shows that an overwhelming number of 127 respondents representing 69% of the population study affirmed that antenatal and poster media enhanced their comprehension of the breastfeeding message. This is followed by a less comparative 28 respondents representing 15% who chose television and another of 24 respondents representing 13% who chose radio respectively as having enhanced their understanding of the breastfeeding message; while for the other 6 respondents representing 3% of the population, their enhancement of the breastfeeding message came from a combination of the newspaper, magazine or books they have read. The result ultimately shows that mothers and pregnant women in Arochukwu get clearer and wider understanding of the breastfeeding practice message mostly through antenatal as well as from illustrative posters that are also usually translated from English to the indigenous language of the people. More so, it was also understood from further interaction with the study participants that the group/interpersonal communication platform of the antenatal channel and its interactive nature which facilitated instant feedback from instructors, as well as the accompanying"moral support", is what gave it so much edge over the other communication channels. This position is supported by Piro and Ahmed (2020), who affirm that literature supports positive effectiveness of antenatal education on increasing breastfeeding self-efficacy (BSE) which refers to a mother's confidence in her capability to breastfeed her infant (Dennis, 1999). Hence, the overwhelming response in favour of the antenatal and poster media as having enhanced their comprehension of the breastfeeding message is not surprising.

CONCLUSIONS
The study, which reviewed audience response to media campaign on the importance of breastfeeding practice among mothers in Arochukwu, also reinforces the importance of the interrelationship between communication and development, and the fact that the process of communication can be effectively applied to achieve development purpose through a systematic way of informing and creating awareness among the people, and in educating and enlightening them. Effort was also made to highlight the vital role of breastfeeding in the formative years of infants' life as well as its benefit to mothers, amidst the rather worrisome trend of its prevailing neglect among most nursing mothers, despite these accruing benefits. Major findings reveal that there is a connection between the influence of social perceptions and lack of proper awareness as part of the reasons why women in Arochukwu neglect breastfeeding practice. The study shows that the media remain 'a vital force' in the campaign for breastfeeding practice, and concludes that with adequate media campaign strategy, lactating mothers (including prospective ones) can demonstrate good knowledge and positive attitudes towards breastfeeding practice. The study, therefore, provides evidence that may be useful for media houses, parents, voluntary agencies and various stakeholders in the health sector as well as policy makers to harness the aroused consciousness of the need for concerted effort in addressing this key challenge of non-adherence to breastfeeding practice facing mothers generally; and young mothers in particular.

Recommendations
Based on the findings of this study, the researchers advance the following recommendations:  Efforts should always be made by media campaigners to appropriately select and utilise suitable media channels, including antenatal, for effective realization of objectives.  Mass media campaigns to promote breastfeeding practice may be more effective if they are linked with counseling by health providers.  Policies aimed at improving breastfeeding uptake and practice should also incorporate significant others (grandmothers, mothers-in-law, and husbands) in the process to encourage breastfeeding mothers.  There should be involvement of influential household members and others who act as gatekeepers of cultural beliefs.  There is need also for the mobilization/incorporation of community leaders as change agents by health authorities in the campaign for the promotion of breastfeeding practice.

13%
15% 69% 3% Figure 6. RQ 6 : Which of this set of media has mostly enhanced your understanding of the BF message? Radio