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Abstract Background The International Code of Marketing of Breast-milk Substitutes, or ‘the Code,’ sets standards to regulate marketing of commercial milk formula (CMF) to protect breastfeeding. World Health Organization member states are advised to legislate the Code into national law, but understanding of its implementation outcomes is limited. This systematic review aimed to examine implementation outcomes in countries implementing the Code as national law. Methods We systematically searched five academic databases in September 2022 for articles published in English from 1982 to 2022. We double-screened titles/abstracts and then full texts for eligible articles reporting implementation outcomes of the Code in 144 eligible countries. We used the Mixed Methods Appraisal Tool for quality assessment and synthesized data thematically. We applied the Proctor et al. framework to guide synthesis of implementation outcomes, organizing our findings according to its taxonomy. Results We included 60 eligible articles of the 12,075 screened, spanning 28 countries. Fifty-seven articles focused on legal compliance, 5 on acceptability, and 1 on feasibility. Compliance was assessed across multiple sources, including mothers, health workers, media, points of sale, and product labels. Maternal exposure to CMF promotion remained widespread, with reports of mothers receiving free samples and coupons, and encountering media advertisements. Compliance of health workers varied across countries, with many reporting contact with CMF companies despite legal prohibitions. Public hospitals generally showed better adherence to the national law than private ones. While implementing the Code as national law effectively regulated the promotion of CMF for infants aged 0–12 months in public settings and in the media, it remains insufficient in addressing the promotion of unregulated products like growing-up milk, which are often marketed through emerging strategies such as cross-promotion and digital advertising. Point-of-sales compliance was inconsistent, with many countries reporting non-compliant price-related promotions. Conclusion To enhance legal compliance, robust monitoring and reporting systems are necessary. Utilizing technology-assisted solutions for monitoring compliance can be an option for countries with limited human resources. Adequate training for health workers and communication strategies targeting shop managers about national law are also essential in enhancing their acceptability and compliance.

Background Early childhood development is essential for lifelong health and well-being. This study aims to assess the proportion of children aged 24–59 months in Thailand who are developmentally on track using the Early Childhood Development Index 2030 (ECDI2030) and to explore associations with household socioeconomic characteristics and environments.Methods A cross-sectional analysis was conducted using data from the 2022 Multiple Indicator Cluster Survey by the Thailand National Statistical Office. The developmental progress of 6557 children was evaluated across health, learning and psychosocial domains using ECDI2030 criteria. Multivariable logistic regression was used to assess associations between developmental status and household and participant characteristics.Results The study found that 81.3% of children were developmentally on track. Factors positively associated with being on track included being female (adjusted OR (AOR)=1.49), higher maternal education (AOR=2.02 for above secondary education), more books at home (AOR=1.59 for 3–9 books; AOR=2.40 for 10+ books) and increased screen time (AOR=1.68). Living in the Northern (AOR=0.45) and Northeastern (AOR=0.56) regions decreased the likelihood of being on track.Conclusion Around 20% of children did not meet ECDI2030 milestones, highlighting the need for targeted policy interventions. Gender, region, maternal education, access to books and screen time were significant factors for developmental outcomes. Policies should prioritise support for parents, nurturing care and educational resources, particularly for socioeconomically disadvantaged groups.

Abstract The promotion of commercial milk formula (CMF) negatively impacts breastfeeding outcomes. In 2019, Singapore updated its 1979 Code of Ethics of the Sale of Infant Foods Ethics Committee Singapore (SIFECS) to increase marketing restrictions on CMF for infants 0–12 months. However, little is known about industry tactics to undermine these restrictions. This qualitative study explores health workers' and mothers' experiences with CMF marketing in Singapore following the 2019 restrictions. We conducted a qualitative study, using semistructured interviews with 14 mothers of infants aged less than 5 months and 20 health workers with expertise in antenatal, maternity, or paediatric care. We analysed data thematically using inductive coding. Five themes were identified. Mothers and health workers reported digital marketing, product line extensions with toddlers' milk and milk for mothers, and CMF sponsorships in the healthcare setting. Expert endorsement, competitive price, nutritional claims, and brand reputation influenced mothers' infant formula choices, yet both mothers and health workers appeared to be unaware of the impact of CMF marketing tactics on their own perceptions. The restriction of CMF marketing and infant feeding practices varied widely between hospitals, with private hospitals and practices having less strict controls on CMF marketing. Despite the updated SIFECS restrictions, CMF companies continue to target mothers and health workers in Singapore. SIFECS restrictions should be tightened to align with international guidelines, by increasing their scope to include toddlers' milk and prohibiting cross‐promotion, digital marketing, and any sponsorships of events targeting health workers that may create a conflict of interest.

BackgroundPhysical inactivity and sedentary behavior are significant risk factors for various non-communicable diseases. Bangkok, Thailand's capital, is one of the fastest-growing metropolitans in Southeast Asia. Few studies have investigated the epidemiology of physical activity and sedentary behavior among Bangkok residents. This study aims to investigate the prevalence of combined physical activity and sedentary behavior patterns among Bangkok residents and examine relationships between participants' characteristics and the combined movement patterns.MethodsWe analyzed data from the nationally representative 2021 Health Behavior Survey conducted by the Thailand National Statistical Office. The Global Physical Activity Questionnaire was used to assess physical activity and sedentary behavior. 'Sufficiently active' was defined as meeting the World Health Organization's guidelines for aerobic physical activity (≥150 minutes of moderate-to-vigorous physical activity per week). 'Low sedentary time' was defined as sitting for ≤7 hours per day. Participants were categorized into one of four movement patterns: highly active/low sedentary, highly active/highly sedentary, low active/low sedentary, and low active/highly sedentary. Multinomial logistic regression was used to identify the factors associated with each group of four movement patterns.ResultsAmong the 3,137 individuals included in the study, the majority were categorized as highly active/highly sedentary (64.8%), followed by highly active/low sedentary (17.9%) and low active/highly sedentary (14.3%). Only a few (3.0%) of participants were categorized as being low active/low sedentary. Compared to males, female participants had a significantly higher likelihood of belonging to the highly active/low sedentary (AOR = 1.69, 95%CI: 1.25, 2.28) or highly active/highly sedentary (AOR = 1.51, 95%CI: 1.19, 1.93) group, rather than the low active/high sedentary group. Compared to unemployed/retired participants, those in labor-intensive occupations had a significantly higher likelihood of being in the highly active/low sedentary group (AOR = 1.89, 95%CI: 1.22, 2.94). Compared to participants with no chronic physical conditions, participants who reported multimorbidity had a significantly lower likelihood of being in the highly active/low sedentary group (AOR = 0.60, 95%CI: 0.37, 0.98).ConclusionThis study provides valuable insights into the patterns of physical activity and sedentary behavior among residents of Bangkok using up-to-date data. The majority belonged to the highly active/highly sedentary group, followed by the highly active/low sedentary group. Correlates such as sex, occupation, and chronic conditions were associated with these patterns. Targeted interventions in recreational activities, workplaces, and urban areas, including screen time control measures, movement breaks and improved built environments, are crucial in reducing sedentary behavior and promoting physical activity.

Abstract Background Global advocates for breastfeeding were evident since the International Code of Marketing of Breast-Milk Substitutes (BMS Code) was adopted in 1981 and fostered by subsequent relevant World Health Assembly resolutions, using a framework that promotes, supports and protects breastfeeding. Global partners provided comprehensive support for countries to achieve breastfeeding targets while progress was closely monitored. This review identifies breastfeeding policy and implementation gaps in Thailand. Main findings Although Thailand implemented three Thai voluntary BMS Codes, ineffective enforcement results in constant violations by BMS industries. In light of strong resistance by the BMS industries and their proxies, it was not until 2017 that the Code was legislated into national law; however regulatory enforcement is a protracted challenge. A Baby-Friendly Hospital Initiative (BFHI), mostly in public hospitals, was successfully applied and scaled up nationwide in 1992, but it later became inactive due to lack of continued support. Several community-based and workplace programmes, which supported breastfeeding, also faced challenges from competing agendas. Although the Labor Protection Law offers 98 days maternity leave with full pay, the conducive environment for successful six- month exclusive breastfeeding (EBF) needs a significant boost. These gaps in policy were exacerbated by a lack of multi-sectoral collaboration, ineffective implementation of existing interventions, inadequate investment, and lack of political will to legislate six-month maternity leave. As a result, the progress of EBF rate during the first 6 months as measured by previous 24 h was erratic; it increased from 12.3% in 2012 to 23.1% in 2015 and decreased to 14% in 2019. There was a deterioration of early initiation from 49.6% in 2006 to 34% in 2019. These low performances hamper the achievement of global targets by 2030. Conclusions We recommend the following. First, increase financial and human resource investment, and support successful exclusive breastfeeding in BHFI, communities and workplaces through multi-sectoral actions for health. Second, implement the active surveillance of violations and strengthen law enforcement for timely legal sanctions of violators. Third, revitalize the BFHI implementation in public hospitals and extend to private hospitals.

Abstract 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.

The article offers information on the theme issue on lessons for effective policy responses to COVID-19 to be published by the periodical "Bulletin of the World Health Organization" in 2022. Topics discussed include the role of lack of effective outbreak management in high incidence of COVID-19 infections and deaths in some countries, interest of the periodical for manuscripts on policy and health system adjustments made to address the pandemic, and schedule of submission and theme launch.