Regulating the marketing of foods for infants and young children: Lessons from assessment of gaps in monitoring and enforcement in Thailand.

Breast milk substitute (BMS) marketing harms breastfeeding and public health. To control BMS marketing, the Member States of the World Health Organization is called upon to adopt all provisions of the International Code of Marketing of Breastmilk Substitutes (the Code) into national law. In 2017, Thailand adopted many provisions of the Code through the Control of Marketing Promotion of Infant and Young Child Food Act B.E. 2560 (the Act), including the establishment of a compliance monitoring system and enforcement mechanisms. Nevertheless, recent research showed widespread violations. This study aims to assess gaps in the monitoring system and the Act's enforcement in its first three years of operation. This qualitative research study employed in-depth interviews between April and June 2020 with 34 key informants (KIs) from the Thai government, academia and civil society organisations. KIs identified gaps in six areas that could be mitigated to increase compliance with the Act. These gaps are unclear provisions on coverage of the Act; communications with retailers and the public; lack of strong direction and processes; inadequate budget allocations; skilled and confident human resources; and external factors which facilitate BMS marketing. Recommendations may be relevant for other countries and include revising and clarifying the Act, developing targeted communication strategies; providing clear monitoring direction including through setting key performance indicators related to the Act; and providing sufficient budget and training for authorised and support officers. Strengthening the health system and workplace support for breastfeeding and social marketing would also help address wider structural factors.

Regulation of baby food marketing in Thailand: a NetCode analysis.

OBJECTIVE: To report on the prevalence of different types of breast-milk substitutes (BMS) marketing and the compliance of such marketing with the 'Control of Marketing of Infant and Young Child Food Act 2017' (The Act) and the 'International Code of Marketing of Breast-milk Substitutes (WHO Code)' in Thailand. DESIGN: Cross-sectional quantitative study, guided by the WHO/UNICEF NetCode Periodic Assessment Protocol. SETTING: Health facilities and retail outlets in Bangkok, Thai media. PARTICIPANTS: Mothers of 0-2-year-old children, health professionals, promotions at retail outlets and health facilities, product labels, marketing on television and the internet. RESULTS: Marketing to mothers was highly prevalent, mostly from electronic or digital media, while BMS companies provided items to health professionals to distribute to mothers. Promotional materials in health facilities displayed company brands or logos. At retail outlets, most promotions were price-related. Approximately two-fifths of labels contained nutrition or health claims. Television marketing was growing-up-milk (GUM) advertisements, while internet promotions were varied from price-related materials to product reviews. Most instances of non-compliant BMS marketing with the Act were advertisements to mothers, and most were infant formula. Most non-compliant BMS marketing with the WHO Code was mainly concerned GUM, which are not covered by the Act and appeared in the media. CONCLUSIONS: BMS marketing does not fully comply with the Act or the WHO Code. The Thai government should conduct regular monitoring and enforcement activities, educate health professionals, and strengthen the Act's provisions on the media and GUM to fully align with the WHO Code.

Self-assessment of attitudes towards conditions to provide safe abortion among new medical graduates in Thailand, 2018: an application of cross-sectional survey with factor analysis.

BACKGROUND: Unsafe abortion is one of the major public health problems in Thailand. Although the penal code of Thailand and the Thai Medical Council permit doctors to perform safe abortion in certain conditions, little is known about the attitudes that new medical doctors have towards abortion. The objectives of this article are to explore the attitudes towards abortion in certain conditions among new medical graduates and to identify factors related to those attitudes. METHODS: A cross-sectional survey was conducted in 2018 among 2017 medical graduates who attended the annual workplace selection forum. The participants came from the two main tracks of admission to Thai medical schools: normal track and special track physicians, namely, the Collaborative Project to Increase Production of Rural Doctors (CPIRD). Of these 2017 graduates, 926 returned the questionnaire with complete information. Descriptive analysis, factor analysis, and multi-variable regression analysis were performed. RESULTS: We found that most physicians agreed to perform abortions in the context of life-threatening conditions for mothers and children, but not under conditions directly related to physical health (such as pregnancy with socioeconomic problems or pregnancy in adolescents). CPIRD doctors were less amenable than normal track doctors in providing abortions if the reason for the termination of pregnancy was related to socioeconomic problems. CONCLUSION: The study suggests that a proactive campaign for new medical graduates to raise awareness and mutual understanding of abortion services should be exercised. The CPIRD curricula relating to safe abortion should enhance the capacity of medical graduates to deal with pregnant women who face not only a physical health-related problem, but also socioeconomic difficulties and well-being as a whole.

Assessment of the stated policies of prominent food companies related to obesity and non-communicable disease (NCD) prevention in Thailand.

OBJECTIVE: To review the publicly available policies and commitments of selected food companies in Thailand relating to obesity and non-communicable diseases (NCDs) prevention, and to assess these stated policies and commitments against global recommendations. METHODS: Nineteen food and beverage companies, including 13 packaged food, three non-alcoholic beverage, two food retailer, and one fast food company were selected, based on their market share by sector and food category. A review of publicly available policies and commitments related to four domains (product reformulation, food marketing, nutrition information and food accessibility) was carried out for each company. Content analysis of all data was conducted, including a comparison of policy content against global recommendations in each domain. RESULTS: Eleven companies (58%) reported at least one policy or commitment across the four domains. The packaged food companies reported policies in all four domains while the beverage companies committed to implement policies in all except the accessibility domain. The food retailers and fast food company only had policies in the reformulation and nutrition information domains. Very few of the policies and commitments covered all of the recommended components in each domain, and most lacked sufficient specificity to allow detailed monitoring and evaluation. CONCLUSION: A small number of the most prominent food companies in Thailand have several nutrition-related policies in place. However, these policies do not sufficiently cover recommended areas for NCD and obesity prevention. Moreover, the extent to which policy statements translate to implementation has yet to be evaluated. Successful implementation of nutrition-related policies by the food industry in Thailand will likely require concrete, measurable indicators to guide both corporate policy making as well as public monitoring. The Thailand Government requires greater capacity to establish effective multi-sector platforms for NCD prevention, and to evaluate food companies' policies and enforce compliance both with regulations and voluntary commitments.

Childhood stunting in Thailand: when prolonged breastfeeding interacts with household poverty.

BACKGROUND: Childhood stunting, defined as the height-for-age standardized score lower than minus two, is one of the key indicators for assessing well-being and health of a child; and can be used for monitoring child health inequalities. Thailand has been successful in improving health and providing financial protection for its population. A better understanding of the determinants of stunting will help fill both knowledge and policy gaps which promote children's health and well-being. This study assesses the factors contributing to stunting among Thai children aged less than five years. METHODS: This study obtained data from the Multiple Indicator Cluster Survey Round 4 (MICS4), conducted in Thailand in 2012. Data analysis consisted of three steps. First, descriptive statistics provided an overview of data. Second, a Chi-square test determined the association between each covariate and stunting. Finally, multivariable logistic regression assessed the likelihood of stunting from all independent variables. Interaction effects between breastfeeding and household economy were added in the multivariable logistic regression. RESULTS: In the analysis without interaction effects, while the perceived size of children at birth as 'small' were positively associated with stunting, children in the well-off households were less likely to experience stunting. The analysis of the interactions between 'duration of breastfeeding' and 'household's economic level' found that the odds of stunting in children who were breastfed longer than 12 months in the poorest household quintile were 1.8 fold (95% Confidence interval: 1.3-2.6) higher than the odds found in mothers from the same poorest quintiles, but without prolonged breastfeeding. However prolonged breastfeeding in most well-off households (those between the second quintile and the fifth wealth quintile) did not show a tendency towards stunting. CONCLUSIONS: Childhood stunting was significantly associated with several factors. Prolonged breastfeeding beyond 12 months when interacting with poor economic status of a household potentiated stunting. Children living in the least well-off households were more prone to stunting than others. We recommend that the MICS survey questionnaire be amended to capture details on quantity, quality and practices of supplementary feeding. Multi-sectoral nutrition policies targeting poor households are required to address stunting challenges.

Cost-Effectiveness Analysis of COVID-19 Vaccine Booster Dose in the Thai Setting during the Period of Omicron Variant Predominance.

The Thai government implemented COVID-19 booster vaccines to prevent morbidity and mortality during the spreading of the Omicron variant. However, little is known about which types of vaccine should be invested in as the booster dose for the Thai population. This study aims to investigate the most cost-effective COVID-19 vaccine for a booster shot as empirical evidence for Thai policymakers. This study applied a stochastic simulation based on a compartmental susceptible-exposed-infectious-recovered model and included system dynamics in the model. We evaluated three scenarios: (1) No booster, (2) A viral vector vaccine as the booster dose, (3) An mRNA vaccine as the booster dose. The incremental cost-effectiveness ratio (ICER) was calculated based on provider perspectives. We found the number of cases in scenarios with viral vector and mRNA booster doses to be lower than in the non-booster group. Likewise, the number of deaths in the viral vector and the mRNA booster scenarios was threefold lower than in the no-booster scenario. Moreover, the estimated grand cost for the no-booster scenario was over 100 billion baht, while viral vector and mRNA scenario costs were 70 and 64.7 billion baht, respectively. ICER shows that viral vector and mRNA scenarios are more cost-effective than the no-booster scenario. Viral vector booster shot appeared to be slightly more cost-effective than mRNA booster shot in terms of death aversion. However, being boosted by an mRNA vaccine seemed slightly more cost-effective than a viral vector vaccine concerning case aversion. In conclusion, policies to promote COVID-19 booster shots in the Thai population by either mRNA or viral vector vaccines are likely to be worthwhile for both economic and public health reasons.

Effect of baby food marketing exposure on infant and young child feeding regimes in Bangkok, Thailand.

BACKGROUND: Baby food marketing undermines breastfeeding by influencing women's attitudes and decision-making favourably toward commercial baby food. This study aimed to explore the effects of various baby food marketing techniques on Thai mothers' opinions about commercial milk formulas (CMF) and commercial complementary foods (CCF) and their infant and young child feeding behaviours. METHODS: This study used a cross-sectional survey employing the World Health Organization (WHO) NetCode Toolkit Protocol for Periodic Assessment, and the United Nations International Children's Emergency Fund (UNICEF) Multiple Indicator Cluster Survey to collect data on mothers' experience with and their opinion on the various types of marketing of CMF and CCF, and their feeding behaviour. Data collection used structured interviews of mothers with children aged two years or below attending 33 health facilities in Bangkok. Univariable and multivariable regression analysis then investigated links between mothers' reported exposure to baby food marketing and their infant and young child feeding behaviours, employing a semantic scale and considering key sociodemographic and other variables. RESULTS: Three hundred and thirty mothers were surveyed in Bangkok. Around 90% reported experiencing exposure to at least one type of baby food marketing during the previous six months, mostly from electronic media. More than half of the women had positive opinions of CMF. Virtually all children had been breastfed initially, but 74.6% were given CMF and 72.8% stopped breastfeeding before six months. Multivariable analysis showed that mothers who lived in a couple were significantly less likely to favour CMF, and mothers in middle-income households and those who had received advice about CMF from others were more likely to have a favourable opinion. Mothers in formal employment were over six times more likely to feed formula than those not in employment. Women who experienced baby food marketing at health facilities were four times more likely to feed CMF to their children than those not experiencing such marketing. CONCLUSIONS: Specific types of baby food marketing were strongly linked to mothers' opinions on and use of CMF in Bangkok, Thailand. It is recommended that breastfeeding policies in health facilities and employment are fully implemented and enforced.

Forecasted Trends of the New COVID-19 Epidemic Due to the Omicron Variant in Thailand, 2022.

Thailand is among many countries severely affected by COVID-19 since the beginning of the global pandemic. Thus, a deliberate planning of health care resource allocation against health care demand in light of the new SARS-CoV-2 variant, Omicron, is crucial. This study aims to forecast the trends in COVID-19 cases and deaths from the Omicron variant in Thailand. We used a compartmental susceptible-exposed-infectious-recovered model combined with a system dynamics model. We developed four scenarios with differing values of the reproduction number (R) and vaccination rates. In the most pessimistic scenario (R = 7.5 and base vaccination rate), the number of incident cases reached a peak of 49,523 (95% CI: 20,599 to 99,362) by day 73, and the peak daily deaths grew to 270 by day 50. The predicted cumulative cases and deaths at the end of the wave were approximately 3.7 million and 22,000, respectively. In the most optimistic assumption (R = 4.5 and speedy vaccination rate), the peak incident cases was about one third the cases in the pessimistic assumption (15,650, 95% CI: 12,688 to 17,603). In the coming months, Thailand may face a new wave of the COVID-19 epidemic due to the Omicron variant. The case toll due to the Omicron wave is likely to outnumber the earlier Delta wave, but the death toll is proportionately lower. Vaccination campaigns for the booster dose should be expedited to prevent severe illnesses and deaths in the population.

Determinants of Complementary Feeding Indicators: A Secondary Analysis of Thailand Multiple Indicators Cluster Survey 2019.

Child complementary feeding (CF) practices meet dietary recommendations more often among educated, high-income groups. Much of the evidence for this association addresses inadequate CF for addressing child undernutrition. However, in many countries, including Thailand, child malnutrition assessments must now address under- and over-nutrition. More comprehensive data is needed to understand this complex situation. This study uses data from the Thailand Multiple Indicators Survey 2019, to identify the determinants of CF practices among 6-23-month children (n = 4125) using the newly developed WHO indicators. Logistic regression analysis was used to measure associations between sociodemographic factors and CF practices. In a fully adjusted model, child age, primary caregivers' education, and household incomes were statistically associated with (in)appropriate CF practices. Older children aged 9-23 months, not only have better minimum dietary diversity (MDD), minimum acceptable diet (MAD), and egg and/or flesh food consumption (EFF), but also tend to consume more unhealthy foods. The proportion of inappropriate CF practices was higher among children living with caregivers other than their mothers. While maternal education and household income were positively associated with MDD and MAD, children of mothers from middle-class households consumed more sweetened beverages. Therefore, nutrition programs addressing different feeding problems should be developed specifically for different primary caregiver and demographic groups.

Thailand Achievement of SDG Indicator 4.2.1 on Early Child Development: An Analysis of the 2019 Multiple Indicator Cluster Survey.

The early years of a child's life are the foundation for their future capability development. Poor health, hunger, poverty, low parental education, lack of parental interaction, high screen time, and poor housing environment hamper their development. There is little evidence of a link between early child development (ECD) and sociodemographic factors in Thailand. In response to monitoring the achievement of SDG target 4.2.1 (the proportion of young children who are developmentally on track in health, learning and psychosocial well-being) as required by all UN Member States, this study analyses the prevalence of appropriate levels of ECD and its correlates of Thai children aged 3 to 4 years. A cross-sectional study of the 6th Multiple Indicator Cluster Survey (MICS) data in 2019 conducted by the National Statistical Office was employed. Face-to-face interviews with mothers and/or legal guardians were conducted. A total of 5787 children aged 3 to 4 were enrolled in this study. The majority of participants, approximately 92.3%, had achieved an appropriate level of ECD index, defined as children who were developmentally on track in at least three out of these four domains: cognitive, physical, social, and learning. Multivariate logistic regression showed that girls had a higher appropriate development index than boys (Adjusted Odds Ratio [AOR] = 1.56, 95% Confidence Interval [95% CI] 1.28-1.90; children living in the 5th wealth quintile had a higher appropriate index than those in a less well-off family the first wealth quintile (AOR = 2.92, 95% CI: 1.86-4.58. Univariate logistic regression showed children living with parents achieving post-secondary education had a significantly greater appropriate index than children living with parents completing secondary education or below (Crude OR = 1.95, 95% CI 1.47-2.58); children who had appropriate parental interactions of more than four out of six interactions, had a significantly higher chance of having an appropriate index than less than four interactions (Crude OR = 1.52, 95% CI 1.14-2.04). Multi-sectoral policies to support child development in low socio-economic households should be strengthened. In addition, family and community should promote parental interactions through reading and playing with young children. Future studies which directly measure ECD in conjunction with regular monitoring through MICS are recommended.

Self-Reported Parental Interactions through Play with Young Children in Thailand: An Analysis of the 2019 Multiple Indicator Cluster Survey (MICS).

Parental interactions through play contributes significantly to child development of cognitive and executive functioning skills. In Thailand, there is little evidence of factors contributing to parental-child interactions. In response to SDG target 4.2.3 monitoring (the percentage of children under 5 years experiencing positive and stimulating home learning environments), this study aimed to assess the prevalence and profile of parental interactions with their children under the age of five. We analysed data from the 6th Multiple Indicator Cluster Survey (MICS) conducted by the National Statistical Office in 2019. Face-to-face interviews with mothers and/or legal guardians were conducted. A total of 8856 children under the age of five were enrolled in this survey. Most participants, 90.3%, had engaged in at least four out of six activities with their children. Multivariate logistic regression analysis showed that children raised by parents with secondary or post-secondary educations had a significantly greater chance to have parental interactions than children raised by parents who completed primary education (adjusted odds ratio (AOR) = 1.66, and AOR = 2.34 for secondary and post-secondary education). Children who possessed three or more children's books and had experience of toy play had a significantly higher chance of having parental interactions (AOR = 3.08 for book possessing, and AOR = 1.50 for the experience of toy play). Children who spent 1-3 h daily screen time had a significantly lower chance of having parental interactions than those who spent less than one hour of screen time (AOR = 0.67). In conclusion, with the emerging influence of digital technology, we recommend family and community promote parental interactions through play with young children.

Corporate political activity of baby food companies in Thailand.

BACKGROUND: Recent studies show corporate political activity (CPA) can have detrimental impacts on health policy processes. The Control of Marketing Promotion of Infant and Young Child Food Act B.E. 2560 (the Act) was implemented in Thailand in 2017, but there have been no studies documenting CPA during its policy processes. Furthermore, the effects of CPA on the Act and how non-industry stakeholders dealt with the CPA have not been explored. This study aimed to analyze the CPA of baby food companies in Thailand, its effects on the Act, and how policymakers have responded to CPA around the Act. METHODS: This qualitative study applied an established framework developed by Mialon and colleagues to collect and systematically analyze publicly available information from seven baby food companies with the highest percentage market share in Thailand. In-depth interviews were also used to explore how people involved in the policy process of the Act experienced the CPA of baby food companies, the consequent effects on the Act, and how they responded to the CPA. RESULTS: During development of the Act, baby food companies used two main strategies, 'information and messaging' and 'constituency building'. We found the companies met policymakers, and they employed evidence or provided information that was favorable to companies. Also, they established relationships with policymakers, health organizations, communities and media. The effects of CPA were that the scope of products controlled by the Act was reduced, and CPA led relevant people to misunderstand and have concerns about the Act. Officials and others countered the influence of CPA by raising awareness and building understanding among involved people, as well as avoiding contact with companies informally. CONCLUSIONS: CPA consists of a variety of practices that resulted in a weakened Act in Thailand. Government officials and other non-industry stakeholders employed strategies to counteract this influence. This study suggests the Department of Health, and other relevant government agencies, would benefit from establishing safeguards and protections against CPA. Efforts to raise awareness about the harms of CPA within and outside of government and establish a systematic monitoring system, including avoid conflict of interest in policy process would improve policymaking and implementation of the Act.

Equity of health workforce distribution in Thailand: an implication of concentration index.

BACKGROUND: Geographical maldistribution has been a critical concern of health workforce planning in Thailand for years. This study aimed to assess the equity of health workforce distribution in public hospitals affiliated to the Office of Permanent Secretary (OPS) of the Ministry of Public Health (MOPH) through the application of "concentration index" (CI). METHODS: A cross sectional quantitative design was employed. The dataset comprised 1) health workforce data from the OPS, MOPH in 2016, 2) regional and provincial-level economic data from the National Economic and Social Development Board in 2015, and 3) population data from the Ministry of Interior in 2015. Descriptive statistics, Spearman's rank correlation, and CI analysis were performed. RESULTS: Thailand had 2.04 health professionals working in public facilities per 1,000 population. Spearman's correlation found positive relationship in all health professionals. Yet, statistical significance was not found in most health professionals but doctors (P<0.001). Positive correlation was observed in all health cadres at regional and provincial hospitals (r s=0.348, P=0.002). In the CI analysis, the distribution of health professionals across provincial income was relatively equitable in all cadres. Significant CIs were found in doctor density (CI =0.055, P=0.001), all professionals density at district hospitals (CI =-0.049, P=0.012), and all professionals density at provincial and regional hospitals (CI =0.078, P=0.003). CONCLUSION: The positive CIs implied that the distribution of all health professionals, especially doctors, at provincial and regional hospitals slightly favored the richer provinces. In contrast, the distribution at district hospitals was slightly more concentrated in less well-off provinces. From a macro-view, the distribution of all health professionals in Thailand was relatively equitable across provincial economic status. This might be due to the extensive health infrastructure development and rural retention policies over the past four decades.

The impact of rural-exposure strategies on the intention of dental students and dental graduates to practice in rural areas: a systematic review and meta-analysis.

BACKGROUND AND OBJECTIVES: The objective of this study was to assess the impact of strategies on the intention of dental students/graduates to practice in rural areas. The strategies included the recruitment of dental students from rural backgrounds and clinical rotations in rural areas during the training of dental students. MATERIALS AND METHODS: The study undertook a systematic review and utilized meta-analysis to assess these strategies. International literature published between 2000 and 2015 was retrieved from three main search engines: Medline, Embase, and Scopus. The selected articles were scanned to extract the main content. The impact of the strategies was quantitatively assessed by meta-analysis, using the random-effect model. The pooled effect was reported in terms of odds ratios (ORs) with 95% confidence intervals. Sensitivity and subgroup analyses were performed. Publication bias was assessed by the Funnel plot and Egger's test. RESULTS: Seven of the initially selected 897 articles were included for the full review. The majority of the selected articles had been published in developed countries. The meta-analysis results revealed that the pooled OR of rural exposure on the intention to practice in rural areas was approximately 4.1, statistically significant. Subgroup analysis showed that clinical rotations in rural areas tended to have a slightly greater influence on rural dental practice than recruiting students from rural backgrounds (OR 4.3 versus 4.2). There was weaker evidence of publication bias, which was derived from small-study effects. CONCLUSION: Enrolling students with rural backgrounds and imposing compulsory clinical rotation in rural areas during their study appeared to be effective strategies in tackling the shortage and maldistribution of dentists in rural areas.