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Tinjauan Sistematis: Pengaruh Perilaku Kebersihan dan Perawatan Kesehatan Lansia Systematic Review: The Impact Analysis and Implementation Policies of Exclusive Breastfeeding Programs

Background: Health promotion is an effort to improve the society's ability in order to make people empower themselves. Exclusive breastfeeding/ASI eksklusif is the practice of giving breast milk to infants for the first six months of life (without any additional food or water) a preventive intervention that addresses the single greatest potential impact on child mortality. Objective: To analyze the impact of the availability and unavailability of program policy that support exclusive breastfeeding in improving the implementation of exclusive breastfeeding policy. Method: The method used in this research was a systematic review technique. The process of searching for articles through Sagepub, Google, and Google Scholar. The keywords used were breastfeeding policy, breastfeeding policy and health promotion, breastfeeding health promotion, workplace breastfeeding policy, and maternity leaves starting from February 20, 2020, to April 15, 2020, and found 153 articles which were then sorted into 35 articles. The articles discussed the implementation of the exclusive breastfeeding program (10), the exclusive breastfeeding policy (12), and the impacts arising from the exclusive breastfeeding policy (13) with articles in Indonesian (10) and English (25). Results: The found policy that have not been implemented by the Indonesian government are policies that adopt the latest version of The International Code of Marketing of Breas Milk Substitutes. Weak implementation of follow-up on sanctions and fines if it violates applicable policy. Coclusion: The exclusive breastfeeding program carried out by Indonesia is still in the scope of classes for pregnant women, companion groups, exclusive breastfeeding socialization, and breastfeeding motivator training. Social, economic, and cultural factors are other supporting factors related to exclusive breastfeeding success.


INTRODUCTION
The definition of health promotion, based on Indonesia's Ministry of Health, is an effort to enhance society's ability to control the health factors through learning by, from, for, and with the people. It is expected that society can help and empower themselves, develop activities using their own resources according to socio-cultural applied, and supported by public policies related to health (Susilowati, 2016).
The 65 th World Health Assembly (WHA) supported the Comprehensive Implementation of the Maternal, Infant and Child Nutrition Plan which includes six global targets. These targets aim to reduce stunting and wasting in children under 5 years, stop the obesity epidemic, and reduce anemia in fertile age women. Other targets include reducing low birth weight and increasing rates of exclusive breastfeeding. Global targets are set to identify priority areas, inspire ambition at the country level and develop accountability frameworks (World Health Organization and UNICEF, 2019).
Exclusive breastfeeding can be defined as the practice of giving only breast milk to an infant for the first six months of life (without additional food or other water). Exclusive breastfeeding is a preventive intervention to deal with the greatest potential impact on child mortality. The optimal part about breastfeeding practice is to start with the initiation within one hour of life. Followed by breastfeeding until the age of two years or more. Exclusive breastfeeding is the cornerstone of the child's survival and health. Breast milk can provide essential and irreplaceable nutrients for the growth and development of children (Heymann and Earle, 2013).
Breastfeeding benefits for both women and infants. Women who are breastfeeding can provide a longer interval between birth and subsequent pregnancies, therefore, the risk of maternal morbidity and mortality rate will be lower. Breastfeedi'ng can reduce the risk of breast cancer before menopause as well as the risk of ovarian cancer, osteoporosis, and coronary heart disease (Heymann and Earle, 2013).
By 2025, WHO targets to increase exclusive breastfeeding in the first six months by up to 50%. This target indicates that the current global average, estimated at 37% for the period 2006-2010, will increase to 50% by 2025. This target would involve a relative increase of 2.3% per year and could result in an estimated more than 10 million children get exclusive breastfeeding until the age of six months. Global rates of exclusive breastfeeding increased from 14% to 38% from 1985 to 1995. Increases in rates of exclusive breastfeeding often exceed the proposed global targets. For example, Cambodia saw an increase from 12% to 60% between 2000and 2005, Mali from 8% to 38% between 1996and 2006, and Peru from 33% to 64% between 1992and 2007(WHO, 2014. The WHA Global Nutrition Targets 2025 define a number of targets in an effort to increase exclusive breastfeeding for infants. The first target is to provide the capacity of hospitals and health facilities to support exclusive breastfeeding, including revitalizing, expanding, and institutionalizing babyfriendly hospital initiatives in the health system. Second, providing a communitybased strategy to support exclusive breastfeeding, including the implementation of a communication campaign tailored to the local context. Third, limiting the marketing of breast milk substitutes by strengthening monitoring, law enforcement, and legislation related to The International Code of Marketing of Breast Milk Substitutes and the World Health Assembly resolutions. The fourth target is to empower women to breastfeed exclusively by imposing six months of mandatory maternity leave and policies that encourage women to breastfeed in the workplace and in public. Fifth, invest in training and capacity building exclusively for the protection, promotion and support of exclusive breastfeeding (Lyell, 2012).
WHA Global Nutrition Targets 2025 intend that countries should enact policies that protect and support women in their efforts to exclusively breastfeed their children. Evidence shows that longer maternity leave has an impact on the longer duration of exclusive breastfeeding. The effects may be limited in countries where women are predominantly employed in the informal sector. Six months of maternity leave allows women to continue breastfeeding for longer without having to choose between earning an income and providing the best nutrition for their infants (Lyell, 2012).
The International Code of Marketing of Breast Milk Substitutes and the World Health Assembly resolutions involve the enforcement, enforcement and monitoring of relevant legislation. Aims to protect and ensure the proper use of breast milk substitutes. Restrictions on the marketing and distribution of breast milk substitutes. The policy includes a ban on the promotion of breast milk substitutes, milk bottles and pacifiers. Countries with strong policies regarding enforcement of protection against the marketing of breast milk substitutes have higher rates of exclusive breastfeeding. Policy monitoring and enforcement engages legislative bodies and government agencies to negotiate, defend trade agreements, and regulate labeling and marketing (Lyell, 2012).
According to the theory of the Implementation Model by George C. Edward III, it discusses factors about the successful implementation of a policy. A policy will be successful with factors including communication, resources, disposition, and bureaucratic structures that interact and support each other in a program policy. Amongst the four factors, the one that can be analyzed, both in terms of stakeholders and working mothers is called resource factors (Tasrin, 2018).
The purpose of conducting this review is to analyze the impact of the availability and unavailability of program policies that support exclusive breastfeeding in enhancing the implementation of exclusive breastfeeding policies. Through the results of this review, he hopes to create exclusive breastfeeding policies and programs that are able to support mothers in exclusive breastfeeding for the first 6 months. Especially for working mothers as one of the factors that can affect the quality and success of exclusive breastfeeding. Moreover, WHO and WHA Nutrition Targets 2025 have regulated a number of policies which are expected to make it easier for mothers to exclusively breastfeed.

METHOD
The method used in this study was by implementing a systematic review technique. The process of searching for articles was through Sagepub, Google, and Google Scholar. The keywords used are breastfeeding policy, breastfeeding policy and health promotion, breastfeeding health promotion, breastfeeding policy in a workplace, and maternity leave. Article searches were conducted from February 20, 2020 to April 15, 2020. Search for articles and review articles based on the articles that have been found.
A total of 153 articles discussing the implementation of exclusive breastfeeding policies. The article was published by the World Health Organization (WHO), the WHA global international target, the Indonesian Ministry of Health, the International Labor Organization (ILO), the International Conference on Applied Science and Health (ICASH), and the Lancet article to identify studies examining the policy impact of program implementation of exclusive breastfeeding.
82 Jurnal Promkes: The Indonesian Journal of Health Promotion and Health Education Vol. 9 No. 1, March 2021, 79-90 doi: 10.20473/jpk.V9.I1.2021. First-party review authors (MTN) took articles based on potentially relevant categories of titles, abstracts, and discussion content and independently assessed the feasibility of the study using pre-determined inclusion criteria. Firstparty review authors (MTN) classify relevant articles, then consult with second party (OS) authors in determining which articles are appropriate for inclusion in the discussion.
A total of 153 articles were found, then selected 35 articles that discuss the impact of exclusive breastfeeding policies. The article was identified into three reviews that discussed the implementation of an exclusive breastfeeding policy (12), an exclusive breastfeeding program (10), and the impact of the implementation of an exclusive breastfeeding policy (13). The articles consist of articles in Indonesian (10) and English (25). Inclusion criteria were determined by selecting all case study articles, literature reviews, systematic reviews, cross-sectional, qualitative, quantitative, and mixedmethod studies. The topics discussed were exclusive breastfeeding policies, exclusive breastfeeding implementation programs, and the impact of the implementation of exclusive breastfeeding policies and programs. Articles were accessed through articles in Indonesian and English. Articles that are not available in Indonesian and English would be excluded.

RESULTS AND DISCUSSION
The review author screened 153 identified titles. A total of 72 articles were selected for full review based on their titles and abstracts. Seventy-two articles were identified and 35 articles fit the inclusion criteria that have been determined. Among them, exclusive breastfeeding policy (12), the exclusive breastfeeding program (10), and the impact of the implementation of the exclusive breastfeeding policy (13) were discussed. The articles consisted of articles in Indonesian (10) and English (25). The articles taken in publication year between 2010 and 2020. The methods used by the article include case studies, literature reviews, systematic reviews, cross-sectional, qualitative, quantitative, and mix-method studies. The topics discussed were exclusive breastfeeding policy, exclusive breastfeeding implementation programs, and the impact and influence of exclusive breastfeeding policy and program.
Articles were identified through database search with searching strategy (n = 153) Exclusion reason: delete duplicate (n=20) The identified unique articles and selected titles (n=133) Exclusion reason: irrelevant with the review (n=33) Articles were assessed based on the abstracts' requisition (n=100) Exclusion reason: irrelevant with the objective (n=28) The completed text article for requisition assessment (n=72)

Existing Policy
The formulation of strategies that will be used is very important in an effort to improve health status. Strategies related to the performance that will be carried out.
The performance improvement consists of several stages. First, starting with involving all levels of society then strengthening leadership and coordination in the team. Second, creating sustainable financing by building infrastructure and resources. Third, by integrating evidence, policy, and practice and increasing equality and justice (Lin and Fawkes, 2015). Studies have found that higher paid maternity leave increases the prevalence of exclusive breastfeeding and the length of breastfeeding in highincome countries. These findings cannot be generalized in low-and middle-income countries (Chai, Nandi and Heymann, 2018).
All citizens of the United Kingdom are legally entitled to free health care through the National Health Service (NHS) and formal support from pregnancy to breastfeeding by midwives (NHS) (Dawn Leeming, Iain Williamson, Sally Johnson, 2015). The government of health in Canada establishes health policies and programs to offer safe, cheap and optimal food supplies for both breastfeeding mothers and toddlers. These policies and programs are an effort to protect infants from malnutrition (Orr et al., 2018 (Walters et al., 2016).
Research conducted on a group of African-American mothers found that there is still a lack of support from the government, both from policies and the provision of health services in the workplace. This condition makes the mother ultimately choose not to exclusively breastfeed (Johnson, Kirk and Muzik, 2015). There are six main issues discussed, namely conceptual changes to breastfeeding choices, categorization of health losses due to not breastfeeding, and a focus on duration and exclusive breastfeeding (Eidelman, 2012) A New York City policy that explains that all local hospitals that provide maternity care have a written and documented policy on postnatal breastfeeding (Hawke, Dennison and Hisgen, 2013).
Maternity leave is defined as any part of what is recognized as the legislative provision of maternity protection. Maternity leave includes maternity leave, benefits, job protection, health protection, workplace breastfeeding arrangements, and child care. The ILO advocates for maternity benefits to be provided as part of the minimum basic social security coverage for working women who wish to breastfeed their children (Navarrorosenblatt, 2018).
The global policy for infant and young child feeding recommends that every workplace has access to full support for maintaining exclusive breastfeeding for up to 6 months complementary feeding, and breastfeeding for up to 2 years. The government is obliged to pass laws promoting the right to breastfeeding for women workers and instituting the means for implementation in accordance with international labor law (Soomro, 2015).
The exclusive breastfeeding policy in Canada is a human right that must be obtained by every citizen, without exception. Canada has laws that regulate female inmates who must exclusively breastfeed. The law stipulates that inmates can make a written statement through the commissioner to allow babies to stay with the prisoner. The government is obliged to provide facilities to have adequate accommodation for detainees to care for children (Paynter, 2018). In 2014, out of 55 countries that did not guarantee 86 Jurnal Promkes: The Indonesian Journal of Health Promotion and Health Education Vol. 9 No. 1, March 2021, 79-90 doi: 10.20473/jpk.V9.I1.2021. leave for exclusive breastfeeding mothers for the first 6 months after birth. Seven countries including Canada, Denmark, Finland, Gambia, Serbia, England and Iceland guarantee paid maternity leave. Such leave can also facilitate exclusive breastfeeding for the recommended 6 months (Atabay et al., 2015).
Taiwan stipulates that employers need to provide 8 weeks of maternity leave for female employees. The construction and implementation of breastfeeding-friendly policies in the workplace is still a new practice in Taiwan. The government encourages companies or industries to provide breastfeeding support services, such as rest, breast pumping, and lactation rooms. Employees must bring their own breast pumps. Employers allow working mothers to perform two breast-pumping every day with each break of no more than 30 minutes (Tsai, 2013).
Research conducted by Soomro, found that as many as 86% of respondents in Pakistan 86% that in some workplaces in Pakistan even though maternity leave still gets paid. Then 15% of the respondents stated that breastfeeding mothers get relief at work. And 12% of respondents stated that they got 1 hour to rest from 6-8 hours of work (Soomro et al., 2016).
There are policies in several states that have resulted, among others, laws for exempting breastfeeding from public pornography laws. Laws specifically allowing women to breastfeed in any public or private location. A law that exempts breastfeeding mothers from work. Laws implementing or encouraging the development of breastfeeding awareness education campaigns. Legislation requiring a reasonable time off from work to deliver breastmilk. Laws requiring private locations and sanitation for employees to pump their milk. Enforcement of workplace pumping laws and enforcement of public breastfeeding laws (Smith-gagen et al., 2020).
The International Code of Marketing of Breast Milk Substitutes has restricted the promotion of breastmilk substitutes, bottles, pacifiers and baby foods. The ban aims to support exclusive breastfeeding for infants up to 6 months. A literature study conducted in 2018 shows that Indonesia has not been able to adopt the latest version of the regulation of The International Code of Marketing of Breast Milk Substitutes. This condition is because it can hurt the feelings of mothers who cannot or choose not to provide exclusive breastfeeding and there are still several health facilities that support formula feeding (Pramono, 2018).

The Promotional Program of Exclusive Breastfeeding Health
Research conducted in 2019 found programs provided in the workplace in the USA such as the provision of lactation rooms (Kim, Shin and Donovan, 2019). Every employee who is breastfeeding has the right to get a breast pump facility from the company where they work. The workplace is obliged to provide temporary storage for breastmilk as well as telephone support and consultation for mothers seeking maternity leave. Workers are entitled to free lactation consultations from health workers who have been provided by the company. Comprehensive lactation programs have been shown to increase breastfeeding duration among mothers planning to breastfeed before maternity leave in upper middle-income families (Kim, Shin and Donovan, 2019).
Previous research states that there are several programs that have been launched by health centers and the Health Office to increase exclusive breastfeeding. The program includes classes for pregnant women, companion groups, exclusive breastfeeding outreach, and breastfeeding motivator training. The existence of this program is expected to increase exclusive breastfeeding for infants for 6 months (Ekawati, Parlindungan and Morita, 2015).

The Impact and Influence in Improving Program's Policy
A number of developing countries provide a large potential market for breastmilk substitutes. Collaboration through health workers is carried out to offer formula milk to mothers by giving gifts as bonuses for health workers (Soomro, 2015). Previous research has shown that the resources of health personnel with special expertise in health promotion are still limited. The manager of the health promotion/Promosi Kesehatan (Promkes) program also doubles as a Maternal and Child Health Polyclinic. This condition explains that the job analysis is not in accordance with the needs of the program, while the original personnel from public health are still in the orientation stage (Paramita et al., 2015).
The cost of a comprehensive lactation program is estimated at $500 per employee and $186 to provide a breast pump for one year (Kim, Shin and Donovan, 2019). There is an obstacle is the lack of budget funds specifically allocated for health promotion. Meanwhile, the Health Promotion itself receives funds from Health Operational Assistance if the program does not receive financial assistance from the health office (Paramita et al., 2015). Funds that are devoted to exclusive breastfeeding health promotion program activities do not yet exist, but these funds are combined with other activities and are also taken from BOK funds (Fitria, 2019).
Enhancing the exclusive breastfeeding program can be done in collaboration with health cadres, breastfeeding advisors and breastfeeding support groups in any health institution and community. There is a need for training related to management on how to communicate with peers and on targets. Collaboration between midwives, nurses and other health professionals has the potential to promote and support exclusive breastfeeding for 6 months. Promoting exclusive breastfeeding is family-centered which can help increase the education and awareness of breastfeeding mothers (Afiyanti and Juliastuti, 2017).
Compared with non-working mothers, the likelihood of stopping breastfeeding among working mothers was four times higher. A study from North India reported that 19% of women breastfeed for one hour and 5% of women exclusively breastfeed for six months (Kumar et al., 2015). Mothers who do not work are 24 times more likely to provide exclusive breastfeeding than mothers who work (Suliasih, Puspitasari and Pawestri, 2019).
The rate of breastfeeding in working mothers rapidly decreases after returning to work. A total of 635 subjects (88.8%) started breastfeeding at the start of maternity leave. The rate of continuing breastfeeding rapidly decreased after returning to work (49.8%). Nearly 39% of working mothers stop breastfeeding within 1 month of returning to work. As many as 7.6% of these women continued to breastfeed for more than 1 year, even if a lactation room was available (Tsai, 2013).
Exclusive breastfeeding in Canada from 1920 to 1960 was lower than it is today. There is an emphasis on scientific knowledge about infant feeding and the use of formulas as a remedy for common childhood illnesses. Since 1970, mothers who provide exclusive breastfeeding have increased consistently, reaching 25-65%. The reason is the increased interest and international advocacy and knowledge of mothers related to breastfeeding (Waddington, 2016).
Mothers aged 25-30 years old are 16 times more likely to provide exclusive breastfeeding than those aged> 30 years (Suliasih, Puspitasari and Pawestri, 2019). Thirty years old mothers give their infants breastfeeding exclusively, while 24 years old mothers do not exclusively breastfeed (Fikawati and Syafiq, 2010).
A number of mothers decide to exclusively breastfeed and try to do it during pregnancy. Exclusive breastfeeding for 6 months is not the norm. Most mothers provide breast milk in combination with formula milk. Many mothers decide to provide exclusive breastfeeding based on their previous breastfeeding experience. Breastfeeding is a learned behavior for both babies and mothers.
Prenatal and postnatal guidelines should be provided about what to expect and how to deal with the challenges that might occur (Francis et al., 2020). Lack of breastfeeding, sore nipples, and previous experiences in children are one of the reasons for the discontinuation of exclusive breastfeeding in several countries. These include Malaysia, America and Australia (Eidelman, 2012).
There are determinants, both direct and indirect. Direct determinants, such as mothers' anxiety about meeting the nutritional needs of their babies and about the baby's satiety and anxiety about the mother's own nutrition. There are indirect determinants such as infant feeding by family members and maternal perceptions of infant feeding norms (Safon et al., 2017).
The majority of respondents, namely 47% stated that they intend to provide exclusive breastfeeding on the 88 Jurnal Promkes: The Indonesian Journal of Health Promotion and Health Education Vol. 9 No. 1, March 2021, 79-90 doi: 10.20473/jpk.V9.I1.2021. grounds that breastfeeding has many benefits and is good for both mother and baby. As many as 25% said they did not intend to provide exclusive breastfeeding because they did not have experience with previous children, working mothers, and the mother's understanding of the baby would not be full if only from breast milk (Yusrina and Devy, 2017).
The breastfeeding gap experienced by low-income women is caused by individual, social and environmental factors. The prevalence of breastfeeding among women enrolled in the Women, Infants, and Children (WIC) Program, is below the national target set in Healthy People 2020. Nationally, mothers enrolled in the Women, Infants, and Children (WIC) Program have breastfeeding rates lower than non-members of Women, Infants, and Children (WIC). Women, Infants, and Children (WIC) continue to strive to encourage breastfeeding through the Loving Support Makes Workfeeding Work campaign and the WIC Peer Counseling Program (Lauer et al., 2019).
Some mothers decide to stop exclusive breastfeeding during the first postpartum month. The influence of mothers' fear of being "deprived" of milk, milk that fails to "come out", and not being able to satisfy their babies with their own milk. Added to this is the influence of family members such as mothers, grandmothers, or mothers-inlaw as a factor in deciding to introduce breastmilk substitutes or complementary foods (Safon et al., 2017).
Parents who provide exclusive breastfeeding for their children will experience negative psychosocial impacts from social stigma. Strong partner support with a positive emotional response can increase exclusive breastfeeding (Schafer, 2018). The strength of support from the family can increase the enthusiasm of the mother in giving breastfeeding exclusively. The success of exclusive breastfeeding is influenced by family, especially husband, parents, family, friends, neighbors and the environment (Handajani, Pamungkasari and Budihastuti, 2018). Social and family support are more important components of the social environment than the physical environment (Morteza, Shokouh and Arab, 2017). Husband's support can increase efforts to breastfeed early after childbirth (Bich et al., 2016). Support from health workers is closely related to the emergence of a mother's confidence in giving exclusive breastfeeding to her child (Ingram et al., 2015). As many as 91.5% of the respondents did not get neonatal visits from health workers. Mothers who received neonatal visits by health workers on the seventh day did not get information about how and when to breastfeed (Amran and Afni Amran, 2015).

CONCLUSION
It was found that policies that have not been implemented by the Indonesian government are policies that adopt the latest version of The International Code of Marketing of Breast Milk Substitutes. Weak implementation of follow-up of sanctions and fines if it violates applicable policies. The exclusive breastfeeding program carried out by Indonesia is still in the scope of classes for pregnant women, companion groups, exclusive breastfeeding socialization, and breastfeeding motivator training. Social, economic and cultural factors are other supporting factors related to the success of exclusive breastfeeding.
It is expected that in the future, Indonesian government will be able to combine all sectors to adopt the latest version of the regulation of The International Code of Marketing of Breast Milk Substitutes, especially in affirming the follow-up of sanctions and fines if they violate the exclusive breastfeeding policy. Indonesian government is able to adopt comprehensive programs such as providing breast pump facilities, storage of breast milk, consultation on maternity leave, and free lactation consultations from health workers from workplaces. This comprehensive program has been shown to increase breastfeeding duration. It is hoped that the Indonesian government will be able to collaborate between sectors in dealing with social, economic and cultural factors which are other supporting factors related to the success of exclusive breastfeeding.