Understanding the Determinants of Infant and Young Child Feeding Practices Among Lebanese Households: A Qualitative Study

Abstract

Background: Early dietary practices play a pivotal role in promoting optimal growth, development, and shaping long-term dietary preferences for infants and young children. Infant and Young Child Feeding (IYCF) practices in Lebanon had been sub-optimal, marked by low exclusive breastfeeding rates and early introduction of complementary food, even prior to the compounded economic, political and health crises that the country witnessed since 2019. Although data on IYCF practices exist in Lebanon, yet findings are mostly highlighting challenges among refugee population groups with limited data exploring the barriers and facilitators of IYCF practices among Lebanese caregivers and households amidst the compounded crises.

Study aim and objectives: This study aimed to explore factors that influence IYCF practices among Lebanese caregivers of children under 2 years of age (CCU2). The objectives of the study were to: 1-examine the perceptions and experiences of CCU2 towards IYCF and optimal feeding practices; 2- explore the potential barriers, facilitators and intervention entry points to improving IYCF practices among CCU2 from national stakeholder perspective; 3- propose a summary of potential recommendations and context-specific interventions that can help meet international and local IYCF guidelines.

Methods: A descriptive exploratory qualitative approach was adopted to fulfill the purpose of the study. The present study was part of a larger regional project conducted by UNICEF and the Pennsylvania State University in collaboration with the American University of Beirut to assess the regional nutrition situation of children, adolescents and women in the MENA region. For the purpose of this study, in-depth interviews were conducted with stakeholders and CCU2 from Lebanese households using a purposive sampling approach. Data collection was conducted in partnership with the Department of Nutrition and Food Sciences at the American University of Beirut (AUB), the Lebanese Ministry of Public Health and UNICEF-Lebanon offices. National stakeholders who had experience in relevant nutrition policies, existing programs, and services targeting infants and young children were selected for interviews. For CCU2, potential participants were first identified through purposive sampling by the UNICEF staff and their implementing partners working in selected primary health care centers (PHCs) in the Greater Beirut area. In-depth interviews were conducted in English with stakeholders and in Arabic with CCU2. The recorded interviews were first transcribed verbatim and then translated from Arabic to English, where applicable. Both the inductive and deductive approach were used in the thematic analysis of the data. The UNICEF framework on the Determinants of Maternal and Child Nutrition, (2020) guided the thematic analysis. Thematic analysis was conducted using “Quirkos” software.

Results: In-depth interviews were conducted with 8 national stakeholders and 13 CCU2 during the period of August and September 2022 (phase 1). In phase 2 of data collection, which occurred in March 2023, 7 additional interviews were conducted with CCU2 for the purpose of reaching thematic saturation. A total of 28 interviews were conducted: 8 interviews with stakeholders who were representatives of NGOs, international NGOs and governmental agencies, and 20 interviews with CCU2. 7 main themes with 14 subthemes emerged from interviews with study participants highlighting the determinants of IYCF among Lebanese households. Major themes were depicted to be underlying and enabling/disabling determinants for optimal feeding practices among CCU2 in Lebanon, as per the UNICEF maternal and child nutrition framework. Underlying determinants included: household food insecurity and limited food safety (theme 1), mixed knowledge and attitudes concerning IYCF (theme 2), CCU2’s psychological distress (theme 3), and limited economic and physical access to necessary services affecting the feeding practices of caregivers (theme 4). The enabling and/or disabling determinants for optimal infant feeding identified by study participants included the mixed cultural norms that influence IYCF (theme 5), limited financial resources in light of an unprecedented compounded crises (theme 6), and limited commitment and accountability of the Lebanese government (theme 7), which affects IYCF through limited resources allocation for IYCF programs, and limited IYCF-related policy implementation and monitoring. Several subthemes emerged under each of these themes with most highlighting concordance between stakeholders and CCU2 with few exceptions. Stakeholders also suggested recommendations (theme 8) to help improve the promotion of optimal IYCF practices including the strengthening of IYCF counseling by lactation specialists, enhancing the provision of nutrition and healthcare services, and advocating for the nutrition sector capacity as well enforcing breastfeeding protection laws, such as the baby-friendly hospital initiative (BFHI) and law 47 that regulates the marketing of breastmilk substitutes.

Conclusion: The present study has shown a trend of mixed IYCF practices, with overall worrisome trends of low rates of EBF, early introduction of formula milk and poor quality of complementary foods among Lebanese CCU2. Interviews with caregivers and stakeholders revealed numerous determinants that impact IYCF practices. Nevertheless, the study underscores the potential to leverage these challenging circumstances as potential opportunities to prioritize IYCF in the governmental agenda and enhance multi-sectoral collaborations that can help promote optimal feeding practices for infants and young children in Lebanon. Future studies need to further examine the effect of food insecurity on children’s diet quality in the early stages of complementary feeding, and the community’s knowledge about available national nutrition services.