Socio-cultural and structural determinants of infant feeding practices: A retrospective qualitative focus group observational study in Kitwe, Zambia

Abstract

Moderate acute malnutrition (MAM) continues to be a serious public health concern among infants in Zambia, despite the implementation of the WHO infant and young child feeding (IYCF) guidelines. This retrospective qualitative study examined the social, cultural, and structural factors that influence IYCF practices among mothers in Kitwe and their links to MAM during the first year of life. Ninety-six mothers of infants aged 3 months at the start and 9 months at the end of the study participated in longitudinal focus group discussions. Using a qualitative approach, data were collected from mothers and caregivers through interviews and focus groups, with emphasis on household, community, and cultural influences on feeding decisions. Reflexive thematic analysis identified six main themes: 1) The Negotiated Feeding Trajectory: From Intention to Early Introduction, 2) Cultural Logics: Water, Insufficient Breast Milk, and Herbal Wisdom; 3) The Social Architecture of Feeding: Grandmothers, Absent Fathers, and Peers, 4) The Material Boundaries of Choice: Economics, Work, and Health, 5) Maternal Experience: Eating Beliefs and Bodily Changes, and 6) Envisioning Improvement: Maternal Prescriptions for Change. Results showed that although mothers aimed for exclusive breastfeeding in the first 6 months, complementary foods were often introduced prematurely (sometimes as early as 3 months). The study reveals that social norms, family dynamics, and structural barriers, rather than lack of knowledge, hinder the adoption of recommended guidelines. Major reasons for early introduction included cultural expectations and advice from elders, especially grandmothers; perceived infant hunger or behaviors; economic challenges and limited food supplies; and maternal work pressures. While health workers' advice recommending complementary feeding at six months was valued, it was frequently ignored due to strong social norms and financial barriers. Traditional remedies were often used when biomedical treatments seemed ineffective, highlighting the persistent influence of cultural beliefs on infant care. Mothers proposed practical solutions, such as routine maternal health checks and improved economic support, to promote optimal feeding, emphasizing the need to address both social-cultural and structural obstacles. The study emphasizes that infant feeding behaviors in Kitwe are shaped by a complex interplay of social, cultural, and structural factors, not solely by knowledge. Feeding choices are influenced not only by medical guidelines but also by cultural beliefs, social networks, and caregivers’ daily realities. Understanding these interactions is essential for developing locally appropriate, culturally sensitive interventions to prevent MAM. The findings call for culturally tailored, community-engaged strategies that involve elders, address household food insecurity, and support working mothers. This research demonstrates that infant feeding decisions in Kitwe are affected not only by maternal knowledge and adherence to health guidelines but also by social negotiations and structural barriers. It advocates shifting from mother-centred, information-only interventions to family-inclusive counselling, culturally sensitive behavior-change strategies, strengthened maternity protections, and stricter regulation of commercial influences. By linking infant feeding recommendations to real-life experiences of urban mothers, the study offers practical insights for creating nutrition policies that are socially grounded and structurally responsive in Zambia.