Global Index

India Spotlight Index

India Spotlight Index

BMS assessment

  • Limited geographic area: This study was restricted to Greater Mumbai. The results should be representative of this particular study area but should not be interpreted to apply to all of India. Different results might be found if the study were conducted in other areas of Mumbai. It is believed that promotion of BMS products is likely to be highest in an urban area such as Mumbai because of the high density of the population, relatively high average income levels and the ease of reaching women. However, ATNF has not seen any evidence from other urban areas or rural areas of India to confirm or refute this assumption.
  • Point-in-time study: This pilot study was a one-time cross-sectional survey (following the IGBM Protocol) that provides reasonable prevalence estimates for the point in time that it was conducted. Follow-up studies in the same geographic area could make the results from this pilot study a valuable baseline to measure improvements or declines over time. Ideally, continual monitoring would be undertaken.
  • Recall bias: The most significant limitation of the Westat study is that much of the information needed to assess compliance comes from interviews with women and health care workers. Such information that relies on memory should, therefore, be treated with caution, as it can be subject to a ‘recall bias’. (See Westat report for further detail). Where the interviews identify only a very small number of possible incidents of non-compliance, the information should be used very cautiously, since they could be recall errors. On the other hand, when many episodes are reported, it is possible to be more confident that a substantial amount of non-compliance did occur even if there are some recall errors. The exact percentage estimate is less important than the obvious magnitude of the problem. 

  • Selection of female respondents within facilities: The initial sampling plan called for a relatively complex, systematic, random sampling of women based on an estimate of the expected number of eligible women who would attend the facility over a two-day period. In practice, it was not possible to fully implement this plan; the interview teams, therefore, frequently conducted interviews on a consecutive basis until 20 were complete (with a few exceptions) within the clinic. There is some possibility that this introduced some bias in the representation of the sample if different types of women showed up at different times of the day or different days of the week. However, given the small number of positive reports by the women, this sampling approach is unlikely to have fundamentally altered the results.
  • Selection of healthcare workers: While healthcare workers were randomly selected within each health facility, those selected might not have been placed to answer facilityrelated questions. Westat attempted to improve on the variability of respondents by employing a “stratified random” approach so that one doctor, one nurse and one other type of healthcare worker was interviewed. The study’s approach might have resulted in the under-reporting of certain items, such as equipment donation and visits by sales representatives.
  • Selection of retail outlets: In terms of the selection of retail outlets to observe point-ofsale promotions, the selection was purposive, not representative. The objective was to select stores judged most likely to have such promotions. Because of the convenience selection methodology, the results cannot be extrapolated to the universe of stores in Mumbai. Further, each store was visited on only one day, so it is possible that some stores would have had promotions if they had been visited over a period of time.
  • The population of women studied: Because the sample was limited to mothers with children only up to 6-months-old, as required by the IGBM Protocol, this does not address the promotion of breastfeeding up to 24 months and may, consequently, underestimate the promotion of BMS products for older children.
  • Limitation of data collection on complementary food: The IMS Act restricts the advertising and promotion of complementary foods up to 24 months of age, but The Code is limited to complementary foods up to 6 months of age as these are breast-milk substitutes. While Westat addressed other elements of local regulations that were stronger than The Code, it limited the products covered to complementary foods for infants up to six months to maintain consistency with the Vietnam and Indonesia studies. Information about the marketing of complementary food products for 6-24 months of age would no doubt be useful to the Indian government; it would be beneficial for future studies to include these products.
  • Breastfeeding rates: While it is important to record and encourage increases in breastfeeding rates, the IGBM Protocol is not designed to assess such practices.

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