Complementary feeding practices: determinants of dietary diversity and meal frequency among children aged 6–23 months in Southern Benin
Complementary feeding practices: determinants of dietary diversity and meal frequency among children aged 6-23 months in Southern Benin
Irene Medeme Mitchodigni 0 1 2
Waliou Amoussa Hounkpatin 0 1 2
Gervais Ntandou-Bouzitou 0 1 2
Hermane Avohou 0 1 2
Celine Termote 0 1 2
Gina Kennedy 0 1 2
D. Joseph Hounhouigan 0 1 2
0 Bioversity International , Nairobi , Kenya
1 Bioversity International, Bioversity International , Cotonou , Benin
2 Faculty of Agronomic Sciences, University of Abomey-Calavi , 03 BP 2819 Jericho, Cotonou , Benin
3 Irene Medeme Mitchodigni
Poor complementary feeding practices have detrimental effects on child growth, development and survival. This cross-sectional study in rural areas of southern Benin examined some determinants of complementary feeding practices using socioeconomic and dietary data collected among 1225 primary caregivers. Determinants of complementary feeding practices in the study areas are multidimensional and include many interacting factors such as socio-economic aspects, farming practices, household demographics, cultural practices and geography. Child age, diversity of food groups produced, income allocated to feeding, commune of residence, ethnicity, caregivers' occupation, marital status and household size were identified as the main factors affecting complementary feeding practices. Food group diversification in farm-systems and overall social behavior and support as well as women's empowerment are necessary to improve children's diets. Reducing women's workload through improved working conditions appears crucial to decrease time burdens and allow more time for child care. Multisectoral interventions should be embraced to improve complementary feeding practices in Benin.
Complementary feeding practices; Dietary diversity; Meal frequency; Diversity of food group produced; Gender; Benin
Complementary feeding refers to children aged 6–23 months,
a challenging period until the child is able to eat like the rest of
the family. It is the process of introducing complementary
foods, which are any non-breastmilk foods or nutritive liquids
that are given to young children from 6 months to above
. It is a transition from exclusive breastfeeding
to family foods and a very vulnerable period in which
malnutrition starts in many infants, contributing significantly to the
high prevalence of malnutrition in children under five years of
age world-wide. Achieving appropriate complementary
feeding of young children is a crucial milestone in efforts to
enhance survival and promote healthier growth and
development of children
complementary feeding practices during the first two years of childhood
drastically increase morbidity, mortality and risks of chronic
diseases. Poor complementary feeding practices have
detrimental effects on overall growth and development of children
(Black et al., 2013; Khanal, Sauer, & Zhao, 2013)
Worldwide, about one-third of the mortality of children under
five years is caused by malnutrition related to inadequate
complementary feeding (WHO, 2003).
Complementary feeding practices are still poor in most
developing countries and are even worsening in some of them
(Lutter et al., 2011)
. For instance, national assessments
available in West African countries reported that the prevalence of a
minimum acceptable diet ranged from 11.0% in Nigeria (2003)
to 29.9% in Ghana (2007)
(Issaka, Agho, Burns, Andrew, &
Dibley, 2014; Ogbo, Page, Idoko, Fernanda, & Agho, 2015)
In Benin, 15% of children met the minimum acceptable diet
. This persistent prevalence of inadequate
complementary feeding requires more intensive and efficient
efforts from different organizations to improve the situation
(Lutter et al., 2011)
, requiring a better understanding of the
drivers of inappropriate complementary feeding as well as
better identification of vulnerable groups
(Lutter et al., 2011;
Issaka et al., 2015c)
. Until now, very few studies have
investigated these drivers in order to understand the complex
processes underlying inappropriate feeding practices at individual,
household and community levels
(Menon, 2012; Chapagain,
2013; Issaka et al., 2015b; Ogbo et al., 2015)
. Moreover, major
explanatory factors highlighted by these studies include
mainly socioeconomic factors such as cultural beliefs and habits,
household poverty, maternal literacy and ignorance of
(Menon, 2012; Chapagain, 2013; Issaka et al.,
2014; Ogbo et al., 2015)
. Maternal education level, for
example, could influence complementary feeding practices with
potentially beneficial effects on child nutritional status. Indeed,
Agueh, Makoutode, Diallo, Soton, and Ouendo (1999) found
that mothers’ instruction level had a tendency to be positively
and significantly associated with child wasting (weight for
Recent studies in Benin showed the important role of crop
diversity in dietary habits of rural people and the complex
relationships between socioeconomic characteristics of
households and their access and use of these resources
Achigan-Dako, 2014; Bellon, Ntandou-Bouzitou, &
. However, the influence of such
socioeconomic factors on complementary feeding practices have rarely
been investigated in Benin.
Therefore, the present study aims to assess the adequacy of
complementary feeding practices of infants aged 6–23 months
in rural areas in Southern Benin and identify key factors that
influence them and key socio-economic characteristics of
vulnerable groups where practices are inadequate. We
hypothesize that the adequacy of complementary feeding practices is
determined by the combined effects of socioeconomic and
cultural factors, household and caregiver characteristics, in
association with factors related to agricultural and food
diversity, availability and accessibility.
2.1 Study design
A cross-sectional survey was performed in two communes of
Mono Department, Southern Benin. Data were collected over
a three month period, from October to December 2013, a
transition period between the short rainy season and the long
dry season. This period corresponded to moderate food
availability. Harvesting is the main agricultural activity undertaken.
2.2 Research setting
The study was carried out in two rural communes Bopa
(latitude: 6.702; longitude: 1.949) and Houeyogbe (latitude:
6.532; longitude: 1.870), in Mono Department, Southern
Benin. Mono department was chosen because of the high level
of malnutrition, which contrasts with the high agricultural
biodiversity in this area. Bopa and Houeyogbe were selected
due to their high food insecurity index (40.5% and 34.1%,
respectively). The study sites are located in slightly
contrasting environmental conditions and socioeconomic contexts.
Bopa is landlocked and less densely populated (264
inhabitants/km2) than Houeyogbe (315 inhabitants /km2)
2010; Benin Consulting, 2011; INSAE-Benin, 2013)
The soil in Bopa is dominated by vertisol while land in
Houeyogbe is dominated by ferralitic and patches of
hydromorphic soils. Vertisols are more fertile than ferralitic soils.
The natural vegetation is more degraded by anthropogenic
pressure in Houeyogbe than Bopa. Thus, Bopa has a more
diversified natural vegetation including tree species such as
baobab (Adansonia digitata) and kapok tree (Ceiba
pentandra). There are reforested perimeters consisting mainly
of teak (Tectona grandis), acacia (Acacia auriculiformis), iroko
(Milicia excelsa), samba (Triplochyton scleroxylon), Elaeis sp.
and fruit trees. The herbaceous vegetation consists of grasses,
marshy grasslands and a mangrove along the BAheme^ lake.
Bopa is also more farming-oriented (82% of households)
compared to Houeyogbe (47% of households). The main
crops produced in the study area include: maize (Zea mays),
cassava (Manihot esculenta), sweetpotato (Ipomoea batatas)
- cereals, roots and tubers group-, cowpea (Vigna
unguiculata), groundnut (Arachis hypogaea), palm oil
(Elaeis guineensis)- legume and nuts group-, Jew’s mallow
(Corchorus olitorius), amaranth (Amaranthus cruentus),
tomato (Solanum ly copersicon ), okra (Ab elmoschus
esculentus), pawpaw (Carica papaya), banana (Musa spp.)
-fruits and vegetables. The main animal species reared are
chicken (Gallus gallus domesticus), duck (Cairina moschata),
goat (Capra aegagrus) and fish (Tilapia guineensis) -flesh
foods group. Gardening is more widely practiced in Bopa
than Houeyogbe. In Bopa with the proximity of the BAheme^
lake, many households also engage in fishing activities.
Women are involved in all agricultural activities, especially
in crop production, livestock keeping and home gardens.
Harvesting and post-harvest activities - drying, storage,
preservation, processing and marketing of agricultural products
are time consuming and are predominately implemented by
women. Regarding living standards, the poverty threshold is
lower in Bopa [291 XOF (= 0.50 USD) per capita (XOF:
means the code of FCFA which is the currency used in the
UEMOA area including Benin.)], with a poverty rate of
33%) compared to Houeyogbe (328 XOF (= 0.56 USD) per
capita with a poverty rate of 43%)
2.3 Respondents and sampling
The study focused on children aged 6 to 23 months and their
mothers or primary caregivers.
The sample size was calculated using a classic formula for
sample size calculation:
N = [Z2 * p(1-p) /m2] * DE * 1/(1-λ)
where N refers to the required sample size in each commune:
Bopa and Houeyogbe; Z is the z-value corresponding to the
level of confidence of 95%, thus equals 1.96; p is the
estimated prevalence of childhood stunting in Mono province in
2006 at 44.7%
; m is the margin of error
at 5% (standard value of 0.05); DE is the design effect fixed at
2.8 (1.4 × 2) - due to cluster sampling with Bopa and
Houeyogbe representing two different clusters; λ is the refusal
rate (household non-response) fixed at 10%.
An initial sample size of 1182 children was obtained and
further extended to 1190.
A multistage sampling method was used in selecting
participant villages and subjects. Briefly, the estimated sample
size (1190) was allocated to the two communes proportionally
to the population size of children from 0 to 2 years old, 47%
for Bopa (n = 560) and 53% for Houeyogbe (n = 630). A total
of 17 villages (8 and 9 in Bopa and Houeyogbe, respectively)
were randomly selected from a list of villages in each
commune with infant populations equal or above 80 subjects. In
each selected village, all households with at least one child
between 6 and 23 months old were systematically selected to
be enrolled in the study upon satisfaction of the following
inclusion criteria: children must be 6 to 23 months old,
complementarily fed, not suffer severe illness or malnutrition;
caregivers and their children must have lived in the village
for the past 2 years and were not planning to leave in the next
year. Twenty one children did not meet inclusion criteria.
Finally, 1263 households were selected of which 1225
households completed all questionnaires. Within each household,
the household head and the mother or child caregiver were
interviewed. Where more than one child aged between 6 and
23 months old was found in the same household, the
interviews focused on the youngest child.
2.4 Data collection and processing
Data were collected in local languages by well trained and
experienced interviewers with bachelor’s degrees as minimum
grade. Structured questionnaires were used to collect
demographic and socioeconomic household characteristics,
including food security status measured by the Household Food
Insecurity Access Scale,
(Coates, Swindale, & Bilinsky,
. Agricultural production and availability of the previous
year as well as utilization of local biodiversity were also
integrated into the questionnaire.
Additionally, gender aspects, households’ sanitation, child
feeding and care practice data were collected. Two
nonconsecutive 24-h recalls were used to assess child dietary
intakes. Primary caregivers recalled the meals, drinks and
snacks the child had consumed the previous day in a 5
stepmethod described in
Gibson and Ferguson (2008)
. Intake data
were entered and processed with Lucille software developed
by Gent University, Belgium. The other data were entered and
processed with Microsoft Access. All filled questionnaires
were cross-checked by field supervisors as well as the
principal investigator (first author). The data were entered twice by
two different individuals who were blind to the other’s entries.
Subsequently, databases were screened for discrepancies and
2.5 Explanatory variables
Five groups of potential explanatory variables were identified
from the literature
(Fein, Labiner-Wolfe, Scanlon, &
Grummer-Strwan, 2008; Upul, Sanjeeva, Hiranya, Indika, &
Michael, 2012; Khanal et al., 2013; Melkam, Molla, Zelalem,
& Azeb, 2013; Brown et al., 2014; Issaka et al., 2015a, b)
The first group of potential variables is related to
socioeconomic characteristics of households. It included 8 variables
n a m e l y : ( 1 ) t h e c o m m u n e o f r e s i d e n c e ( B o p a o r
Houeyogbe), (2) the sex of the household head (male or
female), (3) primary and other income sources of the household,
(4) the sociolinguistic group of household head (native Saxwe
or others), (5) the marital status of the mother (alone - single,
divorced, widowed, married but living alone - or not alone
married and living with husband), (6) the household size, (7)
the number of children under 5 years (categorized on an
ordinal scale, normal is ≤2 and high is >2) and (8) the household
wealth index. The last is a composite variable of a household’s
cumulative living standards. It was developed using a series of
nineteen assets, proxy variables used in the DHS survey and
wealth index construction for rural areas in Benin
Kiersten, 2004; Vyas & Kumaranayake, 2006)
characteristics (house construction materials, energy source for
lighting and meal cooking); durable asset ownership (means
of transportation, media and communication assets); and
access to utilities and infrastructure (health center access,
transportation means used to access markets or health centers, the
availability and quality of household sanitary facilities and
practices such as water sources, state of toilets, waste
management and overall hygiene habits). Each household was
assigned a score for each asset variable using principal
components analysis. The scores were then summed for each
household to derive the corresponding wealth index. Further,
based on the quintiles of the wealth index, households were
classified into five socioeconomic status categories, from the
poorest to the richest category
(Filmer & Pritchett, 2001; Vyas
& Kumaranayake, 2006)
The second group of variables refers to the households’
food insecurity, food availability and accessibility. It includes:
(1) the share of the household income allocated to food
(categorized on an ordinal scale; ≤50% is normal, 50–75% is
moderately high, > 75% is high); if a high percentage is
allocated to food, people are really poor
(2) the food availability (related to the duration of food
shortage experienced by the household
(Bilinsky & Swindale,
and coded on an ordinal scale as follow: very low- 5
to 11 months of shortage, low - 3 to 4 months of shortage,
medium - 2 months of shortage and high – 0 to 1 month of
shortage and (3) the household food insecurity which is an
ordinal scale variable determined with the Household Food
Insecurity Access Scale (HFIAS)
(Coates et al., 2007;
Bilinsky & Swindale, 2010)
. Households were categorized
into four levels of household food insecurity (access): food
secure, mildly, moderately and severely food insecure.
The third group of explanatory variables is related to
production diversity and assets that might affect this diversity. It
includes: (1) production diversity defined as the number of
different food groups produced over the past year in
analogy with the WHO classification for infant and young
child dietary diversity
(WHO, 2008; Berti, 2015)
(minimum = 0 and maximum = 7 food groups); (2) the
ownership of a home garden, which indicates the availability of
vegetables at the household level.
The fourth group of potential explanatory variables refers
to social support. It includes only one binary variable which
refers to any support received by the household in terms of
training, awareness, counseling, financial or material support
related to child care practices. This is a categorical variable:
yes if the household received any type of support or no, if
none of the above cited types of support were received.
The fifth group of variables includes child, maternal and
caregiver characteristics that might influence the feeding
practices: (1) age of the child which may affect the choice of
adequate complementary foods, (2) age of the mother as proxy
of maturity which may reflect her experience, (3) education
level of the mother which may affect her knowledge (coded as
no schooling or any form of formal schooling), (4) mother’s
occupation which may reflect her availability to take care of
the child (coded as no occupation and worker); and (5) the
maternal sociolinguistic group (BSaxwe^ or others) which may
reflect beliefs and dietary habits.
2.6 Outcome variables
Among the set of infant and young child feeding (IYCF)
practices indicators defined by
, two have been
explored in this work as outcome variables: (1) minimum dietary
diversity (MDD) and (2) the minimum meal frequency
(MMF). Child breastfeeding status was taken into account.
The MDD is defined as the proportion of children aged 6–
23 months who consumed foods from at least four food
groups out of the seven referenced food groups within a
24-h time period. The seven food groups are: (1) grains,
roots and tubers, (2) legumes and nuts, (3) dairy products,
(4) flesh foods (meat, fish, poultry and liver/organ meats),
(5) eggs, (6) vitamin A-rich fruits and vegetables and (7)
other fruits and vegetables
The MMF is the proportion of breastfed and
nonbreastfed children aged 6–23 months who received solid,
semi-solid or soft foods (but also including milk feeds for
non-breastfed children), the minimum number of times or
more. The minimum number of times was set to two and
three meals for breastfed infants aged 6–8 months and 9–
23 months, respectively; and four meals for non-breastfed
children aged 6–23 months
The Minimum acceptable diet (MAD) is defined as the
proportion of children 6–23 months of age who had both
minimum meal frequency and dietary diversity (in both
breastfed and non-breastfed children) during the previous
(WHO, 2008; UNICEF, 2011)
The age bracket (6–23 months) was further disaggregated
into the following age groups: 6–11 months, 12–17 months
and 18–23 months
WHO infant and young child feeding (IYCF) indicators
focusing primarily on breastfeeding were outside the scope
of this study on complementary feeding practices. Also, the
paper did not focus on the minimum acceptable diet (MAD),
as this is a composite indicator of MDD and MMF, which
reflects both quality and quantity of diet. Indicators on
‘consumption of iron-rich or iron-fortified foods’ will be discussed
in a subsequent paper dealing with quantitative dietary intake
data and nutrient adequacy of diets.
2.7 Statistical analysis
Descriptive statistics and Wilcoxon rank test and Chi-square
test were used to describe and compare the two study areas.
Simple logistic regressions were computed using MDD and
MMF as dependent variables to preselect candidate
explanatory variables. Multiple logistic mixed regressions were
further used to test significance of the effects of the preselected
explanatory variables. Fixed terms included the preselected
variables and all two-order interactions. Villages were
included as a clustering variable. The final model was constructed
using a backward elimination approach, where non-significant
terms were excluded, based on the likelihood ratio test at a
significance level of 0.05. Plots of predicted probabilities of
meeting MDD or MMF were then used to examine significant
relationships among variables.
Statistical analyses were performed in BR^ software
. For screening of variables with simple logistic
regression, we used the function ‘glm’ of the package ‘stats’.
Logistic mixed regression models were performed with the
function ‘glmer’ of the package ‘lme4’
3.1 Characteristics of the sample
The socio-economic and demographic profiles of children,
primary caregivers and households are presented in Table 1.
Among the 1225 children enrolled in the study, over one-third
was between 6 and 11 months old. The majority of primary
caregivers (98%) were the mothers. They were generally
young (average 28 ± 3.7 years) with more than half of them
under thirty. Most of the mothers did not attend formal school
and were illiterate, with the highest proportion observed in
Bopa commune. Most mothers (97%) pursued income
generating activities such as agriculture, post-harvest handling, food
processing and small trade. The majority of households (94%)
were male-headed. Mean household size was significantly
higher in Bopa (5.5 ± 2.0) than Houeyogbe (5.1 ± 1.8). The
dominant ethnic group is BSaxwe^ (77% of interviewees).
Only 10% of households reached a production diversity of 4
or more food groups, with a higher proportion observed in
Bopa. Mean diversity of food groups produced (DFGP) score
was also significantly higher in Bopa (2.3 ± 1.2) than
Houeyogbe commune (1.3 ± 1.1: Table 1). More than 80%
of households were food insecure with a significantly higher
rate in Houeyogbe commune. On the contrary, the proportion
of the poorest households was significantly higher in Bopa
than Houeyogbe (40% vs 36%; p < 0.001).
3.2 Types of foods given to child by age
Table 2 presents the proportion of surveyed children
consuming the different food groups and the derived dietary diversity
scores (DDS). Cereals, roots and tubers were the most
widespread food groups used to feed children. Half of the children
were fed with vitamin A rich foods but only 2% of the children
consumed eggs. Except for eggs and dairy products, the group
of children aged between 18 and 23 months had the highest
consumption rates for all food groups.
3.3 Complementary feeding indicators
Figure 1 shows the proportion of children meeting the selected
WHO complementary feeding indicators in each commune.
The prevalence of minimum dietary diversity (MDD) among
the children aged 6–11 months in Bopa and Houeyogbe were
49% and 39%, respectively. The corresponding rates among
children aged 12–17 months were 74% vs 62% and were 71%
vs 75% for 18–23 months children. The rates of MDD among
children of Houeyogbe increased significantly with the age of
children. However, the prevalence of minimum meal
frequency (MMF) within age group in Houeyogbe were significantly
3.4 Factors associated with complementary feeding
Four main factors were found significantly associated with
minimum dietary diversity, either positively or negatively:
(1) child’s age, (2) production diversity, (3) combined effect
of share of income allocated to feeding and commune of
residence and (4) the combined effect of ethnicity and commune
(Table 3). While the probability of meeting minimum dietary
diversity increased with child’s age and with increased
diversity of food groups produced (DFGP) (number of food groups
grown) (p < 0.05), it decreased substantially when income
allocated to food purchase increased in Houeyogbe commune
(p < 0.05). However, there was no substantial effect of income
allocated to food on the probability of minimum dietary
diversity in Bopa (p < 0.05). The chance of meeting MDD
decreased substantially for BSaxwe^ people residing in
Houeyogbe while it increased among minority groups
(p < 0.05).
The probability of meeting minimum meal frequency was
significantly affected by three factors namely (1) ethnicity, (2)
caregiver’s occupation and (3) the combined effect of marital
status and size of household (Table 4). Children from minority
ethnic groups (other than the native BSaxwe^ people) were
more likely to meet MMF, while those of large household size
and those whose mother/primary caregivers are involved in
income-generating activities, were less likely to meet MMF
(p < 0.05). Increase in household size had a detrimental effect
on children’s probability of minimum meal frequency among
single mothers (p < 0.05).
To our knowledge, this is one of the first publications in Benin
that explores determinants of complementary feeding
practices using selected WHO recommendations
Factors positively or negatively associated with compliance
to recommended complementary feeding practices were
children’s age, caregivers’ occupation and marital status, ethnicity
of household head, household size, production diversity, share
of household income allocated to feeding and commune of
residence. Interactions noticed between some of these factors
revealed the complexity of determinants of infant and young
child (IYC) complementary feeding practices.
Minimum dietary diversity (MDD) reflects the quality of
foods given to children
(Joseph et al., 2011)
association between MDD and age shows the poor quality of diet
among the youngest children (6 to11 months) who received
fewer different types of foods than older children (Table 2).
This is not surprising, since semi-solid and solid foods are
introduced gradually and stomach capacity at 6 months is
relatively limited. This also confirms the overall tendency
observed in complementary feeding practices in Benin and the
West African region and was consistent with recent findings
from the study on determinants of complementary feeding
practices among children aged 6–23 months in seven
francophone West African countries
(Issaka et al., 2015b)
. The same
trend has been reported in Ethiopia
(Melkam et al., 2013)
This finding could, furthermore, be explained by the quality
of complementary foods introduced. Cereal porridges were
recognized as the most common and first complementary
foods given to children followed by family dishes.
et al. (2014)
showed that the traditional porridges, as
complementary foods in West Africa, generally provided low
nutritional value due to less food diversity. Hence, it is important to
place emphasis on upgrading the quality of porridges,
especially for the youngest age bracket (6–11 months) of children
by providing appropriate nutrition messages, including
handson recipes for improved porridges, and promoting food
Likewise, the association between MDD and age is not
linear and may be mediated by other factors as shown by the
positive association between MDD and the interaction term
DFGP x children’s age (Table 3). In other words, the more
production diversity at household level increases, the more
children meet the requirements for MDD throughout all age
groups. Thus, agricultural diversity was strongly associated
with improving quality of complementary foods. Following
Age of children (months) Cereals, roots and tubers Legumes and nuts Dairy products
Fig. 1 Prevalence of children
meeting minimum dietary
diversity, minimum meal
frequency and minimum
acceptable diet by age group for
each commune a- Bopa and
bHoueyogbe. *p < 0.05;
*** p < 0.001; ns, not significant
the recent PNAS publications
(Berti 2015; Sibhatu et al.
and to obtain a nutrition-relevant indicator,
diversification was defined as the production of different food
groups in farming systems (including home gardens). These
findings show the link between agricultural diversification and
feeding practices, especially dietary diversity. Strengthening
the link between agriculture and dietary diversity can be
proposed as one of the solutions to improve infant and young
child nutrition. A study conducted in Benin by Segnon and
Achigan-Dako (2014) showed that achieving food security
can be fostered through production and consumption policies
that include the valorization of wild edible plants.
The interaction term ‘share of income allocated to feeding x
‘households’ residence’ was strongly associated with MDD.
This means that, in this study, the trend of MDD varied from
one commune to another and according to the share of income
allocated to feeding. The higher the share of income spent on
food, the less probable MDD will be met in Houeyogbe. In
contrast, whatever the share of income allocated to food, the
probability of meeting MDD remains more or less the same in
Bopa. This can be explained by the fact that Bopa is a purely
rural area with high local biodiversity and consumption of own
produced foods while the villages in Houeyogbe are closer to
the main road and more dependent on food purchases.
Furthermore, in the same poverty conditions, the BSaxwe^ living
in Bopa have fewer difficulties accessing local dietary resources
compared to those living in Houeyogbe. The cost of food access
is higher in Houeyogbe than Bopa.
Achigan-Dako et al. (2011)
found that the use of a species as a vegetable depended on socio–
cultural attributes in addition to geographical occurrence.
Bopa provided a better diversity of food groups produced
on-farm than Houeyogbe (Table 1). It is generally known that
the higher share of income a household spends on food, the
more likely the household is poor
. So, poor
households bought probably only cereals/tubers and better-off
households meat, fruits and vegetables. This result could
Factors associated with minimum dietary diversity of 6–23 months children in Southwest of Benin, based on multilevel logistic regression,
DFGP: Diversity of food group produced
Ref: Reference category
P-values are those with likelihood-ratio test
No p-value was computed for terms that are part of higher-order interaction
explain how the purchasing power or market integration could
affect the dietary diversity in Houeyogbe but less so in Bopa.
Hence, the probability of meeting MDD in Houeyogbe decreased
among children from households with moderate or high shares
of income allocated to food. So, in the area under higher urban
influence, increasing share of income allocated to feeding
constitutes a risk factor negatively influencing dietary
diversity. This finding corroborates a recent study where urban
location was significantly associated with inadequate dietary
diversity among mothers in Benin
(Issaka et al., 2015b)
in rural areas households can compensate for potential dietary
deficiency by diversifying their own food production, diets of
people living in urban areas are likely to be more affected by
higher poverty rates.
Supplementation, fortification and dietary diversification
are the potential approaches that decision makers should
explore for improving nutrition, taking into account context,
urgency and resource availability. Besides vitamin A
supplementation integrated into the immunization campaigns by the
ministry of health and salt iodization under the responsibility
of the Ministry of Agriculture, the Benin Government stresses
the importance of food and nutrition security in the national
strategy of the agricultural sector
several initiatives, movements and commitments at global level,
such as the Sustainable Development Goals (SDG), the
Scaling Up Nutrition movement (SUN), the Global Alliance
for Improved Nutrition (GAIN), Renewed Efforts Against
Child Hunger and Nutrition (REACH), the new G8 Food
Security and Nutrition Alliance and Zero Hunger Challenge,
working on reduction of food insecurity and malnutrition,
including micronutrient deficiencies, so far progress is still
insufficient, especially in sub-Saharan Africa. Hence the need
to consider the socio-economic determinants that explain the
lack of progress in each country in order to better
contextualize the interventions. Direct addition of micronutrient
supplements like sprinkles, baobab and moringa powders
et al., 2013)
to home-prepared complementary foods is
gaining ground as a sustainable strategy for improving the
micronutrient quality of children’s diets
et al., 2007)
. Our study shows that nutrition-sensitive
agricultural diversification (including home gardens), appears
to be an endogenous solution. Simultaneously, strategies such
as Integrated Management of Childhood Illnesses (IMCI
management of immunization, deworming, management of
diarrheal and infectious diseases, vitamin A supplementation,
iron and folic acid), should be strengthened in the health
pyramid. Health and food and nutrition security interventions
should also be coupled with WASH (Water Sanitation and
Hygiene). Moreover, education and awareness raising of
appropriate feeding practices and behavior change
communication through counseling and culinary demonstration should be
implemented in order to improve child well-being.
Another important factor affecting the probability of
reaching MDD was the combined effect of the ethnicity of
household heads and the commune of residence. Among
BSaxwe^ households, children living in Bopa had higher
probability of meeting MDD than those living in Houeyogbe. In
contrast, among minority ethnic groups, children living in
Houeyogbe had higher probability of meeting MDD than
those living in Bopa. As the native ethnic group, BSaxwe^
are used to consuming a diversity of local food resources that
are more readily available in Bopa than in Houeyogbe, these
local food resources are part of their food habits.
Avohou et al.
found that ethnicity affected the composition of species
managed at the community level. Moreover, children from
minority ethnic groups had higher probability of meeting
MDD in Houeyogbe than in Bopa owing to the purchase of
foods close to their cultural food habits. This finding could
confirm that the interplay of socio-cultural attributes and
agroecological conditions could explain the diversity of food
plants selected and used by communities
Regarding the minimum meal frequency (MMF), gender
aspects and household size were identified as associated
factors to complementary feeding practices. Child feeding was
influenced by the primary caregivers’ occupation. Caregivers’
occupations could be one of the main factors affecting
complementary feeding practices, especially the frequency of
meals needed (MMF) to cover a child’s nutrient requirements.
This has also been observed by
Maisonneuve et al. (2014)
who pointed out the dynamic between women’s daily
activities and household food security with potential impact on
child feeding practices.
The interaction term household size x marital status of
mothers or primary caregivers had a strong association with
adequate MMF. We observed that children were more
vulnerable to suboptimal meal frequency when they lived in large
female-headed households. On the contrary, household size
did not significantly influence probability of meeting MMF
in male-headed households. This finding shows the important
role of fathers in food security at household level on the one
hand and the limited access of women to material and
immaterial resources such as land, innovations and knowledge, in
the Beninese socio-cultural context on the other hand. As
demonstrated in a recent study focused on household food
availability in Sub-Saharan Africa, crop production was the
major source of energy, contributing 60% of food availability
(Frelat et al., 2016)
. Consequently, it may be difficult for
women in rural areas to ensure food security as household
head where land is a limiting factor for them. Women’s
economic empowerment constitutes one of the Sustainable
Development Goals (SDGs), the implementation of which
would significantly contribute to reducing mothers’
vulnerability and thus contribute to better wellbeing of children.
4.1 Limitations of study
The study was carried out in Southern Benin during a period
of average food availability. Therefore, the results are not
automatically applicable to other seasons or other geographical/
agro-ecological areas in the country. We recommend a similar
study during the lean period in order to document the
determinants of child feeding practices across seasons and to better
orient decisions of policy makers related to appropriate
strategies for child well-being. Since, the study has been carried
out only in Southern Benin, the results should not be
generalized for the whole country.
The study revealed different factors associated with selected
WHO recommended complementary feeding practice
indicators. The factors included: child age, household production
diversity, share of the household income allocated to food,
commune of residence, ethnic group of household head,
caregivers’ occupation, marital status of caregivers and household
size. The results, furthermore, revealed interactions between
some of these factors showing the interdependence or
complementarity of factors in determining feeding practice
behaviors. Providing quantity and quality of diet to meet infants’
requirements implies enhancing households’ food security
related to diversification of the farming system. Socio-cultural
characteristics determining food habits influenced the choice
of local resources used for food within certain environments.
Furthermore, gender aspects and household size influence the
achievement of minimum meal frequency. Achieving
appropriate complementary feeding practices will require
multisectoral interventions encompassing agriculture,
nutrition and social affairs. Emphasis on appropriate nutrition
messaging linked to the promotion of food group diversification in
farming-systems including home gardens or
nutritionsensitive agriculture appear to be important in improving
quality of complementary feeding practices. Reducing women’s
workload through improved working conditions should
decrease the burden on their time availability and create more
time for child care. Targeting women, mainly single-women,
as vulnerable groups, through specific interventions focused
on improving access and control over resources could
improve complementary feeding practices.
Acknowledgements The authors sincerely thank the contribution of all
respondents in the study areas for the time spent attending to the surveys
and sharing their knowledge about complementary feeding practices.
They acknowledge the contribution of: the mayors of the two communes, chiefs of the study villages and Mr. Adolphe Metahou from ESAM, a local NGO, for mobilizing and facilitating field activities and thank the whole team of fieldworkers.
Funding The present study was carried out within the FoodAfrica project
“Enhancing food and nutrition security in Sub-Saharan Africa”. Work
package 4 of the FoodAfrica Project was implemented by Bioversity
International in Southern Benin from 2012 to 2018 and funded by the
Finnish Ministry of Foreign Affairs and the CGIAR research program,
Agriculture for Nutrition and Health (A4NH).
Compliance with ethical standards
Conflicts of interest The authors declare that they have no conflicts of interest. The article is original work and has not been submitted for publication elsewhere.
Ethical clearance was obtained from Benin National Ethics
Committee for Scientific Research. Political authorities of the two com
munes were informed and approved the study. Written informed consent
of the enrolled children’s parents was obtained after they received
complete information about the study in the local language. All children that
were severely malnourished (wasted) during the survey were referred to
the nearest malnutrition management center.
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Irene Medeme Mitchodigni is an
Agronomy engineer with a
diploma in Nutrition and Food Science
from the Faculty of Agronomy
Sciences of the University of
Abomey-Calavi in Benin. She
holds a master ’s de gre e in
Nutrition and Food Technology of
the Louvain Catholic University
and Gembloux University in
Belgium. Since 2012, she has been
working on her PhD, which
focuses on improving complementary
feeding practices for the
wellbeing of children. She has over 14
years of experience in global nutrition
and food security interventions and
has collaborated with many
international organizations, government agencies and research institutions. She
has participated in the elaboration of Policy papers such as The New
Alliance for Food Security and Nutrition Benin Cooperation Framework.
Waliou Amoussa Hounkpatin
has been an Agro-nutritionist
s i n c e 1 9 9 3 w i t h a P h D i n
Nutrition & Health. He obtained
h i s M S c i n P u b l i c H e a l t h
Nutrition at the prestigious
London School of Hygiene and
T r o p i c a l M e d i c i n e . H e i s
Lecturer and Researcher in the
Department of Nutrition and
Food Sciences (DNSA), Faculty
of Agricultural Sciences (FSA),
University of Abomey-Calavi
(UAC) Benin. There he is also in
charge of study and academic
affairs in DNSA. He has been involved in Regional and International
Training in Nutrition for many years and in 2012, became the
Executive Secretary of FINSA - International Training in Nutrition and
Food Science which today has 25 years of experience in regional and
international training in Nutrition and Food security. Dr. Amoussa has
been leading FINSA as Director since 2014. In addition, his main
research interests are Community nutrition, Nutrition and Food Security,
the double burden of nutrition and also the use of stable isotopes to
monitor nutritional outcomes and nutritional status of vulnerable groups.
His recent work has included a Food Based Approach to reduce vitamin
A deficiency, Evidence informed-decision making in nutrition and
several research projects with Bioversity International and International
Atomic Energy Agency (IAEA) such as BContributing to the evidence
base to improve stunting reduction programs^.
Gervais D. Ntandou-Bouzitou
holds a PhD in International
Nutrition from the University of
Montreal. He has 17 years’
experience in research, teaching and
management of Public Health,
Nutrition and Nutrition-Sensitive
Agriculture projects at National
and International levels. He is
currently working as Nutrition and
Food Security Policy Expert at
t h e F o o d a n d A g r i c u l t u r e
Organization of the United
Nations (FAO) supporting the
Government of Niger in
refinement, finalization and costing of the action plan of the National Policy
of Nutrition Security. Before joining FAO, he worked for six years at
Bioversity International, leading research for development projects on
the contribution of agricultural biodiversity to the improvement of
nutrition and health of women and children.
Hermane T. AVOHOU is an
Agronomy engineer and holds an
MSc in Biostatistics at the School
of Statistics, Biostatistics and
Natural Sciences of the Catholic
University of Louvain (LSBA /
UCL). He has developed skills in
statistical control of industrial
quality, in data management and
natural resource management. He
has written, several articles and
some books related to
management of wild edible plants in
agroecology and ethnobotany areas.
Dr. ir. Céline Termote is an
Associate Scientist at Bioversity
International based in Nairobi,
Kenya. Dr. Termote has an MSc
and PhD from Ghent University
in Belgium. Céline started her
career as development worker and
has over 10 years of experience
in multidisciplinary research in
Sub-Saharan Africa. She is
fascinated by the multiple links and
complexity surrounding people
and their food systems and fosters
participatory action research. Her
ethnobotany, agro-ecology, culture, food security, diverse value chains, diets and
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headed several institutions such as the Nutrition and Food Sciences Department of the Faculty of Agronomic Sciences of the University of Abomey-Calavi (FSA/UAC Benin, 13 years), the Nutrition and Food Science International training (12 years), the National Direction of Scientific and Technological Research of the Ministry in charge of scientific research (3 years) . He is the current Dean of the FSA/UAC and coordinates many Food and Nutrition research projects. He has published more than 180 scientific papers in international journals .