Understanding the psychological and social environmental determinants driving infant and young child feeding practices among Rwandan households: a salutogenic approach

Although adequate nutrition and good health are children’s rights, they are often violated, especially in developing countries where undernutrition is one of the leading causes of mortality among children under the age of five. The problem is more pertinent in Sub-Saharan Africa (SSA), that still suffers from the highest under-five mortality rates in the world. Rwanda does not escape from this sad trend because despite continuous policy efforts, chronic malnutrition (stunting) among under-five remains a key public health concern. The 2014/15 Rwanda Demographic and Health Survey (RDHS) shows that 38% of under-five years old children were stunted in 2015. Hence, the Government of Rwanda has implemented numerous strategies to tackle the problem of chronic malnutrition. However, to date, much of our understanding on child chronic (mal) nutrition has been primarily based on research conducted on the nutritional physiological determinants of stunting such as the timing, composition and frequency of infant and young child feeding (IYCF). This view, however, has lacked a holistic orientation, ignoring the contextual and social determinants of IYCF practices. Moreover, the approach to tackle child undernutrition has been predominantly disease and risk-oriented, looking at the factors underlying stunting (pathogenic orientation). From this perspective, IYCF practices have been researched in relation to their contribution to stunting and the determinants of inadequate IYCF practices. Very little is known on factors contributing to good nutritional status, with a particular focus on factors facilitating mothers’ appropriate IYCF in the context of their everyday lives. The overall aim of this thesis is to identify factors that enable healthy IYCF practices in Rwandan households in order to contribute to the development of solution-oriented strategies for reducing child malnutrition. This dissertation is guided by the the salutogenic model of health that, in contrary to pathogenesis (that searches for causes of diseases), focuses on the search for the origins of health.The study was carried out in the catchment areas of Rutobwe and Buramba health centres located in a rural part of the district of Muhanga, in the southern province of Rwanda. The study adopted both cross-sectional and longitudinal designs. Four qualitative studies have been carried out. The first study was conducted among key informants ( mothers and fathers of infant aged 0–23 months, grandmothers and community health workers, n=144), focussed on a general understanding of IYCF practices, the challenges and the responses towards appropriate IYCF practices in the context in which mothers must live their lives (Chapter 2). Next, an in-depth study has been carried out on factors that impede or facilitate appropriate IYCF practices from the perspective of mothers themselves (n=39), specifically during the first 6 months of a child’s life (Chapter 3). The third study focused on coping strategies and facilitating factors among mothers who managed to follow the recommended IYCF practices during the first year of a child’s life (n=17; Chapter 4). Finally, the fourth study focused on unravelling how those mothers managed to do well by exploring the life course learning experiences that play a role in shaping healthy IYCF practices during the first year of a child’s life (n=14; Chapter 5).Based on the studies carried out, this thesis concludes that appropriate IYCF practices reflect not only food related practices to support the physical health but also the social and emotional needs of the mother and the child. In everyday life, mothers face challenges when they try to pursue the recommended IYCF practices. The results from this thesis reveal that mothers experienced an interplay of barriers and facilitators for appropriate IYCF practices, ranging from individual to group and societal levels. The perceived challenges consisted mainly of poverty, food insecurity, heavy workload and the influence of significant others. The results of this thesis also show that in a sea of those challenges, mothers’ sense of agency which refers to the feeling of being in control of one’s own actions play an important role in combatting and overcoming food and non-food related IYCF challenges. This sense of agency results from the combination of intrapersonal factors and the capacity of mothers to develop diverse coping strategies. Intrapersonal factors that facilitated coping with IYCF challenges included mothers’ confidence in the ability to breastfeed, self-efficacy, a sense of responsibility over their children’s health, and religious belief. Coping strategies consisted of balancing work and child feeding, prioritizing childcare, preparing child’s food in advance, active uptake of the recommendations and persistence in overcoming barriers. Furthermore, the findings indicate that appropriate IYCF practices result from the interaction of mothers with their social environment (interpersonal factors) exposed to not only during motherhood but also during earlier life course stages, for instance during childhood.  In view of these findings, policy makers and health professionals that aim to improve IYCF practices and thus reducing child malnutrition have to create optimal preconditions for appropriate IYCFpractices in which mothers’ sense of agency and capacities as well as optimal social conditions are highlighted, enabled and supported

Life course learning experiences and infant feeding practices in rural Rwanda

Most studies about infant and young child feeding (IYCF) practices are often perceived as an individual choice depending on mothers' or caregivers' knowledge or attitudes and are focused on mothers' failure rather than successes in adequately feeding their children. However, the role of life course experiences in IYCF is less investigated. Applying a Salutogenic Model of Health, this study on 14 mothers looks at women's life course learning experiences shaping appropriate IYCF practices during the first year of child's life in a rural district of Rwanda. Transcripts from in-depth interviews were analysed using thematic analysis. Results indicate that positive social interaction with parents or grandmothers during childhood such as sharing meals, parental role models for dietary choices and cooking skills gained by participating in household food preparation played a role in shaping appropriate IYCF practices. Negative experiences during childhood also had a positive influence on IYCF practices for some participants by converting life course constraints into learning opportunities. Motherhood increased mothers' sense of responsibility over their children's health and nutrition. Moreover, mothers' participation in community cooking classes and role modelling approach were strong avenues that enabled their learning through positive interactions and encouragement. Nutrition promotion interventions should consider tailoring nutrition advice to the complexity of mothers' life course experiences by creating opportunities for positive learning experiences of appropriate IYCF practices.</p

Qualitative, longitudinal exploration of coping strategies and factors facilitating infant and young child feeding practices among mothers in rural Rwanda

Background: Mothers in low-income countries face many challenges to appropriately feed their children in the first year such as poverty, food insecurity and high workloads. However, even in the lowest income families there are mothers who succeed to feed their children according to the recommendations. In this paper, we explored the coping strategies that facilitate appropriate breastfeeding and complementary feeding practices among rural Rwandan mothers from birth to one year of a child’s life. Methods: This qualitative longitudinal study recruited a purposive sample of 17 mothers who followed the infant and young child feeding recommendations (IYCF). They were selected from a larger study of 36 mothers. In-depth interviews were conducted with mothers of the total group (36 mothers) within the first week, at 4th, 6th, 9th and 12th months postpartum. Interviews were audio-recorded, transcribed verbatim and analyzed thematically. Results: Coping strategies included improving mothers’ own diet for adequate breastmilk production, prioritizing child feeding over livelihood chores, livelihood diversification and mothers’ anticipatory behaviors such as preparing child’s food in advance. Some of those coping strategies were shifting overtime depending on the development of the children. Personal factors such as breastfeeding self-efficacy, religious beliefs and perceived benefits of breastfeeding were among the facilitating factors. Additionally, social support that mothers received from family members, other mothers in the community, Community Health Workers (CHWs) and health professionals played an important role. Conclusion: In challenging contextual conditions, mothers manage to follow the recommended breastfeeding and complementary feeding practices through the interplay of active coping strategies, feeling to be in control and social support. Nutrition promotion interventions that aim to improve IYCF should consider strengthening mothers’ capability in gaining greater control of their IYCF practices and the factors facilitating their appropriate IYCF practices.</p

Challenges and responses to infant and young child feeding in rural Rwanda: A qualitative study

Background: Despite different interventions to improve child nutrition conditions, chronic malnutrition is still a public health concern in Rwanda, with a high stunting prevalence of 38% among under 5-year-olds children. In Rwanda, only 18% of children aged 6-23 months are fed in accordance with the recommendations for infant and young child feeding practices. The aim of this study was to explore challenges to infant and young child feeding practices and the responses applied to overcome these challenges in Muhanga District, Southern province of Rwanda. Methods: Sixteen (16) focus group discussions were held with mothers, fathers, grandmothers, and community health workers from 4 rural sectors of Muhanga District. The discussions were recorded, transcribed verbatim, and thematically analyzed using qualitative data analysis software, Atlas.ti. Results: Two main themes emerged from the data. Firstly, there was a discourse on optimal infant and young child feeding (IYCF) practices that reflects the knowledge and efforts to align with early initiation of breastfeeding, exclusive breastfeeding for the first 6 months, as well as initiation of complementary foods at 6 months recommendations. Secondly, challenging situations against optimal practices and coping responses applied were presented in a discourse on struggling with everyday reality. The challenging situations that emerged as impeding appropriate IYCF practices included perceived lack of breast milk, infant cues, women's heavy workload, partner relations and living in poverty. Family and social support from community health workers and health facility staff, financial support through casual labor, and mothers saving and lending groups, as well as kitchen gardens, were used to cope with challenges. Conclusion: Factors influencing IYCF practices are multifaceted. Hence, intervention strategies to improve child nutrition should acknowledge the socially embedded nature of IYCF and address economic and social environmental constraints and opportunities, in addition and above knowledge only.</p

Additional file 1 of Child stunting prevalence determination at sector level in Rwanda using small area estimation

Additional file 1. This manusrcipt has separate accompying supplementary files