Awareness & knowledge of frontline workers on infant & young child feeding (IYCF) practices: A qualitative study from Palghar-Maharashtra, India

Materials & Methods

This qualitative study was conducted by the Model Rural Health Research Unit, Dahanu of ICMR-National Institute for Research in Reproductive and Child Health, Mumbai, Maharashtra, India after obtaining necessary administrative and ethical approvals from the Institutional Ethics Committee.

The study findings are a part of a quasi-experimental study (CTRI/2024/06/068427) aimed for improving IYCF practices in tribal block of Palghar District, Maharashtra through involvement of frontline health workers. A qualitative approach was employed for baseline assessment of knowledge, attitude and practices of frontline health workers through conduction of in-depth interviews among ASHAs, anganwadi workers and their supervisors.

A semi-structured interview guide was prepared according to World Health Organization’s (WHO) core IYCF indicators¹¹, and covered key domains: (i) initiation and duration of breastfeeding, (ii) timing and types of complementary feeding, (iii) minimum dietary diversity, (iv) minimum feeding frequency, (v) awareness and preparation of amylase-rich foods, and (vi) current counselling practices. The tools were prepared in English and later translated into local language. The native local language experts in the research team cross checked the translation and made it appropriate to the sociocultural context. The tools were pretested and modified as needed to increase clarity and reliability. Prior to data collection, rapport was established with participants and purpose of the study was explicitly informed to participants about the free will to share the information and views without any judgmental attitudes to break the power dynamics.

To address reflexivity and positionality, investigators shared their background with participants at initiation point to build trust. Efforts were made to foster open dialogue by conducting interviews in local language, using familiar cultural references, and avoiding judgmental or leading language to ensure voluntary participation. This reflexive approach aimed to minimize social desirability bias and elicit authentic responses. The questions were non-leading and open-ended so that views and perspectives of participants could be freely expressed. Frontline health workers were contacted directly by the study team and the interviews were conducted a place convenient to the study participants to maintain privacy and confidentiality. The study employed a purposive sampling strategy to select different cadres of frontline health workers (ASHAs, anganwadi workers, and supervisors) till data saturation.

The conduct and reporting of this study followed the Consolidated criteria for Reporting Qualitative research (COREQ) checklist¹². The interviews were audio recorded, transcribed, translated and back-translated to ensure accuracy. All interview transcripts were translated into English and reviewed for data quality by two researchers (SS and SK). A thematic analysis was conducted using inductive and deductive approach, allowing themes to emerge from the data as well as WHO IYCF domains. After transcription and translation from local language to English, the data were reviewed independently by two researchers (BK and SK) who developed an initial codebook. Coding was done using NVivo 1.7 ( www.lumivero.com ), and intercoder agreement was assessed through discussion and consensus with a third reviewer (RK). Codes were then grouped into broader categories and refined into themes based on WHO IYCF domains and also new themes emerged from the data through an iterative process. While the interview guide provided the structure for initial inquiry, theme development was based on recurring patterns and insights that emerged across the dataset. Thematic saturation was achieved, and findings were interpreted in the context of participant’s roles and experiences. The in-depth interview tool is included as supplementary material.

Results

A total of 56 in-depth interviews, (ASHAs-10, anganwadi workers-44 and anganwadi workers supervisor-2) were conducted during pre-intervention phase (April 2024- September 2024). There were no refusals and no repeat interviews were conducted. The interviews lasted for a median duration of 28 min (IQR: 25-32). The sociodemographic details of study participants are presented in table I. The study participants, consisting of ASHAs and anganwadi workers were Hindus from tribal communities aged between 24 and 59 yr, with median age of 42 yr (IQR 40-49). The majority had completed education up to 10^th standard.

The responses described below primarily reflect the knowledge and attitudes of frontline workers (ASHAs, anganwadi workers, and supervisors) based on their training and personal understanding of IYCF practices, unless explicitly noted as observations from their interactions with the community.

To better capture the scope of the study, the results are presented across three domains: (i) knowledge of IYCF practices, (ii) attitudes toward specific feeding behaviours and service delivery, and (iii) practices related to counselling, food distribution, and referrals.

Predominantly eight themes were considered as follows:

Initiation of breastfeeding

All study participants (anganwadi supervisors, anganwadi workers, and ASHAs) emphasised the critical role of breastfeeding in child development, immunity, and overall health. ASHAs unanimously agreed on immediate initiation of breastfeeding (Table II) and the importance of colostrum for protecting babies from diseases and boosting immunity. Some participants referred to colostrum as the baby’s ‘first immunization’ (Figure; Table II). Several anganwadi workers stressed that breastfeeding should begin within 30 min of birth, few anganwadi workers mentioned that breastfeeding should be initiated at the earliest, as it strengthens the mother-child bond.

Table II. Themes along with participant narratives

Themes	Narratives	Health care workers
		ASHA	AWW	AWS
Initiation of breastfeeding	The baby's weight increases, immunity improves, & intelligence develops through breastfeeding	ü	ü	ü
	Colostrum is the baby’s first vaccination	ü	ü
	Start breastfeeding immediately after delivery	ü	ü
	Frequent breastfeeding should be done for every 2 h		ü
Duration of exclusive breastfeeding and continued breastfeeding	Only breastfeeding should be given for the first 6 months	ü	ü
	Breastfeeding should be continued up to 2 yr		ü	ü
	Breastfeeding should be continued more than 2 yr		ü
	Breastfeeding should be continued up to 12 months (as family planning strategy)		ü
Initiation of complementary feeds	Complementary feeding should be started after 6 months	ü	ü	ü
	While starting complementary feeding, first give liquid foods & then soft/semisolid foods		ü	ü
	Give homemade food instead of outside food		ü
Types of complementary foods	Cereals and grains- rice, rava, chapati to be given as complementary food	ü	ü	ü
	Pulses and legumes- Moong dal, tur dal, to be given as complementary food	ü	ü	ü
	Fruits- Mashed banana & apple should be given to children after 6 months as complementary feeding	ü	ü	ü

AWS, anganwadi supervisor

Close

Figure.

IYCF indicators along with perceptions and practices by frontline workers. The inner circle of the figure represents important themes considered for IYCF practices, such as MDD, MMF, breastfeeding, and complementary feeding practices. The outer circle represents the perspectives of frontline workers on IYCF practices based on the inner circle theme. IYCF, infant and young child feeding; MDD, minimum dietary diversity; MMF, minimum meal frequency.

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Duration of exclusive breastfeeding and continued breastfeeding

Some ASHAs recommended exclusive breastfeeding for the first six months (Table II). Most participants agreed that breastfeeding should be continued up to two years. One anganwadi supervisor suggested extending breastfeeding to 2-2.5 yr with complementary feeding starting from seven months (Figure). More than half of anganwadi workers recommended breastfeeding beyond two years, with some suggesting up to three years. One anganwadi workers mentioned to continue breastfeeding up to 12 months as a family planning strategy (Table II).

Initiation of complementary feeds

The majority of study participants, including anganwadi supervisors, and anganwadi workers, recommended that complementary feeding should start after six months of age with a few anganwadi workers mentioning to start after seven months. Very few ASHAs were aware about initiation of complementary feeding after six months (Figure). Few anganwadi workers mentioned that while starting complementary feeding, first liquid foods followed by soft/semisolid foods such as fruits, cooked vegetables should be given. Few anganwadi workers preferred Indian breads and homemade food instead of outside food (Table II).

Discussion

The study findings suggest that frontline workers exhibited remarkable awareness regarding timely initiation of breastfeeding, exclusive breastfeeding for six months and timepoints for initiation of complementary feeds aligning with earlier studies^13-16. This could be because of continued emphasis on breastfeeding during training and health education in programmatic activities. Further, referring to colostrum as baby’s ‘first immunisation’ underscores their understanding of significance regarding early initiation of breastfeeding. However, this attribute contrasts with the diversity found in the awareness of complementary feeding practices.

The findings indicate lack of uniformity in knowledge with respect to duration of continued breastfeeding which varied from 12 to 36 months. Majority anganwadi workers believed that cow’s milk should be avoided in first six months of age unless mother’s milk is insufficient as reported in previous studies¹⁵. While most health care workers stated initiation of CF after six months, they also mentioned that cow’s milk could be introduced as a complementary food after six months. This reflects a need for targeted education on type, frequency, and nutrient content of complementary feeding among them. Most of the frontline workers were aware about transition from liquid to semisolid to solid complementary feeds. However, they lacked understanding about gradual transition of feeds. Although previous studies have reported inappropriate IYCF practices among mothers, particularly regarding minimal dietary diversity and minimal meal frequency^17,18, majority frontline workers in this study lacked awareness about concept of minimal dietary diversity i.e. necessary inclusion of at least four food groups in infant’s diet out of seven key food groups defined by WHO (flesh foods; dairy; eggs; legumes and nuts; vitamin-A rich fruits and vegetable; other fruits and vegetables; and grains, roots, and tubers)¹⁹.

Despite the fact that the majority of participants were aware that infants should receive at least three to four supplementary feeds, they were unaware about the recommended daily frequency for breastfeeds (3-4 feeds) and non-breastfed infants (5 feeds) suggestive of lack of knowledge about required minimal frequency of semi-solid/solid meals fed to a child per day¹⁷.

It is also important to note that majority of the frontline workers demonstrated awareness about the iron and calcium rich foods. Nevertheless, they lacked knowledge about integration of locally available foods such as finger millets, drumstick leaves in the diet. This indicates a substantial gap in awareness and understanding of knowledge about core indicators of IYCF practices with respect to achieving minimal acceptable diet especially among ASHAs.

Most frontline workers expressed confidence and willingness to promote IYCF practices. Despite that, underlying misconceptions, such as early introduction of cow’s milk or unclear understanding of vitamin sources, were prevalent. These knowledge gaps, if unaddressed, may influence the accuracy of counselling delivered to caregivers. ASHAs serve as first point of contact in community and are primarily expected to provide health education in community to promote positive health practices for mothers and children under the home-based newborn care programme²⁰. Majority of the focus of their work revolves around newborn care practices with limited knowledge with respect to maternal and child health services as reported in earlier studies²¹.

Substantial gaps in knowledge about feeding practices as highlighted in this study, endorse the need of strengthening the technical knowledge and practical counselling skills of all frontline workers²². This may be achieved through community-based interventions with an emphasis on socio-behaviour change communication approach^23,24 for upgrading knowledge of frontline workers on IYCF core indicators. The findings also shed light on operational challenges faced by frontline workers while providing IYCF related services. Despite availability of take-home ration for six months to three-year-old children, the consumption was reported as inadequate. This was mainly attributed to dislikes of taste and sharing it with other family members. Moreover, referral of SAM children to higher centres was also reported to be affected due to reluctance of parents.

Despite the challenges faced in community, the attitudes of frontline workers were highly supportive of recommended practices. Hence, strengthening the capacity of ASHAs and anganwadi workers through, tailored communication tools, focused capacity-building efforts and supportive supervision to improve the quality of service is crucial. A validated, context-specific tool for assessing IYCF-related knowledge, attitude and practice could further enhance programme planning and evaluation. In this context, a coordinated, community-based intervention with an emphasis on social and behaviour change communication and consistent message delivery can help to improve IYCF practices in underserved tribal populations.

The present study reveals considerable gaps in knowledge and practices of frontline workers regarding core IYCF indicators in tribal region where undernutrition is highly prevalent. However, this study has certain limitations. Since study adopted a qualitative design to understand perspectives of frontline workers, the dimension of caregiver perspectives was not explored. While a semi-structured interview guide developed on basis of WHO IYCF indicators was pretested, the lack of formal validation of tool may limit accurate capture of context-specific and sociocultural variations in knowledge, attitudes, and practices of frontline workers. Being limited to one single block, the findings may not be generalized across different socio-cultural and health care settings.

The study underscores the need of coordinated efforts to promote optimal IYCF practices and enhancing skills of frontline workers for ensuring optimal implementation IYCF practices. A comprehensive approach involving training, social and behaviour change communication-based community interventions and robust monitoring is pivotal to improve IYCF practices to optimize nutritional outcomes for infants in the first two years of life.