Suboptimal infant and young child feeding practices in rural Boucle du Mouhoun, Burkina Faso: Findings from a cross-sectional population-based survey

Introduction In Burkina Faso in 2016, 27% and 8% of children under-5 were estimated to suffer from stunting and wasting respectively. Here, we report on infant and young child feeding (IYCF) practices in rural areas of the Boucle du Mouhoun region. Materials and methods A cross-sectional population-based survey was performed in 2017 in a representative sample of mothers of children aged 6 to 23 months. IYCF practices were assessed using 24-hour dietary recall. Logistic regression was used to identify predictors of IYCF practices. All analyses accounted for sampling stratification by child’s age group and for data clustering. Results According to mothers’ reports, 60% (95%CI 55, 65%) of children received the minimum meal frequency, but only 18% (95%CI 15, 22%) and 13% (95%CI 10, 16%) benefited from the minimum dietary diversity and the minimum acceptable diet respectively. Only 16% (95%CI 13, 20%) of mothers reported increasing breastfeeding or liquids and continued feeding during an episode of child illness. Knowledge of timely introduction of complementary foods and recommended feeding practices during an illness were low. Despite positive attitudes towards the introduction of key food groups, mother’s perceived self-efficacy to provide children with these food groups every day was relatively low. Discussion Our findings highlight the need for interventions to improve mothers’ knowledge and practices in relation to IYCF in the Boucle du Mouhoun region. Behaviour change communication strategies have the potential to improve IYCF indicators but should be tailored to the local context. The high attendance of health facilities for preventive well-baby consultations represents an opportunity for contact with caretakers that should be exploited for promotion and child growth monitoring.

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Briefly mention the importance of IYCF practices in tackling malnutrition.

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Baseline findings highlighted suboptimal infant and young child feeding (IYCF) practices in children 6 to 11 84 months old (5), but no data were collected in children aged 12 months or more. Here, we report on IYCF practices

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Boucle du Mouhoun is divided into six health districts, five with a district hospital and one with a regional

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and 20 mother-infant pairs (of whom 10 infants were 6 to 11 months old and 10 infants were 12 to 23 months 112 old) were sampled per village using simple random sampling stratified on child age group.

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Interviews were performed in local languages using a structured questionnaire programmed into electronic

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Attitudes towards IYCF were assessed by asking women whether they were in agreement with a set of 123 statements. Perceived self-efficacy was assessed by asking women whether they felt capable of giving daily key 124 food groups to their child.

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The data collection involved 56 fieldworkers who were deployed in teams of six interviewers and one supervisor.

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Re-interviews were requested in case of incompleteness and/or inconsistencies, and all re-interviews were 128 completed. Prior to the survey, fieldworkers received two-weeks training, including role-play in the four main 129 languages spoken during interviews, and pilot surveys were performed in villages located outside study areas.

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Other indicators related to IYCF practices included: i) Child feeding practices among children whose mother 160 reported an episode of illness in the two weeks prior to interview; ii) Zinc supplementation among children 161 whose mother reported an episode of diarrhoea in the two weeks prior to interview; iii) Vitamin A 162 supplementation in the six months preceding the interview; iv) Proportion of children with their height, weight 163 and mid-upper arm circumference (MUAC) measured during their last W-BC.

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All indicators were computed by age group (children aged 6 to 11 months and 12 to 23 months). As per WHO's 166 guidelines, continued breastfeeding was also calculated at 1 year (children aged 12 to 15 months) and at 2 years 167 (children aged 20 to 23 months), and introduction of soft, semi-solid or solid foods was also calculated in children 168 6 to 8 months old (7).

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Univariable and multivariable logistic regression was used to identify factors predictive of IYCF indicators. All

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The trial is registered at ClinicalTrials.gov (Reference NCT02435524 206 207 Figure 1 shows child feeding patterns on the day and night prior to interview by age. The proportion of children 208 who were breastfed and consumed soft, semi-solid or solid food increased from 29% at the age of 6 months to 209 82% or more from the age of 9 months. From 6 to 14 months old, the proportion of children who consumed 210 breastmilk alone or with either plain water, milk or non-milk liquids decreased from 71% to 7%.

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By far, the most commonly consumed food group was grains, roots and tubers (85%) (figure 2

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With respect to child feeding practices during an episode of illness, for only 9% and 20% of children aged 6 to 11 220 months and 12 to 23 months respectively did mothers report having increased breastfeeding or liquids and 221 continued feeding (table 2).

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About three quarters of mothers (71%) reported having attended W-BC at least once since birth (

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Regarding other soft, semi-solid or solid foods, no substantial imbalances between trial arms were observed and 239 80% or more of mothers correctly stated that a child should be 6 months old or older (around 9 months on 240 average) before dark green leafy vegetables, sweet potato, eggs or meat are introduced. However, among 241 mothers who correctly stated that soft, semi-solid or solid foods should be introduced from the age of 6 months,

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74% in the intervention arm had correct knowledge of minimum meal frequency compared to 64% in the control 243 arm.

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Knowledge of child feeding practices during illness was similar in both trial arms. While 85% of mothers knew 246 that they should continue feeding their child when sick, fewer than a third correctly stated that a child should 247 be breastfed (24%) or given liquids (30%) much more or more than usual (table 5).

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With respect to attitudes, 70% or more of mothers were in agreement with statements that a child aged 6 to 8 250 months old who eats egg, meat, carrots/squash/sweet potato or dark green leafy vegetables will be healthy 251 (  information were the woman's mother (66%), followed by her mother-in-law (48%) and a sister (17%

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should be noted, however, that the minimum dietary diversity reported at baseline in infants aged 6 to 11 13 months was slightly lower, at 2% (5), compared to 7% in this age group at endline. Both baseline and endline 284 surveys were conducted between June and July and possible explanations for this include a secular trend 285 towards improvement, a better harvest or a more detailed dietary recall at endline.

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We also found poor levels of knowledge regarding timely introduction of complementary foods. Although most 288 mothers reported that complementary foods should be introduced from 6 months of age or older, the average 289 reported age for introduction was 9 months. Knowledge that a sick child should be breastfed or given liquids 290 more than usual was particularly poor too. Interestingly, mother's perceived self-efficacy to provide children

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with key food groups on a daily basis was also relatively low compared to generally positive attitudes towards 292 the introduction of these food groups.

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Although the A&T initiative in the Boucle du Mouhoun region primarily targeted breastfeeding practices, some

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We also found evidence for an association of exposure to community-based information with IYCF practices,

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suggesting the potential of behaviour change communication strategies at the community level. Observed 322 associations with mother's ethnicity suggests that social and cultural factors play an important role in nutrition.

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Qualitative data were collected during the trial and revealed that some "food taboos", such as not giving eggs 324 to a child before s/he speaks, and a belief that solid food, if introduced too early, will delay the child's first steps benefiting from recommended IYCF practices at the end of the intervention, so that no effect on growth was 341 detectable at the population level. Low health centre attendance and a relatively low coverage and intensity of 342 the intervention was sometimes reported too. In some settings, food and resource availability may also have 343 constrained sustained practices.

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In our study, women living in poor households, who did not report an income generating activity or being in 346 union with a partner earning an income in cash or kind were less likely to report the recommended practices.

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We gratefully acknowledge all the fieldworkers, supervisors, and data managers for their work in the field. We 386 also thank the study population for their participation.  When a child is sick, should a mother breastfeed her child more, as usual or less?
"much more" or "more" Does not know When a child is sick, should a mother give her child more liquids, as usual or less? "much more" or "more" Does not know "much more, "more", "as usual" or "slightly less" 85.0 82.1 87.5 When a child is sick, should a mother Does not know 0.5 0.3 0.9 feed her child more, as usual or less? 418 419 420