An exploration of cultural influencing factors on dietary diversity in Malagasy children aged 6–59 months | BMC Nutrition

The quantitative results are presented first, in order to get an overview of WHO infant and young child feeding indicators. They are complemented with the specific topic-related qualitative findings. The remaining qualitative results are presented in the ensuing sections. They include the findings from all three used methods, as the results concurred revealed no contradictions. However, only the relevant results of the transect walks are presented in this paper. The results are presented according to the structure of the overarching themes presented in Table 4.

WHO infant and young child feeding indicators

Minimum dietary diversity

All included children across the three communities had received at least one kind of food from the first food group Cereals, Roots & Tubers the day before the interview (Fig. 2). No other food group had been consumed by all children. While around 2/3 of the children had eaten vitamin A rich vegetables, the number was lower for other fruits and vegetables. The number was lowest for animal-derived products. Ankazomiriotra had the highest number of children consuming corresponding foods for most food groups. Only flesh food was consumed more often by children in Behenjy. Children in Ibity received the least varied diet.

Fig. 2

Consumed food groups by community. Results included all study children. Twenty is the maximum number of children selected in each community and indicates 100%

On average, 45% of the children achieved MDD. However, there were considerable differences between communities and age groups. In Ibity, only five out of twenty children reached MDD. 17% of children aged 24–59 months achieved MDD, compared to 38% of 6–23-month-olds. In Ankazomiriotra on the other hand, 71% of the children between 24 and 59 months and every second child below the age of two achieved this indicator. In Behenjy, 45% children were assessed to have attained MDD and no notable difference between the age groups was found (Table 5).

Table 5 Infant and young child feeding indicators

In all three communities, data from twenty children below the age of five were collected.

Minimum meal frequency

Most infants had received meals, snacks or breastmilk sufficiently frequently the day before the interview (96%). In all three communities, fewer children from the age group > 23 months reached MMF (68%). Usually, children receive at least three main meals. In Ibity snacks are not usual, and in Ankazomiriotra and Behenjy several children were reported to receive one snack per day when it is financially possible. Common snacks are fruit, bread or biscuits, whereby the term “bread” mostly refers to a fried ball made of rice flour and sugar.

All but one child below the age of two were breastfed. The importance of breastfeeding came up in the interviews and focus groups. In all three communities, most women mentioned exclusively breastfeeding their babies for the first 6 months and then introducing rice water as a complementary food: “We breastfed them until they are six months and after that we start to give like water of rice [like a soup of rice, very soft rice].” (IBI-FG-02). Toddlers’ diets do not considerably differ from adults’ diets. Exceptions for young children regarding swallowing or digestion difficulties are described further below. Children eat the same as grown-ups after the age of one, or latest at 4 years old.

Minimum acceptable diet

A minimum acceptable diet (MAD) was achieved by 60% of children in Ankazomiriotra, 35% in Behenjy and 25% in Ibity.

Iron-rich or Iron-fortified food

In Behenjy, 45% of children (more in the younger age group) consumed iron-rich foods, whilst in Ankazomiriotra 40% and in Ibity 25% had meat, fish or sausage. None of the children had received any iron-fortified products the day before the interview.

Agricultural practices, consumption of homegrown produce & food procurement

In the transect walks and interviews it became clear that in the study region, almost everyone has access to an agricultural plot. Some own only a small field. Most interviewees grow between two and eight different crops. Crops which are produced throughout the year are listed separately for each community in Table 6. Crop diversity varies between the three communities and is lowest in Ibity. Agricultural activity is highest in November, as the rainy season starts. It falls in the lean season, as the main harvest time only starts in March/April.

Table 6 Commonly produced crops & fruits per community

The decision to sell rather than consume produce depends on three main reasons. The first reason for selling harvest is the family’s need for money. A further reason occurs when the harvest exceeds the family’s needs. Lastly, if the product is perishable and cannot be stored (e.g. vegetables or potatoes), it is sold. Money is often needed to buy more rice, meat, or essentials for daily use such as clothes, coffee, sugar, oil, petrol, or salt. Staples are also sold to pay for school fees, field workers or family emergencies. Peanuts and beans are considered especially valuable commodities in all three communities. Rice on the other hand is rarely sold, as it is considered a crucial staple food. As one participant put it: “It’s the basis of our food, there is no food that can replace rice.” (BEH-FG-01). Whilst fruits are usually consumed directly (mostly by children), beans, rice and dried cassava are stored. Stocks are usually used for feeding the family and the animals, and as seeds for the next planting season. However, in most families the harvest does not provide enough food and feed for the entire year. Foods like rice, cassava, fruits, vegetables and yoghurt or biscuits for the children need to be bought. The weekly market plays a crucial role in all three communities for this reason, as fruit, dairy products, meat and fish are purchased almost exclusively there. Fruit consumption depends highly on the season. Study participants highlighted that fruits are either not available (Ibity) or sometimes not affordable (Behenjy). Dairy products are rather expensive and consequently they are often not affordable for interviewees.

Livestock plays an important role in the study region. A few study participants own zebus. These are mainly males used for ploughing fields. Female zebus are rare. Since they produce milk, which may be consumed by the family or sold, they are even more expensive and valuable. Pigs are raised and sold in all three communities and thus serve as real-life piggy-banks. Most participants own chicken or other poultry. Generally, eggs are allowed to hatch and are rarely consumed, or only exceptionally, as highlighted by the following quote: “No, we keep it [the eggs] to have more chickens but we don’t eat it. [ …] If it is accidentally broken, we eat it but… Sometimes when they [we] have many eggs, like fifteen for example, the chicken can’t cover all of them and we take off [away] maybe three or four eggs [to eat them].” (IBI-FG-01). In Ankazomiriotra it is a little more common to eat some of the eggs: “We eat some and we leave some to hatch. [ …] The number we eat is less than the number we sell [around 20% of the eggs are eaten].” (ANK-PI-14). Chicken and poultry are the most commonly consumed animals. In Behenjy and Ankazomiriotra, most people who own chickens mentioned that they sell a certain amount and eat the rest. In Ibity the focus lies on selling the animals. Participants highlighted three main reasons for slaughtering chickens: 1. As a strengthening food, when feeling tired due to overwork; 2. When a family member is sick; 3. For celebrating special events. As expressed by a woman from Ibity: “Like when we have to work a lot like this and we feel tired, when we are feeling tired, we cut… yes, we kill some chickens to eat them and [ …] when someone is ill, we have to kill it.” (IBI-PI-10). Chicken may also be eaten if a family has enough of them. On the whole, poultry consumption varies greatly between families. While some participants eat chicken once every second week, others reported consuming poultry once every two months or less.

Caregivers’ knowledge and perceptions of child nutrition

Study participants, especially in Behenjy and Ankazomiriotra, acquire their knowledge of child nutrition either from secondary school or from a variety of individuals and programs, such as midwives or physicians at the basic health centres or staff from nutrition centers. In Ankazomiriotra, one participant mentioned the sensitisation campaigns from the National Nutrition Office (Office National de Nutrition (ONN)) and UNICEF on TV. Others explained that they also get advice from older women in the fokontany.

In general, the study participants’ basic knowledge on child nutrition was fairly good. Some were aware of the benefit of a varied diet on child development, as emphasized by an interviewee from Behenjy: “[ …] cheese, eggs, some fishes. Like his friends can have this, but I have not enough money to buy it. [ …] they are well for the brain growth; brain development and they have a lot of vitamins and they strengthen they give antibodies for the immune system.” (BEH-PI-12). Meat, dairy products and fruit were the foods most often mentioned as being healthy for children across all three communities. In Behenjy and Ankazomiriotra, animal-based products as well as food with different colors were mentioned as important for child development, whereas in Ibity the focus was rather on fruits, vegetables and legumes. Additionally, in all communities, micronutrient-rich powders like Koba Aina, Farilac or Spriulina were stressed as products which participants wished they could offer more. Although participants know about healthy foods, they often cannot afford them: “I want to give yoghurt, but I can’t afford it. It is the same for us [two other women in the focus group]. Sometimes we go on the market and we see the yoghurt and we stare at these products, but we cannot afford it.” (IBI-FG-02).

Only a few foods were considered to be unhealthy for children. In Behenjy, legumes, cassava, cabbage, craky chicknuts (a snack similar to chips) and imported pasta in particular were considered difficult to digest. In Ibity, sweet potatoes and maize were mentioned as not being soft enough for the stomach when a child is sick. Eggs were mentioned as being undigestible for the stomach. In Ankazomiriotra, the age of the child played an important role. For children below the age of three there were some restrictions, such as green unripe mango, cassava, beans and avocado. However, participants also emphasized that there is no such thing as an unhealthy food, as only the amount consumed matters.

Lastly, some specific food taboos were mentioned by the study participants (Table 3). Ibity is the region with the most food taboos, whereas in Behenjy and Ankazomiriotra there were only a few. There was, however, a new rumor regarding pasta consumption and a specific birth defect. Such rumors may lead to family or fokontany-specific food taboos, examples of which are listed in Table 7. Although they do not apply to the whole community, they may have an influence on dietary diversity in certain children.

Table 7 Food taboos due to different beliefs

Special events and their influence on Children’s daily diet

In the interviews, commonly cited special yearly events included New Year’s Day, Independence Day (26th of June), Christmas and weddings, On these days, it was considered important that meals be different than usual, with more than one course if possible. Meat is the most important component, accompanied by rice, vegetables and special drinks such as fresh fruit juice or soft drinks. Thus, for celebrating these special events, extra money is needed. It is either gradually saved or obtained by working more. More agricultural products may be sold, or less goods purchased. The month in which the event takes place influences the available assets and the strategy implemented, as expressed by the following quote: “For New Year we have to save money. But at the Independence Day we sell the food.” (ANK-PI-11). Some participants explained that they were used to saving money, while others stated that they had to save money for about a month to afford all the special food. In Behenjy several women mentioned that special events did not have a negative influence on their daily food intake. In Ibity and Ankazomiriotra however, most participants reported that the quantity and diversity of food consumed on the days before and after the event were reduced. In about half of these families, not only adults’ but also children’s diet was affected.

In the Vakinankaratra region, people celebrate another special event of great cultural importance: Famadihana, a ritual reburial ceremony of dead ancestors. It usually takes place every five to nine years and involves the extended family and often whole communities. As a result, several families must provide food for hundreds of people. Further money is needed for the governmental authorization fee. Moreover, in a rather new tradition, every family member should wear the same T-shirt or dress. Families also need money for transportation if the grave is far away from the place of celebration. When asked to estimate the amount of money spent for a whole Famadihana, study participants mentioned sums between 50′000 Ariary (US$13.80, half of the monthly farmer’s salary in the region) and 300′000 Ariary (US$81.52, three monthly farmer’s salaries). In some cases, a certain amount of rice had to be contributed in addition. The amounts varied between 90 and 250 kg per family. An interviewee highlighted that each guest makes a contribution. However, if you are invited back by this guest at a later point in time you are expected to give a higher contribution. Furthermore, contributions from guests are not enough to cover the expenses. As a result, the effect of Famadihana on most families’ budgets is pronounced and long-term. Although some study participants in Ankazomiriotra explained that they only need a few months to save the necessary money, most respondents start preparations more than a year before the event. As a result, many families adapt their diet, as stressed in the following quote: “We starve a little bit [ …] every member of the family has to reduce the food.” (IBI-PI-14). Numerous people stated that the whole family – including children –restrict their diet for quite a long period before and after Famadihana, as illustrated by the following quote: “[ …] We must work more, and we have to reduce also what we eat. I: So, you would reduce for one year? P: Yes. I: [ …] for the whole family? Like also for the little ones? P: Yes.” (BEH-PI-04). This effect persists even after the event, as expressed by another participant: “Like we have [had] some rice at home and we have [had] to spend it for the Famadihana [ …] now, as I must buy rice, I cannot afford anything else like meat. I: [ …] how long does it have this impact? [ …] P: Until the harvest of the new year. Like seven months we are like this. I: So, seven months you have to eat less diverse because of the big amount you had to spend? P: Yes.” (IBI-PI-03).

These results suggest that special events may influence families’ diets, and the diversity thereof, far beyond the day of the celebration.

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