The NetCode protocols focus on promotion of any product that is within the scope of the Code, including milk products specifically targeted for children < 3 years (infant formula, FUF, and GUM), foods or liquids targeted for infants < 6 months, and feeding bottles and teats. As noted in the protocol for periodic assessment, “Periodic assessment is essential to measure the level of compliance with the Code and national laws, assess trends.” The objectives of the protocol are to:
detect violations of the national laws and/or the Code;
document and report such violations;
investigate and validate whether the reported activities are indeed violations;
activate an enforcement mechanism that would stop such violations and deter future violations; and
hold manufacturers, distributors, retail outlets, the health care system and health care workers to account for their breeches of national laws and/or the Code.
The protocol for periodic assessment lays out procedures for data collection from mothers of children 0–23 months of age, health care providers, and primary health care and maternity facilities. It also lays out procedures for data collection in brick-and-mortar retail stores, such as pharmacies and grocery stores, on television, and through the internet and social media. The protocol includes a standard questionnaire for face-to-face interviews with mothers and health care providers (with a recall period of the previous 6 months), a set of procedures for evaluating television and internet advertisements, tools for observing and recording promotions in retail stores and primary health care facilities, and a checklist for evaluating information on product labels.
Our paper consolidates results from use of the protocol for periodic assessment in eight countries: Chile, Ecuador, Mexico, Nigeria, Panama, the Philippines, Thailand, and Uruguay [15–22]. Data were extracted by two coauthors (VLM and ALLT). Whenever there was a discrepancy, a third coauthor reviewed the data (SHC).
We report on all aspects of the protocol, though acknowledge that documentation of promotion of BMS through internet advertisements and social media is likely to be underestimated because of the challenges associated with collection of such data.
All studies were conducted between 2016 and 2020. Approval from the national or institutional ethics committees was obtained for each country. All participating mothers and health care providers signed a letter of informed consent. Each country made some modifications to the protocol to address specific national concerns. As such, the sample sizes for the different instruments of the protocol differ across countries, and in some countries, questionnaires were abbreviated. For example, while the protocol requires data collection only in the largest city of the country, Ecuador and Mexico selected two cities. In Chile, private health clinics were excluded from the sample; however, maternity facilities were included. The studies in Nigeria, the Philippines, and Thailand were conducted primarily for the purpose of assessing infant formula manufacturers’ compliance with the Code and thus used an abbreviated questionnaire for health care providers and did not interview mothers. Details of the studies for each country are shown in Supplemental Table 1.
The protocol calls for a random sample of 33 health care facilities providing well-baby care services. In each facility, five mothers with children < 6 months old and five mothers with children > 6 to 23 months old were selected. The sample size of 330 for the mother’s questionnaire was designed to detect a 10% prevalence rate of exposure to BMS promotions within the health care system, with confidence intervals at 95% and a measurement error of ± 5%, assuming a design effect of 2 to account for the cluster design. For each health care facility, between one and three health providers were interviewed using a convenience sample.
To measure promotion at retail outlets, we selected supermarkets, pharmacies, convenience stores1, corner stores1, and department stores. Corner stores and convenience stores were selected based on proximity to the health care facility selected, whereas chain supermarkets and pharmacies, which carry most of the products available on the national market, were purposively selected.
Data collection at each point-of-sale location included enumeration of products sold under the scope of the Code. In Chile, Ecuador, Mexico, Panama, and Uruguay, a list of the products encountered was recorded. In Nigeria, the Philippines, and Thailand, a preliminary list of products from an internet search was compiled and refined through confirmation of the ones available in each country.
For the review of labels and inserts, we reviewed products, primarily from infant formula and complementary foods, assessing the extent of promotions and compliance of product labels with the Code and national laws.
To examine the association between Code violations and quality of Code legislation, we first estimated a composite violation score for each country as a weighted average of the percent of mothers, health care providers, retail outlets, or product labels that showed violations of the Code. The weights are shown in Supplemental Table 2. We then examined the association between the composite violation score and the quality of the country’s Code legislation as presented in the 2020 Status Report of National Implementation of International Code . That report classified countries according to how well their legislation reflects the provisions of the Code on a scale from 0 to 100.
We used Excel (version 16.50) for all analyses. Results were calculated for each country and for all countries.
 ‘Convenience store’ refers to small‐ to medium‐sized establishments that sell food products, which may be franchises or chains, and ‘corner store’ refers to locally owned establishments that are smaller than convenience stores.