Prospective primary teachers´ knowledge about breastfeeding as part of scientific literacy

Journal of Turkish Science Education, 2025, 22(1), 87-105. DOI no: 10.36681/tused.2025.006 © 2025 Fırtına Akademi A.Ş. All rights reserved. This article published by TUSED is released under the CC BY-NC-ND license. Prospective primary teachers´ knowledge about breastfeeding as part of scientific literacy Mireia Illescas-Navarro1, Marta Cruz-Guzmán2, Ana María Criado3 and Antonio García-Carmona4 1Universidad de Sevilla, Spain, Corresponding autor, [email protected], ORCID ID: 0000-0002-47872274 2Universidad de Sevilla, Spain, ORCID ID: 0000-0003-0018-3620 3Universidad de Sevilla, Spain, ORCID ID: 0000-0002-6224-9253 4Universidad de Sevilla, Spain, ORCID ID: 0000-0001-5952-0340 ARTICLE INFORMATION Received: 03.04.2024 Accepted: 25.07.2024 Available Online: 13.03.2025 KEYWORDS: Breastfeeding, health education, primary education, science education, teacher education. To cite this article: Illescas-Navarro, M., Cruz-Guzmán, M., Criado, A. M., & García-Carmona, A. (2025). Prospective primary teachers´ knowledge about breastfeeding as part of scientific literacy. Journal of Turkish Science Education, 22(1), 87-105. DOI no: 10.36681/tused.2025.006 Introduction Food practices are often socialised and entrenched as being habits difficult to modify (Rodríguez, 2012; Monterrosa et al., 2019). They are adopted as part of a community's traditions, taboos and beliefs; therefore, they are instituted as something cultural that integrates many misinformed ideas and misbeliefs (Kalnina et al., 2022). And this, without doubt, is an obstacle against changing citizens' eating habits to ones that are healthier (Martínez, 2015; Nsiah-Asamoah et al., 2020; Padró, 2020). There is scientific consensus about the advisability of starting breastfeeding (BF) infants during their first hour of life (WHO, 2009). Also, exclusive BF of infants is recommended until they are six months old, and then supplementing this with other foods for however long the mother and infant desire (WHO, 2021, 2023). The practice of BF is proven to have protective effects on the health of both mother and child (Van Acker & Bakker, 2012; Zalewski et al., 2017) and thus society. However, as with ABSTRACT The conceptions that prospective primary teachers (PPTs) have about breastfeeding (BF) were explored as part of their training in school content related to health and the human body. For this, the PPTs answered a questionnaire designed ad hoc, without having received any prior training about the topic. The questionnaire had previously been validated by a panel of experts made up of midwives and researchers in science education. The results show that the PPTs have poorly informed ideas about both the biological processes associated with the genesis of breastmilk and the effects of BF on the mother and infant. Those ideas largely coincide with those of the rest of society (e.g., believing that there are women who produce milk that has insufficient nutritional value for their infants). The results are discussed with the goal of improving PPTs' scientificdidactic training about BF as a topic of scientific, social and environmental importance. Journal of Turkish Science Education 88 other feeding habits, the choice to breastfeed is also influenced by social and cultural factors (Jamie, 2020; Kong & Lee, 2004; Villalobos et al., 2021; Wanjohi et al., 2016) and, in many cases, these are more decisive than scientific factors. The human species is included within the Class Mammalia. Breastfeeding is therefore the natural way to feed human infants (Aguayo-Maldonado et al., 2008; Brines & Billeaud., 2021). But, given that these benefits of breastfeeding, according to science, do not seem to be sufficient or more influential than social or cultural reasons to convince mothers to choose to breastfeed their babies, it is necessary to address this in science education. This should be a subject of study in science education from an early age. Healthy eating is content and/or a basic context for science education. This is stated, for example, in Spain's primary education curriculum (Royal Decree 157/2022), as well as in the international theoretical frameworks for science education TIMSS 2019 (International Study Centre, 2017) and PISA (OECD, 2019). Health is also considered to be a paradigmatic socio-scientific issue in science education (Sibic & Topcu, 2020; Zeyer, 2013). Furthermore, the practice of breastfeeding also contributes to the protection of the environment, avoiding the residues and the carbon footprint produced due to the formula milk consumption, which is why breastfeeding is a central part of the 2030 Agenda for Sustainable Development and is related to many of the Sustainable Development Goals (SDGs) (Katsinde & Srinivas, 2016). Given that formal education in school may contribute to the scientific and cultural literacy, a promotional approach to breastfeeding at the level of primary education seems adequate in order to promote healthy practices, as BF (Galvão & Silva, 2013). Based on this and the virtual absence of previous studies on the issue (Palma-Jiménez et al., 2023, 2024), the objective of this research is to explore the prior knowledge of prospective primary teachers (PPTs) about BF, as a first step, to obtain information to guide the future design of proposals for the training of PPTs about this topic. If socio-scientific issues have to be treated as science centres in schools (Yun et al., 2022), teachers have to be formed in their initial training. Literature Review Scientific Literacy about Healthy Infant Nutrition Food literacy is the set of fundamental knowledge, skills and attitudes about food and nutrition. With this set of knowledge individuals can adopt a healthy diet in an autonomous and reflective way, adapted to their capabilities, needs, and resources. It is a subject closely linked to the values and habits rooted in common knowledge (Cullen et al., 2015; España et al., 2014; Nanayakkara et al., 2017). Therefore, food literacy should facilitate the acquisition of skills for the proper use of the information in a critical and responsible manner (Slater et al., 2018) from both a personal and a social perspective. It would thus be possible from the teaching of the sciences to promote and consolidate appropriate and healthy behaviour through the health literacy of teachers (Banet, 2004; Lamanauskas & Augienė, 2019). From there, the promotion of BF through education, among other areas of action, is one of the four pillars of the prevention of childhood obesity in the Region of Andalusia, southern Spain (Junta de Andalucía, 2021). However, it is also a worldwide concern, especially because obesity is associated with low-level socioeconomic situations and with some minority groups (Lobstein, 2015). That is why it must be a priority of collective responsibility for families, health professionals and teachers. Specifically, the notion of food literacy is included in international scientific literacy frameworks. For example, the latest PISA theoretical framework for assessing scientific competency (OECD, 2019) establishes the issue of nutrition and healthy eating as a context and content with which to develop that competency. Likewise, in the TIMSS Science Framework (International Study Centre, 2017), within the block of human health, emphasis is placed on describing the daily behaviour that favours good health, including those aspects related to diet. Therefore, it is necessary for teachers to have the appropriate knowledge to teach about this issue (Bahamonde & Pujol, 2005; Coccia et al., Illescas-Navarro, Cruz-Guzmán, Criado & García-Carmona, 2025 89 2020; De Jong et al., 1998; Schibeci & Hickey, 2000). With regard to primary education teachers, in Spain the lack of adequate training about healthy eating has been noted for years. De la Cruz (2021) interviewed six experts in nutrition-medicine, three university teachers and three classroom teachers. Among the findings, an educational reality was expressed by the existence of teachers with a lack of training and limited resources; and aspects linked to the curriculum, management and public policies that limit the scope of Food and Nutrition Education. Rodrigo et al. (2014) studied the knowledge of students (183 potential future primary school teachers and 216 primary care nurses) about food and its dietary functions as a basis for improving their dietary education. The authors found that initially the students revealed conceptual gaps on basic food issues, but didactic actions significantly enhanced their knowledge, so they claim for the introduction of some kind of food literacy in teacher and nurse training curricula. This could result in improvements in their future educational and guidance functions for the population in which they work and even for themselves. Health education is included in the basic curriculum for primary education in Spain (Royal Decree 157/2022). However, it is not carried out in a consistent and integrated way (González, 2009; Charro-Huerga & Charro, 2017). This situation has for years been denounced in scientific and educational areas. Among other issues, there is the suggestion for children to be educated in the normality of BF (Angell et al., 2011; Singletary et al., 2017; Stuart-Macadam & Dettwyler, 1995). It is noted that there is a need for teachers, with the support of health professionals, to implement educational measures for their pupils to know about BF in the promotion of health. (Galvão & Silva, 2011). Additionally, there is evidence that prior learning experience is useful for children to apply their reasoning skills when responding to socially context-based problems in their biology learning: the students were able to generate justifications towards the issue using rationalistic thought (Subiantoro et al., 2023). Science education is a propitious scenario for this purpose, given its connection with health education (Harrison, 2005). Let us now look at the status of the issue regarding the knowledge of PPTs on infant feeding, specifically BF. Antecedents in the Diagnosis of Conceptions about Food in Infancy Mothers' knowledge influences the type of feeding chosen during infancy and how long they will breastfeed (Suárez-Cotelo et al., 2019). Given the social and economic context, women of previous generations perceived their body's ability to breastfeed ambiguously (Pallás-Alonso, 2006) since they did not have adequate family and health support to establish satisfactory BF. Therefore, despite the fact that most mothers have the intention to breastfeed, fewer than half of them manage to keep it up over time (Suárez-Cotelo, 2019; Ministerio de Sanidad, 2018). There is an ample bibliography about BF. However, there remain the erroneous beliefs that have classically been part of the population's knowledge regarding this topic, and which tend to hinder the practice of BF (Wahren & De Cunto, 2004; Kim et al., 2017; Padró, 2020; Vargas-Zarate et al., 2020). Some of those misconceptions are: the conviction of equivalence between artificial milk and BF (Koura, 2019); restrictions imposed, often without malice, by medical or family advice on the duration of BF (Nsiah-Asamoah et al., 2020); decreased nutritional capacity of breastmilk, depending on the time elapsed or the type of woman (Davanzo, 2018; Koura, 2019; Padró, 2020); association between small size of the breast and low milk production capacity (Koura, 2019); and ignorance of the effects of BF on health (Hamade et al., 2014; Palomino, 2020). In the few studies carried out with PPTs about this topic, it has been observed that they present difficulties in assigning the function or the type of nutrients that breastmilk contains (Rodrigo & Ejeda, 2009). In addition, PPTs require domain-scientific knowledge to construct and critique arguments about BF (Palma-Jiménez et al., 2023). PPTs also have a lack of knowledge regarding scientific and social aspects of current issues, such as BF (Kokolaki & Stavrou, 2023). For practising biology teachers, a study addressed their biological knowledge and social aspects related to BF (Subiantoro et al., 2021) and concluded that teaching based on socio-scientific issues such as BF improved students' understanding of scientific and social topics. Journal of Turkish Science Education 90 Furthermore, the PPT’s understanding of specific processes related to BF, including the production of breastmilk, is hampered by this lack of understanding of how the human body works as a system. The reason for this is the usual fragmentation when dealing with concepts about the human body in class, where the focus is on the anatomical rather than the functional aspects, as well as the disconnection of this knowledge with everyday life and with health (Charro-Huerga, 2016; Uskola et al., 2022). A lack of knowledge about female anatomy has been detected in secondary students and preservice teachers (Ortuzar-Iragorri et al., 2024; Pozo et al., 2014). It has also been found that primary education teachers tend to be unaware of the effects of BF on the health of the mother and infant (Jiménez, 2016), although they have been found to be willing to incorporate BF into their teaching (Moukarzel et al., 2019; Singletary et al., 2017). In summary, the reviewed literature shows scarce evidence of BF coverage in initial training of primary teachers. It also indicates the need to educate in competencies using socio-scientific issues. The originality of this work lies in the exploration of the PPT´s initial conceptions about BF. This is the first step to train PPTs in the topic. Aims of the Research and Research Questions The aim of this study is to measure what knowledge the PPTs already have about food literacy as the set of fundamental skills, knowledge and attitudes about food and nutrition. In view of the above, and aware of the need to provide PPTs with basic training about BF, this diagnostic study was carried out, guided by the following research questions: (RQ1) What is the PPTs knowledge regarding health implications of BF? (RQ2) What is the PPTs knowledge concerning the human body in relation to BF? Methods Research Design The research consists of an exploratory and descriptive study that aims to survey the knowledge of future teachers about breastfeeding and thus delimit the training needs they present. For this purpose, health as well as didactic experts were consulted, and a questionnaire was designed and used. Participants and Context The sample consisted of 102 PPTs who were studying the subject Didactics of the Experimental Sciences, of a compulsory and annual character, belonging to the 2nd year of the degree of Primary Education (Grado en Educación Primaria) at Seville University (Spain). The sample was chosen for convenience due to the researchers' possibilities of accessing the PPTs during the study. The age range of the participants was between 19 and 28 years (20 years mean), and 80% were women. The objectives of the subject, Didactics of the Experimental Sciences, was for the PPTs to acquire basic formation about (i) the purposes of science education in primary education, (ii) the value of knowing the pupils' ideas about natural phenomena, (iii) the content of school science for primary education, among which are emphasised those related to food and (iv) the design of didactic proposals to teach science in primary education. The present study was implemented before the PPTs had addressed points (iii) and (iv) in class. Illescas-Navarro, Cruz-Guzmán, Criado & García-Carmona, 2025 91 Design and Validation of the Instrument Delphi technique was used, due to the need to obtain expert opinions and to triangulate the points of view of the different groups (Mengual-Andrés et al., 2016). This structured communication framework allowed the development of the instrument to gather PPT’s knowledge. A questionnaire was designed to obtain ideas from PPTs, which was submitted to the validity and reliability processes prescribed by educational research methodology (Olde Bekkink et al., 2016). The questionnaire used to diagnose the PPTs' knowledge about BF was drafted in five phases: consulting midwives about the topic; designing preliminary questions from the literature; validation by a panel of experts; pilot test; and preparing the final version. The bibliographic review to search for antecedents led to the health field. Therefore, help was obtained from experts in infant nutrition from this field, the figure of the midwife and IBCLC (International Board Certified Lactation Consultant). Four midwives were interviewed for 30-40 minutes each in order to know their professional judgment on the minimal knowledge about BF that should be addressed in primary education as part of basic nutrition literacy. Phase i: Interviews with Midwives The midwives interviewed agreed on two fundamental aspects. One was to promote pupils being able to observe mothers breastfeeding their infants, which would normalise this circumstance to counteract the effect of messages often transmitted through advertising, toys, television, etc. The other was to mention the function of BF when dealing with topics such as vital functions, healthy eating and the parts of the human body and their functions. The midwives insisted on the importance of making it clear that humans are mammals, with the corresponding anatomical consequences and infant feeding behaviour. They recommended fostering confidence in one's own body and knowing about the protective role of BF compared with other types of nutrition. They also mentioned knowledge about how the human body functions, since this helps to avoid the tendency to feel disgust with certain bodily fluids such as breastmilk. This was also found by Spear (2007) in informal conversations with nursing staff. Phase ii: Preliminary Design of the Questionnaire The preparation of the instrument followed a process of bibliographic review interspersed with the instrument's gradual restructuring. Given the exploratory nature of this study and the paucity of literature on the subject, the decision was made to combine open and closed ended questions. Each question was related to the duly substantiated desirable response and to the objective being pursued, regarding to health effects and conditions of BF and physiological and anatomical questions. In repeated revisions by the researchers, the number of questions and their form and content were reviewed. The ultimate objective was to achieve a questionnaire that would gather the necessary information without confusing or exhausting the respondents. Phase iii: Validation of the Instrument by Experts After a first complete version of the questionnaire had been prepared, it was submitted to a validation process involving 15 experts. The assessments carried out by experts from different fields were subjected to triangulation. The panel of experts consulted comprised researchers in science teaching (5), experts in language and communication (1), midwife instructors (1), experts in research methods (1), in-service primary education teachers (3), and mothers with experience in breastfeeding (3). Content and construct validation was carried out regarding relevance (appropriateness of each item regarding the objective of diagnosis), clarity (ease of understanding the item by the Journal of Turkish Science Education 92 respondents), relevance of the content of the items (incidence on the essential aspects of the topic), and contributions concerning the wording of the items and the structure of the instrument in general. To this end, the panel of experts had a document listing the items whose conformity with the above criteria they had to assess on a scale of 0 to 5. All of their suggestions were studied and incorporated. They were fundamentally of a semantic type, helping to improve the understanding and sense of the items. The results of the experts' assessment did not lead to any of the items initially considered being eliminated since the mean rating was higher than the 3.5 reference value (Abad et al., 2011). Phase iv: Pilot Testing the Instrument In addition to the expert assessment, a pilot test was carried out in order to ensure the sufficient reliability of the questionnaire. For this, a purposive sample of students from a previous year was selected (also without previous training), opinions were collected, and the coding for the analysis of the responses was tested. The main changes that this led to were related to the interpretation of the items and the time needed to respond. Phase v: Obtaining the Final Version of the Instrument The final instrument was obtained after the different phases of development. Table 1 presents, by way of example, a selection of the phases of the development of an item, after the expert validation, related to the effects of BF on health. The table shows the changes made to avoid conditioning the respondent's answer. Table 1 Example of reformulation of a health questionnaire item Initial proposal Intermediate proposal Three independent open-response items One open-response item What effects does BF have on the infant's health? / What effects does BF have on the infant's immunity? / What effects does BF have on the infant's health in the long term? What effects does BF have on the overall health of the infant? The final instrument consisted of three open-response items and six closed-response items with three options (True, False and I don't know), as well as a series of questions for sociodemographic characterisation of the sample (sex and age). The questionnaires were administered during regular class hours, individually in person, using an online form which the participants accessed from their mobile device. Printed paper questionnaires were also provided for those who could not access the electronic questionnaire. Table 2 relates each item to its specific purpose. The acronyms of the research variables are grouped according to the specific research problem of this study. Illescas-Navarro, Cruz-Guzmán, Criado & García-Carmona, 2025 93 Table 2 Items of the questionnaire related to their purpose and the block they belong to Block Item Content for which the intention is to explore PPTs' knowledge or ideas1 Identity Sex Age: Previous training: BagBF Have you received or sought any kind of information about breastfeeding To check the influence of various sources of information on their knowledge, whether out of interest (informal) or by obligation (formal) Health: Health1 What do you think are the effects of breastfeeding on the mother's health? Positive or negative effects of BF on the mother's health (physical and affective aspects) Health2 What do you think are the effects of breastfeeding on the infant's health? Positive or negative effects of BF on the infant's health (affective aspects / immunity / digestive system / development / long-term effects) Health3 There are women whose milk has less quality and that is why it is better to supplement this with artificial milk (Yes/No/I don't know) The alternative conception that the quality of breastmilk varies from mother to mother Health4 There comes a time, as the months pass by, when breastmilk stops being nutritious (Yes/No/I don't know) The alternative conception: “breast milk is dilute and not nourishing as the months go by” Human body: HB1 What factors do you think breastmilk production depends on? Breastmilk production (intervention of anatomical structures, the physiological part, external factors and/or a combination of the above). HB2 Hypogalactia (low production of milk) is common and can rarely be treated (Yes/No/I don't know) Belief that many women do not produce enough milk HB3 A nursing mother's breast always has milk, and the infant only has to suckle for it to come out (Yes/No/I don't know) Belief that the breast has to refill (and that's why the baby can't breastfeed again soon after doing it) HB4 Breast size is related to the capacity to produce milk (Yes/No/I don't know) Belief that women with small breast size cannot produce enough milk / that big breast size produces more milk Note. 1 In the Health and Human Body blocks, the level of doubt or insecurity is assessed with the response ‘I don't know’. Data Acquisition and Analysis Once the PPTs had answered the questionnaire, the responses were input into a data file for analysis. Certain precautions were taken in order to minimise sources of error in the production of social data (Fernández, 2003) such as eliminating from the sample individuals who answered fewer than 80% of the questions. In the closed-ended items, the response categories correspond to the three types of response (True, False and I don't know). However, for open-ended items, a system of initial categories was established based on a literature review and the experts' contributions, and these were revised and adapted as the data analysis process progressed, with even some new categories emerging (Cisterna, 2005). To reduce as much as possible any deviation errors in the interpretation and categorization of the responses and thus ensure reliable interpretation and classification, an intra-rater analysis was carried out. The first author made a first categorisation of the responses and repeated the process a month later. The degree of coincidence between the two categorizations was greater than 90% of the Journal of Turkish Science Education 94 cases. Then this last categorization was submitted to the assessment of the other researchers in an inter-rater analysis process. The agreement between the researchers was again greater than 90%, as was to be expected given that the category system for classifying the responses had been developed conjointly. The few cases of discrepancies (less than 10% of the total) were discussed by the researchers until reaching majority agreement on the definitive classification. Likewise, in the analysis of the open-response items, low inference descriptors were included (Latorre, 2003) consisting of representative textual extracts of the PPTs' responses, in order to contribute evidence validating the categorisations made, which are shown in the following section. Findings Knowledge about Health Related to Breastfeeding This aspect was investigated through the four items Health1, Health2, Health3 and Health4. The results for item Health1 (effects on the health of the mothers who BF) are given in Table 3. Most of the responses, with 32% of the students stating ‘I don't know’, were found to represent ignorance. On the other hand, 16% considered that it has positive effects on the mother but could not specify what those were. In addition, although the set of responses referring to positive effects was larger (with more than 33% in total), the ‘Physical Negative’ category accounted for 26% of the responses. Table 3 Frequency of responses1 to item Health1 about the effects of BF on nursing mothers Categories Freq. (%)2 Low inference descriptors Positive 15.7 (n=16) ‘I think it has many positive effects’; ‘I imagine they will not be bad, otherwise mothers would not breastfeed their infants’; ‘Good’; ‘I imagine that they are positive, since it is generated by the body itself’; Positive Affective 10.8 (n = 11) ‘Connects her to her infant’; ‘Improves attachment’; ‘Better mood because of having such direct contact with her infant’; ‘Creates a close bond with her infant’; ‘Great self-satisfaction and well-being’ Positive Physical 6.9 (n=7) ‘The possibility of suffering from breast cancer is reduced’; ‘Her cells regenerate as the body produces milk’; ‘The breasts are emptied (retaining milk is bad)’; ‘Improves health’; ‘Prevents diseases’ Negative 3.9 (n=4) ‘Harmful’; ‘Negative’; ‘In many cases it may be harmful to the mother’ Negative Affective 0 (n=0) Negative Physical 25.5 (n=26) ‘Weakness’; ‘She will feel more tired’; ‘Nipple irritation, breast drooping’; ‘Somewhat weakened immune system’; ‘More swollen breasts and they hurt her’; ‘Loss of nutrients, deterioration of the breast, pain’; ‘It can cause cracks in her skin’; ‘Sensitivity’; ‘Lose more energy’; ‘Mastitis’ None 9.8 (n=10) ‘I think it has no affect’; ‘I don't think it has’; ‘I think it doesn't have any negative or positive effect’ Don't Know 32.4 (n=33) ‘I don't know if it brings any positive aspects or if it can cause any difficulty’; ‘I don't know’; ‘I don't know them’ No Response 3.9 (n=4) Note. 1 Student statements translated from Spanish, 2 Freq. (%): Frequency. The number of responses (n) is greater than the number of participants since the same response might be placed in more than one category. Table 4 contains the data about the PPTs' knowledge related to the effects of BF on the infant's health (Health2). There is a quite marked tendency to respond that the effects are positive. However, the top ranked category is ‘Others’ in which are grouped the responses that are not specific or that use indeterminate terms, as can be seen in the examples in the table. It is striking that, despite the fact of Illescas-Navarro, Cruz-Guzmán, Criado & García-Carmona, 2025 95 not being mentioned in the question, a good percentage of the responses compare breastmilk with artificial milk, arguing that ‘it is more than food’, or that ‘it is a better food’. Another aspect to consider is that some responses (in the category ‘Negative Immunity’) link the positive effects to the maternal lifestyle, stating that, if it is inadequate, it is better not to breastfeed. Natural vs artificial arguments were also used, with mentions that artificial milk contains ‘chemicals’ and thus human milk protects as it does not have them. The second most frequent response referred to the positive effects on infant immunity. Table 4 Frequency of responses to item Health2 about the effects of BF on infants Categories Freq. (%)1 Low inference descriptors Positive Immunity 25.5 (n=26) ‘Protects from pathogens’; ‘The mother passes her antibodies through her milk’; ‘Protects their immunological system’; ‘Prevents many diseases’; ‘In breastmilk there are some substances that help their system‘; ‘Improves defences’ Positive Digestive Apparatus 0 (n=0) Positive Affective 4.9 (n = 5) ‘It brings them closer to their mother’; ‘Strengthens the mother-infant bond’; ‘Great closeness with the mother’ Positive Others 73.5 (n=75) ‘They grow stronger’; ‘It will give them more nutrients than if it were artificial milk’; ‘It provides the necessary nutrients for their correct development’; ‘It is healthier and more natural than artificial milk’; ‘It is more nutritious’; ‘It gives them more vitamins (compared to artificial milk)’; ‘It contains essential substances for the optimum growth of the baby’ Negative Digestive Apparatus 0 (n=0) Negative Affective 0 (n=0) Negative Immunity 2.0 (n=2) ‘It can be a means of transmitting disease’; ‘If the breastfeeding mother has some kind of infectious disease, this is not healthy’ Negative Others 1.0 (n=1) ‘If the breastfeeding period is prolonged, it can cause problems for the infant’ None 1.0 (n=1) ‘I think that breastmilk has no influence on the infant's evolutive development’; ‘None’ Don't Know 7.8 (n=8) ‘I don't know’ No Response 2.9 (n=3) Note. 1 Freq. (%): Frequency. The number of responses (n) is greater than the number of participants since the same response might be placed in more than one category. Regarding the item Health3 (quality of the breastmilk), the results (Table 5) show that a large proportion of the PPTs (63%) have the inadequate idea that the common need to supplement with artificial milk is because there are women who produce lower quality milk. Table 5 Frequency of responses to item Health3 (T/F) about the quality of breastmilk and the need to supplement it Categories Frequency (%) Number of responses Correct 20.6 21 Incorrect 62.7 64 Don't know 16.7 17 Journal of Turkish Science Education 102 Illescas-Navarro M., Criado, A. M., and Cruz-Guzmán, M. (2020). El cuerpo humano y la salud en libros de texto de Educación Primaria (6-11 años), ¿qué aportan al problema socio-científico sobre la lactancia materna como parte de la alimentación en la primera infancia? [The human being and the health in the Spanish Primary textbooks (6-11 years old). What do they provide to the socio-scientific problem of the nutrition in the early childhood?]. Revista Eureka sobre Enseñanza y Divulgación de las Ciencias,17(1), 1302. doi:10.25267/Rev_Eureka_ensen_divulg_cienc.2020.v17.i1.1302 International Study Center. (2017). TIMMS 2019 Science Framework. Boston College. Jamie, K., O’Neill, R., Bows, H., & Hackshaw-McGeagh, L. (2020). Healthcare practitioner relationships, cultural health capital and breastfeeding support for adolescent mothers. Health Education Journal, 79(8), 901-913. https://doi.org/10.1177/0017896920915945 Jiménez, A. I. (2016). Educación sanitaria y su influencia en la lactancia materna en el Campo de Gibraltar [Health Education and its influence in breastfeeding in Gibraltar] [Unpublished doctoral dissertation]. Universidad de Málaga. Junta de Andalucía. (2021). Plan Integral de la Obesidad Infantil de Andalucía 2021 [Integral plan about children obesity]. https://www.juntadeandalucia.es/export/drupaljda/2021_Informe_PIOBIN.pdf Kalnina, I., Straumite, E., Klava, D., Kruma, Z., Bartkiene, E., Isoldi, K. K., Correia, P., Ferreira, M. & Guiné, R. P. F. (2022). Analysis of factors that influence eating habits in different countries. Journal of Hygienic Engineering and Design, 38, 169-179. https://keypublishing.org/jhed/wpcontent/uploads/2022/04/06.-Full-paper-Ilze-Kalnina.pdf Katsinde, S. M., & Srinivas, S. C. (2016). Breast feeding and the sustainable development agenda. Indian Journal of Pharmacy Practice, 9(3) 144-146. Kim, J. H., Fiese, B. H. & Donovan S. M. (2017). Breastfeeding is natural but not the cultural norm: A mixed-methods study of first-time breastfeeding, African American mothers participating in WIC. Journal of Nutrition Education and Behavior. 49, S151-S161.e1 Kokolaki, A. & Stavrou, D. (2023). Pre-Service Primary Teachers Develop Teaching Artifacts on Contemporary Socioscientific Issues. Journal of Science Teacher Education, 34(3), 287-306, https://doi.org/10.1080/1046560X.2022.2078546 Kong, S. K., & Lee, D. T. (2004). Factors influencing decision to breastfeed. Journal of Advanced Nursing, 46(4), 369-379. https://doi.org/10.1111/j.1365-2648.2004.03003.x Koura, H. (2019). Myths about breastfeeding. Al-Azhar Assiut Medical Journal, 17(2), 109-113. Lamanauskas, V. & Augienė, D. (2019). Identifying primary school teachers’ health literacy. Journal of Turkish Science Education,16(4),451-466. hhtps://doi.org/10.36681/tused.2020.0 Latorre, A. (2003). Investigación-acción. Conocer y cambiar la práctica educativa [Action-investigation. Knowing and changing the educative practice]. Graó. Lobstein, T. (2015). Prevalence and Trends Across the World. In M.L. Frelut (Ed.), The ECOG’s eBook on Child and Adolescent Obesity. https://ebook.ecog-obesity.eu Martínez Rubio, A. & Grupo PrevInfad Infancia y adolescencia. (2008). Supervisión de la alimentación en la población infantil y juvenil [Food monitoring in the infant and juvenile population]. Revista Pediatría Atención Primaria, 10(37), 99-133. Martínez, P. (2015). Lactancia Materna ¡lo que hay que oír! Compendio de mitos y situaciones absurdas alrededor de la lactancia materna [Breastfeeding. What you have to hear! Myths compendium about breastfeeding]. Columbia. Membiela, P. & Cid, M. C. (1998). Desarrollo de una unidad didáctica centrada en la alimentación humana, social y culturalmente contextualizada [The design of a teaching unit about basic feeding, socially and culturally contextualized]. Enseñanza de las Ciencias, 18(3), 494-511. https://doi.org/10.5565/rev/ensciencias.4124 Mengual-Andrés, S., Roig-Vila, R., & Mira, J. B. (2016). Delphi study for the design and validation of a questionnaire about digital competences in higher education. International Journal of Educational Technology in Higher Education, 13, 1-11. Illescas-Navarro, Cruz-Guzmán, Criado & García-Carmona, 2025 103 Ministerio de Sanidad. (2018). Situación de salud. Informe Anual del Sistema Nacional de Salud 2018 [Health status. Annual Report of the National Health System]. https://www.sanidad.gob.es/estadEstudios/estadisticas/sisInfSanSNS/tablasEstadisticas/InfAnu alSNS2018/Cap.2_SituacionSalud.pdf Monterrosa, E. C., Frongillo, E. A., Drewnowski, A., de Pee, S., and Vandevijvere, S. (2020). Sociocultural Influences on Food Choices and Implications for Sustainable Healthy Diets. Food and Nutrition Bulletin, 41(2), 59S-73S. doi:10.1177/0379572120975874 Moukarzel, S., Mamas, C., Farhat, A., & Daly, A. J. (2019). Getting schooled: teachers’ views on schoolbased breastfeeding education in Lebanon. International breastfeeding journal, 14(1), 3. Nanayakkara, J., Margerison, C., & Worsley, A. (2017). Importance of food literacy education for senior secondary school students: Food system professionals’ opinions. International Journal of Health Promotion and Education, 55(5-6), 284-295. https://doi.org/10.1080/14635240.2017.1372695 Nsiah-Asamoah, C., Doku, D. T., Agblorti, S. (2020). Mothers’ and Grandmothers’ misconceptions and socio-cultural factors as barriers to exclusive breastfeeding: A qualitative study involving Health Workers in two rural districts of Ghana. PLoS ONE, 15(9), e0239278. https://doi.org/10.1371/journal.pone.0239278 Núñez, F., & Banet, E. (1997). Students’ conceptual patterns of human nutrition. International Journal of Science Education, 19(5), 509-526. https://doi.org/10.1080/0950069970190502 OECD (2019), PISA 2018 Assessment and Analytical Framework. OECD Publishing. https://doi.org/10.1787/b25efab8-en Olde Bekkink, M., Donders, A. R., Kooloos, J. G., de Waal, R. M., & Ruiter, D. J. (2016). Uncovering students’ misconceptions by assessment of their written questions. BMC medical education, 16, 17. Ortuzar-Iragorri, A., Uskola, A., & Zamalloa, T. (2024). Early childhood preservice teachers’ knowledge of micro-organisms and cystitis. Journal of Turkish Science Education, 21(1), 1-21. DOI: 10.36681/tused.2024.001 Padró, A. (2020). Somos la leche: Dudas, consejos y falsos mitos sobre la lactancia (Embarazo, bebé y niño) [We are very cool (meaning of a Spanish expression using the word ‘milk’): Doubts, advice and myths about breastfeeding]. Grijalbo. Pallás-Alonso, C. R. (2006). Promoción de la lactancia materna [Breastfeeding promotion]. PrevInfad (AEPap)/PAPPS infancia y adolescencia, 1-29. http://www.aeped.es/sites/default/files/4promocion_de_lactancia_previnfad.pdf Palma-Jiménez, M., Cebrián-Robles, D. & Blanco-López, A. (2023). Impact of Instruction Based on a Validated Learning Progression on the Argumentation Competence of Preservice Elementary Science Teachers. Science & Education. https://doi.org/10.1007/s11191-023-00468-x Palma-Jiménez, M., Cebrián Robles, D., & Blanco López, A. (2024). Razonamiento de profesorado de Educación Primaria en Formación Inicial sobre la controversia sociocientífica “leche materna versus leche de fórmula”. Influencia de una propuesta formativa. Revista Eureka sobre Enseñanza y Divulgación de las Ciencias, 21(1), 1601. https://doi.org/10.25267/Rev_Eureka_ensen_divulg_cienc.2024.v21.i1.1601 Palomino Urbano, N. G. (2020). Nivel de conocimiento sobre la lactancia materna exclusiva en puérperas de 20 a 35 años en el Hospital Rezola [Level of knowledge about exclusive breastfeeding in postpartum women aged 20 to 35 years at Rezola Hospital]. [Unpublished grade’s thesis] Cañete. Paricio, J. M. (2020). El libro de la lactancia [The breastfeeding book]. Vergara. Perez-Escamilla, R. (2020). Breastfeeding in the 21st century: How we can make it work. Social Science & Medicine, 244, 112331. https://doi.org/10.1016/j.socscimed.2019.05.036 Journal of Turkish Science Education 104 Pozo Tamayo, A., Cubero Juánez, J., & Ruiz Macías, C. (2014). Elaboración de cuestionarios para la detección de conocimientos previos en Educación para la Salud, Sexualidad y Nutrición de un grupo de estudiantes de secundaria de un Centro Penitenciario Español. Campo Abierto: Revista de educación, 33(2), 43-64. Real Decreto [Royal Decree] 157/2022, de 1 de marzo, por el que se establecen la ordenación y las enseñanzas mínimas de la Educación Primaria [Organisation and minimum teaching of primary education]. Boletín Oficial del Estado, 52, de 2 de marzo de 2022, p.p. 24386 - 24504. https://www.boe.es/eli/es/rd/2022/03/01/157 Rodrigo, M. (1995). Concepciones de los futuros profesores de primaria sobre Educación para la Salud [Conceptions of prospective primary school teachers about health education]. Revista Interuniversitaria de Formación del Profesorado, 24, 173-180. Rodrigo, M., & Ejeda, J. (2009). Concepciones erróneas sobre alimentación en futuros profesores. Construcción de conocimiento pedagógico [Future teachers’ misconceptions about food. Building pedagogical knowledge]. Teoría de la Educación, 20, 225-247. https://doi.org/10.14201/991 Rodrigo, M., Ejeda, J., González Panero, M., & Mijancos, M. (2014). Concepciones sobre alimentación en estudiantes de magisterio y enfermería. Construcción del conocimiento pedagógico en cuestiones dietéticas [Conceptions on Food for future teachers and nurses. Construction of pedagogical knowledge on dietetic issues]. Teoría de la Educación, 26(1), 187-209. https://doi.org/10.14201/teoredu2014261187209 Rodríguez Vázquez, L. (2012). Prácticas, hábitos y conductas vs educación y cultura alimentarias [Food practices, habits and behaviours vs. food education and culture]. Revista Española de Nutrición Comunitaria, 18(1) 39-52. https://www.renc.es/imagenes/auxiliar/files/Nutr_12012_art%206.pdf Schibeci, R. A., & Hickey, R. (2000). Is it natural or processed? Elementary school teachers and conceptions about materials. Journal of Research in Science Teaching, 37(10), 1154-1170. https://doi.org/10.1002/1098-2736(200012)37:10%3C1154::AID-TEA7%3E3.0.CO;2-6 Sibic, O. & Topcu, M. S. (2020). Pre-service science teachers’ views towards socio-scientific issues and socio-scientific issue-based instruction. Journal of Education in Science, Environment and Health (JESEH), 6(4), 268-281. DOI:10.21891/jeseh.749847 Singletary, N., Chetwynd, E., Goodell, L. S. & Fogleman, A. (2017). Stakeholder views of breastfeeding education in schools: a systematic mixed studies review of the literature. International Breastfeeding Journal, 12, 14. https://doi.org/10.1186/s13006-017-0106-0 Slater, J., Falkenberg, T., Rutherford, J., & Colatruglio, S. (2018). Food literacy competencies: A conceptual framework for youth transitioning to adulthood. Interna, 42, 547-556. https://doi.org/10.1111/ijcs.12471 Spear, H. J. (2007). College students’ experiences and attitudes regarding middle and high school– based breastfeeding education. The Journal of School Nursing, 23(5), 276-282. https://doi.org/10.1177/10598405070230050601 Stuart-Macadam, P., & Dettwyler, K. (1995). Breastfeeding Biocultural Perspectives. Aldine De Gruyter. Suárez-Cotelo, M., Movilla-Fernández, M. J., Pita-García, P., Arias, B. F., & Novío, S. (2019). Breastfeeding knowledge and relation to prevalence. Revista da Escola de Enfermagem da USP, 53, e03433. https://doi.org/10.1590/S1980-220X2018004503433 Subiantoro, A. W., Treagust, D., Tang, K. S. (2023). Student reasoning during socio-scientific issuesbased learning with a role play: a case study of breastfeeding versus milk formula. Journal of Biological Education, 1-18. https://doi.org/10.1080/00219266.2023.2250346 Subiantoro, A. W., Treagust, D., & Tang, K. S. (2021). Indonesian biology teachers’ perceptions about socio-scientific issue-based biology instruction. Asia-Pacific Science Education, 7(2), 452-476. Uskola, A., Zamalloa, T., & Achurra, A. (2022). Using multiple strategies in deepening the understanding of the digestive system. Journal of Biological Education, 58(2), 364–382. https://doi.org/10.1080/00219266.2022.2064896 Illescas-Navarro, Cruz-Guzmán, Criado & García-Carmona, 2025 105 Vallone, F. (2009). Pequeños grandes clientes: la publicidad de sucedáneos de la leche materna en dos revistas pediátricas de Argentina entre 1977 y 2006 [Big little customers: the advertising of breast-milk substitutes in two pediatric journals in Argentina between 1977 and 2006]. Salud colectiva, 5(1), 87-105. Recuperado de http://www.scielo.org.ar/scielo.php?script=sci_arttext&pid=S185182652009000100006&lng=es&tlng=es Van Acker, F., & Bakker, E. (2012). A Functional Assessment of the Impact of Advantages and Disadvantages on Breastfeeding Attitude. Psicológica, 33(3), 533-545. Vargas-Zarate, M., Becerra-Bulla, F., Balsero-Oyuela, S. Y., & Meneses-Burbano, Y. S. (2020). Lactancia materna: mitos y verdades. Artículo de revisión [Breastfeeding: myths and truths. Review article]. Revista de la Facultad de Medicina, 68(4), 608-616. https://doi.org/10.15446/revfacmed.v68n4.74647 Victora, C. G, Bahl, R., Barros, A. J., França, G. V, Horton, S. Krasvec, J., Murch, S., Sankar, M. J., Walker, N., & Rollings, N. C. (2017). Breasfeeding in the 21st Century: epidemiology, machanism, and lifeholf effect. Lancet, 387, 475-490. https://doi.org/10.1016/s0140-6736(15)010247 Villalobos, A. V. K., Davis, C., Turner, M. M., Long, S., Hull, S., Lapinski, M. K. (2021). Breastfeeding in Context: African American Women’s Normative Referents, Salient Identities, and Perceived Social Norms. Health Education & Behavior. 48(4), 496-506. doi:10.1177/10901981211014445 Wahren, C. G. & De Cunto, C. L. (2004). La publicidad en las revistas médicas, esa delgada línea roja [Advertising in medical journals, that thin red line]. Archivos Argentinos de Pediatría, 102(6), 422424. Wanjohi, M., Griffiths, P., Wekesah, F., Muriuki, P., Muhia, N., Musoke, R. N., Fouts, H. N., Madise, N. J., & Kimani-Murage, E. W. (2016). Sociocultural factors influencing breastfeeding practices in two slums in Nairobi, Kenya. International breastfeeding journal, 12(5), 1-8. https://doi.org/10.1186/s13006-016-0092-7 World Health Organization [WHO]. (2009). Baby-friendly hospital initiative: revised, updated and expanded for integrated care. Section 2. Strengthening and sustaining the baby-friendly hospital initiative: a course for decision-makers. https://apps.who.int/iris/handle/10665/43593 World Health Organization [WHO]. (2021). Infant and young child feeding. Key facts. https://www.who.int/news-room/fact-sheets/detail/infant-and-young-child-feeding World Health Organization [WHO]. (2023). e-Library of Evidence for Nutrition Actions (eLENA). Breastfeeding education for increased breastfeeding duration. https://www.who.int/tools/elena/interventions/breastfeeding-education Yun, A., Shi, C. & Jun, B.G. (2022). Dealing with Socio-Scientific Issues in Science Exhibition: a Literature Review. Research in Science Education 52, 99–110. https://doi.org/10.1007/s11165-02009930-0 Zalewski, B. M., Patro, B., Veldhorst, M., Kouwenhoven, S., Crespo Escobar, P., Calvo Lerma, J., Koletzko, B., van Goudoever, J. B., & Szajewska, H. (2017). Nutrition of infants and young children (one to three years) and its effect on later health: A systematic review of current recommendations (EarlyNutrition project). Critical Reviews in Food Science and Nutrition, 57(3), 489-500. https://doi.org/10.1080/10408398.2014.888701 Zeyer, A. (2013). Health Education and Science Education. In R. Gunstone (Ed.), Encyclopedia of Science Education. Springer.