Breast-milk substitute marketing practices in four countries: an analysis using a community-based approach.

Background: This quantitative study engaged volunteer participants and a scavenger hunt application with the purpose of collecting photographic data of the breadth and scope of violations of the World Health Organization's Code of Marketing of Breast-milk Substitutes ("the Code") and subsequent World Health Assembly Resolutions, in four industrialized countries- the United States ("U.S."), Canada, Australia and the United Kingdom ("U.K."). These four countries do not have or do not adequately enforce their related polices or laws. A secondary goal was to provide evidence to inform national strategic planning efforts related to the marketing practices of manufacturers and distributors of breast-milk substitutes (BMS).

Methods: Participants had to be residents of either the U.S., Australia, Canada or the U.K., and had to be 18 years old at minimum. They were recruited via social media, conference attendance and professional networks. Participants completed a demographic survey and downloaded the scavenger hunt application onto their mobile devices. The application directed participants to fulfill as many of the thirty total "missions," which were provided by the research team, by uploading photographic evidence of images that they believed were examples of breaches of the Code. Data collection occurred from July 19, 2023 through July 31, 2024. The research team assessed, recategorized and calculated the numbers of participant submissions after the data collection phase. The Statistical Package for the Social Sciences software was utilized to conduct descriptive statistics, including Pearson's chi-squared and residuals.

Results: In total, 738 individuals were eligible and consented to participation in the study. Of those individuals, 323 continued on to the scavenger hunt application. After evaluation by the research team to assess if participant submissions were submitted under the appropriate "mission" within the application, and then if their submission qualified as a true violation of the Code, 138 submitted violations were verified and included in the analysis. Key findings include the prevalence of digital marketing violations across all four countries, false, unsubstantiated marketing claims on BMS, a lack of key instructions on the preparation, handling and storage on labels of infant formula products and the marketing violations of BMS in healthcare facilities.

Conclusions: Breaches of the Code are prevalent across the U.S., the U.K., Australia and Canada and expose the public to misleading marketing tactics. To safeguard breastfeeding from exploitative digital marketing practices, countries must legislate the Code into national law and commit to its implementation through advocacy, policy and enactment.