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Marketing of Breast-Milk Substitutes 2018Westat In-Country Assessments of Baby Food Companies’ Compliance with the International Code of Marketing of Breast-milk Substitutes Nigeria Report Authors Brenda K. Brewer, MMSc, Associate Director Lena Muwakki, MS, Senior Study Director Catherine Andrzejewski, PhD, Senior Study Director Annie Lo, PhD, Senior Statistician Vibha Vij, MS, MPH, Senior Study Director Alexander Evans, Research Assistant April 2018 Prepared for: Prepared by: Access to Nutrition Foundation Westat An Employee-Owned Research Corporation® 1600 Research Boulevard Rockville, Maryland 20850-3129 (301) 251-1500 Acknowledgements The authors wish to acknowledge the dedication and hard work of the team from our Lagos-based partner organization, the Oxford Policy Management (OPM), without whom this study could not have been successfully completed. In particular, we wish to thank Olufemi Adegoke, MSc, Research Manager/Country Lead, and Ekundayo Arogundade, MPH, Field Manager. Further thanks are extended to Eunice Adekanmbi, MPH, Survey Coordinator, for her tireless efforts in conducting the survey and online media monitoring. We also thank the Lagos-based team of field supervisors and data collection teams for their commitment and efforts on behalf of this study. We wish to acknowledge the other key members of the Westat study team for their major contributions to this study. Rick Mitchell, MS, Associate Director and Information Technology Manager, directed the implementation of all necessary information technology applications for data capture and transfer. Quan Duong, BS, senior database developer, created the data entry applications. Luba Shtipelman, MD, served as the senior data manager. Tesfaye Lule, MS, project assistant, led the tablet training for the field data collection teams and supported the label abstraction efforts. Belinda, Yu, MS and Anna Rukhlya, MA, statistical programmers, provided programming support for the statistical analysis of the data. Anna Rekster, MS, contributed to the sample design, selection, and estimation. Finally, we wish to gratefully acknowledge the health workers and the mothers who generously gave us their time to participate in the survey. Nigeria Report – FINAL i Disclaimer Westat, with its local subcontractor in Nigeria, was responsible for the collection of data related to company compliance with the International Code of Marketing of Breast-milk Substitutes and any additional country-specific regulations related to marketing of these products. Westat is responsible for the analysis of the data related to compliance with the BMS marketing standards and for preparation of summary reports that have been incorporated by the Access to Nutrition Foundation (ATNF) into the scoring of company performance for the 2018 Access to Nutrition Global Index. Westat and its local subcontractor engaged with health care facilities, mothers of infants who attended those facilities, health workers at the facilities, and retailers as part of the data collection and analysis process. The user of the report and the information in it assumes the entire risk of any use it may make or permit to be made of the information. NO EXPRESS OR IMPLIED WARRANTIES OR REPRESENTATIONS ARE MADE WITH RESPECT TO THE INFORMATION (OR THE RESULTS TO BE OBTAINED BY THE USE THEREOF), AND TO THE MAXIMUM EXTENT PERMITTED BY APPLICABLE LAW, ALL IMPLIED WARRANTIES (INCLUDING, WITHOUT LIMITATION, ANY IMPLIED WARRANTIES OF ORIGINALITY, ACCURACY, TIMELINESS, NON-INFRINGEMENT, COMPLETENESS, MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE) WITH RESPECT TO ANY OF THE INFORMATION ARE EXPRESSLY EXCLUDED AND DISCLAIMED. Without limiting any of the foregoing and to the maximum extent permitted by applicable law, in no event shall ATNF, Westat, nor any of their respective affiliates or contractors, have any liability regarding any of the information for any direct, indirect, special, punitive, consequential (including lost profits) or any other damages even if notified of the possibility of such damages. The foregoing shall not exclude or limit any liability that may not by applicable law be excluded or limited. Nigeria Report – FINAL ii Table of Contents Chapter Page Acknowledgements ......................................................................................... i Disclaimer ........................................................................................................ ii Acronyms ......................................................................................................... viii Executive Summary ........................................................................................ ES-1 1 Background ...................................................................................................... 1-1 A. Rationale for Conducting the Nigeria Study .................................... 1-1 B. The Importance of Breastfeeding for Infant and Child Health .................................................................................................. 1-3 C. The Code on Marketing of Breast-milk Substitutes, and related local regulations ..................................................................... 1-4 D. Aspects Covered by the Code and This Study ................................ 1-5 E. Process of Selecting Westat ............................................................... 1-7 F. Westat Description ............................................................................ 1-7 G. In-Country Partner Description ....................................................... 1-8 H. Support from Nigerian Government Bodies and Local Associations ........................................................................................ 1-8 I. Project Management .......................................................................... 1-9 2 Research Objectives ........................................................................................ 2-1 A. Primary Objective .............................................................................. 2-1 B. Study Tool .......................................................................................... 2-1 C. The Code Articles and WHA Resolutions Addressed in the Nigeria Study ................................................................................ 2-2 Article 4. Information and Education .............................................. 2-3 Article 5. The General Public and Mothers ..................................... 2-4 Article 6. Health Care Systems .......................................................... 2-5 Article 7. Health Workers .................................................................. 2-6 Article 9. Labeling .............................................................................. 2-8 3 Methodology: NetCode Protocol .................................................................. 3-1 A. Comparison of the Code to prevailing National Legislation and Label Regulations .................................................... 3-1 B. Adaptations of Forms ........................................................................ 3-2 Nigeria Report – FINAL iii Contents (continued) Chapter Page C. Data Collected .................................................................................... 3-2 D. Sampling of Districts and HCFs in Lagos ....................................... 3-4 E. Selecting the Mothers in HCFs ......................................................... 3-7 F. Selecting the Health Workers in HCFs ............................................ 3-8 G. Selecting and Visiting Retailers ......................................................... 3-9 H. Identifying and Evaluating BMS and CF Products ......................... 3-9 I. Media Monitoring .............................................................................. 3-10 J. Representativeness of Results ........................................................... 3-12 K. Defining Potential Non-Compliance ............................................... 3-12 4 Fieldwork Preparation and Training .............................................................. 4-1 A. Organization of Field Work .............................................................. 4-1 B. Selection and Training of Data Collectors ....................................... 4-1 C. Introductions to Clinics ..................................................................... 4-2 D. Data Collection .................................................................................. 4-3 5 Study Results ................................................................................................... 5-1 A. Article 4: Information and Education .............................................. 5-3 B. Article 5: The General Public and Mothers ..................................... 5-5 C. Article 6: Health Care Systems .......................................................... 5-14 D. Article 7: Health Workers .................................................................. 5-17 E. Article 9: Labeling .............................................................................. 5-19 6 Conclusions and Recommendations ............................................................. 6-1 A. Conclusions about Compliance with the Code and National Regulations .......................................................................... 6-1 B. Conclusions about the Code and the NetCode Protocol ............... 6-5 C. Recommendations ............................................................................. 6-5 7 Limitations of the Study ................................................................................
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