Original Research Article
Sociodemographic and Paternal Determinants of Infant and Young Child Feeding Practices Among Mothers in Ikotos County, Eastern Equatoria, South Sudan: Evidence from a Community-Based Cross-Sectional Survey Lemi Robert Albert ¹ • Supervised by Dr. Gloria Kirungi ² ¹ MSc Human Nutrition, Uganda Christian University; Health Link South Sudan, Ikotos County, Eastern Equatoria, Republic of South Sudan ² Research Supervisor & Lecturer, Faculty of Health Sciences, Uganda Christian University, Mukono, Uganda ✉ Corresponding Author: lemi.loremo85@gmail.com
Key Statistics At A Glance
Mothers enrolled 35.0% Initiated BF within 1 hour 75.0% Exclusive BF (0–6 months) 22.0% Optimal complementary feeding 44.8% Received prelacteal feeds 7 factors Significantly associated with IYCF
Introduction
Infant and Young Child Feeding (IYCF) encompasses a spectrum of feeding behaviours including the early initiation of breastfeeding within one hour of birth, exclusive breastfeeding for the first six months of life, timely introduction of nutritionally adequate complementary foods at six months, and continued breastfeeding up to 24 months and beyond. These practices, endorsed by the World Health Organization (WHO) and UNICEF as the international gold standard, represent the most cost-effective interventions for reducing childhood morbidity, stunting, wasting, and under-five mortality. The first 1,000 days of life—from conception to a child's second birthday—represent the most critical period for physical and cognitive development. Poor IYCF practices during this window have irreversible consequences on nutritional status, immune function, and human capital development. (1,2) Despite widespread global recognition of the IYCF agenda, sub-optimal practices remain pervasive across sub-Saharan Africa, particularly in fragile, conflict-affected, and underdeveloped settings. South Sudan, the world's youngest nation, has been ravaged by protracted civil conflict since 2013, causing mass displacement, destruction of health infrastructure, and collapse of food systems. (3) According to UNICEF's 2019 nutrition brief for South Sudan, only 15% of children aged 6–23 months received minimum dietary diversity, and just 5% received a minimum acceptable diet. (4) The national rate of global acute malnutrition (GAM) among children under five exceeds the WHO emergency threshold of 15% in several states, underscoring the depth of the nutrition crisis. Ikotos County, located in Eastern Equatoria State, presents a particularly challenging environment for IYCF promotion. It is a remote, predominantly rural agro-pastoral community characterised by high poverty rates, limited health facility coverage, low literacy levels especially among women, and deeply embedded cultural practices that influence child feeding. Health Link South Sudan (2018) reported a GAM rate of 13.5% in Ikotos County, approaching the global emergency threshold. (5) Despite government efforts to roll out the South Sudan Policy Guideline on Maternal, Infant, and Young Child Nutrition (MIYCN), data on factors influencing IYCF practices in Ikotos County remain critically absent from the published literature. The second specific objective of this study was to identify the factors associated with IYCF practices among mothers with children below 24 months in Ikotos County. This paper presents findings from that objective—examining how sociodemographic characteristics of mothers, fathers, and children influence key IYCF practices—and discusses policy and programmatic implications for community-based nutrition interventions in South Sudan and comparable low-resource conflict-affected settings.
Maternal Age And Iycf Practices
Maternal age is consistently identified as a significant predictor of IYCF practices across diverse settings. Bolton et al. (2009), Ukegbu et al. (2010), Qureshi et al. (2011), and Brown et al. (2011) collectively found longer durations of breastfeeding among older mothers compared to younger counterparts. (6) This finding is attributed to accumulated maternal experience, stronger social networks, and greater access to health education. Conversely, adolescent mothers are frequently found to be less knowledgeable about optimal breastfeeding duration and complementary feeding practices. Hackett et al. (2012) in Bangladesh found that adolescent females had limited awareness about the benefits of exclusive breastfeeding. (7) In the context of sub-Saharan Africa, where adolescent fertility rates remain high and many young mothers have not completed secondary education, this knowledge gap is of particular public health concern. In South Sudan, where more than half of women marry before age 18, the relationship between maternal age and IYCF outcomes warrants specific investigation.
Marital Status And Spousal Support
Marital status operates as a proxy for social support in IYCF research. Thulier (2009) reported associations between marital status and early cessation of breastfeeding. (8) Alemayehu et al. (2009) found that exclusive breastfeeding was significantly associated with current marital status and economic stability. A study in Urban Nairobi by Kimani-Murage et al. (2011) found that women not in marital unions were more likely to cease breastfeeding early and had increased likelihood of introducing complementary foods prematurely. (9) The social capital that marriage provides—emotional support, financial contribution, and direct paternal involvement in infant care—has been shown to positively influence IYCF. Lande (2003) found a positive association between being married and exclusive breastfeeding, (10) an observation corroborated by numerous studies across Eastern and Western African settings. The mechanism is thought to operate through paternal influence on feeding decisions and reduced maternal stress among partnered mothers.
Maternal Education And Awareness
Maternal education is one of the most extensively studied determinants of IYCF practices. Higher educational attainment is consistently linked to better IYCF outcomes through multiple pathways: improved health literacy, greater access to and utilisation of antenatal care, reduced adherence to harmful cultural beliefs, and increased decision-making autonomy within the household. (11) Ahmed et al. (2012) demonstrated a positive association between lack of education and the emergence of undernutrition resulting from poor IYCF practices. (12) Similarly, Ajibade et al. (2013) documented that mothers with low education levels had lower compliance with exclusive breastfeeding and complementary feeding guidelines, advocating for awareness campaigns in local languages. (13) Kabir et al. (2007) found that children born to mothers with low education were more likely to be introduced to complementary feeds either before or after the recommended six months of age. Paradoxically, some studies present contradictory findings. Jesmin et al. (2012) attributed optimal IYCF to practical knowledge acquisition rather than formal education per se, noting that highly educated working mothers often introduced complementary foods early due to time constraints. (14) Lawoyin et al. (2001) associated lower maternal education with higher breastfeeding rates, arguing that women with limited education were more likely to remain at home and lacked financial capacity to purchase infant formula. These contradictions highlight the importance of context in interpreting education-IYCF relationships, particularly in rural, agro-pastoral settings like Ikotos County.
Maternal Occupation And Income
Maternal employment status influences IYCF through competing mechanisms. Several researchers including Okeh (2010), Raffle et al. (2011), Velpuir (2004), and Ajibade et al. (2013) note that maternal employment may constitute a barrier to exclusive breastfeeding, particularly when workplace breastfeeding support is absent. (15) Mothers engaged in formal employment face particular challenges maintaining exclusive breastfeeding during the return-to-work period. Socioeconomic status also directly influences complementary feeding quality and diversity. Mukuria et al. (2012) found that children born to parents with high socioeconomic status were more likely to receive exclusive breastfeeding in the first six months and appropriately diverse complementary foods. (16) Darmon and Drewnowski (2015) noted that protein- and micronutrient-rich complementary foods are prohibitively expensive for low-income families. In Ikotos County, where over 60% of fathers are unemployed and most families depend on subsistence agriculture and food aid, the income dimension of IYCF determinants is particularly salient.
Paternal Factors And Male Involvement
A growing body of literature highlights fathers as critical, yet historically neglected, actors in IYCF. Sherriff, Hall, and Panton (2014) identified paternal knowledge about breastfeeding as a primary determinant of fathers' practical support for breastfeeding. (17) Aubel (2012) observed that fathers' involvement in maternal and child nutrition was insufficient compared to mothers', attributable to socially constructed gender roles that relegate child care to women. (18) Wolfberg et al. (1994) reported a significant increase in breastfeeding initiation when expectant fathers attended antenatal breastfeeding classes, demonstrating the modifiability of paternal influence. (19) Brown and Davies (2014) and Sherriff et al. (2014) confirmed that education targeting fathers effectively changed infant feeding practices. (20) Bhatta (2013) in Nepal found that fathers with higher education levels showed greater involvement in encouraging spousal breastfeeding. (21) Aronsson et al. (2013), Betoko et al. (2013), and Senarath et al. (2012) collectively found that uneducated men were more likely to advise early or late introduction of complementary foods. (22) Regarding income, Kenney et al. (2008) found that food provision is considered a male role in many African societies, yet fathers with low incomes may be unable to fulfil this role, creating household food insecurity that directly impacts complementary feeding. (23) Conversely, Raub (2013) suggested that fathers with stable incomes may paradoxically disengage from direct IYCF involvement, believing their financial contribution sufficiently fulfils their parental duty. These complexities underscore the need for context-specific investigation of paternal determinants.
Cultural Practices, Gender Roles, And Child Characteristics
Cultural norms and gender preferences shape IYCF outcomes in profound ways. In many African societies, the belief that colostrum is harmful leads to its discarding and early prelacteal feeding. (24) In Ikotos County, cultural explanations for non-optimal IYCF practices include: perception of inadequate milk supply, belief that exclusive breastfeeding weakens the child, and social norms around introducing water and herbal preparations to young infants. Child sex preferences constitute a specific cultural determinant of IYCF. In communities with strong son preference, male children may receive preferential breastfeeding practices, including earlier initiation and longer duration. (25) The prevalence and strength of sex-based IYCF disparities in Ikotos County represent an important empirical question addressed by this study.
Study Design And Setting
A community-based cross-sectional study design was employed, collecting both exposure and outcome data at a single point in time during March 2020. The study was conducted in Ikotos County, Eastern Equatoria State, Republic of South Sudan (coordinates: 4°4'42"N, 33°6'32"E). Ikotos County is bordered by Magwi County to the west, Torit County to the north, and Budi County to the east. It comprises six payams, 33 bomas, and 154 villages, with a projected population of 35,319 (SSRC, 2019). The county has nine health facilities including St. Theresa Mission Hospital and multiple Primary Health Care Centres and Units. The inhabitants are predominantly agro-pastoralists speaking Langi, Dongotono, and Lotuho languages. The economic base consists of subsistence agriculture, sale of charcoal and agricultural produce, and livestock. Civil conflict has led to displacement, asset loss, and reduced agricultural productivity, compounding nutritional vulnerability among young children.
Study Population And Sample Size
The target population comprised 2,532 mothers or caregivers with children below 24 months residing in Ikotos County. The accessible population—those within the 12 selected study villages—numbered 1,279. The study population of 317 participants was determined using the Kish-Leslie formula:
Where: Z = 1.96 (95% CI); P = 0.75 (EBF prevalence, GoSS MNRHS 2009–2012); d = 0.05 (5% margin of error)
Sampling Procedure
Ikotos County was selected by simple random sampling from five counties in Eastern Equatoria State. Four of the county's six payams were selected by simple random sampling: Ikotos Central (\(n=80)\), Losite (\(n=79)\), Lomohidang North (\(n=79)\), and Lomohidang South (\(n=79)\). Within each payam, three villages were randomly selected, yielding 12 study villages with approximately 26 mothers each. Systematic random sampling was used within villages to enumerate eligible participants, with every k-th household selected based on a computed sampling interval. Inclusion criteria required: mothers or caregivers providing written/verbal consent; residence in Ikotos County for the prior 24 months; age ≥18 years; and having a child below 24 months. Very sick mothers and those not meeting inclusion criteria were excluded. If a household had more than one eligible mother, the mother of the youngest child was selected.
Study Variables
The dependent variable was IYCF practices, operationalised as three binary outcomes: (1) initiation of breastfeeding within one hour of birth; (2) exclusive breastfeeding during the first six months; and (3) continued breastfeeding beyond 24 months. Independent variables included maternal sociodemographic characteristics (age, marital status, education level, occupation, source of income), paternal characteristics (education level, occupation), child characteristics (sex, age, caregiver type), place of delivery, household head, and family size. Moderating variables included cultural practices and religion, which were assessed qualitatively through open-ended questionnaire items.
Data Collection And Analysis
Primary data were collected through face-to-face structured interviews using a questionnaire pre-tested among 10 eligible mothers and translated into the local Langi language. Five trained research assistants fluent in Langi and English conducted 30-minute interviews at participants' homes. Questionnaires were coded for anonymity and stored in secured, password-protected locations. Data quality was maintained through daily field editing meetings between the principal investigator and research assistants. Data were entered into Microsoft Excel, cleaned by running preliminary frequencies to detect discrepancies, and exported to SPSS version 21 for analysis. Descriptive statistics were used for sociodemographic characteristics. Bivariate analysis using Chi-square tests assessed associations between independent and dependent variables, with significance set at p<0.05. Multivariate binary logistic regression was used to identify independent predictors of each IYCF outcome after controlling for confounders, with Adjusted Odds Ratios (AOR) and 95% Confidence Intervals (CI) reported.
Sociodemographic Characteristics Of Participants
A total of 317 eligible mothers or caregivers with children below 24 months participated in the study. Table 1 presents the complete sociodemographic profile. The majority of respondents were aged 24–29 years (37.2%), married (79.8%), had no formal education (50.2%), and were engaged in informal employment (47.0%). Male-headed households predominated (80.4%), and most children (66.9%) were in the 0–6 months age bracket.
Variable Frequency (n) Percentage (%) Age of the Mother (Years) 18–23 88 27.8 24–29 118 37.2 30–34 66 20.8
45 14.2 Marital Status Married 253 79.8 Single 56 17.7 Divorced 8 2.5 Maternal Education Level No formal education 159 50.2 Primary education 114 36.0 Secondary education 44 13.8 Maternal Occupation Housewife 109 34.4 Informal employment 149 47.0 Formal employment 59 18.6 Paternal Education Level No formal education 158 49.8 Primary education 86 27.1 Secondary education 41 13.0 Tertiary education 32 10.1 Paternal Occupation None/Unemployed 199 62.8 Informal employment 92 29.0 Formal employment 26 8.2 Head of Household Male 255 80.4 Female 62 19.6 Sex of the Child Male 135 42.6 Female 182 57.4 Source: Primary data, Ikotos County, South Sudan, March 2020
Bivariate Analysis Of Factors Associated With Iycf Practices
Variable BF Initiation <1hr (χ², p) Continued BF >24mo (χ², p) Exclusive BF (χ², p) Significant? Strongest AOR (95% CI) Maternal Age
24.761, p<0.001★ 19.984, p<0.001★ Yes — all 3 outcomes
(1.605–47.916)
Marital Status
15.766, p<0.001★
Yes — 2 outcomes