Influence of individual, household and community power structures on child nutrition in northern Nigeria

Background: Child undernutrition and mortality remain unacceptably high in northern Nigeria, including Jigawa State, where poor infant and young child feeding practices contribute substantially to preventable illness and death. EBF for the first six months of life is a proven, life-saving intervention, yet coverage remains low in this setting. In Jigawa State, breastfeeding and complementary feeding practices are shaped by social norms and household decision-making structures that extend beyond mothers alone. Despite the scale of the problem, there is limited evidence on how participatory or whole-systems interventions influence infant feeding and child nutrition in such high-mortality, socially complex contexts. This thesis addresses this gap by generating context-specific evidence from Jigawa State to inform more effective nutrition interventions. Aim: The aim of this thesis was to investigate how individual, household, and community power structures shape infant and young child feeding practices, and how these practices influence child nutrition, in Kiyawa Local Government Area (LGA), Jigawa State, Nigeria. Methods: A series of complementary studies were conducted in Jigawa State, Nigeria, employing both quantitative and qualitative approaches to examine infant and child feeding practices. Study 1 was a cross-sectional survey of 4,836 women with child under two years, assessing the prevalence and determinants of EBF among infants. Study 2 and 3 used qualitative ethnographic methods to explore household influences and local definitions of EBF and complementary feeding, including 36 women who had breastfed within the previous two years. Study 4 was a secondary analysis of the Integrated Sustainable childhood pneumonia and infectious disease reduction in Nigeria (INSPIRING) cluster-randomized controlled trial, evaluating the impact of a participatory whole-systems intervention on DD and complementary feeding initiation among 9,053 children aged 6-59 months. Data collection included structured questionnaires, in-depth interviews, and household and health facility observations. Quantitative data were analysed using multivariable-adjusted modified Poisson regression for Study 1 and mixed-effects logistic regression models for Study 4. Qualitative data were analysed using reflexive thematic to identify patterns and contextual influences. Results: Quantitative analysis showed that EBF was more common than expected, with 71.3% of infants aged 0-5 months reported as exclusively breastfed. However, multivariable analysis indicated that EBF was socially patterned: women engaged in paid work were less likely to practice EBF, while higher household wealth and recent experiences of pregnancy or child loss were associated with increased likelihood of EBF. Qualitative findings provided critical explanations for these patterns. Although mothers commonly defined EBF as giving "only breastmilk," many routinely gave water, believing water did not violate EBF. Feeding practices were strongly shaped by household power relations, particularly the influence of older relatives, co-wives, mother-in laws and compound hierarchies, often limiting maternal autonomy. Local understandings of adequate complementary feeding also differed from biomedical recommendations, with emphasis placed on satiety rather than dietary quality. As children grew older, feeding challenges shifted from breastfeeding to food quality. DD remained persistently low, with mean scores of 2.24 among children aged 6-23 months and 2.05 among those aged 24-59 months. Fewer than 5% of younger children consumed animal-source foods, and over 80% of older children were classified as food poor. Participation in the INSPIRING intervention was associated with small improvements in DD among older children; however, overall effects were modest, reflecting persistent structural, cultural, and household-level constraints on optimal child feeding. Conclusion: These findings show that EBF and child feeding practices in Jigawa are strongly shaped by power relations at multiple levels. Mothers' decisions are influenced not only by their knowledge but also by household hierarchies, including the roles of fathers, grandmothers, and co-wives, as well as broader community norms that define what is acceptable feeding. Local interpretations of exclusivity, such as the belief that giving water does not break exclusive breastfeeding, reflect how cultural and social authority shapes practice. Addressing infant and young child nutrition therefore requires interventions that engage households and communities, recognising the social and structural constraints that influence mothers' ability to follow recommended feeding practices. List of scientific papers I. Shittu F, Falade AG, Bakare AA, Bakare D, Salako J, Rautiainen S, Colbourn T, Burgess RA, King C. Exclusive breastfeeding among infants in Jigawa State, Nigeria: a cross-sectional analysis. Int Breastfeed J. 2025 Nov 24;20(1):94. https://doi.org/10.1186/s13006-025-00784-8 II. Shittu F, King C, Rautiainen S, Iuliano A, Bakare AA, Colbourn T, Bakare D, Salako J, Graham HR, Falade AG, Burgess RA. Exploring the feeding practices of mothers of under-five children and how household members influence exclusive breastfeeding in Jigawa State, Nigeria - A qualitative study. Glob Public Health. 2024 Jan;19(1):2426135. https://doi.org/10.1080/17441692.2024.2426135 III. Shittu F, King C, Bakare AA, Bakare D, Salako J, Juliano A, Rautiainen S, Colbourn T, Burgess RA, Falade AG. "I just felt there was not going to be issues": Exploring local definitions of exclusive breastfeeding and adequate complementary feeding within communities in Jigawa state, Nigeria. [Manuscript] IV. Shittu F, Falade AG, Colbourn T, Burgess RA, Bakare AA, Bakare D, Salako J, Uchendu OC, Juliano A, Graham HR, McCollum ED, Beard J, King C & Rautiainen S. Impact of a participatory whole-systems intervention on dietary diversity amongst 6-59 month olds in Jigawa State, Nigera: Secondary analysis of the INSPIRING cluster randomised controlled trial. [Manuscript]