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Background: Livelihoods strategies and food security experiences can positively and negatively affect infant and young child feeding (IYCF) practices. This study contributes to this literature by exploring how variation in household economics among rural farmers in Tanzania relates to IYCF patterns over the first 8 months of an infant’s life. Methods: These data were produced from a longitudinal study in which a cohort of mother-infant dyads was followed from birth to 24 months. In addition to baseline maternal, infant, and household characteristics, mothers were queried twice weekly and monthly about infant feeding practices and diet. Weekly and monthly datasets were merged and analyzed to assess infant feeding patterns through the first 8 months. Standard statistical methods including survival and logistic regression analyses were used. Results: Aside from breastfeeding initiation, all other IYCF practices were suboptimal in this cohort. Land and cattle ownership were associated with the early introduction of non-breastmilk food items. Food insecurity also played a role in patterning and inadequate complementary feeding was commonplace. Conclusions: Health promotion programs are needed to delay the introduction of animal milks and grain-based porridge, and to achieve a minimum acceptable diet after 6 months of age among smallholder farmers in rural Tanzania. Results highlight that livelihoods-based health promotion interventions, built from a flexible and integrated design, may be an important strategy to address community-level variation in infant feeding practices and promote optimal IYCF practices.
This longitudinal, community-based prospective cohort study took place at the Haydom Tanzania (TZH) site located in the Manyara Region in north-central Tanzania. TZH was one of eight sites participating in the Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) study; a study designed to explore associations of etiology, risk factors, enteric infections, and dietary intake, to effects on child growth and cognitive development [14]. MAL-ED sites were selected based on epidemiological and geographical diversity, as well as, high rates of stunting and variable rates of diarrhea [14]. In brief, trained study personnel used a community survey to identify a sample of pregnant women. Most women were farmers with variable levels of market economy integration [13]. Inclusion criteria were: 1) healthy singleton newborn; 2) enrollment weight greater than 1500 g; 3) mother is greater than 16 years of age at time of study enrollment. At TZH, a total of 262 mother-infant pairs were recruited; 12 were lost to follow up before 170 days (8 dropped out, 3 passed away, and 1 was excluded due to > 25% data missing). A final sample of 250 mother-infant pairs was included in these analyses. All MAL-ED sites utilized a standardized protocol to ensure that data were comparable across sites [14, 15]. The TZH site and detailed information about poverty and malnutrition are described elsewhere [13]. Institutional Review Boards at each site and the collaborating institutions approved the protocol. Written informed consent was obtained for every participant. Enrollment, biweekly, and monthly interview instruments were used to characterize infants’ key dietary exposures in months 1–9 [15, 16]. At the enrollment interview, trained personnel collected baseline demographic and household data including maternal age, parity, education, marital status, household characteristics, food security, [17] and early breastfeeding practices (first 24 hours after birth). Thereafter, household visits were made twice a week and once monthly to collect information on evolving infant feeding practices and to assess overall infant health (since the last contact, up to 7 days). The biweekly and monthly checklists allowed us to determine age of introduction and habitual consumption of non-breastmilk liquids, semi-solids, and solids. Over the first 6 months, infants were visited a median of 51 times (interquartile range (IQR): 49, 53). At the 6 month follow up, water access and sanitation, eight assets, maternal education, and household income data were collected to construct a WAMI index to comprehensively assess household socioeconomic status [18]. Standard definitions were used to characterize breastfeeding status and practices [19]. The introduction of non-breastmilk liquid, solids, or semi-solids is defined as infant’s age in days at time of first reported introduction of non-breastmilk item, even if it was a single introduction and did not become a regular part of the infant’s diet. Though non-breastmilk nourishment can become habitual at any point after birth, the World Health Organization (WHO) differentiates habitual feeding from complementary feeding, in that complementary feeding is the recommended introduction of nutritious, safe food groups after 6 months of age, when breastmilk alone is no longer sufficient to meet the infant’s metabolic needs [1]. If non-breastmilk items were consumed on three visits in the last 10–12 days, the practice was categorized as habitual [20, 21]. We also evaluated non-breastmilk food introduction patterns and calculated the prevalence (in days) that various food items were present in the diet [21]. Modeled after questions on the Demographic and Health Surveys, a more extensive caretaker/mother monthly food frequency questionnaire was also used. From this data, we estimated the adequacy of complementary foods fed to infants between 6 and 8 months of age [15, 22]. Breastfeeding infants eating two or more meals per day met minimal standards for dietary frequency. If a breastfeeding infant ate foods from four or more food groups, their diet diversity was considered minimally diverse. A minimum acceptable diet (MAD) is a measure combining the dietary diversity (≥4 different food groups) and meal frequency (≥2 per day) standards [23]. The proportion of infants who consumed adequate iron-rich and vitamin A-rich foods were also calculated. Two measures of iron were used. The more restrictive measure included meats and organ meats, whereas the least restrictive measure included meats and organ meats plus fish, eggs, and leafy green vegetables. Descriptive analysis included examination of distribution of the variables, medians, and interquartile ranges. Duration of exclusive breastfeeding (EBF), predominant breastfeeding, and introduction of non-breastmilk foods were estimated using survival analysis. Personal prevalence of days with EBF, water, animal milk, and solids were constructed using the following calculation: first, proportion of total visits with EBF and non-breastmilk foods was estimated and then that total was multiplied by 180 days to yield personal prevalence. After bivariate analysis, a multivariate logistic regression model was constructed to assess factors associated with the early introduction (< 60 days) of non-breastmilk foods. The factors included were: gender, components of the WAMI index (household income, maternal education, improve water source/sanitation facility, assets), food security, land ownership, cattle ownership, maternal age, parity, type of first food given (water, animal milk, solids, other), and age at which first non-breastmilk food was introduced. When variables were collinear (e.g. parity and maternal age), a meaningful variable was kept for contextual relevance and interpretation. Normality of the outcome variables were tested prior to conducting the regression models. Data analyses for this study were conducted using STATA Version 13.1 (StataCorp LP, College Station, TX).
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