Conceptualizing multi-level determinants of infant and young child nutrition in the Republic of Marshall Islands–a socio-ecological perspective

Abstract

The East and Pacific region includes 14 Pacific Island Countries where, between 2000 and 2016, indicators of stunting, wasting, and micronutrient deficiencies have plateaued or worsened, while rates of overweight, obesity, and associated disease have risen. The Republic of Marshall Islands (RMI) is no exception: maternal and child nutrition indicators have not improved in decades. A study of the contemporary factors shaping the RMI nutrition situation was needed for informing policy and tailoring interventions. This formative study had an iterative design utilizing qualitative methods. An exploratory Phase 1 included 59 semi-structured interviews with community members, 86 free lists with caregivers, 8 participatory workshops, and 20 meal observations (round 1). Findings were synthesized to inform a confirmatory Phase 2 where 13 focus groups, 81 pile sorts, 15 meal observations (round 2), and 2 seasonal food availability workshops were conducted. Textual data were analyzed thematically using NVivo while cultural domain analysis was conducted in Anthropac. RMI faces interrelated challenges that contribute to a lack of nutritious and local food availability, which is compounded by high food costs relative to household incomes. A decades-long cultural transition from local to processed diets has resulted in infant and young child diets now characterized by morning meals of doughnuts, bread, and ramen with tea, coffee, or Kool-Aid and afternoon meals that include rice with canned meats (e.g., store-bought chicken, hot dogs). Individual preferences for processed food imports have increased their supply. Low maternal risk perception toward nutrition-related illnesses may further explain sub-optimal diets. Improving the RMI food environment will require approaches that align with the multi-level determinants of sub-optimal diets found in this study. As the ten-year 2013 RMI Food Security Policy soon ends, study findings may be used to inform new policy development and investments for improving the nutrition situation.

Observational Methods in Studies of Infant and Young Child Feeding Practices in Low- and Middle-Income Countries: A Twenty-Year Retrospective Review

“…Despite these limitations, in contrast to a prior review that concentrated on responsive feeding behaviors exclusively, this review explores the application of observations for various IYCF behaviors [ 10 ]. Another strength of this review was the study team who has decades of combined experience using diverse observational methods to study child eating behaviors in both laboratory and field settings [ 23 , 69 , 70 , 71 , 72 ]. We believe that this level of expertise aided in the synthesis and interpretation of findings.…”