Guideline documents and recommendations for feeding infants and young children have been developed across many countries by government agencies, professional groups, and nonprofit organizations. Improving knowledge, attitudes, and feeding practices for children under 2 years, however, requires more than simply providing the information in a guideline document. Effective communication and dissemination of information
is necessary to ensure that health care providers, parents, caregivers, and others are educated about the feeding recommendations, thereby improving their diffusion and uptake. As these concepts are fundamental to the use of the feeding guidance, the committee was asked to assess the guideline documents for descriptions of best practices and implementation strategies to support communication and dissemination of feeding recommendations (see Chapter 1, Box 1-1). The committee’s charge did not stipulate a broad, comprehensive review of communication and dissemination strategies, but rather directed the committee to summarize what could be gleaned from the feeding guideline documents it reviewed. The committee, therefore, looked for information about communication and dissemination strategies within the eligible guideline documents, and drew on select examples from its exploratory scans (for more detail on the methodology, see Chapter 2).
Different groups and disciplines use the terms communication, dissemination, and implementation in various ways. Communication and dissemination are sometimes viewed as synonyms and have been used interchangeably. The committee, within the context of public health and a clinical practice audience (AHRQ, 2012), considered these three concepts interrelated but distinct. For developing and implementing feeding evidence-based guidelines, communication is the broadest of the three concepts, and occurs over the course of the entire guideline process as a way to provide information and influence decisions and actions of a target audience.1Dissemination, by comparison, happens when the evidence-based guidelines are complete and consists of actively engaging with the target populations through identified channels and strategies to spread the recommendations. Implementation focuses on the integration and effect of the evidence-based guidelines once they are disseminated within a setting. The definitions underpinning the committee’s approach to this portion of its task are presented in Box 6-1.
Implementation strategies involve complex, multisector processes, within which dissemination strategies play an important role (Leeman et al., 2017). The feeding guideline documents reviewed by the committee did not describe implementation strategies, as defined in Box 6-1. Accordingly, the committee focused on information contained within the guideline docu-
1 A subset of communication is health communication, which has been defined as “the study and use of communication strategies to inform and influence decisions and actions to improve health” (CDC, 2020). For consistency with the committee’s charge, it uses the term communication throughout, but acknowledges that the goal of communication related to feeding guidelines is generally to inform and influence parents’ and caregivers’ actions related to what and how they feed their infants and young children.
ments concerning changing knowledge, attitudes, or behaviors related to feeding children under 2 years of age, and the channels by which to spread feeding guidance. In this chapter, the committee summarizes communication and dissemination strategies described in the guideline documents, discusses select examples of additional communication and dissemination materials for some of the target audiences, and provides its reflections on the identified strategies. The committee was not tasked with determining the effectiveness of the identified approaches.
As described in Chapter 2, the committee used a multipronged approach to explore feeding guideline communication and dissemination strategies. Each eligible guideline document was reviewed to identify specific guidance related to communicating and disseminating the feeding recommendations. Of the 43 guideline documents reviewed, 25 included a statement or sec-
tion related to communication or dissemination (see Table 6-1). The communication and dissemination guidance varied in length and content. For instance, in the American Academy of Pediatrics (AAP) guideline on fruit juice, there was a single sentence: “Pediatricians should routinely discuss the use of fruit juice and fruit drinks and should educate older children, adolescents, and their parents about differences between the two” (Heyman
|AAFP||AAFP, 2014||Health care providers|
|AAP||AAP Section on Breastfeeding, 2012||Health care providers|
|Baker-Smith et al., 2019||Health care providers|
|Heyman et al., 2017||Health care providers|
|Golden et al., 2014||Health care providers|
|AAP; AAPD||AAPD, 2016||Health care providers|
|AAPD||AAPD, 2017||Health care providers|
|AND||AND, 2016||Health care providers|
|Australian government, NHMRC||NHMRC, 2012||Health care providers|
|Breastfeeding Committee for Canada; CPS; Dietitians of Canada; HC||Health Canada et al., 2014||Health care providers|
|Health Canada et al., 2015b||Health care providers|
|CPS||Grueger et al., 2013c||Health care providers|
|ESPGHAN||Braegger et al., 2013||Health care providers|
|Domellöf et al., 2014||Not speciﬁed|
|Fidler Mis et al., 2017||Health care providers; policy makers|
|New Zealand Dental Association; New Zealand Ministry of Health||New Zealand Dental Association, 2008||Health care providers|
|New Zealand Ministry of Health||Ministry of Health, 2012||Health care providers; program administrators|
et al., 2017). In contrast, the 2005 WHO guideline document on feeding nonbreastfed infants 6–24 months provided an annex that describes 13 steps for developing locally appropriate recommendations based on the information contained within the document (WHO, 2005).
|NICE||NICE, 2008||Health care providers; policy makers|
|NIH||Togias et al., 2017||Health care providers|
|PAHO, WHO||PAHO/WHO, 2003||Community leaders; health care providers; policy makers; program administrators|
|RCPCH||RCPCH, 2019k||Health care providers; policy makers|
|RWJF-HER||Lott et al., 2019||Advocates; health care providers; parents|
|Pérez-Escamilla et al., 2017||Early care and education providers; health care providers; parents|
|SACN; COT||SACN and COT, 2018||Policy makers|
|WHO||WHO, 2005||Policy makers; program administrators|
a Provided a stand-alone summary document of the recommendations.
b No date was provided for this resource. Year in citation reﬂects year the webpage was last updated. The text of the resource indicates it preceded Health Canada et al. (2014).
c Reafﬁrmed in 2018.
d Resources were speciﬁcally for parents.
e The guideline document included discussion of policy implications related to the recommendations.
f The guideline document includes recommendations on deﬁnitions that should be used in regulations and a call to action for policies that support the recommendations.
g The guideline document noted that the materials can be modiﬁed to be age-appropriate and respond to families’ needs.
h The guideline document includes an explanation of how the work can facilitate work of national and local organizations.
i An appendix provides guidance for parents to execute one of the recommendations contained within the document.
j States that stakeholders can use the information in the guideline document to message appropriately.
|Provides Additional Resources, Links, or Tools||Promotes Education, Support, or Advocacy||Provides Discussion Points||Identiﬁes Important Groups to Receive Message||Other|
k Date reﬂects year the webpage was last modiﬁed. The post date is listed as 2017.
l The guideline document explained that the recommendations “provide consistent messages that can be used by health care providers, public health practitioners, and parents and caregivers.”
m Provides context for the systems-level approach to overcoming barriers for implementation.
n Includes some recommendations that embed guidance on the action governments should take and how advice should be stated.
o Describes steps for developing locally appropriate feeding recommendations based on the guideline document.
The committee also drew on materials discovered through its targeted website searches and the screening process to serve as demonstrative examples. The committee found a vast and heterogeneous landscape of webpages, PDF documents, newsletters, videos, podcasts, toolkits, key messages, and other types of resources widely and readily available. It would have been an insurmountable task to catalog all of these materials. Rather, the scan served to identify examples of materials that convey feeding recommendations to various audiences.
Approaches Categorized by Target Audience of Guideline Document
Most of the guideline documents the committee reviewed were specifically developed for one or more target audiences, with a large majority aimed at health care providers (e.g., physicians, nurse practitioners, nurses, dentists, registered dietitian nutritionists, and other nutrition professionals). Other target audiences included parents and guardians, early childhood education providers, program administrators, and policy makers. Communication and dissemination approaches were varied across these different target audiences.
Health Care Providers
Feeding guideline documents most often focused on health care providers as a critical nexus for changing caregiver practice. The guideline documents reviewed by the committee often sought to promote awareness, attitudes, knowledge, and the adoption of feeding recommendations at the individual provider or practice level. Some guideline documents included additional or external resources for health care professionals (AAFP, 2014; AAP Section on Breastfeeding, 2012; AND, 2016; Ministry of Health, 2012; NHMRC, 2012; NICE, 2008; RCPCH, 2019). Three guideline documents included explicit discussion points that could be used to communicate the recommendations to families (Baker-Smith et al., 2019; Health Canada et al., 2014, 2015). Three mentioned adapting the information within the guideline document to be more relevant or messaged appropriately (New Zealand Dental Association, 2008; PAHO/WHO, 2003; WHO, 2005).
Parents and Guardians
Although the importance of providing parents and guardians with specific feeding guidance was acknowledged, these groups were infrequently the target audience for the guideline documents reviewed. Only two of the guideline documents, both from the Robert Wood Johnson Foundation-Healthy Eating Research (RWJF-HER), specifically mentioned parents and
guardians as a target audience (Lott et al., 2019; Pérez-Escamilla et al., 2017). Lott et al. (2019) sought to “provide consistent messages that can be used by health care providers, public health practitioners, and parents and caregivers.” The publicly accessible webpage that hosts the guideline document includes a synopsis, along with an infographic that distills the recommendations and presents them by age group (HER, 2019). Similarly, Pérez-Escamilla et al. (2017) aimed to “empower caregivers to address the nutrition and well-being of infants and toddlers.” On the webpage that hosts the Pérez-Escamilla et al. (2017) guideline document (HER, 2017), there is a link for a series of 12 videos for parents (1,000 Days, 2020); the video webpage was a collaborative effort among the Centers for Disease Control and Prevention, RWJF-HER, and 1,000 Days that provides “accessible and evidence-based information about what, when, and how to feed infants and toddlers.”
Two of the guideline documents provided additional resources or tools specifically for parents and guardians, despite parents and guardians not being a primary target audience of the guideline document itself. The end of a guideline document from the Canadian Paediatric Society (CPS) listed three references as being “resources for parents” (Grueger et al., 2013). The 2017 Addendum Guidelines for the Prevention of Peanut Allergy in the United States included an appendix providing parents and guardians with instructions for feeding peanut protein to low-risk infants at home (Togias et al., 2017). Two guideline documents authored by a consortium of Canadian organizations—Breastfeeding Committee for Canada, CPS, Dietitians of Canada, and Health Canada—were more indirect with regard to guidance for parents (Health Canada et al., 2014, 2015). Both guideline documents provided information and ideas about how to answer the questions of parents and caregivers, but they did not provide direct communication tools for this audience in these online resources.
A host of online resources are available to parents and guardians, but they are sometimes inconsistent in directly mapping back to a guideline document. For instance, one of the Canadian consortium partners, CPS, used its guideline documents in its own communication and dissemination efforts. CPS hosts a website to provide information directly to parents (CPS, 2020). The webpage on breastfeeding provides detailed information for mothers and provides links to additional resources (CPS, 2018), two of which were the collaborative guideline documents in which it participated (Health Canada et al., 2014, 2015). CPS’s parent and guardian guidance on vitamin D (CPS, 2016) also hyperlinks the organization’s position statement on the topic (Godel et al., 2007). AAP also hosts a parenting website (AAP, 2020). Although the website includes guidance on feeding infants and young children, the guidance does not directly map back to specific guideline documents.
Early Care and Education (ECE) Providers
Despite being integral players in infant and young child feeding, ECE providers were often not the target audience of the guideline documents the committee reviewed. Only one guideline document specifically mentioned ECE providers (Pérez-Escamilla et al., 2017), and none exclusively focused on ECE providers as the primary audience. Nevertheless, ECE providers are not without guidance; a number of resources related to infant feeding are available to this audience.
In the United States, a key resource available to ECE providers and others who care for children is Caring for Our Children: National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs (Caring for Our Children) (AAP et al., 2019). Caring for Our Children is a collaborative effort among AAP, the American Public Health Association, and the National Resource Center for Health and Safety in Child Care and Early Education; it contains national standards that “represent the best evidence, expertise, and experience in the country on quality health and safety practices and policies that should be followed in today’s early care and education settings” (AAP et al., 2019, p. xvii). Many of the standards in Caring for Our Children focus on how, what, and when to feed infants and young children. Although not the primary source of feeding recommendations, Caring for Our Children was designed to reflect guidance put forth by other authoritative organizations like AAP, the federal Child and Adult Care Food Program (CACFP),2 or federal nutrition guides from the U.S. Department of Agriculture (USDA). The specific guidance in the standards, however, does not always directly map to guideline documents or federal standards, although references are provided. In addition to the primary Caring for Our Children document, there are a number of other ancillary resources to help ECE providers implement the standards (e.g., tip sheets). Thus, Caring for Our Children serves as an example for how feeding recommendations from authoritative bodies are translated and then communicated and disseminated to “on the ground” providers in ECE settings through both a primary comprehensive resource and secondary materials to help providers implement the standards.
Program administrators play an important role in implementing feeding guidance and serving as a conduit for information for both program participants and staff. Across the guideline documents the committee reviewed, few noted program administrators as a key target audience. Those that did
2 In particular, 7 CFR § 226.20.
envisioned that the recommendations would inform and serve as the basis for health and nutrition programs (Ministry of Health, 2012; PAHO/WHO, 2003; WHO, 2005). As is the case for ECE providers, there are important documents that specifically communicate and disseminate feeding guidance to program administrators, but they largely exist outside of the guideline documents the committee reviewed. Two U.S. national programs with such guidance are CACFP and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).
Administered by the USDA Food and Nutrition Service (FNS), CACFP provides reimbursement for eligible meals and snacks served to qualifying children in participating ECE programs.3 USDA recently revised the CACFP rule to include a number of updates to improve children’s nutritional intake to better align with the Dietary Guidelines for Americans, as required by the Healthy, Hunger-Free Kids Act of 2010 (USDA, 2016). The recent CACFP rule changes guidance to program administrators on meeting the new requirements. One way in which this information was communicated to program administrators was through the document Feeding Infants in the Child and Adult Care Food Program (USDA-FNS, 2019a). This resource provides extensive practical information on how to comply with the new rule, and includes resources such as meal patterns, pictures, and example vignettes. Feeding Infants in the Child and Adult Care Food Program is an example of how feeding recommendations, together with policies and federal regulations, are synthesized and communicated to program administrators.
WIC, also administered through USDA-FNS, provides “nutritious foods to supplement diets, nutrition education (including breastfeeding promotion and support), and referrals to health and other social services” to low-income, nutritionally at-risk women, infants, and children up to age 5 (USDA-FNS, 2020). USDA-FNS recently released Infant Nutrition and Feeding: A Guide for Use in WIC (USDA-FNS, 2019b), designed to be a research-based resource for WIC staff who counsel program participants. The guide notes it “can assist staff in disseminating appropriate and accurate information to participants. It is a resource for planning individual counseling sessions, group classes, and staff in-service training sessions” (USDA-FNS, 2020).
The guideline documents summarized in Table 6-1 that identify policy makers as a target audience did not appear to be designed to reach policy makers directly (Fidler Mis et al., 2017; NICE, 2008; PAHO/WHO, 2003; RCPCH, 2019; SACN and COT, 2018; WHO, 2005). Each included only a
3 CACFP also serves those who are eligible in adult care programs.
brief reference to policy makers. For example, a guideline document for the UK government on the introduction of peanuts and hen’s eggs into infant’s diets included a brief section on recommendations for government that states:
The government should continue to recommend exclusive breastfeeding for around the first 6 months of life…. Advice on complementary feeding should state that foods containing peanut and hen’s egg need not be differentiated from other complementary foods. Complementary foods should be introduced in an age-appropriate form from around 6 months of age, alongside continued breastfeeding, at a time and in a manner to suit both the family and individual child…. The deliberate exclusion of peanut or hen’s egg beyond 6 to 12 months of age may increase the risk of allergy to the same foods. Once introduced, and where tolerated, these foods should be part of the infant’s usual diet, to suit both the individual child and family. If initial exposure is not continued as part of the infant’s usual diet, then this may increase the risk of sensitisation and subsequent food allergy…. Families of infants with a history of early-onset eczema or suspected food allergy may wish to seek medical advice before introducing these foods. (SACN and COT, 2018, pp. 11–12)
Similarly, a Royal College of Paediatrics and Child Health (RCPCH) guideline document noted that the organization “strongly support[s] national policies, practices, and legislation that are conducive to breastfeeding” (RCPCH, 2019, p. 3). In addition, the document contained specific calls to action for policy makers by stating, for instance:
RCPCH calls on: The NHS [National Health Service] in England and the Welsh Government to follow the lead of the Scottish Government and the NHS in Northern Ireland by requiring all maternity services to achieve and maintain Unicef U.K. Baby Friendly Initiative accreditation; this requirement is currently met by all maternity units in Scotland and Northern Ireland. (RCPCH, 2019, p. 4)
The guideline documents the committee reviewed provided a few examples of approaches to communicating the recommendations directly to policy makers. One approach taken was to clearly identify the government as the entity that needed to carry out the recommendation. This strategy is contingent on policy makers identifying and understanding the guideline recommendation. Another approach was an organizational call to action for policies that support the recommendation.
Reflections on Identified Strategies
The guideline documents the committee reviewed were limited in their descriptions of best practices or approaches to communication and dissemi-
nation of the feeding recommendations. Many of the guideline documents were designed for health care providers, who were intended to serve as intermediaries in providing the information to other audiences, particularly parents and guardians. This approach assumes that the health care providers have the skills, time, and resources to be able to individualize and communicate the recommendations in the context of their particular patient population needs or situations.
Some of the guideline documents acknowledged the importance of adapting or tailoring the messages to make them relevant to a particular group or audience with respect to characteristics including socioeconomic status, language and reading comprehension level, food security, age and stage of infant, ethnicity, and cultural practices. For example, the World Health Organization (WHO, 2005) guideline document dedicated an annex to adapting the guidelines for locally appropriate feeding recommendations that are culturally appropriate and affordable, including in resource-poor settings. A guideline document from New Zealand (Ministry of Health, 2012) includes a chapter for Māori infants and toddlers that addresses considerations related to the cultural and spiritual significance of food in the Māori culture. The guideline document also highlights the special needs of Pacific, Asian, and other population groups, especially newly immigrated groups that may have language barriers, low incomes, and challenges related to acculturation. Such examples underline the need to consider equity issues and the characteristics of target audiences in developing tools and approaches for conveying recommendations to parents and guardians (Russel et al., 2016; Schafer et al., 2016), especially in light of an increasing recognition of the association between social determinants of health and persistently observed health disparities.
With the end goal being widespread uptake of the recommendations, consideration needs to be given to how parents and guardians identify resources on infant feeding and what types of resources are most effective. In a study among first-time mothers in Australia, information on breastfeeding was frequently sought from online sources, as well as from health care providers and print sources (Newby et al., 2015). Another study reported that although mothers may be aware that feeding guidelines exist, they may not know the specific recommendations (Begley et al., 2019). The changing landscape of mobile health devices and applications and the role of social networks in influencing knowledge, attitudes, and behaviors have potentially important implications for developing effective strategies for disseminating feeding recommendations to various stakeholders, including parents and guardians, and merit further exploration.
There is little information available as to where and how ECE providers seek guidance on infant and young child feeding or the extent to which regulatory mechanisms determine feeding practices. A survey of ECE providers
in the United Kingdom found that about half obtained information from national reports, but some providers conducted online searches, sought guidance from ECE professional societies, or solicited health care providers (Benjamin Neelon et al., 2015). There is a clear need to better understand effective communication and dissemination techniques for ECE providers.
The communication and dissemination needs of program administrators, with respect to feeding guidelines, appear to be two-fold: (1) they need to understand the recommendations themselves, and (2) they need to understand how to parlay that information into programmatic action or advice for program participants. Unlike some of the other target audiences, program administrators (especially for federal programs) must follow specific regulations for operations.
The goal of communicating and disseminating feeding recommendations to policy makers is to assist them in the creation of evidence-based law or policy. In general, policy makers may adopt and codify recommendations created by professional societies or governments; these laws or policies are then implemented in various settings. Documents and other resources that are explicitly designed to reach policy makers are typically brief and relatively straightforward. They appeal to the issues that are important to policy makers and are often tailored to this specific audience. Cairney and Kwiatkowski (2017, pp. 4–5) outline three strategies for effective communication with policy makers: (1) understand your audience and tailor your response, (2) identify windows of opportunity, and (3) engage with real-world policy making rather than waiting for a rational and orderly process to appear. These strategies could be used by health professionals, public policy groups, and other stakeholders to promote the feeding recommendations put forth by authoritative organizations.
Passive communication and dissemination strategies (e.g., use of websites to promote awareness, educational materials, scientific publications) provide access to information regarding recommendations, but they depend on providers, parents, and others to seek out or find the information themselves (Brownson et al., 2018a). Dissemination does not occur spontaneously, and passive dissemination approaches via report and journal publications may be of limited effectiveness in facilitating widespread adoption of evidence-based practices (Brownson et al., 2018b; Powell et al., 2013; Shelton et al., 2020). There is an average 17-year lag for new information to be incorporated into routine general health care practice (Balas and Boren, 2000), a time lag that is even longer in underresourced communities. Planning for active dissemination by engaging stakeholders, using multiple
strategies (e.g., personalized or interactive strategies), and tailoring content to specific audiences has proven more effective in facilitating uptake and adoption of evidence-based recommendations (Brownson et al., 2013; Koh et al., 2020; Shelton et al., 2020). Application of dissemination and implementation science methods may accelerate the translation and real-world impact of feeding guidelines (Brownson et al., 2018a; Shelton et al., 2020).
Reporting on dissemination approaches might include information on the purpose, the strategy or action taken, target audience, the methods, timing, outcomes, and theoretical justification (Eccles et al., 2012; Powell et al., 2013; Proctor et al., 2013). For evaluative purposes, information on whether stakeholders were engaged, how strategies were customized and framed to the specific characteristics and needs of audiences, or other indicators of uptake (e.g., access to materials) or effect (e.g., knowledge of providers or parents) also need to be consistently addressed (Brownson et al., 2018b). The committee did not explore whether such evaluative processes had occurred. Consistent and transparent descriptions of dissemination activities will allow for comparison of the relative effectiveness of these approaches and their effect on target outcomes (Brownson et al., 2013).
Most of the guideline documents targeted health care providers (e.g., physicians, nurse practitioners, nurses, dentists, registered dietitian nutritionists, and other nutrition professionals), and the communication and dissemination strategies appeared to rely on the practitioner to provide the information to parents and guardians. Parents and guardians were largely not specifically identified as a target audience for the guideline documents themselves. ECE providers in the United States have national standards that include how, what, and when to feed infants and young children. Program administrators must often implement and convey feeding recommendations in the context of programmatic rules and regulations, and some of the available communication resources focused on providing accessible, applied guidance for specific nutrition and food programs. Policy makers often have specific communication needs, particularly brief and straightforward messages. Some guideline documents positioned recommendations toward policy makers or included a call to action. Passive approaches to disseminating recommendations may have limited effectiveness with regard to incorporation of guidance into clinical care and uptake. Consistent and transparent reporting and evaluation of dissemination activities is needed to assess effects on the target outcomes, and to help inform decision making.
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