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doi:10.1111/jpc.12391
ORIGINAL ARTICLE
Cross-border promotion of formula milk in Lao People’s Democratic Republic Phonephay Phoutthakeo,1 Keiko Otsuka,1 Chiaki Ito,2 Panome Sayamoungkhoun,3 Sengchanh Kounnavong4 and Masamine Jimba1 1
Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan, 2Migration Health Division, International Organization for Migration, Nairobi, Kenya, 3Division of Planning and Statistics, Maternal and Child Health Center, The Ministry of Health and 4Division of Health System Research, National Institute of Public Health, The Ministry of Health, Vientiane Capital, Lao PDR
Aim: This study aims to examine the influence of formula milk promotion via the media from Thailand to Lao People’s Democratic Republic (PDR), where a cultural and linguistic proximity are shared. Methods: A cross-sectional study was conducted through a structured questionnaire survey and focus group discussion (FGD) with mothers who had children under 2 years of age and lived in Vientiane Capital, Lao PDR. Multivariate logistic regression models were constructed for quantitative data analysis. Content analysis was used for qualitative data analysis. Results: Among infants aged 6–23 months, exclusive breastfeeding (EBF) rate for 6 months was 16.1% (n = 106/658). Among infants aged 0–5 months, 17.6% (n = 61/346) was exclusively breastfed at the time of survey (24 h recall). Of 1022 mothers, 89.9% reported frequent exposure to the Thai media’s promotion of formula milk through TV commercials and 79.1% identified TV commercial as influential for them to develop a positive attitude towards the use of formula milk. In multivariate logistic regression analyses, mothers who reported a positive attitude towards Thai TV commercial on the formula use (n = 449) were approximately 75% less likely to practice EBF for 6 months than those who reported a negative attitude (n = 64). FGD further revealed that the participants tend to believe in the information in TV commercial for formula milk. Conclusion: The promotion of formula milk via media from Thailand negatively affects breastfeeding mothers in Lao PDR. Cross-border impacts of promoting formula milk should be addressed globally. Key words:
exclusive breastfeeding for 6 months; focus group discussion; formula milk; Lao People’s Democratic Republic; media.
What is already known on this topic
What this paper adds
1 The role of media, especially in the promotion of formula milk, as a factor that influences rates of exclusive breastfeeding. 2 Violation of WHO’s International Code has been reported in Lao PDR. 3 The rates of exclusive breastfeeding in Lao PDR and its neighbour, Thailand, are the lowest in Southeast Asia.
1 The rate of exclusive breastfeeding for 6 months in Vientiane Capital, Lao PDR, is low at 16.1%. 2 Mothers who identified to develop a positive attitude towards the use of formula milk through TV commercials were approximately 75% less likely to practice exclusive breastfeeding for 6 months than those who did not develop a positive attitude. 3 The promotion of formula milk via media from Thailand negatively affects breastfeeding rate of Lao mothers in Vientiane capital.
Although breast milk is a complete form of nutrition,1 many mothers in developing countries either do not breastfeed or only breastfeed for a short period.2 In Lao People’s Democratic Republic (PDR), the prevalence of exclusive breastfeeding
Correspondence: Professor Masamine Jimba, Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, 113-0033, Japan. Fax: +81 3 5841 3422; email: [email protected] Conflict of interest: None declared. Accepted for publication 6 June 2013.
(EBF) for 6 months has declined from 36% in 1995 to 26% in 2006,3,4 whereas continued breastfeeding (CBF) for 2 years has declined from 56% in 1995 to 48% in 2006.3,4 Factors influencing breastfeeding practices and duration have been well studied globally, including in Lao PDR.5,6 Some of these factors include: marital status; education; number of children; income; type of delivery;7–9 geographical area (urban or rural);10 social network support;11 and mothers’ knowledge, attitudes, beliefs and practices regarding to EBF.12,13 Especially, a negative attitude towards breastfeeding is associated with the widespread misconception that formula milk has more nutrients than breast milk and thus makes children grow faster.14–16
Journal of Paediatrics and Child Health 50 (2014) 51–56 © 2013 The Authors Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
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In Lao PDR, two media-related factors were recently identified as potential influences: exposure to TV commercials regarding the use of formula milk from Thailand and the development of a positive attitude towards the use of formula milk through the media.17 Lao PDR has traditionally been exposed to a massive flow of information from Thailand, especially through TV commercials: Lao PDR shares a border with Thailand for 1865 km and also shares a cultural and linguistic proximity. To improve breastfeeding rate, in 2007, the Lao government banned any public promotion of formula milk products18 in compliance with the International Code of Marketing of Breastmilk Substitutes.19 However, violations have been reported,20 and the ban has only been effective for commercials broadcast from Lao TV stations, not from Thai TV stations. Many people in Lao PDR choose to watch Thai TV programmes over Lao TV stations, making control in Lao PDR alone virtually meaningless. In Thailand, rates of both EBF (5.4%) and CBF (18.7%) are the lowest in Southeast Asia.21 Although there is some anecdotal evidence, knowledge of the cross-border media influences on breastfeeding in Lao PDR is limited. We hypothesised that the Thai media’s promotion of the use of formula milk, especially in TV commercials, is one key factor determining breastfeeding practices, in particular EBF for 6 months, in Lao PDR. The objectives were: (i) to measure maternal exposure to the Thai media’s promotion of formula use; (ii) to assess the association between attitudes towards Thai TV commercials on formula use and EBF; and (iii) to investigate the media-influenced attitude to formula use and EBF for 6 months.
Methods This was a cross-sectional study conducted through a structured questionnaire survey and focus group discussion (FGD) involving Lao mothers who had children under 2 years of age at the time of the survey. The data collection was conducted from June 2010 to August 2010.
Survey The study used cluster sampling to represent mothers in urban area of Vientiane Capital. The estimated required sample size was at least 552. Allowing inaccuracy in the vital registration that was used for sampling, 42 out of 339 villages in the target area were randomly selected and 1241 mothers were sampled. World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) defined EBF as ‘no other food or drink, not even water, except breast milk (including milk expressed or from a wet nurse) for 6 months of life, but allows the infant to receive oral rehydration salt (ORS), drops and syrups (vitamins, minerals and medicines)’. This study measured the prevalence of EBF based on the above definition through two sets of indicators. They were from WHO and UNICEF’s Household Baseline Survey of Integrated Management of Childhood Illness and UNICEF’s Multiple Indicator Cluster Surveys, which have been used frequently in Lao PDR since the late 1990s.22,23 One indicator was ‘EBF for infants under 6 months’, which represented the proportion of children under 6 months of age who received only breast milk during the last 24 h before the survey, based on 24 h dietary recall. This was measured in the group of mothers 52
who had infants aged 0–5 months. This indicator did not represent the EBF rate for the entire period of birth until 6 months of age. Instead, it represented the EBF rate at a specific point in time, which in this study was the time of survey. Another indicator was ‘EBF for 6 months’. Unlike the first one, this indicator measured the EBF rate among mothers who had children aged 6–23 months. It represented the entire period from birth until 6 months of age. To measure the exposure to the promotion of formula milk via the media, we modified the questions based on WHO’s Global Youth Tobacco Survey24 in consultation with UNICEF breastfeeding experts. Specifically, the exposure was measured based on a set of questions on self-reported frequency since becoming pregnant until the infant was 6 months (a lot, few and none), media type (TV commercial, TV program, radio, poster, printed material and logo) and media origin (Thailand, Lao PDR and others). Information was obtained through interviews conducted by 14 research assistants who received 3 days training from the first author researcher. Each interview lasted approximately 30 min. The questionnaire used was pre-tested with 60 mothers to confirm the understandability of questions. The survey data were analysed using Statistical Package for the Social Sciences version 18.0 statistical software (SPSS Inc., Chicago, IL, USA). In the multivariate logistic regression model to test the association between media exposure and breastfeeding, known influencing factors on EBF entered as confounders. Percentages and statistics were calculated, excluding ‘I do not know and not sure’, ‘Not applicable’ and ‘Never breastfed’ from the denominator. In all statistical tests, P < 0.05 was considered significant.
FGD In addition to the survey, six FGD sessions were conducted. The objective was to understand how and why exposures to the Thai media’s promotion of formula milk develop into positive attitude towards formula use; this would not be revealed sufficiently by quantitative data. In line with the research objectives, the guiding questions included: ‘How were mothers with children under 2 years of age in urban areas of Lao PDR exposed to the Thai media’s promotion of formula milk?’; ‘How was such an exposure associated with attitudes towards breastfeeding, particularly EBF?’. The first author researcher led and facilitated all FGD sessions by asking the participants the aforementioned questions, whereas four assistants took notes and operated the electronic recording devices. In all, 29 participants were recruited through purposive snowball sampling from three villages, each session was conducted with four to six participants. All notes were taken by the trained assistants and the first author researcher. The notes were compared to check consistency and later were combined into one document, which was further checked against the electronic recording devices. The qualitative data was analysed based on Qualitative Methods in Public Health: A Field Guide for Applied Research.25 First, the transcribed texts were carefully read six times. Subsequently, the texts were tentatively coded and labelled. Next, detailed information relevant to each objective was displayed and reduced to essential points. Comments were then grouped for
Journal of Paediatrics and Child Health 50 (2014) 51–56 © 2013 The Authors Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
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similarities and differences. After this process, two key themes emerged. From these, the core meaning of thoughts, feelings and behaviours of the respondents that represented each theme were searched for. Finally, these were linked to the survey results to examine the respondents’ media-influenced attitude to EBF for 6 months.
Ethics approval and informed consent This study was approved by the Research Ethics Committee of the Graduate School of Medicine in the University of Tokyo, Japan, and the National Ethics Committee for Health Research and the Ministry of Health, Lao PDR. Written informed consent was obtained from all respondents for both the survey and FGD. The interviewed mothers participated voluntarily and were informed that their identities would remain anonymous for confidentiality and privacy.
Results A total of 1022 mothers with children under 2 years of age in 42 villages participated in the survey. The response rate was 84.1% (1022/1214). Table 1 shows key characteristics of survey respondents.
Survey results As shown in Figure 1, most of the participants had initiated breastfeeding. The EBF rate under 6 months was 17.6% (n = 61/346), whereas the EBF rate for 6 months was 16.1% (n = 106/658). Most of the participants reported high exposure to the Thai media including TV commercials (89.9%), logos (76.9%) and TV programmes (73.5%) (Table 2). Furthermore, many respondents identified that Thai TV commercials were influential to developed positive attitude towards formula use (Table 3). As shown in Table 4, 3 variables were found significantly associated with EBF for 6 months: caesarean section as type of delivery (adjusted odd ratio (AOR): 0.25, 95% confidence interval (CI) 0.11–0.60, P = 0.002); early initiation of breastfeeding (AOR: 3.03, 95% CI 1.42–6.46, P = 0.004); and positive attitude towards Thai TV commercials on formula use (AOR: 0.25, 95% CI 0.74–0.83, P = 0.024).
Formula use and breastfeeding in Laos
Table 1
Characteristics of children and mothers n = 1022
Children Sex Boy Girl Age (months)† Place of delivery Public hospital Other‡ Type of delivery Natural birth Caesarean section Birthweight (g)† Mother Age (years)† Marital status Married Single, divorce or widowed Education (years)† Number of children (n)† Monthly income (US dollars)† Occupation Housewife Working Place to go for antenatal care (ANC) Public hospital Other§ Never gone to any place for ANC¶ Plan for breastfeeding before delivery Yes No Husband ever encouraged breastfeeding Yes No I do not know¶
(%)
573 485 9.3
(52.5) (47.5) (6.4)
927 95
(90.7) (9.3)
914 108 3091.9
(89.4) 10.6) (418.9)
26.9
(5.2)
1015 7 9.0 1.7 211.1
(99.3) (0.7) (3.6) (0.9) (236.2)
574 448
(56.2) (43.8)
964 30 28
(97.0) (3.0) –
975 47
(95.4) (4.6)
947 68 7
(93.3) (6.7) –
†Mean (SD). ‡Including private hospital/clinic in Lao PDR and Thailand. §Including Thai hospital/clinic, village health volunteer and traditional healer. ¶Percentages calculated excluding ‘I do not know’ and ‘Never gone to any place for ANC.’
FGD results The 29 mothers and mothers-in-law were aged 19–70 years and had various occupations; some were housewives, business owners and traditional silk weaver or owned a hair salon. None of the participants practiced EBF for 6 months. Sixteen participants responded to the question on the Thai media influence on the formula use and stated that they became familiar with use of formula milk from the Thai TV commercials: I know formula use through commercials from Thai TV and my mother-in-law. I think the formula milk commercials are interesting which are attracting many mothers to try it. Participants also commented that the formula milk commercial is reliable because it is ‘scientific’:
I think the advertisement of formula milk on TV is reliable because it shows a [scientific] result on the child’s development. Another participant pointed the nutritional benefit and quality of formula product, which she thought was safe for newborn babies: It [formula milk] has a lot of nutrition. The formula milk called Lactogent of Nestle product for newborns is very good because it does not create flatulence and stomach ache in newborn baby.
Journal of Paediatrics and Child Health 50 (2014) 51–56 © 2013 The Authors Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
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100.0%
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98.9
Table 3 Types of Thai media that mothers identified as influencing them to develop a positive attitude towards and desire to use formula milk
80.0% 71.0
68.4 60.0%
TV commercial TV programme† Radio Poster Printed material‡ Logo
40.0% 24.7 20.0%
n = 1022
(%)
808 661 214 638 465 703
(79.1) (64.7) (20.9) (62.4) (45.5) (68.8)
59.7
17.6
16.1
†Including drama, health program, talk show, cooking, travelling, etc.). ‡Printed material, excluding posters.
0.0%
Breastfeeding rates*
Fig. 1 Breastfeeding indicators. *Breastfeeding rates were calculated by using WHO (Indicators for assessing breastfeeding practices. 1991. WHO/ CDD/SER/91.4). BF, breastfeeding; CBF continued breastfeeding; EBF, exclusive breastfeeding. , Ever BF; n = 1011/1022; , Early initiation of BF after delivery within 1 h; 1 = 691/1010; , EBF under 6 months (0–5 months) n = 61/346; , EBF for 6 months (6–23 months) n = 106/658; , CBF at 1 year (12–15 months) n = 8/134; , CBF at 2 year (20–23 months) n = 22/89; , Currently BF; n = 718/1022.
Table 2 Types of Thai media for which mothers reported high exposure to the use of formula milk
TV commercial TV programme† Radio Poster Printed material‡ Logo
n = 1022
(%)
919 751 211 667 467 786
(89.9) (73.5) (20.6) (65.3) (45.7) (76.9)
†Including drama, health program, talk show, cooking, travelling, etc. ‡Printed material, excluding posters.
Eight out of 25 participants commented that they had positive attitudes towards formula feeding because of convenience and superiority in health benefits, believing that a child grows taller, and gains weight, and that it develops their child’s brain better. I want to feed my baby with formula milk because it makes the baby taller and helps to develop the brain as the Thai TV commercial tell us. With regard to attitudes towards practicing breastfeeding and EBF, 10 participants had positive attitude towards breastfeeding. However, they also demonstrated a negative attitude towards EBF and reported various challenges in EBF. Breastfeeding is a wonderful culture but EBF is not realistic to follow because we have to give water to prevent the baby from lack of water and jaundice. 54
I like breastfeeding and would like to continue for about 1 year. However, EBF is impossible for me. I have to give water after breastfeeding every time because breast milk can get stuck in baby’s throat.
Discussion As hypothesised, mothers who reported to have a positive attitude towards TV commercials on formula use were significantly less likely to practice EBF for 6 months than those who reported a negative attitude. Participant reported high exposure to commercials of formula milk in Thai language, particularly through TV commercials. In addition, because of the exposure, a considerable number of respondents reported developing a positive attitude towards the use of formula milk. FGD further revealed that mothers tend to believe the information in Thai TV commercials and perceive that they can choose formula milk anytime as a reliable and convenient substitute. This misunderstanding on formula use can be a serious obstacle to the continuation of breastfeeding. Previous studies showed that even a short period use of formula milk can lead an early cessation of breastfeeding unintentionally.2 In addition, as such constructed images were conveyed mostly on TV, the images reached a large audience covering numerous geographical areas and times of day. Therefore, promotion of formula use through Thai TV commercial should be addressed to improve breastfeeding in Lao PDR. Despite the relatively high educational level among the urban mothers, many participants identified that they developed a positive attitude to formula milk through exposure to the Thai media’s promotion. One possible explanation could be that educated mothers are health conscious and susceptible to the ‘scientific’ advantages of formula milk that the manufacturers promote, as shown during the FGD. A study in the Philippines has also found that high educational level could be a factor in reliance on formula milk.16 The FGD suggested that while mothers had a positive attitude towards formula milk, they simultaneously had a positive attitude towards breastfeeding but a less positive attitude towards EBF.12 This may be because mothers perceive that they should breastfeed along with water substitution. A previous study in Lao PDR also found that plain water was the most common
Journal of Paediatrics and Child Health 50 (2014) 51–56 © 2013 The Authors Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
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Table 4
Formula use and breastfeeding in Laos
Factors associating with exclusive breastfeeding EBF for 6 months
Age (years) (26 or less/27 or more) Education (years) (7 or less/8 or more) Number of children (n) (1–2/3 or more) Monthly income (US dollars) (146 or less/147 or more) Occupation (housewife/working) Gender (boy/girl) House ownership (own house/not own house) Place to go for antenatal care (public hospital/other) Place of delivery (public hospital/other) Type of delivery (natural birth/Caesarean section) Plan for breastfeeding before delivery (yes/no) Husband ever encouraged breastfeeding (yes/no) Early initiation of breastfeeding after delivery (1 h or less/1 h or more) Frequency of exposure to Thai TV commercial on formula use (a lot/other) Attitude towards Thai TV commercial on formula use (positive/negative) Frequency of exposure to logo on formula use (a lot/other) Attitude towards logo on formula use (positive/negative)
n
AOR
95% CI
P value
247/266 161/352 424/89 258/255 273/240 246/249 253/260 494/19 471/42 453/60 500/13 481/32 347/166 495/18 449/64 495/18 441/72
0.87 0.74 0.99 0.80 1.02 1.12 1.27 1.38 0.83 0.25 0.70 0.64 3.03 0.84 0.25 0.89 2.17
(0.48–1.58) (0.39–1.40) (0.45–2.23) (0.46–1.39) (0.58–1.78) (0.66–1.94) (0.72–2.24) (0.26–7.29) (0.25–2.74) (0.11–0.60) (0.12–4.07) (0.22–1.85) (1.42–6.46) (0.20–3.54) (0.07–0.83) (0.23–3.57) (0.62–7.56)
0.650 0.349 0.997 0.417 0.950 0.666 0.410 0.705 0.763 0.002 0.689 0.412 0.004 0.815 0.024 0.875 0.224
AOR, adjusted odds ratio; CI, confidence interval.
additional intake among breastfed infants aged 0–5 months.9 As mothers in Lao PDR often believe that water should be given to breastfed infants,13 knowledge about water use to breastfeeding infants should be included in breastfeeding education. There were some limitations for the implementation. First, as this was a cross-sectional study, the consequent of the causal relationships between EBF and the independent variables were not firmly established. Second, due to a long recall period of breastfeeding, some mothers may have provided wrong accounts with inaccurate memory about the time when liquids were introduced. Third, this study did not directly measure if the formula promotions through Thai media have developed the positive attitude to formula milk among Lao mothers. Instead, maternal reports were used to identify if the Thai media is the reason for their positive attitude to formula milk. Finally, we cannot exclude the influence of formula milk promotion from Thailand that is not measured in this study. For example, participants may possibly be also influenced by formula milk promotion through concerts, festivals and religious events in Thailand. Despite these limitations, this study has its value in suggesting the association between cross-border promotion of formula milk and EBF. Cross-border impacts of promoting formula milk should be addressed globally, in particular where culture and language are common.
Conclusion The promotion of formula milk via media from Thailand negatively affects breastfeeding rate of Lao mothers in Vientiane capital.
Acknowledgements We would like to thank the mothers in Lao PDR who gave their valuable time to participate in this study. We would also like to thank research assistants from the National University of Lao PDR as well as the local districts and village authorities who provided enormous support in the field study. There is no conflict of interest and no specific funding.
References 1 Gartner LM, Morton J, Lawrence RA et al.; American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 2005; 115: 496–506. 2 Holmes AV, Auinger P, Howard CR. Combination feeding of breast milk and formula: evidence for shorter breast-feeding duration from the National Health and Nutrition Examination Survey. J. Pediatr. 2011; 159: 186–91. 3 Department of Statistics and UNICEF. Lao PDR Multiple Indicator Cluster Survey 1995, Final Report. Vientiane, Department of Statistics and UNICEF, 1997. 4 Department of Statistics and UNICEF. Lao PDR Multiple Indicator Cluster Survey 2006, Final Report. Vientiane, Department of Statistics and UNICEF, 2008. 5 Li R, Fein SB, Chen J, Grummer-Strawn LM. Why mothers stop breastfeeding: mothers’ self-reported reasons for stopping during the first year. Pediatrics 2008; 122: S69. 6 Gerd AT, Bergman S, Dahlgren J, Roswall J, Alm B. Factors associated with discontinuation of breastfeeding before 1 month of age. Acta Paediatr. 2012; 101: 55–60. 7 National Institute of Public Health. Health Status of the People in Lao PDR 2001: Report on National Health Survey. Vientiane, National Institute of Public Health, 2001.
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8 Barennes H, Simmala C, Odermatt P et al. Postpartum traditions and nutrition practices among urban Lao women and their infants in Vientiane, Lao PDR. Eur. J. Clin. Nutr. 2009; 63: 323–31. 9 Holmes W, Hoy D, Lockley A et al. Influences on maternal and child nutrition in the highlands of the northern Lao PDR. Asia Pac. J. Clin. Nutr. 2007; 16: 537–45. 10 Lynch S, Bethel J, Chowdhury N, Moore JB. Rural and urban breastfeeding initiation trends in low-income women in North Carolina from 2003 to 2007. J. Hum. Lact. 2012; 28: 226–32. 11 Wutich A, McCarty C. Social networks and infant feeding in Oaxaca, Mexico. Matern. Child Nutr. 2008; 4: 121–35. 12 Stuebe AM, Bonuck K. What predicts intent to breastfeed exclusively? Breastfeeding knowledge, attitudes, and beliefs in a diverse urban population. Breastfeed. Med. 2011; 6: 413–20. 13 Arts M, Geelhoed D, De Schacht C, Prosser W, Alons C, Pedro A. Knowledge, beliefs, and practices regarding exclusive breastfeeding of infants younger than 6 months in Mozambique: a qualitative study. J. Hum. Lact. 2011; 27: 25–32. 14 Barennes H, Empis G, Quang TD et al. Breast-milk substitutes: a new old-threat for breastfeeding policy in developing countries. A case study in a traditionally high breastfeeding country. PLoS ONE 2012; 7: e30634. 15 Barennes H, Andriatahina T, Latthaphasavang V, Anderson M, Srour LM. Misperceptions and misuse of Bear Brand coffee creamer as infant food: national cross sectional survey of consumers and pediatricians in Laos. BMJ 2008; 337: a1379. 16 Sobel HL, Iellamo A, Raya RR, Padilla AA, Olivé JM, Nyunt-U S. Is unimpeded marketing for breast milk substitutes responsible for the
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decline in breastfeeding in the Philippines? An exploratory survey and focus group analysis. Soc. Sci. Med. 2011; 73: 1445–8. Putthakeo P, Ali M, Ito C, Vilayhong P, Kuroiwa C. Factors influencing breastfeeding in children less than 2 years of age in Lao PDR. J. Paediatr. Child Health 2009; 45: 487–92. Department of Hygiene and Prevention, MOH. Agreement on Infant and Young Child Food Products Controls in Lao PDR. Vientiane, Department of Hygiene and Prevention, MOH, 2007. WHO. International Code of Marketing of Breast-milk Substitutes. Geneva: WHO, 1981. IBFAN. Report on the Situation of Infant and Young Child Feeding in Lao PDR. Vientiane; 2011 January, p. 8. UNICEF. Multiple Indicator Cluster Survey. 2000; Reanalyzed by UNICEF: UNICEF Global Database on Breastfeeding. 2003. UNICEF. IMCI Household Survey Questionnaire-12 Key Family Practices [internet]. 1999. Available from: http://www.unicef.org/health/ files/health_generic.pdf [accessed 21 October 2012]. UNICEF. Multiple Indicators Cluster Survey. Questionnaire for Children Under Five: Breastfeeding indicators on 24 hour-recall dietary [internet]. 2010. Available from: http://www.childinfo.org/mics4 _questionnaire.html [accessed 21 October 2012]. WHO and the Centers for Disease Control and Prevention (CDC). Core Questions Global Youth Tobacco Survey (GYTS) [internet]. 2008. Available from: http://www.cdc.gov/tobacco/global/ gyts/00_pdfs/gyts_core_questionnaire.pdf [accessed 21 October 2012]. Ulin RP, Robinson TE, Tolley EE. Qualitative Methods in Public Health. Hoboken, NJ: Jossey Bass, 2004.
Journal of Paediatrics and Child Health 50 (2014) 51–56 © 2013 The Authors Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
doi:10.1111/jpc.12391
ORIGINAL ARTICLE
Cross-border promotion of formula milk in Lao People’s Democratic Republic Phonephay Phoutthakeo,1 Keiko Otsuka,1 Chiaki Ito,2 Panome Sayamoungkhoun,3 Sengchanh Kounnavong4 and Masamine Jimba1 1
Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan, 2Migration Health Division, International Organization for Migration, Nairobi, Kenya, 3Division of Planning and Statistics, Maternal and Child Health Center, The Ministry of Health and 4Division of Health System Research, National Institute of Public Health, The Ministry of Health, Vientiane Capital, Lao PDR
Aim: This study aims to examine the influence of formula milk promotion via the media from Thailand to Lao People’s Democratic Republic (PDR), where a cultural and linguistic proximity are shared. Methods: A cross-sectional study was conducted through a structured questionnaire survey and focus group discussion (FGD) with mothers who had children under 2 years of age and lived in Vientiane Capital, Lao PDR. Multivariate logistic regression models were constructed for quantitative data analysis. Content analysis was used for qualitative data analysis. Results: Among infants aged 6–23 months, exclusive breastfeeding (EBF) rate for 6 months was 16.1% (n = 106/658). Among infants aged 0–5 months, 17.6% (n = 61/346) was exclusively breastfed at the time of survey (24 h recall). Of 1022 mothers, 89.9% reported frequent exposure to the Thai media’s promotion of formula milk through TV commercials and 79.1% identified TV commercial as influential for them to develop a positive attitude towards the use of formula milk. In multivariate logistic regression analyses, mothers who reported a positive attitude towards Thai TV commercial on the formula use (n = 449) were approximately 75% less likely to practice EBF for 6 months than those who reported a negative attitude (n = 64). FGD further revealed that the participants tend to believe in the information in TV commercial for formula milk. Conclusion: The promotion of formula milk via media from Thailand negatively affects breastfeeding mothers in Lao PDR. Cross-border impacts of promoting formula milk should be addressed globally. Key words:
exclusive breastfeeding for 6 months; focus group discussion; formula milk; Lao People’s Democratic Republic; media.
What is already known on this topic
What this paper adds
1 The role of media, especially in the promotion of formula milk, as a factor that influences rates of exclusive breastfeeding. 2 Violation of WHO’s International Code has been reported in Lao PDR. 3 The rates of exclusive breastfeeding in Lao PDR and its neighbour, Thailand, are the lowest in Southeast Asia.
1 The rate of exclusive breastfeeding for 6 months in Vientiane Capital, Lao PDR, is low at 16.1%. 2 Mothers who identified to develop a positive attitude towards the use of formula milk through TV commercials were approximately 75% less likely to practice exclusive breastfeeding for 6 months than those who did not develop a positive attitude. 3 The promotion of formula milk via media from Thailand negatively affects breastfeeding rate of Lao mothers in Vientiane capital.
Although breast milk is a complete form of nutrition,1 many mothers in developing countries either do not breastfeed or only breastfeed for a short period.2 In Lao People’s Democratic Republic (PDR), the prevalence of exclusive breastfeeding
Correspondence: Professor Masamine Jimba, Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, 113-0033, Japan. Fax: +81 3 5841 3422; email: [email protected] Conflict of interest: None declared. Accepted for publication 6 June 2013.
(EBF) for 6 months has declined from 36% in 1995 to 26% in 2006,3,4 whereas continued breastfeeding (CBF) for 2 years has declined from 56% in 1995 to 48% in 2006.3,4 Factors influencing breastfeeding practices and duration have been well studied globally, including in Lao PDR.5,6 Some of these factors include: marital status; education; number of children; income; type of delivery;7–9 geographical area (urban or rural);10 social network support;11 and mothers’ knowledge, attitudes, beliefs and practices regarding to EBF.12,13 Especially, a negative attitude towards breastfeeding is associated with the widespread misconception that formula milk has more nutrients than breast milk and thus makes children grow faster.14–16
Journal of Paediatrics and Child Health 50 (2014) 51–56 © 2013 The Authors Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
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Formula use and breastfeeding in Laos
P Phoutthakeo et al.
In Lao PDR, two media-related factors were recently identified as potential influences: exposure to TV commercials regarding the use of formula milk from Thailand and the development of a positive attitude towards the use of formula milk through the media.17 Lao PDR has traditionally been exposed to a massive flow of information from Thailand, especially through TV commercials: Lao PDR shares a border with Thailand for 1865 km and also shares a cultural and linguistic proximity. To improve breastfeeding rate, in 2007, the Lao government banned any public promotion of formula milk products18 in compliance with the International Code of Marketing of Breastmilk Substitutes.19 However, violations have been reported,20 and the ban has only been effective for commercials broadcast from Lao TV stations, not from Thai TV stations. Many people in Lao PDR choose to watch Thai TV programmes over Lao TV stations, making control in Lao PDR alone virtually meaningless. In Thailand, rates of both EBF (5.4%) and CBF (18.7%) are the lowest in Southeast Asia.21 Although there is some anecdotal evidence, knowledge of the cross-border media influences on breastfeeding in Lao PDR is limited. We hypothesised that the Thai media’s promotion of the use of formula milk, especially in TV commercials, is one key factor determining breastfeeding practices, in particular EBF for 6 months, in Lao PDR. The objectives were: (i) to measure maternal exposure to the Thai media’s promotion of formula use; (ii) to assess the association between attitudes towards Thai TV commercials on formula use and EBF; and (iii) to investigate the media-influenced attitude to formula use and EBF for 6 months.
Methods This was a cross-sectional study conducted through a structured questionnaire survey and focus group discussion (FGD) involving Lao mothers who had children under 2 years of age at the time of the survey. The data collection was conducted from June 2010 to August 2010.
Survey The study used cluster sampling to represent mothers in urban area of Vientiane Capital. The estimated required sample size was at least 552. Allowing inaccuracy in the vital registration that was used for sampling, 42 out of 339 villages in the target area were randomly selected and 1241 mothers were sampled. World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) defined EBF as ‘no other food or drink, not even water, except breast milk (including milk expressed or from a wet nurse) for 6 months of life, but allows the infant to receive oral rehydration salt (ORS), drops and syrups (vitamins, minerals and medicines)’. This study measured the prevalence of EBF based on the above definition through two sets of indicators. They were from WHO and UNICEF’s Household Baseline Survey of Integrated Management of Childhood Illness and UNICEF’s Multiple Indicator Cluster Surveys, which have been used frequently in Lao PDR since the late 1990s.22,23 One indicator was ‘EBF for infants under 6 months’, which represented the proportion of children under 6 months of age who received only breast milk during the last 24 h before the survey, based on 24 h dietary recall. This was measured in the group of mothers 52
who had infants aged 0–5 months. This indicator did not represent the EBF rate for the entire period of birth until 6 months of age. Instead, it represented the EBF rate at a specific point in time, which in this study was the time of survey. Another indicator was ‘EBF for 6 months’. Unlike the first one, this indicator measured the EBF rate among mothers who had children aged 6–23 months. It represented the entire period from birth until 6 months of age. To measure the exposure to the promotion of formula milk via the media, we modified the questions based on WHO’s Global Youth Tobacco Survey24 in consultation with UNICEF breastfeeding experts. Specifically, the exposure was measured based on a set of questions on self-reported frequency since becoming pregnant until the infant was 6 months (a lot, few and none), media type (TV commercial, TV program, radio, poster, printed material and logo) and media origin (Thailand, Lao PDR and others). Information was obtained through interviews conducted by 14 research assistants who received 3 days training from the first author researcher. Each interview lasted approximately 30 min. The questionnaire used was pre-tested with 60 mothers to confirm the understandability of questions. The survey data were analysed using Statistical Package for the Social Sciences version 18.0 statistical software (SPSS Inc., Chicago, IL, USA). In the multivariate logistic regression model to test the association between media exposure and breastfeeding, known influencing factors on EBF entered as confounders. Percentages and statistics were calculated, excluding ‘I do not know and not sure’, ‘Not applicable’ and ‘Never breastfed’ from the denominator. In all statistical tests, P < 0.05 was considered significant.
FGD In addition to the survey, six FGD sessions were conducted. The objective was to understand how and why exposures to the Thai media’s promotion of formula milk develop into positive attitude towards formula use; this would not be revealed sufficiently by quantitative data. In line with the research objectives, the guiding questions included: ‘How were mothers with children under 2 years of age in urban areas of Lao PDR exposed to the Thai media’s promotion of formula milk?’; ‘How was such an exposure associated with attitudes towards breastfeeding, particularly EBF?’. The first author researcher led and facilitated all FGD sessions by asking the participants the aforementioned questions, whereas four assistants took notes and operated the electronic recording devices. In all, 29 participants were recruited through purposive snowball sampling from three villages, each session was conducted with four to six participants. All notes were taken by the trained assistants and the first author researcher. The notes were compared to check consistency and later were combined into one document, which was further checked against the electronic recording devices. The qualitative data was analysed based on Qualitative Methods in Public Health: A Field Guide for Applied Research.25 First, the transcribed texts were carefully read six times. Subsequently, the texts were tentatively coded and labelled. Next, detailed information relevant to each objective was displayed and reduced to essential points. Comments were then grouped for
Journal of Paediatrics and Child Health 50 (2014) 51–56 © 2013 The Authors Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
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similarities and differences. After this process, two key themes emerged. From these, the core meaning of thoughts, feelings and behaviours of the respondents that represented each theme were searched for. Finally, these were linked to the survey results to examine the respondents’ media-influenced attitude to EBF for 6 months.
Ethics approval and informed consent This study was approved by the Research Ethics Committee of the Graduate School of Medicine in the University of Tokyo, Japan, and the National Ethics Committee for Health Research and the Ministry of Health, Lao PDR. Written informed consent was obtained from all respondents for both the survey and FGD. The interviewed mothers participated voluntarily and were informed that their identities would remain anonymous for confidentiality and privacy.
Results A total of 1022 mothers with children under 2 years of age in 42 villages participated in the survey. The response rate was 84.1% (1022/1214). Table 1 shows key characteristics of survey respondents.
Survey results As shown in Figure 1, most of the participants had initiated breastfeeding. The EBF rate under 6 months was 17.6% (n = 61/346), whereas the EBF rate for 6 months was 16.1% (n = 106/658). Most of the participants reported high exposure to the Thai media including TV commercials (89.9%), logos (76.9%) and TV programmes (73.5%) (Table 2). Furthermore, many respondents identified that Thai TV commercials were influential to developed positive attitude towards formula use (Table 3). As shown in Table 4, 3 variables were found significantly associated with EBF for 6 months: caesarean section as type of delivery (adjusted odd ratio (AOR): 0.25, 95% confidence interval (CI) 0.11–0.60, P = 0.002); early initiation of breastfeeding (AOR: 3.03, 95% CI 1.42–6.46, P = 0.004); and positive attitude towards Thai TV commercials on formula use (AOR: 0.25, 95% CI 0.74–0.83, P = 0.024).
Formula use and breastfeeding in Laos
Table 1
Characteristics of children and mothers n = 1022
Children Sex Boy Girl Age (months)† Place of delivery Public hospital Other‡ Type of delivery Natural birth Caesarean section Birthweight (g)† Mother Age (years)† Marital status Married Single, divorce or widowed Education (years)† Number of children (n)† Monthly income (US dollars)† Occupation Housewife Working Place to go for antenatal care (ANC) Public hospital Other§ Never gone to any place for ANC¶ Plan for breastfeeding before delivery Yes No Husband ever encouraged breastfeeding Yes No I do not know¶
(%)
573 485 9.3
(52.5) (47.5) (6.4)
927 95
(90.7) (9.3)
914 108 3091.9
(89.4) 10.6) (418.9)
26.9
(5.2)
1015 7 9.0 1.7 211.1
(99.3) (0.7) (3.6) (0.9) (236.2)
574 448
(56.2) (43.8)
964 30 28
(97.0) (3.0) –
975 47
(95.4) (4.6)
947 68 7
(93.3) (6.7) –
†Mean (SD). ‡Including private hospital/clinic in Lao PDR and Thailand. §Including Thai hospital/clinic, village health volunteer and traditional healer. ¶Percentages calculated excluding ‘I do not know’ and ‘Never gone to any place for ANC.’
FGD results The 29 mothers and mothers-in-law were aged 19–70 years and had various occupations; some were housewives, business owners and traditional silk weaver or owned a hair salon. None of the participants practiced EBF for 6 months. Sixteen participants responded to the question on the Thai media influence on the formula use and stated that they became familiar with use of formula milk from the Thai TV commercials: I know formula use through commercials from Thai TV and my mother-in-law. I think the formula milk commercials are interesting which are attracting many mothers to try it. Participants also commented that the formula milk commercial is reliable because it is ‘scientific’:
I think the advertisement of formula milk on TV is reliable because it shows a [scientific] result on the child’s development. Another participant pointed the nutritional benefit and quality of formula product, which she thought was safe for newborn babies: It [formula milk] has a lot of nutrition. The formula milk called Lactogent of Nestle product for newborns is very good because it does not create flatulence and stomach ache in newborn baby.
Journal of Paediatrics and Child Health 50 (2014) 51–56 © 2013 The Authors Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
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Formula use and breastfeeding in Laos
100.0%
P Phoutthakeo et al.
98.9
Table 3 Types of Thai media that mothers identified as influencing them to develop a positive attitude towards and desire to use formula milk
80.0% 71.0
68.4 60.0%
TV commercial TV programme† Radio Poster Printed material‡ Logo
40.0% 24.7 20.0%
n = 1022
(%)
808 661 214 638 465 703
(79.1) (64.7) (20.9) (62.4) (45.5) (68.8)
59.7
17.6
16.1
†Including drama, health program, talk show, cooking, travelling, etc.). ‡Printed material, excluding posters.
0.0%
Breastfeeding rates*
Fig. 1 Breastfeeding indicators. *Breastfeeding rates were calculated by using WHO (Indicators for assessing breastfeeding practices. 1991. WHO/ CDD/SER/91.4). BF, breastfeeding; CBF continued breastfeeding; EBF, exclusive breastfeeding. , Ever BF; n = 1011/1022; , Early initiation of BF after delivery within 1 h; 1 = 691/1010; , EBF under 6 months (0–5 months) n = 61/346; , EBF for 6 months (6–23 months) n = 106/658; , CBF at 1 year (12–15 months) n = 8/134; , CBF at 2 year (20–23 months) n = 22/89; , Currently BF; n = 718/1022.
Table 2 Types of Thai media for which mothers reported high exposure to the use of formula milk
TV commercial TV programme† Radio Poster Printed material‡ Logo
n = 1022
(%)
919 751 211 667 467 786
(89.9) (73.5) (20.6) (65.3) (45.7) (76.9)
†Including drama, health program, talk show, cooking, travelling, etc. ‡Printed material, excluding posters.
Eight out of 25 participants commented that they had positive attitudes towards formula feeding because of convenience and superiority in health benefits, believing that a child grows taller, and gains weight, and that it develops their child’s brain better. I want to feed my baby with formula milk because it makes the baby taller and helps to develop the brain as the Thai TV commercial tell us. With regard to attitudes towards practicing breastfeeding and EBF, 10 participants had positive attitude towards breastfeeding. However, they also demonstrated a negative attitude towards EBF and reported various challenges in EBF. Breastfeeding is a wonderful culture but EBF is not realistic to follow because we have to give water to prevent the baby from lack of water and jaundice. 54
I like breastfeeding and would like to continue for about 1 year. However, EBF is impossible for me. I have to give water after breastfeeding every time because breast milk can get stuck in baby’s throat.
Discussion As hypothesised, mothers who reported to have a positive attitude towards TV commercials on formula use were significantly less likely to practice EBF for 6 months than those who reported a negative attitude. Participant reported high exposure to commercials of formula milk in Thai language, particularly through TV commercials. In addition, because of the exposure, a considerable number of respondents reported developing a positive attitude towards the use of formula milk. FGD further revealed that mothers tend to believe the information in Thai TV commercials and perceive that they can choose formula milk anytime as a reliable and convenient substitute. This misunderstanding on formula use can be a serious obstacle to the continuation of breastfeeding. Previous studies showed that even a short period use of formula milk can lead an early cessation of breastfeeding unintentionally.2 In addition, as such constructed images were conveyed mostly on TV, the images reached a large audience covering numerous geographical areas and times of day. Therefore, promotion of formula use through Thai TV commercial should be addressed to improve breastfeeding in Lao PDR. Despite the relatively high educational level among the urban mothers, many participants identified that they developed a positive attitude to formula milk through exposure to the Thai media’s promotion. One possible explanation could be that educated mothers are health conscious and susceptible to the ‘scientific’ advantages of formula milk that the manufacturers promote, as shown during the FGD. A study in the Philippines has also found that high educational level could be a factor in reliance on formula milk.16 The FGD suggested that while mothers had a positive attitude towards formula milk, they simultaneously had a positive attitude towards breastfeeding but a less positive attitude towards EBF.12 This may be because mothers perceive that they should breastfeed along with water substitution. A previous study in Lao PDR also found that plain water was the most common
Journal of Paediatrics and Child Health 50 (2014) 51–56 © 2013 The Authors Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
P Phoutthakeo et al.
Table 4
Formula use and breastfeeding in Laos
Factors associating with exclusive breastfeeding EBF for 6 months
Age (years) (26 or less/27 or more) Education (years) (7 or less/8 or more) Number of children (n) (1–2/3 or more) Monthly income (US dollars) (146 or less/147 or more) Occupation (housewife/working) Gender (boy/girl) House ownership (own house/not own house) Place to go for antenatal care (public hospital/other) Place of delivery (public hospital/other) Type of delivery (natural birth/Caesarean section) Plan for breastfeeding before delivery (yes/no) Husband ever encouraged breastfeeding (yes/no) Early initiation of breastfeeding after delivery (1 h or less/1 h or more) Frequency of exposure to Thai TV commercial on formula use (a lot/other) Attitude towards Thai TV commercial on formula use (positive/negative) Frequency of exposure to logo on formula use (a lot/other) Attitude towards logo on formula use (positive/negative)
n
AOR
95% CI
P value
247/266 161/352 424/89 258/255 273/240 246/249 253/260 494/19 471/42 453/60 500/13 481/32 347/166 495/18 449/64 495/18 441/72
0.87 0.74 0.99 0.80 1.02 1.12 1.27 1.38 0.83 0.25 0.70 0.64 3.03 0.84 0.25 0.89 2.17
(0.48–1.58) (0.39–1.40) (0.45–2.23) (0.46–1.39) (0.58–1.78) (0.66–1.94) (0.72–2.24) (0.26–7.29) (0.25–2.74) (0.11–0.60) (0.12–4.07) (0.22–1.85) (1.42–6.46) (0.20–3.54) (0.07–0.83) (0.23–3.57) (0.62–7.56)
0.650 0.349 0.997 0.417 0.950 0.666 0.410 0.705 0.763 0.002 0.689 0.412 0.004 0.815 0.024 0.875 0.224
AOR, adjusted odds ratio; CI, confidence interval.
additional intake among breastfed infants aged 0–5 months.9 As mothers in Lao PDR often believe that water should be given to breastfed infants,13 knowledge about water use to breastfeeding infants should be included in breastfeeding education. There were some limitations for the implementation. First, as this was a cross-sectional study, the consequent of the causal relationships between EBF and the independent variables were not firmly established. Second, due to a long recall period of breastfeeding, some mothers may have provided wrong accounts with inaccurate memory about the time when liquids were introduced. Third, this study did not directly measure if the formula promotions through Thai media have developed the positive attitude to formula milk among Lao mothers. Instead, maternal reports were used to identify if the Thai media is the reason for their positive attitude to formula milk. Finally, we cannot exclude the influence of formula milk promotion from Thailand that is not measured in this study. For example, participants may possibly be also influenced by formula milk promotion through concerts, festivals and religious events in Thailand. Despite these limitations, this study has its value in suggesting the association between cross-border promotion of formula milk and EBF. Cross-border impacts of promoting formula milk should be addressed globally, in particular where culture and language are common.
Conclusion The promotion of formula milk via media from Thailand negatively affects breastfeeding rate of Lao mothers in Vientiane capital.
Acknowledgements We would like to thank the mothers in Lao PDR who gave their valuable time to participate in this study. We would also like to thank research assistants from the National University of Lao PDR as well as the local districts and village authorities who provided enormous support in the field study. There is no conflict of interest and no specific funding.
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