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Abstract

This study aimed to characterize the factors influencing dietary diversity scores (DDS) of infants whose caregivers were classified as doers (those who fed a more diverse diet) and non-doers (those who fed a less diverse diet). This study was conducted using a multiphase study design and guided by a biocultural framework. Phase 1. Interviews with community leaders (n = 13) and direct 6-h household observations (n = 10) were used to formatively explore factors influencing diet. Phase 2. A dietary assessment (n = 81) was used to determine dietary diversity of indexed infants. Phase 3. A biocultural survey and direct 3-h. observations were conducted among indexed infants (6-9 months) (n = 80) to understand the biocultural factors influencing infant DDS. Phase 4. Interviews (n = 34) were conducted among indexed caregivers to understand why and how biocultural factors shape infant DDS. Dietary data were analyzed, and biocultural survey variables were subjected to a forward stepwise linear regression. Textual data were analyzed to identify salient biocultural factors. Findings revealed that infants had an average DDS of 2. Having water access in the household, owning land for homestead food production, and feeding infants the same foods caregivers consume were positively associated with DDS. Conversely, adhering to food proscriptions was negatively associated with DDS. Most caregivers were food insecure and employed both food and non-food-based coping strategies to feed their infants. Decreasing adherence to food rules, promoting homestead food production, and promoting non-food-based coping strategies may improve infant DDS in Guinea.

Plain Language Summary

This study aimed to characterize the factors influencing dietary diversity scores (DDS) of infants aged 6 to 9 months whose caregivers were classified as doers (fed a more diverse diet) and non-doers (fed a less diverse diet) by operationalizing an Ecological Model of Food and Nutrition framework. We used semistructured interviews, direct observations, and survey methods to explore the factors influencing the DDS of infants. Based on mixed-methods findings, 10 factors differed between doers and non-doers, such as food rules, food symbolism, water, and land access. Tailored interventions that consider factors that differ between doers and non-doers may help improve infant DDS in Guinea.

Keywords

biocultural infant and young child feeding dietary diversity Guinea

Introduction

Suboptimal diet is one of the key factors contributing to the high rates of wasting (9.2%) and stunting (30.3%) among infants and young children in Guinea.¹ In 2018, only 13.2% of children 6 to 23 months of age consumed a minimally diverse diet and less than a quarter (22.4%) met minimum meal frequency. As a result, just 3.7% of Guinean infants and young children had minimally acceptable diets. Guinea's infant and young child dietary indicators are lower than the regional average, yet little in-depth research has been conducted within the country to explore underlying drivers.^2–4 In addition to dietary quality, the United Nations Children's Fund (UNICEF) conceptual framework on maternal and child nutrition cites the importance of creating a supportive underlying and enabling environment as the foundation for optimal maternal, infant, and young child nutrition.⁵

Caregiver feeding behaviors are influenced by a variety of social, cultural, and environmental factors, also referred to as underlying or enabling determinants.⁶ The Ecological Model of Food and Nutrition (EMFN) provides an integrated theoretical framework for researchers seeking to answer cross-disciplinary research questions related to the interplay between social, cultural, technological, and environmental factors and dietary behaviors.⁶ The model builds on decades of research conducted in the field of cultural anthropology and conceptualizes five biocultural factors.^6–11 The EMFN is unique in the sense that each factor is connected by bidirectional arrows, and each factor holds the same significance until proven otherwise.⁶ The first factor is culture, which includes ideas, knowledge, beliefs, values, perceptions, and emotions that relate to food getting, preparation, and consumption.⁶ The model also conceptualizes the physical and social environment, which encompasses natural resources and the macrolevel social structures where foods are obtained.⁶ The fourth factor is social organization, which includes microlevel social structures, including interpersonal interactions, household economic organization, roles, and responsibilities.⁶ Fifth is technology, which includes the types of tools used to produce, distribute, prepare, and store food, as well as any relevant media platforms.⁶ Finally, global factors are those that influence the whole system (eg, a global pandemic).¹² The EMFN has been used for nearly 50 years across contexts to describe the factors influencing dietary behaviors.^6,13,14 Although the EMFN has been used for nearly 50 years, to our knowledge, few studies have sought to operationalize the framework using a mixed methods approach.

While the EMFN can describe what factors influence infant and young child diets, the doer/non-doer approach can be used to further understand how factors differ between caregivers who feed a diverse diet and those who do not.^15–17 This approach is often used in behavioral research to identify hidden factors that enable outliers within a community to employ a protective behavior and outperform their counterparts.^15,18 Given the sparse literature around the drivers of infant dietary behaviors in Guinea, we conducted a formative study to (1) assess the diets of infants aged 6 to 9 months in Forécariah, and (2) determine the extent to which biocultural factors (ie, social, technological, environmental, and cultural factors) characterize those caregivers (doers) who can feed more diverse diets from those who cannot (non-doers) by operationalizing the EMFN using a mixed methods approach.

Methods

Study Setting

This study was carried out from April to November 2022 in Forécariah, Guinea. Forécariah is a periurban town located on the border between Guinea and Sierra Leone and approximately 60 miles from the country's capital, Conakry. The town is home to the Susu cultural group, and the majority of the population identifies as Muslim. The primary livelihoods in the city center consist of trade, business, and agriculture.¹⁹ The food supply in Forécariah and the rest of Guinea is largely seasonal, with the lean season (ie, periods of higher rates of food insecurity before harvest) occurring from July to September.²⁰

Study Design

We designed a mixed-method, multiphase, iterative study to explore the factors shaping infant diets in Forécariah, Guinea²¹ (Figure 1).

Figure 1.

Study design by research phase, method, and sample size.

^¥ A subset of the caregivers of indexed infants 6 to 9 months of age.

Data Collector Training

A research team, with secondary education in health and who spoke Susu, French, and/or English were responsible for data collection. All research team members were trained during a 2-week intensive research training, which focused on topics such as qualitative interviewing, dietary data collection, and direct observations.

Data Collection Methods and Sampling Procedures

Phase 1. Exploring the Factors Influencing Infant Diet

Semistructured interviews. We purposefully sampled n = 13 community leaders (eg, religious leaders, health workers, village chiefs, community elders, and agricultural workers) to understand context-specific factors that may influence infant diets. This diverse group was sampled to elicit variations in perspectives and experiences.²² The sample size was determined a priori based on a number of interviews expected to yield data saturation based on previous research.²³ Interviews lasted between 1 and 2 h and were digitally recorded in Susu or French. To see all data collection instruments, see Supplemental Material 1 (S1).

Direct 6-h household observations. The aim of the 6-h observation (conducted between 9 am and 5 pm) was to understand meal preparation, infant-caregiver interaction during feeding, household member roles and responsibilities, food storage, and food-related hygiene. The observations were also used as a form of triangulation to inform subsequent phases, in combination with community leader interview findings.²⁴ We purposefully sampled households (n = 10) using a criterion-based approach (ie, child age in months).²² During the observation, the data collector was instructed to sit in a nonobtrusive area of the household with a full view of the infant and to limit conversation with all household members. Behaviors were recorded continually (ie, recording all behaviors as they occurred) and every 10 min for behaviors irrelevant to the study aims (eg, infant sleeping).^25–27 For each behavior, the data collector was instructed to record: the time the behavior occurred, the actor (ie, the person carrying out the behavior), the receiver (ie, the person receiving the behavior), and any reactive behaviors that occurred (ie, socially desirable behaviors) on a semistructured form.^27,28 After returning from the field, data collectors also transcribed field notes onto a semistructured form.

Phase 2. Assessing Infant Diet

Infant dietary assessment. Using the urban health post's vaccination register, we randomly sample indexed infants. Recruitment occurred between May 5, 2022, and October 12, 2022. Infants were excluded if they had a history of underlying health conditions (see S1 for a complete list of underlying health conditions), were not yet consuming complementary foods, were twins, or were moving outside of the study site within the next 3 to 6 months. We collected dietary data from the caregivers of indexed infants using the Infant and Young Child Diet Quality Questionnaire, which collects non-quantitative intake data for the previous 24 h.^29,30 All dietary data were collected on a weekday during the rainy season (May 2022 to November 2022).

Phase 3. Defining the Factors Influencing Infant Diet

Caregiver survey. The caregiver survey aimed to define factors influencing infant dietary diversity score (DDS). We developed the survey based on the EMFN conceptualized by Jerome et al, a review of the literature, and formative findings from phase 1 of this study.⁶ The survey also included the Food Insecurity Experience Scale and a household wealth index.^31,32 The final survey was administered to all primary caregivers of indexed infants.

Direct 3-h observations. The direct 3-h observations sought to understand food types offered, intrahousehold food allocation, food preparation, and storage techniques. Observations were conducted on a random weekday, between 9 am and 5 pm for 2 to 3 h, among indexed infants of doers (n = 20) and non-doers (n = 60). Caregivers were categorized as doers if their infant consumed ≥3 food groups during the dietary assessment conducted in phase 2, and as non-doers if their infant had consumed <3 food groups. All behaviors were recorded as they occurred using a structured observational tool developed based on phase 1 findings and a pre-existing observational coding scheme.^33,34

Phase 4. Explaining Why and How Factors Influence Infant Diet

Semistructured interviews. We conducted semistructured interviews to understand why and how biocultural factors shape infant diets. A subset of indexed caregivers (n = 34), who participated in phase 2, were purposefully sampled to take part in interviews.²⁹ A criterion-based sampling approach was used to select primary caregivers who were classified as doers (n = 14) and non-doers (n = 20). We used 3 food groups as our cutoff for qualitative sampling due to the low overall variability of DDS in our sample. Sample sizes were determined a priori based on the number of interviews expected to reach data saturation among doers and non-doers.²³

Ethical Approval

This study was approved by the Comité National d'Ethique pour la Recherche en Santé in Guinea (N°: 031/CNERS/22) and received exemption from the Institutional Review Board (STUDY00018972). Verbal informed consent and assent were obtained for this study due to the low-risk nature of this formative research study. This method of obtaining consent was approved by both ethical committees and was considered appropriate for this setting.

Data Analysis Methods

Textual Analysis

We followed a multistep, deductive analytic process for analyzing interviews and observational field notes from the 6 h. direct observations. First, the audio recordings of interviews were translated and transcribed from French or Susu to English. Second, a codebook containing a series of provisional codes, or tags for labeling text, was developed deductively using the EMFN and existing literature, with multiple codes corresponding to each component of the EMFN.^6,35 The first cycle of coding occurred during data collection, as recommended by Miles et al, to allow for an emergent and iterative study design.³⁵ During the first cycle of coding, 2 researchers employed the provisional codebook, jotted notes while coding, and met to refine each code and corresponding definitions over multiple meetings.³⁵

This process was repeated until the final codebook was free of lumpers (ie, codes that should be divided) and splitters (ie, codes that need to be split).²² The final codebook was employed by one researcher (TRS) on all textual data following data collection. Finally, each code, attached to textual excerpts, was used for the retrieval and stratification of findings by biocultural factor and participant type (ie, doers, non-doers, and community leaders). Throughout the qualitative data analysis process, memoing was used to understand the relationships between different factors influencing diet.³⁵ Matrices, narrative descriptions, and webs were used to visualize qualitative data and understand connections between themes.³⁵ Preliminary findings from textual analysis conducted during phase 1 were used to inform the development of quantitative data collection tools used in phases 3 to 4.²¹

Statistical Analysis

Caregiver survey variables and quantitative variables from the 3 h observations (eg, foods consumed) were summarized descriptively using STATA-15.³⁶ To generate the primary outcome, infant DDS (ie, 0-8 food groups), we followed guidance published by UNICEF and World Health Organization (WHO).²⁹ To understand what biocultural factors were associated with infant DDS, we used a stepwise approach to select explanatory caregiver survey variables to include in our final model. First, all binary explanatory variables were coded as 0 or 1 (see S2 for variable definitions), and summary statistics were calculated (see S3 for summary statistics). Second, all pertinent variables were assessed for multicollinearity using Pearson and tetrachoric correlations. Third, to select explanatory variables, an alpha-to-enter approach (P < .15) was used, whereby univariate linear regressions were used to assess the relationship between each explanatory variable and infant DDS (see S4 for a list of significant explanatory variables at the univariate level).³⁷ Fourth, significant explanatory variables were subjected to a forward stepwise linear regression with an alpha to stop set to P < .15.³⁷ In order of significance, each explanatory variable was added to the model in a stepwise fashion until the additional explanatory variable was no longer a significant predictor of DDS (see S4 for final model).³⁷ For the final model, P < .05 was considered significant. Variance inflation factor (VIF) was used to assess for multicollinearity, but all variables had a VIF < 5 and thus, were maintained.³⁸ Cooks’ distance was used to assess for outliers, but no participants warranted exclusion.³⁹

Synthesis of Qualitative and Quantitative Data

Throughout the research process, qualitative and quantitative data were iteratively reviewed, with each phase informing the next to understand how and why different biocultural factors shape the behaviors of doers and non-doers. Analytic memos, figures, and tables based on the EMFN components were used to compare the biocultural factors shaping the behaviors of doers and non-doers.⁴⁰

Results

Participant Demographics

At recruitment, indexed infants were 8.6 (standard deviation [SD]: 1.2) months of age on average, and half of the infants in the sample were female (48.1%, 39/81). Primary caregivers of indexed children were 26.3 (SD: 6.5) years of age on average, almost all caregivers (95.1%, 77/81) were the infant's biological mother, and the majority (64.2%, 52/81) attended some level of schooling. Most caregivers (58.0%, 47/81) were classified as severely food insecure (Table 1).

Table 1.

Infant, Caregiver, and Household Demographics (n = 81).

Demographic variable	n (%) or mean (SD)
Infant characteristics
Female	39 (48.1%)
Infant age (months)	8.6 (1.2)
Primary caregiver characteristics
Mother is primary caregiver	77 (95.1%)
Age	26.3 (6.5)
Susu ethnicity	52 (64.2%)
Education level
Some schooling	52 (64.2%)
No schooling	29 (35.8%)
Employment in the past 12 months
Working (past 12 months)	63 (77.8%)
Nonworking	18 (22.2%)
Number of biological children	3.1 (1.8)
Food Insecurity Experience Scale
Food secure	4 (4.9%)
Mild food insecurity	17 (21.0%)
Moderate food insecurity	13 (16.0%)
Severe food insecurity	47 (58.0%)
Household characteristics
Household wealth index
Poorest	3 (4.2%)
Poorer	12 (16.7%)
Middle	22 (30.6%)
Richer	29 (40.3%)
Richest	6 (8.3%)
Household number	10.4 (5.6)
Children < 5 years in the household	2.3 (1.3)

Infant Diet

Based on dietary assessment data, infants consumed an average of 2.0 (SD: 1.2) food groups in the day preceding the survey (Table 2).

Table 2.

Infant Diet Quality Indicators Based on Dietary Assessment (n = 81).

Diet indicator	n (%) or mean (SD)
Breastfeeding indicators
Bottle-fed in the past 24 h	8 (9.9%)
Breastfed in the past 24 h	80 (98.8%)
Diet quality indicators
Egg or flesh food	16 (19.8%)
Sweet beverage consumption	8 (9.9%)
Unhealthy food consumption	29 (35.8%)
Zero fruit and vegetable	64 (79.0%)
Dietary diversity score
Dietary diversity score	2.0 (1.2)

Almost all infants in our sample were still breastfeeding (98.8%, 80/81), but more than a quarter (39.5%, 32/81) were breastfeeding only without the provision of other foods in the day preceding the survey, with little variation based on infant age in months. Seventy-nine percent (64/81) of caregivers fed no fruit and vegetables and 35.8% (29/81) fed unhealthy food to their infants on the day preceding the survey. Overall, most caregivers (92.6%, 75/81) reported that their infants’ consumption was normal (ie, not lower or higher due to sickness or other reasons) on the day preceding dietary assessment.

Doers and Nondoers

Based on caregiver survey, observation, and interview data, the key biocultural factors differed between doers and non-doers (Figure 2).

Figure 2.

Comparative summary of factors characterizing doers and non-doers.

Doers

Stepwise regression findings revealed that for each month increase in age, there was a 0.27 increase in DDS (95% confidence interval [CI]: 0.095-0.445) (Table 3, and S4 for the unadjusted model).

Table 3.

Biocultural Factors Associated With Infant DDS (n = 81) (Adjusted Model).^a

	Coefficients	95% CI	P value
Infant characteristics
Infant age (months)	0.270	(0.095, 0.445)	.003
Physical environment
Water access within household (ref. outside household)^b	0.606	(0.123, 1.089)	.015
Household owns garden or crop land for homestead food production (ref. no land)	0.531	(0.054, 1.001)	.029
Culture
No. food taboo adhered to (0-6 taboos)	−0.262	(−0.374, −0.150)	<.001
Infant eats same food as primary caregiver weekly (ref. less frequently than weekly)	0.582	(0.077, 1.087)	.024

Abbreviations: CI, confidence interval; DDS, dietary diversity score.

^aR² = 0.47, F_{(5, 75)} = 13.22, P < .001, with a sample of 81 infants and 5 predictors in the adjusted model, our sample provided 80% power and a moderate-strong effect size of 0.16.

^bReported travels 0 min to get water (eg, within household or immediately outside of household walls).

Water access within the household (95% CI: 0.123-1.089), owning land for homestead food production (95% CI: 0.054-1.001), and feeding infants the same food as the primary caregiver weekly (95% CI: 0.077-1.087) were positively associated with infant DDS (Table 3, and S4 for the unadjusted model). Interview data revealed that doers used foods produced at the household level to diversify their infants’ diet or to earn money to afford infant foods. A wider variety of foods was symbolized as “clean” by doers and appropriate for infant consumption if prepared hygienically.

Nondoers

For every food taboo (or a social or cultural restriction of a specific food, eg, eggs, meat, fish, acidic foods (ie, oranges, mangoes, lemons), banana, and sweet potato) adhered to, there was a 0.262-point decrease in infant DDS (95% CI: −0.374, −0.150) (Table 3, and S4 for the unadjusted model). Interview findings revealed that locally sourced foods were symbolized as “unclean” by non-doers, limiting their infants’ dietary diversity. Interview data also revealed that non-doers received feeding advice through media channels such as the internet and TV, as well as shop owners who often promoted imported foods such as commercial cereal and formula.

Biocultural Factors

Several biocultural factors were found to shape doer and non-doer feeding behaviors (Figure 3).

Figure 3.

Biocultural factors shaping the diets of infants in Forécariah, Guinea (adapted from).

Global factors. The COVID-19 pandemic contributed to higher food prices in 2021.

COVID-19. Based on interview findings, COVID-19 movement restrictions shaped trade, livelihoods, food availability, and access in Forécariah.

Cultural factors. Culturally bound food rules and food symbolism shape infant diet.

Food taboos. Adherence to cultural food taboos (95% CI: −0.374, −0.150) was negatively associated with infant DDS. During interviews, doers and non-doers described adhering to food rules for a variety of reasons (Table 4).

Table 4.

Reasons for Food Proscriptions Reported During Semistructured Interviews (n = 34).

Proscribed food	Reason for proscription (ie, taboo)
Rice, fish, crab	The infant cannot walk yet, or the infant will not walk early
Rice, cassava, potato, peanuts^a, cheese^a, fish, meat, eggs, mango^a, “fresh foods” (eg, eggplant, cucumber, pepper)	Infant is not old enough
Rice, cassava, potato, peanuts^a, yogurt^a, fish, meat, eggs, “fresh foods” (eg, eggplant, cucumber, pepper), banana	Causes abdominal distress
Rice, cassava, potato, eggs	Bloats stomach/constipation
Peanuts^a, fish, crab, meat, corn	No teeth
Fish, crab	Causes worms in the stomach
Cassava, yogurt^a, banana, citrus fruits	Causes diarrhea
Rice	Makes the child look bad, vomit, and diminishes energy
Eggs	Get stuck in an infant's throat
Banana	Blackens teeth

^aFoods proscribed by only non-doers.

Based on interview findings, non-doers did not allow their children to consume yogurt, cheese, peanuts, and fruits and vegetables such as mangoes and garden vegetables. Reasons for food taboos included the infant's developmental stage (eg, cannot walk, not old enough, no teeth) and fear of adverse side effects (eg, diarrhea, bloating, weight loss).

Rules for introduction to foods. Survey data revealed that 79.0% (64/81) of all caregivers knew foods could be introduced at 6 months of age, but non-doers described introducing fewer food groups than doers during interviews. During interviews, doers described introducing a wider range of foods such as sweet potato, mango, potato, cookies, rice, and cassava between 6 and 8 months of age. Conversely, non-doers waited to introduce more diverse foods (eg, bananas, potatoes, foods produced in the garden) when the infant started to display signs of interest, including reaching for specific food items or when the infant could walk.

Food symbolism. During interviews, non-doers associated or symbolized imported infant cereals as being “clean” compared to locally produced foods. This non-doer describes why she does not feed local foods to her infant.

We cannot use these ingredients of ours [local foods] because when we are preparing them whether you want it or not, you will have dirt in it. And if the baby eats that dirt, the bacteria will affect him. That is why we must have the courage to buy imported and sealed food to keep our children in good shape even though we are poor. That is the reason why we do it. (Non-doer interview, mother of 6.5-month-old infant)

If they were prepared hygienically, doers considered fish, potato, porridge, rice, corn, eggs, yogurt, apples, and bananas, in addition to imported foods, to be acceptable foods for infants.

Family versus infant. Based on survey findings, feeding infants the same foods as their primary caregiver every week, was associated with a 0.582 increase in DDS (95% CI: 0.077-1.087) (Table 3, and S4 for the unadjusted model). Doers’ behaviors echo health workers’ recommendations provided during interviews to feed infants with family foods, which increases diet diversity at an affordable price. During the 3 h direct observations, infants fed alone consumed a less diverse variety of foods than those consuming food with their family (Table 5).

Table 5.

Food Consumed by Infant Alone and by Infant and Family During Observations.

Classification	Foods^a
Infant-specific foods	Cereal porridge (eg, millet porridge, industrial cereal) Rice porridge Commercially produced cheese Biscuits/cookies Milk
Infant and family foods	Tô (ie, cassava dumpling often served with okra or another sauce) Attièké (ie, cassava usually served with light sauce, oil, onion, and fish) Peanut sauce Bread Rice Yogurt Green leaf sauce Cereal porridge (eg, corn or millet porridge)

^aFoods observed being fed to the infant alone during observations or eaten with by infant and other family members during a meal.

Social organization. Feeding advice from elders, roles and responsibilities, livelihood, maternal time, food access, and health worker advice shape infant diet.

Feeding advice from elders. During interviews, caregivers described relying on their mothers and grandmothers to learn how to prepare local porridges which are usually more diverse and cost-effective than imported cereals. Despite this advice, caregivers described receiving conflicting feeding advice through the social organization, social environment, and technological communication channels. Health workers, elderly women, and the radio promoted a diverse diet, while other social environment and technological influencers (ie, media sources including on-package labeling, TV, internet, and salespersons) promoted imported or commercial foods, which tend to contribute to a lower dietary diversity (Figure 4).

Figure 4.

Communication channels used by caregivers for feeding advice.

Roles and responsibilities. Fathers of indexed infants often (75.9%, 60/79) provided money to primary female caregivers every week to support infants, but household-related financial decisions were often (85.2% (69/81)) made by someone other than the primary female caregiver. Based on interviews and direct observations, we found that mothers, grandmothers, and female siblings of indexed infants were typically responsible for purchasing, preparing, and feeding infants. Primary caregivers described that due to their various roles and responsibilities (eg, food preparation, feeding, household chores, and work outside the home), they often struggled to make time for everything.

Maternal time. Lack of time was described as a primary barrier to feeding infants during interviews. Caregivers, such as this non-doer, indicated choosing commercial cereals because they were quick and easy to prepare.

For instance, pound the corn and sieve it and put it in the sun, and then prepare it by adding milk to it…That is why I buy Nutrilac and prepare it for him [the infant]. I lack time for it [to prepare locally sourced foods]. (Non-doer interview, mother of 10-month-old infant)

Caregivers also reported allowing their infants to self-feed, buying a small treat (eg, prepackaged cookies), or preprepared food (eg, food prepared by a street vendor) to save time while tending to other responsibilities.

Livelihood. Biocultural survey findings revealed that most caregivers (77.8%, 63/81) worked in the past year doing daily wage jobs that made it hard to consistently afford a diverse diet. Livelihoods practiced in Forécariah included trade, private enterprises, government jobs, and, to a lesser extent, agriculture. Female caregivers conveyed during interviews that they felt an obligation to work to support their family, but also described difficulties managing work, infant care, and feeding responsibilities. Community leaders explained that women are “more courageous” than men because they will “go up and down” until they make enough money to provide food for their families. Caregiver employment, or engagement in paid work outside of the home, often led to feeding infants according to work schedules rather than an infant's hunger and satiety cues. For example, this observational field note describes a caregiver who is frustrated when her infant does not want to eat before she leaves for work.

She [the caregiver] ended the feeding episode prematurely because another child came to caress the child's feet, so the child became distracted … the mother says bluntly, “As you are not ready [to eat], I will go to re-sell” [goods/food at the market]. (Observational field note of a 9-month-old infant)

Food access. More than half of caregivers (58.0%, 47/81) were classified as severely food insecure based on survey data. Food insecurity was a primary barrier to providing infants with a diverse diet across caregivers. During interviews, one of the most salient reasons for food insecurity included unreliable income streams. Food-based coping strategies reported during interviews included breastfeeding without food, reducing the infant's meal frequency to preserve their food supply, feeding a more affordable food (eg, lafidi: cooked rice with a mixture of white or purple eggplant, dried fish powder, chili, okra, and oil), and reducing portion sizes. Breastfeeding, without the provision of other foods, was observed during direct observations, described in interviews as a food-based coping strategy, and reported by a large proportion of caregivers (39.5%, 32/81) during the infant dietary assessment. Non-food-based coping strategies included getting a job, asking family members for money, or taking out a loan to buy food. Based on multiple data sources, during bouts of food insecurity, those caregivers who had higher social capital to borrow money or the ability to get a job, as well as financial decision-making power were able to prevent their infants from going a day without eating complementary foods.

Health worker advice. During interviews, health workers were reported recommending commercial cereals and formula, as well as a diverse diet consisting of cassava, taro, potato, fish, meat, peanut sauce, apple, tomato, bakha (ie, rice porridge) during cooking demonstrations, one-on-one education sessions, and radio broadcasts. Conflicting advice from health workers made it hard for caregivers to follow recommendations. This health worker describes how maternal time and food access act as barriers to her recommendations.

After giving them all the explanations they need, they tell you “Ah. I do not know how to have all these things that you quoted, I do not know what to do” … For other cases, we just give them explanations [of how to prepare infant food] with our [local] food… like using squash, taro, potato, fish, and tomato. Many women complain because they cannot find those foods every day. We then suggest using the same ingredients for the family dish and dividing quantities to prepare some for the child. Other women do not have the time to devote to cooking these foods and prefer to pay for boxes of [commercial cereal] that only need a little hot water for it to be ready. (Health worker interview)

High-level health officials explained during interviews that the lack of nutrition training opportunities for health staff is a persistent barrier to supplying reliable nutrition education programming in Forécariah.

Physical environment. Water access and homestead food production are influencers of infant dietary diversity.

Water access. Having access to drinking water within the household was positively associated with infant DDS (CI: 0.123-1.089) (Table 3, and S4 for the unadjusted model). Interview findings revealed that the quickest way to prepare infant foods was to buy prefiltered water, but due to financial constraints, this was not always possible. Dodging frequent power outages, broken pumps, long lines, and dealing with fees associated with using someone else's water source, and then treating the water is a time-consuming process for caregivers. Unclean water from easier-to-access water sources (ie, covered, or open wells) was described as being associated with infants having diarrhea, suboptimal appetite, and weight loss.

Homestead food production. Owning land for homestead food production was also positively associated with infant DDS (95% CI: 0.054-1.001) (Table 3, and S4 for the unadjusted model). Interview data suggest that doers feed infants with food produced in their garden (eg, leafy greens, chili peppers, pineapple, cassava, and tomatoes) while non-doers do not. Doers described using gardening as a secondary source of income to support their family and infant's diet.

When it rains, my husband makes mounds, and we grow peanuts. When the crop is ripe, we sell it, and this allows us to support our children…We sell our harvest to buy clothes for the children and cereals in quantity for the baby. (Doer interview, mother of 10-month-old infant)

Social environment. The political environment, food availability, influential actors within the social environment, and available food outlets shape infant diet diversity.

Political environment. Caregivers reported that political instability (September 2021 military coup) at the national level, coupled with the War in Ukraine contributed to increase in food prices, making it difficult to afford food.

Food availability. During interviews, both doers and non-doers explained that Forécariah is a hub for food trade, but seasonality and stockouts limited food availability making feeding more difficult. Despite Forécariah being a food trade hub, community leaders described that food production within the city center has decreased over the past decade, increasing the town's reliance on other municipalities and imported goods. Caregivers explained that imported foods are generally available year-round with a few exceptions (ie, yogurt and mashed potato puree), but fruits such as oranges and mangoes are only available during certain seasons to be incorporated into infant diets.

Influence of shop owners. Non-doers described relying more heavily on feeding advice from shopkeepers and pharmacists, who often promote commercial formula milk and cereals that are low in diversity during interviews. Non-doers often checked the advice given with friends or at the health center, but the advice given by shopkeepers and pharmacists at the point of sale was usually acted on. The views of shop owners and pharmacists were reinforced by the media in the form of television and online advertising.

Food outlets. Non-doers described preferring to buy clean foods that are hermetically sealed, not expired, stored outside of the sun, and preferably from a store that has air conditioning. Doers had similar values when searching for places to buy food, but unlike non-doers, reported buying locally sourced foods (eg, millet, eggs, corn, fruits) at the market and sanitizing them before use. Food outlet choice was also governed by other social organizational factors, such as how much time the caregiver has to prepare food, financial means, and caregiver knowledge of food preparation techniques. Both doers and non-doers frequented the same shops or market stalls, so a relationship could be established with the shop owner, and food could be bought on loan when needed.

Technology. Media, utensil type, food processing, preparation, and storage technologies shape infant diets.

Media. Based on interviews, non-doers relied on the internet (ie, Facebook and Google), TV, and radio as a source of feeding information, while doers primarily relied on the radio. This non-doer describes the type of feeding information, a promotion for commercial cereal, which she receives while watching TV.

They advertise them on TV by saying this food has vitamins while making it for children. Other people who do not watch TV also said that food is not good for children. But, based on my experience since I gave that food to my baby, he looks fine, he stays healthy, and he has a good weight. So, I watch on TV sometimes how they make food for babies…how their baby looks cute and healthy. Even though my baby doesn't look the same as their baby, anyway, my baby is healthy. (Non-doer interview, mother of 7.5-month-old infant)

Interviews revealed that non-doers received feeding information (eg, the importance of commercial cereals and when to introduce foods) on Google and Facebook in the form of videos, images, and articles. Outside of package labeling (eg, fat babies on food cartons) also had a strong influence on caregiver food choices. Nutrition information received through the radio was usually governed by health center staff who delivered regular broadcasts. Implementing advice received through media sources can be difficult for doers and non-doers because of their financial means and time.

Utensils. Interviews and direct observational findings revealed that both doers and non-doers valued sanitary measures when feeding their children, which often meant serving their infant food in a bowl or bottle not used by anyone else in the household. During direct observations, non-doers often used a bottle to feed porridge to their infants and reported during interviews that bottles keep the food cleaner, promote self-feeding, and save time.

Food processing and preparation. In interviews, non-doers described buying preprocessed cereals, which have low diversity, primarily to save time. Community leaders described that food processing and preparation technology have increased drastically over the past 10 years, but they are not always affordable for all caregivers. Based on direct observation and interviews, infant food preparation often relied on a kettle or electric range. Due to frequent power cuts, caregivers often saved hot water in a thermos or had to resort to preparing food using charcoal or a wood-burning fire.

Food storage. The lack of reliable food storage was described as a barrier to supplying infants with a diverse diet year-round during interviews. This community leader describes how unreliable electricity limits household food storage.

… power cuts do not allow you to conserve fish or meat. You are forced to buy the condiments every day because when you put them in the fridge and there are [power] cuts if it is the fish that is in the fridge it will rot and if food how kabissé [fermented milk accompanied by granulated semolina of corn] when you put 400,000 GF, it will spoil … You won't see a woman buy condiments for 2 days or a week because the power cuts current doesn’t allow us to keep food in the fridge. (Community relay interview)

Direct observations echo these findings as more than half of households owned a refrigerator, but only one household was observed storing their infant's food in the refrigerator. Due to a lack of reliable refrigeration and other preservation technologies, certain fruits and vegetables produced through homestead food production (eg, mangoes, apples, watermelons) spoiled if they were not sold. The lack of viable technologies to store food shapes social organizational factors such as maternal time, food access, and livelihood.

Discussion

Overall, dietary assessment data revealed that infants in Forécariah consume an average of 2 food groups on a given day, with little fruit, vegetable, or flesh food consumption. Dietary diversity scores is positively associated with mean micronutrient adequacy and thus, with an average DDS of 2, the majority of infants in our sample are consuming a micronutrient-inadequate diet.^41–43 Although most caregivers were not feeding a diverse diet, our study identified several factors that may help incrementally improve DDS among infants in this population.

Survey and interview data revealed that adherence to food taboos limits infant consumption of a diverse variety of foods. One reason doers fed a higher diversity of foods to their infants may be due to lower adherence to food taboos (eg, eggs, meat, fish, oranges, bananas). Norms against feeding infants and young children certain foods (eg, flesh foods, eggs, vegetables) during the introduction to complementary foods have been observed across contexts.⁴⁴ Food taboos are often the result of deeply rooted social norms and may be a protective mechanism against foods previously associated with adverse outcomes.^44,45 However, dismantling deeply rooted social norms is no easy feat. A review of interventions seeking to change infant and young child feeding (IYCF)-specific norms indicated that various entry points (eg, communities, media, health centers), beneficiaries, and community-level activities (eg, religious leader meetings, support groups, home visits) may be needed to promote a shift in behavior.⁴⁴ Several of these strategies (ie, support groups, radio) are already being used by health workers to promote optimal IYCF practices in Forécariah. However, delivering tailored messaging to decrease adherence to food taboos while broadening the intervention audience (eg, religious leaders, fathers, elder women) and strategies (eg, home visits) may help promote a shift in the integration of locally available nutritious foods into infant diets and improve dietary diversity.⁴⁶

Interview findings revealed that non-doers associated foods obtained from a supermarket as clean and relied more heavily on feeding-related messages received through the media that promote foods with low diversity. Other researchers studying IYCF in the West Africa region also ascribe conceptions of cleanliness and media-based marketing to caregiver food choice.⁴⁷ In Senegal, caregivers prefer commercial cereals because of child food preferences, convenience, health benefits, and because advertisements say they are “good for infants.”⁴⁸ The potential negative impact of food marketing on IYCF is a concern across contexts and has led the WHO to create guidance on ending the inappropriate promotion of foods for infants and young children.⁴⁹ Marketing of commercial foods to caregivers of infants and young children can mislead caregivers’ perceptions about the quality of advertised food, convince caregivers that family foods are inadequate, and increase rates of early introduction to complementary foods.⁴⁹ Although imported food preferred by non-doers may result in lower infant DDS, the nutrient content of some enriched foods should be recognized. Some fortified infant and young child cereals have been found to improve micronutrient intake and growth outcomes among infants and young children in similar contexts.⁵⁰ However, the micronutrients, sodium, sugar, and trans-fatty acids content of commercial cereals can differ greatly across brands, and their price can make them unattainable for many.⁵¹ Given that media-based food promotion may be shaping caregiver food choice, policymakers might consider guidelines against advertising of infant foods and consider similar platforms for promoting affordable and nutritious locally available foods.

More than half of all caregivers were food insecure regardless of infant DDS, suggesting that reducing food insecurity may be key to improving infant dietary diversity. In Guinea, suboptimal food availability and access were widespread in 2022 due to the combined impact of the COVID-19 pandemic and the war in Ukraine.^52,53 To cope, caregivers described employing food-based (decreasing meal size or frequency, breastfeeding only) and non-food-based (caregiver employment, relying on social capital) coping strategies. Food-based coping strategies, such as breastfeeding without the provision of complementary foods, and decreasing meal frequency, may increase the risk of not meeting nutritional needs,⁵⁴ while non-food-based coping strategies may support improved infant DDS. Evidence from other contexts indicates that maternal employment and women's empowerment, measured as access to credit and control over income, are associated with improved infant and young child dietary diversity, as women typically use their income on their infants’ diets.^55–58 In peri-urban Guinea, maternal employment may need to be paired with subsidized childcare to address caregiver time constraints.⁵⁹ Study findings also revealed that land ownership for homestead food production was positively associated with infant DDS in Forécariah, with caregivers using homegrown foods to support their infants’ diets. Across contexts, homestead food production has been found to improve infant and young child nutrition through improved food access, income from food sales, and increased women's empowerment, though in peri-urban contexts such as Forécariah, community gardens may be more realistic in areas where land is scarce.^60,61 Gender-attentive farmer field schools for improved homestead food production, designed to ease and maximize women's participation while also promoting cultivation methods that are sensitive to women's time burden, may hold promise in this regard.⁶² Maternal employment and homestead food production may represent two opportunities for improving infant and young child dietary diversity in peri-urban Guinea.

Strengths and Limitations

This study was not without strengths and limitations. One strength of this study is our use of methodological, participant, and theoretical triangulation, which improves the credibility of our findings.²⁴ Given that no single participant or methodological approach can truly describe reality, our use of multiple participants (eg, community leaders, caregivers) and methods (survey, interview, observation) allowed our research team to deeply explore the factors shaping infant diet from multiple angles.²⁴ We also used multiple theoretical frameworks (eg, EMFN and doer/non-doer approach) to interpret our findings, which allowed for our work to be interpreted using different theoretical assumptions and premises while concurrently being grounded in findings from previous literature.²⁴ Another strength of this study is the iterative study design, which allowed us to gradually explore the factors shaping the diets of indexed infants in our study, with each phase of research building on qualitative or quantitative findings from the previous phase.^21,63

Our study, however, was not without limitations. Due to barriers in recruiting participants willing to participate in all phases of research (ie, 3 visits), our quantitative sample sizes were small, and due to the low dietary diversity among all infants, our sample included more non-doers than doers. However, given that this study was intended to be exploratory, we hope that our findings serve as a foundation for future studies. Second, we collected infant dietary data using a method that solicits intake over the previous 24-h, but direct observations of indexed infants were only conducted over a 3-6 h period.^29,30 Although full-day observations among indexed infants would have been ideal for triangulation, conducting 3-6 h observations before dark proved to be a time-consuming task due to women working outside of the home and the transient nature of the periurban study population.⁶⁴ This barrier to conducting direct observations has been raised by other researchers studying IYCF in Africa.⁶⁵ Future studies might consider participant burden when following indexed participants, the extent to which methods can be triangulated during the study design process, how layering of theoretical frameworks can enhance interpretability of mixed methods findings, and how an iterative methods design can be leveraged to improve the validity of findings.

Conclusion

Infant diets in Forécariah Guinea remain suboptimal, but doers can provide a more diverse diet despite living in the same context as non-doers. Regardless of infant DDS, an important finding from this study is that a variety of factors other than just demographic differences, maternal education, and knowledge shape infant DDS. Programming staff in Forécariah might consider programs to reduce adherence to food rules, promote the incorporation of locally available foods into infant diets, and create opportunities for maternal employment and homestead food production, while also being sensitive to women's time. Communication channels such as interpersonal (ie, health workers, elder women, shop owners) and media (ie, on-package labeling, internet, TV, and radio) may also be considered as possible avenues for reaching caregivers with tailored messaging.

Supplemental Material

sj-docx-1-fnb-10.1177_03795721261428777 - Supplemental material for Understanding the Biocultural Factors Influencing Infant Dietary Diversity in Periurban Guinea: Findings from a Mixed-Methods Study

Supplemental material, sj-docx-1-fnb-10.1177_03795721261428777 for Understanding the Biocultural Factors Influencing Infant Dietary Diversity in Periurban Guinea: Findings from a Mixed-Methods Study by Teresa R. Schwendler, Danny Wang, Muzi Na, Kathleen L. Keller, Leif Jensen, Mohamed L. Fofana, Mamady Daffé, Ibrahima Balde and Stephen R. Kodish in Food and Nutrition Bulletin

Supplemental Material

sj-docx-2-fnb-10.1177_03795721261428777 - Supplemental material for Understanding the Biocultural Factors Influencing Infant Dietary Diversity in Periurban Guinea: Findings from a Mixed-Methods Study

Supplemental material, sj-docx-2-fnb-10.1177_03795721261428777 for Understanding the Biocultural Factors Influencing Infant Dietary Diversity in Periurban Guinea: Findings from a Mixed-Methods Study by Teresa R. Schwendler, Danny Wang, Muzi Na, Kathleen L. Keller, Leif Jensen, Mohamed L. Fofana, Mamady Daffé, Ibrahima Balde and Stephen R. Kodish in Food and Nutrition Bulletin

Supplemental Material

sj-docx-3-fnb-10.1177_03795721261428777 - Supplemental material for Understanding the Biocultural Factors Influencing Infant Dietary Diversity in Periurban Guinea: Findings from a Mixed-Methods Study

Supplemental material, sj-docx-3-fnb-10.1177_03795721261428777 for Understanding the Biocultural Factors Influencing Infant Dietary Diversity in Periurban Guinea: Findings from a Mixed-Methods Study by Teresa R. Schwendler, Danny Wang, Muzi Na, Kathleen L. Keller, Leif Jensen, Mohamed L. Fofana, Mamady Daffé, Ibrahima Balde and Stephen R. Kodish in Food and Nutrition Bulletin

Supplemental Material

sj-docx-4-fnb-10.1177_03795721261428777 - Supplemental material for Understanding the Biocultural Factors Influencing Infant Dietary Diversity in Periurban Guinea: Findings from a Mixed-Methods Study

Supplemental material, sj-docx-4-fnb-10.1177_03795721261428777 for Understanding the Biocultural Factors Influencing Infant Dietary Diversity in Periurban Guinea: Findings from a Mixed-Methods Study by Teresa R. Schwendler, Danny Wang, Muzi Na, Kathleen L. Keller, Leif Jensen, Mohamed L. Fofana, Mamady Daffé, Ibrahima Balde and Stephen R. Kodish in Food and Nutrition Bulletin

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the The College of Health and Human Development Endowment Grant, Mary Frances Picciano Endowment Award, Nutritional Sciences Departmental Endowment Award, The Fulbright U.S. Student Program, Ann Atherton Hertzler Endowment, (grant number N/A).

ORCID iD

Teresa R. Schwendler

Supplemental Material

Supplemental material for this article is available online.

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