Table 2 summarizes the characteristics of the 21 participants. Interviews were undertaken with a total of 13 HCPs (nine women) and eight CCPs (seven women) from a range of disciplines: five pediatricians, five general practitioners, and three PMI physicians (working in maternal and child protection centers) for a sub-total of 13 HCPs, and two childcare assistants, three professionals working in childcare centers, one childminder, and two PMI nurses, for a sub-title of eight CCPs. Eleven of the 21 professionals were aged 25-34 years (8/13 HCPs, 3/8 CCPs), eight were aged 35-49 years and two were aged 50-64 years. Fourteen professionals out of 21 (including 11/13 HCPs and 3/8 CCPs) had from zero to ten years of professional experience. Four professionals had 11-20 years of experience (1/13 HCP, 3/8 CCPs), two professionals had between 21 and 30 years of experience (one HCP, one CCP), and one CCP had over 30 years of experience. Fifteen professionals had children (8/13 HCPs and 7/8 CCP). Nine out of the 21 professionals were working in areas with low poverty rates (< 13.3%), four in areas with high poverty rates (>17.2%) and eight in areas with middle poverty rates (between 13.3% and 17.2%). Fourteen out of the 21 professionals were working in rural areas (urbanization rate over 80%) and seven in semi urban areas (urbanization rate between 40% and 80%).
Table 2
Characteristics of the sample of French professionals (n=21).
Characteristics
|
|
All (n)
|
HCPs1 (n)
|
CCPs2 (n)
|
Totals
|
|
21
|
13
|
8
|
Profession
|
Pediatrician
General practitioner
PMI physician
|
5
5
3
|
5
5
3
|
/
/
/
|
|
Childcare assistant
Professionals working in childcare centers
Childminder
PMI nurses
|
2
3
1
2
|
/
/
/
/
|
2
3
1
2
|
Gender
|
Female
|
16
|
9
|
7
|
|
Male
|
5
|
4
|
1
|
Age range
|
Less than 35 years old
|
11
|
8
|
3
|
|
35-49 years old
|
7
|
4
|
3
|
|
More than 49 years old
|
3
|
1
|
2
|
Years of professional experience
|
0-10 years
|
14
|
11
|
3
|
|
11-20 years
|
4
|
1
|
3
|
|
21-30 years
|
2
|
1
|
1
|
|
>30 years
|
1
|
/
|
1
|
Number of children
|
0
1
2 or more
|
6
5
10
|
5
2
6
|
1
3
4
|
Poverty rate of the department (%) *
|
<13.3%
|
9
|
6
|
3
|
|
13.3 -17.2%
|
8
|
5
|
3
|
|
>17.2%
|
4
|
2
|
2
|
Urbanization rate of the department (%)
|
40-80%
|
7
|
4
|
3
|
|
>80%
|
14
|
9
|
5
|
1 HCPs = Healthcare professionals.
2 CCPs = Childcare professionals.
*Poverty rate: the monetary poverty rate corresponds to the proportion of individuals (or households) in a given department in a situation of monetary poverty. An individual (or a household) is considered poor when he lives in a household with a standard of living below the poverty line. In France and in Europe, the threshold is most often set at 60% of the median standard of living.
|
Two main themes and nine subthemes were developed through the thematic analysis. The main themes were: 1) practices and needs in terms of communication with parents on child feeding, and 2) perceptions of the brochure. Regarding practices and needs, four subthemes were identified: communication practices, communication barriers between professionals and parents, needs of professionals and needs of parents to improve communication. Regarding perceptions of the brochure, subthemes included new recommendations, general impressions, suggestions to improve the brochure, perceptions of the utility of the brochure in HCP and CCP practices, and of the use that parents can make of it. Detected differences between HCPs’ and CCPs’ discourse were reported in the results. The themes and subthemes are illustrated in Table 3 and described in detail below.
Table 3
Overview of themes and subthemes.
Themes
|
Subthemes
|
1) Practices and needs in terms of communication with parents on child feeding
|
Communication practices
|
Communication barriers between professionals and parents
|
Needs of professionals to improve communication with parents
|
|
Needs of parents
|
2) Perceptions of the brochure
|
New recommendations
|
General impressions of the brochure (positive and negative)
|
Suggestions to improve the brochure
|
Perceptions of the utility of the brochure in HCPs and CCPs practice
|
|
Perceptions of the use that parents can have of the brochure
|
1) Practices and needs in terms of communication with parents on child feeding
Communication practices
Professionals mentioned that they mostly provided information on child feeding orally to parents. HCPs also suggest websites to parents where they could search for information and the list of the most cited websites is reported in Table 4. HCPs explained that they systematically spoke with parents about child feeding at regular consultations within the first year of life, especially on complementary feeding (CoF) when the child is from four or five months of age. They mentioned that they do not have a rigid approach on how and when parents should start CoF. However, almost all HCPs reported that they liked to provide parents with a framework (starting with fruits and vegetables and introducing proteins after six months of age).
“So, I recommend starting at five months but only with vegetables, and then introducing fruits. After six months, introduce animal proteins such as meat, fish, and eggs.” (P2, HCP, General practitioner)
HCPs mentioned that exchanges about child feeding become less frequent and less systematic after one year. The media used by HCPs to support oral communication are the child health record booklet, paper documents adapted to the child’s age range, and websites that parents can visit (see Table 4). Professionals working with the most disadvantaged families (especially in PMIs) explained using Google during consultations to show pictures on the computer screen and to translate their speech.
“We adapt to families, for example when we recommend whole milk, we put pictures on the computer, we say “the red cap”, or “the pink cap” for follow-on milk; finally, we manage to find solutions.” (P20, CCP, PMI nurse)
Regarding CCPs, very practical information on child feeding is exchanged with parents (what the child eats at home and at the childcare center), especially orally during the morning (when parents drop off their child) and evening “transmission” times (when parents pick up their child) but also with the support of paper documents. It was also reported that parents’ meetings are occasionally organized in some childcare centers.
Table 4
Websites cited by HCPs (from top to bottom, the most to the least cited).
Websites
|
Mpedia.fr
Pediadoc.fr
MangerBouger.fr
Pédiatre-online.fr
Ameli.fr
Pap-pédiatrie.fr
Alimentationdutoutpetit.fr
|
Communication barriers between professionals and parents
Language was mentioned by professionals as a barrier to communication with parents, especially in PMIs, where professionals meet the most disadvantaged families (often with a foreign origin).
“One of the difficulties we have at the PMI is that we have a lot of very precarious families [...] therefore they face many difficulties other than the problems linked to their daily diet.” (P12, HCP, PMI physician).
The lack of time and training (inconsistent training done on a voluntary basis) were also mentioned as barriers. It was also stated that the perpetual change in the child feeding recommendations confuses parents and impairs communication, since it induces the circulation of conflicting information, even among professionals. Socioeconomic insecurity was reported to impact communication on child feeding.
“It’s supposed to be our role, but we don't necessarily have the training, support or the time.” (P7, HCP, General practitioner)
Needs of professionals to improve communication with parents
Professionals mentioned that they needed “official documents” and nutrition training to improve their communication with parents to standardize the knowledge related to infant and young child feeding.
“There are a lot of different speeches that are not necessarily very serious and not very embarrassing, but I think that by standardizing the speeches, we would have more credit and it would be easier for parents.” (P8, HCP, General practitioner)
Professionals working in PMIs emphasized their need for more adapted media (in particular, a short document with many illustrations and few texts and/or in various languages).
“In fact, we would need either adapted documents in several languages, or much simpler things. We really need things that are quick and simple to show to parents. And that's kind of what we're missing.” (P20, CCP, PMI nurse)
Needs of parents
Professionals reported that parents are asking for information on feeding, especially CoF. They noted that some parents need very specific guidance from HCPs, while other parents prefer flexibility in the information they receive. Parents ask for details on the recommended quantities of food and milk as well as practical advice (e.g., how to introduce an allergen).
2) Perceptions of the brochure
New recommendations
Professionals were aware that it is now recommended to start CoF between four to six months of age to prevent allergies. However, when a mother was breastfeeding, professionals were more likely to recommend starting CoF at six months of age in accordance with the World Health Organization (WHO) recommendations (encouraging exclusive breastfeeding until six months of age).
“Sometimes breastfeeding mothers want to continue exclusive breastfeeding up to six months. In general, I am not really against it because the WHO recommends that. So, I don't have too many reasons to go against it especially if it's desired on their part.” (P2, HCP, Pediatrician)
Recommending introducing all types of food between four to six months of age was still not grounded in practice among the interviewed professionals. Professionals were used to advising introducing proteins from six months of age, as suggested in the previous recommendations. Some doubts about the early introduction of allergens and proteins were expressed.
“Being able to introduce all the foods is the biggest novelty. We can introduce everything, taste more or less anything, in particular and at the same time, without respecting... waiting the six months.” (P8, HCP, General practitioner)
“What’s the point of wanting to absolutely start protein right away between four and six months? […]. The info on the introduction of peanuts, which I used to do previously, but is it really scientifically validated? Because they don't all have the same indications about it between allergology organizations.” (P5, HCP, Pediatrician)
According to the new brochure, pulses and whole grain starches can be introduced to children from four months of age. This recommendation sounded relatively new to professionals, but it appeared to be well accepted despite some doubts about their digestibility were raised. Some CCPs noticed that feeding practices in childcare centers do not meet this recommendation.
“I discovered that at four months you could give that: lentils and mashed beans. I did not know. It was complicated for me because the fiber and the lentil, bean, or chickpea skins have to be very well mixed. But I find it good, it's interesting.” (P21, CCP, PMI nurse)
Most of the professionals knew that it was possible to alternate follow-on milk and full-fat cow milk after the child turned one years old. They found that this was a good option to propose to disadvantaged families. However, there was a tendency to emphasize follow-on formula to avoid iron deficiency. The purpose of this recommendation seemed to be less understood by CCPs.
“And I had to do it before because I know that you can give whole cow's milk instead of follow-on milk. [...] On the other hand, it is true that where I insisted, it was that it should not be exclusively cow's milk. They need a lot of iron and that is not covered by cow's milk.” (P9, HCP, General practitioner)
“I think there is ambiguity, and we are not sure if we are completely marketing or if this follow-on milk really brings more to the children. And again, from one pediatrician to another, we can see that there are two schools, there are really those who switch to UHT milk without worry and others who are reluctant.” (P14, CCP, professional working in a childcare center).
Professionals were familiar with non-recommended foods (e.g., plant-based alternatives to formula, sugar sweetened beverages and foods). Some of them asked for more explanation, especially regarding the new recommendation about avoiding chocolate until three years old.
Professionals mentioned that they particularly enjoyed one section of the brochure on baby-led weaning as they face an increasing number of questions about this topic and need more evidence-based information.
“As I read, I also thought about the baby-led weaning, I wondered if it would be covered when I saw that there was a little passage on it. It's true that sometimes it's not very common, but it so happens that there are parents who say they want to do the baby-led weaning when in fact, frankly, I have no knowledge of it. I do not know what to advise them, as it is really outside the framework of the recommendations that I’ve read.” (P2, HCP, Pediatrician)
“Then, we have more and more questions about baby-led weaning. This is something I had never heard of... I have the feeling that a year ago we didn't talk about it, and in the last year we have talked about it a lot. There is a little insert on it, that's good.” (P17, CCP, Childcare assistant)
General impressions of the brochure
Positive impressions of the brochure outweighed negative impressions (see Table 5). In fact, all 21 professionals expressed at least one positive impression, and overall, they seemed enthusiastic about the brochure (some of them wanted to use it forthwith).
Table 5
Summary of the general impressions about the brochure
Positive impressions
|
Negative impressions
|
Complete and precise document (n=15)
|
Long document (parents might consequently not read it) (n=12)
|
Positive tone (not judging/guilt-inducing) (n=10)
|
Layout (participants were provided with a draft (only with text)) (n=8)
|
Agree on the topics order (from general to age-adapted information) (n=9)
|
Summary table is complex and difficult to read (n=7)
|
Global approach including advice on screens, physical activity (etc.) and parenting advice (n=9)
|
Some recommendations are still guilty-laden (recommendations on breastfeeding, organic foods and industrial foods) (n=3)
|
Summary table is well done and useful (n=7)
|
Unsuitable/Improper advice about child motor development (n=3)
|
Perceptions of the utility of the brochure in HCP and CCP practice
HCPs considered the brochure as a supplement that could facilitate communication with parents. Using the brochure could help save time during consultations (parents could read the brochure at home and return to the next consultation with additional and more precise questions). Moreover, the brochure could enable HCPs to have a more systematic approach in their information delivery to parents about child feeding, and help HCPs update their knowledge of the new recommendations.
“I find that supports our speech by saying: “It’s not just my personal opinion and what I personally believe. This is really what is recommended”.” (P8, General practitioner)
“That [reading the brochure] clarifies the recommendations, so that's great. I am very happy with it. [...] I learned some things.” (P9, HCP, General practitioner)
In PMIs, the brochure could be used only with a few parents because it is too long and complex for serving the most disadvantaged populations. CCPs generally stated that they would give the brochure to parents who have specific questions about infant and young child feeding. The brochure would help CCPs feel more legitimate and precise in giving advice to parents.
“These are somewhat formal documents; we still say to ourselves that it was thoughtfully studied by professionals. It gives us legitimacy and technical consistency.” (P14, CCP, Professional working in a childcare center)
Suggestions to improve the brochure
Most of the participants recommended making the brochure more entertaining (more pictures and less text) as they were provided with a preliminary version of the brochure with no illustrations. Participants suggested translating the brochure in different languages or to make one document with visual explanations and many pictures adapted to PMI populations. Participants also proposed making different detachable sheets adapted for each age range of the child to easily distill the information to parents. Including the brochure in the child health record booklet and adding more explanations and/or scientific references (e.g., why starting CoF between four to six months of age help prevent the development of allergies; why is it recommended to avoid salt until three years of age; scientific references to justify the introduction of gluten and nuts, etc.) were also popular suggestions.
“In fact, we should be able to cut down the number of items to give just the one that corresponds to the needs of the families in the moment. After that there is a need to put images so that we can adapt it to our families.” (P20, CCP, PMI nurse)
Perceptions of the use that parents can have of the brochure
Professionals believe that the brochure is a comprehensive and useful written tool for parents and can serve as a reference for discussing child feeding with doctors. They believe that the brochure will be more useful for parents who are already invested in the topic of child feeding and that its usefulness will be more limited for parents of the most disadvantaged backgrounds. The brochure could encourage parents to change certain habits (e.g., to cook more homemade dishes).