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

Summary

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.