International Journal of Community Medicine and Public Health

Oladeji O et al. Int J Community Med Public Health. 2024 Aug;11(8):3332-3337

http://www.ijcmph.com

pISSN 2394-6032 | eISSN 2394-6040

Review Article

DOI: https://dx.doi.org/10.18203/2394-6040.ijcmph20242199

Gender and child feeding practices in Belize: a trend analysis

Olusola Oladeji1*, Natalia L. Beer2, Angella E. Baithwabusa1, Robyn D. Faber2

1UNICEF Belize

2Ministry of Health and Wellness, Belize

Received: 12 June 2024

Revised: 19 July 2024

Accepted: 20 July 2024

*Correspondence:

Dr. Olusola Oladeji,

E-mail: ooladeji@unicef.org

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

The study aimed to determine the trend and gender differences in child feeding practices in Belize based on consecutive multiple indicator cluster surveys (MICS) using a retrospective quantitative study. The secondary analysis of the last consecutive MICS data from 2006, 2011 and 2015-16 was done using SPSS software version 23. Association between gender and feeding practices was determined by bivariate analysis using chi-square test and p value < 0.05 was considered statistically significant. There was increased gender differentials in optimal feeding practices in children over the study period. The inequalities between male and female increased over the study period for most of the feeding practices except for exclusive breastfeeding where the gender inequality diminished. The exclusive breastfeeding rate among female children was higher than among male children in the three surveys but significant only in 2006 and 2011 surveys, p<0.05. More female children were timely initiated on complementary feeding compared to male children in the three surveys and was found to be significant in 2006 and 2015 surveys, p<0.05. Minimal meal frequency and minimal dietary diversity was higher among female than among male but there was no significant difference(p>0.05). The study shows evidence of gender differential in feeding practices. There is need to improve gender sensitization in terms of feeding practices within the households; develop and implement culturally appropriate gender sensitive guidance and approaches on optimum infant and young child feeding practices in the country.

Keywords: Belize, Child feeding practices, Gender, Inequality, Trend analysis

INTRODUCTION

Adequate nutrition especially within the first 1,000 days of life is vital to a child’s optimal growth, health, and development.1,2 Exclusive breastfeeding is recommended during the first 6 months of life. Complementary feeding is recommended to start at 6 months of age and it has to be timely, adequate for age in quantity, variety, appropriate frequency and consistency using a variety of foods combination to accommodate the nutritional needs of the growing child while continuing breastfeeding.1-3 Childhood malnutrition has been identified as a significant public health issue mostly in low- and middle-income countries and about one-third of these malnutrition cases are attributable to inappropriate nutrition and ineffective feeding practices, which occur during the first two years of life.4,5 Improving infant and young child feeding (IYCF) practices in children aged 0-23 months is therefore critical to improved nutrition, health, and development. UNICEF and World Health Organization (WHO) recommended core indicators to ensure appropriateness and optimal combination of complementary foods for infants and young children. These indicators include early initiation of breastfeeding; exclusive breastfeeding up to 6 months of age; continued breastfeeding till the age of two years; timely introduction of solid, semi-solid or soft foods; ensuring minimum dietary diversity; minimum meal frequency; and minimum acceptable diet.3 However, in numerous regions of the developing world, optimal complementary feeding remains a challenge to children’s health and nutrition status. Globally, most children are not being fed enough of the right foods at the right time in the years of critical development. Even before the current global food and nutrition crisis, only slightly more than two in five children under 6 months of age were exclusively breastfed, and fewer than one in three children aged 6-23 months received foods from the minimum number of food groups needed for healthy growth and to include the reference properly development.5 Many studies on gender and child feeding practices revealed mixed pattern and gender differentials.6-11 The finding varies from country to country and within country, differences exist from one region to the other due to gender disparity in the intra-household food allocation for children which is affected by socio cultural practices, and gender preference in some settings.6-11 However, most of these studies were in Asia pacific countries, little is known about gender differential and child feeding practices in the Latin America and the Caribbean (LAC) region.

This study aimed to examine the relationship between gender and child feeding practices and how these practices change between male and female children across different Multiple Indicator Cluster Surveys (MICS) conducted in Belize between 2006 and 2016.

METHODS

Study design

This was a retrospective quantitative study using secondary analysis of the last consecutive Multiple Indicator Cluster Surveys (MICS) data from 2006, 2011 and 2015-16 in Belize.12-14

Data collection and analysis

The MICS surveys used two stage cluster random sampling based on the enumeration areas and households’ samples. In the first stage, enumeration areas were selected, and households were selected from each enumeration areas in the second stage.

The MICS secondary data analysis was done using SPSS software version 23. Univariate and bivariate analysis were done. Univariate analysis findings were presented using frequency (N) and percentage (%) distribution tables. Association between gender and feeding practices exclusive breastfeeding, timely initiation of complementary feeding, minimum meal frequency and minimum dietary diversity, was determined by bivariate analysis using chi-square test and p value <0.05 was considered statistically significant.

Operational definitions

Exclusive breastfeeding is defined as the child that is fed only breast milk and no additional food, water, or other liquid (except medicine and vitamins if needed) till six months of age. Complementary feeding refers to the provision of semi-solid foods to children from 6-8 months of age up to 24 months in addition to breast milk to meet their daily nutrient requirements. Timely initiation of complimentary feeding is the introduction of complimentary feeding at 6 month-8 months of age. Minimum meal frequency (MMF) is the proportion of children aged ≥6 months who received at least the recommended minimum meal frequency appropriate for age in the last 24 hours prior the survey: at least 2 feeding daily for infants aged 6–8 months and at least 3 times daily for infants aged 9-23 months in the last 24 hours. Minimum dietary diversity (MDD) is the proportion of children aged ≥6 months who received food from at least four out of the seven recommended food groups in the last 24 hours prior the survey. The seven foods groups used for calculating minimum dietary diversity indicator are: grains, roots and tubers; legumes and nuts; dairy products like milk; fleshy foods such as meat and fish; eggs; fruits and vegetables rich in vitamin A; other fruits and vegetables. A child who had eaten at least four out of the seven groups of foods is said to have had minimal dietary diversity based on the 2008 UNICEF/ WHO Infant and Young Child Feeding indicators guideline.

Ethical approval

The analyses were carried out using a publicly available secondary data set with no individual identifiable information on the survey participants, for which ethical approval is not required.

RESULTS

Figure 1: Trend in exclusive breactfeeding rate (%).
Figure 1: Trend in exclusive breactfeeding rate (%).

Figure 1 shows the trend in exclusive breastfeeding rate between male and female children in the last three MICS conducted in 2006, 2011 and 2015-2016. It shows the exclusive breastfeeding rate in the country increased from 10.1% in 2006 to 14.7% and 33.2% in 2011 and 2015-16 respectively. Female children were more exclusively breastfed than male children and the rate among female children increased progressively from 17.6% in 2006 to 21% in 2011 and 37.7% in 2015-2016. While the exclusive breastfeeding rate among male children increased progressively from 4.1% in 2006 to 10.5% in 2011 and 29.1% in 2015-2016. It showed further with the inequalities between male and female decreased over the years (from 2006 to 2015-16).

Table 1 shows the trend in rate of timely initiation of complementary feeding at 6-8 months between male and female children in the last three MICS conducted in 2006, 2011 and 2015-2016. It shows the rate of timely initiation of complementary feeding in the country increased from 44% to 68.55 and to 82% in MICS 2006, 2011 and 2015-16 respectively. Female children were more timely initiated on complementary feeding than male children and the rate among female children increased from 36.5% in 2006 to 72% in 2011 and 90.3% in 2015-2016. The timely initiation on complementary feeding rate among male children was insignificant in 2006, 66.5% in 2011 and 74.5% in 2015-2016. It shows further the inequalities between male and female increased over the years especially from 2011 to 2015/2016.

Table 1: Trend in the timely initiation of complementary feeding over the years (2006,2011, 2015/-2016).
Table reproduced from source PDF page 3

(*) Figures that are based on less than 25 unweighted cases.

Table 2: Trend and change in minimal meal frequency and minimal dietary diversity over the years (2006, 2011 and 2015/2016).
Table reproduced from source PDF page 3

* Data on minimal meal frequency available only for 2006 and 2011 MICS,** Data on Minimal dietary diversity, available only in 2015/2016 MICS.

Table 3: Association between gender and feeding practices using Chi-square test.
Table reproduced from source PDF page 3

(*) figures that are based on less than 25 unweighted cases. ** p value <0.05.

Table 2 shows the trend and change in minimal meal frequency between male and female children in two of the MICS surveys conducted in 2006 and 2011. It shows that the minimal meal frequency in the country increased from 36.8% in 2006 to 48.8% in 2011 with a change of 32.6%. The minimal meal frequency among female children is more than male children with a rate of 37.4% in 2006 which increased to 51.2% in 2011 with a change of 37%. The minimal meal frequency among male children was 36.2% in 2006 and increased to 48.6% in 2011 with a change of 34.3%. The minimal dietary diversity between male and female children in 2015-2016 mics with a rate of 56.9% nationally, and female children had a minimal dietary diversity rate of 57.9% compared to 55.9% among male children. It shows further those inequalities between male and female for minimal meal frequency increased from 2006 to 2011.

Table 3 shows the results of association between gender and child feeding practices following logistic regression analysis using chi square test. The exclusive breastfeeding rate among female children was higher than among male children in the three multiple indicator cluster surveys (MICS), however there was statistically significant association between gender and exclusive breastfeeding rate only in 2006 and 2011, p<0.05. More female children were timely initiated on complementary feeding compared to male children in the three surveys and there was significant association between gender and timely initiation of complementary feeding in 2005 and 2015. (p<0.05). The analysis for minimal meal frequency and minimal dietary diversity shows that higher rate among female for both indicators than among male but there was no significant difference(p>0.05).

DISCUSSION

The study revealed progressive increase in the coverage of children feeding practices in the country over the years with gender differential in feeding practices. The prevalence of exclusive breastfeeding increased over the years from 10.2 percent in 2006 to 33.3 percent in 2015/2016. Although gender differences for exclusive breastfeeding were identified in 2006 and 2011, with girls being more exclusively breastfed than boys, these inequalities decreased over the years.12-14

The progressive increase in exclusive breastfeeding rate is similar to the finding from a study on the Infant and young child feeding practices in Latin America and the Caribbean which reported the prevalence of exclusive breastfeeding increased from 34.3 percent in 2012 to 42.6 percent in 2021 which is below the global estimate of 47.7 percent. When looking at each subregion, South America showed the highest prevalence at 46.8 percent, followed by Mesoamerica at 37.7 percent and the Caribbean with 31.4 percent.15

The review of gender differences in some of the countries in the Latin America and the Caribbean region are similar to the finding in our study. In the latest Jamaica multiple indicator cluster survey (MICS) in 2022, the exclusive breastfeeding (EBF) rate was 33 percent, female were more exclusively breastfed than male with 35 percent of female compared to 31 percent in male.16 Similarly, in Trinidad and Tobago the prevalence of EBF was 30.5 percent and more female were exclusively breastfed than male.17 However, the study in Guyana found male children were exclusively breastfed more than female children.18 Outside the region, studies in Vietnam and Nigeria reported female infants were more likely to be exclusively breastfed than male infant.19,20 However, studies in India, Egypt and Timor-Lester and Cote d’Ivoire shows that male infants are more likely to be exclusively breastfed than girls.21-24 Culturally related gender preference for breastfeeding have been identified as being responsible for the gender difference reported in the various studies.19,24,25 The study in Vietnam reported that even though there is preference for male child, boys were less breastfed than female. The study suggested that formula feeding is considered better than breastfeeding and hence preferred for boys with more boys provided with formula feeding much more than girls. Even though our study didn’t look at any sex preference, more boys in Belize are bottle fed than girls.13,14,25

The study also found progressive increase over the year in the prevalence of timely initiation of complementary feeding from 44 percent in 2006 to 82 percent in 2015. There was significant gender difference for timely initiation of complementary feeding in 2006 and 2015 surveys with girls timely initiated on complementary feeding more than boys and these inequalities increased over the years. An ecological study that evaluated the role of social inequalities in complementary feeding patterns between and within countries in Latin America and the Caribbean found the prevalence of timely initiation of complementary feeding in the 11 countries studied, ranged from 79.8 percent in Guatemala to 96.6 percent in Argentina.26 Similar to the finding in the study, the recent multiple indicator cluster survey (MICS) in Guyana found more female to be timely initiated on complementary feeding than male. 18 However, studies in Nepal, Ethiopia, India, Kenya, Indonesia and Vietnam found more male child timely initiated on complementary feeding than female.6,19,27-30

The study found progressive increase in minimal meal frequency from 36.8 percent in 2006 to 49.8 percent in 2011. There was insignificant gender difference during the period with girls having higher prevalence on minimal meal frequency than boy and these inequalities increased over the years. In 2011, the proportion of girls with minimal meal frequency was 51.2 percent compared to 48.6 percent among boys.13 Likewise, in 2015/2016 MICS which studied minimal dietary diversity, the prevalence of minimal dietary diversity was found to be 56.9 percent; 57.9 percent among girl child and 55.9 percent among boys though the difference was not significant.14 An ecological study that evaluated the role of social inequalities in complementary feeding patterns between and within 16 countries in Latin America and the Caribbean reported prevalence of minimum meal frequency (MMF), varied in the 14 countries studied, from 42.0 percent in Jamaica to 86.9 percent in El Salvador. With regards to minimum dietary diversity (MDD), in the 11 countries examined, prevalence ranged from 25.4 percent in Haiti to 82.2 percent in Peru.26 The recent MICS in Guyana and Jamaica reported similar gender difference similar to our study with minimal meal frequency more among girls than boys while Trinidad and Tobago and Barbados reported minimal meal frequency more among boys than girls.16-18,31 The proportion of girls with minimal meal frequency in Guyana and Jamaica was 17.7 percent, and 35 percent compared to 17.1percent and 32 percent respectively among boys. In Trinidad and Tobago, minimal meal frequency was 65.3 percent among boys compared to 53 percent among girls. Similar to the study higher proportion of girls had minimal dietary diversity than boys in Guyana and Trinidad and Tobago with prevalence of 50.2 percent and 61.4 percent among girls compared to 45.6 percent and 37.8 percent among boys in the two countries respectively.17,18

In a study on gender-common and gender-specific determinants of child dietary diversity in eight Asia Pacific countries, Indonesia had the highest proportion of male (52.3 percent) and female (54.9 percent) children meeting the minimal dietary diversity (MDD), while Pakistan had the lowest (male 12.7 percent and female 14.1 percent). There were no statistically significant gender differences in the proportion of children achieving MDD between male and female children in all eight countries.10

Gender disparity in the intra-household food allocation for children which is affected by socio cultural practices, and gender preference in some settings have been found to be responsible for the gender difference in feeding practice.9,10,32,33 In addition to socio-cultural factors that influences how children eating pattern, food parenting practice and feeding styles have also been identified as critical factor affecting optimal feeding practices.34,35 Even though not the focus of the study, the gender differences in the feeding practices could have contributed to the gender difference in the prevalence of stunting in Belize. Stunting rate decreased from 19.3 percent between 2011 to 15 percent in 2015 as the breastfeeding, timely initiation of complementary feeding and minimal meal frequency rate increased within the same period, however the stunting rate among male was 18.3 in 2011 and decreased to 16.2 percent in 2015 compared to female of 20 percent in 2011 to 13.7 percent in 2015.12-14

There is need for further investigation on socio cultural factors associated with the gender differences identified in the study. Further study is also suggested to determine the relationship between feeding practices and nutrition status. The coverage of child feeding practices were based on the responses from the mothers 24-hour recall during the survey with possibility of recall bias. However, the strength of the study is in the selection of participants, which used nationally representative random sample and the findings can thus be generalized. In addition, the study assessed all the key indicators for optimal feeding practices - exclusive breast feeding, timely initiation of complementary feeding, minimum dietary diversity and minimum meal frequency. This is the first study to our knowledge in Belize to assess gender and feeding practices.

CONCLUSION

There was increased trend in the coverage of all the key indicators for optimal feeding practices over the study period with gender differentials in feeding practices. The inequalities between male and female increased over the study period for most of the feeding practices except for exclusive breastfeeding where the gender inequality diminished. There is need to improve gender sensitization in terms of feeding practices within the households; develop and implement culturally appropriate gender sensitive guidance and approaches on optimum infant and young child feeding practices in the county.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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