“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

“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 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article “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state, Nigeria Funmilayo Shittu, Carina King, Ayobami A Bakare, Damola Bakare, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7618939/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Feb, 2026 Read the published version in Scientific Reports → Version 1 posted 11 You are reading this latest preprint version Abstract Background: Exclusive breastfeeding (EBF) and appropriate complementary feeding (CF) are important for child survival and development. While global guidelines provide clear definitions for these practices, interpretations within communities can differ, influencing infant feeding behaviours. This study explored how EBF and CF are understood, and how these understandings shape infant feeding and nutrition within a community setting in Jigawa State, northern Nigeria. Methods: We conducted a qualitative study using life-history interviews and household observations within an ethnographic process evaluation in Kiyawa LGA, Jigawa State, Nigeria, between July 2020 and November 2022. The data formed part of the INSPIRING Jigawa cluster randomized controlled trial process evaluation. From 90 women recruited for the ethnography, we purposively selected 36 women aged 16–49 years who had breastfed in the preceding two years. Data included midline interviews and notes from monthly facility and household observations. Interviews were conducted in Hausa, transcribed, translated into English, and analysed using reflexive thematic analysis. Results: We found that while most mothers could state the correct definition of EBF as feeding only breastmilk for the first six months, their interpretation allowed for the early introduction of water, and other water solutions without perceiving this as a breach of EBF. Complementary feeding was similarly defined based on infant cues and cultural beliefs, with many mothers introducing family foods before six months in response to perceived signs of hunger or under the influence of older family members. These locally adapted definitions reflected deep-rooted cultural norms and caregiving traditions. Conclusion While communities in Jigawa are aware of global definitions, these are not commonly adopted or practiced. Interventions aiming to improve infant feeding practices must consider these culturally embedded beliefs and engage influential family and community members to align local practices with recommended guidelines. Social science/Anthropology Health sciences/Health care Infant exclusive breastfeeding complementary feeding Nigeria Background Optimal infant and young child feeding practices, particularly exclusive breastfeeding (EBF) and complementary feeding (CF), are widely recognised as critical for child survival, growth, and development ( 1 ). The World Health Organization (WHO) defines EBF as feeding an infant only breast milk for the first six months of life, without any additional food or drink, not even water, except for oral rehydration solution, or drops/syrups of vitamins, minerals, or medicines when medically indicated( 1 ). CF refers to the timely introduction of solid, semi-solid, or soft foods at six months of age, alongside continued breastfeeding, to meet the growing nutritional requirements of the child ( 2 ). Adequate CF is characterised by dietary diversity, meal frequency, and appropriate meal quantity, contributing to a child’s optimal growth and development( 3 ). Despite widespread promotion of these guidelines, there is a large gap between international recommendations and coverage( 1 ). Several studies have documented how sociocultural norms, household power relations, and local beliefs influence how these practices are understood and implemented ( 4 – 6 ). In northern Nigeria, EBF is often misunderstood. Although mothers report practicing EBF, qualitative studies have reported provision of water, herbal concoctions, or gripe water being given to infants, especially during hot weather, periods of perceived illness, or infant discomfort ( 6 , 7 ). These practices were explained by the belief that breast milk alone is insufficient to quench a child’s thirst or provide protection against illness in challenging environmental conditions ( 6 ). Other studies from northern Nigeria indicate that caregivers perceive breast milk to be ‘hot’ or ‘light’ and incapable of fully satisfying a child, particularly during the hot dry season ( 4 , 8 ). This perception often leads to the early introduction of water or traditional herbal preparations within the first months of life. Additionally, the advice of elder female relatives, particularly grandmothers, significantly influences maternal decisions about infant feeding. Grandmothers are often the custodians of traditional knowledge and cultural practices, and their support or disapproval can determine whether EBF is practiced as recommended in this setting ( 9 – 11 ). Similar divergences between global recommendations and local understandings are evident in the case of complementary feeding practices in Northern Nigeria. While biomedical guidelines emphasise the importance of diverse, nutrient-rich complementary foods, local definitions of ‘adequate’ complementary feeding prioritise food quantity and satiety over dietary diversity or nutritional content ( 12 ). Studies have shown that CF typically involves the early introduction of staples (e.g. pap), but little addition of protein-rich or micronutrient-dense foods due to limited availability, poverty, and cultural beliefs about appropriate infant foods ( 13 , 14 ). Decisions regarding what and when to feed a child are also influenced by household hierarchies, with male heads of households controlling food purchases and elder women determining feeding norms ( 15 , 16 ). Although several studies have explored infant feeding practices in northern Nigeria, most have focused on the prevalence and determinants of EBF and CF, without explicitly examining how these concepts are defined and understood within communities ( 4 , 7 , 17 ). A 2016 systematic review on mother’s understanding of EBF identified 4 qualitative studies exploring this topic, which highlighted inaccurate understandings of EBF, including commonly believing that giving water or traditional remedies was still acceptable. Cultural norms, family influence, and unclear health messaging shaped these misconceptions, highlighting the need for clearer, context-specific communication on EBF, however no studies were found from Nigeria ( 18 ). Given the high burden of malnutrition and child mortality in Northern Nigeria, understanding local definitions of EBF and CF are essential for identifying culturally embedded barriers to optimal infant feeding practices and designing interventions that are both acceptable and effective within these communities. We therefore aimed to explore community definitions of EBF and CF in Jigawa State, Northern Nigeria, and how these influence feeding practices and nutrition. Methods Study design We conducted a qualitative study using life-history interviews with women of childbearing age (16–49 years old) and both facility and household observations conducted as part of an ethnographic process evaluation conducted between July 2020 and November 2022. The study was set in Kiyawa Local Government Area (LGA), Jigawa State, Nigeria, and was part of the INSPIRING Jigawa cluster randomized controlled trial process evaluation (ISRCTN3921355, registered: 11th December 2019).( 19 , 20 ) In our previous study exploring household power in EBF practices, the importance of water in feeding practices emerged as a sub-theme under the beliefs and cultural norms within households that impact EBF( 6 ). Given the limited literature in this area, and the unexpectedly high self-reporting of EBF( 19 ), we decided to re-analyse these data to explore in more depth how water is understood as part of the local definition of EBF, as well as exploring definitions of adequate CF. Setting This study was conducted in Kiyawa LGA of Jigawa State, with an estimated state-wide population of over 6 million people, predominantly of Hausa-Fulani ethnicity, with Islam as the dominant religion (National Population Commission ( 21 ). The State is largely rural, with most residents engaged in subsistence farming, animal rearing, and petty trading. Jigawa consistently records some of the poorest maternal and child health indicators in Nigeria, including high neonatal, infant, and under-five mortality rates ( 21 , 22 ). The State has also reported high prevalence of diarrheal diseases among children under five, ( 21 ) which causes 24–30% of post-neonatal under-five deaths in Northern Nigeria ( 23 ). This high burden is attributed to poor sanitation, unsafe water sources, and suboptimal infant feeding practices. Participant selection Full methods for sampling and data collection have been published previously ( 24 ). Our participants of interest were women aged 16–49 years who had reported breastfeeding in the previous two years. The ethnographic process evaluation was organised around six purposively selected health facility clusters from the main INSPIRING Jigawa trial, three from the intervention group and three from the control group, balanced for facility type (i.e., primary health centre, basic health centre, or health post). We then randomly selected five compounds in each cluster and recruited women aged 16–49 years with children younger than 5 years from these compounds using availability sampling, stratifying for age and wife position. Overall, 90 women were recruited for the ethnography. In this study data from36 of these women who reported breastfeeding in the last 2 years (18 from each trial arm) are analysed. Data Collection In-depth life history interviews were conducted at three time points as part of the ethnography, alongside monthly informal household visits, and monthly observations at the six corresponding health facilities. For this paper, we used data from the midline interview conducted in July 2021, in addition to notes taken from monthly household and facility visits. An in-depth interview guide was used, including questions focusing on feeding practices, and pattern of EBF within the wider household ( Appendix 1 ). The guide was prepared by FS and discussed with RAB, CK and AGF. Interviews were conducted by three research assistants, who were trained on how to use the guide, including rephrasing questions in Haua during discussions among the data collection team, led by FS. Interviews were conducted within each participant’s household in line with their preferences, to ensure no interference and smooth rapport with research assistants. Interviews were conducted in Hausa and each lasted for approximately 1 hour. Interviews were recorded, transcribed verbatim and then translated into English by the research assistants and checked by FS. At the end of the interview, an incentive was given to participants as means of appreciating them for their time. Analysis Data was analysed by FS using reflexive thematic analysis ( 25 ). Interview transcripts were read several times as a means of data familiarization and notes of initial trends in the data were taken; thoughts and feelings regarding the data and analytical process were documented. Following this, codes were generated to produce interpretive labels for pieces of information that were of importance to the research aim, which was later developed into themes by collapsing multiple codes that share similar concepts. Once the coding framework was developed, a reading of field notes from facility and household visits was completed by FS, to triangulate these themes. The development of the initial coding framework was supported by RAB and AGF, and the organisation of themes and sub-themes were discussed with CK before finalisation, and all authors provided feedback on the interpretation. Ethics Ethical approval was obtained from Jigawa State Government (ref: JPHCDA/ADM/GEN/073/V. I) and the University College London Research Ethics Committee (ref: 3433/004). Approval was obtained from the Local Government, District, Ward and Village heads of every single community before data collection commenced in any of the communities. All methods were performed in accordance with the relevant guidelines and regulations, including the principles of the Declaration of Helsinki. Verbal consent was sought from all participants, including informing them that participation in interviews was voluntary, data collected would be used for research purposes only and that they have the right to withdraw at any time. Results The 36 women included in the life-history interviews were in the age range of 1649 years and had between 2–9 children. Overall, we found women held positive attitudes towards breastfeeding, with some mothers reporting breastfeeding their children beyond two years, and the initiation of complementary feeding occurring at varying ages. Breastfeeding was widely regarded as an essential cultural norm, with other feeding practices perceived as supplementary rather than as alternatives. Notably, practices such as breastfeeding alongside water was commonly considered acceptable and not viewed as a violation of EBF, reflecting local interpretations of the practice. While some mothers adhered to the recommended six months of EBF, others introduced water as early as newborn period along with breastfeeding. Similarly, the timing of complementary food introduction lacked consistency, with mothers initiating CF between three and seven months, shaped by perceptions of infant readiness, and prevailing community norms. The thematic analysis generated four themes: cognitive polyphasia in the definition of EBF, water as an essential component of EBF – it is harmless and necessary, realities of food insecurity and gendered norms determine complementary feeding, rather than contextualised definitions, and culturally Shaped Understandings and Structural Barriers in the Infant Feeding–Malnutrition Pathway Cognitive polyphasia in the definition of EBF This theme captures the tension between mothers’ conceptual understanding of EBF and the contradictions evident in their infant feeding practices. Although most mothers could accurately articulate the global recommendation that EBF involves feeding an infant solely with breast milk from birth up to six months of age, without the addition of water, other liquids, or foods, their practical interpretations often diverged from this standard. Many mothers demonstrated a form of cognitive polyphasia in their understanding of EBF - holding both biomedical and traditional beliefs simultaneously ( 26 ). While they consistently avoided giving their infants other foods or formulas in line with EBF recommendations, they did not perceive giving water as a breach of EBF, reflecting a complex co-existence of scientific advice and culturally rooted practices. One participant stated: “I never gave my babies milk or any baby formula apart from breast milk and water until they reach the stage of eating semi-solid and solid food like pap, rice, beans or tuwo” (P11, Intervention) Another mother stated: “I only give them breast milk and water and when a child is about to start eating, he/she will display some signs” (P10, Intervention) These responses illustrate a partial and selective adherence to the principles of EBF, where mothers internalized parts of the guideline (excluding formula and foods) while disregarding others (excluding water). This was compounded by a lack of health literacy on why water should be avoided. One participant noted: “I just felt there was not going to be issues even if I give him water.” (P10, Control) Facility observations reinforced this finding. In one instance: “I engaged one of the women who came for routine immunization in discussion around exclusive breastfeeding. She told me she does practice but in addition with water. She claimed babies get thirsty. I am not surprised to hear that, because they also tell us this in the communities. The In-charge stressed further on that as he said they can’t practice EBF without water and that is why diarrhoea among children is high, which eventually leads to malnutrition.” (Facility observation, facility 6) This account highlights how community members perceive water as an essential component of infant care, despite health education efforts promoting strict adherence to EBF. It also illustrates how health workers recognize the challenge of achieving EBF without water within this context, and link the prevailing practice to persistent child health problems like diarrhoea and malnutrition. In some cases, mothers’ decisions to stop giving water were not driven by an understanding of medical recommendations but by personal or communal experiences of adverse events, such as a child choking. A participant recounted: “I once saw a woman who gave water to her baby and the baby got choked and almost fainted, and when the baby was taken to the hospital, the health workers advised that we should not give our babies water until after six months. For me, it was because of fear of what I saw happen to that baby that I stopped giving my children water until they reached six months.” (P 17, Intervention) These narratives and observations suggest that community’s practice of EBF is shaped by a combination of formal knowledge, personal interpretations, community norms, facility-level attitudes, and emotional responses to observed events — a dynamic that fosters cognitive polyphasia between what mothers know, believe, and practice. Water as an essential component of EBF – it is harmless and necessary As introduced in the first theme, water was considered by women as being exempt from EBF, and this was justified through water being seen not only as harmless to infants, but also necessary for the health and wellbeing of their children. This conceptualisation allowed women a degree of flexibility in their feeding practices, which reflects their lived realities of competing priorities and multi-generational childcare. Some mothers reported modifying their infant feeding practices at night to suit personal convenience. One participant shared that she intentionally avoided breastfeeding at night because she believes that nighttime feeds encourage babies to develop habits that disturb their mothers' sleep. This narrative highlights how personal and practical considerations, such as the desire for uninterrupted sleep, can lead to the early introduction of water. Mothers in this situation do not perceive water as a substitute for breastmilk but rather as a harmless way to calm a baby at night: “I don't breastfeed at night because when a child gets used to breastfeeding at night, they become troublesome and wouldn't allow me to sleep well. So, all my children are used to breastfeeding only from early morning to night time. I don't wake up at midnight to breastfeed. If the baby cries, they may have water alone during that time.” (P17, Control) In other cases, past community experiences shaped this understanding that water is something desirable for infants. One respondent recalled: “So many years ago in this our compound, there was a child they started giving water, then after some days when they took him to collect his first vaccine at the hospital the mother was advised not to give the child water. That child cried throughout the whole day, even at night the child kept crying and when the mother decided to give the child water, he stopped crying and fell asleep. Since then, I never pick interest in practicing [exclusive breastfeeding].” (P13, Intervention) These accounts reveal how personal experiences, fear of infant discomfort, social narratives, and a lack of awareness about the risks of early water introduction contribute to the continued use of water during the EBF period. Food insecurity and gender norms: setting the parameters for complementary feeding Unlike EBF, there was limited understanding of adequate CF practices among mothers. Therefore, they exhibited considerable variation in both the timing of food introduction and the types of foods offered to infants and young children. While the WHO recommends introducing a range of complementary foods at six months of age alongside continued breastfeeding, we found flexible and inconsistent patterns, that were shaped by personal preferences, cultural norms, food insecurity, and limited nutrition awareness. For example, mothers reported initiating CF from as early as three to five months to as late as seven months. Some mothers introduced light foods such as pap (a smooth and light-textured porridge made from grains such as maize, millet or sorghum) after five months, others extended breastfeeding with water up to seven months before introducing any complementary food, while a few women stated they adhered to the six-month EBF period. “I make pap for them to drink after about 5 months of birth then gradually, I teach them how to eat other foods like rice, beans, cassava and Tuwo.” (P4, Intervention) “I breastfeed my children with breast milk and water for 7 months before I introduce light food like pap, and when they become older, I introduced other food to them.” (P3, Control) “After 6 months I will start giving the child water, also I will start introducing pap to the child then later on solid food.” (P16, Control) The complementary foods introduced were predominantly locally available, cereal-based dishes with low dietary diversity. The most frequently mentioned first food was pap, followed by Tuwo (solid food made from maize, millet, sorghum) as the child grew older. This mix of early, timely, and delayed initiation of CF, and lack of diversity, reflected factors such as maternal perceptions of child readiness, household food security, and socio-cultural expectations. Severe food insecurity was a key driver of limited dietary options, and many mothers described their reliance on staple foods, often prepared without oil, fish, or meat: “Here in our community, our only food is Tuwo and Kuka [green soup]. Sometimes we can’t even afford oil in the soup, not to talk of fish or meat. Such situation brings about malnutrition in children” (P4, Intervention) . In addition to the testimonies from mothers, facility heads and nurses reported a concerning household dynamic in which husbands/men would go outside of the home to eat nutrient rich foods, while women and children who remain inside the home only had access to staples. This practice not only highlights gendered disparities in food access within households but the poor financial power of women, limiting their ability to procure diverse and nutrient-dense foods for themselves and their children, thereby exacerbating the challenges of achieving adequate CF. “They (facility head and nurses) claimed husbands/men in the community leave wives at home with one particular source of food (Tuwo) which is majorly carbohydrates while they go to tea joints to eat bread and egg or noodles and egg with tea, at times, they eat suya (roasted meat) too” (observational notes, Facility 1). Beyond economic hardship and unequal food distribution, participants also noted that children were frequently fed adult meals, without consideration for their specific nutritional needs: “Here, what I see them do is they give the children the same food we eat as adults but I don't know if there is any other thing, they give them, and I also don't think of any food that a child should be given” (P7, C) . These accounts underscore the combined impact of poverty, intra-household food allocation dynamics, food insecurity, and limited knowledge about appropriate child feeding on how CF is practiced. There was limited awareness of adequate dietary diversity for child growth, and rather than a mis-aligned definition driving poor infant feeding practices, CF was reactive and reflective of circumstance. Structural barriers and misconceptions in the infant feeding–malnutrition pathway Mothers’ accounts revealed a complex relationship between infant feeding practices, episodes of diarrhoea and malnutrition, but also hint at the underlying role of maternal nutrition. Many mothers described how inadequate breastfeeding, early or inappropriate CF, and recurrent childhood illnesses contributed to weight loss and poor growth in children. Diarrhoea was frequently mentioned as both a cause and a consequence of malnutrition. This is evident in the responses below: “The child that was malnourished in this household started with diarrhoea but they didn’t take her to hospital on time which led to malnutrition” (P3, C) . “My son’s own started from teething fever then it led to diarrhoea and I noticed he started losing weight” (P16, C) . While mothers linked these feeding practices to poor health outcomes, they often lacked clear understanding of the underlying biomedical mechanisms by which poor feeding practices and unclean water increase the risk of diarrhoea and malnutrition. Their explanations were frequently shaped by cultural beliefs about hygiene, maternal status during breastfeeding, and childhood illnesses. For instance, some understood that when a breastfeeding mother becomes pregnant, it causes poor nutritional outcomes in the breastfeeding child: “The cause of malnutrition like I told you is dirt and when a woman is pregnant and she is still breastfeeding that makes the child to be malnourished” (P6, Intervention). “The child was very small though it started with when the child was teething and he kept defecating which led to the child losing a lot of weight. Then I got pregnant while I was still breastfeeding the child and I didn’t wean the child, so he lost a lot of weight that led to him looking very slim; the hands and legs were thin, that’s all that happened” (P9, Control). Others emphasized the role of hygiene and timely healthcare seeking: “It is caused by dirtiness; you don’t wash your hands before you feed a child and you don’t take care of the kind of food you feed your children with, or a child is having diarrhoea and you won’t take the child to the hospital on time” (P17, Intervention) . Facility observations echoed these maternal beliefs. Informal discussions with health workers noted that community members often did not believe malnutrition was primarily caused by poor diets. Instead, they attributed it largely to diseases resulting from poor hygiene and environmental dirt. Facility observations also illustrated the scale of the malnutrition problem. In one facility observation, it was noted how shocking it was to observe the sheer number of malnourished children being brought in for care: “They came in masses. These (plumpy nuts) was given to more than 100 children” (observational notes, Facility 6). A facility staff, who was particularly open to engagement, discussed the high prevalence of malnutrition in the community and suggested health education interventions. However, he emphasized that such efforts would only achieve sustained impact if accompanied by| improvements in literacy, as low educational attainment significantly constrained health-seeking behaviors and feeding practices: Another factor mentioned by facility doctor was community members literacy level which has great role in correcting both malnutrition and anaemia, he then caped it all with economic state of the country and increase in the price of food commodities (observational notes, Facility 1). Discussion Our findings demonstrate a clear gap between mothers’ knowledge of EBF and their actual interpretation and practice within the community. Although most mothers could correctly define EBF as feeding an infant only breast milk for six months, it was common practice to introduce water as early as the newborn period, in addition to breastfeeding, driven by beliefs of water being both harmless and necessary. Conversely, adequate CF was not well understood, and practices were responsive to the context of food insecurity and challenges in access to nutrient-rich food given the pervasive poverty and catastrophic flooding events in this setting, rather than medical and scientific knowledge. Elsewhere, we have previously identified cultural and religious beliefs as primary reasons for early water introduction, such as the use of holy water for blessings or the perception that denying water is cruel ( 6 ). In this deeper exploration, we noted while there are symbolic reasons for giving water, that this is supported by the belief that water is not harmful and that infants are seen to need water – both to quench thirst but also comfort the infant. These factors can interact to allow the practice to persist, despite the knowledge that water should not be given. Similar practices have been observed in other settings across Nigeria and Sub-Saharan Africa. Burba et al. (2025)( 27 ) reported that although a majority of mothers in northwestern Nigeria demonstrated good knowledge of EBF, actual practice was limited due to traditional beliefs about the necessity of water and herbal medicines for infants. Likewise, a study by Onah et al. (2014)( 4 ) from Nigeria found that awareness of EBF was high, but the prevalence of early supplementation with water and other fluids remained common. Abdullahi et al. (2017)( 28 ) also documented this knowledge-practice gap in Nigeria, attributing it to the persistence of cultural norms and family influences that override biomedical recommendations. However, our findings suggest that even mothers who are informed about EBF, perceive water as a negligible addition that doesn't mean they are not practicing EBF. This gap in understanding the health implications of introducing water to infants, particularly in regions with unsafe water sources, can lead to increased risks of waterborne diseases like cholera. Nigeria, including Jigawa State, has experienced several significant cholera outbreaks in recent years, namely in 2018, 2021 and most recently in 2024 with over 70 reported cases and associated deaths, predominantly affecting women and children ( 29 – 31 ). Northern Nigeria also reports one of the highest under-five mortality rates globally, with diarrhoeal deaths making up approximately 1 in 4 of these deaths ( 23 ). The persistent practice of giving water to infants undoubtedly contributes to this mortality burden, however the link between contaminated or unsafe drinking water and diarrhoeal diseases did not emerge from interviews or household observations. This has highlighted a critical gap in awareness in this community for why EBF is recommended. Similar misconceptions have been documented in other regions. For instance, in The Gambia, mothers believed that giving water or thin porridge was part of EBF, not recognizing that these additions could pose health risks( 32 ). In Ghana, health workers reported that some mothers perceived breastmilk as insufficient to quench infants' thirst, leading to early water supplementation( 33 ). In the Democratic Republic of Congo, some mothers and grandmothers believed that water should be introduced to infants before six months, despite healthcare providers' advice to the contrary( 34 ). These findings underscore the importance of not only promoting EBF but also ensuring that health education programs effectively communicate the reasons behind the WHO's recommendations. Addressing misconceptions and providing clear explanations about the sufficiency of breast milk, alongside emphasizing the importance clean water and sanitation and adequate maternal nutrition, are crucial steps toward improving adherence to EBF and safeguarding infant health. Patterns of CF reflected a reliance on locally available, low-diversity foods such as pap and Tuwo, introduced at varying ages. Inadequate dietary diversity and inappropriate CF practices – with both early and late introduction of foods posing issues, have been consistently associated with child undernutrition in Nigeria and other low-resource settings ( 35 ). The socioeconomic realities of many households, including food insecurity and limited access to nutrient-rich foods, further constrained mothers' ability to provide optimal CF, as also documented in a qualitative study in rural northern Nigeria( 36 ). An important contribution of this study lies in the exploration of how mothers link infant feeding practices to health outcomes, particularly diarrhoea and malnutrition. While many mothers demonstrated awareness of a connection between inadequate feeding and poor child health, their explanations were often mediated by cultural beliefs, such as attributing diarrhoea to teething, or considering malnutrition a consequence of environmental dirt or maternal pregnancy during breastfeeding. The pathway to malnutrition is complex, and hygiene practices, birth spacing and maternal nutrition, and infections are all critical factors alongside feeding practices. However, the ethnographic observations emphasized the lack of awareness of the importance of appropriate feeding practices within this community as being the main gap in understanding. These perceptions echo earlier studies from northern Nigeria and other parts of Africa, where cultural beliefs significantly shape health-seeking behaviours and child care practices( 37 , 38 ). Our findings highlight the dual burden of risk factors and cultural explanatory models in contributing to child malnutrition, where mothers contain multiple, seemingly contradictory knowledge systems together through their everyday practices. Suboptimal adherence to recommended breastfeeding and CF practices, alongside recurrent diarrheal episodes and delays in seeking care, contribute to a cycle of undernutrition, as outlined in global child survival frameworks( 39 ). Additionally, culturally embedded beliefs and practices, which hold significant meaning and value within the community, may influence feeding and healthcare behaviours in ways that can sometimes limit the adoption of evidence-based recommendations. Conclusion This study identified the need for integrated, culturally sensitive health promotion interventions that address both the practical barriers to optimal feeding — such as food insecurity, at the same time as engaging with underlying beliefs about child health and nutrition. Community-based education programmes, delivered through trusted community structures such as women's groups and religious leaders, could help to correct misconceptions about EBF, water introduction, and the causes of diarrhoea and malnutrition, while promoting affordable and context-appropriate CF practices. Declarations Human Ethics and Consent to Participate Ethical approvals were obtained from Jigawa State Government (ref: JPHCDA/ADM/GEN/073/V.I) and University College London Research Ethics Committee (ref: 3433/004), and from Swedish Ethics Authority for the analysis of personal data within Sweden (ref: 2024-00868-01). We consulted with representatives from Local Government, District, Ward, And Village Heads before commencing project activities. Verbal informed consent was obtained from all research participants in accordance with local guidelines and as approved by the ethics committee. Consent for Publications Not applicable Competing interests No potential conflict of interest was reported by the authors. Funding This work was funded through the GlaxoSmithKline (GSK)-Save the Children Partnership (grant reference: 82603743). Employees of both GSK and Save the Children contributed to the design and oversight of the wider INSPIRING Jigawa trial as part of a co-design process. Authors’ contributions The conceptualisation of this manuscript was done by FS, CK, SR, RAB and AGF. Funding acquisition for the wider study was done by CK, TC and AGF. Data collection was designed and supervised by FS, TC, CK, RAB, AGF, AAB, AI, JS and DB. Analysis was conducted by FS, with support from AGF, RAB and CK. FS drafted the manuscript. All authors read and approved the final version of the manuscript. Acknowledgements We sincerely thank the mothers of under-5 children who participated in this study for their time, trust, and valuable contributions. We also appreciate the efforts of the data collectors and field supervisors for their dedication throughout the data collection process. Special thanks go to the facility staff, who not only supported our visits but also shared valuable insights during informal discussions, enriching the depth of this study. References WHO. Infant and young child feeding [Internet]. 2023 [cited 2025 Apr 11]. 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Sunusi SM, Ayaba AK, Ibrahim UM, Mahmud M, Abulfathi AA, Tsiga-Ahmed FI, et al. Determinants of Infant Feeding Practices among Working and Non-working Mothers in Kano, Nigeria. Nigerian Journal of Nutritional Sciences. 2020;41(1):76–87. Supriatin S, Astriani N, Heri M, Sadli M. Partner and Household Factors Associated with Breastfeeding Practice: A Systematic Review. JURNAL INFO KESEHATAN. 2024 Jun 30;22:429–40. Aubel J. The role and influence of grandmothers on child nutrition: culturally designated advisors and caregivers. Matern Child Nutr. 2011 Sep 28;8(1):19–35. Faye CM, Fonn S, Kimani-Murage E. Family influences on child nutritional outcomes in Nairobi’s informal settlements. Child: Care, Health and Development. 2019 Jul 1;45(4):509–17. Lawan UM, Amole GT, Jahum MG, Sani A. Age-appropriate feeding practices and nutritional status of infants attending child welfare clinic at a Teaching Hospital in Nigeria. J Family Community Med. 2014;21(1):6–12. Anigo K, Ameh A, Ibrahim S, Solomon S. Infant Feeding Practices and Nutritional Status of Children in North Western Nigeria. Asian Journal of Clinical Nutrition. 2009 Jan 1;1. Abdullahi H, Olamuyiwa AO, Ndidi US, Hassan SM, Jajere UM. INFANT AND YOUNG-CHILD FEEDING PRACTICES FOR UNDER-TWO CHILDREN INVOLVED IN COMMUNITY INFANT AND YOUNG CHILD FEEDING PROGRAMME IN ZARIA, NIGERIA. FUDMA JOURNAL OF SCIENCES. 2022 Apr 1;6(1):33–43. Joseph FI, Earland J. A qualitative exploration of the sociocultural determinants of exclusive breastfeeding practices among rural mothers, North West Nigeria. International breastfeeding journal. 2019 Aug 20;14(1):38. Enwere ME. Feeding Practices and Nutritional Status of Infants in Northwest Nigeria. 2019; Hossain S, Mihrshahi S. Exclusive Breastfeeding and Childhood Morbidity: A Narrative Review. International Journal of Environmental Research and Public Health. 2022 Nov 10;19(22):14804. Still R, Marais D, Hollis JL. Mothers’ understanding of the term ‘exclusive breastfeeding’: a systematic review. Maternal & Child Nutrition. 2017;13(3):e12336. Effect of a participatory whole-systems approach on mortality in children younger than 5 years in Jigawa state, Nigeria (INSPIRING trial): a community-based, parallel-arm, pragmatic, cluster randomised controlled trial and concurrent mixed-methods process evaluation - The Lancet Global Health [Internet]. [cited 2025 May 13]. Available from: https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(24)00369-3/fulltext King C, Burgess RA, Bakare AA, Shittu F, Salako J, Bakare D, et al. Integrated Sustainable childhood Pneumonia and Infectious disease Reduction in Nigeria (INSPIRING) through whole system strengthening in Jigawa, Nigeria: study protocol for a cluster randomised controlled trial. Trials. 2022 Dec;23(1):95. National Population Commission (NPC) [Nigeria] and ICF, author. National Population Commission (NPC) [Nigeria] and ICF, author. Nigeria Demographic and Health Survey 2018 Key Indicators Report. Abuja, Nigeria, and Rockville, Maryland, USA: NPC and ICF; 2019. [Google Scholar]. 2019; National Bereau of Statistics. Reports | National Bureau of Statistics [Internet]. 2021 [cited 2025 May 7]. Available from: https://www.nigerianstat.gov.ng/elibrary/read/1241209 Odejimi A, Quinley J, Eluwa GI, Kunnuji M, Wammanda RD, Weiss W, et al. Causes of deaths in neonates and children aged 1–59 months in Nigeria: verbal autopsy findings of 2019 Verbal and Social Autopsy study. BMC Public Health. 2022 Dec;22(1):1–15. King C, Burgess RA, Bakare AA, Shittu F, Salako J, Bakare D, et al. Integrated Sustainable childhood Pneumonia and Infectious disease Reduction in Nigeria (INSPIRING) through whole system strengthening in Jigawa, Nigeria: study protocol for a cluster randomised controlled trial. Trials. 2022 Jan 31;23(1):95. Braun V, Clarke V. Conceptual and design thinking for thematic analysis. Qualitative Psychology. 2022;9(1):3–26. de-Graft Aikins A. Healer shopping in Africa: new evidence from rural-urban qualitative study of Ghanaian diabetes experiences. BMJ. 2005 Oct 1;331(7519):737. Burba, Chia A, Musa D, Adi R. EXCLUSIVE BREASTFEEDING: KNOWLEDGE, ATTITUDE AND PRACTICES OF BREASTFEEDING AMONG NURSING MOTHERS ATTENDING SAMARU PRIMARY HEALTH CARE, NORTHWEST NIGERIA. 2022 Jun 1; Abdullahi KO, Ghiyasvandian S, Hasanpour M. Theory-Practice Gap: The Knowledge and Perception of Nigerian Nurses. Iranian Journal of Nursing and Midwifery Research. 2022 Jan 25;27(1):30. NCDC Cholera Situation Report Monthly Epidemiological Report 22 Epi week 39: (23 September 2024 – 29 September 2024) - Nigeria | ReliefWeb [Internet]. 2024 [cited 2025 May 4]. Available from: https://reliefweb.int/report/nigeria/ncdc-cholera-situation-report-monthly-epidemiological-report-22-epi-week-39-23-september-2024-29-september-2024 Onwunta IE, Ozota GO, Eze CA, Obilom IF, Okoli OC, Azih CN, et al. Recurrent cholera outbreaks in Nigeria: A review of the underlying factors and redress. Decoding Infection and Transmission. 2025 Jan 1;3:100042. Elimian KO, Musah A, Mezue S, Oyebanji O, Yennan S, Jinadu A, et al. Descriptive epidemiology of cholera outbreak in Nigeria, January–November, 2018: implications for the global roadmap strategy. BMC Public Health. 2019 Sep 13;19(1):1264. Sosseh SAL, Barrow A, Lu ZJ. Cultural beliefs, attitudes and perceptions of lactating mothers on exclusive breastfeeding in The Gambia: an ethnographic study. BMC Women’s Health. 2023 Jan 13;23(1):18. Ayawine A, Ae-Ngibise KA. Determinants of exclusive breastfeeding: a study of two sub-districts in the Atwima Nwabiagya District of Ghana. Pan Afr Med J. 2015 Nov 17;22:248. Kavle JA, LaCroix E, Dau H, Engmann C. Addressing barriers to exclusive breast-feeding in low- and middle-income countries: a systematic review and programmatic implications. Public Health Nutr. 2017 Dec;20(17):3120–34. Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, De Onis M, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. The Lancet. 2013 Aug;382(9890):427–51. Akpoghelie EO, Chiadika EO, Edo GI, Al-Baitai AY, Zainulabdeen K, Keremah SC, et al. Malnutrition and food insecurity in northern Nigeria: an insight into the United Nations World Food Program (WFP) in Nigeria. Discov Food. 2024 Nov 26;4(1):165. Yaya S, Odusina EK, Adjei NK. Health care seeking behaviour for children with acute childhood illnesses and its relating factors in sub-Saharan Africa: evidence from 24 countries. Tropical Medicine and Health. 2021 Dec 14;49(1):95. Bakare AA, King C, Salako J, Bakare D, Uchendu OC, Burgess RA, et al. Pneumonia knowledge and care seeking behavior for children under-five years in Jigawa, Northwest Nigeria: a cross-sectional study. Front Public Health. 2023 Jul 18;11:1198225. Victora CG, Christian P, Vidaletti LP, Gatica-Domínguez G, Menon P, Black RE. Revisiting maternal and child undernutrition in low-income and middle-income countries: variable progress towards an unfinished agenda. The Lancet. 2021 Apr 10;397(10282):1388–99. Additional Declarations No competing interests reported. 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The World Health Organization (WHO) defines EBF as feeding an infant only breast milk for the first six months of life, without any additional food or drink, not even water, except for oral rehydration solution, or drops/syrups of vitamins, minerals, or medicines when medically indicated(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). CF refers to the timely introduction of solid, semi-solid, or soft foods at six months of age, alongside continued breastfeeding, to meet the growing nutritional requirements of the child (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Adequate CF is characterised by dietary diversity, meal frequency, and appropriate meal quantity, contributing to a child\u0026rsquo;s optimal growth and development(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Despite widespread promotion of these guidelines, there is a large gap between international recommendations and coverage(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSeveral studies have documented how sociocultural norms, household power relations, and local beliefs influence how these practices are understood and implemented (\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In northern Nigeria, EBF is often misunderstood. Although mothers report practicing EBF, qualitative studies have reported provision of water, herbal concoctions, or gripe water being given to infants, especially during hot weather, periods of perceived illness, or infant discomfort (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). These practices were explained by the belief that breast milk alone is insufficient to quench a child\u0026rsquo;s thirst or provide protection against illness in challenging environmental conditions (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Other studies from northern Nigeria indicate that caregivers perceive breast milk to be \u0026lsquo;hot\u0026rsquo; or \u0026lsquo;light\u0026rsquo; and incapable of fully satisfying a child, particularly during the hot dry season (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). This perception often leads to the early introduction of water or traditional herbal preparations within the first months of life. Additionally, the advice of elder female relatives, particularly grandmothers, significantly influences maternal decisions about infant feeding. Grandmothers are often the custodians of traditional knowledge and cultural practices, and their support or disapproval can determine whether EBF is practiced as recommended in this setting (\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSimilar divergences between global recommendations and local understandings are evident in the case of complementary feeding practices in Northern Nigeria. While biomedical guidelines emphasise the importance of diverse, nutrient-rich complementary foods, local definitions of \u0026lsquo;adequate\u0026rsquo; complementary feeding prioritise food quantity and satiety over dietary diversity or nutritional content (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Studies have shown that CF typically involves the early introduction of staples (e.g. pap), but little addition of protein-rich or micronutrient-dense foods due to limited availability, poverty, and cultural beliefs about appropriate infant foods (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Decisions regarding what and when to feed a child are also influenced by household hierarchies, with male heads of households controlling food purchases and elder women determining feeding norms (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAlthough several studies have explored infant feeding practices in northern Nigeria, most have focused on the prevalence and determinants of EBF and CF, without explicitly examining how these concepts are defined and understood within communities (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). A 2016 systematic review on mother\u0026rsquo;s understanding of EBF identified 4 qualitative studies exploring this topic, which highlighted inaccurate understandings of EBF, including commonly believing that giving water or traditional remedies was still acceptable. Cultural norms, family influence, and unclear health messaging shaped these misconceptions, highlighting the need for clearer, context-specific communication on EBF, however no studies were found from Nigeria (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Given the high burden of malnutrition and child mortality in Northern Nigeria, understanding local definitions of EBF and CF are essential for identifying culturally embedded barriers to optimal infant feeding practices and designing interventions that are both acceptable and effective within these communities. We therefore aimed to explore community definitions of EBF and CF in Jigawa State, Northern Nigeria, and how these influence feeding practices and nutrition.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design\u003c/h2\u003e\u003cp\u003eWe conducted a qualitative study using life-history interviews with women of childbearing age (16\u0026ndash;49 years old) and both facility and household observations conducted as part of an ethnographic process evaluation conducted between July 2020 and November 2022. The study was set in Kiyawa Local Government Area (LGA), Jigawa State, Nigeria, and was part of the INSPIRING Jigawa cluster randomized controlled trial process evaluation (ISRCTN3921355, registered: 11th December 2019).(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eIn our previous study exploring household power in EBF practices, the importance of water in feeding practices emerged as a sub-theme under the beliefs and cultural norms within households that impact EBF(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Given the limited literature in this area, and the unexpectedly high self-reporting of EBF(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), we decided to re-analyse these data to explore in more depth how water is understood as part of the local definition of EBF, as well as exploring definitions of adequate CF.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSetting\u003c/h3\u003e\n\u003cp\u003eThis study was conducted in Kiyawa LGA of Jigawa State, with an estimated state-wide population of over 6\u0026nbsp;million people, predominantly of Hausa-Fulani ethnicity, with Islam as the dominant religion (National Population Commission (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The State is largely rural, with most residents engaged in subsistence farming, animal rearing, and petty trading. Jigawa consistently records some of the poorest maternal and child health indicators in Nigeria, including high neonatal, infant, and under-five mortality rates (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The State has also reported high prevalence of diarrheal diseases among children under five, (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) which causes 24\u0026ndash;30% of post-neonatal under-five deaths in Northern Nigeria (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). This high burden is attributed to poor sanitation, unsafe water sources, and suboptimal infant feeding practices.\u003c/p\u003e\n\u003ch3\u003eParticipant selection\u003c/h3\u003e\n\u003cp\u003eFull methods for sampling and data collection have been published previously (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Our participants of interest were women aged 16\u0026ndash;49 years who had reported breastfeeding in the previous two years. The ethnographic process evaluation was organised around six purposively selected health facility clusters from the main INSPIRING Jigawa trial, three from the intervention group and three from the control group, balanced for facility type (i.e., primary health centre, basic health centre, or health post). We then randomly selected five compounds in each cluster and recruited women aged 16\u0026ndash;49 years with children younger than 5 years from these compounds using availability sampling, stratifying for age and wife position. Overall, 90 women were recruited for the ethnography. In this study data from36 of these women who reported breastfeeding in the last 2 years (18 from each trial arm) are analysed.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eIn-depth life history interviews were conducted at three time points as part of the ethnography, alongside monthly informal household visits, and monthly observations at the six corresponding health facilities. For this paper, we used data from the midline interview conducted in July 2021, in addition to notes taken from monthly household and facility visits. An in-depth interview guide was used, including questions focusing on feeding practices, and pattern of EBF within the wider household (\u003cb\u003eAppendix 1\u003c/b\u003e). The guide was prepared by FS and discussed with RAB, CK and AGF. Interviews were conducted by three research assistants, who were trained on how to use the guide, including rephrasing questions in Haua during discussions among the data collection team, led by FS. Interviews were conducted within each participant\u0026rsquo;s household in line with their preferences, to ensure no interference and smooth rapport with research assistants. Interviews were conducted in Hausa and each lasted for approximately 1 hour. Interviews were recorded, transcribed verbatim and then translated into English by the research assistants and checked by FS. At the end of the interview, an incentive was given to participants as means of appreciating them for their time.\u003c/p\u003e\n\u003ch3\u003eAnalysis\u003c/h3\u003e\n\u003cp\u003eData was analysed by FS using reflexive thematic analysis (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Interview transcripts were read several times as a means of data familiarization and notes of initial trends in the data were taken; thoughts and feelings regarding the data and analytical process were documented. Following this, codes were generated to produce interpretive labels for pieces of information that were of importance to the research aim, which was later developed into themes by collapsing multiple codes that share similar concepts. Once the coding framework was developed, a reading of field notes from facility and household visits was completed by FS, to triangulate these themes. The development of the initial coding framework was supported by RAB and AGF, and the organisation of themes and sub-themes were discussed with CK before finalisation, and all authors provided feedback on the interpretation.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eEthics\u003c/h2\u003e\u003cp\u003eEthical approval was obtained from Jigawa State Government (ref: JPHCDA/ADM/GEN/073/V. I) and the University College London Research Ethics Committee (ref: 3433/004). Approval was obtained from the Local Government, District, Ward and Village heads of every single community before data collection commenced in any of the communities. All methods were performed in accordance with the relevant guidelines and regulations, including the principles of the Declaration of Helsinki. Verbal consent was sought from all participants, including informing them that participation in interviews was voluntary, data collected would be used for research purposes only and that they have the right to withdraw at any time.\u003c/p\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe 36 women included in the life-history interviews were in the age range of 1649 years and had between 2\u0026ndash;9 children. Overall, we found women held positive attitudes towards breastfeeding, with some mothers reporting breastfeeding their children beyond two years, and the initiation of complementary feeding occurring at varying ages. Breastfeeding was widely regarded as an essential cultural norm, with other feeding practices perceived as supplementary rather than as alternatives. Notably, practices such as breastfeeding alongside water was commonly considered acceptable and not viewed as a violation of EBF, reflecting local interpretations of the practice. While some mothers adhered to the recommended six months of EBF, others introduced water as early as newborn period along with breastfeeding. Similarly, the timing of complementary food introduction lacked consistency, with mothers initiating CF between three and seven months, shaped by perceptions of infant readiness, and prevailing community norms. The thematic analysis generated four themes: cognitive polyphasia in the definition of EBF, water as an essential component of EBF \u0026ndash; it is harmless and necessary, realities of food insecurity and gendered norms determine complementary feeding, rather than contextualised definitions, and culturally Shaped Understandings and Structural Barriers in the Infant Feeding\u0026ndash;Malnutrition Pathway\u003c/p\u003e\n\u003ch3\u003eCognitive polyphasia in the definition of EBF\u003c/h3\u003e\n\u003cp\u003eThis theme captures the tension between mothers\u0026rsquo; conceptual understanding of EBF and the contradictions evident in their infant feeding practices. Although most mothers could accurately articulate the global recommendation that EBF involves feeding an infant solely with breast milk from birth up to six months of age, without the addition of water, other liquids, or foods, their practical interpretations often diverged from this standard.\u003c/p\u003e\u003cp\u003eMany mothers demonstrated a form of cognitive polyphasia in their understanding of EBF - holding both biomedical and traditional beliefs simultaneously (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). While they consistently avoided giving their infants other foods or formulas in line with EBF recommendations, they did not perceive giving water as a breach of EBF, reflecting a complex co-existence of scientific advice and culturally rooted practices. One participant stated:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I never gave my babies milk or any baby formula apart from breast milk and water until they reach the stage of eating semi-solid and solid food like pap, rice, beans or tuwo\u0026rdquo; (P11, Intervention)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAnother mother stated:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I only give them breast milk and water and when a child is about to start eating, he/she will display some signs\u0026rdquo; (P10, Intervention)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThese responses illustrate a partial and selective adherence to the principles of EBF, where mothers internalized parts of the guideline (excluding formula and foods) while disregarding others (excluding water). This was compounded by a lack of health literacy on why water should be avoided. One participant noted:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I just felt there was not going to be issues even if I give him water.\u0026rdquo; (P10, Control)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eFacility observations reinforced this finding. In one instance:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I engaged one of the women who came for routine immunization in discussion around exclusive breastfeeding. She told me she does practice but in addition with water. She claimed babies get thirsty. I am not surprised to hear that, because they also tell us this in the communities. The In-charge stressed further on that as he said they can\u0026rsquo;t practice EBF without water and that is why diarrhoea among children is high, which eventually leads to malnutrition.\u0026rdquo; (Facility observation, facility 6)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThis account highlights how community members perceive water as an essential component of infant care, despite health education efforts promoting strict adherence to EBF. It also illustrates how health workers recognize the challenge of achieving EBF without water within this context, and link the prevailing practice to persistent child health problems like diarrhoea and malnutrition.\u003c/p\u003e\u003cp\u003eIn some cases, mothers\u0026rsquo; decisions to stop giving water were not driven by an understanding of medical recommendations but by personal or communal experiences of adverse events, such as a child choking. A participant recounted:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I once saw a woman who gave water to her baby and the baby got choked and almost fainted, and when the baby was taken to the hospital, the health workers advised that we should not give our babies water until after six months. For me, it was because of fear of what I saw happen to that baby that I stopped giving my children water until they reached six months.\u0026rdquo; (P 17, Intervention)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThese narratives and observations suggest that community\u0026rsquo;s practice of EBF is shaped by a combination of formal knowledge, personal interpretations, community norms, facility-level attitudes, and emotional responses to observed events \u0026mdash; a dynamic that fosters cognitive polyphasia between what mothers know, believe, and practice.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eWater as an essential component of EBF \u0026ndash; it is harmless and necessary\u003c/h2\u003e\u003cp\u003eAs introduced in the first theme, water was considered by women as being exempt from EBF, and this was justified through water being seen not only as harmless to infants, but also necessary for the health and wellbeing of their children. This conceptualisation allowed women a degree of flexibility in their feeding practices, which reflects their lived realities of competing priorities and multi-generational childcare.\u003c/p\u003e\u003cp\u003eSome mothers reported modifying their infant feeding practices at night to suit personal convenience. One participant shared that she intentionally avoided breastfeeding at night because she believes that nighttime feeds encourage babies to develop habits that disturb their mothers' sleep. This narrative highlights how personal and practical considerations, such as the desire for uninterrupted sleep, can lead to the early introduction of water. Mothers in this situation do not perceive water as a substitute for breastmilk but rather as a harmless way to calm a baby at night:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I don't breastfeed at night because when a child gets used to breastfeeding at night, they become troublesome and wouldn't allow me to sleep well. So, all my children are used to breastfeeding only from early morning to night time. I don't wake up at midnight to breastfeed. If the baby cries, they may have water alone during that time.\u0026rdquo; (P17, Control)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eIn other cases, past community experiences shaped this understanding that water is something desirable for infants. One respondent recalled:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;So many years ago in this our compound, there was a child they started giving water, then after some days when they took him to collect his first vaccine at the hospital the mother was advised not to give the child water. That child cried throughout the whole day, even at night the child kept crying and when the mother decided to give the child water, he stopped crying and fell asleep. Since then, I never pick interest in practicing [exclusive breastfeeding].\u0026rdquo; (P13, Intervention)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThese accounts reveal how personal experiences, fear of infant discomfort, social narratives, and a lack of awareness about the risks of early water introduction contribute to the continued use of water during the EBF period.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eFood insecurity and gender norms: setting the parameters for complementary feeding\u003c/h2\u003e\u003cp\u003eUnlike EBF, there was limited understanding of adequate CF practices among mothers. Therefore, they exhibited considerable variation in both the timing of food introduction and the types of foods offered to infants and young children. While the WHO recommends introducing a range of complementary foods at six months of age alongside continued breastfeeding, we found flexible and inconsistent patterns, that were shaped by personal preferences, cultural norms, food insecurity, and limited nutrition awareness.\u003c/p\u003e\u003cp\u003eFor example, mothers reported initiating CF from as early as three to five months to as late as seven months. Some mothers introduced light foods such as pap (a smooth and light-textured porridge made from grains such as maize, millet or sorghum) after five months, others extended breastfeeding with water up to seven months before introducing any complementary food, while a few women stated they adhered to the six-month EBF period.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I make pap for them to drink after about 5 months of birth then gradually, I teach them how to eat other foods like rice, beans, cassava and Tuwo.\u0026rdquo; (P4, Intervention)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I breastfeed my children with breast milk and water for 7 months before I introduce light food like pap, and when they become older, I introduced other food to them.\u0026rdquo; (P3, Control)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;After 6 months I will start giving the child water, also I will start introducing pap to the child then later on solid food.\u0026rdquo; (P16, Control)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe complementary foods introduced were predominantly locally available, cereal-based dishes with low dietary diversity. The most frequently mentioned first food was pap, followed by Tuwo (solid food made from maize, millet, sorghum) as the child grew older. This mix of early, timely, and delayed initiation of CF, and lack of diversity, reflected factors such as maternal perceptions of child readiness, household food security, and socio-cultural expectations. Severe food insecurity was a key driver of limited dietary options, and many mothers described their reliance on staple foods, often prepared without oil, fish, or meat:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Here in our community, our only food is Tuwo and Kuka [green soup]. Sometimes we can\u0026rsquo;t even afford oil in the soup, not to talk of fish or meat. Such situation brings about malnutrition in children\u0026rdquo; (P4, Intervention)\u003c/em\u003e.\u003c/p\u003e\u003cp\u003eIn addition to the testimonies from mothers, facility heads and nurses reported a concerning household dynamic in which husbands/men would go outside of the home to eat nutrient rich foods, while women and children who remain inside the home only had access to staples. This practice not only highlights gendered disparities in food access within households but the poor financial power of women, limiting their ability to procure diverse and nutrient-dense foods for themselves and their children, thereby exacerbating the challenges of achieving adequate CF.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;They (facility head and nurses) claimed husbands/men in the community leave wives at home with one particular source of food (Tuwo) which is majorly carbohydrates while they go to tea joints to eat bread and egg or noodles and egg with tea, at times, they eat suya (roasted meat) too\u0026rdquo; (observational notes, Facility 1).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eBeyond economic hardship and unequal food distribution, participants also noted that children were frequently fed adult meals, without consideration for their specific nutritional needs:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Here, what I see them do is they give the children the same food we eat as adults but I don't know if there is any other thing, they give them, and I also don't think of any food that a child should be given\u0026rdquo; (P7, C)\u003c/em\u003e.\u003c/p\u003e\u003cp\u003eThese accounts underscore the combined impact of poverty, intra-household food allocation dynamics, food insecurity, and limited knowledge about appropriate child feeding on how CF is practiced. There was limited awareness of adequate dietary diversity for child growth, and rather than a mis-aligned definition driving poor infant feeding practices, CF was reactive and reflective of circumstance.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eStructural barriers and misconceptions in the infant feeding\u0026ndash;malnutrition pathway\u003c/h2\u003e\u003cp\u003eMothers\u0026rsquo; accounts revealed a complex relationship between infant feeding practices, episodes of diarrhoea and malnutrition, but also hint at the underlying role of maternal nutrition. Many mothers described how inadequate breastfeeding, early or inappropriate CF, and recurrent childhood illnesses contributed to weight loss and poor growth in children. Diarrhoea was frequently mentioned as both a cause and a consequence of malnutrition. This is evident in the responses below:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The child that was malnourished in this household started with diarrhoea but they didn\u0026rsquo;t take her to hospital on time which led to malnutrition\u0026rdquo; (P3, C)\u003c/em\u003e.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;My son\u0026rsquo;s own started from teething fever then it led to diarrhoea and I noticed he started losing weight\u0026rdquo; (P16, C)\u003c/em\u003e.\u003c/p\u003e\u003cp\u003eWhile mothers linked these feeding practices to poor health outcomes, they often lacked clear understanding of the underlying biomedical mechanisms by which poor feeding practices and unclean water increase the risk of diarrhoea and malnutrition. Their explanations were frequently shaped by cultural beliefs about hygiene, maternal status during breastfeeding, and childhood illnesses. For instance, some understood that when a breastfeeding mother becomes pregnant, it causes poor nutritional outcomes in the breastfeeding child:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The cause of malnutrition like I told you is dirt and when a woman is pregnant and she is still breastfeeding that makes the child to be malnourished\u0026rdquo;\u003c/em\u003e (P6, Intervention).\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The child was very small though it started with when the child was teething and he kept defecating which led to the child losing a lot of weight. Then I got pregnant while I was still breastfeeding the child and I didn\u0026rsquo;t wean the child, so he lost a lot of weight that led to him looking very slim; the hands and legs were thin, that\u0026rsquo;s all that happened\u0026rdquo; (P9, Control).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eOthers emphasized the role of hygiene and timely healthcare seeking:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It is caused by dirtiness; you don\u0026rsquo;t wash your hands before you feed a child and you don\u0026rsquo;t take care of the kind of food you feed your children with, or a child is having diarrhoea and you won\u0026rsquo;t take the child to the hospital on time\u0026rdquo; (P17, Intervention)\u003c/em\u003e.\u003c/p\u003e\u003cp\u003eFacility observations echoed these maternal beliefs. Informal discussions with health workers noted that community members often did not believe malnutrition was primarily caused by poor diets. Instead, they attributed it largely to diseases resulting from poor hygiene and environmental dirt. Facility observations also illustrated the scale of the malnutrition problem. In one facility observation, it was noted how shocking it was to observe the sheer number of malnourished children being brought in for care:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;They came in masses. These (plumpy nuts) was given to more than 100 children\u0026rdquo; (observational notes, Facility 6).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eA facility staff, who was particularly open to engagement, discussed the high prevalence of malnutrition in the community and suggested health education interventions. However, he emphasized that such efforts would only achieve sustained impact if accompanied by| improvements in literacy, as low educational attainment significantly constrained health-seeking behaviors and feeding practices:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eAnother factor mentioned by facility doctor was community members literacy level which has great role in correcting both malnutrition and anaemia, he then caped it all with economic state of the country and increase in the price of food commodities (observational notes, Facility 1).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur findings demonstrate a clear gap between mothers\u0026rsquo; knowledge of EBF and their actual interpretation and practice within the community. Although most mothers could correctly define EBF as feeding an infant only breast milk for six months, it was common practice to introduce water as early as the newborn period, in addition to breastfeeding, driven by beliefs of water being both harmless and necessary. Conversely, adequate CF was not well understood, and practices were responsive to the context of food insecurity and challenges in access to nutrient-rich food given the pervasive poverty and catastrophic flooding events in this setting, rather than medical and scientific knowledge.\u003c/p\u003e\u003cp\u003eElsewhere, we have previously identified cultural and religious beliefs as primary reasons for early water introduction, such as the use of holy water for blessings or the perception that denying water is cruel (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In this deeper exploration, we noted while there are symbolic reasons for giving water, that this is supported by the belief that water is not harmful and that infants are seen to need water \u0026ndash; both to quench thirst but also comfort the infant. These factors can interact to allow the practice to persist, despite the knowledge that water should not be given. Similar practices have been observed in other settings across Nigeria and Sub-Saharan Africa. Burba et al. (2025)(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) reported that although a majority of mothers in northwestern Nigeria demonstrated good knowledge of EBF, actual practice was limited due to traditional beliefs about the necessity of water and herbal medicines for infants. Likewise, a study by Onah et al. (2014)(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) from Nigeria found that awareness of EBF was high, but the prevalence of early supplementation with water and other fluids remained common. Abdullahi et al. (2017)(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) also documented this knowledge-practice gap in Nigeria, attributing it to the persistence of cultural norms and family influences that override biomedical recommendations. However, our findings suggest that even mothers who are informed about EBF, perceive water as a negligible addition that doesn't mean they are not practicing EBF.\u003c/p\u003e\u003cp\u003eThis gap in understanding the health implications of introducing water to infants, particularly in regions with unsafe water sources, can lead to increased risks of waterborne diseases like cholera. Nigeria, including Jigawa State, has experienced several significant cholera outbreaks in recent years, namely in 2018, 2021 and most recently in 2024 with over 70 reported cases and associated deaths, predominantly affecting women and children (\u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Northern Nigeria also reports one of the highest under-five mortality rates globally, with diarrhoeal deaths making up approximately 1 in 4 of these deaths (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The persistent practice of giving water to infants undoubtedly contributes to this mortality burden, however the link between contaminated or unsafe drinking water and diarrhoeal diseases did not emerge from interviews or household observations. This has highlighted a critical gap in awareness in this community for why EBF is recommended.\u003c/p\u003e\u003cp\u003eSimilar misconceptions have been documented in other regions. For instance, in The Gambia, mothers believed that giving water or thin porridge was part of EBF, not recognizing that these additions could pose health risks(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). In Ghana, health workers reported that some mothers perceived breastmilk as insufficient to quench infants' thirst, leading to early water supplementation(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). In the Democratic Republic of Congo, some mothers and grandmothers believed that water should be introduced to infants before six months, despite healthcare providers' advice to the contrary(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). These findings underscore the importance of not only promoting EBF but also ensuring that health education programs effectively communicate the reasons behind the WHO's recommendations. Addressing misconceptions and providing clear explanations about the sufficiency of breast milk, alongside emphasizing the importance clean water and sanitation and adequate maternal nutrition, are crucial steps toward improving adherence to EBF and safeguarding infant health.\u003c/p\u003e\u003cp\u003ePatterns of CF reflected a reliance on locally available, low-diversity foods such as pap and Tuwo, introduced at varying ages. Inadequate dietary diversity and inappropriate CF practices \u0026ndash; with both early and late introduction of foods posing issues, have been consistently associated with child undernutrition in Nigeria and other low-resource settings (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). The socioeconomic realities of many households, including food insecurity and limited access to nutrient-rich foods, further constrained mothers' ability to provide optimal CF, as also documented in a qualitative study in rural northern Nigeria(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAn important contribution of this study lies in the exploration of how mothers link infant feeding practices to health outcomes, particularly diarrhoea and malnutrition. While many mothers demonstrated awareness of a connection between inadequate feeding and poor child health, their explanations were often mediated by cultural beliefs, such as attributing diarrhoea to teething, or considering malnutrition a consequence of environmental dirt or maternal pregnancy during breastfeeding. The pathway to malnutrition is complex, and hygiene practices, birth spacing and maternal nutrition, and infections are all critical factors alongside feeding practices. However, the ethnographic observations emphasized the lack of awareness of the importance of appropriate feeding practices within this community as being the main gap in understanding. These perceptions echo earlier studies from northern Nigeria and other parts of Africa, where cultural beliefs significantly shape health-seeking behaviours and child care practices(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOur findings highlight the dual burden of risk factors and cultural explanatory models in contributing to child malnutrition, where mothers contain multiple, seemingly contradictory knowledge systems together through their everyday practices. Suboptimal adherence to recommended breastfeeding and CF practices, alongside recurrent diarrheal episodes and delays in seeking care, contribute to a cycle of undernutrition, as outlined in global child survival frameworks(\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Additionally, culturally embedded beliefs and practices, which hold significant meaning and value within the community, may influence feeding and healthcare behaviours in ways that can sometimes limit the adoption of evidence-based recommendations.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study identified the need for integrated, culturally sensitive health promotion interventions that address both the practical barriers to optimal feeding \u0026mdash; such as food insecurity, at the same time as engaging with underlying beliefs about child health and nutrition. Community-based education programmes, delivered through trusted community structures such as women's groups and religious leaders, could help to correct misconceptions about EBF, water introduction, and the causes of diarrhoea and malnutrition, while promoting affordable and context-appropriate CF practices.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eHuman Ethics and Consent to Participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEthical approvals were obtained from Jigawa State Government (ref: JPHCDA/ADM/GEN/073/V.I) and University College London Research Ethics Committee (ref: 3433/004), and from Swedish Ethics Authority for the analysis of personal data within Sweden (ref: 2024-00868-01). We consulted with representatives from Local Government, District, Ward, And Village Heads before commencing project activities. Verbal informed consent was obtained from all research participants in accordance with local guidelines and as approved by the ethics committee.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for Publications\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNo potential conflict of interest was reported by the authors.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis work was funded through the GlaxoSmithKline (GSK)-Save the Children Partnership (grant reference: 82603743). Employees of both GSK and Save the Children contributed to the design and oversight of the wider INSPIRING Jigawa trial as part of a co-design process.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors\u0026rsquo; contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe conceptualisation of this manuscript was done by FS, CK, SR, RAB and AGF. Funding acquisition for the wider study was done by CK, TC and AGF. Data collection was designed and supervised by FS, TC, CK, RAB, AGF, AAB, AI, JS and DB. Analysis was conducted by FS, with support from AGF, RAB and CK. FS drafted the manuscript. All authors read and approved the final version of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe sincerely thank the mothers of under-5 children who participated in this study for their time, trust, and valuable contributions. We also appreciate the efforts of the data collectors and field supervisors for their dedication throughout the data collection process. Special thanks go to the facility staff, who not only supported our visits but also shared valuable insights during informal discussions, enriching the depth of this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWHO. Infant and young child feeding [Internet]. 2023 [cited 2025 Apr 11]. Available from: https://www.who.int/news-room/fact-sheets/detail/infant-and-young-child-feeding\u003c/li\u003e\n\u003cli\u003eUNICEF. United Nations Children\u0026rsquo;s Fund (UNICEF). (2020). Infant and young child feeding: A programming guide. UNICEF. https://www.unicef.org/media/96116/file/IYCF-Programming-Guide.pdf - Google Search [Internet]. 2020 [cited 2025 May 26]. Available from: https://www.google.com/search?client=firefox-b-d\u0026amp;q=United+Nations+Children%E2%80%99s+Fund+%28UNICEF%29.+%282020%29.+Infant+and+young+child+feeding\u003cbr\u003e%3A+A+programming+guide.+UNICEF.+https%3A%2F%2Fwww.unicef.org%2Fmedia%2F96116%2Ffile%2FIYCF-Programming-Guide.pdf#vhid=zephyr:0\u0026amp;vssid=atritem-https://www.unicef.org/media/93981/file/Complementary-Feeding-Guidance-2020.pdf\u003c/li\u003e\n\u003cli\u003eTololu AK, Teshome B, Fessaha HZ, Kaso AW. Determinants of appropriate complementary feeding practices among mothers of children aged 6\u0026ndash;23 months in Bokoji town, Oromia region, Ethiopia. BMC Pediatr. 2025 Jan 31;25:82. \u003c/li\u003e\n\u003cli\u003eOnah S, Osuorah DIC, Ebenebe J, Ezechukwu C, Ekwochi U, Ndukwu I. Infant feeding practices and maternal socio-demographic factors that influence practice of exclusive breastfeeding among mothers in Nnewi South-East Nigeria: a cross-sectional and analytical study. International Breastfeeding Journal. 2014 May 20;9(1):6. \u003c/li\u003e\n\u003cli\u003eOkafor AE, Uche OA, Uche IB. Sociocultural Factors as Predictor to Exclusive Breastfeeding (EBF) Practice among Nursing Mothers in some Communities in Eastern, Nigeria. Soc Work Public Health. 2023 May 19;38(4):298\u0026ndash;310. \u003c/li\u003e\n\u003cli\u003eShittu F, King C, Rautiainen S, Iuliano A, Bakare AA, Colbourn T, et al. Exploring the feeding practices of mothers of under-five children and how household members influence exclusive breastfeeding in Jigawa State, Nigeria \u0026ndash; A qualitative study. Global Public Health. 2024 Dec 31;19(1):2426135. \u003c/li\u003e\n\u003cli\u003eNwaodu-Ufomba L. Complementary Feeding Perception among Nursing Mothers in Nigeria. Indonesian Journal of Global Health Research. 2024 Sep 3;7:235\u0026ndash;46. \u003c/li\u003e\n\u003cli\u003eSunusi SM, Ayaba AK, Ibrahim UM, Mahmud M, Abulfathi AA, Tsiga-Ahmed FI, et al. Determinants of Infant Feeding Practices among Working and Non-working Mothers in Kano, Nigeria. Nigerian Journal of Nutritional Sciences. 2020;41(1):76\u0026ndash;87. \u003c/li\u003e\n\u003cli\u003eSupriatin S, Astriani N, Heri M, Sadli M. Partner and Household Factors Associated with Breastfeeding Practice: A Systematic Review. JURNAL INFO KESEHATAN. 2024 Jun 30;22:429\u0026ndash;40. \u003c/li\u003e\n\u003cli\u003eAubel J. The role and influence of grandmothers on child nutrition: culturally designated advisors and caregivers. Matern Child Nutr. 2011 Sep 28;8(1):19\u0026ndash;35. \u003c/li\u003e\n\u003cli\u003eFaye CM, Fonn S, Kimani-Murage E. Family influences on child nutritional outcomes in Nairobi\u0026rsquo;s informal settlements. Child: Care, Health and Development. 2019 Jul 1;45(4):509\u0026ndash;17. \u003c/li\u003e\n\u003cli\u003eLawan UM, Amole GT, Jahum MG, Sani A. Age-appropriate feeding practices and nutritional status of infants attending child welfare clinic at a Teaching Hospital in Nigeria. J Family Community Med. 2014;21(1):6\u0026ndash;12. \u003c/li\u003e\n\u003cli\u003eAnigo K, Ameh A, Ibrahim S, Solomon S. Infant Feeding Practices and Nutritional Status of Children in North Western Nigeria. Asian Journal of Clinical Nutrition. 2009 Jan 1;1. \u003c/li\u003e\n\u003cli\u003eAbdullahi H, Olamuyiwa AO, Ndidi US, Hassan SM, Jajere UM. INFANT AND YOUNG-CHILD FEEDING PRACTICES FOR UNDER-TWO CHILDREN INVOLVED IN COMMUNITY INFANT AND YOUNG CHILD FEEDING PROGRAMME IN ZARIA, NIGERIA. FUDMA JOURNAL OF SCIENCES. 2022 Apr 1;6(1):33\u0026ndash;43. \u003c/li\u003e\n\u003cli\u003eJoseph FI, Earland J. A qualitative exploration of the sociocultural determinants of exclusive breastfeeding practices among rural mothers, North West Nigeria. International breastfeeding journal. 2019 Aug 20;14(1):38. \u003c/li\u003e\n\u003cli\u003eEnwere ME. Feeding Practices and Nutritional Status of Infants in Northwest Nigeria. 2019; \u003c/li\u003e\n\u003cli\u003eHossain S, Mihrshahi S. Exclusive Breastfeeding and Childhood Morbidity: A Narrative Review. International Journal of Environmental Research and Public Health. 2022 Nov 10;19(22):14804. \u003c/li\u003e\n\u003cli\u003eStill R, Marais D, Hollis JL. Mothers\u0026rsquo; understanding of the term \u0026lsquo;exclusive breastfeeding\u0026rsquo;: a systematic review. Maternal \u0026amp; Child Nutrition. 2017;13(3):e12336. \u003c/li\u003e\n\u003cli\u003eEffect of a participatory whole-systems approach on mortality in children younger than 5 years in Jigawa state, Nigeria (INSPIRING trial): a community-based, parallel-arm, pragmatic, cluster randomised controlled trial and concurrent mixed-methods process evaluation - The Lancet Global Health [Internet]. [cited 2025 May 13]. Available from: https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(24)00369-3/fulltext\u003c/li\u003e\n\u003cli\u003eKing C, Burgess RA, Bakare AA, Shittu F, Salako J, Bakare D, et al. Integrated Sustainable childhood Pneumonia and Infectious disease Reduction in Nigeria (INSPIRING) through whole system strengthening in Jigawa, Nigeria: study protocol for a cluster randomised controlled trial. Trials. 2022 Dec;23(1):95. \u003c/li\u003e\n\u003cli\u003eNational Population Commission (NPC) [Nigeria] and ICF, author. National Population Commission (NPC) [Nigeria] and ICF, author. Nigeria Demographic and Health Survey 2018 Key Indicators Report. Abuja, Nigeria, and Rockville, Maryland, USA: NPC and ICF; 2019. [Google Scholar]. 2019; \u003c/li\u003e\n\u003cli\u003eNational Bereau of Statistics. Reports | National Bureau of Statistics [Internet]. 2021 [cited 2025 May 7]. Available from: https://www.nigerianstat.gov.ng/elibrary/read/1241209\u003c/li\u003e\n\u003cli\u003eOdejimi A, Quinley J, Eluwa GI, Kunnuji M, Wammanda RD, Weiss W, et al. Causes of deaths in neonates and children aged 1\u0026ndash;59 months in Nigeria: verbal autopsy findings of 2019 Verbal and Social Autopsy study. BMC Public Health. 2022 Dec;22(1):1\u0026ndash;15. \u003c/li\u003e\n\u003cli\u003eKing C, Burgess RA, Bakare AA, Shittu F, Salako J, Bakare D, et al. Integrated Sustainable childhood Pneumonia and Infectious disease Reduction in Nigeria (INSPIRING) through whole system strengthening in Jigawa, Nigeria: study protocol for a cluster randomised controlled trial. Trials. 2022 Jan 31;23(1):95. \u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Conceptual and design thinking for thematic analysis. Qualitative Psychology. 2022;9(1):3\u0026ndash;26. \u003c/li\u003e\n\u003cli\u003ede-Graft Aikins A. Healer shopping in Africa: new evidence from rural-urban qualitative study of Ghanaian diabetes experiences. BMJ. 2005 Oct 1;331(7519):737. \u003c/li\u003e\n\u003cli\u003eBurba, Chia A, Musa D, Adi R. EXCLUSIVE BREASTFEEDING: KNOWLEDGE, ATTITUDE AND PRACTICES OF BREASTFEEDING AMONG NURSING MOTHERS ATTENDING SAMARU PRIMARY HEALTH CARE, NORTHWEST NIGERIA. 2022 Jun 1; \u003c/li\u003e\n\u003cli\u003eAbdullahi KO, Ghiyasvandian S, Hasanpour M. Theory-Practice Gap: The Knowledge and Perception of Nigerian Nurses. Iranian Journal of Nursing and Midwifery Research. 2022 Jan 25;27(1):30. \u003c/li\u003e\n\u003cli\u003eNCDC Cholera Situation Report Monthly Epidemiological Report 22 Epi week 39: (23 September 2024 \u0026ndash; 29 September 2024) - Nigeria | ReliefWeb [Internet]. 2024 [cited 2025 May 4]. Available from: https://reliefweb.int/report/nigeria/ncdc-cholera-situation-report-monthly-epidemiological-report-22-epi-week-39-23-september-2024-29-september-2024\u003c/li\u003e\n\u003cli\u003eOnwunta IE, Ozota GO, Eze CA, Obilom IF, Okoli OC, Azih CN, et al. Recurrent cholera outbreaks in Nigeria: A review of the underlying factors and redress. Decoding Infection and Transmission. 2025 Jan 1;3:100042. \u003c/li\u003e\n\u003cli\u003eElimian KO, Musah A, Mezue S, Oyebanji O, Yennan S, Jinadu A, et al. Descriptive epidemiology of cholera outbreak in Nigeria, January\u0026ndash;November, 2018: implications for the global roadmap strategy. BMC Public Health. 2019 Sep 13;19(1):1264. \u003c/li\u003e\n\u003cli\u003eSosseh SAL, Barrow A, Lu ZJ. Cultural beliefs, attitudes and perceptions of lactating mothers on exclusive breastfeeding in The Gambia: an ethnographic study. BMC Women\u0026rsquo;s Health. 2023 Jan 13;23(1):18. \u003c/li\u003e\n\u003cli\u003eAyawine A, Ae-Ngibise KA. Determinants of exclusive breastfeeding: a study of two sub-districts in the Atwima Nwabiagya District of Ghana. Pan Afr Med J. 2015 Nov 17;22:248. \u003c/li\u003e\n\u003cli\u003eKavle JA, LaCroix E, Dau H, Engmann C. Addressing barriers to exclusive breast-feeding in low- and middle-income countries: a systematic review and programmatic implications. Public Health Nutr. 2017 Dec;20(17):3120\u0026ndash;34. \u003c/li\u003e\n\u003cli\u003eBlack RE, Victora CG, Walker SP, Bhutta ZA, Christian P, De Onis M, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. The Lancet. 2013 Aug;382(9890):427\u0026ndash;51. \u003c/li\u003e\n\u003cli\u003eAkpoghelie EO, Chiadika EO, Edo GI, Al-Baitai AY, Zainulabdeen K, Keremah SC, et al. Malnutrition and food insecurity in northern Nigeria: an insight into the United Nations World Food Program (WFP) in Nigeria. Discov Food. 2024 Nov 26;4(1):165. \u003c/li\u003e\n\u003cli\u003eYaya S, Odusina EK, Adjei NK. Health care seeking behaviour for children with acute childhood illnesses and its relating factors in sub-Saharan Africa: evidence from 24 countries. Tropical Medicine and Health. 2021 Dec 14;49(1):95. \u003c/li\u003e\n\u003cli\u003eBakare AA, King C, Salako J, Bakare D, Uchendu OC, Burgess RA, et al. Pneumonia knowledge and care seeking behavior for children under-five years in Jigawa, Northwest Nigeria: a cross-sectional study. Front Public Health. 2023 Jul 18;11:1198225. \u003c/li\u003e\n\u003cli\u003eVictora CG, Christian P, Vidaletti LP, Gatica-Dom\u0026iacute;nguez G, Menon P, Black RE. Revisiting maternal and child undernutrition in low-income and middle-income countries: variable progress towards an unfinished agenda. The Lancet. 2021 Apr 10;397(10282):1388\u0026ndash;99. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Infant, exclusive breastfeeding, complementary feeding, Nigeria","lastPublishedDoi":"10.21203/rs.3.rs-7618939/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7618939/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003eExclusive breastfeeding (EBF) and appropriate complementary feeding (CF) are important for child survival and development. While global guidelines provide clear definitions for these practices, interpretations within communities can differ, influencing infant feeding behaviours. This study explored how EBF and CF are understood, and how these understandings shape infant feeding and nutrition within a community setting in Jigawa State, northern Nigeria.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eWe conducted a qualitative study using life-history interviews and household observations within an ethnographic process evaluation in Kiyawa LGA, Jigawa State, Nigeria, between July 2020 and November 2022. The data formed part of the INSPIRING Jigawa cluster randomized controlled trial process evaluation. From 90 women recruited for the ethnography, we purposively selected 36 women aged 16\u0026ndash;49 years who had breastfed in the preceding two years. Data included midline interviews and notes from monthly facility and household observations. Interviews were conducted in Hausa, transcribed, translated into English, and analysed using reflexive thematic analysis.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eWe found that while most mothers could state the correct definition of EBF as feeding only breastmilk for the first six months, their interpretation allowed for the early introduction of water, and other water solutions without perceiving this as a breach of EBF. Complementary feeding was similarly defined based on infant cues and cultural beliefs, with many mothers introducing family foods before six months in response to perceived signs of hunger or under the influence of older family members. These locally adapted definitions reflected deep-rooted cultural norms and caregiving traditions.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eWhile communities in Jigawa are aware of global definitions, these are not commonly adopted or practiced. Interventions aiming to improve infant feeding practices must consider these culturally embedded beliefs and engage influential family and community members to align local practices with recommended guidelines.\u003c/p\u003e","manuscriptTitle":"“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","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-16 09:45:24","doi":"10.21203/rs.3.rs-7618939/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-03T14:19:05+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-02T21:47:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"138489551016279307350389036663921378114","date":"2025-11-27T12:09:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"53136625408915695779215060543798941418","date":"2025-10-14T16:41:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-11T09:45:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"304135011073169273817037222785288513650","date":"2025-10-06T07:50:57+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-03T13:48:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-03T13:39:58+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-19T11:01:51+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-18T13:43:49+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-09-18T12:14:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"512e86d8-58c3-4332-b150-af090eb497d7","owner":[],"postedDate":"October 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":56293931,"name":"Social science/Anthropology"},{"id":56293932,"name":"Health sciences/Health care"}],"tags":[],"updatedAt":"2026-03-02T16:02:27+00:00","versionOfRecord":{"articleIdentity":"rs-7618939","link":"https://doi.org/10.1038/s41598-026-41749-z","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2026-02-26 15:58:14","publishedOnDateReadable":"February 26th, 2026"},"versionCreatedAt":"2025-10-16 09:45:24","video":"","vorDoi":"10.1038/s41598-026-41749-z","vorDoiUrl":"https://doi.org/10.1038/s41598-026-41749-z","workflowStages":[]},"version":"v1","identity":"rs-7618939","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7618939","identity":"rs-7618939","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}