Breastfeeding practices, beliefs, and social norms in low-resource communities in Mexico: Insights for how to improve future promotion strategies

INTRODUCTION

Breastfeeding is recommended exclusively for the first 6 months after birth, with continued breastfeeding for at least 2 years. Yet prevalence of these recommendations is low globally, although it is an effective and cost-effective way to prevent serious infections and chronic illness. Previous studies have reported that social support greatly influences breastfeeding, but there is little evidence on perceived social norms in Mexico and how they affect actual behavior.

OBJECTIVE

Our objective was to investigate breastfeeding intention, practices, attitudes, and beliefs, particularly normative, among low-resource communities in central and southern Mexico.

METHODS

We performed a secondary analysis using the theory of planned behavior with cross-sectional data, which included semi-structured individual interviews with fathers (n 10), 8 focus groups with mothers (n 50), and 8 focus groups with women community leaders (n 44) with a total of 104 participants. Our data also included a quantitative survey among pregnant women and mothers (n 321).

RESULTS

Women reported supplementing breast milk with water and teas soon after birth, as well as introducing small bites of solid food a few months after birth. Social norms appeared to support breastfeeding, but not exclusive breastfeeding or breastfeeding for periods longer than about a year. This may be partially explained by: a) behavioral beliefs that for the first 6 months breast milk alone is insufficient for the baby, and that water in addition to breast milk is necessary to hydrate an infant and b) normative beliefs related to the appropriateness of breastfeeding in public and as the child gets older.

CONCLUSIONS

Future strategies should focus on positively influencing social norms to support recommended practices, and emphasize the specific reasons behind the recommendations. Future efforts should take a multi-pronged approach using a variety of influences, not only directed at healthcare providers but close family members, including fathers.

Pitfalls of the self-regulation of advertisements directed at children on Mexican television

BACKGROUND

There are no academic studies that characterize advertisements directed at children from the companies that signed the self-regulation.

OBJECTIVE

The aim of this paper was to assess the extent and nature of food advertisements and the persuasive techniques used to market unhealthy food and beverages (UFB) to children, by signatory companies of self-regulation.

METHODS

From December 2012 to April 2013, 600 h of programming were recorded on the four broadcast public television channels in Mexico with the highest rating nationwide. Marketing aimed at children directly (broadcast on children's programmes or advertisements with a specific appeal to children) or indirectly (aimed at other target audiences with messages or scenes that link children to the product) were considered.

RESULTS

About 74.9% (2148) of the total food and beverage advertisements tried to influence children directly and indirectly. Companies, which had signed the self-regulation, focused 92.7% of their advertisements on UFB. Of the total number, 23.9% were aimed at children, 7.1% at adolescents, 12.5% at parents and 56.2% at the general public. Most of these advertisements were broadcast on movies (29.8%), cartoons (18%), soap operas (17.6%), entertainment shows (17.2%) and sports programs (6.4%).

CONCLUSION

Despite the self-regulation of television marketing, children were surrounded by UFB advertisements. Signatory companies influence children indirectly by targeting other audiences and by marketing during family television programs, which are also watched by children.

Translating Evidence-Based Program Recommendations into Action: The Design, Testing, and Scaling Up of the Behavior Change Strategy EsIAN in Mexico

BACKGROUND

The Integrated Strategy for Attention to Nutrition (EsIAN in Spanish) is a national strategy within Mexico's conditional cash transfer program (initially Progresa, then Oportunidades, then Prospera, CCT-POP) designed to strengthen the health and nutrition component, address the nutrition transition, and improve the health and nutritional status of its beneficiaries, through 3 main components: 1) procurement of functioning equipment to primary health care (PHC) units; 2) providing free micronutrient supplements to beneficiary women and children; 3) implementing a behavior change communication (BCC) strategy and a training system for PHC providers (PHCPs).

OBJECTIVE

We aim to describe the iterative process and evidence-based approach used to design and roll-out the EsIAN at scale, by focusing on the BCC component.

METHODS

The BCC strategy was developed by following an iterative process through the following phases: situational analysis, formative research and design of the BCC strategy (using the socioecological framework and the social marketing approach), large-scale feasibility study, redesign, and national scale-up.

RESULTS

The review and formative research revealed several barriers and issues that limited program coverage, utilization, and acceptance. These included misconceptions about pregnancy and infant feeding, nonalignment of practices with international recommendations, and lack of knowledge on nutrition and related topics, among others. These results were used to identify priority behaviors and elaborate key messages for mothers/caregivers and providers to develop the BCC strategy. The feasibility study resulted in significant improvements in PHCPs' knowledge, counseling (breastfeeding, and supplement use and consumption), and caregivers' complementary feeding behaviors, and highlighted several design and delivery aspects that needed strengthening. Based on these findings, the BCC strategy was adapted prior to a national scale-up.

CONCLUSIONS

The theory-based iterative approach resulted in the identification of specific actions to target, and approaches to do so, as part of the design and roll-out of the BCC strategy at scale.

Digital marketing of products with poor nutritional quality: a major threat for children and adolescents

OBJECTIVES

To identify general characteristics, the use of persuasive techniques, and the nutritional quality of Mexican digital marketing of food and beverages/brand with the greatest number of followers and views (Facebook, Twitter, and YouTube) with specific appeal to children/adolescents.

STUDY DESIGN

Cross sectional, quantitative, exploratory, and descriptive study.

METHODS

Multistep process to select a sample of 46 products with a Mexican website and major audiences on social networks. The energy and nutrient content of the foods and beverages were analyzed with the Pan American Health Organization Nutrient Profile Model.

RESULTS

Cola and soft drinks, sweetened juices were the products with the greatest number of followers on Facebook and Twitter (13,321,274 and 1,020,504). Companies used diverse persuasive techniques combining promotional characters (79.1%), incentives (65.1%), and digital techniques (78.3%). Products with excess critical nutrients were most frequently advertised regardless of the type of social network and the marketing techniques used.

CONCLUSION

Digital Marketing represents a major threat for children and adolescents in Mexico, and probably all over the world, because of its persuasive techniques, and it shall be regulated.

Sociocultural Influences on Poor Nutrition and Program Utilization of Mexico's Conditional Cash Transfer Program

BACKGROUND

The impact of the Conditional Cash Transfer Program in Mexico was significant but smaller than expected. Several bottlenecks related to program design and implementation have been identified that may have limited its impact; population and other contextual factors may be equally important to analyze.

OBJECTIVES

We aimed to explore how sociocultural context contributes to poor nutrition in Mexico and how it shaped the acceptability, fidelity, and penetration of the fortified food and of education sessions provided by the program.

METHODS

We carried out qualitative research studies in the central and southern states in urban, rural, and indigenous settings between 2001 and 2014 with different informants and by using interviews, focus group discussions, and nonparticipatory observation. We explored 4 dimensions of the sociocultural context: objective dimension (e.g., food availability and family organization), social norms and symbolic meaning related to child feeding, literacy and communication with the biomedical culture, and knowledge related to child care generally and child feeding. We generated information about the experience of the beneficiaries with fortified food and education sessions.

RESULTS

Several sociocultural factors, including patriarchal family organization, high availability of nonnutritious food, social norms promoting the consumption of food in liquid form for young children, sharing of food among family members, traditional knowledge, and communication barriers with the biomedical culture, participated in shaping the poor nutrition situation, the inadequate utilization of fortified foods, and the inappropriateness of the education sessions.

CONCLUSIONS

Our studies revealed the importance of local context and culture to understand the acceptance, utilization, and impact of a nutrition program and shed light on infant and child feeding practices. This knowledge is critical to strengthen program designs and ensure adequacy with the diversity of cultural and social contexts in which programs are implemented.

Use of advertising strategies to target children in sugar-sweetened beverages packaging in Mexico and the nutritional quality of those beverages

BACKGROUND

A product package can be a powerful marketing tool to persuade and attract consumers at the point-of-sale. Evidence shows that most advertised products have low nutritional quality. Currently, Mexico has incorporated advertising regulations on food and beverage packaging.

OBJECTIVES

To analyze the advertising strategies used to target children on packaging and to assess the nutritional quality of sugar-sweetened beverages available in the Mexican market.

METHODS

Photographs of 2380 beverages available in retail stores in Mexico City from January to March 2017 were analyzed. Beverages were classified as displaying child-directed strategies or nondirected strategies. Nutrition quality was evaluated using the Pan American Health Organization nutrient profile model.

RESULTS

The use of characters was the most frequent strategy among beverages with child-directed strategies (82.0%). The evaluation of nutrition quality found that 88.0% (P < .001) of sugar-sweetened beverages with child-directed strategies were excessive in free sugars and 56.9% (P < .001) contained other sweeteners. Beverages with more than two advertising strategies have the highest proportion of excessive free sugars (93.4%, 95% CI 82.8-98.6).

CONCLUSIONS

The use of characters and other visual strategies were frequently used in the packaging of sugar-sweetened beverages with child-directed strategies. In addition, these beverages are excessive in free sugars and contain a large number of products with other sweeteners.

Contribution of formative research to design an environmental program for obesity prevention in schools in Mexico City

Objective. This paper describes the methods and key findings of formative research conducted to design a schoolbased program for obesity prevention. Materials and methods. Formative research was based on the ecological model and the principles of social marketing. A mixed method approach was used. Qualitative (direct observation,indepth interviews, focus group discussions and photo-voice)and quantitative (closed ended surveys, checklists, anthropometry)methods were employed. Results. Formative research key findings, including barriers by levels of the ecological model, were used for designing a program including environmental strategies to discourage the consumption of energy dense foods and sugar beverages. Conclusion. Formative research was fundamental to developing a context specific obesity prevention program in schools that seeks environment modification and behavior change.

Vulnerability and risk: reflections on the COVID-19 pandemic

At the end of December 2019, SARS-COV-2 virus was identified as responsible for the COVID-19 pandemic. The rapid spread of transmission exposed structural failures of modern societies and of the health systems in preventing and containing a health threat. Scientific discussion has focused on the search for a vaccine, but less on understanding the social response to the current global threat and fear of outbreaks. In this essay, we reflect, based on the social sciences, on the importance of linking three concepts: vulnerability-perception-risk. This is necessary to develop preventive strategies appropriate to population circumstances, especially with the most vulnerable population, in favor of health equity.

The Challenges of Tobacco Fiscal Policy Implementation in Mexico From the Perspective of Key Actors

INTRODUCTION

Raising tobacco taxes is considered the most effective strategy to avoid smoking initiation and discourage its use, especially among vulnerable groups. However, few low- and middle-income countries have adopted high tobacco taxes. Raising taxes is, therefore, an opportunity to strengthen and accelerate tobacco control. The objective of this study is to analyze the barriers and facilitators to the tobacco tax increase in Mexico.

AIMS AND METHODS

Based on the Governance Analytical Framework, data were generated through 17 in-depth interviews with key intersectoral actors for fiscal policy. The interviews were transcribed and coded according to Hufty's theory of governance.

RESULTS

Robust scientific evidence, intersectoral coordination, and the presence of "champions" boosted progress in tobacco control (facilitators). The main barriers were the incomplete implementation of the World Health Organization-Framework Convention on Tobacco Control (WHO-FCTC) and MPOWER package and lack of commitment ("political will") by government decision makers and legislators, misinformation about the effects of tobacco taxes, and strong tobacco industry interference.

CONCLUSIONS

Robust evidence is necessary but not sufficient to advance the implementation of the MPOWER (WHO-FCTC) actions. To achieve tobacco tax increases and public policies that protect people from unhealthy products in general, the implementation of policies or legal frameworks against industry interference in the development of public policies is imperative.

IMPLICATIONS

By analyzing the barriers and facilitators to increasing the tobacco tax in Mexico, this study identifies two key messages: (1) The need to sensitize legislators and the general population to the problem of smoking not only through epidemiological data but also through testimonies that highlight the life experiences and adversities faced by people who smoke. (2) The need for a regulatory framework to prevent industry interference in public affairs and conflicts of interest. The same framework could be very useful for public health policies to control the consumption of ultra-processed food products or alcohol.

Soda Consumption Among Mexican Construction Workers in the Context of the Sugar-Sweetened Beverage Tax

This study explored the psychosocial determinants of consumption of soda and other taxed sugar-sweetened beverages (SSBs) in Mexican construction workers (CWs) and whether consumption changed as a result of the 2014 SSB tax. We conducted a qualitative case study involving in-depth interviews and focus groups (FGs) with 30 Mexican CWs; supplemented with descriptions of the food and beverages consumed during lunch breaks. We used NVivo 10 to classify information according to the analysis categories, primarily informed by the Reasoned Action Approach (RAA). CWs reported not having changed their consumption of soda and other taxed SSBs as a result of the SSB tax, despite the price increase and "knowing" the potential negative consequences of soda drinking. The most important determinants of soda consumption are a deep-seated social norm of soda drinking and use of soda drinking as part of their professional identity; their likeness for soda; a wide availability of soda in their environments; and a low perceived behavioral control (because they thought themselves as addicted to it). Participants indicated that the best way for them not to consume soda would be if it were not available. These findings lend support for the tight regulation of the availability of SSBs. To have a meaningful impact on these consumers, the SSB tax may need to be much higher. Policy-level interventions should be coupled with interventions at the individual and community levels that aim at denormalizing soda consumption, create new meanings in relation to water consumption, and develop behavioral control to decrease soda consumption.

Contribution of formative research to design an environmental program for obesity prevention in schools in Mexico City

OBJECTIVE

This paper describes the methods and key findings of formative research conducted to design a school-based program for obesity prevention.

MATERIALS AND METHODS

Formative research was based on the ecological model and the principles of social marketing. A mixed method approach was used. Qualitative (direct observation, indepth interviews, focus group discussions and photo-voice) and quantitative (closed ended surveys, checklists, anthropometry) methods were employed.

RESULTS

Formative research key findings, including barriers by levels of the ecological model, were used for designing a program including environmental strategies to discourage the consumption of energy dense foods and sugar beverages.

CONCLUSION

Formative research was fundamental to developing a context specific obesity prevention program in schools that seeks environment modification and behavior change.

Effectiveness and Implementation of a Text Messaging mHealth Intervention to Prevent Childhood Obesity in Mexico in the COVID-19 Context: Mixed Methods Study

BACKGROUND

Promoting physical activity (PA) and healthy feeding (HF) is crucial to address the alarming increase in obesity rates in developing countries. Leveraging mobile phones for behavior change communication to encourage infant PA and promote HF is particularly significant within the Mexican context.

OBJECTIVE

This study aims to explore the effectiveness and feasibility of mHealth interventions aimed at promoting PA and HF among primary caregivers (PCs) of Mexican children under the age of 5 years. Additionally, the study aims to disseminate insights gained from intervention implementation amidst the COVID-19 pandemic and assess the potential of behavior change mHealth interventions on a broader population scale.

METHODS

NUTRES, an mHealth intervention, underwent an effectiveness-implementation hybrid trial. Over 36 weeks, participants in the intervention group (IG), totaling 230 individuals, received approximately 108 SMS text messages tailored to their children's age. These messages covered topics such as PA and HF and emphasized the significance of proper child nutrition amidst the COVID-19 pandemic. NUTRES participants were recruited from both urban and rural health units across 2 states in Mexico. Given the COVID-19 context, both baseline and follow-up surveys were conducted via mobile or fixed telephone. The evaluation of effectiveness and implementation used a mixed methods approach. Qualitative analysis delved into participants' experiences with NUTRES and various implementation indicators, including acceptance, relevance, and coverage. Grounded theory was used for coding and analysis. Furthermore, difference-in-differences regression models were used to discern disparities between groups (comparison group [CG] versus IG) concerning knowledge and practices pertaining to infant PA and HF.

RESULTS

Of the total 494 PCs enrolled in NUTRES, 334 persisted until the end of the study, accounting for 67.6% (334/494) participation across both groups. A majority of PCs (43/141, 30.5%, always; and 97/141, 68.8%, sometimes) used the SMS text message information. Satisfaction and acceptability toward NUTRES were notably high, reaching 98% (96/98), with respondents expressing that NUTRES was "good," "useful," and "helpful" for enhancing child nutrition. Significant differences after the intervention were observed in PA knowledge, with social interaction favored (CG: 8/135, 5.9% vs IG: 20/137, 14.6%; P=.048), as well as in HF practice knowledge. Notably, sweetened beverage consumption, associated with the development of chronic diseases, showed divergence (CG: 92/157, 58.6% vs IG: 110/145, 75.9%; P=.003). In the difference-in-differences model, a notable increase of 0.03 in knowledge regarding the benefits of PA was observed (CG: mean 0.13, SD 0.10 vs IG: mean 0.16, SD 0.11; P=.02). PCs expressed feeling accompanied and supported, particularly amidst the disruption of routine health care services during the COVID-19 pandemic.

CONCLUSIONS

While NUTRES exhibited a restricted impact on targeted knowledge and behaviors, the SMS text messages functioned effectively as both a reminder and a source of new knowledge for PCs of Mexican children under 5 years of age. The key lessons learned were as follows: mHealth intervention strategies can effectively maintain communication with individuals during emergencies, such as the COVID-19 pandemic; methodological and implementation barriers can constrain the effectiveness of mHealth interventions; and using mixed methods approaches ensures the complementary nature of results. The findings contribute valuable evidence regarding the opportunities and constraints associated with using mobile phones to enhance knowledge and practices concerning PA and HF among PCs of children under 5 years old.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04250896; https://clinicaltrials.gov/ct2/show/NCT04250896.

[Use of social marketing to increase water consumption among school-age children in Mexico City]

OBJECTIVE

To increase water consumption in school children in Mexico City through a social marketing intervention.

MATERIALS AND METHODS

Cluster quasi-experimental design. Intervention of three months in schools, including water provision and designed based on social marketing. Reported changes in attitude, knowledge and behavior were compared pre and post intervention.

RESULTS

Children of the intervention group (n=116) increased in 38% (171 ml) water consumption during school time, control group (n=167) decreased its consumption in 21% (140 ml) (p<0.05), according to their reported consumption. In a sub-sample reported consumption of sweetened beverages decreased 437 ml in the IG and 267 ml in the CG (p<0.05).

CONCLUSION

Social marketing and environmental modifications were effective on increasing water consumption among children, strategy that might contribute to mitigate childhood obesity.

Trayectorias de atención en Mayas de México que padecen diabetes tipo 2

Objetivo:

mostrar cómo pacientes de pueblos originarios (Mayas) que padecen diabetes tipo 2 manejan recursos de los diferentes modelos de atención para atender su enfermedad.

Material y métodos:

el diseño del estudio fue de métodos mixtos de tipo secuencial; incluyó un cuestionario ( n=195), entrevistas cualitativas cortas ( n=103) y 20 entrevistas a profundidad entre población originaria Maya diagnosticada con diabetes tipo 2, usuarios de servicios de atención pública para la salud en tres estados de México: Chiapas, Yucatán y Quintana Roo.

Resultados:

las trayectorias de atención se orientaron de acuerdo con las creencias sobre el origen de la enfermedad. La ruta seguida puede iniciar en los servicios públicos de salud, la medicina privada, tradicional o alternativa, o en el ámbito de las creencias religiosas; pero en algún punto se transita por todos estos recursos. La utilización de los recursos institucionales de la atención pública en salud depende de la apreciación de los pacientes sobre la eficacia del sistema de salud y las causas de la enfermedad, frecuentemente emocionales: sustos, enojos y/o preocupaciones.

Conclusiones:

las y los participantes buscaron activamente atender su salud por varios medios; esto implica que en la trayectoria de atención se mezclan modelos, recursos y medicamentos, en parte debido a las condiciones de pobreza. La evidencia puede ser usada para ajustar los programas de educación para la salud, siguiendo la propuesta de la promoción de la salud sobre impulsar que las personas tengan mayor control de su propia salud.

Exploring barriers and facilitators to feeding children with minimal or no "Junk Food": Insights from Mexican women

OBJECTIVE

This study aims to investigate the factors that promote or hinder the feeding of children with minimal or no ultra-processed products to inform the design of an mHealth strategy in Mexico and prevent child malnutrition among the economically vulnerable.

METHODS

An exploratory qualitative study was conducted, involving 24 in-depth face-to-face interviews with caregivers of children aged 24-59 months from both urban and rural communities. To analyze the data, we used thematic analysis and incorporated a few elements of grounded theory.

RESULTS

More barriers than facilitators were identified. Key barriers included: misconceptions and the widespread availability of junk food through an extensive network of grocery stores; neighbors and family gifting junk food; the association of soda with celebrations; the practice of indulging children with junk food; and the normalization of junk food consumption by both adults and children. Facilitators included: caregivers' awareness of the health risks associated with junk food; economic constraints limiting junk food purchases; support from husbands in regulating children's junk food consumption; the presence of a family member with diabetes; specific cultural beliefs about children's digestive health; as well as displacement of "healthy" foods that nourish children.

CONCLUSION

Based on our findings, we formulated recommendations for interventions at intrapersonal, interpersonal, organizational, community, and public policy levels to support healthier feeding practices for children.