The availability and use of written The availability and use of written The availability and use of written The availability and use of written

information on infant feeding in five information on infant feeding in five information on infant feeding in five information on infant feeding in five

European countriesEuropean countriesEuropean countriesEuropean countries

Monique Raats

University of Surrey, UK

Note: for non-commercial purposes only

Research teamResearch teamResearch teamResearch team

ENGLAND: H. Gage, J. Morgan, M. Schmid, P. Williams, M. Raats, Food, Consumer Behaviour and Health Research Group, University of Surrey, Guildford, GU2 7XH

FINLAND: K. Laitenen, Department of Biochemistry and Food Chemistry, University of Turku, Finland

GERMANY: J. Von Rosen, B. Koletzko, Dr von HaunerChildren’s Hospital, Munich, Germany

HUNGARY: T. Decsi, V. Jacobi, Department of Pediatrics, University of Pecs, Hungary

SPAIN: E. Martin-Bautista, C. Campoy, Department of Pediatrics, University of Grenada, Spain

Sources Sources Sources Sources

influencing influencing influencing influencing

feeding feeding feeding feeding

decisionsdecisionsdecisionsdecisions

%*8-MONTH FOLLOW-UP%*BASELINE - BIRTHRANK

11.9Videos / DVDs10.4Radio programmes17

14.0Radio programmes10.8Videos / DVDs16

18.7Private antenatal class17.8TV programmes15

23.5TV programmes20.2Advertising14

29.0Advertising28.0GP, Doctor13

33.0Other relatives29.9Other relatives12

38.5Staff in hospital31.9Internet11

43.7Friends33.3Other health professionals10

43.9Internet33.8Private ante natal class9

45.4Other health professionals34.2Parents8

50.0Magazines35.8Friends7

50.6Leaflets39.6Magazines6

56.7GP, Doctor46.5Leaflets5

58.6Antenatal midwife47.5Staff in hospital4

59.6Parents47.7Partner3

69.8Books52.6Books2

70.7Partner55.2Antenatal midwife1

* % responding moderately/very much/extremely vs slightly/not at all

Commentary on influencesCommentary on influencesCommentary on influencesCommentary on influences

• ‘Grade inflation’ – proportions generally higher at 8 month follow up

• Significant variation between countries especially for some sources, e.g. books, GP/Dr, leaflets, magazines (supplementary table)

• Written sources are very important to mothers:

– especially books (ranked 2nd both surveys)

– leaflets and magazines are important sources to around half of mothers (ranked 4th/ 5th / 6th)

Methods Methods Methods Methods –––– availability of leaflets & magazinesavailability of leaflets & magazinesavailability of leaflets & magazinesavailability of leaflets & magazines

• Protocol established and agreed, 2006

• Open internet search for leaflets – websites of relevant organisations (govt agencies, professional associations, specialinterest groups, industry)

• Include if refers to feeding or nutrition of healthy infant aged 0-12 months, dated 2000 or later

• Magazine – most popular (highest annual circulation) monthly parenting magazine in each country: articles and notes identified on feeding healthy infants 0 - 12 months

• Two independent reviewers in each country screen text of leaflets/ magazine articles and notes for statements that relate choice ofbreast vs formula milk to lifelong health outcome for the baby

Coding of health outcomesCoding of health outcomesCoding of health outcomesCoding of health outcomes

• 4 categories (22 health outcomes)

– general health benefits, growth and development, including neuro, composition of breast milk

– protection against infections

– protection against allergies

– long term conditions, eg Crohns, cancer, diabetes, obesity

Leaflets Leaflets Leaflets Leaflets –––– who produces them?who produces them?who produces them?who produces them?

328341921105All

156101133Spain

012185035Hungary

0731213Germany

012014Finland

2353720England

OtherIndustrySpecial

interest

Professional

Association

Government

agency

TotalCountry

Leaflets Leaflets Leaflets Leaflets ––––

Health outcomes from breastfeedingHealth outcomes from breastfeedingHealth outcomes from breastfeedingHealth outcomes from breastfeeding

4.881939.56963131132105 (81)All

4.6311252316493733 (27)S

4.5251043323242435 (23)H

6.45971813143613 (11)G

3.000900274 (3)F

5.06486511422820 (17)E

Long term

conditions

Allergy

protection

Infection

protection

General

benefits

Statements

per

leaflet

Mention

6

month

exclusive

Total

State-

ments

Number of statements onNo of

leaflets

(with

state-

ments)

Magazines Magazines Magazines Magazines

Health outcomes from breastfeedingHealth outcomes from breastfeedingHealth outcomes from breastfeedingHealth outcomes from breastfeeding

2.15211312725402961All

1.08013505317S

0.420510134H

1.17114443313G

0.251302104F

7.1719861719302023E

Long term

conditions

Allergy

protection

Infection

protection

General

benefits

Statement

per

leaflet

Mention 6

month

exclusive

Total

StatementsNumber of statements onNo of

articles

and

notes

Information environment Information environment Information environment Information environment

and mothersand mothersand mothersand mothers’’’’ perceived influenceperceived influenceperceived influenceperceived influence

Tendency that mothers reported leaflets were relatively more influential in their infant feeding decisions in countries where the search found a smaller number of leaflets – so distribution may be important.

50.646.5105All

28.824.735Hungary

51.425.533Spain

38.146.120England

74.263.313Germany

53.369.54Finland

% of mothers at 8 months*

% of mothers at birth*

Number of leaflets

Country

* Reporting moderately/ very much/ extremely influential vsslightly / not at all

LimitationsLimitationsLimitationsLimitations

• No quality check of statements for appropriateness, accuracy or consistency with contemporary scientific knowledge

– BUT: Assessment of quality of infant nutrition statements complicated because scientific evidence is not definitive in all areas, eg with respect to:

• relation between breastfeeding and allergy protection;

• effect of breast feeding on long term conditions (vs lifestyle factors)

• Also views differ on the importance of the WHO 6 month exclusivebreastfeeding recommendation in developed countries

• We could have missed leaflets or statements, although the methodwas systematic and corpus of leaflets may alter over time

• Countries may not be representative

• Use of frequencies may not capture overall significance

ConclusionsConclusionsConclusionsConclusions

• Mothers use multiple sources of information, and written media are relatively important influences, especially books, also leaflets and magazines

• Generally promotion of health advantages of breastfeeding is:

– variable between countries

– patchy regarding citing of health effects

– poor regarding 6m exclusive recommendation

– (more coverage of process / techniques of breastfeeding)

• Leaflets – purpose is to convey a message, more focused than magazines, more health outcome statements

• Magazines – wider content, aim to sell copy and make profit, less on health outcomes

Policy implicationsPolicy implicationsPolicy implicationsPolicy implications

• Scope to increase promotion of health effects of breastfeeding in leaflets and magazines and to be more consistent in details of message

• Leaflets likely to be better than magazines to promote message:

– can influence distribution / increase circulation

– can quality assure, check for readability, make attractive and free

– can increase credibility by circulate through health professionals

• Magazines – potential for opportunistic dissemination of messages

• Books are more important overall than leaflets and magazines andneed further investigation for the way they influence mothers’decisions